Pulmonology Coding Alert

Find out which of these new codes you should use to gain reimbursement

If your pulmonology practice stays open every evening, you're in luck. CPT 2006 opens the door to coding special services when a physician has scheduled evening or Saturday hours, as well as when he provides late-night services at a 24-hour facility.

CPT revamped the special services, procedures and reports subsection. "The new and revised codes give coders more options to describe the services their practice provides," says Kim Kieke, CPC, a coding quality specialist at a multi-specialty clinic with over 60 physicians in Austin, Texas. Changes include:

Deletions

• 99052--Services requested between 10:00 PM and 8:00 AM in addition to basic service

• 99054--Services requested on Sundays and holidays in addition to basic service.

Additions

• 99051--Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service

• 99053--Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service

• 99060--Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service.

Revisions

• 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

• 99056--Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic service

• 99058--Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service.

Use 99051 for Posted Nontraditional Hours

You can now use 99051 for services provided during posted evening, weekend and holiday hours. "Some payers allowed coders to use 99050 when a clinic provided services outside traditional office hours," Kieke says. Insurers sometimes understood the cost-saving benefit of treating a patient in an office setting as opposed to the emergency department and applied 99050 more liberally.

CPT 2006's new code 99051, however, more appropriately describes the special service. "We never had a code to use for after traditional business hours," Kieke says.

How it works: A non-24-hour practice is open evenings, Saturdays and holidays. When a pulmonologist provides an E/M service during these times, you should report new code 99051 for a service "provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service."

Old way: Because the office had posted Saturday hours, 99050 would not have accurately described the special service. "CPT's creation of 99051 recognizes medical care's move toward more extended hours of operation," Kieke says.

Alternative: If your office operates on a traditional schedule--Monday through Friday 9 a.m. to 5 p.m.--you can report services provided outside those hours and days with revised code 99050.

Capture Late-Night Facility Services With 99053

You can use another new special service code when your pulmonologist is called in to provide a red-eye or early-bird service at a 24-hour facility. "Code 99053 replaces deleted code 99052 and adds the facility stipulation," says Tina Landskroener, CCS-P, CPC, senior director of compliance at Quincy Medical Group in Illinois.

Code 99053's inclusion of "24-hour facility" imposes a new limit on the late-night service code. If a physician met a patient in the office between 10 p.m. and 8 a.m., you could previously report a special service with 99052, Landskroener says. "CPT attached no place of service (POS) to the code."

New method: The POS drives the after-hours code's applicability. For you to report 99053, the service must occur at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency department (POS 23), Landskroener says.

Don't assume that you may automatically assign 99053 for all late-night services at 24-hour facilities. "CPT intends the code for situations in which the physician has to make a special trip in to provide the service," Landskroener says. If the physician provides late-night care as part of his normal job responsibilities, you should not use 99053.

Count Schedule Interruption as Emergency

The trend toward greater specificity for special service codes marches on with the AMA's clarification of an emergency. When a practice allows walk-ins and works them into the daily schedule, it was unclear whether the encounter met the requirements of an emergency service code. "The term 'emergency basis' was always the confusing part of 99058," Landskroener says.

Code 99058's revised text now defines a service on an emergency basis as one that "disrupts other scheduled office services."

Caution: Don't use 99058 for services at an urgent care facility. "Because we routinely take patients on a walk-in emergency basis, we never use the emergency service code," says Kathy Williams deHaan, clinic manager at West Park Hospital's Urgent Care Clinic in Cody, Wy.

Also: If a pulmonologist has to interrupt his schedule to provide services outside the office, use new out-of-office emergency code 99060.

Tip: Before beginning to use these codes, you must check to see if the insurer accepts them. Creation of special service codes does not guarantee use or payment. If the patient has Medicare or an insurer that follows Medicare guidelines, these services are integral to standard E/M codes and you cannot report them separately.

Private insurers may have contracts that prevent providers from billing them or their beneficiaries for these special services. More important, if the insurer does not pay for these codes but allows you to directly bill the patient for these additional fees, the patient may be upset. This potentially compromises the physician-patient relationship and sets the practice up for negative publicity.