CPT® code 99243 is used to report an office or outpatient consultation for an established patient that requires a detailed history, detailed examination, and moderate complexity medical decision-making. This code is commonly applied when a patient is referred for evaluation and management of a new or existing condition that requires focused attention and clinical assessment.
When to Use CPT® Code 99243
- When an established patient is referred to a specialist for consultation.
- When the visit involves a detailed history and detailed physical examination.
- When moderate complexity medical decision-making is required, such as reviewing multiple treatment options, interpreting diagnostic tests, or managing chronic conditions.
- When documentation clearly supports the need for consultation rather than routine follow-up.
Billing Requirements
- Document history, exam, and medical decision-making elements in detail.
- Include the reason for consultation, patient’s presenting problem, and any prior treatments.
- Only one provider may bill for the same consultation; coordination with the referring provider may be documented but does not generate a separate claim.
- Ensure the service meets payer requirements for outpatient consultation coding.
Common Clinical Scenarios
- A primary care physician refers a patient with persistent abdominal pain to a gastroenterologist for evaluation and management.
- A patient with uncontrolled hypertension is referred to a cardiologist for a detailed consultation and treatment plan.
- An orthopedic specialist evaluates an established patient with a new joint complaint requiring imaging review and moderate complexity treatment decisions.
Simplify Consultation Documentation with OptiMantra
Consultations billed under CPT® 99243 require thorough documentation to support medical necessity and appropriate billing. OptiMantra’s EMR and practice management system allows providers to capture detailed histories, examinations, and treatment plans efficiently. For specialty practices and multidisciplinary clinics, OptiMantra streamlines consultation workflows, ensures compliance, and helps secure accurate reimbursement—so providers can focus on patient care rather than administrative tasks.
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