CurrentUnitedHealthcarePolicy 2025R0129A

CMS-1500 Consultation Services Reimbursement

Defines UnitedHealthcare reimbursement stance and submission requirements for consultation and related E/M services billed on the CMS-1500 (or electronic equivalent) for Commercial and Individual Exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyCMS-1500 Consultation Services Reimbursement

Policy CodePolicy 2025R0129A

Change TypeAdministrative revision (no material clinical changes)

Effective Date

Next Review Date

Key ActionDo not bill CPT consultation codes 99242-99245 or 99252-99255 for dates of service on/after the policy effective thresholds; submit interprofessional consultation codes (99451-99452, 99446-99449, G9037) with required documentation and identify the requesting provider on the claim.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99242-99245, 99252-99255CPT consultation codes excluded

G0406-G0408, G0425-G0427, G0508-G0509Telehealth consultation codes

99451-99452, 99446-99449, G9037Interprofessional consults considered

YesDocumentation required

All products/providers

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Coverage and Reimbursement Criteria

Consultation reimbursement criteria

Reimbursable consultation-related services and documentation requirements:

Interprofessional consultation codes 99451-99452, 99446-99449 and G9037 are considered for reimbursement when documentation requirements are met.

Documentation must include: a written or verbal request for consult made by an appropriate source; the request documented in the patient’s medical record; the consultant’s opinion documented in the patient’s medical record; and the consultant’s opinion communicated by written report to the requesting physician or other appropriate source.

The requesting physician or other appropriate source must be identified on the claim (NPI in field 17B or name in field 17) or the consultation will be denied.

Telehealth consultation allowance: Telehealth consultation HCPCS codes G0406-G0408, G0425-G0427, and G0508-G0509 are considered for reimbursement when the requesting physician or appropriate source is identified on the claim and the service is billed with a telehealth place of service.

Exclusion - CPT consultation codes: CPT consultation codes 99242-99245 and 99252-99255 are not reimbursed for dates of service on or after June 1, 2019 for certain providers/payment methodologies and for all providers on or after October 1, 2019; when denied, resubmit with an appropriate non-consultation E/M code per 1995/1997 guidelines.

Operational note

Claims must be submitted on the CMS-1500 (or electronic equivalent) with all required fields completed accurately; policy applies to UnitedHealthcare Commercial and Individual Exchange benefit plans.

Consultation and Related E/M Codes

Non-reimbursable CPT consultation codesCPTNot Covered

99242-99245	Office/outpatient consultation codes (not reimbursed for specified dates)
99252-99255	Inpatient consultation codes (not reimbursed for specified dates)

Telehealth consultation HCPCS codes (considered)HCPCSCovered

G0406-G0408	Telehealth inpatient/outpatient consultation codes (considered)
G0425-G0427	Telehealth consultation codes (considered)
G0508-G0509	Telehealth consultation codes (considered)

Interprofessional consultation codes (considered)CPT | HCPCSCovered

99451-99452	Interprofessional consultation codes (considered)
99446-99449	Interprofessional consultation codes (considered)
G9037	Interprofessional consultation code (considered)

Effective dates for non-reimbursement of CPT consultation codes

Effective date (limited providers/payment methodologies)On or after 6/1/2019 — UnitedHealthcare does not reimburse CPT consultation codes 99242-99245 and 99252-99255 for providers whose primary payment methodology is CMS RVUs (2010 or later), percent of charge, and for non‑network providers.

Effective date (all providers)On or after 10/1/2019 — UnitedHealthcare does not reimburse CPT consultation codes 99242-99245 and 99252-99255 for any practice or care provider regardless of fee schedule or payment methodology.

Telehealth modifier exceptionAlthough the CPT consultation codes above are not reimbursed, UnitedHealthcare continues to consider telehealth consultation HCPCS codes (G0406-G0408, G0425-G0427, G0508-G0509) for reimbursement when submission requirements are met.

Resubmission guidanceClaims submitted with non‑reimbursed consultation codes should be resubmitted with an appropriate non‑consultation E/M code per 1995/1997 guidelines when denied.

Provider Submission & Documentation Requirements

Documentation Required

Documentation & submission requirements for reimbursable consultation codes

Documentation required for reimbursable interprofessional consultation codes (99451, 99452, 99446-99449, G9037): Ensure a documented consult request and the consultant's documented opinion are present in the medical record, and that the consultant's opinion is communicated back to the requesting provider.

A written or verbal request for consult must be made by an appropriate source.
The consult request must be documented in the patient's medical record.
The consultant's opinion must be documented in the patient's medical record.
The consultant's opinion must be communicated by written report to the requesting physician or other appropriate source.
The requesting physician or other appropriate source must be identified on the claim (include NPI in field 17B when available; otherwise include name in field 17).
Claims missing identification of the requesting entity will be denied.
Telehealth teleconsults: bill with appropriate telehealth place of service and include requesting entity on the claim.

Definitions and Sources

Consultation (as used historically in CPT)

Historic CPT definitionA consultation is an E/M service provided at the request of another physician or appropriate source to recommend care for a specific condition or problem, or to determine whether to accept responsibility for ongoing management of the patient’s care or a specific condition.

Context of usePrior to 6/1/2019 UnitedHealthcare reimbursed consultation services in alignment with the AMA CPT consultation description.

Transfer of care noteCPT consultation services (and telehealth HCPCS consultation services) should only be reported when a transfer of care has not occurred — a transfer occurs when the requesting clinician expects the consultant to assume responsibility for ongoing care.

Appropriate source — citation and submission guidance

Who qualifies as an appropriate sourceThe requesting physician or other qualified source must be identified on the claim; if an NPI exists it should be in field 17B of the CMS‑1500, or the requester’s name should be in field 17.