Pediatric Coding Alert

Let these 3 answers and 4 notes of caution add up to accurate coding.

Your pediatrician sees a patient after scheduled hours. Your scheduled office services are disrupted due to an emergency situation with a patient.

You know that such unusual circumstances require a code from the 99000-99082 series. But before you turn to the Special Services, Procedures, and Reports section of CPT^® and select a code, make sure you read the answers to these four key questions. Not only will they help you find the right code, but they will also help you apply the code correctly every time.

What Code Do I Use When a Patient Is Scheduled After Posted Office Hours?

Simply put, you should use 99050 (Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service) whenever your pediatrician sees a patient outside of regularly posted office hours.

Consider this following example. Your office has posted hours of 8:00 AM-6:00 PM Monday through Friday, and 8:00 AM-12:00 PM on Saturdays. Your provider then sees a sick patient at 7:00 PM on Tuesday evening.

In this example, you would use 99050 in addition to the appropriate evaluation and management (E/M) service code from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …).

Coding caution 1: “You can only use 99050 for patients scheduled outside of your posted business hours,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “So, it will not apply for a patient who was scheduled, say, for 4:00 PM on a weekday but not seen by the provider until 6:30 PM on that day.”

Coding caution 2: Codes from the 99000-99082 series must never be used on their own. That’s because CPT^® guidelines state that the codes enable you to record “special reports and services that are an adjunct to the basic service rendered.” This means you must first use a base code, or codes, that report the service or services your pediatrician performed before you add a code from 99000-99082 to describe any context for them. 

And remember: CPT^® guidelines also state that you do not need to append modifier 51 (Multiple procedures) when you report any of the 99000-99082 codes, even if you report more than one of the codes in this series.

How Does 99050 Differ From 99051?

Many coders confuse 99050 with another, similar code: 99051 (Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service). But the two codes have distinctly different purposes.

You should use 99051 whenever your pediatrician sees a patient during evening, weekend, or holiday hours that the practice has posted.

Consider another example. Your practice decides to stay open from 8:00 AM to 3:00 PM on Thanksgiving Day, and your office manager publicizes the hours at your practice, on your practice website, via email, and on social media. Because the hours have now been posted, you would use 99051 for any patients scheduled on that day, as the holiday hours are regarded as a regular part of your schedule, even if that schedule is only temporary.

Coding caution 3: While the definitions of weekend and holiday hours are pretty self-explanatory, the definition of evening hours is unclear as far as CPT^® is concerned. However, “evening hours are generally regarded as any time after 6:00 PM and before 8:00 AM,” says Falbo, though most pediatric groups would consider evening hours as the period between 5:00 PM to midnight.

What is the Definition of an Emergency in 99058/99060?

CPT^® is similarly vague when it comes to defining what constitutes an emergency, which creates problems when it comes time for you to decide whether you should use either 99058 (Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) or 99060 (Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service).

In addition, CPT^® is also unclear how much your schedule has to be disrupted before the codes apply. However, “99058/99060 mean that the patient’s condition is such that they have to be seen immediately while other scheduled patients have to wait until the emergent situation is resolved,” says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin. 

This does not mean you should use 99058 for any walk-in patient. The code only applies when the patient is seen before anyone else in the office, usually when the provider is called out of the room they are currently in. So, if a patient presents with trouble breathing and low pulse oximetry, and the pediatrician is called into the exam room immediately to see the patient, you can justify coding 99058 providing you document the emergent situation.

Coding caution 4: “Some payers will pay for 99058/99060, and others will not. The ones that do pay most likely will pay 99058, because they figure it is less expensive for an emergency to be seen in an office setting rather than in a facility emergency room, where there will be a facility fee in addition to the physician charge,” says Rasmussen.