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After hours and Weekend care CPT codes 99050, 99051, 99053, 99056, 99058 and 99060 - Reimbursement

Americhoice insurance

The Centers for Medicare and Medicaid Services (CMS) considers reimbursement for Current Procedural Terminology (CPT®) codes 99050, 99051,99053, 99056, 99058 and 99060 to be bundled into payment for other services not specified.

AmeriChoice, however, will provide additional compensation to physicians 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.
CPT Code 99050

AmeriChoice will reimburse after hours CPT code 99050 when reported with basic service codes 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)

Consistent with CMS and with the intent of this policy, AmeriChoice will not separately reimburse CPT codes 99051, 99053, 99056, 99058 or 99060 unless specific state regulations call for other payment guidelines. These exceptions are listed below

APIPA - Excluded from policy until contract updates are complete
Maryland - CPT code 99058 is reimbursable but CPT code 99050 is not reimbursable

Nebraska - Excluded from policy

Texas - Office based providers may use 99056 or 99060 for services outside of business hours

Wisconsin CPT code 99050 is not covered except for IPN providers.

Why doesn't AmeriChoice provide reimbursement for CPT codes 99051, 99053, 99056, 99058 or 99060?

The After Hours and Weekend Care policy is intended to reimburse physicians for services that are outside their normal office routines as an alternative to more costly emergency room or urgent care center services. Reimbursement for CPT codes 99051, 99053, 99058 or 99060 would not accomplish this purpose and are not reimbursed by CMS.

United Health Care Insurance company of Newyork
UnitedHealthcare covers after-hours and weekend care in addition to the office visit charge (CPT codes 99050-99060) when an office visit is used in lieu of an emergency room or urgent care visit. After-hours and weekend care are defined as care provided when the physician is required to open his or her office outside of regular posted office hours to treat a patient's urgent illness or condition or is required to leave or disrupt his/her regular practice. Please note only one of the after-hours codes can be used per visit (i.e., after regular hours, weekend, holiday, etc.). Charges for after-hours services will not be covered when billed for Emergency Department, Urgent Care, Critical Care, Hospital Care or Nursing Facility. 

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