Wiki After Hours Codes

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Kathy Leff

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Can an after hours code be billed in the following circumstance:

99051
Provider works all day in office which closes at 5PM. In the evening he takes call for the urgent care for the same provider system. Can after hours code be billed for his services after 5PM?
 
if he sees the patient in his office after hours yes but it would be the 99050 not the 99051. And it is appended to the appropriate E&M code.
 
Kathy Leff said:
Can an after hours code be billed in the following circumstance:

99051
Provider works all day in office which closes at 5PM. In the evening he takes call for the urgent care for the same provider system. Can after hours code be billed for his services after 5PM?
Click to expand...

There's more that goes into answering this, than a simple 'yes' or 'no'...

99051's description states: "Services provided in the office during regularly scheduled evening, weekend, or holiday hours, in addition to basic service."

So:
Question 1: Is he providing services in an office, or an actual "urgent care facility"? There are places labeled "urgent care", which are really just regular offices, that only treat acute illnesses, and then there are true urgent care facilities, which are essentially mini-ED's. The POS code that you bill should tell you which it is - if it's 11, then it's an 'office', but if it's 20, it's an Urgent care facility. It's important to know which you're dealing with, because the after hours service codes are only applicable to POS code 11.

Question 2: Is the office he's providing services in supposed to be open after 5:00pm? If yes, then 99051 is appropriate, but if it's not normally open during the time he's there, 99050 would be a better fit.

Question 3: Do you have any special contracts with insurers, requiring you to report after hours services with a particular code? (I only ask this, because I know providers that are contracted with a specific Medicaid MCO, to bill 99050 for all after hours services - I thought it was odd, since 99051 described the service better, but they do have the power to make their own rules, so whatever...)

99051 has begun to pay more lately, but many payers still deny it. (For example, UHC doesn't pay it: https://www.unitedhealthcareonline....taticFilesHtml/ReimbursementPolicies/AH_After Hours_v2012A.htm)

I also had a ridiculous battle with Aetna over the use of 99051, because they denied it for not having a 25 modifier on it. (I won! :D See: https://www.aapc.com/memberarea/forums/showthread.php?t=62890)

Hope that answers your question. ;)
 
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Hey Debra and Brandi, love it when the two of you answer on some of these posts. Always glean some new info, and yes I had my battle with Cigna over the same issue.
 
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