CurrentHighmark Blue Cross Blue Shield WnyPolicy G-05006

Reimbursement Policy Consultations

Defines Highmark BCBS WNY reimbursement rules for face-to-face medical consultations for Medicaid Managed Care (MMC), HARP, Child Health Plus, and Essential Plan members; applies to physicians and qualified nonphysician practitioners providing consultations.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyReimbursement Policy Consultations

Policy CodePolicy G-05006

Change TypeReview — no changes

Effective Date12/02/2025

Next Review Date

Key ActionDocument and maintain required consultation records, including history, exam, findings, recommendations, the requesting provider's reason, and evidence of communication to the requesting provider or member representative to support reimbursement.

SourceLink

POLICY UPDATE CHANGES

12/02/2025 review approved and effective: no changes

G-05006Policy Number

12/02/2025Effective Date / Last Approval Date

MMC, HARP, CHPlus, EPPrograms covered

Reimbursement Criteria for Consultations

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ALL of the following

Consultation is requested by the attending provider or appropriate source (verbal or written).
Consulting provider acts within their scope and practice.
Consultation includes a personal (face-to-face) examination of the patient.
Consulting provider completes a written report including: member history (chief diagnosis/complaint), examination, physical findings, recommendations for future management/ordered services, the attending provider's request and reason for the consultation, documentation of communication to attending provider and member's authorized representative, and the consulting provider's written report.
Member medical record contains documentation to support the consultation (includes lab consultations relating to abnormal test results outside clinically significant range when applicable).

Modifier and same-day procedure rules

Rules for billing consultations when definitive therapeutic procedures occur same day.

ALL of the following

If consulting provider performs a definitive therapeutic surgical procedure same day for same member, report the consultation with modifier 25 or 57 as appropriate.
If appropriate modifier is not reported, the consultation is considered included in the surgical procedure reimbursement and is not separately reimbursable.

Preoperative and postoperative consultation rules

Additional conditions when consultations relate to preoperative clearance or postoperative evaluation.

ANY of the following

A surgeon may request consultation as part of preoperative clearance or postoperative evaluation; consultation guidelines must be met.
A consulting provider may be reimbursed for a postoperative evaluation only if the requesting surgeon requires a professional opinion and the consulting provider has not performed the preoperative clearance.
A consulting provider performs a preoperative clearance and subsequent management is transferred to same consulting provider — postoperative visits are considered concurrent care and do not qualify as consultations.

When a PCP may perform a consultation

Circumstances under which primary care physicians may bill consultations for their own patients.

ANY of the following

PCP performs requested preoperative clearance or postoperative evaluation when surgeon specifically requests and guidelines are met; reimbursement based on state guidance or contract.
Behavioral health provider specifically requests PCP to perform medical evaluation for a member admitted to inpatient psychiatric unit — usually billed as E/M; medical review may be required.

ALL of the following

Note: PCP typically does not qualify to perform consultations for their own patient because services are considered evaluations and the PCP has an established medical record/history on the member.

Documentation, Billing Rules, and Risk of Denial

Documentation Required

Required documentation for consultation reimbursement

Consultation reimbursement requires a written report and supporting medical record documentation that demonstrates the consultation met policy criteria. The consulting provider must document the member history, examination, physical findings, recommendations for future management/ordered services, the attending provider's request and reason for the consultation, and communication of findings to the attending provider and the member's authorized representative.

Member history, including chief diagnosis and/or complaint
Examination
Physical finding(s)
Recommendations for future management and/or ordered service(s)
The attending provider's request for the consultation and the reason for the consultation
Documentation that the consulting provider communicated information to the attending provider and the member's authorized representative
Medical record must support the consultation and any associated services; laboratory consultations must relate to abnormal test results when applicable

Billing Rule

Same-day procedure billing requirement

When a definitive therapeutic surgical procedure is performed the same day as a consultation for the same member, the consultation must be reported with modifier 25 or modifier 57, as appropriate; if the appropriate modifier is not reported the consultation is considered included in the procedure reimbursement and is not separately reimbursable.

Report consultation with modifier 25 or 57 when definitive therapeutic surgical procedure is performed same day for same member
Absence of appropriate modifier means consultation is included in surgical procedure reimbursement and not separately payable
Affected modifiers: 25, 57

Billing Rule

Nonreimbursable consultation situations

The policy lists specific consultation situations that are not reimbursable and must not be billed as consultations.

Consultations performed by telephone (telephone calls are not telemedicine)
Split/shared E/M visits
Consultations performed in addition to an E/M visit for the same member by the same provider, unless modifier 25 is appropriate
Second or third opinions requested by the member or the member's authorized representative
Consultations for non-covered services
When transfer of care to the consulting provider occurs
Both preoperative clearance and postoperative evaluation of the same member by the same consulting provider
Services that do not meet the specified consultation guidelines

Denial Risk

Potential actions for noncompliance

If coding/billing guidelines or documentation requirements are not followed, claims may be rejected or denied and payments may be recovered or adjusted per policy.

Claim may be rejected or denied
Payment may be recovered and/or recouped
Reimbursement may be adjusted to reflect appropriate services performed

Scope and Policy Context

This policy defines Highmark Blue Cross Blue Shield WNY reimbursement rules for face-to-face medical consultations and applies specifically to members enrolled in Medicaid Managed Care (MMC), HARP, Child Health Plus, and the Essential Plan. It addresses consultations provided by physicians and qualified nonphysician practitioners and outlines documentation, billing, and reimbursement requirements that must be met unless superseded by provider, state, federal, or CMS contract requirements.

Reimbursement is allowed when consultations meet the policy's criteria and is based on the fee schedule or contracted/negotiated rate using the appropriate consultation code per state Medicaid guidelines or CPT® guidance. Providers should follow standard correct coding and refer to authoritative coding resources including CPT 2025, CMS, and Optum EncoderPro 2025, and consult their provider contract as applicable.

Providers should verify the most current policy on the Highmark BCBS WNY provider website (https://providerpublic.mybcbswny.com) before submitting claims. Failure to follow the applicable coding, billing, or documentation requirements may result in claim rejection or denial, recovery/recoupment of payments, or reimbursement adjustment.

Defined Terms

Definitions

ConsultationThe opinion or advice of a specialist requested by another physician or other appropriate source regarding evaluation and/or management of a specific problem.

Second OpinionAn opinion obtained from an additional healthcare professional prior to the performance of a medical service or a surgical procedure; may relate to a formalized process used to educate a patient on treatment alternatives or determine medical necessity.

Policy Update Changes

12/02/2025Review approved / EffectiveLatest

Review approved and effective; no changes.

12/19/2023Review approved / Effective

Updated Consultations in Definitions section.

09/15/2020Review approved

Review approved (no further detail provided).

04/20/2018Review approved / Effective

Policy language updated.

01/01/2017Initial approval / Effective

Initial approval and effective date of the policy.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyReimbursement Policy Consultations

Policy CodePolicy G-05006

Change TypeReview — no changes

Effective Date12/02/2025

Next Review Date

SourceLink

On This Page

OpenPayer

Reimbursement Policy Consultations

Reimbursement Criteria for Consultations

Relevant Codes and Modifiers

Documentation, Billing Rules, and Risk of Denial

Scope and Policy Context

Defined Terms

Policy Update Changes

25	Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service.
57	Decision for surgery (E/M service that results in the initial decision to perform the surgery).

Reimbursement Policy Consultations

Reimbursement Criteria for Consultations

Relevant Codes and Modifiers

Documentation, Billing Rules, and Risk of Denial

Scope and Policy Context

Defined Terms

Policies to Read With This One

Policy Update Changes