CPT 99246 Reimbursement Benchmarks & Policy | OpenPayer

Summary & Overview

CPT 99246: Office Consultation Evaluation and Management (Inactive Code)

CPT code 99246 is referenced as an Evaluation and Management (E/M) service, commonly associated with office consultations. Despite its presence in some billing systems, the American Medical Association does not recognize 99246 as an active CPT code, and no official description is available. This ambiguity has implications for providers and payers, as the code may appear in legacy documentation or payer-specific policies but lacks national standardization.

Blue Cross Blue Shield is the primary payer covered in this analysis. The publication provides an overview of the clinical context in which E/M codes are used, typical sites of service, and related codes that are active and commonly billed for office consultations and outpatient visits. Readers will gain insight into the challenges of coding accuracy, policy updates, and benchmarks for office-based E/M services. The summary also highlights the importance of understanding payer-specific requirements and the impact of code validity on reimbursement and compliance.

Key topics include the role of E/M codes in outpatient care, the significance of code activation status, and the relationship between CPT codes and payer policies. The publication is designed to inform healthcare professionals, billing specialists, and policy analysts about the nuances of medical coding and its effect on clinical and administrative workflows.

Blue Cross Blue ShieldCPT 99246Evaluation and ManagementOffice ConsultationMedical CodingBilling ComplianceHealthcare PolicyOutpatient ServicesClinical DocumentationCPT Code Status

CPT Code Overview

CPT code 99246 is listed as an Evaluation and Management service, typically performed in an office setting (Place of Service 11). However, no official description is available for CPT code 99246, and it is not recognized as an active code by the American Medical Association. This code is generally associated with office consultations, but specific details regarding its clinical use or procedural requirements are not available in the input. Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A patient presents to the office with symptoms such as abdominal pain, chest pain, fever, weakness, or headache. The provider, who may be an internal medicine physician, family medicine physician, general practice physician, obstetrics & gynecology physician, or anesthesiology physician, conducts an evaluation and management service. The clinical workflow involves a detailed assessment of the patient's history, a physical examination, and medical decision-making to determine the cause of the symptoms and appropriate next steps. The service is performed in an office setting (Place of Service 11), and may involve consultation with other specialists or consideration for surgical intervention.

Coding Specifications

Modifier 25: Used when a significant, separately identifiable evaluation and management service is performed by the same physician on the same day as another procedure or service.
Modifier 57: Used when the evaluation and management service results in a decision for surgery.

Modifier Code	Description
`25`	Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service

National Reimbursement Benchmarks

Nationally, Blue Cross Blue Shield and BUCA (average commercial) both reimburse CPT code 99246 at a mean rate of $80.02. Medicare rates are not available in the input for comparison. The commercial mean rates are identical across these payers.

Rate dispersion is minimal, with the 25th, 50th, and 75th percentiles all at $80.00 for both Blue Cross Blue Shield and BUCA. This indicates a very tight rate distribution, with no variation between the lower and upper quartiles. The table and chart below present the full breakdown of national benchmarks for CPT code 99246.

National Mean Rates for CPT Code `99246` by Payer

CPT 99244: Office or Outpatient Consultation, Moderate Complexity

99253-THE-PROVIDER-SEES-A-PATIENT-FOR-AN-INPATIENT-OR-OBSERVATION

CPT 99253: Inpatient or Observation Consultation, Low Complexity

99241-OFFICE-CONSULTATION-FOR-A-NEW-OR-ESTABLISHED-PATIENT-WHICH

CPT 99241: Office Consultation for New or Established Patients, Problem Focused

99255-INPATIENT-OR-OBSERVATION-CONSULTATION-FOR-A-NEW-OR

CPT 99255: Inpatient or Observation Consultation, High Complexity

99252-99252-OFFICE-OR-OTHER-OUTPATIENT-CONSULTATION-FOR-A-NEW-OR

CPT 99252: Inpatient or Observation Consultation, Moderate Complexity

99212-OFFICE-OR-OTHER-OUTPATIENT-VISIT-FOR-THE-EVALUATION-AND

CPT 99212: Office Visit for Established Patients, Straightforward Decision Making

99245-THE-PROVIDER-SEES-A-PATIENT-FOR-AN-OFFICE-OR-OTHER

CPT 99245: Office or Outpatient Consultation, High Complexity

99211-OFFICE-OR-OTHER-OUTPATIENT-VISIT-FOR-THE-EVALUATION-AND

CPT 99211: Office Visit for Established Patients, Minimal Complexity

99242-OFFICE-OR-OTHER-OUTPATIENT-CONSULTATION-FOR-A-NEW-OR

CPT 99242: Office Consultation for New or Established Patients, Low to Moderate Severity

99248-SUBSEQUENT-OBSERVATION-CARE-PER-DAY-FOR-THE-EVALUATION-AND

CPT 99248: Subsequent Observation Care, Moderate Complexity

Showing 1–10 of 14

Taxonomy Code	Specialty
`207R00000X`	Internal Medicine Physician
`207Q00000X`	Family Medicine Physician
`208D00000X`	General Practice Physician
`207V00000X`	Obstetrics & Gynecology Physician
`207L00000X`	Anesthesiology Physician

Related CPT Codes

CPT Code	Description
`99245`	Office consultation for a new or established patient, typically 80 minutes
`99244`	Office consultation for a new or established patient, typically 60 minutes
`99243`	Office consultation for a new or established patient, typically 30 minutes
`99213`	Established patient office or other outpatient visit, typically 15 minutes
`99214`	Established patient office or other outpatient visit, typically 25 minutes

99245, 99244, 99243: These codes represent office consultations for new or established patients and are used for varying levels of complexity and time spent. They are related to the primary CPT code as alternative options depending on the clinical scenario and documentation.
99213, 99214: These codes are used for established patient office visits and may be used in follow-up scenarios or when the patient returns for ongoing management. They are commonly used together in clinical workflows for evaluation and management services.

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Summary & Overview

CPT 99246: Office Consultation Evaluation and Management (Inactive Code)

CPT Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

National Reimbursement Benchmarks

Related Codes

Related Diagnoses

Related CPT Codes

National Reimbursement Benchmarks

Related Codes