Neurosurgery Coding Alert

Question: Is it appropriate to report the after-hours codes if the physician sees the patient in the emergency department while he or she is on call? The hospital pays the physician for on-call status.

California Subscriber  
Answer: No, this is not appropriate. In this case the physician is already being paid by the hospital for his or her presence after hours, and therefore additional payment is not warranted.
 
The after-hours codes 99050 (services requested after office hours in addition to basic service), 99052 (... between 10:00 p.m. and 8:00 a.m. ...) and 99054 (... on Sundays and holidays in addition to basic service) are used only when the physician sees a patient outside regular office hours. For instance, if the doctors office closes at 5 p.m. but he or she sees a patient on an emergency basis at 7 p.m., report 99050 in addition to any other services provided. If the patient is seen at 12 a.m., report 99052 with any other billable services. If the office is open during the hours/times specified, the after-hours codes cannot be billed. For example, if the physician holds regular office hours on Sundays, 99054 cannot be reported for a patient who visits during that time.
 
According to HealthCare Consultants 2001 Physician Fee & Coding Guide, Some payers do not consider these codes in addition to other services. Also, they have been assigned no relative value units, and Medicare and many other payers consider them nonreportable services. For insurers that recognize the codes, payment can vary dramatically, from $23 to $100 per code.