Pediatric Coding Alert

There are three potentially lucrative codes to be used in addition to office-visit codes when a pediatric patient is seen on a Sunday, holiday, or after office hours. The codes are:

1) 99050 (services requested after office hours in addition to basic service),

2) 99052 (services requested between 10:00 p.m. and 8:00 a.m. in addition to basic service), and

3) 99054 (services requested on Sundays and holidays in addition to basic service).

These codes could be a boon to pediatric practices which find that they are commonly seeing patients on an urgent-care basis. The codes are supposed to provide you with a surcharge for the extra overhead entailed in opening your office at a time when you normally wouldnt. These codes are not for use when you have regularly scheduled appointments, even if the appointments are on a Sunday. Yet this is not a black-and-white issue for most pediatric practices.

Saturday Coding

Our office has hours specifically listed as 9 to 5 Monday through Friday, says Helen W. Meares, office manager for Round Rock Pediatrics, a 3-physician practice in Round Rock, TX. We do open our office for urgent-care appointments on Saturday afternoon. But not everyone seen on Saturday is coded CPT 99050 . If the pediatrician requests that a child return on Saturday as a follow-up, that is not coded after hours, says Meares. If its our decision to bring the patient in, theres no after-hours charge, she adds. On the other hand, if a mother calls on Friday night or Saturday morning knowing the office will be open on Saturday afternoon and says she wants to bring her child in, the bill does include the after-hours fee. Its a discretionary call, says Meares.

We have to pay overtime for the front office person and a nurse, says Meares. Even if the insurance company says the doctor has to provide coverage 24-hours-a-day, we have to get reimbursed for after-hours services to cover our additional expenses.

Obviously, not everyone who is seen after hours gets the surcharge code. Were never really out of here at 5 oclock, says Meares. If we have scheduled a patient for 4:30, and we dont see them until 5:15 because were running late, theres no after-hours fee, because its our fault, she adds.

Sunday/Holiday Coding

Gina Scharwarth, office manager for Rothschild Pediatrics, Metairie, LA, closes her 9-pediatrician office at 5:00 p.m., and never uses after-hours codes for weekdays. However, the office is open on Sundays and holidays for urgent care only. The appointments are made by the physician directly with the parent, who may call in on Saturday when the office is closed. The pediatrician on call returns their call, and if he decides the patient doesnt need an emergency room but does need to see a doctor, he will arrange to meet the child in his office on Sunday morning. No office staff is involved. The pediatrician tells the parent to come to the office at 9 a.m. Sunday morning, says Scharwarth. The doctor may tell 10 patients the same thing, and they may all show up at 9. Its kind of a walk-in situation, says Scharwarth. All of these patients are coded 99054, and we usually receive the additional reimbursement for them.

(Tips: 1. After-hours codes are to be used in addition to the office-visit codes, not by themselves -- or you will be cutting yourself out of the bigger part of the fee.

2. One of the drawbacks of these codes is that they dont work with many HMOs, who simply dont recognize them. If you would like to get additionally reimbursed for seeing patients after hours from your managed care company, its a good idea to get these surcharges included into your contract. You can go to the HMO and say, Were keeping these patients out of the emergency room, and we want a surcharge when we see them after hours. Show the HMO that this surcharge is much less than what they would pay if the child went to the ER, and you may have a better chance at getting the HMO to pay-up and reimburse you for your additional expenses.)