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CPT 99245: Office or Outpatient Consultation, High-Complexity

CPT code 99245 represents a high-complexity office or other outpatient consultation for evaluation and management, performed when the medical decision making is at a high level or the physician documents at least 55 minutes of total encounter time. Nationally, this code captures resource-intensive outpatient assessments often used for complex diagnostic evaluation, treatment planning, and care coordination. It is relevant to physicians across internal medicine, family medicine, general practice, pediatrics, and obstetrics–gynecology who provide consultative services in ambulatory settings.

Key payers included in the analysis are Aetna, Blue Cross Blue Shield, Cigna Health, United Healthcare, and Medicare. Readers will find a concise explanation of clinical context and service expectations for 99245, comparisons to commonly related office and consultation codes, and practical information on typical clinical indications. The publication outlines where 99245 fits within outpatient E/M coding, how it differs from lower-level consultation and established patient visit codes, and which clinical scenarios commonly align with its use (for example, complex diagnostic workups, multisystem issues, or extensive care coordination). The paper also highlights related prolonged-service considerations and the typical ambulatory sites where this level of service is billed. Data not available in the input is noted where appropriate.

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Billing Code Overview

CPT code 99245 describes an office or other outpatient consultation that involves evaluation and management (E/M) at a high level of medical decision making or when the provider spends at least 55 minutes of total time on the encounter on a single date. This service is delivered for patients requiring complex assessment, coordination, and planning.

Service type: Office or other outpatient consultation involving high-complexity E/M or prolonged total time
Typical site of service: Office or other outpatient setting

National Reimbursement Benchmarks

Commercial rates for CPT 99245 center around a BUCA average commercial rate of $250.90, which serves as a useful midpoint for national commercial reimbursement. Among the individual payers, UnitedHealth Group has the highest mean at $315.50 and Cigna follows at $268.90; Blue Cross Blue Shield’s mean is $241.80 and Aetna’s is $195.80. These means illustrate that payer-level commercial reimbursements vary substantially above and below the BUCA average.

Dispersion measured by the interquartile range (P75 minus P25) highlights variation in contract pricing: UnitedHealth Group’s IQR is $155.90 (from $214.50 to $390.40), Cigna’s IQR is $141.00, Blue Cross Blue Shield’s IQR is $52.00, BUCA’s IQR is $118.80, and Aetna’s IQR is $89.00. Blue Cross Blue Shield exhibits the tightest IQR at $52.00, while UnitedHealth Group shows the widest IQR at $155.90, indicating the largest spread in middle-50% commercial rates.

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CPT 99245: Office or Outpatient Consultation, High-Complexity

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Billing Code Overview

Service type: Office or other outpatient consultation involving high-complexity E/M or prolonged total time
Typical site of service: Office or other outpatient setting

National Reimbursement Benchmarks

National Payer Mean Reimbursement Rates

Clinical & Coding Specifications

Clinical Context

A 52-year-old woman is referred by her primary care physician for an outpatient consultation regarding recurrent, severe headaches and new-onset fatigue. The consulting physician is an internist in an office-based practice who performs a comprehensive history, focused physical and neurologic examination, reviews prior records and recent laboratory results, and orders targeted imaging. The visit involves a high level of medical decision making with discussion of differential diagnoses (migraine, medication-overuse headache, thyroid disease, anemia), review of prior treatments, coordination of care with neurology and primary care, and formulation of a detailed diagnostic and management plan. Total provider time spent on the date of service, including face-to-face time, record review, telephone coordination, and documentation, meets or exceeds 55 minutes, supporting billing with 99245.

Typical workflow steps:

Referral receipt and chart review before patient arrival
Extended face-to-face evaluation and focused examination
Review and interpretation of prior imaging and lab results
High complexity medical decision making and care coordination
Ordering of further diagnostic studies (e.g., MRI, CBC, thyroid panel)
Detailed documentation and communication of recommendations to referring clinician

Coding Specifications

Modifier	Description	When to Use
`25`	Significant, separately identifiable E/M service by the same physician on the same day of a procedure	Use when `99245` is reported on same day as a minor procedure if E/M is distinct and documented

| 22 | Increased procedural services | Use when the complexity or time for the consultation far exceeds typical and documentation supports substantial additional work

| 26 | Professional component | Use when only the physician professional component of a diagnostic service is billed alongside the consultation

| 52 | Reduced services | Use if the service was partially reduced or not fully performed as reported for 99245

| 53 | Discontinued procedure | Use when the consultation encounter/procedure is discontinued due to extenuating circumstances

| 57 | Decision for surgery | Use when the consultation results in the decision to perform surgery on the same day

| 95 | Synchronous telemedicine service rendered via real-time interactive audio and video | Use when the 99245 consultation is provided via live telehealth and payer accepts modifier 95

| 24 | Unrelated E/M service by the same physician during a postoperative period | Use when the consultation is unrelated to the prior surgical global period

| 26 | Professional component | (listed above) Included because imaging review or tests may carry a professional component billed separately

| 78 | Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period | Use when consultation leads to an immediate return/procedure; rare for outpatient consults

| 62 | Two surgeons | Use when two surgeons of different specialties work together and the consultation documents shared responsibility

Taxonomy Code	Specialty	Notes
`207R00000X`	Internal Medicine Physician	Common consultants for complex adult medical issues and high MDM

| 208D00000X | General Practice Physician | May perform comprehensive outpatient consultations in community settings

| 207Q00000X | Family Medicine Physician | Provides broad-scope outpatient evaluation and coordination of care

| 208000000X | Pediatrics Physician | Included in taxonomy list though pediatric providers would use pediatric-appropriate visit codes

| 207V00000X | Obstetrics & Gynecology Physician | May perform consults for gynecologic or pelvic pain issues referenced in diagnoses

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z00.00`	Encounter for general adult medical examination without abnormal findings	Supports preventive or baseline evaluation when a comprehensive consultation includes routine health maintenance elements

| Z01.419 | Encounter for gynecological examination (general) (routine) without abnormal findings | Relevant when gynecologic review or pelvic exam is part of the comprehensive consultation

| R51 | Headache | Common presenting symptom prompting high-complexity diagnostic evaluation and specialist consultation

| R53.83 | Other fatigue | Nonspecific symptom that may require extensive diagnostic workup and care coordination

| R07.9 | Chest pain, unspecified | Presents high-risk differential requiring urgent evaluation and may justify elevated MDM during consultation

| R10.9 | Unspecified abdominal pain | Nonspecific pain complaint often requiring broad evaluation, imaging, and specialist input during a consultation

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99244`	Office consultation for a new or established patient, typically 60 minutes	Slightly higher time/MDM level than `99245`; used for prolonged, intensive consultations in the outpatient setting

| 99243 | Office consultation for a new or established patient, typically 40 minutes | Lower time/MDM level than 99245; alternative when the visit does not meet the higher time or complexity threshold

| 99213 | Established patient office or other outpatient visit, typically 15 minutes | Used for lower complexity follow-up visits after the initial consultation

| 99214 | Established patient office or other outpatient visit, typically 25 minutes | Used for moderate complexity follow-up visits that do not meet consultation-level complexity/time

| 99354 | Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour | Use when additional face-to-face prolonged time beyond the typical E/M is provided in conjunction with 99245 and documentation supports prolonged service

CPT 99242: Outpatient Consultation, E/M for Straightforward Decision Making or ≥20 Minutes

CPT-99243-OUTPATIENT-CONSULTATION-LOW-COMPLEXITY-30-MINUTE-VISIT

CPT 99243: Outpatient Consultation, Low Complexity or ≥30 Minutes

CPT-99244-OUTPATIENT-CONSULTATION-MODERATE-COMPLEXITY-40-MINUTES

CPT 99244: Office/Outpatient Consultation, Moderate Complexity

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

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