CPT Code G0463 - What Hospitals Need to Know About Clinic Visit Billing

In hospital billing, CPT code G0463 holds a unique role as the charge for outpatient clinic visits, essentially the hospital’s facility fee for evaluation and management services. This code is critical for provider-based clinics and hospital outpatient departments, and understanding its use is vital for compliance and optimal reimbursement. 

In this detailed guide, we’ll explain what CPT/HCPCS code G0463 represents, who can bill it, how it differs from professional E/M codes like 99213, its usage across Medicare and private insurers, CMS billing guidelines, reimbursement models, required revenue codes, modifier usage (including modifier 25), bundling rules, common mistakes, and compliance tips. 

Revenue cycle managers, billing professionals, and coding compliance officers will find actionable insights, along with a handy compliance checklist and a reimbursement table for quick reference.

What is CPT/HCPCS Code G0463? (Official Description and Purpose)

HCPCS Code G0463 is defined by CMS as a “Hospital outpatient clinic visit for assessment and management of a patient”. 

In practical terms, it represents the facility component of an outpatient visit – often called a “facility fee.” 

This code is used only by hospitals (not individual physicians) to bill for the overhead, nursing, and resources of a clinic visit in a hospital outpatient department. 

Key points about the G0463 CPT code description include:

• Single Unified Clinic Visit Code: Unlike physician E/M services that have multiple levels (99211–99215 for established patient visits, etc.), procedure code G0463 is a single code that covers all levels of clinic visit intensity. Whether the visit is a brief check-up or a complex evaluation, the hospital reports G0463 for the facility’s part of that encounter. This simplification was implemented by Medicare in 2014 to replace the range of outpatient visit CPT codes for facility billing.

• “Facility Fee” Nature: G0463 does not represent the physician’s work; it represents hospital expenses such as nursing staff, exam room use, equipment, supplies, and administrative support for the visit. Essentially, when a patient is seen in a hospital outpatient clinic, there are two billable components: the professional service (billed by the physician or provider with CPT 99xxx codes) and the facility service (billed by the hospital with G0463).

• Official CMS Description: Per CMS’s Medicare Learning Network, “We use HCPCS code G0463 to describe a hospital outpatient clinic visit for assessing and managing a patient.” It can be billed as a stand-alone visit or alongside other services if criteria are met. This definition reinforces that G0463 accounts for a hospital-based clinic visit where a patient is evaluated and managed in an outpatient setting.

Who Can Bill CPT Code G0463?

Who can bill CPT code G0463? In short: only hospital outpatient departments and provider-based clinics that are part of a hospital system. According to CMS and coding guidelines, G0463 is “for hospital use only”. Here’s a breakdown of eligible settings versus who cannot bill G0463:

• Hospital Outpatient Departments (HOPDs): This includes on-campus hospital clinics and provider-based clinics that operate under the hospital’s license. These departments can charge G0463 on a UB-04 claim as the facility fee for a clinic visit. The code reimburses the hospital for clinic overhead and is restricted to outpatient facility claims.

• On-Campus vs. Off-Campus Provider-Based Clinics: Both can use G0463. An on-campus hospital clinic (within or adjacent to the hospital) bills G0463 normally. An off-campus provider-based department (located more than 250 yards from the main hospital) can also bill G0463, but must append specific modifiers (discussed later) to designate its off-campus status.

• Physician Offices & Freestanding Clinics: Independent physician practices and freestanding clinics cannot bill G0463. In a private practice or freestanding clinic setting (not hospital-owned), there is no separate facility fee – the physician’s E/M CPT code (e.g. 99213) already includes practice overhead. G0463 is not recognized on professional claims. As one coding expert succinctly noted, “G0463 is a facility code. In an outpatient clinic setting, the physician bills the E/M visit and the facility bills the clinic visit code”. Thus, physicians or group practices should not report G0463 on their claims; it is exclusively a hospital billable code.

• Critical Access Hospitals (CAHs) and Other Special Facilities: CAHs and certain other hospitals that are not on OPPS may have different billing mechanisms (CAHs use cost-based methods, for example). However, many still report clinic visits similarly for tracking. Always refer to specific regulations if you are a CAH or an exempt unit. Generally, provider-based Rural Health Clinics (RHCs) or Federally Qualified Health Centers (FQHCs) do not use G0463 for their encounters (they have separate encounter rates or all-inclusive rates).

Only hospital outpatient entities can charge CPT G0463. It cannot be billed by a physician in private office or any site that isn’t designated as a hospital outpatient department. This ensures that who can bill CPT code G0463 is limited to those incurring hospital facility costs, maintaining clear separation between professional and facility billing.

Hospital Facility Billing vs Professional Billing (G0463 vs 99213)

A crucial concept for revenue cycle staff is understanding the difference between hospital facility billing and professional billing for clinic visits. CPT G0463 vs 99213 is a common point of confusion, since both relate to an office visit – but for different entities:

• Professional E/M Codes (e.g. 99213): These are physician billing codes for evaluation and management of patients. For example, 99213 is an established patient office visit (low complexity) billed by the provider under the Physician Fee Schedule. It represents the work and expertise of the provider – history, examination, medical decision-making – and also implicitly includes the practice expenses for an office setting when billed by a physician.

• Facility E/M Code (G0463): By contrast, G0463 is billed by the hospital as the facility’s charge for that same visit. It does not pay the physician; it pays the hospital for providing the infrastructure. When a patient is seen in a provider-based hospital clinic, they will typically see two charges: one from the physician (e.g. 99213 on a CMS-1500 claim) and one from the hospital (G0463 on a UB-04 claim). Can you bill G0463 with 99213? Yes – in fact this is standard in hospital outpatient clinics. However, they are billed by different parties: the hospital bills G0463 and the physician (or physician group) bills 99213. They are not “duplicative” but rather two components of the same patient encounter.

• Why Two Charges? Medicare allows hospitals to bill a facility fee (as if the hospital is “renting out” space and staff for the visit) separate from the physician’s fee, when the clinic is hospital-owned. This often results in patients seeing a “Facility Charge” on their bill (coded G0463) in addition to the physician’s charge (coded 99213 or other appropriate E/M code). In a freestanding physician office, only one charge (99213, etc.) is billed, which covers everything, so there is no G0463 in that scenario.

• Documentation and Coding Levels: Another difference is that physicians select 99211–99215 based on the complexity of the visit (or time, under 2021+ E/M rules). The hospital, however, always uses G0463 for any clinic visit level – there is no separate coding of level 1 vs level 5 for facility. Internally, hospitals may triage visits by resource intensity (for internal audits), but ultimately all clinic visits map to G0463 for billing. CMS designed G0463 to replace all clinic visit levels under OPPS, basing its payment on the weighted average cost of all those visits. So, whether a visit would clinically equate to a 99212 or a 99215, the hospital reports G0463 just once.

• Example: A patient sees a cardiologist in a hospital outpatient clinic. The cardiologist’s office (professional) claim will use 99213 (assuming a level 3 visit). The hospital will submit G0463 on the facility claim for that same encounter. Both can be paid – the key is they are different “silos” of billing (one professional, one facility). If the same scenario occurred in a private office, only the 99213 would be billed.

G0463 (facility fee) and 99213 (professional fee) are complementary, not interchangeable. G0463 is never billed on a physician’s claim and 99213 is never billed on a hospital facility claim for Medicare. For Medicare, since 2014, hospitals must use G0463 in lieu of 99201–99215 on facility (UB-04) claims. The physician’s use of 99213 is unchanged and reported separately on the professional (1500) claim. Understanding this facility vs professional split ensures correct billing and avoids inadvertent “double billing” or omissions.

Is G0463 a Medicare-Only Code, or Do Private Insurers Use It?

A common question is “Is CPT code G0463 Medicare-only?” – in other words, do other payers recognize this code? The answer: G0463 originated as a Medicare HCPCS code, but many other payers now accept it. Here’s the breakdown:

• Medicare: G0463 was created by Medicare specifically for hospital outpatient clinic visits under the OPPS (Outpatient Prospective Payment System). Medicare requires hospitals to use G0463 for clinic visits on all Medicare outpatient claims. So for Medicare fee-for-service beneficiaries, this code is definitely used and covered (when billed appropriately). It is covered by Medicare as the standard facility visit code for clinics.

• Medicaid: Medicaid policies vary by state, but many state Medicaid programs also recognize and reimburse G0463 for hospital outpatient clinic visits. For example, guidance from Medicaid managed care (e.g. Anthem Medicaid) has clarified that HCPCS code G0463 is to be used for hospital outpatient clinic visits in their coding policies. Some Medicaid programs use a similar APC or ambulatory payment grouping, which incorporates G0463. However, a few state Medicaid plans might not separately pay for a facility clinic fee (depending on their payment methodology or if they consider it bundled). Always check your state’s Medicaid billing manual. In general, if the Medicaid payer allows provider-based billing, they likely allow G0463, but verify specific coverage.

• Commercial Private Insurers: Many commercial insurers do accept G0463, especially larger ones who follow Medicare’s lead for hospital billing. In fact, many commercial plans recognize G0463 for outpatient clinic visits. However, there is variability:

  • Some commercial payers mimic Medicare exactly, requiring hospitals to bill G0463 (and not 99211-99215) for facility charges. UnitedHealthcare, for instance, explicitly instructs that hospitals bill G0463 for clinic visits and even follows Medicare’s payment reductions for off-campus clinics.

  • Other payers might still accept traditional E/M CPT codes for facility claims or bundle facility fees differently. A few insurers (or employer plans) might even deny or not cover facility fees for clinic visits, considering them unnecessary. For example, some health plans have policies stating that revenue code 510 facility clinic charges are not separately covered under certain commercial benefit plans. This is part of a trend toward site-neutral payments – paying the same whether it’s a hospital outpatient or freestanding office.

  • Best Practice: Always consult the specific payer’s provider manual or billing policy. Many major insurers have published guidelines aligning with CMS for G0463, but payer acceptance is not universal. If a private payer does not accept G0463, they may expect no facility fee or a different coding approach. Verifying with each payer is recommended to avoid denials.
     

• Medicare Advantage: Medicare Advantage (MA) plans, though private, generally follow Medicare rules. So MA plans typically allow G0463 on hospital claims since it’s a Medicare-defined code. They pay according to the contract (often similar to Medicare rates unless negotiated differently).
   

CMS Guidelines for Billing G0463 (Documentation & Appropriate Use)

To ensure compliance, it’s essential to follow CMS guidelines for G0463 on when and how to bill it, and how to document the service. Key points from official Medicare instructions include:

Only When a Visit Occurs: G0463 should be billed only when a medically necessary, face-to-face clinic visit by a physician or qualified provider occurs in the hospital outpatient setting. The documentation must support that an evaluation and management service was provided. If a patient merely receives a test or treatment without an evaluation (for example, a simple lab draw or a nurse-only injection visit with no provider assessment), do not bill G0463 – only bill the procedure or service that occurred. In other words, no provider E/M = no G0463 facility charge. This avoids improper billing of a facility fee when there was no distinct visit.

Order and Documentation: Physician (or NPP) order for visit: Medicare expects that the clinic visit is ordered or documented by the provider. The medical record should show that the visit service was provided and by whom, along with the patient’s presenting issue and the work done. CMS explicitly states that documentation should clearly show the physician or qualified NPP “ordered and performed the patient visit service” and that it was distinct from any other procedure done. Include details of the patient’s condition, symptoms, history, exam findings, and any tests or treatments done during the visit. Essentially, charting for a facility visit should mirror what you’d expect in a professional E/M note (minus the physician’s own billing nuances) – enough to substantiate an evaluation occurred.

Separately Identifiable from Procedures: If other procedures or services (e.g. minor surgeries, infusions, diagnostic tests) are done on the same day, the encounter for G0463 must be a significant, separately identifiable visit. CMS guidelines require that “The encounter should be identifiable as separate from the other procedure performed”. This typically means the patient had a distinct reason for an evaluation beyond just coming in for a scheduled procedure. The documentation should reflect that separate E/M work (e.g., an exam, assessment, or decision-making for a new or existing problem) was done in addition to the procedure.

Modifier -25 Use (Significant E/M on Same Day): In line with the above, when billing G0463 with another procedure on the same date, append modifier 25 to G0463 to indicate it was a significant, separately identifiable E/M service. The CMS MLN booklet and NCCI policy concur that a same-day procedure doesn’t preclude billing a clinic visit code if the E/M is beyond the usual pre/post-op care. 

Does G0463 require a modifier? Not in general, but yes, modifier 25 is required whenever you report G0463 with another billable service (like a minor procedure) to avoid bundling edits. Failing to use the 25 modifier in these cases will likely result in G0463 being denied as bundled. (More on modifiers in a dedicated section below.)

Frequency: Generally, only one G0463 per patient per day per hospital is billed (since it covers the entire visit). If a patient coincidentally has two separate clinic visits on the same day (morning and afternoon, for different clinics or distinct sessions), Medicare allows billing two G0463s with appropriate condition codes (e.g., condition code G0 for distinct visits) – but this is rare and requires clear documentation that two separate encounters occurred. For most scenarios, one visit = one G0463.

Telehealth and G0463: During the COVID-19 Public Health Emergency, CMS temporarily allowed hospitals to bill G0463 for certain telehealth instances (with modifier “PN” or “PO” and using the hospital as originating site, etc.). However, post-PHE, G0463 is generally NOT billable for telehealth unless both the patient and provider are physically in the hospital facility (which isn’t telehealth at all). After the waiver period, CMS clarified G0463 is meant for in-person outpatient visits where patient is in the hospital outpatient department. For hospital involvement in telehealth, typically the code Q3014 (telehealth originating site fee) is used instead, if applicable.

CMS Transmittals/Manual References: The Medicare Claims Processing Manual (Pub.100-04, chapter on outpatient billing) reinforces that hospitals bill their “facility charge” for clinic visits using G0463 (or previously 99201-99245) under revenue code 0510. It also notes that this is separate from the physician billing to Part B. The manual and OPPS rules emphasize that clinic visit charges are allowed only in hospital settings and outline how they are excluded from certain bundling (e.g., SNF consolidated billing) when coded with rev code 0510.

Documentation Tips: To meet CMS guidelines:

• Ensure each outpatient clinic visit has a detailed note: chief complaint, history, exam, assessment, plan – supporting medical necessity for that visit.

• If a procedure or treatment was done, make sure the note explicitly states that a separate evaluation was performed and why it was necessary in addition to the procedure (for example, “Patient evaluated for ongoing knee pain; exam and medical management provided, and additionally a knee injection was administered. The evaluation and decision-making were above and beyond the injection procedure.”).

• If using an EMR, link the appropriate documentation to the facility charge and ensure internal coding guidelines for level of service (if any) are followed to justify using G0463 (most hospitals have internal criteria for when to bill a visit vs. just a tech service).

Reimbursement Under OPPS and Commercial Payer Models

One of the most important aspects for billing professionals is understanding how CPT code G0463 reimbursement works. The payment for G0463 can vary significantly between Medicare and other payers. Let’s break down reimbursement by payer type:

1. Medicare OPPS (Outpatient Prospective Payment System): Under Medicare’s OPPS, G0463 is assigned to an Ambulatory Payment Classification (APC) group that determines its payment rate. Currently, HCPCS G0463 is mapped to APC 5012 (Clinic Visits and Related Services). Medicare calculates a national base payment for this APC annually:

• For example, the Medicare OPPS payment for G0463 in Calendar Year 2025 is about $128.87 on average. This is the national unadjusted payment for a single outpatient clinic visit at a hospital. (The exact payment to a given hospital will be adjusted by factors like the wage index and any rural/frontier adjustments.)

• This APC payment is intended to cover the facility resources for an average clinic visit. It was set by averaging costs of prior level 1–5 visits; CMS no longer differentiates levels for payment.

• Importantly, site-neutral payment policy affects certain G0463 claims. If the clinic is an off-campus provider-based department that is non-excepted (established after the Bipartisan Budget Act of 2015 or otherwise not grandfathered), Medicare pays a reduced rate. CMS policy (fully implemented by 2019) is to pay only 40% of the OPPS rate for G0463 in non-excepted off-campus clinics. That means instead of ~$128, an off-campus clinic visit might be paid roughly $51 (40% of $128) by Medicare. Excepted off-campus departments (those allowed to bill full OPPS) use modifier “PO” and still get the full rate, whereas non-excepted use “PN” and get the reduced rate (details in modifier section).

• Medicare updates the payment rate annually. In recent years, it’s generally in the $100-$130 range. (For historical context, when G0463 first came out in 2014, payments were around $98; they have incrementally increased. By 2024 it was in the $120s, and 2025 as noted is $128.87.)

2. Medicare Advantage: MA plans typically pay according to the contract with the hospital, often indexing to Medicare rates. Many MA plans reimburse G0463 at or near the Medicare fee schedule amount (some at 100% of OPPS, some possibly different percentages). Since MA plans must provide at least equal coverage, they do cover clinic visits. The actual payment could vary if the hospital negotiated a rate (e.g., “OPPS +2%” or a case rate, etc.), but generally one can assume MA reimbursement will be similar to Medicare FFS for G0463.

3. Medicaid: State Medicaid programs have a variety of payment models:

• Some states use APCs or Ambulatory Payment Groups (APGs) for hospital outpatient services, meaning they might pay a set fee for a clinic visit (which could be comparable to Medicare or often lower).

• Other states might bundle the facility fee into encounter payments or pay a flat facility visit rate. For instance, a state could have a fixed payment (e.g., $80) for any outpatient visit.

• Many Medicaid plans do recognize G0463, as it replaced the old clinic visit codes. For example, a state Medicaid or its MCO might instruct providers to bill G0463 under revenue code 510 for clinic visits (similar to Medicare).

• Medicaid reimbursement is generally lower than Medicare. An approximate average might be on the order of $60–$90 for a facility clinic visit, but this varies widely. Some Medicaid plans might pay nearly what Medicare does, while others pay substantially less. (It’s best to look at your state’s fee schedule if available.)

• One important note: if Medicaid does not separately recognize facility fees (some managed care plans might consider it part of a global payment), they may deny G0463 or not pay it. The Colorado Medicaid analysis noted Medicaid uses a “grouper methodology and does not reimburse distinct incremental facility fees” in some cases – meaning it’s built into other payments.

• Takeaway: Check Medicaid guidelines. If reimbursed, expect a lower rate than Medicare in many cases, unless your state aligns with Medicare APC.

4. Commercial Insurance (Private Payers): This is the most variable category:

• Negotiated Rates: Commercial insurers negotiate payment rates with each hospital. Facility fees like G0463 might be paid in several ways:

  • Percent of Charges: Some contracts pay a percentage of billed charges for outpatient services. In that case, the actual payment for G0463 depends on the hospital’s charge and the percentage. Hospitals often have high charge master rates (e.g., a hospital might charge $300–$500 for a clinic visit), but the insurer might pay, say, 30% of charges. That could yield payments roughly $90–$150 depending on the charge.

  • Fixed Fee Schedules: Other contracts explicitly list a fee for G0463. Because of transparency data now available, we can see examples: negotiated private rates for G0463 range widely. For instance, one analysis of insurer data showed contracted payments from about $144 up to $288 for G0463 at different hospitals – all with the same insurer in one state. The average in that sample might be around $200. Another source noted an “adjusted payment rate approximately $115 for on-campus and $46 for off-campus” for one scenario (perhaps reflecting some insurers paying near Medicare rates, others higher).

  • Site-Neutral Approaches: Some payers now adopt site-neutral payments, meaning they will not pay more for a hospital clinic than they would for a doctor’s office. In practice, this could mean a payer might reimburse G0463 at a rate similar to the physician office overhead. For example, Blue Cross NC stated they require modifier -25 on E/M and may only pay one or the other in certain combos. Another example: a policy might say “facility fees for clinic visits (rev code 510) are not covered”, effectively disallowing G0463 for certain plans.

  • Medicare-aligned or Not: It truly varies. UnitedHealthcare Commercial has adopted Medicare’s approach: as of 2025, UHC will require modifier PO for off-campus clinic services and reduce payment by 60% (pay 40%) for G0463 with PO modifier, aligning with CMS’s site-neutral rate. This shows large private payers following Medicare logic, at least for off-campus departments.

  • Meanwhile, other payers might pay full negotiated rate regardless of campus (especially if negotiated before site neutrality was a trend).

• On average, commercial payers tend to pay higher than Medicare for hospital outpatient services (often 1.5 to 2 times Medicare, depending on hospital leverage). So it’s not uncommon to see a commercial plan paying around $150–$250 for a clinic visit that Medicare pays $128 for. But again, the range is broad.

• Other Payer Types:

  • Tricare (for military) – generally follows Medicare APC methodology for hospital payments, so likely similar to Medicare rates for G0463.

  • Self-Pay Patients – hospitals often have a set “facility fee” charge (which can be high on the chargemaster), but they may offer discounts or financial assistance. Some states now require disclosure of facility fees to self-pay patients. The actual collected amount from self-pay will vary (many will not pay full charges).

  • Work Comp or Auto Insurance – if a hospital bills those, they may have their own fee schedules.

To summarize reimbursement:

• Medicare (OPPS, on-campus or excepted off-campus): ~$128 per visit (2025 national average).

• Medicare (Non-excepted off-campus, PN modifier): ~$51 (40% of OPPS).

• Medicaid: Varies by state, often lower (e.g. ~$70, or bundled).

• Commercial Insurance: Negotiated – often higher than Medicare; e.g. commonly in the $150–$250 range per visit on average, but with significant variability.

• Medicare Advantage: roughly akin to Medicare allowed, per contract.

• Others: case-by-case.

Below is a reimbursement table for CPT G0463 illustrating typical payment ranges by payer type:

Payer Type	Approximate Payment for G0463
Medicare (OPPS – Hospital Outpatient)	~$128 (national base rate for CY 2025). Adjusted by local factors.
Medicare (Off-Campus PBD, non-excepted)	~$51 (40% of OPPS rate due to site-neutral policy). Uses PN modifier.
Medicaid (State programs)	Varies widely. Many states pay $60–$100 per visit (often < Medicare). Some use APC or flat rates; others bundle into overall payment.
Commercial Insurance (PPO/HMO)	Negotiated – e.g. average ~$200 per visit, but range is large (e.g. $150–$300). Higher than Medicare at many hospitals. Some plans may reduce to Medicare-like levels.
Medicare Advantage	Similar to Medicare FFS (depending on contract). Often pays at 100% of Medicare rate or per contract terms.
Self-Pay / Uninsured	Hospital charge may be high (e.g. $300+), but uninsured discounts often apply. Patient may negotiate or be offered charity care per hospital policy.

Note: The above figures are illustrative averages; actual payment depends on geographic adjustments and specific contracts. For commercial payers, each hospital’s negotiated rate will differ – transparency data shows substantial variation. Always refer to current contracts and fee schedules for precise amounts.

Understanding these reimbursement models helps hospitals set expectations for revenue. It also underscores why accurate coding is important – incorrect coding (e.g., missing a required modifier or using wrong revenue code) can lead to full denial of that payment. In the next sections, we’ll discuss the coding specifics, such as revenue codes and modifiers, that directly tie into getting these reimbursements.

Revenue Codes for G0463 (Facility Clinic Visits)

When billing G0463 on a UB-04 claim, the Revenue Code must be appropriate for a clinic visit. The correct revenue code to bill with G0463 is typically in the 0510–0519 series (Clinic). Key points:

• Revenue Code 0510 – Clinic, General: This is the most commonly used revenue code for clinic visits. CMS instructions specifically mention that G0463 should be billed under revenue code 0510 (clinic visit) for the claim to be recognized. In fact, Medicare’s systems bypass certain edits when they see G0463 reported with rev code 0510, confirming that’s the expected code.

• Specialty Clinic Codes (051x): Depending on the hospital’s billing practices or the nature of the clinic, you might use a more specific 051x sub-code:

  • For example, 0511 for Chronic Pain Clinic, 0512 for Dental Clinic, 0513 for Psychiatric Clinic, 0514 for OB/GYN Clinic, 0516 for Urgent Care Clinic, etc., up to 0519 (Other Clinic). These are UB-04 revenue code definitions. Using a specialized clinic revenue code is acceptable as long as it correctly represents the clinic’s cost center in the hospital’s system.

  • However, many hospitals default to 0510 for all general clinic visits regardless of specialty, unless segregating for internal accounting.

  • Check with your billing department or chargemaster coordinator: ensure that whatever revenue code you use is one that your payer expects for a clinic visit. For Medicare, 0510 is a safe bet (or 0519 if truly “other”).

• Why it Matters: Revenue codes on facility claims categorize charges. If the wrong revenue code is used, the payer’s system might not recognize the charge as a clinic visit. For instance, if someone erroneously bills G0463 under revenue code 0761 (treatment room) or 0450 (ER), it could confuse the payer or trigger denials or mis-payment. Always use a 051x code for G0463.

  • Some payers explicitly tie coverage of G0463 to rev code 0510. For example, Cigna noted they consider G0463 valid when billed with rev code 0510. If a different rev code is used, they might not pay the facility fee (thinking it’s not an office visit charge).

  • Medicare’s SNF consolidated billing edits specifically look for revenue code 0510 with G0463 to allow separate payment outside the SNF bundle – another reason the combination is expected.

• Hospital Chargemaster Setup: Ensure the hospital’s chargemaster links the G0463 charge line to the correct revenue code. This way, whenever it’s charged, it automatically drops under 0510 (or the specific clinic rev code you’ve designated).

• Additional Codes: Often G0463 will be the only line item (with its revenue code) representing the facility E/M. Any other services (labs, drugs, procedures) will have their own appropriate revenue codes (030x for lab, 025x for pharmacy, etc.). G0463’s revenue code just needs to denote “clinic visit.”

What revenue code should be billed with G0463? Answer: 0510 (clinic services) in most cases. This aligns with correct coding guidelines and ensures your claim is processed under the right category. If your clinic is a distinct type, you may use a variant like 0513 for psych (for example), but confirm that the payer accepts G0463 under that sub-class. Many hospitals stick to 0510 for simplicity.

In summary: Always pair G0463 with an appropriate 051x revenue code on the UB claim. The classic pairing is 0510 – Clinic Visit which is widely recognized by Medicare and commercial payers for outpatient clinic E/M charges. This small detail is an important part of billing compliance that can impact reimbursement.

Modifier Requirements for G0463 (PO, PN, 25, etc.)

Modifiers play a critical role in conveying extra information about how a service was provided. For HCPCS code G0463, the common modifiers to know are:

1. Site-of-Service Modifiers (PO and PN): These are unique to hospital outpatient department billing and indicate whether the clinic is excepted or non-excepted under the outpatient site neutrality rules:

• Modifier PO – “Excepted Off-Campus Provider-Based Department”. This is appended to G0463 (and any outpatient service) for departments that are off-campus (more than 250 yards from main hospital) but were grandfathered (excepted) from the Section 603 payment reductions. Generally, clinics billing before Nov 2015 and meeting certain criteria are excepted. On-campus departments (which are by definition within the main campus) also do not use PO or PN – they are simply considered on-campus and fully paid.

• Modifier PN – “Non-excepted Off-Campus Provider-Based Department”. This is used for off-campus hospital clinics established after the cut-off (or otherwise not meeting exceptions). By appending PN, the hospital indicates this service is subject to Medicare’s site-neutral reduced rate (roughly 40% of OPPS for clinic visits). CMS requires modifier PN on G0463 for non-excepted off-campus clinics.

• When to use: If your hospital clinic is physically separate from the hospital, determine if it’s excepted or not. Use PO for excepted off-campus services and PN for non-excepted off-campus. Failing to use these can result in claims returned or paid incorrectly. Medicare and some payers actively enforce this. UnitedHealthcare, for example, aligns with CMS by requiring PO on off-campus claims and reducing payment accordingly.

• On-campus clinics (located within the hospital main buildings or within 250 yards) use neither PO nor PN (those modifiers were created only for off-campus distinctions).

• Tip: This is only applicable to hospital claims. It’s not relevant to physician claims or freestanding offices.

2. Modifier -25 (Significant, Separately Identifiable E/M Service on the same day as another procedure):

• Modifier 25 is critical when a clinic visit (G0463) is provided on the same date as a minor procedure or other service. The modifier signifies that the E/M portion was above and beyond the usual pre/post-procedure care and thus both the procedure and the visit are billable.

• Use with G0463: Yes, you should append -25 to G0463 when appropriate. For example, if a patient has a clinic visit and during that visit also receives a procedure (like an injection, skin procedure, infusion, etc.), the hospital should put modifier 25 on G0463 to indicate the clinic visit is distinct from the procedure. If you don’t, Medicare’s outpatient code editor (OCE) or NCCI edits may bundle the visit into the procedure and deny payment for G0463.

• Same Physician Rule: Modifier 25 concept is usually described on the physician side (“same physician performed a separate E/M”). For facility billing, it’s more about indicating separate hospital resources for the visit vs. procedure. The concept is parallel: the facility did work for a visit in addition to the procedure.

• CMS guidance indirectly covers this by requiring documentation of a separate visit service. The coding practice, confirmed by coding professionals, is that “the use of the modifier 25 applies the same to [G0463] as it would to [a regular E/M code]”. Also, coding forums note that when hospitals bill infusions or other technical services alongside the E/M, they attach mod -25 to the E/M code.

• Examples of when to use -25: A patient comes in for a scheduled injection but also has new complaints that a nurse practitioner evaluates (significant eval beyond just injection prep) – bill G0463-25 and the injection CPT. Or, patient seen in clinic (G0463-25) and during that visit a minor procedure (laceration repair, etc., CPT code) is done. Modifier 25 on the G0463 tells the payer both can be paid.

• Do NOT use -25 if: The visit was purely for the procedure and there was no separate E/M work (e.g., patient only came for a routine allergy shot, nurse gave injection, no provider exam – in that case, you shouldn’t even bill G0463 at all; and if you did, it certainly wouldn’t warrant a 25 because the injection was the sole service).

• Audit risk: Overusing modifier 25 without proper documentation can raise flags. Ensure that the medical record supports a separate E/M service necessitating the visit code. Payers may audit to ensure mod 25 usage is justified.

3. Preventive/Other E/M on Same Day: If a preventive visit (e.g., Medicare AWV or preventive physical) and a problem-oriented visit occur on the same day in a provider-based clinic, you might see the professional side use modifier 25 on the problem-oriented CPT. On the facility side, since G0463 is essentially the “problem-oriented” visit code, how to handle a concurrent preventive service? Medicare typically doesn’t allow a separate facility charge for a purely preventive service in OPPS (they don’t have a G code for facility AWV – the facility just bills G0463 if a significant visit occurred). If the preventive service was purely counseling and no problem-based evaluation, some hospitals might not bill G0463 at all (since AWV has no facility reimbursement distinct from overhead captured in cost reports). If there was a separate problem addressed, then G0463-25 could be billed in addition to perhaps coding the preventive service (if any facility code exists, which often it doesn’t). This is a complex area and not directly addressed in our main points, but in general, hospitals usually bill G0463 for any billable visit including when preventive services are furnished, as long as there’s an encounter by a provider.

4. Other Modifiers (rarely applicable):

• Modifier -CS: During the COVID-19 period, modifier CS was used to indicate cost-sharing waiver for certain E/M visits related to testing. If applicable, hospitals did put CS on G0463 for COVID-related visits (to waive patient copay). Post-PHE, this is less of an issue.

• Modifier -GT or -95: Telehealth modifiers – not typically used on facility G0463 (since, as discussed, G0463 not billed for telehealth once waivers ended, except when patient is hospital outpatient location).

• Condition Code G0: If two visits same day, use condition code G0 to denote distinct visits (not a modifier on the line item, but a claim-level code).

Summary of Modifier Usage for G0463:

• Always apply PO or PN as required for off-campus clinics (to comply with CMS rules).

• Apply -25 on G0463 whenever you bill it alongside any other significant procedure on the same day, to indicate a significant, separately identifiable E/M took place.

• Ensure the medical record justifies the modifier (especially -25).

• Do not routinely add modifiers if not needed (e.g., don’t add -25 if G0463 is the only service or only with labs/X-rays that don’t require -25).

• For Medicare, failing to use required modifiers can lead to payment adjustments. For commercial, it’s equally important as many follow suit or have edits.

By using the appropriate modifiers for G0463 – particularly modifier 25 when warranted and PO/PN for location – you’ll align with CMS guidelines for G0463 and payer policies, ensuring proper reimbursement and compliance. As a rule: does G0463 require a modifier? – not by itself, but context may require one. Always evaluate the scenario for needed modifiers.

Bundling Scenarios: Billing G0463 with Other Services (e.g. Procedures or 99213)

Bundling refers to whether two services can be billed and paid separately or if one is considered part of another. For G0463, bundling questions arise in two contexts: with procedures on the same day and with professional E/M codes (like 99213) in provider-based settings. We’ve touched on these, but here we’ll clarify common scenarios and how to handle them:

G0463 with Minor Procedures or Other Outpatient Services:

When a patient has a clinic visit and a procedure on the same day, payers often consider the E/M included in the procedure by default, unless a -25 modifier is used. Here’s how to handle bundling:

• Medicare NCCI Bundling Edits: Medicare’s National Correct Coding Initiative (NCCI) generally bundles E/M with procedures that have global periods, unless modifier 25 is present. For example, NCCI policy manual indicates E/M (like 99211–99213 or G0463) may be reported with minor procedures “if the E/M service is significant and separately identifiable” beyond the usual pre- and post-op care (implying use of -25). The same principle applies in facility billing.

• OCE Edits: The Outpatient Code Editor will typically flag G0463 as a “significant visit” payable only if not already packaged into something else. If a procedure (with status indicator T for example) is on the claim, and G0463 lacks -25, the OCE might not pay G0463. With -25, it should pass through if criteria met.

• Examples:

  • Patient comes for a wound check and also has a laceration repair. The hospital should bill G0463-25 and the repair CPT. The -25 tells Medicare to pay both. If the -25 were omitted, Medicare would likely package the visit into the procedure payment (assuming the procedure has zero-day global and is considered a significant procedure).

  • Patient has a clinic visit and an intravenous infusion (e.g., for medication). The hospital bills G0463-25 and the infusion codes (96365, etc.) plus drug. The facility portion of E/M is distinct from the infusion administration, so -25 is needed. Many hospitals get denials on clinic visits when infusions or injections are done if they forget the -25 modifier – payers see it as bundled otherwise. In fact, an AAPC facility coding forum explicitly advises: “If the clinic is part of the hospital, the facility will bill all the technical services – the infusion, drugs, and also the facility portion of the E/M service with a modifier 25, if supported...”, confirming this practice.

  • Patient in an outpatient clinic receives a preventive service (say a flu vaccine administration) and nothing else. Generally, an E/M isn’t billed unless there was a separate exam. If they did do a brief exam and counseling, you could bill G0463-25 and the vaccine admin code, but if it was just a nurse giving a shot, you’d only bill the vaccine/admin (no G0463 at all).

• Coding Best Practice: Only bill G0463 with other same-day services if a true separate E/M was performed. Always append -25 in those cases. If the visit was only to do the procedure (no separate E/M), do not bill G0463. This avoids bundling issues altogether and is the compliant approach.

• Payer Variances: Medicare is generally consistent (requires -25). Many private payers also require -25 or they will deny one of the services. Some insurers might outright not pay a facility E/M if certain procedures are billed, considering it always bundled. For example, some policies say they won’t pay a facility E/M with a surgery code regardless (though Medicare would if -25 and justified). Know your payer policies – but following Medicare rules is a good default, as it’s usually accepted by others.
   

G0463 with Professional E/M (99213) – Provider-Based Clinic Scenario:

We addressed “Can you bill G0463 with 99213?” earlier, but to reiterate in terms of bundling:

• Different Claims: G0463 (UB-04 by hospital) and 99213 (CMS-1500 by physician) are never on the same claim, so in one sense, bundling doesn’t occur the way it does with two services on one claim. The bundling concern here is more about patient perception and payer coordination.

• Patient Perception: Patients often question why they were “billed twice for one visit” – one charge by doctor, one by hospital. It’s crucial for billing staff to educate that this is normal in a provider-based clinic and not an duplicate billing. Many hospitals send informational letters explaining facility fees.

• Payer Payment: Most payers (Medicare included) will pay both the professional and facility claim. Medicare explicitly carves out that the facility charge (G0463) is not considered part of the physician’s service and thus both Part B physician claim and Part A (hospital outpatient) claim can be paid. There is no bundling of 99213 and G0463 within Medicare – they are paid from different “pockets” (the physician fee schedule vs OPPS).

• Commercial: Commercial payers also usually process them separately; however, some unified systems might apply a single copay or have policies: for instance, some insurance might apply only one copay if a doctor and facility claim come in same day. Some others might try to deny the facility fee if their plan doesn’t allow it (which is not bundling in coding sense, but a coverage limitation).

• Key point: Don’t put 99213 on a facility claim and don’t put G0463 on a professional claim – each stays in its lane. If you do that correctly, you avoid any direct bundling edits. The combination of G0463 and 99213 is expected in a hospital-based clinic scenario and is not considered duplicate billing by payers, as long as they are billed by the appropriate entities.

Other Bundling Considerations:

• Multiple G0463 on same day: Generally not allowed (the second would be denied as duplicate). If there truly were two distinct visits (e.g., morning in cardiology clinic, afternoon in oncology clinic), Medicare says use condition code G0 to indicate it’s not duplicate. But many hospitals try to combine into one if possible. If billed separately, expect to justify the medical necessity of two visits in one day.

• Global Surgical Periods: If a patient is in a post-op global period (surgeon’s services are bundled), that global concept doesn’t strictly apply to hospital facility billing for clinic visits – the hospital can still charge a facility fee for post-op visits because the global surgical package only covers physician fees, not facility charges. However, some payers (like certain Medicare Advantage or others) might choose not to pay facility fees for routine post-op visits as a policy. Medicare fee-for-service will pay G0463 for a post-op visit (since the hospital wasn’t paid for it as part of surgery – the global surgical payment was to the surgeon only).

• Emergency Department vs Clinic: If a patient is seen in the ED and then sent to clinic same day or vice versa, how to bill? Typically, hospitals would bill one or the other or combine charges under one encounter if appropriate. You generally should not bill two E/M facility fees (ED visit and clinic visit) for the same patient on the same day unless they are entirely unrelated settings. Medicare has rules to prevent billing two visits in same day in same facility unless condition code G0. So bundling might occur (one may be denied). Use good judgment and possibly consult the outpatient code editor logic.

In summary, bundling with G0463 mainly concerns using modifier 25 to unbundle from procedures. Always ask: Does G0463 require a modifier in this scenario? If another service is on the claim, the answer is likely yes (modifier -25). If it’s alone, no mod needed. And remember, billing G0463 alongside a physician’s 99213 is normal and not a coding edit issue – just ensure it’s done by the correct entities. Proper handling of these scenarios prevents lost revenue (due to inappropriate bundling denials) and safeguards against unbundling (fraudulent separate billing) if one were to bill things that should be included. Following Medicare’s guidance – only separate the services when significant and use -25 – is the gold standard.

Common Billing Mistakes and Audit Risks with G0463

Even experienced billing departments can trip up on CPT G0463 billing, given its unique nature. Here are common mistakes and pitfalls to avoid, and the audit risks associated with them:

1. Billing G0463 in Ineligible Settings: The most fundamental error is attempting to bill G0463 for a setting that isn’t a hospital outpatient clinic. Examples:

• A physician office (not provider-based) submitting a UB-04 with G0463 – this will be denied, as only hospital-based clinics have the means to bill it.

• An independent free-standing clinic (like an urgent care or ASC) trying to use G0463 – also inappropriate.

• Audit risk: Using G0463 where it doesn’t belong could be seen as misrepresenting the site of service. Regulators could construe this as upcoding if a practice bills a facility fee without actually being a facility.

2. Not Using Modifier 25 When Required: As discussed, failing to append -25 modifier when a procedure is done the same day will often result in denial of G0463 (the payer bundles it). This is a common cause of denial for hospital clinic visits. For instance, if a clinic visit with an injection is billed as G0463 (no modifier) and CPT for injection, Medicare will likely deny G0463 as included in the injection. Fix: Always check claims for same-day procedures and ensure G0463 has -25 in those cases. Conversely, overusing modifier 25 without justification can be a red flag in audits – some hospitals mistakenly put -25 on every G0463 “just in case.” That can trigger payer reviews; it should only be used when needed and supported.

3. Missing Required Modifiers PO/PN: Hospitals sometimes forget to append PO or PN on the claim for off-campus clinics. Medicare will return or pay incorrectly until corrected. Some commercial plans may also require it now. This is an easy detail to miss if the chargemaster or billing system isn’t set up to add it automatically based on clinic location. Audit risk: Repeated failure to use PN for non-excepted clinics could be seen as seeking overpayment (since without PN the claim might pay full OPPS). CMS specifically monitors this. Ensure billing staff and systems apply these correctly.

4. Wrong Revenue Code: Putting G0463 under a revenue code other than 051x (clinic). This might cause the code to be unrecognized or denied. It’s a subtle error but can significantly delay reimbursement as claims may recycle or require rebilling.

5. Billing When No Provider Service Occurred (Lack of Medical Necessity): Some hospitals have been cited for charging facility fees in situations where the patient did not truly have an evaluative service. For example:

• Patient comes to hospital lab for a blood draw and leaves, and the hospital tacks on G0463 – inappropriate, as there was no clinic visit or exam.

• Patient gets scheduled injection or vaccine from a nurse, with no provider exam or decision-making – generally, you should not bill G0463 (the injection administration fee covers the nursing work).

• These practices can lead to audits and takebacks. The Office of Inspector General (OIG) has scrutinized provider-based clinic billing for “facility fees” that may not be warranted. Auditors will check if each G0463 has corresponding documentation of a visit with a practitioner. If not, it’s an overpayment scenario.

• Best practice: Implement internal controls – require evidence of a signed provider note or billing record for each G0463 charged. If it’s just a nurse-only encounter, consider whether it qualifies under incident-to or a similar billable visit (and if not, don’t bill a visit code).

6. Unbundling or Duplicate Billing with Physicians: While G0463 and 99213 on separate claims is correct, a mistake would be if a hospital inadvertently billed both a facility and professional claim for the same service under the same NPI. For instance, a hospital-employed NP sees a patient and the billing staff mistakenly files both a UB04 (with G0463) and a 1500 (with 99213) under the hospital’s provider number, essentially double-billing the service. In a proper setup, the NP’s service should either be billed as professional (99213) under the hospital’s group NPI (if they bill pro services) OR as facility (G0463) plus perhaps a physician overhead if incident-to – but not both separately. This is a complex scenario, but some integrated systems need to be careful not to duplicate. Audit risk: Payers may catch this via duplicate logic or post-pay review – resulting in recoupment of one of the charges.

7. Upcoding Documentation: Though G0463 itself has no levels, upcoding concerns come from the documentation side. For example, if an audit finds that many G0463s did not have a true evaluation (see #5 above), it’s essentially billing a visit when maybe it should have been just a nurse service – that’s considered an upcoding of the encounter. Another angle: if a hospital tries to bill multiple G0463s by splitting what should have been one visit into parts (to get paid twice), that’s fraud. Always bill one inclusive visit per patient per day unless truly separate sessions occurred.

8. Modifier 25 misuse on facility side: Occasionally, auditors may examine whether the E/M was really separate. If you append -25 but the documentation doesn’t clearly support a distinct service (for instance, the note just describes the procedure and minimal evaluation), the payer could deny the visit retrospectively. Ensure that when -25 is used, the documentation has an appropriate separate assessment/plan to justify it.

9. Not Keeping Up with CMS Updates: Rules do change. For example, CMS introduced HCPCS add-on code G2211 (complex visit add-on for office visits) – currently that’s an add-on for physician claims, but CMS signaled that facilities could bill it in future with certain criteria. If that becomes active, hospitals might have a complexity adjustment code to add with G0463 under some circumstances. Failing to implement new codes or guidelines (like the recent telehealth post-PHE changes) can lead to lost revenue or improper billing.

10. Charge Capture Errors: Sometimes the issue is not overbilling but underbilling – hospital outpatient clinics might forget to charge G0463 when appropriate (especially if they are new to provider-based billing). This results in missed revenue. Ensure front-end or coding staff assign G0463 for every qualified visit encounter. Conversely, ensure it’s not charged when not appropriate (balance is key).

Audit Risks: Medicare contractors (MACs), Recovery Audit Contractors (RACs), and even payer SIUs (fraud units) pay attention to clinic visit billing. Red flags for audit include:

• High volume of G0463 charges with no corresponding physician bills (could indicate inappropriate use in non-provider-based context).

• Frequent G0463 on same day as certain services (could prompt check if mod 25 used and justified).

• Billing facility fees for telehealth or other non-covered scenarios.

• Patient complaints about facility fees have even spurred audits – e.g., state attorney general investigations into hospitals charging facility fees without proper disclosure.

To avoid these pitfalls:

• Train staff on appropriate use of G0463.

• Perform internal audits regularly: sample a few G0463 claims each month, verify documentation and coding accuracy.

• Use billing edits: implement pre-bill edits that flag G0463 without a corresponding provider note or missing mod 25 when procedure present.

• Keep an eye on payer policy updates to adapt quickly.

Common mistakes summary: Billing G0463 outside hospital outpatient clinics, forgetting modifiers (25, PO/PN), insufficient documentation, and billing visits that aren’t truly visits are mistakes to watch for. These can lead to denials or even accusations of improper billing. By proactively addressing these areas, hospitals can minimize audit risks and ensure they’re billing CPT code G0463 correctly for compliance and optimal reimbursement. 

Conclusion

CPT/HCPCS code G0463 is a cornerstone of hospital outpatient clinic billing – essentially representing the hospital’s facility fee for patient visits. Mastering its use is crucial for revenue cycle success in provider-based clinics and outpatient departments. We’ve learned that G0463’s official description is a clinic visit for assessment & management, and it is billed exclusively by hospitals for outpatient visits (with physicians continuing to bill their professional E/M codes separately). We clarified that hospital outpatient departments and provider-based clinics can bill G0463, while independent physician offices cannot. We distinguished facility billing vs professional billing (G0463 vs 99213) to highlight how both charges work in tandem without duplication.

We also addressed the misconception of G0463 being Medicare-only – noting that while it’s a Medicare-defined code, many private payers recognize and reimburse it (though always verify payer-specific rules). We detailed CMS guidelines: only bill G0463 for true visits, document thoroughly, use appropriate modifiers, and ensure it’s separate from any procedures if billed together. The discussion on reimbursement showed how Medicare pays via OPPS APC (roughly $128 per visit in 2025) and how off-campus clinics get a reduced rate (40%), while private payer payments vary widely but often exceed Medicare rates. We provided a revenue code roadmap (0510 clinic) and explained the critical modifier usage: PO/PN for location and -25 for same-day procedures, among others. We explored bundling scenarios, reaffirming the need for modifier 25 to unbundle legitimate E/M services from procedures and confirming that G0463 and 99213 can both be billed (by the facility and professional, respectively) for the same encounter in a compliant way.

Additionally, we highlighted common billing mistakes – such as billing G0463 without a provider service, missing modifiers, or using it in the wrong setting – and the audit risks they pose, along with strategies to avoid them.