Pediatric Coding Alert

The after-hours codes (99050-99054) can help pediatricians increase their reimbursement when providing services after the office is normally closed. These codes, however, cannot be used for evening or weekend visits, if the office is regularly open then. They should be used when services are provided and the office is not open.

But what about cases in which the pediatrician goes to the hospital in the middle of the night to attend a delivery, for example? Can you use an after-hours code? Some pediatric coding experts say yes, but Medicare coding experts say no.

Charles Schulte, MD, FAAP, CPT advisor for the American Academy of Pediatrics, states that, at least in theory, you should be able to use the after-hours codes for inpatient visits. I dont see anything in CPT Codes that keeps after-hours codes for outpatient, he says. But he does think that insurance companies might pick up on the fact that the place of service the hospital is open 24 hours a day. The hospital is never closed, so its never after hours there.

Dari Bonner, CPC, CCS, CCS-P, says the after-hours codes were never meant for hospital use. Bonner, president and owner of Xact Coding & Reimbursement Consulting in Port Saint Lucie, Fla., agrees with Schulte that there is no after hours in a hospital, so the phrase after hours does not apply. But theres more to it than that working in a hospital at any hour of the day doesnt warrant extra reimbursement, Bonner says. If you get called in to the hospital in the middle of the night, thats part of the job, she says. You cant be paid extra for doing that.

After-hours codes are important for pediatricians, Bonner notes, because commercial payers do pay for these codes. But pediatricians need to be careful with these codes, the consultant says. Commercial payers could stop paying for them if they think theyre overused.

Regardless of whether a payer will reimburse for the after-hours codes, if you go to your office in the middle of the night to see a patient, you should report the after-hours codes, Bonner says. Its a good tracking mechanism, she says. For example, seeing the febrile infant in your office at 3 a.m. can prevent a trip to the emergency room which makes both the mother and the insurance company happy and it can also be used in negotiations with that insurance company later. The pediatrician can show that by providing after-hours care, he or she saved the payer money by keeping the patient out of the emergency room and therefore should get [...]