2025 CPT code 99242
(Revised) Effective Date: N/A Revision Date: N/A Evaluation and Management - Consultations Evaluation and Management Feed
Office or other outpatient consultation; straightforward medical decision making or at least 20 minutes of total time.
Modifiers may apply depending on the circumstances of the consultation. For example, modifier 25 may be used if a significant and separately identifiable E/M service is performed on the same day as another service. Modifier 32 may be used if the consultation is mandated by a third-party payer.
The consultation must be medically necessary, meaning that the services provided are appropriate and necessary for the diagnosis and management of the patient's condition. The referring physician must request the consultation, specifying a particular condition or problem for evaluation. The consultation must add value beyond the services provided by the referring physician.
The physician performs a consultation, assessing the patient's condition, reviewing information from the referring physician, performing a medically appropriate examination and history (if applicable), making a medical decision, and communicating findings and recommendations to the referring physician or other qualified healthcare professional.
In simple words: The doctor sees a patient for a consultation at the office or other outpatient location.The visit involves a straightforward medical decision or takes at least 20 minutes. The consultation was requested by another doctor or healthcare professional.
This CPT code represents an office or other outpatient consultation for a new or established patient.The service requires a medically appropriate history and/or examination, and the level of medical decision-making (MDM) is straightforward. Alternatively, if total time is used for code selection, a minimum of 20 minutes must be met or exceeded.Total time includes face-to-face and non-face-to-face time on the encounter date. The consultation must be requested by an appropriate source (another physician, qualified healthcare professional, or other appropriate source), and the consultant must communicate findings to the requesting source.
Example 1: A cardiologist consults on a patient with chest pain who is seen in the office by their primary care physician. The cardiologist reviews the patient's history, performs an EKG and physical exam, orders cardiac enzymes, and communicates the results to the primary care physician., A neurologist provides a consultation for a patient who experienced a sudden headache and loss of vision; the consultation is requested by the patient’s ophthalmologist.The neurologist reviews records, performs a neurological exam, orders an MRI, and discusses findings and treatment options with the ophthalmologist., A patient requests a second opinion regarding a complex surgical procedure. The surgeon reviews existing medical records, conducts a detailed history and physical exam, and prepares a comprehensive written report describing a surgical plan to the patient and his primary care doctor.
Complete medical record including patient history (if applicable), relevant physical exam findings, results of any ordered tests, the consultant's assessment and plan, and communication with the requesting source.
** Always confirm payer-specific policies regarding coverage and reimbursement for this code.
- Payment Status: Active
- Specialties:Multiple specialties may use this code, depending on the patient's condition and the reason for the consultation.
- Place of Service:Office, Outpatient Hospital, Other Outpatient Setting