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Neurosurgery Coding Alert

Reader Question:

When Is After Hours?

Published on Fri Aug 01, 2003

Question: Recently we've had an unexpected patient load and were thinking of offering extended office hours on Saturdays once per month or so. If we do this, can I bill the "after hours" codes for visits scheduled during that time?

Illinois Subscriber

Answer: CPT offers three codes to describe "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 ...
     
    You may not report 99050-99054 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 6 p.m., a 5:45 visit does not warrant 99050 in addition to the basic service. Likewise, if the physician office regularly holds hours twice a month on Saturday (from noon until 5 p.m., for instance), you should not report 99054 for any appointment scheduled during those hours. The same is true if the office remains open on a holiday. In the situation you cite, therefore, you would not use after-hours codes.

    The only appropriate application of 99050-99054 is if the physician sees a patient 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, report 99050.

    In all cases you should report after-hours codes 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.

    But some private payers do not consider 99050-99054 to be in addition to other services. Although these payers are the exception rather than the rule, you should ask your individual carrier for its specific billing requirements.

    You should consider that Medicare and Medicaid do not recognize the after-hours codes under any conditions. 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' after-hours policies), states, "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.

    Blue Cross/Blue Shield of North Dakota's LMRP further states, "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)."

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