Commercial

Medical Policy

Notification

Consultation Services

Notification Issued Date:

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.

Title:

Consultation Services

Policy #:

00.01.69b

Policy

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

Centers for Medicare and Medicaid Services [CMS]. Evaluation and Management Services Guide. Medical Learning Network Booklet: MLN 006764. 2/2021. Available at: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf. Accessed April 6, 2022.

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 April 4, 2022.

Coding

CPT Procedure Code Number(s)

THE FOLLOWING CODES ARE USED TO REPRESENT CONSULTATION SERVICES

99242, 99243, 99244, 99245, 99252, 99253, 99254, 99255

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 00.01.69b:

05/15/2024

This policy has been reissued in accordance with the Company's annual review process.

01/01/2023

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/20223.

The following procedure codes had narrative revisions:

99242, 99243, 99244, 99245, 99252, 99253, 99254, and 99255

The following procedure codes were removed from the policy:

99241 and 99251

Revisions From 00.01.69a:

06/06/2022

This version of the policy will become effective 06/06/2022. The intent of this policy remains unchanged, but the policy has been updated to further clarify current benefits

Revisions From 00.01.69:

04/15/2020

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.

Version Effective Date:

1/1/2023

Version Issued Date:

2/10/2023

Version Reissued Date:

5/15/2024