Reimbursement Policy Consultations
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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.
12/02/2025 review approved and effective: no changes
Reimbursement Criteria for Consultations
General reimbursement criteria for consultations
Consultations are reimbursable only when ALL of the following are met.
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.
Relevant Codes and Modifiers
| 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). |
Documentation, Billing Rules, and Risk of Denial
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
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
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
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
Policy Update Changes
Review approved and effective; no changes.
Updated Consultations in Definitions section.
Review approved (no further detail provided).
Policy language updated.
Initial approval and effective date of the policy.
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