ED Coding and Reimbursement Alert

Although some coders argue that submitting for after-hours work in the ED is contrary to the mission of an emergency facility, there are several good reasons to make after-hours codes a part of your regular coding workday even if Medicare doesn't agree. If your facility decides to employ after-hours codes to report services the occur outside the "normal" work day, use codes 99050 (Services requested after office hours in addition to basic service), 99052 (Services requested between 10:00 pm and 8:00 am in addition to basic service) and 99054 (Services requested on Sundays and holidays in addition to basic service). John Stimler, DO, ACEP, founder and managing member of Bettinger, Stimler & Associates LLC in Pinecrest, Fla., has this tip for coders: Pay attention to the day of service and the time of entry. Notice the check-in time, even though it may be later than the triage time, and use that as your basis for starting the after-hours clock. The predominant school of thought, which includes the American Medical Association, holds that you can submit the after-hours codes in conjunction with the typical E/M codes for emergency care. "EDs are the true safety net for our entire healthcare system during times when our other physicians are frequently unavailable," Stimler says. After-hours codes emerged as "adjunctive codes" intended to be reported for office-based practices whose usual posted hours did not include 10:00 p.m. through 8:00 a.m. or Sundays and holidays. However, since medical practices have seen greatly increased demand for physician availability and cross-specialty interaction, Stimler and other experts agree that the use of these codes is not restricted to any specialty group, including emergency department physicians.

Billers in favor of using after-hours codes also cite CPT's mandate that "[a]ny procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified healthcare professional."

These arguments do not convince a second school of thought which includes many payers that looks to the CPT definition of an emergency room as "an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention." Since the facility must, by definition, be available 24 hours a day, it is logically inconsistent, these payers say, to bill for events that happen outside of normal operating hours. The True Cost of After-Hours Care Frontline billing experts contend that more is at stake than the definition of an ED. "Just because EDs are required to be here doesn't mean they're not providing a service," asserts Sharon Foster, clinical reimbursement manager for the Stamford Hospital Emergency Department in Stamford, Conn. In effect, EDs are covering for the physician offices and [...]