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Practice Management Alert

Coding and Billing:

Know the Ins and Outs for These Special Services

Don’t let money walk out the door in situations where the coding guidance may be hazy.

There are six after-hours/special services codes in the Special Services, Procedures, and Reports section of CPT®. Four of these codes tend to present a challenge for coders because of the vagueness of guidelines or the inexplicit code descriptors.

Check out the following examples and guidance before you next utilize those adjunct codes.

Use 99050 for These Situations

Perhaps the biggest source of confusion occurs when you try to decide when to apply 99050 (Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service) or 99051 (Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service) for services outside of regular office hours or during holidays.

For example: Your office has posted hours of 8:00 a.m. — 6:00 p.m. Monday through Friday, and 8:00 a.m. — 12:00 p.m. on Saturdays. Your provider then sees a patient at 2:00 p.m. on Saturday afternoon. Which code would you use in addition to an evaluation and management (E/M) service code from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …)?

In this scenario99050 would be the correct code choice, as the physician provided the service after the practice had closed.

Coding top tip: “You can only use 99050 for patients scheduled outside of your posted business hours,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “So, it will not apply for a patient who was scheduled, say, for 4:00 p.m. on a weekday but not seen by the provider until 6:30 p.m. on that day.”

Avoid 99050 for Scheduled Hours

Whenever your provider sees a patient during regularly advertised hours, however, 99050 cannot apply. Instead, you will need to use 99051 whenever your provider sees a patient during evening, weekend, or holiday hours that the practice has posted. This is true even if those hours are temporary, such as extra hours that have been added on to your regular schedule for, say, flu shots or when your office decides to stay open for a holiday such as July 4.

For example: Your office regularly keeps the hours listed above. However, in November and December, you decide to stay open until 9:00 p.m. on Mondays and Wednesdays, primarily to provide flu shots. Because the hours have been posted, you will not be able to use 99050 for patients seen during those hours. Instead, you would use 99051, as the hours are regarded as part of your schedule, even if that schedule is only temporary for the months of November and December.

Coding top tip: CPT® offers no clear definition of what constitutes evening hours. However, “evening hours are generally regarded as any time after 6:00 p.m. and before 8:00 p.m.,” says Falbo.

Use These Codes For These Emergencies

Suppose your provider is called upon to treat a patient in an emergency situation. Coding 99058 (Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) or 99060 (Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service) if the physician has to leave the practice seems pretty logical.

But exactly what constitutes an emergency? And how disrupted does your schedule have to be before you can use the codes?

Again, CPT® offers no clear guidance for you in either situation. It is for those office patients whose condition, in the clinical judgement of the physician, warrants the physician interrupting his/her care of another patient to deal with the “emergency.” But coding “99058/99060 means that the patient’s condition is such that they have to be seen immediately while other scheduled patients have to wait until the emergent situation is resolved,” says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin.

Coding top tip: “Some payers will pay for 99058/99060, and others will not. The ones that do pay most likely will pay 99058, because they figure it is less expensive for an emergency to be seen in an office setting rather than in a facility emergency room, where there will be a facility fee in addition to the physician charge,” says Rasmussen.

Prioritize Service Codes First

Finally, before you reach for any of these codes, remember to follow CPT® guidelines, which state that the codes enable you to record “special reports and services that are an adjunct to the basic service rendered.” In other words, you must first report a code, or codes, that reflect the service or services your provider performed before you add a code from 99000-99082 to describe any context for them.