Neurosurgery Coding Alert

Trauma can happen at any time. Neurosurgeons may receive calls at two in the morning because a patient has been in a car accident and suffered massive head injuries that require immediate surgical attention. Or a neurosurgeon may be pulled into the operating room on a Sunday afternoon because an athletes spine has been severely damaged during a sporting event. Conditions requiring treatment by a neurosurgeon tend to have a quick onset and require immediate care.

There are three basic codes that can be used for after- hours patient encounters:

99050 services requested after office hours in addition to basic service;

99052 services requested between 10:00 p.m. and 8:00 a.m. in addition to basic service, and;

99054 services requested on Sundays and holidays in addition to basic service.

Know When to Use the Codes

Appropriate use of these codes hinges on the definition of the phrase after-hours. If your practice is always open until 9:00 p.m., you cant bill the after-hours codes for a patient who comes in at 8:30, says Sue Magalnick, president of Doctors Resource Specialists, a medical practice management and reimbursement consulting firm in Phoenix. You can only bill the after- hours codes if it is actually after-hours for your practice.

For example, a patient who has been implanted with a deep brain stimulator to help regulate the debilitating symptoms of Parkinsons disease (332.0) receives an adjustment of the stimulator in the office at 10:00 a.m. and goes home at 11:15. At 5:00 p.m., as the neurosurgeons office is about to close, the patient calls and says she is suddenly dizzy (780.4) and experiencing nausea (787.02), and she is worried that these symptoms could be a result of some defect in the stimulator. She is told to come back to the office, and she arrives at 5:30, when the office is closed. The neurosurgeon performs an evaluation and determines that the patient is suffering from heart palpitations (785.1), which he does not believe are associated with the deep brain stimulator. The neurosurgeon bills 99213 (office or other outpatient visit for the evaluation and management of an established patient) with a modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that the visit is not associated with the neurostimulator adjustment, and then also bills 99050.

The after-hours codes are add-on codes, says Magalnick. Its common for practices to make the mistake of billing just the 99050 and not billing it as an add-on.

Magalnick advises that the Sunday code (99054) is an exception because it can be billed on Sundays and holidays, even if the neurosurgery practice has published office hours on Sundays and/or holidays. Even if youre open on Sundays, you can still bill 99054, says Magalnick. Its the only exception to the rule.

Getting Paid Can Be Tricky

Scenario: A patient trips and falls down a flight of stairs in the middle of the night, suffering severe head trauma (850.2). The neurosurgeon must operate immediately to release a subdural hematoma (61108), a swell of blood in the brain that may cause permanent brain damage or even fatal. The after-hours code 99052 is added to the hospital admission to indicate that the procedure was performed during non-routine hours.

Most Medicare carriers dont cover the after-hours codes, though many Medicaid carriers do recognize them as a way to keep patients out of the emergency room. These codes should really be used for sick patients only, says Magalnick. If you had a patient come in for a well visit after-hours, insurance would probably deny it.

Some HMOs are strongly in favor of the after-hours codes. Some managed-care providers will provide extra capitation points for these codes, depending on the plan and how they structure it, says Magalnick.

For example, Aetna US Healthcare uses a quality factor to adjust member primary care physicians capitation points, which includes advantages for physicians who are open additional hours, and who care for more than the expected number of seriously ill patients.

Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, a coder who specializes in surgical and neurosurgical procedures, says that neurosurgeons should consider negotiating for payment on these codes when signing on or renewing contracts with managed care companies.

Regardless of whether private insurers cover after-hours codes, its a good idea to use them anyway. For one thing, it helps build a case at the insurance carrier for future reimbursement. Also, its correct coding to bill for every service your practice provides. (Note: This does not include Medicare, as many carriers do not allow billing for services that they do not cover. The neurosurgeon should check his or her local Medicare policy before submitting charges for any after-hours codes.)

Its okay to bill these codes, and practices shouldnt be afraid to use them, says Magalnick. If you bill for the services you perform, and after hours codes are the exception rather than the norm, you shouldnt have a problem. If a patient disrupts your schedule and you have to treat them because the problem is urgent, you should bill extra because you took care of the patient when they needed it. You shouldnt be afraid of audits as long as youre just billing for what you do and you can substantiate the medical necessity. And, reminds Magalnick, the neurosurgeon should always document why he or she was seeing the patient after-hours, and what type of services he or she performed.

Note: Medicare considers these after-hours services to be bundled into the evaluation and management codes. As Medicare considers them to already be paid, it would be improper to bill the patient as if these were non-covered services.

K. S. J. Murkowski, FICA, FMCC, president of Master Practice Counselors, a compliance consulting firm in the areas of corporate and individual practice, malpractice, managed care, and PPO, and chairman of the ICD-10-CM committee for the World Heath Organization, and in private practice in Jackson, Michigan, advocates the use of after-hours codes. Murkowski says, Any code in the CPT that best explains what a physician does, and whether the services are performed during regular hours or after-hours, should be used.