After-Hours Codes

I. Description

HMSA recognizes the use of three after-hours modifier codes:

Visit or service must begin and end between the designated hours.

II. Criteria/Guidelines

Only one of the codes may be billed. They may not be billed together.

The claim and medical record must include documentation that indicates the time of the service and the special circumstances that required the code. Early scheduling of the Operating Room does not constitute a special circumstance particularly if the services are routinely scheduled services.

These codes may only be used if the provider makes a special trip outside of established office hours to the hospital or office to treat a patient.

III. Limitations/Exclusions

After-hours codes cannot be used for routine hospital rounds, even if the visits occur after regular office hours.

After-hours codes may not be used by providers staffing emergency rooms.

IV. Claims Filing Instructions

Example

The hospital calls a physician at home at 2 a.m. because one of their patients is in crisis. The physician goes to the hospital to direct the hospital staff to treat the patient. The claim should be completed as follows:

Revision History