Update to Evaluation and Management Services Reimbursement Policy for Consultation Codes – Commercial

Beginning November 1, 2022, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will not allow separate reimbursement for office/outpatient or inpatient consultation codes. This change is in alignment with a 2010 decision by the Centers for Medicare & Medicaid Services (CMS) and will enable providers to represent performed services more accurately using the newer Evaluation and Management (E&M) leveling criteria. 

Office/outpatient consultation codes for CPT® codes 99241–99245, and inpatient consultation codes for CPT® codes 99251–99255 will not be recognized for separate reimbursement. 

Consultation services should be reported with an appropriate office/outpatient or inpatient E&M code representing the location where the visit occurred and the level of complexity of the visit performed, such as CPT® code ranges 99221-99223, 99304-99306, and 99202-99215. 

For more information, please refer to our Evaluation and Management Services policy. 

Please note:  

No changes were made to interprofessional CPT® codes 99446, 99447, 99448, 99449, 99451, 99452. These are considered incidental and are not separately reimbursed. 

For Telehealth consultation codes which qualify for reimbursement, please refer to the Commercial Telehealth Reimbursement Policy. 

This change applies to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states, or to Blue Cross NC Medicare Advantage or Managed Care Medicaid members.