Urology Coding Alert

Staying open late isn’t just a patient convenience it can bring in cash, too.

If your practice is open during “non-traditional” hours or your urologist provides after-hours services to a patient, and you aren’t billing for those “extra” services, your practice may be missing out on additional reimbursement.

To make sure you’re bringing in every dollar your urologists deserve, you need to know the proper codes to bill for after-hours services, as well as what qualifies as “after-hours.”

Let the Clock Determine 99050 vs. 99051

If your urologist sees a patient in the office during hours when the practice would normally be closed, such as on weekends or after 6 p.m., CPT guidelines allow you to bill +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) as long as the documentation supports the after-hours service, says Jetton Torix, CCS-P, CPC-H, course director of Knowledge Source Seminars in Star, Idaho.

Keep in mind: A patient is considered an after-hours patient only if he reports to the office after your normal office hours end -- not when he presents during normal office hours and the appointment runs past closing time.

When your urologist provides an E/M service in the office during regularly scheduled “evening, weekend, or holiday office hours,” by contrast, you should bill 99051 (Service[s] provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service), according to AMA guidelines outlined in the CPT Assistant (Vol. 13, Issue 6, June 2003).

Key: Whether you select 99050 or 99051, you would report the after-hours code in addition to the appropriate E/M service code for the visit. These codes are add-on codes and therefore require you to bill them only in addition to the base E/M codes, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network. Do not base your billing of 99050 and 99051 on the patient’s diagnosis. These codes simply require that your office have posted evening, weekend, and holiday hours and the physician provide the basic service (such as 99201-99245) during those times.

Scenario: Your practice normally closes at 4 p.m. on Fridays, but your urologist sees a patient with flank pain and pain during urination at 7 p.m. The urologist conducts a level-three established patient visit. You should bill 99213 (for the E/M) and 99050 (for the after-hours visit). If, however, your practice is normally open during evening hours (say, until 9 p.m.), and the physician sees the patient for the same service, you would still bill 99213, but with 99051 to establish that although the service occurred after usual “business hours,” the appointment was still within your practice’s posted hours.

Use 99058 for Emergent Situations

If a patient’s condition requires your urologist to interrupt his schedule to provide emergent care to the patient, you could report 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) in addition to the office visit code. You can report this code with 99050 or 99051 in addition to the E/M code, if the clinical circumstance warrants.

“The code 99058, to my understanding, should be used when a patient comes into the doctor’s office with an emergency situation that basically stops or disrupts the entire flow of the office,” explains Kathleen Goodwin, CPC, coding coordinator for La Porte Regional Physician Network in Indiana.

“This could be [when] the patient presents on his own or another physician office calls saying the patient needs to be seen ASAP and they are sending the patient over,” Torix says. “Once again the documentation has to support this,” before you report 99058, she adds.

Example: During regular Saturday morning office hours an established patient comes to your urologist’s office because of a traumatic 2-inch laceration of his scrotum following a bicycle accident. The physician assesses the injury as soon as the patient arrives and decides that immediate treatment is necessary.Without delay, the urologist proceeds with the scrotal repair under local anesthesia. In this particular scenario, because of the nature of the patient’s injury, your physician interrupted his scheduled appointments to treat this patient as soon as he arrived in the office. In this case, you could bill the following:

• 99213-25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) with ICD-9 diagnostic codes 959.14 (Other injury of external genitalia) for the scrotal injury evaluation and E826 (Pedal cycle accident) indicating the circumstances that caused the injury. You should list the E code last. That code is not mandatory for payment but is informational in nature.

• 99051 for the Saturday morning treatment

• 99058 for the emergency-based service

• 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) for the repair of the superficial scrotal laceration.

No Payment Doesn’t Mean No Billing

Many payers, including Medicare, do not reimburse you for these after-hours codes. Additionally, even if a payer does pay for after-hours claims, they may not reimburse you for multiple special service codes on one claim.

“Medicare won’t pay on any of these codes,” Goodwin agrees. “This seems backward. If the patient goes to the hospital instead of the doctor’s office, Medicare winds up paying more. Why wouldn’t they want to encourage doctors to offer these additional services?”

Some private payers may actually prefer physicians to make use of after-hours codes. After all, experts say, the  alternative to seeing the patient after hours in the office is to send him to the emergency room, which will cost the insurer a great deal more (facility fees, physician fees, radiology fees, anesthesia fees, etc).

Best bet: A number of coding experts suggest negotiating payment for after-hours codes with private payers as part of any contractual agreement, and you can use the cost-saving argument as leverage. You should devise a simple, specific scenario to demonstrate to the insurer the cost savings of paying after-hours codes versus emergency room visits.

Remember: Just because a payer doesn’t reimburse you on a code you bill, that doesn’t mean you should stop billing that code, Torix says. “I recommend that if there is a code for the service being preformed that it be coded, as the codes being used go into the data banks,” she explains.

“That is our way of letting the insurance companies know what services are actually happening.”

Downside: “The problem with billing these to the insurance is that it jacks up the A/R and contractuals. Those numbers never look good to administration,” Goodwin says. “[However], I believe they should be reported. Even if we enter a zero charge and don’t bill it to the insurance. This way we can track the amount of additional services we provide internally. When it comes time to renew our contracts, we could use that information to help negotiate a better rate for our regular office visits by showing the carrier how much we saved them by the patient not going to the ER. Or maybe the carrier would want to reconsider paying for those codes.”

You should bill for after-hours codes, and when the payer rejects reimbursement, write off the amount with an adjustment code specific to that special service code. Then, compile a record of these charges and write-offs to show the insurer in black and white how often you provided these after-hours services, and how much the insurer would have saved by not having to pay for the higher costs of the same patients being treated in the emergency department, Cobuzzi suggests. In addition,

when an insurer sees that physicians are using a particular code, they are more apt to assign a fee to that service.