Neurology & Pain Management Coding Alert

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 [...]