After-Hours, Emergency, and Miscellaneous E/M Services - Professional and Facility
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Defines Anthem's reimbursement rules for separate payment of after-hours E/M services for professional providers and notes restrictions for facility billing; applies to commercial lines and providers submitting claims to Anthem.
Note: After-hours services are not eligible for reimbursement to facility providers when billed on a UB-04 form.
Policy updated to apply to both professional and facility providers; no longer allows separate reimbursement for claims billed with POS 20, nor facility providers (prior revision history).
After-hours Reimbursement Criteria
After-hours reimbursement criteria
Covered when ALL of the following are met:
ALL of the following
ALL of the following
- Billed by a professional provider on a CMS-1500 form
- Billed with an office place of service (POS 11)
ALL of the following
- Rendered between 5:00 p.m. and 8:00 a.m. on weekdays
- Rendered anytime on weekends (eligibility based on patient arrival time, not when the service commenced)
- If a holiday falls on a weekday, the 5:00 p.m. to 8:00 a.m. weekday rule applies; if a holiday falls on a weekend, the weekend rule applies
ALL of the following
Eligible codes
- CPT 99050 — services provided in the office at times other than regularly scheduled office hours; eligible for separate reimbursement if reported without a preventive diagnosis and/or a preventive service
- CPT 99051 — services provided in the office during regularly scheduled evening, weekend, or holiday office hours; eligible for separate reimbursement
Not eligible codes
- CPT 99053 — provided between 10:00 PM and 8:00 AM at a 24-hour facility; not eligible for separate reimbursement
- CPT 99056 — typically provided in the office but provided out of the office at patient request; not eligible for separate reimbursement
- CPT 99058 — emergency basis in the office disrupting scheduled services; not eligible for separate reimbursement
- CPT 99060 — emergency basis out of the office disrupting scheduled services; not eligible for separate reimbursement
ALL of the following
- After-hours services are not eligible for reimbursement to facility providers when billed on a UB-04 form
- POS 20 and facility applicability history
Policy history: as of 04/01/2024 the policy was updated to apply to both professional and facility providers and no longer allows separate reimbursement for claims billed with POS 20 (urgent care)
- Services must be billed with appropriate CPT/HCPCS codes and be fully supported in the medical record; reimbursement is subject to authorization and medical necessity guidelines and applicable provider/state/federal/contractual mandates
- Applies to participating and nonparticipating professional providers unless superseded by provider, state, federal, or contractual mandates
Relevant CPT Codes and Timing Rules
| 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. Eligible for separate reimbursement if reported without a preventive diagnosis and/or a preventive service. |
| 99051 | Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service. Eligible for separate reimbursement. |
| 99053 | Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. Not eligible for separate reimbursement. |
| 99056 | Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic service. Not eligible for separate reimbursement. |
| 99058 | Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service. Not eligible for separate reimbursement. |
| 99060 | Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service. Not eligible for separate reimbursement. |
Authorization, Documentation, and Billing Actions
Authorization, Coding and Documentation Required for After‑Hours Reimbursement
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence; services must be billed with appropriate CPT/HCPCS codes and fully supported in the medical record or office notes. Failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection, denial, or recoupment.
- Use industry-standard, compliant CPT, HCPCS and/or revenue codes on all claim submissions.
- Ensure documentation in the medical record/office notes fully supports billed services.
- Follow applicable provider, state, federal, or CMS mandates that may supersede this policy.
Policy Definitions
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