General Surgery Coding Alert

If your surgeon provides a service during "non-traditional" hours, CPT offers a way to gain additional compensation. The key to using these codes successfully is to create a win/win situation for your practice, your patients and your payers.

If your surgeon 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 report 99050 (Services provided in the office at times other than regularly scheduled office hours, or days when the office is closed [e.g., holidays, Saturday or Sunday], in addition to basic service).

When your surgeon provides an E/M service in the office during regularly scheduled "evening, weekend, or holiday office hours," by contrast, you should report 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).

Important: 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, says Tara L. Conklin, CPC, a Wesley Chapel, Fla.-based coding analyst with CodeRyte.

Signage is the key to choosing the correct after-hours code. Practices should make sure to post their office hours. That way, when a physician provides services after those hours, you can use 99050. Or assign 99051 when your office regularly schedules evening, weekend or holiday appointments, and the physician provide services during those hours.

For example: If your practice normally closes at 4 p.m. on Fridays, but your surgeon sees a patient at 7 p.m. and conducts a level-three established patient visit, you would report 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 surgeon sees the patient for the same service, you would still report 99213, but with 99051 to establish that although the service occurred after usual "business hours," the appointment was still within your posted hours.

When a 24-hour facility calls your surgeon in to provide a red-eye or early-bird service, you may report 99053 (Service[s] provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service) in addition to the basic service. Remember, however, that place of service (POS) drives this after-hours code's applicability.

Simply stated: To report 99053, the late-night service the physician provides 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).

This code can apply whether the physician is already at the facility, or whether he must make a special trip to care for the patient.

"Emergency department physicians, for instance, can bill 99053 for basically all services rendered between 10 p.m. and 8 a.m., and regularly do," Conklin says.

The American College of Emergency Physicians supports this use of 99053 and states on its Web site, "It is appropriate to apply" 99053 for late-night services, "especially given the nighttime practitioner availability costs typically incurred by all medical practices, including emergency medicine."

The AMA, Conklin further notes, also supports using 99053 this way. CPT Assistant (August 2006) offers examples of proper use both for a physician who must travel to the hospital to treat an inpatient at 2 a.m., and for an on-site emergency physician who treats a patient for severe abdominal pain in the ED at 4 a.m.

"As long as the service is provided at a 24-hour facility and the physician treats the patient between the hours of 10 p.m. and 8:00 a.m., 99053 is separately reportable in addition to the appropriate E/M code," Conklin says.

You May Have to Work for Payment

You will not gain extra reimbursement for after-hours services from Medicare or other payers that follow Medicare guidelines -- but that doesn't mean you should give up on the codes, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, consulting director of education for The Coding Institute in Naples, Fla.

Some private payers may actually prefer physicians to make use of after-hours codes. After all, Cobuzzi says, the alternative to seeing the patient after-hours in the office is to send him to the ED -- which will cost the insurer a great deal more.

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 ED visits.

Here's how: One way to reflect cost savings is to bill for after-hours codes and, if (more likely, when) the payer rejects reimbursement, write off the amount, Cobuzzi says. Over time, you can compile a record of claimed charges that lets you show the insurer in black and white how often you provide after-hours services, and how paying these services can save the insurer the much higher price of sending the patient to the ED.