Pediatric Coding Alert

Pediatric practices are extending their hours to accommodate parents, make managed-care companies happy, and in general to improve their own lot. As they are doing this, however, some are falling for the lure of the after-hours codes Were going to be open late now, they say. That means we can charge extra using the after-hours codes. Wrong. Do not try to use after-hours codes when your offices would be open anyway.

There are three basic after-hours codes:

CPT 99050 services requested after office hours in addition to basic service;

99052 services requested between 10:00 p.m. and 8:00 a.m. in addition to basic services; and

99054 services requested on Sundays and holidays in addition to basic service.

Appropriate use of these codes hinges on the definition of the phrase after hours.

The standard understanding is that these codes can only be used outside of posted office hours, says Richard H. Tuck, MD, FAAP, of Primecare Pediatrics in Zanesville, OH. In other words, the hours that you have posted or published are the hours in which you cannot bill after-hours codes, even if these hours are on a Sunday or in the middle of the night.

Note: An all-night walk-in clinic may well contract with managed-care companies to be able to code and get paid for these after-hours services. But that is a contractual issue; correct coding still dictates that these codes should only be used after posted office hours.

But Tuck concedes that this can be a gray area. Its one thing if the hours are posted and published in the yellow pages, and another if its just that people know you may be staying late, so they call and ask to come in. There are practices that say, Were usually here until 7:30, even though we close at 6:00. If a parent calls at 7:00 and asks to bring a child in, that is an occasion which may well call for 99050.

Getting Paid Can be Tricky

Then there is the matter of getting paid for these codes. Many insurance companies dont know about these codes, says Tuck. But some do know about them and like them. In Ohio, Medicaid recognizes the value of these codes in keeping children out of the emergency room, he says. And they reimburse for them.

North Park Pediatrics in Bellair, MD, is open four nights and Saturdays, so the after-hours times that it can bill are limited. Its worth staying open late and on weekends, however, the practice reports. First of all, the parents love it. Second, its easier on the pediatrician who is on call. And last but not least, says office manager Barbara Brenton, HMOs are strongly in favor of itso much so that they will increase their capitation rates to these practices in response. U.S. Healthcare calls it quality care compensation, she says. If you have scheduled office hours later than normal, you get more capitation points, which leads to a higher cap rate.

You can start to bill after-hours codes when your published office hours end. Lets say the office closes at 8:00, and the child gets there at 8:30, she says. The child is having an asthma attack, and needs nebulization. That means the pediatrician has to stay for another hour. That definitely qualifies for the after-hours codes.

Janet Klemash, ART, reimbursement coordinator for Childrens Community Care in Pittsburgh, PA, uses after-hours codes frequently, but doesnt get paid for them. We use them on weekends, if the pediatrician has to come in to see a patient, she explains. Even though we dont get paid for them, its a useful way to track this for our database. Many of the 22 sites which make up Childrens Community Care are open at least two nights a week and Saturday mornings.

In some cases its a good idea to approach the issue of contracting as an opportunity, suggests Thomas Kent, CMM, president of Kent Medical Management and a former practice manager of a pediatric practice. If the practice is large and is open for many extended hours, you can request that the managed-care plan pay the after-hours codes on all patients seen after 5:00 p.m. or on weekends and holidays, he says. The managed-care companies contract away our rights under CPT in many other cases. Here is an opportunity to get something back.

Also, pediatricians who are not getting paid for after-hours codes might consider photocopying that page from CPT and sending it to insurance companies they contract with. A letter accompanying the photocopy could explain that paying pediatricians for the after-hours codes is far less expensive than paying for patients to go to the emergency room.

Note: After-hours codes are to be used in addition to the office visit that you are charging, and may be stacked. Lets say you see a patient on a Sunday and in the middle of the night. You can bill for both 99052 and 99054. True, most insurance companies wont pay for more than one after-hours code, but you should bill for both nevertheless. That is correct coding.