Definition:
CPT® code 99241 describes an office or other outpatient consultation provided to a new or established patient. This level of consultation is generally characterized by a straightforward or low-complexity medical decision-making process and requires approximately 20 minutes of face-to-face time with the patient.
When to Use:
- The patient presents with a new concern, minor symptoms, or requests advice on a specific problem.
- Evaluation involves a problem-focused history and examination, typically limited in scope.
- Medical decision-making is straightforward, with minimal risk to the patient.
- Counseling or coordination of care may be provided but is not extensive.
Documentation Requirements:
To support billing for 99241, clinicians should document:
- Chief complaint and reason for consultation.
- Relevant history, including past medical history and medications.
- Focused examination findings.
- Assessment and clinical decision-making rationale.
- Any patient counseling or education provided during the visit.
Key Notes:
- Time is considered approximate and guideline-based; actual time spent may vary.
- 99241 is appropriate for consultations where low-complexity decisions are made without extensive testing or follow-up planning.
- Avoid using this code for high-complexity or extended evaluations; higher-level codes like 99242–99245 may be more appropriate.
How OptiMantra Supports 99241 Documentation:
OptiMantra’s EMR and practice management platform helps providers efficiently capture all necessary consultation details, track medical decision-making, and generate clean claims. Customizable templates and structured charting ensure that documentation meets CPT® requirements, while integrated billing tools streamline reimbursement, reducing the risk of claim denials.
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