Outpatient Consultations

Reimbursement Policy:
Outpatient Consultations

Effective Date:
April 1, 2012

Last Revised Date:
April 15, 2015

Purpose:
Provide guidelines for the reimbursement of office consultations for new or established patient procedure codes 99241-99245.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:
Consultation is a service provided by a physician at the request of another healthcare professional to recommend care for a specific condition or determine whether the consultant will accept responsibility for continued management of the patient’s care for the duration of the condition.

Policy:
Horizon BCBSNJ shall not reimburse claim lines containing an outpatient consultation code (99241-99245) when another outpatient consultation code was billed for the same member, by the same provider, with at least one (1) matching diagnosis within the previous 180 days.

Guidelines for billing for a new or established patient are as follows:

  • The written or verbal request for a consultation may be made by a physician or other healthcare professional and must be documented in the patient’s medical record by either the consulting or requesting healthcare professional.
  • The consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record.
  • A written report must be communicated to the requesting physician or other healthcare professional.

If the consultant assumes responsibility for management of the patient’s condition for which a consultation was provided, the consultant should bill with the appropriate Evaluation and Management (E&M) code.

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.

Procedure:
The consultation code shall deny when there is a finalized claim containing another outpatient consultation code billed for the same member, by the same provider, with at least one (1) matching diagnosis within the previous 180 days.

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.

History:
4/16/2015: Added CPT nomenclature statement.

CPT® is a registered mark of the American Medical Association

Policy 063_v1.0_07152015