CurrentBlue Cross Blue Shield - MainePolicy C-09010

Consultation Services Professional

Defines Anthem Blue Cross and Blue Shield commercial reimbursement stance for professional consultation services (inpatient and office/outpatient) and which CPT codes are eligible for reimbursement; applies to Anthem commercial members including Blue Cross Blue Shield - Maine.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyConsultation Services Professional

Policy CodePolicy C-09010

Change TypeRevised (policy language and code removals)

Effective DateDec 29, 2023

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and submit claims with proper CPT/HCPCS codes supported by clinical documentation.

SourceLink

POLICY UPDATE CHANGES

Policy language updated to no longer allow reimbursement for inpatient and office-and-other-outpatient CPT codes 99241-99245 and 99251-99255 for consultations; Colorado market exempted.

Removed deleted CPT codes 99241 and 99251.

99202-99205office/outpatient new patient codes eligible

99212-99215office/outpatient established patient codes eligible

99242-99245office/outpatient consultation codes not eligible

99252-99255inpatient consultation codes not eligible

2023-12-29policy effective/last approval date

Consultation Reimbursement Criteria

Consultation reimbursement criteria

Stance on reimbursement for consultation procedure codes:

ALL of the following

Face-to-face medical consultations billed with inpatient consultation codes (CPT 99252-99255) are not eligible for reimbursement.
Face-to-face medical consultations billed with office-and-other-outpatient consultation codes (CPT 99242-99245) are not eligible for reimbursement.
Use the appropriate E/M CPT code to report office or outpatient visits that describe the services provided; examples include CPT 99202-99205 for new patients and CPT 99212-99215 for established patients — these E/M codes are eligible for reimbursement when the documentation supports the service provided.
Claims must be supported by medical record/office notes, meet medical necessity and authorization requirements, and follow proper billing and submission guidelines; Anthem may recover payment or deny claims if guidelines are not followed.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyConsultation Services Professional

Policy CodePolicy C-09010

Change TypeRevised (policy language and code removals)

Effective DateDec 29, 2023

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and submit claims with proper CPT/HCPCS codes supported by clinical documentation.

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 and E/M Codes

Consultation and E/M codesCPT

99202-99205	Office or other outpatient visit for new patient
99212-99215	Office or other outpatient visit for established patient
99242-99245	Office and other outpatient consultation services for a new or established patient
99252-99255	Inpatient consultation services for a new or established patient

Eligible for reimbursementCPTCovered

99202-99205	Office or other outpatient visit for new patient
99212-99215	Office or other outpatient visit for established patient

Not eligible for reimbursementCPTNot Covered

99242-99245	Office and other outpatient consultation services for a new or established patient
99252-99255	Inpatient consultation services for a new or established patient

Documentation support

Documentation requirementClaims must be fully supported in the medical record and/or office notes and meet medical necessity and authorization requirements.

Coding standardsUse industry-standard CPT, HCPCS, and revenue codes on all claim submissions; codes must accurately denote services performed.

Authorization expectationServices must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.

Consequences of noncomplianceIf coding/billing guidelines or reimbursement policies are not followed, Anthem may recover/recoup payment or reject/deny the claim.

Authorization and Billing Expectations

Billing Rule

Authorization, documentation, and billing requirements

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence. Follow proper billing and submission guidelines using CPT/HCPCS codes and revenue codes, and ensure claims are fully supported in the medical record and/or office notes. Failure to follow coding/billing guidelines or current reimbursement policies may result in Anthem recovering/recouping payment, or rejecting or denying the claim.

Use industry-standard, compliant CPT, HCPCS, and revenue codes on all claim submissions.
Ensure clinical documentation in the medical record/office notes fully supports billed services.
Adhere to authorization and medical necessity requirements for the procedure, diagnosis, and member's state of residence.
Anthem may recover/recoup payment or reject/deny claims if guidelines are not followed.

OpenPayer

Consultation Services Professional

Consultation Reimbursement Criteria

Consultation and E/M Codes

Authorization and Billing Expectations

Key Definitions