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Neurology & Pain Management Coding Alert

Everyone Can Win With After-Hours Codes

Published on Thu Apr 22, 2004

Gain an additional $50 for urgent visits and still save the payer money

Payers frequently ignore claims for after-hours services 99050-99054. But with a little persuasion, you can convince non-Medicare insurers that after-hours services provide a benefit to both patients and payers.

Use After-Hours Only for 'Emergency' Visits

You should only report after-hours codes in urgent situations. CPT includes 99050-99054 to allow additional reimbursement for physicians who see patients at unusual (in other words, unscheduled) times, such as after posted office hours or on Sundays or holidays, says Richard H. Tuck, MD, FAAP, AAP, representative to the AMA RBRVS Review Update Committee.

Example: A patient who recently received implanted neurostimulators calls the office at 5:45 p.m. -- 15 minutes before closing -- and asks to see the doctor immediately because of mild seizure-like episodes. Fearing problems with the neurostimulator settings, the neurologist agrees to see the patient, who arrives at the office at 6:30 p.m. In this case, you are justified in reporting after-hours codes.

When NOT to claim after-hours: You should not, however, report after-hours codes for a prescheduled appointment after regular office hours. "Let's say the neurologist decides to stay open an extra hour on Friday because of the large number of patients who wish to see him that week," says David Davis, a medical policy analyst at iHealth Technologies Inc. in Atlanta. "If the neurologist preschedules the appointments, he's not really seeing patients after-hours. He's just extending his hours."

By the same token, if the neurologist "overbooks" and does not see his final scheduled appointment of the day until after the posted office hours, you cannot report an after-hours service. "Insurers won't pay because the physician is running behind or overbooked," Davis says.

Report After-Hours in Addition to Other Services

Although CPT does not list 99050-99054 as after-hours codes, the code descriptors clearly state "in addition to basic service." And CPT Assistant November 1997 clearly states that 99050-99054 "are an adjunct to the basic service(s) rendered" and "are intended to be reported in addition to the basic service(s) provided." Therefore, you should only claim after-hours codes in addition to any other E/M service you report.

CPT includes three codes to report after-hours services:

 

  • 99050 -- Services requested after posted office hours in addition to basic service
     
  • 99052 -- ... between 10:00 PM and 8:00 AM
     
  • 99054 -- ... on Sundays and holidays.

    For example, in the case of the neurostimulator patient who arrives at 6:30 p.m., you should claim the E/M service level supported by documentation (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) along with 99050.

    Don't Use After-Hours for Hospitals, Medicare

    You should never report after-hours codes for patients the neurologist sees in the hospital. There's no such thing as after hours at a hospital.

    And Medicare will not reimburse for 99050-99054. Rather, Medicare bundles after-hours codes to any E/M services the physician claims.

    Negotiate With Private Payers for Payment

    Although Medicare won't recognize after-hours codes, you can and should negotiate with private insurers for payment of these services, says Linda J. Walsh, MAB, division of healthcare finance and practice senior health policy analyst manager for the AAP committee on coding and nomenclature in Elk Grove Village, Ill.

    "In most cases, the alternative to the physician seeing the patient after hours is to send the patient to the emergency room, which is probably going to cost the insurer a great deal more money," says Dianna Hofbeck, RN, CCM, ACFE, president of North Shore Medicine Inc., a national billing service in southern New Jersey. "You can use this as leverage when negotiating contracts."

    You should devise a simple, specific scenario to demonstrate to the insurer the cost savings of paying after-hours visits rather than emergency department visits, Hofbeck says. "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."

    CMS has not established a fee schedule value for 99050-99054, but many practices charge in the range of $30-$50 for these codes (above the fee for any basic E/M services provided at the same time), which is in line with the fees private insurers are willing to pay, Davis says.

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