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.

Notification

Consultation Services

Notification Issue Date:

Effective August 1, 2018,

Independence will update its reimbursement position on the Current Procedural Terminology (CPT®) codes used to report consultation services provided to Independence’s Medicare Advantage HMO and PPO members. Based on a review of the Centers for Medicare & Medicaid Services (CMS) standards, Independence will no longer recognize the following CPT consultation codes as eligible for reimbursement:

99241, 99251, 99242, 99252, 99243, 99253, 99244, 99254, 99245, 99255

When rendering services to Independence Medicare Advantage HMO and PPO members, all providers should report the code(s) representing the appropriate level of evaluation and management (E&M) service in lieu of consultation codes.

This change to our reimbursement position for CPT consultation codes used to report consultation services also affects our Medicare Advantage policies on preoperative anesthesia consultations and Modifier 25 as outlined below.

Changes to the following Medicare Advantage policies will also go into effect

August 1, 2018:

#MA01.002: Preoperative Consultations Performed by Providers in Anesthesia Specialties: This policy will be archived, and anesthesia providers should report the CPT codes that represent the most appropriate level of E&M service.
#MA03.003d: Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: The following CPT codes will be removed from this policy and will no longer be eligible for reimbursement: 99241, 99242, 99243, 99244, and 99245

Title:

Consultation Services

Policy #:

MA00.049a

Policy

Current Procedural Terminology (CPT) consultation codes are not eligible for reimbursement. The appropriate level of Evaluation and Management (E&M) service should be reported.

For a list of CPT consultation codes, refer to the Coding Table in this policy.

Guidelines

This policy is consistent with Medicare’s coverage determination.

Description

A consultation is a type of service provided by a physician or other qualified healthcare professional whose opinion or advice regarding the evaluation and management (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 April 6, 2022.

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 April 4, 2022.

Coding

CPT Procedure Code Number(s)

99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

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:

6/6/2022

Version Issued Date:

6/6/2022

Version Reissued Date: