CurrentHighmark DelawarePolicy RP-063

Consultation Services reimbursement

Governs reimbursement for outpatient and inpatient consultation CPT codes and instructs providers to report appropriate E&M codes for the visit location and complexity; applies to Highmark markets listed (commercial and Medicare Advantage) including DE.

Policy Summary

PayerHighmark Delaware

PolicyConsultation Services reimbursement

Policy CodePolicy RP-063

Change TypeAdministrative review; historical code deletions noted

Effective DateJan 4, 2021

Next Review Date

Key ActionDo not bill consultation CPT codes; report the service with an appropriate E&M code for the visit location and ensure documentation supports the billed E&M.

SourceLink

POLICY UPDATE CHANGES

Added NY region applicable to the policy.

Added Delaware Medicare Advantage applicable to the policy.

Updated Reference link to CMS MM6740.

Deleted codes 99241 and 99251.

Administrative policy review with no changes in policy direction.

Added Delaware Medicare Advantage applicable to the policy.

Added NY region applicable to the policy.

PA, WV, DE, NYGeographic applicability

99242-99245; 99252-99255Consultation CPTs referenced

10Total consultation codes listed

Coverage Criteria for Consultation Services

Consultation code coverage

Coverage stance and documentation requirements

ALL of the following

Consultation codes (not reimbursed): Outpatient consultation: 99242, 99243, 99244, 99245; Inpatient consultation: 99252, 99253, 99254, 99255.

Billed services for these encounters should be reported using an appropriate Evaluation and Management (E&M) code that reflects the location and level of complexity of the visit (e.g., office/outpatient, inpatient hospital, nursing facility).

Billed E/M code(s) must be fully supported in the medical record and/or office notes.

E&M reporting requirements

Substitute coding and documentation requirements

Report an appropriate E&M code that represents the location where the visit occurred and the level of complexity of the visit performed.

Select the E&M code consistent with CPT and Plan guidance for the visit location (office/other outpatient, inpatient hospital, nursing facility, etc.).

Ensure the medical record and/or office notes fully support the billed E&M code.

Referral and documentation

Coordination of care and documentation

Physicians making a referral must document the referral request in the medical record.

Physicians accepting a referral must provide an evaluation of the patient and document that evaluation in the medical record.

Communicate the results of the patient's evaluation to the requesting physician as part of coordination of care.

Billed E&M codes related to the referral must be supported by the medical record and/or office notes.

Consultation reimbursement criteria

Coverage stance and required provider actions:

Consultation CPT codes 99242-99245 (outpatient) and 99252-99255 (inpatient) are not reimbursed by the Plan.

Providers should report these services using an appropriate E&M code that reflects the location (office/outpatient, inpatient hospital, nursing facility) and level of complexity of the visit.

Billed E&M code(s) must be fully supported in the medical record and/or office notes.

Physicians making and accepting referrals must document the request, provide an evaluation, and communicate results to the requesting physician.

This policy follows CMS guidance (discontinuation of outpatient/inpatient consultation codes) and aligns with CPT/Plan documentation requirements.

Coding and Billing Guidance

Consultation codes (not reimbursed)CPTNot Covered

99242	Outpatient consultation
99243	Outpatient consultation
99244	Outpatient consultation
99245	Outpatient consultation
99252	Inpatient consultation
99253	Inpatient consultation
99254	Inpatient consultation
99255	Inpatient consultation

Consultation codes not reimbursedCPTNot Covered

99241-99245	Outpatient consultation CPT codes (not reimbursed)
99251-99255	Inpatient consultation CPT codes (not reimbursed)

Replacement codingCPT

No codes listed

Documentation support

RequirementBilled E/M codes must be fully supported in the medical record and/or office notes.

Documentation basisDocumentation must follow CPT and Plan guidance to support coordination of care and billing.

Physician responsibilitiesPhysicians making and accepting referrals must document the request, provide an evaluation, and communicate results to the requesting physician.

Applicable locationsE/M codes should reflect the location of the visit (office/outpatient, inpatient hospital, nursing facility, etc.).

Provider Actions and Billing Expectations

Prior Authorization

Do not bill consultation CPT codes; use an appropriate E&M code

The Plan will not reimburse consultation CPT codes. Report these services using an appropriate Evaluation and Management (E&M) code that represents the location where the visit occurred and the level of complexity of the visit performed. Physicians making and accepting referrals must document the request, provide an evaluation, and communicate the results to the requesting physician.

Do not bill consultation CPT codes (outpatient 99242-99245; inpatient 99252-99255) for reimbursement.
Select an appropriate E&M code that reflects the visit location (office/outpatient, inpatient hospital, nursing facility, etc.) and complexity.
Document the referral request, the evaluation performed, and communication of results to the requesting physician; ensure billed E&M code(s) are fully supported in the medical record and/or office notes.

Definitions

Consultation — definition

TermConsultation

DefinitionA service provided by a physician or other qualified healthcare professional whose opinion or advice regarding the evaluation and management (E/M) of a specific clinical problem is requested by another physician or qualified healthcare professional.

Requesting relationshipRequested by another physician or qualified healthcare professional; involves providing an opinion or advice regarding E/M of a specific clinical problem.

Provider typesPhysicians or other qualified healthcare professionals may provide or request the consultation.

Consultation — alternative definition

Service describedA service where a physician's or qualified healthcare professional's opinion or advice regarding evaluation and management (E/M) of a specific clinical problem is requested by another physician or qualified healthcare professional.