Description
The purpose of this policy is to provide direction on the reimbursement of consultation services.
Definition
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Consultation
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A type of service provided by a physician or other qualified healthcare professional (QHP) whose opinion or advice regarding the evaluation and management (E/M) of a specific clinical problem is requested by another physician or other QHP.
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Policy
At the beginning of 2010, CMS no longer recognized the outpatient and inpatient consultation codes as valid codes and therefore, the codes were not reimbursed. Following these same CMS guidelines, Blue Cross Blue Shield of North Dakota (BCBSND) will not reimburse these consultation codes.
These services include the following procedure codes:
- Outpatient consultation: 99242, 99243, 99244, 99245
- Inpatient consultations: 99252, 99253, 99254, 99255
Consultation services should be reported with an appropriate outpatient or inpatient E/M code representing the location where the visit occurred and the level of complexity of the visit performed. Such locations include, but are not limited to, the office or other outpatient setting, the inpatient hospital setting or nursing facility setting.
Physicians and QHPs must follow appropriate medical documentation, based on CPT and BCBSND guidance and communicate the results of the patient’s evaluation to the requesting physician or QHP to support proper coordination of care. The billed E/M code(s) are required to be fully supported in the medical record and/or office notes. Physicians making a referral and physicians accepting a referral need to document the request and provide an evaluation for the patient.
Limitations & 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, payment integrity edits and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
History
Date
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Updates
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11/2/2020
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Created Consultation Services Policy
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9/20/2021
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Updated format
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7/26/2022
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Policy reviewed
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11/21/2022
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Removed codes 99241 and 99251 from policy as these codes are deleted as of 1/1/2023
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11/20/2023
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Annual review of policy completed. Added “payment integrity edits” to Limitations and Exclusions section.
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