What insurance policy changes affect CPT 99242?

There are 8 tracked policy changes affecting CPT 99242, including updates from CareSource, Maryland Medicaid, CareFirst BlueCross BlueShield. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 99242?

Payers that have issued tracked updates for CPT 99242 include: CareSource, Maryland Medicaid, CareFirst BlueCross BlueShield, New Jersey Medicaid, Nevada Medicaid, Medical Mutual of Ohio, Blue Cross of Idaho.

How do I get notified when CPT 99242 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 99242. You will receive a daily digest email whenever a new policy change references this code.

Why do payers change policies for CPT 99242?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

99242 — A doctor provides an initial consultation with a new or established patient in their office or another setting, spending about 20 minutes.: Insurance Policy Changes

99242 Insurance Policy Changes

CPT 99242, in plain terms, covers A doctor provides an initial consultation with a new or established patient in their office or another setting, spending about 20 minutes. CPT 99242 is referenced in 8 tracked payer policy changes from CareSource, Maryland Medicaid, and 5 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 99242 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

High impact

[Georgia] 2025 Order, Prescribe and Refer (OPR) Update

CareSource·Effective Feb 1, 2025

Georgia Medicaid is implementing revised OPR (Order, Prescribe and Refer) provider enrollment requirements effective February 1, 2025. Claims billed with OPR provider numbers for independently rendered services will be denied. New billing requirements mandate that specific claim types include valid, active OPR-registered referring/ordering/attending provider NPIs, with strict rules prohibiting OPR-only providers from billing as rendering providers and preventing the same physician from being listed as both rendering and ordering/referring provider.

99242 Insurance Policy Changes

[Ohio] OAC Rule 5160-1-17.9 Ordering, Referring and Prescribing Providers

PT 66-26: Federally Qualified Health Center and Rural Health Center Coding Guidelines

Maryland Medicaid enhanced reimbursement rates for eligible primary care providers, effective August 1, 2025

Newsletter Vol. 35, No.08

[Georgia] 2025 Order, Prescribe and Refer (OPR) Update

Attention Federally Qualified Health Center (FQHC) Providers: Clarification of Pharmacist Codes Billable for Encounters

Best Practices and Coding to Accurately Capture Follow-Up Visits for TRC and FMC HEDIS Measures

PAP304 - Prenatal and Postpartum Care Coding for HEDIS Quality - New