ED Coding and Reimbursement Alert

Although some coders argue that submitting for after-hours work in the ED is contrary to the mission of an emergency facility, there are several good reasons to make after-hours codes a part of your regular coding workday even if Medicare doesn't agree.

If your facility decides to employ after-hours codes to report services the occur outside the "normal" work day, use codes 99050 (Services requested after office hours in addition to basic service), 99052 (Services requested between 10:00 pm and 8:00 am in addition to basic service) and 99054 (Services requested on Sundays and holidays in addition to basic service). John Stimler, DO, ACEP, founder and managing member of Bettinger, Stimler & Associates LLC in Pinecrest, Fla., has this tip for coders: Pay attention to the day of service and the time of entry. Notice the check-in time, even though it may be later than the triage time, and use that as your basis for starting the after-hours clock.

The predominant school of thought, which includes the American Medical Association, holds that you can submit the after-hours codes in conjunction with the typical E/M codes for emergency care. "EDs are the true safety net for our entire healthcare system during times when our other physicians are frequently unavailable," Stimler says.

After-hours codes emerged as "adjunctive codes" intended to be reported for office-based practices whose usual posted hours did not include 10:00 p.m. through 8:00 a.m. or Sundays and holidays. However, since medical practices have seen greatly increased demand for physician availability and cross-specialty interaction, Stimler and other experts agree that the use of these codes is not restricted to any specialty group, including emergency department physicians.

Billers in favor of using after-hours codes also cite CPT's mandate that "[a]ny procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified healthcare professional."

These arguments do not convince a second school of thought which includes many payers that looks to the CPT definition of an emergency room as "an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention." Since the facility must, by definition, be available 24 hours a day, it is logically inconsistent, these payers say, to bill for events that happen outside of normal operating hours.

Frontline billing experts contend that more is at stake than the definition of an ED. "Just because EDs are required to be here doesn't mean they're not providing a service," asserts Sharon Foster, clinical reimbursement manager for the Stamford Hospital Emergency Department in Stamford, Conn. In effect, EDs are covering for the physician offices and allowing them to go home at night, so it's important that they be recognized for their second- and third-shift coverage.

And, she says, because they foreclose on some lifestyle choices, "these shifts are tough on families" and may contribute to divorce rates. Because second- and third-shift premiums are costly to hospitals at both human and financial levels, you need to negotiate appropriate adjustments into your contracts, Foster says.

Third-party payers may have specific reporting and reimbursement policies for this series of codes. You should always ask your local payer for its rules for reporting after-hours services. You may find that most secondary payers are swayed by the second interpretation of EDs and do not want to reimburse after-hours codes in conjunction with ED service codes 99281-99285 because the ED is a 24-hour facility.

But if Medicare and many secondary payers won't reimburse for these codes, are they worth the trouble? Many experts think they are. Not all payers reimburse for these codes, but their use is nonetheless appropriate and permitted. In fact, Stimler says, "We have been pleasantly surprised to find that some groups are reimbursing" for after-hours codes.

You can't lose by referring reluctant payers to the rules, Foster and Stimler agree. "The hospitals that charge feel they should be able to offset the shift/weekend premiums needed to attract staffing for those hours," Foster says. Stimler points out that "many physician groups reimburse their doctors for nights, weekends and holidays" and, therefore, after-hours codes documentation can assist you in building a case for increased reimbursement from third-party payers.