CPT 99452, in plain terms, covers Interprofessional referral service by the treating physician requesting a specialist consultation, 30 minutes of preparation and communication. CPT 99452 is referenced in 5 tracked payer policy changes from CareFirst BlueCross BlueShield, Maryland Medicaid, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 99452 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 99452 on AAPC
Maryland Medicaid has implemented enhanced reimbursement rates for eligible primary care providers effective August 1, 2025. The higher rates apply to evaluation and management codes 99202-99499 and G2211, with Managed Care Organizations required to pay these minimum rates to in-network PCPs.
This Maryland Medicaid MCO policy clarifies billing requirements for resident-provided E/M services under the primary care exception using the GE modifier. Teaching physicians can bill for lower- and mid-level E/M services (99211-99213, 99202-99203) and specific preventive/telehealth codes when residents work independently, but visit level selection must be based on Medical Decision Making only (not time), and teaching physicians cannot bill level 4-5 office/outpatient visits.
Maryland Medicaid clarifies that residents in GME programs with primary care exception can bill lower and mid-level E/M services (99202-99203, 99211-99213) using the GE modifier without teaching physician physical presence. Teaching physicians must still review care and can only use Medical Decision Making (not time) for visit level selection.
Effective April 1, 2019, the provider taxonomy code must be submitted on all claims. Reported as already effective in the historical source, Medicare Advantage claims for out-of-network payments require the Health Trio referral number in box 23 of the CMS-1500 form. January 2019 CPT and HCPCS code changes are effective January 1, 2019, and the code lists carry coverage designations such as Subject to Medical Review, Not Medically Necessary, Not Separately Reimbursed and Not Covered.
The IHCP reviewed the Outpatient Fee Schedule, found discrepancies, and will reflect the changes in the next regular update to that schedule. Codes listed twice on previous versions will appear only once, codes missing from the schedule are covered in the outpatient setting and can be billed for dates of service on or after the date listed for each code, and other listed codes are noncovered and will be added to the schedule. Codes that have been nationally end dated will be removed from the schedule, and Current Dental Terminology (CDT) codes cannot be billed on institutional claims (UB-04 claim form or electronic equivalent).
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