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 service
99058 Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service
99060 Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service
Services Outside of Business Hours
Texas Medicaid limits reimbursem*nt for after-hours charges (procedure codes 1-99050, 1-99056, and 1-99060) to office-based providers rendering services after routine office hours and/or on an emergency basis. An office-based provider may bill an after hours charge in addition to a visit for providing services after his/her routine office hours. This should be billed when a provider, in his/her clinical judgment, deems it medically necessary to interrupt his/her schedule to care for a client with an emergent condition. A provider’s routine office hours are those hours posted at the physician’s office as the usual office hours.
Texas Medicaid reimburses office-based physicians an inconvenience charge when any of the following exists:
The physician leaves the office or home to see a client in the emergency room.
The physician leaves the home and returns to the office to see a client after the physician’s routine office hours.
The physician is interrupted from routine office hours to attend to another client’s emergency outside of the office. Charges for inconvenience or after hours services, by emergency department-based physicians or emergency department-based groups are not reimbursed separately.
Policy Overview
After hours or weekend care (CPT®) codes represent services provided,when anindividual physicianor other health care professionalis required to render the services outside of regular posted office hours to treat a patient’s urgent illness or condition.This policy outlines when after hours or weekend care codes are considered for separate reimbursem*nt.
Reimbursem*nt Guidelines
The Centers for Medicare and Medicaid Services (CMS) considers reimbursem*nt for Current Procedural Terminology (CPT®) codes 99050, 99051, 99053, 99056, 99058 and 99060 to be bundled into the payment for other services provided on the same day.
CPT Codes 99053, 99056, 99058 or 99060
Consistent with CMS, UnitedHealthcare will not separately reimburse CPT codes 99053, 99056, 99058 or 99060.
CPT Codes 99050 and 99051
Although CMS considers CPT codes 99050 and 99051 to be bundled into the payment for other services provided on the same day, UnitedHealthcarewill 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 servicesand CPT code 99051 in addition to acute care services (not preventive medicine codes).
UnitedHealthcare will reimburse after hours CPT codes99050 and 99051 to participating primary care providers when reported in one of the following CMS non-facility place of service (POS) designations only:
**School (CMS POS 03)
**Indian Health Service Free-standing Facility (CMS POS 5)
**Tribal 638 Free-Standing Facility (CMS POS 7)
**Office (CMS POS 11)**Independent Clinic (CMS POS 49)
**Federally Qualified Health Center (CMS POS 50)
**State or Local Public Health Clinic (CMS POS 71)
**Rural Health Clinic (CMS POS 72)UnitedHealthcare will reimburse the following participating primary care providers for CPT codes 99050and 99051:
**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 Midwife
Q: Why doesn’t UnitedHealthcare provide reimbursem*nt 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 hours as an alternative to more costly emergency room or urgent care center services. Reimbursem*nt for CPT codes 99053, 99056, 99058 or 99060 would not accomplish this purpose and are not reimbursed by CMS.
2Q: When will UnitedHealthcare provide reimbursem*nt for CPTcode 99050?
A: UnitedHealthcare will provide reimbursem*nt for CPT code 99050 during times other than regularly scheduledoffice hours, or days when the office is normally closed(eg, holidays, Saturday or Sunday), in addition to basic service.
3Q: When will UnitedHealthcare provide reimbursem*nt for CPT code 99051?
A: UnitedHealthcare will provide reimbursem*nt for CPT code 99051 during regularly scheduled evening, weekend, or holiday office hours, in addition to acute care services (not preventive medicine services).
CPT Code 99050 and 99051
Although CMS considers CPT codes 99050 and 99051 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 and CPT code 99051 in addition to acute care services (not preventive medicine codes).
Oxford will reimburse after hours CPT code s99050and 99051 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
71State or local public health clinic
72 Rural health clinic
Oxford will reimburse the following participating primary care providers for CPT codes 99050and 99051:
* 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 midwif
POLICY from BCBS insurance
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 reimbursem*nt, 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 reimbursem*nt 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 reimbursem*nt, 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.
Adjunctive E/M services described by the codes 99053, 99056, 99058, and 99060 are not eligible for separate reimbursem*nt.
