Summary & Overview
CPT 99245: Office or Outpatient Consultation, High Complexity
CPT code 99245 represents a high-complexity office or outpatient consultation, requiring either a high level of medical decision making or a minimum of 55 minutes spent with the patient. This code is significant in the national healthcare landscape as it is frequently used by providers across multiple specialties, including internal medicine, family medicine, pediatrics, and obstetrics & gynecology, to address complex patient needs in an outpatient setting. The code is recognized by major commercial payers such as Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare, making it a key component in reimbursement and policy discussions.
This publication provides a comprehensive overview of 99245, including clinical context, payer coverage, and related billing codes. Readers will gain insight into benchmarks for utilization, recent policy updates, and the role of this code in managing patients with conditions ranging from routine examinations to complex symptoms like headache, fatigue, chest pain, and abdominal pain. The analysis also covers common modifiers used with 99245, associated provider taxonomies, and relevant ICD-10 diagnoses. By understanding the scope and application of this code, stakeholders can better navigate the evolving landscape of outpatient consultation billing and compliance.
CPT Code Overview
CPT code 99245 is used for office or other outpatient consultations involving evaluation and management (E/M) services. This code applies when the provider engages in a high level of medical decision making or spends at least 55 minutes of total time with the patient on a single date. The typical site of service for this encounter is the office, designated as Place of Service (POS) 11. These consultations are critical for patients requiring comprehensive assessment and management, often involving complex medical issues.
Clinical & Coding Specifications
Clinical Context
A patient is referred to an internal medicine physician for a comprehensive evaluation due to persistent symptoms such as headache, fatigue, chest pain, or abdominal pain. The provider conducts an office consultation, which involves a high level of medical decision making or at least 55 minutes of total time spent on the encounter. The workflow includes reviewing the patient's history, performing a detailed examination, assessing potential diagnoses, and formulating a management plan. This consultation may also be requested for routine adult or gynecological examinations without abnormal findings. The service is typically performed in an office setting (Place of Service 11) and may involve specialties such as internal medicine, general practice, family medicine, pediatrics, or obstetrics & gynecology.
Coding Specifications
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Modifier
25: Used when a significant, separately identifiable evaluation and management service is performed in addition to another procedure or service on the same day. -
Modifier
95: Indicates that the service was rendered via synchronous telemedicine using real-time interactive audio and video telecommunications.
| 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 consultations involving routine adult check-ups with no abnormal findings.
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Z01.419: Encounter for gynecological examination (general) (routine) without abnormal findings- Used for consultations related to routine gynecological exams.
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R51: Headache- Applicable when the consultation is for evaluation of headache symptoms.
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R53.83: Other fatigue- Used when the patient presents with fatigue requiring evaluation.
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R07.9: Chest pain, unspecified- Relevant for consultations addressing chest pain without a specific diagnosis.
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R10.9: Unspecified abdominal pain- Used for consultations involving abdominal pain where the cause is not yet determined.
Related CPT Codes
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99244: Office consultation for a new or established patient, typically 60 minutes. Used for consultations requiring slightly less time or complexity than99245. -
99243: Office consultation for a new or established patient, typically 40 minutes. Used for moderate complexity consultations. -
99213: Established patient office or other outpatient visit, typically 15 minutes. Used for routine follow-up visits, not consultations. -
99214: Established patient office or other outpatient visit, typically 25 minutes. Used for more complex follow-up visits, not consultations. -
99354: Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour. Commonly used in conjunction with99245when the consultation exceeds the typical time.
Codes 99244 and 99243 are alternatives to 99245 for consultations of lower complexity or shorter duration. Code 99354 may be used together with 99245 for prolonged services. Codes 99213 and 99214 are used for established patient visits, not consultations, but may be relevant in ongoing care.
National Reimbursement Benchmarks
National mean rates for CPT code 99245 show that commercial payers, represented by BUCA, average $248.07, while Medicare rates are not available in the input. Among individual commercial payers, UnitedHealth Group has the highest mean rate at $313.24, and Aetna has the lowest at $209.10.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Aetna has the tightest range at $60.21, indicating less variability in contracted rates. Cigna and UnitedHealth Group exhibit the widest dispersions, with ranges of $168.54 and $169.00 respectively, reflecting greater variability in their national reimbursement rates.
The table and chart below present a full breakdown of national benchmarks for CPT code 99245 across major commercial payers.
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