Wiki 99050 and 99058 codes for emergency visits

[Cheezum51]

We often see patient outside of normal office hours for ocular emergencies and would bill a 99050 in addition to the E/M or 92xxx code. If an emergency patient comes in during regular hours with an emergency and a doctor has to attend to them immediately, due to the nature of the injury, we would bill a 99058 code in addition to the E/M or other CPT procedure code for the visit.

We've never had an insurer ever pay for those emergency visit codes. In order to receive payment for the emergent nature of the visit, how would you recommend that we handle that? I've read one article that stated that we should have the patient sign an ABN form and file the 99050 or 99058 with a GA modifier and bill the patient after the charge is denied which, as you can imagine would probably be difficult to collect from the patient once they left the office. However, since we are never paid for those two codes, would it be more advisable to have the patient sign an NEMB, or equivalent, form and collect that "emergency" fee at the time of visit?

Any advice or suggestions as to other ways to do this and be paid for the emergency services aspect of care welcome.

Tom Cheezum, O.D., CPC, COPC

 

[thomas7331]

As far as Medicare goes, I don't believe you will be allowed to collect this fee from patients even if they sign one of these forms. The 99050/99058 are status B codes which means they always bundle into your other services that are billed and are never paid separately. They don't meet the definition of excluded or non-covered services that these forms are intended for, as Medicare considers the cost of these to be inclusive in the fees paid for your other services. I believe it would not be a compliant practice to bill or collect from a Medicare patient for this.

With commercial payers, you may have other options, though. For payers with which you do not have contracts, you can bill these and if they are not paid, then you have every right to charge the patient or collect in advance. For your contracted payers, I'd recommend reviewing your contracts as that will determine the answer as to when and whether you can charge and collect for this. Most contracts probably will already have a provision as to whether or not you have agreed to offer care outside of hours and should also specify in what cases you are allowed to collect payment from their patients. In either case though, if you can track the quantities of emergency care service you provide to your patients, you can use this as a bargaining chip in your negotiations with the payers and request that the contract be amended to compensate you for it. The payer may be able to add these codes to your fee schedule. If that isn't possible, payers will sometimes offer to raise the rates they pay you for your other services by an amount that will offset for any lost revenue for the services that they deny. I've seen providers have some success with these strategies, but a lot will depend on the volume of patients that the payers sends to your practice and how much competition there is in your area for the types of services you offer. Hope this helps some.