Summary & Overview
CPT 99242: Office Consultation for New or Established Patients, Low to Moderate Severity
CPT code 99242 represents an office or other outpatient consultation for new or established patients, focusing on cases with low to moderate severity. This code is significant in the national healthcare landscape as it defines the parameters for straightforward medical decision making, problem focused history, and examination, which are essential for efficient patient care and resource allocation. The code is widely recognized and reimbursed by major payers including Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare, making it a key component in outpatient evaluation and management billing.
Readers will gain insight into the clinical context of 99242, including its requirements and typical use cases. The publication covers payer coverage, common modifiers, associated provider taxonomies, and relevant ICD-10 diagnoses, offering a comprehensive overview for stakeholders interested in policy updates, billing benchmarks, and clinical applications. Understanding the scope and application of 99242 is crucial for healthcare organizations, billing professionals, and clinicians seeking clarity on outpatient consultation coding and reimbursement trends.
CPT Code Overview
CPT code 99242 is used for office or other outpatient consultations for new or established patients. This code requires three key components: a problem focused history, a problem focused examination, and straightforward medical decision making. Counseling and coordination of care with other physicians, qualified health care professionals, or agencies are provided as appropriate to the patient's needs. The presenting problems are typically of low to moderate severity. The service type is Evaluation and Management – Office or Other Outpatient Consultation, and the typical site of service is Office or Other Outpatient (POS 11).
Clinical & Coding Specifications
Clinical Context
A patient presents to the office for a consultation regarding a new or ongoing health concern. The provider conducts a problem-focused history and examination, addressing a specific issue such as cough, abdominal pain, headache, or for a routine general or gynecological examination. The medical decision making is straightforward, and the provider may offer counseling or coordinate care with other healthcare professionals as needed. The presenting problem is typically of low to moderate severity. This service is performed in an office or other outpatient setting, and the patient may be referred by another provider or self-referred for evaluation and management.
Coding Specifications
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Modifiers:
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Modifier
25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. Used when an E/M service is provided in addition to another procedure or service on the same day. -
Modifier
57: Decision for Surgery. Used when the E/M service results in the decision to perform surgery.
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Provider Taxonomies:
| Taxonomy Code | Specialty Name |
|---|---|
207Q00000X | Family Medicine Physician |
207R00000X | Internal Medicine Physician |
208D00000X | General Practice Physician |
These taxonomies represent providers who commonly perform office or outpatient consultations for evaluation and management services.
Related Diagnoses
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Z00.00- Encounter for general adult medical examination without abnormal findings- Used when the consultation is for a routine general check-up with no abnormal findings.
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Z01.419- Encounter for gynecological examination (general) (routine) without abnormal findings- Relevant for consultations involving routine gynecological exams without abnormal findings.
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R05- Cough- Applied when the patient presents with cough as the primary concern for the consultation.
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R10.9- Unspecified abdominal pain- Used when the patient is evaluated for abdominal pain without a specific diagnosis.
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R51- Headache- Relevant for consultations where headache is the presenting symptom.
Related CPT Codes
99483- Cognitive assessment and care plan services
This code is related to 99242 as it may be used in situations where cognitive assessment is required during an outpatient consultation. While 99483 focuses specifically on cognitive evaluation and care planning, 99242 is used for general evaluation and management consultations. These codes may be used together if both services are provided during the same encounter, or as alternatives depending on the clinical scenario.
National Reimbursement Benchmarks
National mean rates for CPT code 99242 show that UnitedHealth Group has the highest average reimbursement at $120.28, while Aetna is the lowest among the major commercial payers at $83.95. The BUCA (average commercial) mean rate stands at $95.59, which is notably higher than Aetna and Blue Cross Blue Shield, but lower than Cigna and UnitedHealth Group. Medicare rates are not available in the input for comparison.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Aetna has the tightest range at $32.83, indicating less variability in rates, while Cigna exhibits the widest spread at $62.00, reflecting greater variability in reimbursement. UnitedHealth Group and Blue Cross Blue Shield also show substantial dispersion, with ranges of $64.00 and $33.69, respectively.
The table and chart below present a detailed breakdown of national benchmarks for each payer, including mean rates and percentile values.
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