CPT 99243: Office Consultation, Low Complexity
Office or other outpatient consultation for a new or established patient with low medical decision making complexity.
Why CPT 99243 Claims Get Denied
Claims billed under CPT 99243 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 cover consultation codes
Consultation requirements not fully documented
Level of service not supported
Written report not sent to requesting provider
Billing Tips for CPT 99243
For Medicare, use new/established patient codes. Commercial payers may accept 99243. Document all three consultation elements. Medical decision making must support low complexity.
Documentation Requirements
To support a clean claim for CPT 99243, your clinical documentation should include:
Request for consultation documented
Complete history and examination
Medical decision making — low complexity
Written report to requesting provider
Assessment and recommendations
Common Modifiers for CPT 99243
Reduce CPT 99243 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.