Pediatric Coding Alert

Pediatricians don't always see patients during regular office hours, which means you may be left with a coding headache. If you're confused by the differences between 99050 and similar codes -- or don't think they're worth reporting -- read on for some real-world advice.

When looking at after-hours codes, your first choice often will be 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). Code 99050 comes into play when the physician sees the patient in the office during hours when the office normally would be closed.

Example: Your practice usually closes at 4 p.m. on Wednesday, but the pediatrician sees a patient at 6 p.m. If your posted closing time is 4 p.m., you can report 99050 for the 6 p.m. visit along with the appropriate treatment codes.

Caveat: You can only consider reporting 99050 if the patient can only come after your normal office hours end. "If you see him after hours because the doctor is running behind or because of similar issues, the patient isn't considered 'after hours,'" explains Victoria S. Jackson, a practice management consultant with JCM Inc. in California."But if the parent calls for an appointment and asks if you can see the child late because she can't get there until 6 p.m., that's after hours."

If your practice has routine hours for seeing patients in the evenings or on weekends or holidays, don't for get about 99051 (Service[s] provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service).

Example: Your office stays open until 9 p.m. on Thursday evenings. A patient who comes at 7 p.m. is still within your posted office hours, but outside "usual business hours." Explain the situation to your payer by including 99051 on the claim.

"This rule changed a few years back and people are confused by it," says Chip Hart, director of Pediatric Solutions in Winooski, Vt. "They don't understand that they can bill a 99051 any time it's after hours."

CPT doesn't clearly define "after hours times," which adds to the confusion. "When people ask, 'When is after hours?' I tell them it's when the insurance company stops answering the phone," Hart adds.

Caution: Most large plans don't recognize 99051, says Richard Lander, MD, FAAP, a pediatrician at Essex- Morris Pediatric Group in Livingston, N.J. Some payers do recognize it when reported with an office visit code (99212-99215), he says, but not with all well visits (99381-99395).

Think "emergency" and "interruption" when considering whether to include 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) ona claim.

"99058 is for a true emergency or when the doctor needs to see the patient right then," Jackson says. "It could be because the mom is demanding it, or could be because the child is screaming in pain or has a serious laceration or other problem."

Tip: Cases that merit 99058 are urgent care situations that disrupt the office schedule, such as a child with asthma who is experiencing active wheezing and shortness of breath (493.02, Extrinsic asthma; with [acute] exacerbation).The patient's parent could bring the child himself, or another physician office could call saying the patient needs to be seen right away. Be sure the pediatrician adequately documents the situation, however, before submitting 99058 -- payers want to know that the physician treated the patient for an emergent problem and fit the child into the schedule because of that problem.

Fine line: Don't routinely report 99058 for walk-in patients. The child must present with an acute problem that needs assessment and treatment before meriting 99058.

At first glance, codes 99050, 99051, and 99058 seem comprehensive enough to stand on their own. Take a closer look, however, and the phrase "in addition to basic service" is your clue that more codes are needed.

CPT doesn't designate the status with a plus sign, but the codes technically are considered add-on codes. Therefore, you can only report them in conjunction with the appropriate E/M code.

Some payers, including Medicare, do not reimburse for the after-hours codes -- but others do.

Example: Medicaid Ohio pays for 99050, as do many other payers. Fewer pay for 99051 and 99058, but don't give up hope. Coverage and payment amounts can be regionally and payer specific, but can be negotiated at contract time.

Reimbursement rates might not be high, but every little bit adds up. You can also use what payments you are receiving to help garner more from non-payers. "Even if you aren't being paid right now by BCBS, wouldn't you like to count all those codes so that the next time you sit down for your negotiation with them, you have the data?" Hart asks. "Every one of those 9905x codes saves the insurance company hundreds or thousands of dollars in the ER."

"I strongly encourage practices to open up earlymorning and after-work well visit slots for working families," Hart adds. "Get those important well visits, make your families happy, and collect a well-deserved premium. It's good business, but more importantly, it's good medicine."