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 [...]