Consultation Services Payment

Reimbursement Policy:
Consultation Services Payment

Effective Date:
November 16, 2015

Purpose:
Provide guidelines for the reimbursement of CPT® consultation codes (99241-99245 or 99251-99255) for Medicare Advantage products.

Scope:
Medicare Advantage Products Only

Policy:
Horizon BCBSNJ shall not reimburse physicians for CPT consultation codes (99241-99245 or 99251-99255).

Horizon BCBSNJ will consider services when resubmitted with the recommended new or established evaluation and management code (99201-99205; 99281-99285; 99221-99223, 99304-99306) as per CMS guidelines for physicians who see patients in the office or an outpatient/inpatient setting.

This policy shall apply to participating and non-participating professional providers.

Procedure:
CPT consultation codes (99241-99245 or 99251-99255) shall be denied. The provider will need to resubmit the claim with the appropriate new or established evaluation and management codes (99201-99205; 99281-99285; 99221-99223, 99304-99306).

In denied instances where the provider is participating, there shall be no member liability.

In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Denied Consultation Codes Allowed Consultation Codes
99241 99201, 99211, 99281
99242 99202, 99212, 99282
99243 99203, 99213, 99283
99244 99204, 99214, 99284
99245 99205, 99215, 99285
99251 99221-99223, 99304-99306*
99252 99221-99223, 99304-99306*
99253 99221-99223, 99304-99306*
99254 99221-99223, 99304-99306*
99255 99221-99223, 99304-99306*

* For initial inpatient hospital visits & nursing facility care, the admitting/principal physician will have to append a modifier AI for the consulting physician to receive reimbursement.

The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Limitations and Exclusions:

  • While reimbursement is considered, payment determination is subject to, but not limited to:
  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

CPT is a registered trademark of the American Medical Association

Policy 088_v1.0_08012015