Wiki CPT Code 99058 modifier 25

[cosmcvt]

I work at an urgent care facility at the base of a ski mountain. We use the code 99058 - 25 for all incidents that are seen that day without having to make an appointment. We then bill out the remainder of the services, which can include 99204. I have had a person contact me and say that this is illegal because they are the same services. We have used these codes regularly but I would like to know if it is ligimate that we can or can't use these codes together? And the official reason why or why not. Any help in sorting this all out would be greatful.

 

[MarcusM]

http://www.aafp.org/fpm/2004/0100/p22.html

Emergency office services
Q:Can you explain the proper use of CPT code 99058, “Office services provided on an emergency basis”? Does it require the physician to be called out of a room in which he or she is seeing another patient?

A:Code 99058 involves the physician interrupting his or her care of another patient to deal with an emergency. The winter 1994 CPT Assistant states that “if a patient presents at the physician’s office and requires unscheduled emergency care, code 99058 is reported in addition to the other services provided. This is reported for those office patients whose condition, in the clinical judgment of the physician, warrants the physicians interrupting his/her care of another patient to deal with the ‘emergency.’ This code is not reported when the doctor’s practice is to have urgent care slots available in the schedule and patients are ‘fit in’ to the schedule.”

However, neither CPT nor CPT Assistant states that this interruption necessarily extends to being called out of the room in which the physician is currently caring for another patient. For example, a physician could “deal with” an office emergency by providing initial instructions to the clinical staff member who interrupts the physician’s care of another patient to advise him or her of the emergency. The physician could then treat the emergent patient after completing his or her care of the current patient. In this case, the intent of code 99058 would be met, even though the interruption of the physician’s care of another patient did not include leaving the exam room before the encounter was complete.

Note that since CPT considers 99058 to be an “adjunct to the basic services rendered,” it should not be submitted alone; rather, it should be submitted in addition to the other service(s) you rendered to the patient. And Medicare and many other payers consider 99058 bundled with the other service(s) you provided to that patient on that date, so they will not separately reimburse for 99058.

 

[ollielooya]

Marcus, your provided excellent resources to answer the question. We had limited success when billing this code out, and since it was an adjunct code we did not add modifier 25 to it. When it did pay, was usually in the amount of $3x.xx. Providers do a great service by offering emergent care in these type of scenarios. They save the carriers big dollars by keeping patients out of the ER. Hopefully, one day, they'll see the logic in allowing for payment of the small fee in comparison to what they would be billed by the ER, and render payment to the providers.