99243 vs 99204/99203 (non-medicare patients)

Our office uses 99243 for new patients (not medicare) if referred by a doctor and 99204 or 99203 for new patients (not medicare) if self referred.  Is this correct?  Or when it is appropriate and best to use which code to maximize payout and avoid denials/appeals?  Is it commercial carrier dependent?

The criteria is met for time, history and exam for all codes.

Thank you for your input.


  • If the new patient is referred for a consultation, then the 99243 would be correct for the non-Medicare/VA insurance groups but the 3 R's have to be met to qualify for a consult - request, reason for seeing the patient, reply/response back to the requesting provider.  If all three of the R's are not met then you should not bill the consult code and only bill the new patient codes 99201-99205 depending on the level of care and MDM.
  • Medicare no longer pays for consultation codes (except telehealth consultations), and requires
    that consultation services be billed with the most appropriate (non-consultation) E/M code for the
    service. The consultant must submit a written report back to the requesting physician (or other appropriate source).The request can be written or verbal; if verbal, the request must be documented in the patient’s medical record. Source Medical Coding Training Medesun.
Sign In or Register to comment.