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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyHealth Choice Arizona Consultation Update | OpenPa…
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    CurrentHealth Choice ArizonaPolicy N/A

    Consultation Services Pricing Guideline

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    Guidelines for coding and reimbursement of consultation services submitted by physicians and other qualified healthcare professionals, subject to member benefit eligibility and applicable pricing criteria.

    Policy Summary
    PayerHealth Choice Arizona
    PolicyConsultation Services Pricing Guideline
    Policy CodePolicy N/A
    Change TypeRevision
    Effective DateMay 1, 2022
    Next Review DateN/A
    Key ActionReport consultation services using the appropriate CPT code from the 99201-99215 E/M range.
    SourceLink
    POLICY UPDATE CHANGES

    CPT codes 99251-99255 were removed from the pricing guideline effective May 1, 2022.

    99201-99215Required E/M code range
    99241-99245Not reimbursable
    99251-99255Historical exclusion
    New or establishedPatient status

    Consultation Services Pricing Criteria

    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.

    Consultation services pricing criteria

    Apply the following pricing and coding criteria to consultation services:

    ALL of the following

    • The service is submitted by a physician or other qualified healthcare professional.
    • For claims received on or after July 1, 2019, report consultation services using the appropriate CPT E/M code from the 99201-99215 range.
    • Select the code that best describes the place of service, complexity, and whether the patient is new or established to the physician.
    • CPT codes 99241-99245 are not eligible for reimbursement for claims received on or after July 1, 2019.
    • CPT codes 99251-99255 are not eligible for reimbursement for claims received between July 1, 2019 and May 1, 2022.

    Consultation Service Coding

    Required consultation service reporting codesCPTCovered
    99201-99215Evaluation and management codes used to report consultation services based on place of service, complexity, and new or established patient status
    Non-reimbursable outpatient consultation codesCPTNot Covered
    99241-99245Consultation service codes not eligible for reimbursement for claims received on or after July 1, 2019
    Historical non-reimbursable consultation codesCPTNot Covered
    99251-99255Consultation service codes not eligible for reimbursement for claims received between July 1, 2019 and May 1, 2022
    Coding
    Required E/M code range99201-99215
    Coding
    Exclusion start date for CPT 99241-99245Claims received on or after July 1, 2019
    Coding
    Historical exclusion period for CPT 99251-99255Claims received between July 1, 2019 and May 1, 2022

    Provider Billing Actions

    Billing Rule

    Applicable providers

    Apply this pricing guideline to claims submitted by physicians and other qualified healthcare professionals.

    Billing Rule

    Report consultation services with appropriate E/M codes

    For claims received on or after July 1, 2019, report consultation services using the appropriate CPT code from the E/M 99201-99215 range. Select the code that best describes the place of service, complexity, and whether the patient is new or established to the physician.

    Denial Risk

    Avoid non-reimbursable consultation codes

    Do not submit CPT codes 99241-99245 for reimbursement for claims received on or after July 1, 2019. CPT codes 99251-99255 are not eligible for reimbursement for claims received between July 1, 2019 and May 1, 2022.

    Consultation Service Definition

    Definitions
    Consultation ServiceA type of evaluation and management (E/M) service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem.
    Policy Summary
    PayerHealth Choice Arizona
    PolicyConsultation Services Pricing Guideline
    Policy CodePolicy N/A
    Change TypeRevision
    Effective DateMay 1, 2022
    Next Review DateN/A
    Key ActionReport consultation services using the appropriate CPT code from the 99201-99215 E/M range.
    SourceLink
    On This Page
    Consultation Services Pricing CriteriaConsultation Service CodingProvider Billing ActionsConsultation Service Definition