Date Posted: Monday,
April 17, 2023
Reporting outpatient E/M services in a facility setting is a little different than other outpatient services. It is important to follow payer guidance. Novitas has provided some guidance on which codes to report based on the type of service provided.
They have an FAQ page that covers both emergency department (99281-99285, G0380-G0384) and clinic visits, which states the following:
Hospital outpatient clinic visits for assessment and management are billed with G0463.
For a list of condition codes, occurrence codes, occurrence span codes, value codes, revenue codes, and all other required data reported on the UB-04, please visit the NUBC website for the official UB-04 data specifications manual. We also have a UB-04 Form Locator Lookup on our website.
Prior to January 1, 2014, these services were billed with 99205 or 99215, but they were replaced with code G0463 as of January 1, 2014 for Medicare beneficiaries. Beginning in 2015, CMS began allowing the voluntary use of modifier PO to be reported with these services when they are provided in "an excepted off-campus provider-based department of a hospital." Reporting modifier PO became mandatory in 2016.
Beginning in 2019, payment for services reported with modifier PO began to be paid at a percentage of the Physician Fee Schedule (PFS) amount as noted in the following statement:
"The PFS-equivalent amount paid to nonexcepted off-campus PBDs is 40 percent of OPPS payment (that is, 60 percent less than the OPPS rate) for CY 2019. We are phasing this policy in over a two year period. Specifically, half of the total 60-percent payment reduction, a 30-percent reduction, will apply in CY 2019. In other words, these departments will be paid 70 percent of the OPPS rate (100 percent of the OPPS rate minus the 30-percent payment reduction that applies in CY 2019) for the clinic visit service in CY 2019." (Medicare Claims Processing Manual, Chapter 4, Section 20.6.11)
For more information about the usage of other modifiers (e.g., modifier 25), and other services (e.g., pulmonary function testing, audiology testing), performed at the same time in these settings, see the FAQ.
Wyn Staheli is the Director of Content Research for innovHealth. She has over 30 years of experience in the healthcare industry. With her degree in Management Information Systems (MIS), she has been a programmer for a large insurance carrier, as well as a California hospital system. She is also the author and editor of many medical resource books and the founder of InstaCode Institute.
