Primary Care Coding Alert

Question: How do the new on-call codes apply? Insurers will likely not pay for the time we are on-call but not seeing patients (even though that sounds like what the code describes "on-call services" in or out of the hospital). How can we use this code when no patient is seen? Can you clarify when I should use this code?

Louisiana Subscriber

Answer: Unfortunately, the 2003 Medicare National Physician Fee Schedule does not grant any relative value units (RVUs) for either of the new on-call codes, 99026 (Hospital-mandated on-call service; in-hospital, each hour) and 99027 ( out-of-hospital, each hour). In the schedule's preamble, CMS notes that the AMA's relative value scaleupdate committee (RUC) made no recommendations for these codes.

Most important, Medicare does not cover standby and on-call services and will not pay for them when billed using these codes, according to the preamble. Therefore, 99026 and 99027 may fall into the typical non coverage scenario similar to that for telephone calls codes exist that describe the service (99371-99373), but most insurers will not pay for them. Although you cannot bill on-call services to Medicare carriers, you should try billing third-party payers.

"Most family physicians will probably not try to bill for on-call services," says Daniel Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City. If the doctor doesn't actually care for anyone, he will have a hard time proving to a payer that the service added any value to the patient.

The Special Services, Procedures and Reports subsection (99000-99091) allows the reporting physician to identify the completion of special reports and services in addition to the basic services rendered, according to the subsection's introductory notes. You may bill 99026-99027 with other codes in this section, such as 99050 (Services requested after office hours in addition to basic service).

The on-call codes do not replace physician standby service (99360). If another doctor requests that you provide prolonged physician attendance for a patient who may need attention and the service does not result in a procedure (the service does not involve any face-to-face patient contact), you should report 99360 (Physician standby service, requiring prolonged physician attendance, each 30 minutes [e.g., operative standby, standby for frozen section, for cesarean/high-risk delivery, for monitoring EEG]). Obviously, you would bill 99360 to the patient for whom the doctor was on-call.

Many coders, however, have requested information regarding whom they would bill for 99026-99027. In this regard, coders are interpreting hospital-mandated on-call service in the general sense of physician on-call duties. But this interpretation creates a billing dilemma in that no patient exists to bill the service. CPT Changes 2003 and the Coders' Desk Reference offer no further interpretations concerning how to apply the on-call codes. Therefore, until CPT Assistant further clarifies the codes, consider 99026-99027 the equivalent of 99360 when the hospital, rather than a physician, requires you to remain on-call for a specific patient. In this way, you have a specific person you can bill. If you provide physician-requested attendance at delivery for a newborn, you should report 99436 (Attendance at delivery [when requested by delivering physician] and initial stabilization of newborn).

For instance, a rural hospital does not have a neonatologist and requests that a local family physician remain on-call out of the hospital for at-risk pregnancies that may require emergency procedures, such as endotracheal intubation (31500) and bladder catheterization (e.g., 51701). If the physician assumes care, he or she would bill initial neonatal critical care (99295), which includes 31500 and 51701in addition to other procedures. The family doctor could bill 99027 per on-call hour provided to the newborn as long as the physician's services are not otherwise required. If the pregnancy occurs on a Sunday, the doctor could also bill 99054 (Services requested on Sundays and holidays in addition to basic service). Remember that 99027 applies to a hospital's request only. So, if a physician, such as an obstetrician, rather than a hospital requests the family practitioner's services, the physician would bill 99436 instead of 99027.

Answers to You Be the Coder and Reader Questions provided by Daniel Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City; Richard H. Tuck, MD, FAAP, medical director of quality care partners, PrimeCare of Southeastern Ohio in Zanesville, and founding member of the AMA's resource-based relative value scale review update committee. Special thanks to Kelly Skelly, MD, University of Iowa, College of Medicine in Iowa City, for her clinical review of this Family Practice Coding Alert.