Pediatric Coding Alert

Question: We are not usually open in the evenings or on the weekends, but we have decided to open our doors for several Saturdays and weekday evenings during the fall for flu/sick clinics. Should we charge after hours code 99050 at these appointments? Codify Subscriber

Answer: You should instead use 99051 (Service[s] provided in the office during regularly scheduled evening, weekend, or holiday hours, in addition to basic service), which is for services occurring on evenings and weekends during scheduled hours. In contrast, code 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) is for services outside regular scheduled hours.

Since your office is planning to be open for evening and weekend hours albeit on a temporary basis, those nonroutine hours become your regularly scheduled hours.  Therefore, the appointments scheduled during those added hours do not qualify for 99050. "Code 99050 is intended to describe circumstances under which patient requested care is outside of the usual timeframe of the routine scheduling," according to CPT Assistant, August 2010. Check with your major insurers' payment policies on special services codes. Payers may view extra hours for preventive medicine services as a convenience and restrict the coverage of 99051 to problem E/M visits, such as your sick clinic would offer. These payers, however, may not pay for 99051 when billed with preventive codes, such as administration codes (90465-90474) that would be billed for flu shot clinics.

Reason: Some payers will pay for special services only when the reason the patient is seeing the physician is for a condition that might require urgent care visit. The insurer is willing to pay extra for the special services code in order to avoid incurring the additional costs associated with shorter appointment shours which could force the patient to  instead seek a more expensive urgent care visit.