Procedure code and Description
99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service
99051 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service
99053 Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service
99056 Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic
Medicaid Guideline for office hour CPT
After-hours office visit codes cannot be used in a hospital setting, including emergency department, by private or staff physicians. They cannot be used for standby for surgery, delivery, or other similar circumstances, and they cannot be used when seeing a new patient. Billing for after-hours service in an established patient requires the service be provided outside of scheduled staff hours as described in the Medicaid manual.
Policy Name After Hours and Weekend Care
This policy addresses reimbursement of after hours and weekend care services (Current Procedural Terminology (CPT) codes 99050-99060).
The Centers for Medicare and Medicaid Services (CMS) considers reimbursement for CPT codes 99050, 99051, 99053, 99056, 99058 and 99060 to be bundled into payment for other services not specified.These codes have a Status Indicator of “B” in the National Physician Fee Schedule (NPFS). Consistent with CMS, Medica considers these codes not eligible for reimbursement.
Definitions
Same Physician The same individual rendering health care services reporting the same Federal Tax Identification number.
Status Indicator B
Bundled code. Payment for covered services is always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient).
BCBS payment Guidelines
CPT 99050 is reported when services are provided in the office at times other than regularly scheduled office hours or days when the office is normally closed. The Health Plan refers to this time as “After Hours,” and defines “After Hours” as services rendered between 5:00 p.m. and 8:00 a.m. on weekdays, and anytime on weekends and holidays when the office is usually closed.
CPT code 99050 is eligible for separate reimbursement, in addition to the basic covered service, if the basic service provided meets all of the criteria described below:
•It is reported with an office setting place of service;
•It is rendered at a time other than the practice’s regularly scheduled and/or posted office hours; and
•The basic service time is based on arrival time, not actual time services commence.
CPT code 99050 is not eligible for separate reimbursement when it is reported with a preventive diagnosis and/or a preventive service.CPT code 99051 is reported when services are provided in the office during regularly scheduled evening, weekend, or holiday office hours.
CPT code 99051 is eligible for separate reimbursement, in addition to the basic covered service, if the basic service provided meets all of the criteria described below:
•It is reported with an office setting place of service; and
•The basic service time for evening hours is based on arrival time, not actual time the service commenced. E/M services described by the codes 99053, 99056, 99058, and 99060 are not eligible for separate reimbursement
CPT Code 99050
Although CMS considers CPT code 99050 to be bundled into the payment for other services provided on the same day, Oxford will provide additional compensation to participating primary care providers for seeing patients in situations that would otherwise require more costly urgent care or emergency room settings by reimbursing CPT code 99050 in addition to basic service codes.
Oxford will reimburse after hours CPT code 99050 to participating primary care providers when reported with basic services in one of the following CMS non-facility place of service (POS) designations only:
POS Code Description
03 School
05 Indian health service free-standing facility
07 Tribal
638 free-standing facility
11 Office
49 Independent clinic
50 Federally qualified health center
71 State or local public health clinic
72 Rural health clinic Oxford will reimburse the following participating primary care providers for CPT 99050:
* Adolescent medicine, pediatric-adolescent, pediatrics
*Family nurse practitioner, nurse practitioner, pediatric nurse practitioner, advanced registered nurse practitioner
*Family practice
*General practice
*Geriatric medicine
*Gynecology, obstetrics & gynecology, obstetrics
*Internal medicine
*Certified nurse mid
Questions and Answers
1Q: Why doesn’t United Healthcare provide reimbursement for CPT codes 99053, 99056, 99058 or 99060?
A:The After Hours and Weekend Care policy is intended to reimburse participating primary care providers for services that are outside their regular posted business hour as an alternative to more costly emergency room or urgent care center services. Reimbursement for CPT codes 99053, 99056, 99058 or 99060 would not accomplish this purpose and are not reimbursed by CMS.
2Q: When will United Healthcare provide reimbursement for CPT code 99050?A: United Healthcare will provide reimbursement for CPT code 99050 during times other than regularly scheduled office hours, or days when the office is normally closed(eg, holidays, Saturday or Sunday), in addition to basic service.
3Q: When will United Healthcare provide reimbursement for CPT code 99051?
A: United Healthcare will provide reimbursement for CPT code 99051 during regularly scheduled evening, weekend, or holiday office hours, in addition to acute care services (not preventive medicine services).
