Ophthalmology and Optometry Coding Alert

Question: The ophthalmologist returned to the office at midnight to see a patient with an emergency. Because he provided the service at a non-24-hour facility, should we report 99050?

Georgia Subscriber

Answer: Yes, you should now use the after-hours code 99050 instead of the late-night code 99052.
 
CPT previously delineated the after-hours codes based on time and day. For services provided after posted office hours, you used 99050 (Services requested after posted office hours in addition to basic service).
 
When you provided late-night services, you used 99052 (Services requested between 10:00 PM and 8:00 AM in addition to basic service).
 
For services you performed on a holiday or on a Sunday, you used 99054 (Services requested on Sundays and holidays in addition to basic service).
 
But CPT now restricts the late-night service code -- 99053 (Service[s] provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service) -- to 24-hour facilities.
 
CPT 2006 deletes 99052 and 99054, which leaves offices with two possible after-hours codes:
 
• 99050 -- Services provided in the office at times    other than regularly scheduled office hours, or days    when the office is normally closed (e.g., holidays,    Saturday or Sunday), in addition to basic service
 
• 99051 -- Service(s) provided in the office during    regularly scheduled evening, weekend, or holiday    office hours, in addition to basic service.
 
When you provide services outside scheduled hours, as in your example, use 99050. When your office regularly schedules evening, weekend or holiday appointments and you provide services during those times, assign 99051.
 
You cannot also use an emergency-service code. CPT 2006 clarifies that an emergency must disrupt other scheduled office services. Because your office does not schedule late-night appointments, the midnight visit causes no service interruptions.
 
Therefore, the encounter fails to meet the criteria for 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service). This code previously stipulated only "office service provided on an emergency basis."
 
Bottom line: For the scenario you describe using CPT 2005's special-service descriptions, you could have assigned multiple special-service codes, such as 99058 and 99052, in addition to 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...).
 
On claims such as these in 2006, you should report the after-hours emergency service with special-service code 99050 and 99211-99215.

 -- Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla; and Raequell Duran, CPC, president of Practice Solutions in  Santa Barbara, Calif.