Optometry Coding & Billing Alert

Question: How should I code for a patient who was seen at 10:30 p.m. to collect for the after-hours office visit as well as for evaluation and management of conjunctivitis? Would I need to append a modifier to the after-hours code or link it to a different diagnosis? I'm linking the office visit to 077.99.

South Carolina Subscriber

Answer: Report 99052 (Services requested between 10:00 p.m. and 8:00 a.m. in addition to basic service) along with the appropriate E/M code. You do not need to append any modifiers to either code. Link both codes to the conjunctivitis diagnosis, 077.99 (Unspecified diseases of conjunctiva due to viruses). Although Medicare carriers, some private carriers and Medicaid never reimburse after-hours codes (9905x), some private carriers do.

If the private carrier denies your claim and does not have a policy against reimbursing after-hours codes, consider appealing the denial. If you kept the patient from having to go to the emergency department, which would have cost the carrier a good deal more money, be sure to point that out. CMS has not established a fee schedule for the 9905x codes yet, so you may have to negotiate with the carrier. 

Watch for: Some companies handle the 9905x codes uniquely. They don't deny the procedure but automatically consider it "patient responsibility." Be sure to read your explanations of benefits carefully.