Consultation Services
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Governs billing, coding, and reimbursement requirements for CPT and HCPCS consultation services billed to Florida Blue across all lines of business; affects providers submitting CMS-1500 or equivalent claims and Medicare Advantage members with special coding rules.
No material clinical or coverage changes in this revision.
Consultation Coverage Criteria
Consultation coverage criteria
Covered when ALL of the following requirements and rules are met:
Consultation CPT and HCPCS Codes
| 99242 | medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 |
| 99243 | medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 |
| 99244 | Description = 99244 |
| 99245 | Description = 99245 |
| 99252 | Description = 99252 |
| 99253 | Description = 99253 |
| 99254 | Description = 99254 |
| 99255 | Description = 99255 |
| G0406 | Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth. |
| G0407 | Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth. |
| G0408 | Follow-up inpatient consultation, complex, physicians typically spend 35 minutes communicating with the patient via telehealth. |
| G0425 | Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth. |
| G0426 | Telehealth consultation, emergency department or initial inpatient, typically 50 |
| G0427 | Description = G0427 |
| G0508 | Description = G0508 |
| G0509 | Description = G0509 |
Billing and Provider Requirements
Identify requesting provider on the claim
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 written report to the requesting provider.
- If consultation criteria are not met, submit or resubmit the claim with an appropriate non-consultation E/M procedure code.
Medicare Advantage: do not use consultation CPT codes
For Medicare Advantage products Florida Blue does not recognize consultation CPT codes 99242-99245 and 99252-99255; code the encounter using site-appropriate E/M codes (for example 99202-99215, 99221-99223, or 99304-99306).
- Do not submit 99242-99245 or 99252-99255 for Medicare Advantage members — use appropriate office, hospital, or domiciliary E/M codes that reflect site and complexity.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.