Primary Care Coding Alert

Test your coding knowledge.  Determine how you would code this situation before looking at the box below for the answer.
Question: Our group has a pediatric night clinic for the convenience of the families of our patients. We regularly assign 99050 for evening appointments, but last week I was told it shouldn't be used if these appointments occur during posted office hours -- even when the office hours are unusual. Are we using this code correctly?

Illinois Subscriber   Answer: No, the information you recently were given is correct. The so-called "after hours code" is not to be used for patient encounters that occur during regularly scheduled office hours, no matter when those hours are offered. Many practices routinely advertise and make available evening or Saturday morning appointments for the convenience of their patients.

E/M services or other procedures performed during those times should not be coded with 99050 (services requested after office hours in addition to basic service), but should instead be reported with only the appropriate CPT or HCPCS code.

CPT 2001 offers a number of after hours codes that may be assigned, depending on the time and location of the patient encounter. All are used when a patient contacts the practice's on-call physician, who then meets the patient at the office for a face-to-face encounter. These codes are reported in addition to whatever E/M or procedure code is used to describe the services performed. Code 99050 is used for Saturday or early evening visits occurring after the office is closed for the day. Code 99052 describes late-night services, between 10 p.m. and 8 a.m., while 99054 is assigned for encounters taking place on Sundays and holidays.

For example, a parent contacts the on-call physician at midnight about a child with a high fever and severe diarrhea. The physician agrees to meet the family at the office, to determine if the child is in danger of dehydration. Depending on the extent of the visit and the documentation, the physician would report the E/M code (e.g., 99213) and 99052.

Finally, related code 99056 is defined as services provided at request of patient in a location other than physician's office which are normally provided in the office. This code may be assigned in addition to the appropriate home service code (e.g., 99348), for instance, if the physician needs to visit the patient's home during the night or on the weekend because the patient has no transportation to the office.

Payment for these after-hours codes varies greatly from payer to payer. Some accept these codes, while others don't recognize them. Coders should check with individual insurers about their policies.