Can someone please explain the CMS rationale for including CPT® 99060 and related codes but refusing payment for services rendered on an emergency basis that is disruptive or out of normal working hours?
Bundled Code. Payment for covered services are always bundled into payment for other services not specified. There will be no RVUs or payment amount for these codes, and no separate payment is made. When 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.)
Basically it's considered a bundled code and no RVU's.
If that's the case, why have the code?
As I understand it, the purpose is to recompense for disruption of orderly flow, or in the case of a middle-of-the-night visit for an emergency:
Case: Patient discharged from the hospital earlier in the evening - no neurological or metabolic defect found. Within an hour of reaching home, the patient again became confused and stuporous. Physician was called out to the home late in the evening and patient was transfered to the ER by ambulance for re-admission.
This case fits the definition of 99060: Out patient service rendered on an emergency basis outside the office, disruptive of normal operations, or outside regular hours. The RVU doesn't account for disruption or emergency nature of the service rendered... an afternoon house call is not the same as a middle of the night house call. A telephone call from a nurse isn't the same as an emergency house call in the middle of the night. BTW: Nurses don't get paid by RVUs.
CPT® develops CPT® codes that describe the services medical practices perform. Medicare and other payers develop reimbursement policies. Just because there is a CPT® code doesn't mean that a payer will pay it.