Fee Navigator

    Governing Rule: 15

    OFF HOURS PREMIUM BENEFITS

    • 15.1

      In the case of physicians working exclusively in a hospital setting on either a full-time basis or as a part of their normal practice for a specified period of time (e.g. weekly hospital rotations among a practice group) off hours premium benefits may be claimed in accordance with the GRs for those claims as long as the claiming physician is the attending physician or is primarily responsible for the patient's care, or is claiming concurrent care in accordance with GR 4.8. In the case of physicians working in an AACC or UCC, off hours premium benefits may be claimed in accordance with the GRs for those claims as long as the claiming physician is the attending physician.

    • 15.2

      Deleted

    • 15.3 UNSCHEDULED SERVICES/SPECIAL CALLBACKS - AACC, UCC, HOSPITAL INPATIENT, OUTPATIENT AND EMERGENCY DEPARTMENTS

      Benefits for UNSCHEDULED services (modifier SURC) and special callback HSCs 03.03LA, 03.03MC, 03.03MD, 03.05P, 03.05QA, 03.05QB and 03.05R are intended to cover a degree of disruption that a physician would have to experience to provide such services during:

      • the evening on weekdays (1700 - 2200 hours),
      • the day and evening on weekends and statutory holidays (0700 - 2200 hours)
      • any night of the week (2200 - 0700 hours)
    • 15.4

      In situations where the physician initiates the service, the unscheduled service or special callback benefits may not be claimed. Claims may however, be made for the after hours time unit premium benefit (modifier SURT) under 03.01AA. See GR 15.13.

    • 15.5

      Only one unscheduled service or special callback benefit may be claimed for each encounter with a patient. In the event of a special callback, the following visit services may be claimed in addition: HSC 03.02A, 03.03A, 03.03B, 03.04A, 03.03DF or 03.03EA.

    • 15.6

      The unscheduled service and special callback benefit must be claimed according to the time at which the encounter commences and not from the time of the call for attendance.

    • 15.7 Claims for Unscheduled Services/Special Callback Benefits
    • 15.7.1

      Claims for the unscheduled service benefit (modifier SURC) must meet all of the following conditions:

      1. a special call for attendance is made on the patient's behalf;
      2. the physician responds to such a call on an unscheduled basis outside of his/her normal working hours;
      3. the patient is attended on a priority basis;
      4. there is direct attendance by the physician.
    • 15.7.2

      Claims for special callbacks must meet all of the following conditions:

      1. a special call for attendance is made on the patient's behalf;
      2. the physician responds to such a call from outside the hospital, auxiliary hospital, nursing home, AACC or UCC on an unscheduled basis;
      3. the patient is attended on a priority basis;
      4. there is direct attendance by the physician.
    • 15.8

      Special callback benefits may not be claimed for subsequent patients seen during the same callback or in association with another service during the same encounter. However:

      1. HSC 03.03AR may be claimed for second and subsequent hospital inpatients.
      2. for second and subsequent emergency/outpatients, or AACC or UCC patients seen during the same callback, see GR 5.2.3.
      3. HSCs 03.03DF and 03.03EA may be claimed in addition to a callback in accordance with GR 15.5.
    • 15.9

      The unscheduled service benefit (modifier SURC) may be claimed for the services outlined in GRs 15.9.1 through 15.9.3.

    • 15.9.1

      selected "V" category code services:

      1. consultations, including telehealth (except those provided using store and forward videotechnology);
      2. intensive care unit visits (HSC 03.05A);
      3. psychiatric mental status determination requiring complete mental health status examination and investigation (HSC 08.11A);
      4. for complex patient, requiring complete mental status examination and investigation (HSC 08.11C);
      5. certification under the Mental Health Act (HSC 08.12A);
      6. trauma assessment, multiple trauma, severely injured patient (HSC 13.99GA);
      7. hyperbaric oxygen therapy detention time (HSC 13.99I);
      8. medical emergency detention (HSC 13.99J);
      9. management of complex labor, per 15 minutes (HSC 13.99JA);
      10. donor maintenance prior to cadaveric harvesting of organs (HSC 13.99L);
      11. examination and crisis counseling for sexual/physical abuse (HSC 13.99V);
      12. attendance at delivery (HSC 87.98E).
    • 15.9.2

      radiology, pathology and other diagnostic and therapeutic services if the physician is directly involved in the provision of services of an invasive nature;

    • 15.9.3

      procedures including surgical assists, obstetrical deliveries, anesthesia, major surgery and minor surgery.

    • 15.9.4

      The unscheduled service benefit (modifier SURC) may also be claimed for services outlined in GRs 15.9.1 through 15.9.3 when provided to second and subsequent patients seen during the same special call for attendance at the same facility.

    • 15.10

      The unscheduled service benefit (modifier SURC) may not be claimed for:

    • 15.10.1

      stand-by time;

    • 15.10.2

      services provided by physicians who are on-site and working a scheduled rotation duty shift in a hospital emergency department, AACC or UCC or providing first call coverage in an emergency department with greater than 25,000 visits per year;

    • 15.10.3

      additional procedures, i.e., those performed in association with another procedure;

    • 15.10.4

      non-invasive diagnostic procedures;

    • 15.10.5

      "V" category code services except for those listed under GR 15.9.1; and

    • 15.10.6
    • 15.11 MAXIMUMS FOR SPECIAL CALLBACKS
    • AMA billing tips:

      • Maximums that include both callbacks to in- and outpatients per physician per day apply:

        • 03.03KA or 03.05N — Maximum five or any combination on any weekday (07:00-17:00 hours).
        • 03.03LA or 03.05P — Maximum five or any combination on any weekday (17:00-22:00 hours).
        • 03.03LA or 03.05R — Maximum 15 or any combination on any weekend day or statutory holiday (07:00-17:00 hours).
        • 03.03MC or 03.05QA — Maximum two or any combination any day (22:00-24:00 hours).
        • 03.03MD or 03.05QB — Maximum seven or any combination any day (24:00-07:00 hours).
    • 15.11.1

      A maximum of five (5) special callbacks, either HSC 03.03KA, 03.05N or any combination thereof may be claimed, per physician, in any given weekday day. The weekday day is defined as Monday - Friday (0700 - 1700 hours).

    • 15.11.2

      A maximum of five (5) HSC 03.03LA, 03.05P or any combination thereof may be claimed, per physician, in any given weekday, Monday - Friday (1700 - 2200 hours).

    • AMA billing tips:

      • Maximums that include both callbacks to in- and outpatients per physician per day apply:

        • 03.03KA or 03.05N — Maximum five or any combination on any weekday (07:00-17:00 hours).
        • 03.03LA or 03.05P — Maximum five or any combination on any weekday (17:00-22:00 hours).
        • 03.03LA or 03.05R — Maximum 15 or any combination on any weekend day or statutory holiday (07:00-17:00 hours).
        • 03.03MC or 03.05QA — Maximum two or any combination any day (22:00-24:00 hours).
        • 03.03MD or 03.05QB — Maximum seven or any combination any day (24:00-07:00 hours).
    • 15.11.3

      A maximum of fifteen (15) HSC 03.03LA, 03.05R or any combination thereof may be claimed, per physician, on any day of the weekend or statutory holiday, (0700 - 2200 hours).

    • AMA billing tips:

      • Maximums that include both callbacks to in- and outpatients per physician per day apply:

        • 03.03KA or 03.05N — Maximum five or any combination on any weekday (07:00-17:00 hours).
        • 03.03LA or 03.05P — Maximum five or any combination on any weekday (17:00-22:00 hours).
        • 03.03LA or 03.05R — Maximum 15 or any combination on any weekend day or statutory holiday (07:00-17:00 hours).
        • 03.03MC or 03.05QA — Maximum two or any combination any day (22:00-24:00 hours).
        • 03.03MD or 03.05QB — Maximum seven or any combination any day (24:00-07:00 hours).
    • 15.11.4

      A maximum of two (2) HSC 03.03MC, 03.05QA or any combination thereof may be claimed, per physician, any day, (2200 - 2400 hours).

    • AMA billing tips:

      • Maximums that include both callbacks to in- and outpatients per physician per day apply:

        • 03.03KA or 03.05N — Maximum five or any combination on any weekday (07:00-17:00 hours).
        • 03.03LA or 03.05P — Maximum five or any combination on any weekday (17:00-22:00 hours).
        • 03.03LA or 03.05R — Maximum 15 or any combination on any weekend day or statutory holiday (07:00-17:00 hours).
        • 03.03MC or 03.05QA — Maximum two or any combination any day (22:00-24:00 hours).
        • 03.03MD or 03.05QB — Maximum seven or any combination any day (24:00-07:00 hours).
    • 15.11.5

      A maximum of seven (7) HSC 03.03MD, 03.05QB or any combination thereof may be claimed, per physician, any day, (2400 - 0700 hours).

    • AMA billing tips:

      • Maximums that include both callbacks to in- and outpatients per physician per day apply:

        • 03.03KA or 03.05N — Maximum five or any combination on any weekday (07:00-17:00 hours).
        • 03.03LA or 03.05P — Maximum five or any combination on any weekday (17:00-22:00 hours).
        • 03.03LA or 03.05R — Maximum 15 or any combination on any weekend day or statutory holiday (07:00-17:00 hours).
        • 03.03MC or 03.05QA — Maximum two or any combination any day (22:00-24:00 hours).
        • 03.03MD or 03.05QB — Maximum seven or any combination any day (24:00-07:00 hours).
    • 15.11.6

      Deleted

    • 15.11.7

      A maximum of five (5) special callbacks to a closed office, HSC 03.03ME, may be claimed, per physician, in any given weekday, Monday - Friday (0000 - 2400 hours).

    • 15.11.8

      A maximum of ten (10) special callbacks to a closed office, HSC 03.03MF may be claimed, per physician, on any day of the weekend or statutory holiday, (0000 - 2400 hours).

    • 15.12

      Deleted

    • 15.12.1

      Deleted

    • 15.12.2

      Deleted

    • 15.12.3

      Deleted

    • 15.12.4

      Deleted

    • 15.12.5

      Deleted

    • 15.12.6

      Deleted

    • 15.12.7

      Deleted

    • 15.12.8

      Deleted

    • 15.12.9

      Deleted

    • 15.13 AFTER HOURS TIME PREMIUM - HOSPITAL INPATIENT, OUTPATIENT AND EMERGENCY

      DEPARTMENTS, AACCs, UCCs, AUXILIARY HOSPITALS AND NURSING HOMES

    • 15.13.1

      Benefits for the AFTER HOURS TIME PREMIUM (modifier SURT) are intended to provide physicians with compensation for services provided after hours during:

      • the evening on weekdays (1700 - 2200 hours),
      • the day and evening on weekends and statutory holidays (0700 - 2200 hours),
      • any night of the week (2200 - 0700 hours).
    • 15.13.2

      The after hours time premium modifier applies to both scheduled and unscheduled services. In the case of unscheduled services, the unscheduled services modifier will also apply according to GRs 15.3 through 15.10.6.

    • 15.13.3

      Deleted

    • 15.13.4

      The after hours time premium modifier is to be claimed on a per 15 minute basis beginning at the time of contact with the patient and may only be claimed for direct patient care time related to the provision of an insured service. The after-hours time premium units may not be claimed for stand by time, e.g. time spent waiting for results of diagnostic tests.

    • 15.13.5

      Time for the after hours time premium may be determined on a cumulative basis, and claimed according to the time period(s) in which the majority of the service occurred. HSC 03.01AA should be used to claim the after-hours time modifier for all services.

    • 15.13.6

      In the event that one 15 minute period covers two time periods, the modifier claimed will be based on the time period where the majority of the 15 minute period occurred.

    • 15.13.7

      In the event that the time spent with the patient covers more than one time period, additional modifiers may be claimed, each according to the time spent with the patient in that particular time period.

    • 15.13.8

      Deleted

    • 15.13.9

      The after hours time premium modifier may not be claimed for:

      • stand-by time;
      • non-invasive diagnostic procedures.
    • 15.13.10

      The maximum number of after hours time premium modifiers per hour, per physician is 4.