CPT code 99050, 99051, 99053, 99056 - After Office hour procedures

Procedure code and Description

99050 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 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service

99053 Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service

99056 Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic

Medicaid Guideline for office hour CPT

 After-hours office visit codes cannot be used in a hospital setting, including emergency  department, by private or staff physicians. They cannot be used for standby for surgery, delivery, or other similar circumstances, and they cannot be used when seeing a new patient.  Billing for after-hours service in an established patient requires the service be provided outside  of scheduled staff hours as described in the Medicaid manual.

Policy Name After Hours and Weekend Care

This policy addresses reimbursement of after hours and weekend care services (Current Procedural Terminology (CPT) codes 99050-99060).

The Centers for Medicare and Medicaid Services (CMS) considers reimbursement for CPT codes 99050, 99051, 99053, 99056, 99058 and 99060 to be bundled into payment for other services not specified.These codes have a Status Indicator of “B” in the National Physician Fee Schedule (NPFS).  Consistent with CMS, Medica considers these codes not eligible for reimbursement.


Same Physician The same individual rendering health care services reporting the same Federal Tax Identification number.

Status Indicator B

Bundled code. Payment for covered services is always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient).

BCBS payment Guidelines

CPT 99050 is reported when services are provided in the office at times other than regularly scheduled office hours or days when the office is normally closed. The Health Plan refers to this time as “After Hours,” and defines “After Hours” as services rendered between 5:00 p.m. and 8:00 a.m. on weekdays, and anytime on weekends and holidays when the office is usually closed.

CPT code 99050 is eligible for separate reimbursement, in addition to the basic covered service, if the basic service provided meets all of the criteria described below:

•It is reported with an office setting place of service;

•It is rendered at a time other than the practice’s regularly scheduled and/or posted office hours; and

•The basic service time is based on arrival time, not actual time services commence.

CPT code 99050 is not eligible for separate reimbursement when it is  reported with a preventive diagnosis and/or a preventive service.CPT code 99051 is reported when services are provided in the office during regularly scheduled evening, weekend, or holiday office hours.

CPT code 99051 is eligible for separate reimbursement, in addition to the basic covered service, if the basic service provided meets all of the criteria described below:

•It is reported with an office setting place of service; and

•The basic service time for evening hours is based on arrival time, not actual time the service commenced. E/M services described by the codes 99053, 99056, 99058, and 99060 are not eligible for separate reimbursement

CPT Code 99050

Although CMS considers CPT code 99050 to be bundled into the payment for other services provided on the same day, Oxford will provide additional compensation to participating primary care providers for seeing patients in situations that would otherwise require more costly urgent care or emergency room settings by reimbursing CPT code 99050 in addition to basic service codes.

Oxford will reimburse after hours CPT code 99050 to participating primary care providers when reported with basic services in one of the following CMS non-facility place of service (POS) designations only:

POS Code  Description

03 School
05 Indian health service free-standing facility
07 Tribal
638 free-standing facility
11 Office
49 Independent clinic
50 Federally qualified health center
71 State or local public health clinic
72 Rural health clinic Oxford will reimburse the following participating primary care providers for CPT 99050:

* Adolescent medicine, pediatric-adolescent, pediatrics
*Family nurse practitioner, nurse practitioner, pediatric nurse practitioner, advanced registered nurse practitioner
*Family practice
*General practice
*Geriatric medicine
*Gynecology, obstetrics & gynecology, obstetrics
*Internal medicine
*Certified nurse mid

Questions and Answers

1Q: Why doesn't United Healthcare provide reimbursement for CPT codes 99053, 99056, 99058 or 99060?

A:The After Hours and Weekend Care policy is intended to reimburse participating primary care providers for services that are outside their regular posted business hour as an alternative to more costly emergency room or urgent care center services. Reimbursement for CPT codes 99053, 99056, 99058 or 99060 would not accomplish this purpose and are not reimbursed by CMS.

2Q:  When will United Healthcare provide reimbursement for CPT code 99050?A:  United Healthcare will provide reimbursement for CPT code 99050 during 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.

3Q:  When will United Healthcare provide reimbursement for CPT code 99051?

A:  United Healthcare will provide reimbursement for CPT code 99051 during regularly scheduled evening, weekend, or holiday office hours, in addition to acute care services (not preventive medicine services).

CPT code 92540, 92541, 92543, 92545- 92547 - Vesticular Evaluation

Procedure code and Description

92540 Basic vestibular evaluation…

92541 Spontaneous nystagmus including gaze and nystagmus, with recording  test, fixation

92542 Positional nystagmus test, minimum of 4 positions, with recording

92543  Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests), with recording

92544 Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording

92545 Oscillating tracking test, with recording

92546 Sinusoidal vertical axis rotational testing

92547  Use of vertical electrodes (List separately in addition to code for primary procedure)

Reimbursement Guidelines from UHC insurance

UnitedHealthcare Community Plan reimburses for audiologic/vestibular function testing (CPT codes 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92546, 92547, 92550, 92553, 92555, 92556, 92557, 92561, 92562, 92563, 92564, 92565, 92567, 92568, 92570, 92571, 92572, 92575, 92576, 92577, 92582, 92583, 92584, 92585, 92597, 92620, 92621, 2625) when one of the diagnosis codes are listed on a claim denoting problems associated with either balance or hearing.

UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD9/ICD-10 diagnostic codes being included on the claim accurately reflecting the member’s condition.

Basic Vestibular Evaluation

 The basic vestibular evaluation (92540) is a bundled code, defined as including ƒ 92541,92542, 92544, 92545 .

These procedural components must be included in their entirety, including a minimum of four positional tests. If all four of these procedural components are not
completed on a patient in a single encounter, it is inappropriate to use the bundled 92540 code. Instead, you report the individual codes for the procedures that were performed.

However, since the intent of the basic vestibular evaluation is bundled to include four components, when filing the claim for this evaluation a modifier must be added to indicate the procedure was not completed as intended.

In such a situation in which all four of the procedures of the vestibular evaluation were not completed, a modifier 59 would be added to each of the individual codes that were performed to indicate that they were separate and distinct diagnostic procedures to indicate a distinct procedural service. When using the modifier 59, make sure there is appropriate documentation in the report as to why the full basic vestibular evaluation was not performed. Always remember, it is inappropriate to unbundle the vestibular evaluation code for the sole purpose of higher reimbursement by billing the components separately


There is no specific CPT code for “Dix-Hallpike.” This maneuver is typically considered a positional component of 92542, positional nystagmus test, minimum of four positions. As noted earlier, CPT code 92542 is also included as part of the basic vestibular evaluation (92540). If performed in isolation, 92542 should be reported with the modifier 59 to indicate a distinct procedural service

Humana insurance billing Guide

CPT code 92540 (basic vestibular evaluation) includes all the services separately included in CPT codes 92541 (spontaneous nystagmus test), 92542 (positional nystagmus test), 92544 (optokinetic nystagmus test), and 92545 (oscillating tracking test). Therefore, none of the component test CPT codes (92541, 92542, 92544, and 92545) may be reported with CPT code 92540. Additionally, if all four component tests are performed, CPT code 92540 should be reported rather than the four separate individual CPT codes. If one, two, or three of the component tests are performed without the others, the individual test codes may be reported separately. However, if two or three component test codes are reported, NCCI-associated modifiers should be utilized

Billing and coding Guidelines

This bundled code is used to bill for codes 92545, 92542, 92544, and 92545 when they are performed on the same patient on the same date of service.

92543 is not included in this bundle and should still be billed separately with the appropriate number of units to reflect the number of irrigations performed.

Spontaneous nystagmus portion of the common ENG/VNG test protocol; if billed with either 92542, 92544 and/or 92545 (two or three of the 92540 codes) add ‐59 modifier.

Positional portion of the common ENG/VNG test protocol, including all positions and the Hallpike maneuver; if billed with either 92541, 92544 and/or 92545 (two or three of the 92540 codes) add ‐59 modifier.

Optokinetic portion of the common ENG/VNG test protocol; if billed with either 92541, 92542 and/or 92545 (two or three of the 92540 codes) add ‐59 modifier.

Tracking portion of the common ENG/VNG test protocol; if billed with either 92541, 92542 and/or 92544 (two or three of the 92540 codes) add ‐59 modifier.

Use 92547 in conjunction with codes 92541‐ 92546

Medical Bill dispute - How to avoid and how to resolve

The crucial Guide of Disputing Medical Bills or Insurance Policy (Complete Guide)

Over the years, the majority of the folks are encountering complicated issues with medical billing.  Therefore, it is highly recommended that you have to know how to dispute a medical bill or denied insurance. Fixing errors in medical bills can be challenging as one need to follow the complete procedure.  These days, lots of people are frustrated with expensive hospital bills.  Thus, it is your responsibility to invest proper time in the proper analyzation and find out the errors in the bills.

For dispute, a person should make contact with a hospital and Fix the errors.  If you want to dispute a medical bill effectively then firstly you should find out the errors.  In order to know more regarding Disputing medical bills or denied insurance policy, then you should read forthcoming paragraphs properly.

Steps to be taken to resolve

How to review your Medical bills.

* All you need to review your bills. Make sure that you are analyzing all the parts in the statement invoice or medical bills. Most of the hospitals are charging a lot of additional costs like full-day rate of the room and other charges. 

* Check all the procedure code which they mentioned in invoice . Most of them cost based on the time and hence double verify the time you spend with provider and what is mentioned in the invoice.

* Check how much insurance are paid and what the left over from the insurance . Compare with insurance EOB.

* If any non covered service from insurance then you need to make contact with an insurer and get to know regarding the coverage.  Make sure that it is covering all the legitimate charges with ease.  A professional call will able to resolve the claim dispute with ease. 

* After that, you have to invest a significant amount of time in the research and check the fair price of medicines or injections.  If you want to raise any dispute, then it is your responsibility to show any proof.  All you need to make a relevant comparison and find out the Fair price of each medicine or other materials.

* You should have paid copay , coins, insurance Deductible and other patient responsibilities  at the time of visit but they charged again.

If you find any mismatch, follow the below procedures.

Make contact with a hospital

In order to raise the dispute, then it is your responsibility to call the hospital. All you need to share the biggest errors and what you find in he bills.  You need to keep essential notes like Name of the Person, and other crucial details like receipt which you paid or EOB reference regarding the bill. 

Most of the time the problem and dispute would be solved just by calling them directly.

Finance help - Make a call with Doctor office Manager or Billing office.

If possible, then the user should make contact with a doctor office manager and discuss problems with him.  Lots of medical office are offering financial assistance programs which are helpful for those who are raising the disputes.  According to professionals, almost 90% of the medical bills are associated with some sort of mistakes.  It is really dangerous that is creating a big hole in the pocket.

Sample Medical Dispute letter
Disputing complicated mistakes on the medical bill isn't the task of the kids as you need to invest proper time and efforts in the correction.  Make sure that you are following the proper terms and conditions. If you don't have proof, then you will not be able to get the claim.  It would be better to find out the sample medical dispute letter and raise a particular dispute. Make sure that you are sending a particular dispute letter to the billing department.  Lots of disputes are always associated with honest mistakes. According to professionals, you will able to dispute solved if you a claim within 90 days. 

Self Pay – No insurance cases

Before raising any dispute, the patient should pay close attention to the law of the state. Most of the hospitals are overcharging from the self-pay patient. Therefore, it would be better to obtain a particular sample of allowed amount for that procedure mainly Medicare. After that, you have to attach essential copies along with a letter. If you are providing proof such receipts, fee schedule document, then one will able to get the dispute very easily.

Currently, if you don't have any Insurance policy, then it would be better to pay the bill via Cash. Lots of healthcare providers are giving a discount to every customer.  If you are negotiating, then it would be better to initiate with a lower offer.

Raise a particular complaint

It is highly recommended that you should take the dispute to another level.  If a claim is expensive, then you must find out the insurance codes from the bills and allowed amount from the common insurance.

Going to attorney

Its not advisable to attorney for small amount, If you want to avoid the hassle, then you should hire a personal attorney who would be helpful for you.  Before hiring any advocate, one should discuss the fee with him/her. Majority of the lawyers are charging a fee on an hourly basis. User will able to find a personal lawyer from the Internet

How do I dispute an old medical bill?

Want to dispute Old medical bills? You will able to rise for the dispute, but chances of success are relatively lower.  Make sure that you are following the proper rules & regulations of the hospital. For effective outcomes, one should make contact with a debt attorney who will assist you in raising the dispute against old medical bills.  If you have evidence, then you will able to get the dispute solved.  According to professionals, it is a little bit complicated or lengthy process to obtain the claim. You have to fight with the hospitals.  It is your responsibility to make contact with the hospital related to the dispute. It would be better to grab a complete copy of incorrect bills with them.

Proper research is mandatory

Before initiating any dispute, it is your responsibility to invest proper time in the research.  You should check the current worth of medicines, injections, and other things. If you want to claim instantly, then the user must make contact with an anesthesiologist office.

Moving further, if you don't want to invest precious time in the research, then the user should find out a personal attorney who will able to raise the dispute.  An experienced lawyer would be helpful  in filing a particular appeal.  He will surely file the complaint according to the proper instructions.

Avoiding Dispute tips

Always keep the all the records related healthcare whether its from insurance, hospital or Doctor office receipt. That would solve most of the problem and most importantly your time.

Medical billing specialist salary - How much they can earn and requirements

Medical billing specialist salary

Becoming a proficient medical biller isn't easy as one should invest proper time in learning.  Specialists are relatively expert in verifying medical bills, claims and insurance and patient invoices.  Being a medical biller, it is your responsibility to invest proper time in the internship. This particular job requires a lot of important things, and basic degree and certificate in code or billing specialist.

 According to professionals, a proficient medical biller is getting anywhere between $3k to $6k (Big practice, big companies and hospitals) per month as salary.  No doubt, salary depends on a lot of important facts like certifications, additional skills, and education as well mainly with experience and your position.  Therefore, a person must grab certificate courses and increasing the knowledge in different domain that is proven to be mandatory. After becoming a proficient medical biller, one will able to work on not paid aged claims and which would be making him specialist.

So we could tabulate the Medical billing specialist salary as below, All are given per month.

1. Entry level - $2.5k - $3.5k ( Hourly basis too)
2. Mid level - 4.5k - $5k
3. Experience level - Specialist in one area - $6k and More

 How much does a medical billing specialist make an hour?

According to researchers, coders or medical billers are high in the demand.  They are making $16.42 per hour.  Federal Government is offering a lot of incentives to the potential users to attract more people in the company. In order to become a proficient medical biller, then you must be pass out from the college.   Medical billers are growing with at least 20%.  It is a little bit tough job where the user needs to maintain the patient records and handling the medical records, scheduling patients and entry job as well. If you are Medical coder need to be proficiency with CPT and ICD 10 code and insurance coverage policy according to thier edit.   They have to analyses super billing and visit note and covert into codes according to the history of treatment and diagnoses as well.

The pay scale of Medical Billers

No doubt, wages of the medical billers is growing continually.  A professional or experienced medical biller is earning $34,160 yearly. All things depend on the location, level of experience, and skills.  Top medical billers are earning almost $56000 each year. If you are one who wants to become a proficient college degree, then a college degree is required to enroll in the job. After that, it is your responsibility to invest a significant amount of time in learning through certification and get the required knowledge.

• How much do billers get paid?

You will find a lot of certified Hospitals, which is employing the proficient Medical billers to calculate the overall worth of the services.  They are preparing essential bills and sending them to the insurance and patients.  Proficient billers are already familiar with a lot of important things like fee structure and other CPT , ICD codes.  They have an answer to every question related to the denial management.  Most of the professional medical billers are working in surgical or general hospitals.

It is a great opportunity for those who want to complete their studies, along with work.  Medical billing system totally depends on the medical coders. Insurance coverage is making the use of essential codes for the coverage. Salary of a medical biller always depends on the certifications, level of experience, skills as well. If you want to maximize the salary, then it is your responsibility to complete an essential program. As we previously said salary is totally differ to person to person.

Requirement for Medical billing specialist

Following are some essential things that will assist you in becoming a proficient medical biller specialist.

* Level of Qualification

Majority of the small clinics are hiring the coders or billers without prior experience and high level of education.  They are just asking for the certificate training program only. You will able to complete specific training using online websites. Lots of colleges or technical schools are out there where one can learn regarding medical terminology.  This specific program is associated with basic information related to physiology and human anatomy.

** Requirements of career

A person must obtain medical coding and billing degree, which is proven to be essential for a newbie. All you need to find out a perfect institution from where you can learn more regarding codes and another medical billing process. I dont say its must but it helps to get the job easily.

** Education qualification

A medical biller must have essential things like a post secondary certificate and an essential degree as well.  These crucial things will assist you in earning more salary.

** Certifications

If you are obtaining at least one or two coding and billing certification, then you will be surely able to earn a lot of money.  Experienced and skilled persons are also earning huge amount of money. Certification course usually take  6- 12  months.

AR specialists specialize in one or more of the following areas:

• Claims reviewer. Provides expert advice to healthcare providers.

• Coding reviewer. Prepares claims for doctors to submit to the claims. Checking ICD and CPT combination and document verification.

** Experience is must

After getting the degree, it is your responsibility to invest proper time in the internship and get the experience in all domain charge entry, payment posting, denial management with medical code knowledge. Additional training has become mandatory for those who want to become a proficient medical biller.

Is it easy to get into Healthcare industry ?

Absolutely No, These days, lots of organizations are making the use of Paper-based system that is a little bit complicated and time-consuming. Some clinics or hospitals are packed with thousands of patients.  Neither Doctors nor their staff has time for such a tougher task. Therefore, lots of hospital and clinicians are opting for medical billing and coding process.  According to professionals, certified medical billing companies are investing a significant amount of time in the precious HER technology as it is quite better than others. 

Medical billing and coding both are different things.  To become a professional medical biller, then the user needs to invest proper time in the learning.  You need to consider various diagnosis and procedure as well.  Here I have recapitulated vital things related to medical billing and coding where you have a glance.

How is Job Growth ?

Medical billers are on its hype, and a potential biller is earning a significant amount of money. If a person has knowledge related to crucial codes, then he/she will able to become a perfect medical biller with ease.  It is considered a little bit tough task where you need to maintain the significant amount of information in the records. Hospitals are making the use of electronic health records.

Conclusive words

Lastly,   Medical billing has become one of the most important things in hospitals. For such a process, every hospital is looking for the proficient biller.  They are keeping the records and giving information to the insurance companies for the coverage.  Sometimes, hospitals are paying a little part of the insurance, which is known as co-paying.  Along with codes, you have to make the use of software where one can easily keep the records.

Medical billing (RCM) Process - step by step explained

An efficient RCM process in medical billing can enhance medical practice revenues.
The primary job of any medical practice is to provide the best medical care to ensure positive results. However, bogged down by numerous administrative procedures that include insurance verification, charge entry processing, claim submission process etc, it is becoming increasingly difficult to keep a firm focus on what matters the most, restoring the health of the patient.

Enter medical billing specialists at this stage. These are trained professionals who ensure that billing, coding, claims processing happens smoothly in a process called revenue cycle management (RCM).  Read on to take a closer look at what is the RCM process in medical billing. To understand the RCM process, we will have to begin by telling you what are the steps in medical billing process. Let’s go step by step to understand the process in detail.

Process involved in Medical billing

1. The patient makes an appointment

The RCM process kicks in at the time that a patient himself or his family seeks an appointment at a medical care facility. Upon receiving the call, an employee from the medical care facility provides a confirmation of the appointment, gets the details and makes a record of the demographics and the insurance information of the patient in the RCM software that is installed inhouse, if the medical care facility is small or is outsourced to a revenue cycle management company if it is a larger organisation or a hospital network in question, this job is outsourced to a RCM company.

2 Insurance Verification Process

Once you confirm the appointment and get the patient information. We should validate the patient insurance information either by checking online and calling the insurance directly. Also get copay, deductible and out of pocket information. Only if the insurance is active we could confirm the patient appointment otherwise call patient and inform them what is wrong and get clarified. In this stage we have to get the pre authorization too if the procedure required.

3. The patient’s arrival

Once the patient arrives for the appointment, he undergoes some pre-checkup and updation of medical records according to his specification and prescription drugs, procedures, services and all information has been recorded.  The best practices here is, collect all copay, deductible and previous visit balance billing if any. This would avoid lot of billing process and billing life would be easier. Once these payments are made, they are recorded in the RCM system, under the patient’s account.

Tip: Patient payment information has to be conveyed to patient during the appointment confirmation stage itself.

4. Creation of superbill.

The doctor examines the patient and specify all diagnosis and treatment information into filling out a superbill on the RCM system. This could be either paper super bill or electronic super bill which doctor enter the CPT and DX in the RCM software itself.

5. Review of the superbill and entering the charges

The medical coding or RCM specialist reviews this super bill at this stage, to ensure that the correct ICD codes, CPT codes and modifiers have been used according to patient visit notes (Medical records). In case any changes are required, the doctor is informed and to make the modifications as necessary. Most of the providers only entering description of the services and Diagnosis. Hence choosing right ICD code matching with CPT code is key element here.

6. Claim submission process

After the superbill has been entered by the RCM team, the billing software kicks into action and sends it to the clearing house for a final review.  If there are any mistakes in codes at this stage, the clearing house sends the claim back as rejection. Only if the claims have been successfully passed through and reach the insurance with acknowledgment report make the claim submission process complete. If all the codes match correctly and patient is active during that time, the bill is sent on further for processing of claims. If the insurance company finds errors or a lapse at this stage, the claim would be denied at this stage. A good RCM company under the supervision of a qualified medical billing specialist has a 98-99% success rate in the first pass claims acceptance ie clean claims.

7. Payment posting and denial management

Once all the approvals are in place, it is time for the insurance company to make the payments. Post claims acceptance and processing, the practice receives that payment. After the receipt of the payments the RCM team reconciles the payment under the patient’s account.  Posting under correct patient and correct DOS is main requirement here. If we choose anything wrong, the system balance would not tallied correctly and that give us indication to choose the right patient and DOS, CPT.

Tip: Choosing the correct denial would reduce the lot of unnecessary work. Educate the team in that manner.

8. AR & RCM process.

This would be most complicated process in RCM process as we don’t have anything to enter or do the quality check-up but need to take the action on non-paying claims. Not all the claim which we submitted to insurance would automatically paid hence we have to run the report of non-paying claims (Aged claims) and do the follow up with insurance is main process here. Unless we call the insurance and ask the status some of the claims will not be paid at all. Hence follow up with insurance is must process.

Tip : The good practice is review of unpaid claim every 15 days. Some action has to be taken on every 15 days in each and every single unpaid claims

Why following medical billing process improve the revenue

Trusting a reputed medical billing service provider who follows the correct process may seem expensive but it is what efficiently streamlines the RCM process for your practice to navigate through the complicated  medical billing procedures. These service providers provide end-to end services right from reviewing patient eligibility and payments, recording, coding, reviewing and final submission for a smooth claim processing.

With an efficient RCM partner at your service you never have to worry about unnecessary financial losses due to lapses in the medical billing process. Further, with 24x7 back end support, you can rely on an expert to guide you through and solve technological glitches if any in the system. In this hyperconnected age, if you are a medical care practitioner it makes financial sense for you to invest in either efficient RCM software or outsource the process to a medical billing services provider at the earliest.

Top Medicare billing tips