CPT® Code 99244

Last Updated: January 2026 | Verified for 2026 AMA, CPT & CMS Guidelines

Quick Reference: CPT 99244

• Definition: Office or other outpatient consultation (evaluation & management service) for a new or established patient, typically at the request of another provider.
• MDM Level: Moderate Complexity (e.g., prescription management, 2+ stable chronic illnesses, or 1 acute illness w/ systemic symptoms).
• Time Threshold: 40 minutes total time spent on the date of the encounter (if coding by time).
• Frequency: Generally one consultation per patient per consultant (per issue). Follow-up visits after the initial consult should be coded as routine E/M visits, not repeated consults.
• Exclusion: Not recognized by Medicare (since 2010); for Medicare patients, use alternative E/M codes (e.g. 99204/99214) instead of 99244. CPT 99244 represents a higher-level office/outpatient consultation (the second-highest in the outpatient consult family, below 99245). It is intended for situations where a physician or other qualified healthcare professional is formally requested to provide an opinion, evaluation, or advice regarding a patient’s problem in an outpatient setting, and where the work performed supports moderate Medical Decision Making (MDM) or at least 40 minutes of total time on the date of service. Under current E/M rules (2023–2026), selection is based on MDM or time, with only a medically appropriate history and/or examination expected rather than rigid history/exam “bullet” requirements.

Operationally, 99244 is the code many specialists reach for when a consult involves multiple chronic problems, an undiagnosed or uncertain-prognosis issue, meaningful record review, coordination with the referrer, and at least one management action that increases risk (commonly prescription drug management). However, correct use is not only about complexity. Consultation coding requires the underlying consult structure—often summarized as “request and report”—to be clear in the record: a request for consult services, a documented reason, rendering of an opinion, and a report back to the requesting source.

A critical payer distinction shapes how 99244 is used in practice: Medicare stopped paying consultation codes in 2010. For Medicare beneficiaries, services that might otherwise qualify as 99244 should be reported using the appropriate office/outpatient visit code (e.g., 99204 for a new patient or 99214 for an established patient), consistent with CMS instruction. Many commercial payers still recognize and reimburse consultation codes, but policies vary; therefore, the same clinical service may be coded differently depending on payer rules and contractual requirements.

1. MDM Requirements and Time Criteria

Under the current E/M framework, office/outpatient consultation codes are selected by either Medical Decision Making (MDM) or total time on the date of the encounter. The practical implication is that documentation should be written to support one approach clearly. If you code by MDM, your note should make the problem complexity, data reviewed/ordered, and risk explicit. If you code by time, you should document the total minutes and a brief description of the qualifying work performed that day, including non-face-to-face activities that are counted by CPT/AMA guidance.

Many audits of consultation codes are not based on whether the clinician is a “specialist,” but on whether the record clearly supports the selected MDM level and shows the consult elements (request and report). For 99244, MDM is typically the more stable rationale when complexity is evident; time can be useful when record review, coordination, and counseling are substantial but data/risk elements are not easily conveyed without over-documentation.

1. Medical Decision Making (Moderate)

To bill 99244 by MDM, the encounter must meet moderate complexity in at least 2 of the 3 MDM elements: (1) problems addressed, (2) data reviewed/ordered/analyzed, and (3) risk of complications and/or morbidity of management. This “2 out of 3” structure is central. A common mistake is to assume that “consultation” automatically equals high complexity; in reality, the chosen code must match the documented MDM or time.

• Element 1: Number & Complexity of Problems 1 acute illness with systemic symptoms (e.g., pneumonia, pyelonephritis).
• 1 chronic illness with mild exacerbation or progression (e.g., asthma flare responding to treatment).
• 2 or more stable chronic illnesses (e.g., well-controlled hypertension + diabetes).
• 1 undiagnosed new problem with uncertain prognosis (e.g., new lump or unexplained weight loss). In consults, this element is often met through either (a) multiple chronic problems that the consultant must consider together (comorbidities are frequently clinically relevant in specialty care), or (b) an undiagnosed/uncertain-prognosis presentation prompting a differential diagnosis and targeted evaluation. Document the actual clinical reasoning: what makes the case uncertain, and what problem(s) are being addressed today.
• Element 2: Amount and/or Complexity of Data (Must meet 1 of 3 categories) Category 1: Combination of data review/ordering (at least 3 items). Example: review of external records and review of results from 2 unique tests (lab + EKG).
• Category 2: Independent interpretation of a test performed by another provider (e.g., personally reviewing CT images, not only reading the report).
• Category 3: Discussion of management or test results with an external physician or other qualified healthcare provider (e.g., discussion with the referring doctor about options or next steps). Consultants frequently satisfy the “data” element through Category 1 plus Category 3. The key is specificity: name the outside records, list the unique tests, and document the fact and content of physician-to-physician discussion when it occurs. If you independently interpret imaging (for example, reading actual echo clips or CT slices), explicitly state that you performed independent interpretation. Vague phrasing like “reviewed records” is much weaker support than identifying what was reviewed and how it influenced medical decision making.
• Element 3: Risk of Complications and/or Morbidity of Management (Moderate Risk) Prescription drug management: Starting, stopping, or adjusting prescription medications (or deciding to maintain after re-evaluation).
• Decision regarding minor surgery with identified patient risk factors.
• Elective major surgery without significant risk factors (as defined in E/M risk tables).
• Diagnosis or treatment significantly limited by Social Determinants of Health (SDOH) (e.g., homelessness, inability to afford meds) affecting management. For 99244, prescription drug management is the most common “risk” anchor. In consult notes, explicitly describe what changed or what medication decision was made. If SDOH limits management, document how it changes clinical options (for example, formulary constraints that materially alter therapy selection) rather than merely listing a social history detail. Sources discussing consult scenarios emphasize that SDOH can elevate risk when it meaningfully constrains care decisions.

In practice, moderate MDM is often met with: (1) a moderately complex problem (exacerbated chronic condition or uncertain prognosis issue) plus (3) prescription management; or (2) meaningful data review plus (3) moderate risk management decisions. When writing the assessment and plan, think like a reviewer: can an auditor see—without inference—why today’s work is “moderate” rather than “low”?

2. Total Time (40 Minutes)

You may instead select 99244 based on time if you document at least 40 minutes of total time spent on the date of the encounter. This includes face-to-face and non-face-to-face work performed by the billing provider on the same calendar date. Time-based coding can be particularly helpful when extensive counseling, chart review, or coordination occurs, but the risk element is limited (for example, diagnostic consultation with extensive interpretation of prior workup before selecting next steps).

What Counts:

• Reviewing patient records, labs, or imaging before the visit (same day).

• Performing the consultation: evaluation, medically appropriate history/exam, and counseling.

• Ordering tests, medications, or procedures during the encounter.

• Documenting the consult note and care plan.

• Communicating with family/caregivers as needed for patient care.

• Coordinating with other healthcare professionals, including discussion with the referrer. What Does Not Count:

• Time spent by clinical staff (nurses, MAs) separate from the billing provider’s work.

• Work performed on days other than the encounter date (e.g., next-day charting), even if related to the consult. If coding by time, document the total minutes and at least a concise breakdown of major components. A practical model is: “Total time on date of service: X minutes. Activities included: review of external records and imaging, face-to-face evaluation and counseling, medication review and ordering, and communication with requesting clinician.” This level of clarity supports compliance while keeping documentation efficient.

2. Audit-Proof Documentation Standards

Consultation services can be scrutinized because payers often distinguish them from routine referrals. A strong 99244 note should demonstrate both (1) the consult elements (request, reason, render, report) and (2) the complexity/time requirements for the selected code level. The goal is that a reviewer can confirm the consult was requested, understand the question being asked, see the consultant’s opinion, and identify that the opinion was communicated back.

• Consult Request & Reason: Identify who requested the consult and the specific reason. Example: “Consult requested by Dr. Smith for evaluation of persistent uncontrolled hypertension and medication strategy.” This “request + reason” structure is emphasized as foundational consultation documentation.
• Confirm the Consult Question: A high-yield practice is to restate the clinical question in the HPI or assessment. Example: “Question: secondary causes vs medication resistance; advise on workup and regimen.” This makes the consult nature explicit.
• Problem Complexity Language: Replace generic labels (e.g., “uncontrolled”) with clinical descriptors: severity, trajectory, complications, and why prognosis is uncertain. If the consult involves multiple chronic conditions, clarify how they influence management decisions.
• Data Reviewed (with Specificity): Identify external records and unique tests reviewed and how they affect decisions. If you performed independent interpretation (Category 2), document that you reviewed images/tracings (not only reports). If you discussed the case with an external provider (Category 3), note the discussion and key points.
• Risk and Plan Anchors: If prescription drug management is used to support risk, document medication initiation/adjustment/discontinuation and counseling on monitoring and adverse effects. If SDOH limits management, document the impact on therapy selection and follow-up plan.
• Report Back to Requester: Conclude with explicit language: “Consultation report sent to Dr. ___” or “Recommendations communicated to referring clinician.” The “report” element is central to consultation documentation frameworks. A common compliance pitfall is using consult codes for visits that function as transfers of care without clear “opinion/advice” and without evidence of reporting back. Another pitfall is using 99244 for cases that document only low complexity (single stable problem, minimal data, no meaningful risk decision). If the note reads like routine follow-up care rather than a requested opinion, it may be safer—depending on payer rules—to use a standard office visit code instead.

3. Common ICD-10 Diagnosis Codes

CPT 99244 is not diagnosis-specific. Medical necessity is established by the clinical scenario: the diagnosis (or symptom complex) prompting referral, the uncertainty or complexity requiring specialty input, and the management choices made during the encounter. ICD-10 coding should reflect (a) the condition(s) evaluated and (b) any complicating comorbidities that materially affect the consult work.

• Z01.818: Encounter for other preprocedural examination – common for pre-operative clearance consults, where multiple comorbidities and perioperative risk decisions often support moderate MDM.
• R07.9: Chest pain, unspecified – frequently prompts cardiology consults; uncertainty plus diagnostic workup and risk assessment can support moderate MDM.
• E11.65: Type 2 diabetes mellitus with hyperglycemia – endocrine consults often involve medication adjustments (prescription management) and review of labs/complications.
• N18.4: Chronic kidney disease, stage 4 – nephrology consults often involve complex risk-benefit decisions, medication dosing constraints, and planning.
• R55: Syncope – uncertain prognosis, differential diagnosis, and multi-test evaluation frequently align with moderate MDM. When multiple conditions are clinically relevant, include them as additional ICD-10 codes (for example, CKD plus hypertension, diabetes, or coronary artery disease). The point is not to maximize the problem list; it is to reflect the conditions that influenced evaluation and management. This strengthens the narrative that the consult was medically necessary and that complexity was appropriate for 99244.

4. Medicare & Payer Guidelines

Medicare Does Not Pay for Consultations: Since 2010, Medicare no longer recognizes CPT 99244 (or any consultation codes) for payment. Implication: For Medicare patients, report an appropriate office/outpatient E/M code (e.g., 99204/99214) rather than 99244. CMS guidance instructs providers to use the corresponding visit codes instead.

Different payer policies

Many commercial payers and some Medicaid plans still reimburse consult codes when criteria are met, but this cannot be assumed. Some payers follow Medicare’s approach and require standard office/outpatient codes even when a visit has the consult structure. Because payer rules vary, it is common for practices to build payer-specific logic into their billing workflows (for example, “bill consult codes only for payers A/B/C; use office visit codes for payer D and Medicare”). Scenario-based consultation coding discussions emphasize verifying payer requirements and documenting consult elements consistently to reduce denials.

Multiple consultants on the same day

A patient may see multiple specialists on the same date if multiple consult requests exist. Each specialist may report a consult code if the consult is distinct, separately requested, and addresses a different clinical question. The primary documentation risk is duplication: if notes appear to address the same question without distinct consult requests and separate reporting, payers may challenge the claims. Within a single specialty/group, repeat “initial consult” billing for the same issue is generally inappropriate; follow-ups are typically billed with established patient E/M codes, not repeated consults.

Transfer of care vs consultation

The conceptual distinction remains important: a consultation is an opinion/advice service requested by another clinician, with recommendations communicated back; a transfer of care is a referral for the consultant to assume management. Consultation guidance and commentary note that confusion in this area is a frequent cause of consult code misuse. If you are taking over ongoing management immediately, many payers will expect a standard new/established patient office visit code rather than a consult code. Medicare explicitly frames the post-consult period as routine E/M once ongoing care is assumed.

5. Modifier Usage (32, 25, 57, 95)

Modifiers can be essential for accurate payment when special circumstances apply. For 99244, modifiers commonly clarify whether a consult was mandated, whether a procedure was performed on the same date, whether the visit represents the decision for major surgery, or whether the service was delivered via synchronous telehealth.

Modifier 32 (Mandated Service)

Use modifier -32 when the consultation is mandated by a third party rather than voluntarily requested by a treating provider (for example, insurer-required second opinions or workers’ compensation requirements). Append -32 to indicate the service was required as a condition of coverage or adjudication. Document the mandate explicitly (who required it and why) to support the modifier’s use. Consultation coding updates and scenario discussions commonly describe -32 as appropriate for required second opinions.

Modifier 25 (Significant, Separate E/M on Same Day)

If you perform a minor procedure or other separately billable service on the same day as the consult, modifier -25 may be necessary to demonstrate the E/M service was significant and separately identifiable from the procedure. The note should clearly separate the consult’s cognitive work (evaluation, decision making, counseling) from the procedure itself. Consult scenario guidance emphasizes documenting distinct work and checking payer edits when combining E/M and procedures.

Modifier 57 (Decision for Surgery)

Append modifier -57 when the consultation results in the initial decision to perform a major surgery (generally a 90-day global). This indicates the E/M service is payable separately and should not be bundled into the surgical global package. The medical record should explicitly state that the decision for surgery was made during the consult and should outline the reasoning and informed consent elements as appropriate. The modifier’s purpose and use in surgical decision contexts is widely discussed in payer policies and coding commentary.

Modifier 95 (Telehealth Service)

Use modifier -95 for synchronous audio-visual telemedicine services when required by payer policy. Telehealth billing requirements vary, and some payers rely primarily on place-of-service codes while others require modifier 95 for identification. Document the modality (real-time audio-visual), patient consent if required, and any relevant limitations. Consult scenario discussions frequently include telehealth consult examples and payer variability considerations.

6. Global Period Considerations

CPT 99244 itself is an E/M code and does not have a global period. However, global surgical package rules can affect payment when a consult leads to a procedure—especially major surgery. If the consultant becomes the operating surgeon, the consult may be separately payable when it represents the decision for surgery and is billed with modifier -57 (when applicable), while routine pre/post-operative care is generally included in the surgical global package. Clear documentation of timing and decision-making is essential to avoid denials.

Another common global-related scenario involves unrelated problems during a global period. If a patient is in a post-operative global period for one procedure and receives evaluation for an unrelated problem, an E/M service may be payable with the appropriate modifier (commonly -24 for unrelated E/M in the post-op period). While this is more often applied to surgeons, the broader point is that global rules can constrain billing when services are related to the procedure, and careful documentation of unrelatedness is necessary when applicable.

Finally, consultation is generally a one-time service per issue per consultant. After the initial consultation—especially if the consultant assumes ongoing management—subsequent visits are typically reported as established patient office/outpatient E/M codes (e.g., 9921x) rather than repeated consult codes. Medicare’s approach reinforces that follow-up management is billed as routine E/M rather than consultation services.

7. Comparison: 99242 vs 99243 vs 99244 vs 99245

The outpatient consultation family (99242–99245) scales by MDM and time. 99244 occupies the moderate complexity tier and is commonly used when the consult meaningfully changes management or requires substantial evaluation. The table below summarizes typical thresholds and examples.

Because MDM or time selection is permitted, the same patient presentation can sometimes map to different codes depending on the work performed and documented. The safest approach is to choose the code that most directly matches the clearly documented basis (either MDM elements at the required level or time at/above the threshold), while ensuring consult criteria are met (request and report).

8. Complex Clinical Scenarios

The scenarios below illustrate how 99244 can be supported under moderate MDM or by time, and how modifiers and payer rules can alter coding choices. These examples emphasize documentation elements that commonly decide whether a consult is paid or denied.

Scenario 1: Uncontrolled Hypertension Consultation (Moderate MDM)

Patient: 58-year-old with long-standing hypertension on three medications, still with BP ~170/100. Referred by primary care for resistant hypertension strategy.

Data: Cardiologist reviews outside echo report (mild LVH) and recent labs (creatinine trend affecting medication choice). Discusses management approach with PCP (Category 3).

Risk/Plan: Adds a new antihypertensive and discontinues a medication causing adverse effects (prescription management). Orders follow-up labs and provides monitoring plan. Report sent to referrer.

Coding: 99244. Rationale: Chronic illness with progression + prescription management supports moderate MDM; consult request and report are documented.

Scenario 2: Pre-Op Clearance for Surgery (Moderate MDM, Emphasis on Risk Assessment)

Patient: 75-year-old with CAD and diabetes referred by orthopedic surgeon for clearance before elective hip replacement.

Action: Consultant reviews stress test, EKG, and medication regimen; adjusts diabetes plan; outlines perioperative medication instructions and risk mitigation steps; communicates recommendations to surgeon.

Coding: 99244. Rationale: Multiple stable chronic illnesses plus prescription management and substantive data review supports moderate MDM; consult request and report are clear.

Scenario 3: Decision for Major Surgery (Modifier 57)

Patient: 62-year-old referred urgently to general surgery for symptomatic gallbladder disease with recurrent biliary colic and abnormal labs.

Action: Surgeon evaluates, reviews imaging and labs, discusses risks/benefits, and determines that a cholecystectomy is indicated (major surgery scheduled next day). Consult report sent back to requesting clinician.

Coding: 99244-57. Rationale: The consult is the visit where the decision for major surgery is made; modifier 57 supports separate payment when the procedure has a global period.

Scenario 4: Telehealth Second Opinion with SDOH Constraints (Time-Based + Modifier 95)

Patient: 50-year-old rural patient with chronic migraines and depression; transportation barriers and medication affordability issues limit treatment choices.

Action: Neurologist performs synchronous video consult, reviews outside imaging and logs, selects a more affordable regimen, coordinates follow-up plan with local PCP. Total time 45 minutes (same-day review + visit + coordination).

Coding: 99244 (by time) with modifier 95. Rationale: Time meets the 40-minute threshold; SDOH meaningfully limits management options (risk consideration) and consult elements are documented.

Scenario 5: Mandated Second Opinion (Modifier 32)

Patient: 47-year-old with chronic back pain scheduled for elective spine surgery; insurer requires a second-opinion specialist consultation.

Action: Specialist reviews imaging and prior treatment course, evaluates patient, and issues a formal recommendation to the insurer and treating surgeon about appropriateness of surgery vs conservative management. Documentation explicitly states the consult was insurer-mandated.

Coding: 99244-32. Rationale: Mandated service modifier signals third-party requirement; record supports moderate MDM due to review complexity and management recommendations.