CPT code 99060, CPT code 99058, CPT code 99056, CPT code 99053, CPT code 99051, & CPT code 99050 can be reported for After Hours And Weekend Care. Descriptions of the CPT codes and reimbursement and coding guidelines can be found below.
CPT Code 99060
Description of CPT 99060: Service (or services) provided, out of the office, on an emergency basis, in addition to basic service which disrupts other scheduled office services.
CPT Code 99058
Description of CPT 99058: Service (or services) provided in addition to basic service, on an emergency basis in the office which disrupts other scheduled office services.
CPT Code 99056
Description of CPT 99056: Service or services provided out of the office at request of patient (typically provided in the office) in addition to basic service.
CPT Code 99053
Description of CPT 99053: Service or services provided in addition to basic service between 10:00 PM and 8:00 AM at a 24-hour facility.
CPT Code 99051
Description of CPT 99051: Services or services provided in addition to basic service (in the office during regularly scheduled evening) during a weekend or holiday office hours.
CPT Code 99050
Description of CPT 99050: Service or services provided in the office days when the office is normally closed (eg, holidays, Saturday or Sunday) or at times other than regularly scheduled office hours, in addition to basic service.
Reimbursement & Coding Guidelines
The Centers for Medicare and Medicaid Services (CMS) considers reimbursement for CPT code 99050, CPT code 99051, CPT code 99053, CPT code 99056, CPT code 99058 and CPT code 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.
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 code 99051, CPT code 99053, CPT code 99056, CPT code 99058 or CPT code99060 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 CPT code 99056 or CPT code 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, CPT code 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, CPT code 99053, 99058 or 99060 would not accomplish this purpose and are not reimbursed by CMS.
United Health Care INsurance Company of New York
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.