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24.3.12.7 Services Outside of Business Hours
The CSHCN Services Program limits reimbursement for after hours charges (procedure codes 1-99050, 1-99056, and 1-99060) to office-based providers rendering services after routine office hours and/or on an emergency basis.
An office-based provider may bill an after hours charge in addition to a visit for providing services after routine office hours. After hours charges may be billed when the provider's clinical judgment deems it medically necessary to interrupt the routine schedule to care for a client with an emergent condition. A provider's routine office hours are those hours posted at the physician's office as the usual office hours. The CSHCN Services Program may reimburse office-based physicians when any of the following exists:
• The physician leaves the office or home to see a client in the emergency room.
•The physician leaves the home and returns to the office to see a client after the physician's routine office hours.
•The physician is interrupted from routine office hours to attend to another client's emergency outside of the office.
Procedure codes 1-99050, 1-99056, and 1-99060 are not reimbursed separately to emergency department-based physicians or emergency department-based groups.
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