What are the CPT codes for new patient consults?

Editorial team Published on

New patient consults are typically billed using standard New Patient Office/Outpatient E/M Codes (99202–99205), because Medicare and many commercial insurance plans no longer accept traditional formal consultation codes.

Standard New Patient Visit Codes (Office / Outpatient)

  • 99202: Straightforward medical decision-making (MDM) or 15–29 minutes of total time.
  • 99203: Low complexity MDM or 30–44 minutes of total time.
  • 99204: Moderate complexity MDM or 45–59 minutes of total time.
  • 99205: High complexity MDM or 60–74 minutes of total time.

Formal Consultation CPT Codes (By Payer Rules)

While the American Medical Association (AMA) still maintains formal outpatient consultation code numbers in the CPT manual, they are widely inactive for direct reimbursement:

  • 99242–99245: Office or other outpatient consultations.
  • 99252–99255: Inpatient or observation consultations.

Note: Always verify specific guidelines with your local Centers for Medicare & Medicaid Services (CMS) contractor or private commercial payers, as reimbursement policies for consultation versus standard E/M codes vary.

What is the CPT code for a new patient consult?

New patient office visits are reported using American Medical Association (AMA) CPT codes 99202 through 99205, selected based on the level of medical decision-making (MDM) or total time spent on the date of the encounter.

New Patient Office Visit CPT Codes

  • 99202: Straightforward MDM; 15–29 minutes of total time.
  • 99203: Low complexity MDM; 30–44 minutes of total time.
  • 99204: Moderate complexity MDM; 45–59 minutes of total time.
  • 99205: High complexity MDM; 60–74 minutes of total time.

Note on Formal Consultation Codes

While formal office consultation codes (99242–99245) exist in the CPT codebook, they are often not reimbursed by Medicare and many commercial insurance payers. For outpatient office consultations, most payers require you to report the standard new patient office visit codes (99202–99205) instead.

What are the new CPT codes for consultations in 2026?

There are no brand-new CPT consultation code sets introduced for 2026; instead, the active office/outpatient and inpatient consultation codes established in previous years remain the standard for reporting specialist opinions.

Active Office and Outpatient Consultation Codes

  • 99242: Level 2, straightforward medical decision-making (MDM) or 30 total minutes.
  • 99243: Level 3, low complexity MDM or 40 total minutes.
  • 99244: Level 4, moderate complexity MDM or 50 total minutes.
  • 99245: Level 5, high complexity MDM or 55 total minutes.

Active Inpatient and Observation Consultation Codes

  • 99252: Level 2, straightforward MDM or 35 total minutes.
  • 99253: Level 3, low complexity MDM or 45 total minutes.
  • 99254: Level 4, moderate complexity MDM or 60 total minutes.
  • 99255: Level 5, high complexity MDM or 80 total minutes.

(Note: Traditional Medicare does not accept standard consultation codes 99242–99255, requiring initial care or office visit codes instead, while commercial and private payers vary.)

Is CPT 99223 a consult code?

No, CPT code 99223 is technically an initial hospital inpatient or observation care code, not a dedicated inpatient consultation code.

However, depending on your payer and patient type, it is often used to bill for initial hospital consultations.

Medicare and Payers Following CMS Rules

  • No separate consult codes: Medicare does not accept or pay for traditional inpatient consultation codes (such as 99252–99255).
  • Use of 99221–99223: For Medicare patients, consulting physicians performing an initial inpatient evaluation must report codes 99221–99223 (based on high-complexity medical decision making or time) instead of consult codes.
  • Code 99223 requirements: It requires high-complexity medical decision-making (MDM) or a minimum of 75 minutes of total time on the date of the encounter.

Commercial and Private Payers

  • Dedicated codes exist: Many non-Medicare commercial insurance companies still recognize and require specific inpatient consultation codes (99252–99255) for specialist consults.
  • Always check the specific AAPC Code Lookup or individual payer guidelines before submitting a claim.

What CPT codes are used for consults?

Outpatient and inpatient medical consultation services are reported using the CPT® Code Range 99242–99255 set maintained by the American Medical Association.

Outpatient Consultation Codes (Office/Outpatient/ED/Home)

  • 99242: Low-to-moderate level, based on time or medical decision making (MDM)
  • 99243: Moderate level decision making / time thresholds
  • 99244: Moderate-to-high level decision making / time thresholds
  • 99245: High level decision making / time thresholds (prolonged service code +99417 applies after 70 minutes)

Inpatient or Observation Consultation Codes

  • 99252: Straightforward/low level MDM
  • 99253: Low level MDM, 45 minutes
  • 99254: Moderate level MDM, 60 minutes
  • 99255: High level MDM, 80 minutes (prolonged service code +99418 applies after 95+ minutes)

Interprofessional Consultation Codes (Patient Not Present)

  • 99446–99449: Telephone/internet/EHR peer-to-peer consultation by a consulting physician (5 to 31+ minutes with a written report)
  • 99451: Written report only from a consultant (≥5 minutes)

Important Billing Rules

  • Medicare Policy: Medicare and many Medicare Advantage plans do not accept or reimburse traditional consultation codes. For Medicare, providers must bill regular office/outpatient E/M codes or initial hospital care codes (99221–99223) instead.
  • Core Requirements: To use a consultation code, documentation must show the 3 R's: a formal Request from an external provider, Rendered evaluation/opinion, and a written Report sent back to the requesting professional.

CPT Code Sequencing: Essential Tips and Tricks

9 related questions found

What are the three "R's" of consultation codes?

The three "R's" of medical consultation coding are Request, Render, and Report (sometimes referred to as Reply or Response).

These three criteria must be fully met and documented in the patient's medical record to legally justify billing using consultation Evaluation and Management (E/M) codes.

The Three R's Explained

  • Request: Another physician or an appropriate qualified healthcare source must formally ask for an opinion, advice, or evaluation regarding a specific patient problem. This verbal or written request must be noted in the medical record.
  • Render: The consulting physician must personally examine the patient, perform the requested evaluation, and render the service. During this time, the consultant may also initiate diagnostic or therapeutic recommendations, but care is not permanently transferred.
  • Report: The consultant must write a formal report of their findings, opinions, and treatment recommendations and communicate it back to the original requesting provider.

What is the difference between 26010 and 10060?

The main difference between CPT code 26010 and CPT code 10060 is the depth and anatomical compartment of the finger infection being treated.

CPT Code 10060

  • Definition: Incision and drainage (cutting open and cleaning out) of a simple, superficial skin or subcutaneous abscess.
  • Location: Found in the Integumentary System section of the CPT manual.
  • Common Examples: Surface skin boils, simple cysts, or a superficial paronychia (a minor infection around the edge of a fingernail) on a digit, trunk, or arm.
  • Rule: Use this code if the provider only cuts into the top layer of skin or surface tissue on a finger, without entering closed deep spaces. You can review more details on these minor procedures via the AAPC Urgent Care Guide.

CPT Code 26010

  • Definition: Drainage of a simple finger abscess that involves deeper compartments.
  • Location: Found in the Musculoskeletal System section of the CPT manual.
  • Common Examples: A felon, which is a deep infection inside the closed pulp space (the soft fat pad at the tip of the finger).
  • Rule: Use this code if the provider documents entering the deep fascial pulp space of the digit. Learn more about specific structural criteria with this CPT 26010 Reference.

Key Summary Points

  • Depth Decides: Surface skin infection = 10060; deep pulp space infection = 26010.
  • Documentation: The medical chart note must explicitly state the depth or mention "pulp space" to support using 26010.
  • Reimbursement: Code 26010 usually carries a higher relative value and payment rate because working in the deep finger compartment requires more complex care.

What are the new CPT changes for 2026?

The AMA CPT 2026 Code Set features 418 total editorial changes, including 288 new codes, 84 deletions, and 46 revisions effective January 1, 2026.

Key Focus Areas

  • Digital Health & Remote Monitoring: Modernized remote physiologic monitoring (RPM) features new and revised codes for shorter durations (2–15 days within a 30-day window) and reduced management time thresholds starting at 10 minutes per calendar month.
  • Artificial Intelligence (AI): Introduction of AI-assisted service codes for coronary plaque analysis, perivascular fat, multispectral burn imaging, and cardiac dysfunction detection.
  • Cardiovascular System: Complete overhaul of lower extremity revascularization (LER) codes, replacing legacy codes with 46 new specific options, alongside revisions to TEVAR coding.
  • Surgery & Specialties: New codes for endoscopic sleeve gastroplasty (43889), liver tumor IRE ablation (47384), comprehensive audiology/hearing devices, and restructured prostate biopsy and treatment codes.
  • Pathology & Medicine: Expanded multianalyte assays with algorithmic analyses (MAAA), new immunization counseling codes, and specialized infectious disease panels.

You can review a full breakdown of the guidelines and additions through the AAPC 2026 CPT Coding Workshop.

What are the coding guidelines for consultation services?

Coding guidelines for consultation services require documenting the three Rs (request, render, and report) and selecting codes based on the setting and medical decision-making or time.

Core Documentation Requirements (The Three Rs)

  • Request: A written or verbal request from an attending physician or qualified provider for an opinion or advice on a specific clinical problem.
  • Render: The evaluation, examination, and medical decision-making (MDM) performed by the consulting specialist.
  • Report: A formal written or verbal report of the findings and recommendations communicated back to the requesting provider.

Code Categories and Settings

  • Office / Outpatient Consultations: Reported using CPT codes 99242–99245 for ambulatory settings, homes, residences, or emergency departments.
  • Initial Inpatient Consultations: Reported using CPT codes 99251–99255 and limited to once per patient per hospital admission.
  • Interprofessional Telephone/Internet Consults: Reported using CPT codes 99446–99449 or 99451 when the patient is not present and the consultant provides a written/verbal report to the treating provider.

Important Restrictions

  • No Transfer of Care: If care for a specific condition is completely transferred to the consultant, standard initial or subsequent visit codes must be used instead of consultation codes.
  • Payer Variations: Check individual payer rules, as some major insurers or Medicare policies require standard office or inpatient evaluation and management (E/M) codes instead of dedicated CPT consultation codes.

What are all the new patient CPT codes?

The standard new patient CPT® code set range for office and outpatient evaluation and management (E/M) visits is 99202 through 99205.

New Patient Office/Outpatient CPT Codes

Each code level depends on the total time spent on the date of the encounter or the level of medical decision-making (MDM):

  • 99202: Office or other outpatient visit for the evaluation and management of a new patient, requiring a medically appropriate history and/or examination and straightforward medical decision-making. Typically 15–29 minutes of total time.
  • 99203: Office or other outpatient visit for a new patient, requiring low-level medical decision-making. Typically 30–44 minutes of total time.
  • 99204: Office or other outpatient visit for a new patient, requiring moderate-level medical decision-making. Typically 45–59 minutes of total time.
  • 99205: Office or other outpatient visit for a new patient, requiring high-level medical decision-making. Typically 60–74 minutes of total time.

Definition of a New Patient

A new patient is generally defined as someone who has not received any professional, face-to-face services from the physician—or another physician of the exact same specialty and subspecialty in the same group practice—within the past 3 years.