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Reimbursement for consultation and interprofessional consultation services

Defines Optum reimbursement policy for consultation services and interprofessional/telehealth consultation codes for providers submitting claims on the CMS-1500 (or electronic equivalent). Applies to Commercial, Medicare, Individual Exchange plans and network and non-network physicians and qualified health care professionals whose behavioral health benefits are administered by Optum.

Policy Summary

PayerOptum

PolicyReimbursement for consultation and interprofessional consultation services

Policy CodePolicy N/A

Change TypeCode additions and reimbursement guideline updates

Effective Date

Next Review Date

Key ActionWhen billing interprofessional consultation codes, document the requesting physician/QHP and reason for the consult, record verbal patient/family consent, include the requesting entity on the claim (field 17/17b), and report cumulative time meeting the code-specific minimums.

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POLICY UPDATE CHANGES

CPT code 99452 was added to the list of interprofessional consultation codes considered for reimbursement.

Clarified reimbursement stance: Optum aligns with CMS and does not reimburse in-person consultation CPT codes 99242-99245 and 99252-99255, including telehealth.

Updated documentation and billing rules for interprofessional consultation codes 99451, 99446-99449 and 99452 including time thresholds and reporting requirements.

Removed deleted CPT codes 99241 and 99251 effective 1/1/2023.

99242-99245, 99252-99255In-person consultation CPT code ranges not reimbursed

99451, 99446-99449, 99452

Reimbursement Criteria for Interprofessional Consultations

Interprofessional consultation (consultant billed codes 99451, 99446-99449) reimbursement criteria

Covered when ALL of the following conditions are met:

ALL of the following

Consultation reported by a consultant when requested by another physician or qualified health professional (QHP).
Request and reason for the consult must be documented in the medical record.
Verbal consent from the patient/family for the interprofessional consultation must be documented in the medical record.
Requesting physician or appropriate source must be identified on the claim (field 17/17b on CMS-1500 or electronic equivalent).
Can be reported for new or established patients and for new or exacerbated problems.
Cannot be reported more than once per 7 days; if multiple contacts for same patient, include cumulative billing time.
Maximum frequency: no more than once per 7 days; cumulative time may be billed.
Reported based on cumulative time, even if time occurs on subsequent days.
Not reportable if a transfer of care or request for face-to-face consult occurs as a result of the consultation within the next 14 days.
Not reportable if the patient was seen by the consultant within the past 14 days.
Minimum time threshold applies for consultant-billed code 99451: 5 minutes or more.
Threshold: >= 5 minutes

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Interprofessional consultation (consultant billed codes 99451, 99446-99449) reimbursement criteria

Interprofessional consultation (requesting/treating physician/QHP billed code 99452) reimbursement criteria

Covered when ALL of the following conditions are met:

ALL of the following

Reported by the treating/requesting physician or QHP who is requesting the non-face-to-face consult for medical advice or opinion, not for transfer of care or to arrange a face-to-face consult.
Patient must not be on-site with the requesting physician/QHP at time of the consultation.
Cannot be reported more than once per 14 days per patient.
Includes time preparing for the referral and/or communicating with the consultant; requires a minimum of 16 minutes.
Threshold: >= 16 minutes

Situations where 99451 and 99446-99449 are not reimbursed

Not reimbursed when ANY of the following apply:

ANY of the following

An in-person visit with the psychiatric consultant occurred within the previous 14 days.
An in-person visit with the psychiatric consultant will occur within the next 14 days.
The sole purpose of the contact is to transfer care or arrange for an in-person consultation with the psychiatric consultant.

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Relevant CPT Codes and Coverage Status

Interprofessional consultation codes considered for reimbursementCPTCovered

99451	Interprofessional telephone/Internet/EHR assessment and management service by consultative physician or QHP; 5 minutes or more of medical consultative time.
99446	Interprofessional assessment and management service by consultative physician/QHP; typically 5-10 minutes (includes verbal and written report).
99447	Interprofessional assessment and management service; typically 11-20 minutes (includes verbal and written report).
99448	Interprofessional assessment and management service; typically 21-30 minutes (includes verbal and written report).
99449	Interprofessional assessment and management service; 31 minutes or more (includes verbal and written report).
99452	Interprofessional referral service(s) by treating/requesting physician or QHP; includes time preparing referral and/or communicating with consultant; minimum 16 minutes; reported by requesting physician/QHP.

Documentation and Billing Requirements — Actions to Avoid Denials

Documentation Required

Document request and consent

Record the requesting physician or qualified health professional (QHP) and the reason for the consult in the medical record. Document verbal consent from the patient or family for the interprofessional consultation in the patient's medical record.

Date of call
Patient name and identifiers (insurance information, date of birth)
Brief problem statement/reason for request
Pertinent findings reported by requesting/treating physician (labs/x-rays if applicable)
Differential diagnosis (if applicable)
Focused recommendations

Billing Rule

Time and Frequency Thresholds

Time and frequency thresholds for interprofessional consultation codes

Minimum time for 994515 minutes

Minimum time for 9945216 minutes

Maximum frequency for consultant codes (99451, 99446-99449)No more than once per 7 days (cumulative time allowed)

Maximum frequency for 99452No more than once per 14 days per patient

Policy Background and Scope

This policy applies to consultation and interprofessional consultation services for behavioral health benefits administered by Optum, including OptumHealth Behavioral Solutions of California. It governs claims submitted on the CMS-1500 (or electronic equivalent) and applies to Commercial, Medicare, and Individual Exchange plans, for both network and non-network physicians and other qualified health care professionals whose behavioral health benefits are administered by Optum. Billing for interprofessional services is limited to practitioners who can independently bill Medicare for E/M services.

Required documentation elements and examples are provided in the policy body, including Q&A guidance and documentation examples that specify the elements to include in the record (for example: date of call, patient identifiers, brief problem statement, pertinent findings, labs/x-rays if applicable, differential diagnosis if applicable, and focused recommendations). The policy also includes a Q&A section explaining how to report the referring entity on the claim (field 17/17b on the CMS-1500) and other documentation expectations.

Defined Terms

Key definitions

Consultation (CPT definition)A type of evaluation and management service provided at the request of another physician or appropriate source to recommend care for a specific condition or to determine whether to accept responsibility for ongoing management of the patient's care or a specific condition.

Interprofessional consultationNon-face-to-face assessment and management services provided via telephone, internet, or electronic health record between a consultative physician/QHP and a treating/requesting physician/QHP, documented by verbal and/or written report, billed using CPT codes 99451, 99446-99449, and 99452 per policy criteria.

Policy Updates

November, 2024updated

Updated Applicability and Reimbursement Guidelines sections and added CPT code 99452 to the list of interprofessional consultation codes considered for reimbursement.

March, 2023updated

Modified Reimbursement Guidelines related to interprofessional consultation codes 99451 and 99446-99449 and added Q&A clarifying documentation, time ranges, and reporting expectations.

January, 2023removedLatest