Eli's Rehab Report

Published on Sun Oct 01, 2000 PDF

Over the past several years, many physical medicine and rehabilitation (PM&R) practices have started extending their office hours to accommodate patients who work late. As they do this, however, some are falling for the lure of the after-hours codes (99050, 99052, 99054). Were going to be open late now, they say. That means we can charge extra using the after-hours codes. Wrong. In most cases, practices cannot use after-hours codes when their offices would be open anyway.

There are three basic after-hours codes:

CPT 99050 services requested after office hours
in addition to basic service,
99052 services requested between 10:00 p.m.
and 8:00 a.m. in addition to basic services, and
99054 services requested on Sundays and holiday in addition to basic services .

Appropriate use of these codes hinges on the definition of the phrase after hours. If your practice always is open until 9:00 at night, you cant bill the after-hours codes for a patient who comes in at 8:30, says Sue Magalnick, president of Doctors Resource Specialists, a medical practice management and reimbursement consulting firm in Phoenix. You can bill the after-hours codes only if the visit is after your normal practice hours.

A sciatica (722.10 , displacement of thoracic or lumbar intervertebral disc without myelopathy) patient phones the PM&R office at 4:45, stating that she is experiencing severe lower back pain and that her left hip is almost immovable. Although your office normally closes at 5:00, you stay late to see the patient, who arrives at 5:15. The physiatrist performs an evaluation and gives the patient an epidural cortisone injection (62311) to reduce inflammation and ease the patients pain. The physiatrist bills 62311 for the injection and the established E/M code 99213 with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that the epidural injection is separate from the E/M code. In addition, the physiatrist bills 99050 to reflect the time spent with the patient after hours.

The after-hours codes are add-on codes, says Magalnick. Its common for practices to make the mistake of billing just the 99050 and not billing it as an add-on.

Magalnick advises that the Sunday code (99054, services requested on Sundays and holidays in addition to basic service) is an exception because you may bill for Sundays and holidays even if your practice has published office hours on Sundays and/or holidays.

Getting Paid Can Be Tricky

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]) after work to ease the pain, says Lois Clayden, office manager at the Bone and Joint Center in Chicago, a multispecialty practice with one physiatrist, three rheumatologists and an orthopedist. A lot of times, she doesnt make it into the office until were about to leave, and we end up staying late to treat her. But we dont bill the after-hours codes because a lot of insurers wont pay for them.

Most Medicare carriers dont cover the after-hours codes, although many Medicaid carriers do recognize them as a way to keep patients out of the emergency room. These codes should be used for sick patients only, says Magalnick. If you had a patient come in for a well visit after hours, insurance probably would deny it.

Why HMOs Like After-hours Codes

Several HMOs are strongly in favor of the after-hours codes. Some managed care providers will provide extra capitation points for these codes, depending on the plan and how they structure it, says Magalnick. Aetna U.S. Healthcare uses a Quality Factor to adjust member primary care physicians capitation points, which includes advantages for physicians who are open additional hours and who care for more than the expected number of seriously ill patients.

Regardless of how your private insurers cover after-hours codes, you should use them anyway. It helps build a case at the insurance carrier for future reimbursement. Also, its correct coding to bill for every service your practice provides.

Note: Many third-party carriers, including Medicare, do not allow billing for uncovered services. Check your local Medicare policy before submitting charges for any after-hours codes.

Its OK to bill these codes, and practices shouldnt be afraid to use them, says Magalnick. If you bill for the services you perform, and after-hours codes are the exception rather than the norm, you shouldnt have a problem. If a patient disrupts your schedule and you have to treat him or her because the problem is urgent, you should bill extra. You took care of the patient when he or she needed it. You shouldnt be afraid of audits as long as youre billing just for what you do and you can substantiate the medical necessity. And, reminds Magalnick, physicians must document why they are seeing the patient after hours, and what type of services they perform.