Medicaid Payments for After-Hours Services

Using the 2008 Medicaid Statistical Information System (MSIS) data, we identified one biller accounting for 68 percent of the $99,822 in inappropriate Medicaid payments for after hours add-on codes. In general, we did not find a large problem with inappropriately paid after-hours add-on codes. We decided not to produce a full evaluation report and instead to provide a memorandum report.

After-hours services are not among the services that State Medicaid programs must cover, as specified in 42 CFR '' 440.210 and 440.220. Therefore, each State Medicaid program decides whether and under what circumstances providers may be reimbursed for after-hours services. Specifically, Current Procedural Terminology (CPT) codes 99050 and 99051 may be used to bill for after hours services as an "add-on" to the appropriate evaluation and management codes for a visit. CPT code 99050 is defined as "services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed, in addition to basic service." CPT code 99051 is defined as "services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service." Both codes provide additional payments to compensate providers for the additional costs associated with providing services outside of posted or normal business hours. For the purposes of this review, inappropriate payments occurred when billers were reimbursed for after-hours add-on codes for places of service not allowed by the respective State Medicaid programs.

According to the 2008 MSIS data, three States-North Carolina, Kentucky, and Massachusetts-made 77 percent of the $8.1 million total in payments for after-hours add-on codes. Nationwide, 6 of the 3,228 billers that billed for after-hours add-on codes were responsible for more than 12 percent ($1 million) of the payments for these codes, and 46 billers were responsible for 50 percent of all such payments. Twenty-one States inappropriately paid $99,822 for after-hours add-on codes. One biller in the State of Kentucky was inappropriately paid $68,317, or 68 percent of all inappropriate payments.

We are issuing our memorandum report directly in final form because it contains no recommendations. However, CMS may want to work with the Kentucky State Medicaid program and make States aware of the issues identified in this report to prevent billers from seeking inappropriate additional reimbursement for evaluation and management services.