How to Code for After Hours Visits and other Special Encounters

by | Published on Nov 16, 2017 | Medical Coding News (A), Resources | 0 comments

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After-hours health care services improve revenue and increase satisfaction among patients, office staff and physicians. This is especially relevant in primary care and pediatric practices as children’s illnesses and injuries always seem to occur at an odd time, usually after business hours. As a medical billing company, we are well aware of the fact that payer cooperation is crucial to enhancing patients’ access to after-hours care. To get paid for these services, physicians should use specific “add on” CPT codes that can help describe an encounter’s special or unusual circumstances.

CPT Codes for After-hours Visits

AMA/CPT guidelines provide the codes that should be used to report after-hours care are:

  • 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
    • 99050 should be reported only for services provided in the office at a time when the practice would normally be closed (such as weekends or evenings).
    • It is not reported when the office is open for emergency appointments (i.e., walk-ins) before or after regularly scheduled appointments.
    • It is reported in addition to the code for the basic service.
  • 99051 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service
    In addition to the code for basic service, the practitioner should use 99051 if the practice already maintains regular hours on evenings, weekends, or holidays, and provide a service during those hours.

    • According to the American Academy of Pediatrics (AAP), as a general rule, a “holiday” can be considered a federal holiday, and appointments “when evening begins” as any appointment after 6 p.m.
    • CPT does not define what represents a holiday or when evening begins, but providers should check with payers to ascertain how they perceive these terms.
    • 99051 can be appended to preventive services that are provided during the designated times.
  • 99053 Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service
    The circumstances in which this code can be used are:

    • The physician provides a redeye or early-bird service based on the request by a 24-hour facility.
    • It can be used whether the provider is already at the facility, or if the physician makes a special trip to care for the patient.
    • The after-hours care should be provided at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency department (POS 23).
    • If the facility is not open 24 hours, 99053 is not applicable.
      Code 99053 can also be used by emergency department physicians to report services rendered between the hours of 10 p.m. and 8 a.m. The American College of Emergency Physicians supports the use of this code for late-night services, “especially given the nighttime practitioner availability costs typically incurred by all medical practices, including emergency medicine.”
  • 99056 Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic service
    This code is used when the physician is requested to see a patient outside the office, but the encounter does not disrupt any encounters in the office.
  • 99058 Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service
    The AAP provides the following guidelines for the use of this code by primary care physicians:

    • It is reported only when the patient’s medical condition requires the physician to disrupt what he/she is doing to attend to the patient.
    • It is not reported when a patient (or sibling) is “squeezed into” the schedule unless it meets the criteria.
    • 99058 is not reported for “same-day” appointments that are set aside unless it meets the criteria.
    • This code should be supported by the diagnosis code that is linked to it.
  • 99060 Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service

Points to note:

The AAP says that primary care providers using after-hours care codes should note the following:

  • Each code is reported in addition to other services provided at the encounter.
  • Each can be reported in addition to any service (does not require an evaluation and management (E/M) service).
  • These codes do not require a modifier (as the code already states “in addition to basic services”).
  • Each code can be reported with other special services (no modifier is required).

A 2012 study published in the Journal of General Internal Medicine found that after-hours care coordinated with primary care is facilitated by consideration of patient demand, provider capacity, electronic health record sharing, systematic notification procedures, and a broader practice approach to improving primary care access and continuity. The researchers note that continuity of primary care, including care received at a time outside of usual business hours, is linked to improved patient outcomes and lower emergency department (ED) use for non-urgent problems. Ensuring after-hours care for patients can also save money as ED visits cost more than primary care visits.

While after-hours care offers many benefits for patients, physicians should also receive appropriate payment for their services. As per CPT, special services codes can be reported by any physician/other qualified health care professional, but third party payers may have different rules. Medicare and private health insurance companies that strictly follow CMS guidelines do not pay additional reimbursement for after-hours services.

An article in Physicians Practice says that third-party insurers may allow additional reimbursement for after-hours services if physicians can prove to them that it is in their best interest. The report recommends these strategies to get paid for services provided during “nontraditional” hours:

  • Providers can negotiate payment with private payers for after-hours codes as part of a contractual agreement.
  • They must also demonstrate the cost savings of after-hours care provided in practices. To get paid, they should inform the insurance company that the patient could have been sent to ED instead of being treated in-office after business hours, but that the cost of ED services is much higher than comparable primary care services.
  • Providers can start billing all applicable after-hours codes their practice. They can then compile an archive of claimed charges and show this to the insurer to demonstrate the frequency of these services.
  • When reporting after-hours services to the insurer, providers can provide a comparison of the price of ED visits and the price of the same services in their practice.

Reporting these special services correctly is much easier with help from an expert. Experienced coders in medical billing and coding companies are knowledgeable about CPT rules as well as the different billing requirements of third-party payers. A reliable medical coding service company can help providers get the reimbursement they deserve.

Outsource Strategies International.

Being an experienced medical billing and coding company in the U.S., OSI is dedicated to staying abreast of the latest industry guidelines. Our services provide comprehensive support for the success of your practice.

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