CPT Coding for Office Visits and Consultations

Current Procedural Terminology (CPT) codes are essential for accurately reporting medical procedures and services. Among the most commonly used CPT codes in outpatient settings are those related to office visits and consultations. Understanding how to apply these codes properly is critical for compliance, correct reimbursement, and streamlined medical documentation.

In this blog, we’ll break down how CPT coding works for office visits and consultations, explore the major code categories, and highlight documentation tips to ensure accuracy.

Office Visit CPT Codes: An Overview

Office visits are typically coded using the Evaluation and Management (E/M) CPT code range. These codes reflect the complexity and length of the patient encounter, and they are divided into categories for new patients and established patients.

New Patient Office Visits (CPT 99202–99205):

A new patient is someone who has not received any professional services from the physician (or another physician of the same specialty in the same group) within the past three years.

Code Complexity Typical Time

99202 Straightforward 15-29 mins

99203 Low complexity 30-44 mins

99204 Moderate complexity 45-59 mins

99205 High complexity 60-74 mins

Established Patient Office Visits (CPT 99211–99215):

These visits are for patients previously seen by the provider or group.

Code Complexity Typical Time

99211 Minimal services 5 mins

99212 Straightforward 10-19 mins

99213 Low complexity 20-29 mins

99214 Moderate complexity 30-39 mins

99215 High complexity 40-54 mins

Note: As of 2021, E/M office visit codes are primarily based on medical decision making (MDM) or total time spent on the date of the encounter, rather than history and exam alone.

CPT Codes for Consultations

Consultations are services provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another provider.

Office or Outpatient Consultations (CPT 99242–99245):

Code Complexity Typical Time

99242 Straightforward 20 mins

99243 Low complexity 30 mins

99244 Moderate complexity 40 mins

99245 High complexity 55 mins

Note: Medicare and some private insurers no longer reimburse outpatient consult codes. Instead, use the appropriate new or established E/M code (e.g., 99203 or 99213).

Documentation Tips

To code accurately, documentation must support the code level based on:

Medical Decision Making (MDM): Number of diagnoses, data reviewed, and risk level.

Time-Based Coding: Total time spent by the provider on the date of service.

Nature of Visit: For consultations, documentation must clearly indicate that a consult was requested and include the reason, findings, and a report back to the referring provider.

Final Thoughts

CPT coding for office visits and consultations requires attention to detail, especially with evolving guidelines. Understanding whether a patient is new or established, knowing the current MDM requirements, and properly documenting the encounter are all essential for correct coding and reimbursement.

As coding guidelines continue to adapt to new healthcare models, staying up to date with CPT changes and payer requirements is vital for compliance and efficient practice management.

Learn : Medical Coding Training Course

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