(2023) CPT Code G0463 – Description, Guidelines, Reimbursement, Modifiers & Examples

CPT code G0463 will be reported by the physician when service renders at the hospital outpatient clinic visit for assessment and management of a patient.

Summary

In 2014, CMS proposed three new HCPCS G codes in OPPS (Outpatient Prospective Payment System) to substitute for five levels of evaluation and management settings.

It includes one G code for type A ED (Emergency Dept) visits and one for type B ED visits.

The new HCPCS code G0463 is an alternative to all clinic visits for new and established patients when billed to Medicare carriers.

G0463 is effective from January 1, 2014, in the place of Clinic visits codes (99201-99215).

The hospital requires to place only one G code instead of CPT (99201-99215) when billed to Medicare insurances. G0463 does not differentiate between new and established patients.

There are two types of charges as one is billed under facility or hospital charge while the other is physician charge.

G code is only used for hospital or facility-based payments when billed to Medicare under the OPPS.

Therefore, it eradicates the criteria of choosing level evaluation and management visits.

Also, it does not require any specific measures to meet for the service provided.

CPT Code G0463 Description  

CPT code G0463 will be reported by the physician when service renders at the Hospital outpatient clinic visit for assessment and management of a patient.

CPT Code G0463 Reimbursement

A maximum of zero units of CPT code G0463 is allowed to bill on the same day.

In contrast, a maximum of three times are allowed when documentation supports the medical necessity of CPT code G0463.

The CPT code G0463 cost and RUVS are as follows when performed in the outpatient off-campus hospital, it will be $47.50 and 0, respectively.

In contrast, the off-campus provider will be $47.50 and 0, respectively.

CPT Code G0463 Modifiers

There is the following list of modifiers that are applicable with CPT code G0463:

• 24, 25, 27, 57, 99, AI, CS, CR, CC, EY, ET, G0, GC, GA, GJ, GK, GT, GQ, GR, GU, GZ, KX, Q5, QJ and Q6

The most frequent modifiers used with G0463 CPT code are 24, 25, and 57.

Modifier 25 will be appended with G0463 CPT code when services are done in conjunction with other services generally not billed together on the same day.

While 24 will be appended with services done in the postoperative period with unrelated procedures or services. 

Modifier 57 will be attached to G0463 CPT code if physicians plan to do surgery on the same date of service when the E/M visit is done.

Modifier 27 is applicable when a patient saw multiple times by the physician on the same day for evaluation and management visit codes. 

CPT Code G0463 Billing Guidelines

Documentation should support the medical necessity of service and be medically appropriate.

It reflects the patient’s current condition. 

G0463 CPT code bills for facilities or hospital charges only and physician charges will be billed separately.

Any service billed under facility or clinic visit billed to Medicare will be under OPPS with appropriate HCPCS G codes.

Q3014 is applicable when telemedicine service is provided by the hospital as an origin site to other outpatient hospital patients.

G0463 CPT code will not be more appropriate to report for telehealth services due to COVID 19. 

CPT G0463 is only applicable when service bills to Medicare insurance. Time is not a determining factor when G0463 CPT code will be billed.

CPT 99201-99215 code has time factors in choosing the appropriate level of evaluation and management CPT code. 

All the five levels of CPT codes such (as 99201-99205) will be billed as single HCPCS code G0463 CPT code when billed to Medicare.

History, physical exam, assessment, and plan are necessary to be mentioned on the chart.

Otherwise, service will be denied by Medicare insurance. 

HCPCS code G0463 is the substitute of hospital outpatient department visit codes 99201-99205, 99211-99215 when insurance is Medicare.

Commercial insurances do not accept G codes.

Check the appropriate guidelines of third parties or payers regarding the billing of CPT code G0463. 

CPT Code G0463 Examples

The following are examples of when CPT code G0463 service is billed.

Example 1

 67-year-old-male with a PMH of HTN, HLD, hypothyroidism presenting to the clinic because of a headache and high blood pressure before arrival. His primary insurance is Medicare.

The patient lays down in bed at 10 pm and begins having a gradual onset pulsating frontal and occipital headache.

He reports that the pain was very severe. His headaches are usually associated with HTN.

The blood pressure shows a value of 210/100 and denies associated dizziness, chest pain, shortness of breath, motor weakness, numbness/tingling, abdominal pain, nausea/vomiting.

The physician ordered a series of diagnostic tests CT, MRI, and EKG. EKG was independently interpreted and reviewed by the doctor.

Patient reports improvement in HA with Tylenol.  

Example 2

A 51-year-old-female presents to the office with syncope. Her primary insurance is Medicare.

The patient applies a nicotine patch earlier. The patient had a brief episode of feeling hot, numbness, and tanginess in her b/l hands, “gas discomfort” in her stomach, headache.

When she tried to get up, she lost consciousness (witnessed by her partner, who I spoke to for more hx).

Partner states she was only out for a few seconds before perking up to routine. Pt states she has had episodes like this in the past but several years ago. No known cardiac history.

Physicians plan to order CBC, CMP, mg, phos, trop, EKG, Tylenol, Pepcid, Zofran. 

EKG: Normal sinus rhythm. 70 bpm. No ST elevation or T wave inversions. 

CXR: My interpretation showed no acute abnormalities. 

Example 3

36-year-old male presents to the office with PMH HTN, HLD, Afib (on eliquis), Mitral valve replacement, and gout presenting today for dark blood stools for two days.

He states that he started having diarrhea yesterday and has had 4 BM in the past two days. His primary insurance is Medicare.

The patient denies nausea, vomiting, CP, SOB, dizziness, fevers, chills, took eliquis this morning.

The physician also notes worsening bilateral lower extremity edema for which he takes Lasix.

He took Indomethacin for four days for a presumed gout flare.

The colonoscopy was done three years ago, found benign polyp but otherwise WNL.

Physician plan to admit and Plan Labs, EKG, CT abdomen, and Pelvis, and prescribed Medicine. 

Example 4

70-year-old female presents to clinic with hx of HLD presenting to the OPD for substernal chest pain.

Her primary insurance is Medicare. The patient worked out daily, was a very healthy, active senior, lived at home, and worked out today.

After the workout, she took a sip of water, and she had substernal chest pain, none radiating, associated with weakness.

However, Gatorate helped with the substernal chest pain.

She had no chest pain shortly after. However, her trainer told her to see a provider.

She went to urgent care with asymptomatic resolved chest pain, and they sent her over here because she had a family history of MI in her family.

Her brother died of MI at age 48 EKG without ischemic changes. Low suspicion for ACS. HEART score 3.

Example 5

38-year-old female past medical history of chronic gastritis diagnosed on endoscopic two weeks ago presenting with one month of on and off palpitations and lightheadedness.

The patient states that she has been feeling off for the last month and describes her symptoms as when she wakes up in the morning and feels fogginess has bouts of palpitations with associated lightheadedness without syncope.

The patient cannot pinpoint a trigger and states her symptoms resolve independently. 

Palpitations last anywhere in the body for seconds to minutes.

The patient endorses that she has a healthy diet and does not do any narcotics drink alcohol, or smoke.

The patient otherwise denies fevers, chills, syncope, headaches, neck pain, chest pain, shortness of breath, back pain, abdominal pain, nausea, vomiting, diarrhea, constipation.

The physician decided will obtain EKG labs chest x-ray reassess

EKG normal sinus rhythm at 74 bpm with a QTC of 426 no ST elevations or depressions.