Office consultation, high complexity

Reflecting a pinnacle in Evaluation and Management (E/M) services, CPT code 99245 designates an outpatient consultation with a comprehensive assessment and high-complexity decision-making. This code is reserved for medical encounters demanding an exhaustive evaluation and intricate decision-making processes.

CPT code:

99245

Category:

Category I

Section:

Explore Evaluation and Management CPT Codes

Specialty:

Office or Other Outpatient Consultations

Type:

New or Established Patient

99245 represents the highest level of outpatient consultation services based on either medical decision-making (MDM) or total time spent during the encounter. The code signifies encounters that require a comprehensive assessment, involving an extensive examination and high-complexity decision-making. Its application ensures accurate documentation of the intensity and sophistication inherent in managing patients with severe and intricate health conditions.

Under what category does Office consultation, high complexity fall?

Category I

What is the billing unit for Office consultation, high complexity?

Per Encounter

Modifiers

Modifiers are used to specify the nature of the consultation and ensure proper billing. Common modifiers for CPT 99245 include: Modifier 25 – If the consultation is performed on the same day as another service. Modifier 95 – If the consultation is conducted via telehealth. Modifier 33 – If the consultation is for preventive services.

Clinical use

Office or other outpatient consultation for a new or established patient, comprehensive assessment and management, such as: A specialist evaluating a complex case referred by a primary care provider. A second opinion for a high-risk medical condition. A surgeon assessing a patient’s suitability for a high-risk procedure. Any situation requiring high-complexity medical decision-making or 55+ minutes of consultation time.

Documentation

Proper documentation is crucial for compliance and reimbursement. Providers must include: Referral request Comprehensive history and physical examination High-complexity MDM or time documentation (at least 55 minutes of total consultation time) Consultation report Payer considerations: Medicare does not recognize CPT 99245 for reimbursement. Instead, alternative codes such as 99205 (new patient visit) or 99215 (established patient visit) may be used. Private payers may have different rules for consultations. Providers should verify reimbursement policies before billing. Understanding documentation and payer guidelines ensures proper billing and reimbursement.