Neurosurgery Coding Alert

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

Medicare payers won't reimburse for "after-hours" codes 99050-99054, but you can persuade private payers to reimburse for the services by showing how after-hours visits -- on an emergency basis -- can benefit patients and, at the same time, reduce the cost of claims.

Use After-Hours Only for 'Emergency' Visits

You should report after-hours codes only in urgent situations. CPT includes 99050-99054 (see box, for complete code descriptors) 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 recently released from the hospital following low-back surgery calls the office at 5:45 p.m. - 15 minutes before closing - and asks to see the doctor immediately because of extreme back pain. The surgeon agrees to see the patient, who arrives at the office at 6:30. In this case, you are justified in choosing to report after-hours codes.

In another scenario, an established patient pages the surgeon at home on the July 4th holiday after injuring his back playing softball at a family picnic. The surgeon agrees to meet the patient at the office to evaluate his condition. Here again, because the surgeon did not pre-schedule the appointment and would not normally have been at the office during the time the visit takes place, you may select an after-hours code.

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 surgeon 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 surgeon preschedules the appointments, he's not really seeing patients 'after hours.' He's simply extending his office hours."

And, if the surgeon "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 simply 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 "add-on" 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 report after-hours codes in addition to any other E/M service you report.

For example, in the above case of the patient who arrives at 6:30 for low-back pain, the surgeon 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 surgeon sees in the hospital. There's no such thing as "after-hours" at a hospital: Even if the surgeon is called to the hospital at 3 in the morning for emergency surgery, you can't claim an after-hours service.

Medicare will not recognize or reimburse for 99050-99054. Rather, Medicare "bundles" after-hours codes to any E/M services the physician claims. Because Medicare will not cover these services, you may not charge the patient individually for an after-hours visit.

Negotiate With Private Payers for Payment

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 charge 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.

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 with private payers."

You should devise a simple, specific scenario to demonstrate to the insurer the cost savings of paying after-hours codes rather than ED 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."