CPT 99026, 99027, 99360, 99464

CPT Code Description

Non-Reimbursable

99026 Hospital mandated on call service; in-hospital, each hour

99027 Hospital mandated on call service; out-of-hospital, each hour

99360 Standby service, requiring prolonged physician attendance, each 30 minutes (e.g., operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG)


QUESTIONS AND ANSWERS

1 Q: If a pediatrician or other physician is requested by the delivering physician to attend at delivery and provide services to stabilize a newborn, are those services considered standby services?

A: No. If a physician is requested by the delivering physician to attend at delivery and to provide stabilization of a newborn, the physician may bill for those direct face-to-face services provided to the newborn using CPT code 99464.


APPLICABLE LINES OF BUSINESS/PRODUCTS

This policy applies to Oxford Commercial plan membership.

This reimbursement policy applies to services reported using the UB-04 claim form, the 1500 Health Insurance Claim Form (a/k/a CMS-1500), or their electronic equivalents or their successor forms. This policy applies to all network and non-network providers, including hospitals, ambulatory surgical centers, physicians and other qualified healthcare professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals.



OVERVIEW

This reimbursement policy addresses reimbursement for standby services and hospital mandated on-call services.



Current Procedural Terminology

Per Current Procedural Terminology (CPT) definition, code 99360 is used to report physician or other qualified health care professional standby services that are requested by another individual that involves prolonged attendance without direct (face-to-face) patient contact. Care or services may not be provided to other patients during this period.

This code is not used to report time spent proctoring another individual. It is also not used if the period of standby ends with the performance of a procedure subject to a surgical package by the individual who was on standby.




REIMBURSEMENT GUIDELINES

Centers for Medicare and Medicaid Services

The Centers for Medicare and Medicaid Services (CMS) does not reimburse for physician standby services. These services are considered by CMS to be included in the payment to a facility as part of providing quality care and are not separately reimbursable.

Standby Services

In accordance with CMS, Oxford does not reimburse physician or other qualified health care professional standby services submitted with CPT code 99360. If a specific service is directly rendered to the patient by the standby physician or other qualified health care professional (i.e., tissue examination of frozen section biopsy), the service or procedure would be reported under the appropriate CPT code (i.e., 88331).


Mandated Hospital On-Call Service 

Oxford does not reimburse for hospital mandated on-call services billed under CPT codes 99026 and 99027 because they do not involve direct patient contact.