Summary & Overview
CPT 99244: Office or Outpatient Consultation, Moderate Complexity
CPT code 99244 represents a moderate complexity office or outpatient consultation for new or established patients, requiring a medically appropriate history and/or examination and moderate level of medical decision making, or at least 40 minutes of total time spent on the date of the encounter. This code is widely used across the United States in ambulatory care settings, including primary care, internal medicine, pediatrics, and obstetrics & gynecology.
Major national payers such as Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare recognize and reimburse for services billed under CPT code 99244. The code is central to evaluation and management billing, reflecting the clinical complexity and time required for patient consultations.
Readers will gain insight into the clinical context of CPT code 99244, including its definition, typical site of service, and its role in outpatient care. The publication also covers payer coverage, common modifiers, associated provider taxonomies, relevant ICD-10 diagnoses, and related CPT codes. Policy updates and benchmarks are discussed to provide a comprehensive overview of how this code is utilized in medical billing and reimbursement.
CPT Code Overview
CPT code 99244 is used for office or other outpatient consultations for new or established patients. This code applies when a medically appropriate history and/or examination is performed, and the encounter involves a moderate level of medical decision making. Alternatively, when selecting the code based on total time, the visit must meet or exceed 40 minutes on the date of the encounter.
Service Type: Evaluation and Management – Office or Other Outpatient Consultation
Typical Site of Service: Office or outpatient setting, such as Office (POS 11).
Clinical & Coding Specifications
Clinical Context
A patient is referred to an office or outpatient setting for a consultation regarding a new or ongoing health concern. The provider, such as an internal medicine physician, family medicine physician, pediatrician, general practice physician, or obstetrics & gynecology physician, conducts a medically appropriate history and/or examination. The clinical workflow involves moderate complexity medical decision making, which may include reviewing prior records, ordering diagnostic tests, and discussing management options. The encounter requires at least 40 minutes of total time on the date of service if time is used for code selection. Common scenarios include evaluation for headaches, abdominal pain, fatigue, or routine medical or gynecological examinations without abnormal findings.
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
95: Synchronous Telemedicine Service Rendered via a Real-Time Interactive Audio and Video Telecommunications System. Used when the consultation is performed via telemedicine.
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Provider Taxonomies:
| Taxonomy Code | Specialty |
|---|---|
207R00000X | Internal Medicine Physician |
208D00000X | General Practice Physician |
207Q00000X | Family Medicine Physician |
208000000X | Pediatrics Physician |
207V00000X | Obstetrics & Gynecology Physician |
Related Diagnoses
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Z00.00: Encounter for general adult medical examination without abnormal findings- Relevant for routine health assessments where no abnormal findings are present.
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Z01.419: Encounter for gynecological examination (general) (routine) without abnormal findings- Used for routine gynecological consultations without abnormal findings.
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R51: Headache- Applicable when the consultation is for evaluation of headache symptoms.
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R10.9: Unspecified abdominal pain- Used when the patient presents with abdominal pain of unknown cause.
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R53.83: Other fatigue- Relevant for consultations addressing unexplained fatigue or tiredness.
Related CPT Codes
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99243: New or established patient office or other outpatient consultation involving evaluation and management at a lower level. Used when the consultation requires less time or lower complexity than99244. -
99245: New or established patient office or other outpatient consultation involving evaluation and management at a higher level. Used when the consultation requires more time or higher complexity than99244.
Clinical Workflow Relation:
99243,99244, and99245are part of a tiered system for outpatient consultations. Providers select the appropriate code based on the complexity of medical decision making and time spent. These codes are alternatives, not used together for the same encounter.
National Reimbursement Benchmarks
National mean rates for CPT code 99244 show that UnitedHealth Group has the highest average reimbursement at $253.49, while Aetna is the lowest among the major commercial payers at $170.68. The BUCA average (Blue Cross Blue Shield, UnitedHealth Group, Cigna, Aetna) stands at $195.94, which is significantly higher than typical Medicare rates for this code, though Medicare data is not available in the input.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies notably across payers. Aetna has the tightest range at $58.68, indicating less variability in contracted rates. Cigna and UnitedHealth Group exhibit the widest dispersions, with Cigna at $141.17 and UnitedHealth Group at $136.33, reflecting broader variability in negotiated rates.
The table and chart below present a full breakdown of national benchmarks for CPT code 99244 by payer, including mean rates and percentile values.
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