BlueCross BlueShield Reimbursement Change for Consultation Services

Numerous BlueCross BlueShield plans do not currently cover Consultation services; however, several do. BlueCross BlueShield (BCBS) of Illinois is the most recent commercial plan to update its Clinical Payment and Coding Policy for Evaluation and Management Coding (CPC2024) to align with the Centers for Medicare and Medicaid (CMS) policy not to reimburse Consultation service codes 99242-99245 and 99252 – 99255.

Under the revised policy, BCBS of Illinois will no longer reimburse for outpatient or inpatient services billed with the current Consultation CPT codes 99242 -99245 and 99252 -99255. Consultation services should be reported to the appropriate office, outpatient or inpatient evaluation, and management code representing where the visit occurred, as well as the complexity of the visit

performed. Click the link below for more understanding!

http://aem.bcbsil.com/provider/education/education-reference/news/2024/05-28-2024

In addition, BlueCross BlueShield Texas and BlueCross BlueShield of New Mexico have updated their clinical policies for evaluation and management coding for Consultations, effective November 18, 2024, to reflect the same change. Both carriers instruct providers to report the appropriate office, outpatient, or inpatient evaluation and management code representing where the visit occurred and the complexity of the visit performed. 

Stay tuned! There is currently no national BlueCross BlueShield policy regarding Consultation services. KZA does anticipate, however, that they may implement a national policy for submitting the non-consultative E/M code that describes the service, like UnitedHealth and Cigna’s policies.

What steps do you need to take? If you report Consultation services, ensure your physicians and staff know specific payor policies relevant to your practice.