Notification

Consultation Services


Notification Issue Date: 01/15/2020

This is a new policy that will be effective 4/15/2020. It has been developed to communicate the Company's position that consultation codes are not eligible for reimbursement.



Claim Payment Policy


Title:Consultation Services

Policy #:00.01.69


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Current Procedural Terminology (CPT) consultation codes are not eligible for reimbursement. The appropriate level of Evaluation and Management (E&M) service should be reported.

For a list of CPT consultation codes, refer to the Coding Table in this policy.
Guidelines


Description

A consultation is a type of service provided by a physician or other qualified healthcare professional whose opinion or advice regarding the evaluation and management (E/M) of a specific clinical problem is requested by another physician or other qualified healthcare professional.
References


Center for Medicare and Medicaid Services [CMS]. Medicare Claims Processing Manual: Chapter 12 - Physicians/Nonphysicians Practitioners. 07/25/2019. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed November 23, 2019.

Center for Medicare and Medicaid Services [CMS]. Revisions to Consultation Services Payment Policy. Medical Lives Network Matters Number: MM6740 Revised.November 8, 2011. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6740.pdf. Accessed: November 23, 2019.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)


THE FOLLOWING CODES ARE USED TO REPRESENT CONSULTATION SERVICES
99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Coding and Billing Requirements



Policy History

00.01.69
4/15/2020This is a new policy that will be effective 4/15/2020. It has been developed to communicate the Company's position that consultation codes are not eligible for reimbursement.
Version Effective Date: 04/15/2020
Version Issued Date: 04/15/2020
Version Reissued Date: N/A



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