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Consultation Services - Professional
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Governs reimbursement for professional consultation services billed to Blue Cross Blue Shield - Maine; specifies that face-to-face consultations should not be reimbursed when billed with consultation CPT codes and directs use of appropriate new or established E/M CPT codes. Affects providers submitting professional claims to the plan.
10/01/2026 review approved and effective 10/01/2026: no changes.
10/01/2026 review approved and effective 01/01/2026: updated Definition section.
Coverage Criteria for Consultation Services
Coverage criteria for consultation services
Reimbursement stance for consultation-related CPT codes and alternative coding to use:
ALL of the following
NOT ELIGIBLE WHEN
- Face-to-face consultations billed with office and other outpatient consultation CPT codes (99242-99245) are not eligible for reimbursement.
- Face-to-face consultations billed with inpatient consultation CPT codes (99252-99255) are not eligible for reimbursement.
- Report consultation services using the appropriate new patient E/M CPT code (99202-99205) or established patient E/M CPT code (99212-99215) that accurately describes the services provided; these E/M codes are eligible for reimbursement when supported by documentation.
- Services must meet authorization and medical necessity guidelines and be supported by medical record documentation; improper coding or failure to follow these billing guidelines may result in claim rejection, denial, or recoupment.
Consultation and E/M Codes — Reimbursement Status
| 99202-99205 | Office or other outpatient visit for new patient — eligible for reimbursement |
| 99212-99215 | Office or other outpatient visit for established patient — eligible for reimbursement |
| 99242-99245 | Office and other outpatient consultation services for a new or established patient — not eligible for reimbursement |
| 99252-99255 | Inpatient consultation services for a new or established patient — not eligible for reimbursement |
Billing and Authorization Expectations
Billing and authorization expectations for consultations
Do not bill inpatient (99252-99255) or office-and-other-outpatient consultation (99242-99245) CPT codes for face-to-face consultations; instead report the service with the appropriate new (99202-99205) or established (99212-99215) E/M CPT code that accurately describes the services provided. Services must meet authorization and medical necessity guidelines and be fully supported in the medical record; failure to follow proper coding/billing guidelines may result in claim rejection, denial, or recovery/recoupment.
- Report consultation services using the appropriate new or established E/M CPT code rather than consultation CPT codes for face-to-face visits.
- Ensure documentation in the medical record supports the E/M code billed and meets authorization and medical necessity requirements.
- Use industry-standard CPT/HCPCS codes on claims; improper coding may lead to claim rejection, denial, or recoupment.
Definitions
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