DAVID STERN, MD (Practice Velocity)
Q.A patient with a finger laceration walked into our urgent care center at 8:05 p.m., five minutes after our closing time. Rather than turn the patient away, our team decided to care for the patient. Three of our staff, including the physician, stayed for 50 minutes after our posted closing time. If we had not stayed after our scheduled closing time, the patient would have been forced to go to the hospital emergency department, where the services would have cost the insurer two to three times more. Is there a way for our center to receive compensation for providing this service—a cost-saver for the payor but a significant additional expense for our urgent care center?
A.CPT code 99050 (“Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed, e.g., holidays, Saturday or Sunday, in addition to basic service”) has been designated as a code for physicians to obtain reimbursement for services rendered after regularly scheduled office hours.
Q.For code 99050, what determines whether a service is provided “after hours”?
A.The key here is your posted hours. Make sure that your signage, brochures, and website clearly denote the hours of operation for your urgent care center. If the service begins during your posted hours, you should not use this code to denote caring for patients whose visits may last beyond the posted closing time of your clinic.
Q.We have a family practice that is open on Saturday mornings for scheduled appointments. Sometimes patients walk in during these hours, and the doctor will see them as an unscheduled, episodic visit. Since this is essentially an urgent care visit, would it be appropriate to code with 99050?
A.No. Since the patient is being seen when the office is normally open, you should not use code 99050. Some payors, however, may reimburse for code 99051 (“Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service”).
Q.Our urgent care center provides services on evenings, weekends and holidays—including Christmas and New Years Day. We have to pay our staff time-and-a-half to work holidays. To hire and retain staff to work these extended hours, we need to pay more than a typical (9 a.m. to 5 p.m., Monday through Friday) family practice.
Is there any code to use to get compensated for providing extended hours services and incurring these additional costs?
A.CPT code 99051 was designed to compensate your practice for these additional costs. Never use this code for Medicare. Some other payors will not reimburse you for this code, so you may want to check the policy of each of your payors.
Q.At what time does “evening” start?
A.Most consultants consider it appropriate to start using this code after 5 p.m. on weekdays. If you are unsure, check with your local payors.
Q.If I code with 99050 or 99051, does this replace the evaluation and management (E/M) code or an other code?
A.No. The codes 99050 and 99051 are add-on codes. Thus, it is coded in addition to all other codes (E/M, CPT, HCPCS and ICD-9) that you would code for the services rendered.
Q.Some payors will not reimburse for either code. Do we have any recourse?
A.Just because a code exists does not mean that any payor is required to reimburse for that code. Unless your contract with the payor specifically states that this code will be reimbursed, you do not have a legal recourse, but you may want to appeal to their sense of reason. If a payor does not reimburse for this code, you may want to lobby and negotiate for policy change.
Note: Medicare will never reimburse for this code, and it is illegal for a participating provider to balance bill a Medicare recipient for this code.
Q.How can we get payors to start reimbursing for 99051?
A.It is important to always keep a good relationship with your payors. Urgent care centers have been quite successful (even with large payors) in making their case and obtaining reimbursement for the after-hours code. For example, in 2006 Blue Cross and Blue Shield of North Carolina made the decision to reimburse urgent care centers for 99051.
If you decide to lobby or negotiate for this reimbursement, be sure that you present your case as reasonable and in the payor’s best interest. You are merely asking to be compensated for your considerable additional expenses. Remind the payor that if your urgent care center is not providing services during extended hours, then the public will be forced to utilize emergency department services. This will cost the payor two- to three times the cost of care in an urgent care center.
Payment for this code may also provide sufficient added revenues to enable your urgent care center to provide additional hours to help reduce emergency department utilization.
Q.If a patient is seen after 5 p.m. and also after regularly scheduled closing hours, can we code both 99050 or 99051?
A.No, it is never appropriate to use both codes for the same patient visit. If the service is after your clinic’s regularly scheduled hours, use code 99050. If it is during your regularly scheduled hours during evenings, weekends, or holidays, use code 99051.
Q.What constitutes a “holiday” for code 99051? Can we include Jewish, Christian, and Muslim holy days?
A.Some states have their own significant holidays (such as Casimir Pulaski Day in Illinois), and you may consider asking payors if they will reimburse for services rendered on these state holidays. Choosing multiple additional religious holidays is likely to be seen by payors as abuse of the system and may produce denials or reconsideration of the policy to reimburse for these services. Thus, it is my recommendation that urgent care centers limit the use of this code to Federal holidays.
Check with your payors before using 99051 for any holidays other than Federal holidays.
Q.We open at 6 a.m. Can we code with 99051 for services before 9 a.m.?
A.The strict definition of this code is that on weekdays it is for use only during “evening” hours. Thus, you should not use this code for early morning services.
Q.Our urgent care center stays open until midnight. We are thinking about using code 99053 for services rendered between 10 p.m. and 8 a.m. We think that payors are more likely to reimburse for 99053 than 99050. Is this a good idea?
A.No. Unless your urgent care center is open for 24 hours on a given day, you should not use code 99053. This CPT code (99053) is reserved for use in centers that operate on a 24-hour schedule. Although it is a growing trend to keep urgent care centers open for 24 hours, the vast majority of urgent care centers do not operate a 24- hour schedule.
If you do operate a 24-hour urgentcare, code 99053 is appropriate as an add-on code to obtain reimbursement for these services. If your facilit is not open for 24 hours, you should not use 99053. Use 99050 or 99051 instead.