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How to Code, Negotiate After-Hours Reimbursement at Your Practice


Here's why you should seek - and more importantly, how to code - reimbursement for after-hours services at your medical practice.

There are codes in the CPT® code book to report services a physician provides during "nontraditional" hours. If you prove that it’s in the payer’s best interest, third-party insurers may allow additional reimbursement for after-hours services.

Medicare and payers that strictly follow CMS guidelines will not pay additional reimbursement for after-hours services. However, you might succeed with private payers in negotiating payment for after-hours codes as part of a contractual agreement, especially if you use savings potential as leverage. Have your negotiator make it clear to the insurer’s representative that you’ll willingly send patients to the emergency department (ED) instead of offering in-office after-hours services, but that ED services can cost as much as 10 times more than comparable physician services.

To further demonstrate cost savings, you could also start billing all applicable after-hours codes for your practice. Over time, you will have compiled an archive of claimed charges, which you can use to show the insurer how often you provide these services. In this report to the insurer, consider adding data on the much higher price of ED visits for the same services.

Know the Codes

Based on the CPT®/AMA guidelines, you may report 99050 - Services provided in the office at time other than regularly scheduled office hours, or days when the office is closed (e.g., holidays Saturday or Sunday), in addition to basic service - for any service provided in the office at a time when the practice would normally be closed (e.g., weekends or evenings). Code 99050 is reported in addition to the code for the basic service.

If your practice already maintains regular hours on evenings, weekends, or holidays, and you provide a service during those times, you should skip 99050 and use 99051 - Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.

If a 24-hour facility requests that your physician provide a redeye or early-bird service, AMA guidelines allow you to claim 99053 - Service(s) provided between 10:00 p.m. and 8:00 a.m. at 24-hour facility, in addition to basic service, in addition to the basic service. Code 99053 can be used whether the provider is already at the facility, or if the physician has to make a special trip to care for the patient. The code 99053 can only be used if the service provided occurs at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency department (POS 23).

Emergency department physicians may report 99053 for services rendered between the hours of 10 p.m. and 8 a.m. The American College of Emergency Physicians fully supports this use of 99053, stating that this code is appropriate for late-night services, "especially given the nighttime practitioner availability costs typically incurred by all medical practices, including emergency medicine."

G. John Verhovshek, MA, CPC, is the managing editor for AAPC's publications. He has written, co-written, and edited dozens of coding and compliance resource manuals, including the Part B Survival Guide (1st edition) and The Official CPC Certification Study Guide (1st edition). E-mail him here.

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