QUESTION: What is considered after hours for 99050 and 99051 CPT codes? Our office has two physicians who work Mon-Thurs 8-4:30 and a nurse practitioner who works Mon-Thurs 10-6, Fri 8-4:30 and Sat 8-noon. Limited staff is here in the evening from 4:30-6 Mon-Fri and on Sat to assist her.

When patients call after 4:30 pm on weekdays and on Saturdays that they have reached the after-hours clinic and physicians are not available to see patients until the next business day. The nurse practitioner’s hours are indicated on our practice’s door. Would I be able to bill an additional fee for patients seen during the “extended hours”?  

Racine, Wisconsin

ANSWER: CPT includes two special service codes that apply to offices:

• 99050 CPT code is used to compensate staff for the extra work of having come in to open an office that was closed to specifically see a patient. The code is defined as: “Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service.”
• 99051 CPT code is for providing services when the office has posted hours and is open later and more days than the standard M-F business hours. The code is defined as “Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.”

Since the nurse practitioner (NP) sees patients when your staff are in the office and the office has regularly scheduled hours, 99050 does not apply to your situation.

In your case, 99051 CPT code applies to the NP’s Saturday appointments an potentially to the weekday evening appointments. When she sees patients on Saturdays, you may bill 99051 in addition to the basic E/M service code.

Catch: There are no defined evening hours for CPT code 99051 so check with your payers for their guidelines. While the American Academy of Pediatrics indicates appointments after 6 pm as a general rule qualify for 99051, some insurers consider appointments after 5 pm to be evening hours.

Help get the additional fee covered by insurers by showing them the savings that your NP’s evening and weekend hours provide the insurer. Explain that you are offering additional acute care for a nominally higher fee. If your practice did not offer these special services, patients would instead use urgent care centers, EDs or hospitals increasing their healthcare costs.

It is good that you inform patients of the added care you are offering. This also helps tell the insurance company that you are providing extended care.

Remember 3 More 99050, 99051 CPT Code Billing Rules

• CMS never pays for CPT codes 99050 and 99051.
• An appointment that starts before the extended hours and ends after them, such as an appointment at 4 pm that runs to 6:30 pm does not count for 99051.
• Some insurers also restrict coverage for 99051 to urgent cases. For instance, UnitedHealthcare provides reimbursement for 99051 in addition to acute care services (99201-99215), not preventive medicine services (99381-99397), according to the insurer’s “After Hours and Weekend Care Policy, Professional”.

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