Neurosurgery Coding Alert

After-hours codes 99050-99054 are designed to reimburse physicians who see patients at unusual times, such as after regular office hours or on Sundays or holidays. Although these codes can increase reimbursement, payment is not automatic -- and often requires that special arrangements be made with insurers.

 
CPT includes three codes for after-hours services:
 

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

99052 -- ... between 10:00 p.m. and 8:00 a.m. ...
 

99054 -- ... on Sundays and holidays ... .

 
"CPT offers few guidelines for billing after-hours services," says Kathy Pride, CPC, CCS-P, coding supervisor for Martin Memorial Medical Group, a 55-physician group practice with two neurosurgeons, in Stuart, Fla. "And you won't find a lot of information about them elsewhere, either. That makes it tough to know exactly what 'after hours' means." Nevertheless, Pride says there are very specific instances in which these codes may be applied.
 
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 office regularly holds 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 is 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, a patient scheduled for a 4:45 appointment doesn't see the doctor until 5:15 -- 15 minutes after the office normally closes. "No insurer will accept an after-hours claim just because the physician was running behind," explains Dari Bonner, CPC, CCS, CCS-P, president and owner of Xact Coding & Reimbursement Consulting in Port Saint Lucie, Fla. Other consultants agree that this would be bad for patient relations as well. These codes should be used only in cases of patient need.
 
The only appropriate application of 99050-99054 is if a patient is seen for an unscheduled appointment at a time when the physician 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 neurosurgeon advises the patient to come to the office immediately. The patient arrives 40 minutes later. In this case, it is appropriate to report 99050.
 
Note that in all cases the after-hours codes should be reported in addition to any other services provided, including E/M services. According to CPT Assistant, November 1997, "These codes [special services codes, including 99050-99054] are an adjunct to the basic service(s) rendered -- they are intended to be reported in addition to the basic service(s) provided." Therefore, never report 99050, 99052 or 99054 alone.
 
Note: Some private payers do not consider these codes in addition to other services. Although these payers are the exception rather than the rule, you should contact your individual carrier for its specific billing requirements.

 
After-hours codes should never be used for hospital visits, regardless of whether the neurosurgeon is on call. The special services and reports codes (e.g., 99052 and 99054) were created as adjunctive codes to be reported for office-based practices whose usual posted hours (with scheduled staff and physician[s]) did not include 10 p.m. through 8 a.m. or Sundays/holidays.
 
"There is no 'after hours' at a hospital," Bonner confirms. "These codes were never intended for hospital use." Therefore, even if the neurosurgeon is called to the hospital for emergency surgery on a trauma patient at 2 a.m., after-hours code 99052 may not be claimed.   

Because such services will be delivered on an emergency basis, however, the highest-available E/M level (without after-hours codes) may be billed -- provided the documentation is complete -- says Dianna Hofbeck, RN, CCM, ACFE, president of North Shore Medicine Inc., a national billing service in southern N.J. "Document what you see in addition to what you do," she says. "If the patient has slurred speech, a high fever, massive bleeding, etc., be sure to note that. These factors contribute to the level of exam and medical decision-making." If the documentation is not thorough, the neurosurgeon will forfeit deserved reimbursement.

 
"Medicare and Medicaid do not recognize the after-hours codes," Pride says. Rather, these are considered to have been paid 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.
 
As a result, when billing Medicare and Medicaid payers, never report the after-hours codes, even if you meet the conditions for their use.
 
Blue Cross/Blue Shield of North Dakota's LMRP further notes, "When services designated as bundled are denied, the physician may not collect from the patient or the patient's supplemental insurer for the denied service. This would represent either a limiting charge violation (if the claim is nonassigned) or an assignment violation (if the claim is assigned)."

 
Many private payers recognize the after-hours codes, but guidelines are inconsistent. CMS has assigned 99050-99054 no relative value units, and therefore payment can vary dramatically (HealthCare Consultants' Guide cites a payment range of $20 to $100, depending on the payer and code).
 
Pride and other coding experts suggest negotiating payment for after-hours codes with private payers as part of any contract. Unlike Medicare, private payers may prefer that physicians use after-hours codes. The alternative to seeing the patient after hours in the office is to send him or her to the emergency department -- which will cost the insurer even more. Use this as leverage when negotiating with payers.
 
Hofbeck recommends devising a simple, specific scenario to demonstrate to the insurer the cost savings of paying after-hours codes versus ED visits. "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." 
 
Pride says that with capitated contracts, the insurer may even agree to a "bill above" charge for these codes. Bonner cautions physicians not to overuse the codes, however, and to reserve them for truly urgent cases: "Commercial payers could stop paying for them if they think they're being abused."

 
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 or not the payer reimburses for the codes. Not only is this correct coding, but recording each occasion when these codes are used provides evidence that may be accessed in future negotiations with the insurer.