Pediatric Coding Alert

The after-hours and related codes (99050, Services requested after office hours in addition to basic service; 99052, Services requested between 10:00 PM and 8:00 AM in addition to basic service; and 99054, Services requested on Sundays and holidays in addition to basic service), frequently ignored by managed care companies in the past, are starting to win the recognition they deserve. These codes enable a physician to receive extra reimbursement for work done on a weekend, a holiday or at night. According to Richard Lander, MD, FAAP,American Academy of Pediatrics regional coding trainer for New Jersey, these codes are now accepted by Cigna.

If these codes are to survive in practice, however, they must be used within strict parameters. Misuse most likely will result in payers quickly deciding that it is not wise to cover them. The strongest although not the only case for using these codes is when the office is closed and the pediatrician agrees to meet a patient there.

The specific criteria for using these codes include the following:

1. Define "after hours." "After hours" generally means after the office is closed. "You have to walk a fine line to use these codes," Lander says. For example, a practice schedules patients until 7:00 p.m., usually going home at 8:00 p.m. But on busy evenings, the last patient may not be seen until 8:30 p.m. Do not use 99050 for this patient, who is being seen late because of overbooking, not due to an appointment given after hours. On the other hand, if the same practice receives an urgent call at 7:30 from a parent whose toddler has just gotten burned on the stove, and you want to see this patient as a service instead of directing the mother to the emergency room, you can use 99050 for the visit, which takes place after your posted hours. You also should use the emergency code (99058, Office services provided on an emergency basis) for this case, as well as the E/M code (99211-99215) for the office visit.

2. Define "posted" hours. Use of the Sunday code (99054) requires a clear understanding of your posted hours. For example, some practices are open Sunday mornings for sick visits only. The practice may let parents know that a pediatrician will be available if needed on Sunday from 8 a.m. to 10 a.m. "Thats telling people youre opening the office," Lander says. Do not ever use 99054 for these visits, even if a patient calls with an emergency. "If youre in the office anyway, and you tell someone to come in, do not use the add-on codes." If you make a special trip to the office to see a patient on a Sunday, however, use 99054.

3. Look at the time. Code 99050 is for "after office hours," and 99052 is for 10:00 p.m. until 8:00 a.m. Reporting 99050 if you met the patient at midnight would be submitting a bill for less than you are entitled to because these codes are designed to compensate the physician for inconvenience. However, if you meet a patient on a Saturday and your office is closed on Saturday use 99050 for all hours except 10:00 p.m. to 8:00 a.m.

4. In addition to basic service. These codes should be used in addition to the "basic service," which may be an E/M code or a procedure. For example, if a pediatrician comes into the office at 9:30 p.m. to meet a patient who is wheezing and performs an examination and a nebulizer treatment, report 99211-99215 and 94640 (Nonpressurized inhalation treatment for acute airway obstruction). You also should report 99050. If the pediatrician meets a patient on Christmas Day in the office to remove a new toy from the childs nose, code 30300* (Removal foreign body, intranasal; office type procedure) and 99054.

5. Stackable codes. If the pediatrician sees a patient for wheezing (99214 and 94640) on Sunday (99054) at 11:30 p.m. (99052) for an emergency (99058) in the office, report all applicable codes: 99214, 94640, 99054, 99052 and 99058. The managed care payer may object to this bill, which would probably exceed a night in the hospital, but it would be proper coding.