This page is expanded from a column by David Stern, MD, CPC in the Journal of Urgent Care Medicine, May 2007
Q. Our urgent care center is open evenings, weekends, and holidays, including Christmas and New Year’s Day. In order to hire and keep staff who are willing to work these extended hours, we have to pay more than a typical (9 a.m. to 5 p.m., Monday through Friday) primary care practice, including time-and-a-half on holidays. Is there a code we can use to obtain compensation for providing extended hours services, since we are incurring these additional costs?
A.CPT code 99051 can be used when you provide services “during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.” Evening hours are generally considered to start at 5 p.m. This code was designed to compensate your practice for the additional costs of being open extended hours. Not all payors will reimburse you for this code, but many payors recognize the value and cost of these services and will reimburse for this code. Check the policies of each of your payors to see if you can receive compensation from them. There is no need to check Medicare’s policy, though: Medicare will never reimburse for this code, so never use it with them.
Q. If we code with 99051, does this replace other codes, such as the evaluation and management (E/M) code?
A. No. 99051 is an add-on code. It is coded in addition to any and all other codes (E/M, CPT, HCPCS and ICD-9) that you would normally code for a given patient visit.
Q. Some payors will not reimburse for this code. Do we have any recourse? How can we get payors to start reimbursing for it?
A. The fact that a code exists does not mean that payors are required to reimburse for it. Unless your contract with the payor specifically states that this code will be reimbursed, you do not have a legal recourse. You can, however, appeal to their sense of reason. You may want to lobby and negotiate for reimbursement.
It is important to maintain good relationships with your payors. If you do decide to lobby or negotiate for a policy change with a payor who does not pay on 99051, be sure that you present your case as reasonable. Make it clear that paying on this code is in the payor’s best interest. You merely want to be compensated for the significant additional expense of being open extended hours. Remind the payor that the public will have to utilize the emergency department (ED) if your urgent care center is not open during its extended hours. ED visits cost the payor two to three times more than the same services in an urgent care. Point out to the payor that payment for this code could provide your center with sufficient added revenues to allow your urgent care to remain open even more hours, which would further reduce emergency department utilization.
Urgent care centers in the past have been successful (even with large payors) in making their case and obtaining reimbursement for the extended-hours code. For example, Blue Cross and Blue Shield of North Carolina decided in 2006 to begin reimbursing urgent care centers for 99051.
Note: Medicare never reimburses CPT code 99051.
Q. What holidays count for code 99051? Can we include religious holy days?
A. You can use 99051 for all the Federal holidays. Selecting multiple additional holidays to use 99051 on will likely be seen by payors as abuse of the system. It may cause denials or reconsideration of the policy to reimburse for 99051 in the first place. Thus, I recommend that urgent care centers use the “holiday” aspect of this code only for Federal holidays, but you can check with your payors if you decide that you want to try using 99051 for any additional holidays.
Q. If our clinic opens at 6 a.m., can we use code 99051 for patient visits before 9 a.m.?
A. The definition of this code is that it is for use during “evening” hours on weekdays, so you should not code with it for early morning services.
Q. If a patient arrives at 4:30p.m. but services are rendered after 5 p.m., can we use code 99051 for this visit?
A. No, use arrival time to determine whether services were rendered during “evening” hours on weekdays.