Coverage criteria and payer-specific rules for after-hours and emergency add-on codes
Payment is conditional based on service timing, location, documentation, and product type.
99050: Services provided in the office at times other than regularly scheduled office hours (including evenings, holidays, weekends). Documentation requirement: medical record must document date and time of the encounter; without date/time the code will not be considered for payment.
99051: Effective January 1, 2015, services provided in the office during regularly scheduled evening, weekend, or holiday office hours. Documentation requirement: medical record must document date and time of the encounter; without documentation the code will not be considered for payment. Do not pay when rendered outside a physician office/clinic (e.g., hospital, ED, urgent care).
99053: Services provided between 10:00 PM and 8:00 AM at a 24‑hour facility, reported with the initial inpatient or outpatient hospital visit. Documentation requirement: record must specify the time the service was rendered; paid only for that time window and only when provider was not coincidentally present at the site prior to the service (e.g., not paid for scheduled ED or trauma call).
99056: Services typically provided in the office but provided out of the office at the patient's request. Documentation requirement: medical record must support that the patient requested the service at a location other than the provider's office. Do not pay when the service is rendered in the provider's office or when the provider is coincidentally in the non‑office setting.
99058: Services provided on an emergency basis in the office that disrupt other scheduled office services. Default policy: denied as included in E/M; reimbursed only on appeal when documentation shows unscheduled emergent hands‑on personal care by the provider that interrupted care of other patients. Do not reimburse if provider directed others or did not document interruption of other patients' care.
99060: Services provided on an emergency basis out of the office that disrupt other scheduled office services. Documentation requirement: record must support unscheduled out‑of‑office emergent care requiring the provider's hands‑on personal care, including date/time and evidence that scheduled patients were left or their care was interrupted. Do not reimburse if provider directed others, was coincidentally present, or if care was part of a scheduled ED shift or trauma call.
S9088: Services provided in an urgent care center (list in addition to code for service). Denied as included in the E/M or basic service (effective January 1, 2009).
Product‑specific rule: SelectHealth Advantage (Medicare): All after‑hour add‑on codes are 'B'‑status and are bundled into the primary procedure; not paid separately.
Product‑specific rule: Select Health Community Care (Medicaid): 99050 and 99058 are covered when appended to basic E/M office visit codes for new patients (99201‑99205) and established patients (99212‑99215). When services occur during regularly scheduled evening, weekend, or holiday office hours, 99051 may be billed with documentation of date/time. Only one after‑hours office add‑on code may be billed per visit in addition to the E/M or service code.
Effective January 1, 2015, providers may bill 99051 for services provided during regularly scheduled evening, weekend, or holiday office hours when documentation supports timing (replacing prior practice of denying as included in basic service).
Operational change