Consultation Pricing Guidelines Form

PRICING GUIDELINES
ORIGINAL EFFECTIVE DATE: 7/1/2019

Changes: Removed 99251-99255 from policy effective 5/1/2022
REVISION DATE: 4/22/2022

Page 1 of 2of 2 CONSULTATION SERVICES PRICING GUIDELINE

Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This pricing guideline must be read in its entirety to determine coverage eligibility, if any. The sections identified as “Description” and “Definitions” define or describe a service, procedure, medical device, or drug and is in no way intended as a statement of medical necessity and/or coverage. The sections identified as “Criteria” and “Pricing criteria” define criteria to determine the appropriate reimbursement, coding, or unit limit of a service, procedure or device according to BCBSAZ coding/pricing guidelines. Pricing guidelines are subject to change as new information becomes available.

Description
Consultation services for a new or established patient.

Definitions Consultation Service: A type of evaluation and management (E/M) service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.

Criteria
This policy applies to physicians and other qualified healthcare professionals.

Pricing Criteria
For claims received on or after 7/1/2019, consultation services must be reported using the appropriate CPT® code from the E/M 99201-99215 range. Select the code that best describes the place of service, complexity, and whether the patient is new or established to the physician.
• For claims received on or after 7/1/2019 CPT codes 99241-99245 are not eligible for reimbursement.
• For claims received between 7/1/2019 and 5/1/2022 CPT codes 99251-99255 are not eligible for reimbursement.

Coding Referenced 99241-99245, 99251-99255, 99201-99215

Resources

1. American Medical Association; Current Procedural Terminology (CPT®)
2. Centers for Medicare & Medicaid Services (CMS®)

PRICING GUIDELINES
ORIGINAL EFFECTIVE DATE: 7/1/2019

Changes: Removed 99251-99255 from policy effective 5/1/2022
REVISION DATE: 4/22/2022

Page 2 of 2of 2

CONSULTATION SERVICES PRICING GUIDELINE (cont.)

American Medical Association CPT Copyright Statement CPT copyright American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. Applicable FARS/DFARS restrictions apply to government use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.