Consultation Services Payment

Effective Date: September 1, 2021

Purpose:
This policy provides changes on how Horizon NJ Health will reimburse outpatient Evaluation and Management (E&M) consultation services. This policy only applies to professional providers.

Scope:
Products included:

  • NJ FamilyCare/Medicaid Plan
  • Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

  • Consultation Service: Encounters where another qualified clinician's advice or opinion regarding diagnosis and treatment or determination to accept transfer of care of a patient is rendered at the request of the primary treating provider.

Policy:
For dates of service beginning on September 1, 2021 and thereafter, Horizon NJ Health will deny outpatient consultation services, CPT codes 99241-99245. Instead of billing for consultation codes, providers must use the appropriate evaluation and management code from range 99202-99215, in accordance with the chart below, depending on the complexity of the visit and whether the patient is a new or established patient to that physician.

Level

Consultation Code

E/M Code Options to Use

1

99241

99202, 99211

2

99242

99202, 99212

3

99243

99203, 99213

4

99244

99204, 99214

5

99245

99205, 99215

Procedure:
Horizon NJ Health will not consider for reimbursement outpatient CPT consultation codes 99241, 99242, 99243, 99244 and 99245.

Horizon NJ Health will consider for reimbursement claims billed with the appropriate evaluation and management code from range 99202-99215 as described in this policy.

Resources:
Medicare Benefit Policy Manual: Chapter 15 – Covered Medical and Other Health Services
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

Claims Processing Manual: Chapter 12 - Physicians/Nonphysician Practitioners
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf\

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

  • Benefit limitations;
  • The terms of any applicable provider participation agreement;
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
  • Medical necessity; and
  • Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.