Summary & Overview
CPT 99247: Office Consultation for New or Established Patients, 40 Minutes
CPT code 99247 represents an office consultation for a new or established patient, typically lasting 40 minutes. This code is significant in the national healthcare landscape as it is used by physicians to bill for comprehensive evaluation and management services that require a higher level of clinical expertise and time commitment. The code is most commonly utilized in office settings and is relevant for specialties such as internal medicine, family medicine, and general practice.
Blue Cross Blue Shield is a key payer covered in this analysis, providing insight into reimbursement policies and coverage for office consultations. Readers will gain an understanding of the clinical context in which CPT 99247 is used, including typical patient scenarios and associated diagnoses. The publication also covers relevant modifiers, such as 25 and 57, which may impact billing and reimbursement, as well as related CPT codes for comparison.
This summary offers benchmarks, policy updates, and a clear overview of how CPT 99247 fits within the broader evaluation and management service line. It is designed to inform healthcare professionals, administrators, and policy analysts about the practical and regulatory aspects of billing for office consultations, ensuring clarity on payer coverage and clinical application.
CPT Code Overview
CPT 99247 is designated for an office consultation involving a new or established patient, typically lasting 40 minutes. This code falls under the Evaluation and Management service type and is most commonly performed in an office setting (Place of Service 11). The consultation is intended to address complex medical issues requiring a detailed assessment and professional advice. Providers use this code to document and bill for comprehensive consultations that go beyond routine office visits, reflecting the time and expertise required for thorough patient evaluation.
Clinical & Coding Specifications
Clinical Context
A patient presents to the office for a consultation regarding new symptoms such as fatigue, abdominal pain, or chest pain. The consultation is requested by another provider or the patient’s primary care physician. The evaluating physician, who may be an internal medicine, family medicine, or general practice specialist, conducts a comprehensive assessment, including history, examination, and medical decision-making. The visit typically lasts about 40 minutes. The consultation may address general medical concerns, preprocedural evaluations, or specific symptoms, and results in recommendations for further management or diagnostic testing.
Coding Specifications
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Modifier
25: Used when a significant, separately identifiable evaluation and management service is performed on the same day as another procedure or service. -
Modifier
57: Used when the evaluation and management service results in the decision for surgery.
| Modifier Code | Description |
|---|---|
25 | Significant, Separately Identifiable Evaluation and Management Service |
57 | Decision for Surgery |
- Provider Taxonomies:
| Taxonomy Code | Specialty |
|---|---|
207R00000X | Internal Medicine Physician |
207Q00000X | Family Medicine Physician |
208D00000X | General Practice Physician |
Related Diagnoses
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Z00.00: Encounter for general adult medical examination without abnormal findings- Used when the consultation is for a routine check-up without any abnormal findings.
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Z01.818: Encounter for other preprocedural examination- Relevant when the consultation is for evaluation prior to a procedure.
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R53.83: Other fatigue- Used when the patient presents with fatigue as a primary symptom for evaluation.
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R10.9: Unspecified abdominal pain- Used when the patient presents with abdominal pain that requires assessment.
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R07.9: Chest pain, unspecified- Used when the patient presents with chest pain needing evaluation during the consultation.
Related CPT Codes
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99213: Established patient office or other outpatient visit, typically 15 minutes. Used for shorter, less complex visits; may be an alternative for follow-up or less intensive consultations. -
99214: Established patient office or other outpatient visit, typically 25 minutes. Used for moderately complex visits; may be used for follow-up after a consultation. -
99215: Established patient office or other outpatient visit, typically 40 minutes. Used for highly complex visits; similar in duration to99247but for established patients rather than consultations. -
99244: Office consultation for a new or established patient, typically 60 minutes. Used for more complex consultations requiring extended time; may be used as an alternative when the consultation is more involved.
These codes are commonly used as alternatives or in sequence depending on the complexity and duration of the patient encounter. 99247 is specifically for consultations, while 99213, 99214, and 99215 are for established patient visits. 99244 is for longer consultations.