Payment Policy: Physician’s Consultation Services Form

CENTENE
Corporation

Payment Policy: Physician’s Consultation Services
Reference Number: CC.PP.054
Last Review Date: 06/2025

Coding Implications
Revision Log

See Important Reminder at the end of this policy for important regulatory and legal
information.

Policy Overview
To ensure providers bill the correct level of evaluation and management (E&M) CPT® codes
when billing for physician’s consultation services. Furthermore, to encourage providers to bill
consultation services based on 1) where the visit occurred and 2) the complexity of the visit
performed.

The purpose of this policy is to define payment criteria for consultation services to be used in
making payment decisions and administering benefits.

Application
Physician and other qualified health professionals that perform initial E&M services.

Policy Description
The American Medical Association (AMA) Current Procedural Terminology (CPT ®) book
describes a consultation as a type of evaluation and management 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. Consultation codes are
found in the 99242-99255 range of the CPT® code book.

In 2006 the Office of Inspector General (OIG) reported that 75 percent of services billed as
consultations were improperly paid and did not meet correct coding standards. Specifically,
provider documentation did not support that a consultation service had been rendered and in the
case where a consultation service was supported by the documentation, many visits were coded
at the incorrect type or level of service.

In 2011, the Center for Medicare and Medicaid Services (CMS) eliminated the use of
consultation codes for payment of E&M services furnished to fee-for-service Medicare
recipients. The services can still be covered if they are medically necessary using the appropriate
office visit, emergency office visit and initial hospital services codes.

Reimbursement
The Health Plan will reimburse consultation codes at the corresponding E&M visit level. The
provider should bill the E&M code (other than the consultation code) that describes the service
provided.

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