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Using CPT 99451 Billing Code in Headache Medicine

Date: 03/07/2025
American Headache Society Practice Tips

The CPT code 99451 is one of the non-face-to-face codes that has relevance to headache medicine. It allows headache medicine specialists to answer directed patient specific questions on management through review of the electronic medical record only, without a face-to-face visit. This could facilitate headache care in certain clinical scenarios, given the limited access to headache care across the U.S.

The work RVU associated with CPT 99451 is 0.70

Top 10 Key Education Points:

  1. The e-consult code is relevant to headache medicine in being able to advise on patient specific management questions without a face-to-face visit and through review of the electronic medical record as the main source of information. For example, a 28 year old woman with a known primary headache disorder where red flags are ruled out and neuroimaging is normal, has failed nortriptyline and topiramate, what other medications are recommended as next steps for her history of 8 monthly migraine days?
     
  2. The e-consult code is more challenging when used for headache diagnostic questions as the consulting physician or APP is unable to perform a history or physical/neurologic exam on the patient since there is no face-to-face visit.
     
  3. Typical scenario: the treating physician is a primary care physician or APP (family medicine, medicine-pediatrics, internal medicine) requesting the advice of a consulting physician (headache medicine specialist) for assistance with a specific management question without direct face-to-face contact with the patient.
     
  4. The consulting physician will answer a patient specific treatment question through review of the electronic health record without an in-person visit.
     
  5. Documentation should include recommendations on management, rationale and may include contingencies. This written report is required within 3 business days of the request.
     
  6. The treating physician must document consent, including potential cost-sharing by the patient (copays, coninsurance, etc).
     
  7. If the recommendation is that a face-to-face visit is needed to answer the clinical question, the econsult code 99451 should NOT be reported.
     
  8. The code cannot be billed if the patient was seen by the consulting physician within 14 days prior or will be seen for a future available appointment.
     
  9. The amount of time spent by the consulting physician should be documented in the written note and CPT 99451 requires a minimum of 5 minutes of consultative time spent.
     
  10. This code works well within and between organizations, practices or health care systems that have shared electronic health record systems.

About the Author

Dr. Raissa Villanueva is a practicing general neurologist and headache medicine specialist. She is Chief of Headache and General Neurology and Medical Director of Compliance at the University of Rochester Medical Center in Rochester, NY. She is also Co-chair of the Practice Management Committee at AHS and a member of the Coding and Payment Policy Subcommittee at the American Academy of Neurology. Her areas of expertise are in practice management, ambulatory operations, billing and coding.