ModifiedBlue Cross Blue Shield - IllinoisPolicy CPCP024

Evaluation and Management (E/M) coding for professional provider services

Governs coding, billing, and reimbursement rules for professional providers billing Evaluation and Management services (CMS 1500/UB04) to Blue Cross Blue Shield of Illinois; applies to physicians and other qualified healthcare professionals submitting claims.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyEvaluation and Management (E/M) coding for professional provider services

Policy CodePolicy CPCP024

Change TypeRemoved reimbursement for consultation CPT codes

Effective DateNov 18, 2024

Next Review DateN/A

Key ActionDo not bill consultation CPT codes 99242-99245 or 99252-99255 for dates on/after 11/18/2024; report encounter with appropriate E/M codes by location and complexity.

SourceLink

POLICY UPDATE CHANGES

The plan will no longer reimburse for office/outpatient consultation codes (CPT codes 99242-99245) and inpatient consultation codes (CPT codes 99252-99255).

99202-99205, 99212-99215Primary office/outpatient E/M code ranges referenced

99490, 99491Chronic Care Management CPT codes referenced

7Prolonged service codes discussed

Two of threeMDM selection requires

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7Related policies listed

Coverage and Billing Criteria

General coverage and documentation requirements

Requirements for reimbursement and claims review

Medical record must document presenting symptoms, diagnoses, treatment plan, and written orders when applicable; include clinical notes, consultation notes, lab/pathology and radiology testing as appropriate.

Medical records and itemized bills may be requested to validate site of service, level of care rendered, and services billed; records will be reviewed for extent of history/examination, complexity of medical decision making (MDM), and services rendered to determine appropriate billing level.

Supports claim review and payment validation.

Providers must submit claims using valid HIPAA-approved code combinations and appropriate modifiers; claims are subject to code edit protocols and review against plan documents, provider contracts, medical policies, coding policies, and code edit protocols.

E/M level selection must be based on either: (1) the level of Medical Decision Making (MDM) per policy definitions (two of three MDM elements must be met or exceeded), OR (2) total time for the E/M services performed on the date of the encounter. Documentation must include a medically appropriate history and physical exam.

The policy references AMA/CPT guidance for specific code descriptions and time parameters; providers should refer to the current CPT book for time thresholds and detailed E/M coding guidance.

Consultation CPT codes 99242-99245 and 99252-99255 are not reimbursed effective 11/18/2024; encounters previously billed with consultation codes should be reported with the appropriate E/M codes by location and complexity.

Material change effective 11/18/2024.

Split/shared visit billing must identify both providers and include the split/shared modifier -FS and documentation identifying the substantive provider and signatures as required.

Prolonged service codes may be billed according to CPT guidance and policy restrictions; documentation must support time billed and certain prolonged codes are not reportable together as specified in policy.

Chronic Care Management codes (e.g., 99490, 99491) may be reported per monthly reporting rules and required elements, and are reportable only once per calendar month with required time thresholds.

Prolonged E/M coverage criteria

Billing constraints and pairings for prolonged E/M codes:

Use +99418 for prolonged inpatient or observation E/M time beyond the required time of the primary service when the primary service level was selected using total time; bill each additional 15 minutes in conjunction with specified primary inpatient/observation E/M codes (e.g., 99223, 99233, 99236, 99255, 99306, 99310).

Do not bill +99418 on the same date of service as 90833, 90836, 90838, 99358, or 99359.

Use G2212 for prolonged office or other outpatient E/M beyond the maximum required time of the primary procedure (selected using total time); report each additional 15 minutes by the physician or QHP. G2212 is listed in addition to CPT codes such as 99205, 99215, and 99483.

Do not report G2212 on the same date of service as CPT codes 99358, 99359, 99415, or 99416. G2212 is not reportable for any time unit less than 15 minutes.

Code Lists, Time Thresholds, and Billing Rules

Office/Outpatient E/MCPTCovered

99202-99205	Office/outpatient new patient E/M codes with time/MDM-based levels
99212-99215	Office/outpatient established patient E/M codes with time/MDM-based levels
99211	Established patient basic service; supervision of clinical staff

Chronic Care ManagementCPTCovered

99490	Chronic care management - first 20 minutes of clinical staff time per calendar month
99491	Chronic care management - first 30 minutes personally by physician/QHP per calendar month

Prolonged ServicesmixedCovered

99358	Prolonged service before/after direct patient care (non-face-to-face)
+99359	Add-on for each additional 30 minutes beyond first hour for 99358
+99415	Prolonged clinical staff service add-on (office/outpatient)
+99416	Additional 30-minute add-on for +99415
+99417	Prolonged office/outpatient E/M add-on each 15 minutes
+99418	Prolonged inpatient/observation E/M add-on each 15 minutes
G2212	Medicare prolonged office E/M add-on (each 15 minutes); not reportable with +99417

Consultation Codes (discontinued reimbursement)CPTNot Covered

99242-99245	Office/outpatient consultation codes - no longer reimbursed
99252-99255	Inpatient consultation codes - no longer reimbursed

Prolonged service and associated primary E/M codesmixed

99418	Prolonged inpatient/observation E/M each 15 minutes (used with 99223, 99233, 99236, 99255, 99306, 99310)
G2212	Prolonged office/outpatient E/M each additional 15 minutes (listed separately with 99205, 99215, 99483)
99223	Inpatient initial (example primary service referenced)
99233	Subsequent inpatient care (example primary service referenced)
99236	Prolonged inpatient discharge/day (example primary service referenced)
99255	History/physical consult (example primary service referenced)
99306	Nursing facility initial (example primary service referenced)
99310	Nursing facility discharge (example primary service referenced)
99205	Office/outpatient high-level E/M (example primary service referenced)
99215	Office/outpatient established patient E/M (example primary service referenced)

1–10 of 11

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Time thresholds for office/outpatient E/M codes

99202 (New, Straightforward)15-29 minutes

99203 (New, Low Complexity)30-44 minutes

99204 (New, Moderate Complexity)45-59 minutes

99205 (New, High Complexity)60-74 minutes

99212 (Established, Straightforward)10-19 minutes

99213 (Established, Low Complexity)20-29 minutes

Provider Billing Guidance and Required Actions

Documentation Required

Documentation and Claim Review

Providers are responsible for submission of accurate documentation of services performed. Providers must submit claims using valid HIPAA-approved code sets and may be requested to provide medical records and itemized bills to support services billed. Claims are subject to review for coding edits, benefit coverage, provider contract terms, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should promptly furnish additional documentation to avoid delays or denials.

Billing Rule

Consultation code billing change

Do not bill consultation CPT codes 99242-99245 or 99252-99255 for dates of service on or after 2024-11-18. Report consultation encounters using the appropriate office/outpatient or inpatient E/M codes that reflect the visit location and complexity (for example: 99202-99215, 99221-99223, 99304-99306).

Definitions and Terminology

Established patient (billing definition)

DefinitionEstablished Patient: a member who has received professional services from the physician or other Qualified Healthcare Professional, or another physician or QHP of the exact same specialty and subspecialty in the same group practice, within the last three years.

Same specialty/subspecialty requirementMust be the exact same specialty and subspecialty within the same group practice to qualify as established.

TimeframeThe look-back period for established patient status is three years.

New patient (billing definition)

DefinitionNew Patient: a member who has not received any professional services from the physician or other Qualified Healthcare Professional, or another physician or QHP of the exact same specialty and subspecialty in the same group practice, within the last three years.

Determining new vs established

Policy Revision History

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyEvaluation and Management (E/M) coding for professional provider services

Policy CodePolicy CPCP024

Change TypeRemoved reimbursement for consultation CPT codes

Effective DateNov 18, 2024

Next Review DateN/A

Key ActionDo not bill consultation CPT codes 99242-99245 or 99252-99255 for dates on/after 11/18/2024; report encounter with appropriate E/M codes by location and complexity.

SourceLink

On This Page

99214 (Established, Moderate Complexity)

CCM monthly reporting and time thresholds

99490 (CCM by clinical staff)Report once per calendar month for the first 20 minutes of clinical staff time directed by a physician or QHP; services less than 20 minutes in a month are not reported separately.

99491 (CCM by physician/QHP)Report once per calendar month for the first 30 minutes personally provided by the physician or other QHP; required CCM elements apply.

Reporting frequencyEach CCM code may be reported only one time per calendar month by the single physician or QHP providing the care management role.

Prolonged add-on minimums and reporting rules

Prolonged add-on incrementsAdd-on prolonged codes (+99417, +99418, G2212, +99415/+99416, +99359) are reported in specified increments (typically 15- or 30-minute units) per CPT guidance.

Minimum reportable unitServices or prolonged time less than the minimum increment (commonly 15 minutes) should not be billed using the add-on codes (e.g., do not bill +99417/+99418/G2212 for <15 minutes).

Paired billing rulesSome add-on codes must be billed in conjunction with specific primary codes (e.g., +99417 with 99205/99215; +99418 with certain inpatient codes) and certain prolonged add-ons cannot be reported together.

Minimum time unit for prolonged/add-on codes

Minimum time unit15 minutes — prolonged and add-on codes are reported only for each full 15-minute increment; not reportable for any unit less than 15 minutes.

Applicable codesCodes specifically identified as 15-minute increment codes include +99417, +99418, and G2212 (G2212 also not reportable for <15 minutes).

Documentation requirementDocumentation must support the total additional time billed in full 15-minute increments.

Effective date: 2024-11-18
Consultation codes affected: CPT 99242-99245, 99252-99255
Suggested replacement code ranges: 99202-99215, 99221-99223, 99304-99306

Billing Rule

Prolonged E/M billing guidance

For prolonged evaluation and management (E/M) services beyond the primary E/M service time, use the specified prolonged-service codes with the appropriate primary inpatient/observation or outpatient E/M codes: use 99418 for prolonged inpatient/observation E/M time in 15-minute increments in conjunction with primary inpatient/observation E/M codes (example allowed primary codes: 99223, 99233, 99236, 99255, 99306, 99310). Use G2212 for prolonged office or other outpatient E/M services beyond the maximum required time of the primary outpatient E/M code (listed additionally with 99205, 99215, 99483). Both codes report each additional 15-minute unit; do not report for units less than 15 minutes. Do not report 99418 on the same date of service as 90833, 90836, 90838, 99358, or 99359. Do not report G2212 on the same date of service as 99358, 99359, 99415, or 99416.

99418 — Prolonged inpatient/observation E/M, each additional 15 minutes (use with eligible inpatient/observation E/M primary codes)
G2212 — Prolonged office/outpatient E/M, each additional 15 minutes (use in addition to primary outpatient E/M codes such as 99205, 99215)
Do not report time units < 15 minutes
Mutually exclusive same-day code restrictions noted above

If no services from the same specialty/subspecialty in the same group practice occurred within three years, the patient is new for billing purposes.

Look-back periodThree-year period used to determine new patient status.

Qualified Healthcare Professional (QHP)

DefinitionQualified Healthcare Professional: an individual qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within their scope of practice and independently reports that professional service.

Scope and reportingThe QHP must perform services within their scope of practice and independently report the professional service for billing.

Credential requirementsQualification is established by education, training, licensure/regulation, and facility privileging as applicable.

Medical Decision Making (MDM) — selection criteria

MDM componentsMedical Decision Making complexity is determined by: 1) number and complexity of problems addressed, 2) amount and/or complexity of data to be reviewed, and 3) risk of complications and/or morbidity or mortality.

Two-of-three ruleTo qualify for an MDM level, two of the three MDM elements must be met or exceeded.

Examples of elementsElements include problem complexity (minimal to high), data reviewed (minimal to extensive), and risk (minimal to high).

Prolonged E/M service — definition and reporting

DefinitionProlonged E/M service: codes that represent additional E/M time beyond the required time of the primary service and are reported in specified increments (commonly 15 minutes); examples include +99417, +99418, and G2212.

Reporting incrementsTypically reported in 15-minute increments (+99417, +99418, G2212); some prolonged clinical staff/add-on codes use 30-minute increments (+99415, +99416, +99359 as add-on to 99358).

Pairing and exclusion rulesProlonged codes must be billed with designated primary E/M codes and certain prolonged/add-on codes cannot be reported together on the same date of service (e.g., +99417 and G2212; G2212 not reportable with 99358/99359/99415/99416).