Pediatric Coding Alert

Question: The July 2004 Pediatric Coding Alert reader question "Open on Sundays? Charge 99054" states that we may bill 99054 for Sunday services and that if an insurer doesn't cover the code, we may charge the patients. We run an urgent care clinic, which is open Monday through Friday from 6 to 8 p.m. and on Sundays from 1 to 4 p.m.
 
Blue Cross Blue Shield (BCBS) notified us that effective May 1, 2004, the insurer would no longer separately reimburse after-hours services. The payer considers 99050, 99052, 99054, 99056 and 99058 part of any other billed procedure. Because we participate with BCBS, our contract doesn't allow us to bill the patient.
 
Should we challenge the insurer based on the article's information?

Nebraska Subscriber

Answer: When your contract comes up for renewal, you may want to negotiate payment for special-service codes 99052 (Services requested between 10:00 PM and 8:00 AM in addition to basic service) and 99054 (Services requested on Sundays and holidays in addition to basic service). Although CPT doesn't restrict 99052-99054 to any specialty group, not all payers reimburse night and Sunday/holiday services. 
 
You may have to educate your BCBS representative on CPT 99052-99054 reporting guidelines. The insurer may think that the special-service codes don't apply to urgent care centers. Because a clinic is supposed to be open on evenings, weekends and holidays, your representative may assume that you shouldn't bill special services - your business is to provide care at these hours.
 
CPT, however, scrapped this notion. Historically, CPT created 99052-99054 to compensate physicians for work provided outside their "normal" office schedule: Monday-Friday, 9 a.m.-5p.m. When physicians began to extend their office hours, CPT Assistant clarified that any specialty group, including emergency department (ED) physicians, may use 99052-99054. By extension then, urgent care centers also qualify for special-service reporting.
 
But using 99052-99054 appropriately doesn't guarantee reimbursement. To get 99052-99054 paid, follow these steps:

 1. Discuss 99052-99054 coverage with payers at contract time.
 2. Negotiate with representatives when (any Sunday/holiday) and how (limited to only 99054 or in addition to 99052 when appropriate) they will agree to pay for 99054
 3. Add 99052-99054 to the contract as a paid service.
 If the payer won't add 99052-99054 as a paid service, negotiate to have the contract designate these codes as a noncovered service. Therefore, you may bill the patient.