CPT® Code 99245

Key Takeaways:

• CPT 99245 is the highest-level outpatient consultation code. It requires high complexity Medical Decision Making (MDM) or 55 minutes or more of total time on the encounter date. A medically appropriate history and/or exam is still required, but code selection is driven by MDM or time.
• 2023-2026 E/M alignment: Office/outpatient consultation codes (99242-99245) follow the same "MDM or total time" selection model used for office/outpatient visits. History and exam no longer set the level, but must be documented as medically appropriate.
• Medicare vs commercial payers: Medicare Part B does not pay consultation codes and instructs reporting of equivalent covered E/M visit codes instead. Many commercial payers still recognize consult codes when consultation criteria are met, but policies vary.
• Consultation documentation ("3 Rs"): The record should show a request for consult, the consultant's evaluation/opinion, and a written reply/report back to the requester. For 99245, the note must also justify high MDM (problems, data, and risk) or the time threshold.
• Modifiers and special situations: Use modifier 25 for a significant, separately identifiable E/M on the same day as a minor procedure and modifier 24 for an unrelated E/M during a postoperative global period. For synchronous audio-video telehealth, many payers use modifier 95; some programs still require GT. In teaching settings, modifier GC indicates resident involvement under teaching physician supervision when required.

What is CPT 99245? Definition and Usage

CPT 99245 is an "office or other outpatient consultation for a new or established patient" at the highest outpatient consult level. The descriptor requires a medically appropriate history and/or examination and high MDM, or it can be selected by time when 55 minutes or more of total time is met on the encounter date. The "new or established" wording means the code family does not split by patient status; instead, consult qualification plus service intensity determines the code.

Operationally, 99245 is most often used when another clinician requests an expert opinion on a complicated clinical question: diagnostic uncertainty, multiple interacting comorbidities, or high-risk treatment decisions. A visit is not a consultation simply because a specialist sees a patient. The hallmark is that an appropriate source requested the opinion and the consultant provides a written report back (the consult "loop"). Classic guidance summarizes this as "request, render, reply."

Because 99245 represents the top of the range, it should map to circumstances where the consultant's synthesis and recommendations meaningfully drive care. Examples include major decision points (surgery candidacy, toxic therapy initiation, escalation of immunosuppression), high-acuity differentials, or cases where extensive outside data must be reviewed and reconciled. When the clinical problem is stable and the decision-making is low risk, a lower consult level is more accurate even if the visit feels "specialized."

2026 Coding Requirements: MDM vs. Time for 99245

For 2026, consultation codes are selected the same way as office/outpatient visit E/M: by documenting either MDM or total time on the date of the encounter. You do not need to meet both. History and exam must be medically appropriate but do not drive the level.

flowchart TD
    A[Outpatient Consultation Visit] --> B{Select coding basis}
    B -->|MDM| C[Assess MDM Complexity]
    B -->|Time| D[Calculate Total Time on Date of Encounter]
    C --> C1{Problems addressed?}
    C1 --> C2{Data reviewed/analyzed?}
    C2 --> C3{Risk of management?}
    C3 -->|All 3 meet High threshold| E[Report 99245]
    C3 -->|Moderate threshold| F[Report 99244]
    C3 -->|Low threshold| G[Report 99243]
    C3 -->|Straightforward| H[Report 99242]
    D -->|55+ minutes| E
    D -->|40-54 minutes| F
    D -->|30-39 minutes| G
    D -->|20-29 minutes| H

MDM-based coding (high complexity)

High MDM is assessed using three elements: (1) problems addressed, (2) amount/complexity of data reviewed and analyzed, and (3) risk of complications and/or morbidity/mortality of patient management. In practice, high MDM usually shows up when the consultant addresses a life- or function-threatening condition, manages multiple severe problems, or makes high-risk decisions. The note should explain why the problems are severe (not only that they exist), describe the data that had to be integrated, and show the management decision(s) that carry high risk.

Two documentation habits improve defensibility. First, tie the data to decisions (for example: "outside imaging reviewed; findings narrow differential and support treatment escalation"). Second, explicitly state the risk-driving management decision and the alternatives considered (for example: "discussed surgery vs medical therapy; chose surgery due to X, with Y risk mitigation"). This "why" language often differentiates notes that support high MDM from notes that look like templated summaries.

Time-based coding (55 minutes or more total time)

If time is used for selection, 99245 requires 55 minutes or more of total time on the date of service. Total time includes face-to-face and qualifying same-day non-face-to-face work that is directly related to the consultation, such as reviewing records, documenting, counseling, ordering/interpreting tests, and communicating with other professionals. A simple, audit-friendly time statement records the total minutes and briefly summarizes the work performed (record review, evaluation, counseling, coordination, documentation). Time should not include work done on other dates or time attributable to separately billed procedures.

Comparison of Consultation Codes 99242-99245

Outpatient consult codes run from 99242 to 99245. CPT 99241 was deleted effective 2023, making 99242 the lowest outpatient consult level. The level is chosen by MDM or time; history/exam remain required but do not determine the level.

Table notes: All consult levels require a medically appropriate history and/or exam, but the level is determined by MDM or total time. Deletion of 99241 leaves four outpatient consult levels.

A practical distinction between 99244 and 99245 is whether the plan involves high-risk decisions or the problem severity is high enough that the consultant's choices carry significant morbidity/mortality implications. If the plan is primarily routine testing and standard counseling without high-risk management, 99244 is often the better fit.

Medicare vs. Commercial Payers -- Consultation Code Policies

Medicare Part B: CMS does not recognize outpatient consult codes (99242-99245) for payment and instructs reporting of appropriate alternative E/M visit codes. For Medicare beneficiaries, the clinician can still perform a consultative service clinically, but billing must use covered office/outpatient visit codes (new or established patient status becomes relevant again for those codes). Many practices maintain consult-style documentation (request and reply) even when billing a visit code, because it improves care coordination and supports medical necessity if records are requested.

Commercial payers: Many commercial insurers still accept outpatient consult codes when the consultation criteria are met, but acceptance is not uniform. Coding guidance emphasizes verifying payer policies and understanding that Medicare's nonpayment policy is not automatically adopted by every payer. When a payer does recognize consult codes, the "3 Rs" documentation becomes the main coverage and audit vulnerability: if request or reply is missing, the claim may be denied or downcoded to an office visit.

Modifier Guidance for Consultations (25, 24, 95, GT, GC)

When modifiers are needed, they should reflect the specific circumstance and be supported in the note.

• Modifier 25: Append 25 to the consult E/M when a significant, separately identifiable E/M service is performed on the same day as a minor procedure. CMS global surgery guidance describes modifier 25 usage for distinct E/M work beyond what is inherent to the procedure.
• Modifier 24: Append 24 to indicate an unrelated E/M during a postoperative global period; CMS guidance emphasizes that the E/M must be unrelated to the procedure diagnosis and postoperative care.
• Modifier 95 and GT: Telehealth coding guidance describes modifier 95 for synchronous audio-video visits and notes that GT may still be required in certain contexts or by specific payer rules. Follow payer instructions and do not bill both on the same service.
• Modifier GC: Medicare teaching physician guidance explains modifier GC usage when a resident participates under the direction of a teaching physician, along with documentation expectations for teaching physician involvement.

ICD-10-CM Examples for Consultation Encounters

ICD-10-CM selection should match the consult request and the conditions addressed. The principal diagnosis is typically the condition or concern prompting the referral; secondary diagnoses capture comorbidities and context that influenced MDM.

• Complex diagnostic consult: A rheumatology consult for suspected lupus may use a working diagnosis (for example M32.10) and relevant symptom codes when diagnosis is not yet confirmed.
• Preprocedural evaluation: Pre-op consults often use Z01.818 with comorbidities (for example I10, E11.9) to show why risk assessment and optimization are clinically necessary.
• Second opinion: For oncology second opinions, the malignancy code (for example C61) is often the most direct explanation of medical necessity because the consult centers on treatment decision making.
• Undiagnosed neurologic symptoms: Symptom codes (for example R20.0, H53.8) remain appropriate when the consult is for evaluation of undiagnosed symptoms and a definitive diagnosis has not yet been established.

Documentation Tips for Audit-Proof Consult Notes

For 99245, the goal is to make three things easy for a reviewer to find: (1) why this was a consultation, (2) why the service was high level, and (3) how recommendations were communicated back to the requester.

• Document the request: Identify the requesting clinician and the consult question.
• Show the reasoning: Make the MDM traceable: problems considered, data reviewed, and the risk and rationale of management decisions.
• Capture time when used: If coding by time, document total minutes and main activities.
• Document the reply: State how the report was sent (shared EHR note, letter, direct call).
• Teaching physician requirements: If residents are involved and Medicare is billed, use compliant attestations and modifier GC as appropriate.

A short but specific MDM narrative often supports 99245 better than long templated text. Notes that state what was reviewed, what was considered, and why a particular high-risk plan was chosen are typically easier to defend than notes that only list findings without decision logic.

Common audit triggers and how to neutralize them: Payers typically challenge high-level consultations for predictable reasons: missing consult request language, no evidence of a reply to the requester, vague statements such as "records reviewed," and assessment/plan sections that do not justify the billed risk level. A defensible 99245 note makes each potential question answerable in one pass. Start by naming the requester and the precise consult question, then show what you did with that question: key history and exam findings, the relevant data you reviewed, and how that information narrowed the differential or changed management. When data drives the level, list the meaningful items (outside notes, imaging, labs) and add one sentence explaining impact. When risk drives the level, document the high-risk decision, the alternatives considered, and the mitigation or monitoring plan. If you code by time, record the total minutes and briefly describe the work categories so the time appears clinically plausible. Finally, close the loop by documenting the reply (shared note, letter, or call) and what recommendations were communicated. These steps align with the consultation "3 Rs" and the MDM/time framework and reduce both denials and downcoding in retrospective review. One practical approach is a brief internal checklist in the note: "Request documented," "Data sources listed," "Risk decision stated," "Time statement included when applicable," and "Report sent." If any item is missing, fix it before signing. This tends to be faster than responding to payer documentation requests later, and it improves clinical communication with the referring clinician and supports consistent team coding.

Real-World Coding Scenarios

1. Consult plus same-day minor procedure: A dermatologist evaluates a referred patient and performs a biopsy. Report the biopsy and the consult E/M with modifier 25 to show the E/M was significant and separately identifiable.
2. Unrelated issue during global period: A surgeon evaluates a postoperative patient for an unrelated condition during the global period. Report the E/M with modifier 24 and use an unrelated diagnosis, consistent with CMS global surgery rules.
3. Telehealth consultation: A specialist provides a consult via real-time audio-video and coordinates recommendations with the requester. Append modifier 95 (or GT if required) per telehealth guidance.
4. Medicare billing substitution: The service is clinically a consultation, but for Medicare the consultant bills an appropriate office/outpatient visit code because consult codes are not recognized for payment.