99051 Real Life Example

A faithful reader sent the following to me and allowed me to post it, as I think the information is valuable to you all.  I have a lot to say about it at the end.


I would like to share our preliminary results for CPT 99051. After reading your post about this code, we decided to start using it. Below the results for the month of July only.


BCBS 0.00
Cigna 0.00
Humana 0.00 sometimes 16.88
United 0.00
Great West 17.17
Allied Benefit 22.50

We’ve billed it a total of 21 times in July and our total reimbursement for the code has been $73.72. If we multiply $74 by 12 months we get $888 (assuming of course the same reimbursement trend and similar code utilization).

It might not be an impressive number, but if we continue doing it, that 800 bucks will pay for my doctor’s flight and hotel to Columbus next month for a little coding and billing conference thing they will be doing.

I was trying to be funny; my point is that even though the results are not impressive, every little bit counts.

We also implemented the 99058 code. Only three encounters thus far. United reimbursed us $23.00. BCBS - our biggest private payer - pays zero ($0.00)

Our data is preliminary, so the jury is still out if these codes add to the bottom line in a significant way. But the way I look at it, we are doing the work anyway. So it doesn’t cost more to add the code.


It’s the weekend, so my points will be fast and furious:

  • First, thanks for this input, Brandon.  I’m sure you’ll recall from the post that started this conversation that I challenge anyone who says they won’t be paid for these codes.  Sure, you may not be hitting all the bases yet, but as you pointed out, the ROI on this “investment” is pretty good.
  • To be more specific: your attitude is completely correct.  Every bit counts. Additionally, even if you aren’t being paid right now by BCBS, wouldn’t like like to count all of these codes so that the next time you sit down for your negotiation with them, you have the data?
  • I’m curious to learn whether you have tried using the 99050, especially with the new definition in 2008. Given that you should be billing it for anything that happens before 8am or after 5pm, I strongly encourage practices to open up early-morning and after-work well visit slots for working families.  Get those important well visits, make your families happy, collect a well-deserved premium.
  • I suspect that your usage of these codes will actually increase.  Not only is July usually the slowest of the pediatric months, you’ll likely get better at using the code.  So, your 21 times in July could easily become 21 times on a single evening when strep/flu hits town.
  • Finally, there are a couple things you can do to work on getting paid for these codes.  The two most obvious things are:
    • Use a waiver.  I know many practices who swear by them.
    • Send the patients from non-paying payers to the ER.  It sounds cruel, but you are under no obligation to provide 24/7 care in your office. One trip to the ER pays for dozens and dozens of 99051s.  Eventually, most payers learn.
  • Again…thanks, Brandon!