CurrentPremera BluecrossPolicy N/A

Consultation code services reimbursement

Defines Premera Blue Cross's reimbursement limitations for inpatient and outpatient consultation CPT codes billed on professional claims and which contracted providers these apply to.

Policy Summary

PayerPremera Bluecross

PolicyConsultation code services reimbursement

Policy CodePolicy N/A

Change TypeClarified reimbursement eligibility and Alaska exception

Effective Date

Next Review Date

Key ActionReport consultation services only when billed by providers contracted on a 2009-or-earlier RBRVS fee agreement; otherwise bill an appropriate E&M code for consideration.

SourceLink

POLICY UPDATE CHANGES

Consultation codes, both inpatient and outpatient, are eligible for reimbursement only when billed by providers contracted on a 2009 or earlier RBRVS fee agreement.

Exception for contracted Alaska providers: consultation charges for dates of service prior to December 11, 2023, will be eligible for reimbursement; on or after that date they are subject to the policy criteria.

Interprofessional Telephone/Internet Consultation codes were removed from Medicare 'Status B' and are covered elsewhere (Telehealth Services); codes were updated to reflect CPT changes including deletion of 99241 and 99251 effective 1/1/2023.

2009-or-earlierRBRVS contract requirement for reimbursement of consultation codes

12/11/2023Alaska exception cutoff date for prior reimbursement treatment

99242-99245; 99252-99255Consultation CPT codes enumerated in policy coding section

Annual through 03/12/26Policy review history

Consultation Reimbursement Criteria

Consultation code reimbursement criteria

Policy stance and rules for reimbursement of consultation codes on professional claims:

Consultation codes (inpatient and outpatient) are eligible for reimbursement only when billed by providers contracted on a 2009 or earlier Resource Based Relative Value System (RBRVS) fee agreement; consultation codes billed by all other providers are not eligible for reimbursement.

When consultation services previously reported with one of the consultation codes are billed by a provider not eligible to use consultation codes under this policy, the service must be reported with an appropriate Evaluation and Management (E&M) procedure code (for example: office visit, hospital care, nursing facility care, or home visit) to be considered for reimbursement.

Exception for contracted Alaska providers: consultation charges for dates of service prior to December 11, 2023, will be eligible for reimbursement; consultation charges for dates of service on or after December 11, 2023, will be subject to the policy criteria (i.e., reimbursable only if billed by providers contracted on a 2009-or-earlier RBRVS fee agreement).

Time-based code selection

Policy Summary

PayerPremera Bluecross

PolicyConsultation code services reimbursement

Policy CodePolicy N/A

Change TypeClarified reimbursement eligibility and Alaska exception

Effective Date

Next Review Date

Key ActionReport consultation services only when billed by providers contracted on a 2009-or-earlier RBRVS fee agreement; otherwise bill an appropriate E&M code for consideration.

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.

Applicable CPT Codes and Time Thresholds

Consultation CPT codesCPTCovered

99242	Office or other outpatient consultation — requires a medically appropriate history and/or examination and straightforward medical decision making; when using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
99243	Office or other outpatient consultation — requires a medically appropriate history and/or examination and low level of medical decision making; when using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
99244	Office or other outpatient consultation — requires a medically appropriate history and/or examination and moderate level of medical decision making; when using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
99245	Office or other outpatient consultation — requires a medically appropriate history and/or examination and high level of medical decision making; when using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded.
99252	Inpatient or observation consultation — requires a medically appropriate history and/or examination and straightforward medical decision making; when using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.
99253	Inpatient or observation consultation — requires a medically appropriate history and/or examination and low level of medical decision making; when using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
99254	Inpatient or observation consultation — requires a medically appropriate history and/or examination and moderate level of medical decision making; when using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.
99255	Inpatient or observation consultation — requires a medically appropriate history and/or examination and high level of medical decision making; time threshold as specified in policy (see coding guidelines).

Time thresholds for consultation codes

99242 (outpatient)Office or other outpatient consultation — when using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.

99243 (outpatient)Office or other outpatient consultation — time threshold: 30 minutes when using total time on the date of the encounter.

99244 (outpatient)Office or other outpatient consultation — time threshold: 40 minutes when using total time on the date of the encounter.

99245 (outpatient)Office or other outpatient consultation — time threshold: 55 minutes when using total time on the date of the encounter.

99252 (inpatient)Inpatient or observation consultation — when using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.

99253 (inpatient)Inpatient or observation consultation — time threshold: 45 minutes when using total time on the date of the encounter.

99254 (inpatient)Inpatient or observation consultation — time threshold: 60 minutes when using total time on the date of the encounter.

Reimbursement Eligibility & Billing Rules for Providers

Billing Rule

Reimbursement limited to providers on 2009-or-earlier RBRVS fee agreements

Consultation codes (listed) are eligible for reimbursement only when billed by providers contracted on a 2009 or earlier Resource Based Relative Value System (RBRVS) fee agreement; consultation codes submitted by all other providers are not eligible for reimbursement. Consultation services previously reported with a consultation code must be reported with an appropriate E&M procedure code (for example, an office visit, hospital care, nursing facility care, or home visit code) to be considered for reimbursement.

Applies to inpatient and outpatient consultation CPT codes enumerated in the policy (e.g., 99242–99245; 99252–99255).
If billed by providers without a 2009-or-earlier RBRVS fee agreement, use an appropriate E&M code for consideration of reimbursement.

Definitions and Scope

Consultation codes and reimbursement limitation

Defined consultation CPT codesCovered consultation CPT codes enumerated in policy: 99242, 99243, 99244, 99245 (outpatient) and 99252, 99253, 99254, 99255 (inpatient).

Reimbursement eligibility restrictionConsultation codes (both inpatient and outpatient) are eligible for reimbursement only when billed by providers contracted on a 2009 or earlier RBRVS fee agreement; consultation codes submitted by all other providers are not eligible for reimbursement.

When not reimbursableIf consultation codes are not eligible, services previously reported with consultation codes must be reported with an appropriate E&M procedure code (for example: office visit, hospital care, nursing facility care, or home visit) to be considered for reimbursement.

Alaska exceptionFor contracted Alaska providers: consultation charges for dates of service prior to December 11, 2023, will be eligible for reimbursement; on or after that date they are subject to the policy criteria.