ED Coding and Reimbursement Alert

Read on for a review of how to use this code and get the lowdown on its reimbursement reality.

As an ED Coder, you know this site of service is not like other outpatient venues, because we never close. That lack of down time creates added expense, but you may be able to recapture some of those costs. Many industries have long acknowledged--and paid--shift, weekend and holiday differentials to fill staffing needs during less favorable hours including nights and weekends. Hospitals have a lengthy history of paying nurses additional salary incentives to work unpopular shifts. Likewise, CPT® has long recognized additional physician services beyond the scope of standard office hours via Special Services codes. Through the years, CPT® has refined these special service codes to specify physician on-call and after-hours services by location.

There is one code that specifically applies to Emergency Medicine says Betty Ann Price, BSN, RN President and CEO of PRCS, Inc. in Palmetto, Florida. CPT® 99053 (Services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service)

99053 is an adjunct service code that is reportable in addition to the basic Evaluation/Management Level; you should never report it without also capturing an E/M Level. The code is located within Special Services, Procedures and Reports in CPT® and is used to describe special circumstances under which physician services are performed. See this clinical example from CPT Assistant®:

A patient arrives at the emergency department of a 24-hour facility at 4:00 AM and is treated by the physician for severe abdominal pain. CPT® code 99053 is reported in addition to the basic service. (CPT Assistant®, Vol. 16, Issue 8, Aug. 2006)

Have a Consistent Policy in Place

Price offers these tips for use of 99503. Clock time should be clearly documented for services provided between 10:00 PM and 8:00 AM. Be consistent by choosing a standard start time for appropriate capture of these services. Some practices choose time of registration, while others capture triage time or the time a physician begins evaluating the patient as the standard to appropriately capture 99053. Any of these options are appropriate. The key is to be consistent, she says.

Medicare has not assigned relative value units (RVU) for 99053. As a result, Price explains, there is no Medicare reimbursement for the special service code, and other payers have similarly adopted non-payment status. Some billers have reported success obtaining payment for 99053 by working with their local payers to demonstrate increased overhead costs paid for physician staffing during the hours of 10:00 PM-8:00 AM, she adds.