CurrentAmbetter NevadaPolicy CC.PP.054

Payment Policy: Physician's Consultation Services

Defines how Ambetter Nevada reimburses physician consultation services (CPT 99242-99255) and how those consultation codes are crosswalked to corresponding E&M visit codes; applies to physicians and other qualified health professionals billing initial E&M services.

Policy Summary

PayerAmbetter Nevada

PolicyPayment Policy: Physician's Consultation Services

Policy CodePolicy CC.PP.054

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIdentify billed consultation codes (99242-99255) and crosswalk them to the appropriate office visit, initial inpatient, or emergency department codes for payment per the fee schedule.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99242-99255Consultation CPT codes addressed

CrosswalkedCrosswalked to E&M/initial visit codes

Time minutesTime thresholds listed

75%OIG improper payment finding

CMS 2011CMS Medicare change

Consultation Payment and Processing Rules

Consultation payment criteria

Payment and processing rules when consultation codes are billed.

When providers bill consultation codes 99242-99255, the Health Plan will crosswalk those codes to the corresponding E&M office visit, initial inpatient, or emergency department code and reimburse at the equivalent E&M visit level per the fee schedule.

Providers should bill the E&M code (rather than the consultation code) that describes the service provided; the Health Plan will reimburse at the corresponding E&M visit level.

ALL of the following

99242 — 20 minutes (office/outpatient consultation; straightforward MDM).
99243 — 30 minutes (office/outpatient consultation; low level MDM).

Policy Summary

PayerAmbetter Nevada

PolicyPayment Policy: Physician's Consultation Services

Policy CodePolicy CC.PP.054

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIdentify billed consultation codes (99242-99255) and crosswalk them to the appropriate office visit, initial inpatient, or emergency department codes for payment per the fee schedule.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Consultation CPT Codes and Time Thresholds

Consultation codesCPT

99242-99245	Office or other outpatient consultations (see descriptors and time thresholds in policy).
99252-99255	Inpatient or observation consultations (see descriptors and time thresholds in policy).

Time thresholds for CPT consultation codes — minute thresholds per code

9924220 minutes (total time on date of encounter must be met or exceeded)

9924330 minutes (total time on date of encounter must be met or exceeded)

9924440 minutes (total time on date of encounter must be met or exceeded)

9924555 minutes (total time on date of encounter must be met or exceeded)

9925235 minutes (total time on date of encounter must be met or exceeded)

9925345 minutes (total time on date of encounter must be met or exceeded)

9925460 minutes (total time on date of encounter must be met or exceeded)

9925580 minutes (total time on date of encounter must be met or exceeded)

Billing Actions and Crosswalks

Billing Rule

Crosswalk billed consultation codes to equivalent E&M/initial visit codes and pay per fee schedule

When providers bill consultation codes 99242–99255, the Health Plan will identify those codes and crosswalk them to the more appropriate level of office visit, initial inpatient visit, or emergency department procedure code; payment will follow the fee schedule amount for the equivalent E&M/initial visit code.

Identify billed consultation CPT codes 99242–99255 on claims.
Crosswalk each billed consultation code to the corresponding office visit, initial inpatient, or emergency department code for payment.
Reimburse at the fee schedule amount for the equivalent E&M/initial visit code.

Key Definitions Used in This Policy

Consultation — definition per AMA CPT

Definition (AMA CPT)An evaluation and management service provided at the request of another physician or appropriate source to recommend care for a specific condition or to determine whether to accept responsibility for ongoing management of the patient's entire care or for care of a specific condition.

PurposePerformed to recommend care or determine responsibility for ongoing management.

Documentation riskOIG found high improper payment rates when documentation did not support that a consultation was rendered or when visits were coded at incorrect levels.

99242-99255 — consultation CPT code range used in policy

Code range99242-99245: Office or other outpatient consultations; 99252-99255: Inpatient or observation consultations.

DescriptorsCodes describe consultations for new or established patients with varying levels of history/exam and medical decision making per CPT descriptors.

Policy useThese consultation codes are identified by the plan and crosswalked to corresponding E&M office visit, initial inpatient, or ED codes for payment.