Consult Codes: Which Payers Still Pay?
The consult isn't dead… but it depends on who's paying.
One of the most common questions we receive from physicians and practice managers is: "Can we still bill consult codes?"
The answer is one of the most frustrating phrases in healthcare: it depends.
Many providers assume consult codes disappeared years ago. Others bill them to every payer. Both approaches can cost your practice money.
The reality is that while Medicare stopped recognizing most consultation codes in 2010, many commercial insurance carriers continue to reimburse them. Knowing the difference can have a significant impact on your revenue.
First, What Is a Consultation?
A consultation is not simply seeing a new patient. A consultation occurs when another qualified healthcare professional requests your opinion or advice regarding the evaluation or management of a specific problem.
Three elements must generally be present:
- A request — another physician or qualified healthcare professional requests your opinion.
- An evaluation — you evaluate the patient and provide your recommendations.
- A report — you communicate your findings back to the requesting provider.
Without these elements, the service generally does not qualify as a consultation.
What Happened to Medicare?
In 2010, the Centers for Medicare & Medicaid Services (CMS) eliminated payment for:
- Office consultations (99242–99245)
- Inpatient consultations (99252–99255)
Instead, Medicare instructs physicians to report new patient E/M codes, established patient E/M codes, initial hospital care codes, or initial nursing facility codes — depending on the setting and circumstances.
That means if your patient has traditional Medicare, consultation codes are generally not payable.
So Why Do We Still See Consult Codes?
Because many commercial insurance companies never adopted Medicare's policy. Several commercial payers continue to recognize consultation codes if their billing guidelines are met.
Examples may include certain plans offered by:
- Blue Cross Blue Shield organizations
- Aetna
- Cigna
- UnitedHealthcare
- Regional commercial health plans
However, policies vary by state, plan type, employer group, and even individual contracts. One Blue Cross plan may reimburse consult codes while another does not.
That's why relying on assumptions can create denials — or missed revenue opportunities.
What About Medicaid?
Medicaid is administered by each state. Some state Medicaid programs recognize consult codes. Others follow Medicare and do not.
If your practice participates in Medicaid, it is important to verify your state's billing policies rather than assuming they mirror Medicare.
The Biggest Mistake We See
Many practices build one billing workflow and use it for every payer. For example, a physician performs a legitimate consultation, and the billing system automatically converts every consult into a new patient visit because "Medicare doesn't pay consults."
The problem? Your commercial payer may have reimbursed the consultation code at a higher rate. Over time, those missed opportunities can add up.
The opposite mistake is just as common. Practices bill consultation codes to every payer and experience avoidable denials because Medicare and certain commercial plans no longer recognize them.
Consultation vs. Referral
These terms are often confused.
A consultation asks: "What do you recommend?"
A referral says: "Please take over the patient's care."
If another physician transfers responsibility for managing the patient's condition to you, the service is generally not considered a consultation. The distinction matters because consultation codes are intended for requests for opinion — not transfers of care.
Documentation Matters
Even if the payer recognizes consultation codes, documentation must support the service. Your record should clearly identify:
- Who requested the consultation
- Why the consultation was requested
- Your evaluation and recommendations
- Communication back to the requesting provider
If the documentation doesn't support these elements, the payer may downcode or deny the claim.
Questions Every Practice Should Ask
Before submitting a consultation code, ask:
- Does this payer recognize consultation codes?
- Was there a documented request for my opinion?
- Am I providing advice — or assuming ongoing management?
- Was my recommendation communicated back to the requesting provider?
- Does my documentation clearly support a consultation?
If the answer to any of these questions is "no," another E/M code may be more appropriate.
How Practices Can Avoid Lost Revenue
The best-performing organizations don't guess. They maintain payer-specific billing rules that identify:
- Which payers recognize consultation codes
- Which payers follow Medicare rules
- Documentation requirements for each payer
- State Medicaid variations
- Internal coding workflows to prevent automatic miscoding
Regular education for providers, coders, and billing staff is equally important because payer policies continue to evolve.
The Bottom Line
Consultation codes didn't disappear. Medicare stopped paying them. Many commercial payers did not.
Assuming every payer follows Medicare can leave revenue on the table. Assuming every payer still pays consult codes can lead to denials.
The key is understanding each payer's policy, documenting the consultation appropriately, and coding the service based on both the clinical encounter and the payer's billing requirements.
Because in today's healthcare environment, knowing who is paying is just as important as knowing what to bill.
One patient. One consultation. Two different payers. Two very different coding outcomes.
