Do you bill Medicare for consults for new or established patients?  Are they complex and fall under a CPT 99245 Code?  If so, you may be the subject of a prepayment review.  Medicare is conducting prepayment medical reviews for CPT 99245 Code claims submitted by providers in the NY area. A prepayment review is exactly what it sounds like, a review before you get paid that oftentimes requires you submit additional documentation for billing submitted.  Medicare will review the requested documentation once received and notify the provider of whether it will pay the claim or not. The main impact of a prepayment review is on a practice’s account receivables, as prepayment reviews make it more difficult for providers to get paid under higher scrutiny.

CPT 99245 is a difficult code to substantiate because providers must meet the requirements of a consult and also the strict requirements of a level “5”, which requires that the level of medical decision making be complex, as well as there be a detailed history and exam performed that include the review of a requisite number of systems. Below is a non-exclusive checklist for 99245 claims.

Non-Exclusive Checklist for billing 99245:

Providers who submit claims for CPT 99245 should keep the following in mind prior to submitting a claim in order to increase the chances of getting paid.    

Documentation of the requests for consultations should not be missing or incomplete.
Consultation reports should not be missing or incomplete.

The reason for the consultation should be clearly stated.

Documentation should indicate that the service is a request for a consultation and not a request for a transfer of care.  

The service billed should not be a subsequent visit, or a continuation of care by the consultant for an established clinical problem of an established patient.

Documentation should support the level of service billed according to the CPT definition of CPT 99245.  A level “5” consult is complex, and there are several specifications that need to be met and documented in order to qualify for a 99245 consult.

Documentation should contain the provider signature, appropriate patient identification, and correct dates of service.


For additional information on this topic, contact Jennifer Kirschenbaum at (516)-747-6700 ext. 302 or at


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