CPT Code 99243: Outpatient Consultation, Low MDM

CPT code 99243 reports an outpatient or office consultation for a new or established patient involving low medical decision-making. 

It belongs to the consultation E/M category — distinct from standard office visits — and requires a formal three-part consultation structure (request, rendering, report). Providers select 99243 through either low MDM (two of three elements at the low level) or 40-54 minutes of qualifying physician time.

The most consequential billing fact about 99243 is that Medicare eliminated separate payment for all outpatient consultation codes (99241-99245) in 2010. Medicare beneficiary consultations are reported using the appropriate new-patient or established-patient office E/M code instead. 

However, many commercial payers, Medicaid programs, and workers’ compensation carriers still recognize and separately reimburse 99241-99245. Billing 99243 without verifying payer policy first is a guaranteed denial for Medicare and a potential denial for any commercial plan that follows Medicare’s policy.

What does CPT code 99243 cover?

The essential reference facts for 99243 billing.

Detail	CPT 99243
Description	Outpatient consultation, low MDM
Category	Consultation E/M
Patient type	New or established
MDM level	Low
Time	40-54 total physician/QHP minutes
Common modifiers	25, 95
Medicare coverage	Not separately payable (use office E/M)
Commercial rate (median)	~$140-$160
Commonly compared with	CPT 99213/99203 (Medicare-equivalent)

A consultation under 99243 involves a specialist rendering an expert opinion at the formal request of another physician. The encounter is advisory — the requesting physician retains management responsibility unless the consultant explicitly assumes ongoing care.

When should you use CPT 99243?

99243 requires a formal consultation structure — not just a referral or a “see the specialist” appointment.

Use CPT 99243 when

• Another physician formally requests the consultant’s opinion on a specific clinical question
• The consultant renders an opinion, recommendation, or advisory report
• The consultant sends a written report back to the requesting physician
• All three elements (request, rendering, report) are documented
• The payer recognizes and reimburses consultation codes
• MDM reaches the low level (two of three elements) or 40-54 qualifying minutes are spent

When not to use it

• The payer is Medicare — use the corresponding new-patient (99203) or established-patient (99213) office E/M
• No formal request from another physician exists — bill office E/M instead
• The consultant assumes ongoing management of the condition — that becomes a transfer of care, not a consultation
• The patient self-referred — consultations require a physician-initiated request
• The payer’s commercial policy follows Medicare’s consultation elimination — verify before billing

How is CPT 99243 selected?

99243 uses the same MDM grid as office E/M codes, plus the three-part consultation requirement.

Consultation requirements

All three must be documented per CPT consultation guidelines.

• Request — A physician or other appropriate source formally requests the consultant’s opinion (documented in the medical record)
• Rendering — The consultant evaluates the patient and forms a clinical opinion
• Report — The consultant communicates findings and recommendations back to the requesting physician in writing

MDM pathway

Low MDM (identical thresholds as 99213/99203) — two of three elements at low.

Time pathway

40-54 total physician/QHP minutes on the date of service. Consultation time thresholds differ from office E/M — 99243 starts at 40 minutes while the low-MDM office codes (99213, 99203) start at 20 and 30 minutes respectively.

What documentation supports CPT 99243?

The documentation must prove the formal consultation structure and support the MDM level.

The record should include the requesting physician’s name and the clinical question, the consultant’s evaluation findings and opinion, the consultant’s written report to the requesting physician, and MDM-supporting documentation at the low level (problems, data, risk). When billing by time, record actual total minutes.

How much does CPT 99243 reimburse?

99243 is not Medicare-payable. Payment applies to commercial and Medicaid plans that recognize consultation codes.

Payment type	2026 rate
Medicare	Not separately payable
Commercial payers (median)	~$140-$160
Workers’ compensation	Varies by state fee schedule
Medicaid	Varies by state

For Medicare beneficiaries, report the appropriate office E/M code instead. A new-patient low-MDM consultation maps to 99203; an established-patient low-MDM consultation maps to 99213.

Which modifiers apply to CPT 99243?

Modifier	When it applies
25	Significant, separately identifiable E/M same day as a procedure
95	Telehealth — when the payer recognizes telehealth consultations

Do not apply Medicare telehealth modifiers to 99243 since Medicare does not pay the code.

CPT 99243 vs. 99213/99203 — which one fits?

The choice depends on the payer, not the clinical work.

Feature	CPT 99243	CPT 99213/99203
Type	Consultation	Office visit
Patient	New or established	Established/New respectively
MDM	Low	Low
Requires formal request	Yes	No
Medicare payable	No	Yes
Commercial payable	Most plans	Yes

Use 99243 when a payer recognizes consultations, all three consultation elements are documented, and the MDM is low.

Use 99213 or 99203 when the payer is Medicare or does not recognize consultation codes, or when no formal consultation request exists.

What billing errors should you avoid with CPT 99243?

Five errors drive the majority of 99243 denials.

1. Billing 99243 to Medicare 

Medicare eliminated outpatient consultation codes in 2010. Submitting 99243 to Medicare results in automatic denial.

2. Missing the formal request documentation 

Without a documented physician request, the encounter does not meet the consultation definition. Bill office E/M instead.

3. No written report to the requesting physician 

The third consultation element requires the consultant to communicate findings back in writing. A note in the consultant’s chart alone is not sufficient.

4. Confusing a transfer of care with a consultation 

When the consultant assumes ongoing management of the condition, the encounter becomes a transfer of care — reportable as office E/M, not consultation codes.

5. Not verifying payer consultation policy 

Some commercial plans follow Medicare’s elimination. Always verify the specific plan’s current consultation-code policy before billing 99243.

Frequently asked questions about CPT 99243

Some commonly asked questions on this topic: