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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