Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Title:

Reimbursement for Certain Evaluation and Management (E/M) Services

Policy #:

MA00.049c

Policy

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p.

The intent of this policy is to communicate services that are not eligible for reimbursement consideration by the Company, as outlined below.

NOT ELIGIBLE FOR REIMBURSEMENT

CONSULTATION CODES

Current Procedural Terminology (CPT) consultation codes are not eligible for reimbursement consideration by the Company. The appropriate level Evaluation and Management (E/M) service should be reported. Participating professional providers may not bill members for these services.

E/M SERVICES REPORTED BY RADIOLOGY OR NUCLEAR MEDICINE SPECIALTY PROVIDERS

E/M services reported by Radiology and Nuclear Medicine specialty professional providers are not eligible for reimbursement consideration by the Company. This does not apply to Interventional Radiology providers. Participating professional providers may not bill members for these services.

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

E/M SERVICES REPORTED WITH PULMONARY FUNCTION TESTS

The Company covers E/M services; however, they are not eligible for separate reimbursement consideration when reported in conjunction with pulmonary function tests by the same provider, for the same member, on the same date, unless the E/M service is a significant separately identifiable service. Participating professional providers may not bill members for these services.

E/M SERVICES REPORTED WITH INJECTION/INFUSION ADMINISTRATION SERVICES

The Company covers E/M services; however, they are not eligible for separate reimbursement consideration when reported in conjunction with injection/infusion administration services by the same provider, for the same member, on the same date, unless the E/M service is a significant separately identifiable service. Participating professional providers may not bill members for these services.

VENIPUNCTURE SERVICES REPORTED WITH E/M SERVICES

The Company covers venipuncture services; however, they are not eligible for separate reimbursement consideration when reported in conjunction with E/M services by the same provider, for the same member, on the same date. Participating professional providers may not bill members for these services.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

Description

Evaluation and Management (E/M) services are a category of medical services used to describe physician or other qualified healthcare professional visits that involve assessing and managing an individual's health. The Company has established claims processing guidelines for the reimbursement of certain E/M services.

The performance of diagnostic tests or procedures for which specific codes are available may be reported separately, in addition to the appropriate E/M code. The physician or other qualified healthcare professional may need to indicate that on the day a procedure or service code was performed, the individual’s condition required a significant separately identifiable E/M service. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service.

A consultation is a type of service provided by a physician or other qualified healthcare professional whose opinion or advice regarding the E/M of a specific clinical problem is requested by another physician or other qualified healthcare professional.

References

Centers for Medicare and Medicaid Services [CMS]. Evaluation and Management Services Guide. Medical Learning Network Booklet: MLN 006764. 2/2021. Available at: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf. Accessed November 12, 2025.

Center for Medicare and Medicaid Services [CMS]. Medicare Claims Processing Manual: Chapter 12 - Physicians/Nonphysicians Practitioners. 07/25/2019. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed November 12, 2025.

American Medical Association (AMA). CPT Professional Edition: Current Procedural Terminology (Current Procedural Terminology, Professional Edition) 2025 Edition.

Coding

CPT Procedure Code Number(s)

REFER TO CPT DEFINED EVALUATION AND MANAGEMENT, INCLUDING CONSULTATION SERVICES, AND VENIPUNCTURE CODES.

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

REFER TO HCPCS DEFINED EVALUATION AND MANAGEMENT AND VENIPUNCTURE CODES.

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA00.049c:

03/02/2026

This version of the policy will become effective 03/02/2026.

The policy title has been changed from "Consultation Services" to "Reimbursement for Certain Evaluation and Management (E/M) Services." This policy is being updated to communicate the Company's reimbursement position for certain E/M and venipuncture services that are considered not eligible for reimbursement as outlined in this policy.

Revisions From MA00.049b:

05/15/2024	This policy has been reissued in accordance with the Company's annual review process.
01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.

01/01/2023

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/20223.

The following procedure codes had narrative revisions:

99242, 99243, 99244, 99245, 99252, 99253, 99254, and 99255

The following procedure codes were removed from the policy:

99241 and 99251

Revisions From MA00.049a:

06/06/2022

This version of the policy will become effective 6/06/2022. The intent of this policy remains unchanged, but the policy has been updated to further clarify current benefits.

Revisions From MA00.049:

10/07/2020	This version of the policy will become effective 10/07/2020. The policy has been reviewed and reissued to communicate the Company’s continuing position on Consultation Services.
08/01/2018	This is a new policy that will be effective 08/01/2018. This policy has been created to indicate that Current Procedural Terminology (CPT) consultation codes 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255 are not eligible for reimbursement. The appropriate level of evaluation and management (E&M) service should be reported.

Version Effective Date:

3/2/2026

Version Issued Date: