Pediatric Coding Alert

The after-hours codes (99050-99054) can help pediatricians increase their reimbursement when providing services after the office is normally closed. These codes, however, cannot be used for evening or weekend visits, if the office is regularly open then. They should be used when services are provided and the office is not open.

But what about cases in which the pediatrician goes to the hospital in the middle of the night to attend a delivery, for example? Can you use an after-hours code? Some pediatric coding experts say yes, but Medicare coding experts say no.

Charles Schulte, MD, FAAP, CPT advisor for the American Academy of Pediatrics, states that, at least in theory, you should be able to use the after-hours codes for inpatient visits. I dont see anything in CPT Codes that keeps after-hours codes for outpatient, he says. But he does think that insurance companies might pick up on the fact that the place of service the hospital is open 24 hours a day. The hospital is never closed, so its never after hours there.

Dari Bonner, CPC, CCS, CCS-P, says the after-hours codes were never meant for hospital use. Bonner, president and owner of Xact Coding & Reimbursement Consulting in Port Saint Lucie, Fla., agrees with Schulte that there is no after hours in a hospital, so the phrase after hours does not apply. But theres more to it than that working in a hospital at any hour of the day doesnt warrant extra reimbursement, Bonner says. If you get called in to the hospital in the middle of the night, thats part of the job, she says. You cant be paid extra for doing that.

After-hours codes are important for pediatricians, Bonner notes, because commercial payers do pay for these codes. But pediatricians need to be careful with these codes, the consultant says. Commercial payers could stop paying for them if they think theyre overused.

Regardless of whether a payer will reimburse for the after-hours codes, if you go to your office in the middle of the night to see a patient, you should report the after-hours codes, Bonner says. Its a good tracking mechanism, she says. For example, seeing the febrile infant in your office at 3 a.m. can prevent a trip to the emergency room which makes both the mother and the insurance company happy and it can also be used in negotiations with that insurance company later. The pediatrician can show that by providing after-hours care, he or she saved the payer money by keeping the patient out of the emergency room and therefore should get a higher fee. Your whole purpose in coding is to report what you do, Bonner says. If you see a patient in your office when your office is closed, you should report these codes.

Joel Bradley, MD, FAAP, editor of the current edition of Coding for Pediatrics, published by the American Academy of Pediatrics (AAP), and a pediatrician with the FPA Medical Group in Clarksville, Tenn., encourages pediatricians to include after-hours codes in their contracts with payers. In general, commercial carriers prefer that a child be seen by the pediatrician in the office after hours because it keeps patients out of the emergency room.

Richard H. Tuck, MD, FAAP, a member of the AAPs coding and reimbursement committee, notes that not all after-hours codes include the phrase office hours in their descriptor. Code 99050, used for services requested after office hours, does. But 99052, for services requested late at night or early in the morning, and 99054, for weekends, do not. This would seem to indicate that 99050, at least, would not be for hospital use.

Note: For situations in which the practice has posted office hours from 7 a.m. to 6 p.m., but still has 10 patients in the waiting room at 6:30, after-hours codes cannot be billed if the patients were previously scheduled. Why should you be paid more because youve overbooked? Bonner says. If, however, a patient comes in without an appointment at 7:30 p.m., you can bill an after-hours code because you were supposed to be closed then even though you are still there seeing previously scheduled patients.