Orthopedic Coding Alert

Overbooked Practices May Not Count

You should not report after-hours codes if scheduled patients remain in the waiting room after normal business hours due to delays or overbooking. For instance, if a patient scheduled for a 4:45 p.m. appointment doesn't see the orthopedist until 5:15 - 15 minutes after the office normally closes - you can't report the service as an "after-hours" visit.
 
No insurer will accept an after-hours claim just because the physician was running behind, Davis says. "If you make an extended effort to keep the doors open for the patient, then use the codes." The physician overbooking his schedule, however, does not warrant the use of after-hours codes.
 
You should use 99050-99054 only if the physician sees a patient for an unscheduled appointment at a time when his or her office would otherwise be closed. For instance, a patient with a scheduled spinal fusion procedure calls 10 minutes before the office closes, complaining of extreme back pain after a fall. Concerned that the patient may have an injury that would preclude surgery, the surgeon advises the patient to come to the office immediately. The patient arrives 40 minutes later. In this case, you may appropriately report 99050.
 
If, however, you've known all along that the patient was planning to arrive after hours, you should not report the codes. "One of our patients often gets bursitis (726.5, Enthesopathy of hip region) flare-ups at the end of her workday, and she comes in for an injection (20610*, Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) to ease the pain," says Lois Clayden, office manager at the Bone and Joint Clinic in Indiana. "A lot of times, she doesn't make it into the office until we're about to leave, and we end up staying late to treat her." Clayden does not report the after-hours codes for this type of arrangement, because she expects the patient to arrive at the same time each day.

Never Report After-Hours Codes Alone

Note that in all cases, the after-hours codes should be reported in addition to any other services provided, including E/M services. According to the November 1997 CPT Assistant, "These codes [special services codes, including 99050-99054] are an adjunct to the basic service(s) rendered ... they are intended to be reported in addition to the basic service(s) provided." Therefore, never report 99050, 99052 or 99054 alone.
 
You should not report after-hours codes for hospital visits, regardless of whether the surgeon is on-call. Even if the surgeon is called to the hospital for emergency surgery on a trauma patient at 2 a.m., you may not report after-hours code 99052.
 
Don't Report After-Hours Codes to Medicare

Medicare and Medicaid do not recognize the after-hours codes, and bundle them into any other services that you provide. Blue Cross/Blue Shield of North Dakota, a Part B Medicare Carrier for four states, notes in its local medical review policy (LMRP), "Certain codes ... are considered by CMS to be 'bundled' services. Bundled services are not payable, nor should they be billed, even when performed incident-to or with a separate service."
 
Codes 99050-99054 are specifically included in this group. The LMRP further states, "When services designated as bundled are denied, the physician may not collect from the patient or the patient's supplemental insurer for the denied service."

Negotiate With Private Payers

Some private payers recognize the after-hours codes, but guidelines are inconsistent. CMS assigns no relative value units to 99050-99054, so payment can vary dramatically. "Insurers who reimburse for these codes usually pay about $30 for them," Davis says.
 
A number of coding experts suggest negotiating payment for after-hours codes with private payers as part of any contractual agreement. Unlike Medicare, private payers may prefer that physicians use after-hours codes. The alternative to seeing the patient after hours in the office is to send him or her to the emergency department (ED) - which will cost that insurer even more. Use this as leverage when negotiating with payers.
 
You should use caution to avoid overusing after-hours codes, and to reserve them for truly urgent situations. Otherwise, commercial payers could stop paying for them if they think they're being abused.