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Thread: Cpt 99053 - encompases so much

  1. #1

    Default Cpt 99053 - encompases so much

    AAPC: Back to School
    We have coding done by a Texas firm for our ER physicians. I am now finding that they are billing for the cpt code 99053 which states that the services provided are in addition to basic service. What, in the Emergency Room is considered to be more than basic service as it encompases so much?

  2. #2


    99053 is used in the ED if a patient is seen between 10 pm and 8 am. Some ED's code it, some don't. Some insurances will pay, some won't. It is up the ED as to whether they want it billed or not. There are a lot that do and some that don't.

  3. #3
    Join Date
    Apr 2007
    Fresno, Ca


    What is "a basic service"? I realize the E/M CPT is separate from this. What is "outside" basic? This is a pro-fee bill for a 24 hour ED. No procedures were performed on the pt. at all. I was actually there.

    This is a self-pay pt. Reimbursement is not an issue. Fraud is my issue.
    Last edited by QuadRider; 09-07-2011 at 05:14 PM.

  4. #4

    Default No Fraud Concerns

    The basis for coding for 99053 has more to do with the differential expense of staffing an ED over night than whether it is a service in addition to a basic service. But in many cases the basic service would be an Evaluation and Management Service. The 99053 really has nothing to do with that and doesn't have to be something specific in addition to the E&M. Again it is about the time and the cost involved in staffing for 24 hours. And as others stated it's a mixed bag as to which payors will reimburse for it.


  5. #5
    Join Date
    Apr 2007
    Fresno, Ca


    Staffing is a facility issue to me. Not a physician issue. The physician charged this code in the ED. I totally get the resources and what it takes to run the hospital, but the physician doesn't work for the hospital...

  6. #6

    Default Cost to Group

    But staffing the ED at night is usually a higher cost to the ED group per physician since they often pay a differential.. As you know many EDs are staffed by physicians who are in an independent group whether small and local or part of a large ED company. This is entirely separate from the hospital and their costs and revenue really have nothing to do with the hospital . But it is staffing. There are some exceptions where the hospital will provide a stipend for an EDgroup that can't survive on the physician revenue from the ED.Other non physician staff is a different issue.


  7. #7
    Join Date
    Apr 2007
    Fresno, Ca


    Thank you for your input, I rely on the "forum" to get coder knowledge. I guess I just figure that if a physician is an ED physician that it is a given that they will get patients after 10pm, that is what the ED is for. I don't see the logic in charging a patient more after a centain time. The physicians work 12 hr shifts (most often more). The shift differential pay to a physician should not be billed to the patient, I believe.

  8. #8

    Default How to count the hours

    Hi just curious on the topic - let's say a patient came in at 6:00 pm and was seen by an ED physician until 10 pm - can we still code 99053 even if the pt was registered at 6:00 pm? Also same if the pt came in at 3:00 am and was seen by physician at 5:00 am - can we also bill for 99053 with the regular E/M ED code?


  9. #9

    Smile How to Count the Hours

    99053 Service(s) provided between 10:00 p.m. (22:00) and 08:00 a.m. at 24 hour facility; in addition to basic service i.e basic service would encompass the Evaluation and Management services and any procedures performed. 99053 is used on the Professional side for the ED group/physician's availability between the hours that private practice physician would normally not be available. The thought process is it costs more for staffing night services (has nothing to do with facility resources). If a patient arrives at 3:00 p.m (15:00)and spends time being evaluated in the ED until 22:00 no it would not be appropriate to use this code, because a normal PCP or Urgent care would be open and available at the time the patient presented to the ED. However, in your second scenario where the patient presented at 03:00 or 3 a.m and was in the ED until 05:00 or 5 a.m it would be appropriate to use the night services code in addition to the E/M and any procedures performed. Same is true if the patient presented at 01:00 and was in the ED until 09:30 a.m. the night services would apply.

    Cheryl Anderson, LPN, CPC, CEMC

  10. #10
    Join Date
    Apr 2007
    Austin, Texas


    Special Service Code (99053) FAQ

    Service(s) provided between 10:00pm and 8:00am at a 24 hour facility, in addition to basic service.

    FAQ 1. Is CPT code 99053 an Evaluation and Management (E/M) code?
    No, CPT 99053 is not an E/M code. It is a Special Services, Procedures and Reports code listed in the Medicine Section of CPT. Special Services, Procedures and Reports codes provide the reporting physician with a means for identifying the completion of a service that is an adjunct to the basic services rendered. These adjunctive codes can be reported with any E/M or other CPT basic service satisfying the stated requirements. It is in addition to another service CPT code such as but not limited to 99281-99285.

    FAQ 2. Is it appropriate to use the CPT 99053 code for care provided in an ED and will it be reimbursed?
    It is appropriate to apply this code and bill for this service, especially given the nighttime practitioner availability costs typically incurred by all medical practices, including emergency medicine. The reference to a "24-hour facility" in the CPT description of this code clearly delineates the appropriateness of its use in the ED, which is further clarified by a clinical example of appropriate reporting published in the August 2006 CPT Assistant (i.e., "A patient arrives at the emergency department of a 24-hour facility at 4:00 AM and is treated by the physician for severe abdominal pain. CPT code 99053 is reported in addition to the basic service.")

    Unfortunately, as there are no RVUs applied to this code in the Medicare (CMS) physician fee schedule, reimbursement may be problematic. Accordingly, check with local government payers and review your contracts with commercial payers prior to reporting this code.

    FAQ 3. What is the correct method for determining whether patient care was provided between "10 PM and 8 AM?"
    It should be clearly documented that patient care was provided during the defined period. There can be a number of ways of achieving such documentation, e.g., timed practitioner notation(s) of commencement and/or continuation of care, patient registration time, patient disposition time, etc. Some practitioners have focused on a particular timing measure for reasons of consistency and availability.

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