Coverage of Consultations

Inpatient and outpatient office consultations (Current Procedural Terminology procedure codes 99241-99255) are covered by Wisconsin Medicaid when provided to a recipient at the request of another provider and when medically necessary and appropriate. If an additional request for an opinion or advice regarding the same or a new problem for the same recipient is received from a second provider and documented in the medical record, the consultation procedure codes may be used again by the consulting provider. Any qualified provider may request a consultation.

If the consulting provider assumes responsibility for management of a portion or all of the recipient’s medical condition, the use of consultation procedure codes is no longer appropriate by that provider. The provider should then use the appropriate level evaluation and management (E&M) code for the place of service.

For a “consultation” initiated by the recipient or recipient’s family (e.g., a request for a second surgical opinion) and not requested by a provider, the “consulting” provider should use the appropriate level E&M code, rather than consultation procedure codes.

Covered Consultations

An E&M consultation requires face-to-face contact between the consultant and the recipient, either in person or via telemedicine, where appropriate. A consultation must always result in a written report that becomes a part of the recipient’s permanent medical record.

Claim Submission

Claims for consultations must include the referring provider’s name and Medicaid provider number.

Information Regarding Medicaid HMOs

This Wisconsin Medicaid and BadgerCare Update contains Medicaid fee-for-service policy and applies to providers of services to recipients on fee-for-service Medicaid only. For Medicaid HMO or managed care policy, contact the appropriate managed care organization. Wisconsin Medicaid HMOs are required to provide at least the same benefits as those provided under fee-for-service arrangements.