Neurosurgery Coding Alert

Question: Will Medicare pay extra for the surgeon seeing the patient for an unscheduled appointment on a holiday? We can count on this happening at least once every year between Thanksgiving and New Year.

Florida Subscriber Answer: In a word: No.
 
CPT does provide three codes to describe "after-hours" services, such as those provided on a holiday:
99050 - Services requested after posted office hours in addition to basic service
99052 - ... between 10:00 PM and 8:00 AM
99054 - ... on Sundays and holidays.
 
Medicare and Medicaid do not recognize after-hours codes. Rather, they consider such care to be part of any E/M service provided.
 
A typical local Medicare carrier policy 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)." The carrier specifically includes 99050-99054 in this group.
 
Private payers may recognize the after-hours codes, however, but guidelines and reimbursement rates are inconsistent. To improve your chances for payment, you may wish to negotiate with private payers for payment of after-hours codes as part of any contractual agreement. 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 to the emergency department - which will cost that insurer even more. Use this as leverage when negotiating with payers.
 
For payers that will allow 99050-99054, report the codes only if the physician sees a patient for an unscheduled appointment at a time when his office would otherwise be closed.

For 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 may appropriately report 99050.