Primary Care Coding Alert

Go beyond guidelines, apply crucial definitions for correct application.

Of the six after-hours/special service codes that appear in the Special Services, Procedures, and Reports section of CPT®, four present the biggest challenges for coders. That’s because they rely on definitions that aren’t always readily apparent in the CPT^® code descriptors or guidelines.

So, to help you use these adjunct codes, here is a list of dos and don’ts, along with some pro coding hints to help you learn how and when to apply them.

DO Use 99050 for Special Services Outside Regular Hours …

Perhaps the biggest source of confusion occurs when you try to decide when to apply 99050 (Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service) or 99051 (Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service) for services outside of regular office hours or during holidays.

Consider this following example: Your office has posted hours of 8:00 AM — 6:00 PM Monday through Friday, and 8:00 AM — 12:00 PM on Saturdays. Your provider then sees a patient at 2:00 PM on Saturday afternoon. Which code would you use in addition to an evaluation and management (E/M) service code from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …)?

In this scenario, 99050 would be the correct code choice, as the physician provided the service after the practice had closed.

Pro coding hint 1: “You can only use 99050 for patients scheduled outside of your posted business hours,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “So, it will not apply for a patient who was scheduled, say, for 4:00 PM on a weekday but not seen by the provider until 6:30 PM on that day.”

… but DON’T Use 99050 During Scheduled Hours

Whenever your provider sees a patient during regularly advertised hours, however, 99050 cannot apply. Instead, you will need to use 99051 whenever your provider sees a patient during evening, weekend, or holiday hours that the practice has posted. This is true even if those hours are temporary, such as extra hours that have been added on to your regular schedule for, say, flu shots or when your office decides to stay open for a holiday such as July 4.

Consider this following example: Your office regularly keeps the hours listed above. However, in November and December, you decide to stay open until 9:00 PM on Mondays and Wednesdays, primarily to provide flu shots. Because the hours have been posted, you will not be able to use 99050 for patients seen during those hours. Instead, you would use 99051, as the hours are regarded as part of your schedule, even if that schedule is only temporary for the months of November and December.

Pro coding hint 2: CPT^® offers no clear definition of what constitutes evening hours. However, “evening hours are generally regarded as any time after 6:00 PM and before 8:00 AM,” says Falbo.

DO Use 99058/99060 When Emergencies Disrupt Scheduled Hours …

Suppose your provider is called upon to treat a patient in an emergency situation. Coding 99058 (Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) or 99060 (Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service) if the physician has to leave the practice seems pretty logical.

But exactly what constitutes an emergency? And how disrupted does your schedule have to be before you can use the codes?

Again, CPT^® offers no clear guidance for you in either situation. It is for those office patients whose condition, in the clinical judgement of the physician, warrants the physician interrupting his/her care of another patient to deal with the “emergency.” But coding “99058/99060 means that the patient’s condition is such that they have to be seen immediately while other scheduled patients have to wait until the emergent situation is resolved,” says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB,  owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin.

Pro coding hint 3: “Some payers will pay for 99058/99060, and others will not. The ones that do pay most likely will pay 99058, because they figure it is less expensive for an emergency to be seen in an office setting rather than in a facility emergency room, where there will be a facility fee in addition to the physician charge,” says Rasmussen.

… But DON’T Use Special Service/After Hours Codes Alone

Finally, before you reach for any of these codes, remember to follow CPT^® guidelines, which state that the codes enable you to record “special reports and services that are an adjunct to the basic service rendered.” In other words, you must first report a code, or codes, that reflect the service or services your provider performed before you add a code from 99000-99082 to describe any context for them.