CurrentUnitedHealthcarePolicy 2025R0129B

REIMBURSEMENT POLICY CMS-1500

Defines UnitedHealthcare Community Plan reimbursement policy for consultation E/M codes billed on CMS-1500 (and when specified UB04) and describes documentation and claim requirements for Medicaid members.

Policy Summary

PayerUnitedHealthcare

PolicyREIMBURSEMENT POLICY CMS-1500

Policy CodePolicy 2025R0129B

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionIdentify the requesting or referring provider (NPI in CMS-1500 field 17B or name in field 17) on the claim for Medicaid members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99242-99245, 99252-99255Codes discussed

1 per admissionInpatient limit

Referrer ID requiredMedicaid requirement

CMS-1500 (+UB04)Form applicability

AZ, MO, INState exceptions

Consultation Reimbursement Criteria

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Consultation reimbursement criteria

Covered when ALL of the following are met:

ALL of the following

A requesting or referring provider or other appropriate source is identified on the claim (if an NPI exists it should be in CMS-1500 field 17B; if no NPI, the name should be in field 17).
There is a written or verbal request for the consultation made by an appropriate source, and that request is documented in the patient’s medical record.
The consultant’s opinion is documented in the patient’s medical record and communicated by written report to the requesting provider or other appropriate source.
Services initiated by the patient or family and not requested by an appropriate source must not be reported with consultation codes (use appropriate non-consultation E/M codes instead).
Only one inpatient consultation (CPT 99252-99255) should be reported by a consultant per admission; subsequent E/M services during the same admission should be reported using non-consultation E/M codes.

Applicable Consultation Codes and Limits

Consultation codes discussedmixed

99242-99245	CPT consultation codes (office/outpatient)
99252-99255	CPT inpatient consultation codes
G0406-G0408	HCPCS consultation codes
G0425-G0427	HCPCS consultation codes

Inpatient consultation per admission — billing limit (inv-03)

LimitOnly one inpatient consultation (CPT 99252-99255) should be reported by a consultant per admission.

Subsequent servicesE/M services after the initial inpatient consultation during the same admission should be reported using non‑consultation E/M codes.

Applicable codesCPT 99252-99255 (inpatient consultation codes).

Claim Submission, Documentation, and Denial Risks

Documentation Required

Consultation documentation requirements

A request for a consultation must come from an appropriate source (for example: physician, physician assistant, nurse practitioner, psychologist, social worker). The request must be documented in the patient's medical record and the consultant's opinion must be documented. The consultant's opinion must be communicated by written report to the requesting physician or other appropriate source.

Request must be documented in the patient's medical record
Consultant's opinion must be documented in the patient's medical record
Consultant's opinion must be communicated by written report to the requesting physician or appropriate source
Appropriate sources include physicians, physician assistants, nurse practitioners, psychologists, social workers

Note

Claim submission identification

For UnitedHealthcare Community Plan Medicaid members, the requesting or referring provider or appropriate source must be identified on the claim (CMS-1500 field 17/17B or electronic equivalent). If the requesting entity has an NPI, include it in field 17B; if no NPI, include the name in field 17.

Include requesting/referring provider NPI in CMS-1500 field 17B when available
If no NPI, include requesting/referring provider name in field 17
Complete all claim fields with valid, accurate information

Denial Risk

Denial risk for missing referrer

If the requesting or referring entity is not identified on the claim for a Medicaid member, the consultation service will be denied because it does not meet AMA reporting requirements.

A denied consultation may be resubmitted with an appropriate non-consultation E/M code if consultation criteria are not met
Only one inpatient consultation (99252-99255) should be reported by a consultant per admission; subsequent E/M services during the same admission should use non-consultation E/M codes

Key Definitions

Consultation Service — definition (inv-07)

DefinitionA consultation is an evaluation and management (E/M) 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 or a specific condition.

Request requirementA written or verbal request for the consult must be made by an appropriate source and documented in the patient’s medical record.

Documentation and communicationThe consultant’s opinion must be documented in the medical record and communicated by written report to the requesting physician or other appropriate source.

Appropriate source — who may request a consultation (inv-08)

Who qualifiesAppropriate sources include physicians, physician assistants, nurse practitioners, psychologists, social workers, etc.

Who does not qualifyThe patient and the patient’s family are not considered appropriate sources for reporting a consultation code.

Claim reporting noteIf a consultation code is denied because an appropriate referring entity is not identified, services may be submitted or resubmitted with an appropriate non‑consultation E/M code.