CurrentFlorida BluePolicy 17-055

Consultation Services

Defines Florida Blue's payment policy for physician and qualified health care professional consultation services billed on CMS-1500 or equivalent claim forms, covering all lines of business and providers of service; includes special guidance for Medicare Advantage products.

Policy Summary

PayerFlorida Blue

PolicyConsultation Services

Policy CodePolicy 17-055

Change TypeAdministrative review (no material changes)

Effective DateMay 11, 2025

Next Review Date

Key ActionRequesting physician or qualified source must be identified on the claim for the consultation service to be considered for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99242-99245, 99252-99255CPT consultation codes listed

G0406-G0408, G0425-G0427, G0508-G0509HCPCS/telehealth codes

All linesPolicy applicability

One per admissionInpatient consultation limit

MA does not recognizeMA coding exception

Consultation Coverage Criteria

Consultation coverage criteria

Coverage and coding rules for consultation services:

Florida Blue Medicare Advantage does not recognize consultation CPT codes 99242-99245 and 99252-99255; providers should code a patient E/M visit with procedure codes that represent where the visit occurs and identify visit complexity (for example 99202-99215, 99221-99223, 99304-99306).

For Florida Blue commercial products, the consultant’s opinion and any services ordered or performed must be communicated by written report to the requesting physician, other qualified health care professional, or other appropriate source.

For commercial products, documentation must support the codes reported; for consultation services this includes a request for the consultation and the written report to the requesting provider. In order for Florida Blue to consider a consultation service for reimbursement, the requesting physician or other qualified source must be identified on the claim. If not identified, the consultation service will be returned or denied.

Services initiated by a patient and/or family and not requested by a physician, other qualified health care professional, or other appropriate source should not be billed with consultation codes (99242-99245, 99252-99255, G0406-G0408, G0425-G0427, G0508-G0509) but may be reported using appropriate non-consultation office, hospital, home or residence service E/M procedure codes.

Policy Summary

PayerFlorida Blue

PolicyConsultation Services

Policy CodePolicy 17-055

Change TypeAdministrative review (no material changes)

Effective DateMay 11, 2025

Next Review Date

Key ActionRequesting physician or qualified source must be identified on the claim for the consultation service to be considered for reimbursement.

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.

CPT and HCPCS / Telehealth Codes

CPT consultation codesCPT

99242	99242
99243	99243
99244	99244
99245	99245
99252	99252
99253	99253
99254	99254
99255	99255

HCPCS/telehealth consultation codesHCPCS

G0406	Follow-up inpatient consultation, limited
G0407	Follow-up inpatient consultation, intermediate
G0408	Follow-up inpatient consultation, complex
G0425	Telehealth consultation, emergency department or initial inpatient (~30 minutes)
G0426	Telehealth consultation, emergency department or initial inpatient (~50 minutes)
G0427	Telehealth consultation, emergency department or initial inpatient (~70 minutes)
G0508	Telehealth consultation, critical care, initial (~60 minutes)
G0509	G0509

E/M code selection basis

Basis for level selectionSelect E/M service level based on medically appropriate history and/or examination and the level of Medical Decision Making (MDM) for the service, or total time personally performed on the date of the encounter.

Effective date for guidanceEffective January 1, 2023 — CPT guidance applies for selection of consultation service level.

Applicable claim formsPolicy applies to services billed on a CMS-1500 or equivalent claim form.

Who may perform time-based selectionTotal time personally performed by the physician or other qualified health care professional on the date of the encounter may be used to select level.

Reference standardFollow AMA CPT definitions for history, exam, and MDM when determining E/M level.

Provider Billing and Documentation Requirements

Documentation Required

Claim documentation requirement for consultations

In order for Florida Blue to consider a consultation service for reimbursement, the requesting physician or other qualified source must be identified on the claim; if the requesting entity is not identified on the claim, the consultation service will be returned or denied. Documentation must include the request for the consultation and the consultant's written report to the requesting provider; services initiated by a patient/family and not requested by an appropriate source should not be billed with consultation codes.

Include the requesting physician or other qualified source on the claim.
Maintain and submit the consultation request and the consultant’s written report as part of the documentation.
Do not report consultation codes for services initiated by patient or family without a request from an appropriate source; instead bill an appropriate non-consultation E/M code.

Billing Rule

Inpatient consultation limit and follow‑up visit rules

Florida Blue will consider only one inpatient consultation (CPT 99252-99255) per admission by the same physician or other health care professional; subsequent E/M services during the same admission should be reported with appropriate non-consultation E/M procedure codes. Follow-up office or outpatient visits initiated by the consultant or patient are reported with appropriate E/M visit codes, and an office consultation may be used again only if another physician or appropriate source requests an additional opinion and that request is documented.

Limit of one inpatient consultation (99252-99255) per admission by the same provider—additional inpatient E/M services billed as non-consultation E/M codes.
Follow-up visits initiated by consultant or patient use appropriate E/M visit codes (not consultation codes).
If another physician or appropriate source requests an additional opinion, an office consultation code may be used again only with documented request in the patient record (Florida Blue may request this documentation).

Definitions

Consultation

Definition of consultationAn evaluation and management service provided at the request of another physician, other qualified health care professional, or appropriate source to recommend care for a specific condition or problem.

Selection of service levelConsultation service level is selected using medically appropriate history and/or exam and MDM, or total time personally performed on the date of the encounter.

Billing form applicabilityThis definition and guidance apply to services billed on a CMS-1500 or equivalent claim form.

Same provider

Same provider definitionIncludes all physicians and/or other health care professionals reporting under the same Federal Tax Identification Number.

Scope for inpatient rules'Same provider' is used to determine limits such as one inpatient consultation per admission by the same physician or health care professional.

Claim reporting implicationProviders reporting under the same Federal Tax Identification Number are considered the same provider for this policy's application to billing and reimbursement.