CurrentHealth NetPolicy CC.PP.054

Physician's Consultation Services

Defines how Health Plan reimburses physician consultation E&M services and how consultation CPT codes are mapped to equivalent E&M visit codes; applies to physicians and other qualified health professionals billing consultation services to the Health Plan.

Policy Summary

PayerHealth Net

PolicyPhysician's Consultation Services

Policy CodePolicy CC.PP.054

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders should bill consultation services based on where the visit occurred and the complexity of the visit; bill the E&M code that describes the service provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99242-99255Consultation CPT code range referenced

75%OIG finding of improperly paid consultations (2006)

CrosswalkCrosswalked for payment

NCApplicable state

Coverage and Payment Rules

Coverage and payment rules for consultation codes

How the Health Plan handles billed consultation codes:

Health Plan reimbursement approach: Consultation CPT codes billed to the plan will be reimbursed by crosswalking to the corresponding E&M visit level; providers should bill the E&M code (not the consultation code) that describes the service provided.

Utilization mapping: Consultation codes 99242-99255 will be identified and crosswalked to the appropriate office/other outpatient visit, initial inpatient visit, or emergency department visit code and paid according to the fee schedule for the equivalent procedure code.

Coding guidance and provider responsibility: Codes referenced in this payment policy are informational only; inclusion or exclusion of any codes does not guarantee coverage. Providers must reference current CPT guidance and the most up-to-date professional coding resources prior to claim submission.

Medicare members: For Medicare members, applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) should be reviewed prior to applying this payment policy to ensure consistency with Medicare guidance.

Policy Summary

PayerHealth Net

PolicyPhysician's Consultation Services

Policy CodePolicy CC.PP.054

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders should bill consultation services based on where the visit occurred and the complexity of the visit; bill the E&M code that describes the service provided.

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 Codes and Time Thresholds

Consultation CPT Codes (office/outpatient)CPT

99242	Office or other outpatient consultation — straightforward; typical time 20 minutes
99243	Office or other outpatient consultation — low level MDM; typical time 30 minutes
99244	Office or other outpatient consultation — moderate level MDM; typical time 40 minutes
99245	Office or other outpatient consultation — high level MDM; typical time 55 minutes

Consultation CPT Codes (inpatient/observation)CPT

99252	Inpatient or observation consultation — straightforward; typical time 35 minutes
99253	Inpatient or observation consultation — low level MDM; typical time 45 minutes
99254	Inpatient or observation consultation — moderate level MDM; typical time 60 minutes
99255	Inpatient or observation consultation — high level MDM; typical time 80 minutes

Time thresholds for CPT consultation codes — mapping of individual CPT consultation codes to their typical time thresholds

9924220 minutes

9924330 minutes

9924440 minutes

9924555 minutes

9925235 minutes

9925345 minutes

9925460 minutes

9925580 minutes

Billing Guidance and Applicability

Billing Rule

Billing guidance and applicability

Providers must bill consultation services based on where the visit occurred (office/outpatient, inpatient/observation, or emergency department) and the complexity of the visit; bill the E&M code that describes the service rather than the consultation code. This policy applies to physicians and other qualified health professionals who perform initial E&M services.

Bill the E&M code for the site of service and complexity of the visit (do not submit consultation CPTs as billed when an equivalent E&M code describes the service).
Policy scope: physicians and other qualified health professionals performing initial E&M services.

OpenPayer

Physician's Consultation Services

Coverage and Payment Rules

Consultation Codes and Time Thresholds

Billing Guidance and Applicability

Key Definitions