ED Coding and Reimbursement Alert

Compensation may come with a price

A patient with a high fever and vomiting presents to the emergency department at 9 p.m. on a Thursday. Should you report a regular ED visit and leave the claim at that, or also report an after-hours code?

If you're reporting codes 99052 or 99054 for after-hours services in the ED, you may want to take a second look at several factors before dropping those claims: whom you're billing, the reason for reporting the code, and the costs and benefits that go with the codes.

According to the August 1996 CPT Assistant, ED physicians are indeed allowed to report 99052 (Services requested between 10:00 p.m. and 8:00 a.m. in addition to basic service) and 99054 (Services requested on Sundays and holidays in addition to basic service) to describe after-hours services. The American Medical Association agrees, advising that use of these codes is not restricted to any specialty group. But whether you should really report them is a more complicated story. Here's how to decide.

If the physician's office is open after hours or on weekends, the physician incurs extra costs of operation, such as ancillary staff and electricity. "The after-hours/weekend codes were designed to offset that additional cost," says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City.

"The allowable payments for CPT codes include a portion of the cost of the physicians'overhead built into them," Thomas says. From utilities to staffing, physicians bear the cost of providing services to their patients. "The intent of after-hours codes," Thomas says, "was not to pay for the inconvenience of coming to the office after hours, but to reimburse the physician for the added expense of providing service during the hours listed."

Here's how it works with ED doctors: In order to serve the public, EDs must be open 24 hours a day, 365 days a year. ED physician groups and hospitals generally must pay a shift differential to doctors for nights and weekends to get these less desirable shifts covered.

And while ED physicians'services are reimbursed based on the services provided, most ED doctors earn an hourly wage -- which means that even when they aren't seeing patients, they're still getting paid the higher night wage. This is an added expense, because the number of ED visits per hour is far less than it is during the day. "The cost-to-income ratio is skewed considerably," Thomas says.

Bottom line: Government payers don't recognize these codes when assigned for ED services -- and in some cases, specifically prohibit reporting them. "Medicare considers these codes bundled in the other services that the physician is reporting, so it is not separately billable to Medicare or the Medicare beneficiary," says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources in Deer Park, Ill. "Most managed-care plans don't pay for it separately, either."

If you're in a contract with a managed-care payer that doesn't accept the code, Gilhooly says, you'll have to write off whatever after-hours charge was billed. If you're not contracted, though, you can charge the patient -- but don't expect the exchange to be pretty, she warns. "You can expect to receive patient complaints about the extra charge, because patients expect the ED to be open 24/7," she says.

If you're billing a private payer, you may have better luck and less friction. Many commercial insurers reimburse ED practices for after-hours codes, Thomas says. Contact the payer about its policy before dropping the claim.

Warning: Don't pick and choose which payers you can bill for after-hours charges, Gilhooly says. Unless you want to invite a fraud investigation, you shouldn't report the after-hours codes to certain payers (that you know will reimburse you) and not to others (that you know won't).

With the exception of Medicare, Medicaid, and any other payer with a contract specifying that you bundle the codes before submitting the claim, "if you're going to bill any carrier for the [after-hours] service, you have to bill everyone for it," Gilhooly says.