Difference between usage of cpt 99241, 99242

The CMS concurs with American Medical Association “Current Procedural Terminology (CPT)” guidelines related to physician reporting of inpatient and outpatient consultation services 99241-99243, 99244-99255:

CPT 99241

Office consultation for a new or established patient, which requires these three key components:

• a problem focused history;

• a problem focused examination; and

• straightforward medical decision making

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

99242

Office consultation for a new or established patient, which requires these three key components:

• an expanded problem focused history;

• an expanded problem focused examination; and

• straightforward medical decision making

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 30 minutes face-to-face with the patient and/or family.

The CMS will pay a consultation fee when the service is provided by a physician at the request of the patient’s attending physician when:

• All of the criteria for the use of a consultation code are met;

• The consultation is followed by treatment;

• The consultation is requested by members of the same group practice;

• The documentation for consultations has been met (written request from an appropriate source and a written report furnished the requesting physician);

• Pre-operative consultation for a new or established patient performed by any physician at the request of the surgeon; and

• A surgeon requests that another physician participate in post-operative care (provided that the physician did not perform a pre-operative consultation).

Italicized and/or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.