Pediatric Coding Alert

CPT Codes 2006 opens the door to capturing posted evening-hour surcharges

Because old special service code rules no longer ring true, now’s the time to check out which 99050-99060 codes apply to your pediatricians’ nontraditional services. CPT 2006 has revamped the special services, procedures and reports subsection. “The new and revised codes give coders more options to describe the services their practices provide,” says Kim Kieke, CPC, a coding quality specialist at a multispecialty clinic with more than 35 pediatricians in Austin, Texas. Changes include:

Deletions:

• 99052--Services requested between 10:00 PM and 8:00 AM in addition to basic service
• 99054--Services requested on Sundays and holidays in addition to basic service.

Additions:

• 99051--Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service

• 99053--Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service

• 99060--Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service.

Revisions:

• 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

• 99056--Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic service

• 99058--Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service.

1. Specify Extended Office Hours With 99051

In the new year, you can look forward to a new code for services provided during posted evening, weekend and holiday hours. “Some payers allowed coders to use 99050 when a clinic provided services outside traditional office hours,” Kieke says. Insurers sometimes understood the cost-saving benefit of treating a patient in an office setting as opposed to the emergency department and applied 99050 more liberally.

CPT 2006’s new code 99051, however, more appropriately describes the special service. “We never had a code to use for after traditional business hours,” Kieke says. In 2006, coders can use 99051.

How it works: A non-24-hour clinic is open evenings, Saturdays and holidays. When a pediatrician provides an E/M service during these times, you should report new code 99051 for a service “provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.”

For instance, a mother presents with a 16-month-old on a Saturday afternoon to a local clinic that is open 9 a.m. to 7 p.m. The child has a fever and a runny nose and is pulling on her ear. The pediatrician performs a new patient office visit that involves a detailed history, a detailed examination and low-complexity medical decision-making.

She diagnoses the child with an ear infection (382.00, Acute suppurative otitis media without spontaneous rupture of ear drum), prescribes an antibiotic, and recommends follow-up treatment in two weeks and over-the-counter virus remedies. Based on the office visit’s key components, you should report 99203 (Office or other outpatient visit for the evaluation and management of a new patient …) with 382.00. In addition to the basic service, you should also assign 99051 to represent the Saturday visit during regularly scheduled hours.

Old way: Because the office had posted Saturday hours, 99050 would not have accurately described the special service. “CPT’s creation of 99051 recognizes medical care’s move toward more extended hours of operation,” Kieke says.

Alternative: If your office operates on a traditional schedule--Monday through Friday, 9 a.m. to 5 p.m.--you can report services provided outside those hours and days with revised code 99050. CPT 2006 revises 99050 to reflect 99051’s complement for services provided in the office outside “regularly scheduled office hours, or on days when the office is normally closed,” such as holidays and weekends.

2. Count Late-Night Facility Service as 99053

When a pediatrician provides a red-eye or early-bird service at a 24-hour facility, you can report another new special service code. CPT 2006 creates 99053 “for services between 10 p.m. and 8 a.m. in 24-hour facilities,” says Jack Percelay, MD, MPH, FAAP, pediatric hospitalist with the Virtua Health System in southern New Jersey. “This new code impacts both hospitalists and ER physicians.”

Code 99053’s inclusion of “24-hour facility” imposes a new limitation on the late-night service code. If a physician met a patient in the office between 10 p.m. and 8 a.m., you could previously report a special service with 99052, says Tina Landskroener, CCS-P, CPC, senior director of compliance at Quincy Medical Group in Illinois. “CPT attached no place-of-service (POS) to the code.”

New method: The POS drives the after-hours code’s applicability. For you to report 99053, the service must occur at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency room (POS 23), Landskroener says.

Although CPT makes 99053’s time and location requirements clear, whether the code requires that the physician make a special trip in to provide the service is a source of debate. “Code 99053’s description does not indicate that’s the case,” says Jeffrey F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG--Children’s Healthcare of Atlanta at Egleston. “CPT Assistant will probably have to address whether the code can apply to any physician who is in the hospital and provides late-night services.”

Safe way: Because a teenage girl refuses medical attention from an emergency department physician, the doctor requests the patient’s pediatrician come in to treat her. The pediatrician provides a level-three ED service starting at 1 a.m.

“Because the service occurs between 10 p.m. and 8  a.m. at a 24-hour facility, you may report new late-night hour code 99053,” Linzer says. Remember to use 99053 in addition to the basic service, as the code’s descriptor specifies. In the above ED scenario, you may report 99053 in addition to the E/M service code that represents the level-three ED service or basic service: 99283 (Emergency department visit for the evaluation and management of a patient …).
 
3. Report 99058 for Schedule Disruption

Although the AMA opens the door to controversy with 99053, it has ended the controversy over the definition of an emergency. When a practice allows walk-ins and works them into the daily schedule, it was unclear whether the encounter met the requirements of an emergency service code. “The term ‘emergency basis’ was always the confusing part of 99058,” Landskroener says.

Code 99058’s revised text now defines a service on an emergency basis as one that “disrupts other scheduled office services.” “The pediatrician must stop his normal course of scheduling” to treat the patient in the office, Landskroener says.

Caution: Don’t use 99058 for services at an urgent care facility. “Because we routinely take patients on a walk-in emergency basis, we never use the emergency service code,” says Kathy Williams deHaan, clinic manager at West Park Hospital’s Urgent Care Clinic in Cody, Wyo.

Also: If a pediatrician has to interrupt his schedule to provide services outside the office, use new out-of-office emergency code 99060.