Gastroenterology Coding Alert

Question: Our normal office hours are 8:30 a.m. to 5:30 p.m. Monday through Friday. Occasionally, we see patients during non-office hours, but we're stuck on how to bill these visits. In what situations should we consider reporting after-hours codes?

Wisconsin Subscriber Answer: You should never report after-hours codes to Medicare, because it never pays for them. With private payers, however, consider after-hours codes only if the patient presents after your normal office hours end - not when a patient presents during normal office hours and the appointment runs past "closing time."
 
Scenario 1: The office closes at 5:30 p.m., and a new patient reports at 5:45 p.m. for a level-two E/M visit. You should:

  report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision-making) for the E/M visit
  report 99050 (Services requested after posted office hours in addition to basic service) for the after-hours service.  Scenario 2: The office closes at 5:30 p.m., and the gastroenterologist takes until 6:00 performing a level-three E/M service on an established patient. You should:

  report only 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key  components: an expanded problem-focused history; an  expanded problem-focused examination; medical decision-making of low complexity). Remember: There are three different after-hours codes, each designed for use in specific situations. If the gastro sees a patient at 2 a.m. on a Wednesday, you should include the after-hours code 99052 (Services requested between 10:00 p.m. and 8:00 a.m. in addition to basic service) in addition to the service code.
 
If the physician provides services on a Sunday or holiday, opt for 99054 (Services requested on Sundays and holidays in addition to basic service) in addition to the service code.
 
Make sure to contact the insurance company before filing with after-hours codes; some private payers have followed Medicare's lead and won't accept the codes.