CurrentPremera BluecrossPolicy N/A

Consultation Code Services (Consultation CPT code reimbursement limits)

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

Policy Summary

PayerPremera Bluecross

PolicyConsultation Code Services (Consultation CPT code reimbursement limits)

Policy CodePolicy N/A

Change TypeClarified reimbursement criteriaAlaska exceptionCPT updates

Effective DateN/A

Next Review DateN/A

Key ActionReport consultation services with an appropriate E/M code unless the provider is contracted on a 2009-or-earlier RBRVS fee agreement.

SourceLink

POLICY UPDATE CHANGES

Policy statement clarified that 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.

Codes 99241 and 99251 deleted and code descriptions updated to reflect CPT revisions effective January 1, 2023.

2009-or-earlierRBRVS contract vintage required

Dec 11, 2023Alaska DOS cutoff

99242-99245,99252-99255Consultation CPTs referenced

AnnualReview cadence

Consultation Reimbursement Eligibility

Consultation code reimbursement criteria

Reimbursement eligibility and exceptions for consultation codes on professional claims.

Consultation codes (CPT codes 99242-99245 and 99252-99255) are eligible for reimbursement only when billed by providers contracted on a 2009 or earlier Resource Based Relative Value System (RBRVS) fee agreement.

Providers not meeting the 2009-or-earlier RBRVS contract requirement: consultation services submitted with consultation CPT codes are not eligible for reimbursement; such services 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.

Time‑based code selection thresholds (when using total time on the date of the encounter): 99242 = 20 minutes; 99243 = 30 minutes; 99244 = 40 minutes; 99245 = 55 minutes; 99252 = 35 minutes; 99253 = 45 minutes; 99254 = 60 minutes; 99255 = 75 minutes (or greater).

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

Policy Summary

PayerPremera Bluecross

PolicyConsultation Code Services (Consultation CPT code reimbursement limits)

Policy CodePolicy N/A

Change TypeClarified reimbursement criteriaAlaska exceptionCPT updates

Effective DateN/A

Next Review DateN/A

Key ActionReport consultation services with an appropriate E/M code unless the provider is contracted on a 2009-or-earlier RBRVS fee agreement.

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.

Consultation CPT Codes and Time Thresholds

Consultation CPT codes referencedCPT

99242	Office or other outpatient consultation — 20 minutes (when using time)
99243	Office or other outpatient consultation — 30 minutes (when using time)
99244	Office or other outpatient consultation — 40 minutes (when using time)
99245	Office or other outpatient consultation — 55 minutes (when using time)
99252	Inpatient or observation consultation — 35 minutes (when using time)
99253	Inpatient or observation consultation — 45 minutes (when using time)
99254	Inpatient or observation consultation — 60 minutes (when using time)
99255	Inpatient or observation consultation — 75+ minutes (when using time)

Time thresholds for consultation code selection (minutes)

9924220 minutes (when using total time on the date of the encounter)

9924330 minutes (when using total time on the date of the encounter)

9924440 minutes (when using total time on the date of the encounter)

9924555 minutes (when using total time on the date of the encounter)

9925235 minutes (when using total time on the date of the encounter)

9925345 minutes (when using total time on the date of the encounter)

9925460 minutes (when using total time on the date of the encounter)

9925575+ minutes (when using total time on the date of the encounter)

Billing Restrictions and Provider Requirements

Billing Rule

Consultation code billing restriction for RBRVS contract vintage

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. Providers not contracted on a 2009-or-earlier RBRVS fee schedule must report consultation services with an appropriate E/M code (e.g., office visit, hospital care, nursing facility care, or home visit) to be considered for reimbursement.

Consultation codes submitted by all other providers are not eligible for reimbursement.
Consultation services previously reported with one of the consultation codes must be reported with an appropriate E&M procedure code to be considered for reimbursement.

OpenPayer

Consultation Code Services (Consultation CPT code reimbursement limits)

Consultation Reimbursement Eligibility

Consultation CPT Codes and Time Thresholds

Billing Restrictions and Provider Requirements

Key Terms and Contract Vintage