Effective April 15, 2020, AmeriHealth will update its reimbursement position on the Current Procedural Terminology (CPT®) codes used to report consultation services provided to AmeriHealth commercial members.
Based on a review of the Centers for Medicare & Medicaid Services (CMS) standards, AmeriHealth has created Claim Payment Policy #00.01.69: Consultation Services, which outlines its reimbursement position on CPT consultation codes. This new policy was posted as a Notification on January 15, 2020, and will go into effect April 15, 2020.
The policy states that AmeriHealth will align with CMS’s position of no longer recognizing the following CPT consultation codes as eligible for reimbursement:
● 99241 ● 99251
● 99242 ● 99252
● 99243 ● 99253
● 99244 ● 99254
● 99245 ● 99255
When rendering services to AmeriHealth commercial members, all providers should report the appropriate level of evaluation and management (E&M) service in lieu of consultation codes.
Affected policies
This change to our reimbursement position for CPT consultation codes used to report consultation services also affects additional Claim Payment Policies as outlined below.
Changes to the following Claim Payment Policies, which were posted as Notifications (unless noted otherwise) on January 15, 2020, will go into effect April 15, 2020:
- #01.00.08: Preoperative Consultations Performed by Providers in Anesthesia Specialties: This policy will be archived, and anesthesia providers should report the CPT codes that represent the most appropriate level of E&M service.
- #03.00.06: Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: The following CPT codes will be removed from this policy and will no longer be eligible for reimbursement:
- 99241, 99242, 99243, 99244, and 99245
- #00.06.02: Preventive Care Services: This update was addressed through News and Announcements on the Medical Policy Portal. The consultation codes will be removed from the pre-procedure consultation for colorectal cancer screening procedures. The providers should report the CPT codes that represent the most appropriate level of E&M service.
- #00.10.42d: Telemedicine and Telehealth Services (AmeriHealth New Jersey): The following CPT consultation codes will be removed from this policy, and the most appropriate level of E&M service should be reported:
- 99241, 99242, 99243, 99244, and 99245
Learn more
To view the Notifications for these policies, visit our Medical Policy Portal.
For questions about this new policy, please review our Reimbursement position for consultation codes (Commercial): Frequently Asked Questions (FAQ), which can also be found on AmeriHealth NaviNet® web portal (NaviNet Open) Plan Central or in the Quick Links section on the right-hand side of this page. The FAQ will be updated as more information becomes available.
If you still have questions after reviewing the FAQ, email us at CommercialConsultCodes@amerihealth.com. Be sure to include your name, contact number, and provider ID number in your email.
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