Ophthalmology and Optometry Coding Alert

Your point of service determines which 2006 CPT codes are right for you

When you offer services at nontraditional hours, CPT 2006 provides special codes to fit your situation. Just remember, the code you use depends on whether you provide standard office hours or are open evenings and weekends.

CPT revamped the special services, procedures and reports subsection. "The new and revised codes give coders more options to describe the services their practice provides," says Kim Kieke, CPC, a coding quality specialist at a multi-specialty clinic with over 60 physicians in Austin, Texas. Here are four tips to putting these new tools to good use.

1. Use 99051 for Posted Nontraditional Hours

You can now use code 99051 for services provided during posted evening, weekend and holiday hours.

Old way: "Some payers allowed coders to use 99050 when a clinic provided services outside traditional office hours," Kieke says. Insurers sometimes understood the cost-saving benefit of treating a patient in an office setting as opposed to the emergency department and applied 99050 more liberally.

Now: CPT 2006's new code 99051, however, more appropriately describes the special service. "We never had a code to use for after traditional business hours," Kieke says.

How it works: A non-24-hour practice is open evenings, Saturdays and holidays. When your ophthalmologist provides an E/M service during these times, you should report new code 99051 for a service "provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service."

Before: Because the office had posted Saturday hours, in the past, 99050 would not have accurately described the special service. "CPT's creation of 99051 recognizes medical care's move toward more extended hours of operation," Kieke says.

Alternative: If your office operates on a traditional schedule--Monday through Friday 9 a.m. to 5 p.m.--you can report services provided outside those hours and days with revised code 99050.

2. Capture Late-Night Facility Services With 99053

You can use another new special-service code when your physician is called in to provide a red-eye or early-bird service at a 24-hour facility.

What it is: "Code 99053 replaces deleted code 99052 and adds the facility stipulation," says Tina Landskroener, CCS-P, CPC, senior director of compliance at Quincy Medical Group in Illinois.

Code 99053's inclusion of "24-hour facility" imposes a new limit on the late-night service code.

If an ophthalmologist met a patient in the office between 10 p.m. and 8 a.m., you could previously report a special service with 99052, Landskroener says. "CPT attached no place of service (POS) to the code."

New method: The POS drives the after-hours code's applicability. For you to report 99053, the service must occur at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency room (POS 23), Landskroener says.

Be careful: Don't assume that you may automatically assign 99053 for all late-night services at 24-hour facilities.
 
"CPT intends the code for situations in which the physician has to make a special trip in to provide the service," Landskroener says. If the physician provides late-night care as part of his normal job responsibilities, you should not use 99053.

3. Count Schedule Interruption as Emergency

The trend toward greater specificity for special-service codes marches on with the American Medical Associa-tion's clarification of an emergency.

Ambiguity: For a practice that allows walk-ins and works them into the daily schedule, it was previously unclear whether the encounter met the requirements of an emergency service code. "The term 'emergency basis' was always the confusing part of 99058," Landskroener says.

Clarification: Code 99058's revised text now defines a service on an emergency basis as one that "disrupts other scheduled office services."

Caution: Don't use 99058 for services at an urgent care facility. "Because we routinely take patients on a walk-in emergency basis, we never use the emergency service code," says Kathy Williams deHaan, clinic manager at West Park Hospital's Urgent Care Clinic in Cody, Wy.

Also: If a physician has to interrupt his schedule to provide services outside the office, use new out-of-office emergency code 99060.

4. Follow Medicare's Rules for New Codes

Remember: Creation of special service codes does not guarantee use or payment. Before you use these codes, check in with your insurers.

When you use Medicare (or an insurer that follows Medicare guidelines), these services are integral to standard evaluation and management codes and you cannot report them separately.

Private insurers may have contractual arrangements with providers that prevent providers from billing them or their beneficiaries for these special services.