CPT 99242: Office Consultation, Straightforward
Office or other outpatient consultation for a new or established patient with straightforward medical decision making. Note: Medicare no longer recognizes consultation codes — use new or established patient E/M codes instead.
Why CPT 99242 Claims Get Denied
Claims billed under CPT 99242 are frequently denied or downcoded for the following reasons. Understanding these patterns helps your practice reduce denial rates and recover revenue faster.
Medicare does not recognize consultation codes since 2010
Missing documentation of the request for consultation
No written report sent back to the requesting provider
Level of service not supported by documentation
Billing Tips for CPT 99242
For Medicare patients, bill new patient (99202-99205) or established patient (99211-99215) codes instead. For commercial payers that still recognize consultations, ensure all three requirements are met: request from another provider, rendering of the service, and written report back to the requesting provider.
Documentation Requirements
To support a clean claim for CPT 99242, your clinical documentation should include:
Written or verbal request from another provider
Reason for consultation
Complete evaluation and assessment
Written report back to requesting provider
Medical decision making documentation
Common Modifiers for CPT 99242
Reduce CPT 99242 Denials by 60%
RediClaim's pre-submission scrubber catches documentation gaps and coding errors before you submit, while the appeal generator handles denials that slip through.