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Neurology & Pain Management Coding Alert

Reader Question:

After-Hours Visit

Published on Mon Apr 01, 2002

Question: Due to a tight schedule, we agreed to see an established patient after our regularly scheduled office hours. Is there a special way to code for this?

Pennsylvania Subscriber

Answer: CPT includes three codes for reporting after-hours services:
 
  • 99050 Services requested after office hours in addition to basic service
     
  • 99052 between 10:00 PM and 8:00 AM
     
  • 99054 on Sundays and holidays.
     
     In your case, because the appointment was scheduled and not provided on an "emergency" basis, the after-hours codes do not apply.
     
    Codes 99050-99054 may not be reported 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 p.m., a 6:45 visit does not warrant 99050 in addition to the basic service. Likewise, if the physician regularly holds office hours every second Sunday (from noon until 4 p.m., for instance), it is improper to report 99054 for any appointment scheduled during those hours. The same holds true if the office remains open on a holiday. Neither may after-hours codes be claimed if scheduled patients remain in the waiting room after normal business hours due to delays or overbooking. For instance, if a patient scheduled for a 4:45 appointment doesn't see the doctor until 5:15 15 minutes after the office normally closes an after-hours code is not appropriate.
     
    The only appropriate application of 99050-99054 is if a patient is seen for an unscheduled appointment at a time when the office would otherwise be closed. For instance, a Parkinson's patient with an implanted deep-brain stimulator calls 10 minutes before the office closes, complaining of dizziness and nausea. Concerned that the patient may be having problems with the stimulator, the neurologist advises the patient to come to the office immediately. The patient arrives 40 minutes later. In this case, it is appropriate to report 99050.
     
    In all cases, after-hours codes should be reported in addition to any other services provided, including E/M services.
     
    Medicare and Medicaid never recognize the after-hours codes. Rather, they are included as part of the E/M service. Blue Cross/Blue Shield of North Dakota, the Part B Medicare Carrier for Colorado, North Dakota, South Dakota and Wyoming, in its local medical review policy (which is representative of other carriers' position), notes, "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. When billing Medicare and Medicaid do not report after-hours codes, even if the conditions for their use are met.
     
    Many private payers will recognize after-hours codes, but guidelines are inconsistent. In addition, CMS has assigned 99050-99054 no relative value units, so payment can vary dramatically.
     
    Negotiate payment for after-hours codes with private payers as part of any contract. Unlike Medicare, private payers may actually prefer that physicians use after-hours codes instead of sending the patient to the emergency department which will cost that insurer even more. Use this as leverage when negotiating.
     
    Although physicians must be careful not to report after-hours codes to Medicare and Medicaid payers, complete and proper coding dictates that 99050, 99052 and 99054 should always be reported, when appropriate, to private payers   whether the payer reimburses for the codes or not. Not only is this correct coding, but recording each occasion when these codes are used also provides evidence that may be accessed in future negotiations with the insurer.

    • Clinical and coding expertise for You Be the Coder and Reader Questions provided by Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine; and Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, consultant and CPC trainer for A+ Medical Management and Education in Egg Harbor City, N.J.

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