Sample Letter for Special Services (CPT 99053)

Date

Attn:

Appeals Department

Address

City, State, ZIP Code

Re: Special Services (CPT 99053)

Health Plan ID Number:                                  Group Number;

Insured/Plan Member:                                      Patient Name:

Claim Number:                                                Claim Date:

Dear Sir/Madam:

The original claim for your insured member identified above was submitted correctly for Special Services (CPT 99053).

The following information is provided to clarify the proper use of the Special Services Code billed by Emergency Medicine physicians, from the CPT 2009 manual, page 446.

CPT code 99053 describes service provided between 10:00 PM and 8 AM at a 24-hour facility, in addition to basic service. 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. CPT 2009 states, “Codes 99050-99060 are reported in addition to an associated basic service.”

It is appropriate to apply this code and bill for this service, especially given the nighttime practitioner availability costs typically incurred by certain 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.”) 

Please remit payment per the CPT definition described above. Thank you for your prompt attention to this matter. Please contact (staff name) at (telephone number) in our office should you have any questions regarding this claim.

Sincerely,

Physician Name