ED Coding and Reimbursement Alert

Question: What's the deal with ED physicians getting paid for 99053? I know Medicare doesn't reimburse for it, but I-ve got some ED coder friends at other places who say they-re getting paid for it.

Illinois Subscriber

Answer: Special-services codes such as 99053 (Service[s] provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service) are popping up again, Caral Edelberg, CPC, CCS-P CHC, told attendees at the American Academy of Professional Coders (AAPC) National Conference in Seattle. "They were really big back in the dark ages, but people stopped using them because Medicare doesn't pay for them," Edelberg says. But now, a lot of Medicaid payers and some commercial payers are reimbursing ED physicians for 99053.

Some ED physicians and coders may have philosophical reservations about billing 99053 in an ED that is, by its very nature, supposed to be open all the time, Edelberg says. And some patients may not be happy about paying their portion of the charges.

But there are strong justifications for the code as well. Many EDs have night staffing troubles because they don't treat enough patients to justify the presence of an entire ED staff.

However, if you audit relative value units (RVUs) by registration hour, you-ll see that the most acute cases come in at night, says Edelberg, who has audited many facilities from this perspective.

So EDs must have a full qualified staff to take care of the night's most acute cases, and billing 99053 can help some facilities pay for that staff.