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: We provide "urgent care hours," which become effective 5-8 p.m. The majority of carriers deny 99050 (Services requested after office hours in addition to basic service) and 99054 (Services requested on Sundays and holidays in addition to basic service) when billed with E/M services, stating we cannot bill the patient due to our PPO contract. How do we get paid for these extra hours? North Carolina Subscriber Answer: Two separate issues need to be addressed here. The first is the appropriate use of codes 99050 and 99054. These codes are adjunct codes reported in addition to the E/M code for the basic service provided when that service is provided at times other than regular posted office hours with scheduled staff and physicians. Your question implies that the "urgent care hours" are a regularly scheduled and staffed expansion of physician availability through extended office hours. Therefore, it would be inappropriate coding to additionally report code 99050 in this scenario.An example of appropriate use is a physician opening his "closed" office, outside of posted office hours, to treat a patient at the patient's request. It would be appropriate to code 99054 if a patient is treated in the office on a Sunday or holiday and there are no scheduled "urgent care hours" for Sundays and holidays. The second issue is how to get paid for appropriate use of these codes. You must honor your contracts with third-party payers. If they do not recognize these codes, and your contracts prohibit you from billing the patient, you must abide by your contractual agreements. However, you can try to educate your contracted insurers by filing appeals with supporting documentation for your appropriate use of these codes. Answered by Marie Felger, CPC, an American Academy of Professional Coders (AAPC) certified coding instructor with Joy Newby & Associates Inc. in Indianapolis.