General Surgery Coding Alert

"CPToffers few guidelines for billing after-hours services," says Alice Church, CCS-P, coding and reimbursement analyst for Wolcott, Wood & Taylor Inc., chief billing officer for the University of Illinois Hospital physicians in Chicago. "And you won't find a lot of information about them elsewhere, either. That makes it tough to know exactly what 'after-hours'means." Nevertheless, there are times when you can use these codes.

Do not report 99050-99054 for any service provided when the office is normally open, even if those hours fall outside "regular" 9-to-5, Monday-through-Friday business hours. For instance, if the office is open until 7:00 p.m., a 6:45 visit does not warrant 99050 in addition to the basic service. Likewise, if the physician office regularly holds office hours every second Sunday (from noon until 4:00 p.m., for instance), you should not report 99054 for any appointment scheduled during those hours. The same holds true if the office remains open on a holiday.

Nor may you claim after-hours codes if scheduled patients remain in the waiting room after normal business hours due to delays or overbooking. For instance, a patient scheduled for a 4:45 appointment doesn't see the doctor until 5:15 15 minutes after the office normally closes. "No insurer will accept an after-hours claim because the physician was running behind," says Dari Bonner, CPC, CCS, CCS-P, president and owner of Xact Coding & Reimbursement Consulting in Port Saint Lucie, Fla.

You should use 99050-99054 only if the physician sees a patient for an unscheduled appointment at a time when his or her office would otherwise be closed. For instance, a patient with a scheduled hernia procedure calls 10 minutes before the office closes, complaining of extreme abdominal pain after a fall. Concerned that the patient may have seriously aggravated his condition, the surgeon advises the patient to come to the office immediately. The patient arrives 40 minutes later. In this case, you may appropriately report 99050.

Note that in all cases the after-hours codes should be reported in addition to any other services provided, including E/M services. According to CPT Assistant, November 1997, "These codes [special services codes, including 99050-99054] are an adjunct to the basic service(s) rendered they are intended to be reported in addition to the basic service(s) provided." Therefore, never report 99050, 99052 or 99054 alone.

Never report after-hours codes for hospital visits, regardless of whether the surgeon is on-call. CPT created the special services and reports codes (for example, 99052 and 99054) as adjunctive codes intended to be reported for office-based practices whose usual posted hours (with scheduled staff and physician[s]) did not include 10:00 p.m. through 8:00 a.m. or Sundays/holidays.

"There is no 'after-hours'at a hospital," Bonner confirms. "These codes were never intended for hospital use." Therefore, even if the surgeon is called to the hospital for emergency surgery on a trauma patient at 2:00 a.m., you may not report after-hours code 99052.

Because such services will be delivered on an emergency basis, however, you may generally claim the highest-available E/M level (without after-hours codes) if the documentation is complete says Dianna Hofbeck, RN, CCM, ACFE, president of North Shore Medicine Inc., a national billing service in southern New Jersey. "Document what you see in addition to what you do," she says. "If the patient has slurred speech, a high fever, massive bleeding, etc., be sure to note that. These factors contribute to the level of exam and medical decision-making." If the documentation is not thorough, the surgeon will forfeit deserved reimbursement.

"Medicare and Medicaid do not recognize the after-hours codes," Church says. Rather, they consider such care to be part of any E/M service provided. Blue Cross/Blue Shield of North Dakota, the Part B Medicare Carrier for Colorado, North Dakota, South Dakota and Wyoming, notes in its local medical review policy (which is representative of other carriers'position), "Certain codes are considered by CMS to be 'bundled'services. Bundled services are not payable, nor should they be billed, even when performed incident-to or with a separate service." Codes 99050-99054 are specifically included in this group. Blue Cross/Blue Shield of North Dakota's LMRP further notes, "When services designated as bundled are denied, the physician may not collect from the patient or the patient's supplemental insurer for the denied service. This would represent either a limiting charge violation (if the claim is nonassigned) or an assignment violation (if the claim is assigned)."

Therefore, do not report the after-hours codes for Medicare and Medicaid payers, even if the conditions for their use are met.

Many private payers recognize the after-hours codes, but guidelines are inconsistent. In addition, CMS has assigned 99050-99054 no relative value units, so payment can vary dramatically.

A number of coding experts suggest negotiating payment for after-hours codes with private payers as part of any contractual agreement. Unlike Medicare, private payers may prefer that physicians use after-hours codes. The alternative to seeing the patient after-hours in the office is to send him or her to the emergency department (ED) which will cost that insurer even more. Use this as leverage when negotiating with payers.

You should devise a simple, specific scenario to demonstrate to the insurer the cost savings of paying after-hours codes versus ED visits, Hofbeck recommends. "Show the insurer in black and white, 'Here's the price of sending the patient to the ED, and here's what you could save by paying for after-hours services instead.'Project the savings for 50 or 100 patients. Prove to the insurer that it is to its benefit to pay you."

Under capitated contracts, the insurer may even agree to a "bill above" (that is, additional) charge for these codes. Bonner cautions physicians not to overuse the codes, however, and to reserve them for truly urgent situations. "Commercial payers could stop paying for them if they think they're being abused."

Although physicians must be careful not to report after-hours codes to Medicare and Medicaid payers, complete and proper coding dictates that you should report 99050, 99052 and 99054, when appropriate, to private payers regardless of whether the carrier reimburses for the codes. Not only is this correct coding, but recording each occasion for which you use these codes also provides evidence that may be accessed in future negotiations with the insurer.