Guide

Consult codes in 2026: who still pays and who crosswalks

Summary

It depends on the payer, and the answer changes over time — CPT still defines and the AMA still maintains consultation codes 99242-99245, but whether a specific payer's current fee schedule recognizes them is not something worth assuming from memory or a colleague's practice. Check that payer's own published policy or a claim-status inquiry before billing at volume, and have the standard office-visit crosswalk ready for the payers that don't.

By Gale Editorial · Updated 2026-07-26. Every figure cited to a dated source. How we write.

Do any payers still pay consult codes 99242-99245?

It depends on the payer, and it is not a fact that holds still — CPT continues to define outpatient consultation codes 99242 through 99245, and the AMA continues to maintain and update CPT annually, so the codes themselves are not retired 1. Whether any specific payer's current fee schedule recognizes them for payment is a separate, payer-by-payer question, and treating it as settled because it was true somewhere, sometime, is how a clean claim turns into an unexpected denial.

For Medicare specifically, the Physician Fee Schedule Search tool publishes a payment indicator for every code, showing whether it is currently payable, priced only by the contractor, bundled into another service, or not recognized at all — checking that indicator directly answers the Medicare half of the question without relying on secondhand billing guidance 2.

Why "still pays" is the wrong question to build a workflow on

A payer's recognition of a code family is a policy choice that can change, and consult codes are exactly the kind of code where assuming continuity goes wrong. The same discipline applies to other unevenly recognized families — after-hours add-ons: which payers recognize them is a similar case — and the fix is identical: check the specific payer's own current, published policy rather than extrapolating from one payer to all of them.

A billing habit built on "payer X used to pay this" ages badly, and a habit built on "payers generally pay this" was never accurate to begin with, since payer policy on consult codes has never been uniform across commercial, Medicare, and Medicaid lines.

Checking Medicare's current position before you bill

The Physician Fee Schedule Search tool is the fastest, most current way to see whether Medicare's fee schedule assigns a payable amount to 99242-99245 in a given year, rather than relying on what a prior employer's system did or a training document said 2. The payment indicator tells you plainly whether the code carries an active rate, and that answer is worth re-checking at the start of each year rather than assumed to be stable.

Building a one-time lookup into the annual fee-schedule update a practice already has to do for every other code — rather than treating consult codes as a special case to remember separately — folds this into a habit that already exists instead of adding a new one.

Checking a commercial or other payer's own policy

For a payer other than Medicare, the definitive answer lives in that payer's own published fee schedule or medical policy, not in what another practice reports informally. Once a claim is actually submitted, a standardized claim-status inquiry — the 276/277 transaction that CAQH CORE's operating rules require payers to support in a consistent format — is the fastest way to confirm what happened to that specific claim rather than waiting on a phone queue 3.

For a solo practice billing consult codes to more than one payer, keeping a short, current reference of which payers on the panel actually recognize 99242-99245 — checked and dated, not assumed — turns this from a recurring guessing game into a five-minute lookup before the claim goes out. Sharing that reference with front-desk staff, so the scheduling and coding decision happens before the visit rather than after the claim is built, keeps the check from becoming a bottleneck at billing time.

The crosswalk: what to bill when a payer doesn't recognize it

When a payer's policy does not recognize the consult codes, the standard alternative is the ordinary new-patient or established-patient office visit code, leveled by medical decision making or by total time under the same 2021 framework that governs every other office E/M visit 4. That framework — covered in full in the mechanics of e-m-coding — applies identically whether the visit began as a requested consultation or an ordinary referral; what changes is only which code family captures it.

Documenting the visit for MDM or time from the start, rather than only after a consult-code denial arrives, means the crosswalk is a code change, not a scramble to reconstruct the note's support for a different code family after the fact.

If you bill one anyway and it comes back different or denied

When a submitted consultation code is denied, downcoded, or redirected, the Claim Adjustment Reason Code on the remittance states why the payer treated the claim differently than billed — the standard, X12-maintained code list every payer uses for this purpose 5. Reading the CARC first, rather than resubmitting the same code again, tells you whether the payer's answer is "not covered," "crosswalk to E/M," or something else entirely.

The Remittance Advice Remark Code riding alongside the CARC often adds the specific detail — which code the payer expected instead, or which policy governs — supplying context the CARC alone doesn't carry 6. Between the two, most consult-code remittances explain themselves well enough to correct and resubmit without a phone call.

Keeping this current, not memorized

Because cpt is copyrighted and revised by the AMA on an annual cycle, the safest habit for any code whose payer recognition is inconsistent — consult codes chief among them — is re-checking the current CPT definition and each contracted payer's current policy at the start of every year, not relying on what was true when a biller first learned the rule 1. A code family this uneven rewards the practice that checks over the practice that remembers.

For a practice of one without a coder cross-checking this in the background, building that annual check into the same calendar reminder used for the fee schedule update is the low-effort way to keep consult-code billing decisions current instead of inherited from whichever year they were first learned. That single habit does more to keep a solo practice's consult-code decisions accurate than any rule of thumb passed between practices ever will.

Common questions

Check the payment indicator for those codes in CMS's Physician Fee Schedule Search tool for the current year rather than assuming an answer from memory or a prior job. That tool shows directly whether a code currently carries a payable Medicare rate, and it's worth re-checking annually since fee schedule content updates every year.

Check that payer's own published fee schedule or medical policy directly — payer recognition of consultation codes is not uniform, and one payer's policy tells you nothing reliable about another's. Once a claim is submitted, a standardized 276/277 claim-status inquiry confirms what actually happened to it.

The standard new-patient or established-patient office visit code, leveled by medical decision making or total time under the 2021 E/M framework — the same framework every other office visit uses. Documenting the visit to support that level from the start avoids a scramble to reconstruct support for a different code after a denial.

Read the Claim Adjustment Reason Code on the remittance first — it states why the payer processed the claim differently than billed. The accompanying Remittance Advice Remark Code often adds specifics, such as which code the payer expected instead, which is usually enough to correct and resubmit without a phone call.

At least annually. CPT is revised by the AMA every year, and payer policies on unevenly recognized code families like consultation codes change independently of that. Folding a consult-code check into the same annual review a practice already runs for its fee schedule keeps the answer current instead of inherited from an earlier year.

Run your practice on Gale

The software is free. Gale earns one flat 3.5% all-in per paid transaction — only on transactions that actually pay. No subscription, no setup fee, no network cut.

Start or manage a practice →

References

  1. 1.American Medical Association (2026). CPT® (Current Procedural Terminology). American Medical Association (AMA). link ✓That CPT, including the consultation codes, is maintained by the AMA CPT Editorial Panel and updated annually, used here to explain that the codes themselves remain defined even though individual payers' recognition of them varies and changes.
  2. 2.Centers for Medicare & Medicaid Services (2026). Physician Fee Schedule Search. Centers for Medicare & Medicaid Services (CMS). link ✓That CMS publishes a public Physician Fee Schedule look-up tool showing the current national and locality payment amount and payment indicator for any code, used here as the method for checking whether Medicare currently pays 99242-99245 rather than assuming from memory.
  3. 3.CAQH (2026). CAQH CORE Operating Rules. CAQH CORE. link ✓That CAQH CORE operating rules standardize the claim-status (276/277) transaction payers must support, used here as the method for confirming what happened to a specific submitted claim rather than waiting on a payer phone line.
  4. 4.American Medical Association (2023). CPT evaluation and management (E/M) revisions. American Medical Association (AMA). link ✓That the AMA's 2021 E/M revisions set office and outpatient visit levels by medical decision making or total time, used here to describe the standard office-visit crosswalk when a payer does not recognize a consultation code.
  5. 5.X12 (2026). Claim Adjustment Reason Codes. X12. link ✓That CARCs are the standard X12 code list explaining why a claim or service line was paid differently than billed, used here to explain reading the remittance before resubmitting a denied or redirected consult-code claim.
  6. 6.X12 (2026). Remittance Advice Remark Codes. X12. link ✓That RARCs supply the supplemental explanation beyond the CARC on a remittance, maintained by X12 as a public list, used here as the read that can specify which code a payer expected instead of the billed consultation code.

https://www.gale.care/for-providers/em-consult-codes-dead · 6 sources. Competitor details are cited to dated public sources and maintained as they change; figures are estimates, not commitments. Synthetic demonstration.

← Back to for providers

Findability, by specialty

How practices like yours get found in local search and AI answers — the honest playbook, per specialty.

SEO for private practices · SEO for AI search / answer engines (all verticals)