In simple words: This code is used when a doctor sees a patient for a detailed consultation in their office or another outpatient setting. The doctor spends at least 55 minutes with the patient or the situation is very complex and requires a lot of decision-making.

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 a high level of medical decision-making (MDM) or a total time of at least 55 minutes on the date of the encounter. Total time includes face-to-face and non-face-to-face time spent on the encounter date (e.g., reviewing tests, preparing for the visit, performing the exam, counseling, ordering tests, communicating with other providers, documentation, interpreting and communicating results, coordinating care).For encounters exceeding 70 minutes, use CPT code 99417 (Prolonged Services).

Example 1: A 65-year-old male with a complex medical history (diabetes, hypertension, coronary artery disease) presents for a consultation regarding new-onset chest pain. The physician spends over an hour reviewing the patient's records, performing a thorough examination, ordering multiple diagnostic tests (ECG, cardiac enzymes, chest X-ray), and discussing the treatment plan with the referring physician.High MDM and total time are met., A 40-year-old female with a newly diagnosed autoimmune disorder requires a comprehensive evaluation involving detailed history taking, multiple laboratory tests, and coordination of care with specialists (rheumatologist, gastroenterologist). The physician spends over 55 minutes on the encounter date managing this complex case. Total time criteria are met., An 80-year-old patient with multiple comorbidities (dementia, heart failure, renal insufficiency) is referred for a geriatric consultation to optimize medication management and address multiple complex problems. The physician spends more than an hour reviewing the patient's medical records, performing a thorough physical examination, and collaborating with other healthcare providers to develop a comprehensive care plan. High MDM criteria are met.

Detailed medical history, physical examination findings (if performed), results of diagnostic tests (including all imaging and labs), treatment plan, communication with referring and/or other involved providers, and documentation of total time spent on the encounter date.

** Always confirm payer-specific policies regarding coverage and reimbursement for this code. Accurate documentation is crucial for proper coding and payment.