CurrentAnthemPolicy C-09010

Consultation Services - Professional

Governs reimbursement for face-to-face medical consultation services billed to Anthem commercial plans; specifies when consultation CPT codes are not reimbursed and that appropriate new or established E/M codes should be used instead. Affects professional providers submitting claims for consultations.

Policy Summary

PayerAnthem

PolicyConsultation Services - Professional

Policy CodePolicy C-09010

Change TypeNo material changes

Effective DateDec 29, 2023

Next Review Date

Key ActionDo not bill inpatient or office-and-other-outpatient consultation procedure codes for face-to-face consultations; report services with the appropriate new or established E/M CPT code.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99242-99245Outpatient consultation codes not eligible

99252-99255Inpatient consultation codes not eligible

99202-99205, 99212-99215Office visit E/M codes eligible

12/29/2023Definition update

Consultation Reimbursement Criteria

Consultation reimbursement criteria

Reimbursement criteria for consultation and E/M coding:

ALL of the following

ALL of the following
- ANY of the following
  - Office and other outpatient consultation codes 99242-99245 are not eligible for reimbursement.
  - Inpatient consultation codes 99252-99255 are not eligible for reimbursement.
Services are reported using the appropriate new or established patient E/M CPT code that accurately describes the services provided (examples: 99202-99205 for new patients; 99212-99215 for established patients).

Policy Summary

PayerAnthem

PolicyConsultation Services - Professional

Policy CodePolicy C-09010

Change TypeNo material changes

Effective DateDec 29, 2023

Next Review Date

Key ActionDo not bill inpatient or office-and-other-outpatient consultation procedure codes for face-to-face consultations; report services with the appropriate new or established E/M CPT code.

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.

Services meet authorization and medical necessity guidelines and any member benefit plan limitations; documentation and billing should follow applicable guidelines.

NOT eligible—do NOT bill these codes for face-to-face consultations:

Office and other outpatient consultation services: CPT 99242-99245.
Inpatient consultation services: CPT 99252-99255.

Eligible codes—use these E/M visit codes instead:

Office or other outpatient visit for new patient: CPT 99202-99205 (eligible for reimbursement).
Office or other outpatient visit for established patient: CPT 99212-99215 (eligible for reimbursement).

Relevant E/M and Consultation CPT Codes

Office or other outpatient visit for new patientCPTCovered

99202-99205

Office or other outpatient visit for new patient

Office or other outpatient visit for established patientCPTCovered

99212-99215

Office or other outpatient visit for established patient

Office and other outpatient consultation servicesCPTNot Covered

99242-99245

Office and other outpatient consultation services for a new or established patient

Inpatient consultation servicesCPTNot Covered

99252-99255

Inpatient consultation services for a new or established patient

Billing Expectations and Authorization

Billing Rule

Do not bill consultation procedure codes; use appropriate E/M code and meet authorization requirements

Do not bill inpatient (99252-99255) or office-and-other-outpatient consultation procedure codes (99242-99245) for face-to-face consultations; report the service using the appropriate new or established patient E/M CPT code that accurately describes the services provided. Ensure services meet authorization and medical necessity guidelines and comply with member benefit limitations and billing/submission requirements.

Report services with the appropriate new or established E/M CPT code rather than consultation procedure codes.
Services must meet authorization and medical necessity guidelines and be supported in the medical record.
Use proper CPT/HCPCS codes on claims; failure to follow coding/billing guidelines may result in claim rejection, denial, or recoupment.

Key Definitions

Consultation

DefinitionThe opinion or advice of a specialist requested by another physician or other appropriate source regarding evaluation and/or management of a specific problem.

ScopeApplies to face-to-face medical consultation services billed to Anthem commercial plans; consults billed with consultation CPT codes may not be reimbursed per policy.

Effective updateConsultation definition updated effective 12/29/2023.

Policy development sourcesPolicy developed through consideration of CMS and Optum EncoderPro 2025.