After Hour Add On Service Codes

Effective for dates of services on or after April 1, 2013, the South Carolina Department of Health and Human Services (SCDHHS) will cover CPT codes:

  • 99050 – Service(s) provided in  the office at times other than regularly scheduled office hours, or days when the office is normally closed (i.e., holidays, Saturday or Sunday), in addition to basic service
  • 99051 - Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service

The above reference procedure codes are ONLY authorized for Primary Care providers (i.e. Pediatricians, Family Practice, General Practice, Internal Medicine, and Obstetrics and Gynecology).  Providers will still be able to bill the Evaluation & Management code that best describes the level of service being rendered. 

The intent of this change is to encourage the expansion of office hours to evenings, holidays, and weekends to reduce the need for Medicaid beneficiaries to seek services in the emergency room.  SCDHHS defines CPT code 99050 to mean all patients scheduled outside published business hours; this would not include a visit that was scheduled at 4:00 p.m. and the patient was not seen by the physician until 6:30 p.m.  For CPT code 99051, SCDHHS defines evening hours to be any time after 6:00 p.m. and before 8:00 a.m.  Weekends are defined as Saturday 8:00 a.m. to Monday 8:00 a.m.  Providers may only bill for the following holidays: the day of New Year’s, Independence, Labor, Thanksgiving and Christmas.  Holidays are defined as 8:00 a.m. the morning of the holiday until 8:00 a.m. the following morning.  After hours procedure codes are not covered when the service is provided in a hospital emergency department, an inpatient hospital setting, outpatient hospital setting, or an urgent care facility (place of service codes 20, 21, 22, and 23).  The reimbursement for each of these CPT codes will be $12.00.  CPT code 99050 and 99051 are add on codes which would be reported in addition to an associated Evaluation and Management service code.  All CPT codes, claims submission, office hour schedules, and policy are subject to review by the Department of Program Integrity. 

This bulletin applies to Fee-For-Service and Medical Homes Networks (MHNs). Please contact the appropriate Managed Care Organization (MCO) for their coverage policy.  If you have any questions regarding this bulletin, contact the Provider Service Center at (888) 289-0709.  Thank you for your continued support of the South Carolina Healthy Connections Medicaid Program.

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