Practice Management Alert

If your practice is open during "non-traditional" hours, or your physician provides after-hours services to a patient, and you aren't billing for those "extra" services, your practice may be missing out on additional reimbursement.

To make sure you're bringing in every dollar your physicians deserve, you need to know the proper codes to bill for after-hours services, as well as what qualifies as "after-hours."

If your physician 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 bill 99050 (Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed [e.g., holidays, Saturday or Sunday], in addition to basic service) as long as the documentation supports the after hours service, says Jetton Torix, CCS-P, CPC-H, course director of Knowledge Source Seminars in Star, Idaho.

Keep in mind: A patient is considered an after-hours patient only if he reports to the office after your normal office hours end -- not when he presents during normal office hours and the appointment runs past closing time. When your physician provides an E/M service in the office during regularly scheduled "evening, weekend, or holiday office hours," by contrast, you should bill 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).

Key: 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. These codes are add-on codes and therefore require you to bill them only in addition to the base E/M codes, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network.

Do not base your billing of 99050 and 99051 on the patient's diagnosis. These codes simply require that your office have posted evening, weekend, and holiday hours and that the physician provide the basic service (such as 99201-99245, Office or other outpatient visit...) during those times.

Scenario: If your practice normally closes at 4 p.m. on Fridays, but your physician sees a patient at 7 p.m. and conducts a level-three established patient visit, you should bill 99213 (for the E/M) and 99050 (for the afterhours visit).

If, however, your practice is normally open during evening hours (say, until 9 p.m.), and the physician sees the patient for the same service, you would still bill 99213, but with 99051 to establish that although the service occurred after usual "business hours," the appointment was still within your practice's posted hours.

If a patient's condition requires your physician to interrupt his schedule to provide emergent care to the patient, you could report 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) in addition to the office visit code. You can report this code with 99050 or 99051 in addition to the E/M code, if the clinical circumstance warrants.

"99058 is used in the office when a patient presents for urgent care and it disrupts the office schedule," Torix explains. "This could be [when] the patient presents on his own or another physician office calls saying the patient needs to be seen ASAP and they are sending the patient over. Once again the documentation has to support this," before you report 99058, she adds. Also, make sure that the physician is seeing the patient for an emergent problem, being fit in due to that problem, without an appointment, Cobuzzi cautions.

Example: A patient who fell from his bike comes into your office during your office's regular Saturday office hours. The physician assesses a head injury and repairs a 2.3 cm leg laceration. Because of the nature of the patient's injuries, the physician interrupts his schedule to treat this patient as soon as he arrives. In this case, you could bill the following:

• 99213-25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) with 959.01 (Injury, other and unspecified; head injury, unspecified) for the head injury evaluation and E826 (Pedal cycle accident)

• 12031 (Repaid, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less) linked to 891.0 (Open wound of knee, leg [except thigh], and ankle; without mention of complication) and E826

• 99051 with 959.01, 891.0, E826 for the Saturday treatment

• 99058 linked to 891.0 and E826 for the emergencybased service.

Many payers, including Medicare, do not reimburse you for these after-hours codes. Additionally, even if a payer does pay for after-hours claims, it may not reimburse you for multiple special service codes on one claim.

Some private payers may actually prefer physicians to make use of after-hours codes. After all, experts say, the alternative to seeing the patient after hours in the office is to send him to the emergency room, which will cost the insurer a great deal more (facility fees, physician fees, radiology fees, anesthesia fees, etc).

Best bet: 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 emergency room visits.

Remember: Just because a payer doesn't reimburse you on a code you bill, that doesn't mean you should stop billing that code, Torix says. "I recommend that if there is a code for the service being preformed that it be coded, as the codes being used go into the data banks," she explains.

"That is our way of letting the insurance companies know what services are actually happening."

You should bill for after-hours services using the after-hours codes, and when the payer rejects reimbursement, write off the amount with an adjustment code specific to that special service code. Then, compile a record of claimed charges and write offs, based on the adjustments, 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 cost of sending the patient to the emergency department, Cobuzzi suggests. Plus, when an insurer sees that physicians are using a code, they are more apt to assign a fee to that service.