Pediatric Coding Alert

Catch: July 4th can fall under 99050 or 99051--your hours make the difference

You can't get insurers to ante up additional pay for special service codes unless you watch for scenarios that could take these six add-on codes.

CPT 2006 rewrote the special service codes, which are always reported in addition to an E/M service. See if you know which code applies in the following cases. Discover Add-on Code for Sunday E/M Case 1: Although your office is closed on Sundays, you decide to see a patient due to ear drainage with puss, severe ear pain, and high fever on Sunday afternoon. You diagnose an ear infection without ear-drum rupture (382.00, Acute suppurative otitis media without spontaneous rupture of ear drum) and write a prescription for Amoxicillin.

Answer: When an office is closed but you come back to see a patient, you can use 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) in addition to the E/M service code, such as 99213-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...), says Richard Lander, MD, FAAP, with Essex-Morris Pediatric Group in Livingston, N.J. You can apply this code anytime the office is closed and a patient is seen including:

• Sunday afternoon

• Independence Day

• Christmas. Try this: If an insurer balks at paying for 99050 for service on a Sunday afternoon, show them the cost savings of in-office care. "Tell the representative that you'd be happy to send patients on Sundays to the emergency department instead of treating them in the office," Lander says. Compare the visit-plus-99050-payment rate to the significantly higher ED-visit rate (generally about eight times more than a physician visit).

Consider This Code for Working Holidays Case 2: To serve the pediatric community, your clinic remains opens on Independence Day and your two staff pediatricians see 26 patients.

Answer: For seeing patients on a holiday that your office did not close for, you may report 99051 (Service[s] provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service) per encounter plus the appropriate service code (99201-99215), Lander says.

Details: Code 99051 is for keeping an office open, says Joel Bradley Jr., MD, FAAP, a pediatrician with Premier Medical Group in Clarksville, Tenn. "If you incur an extra cost in keeping staff there, you can use 99051." Consider using the code for visits during:

• evening office hours

• Saturdays and Sundays. Choose 99050 Vs. 99051 Based on Status Case 3: On Independence Day your office closes, but you see an established 6-month-old patient who has [...]