CMS Adopts “One Code Fits All” for Hospital Clinic Visits

December 6th, 2013

This past summer, the Center for Medicare & Medicaid Services (CMS) issued notice that it was considering a radical change for emergency department (ED) and hospital clinic evaluation and management (E/M) coding. With the release of the 2014 hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Payment System (ASC PS) final rule, that proposal becomes reality for hospital clinic visits. ED E/M coding remains unaffected—for now.

The Proposal

In a letter dated July 18, CMS proposed replacing the current five levels of service (based on CPT® 99281-99285 for the ED, and 99201-99205/99211-99215 for hospital clinics) “with a single Healthcare Common Procedure Coding System (HCPCS) for each unique type of outpatient hospital visit.” For example, CMS would reimburse a single ED HCPCS code, which would be based on an average of the five current ambulatory payment classifications (APCs) ($212.40, proposed).

The stated goals of the proposal were “to maximize hospitals’ incentive to provide care in the most efficient manner.” Specifically, the move was seen as a way to discourage upcoding, to remove hospital incentives to provide medically unnecessary services, and to reduce administrative burden.

The American Hospital Association, the American College of Emergency Physician, and other professional societies objected to “one code fits all” on the grounds that it did not appropriately reflect the reality of ED and clinic medicine, and that one payment for all levels would unfairly penalize inner-city EDs that treat high acuity cases. Observers also expressed concern that single-level coding would result in additional bundling of services, payment reductions, and potentially compromised patient care.

The Final Rule

CMS published the 2014 OPPS and ASC PS final rule Nov. 27. The rule does not adopt one-level coding for the ED, stating “For CY 2014, we believe it is best to delay any change in ED visit coding while we [CMS] reevaluate the most appropriate payment structure for … ED visits.” CPT®/HCPCS and APC coding for ED visits (both Type A and Type B) remain unchanged in the coming year.

Despite opposition, however, CMS has elected to collapse hospital clinic E/M services to a single level for Medicare payment in 2014, stating “we believe that the spectrum of hospital resources provided during an outpatient hospital clinic visit is appropriately captured and reflected in the single level payment for clinic visits. We also believe that a single visit code is consistent with a prospective payment system, where payment is based on an average estimated relative cost for the service, although the cost of individual cases may be more or less costly than the average.”

Under the final rule, beginning Jan. 1, 2014 all hospital clinic E/M visits—regardless of patient status (new or established) or intensity of service—will be reported using new HCPCS Level code G0463 Hospital outpatient clinic visit for assessment and management of a patient, which is assigned to new APC 0634.

Note that this change affects facility billing only, not coding for physician services.


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24 Responses to CMS Adopts “One Code Fits All” for Hospital Clinic Visits

  1. Donna M. Beaulieu Says:

    Good afternoon.

    I am a little confused by the hospital putpatient scenario. We are a very large, multi-facility teaching hospital. We do have POS 11 offices both in the hospital (connected, etc.), as well as free-standing physician offices still under our facility name but scattered around many miles from the actual facilities. Do these fall under that flat fee reimbursement structure?

    I look forward to hearing responses…

    Donna

  2. Tonya Ceena Says:

    Hello,

    Is this only for facility coding or does the also affect professional coding.

    Thank you,
    Tonya

  3. Ann M. Adams Says:

    The last line in the note article states “Note that this change affects facility billing only, not coding for physician services.”

  4. Michelle White Says:

    I am confused also. We are a Critical access hospital that bills provider based in our clinics. We have a RHC in one clinic and another clinic Part B that we file. We also have 2 clinics within our hospital that do bill outpatient. Does this code affect all clinics or just one’s within hospital that bill as outpatient not office.

  5. Eleanor Norling Says:

    We are also Critical Access. Do we bill G0463 for every facility portion of a split-bill and the usual 99xxx for the provider portion?

    The description indicates “…the spectrum of hospital resources provided during an outpatient hospital clinic visit is appropriately captured and reflected in the single level payment for clinic visits…”. Does this mean that EKG tracings, vaccinations, etc are now included in the one fee?

    Also, has the fee for facility billing been finalized as $212.40?

  6. Eleanor Norling Says:

    And, another question: Does this affect the IPPE code for facility of G0402f?

  7. Tina McCart Says:

    we are a facilty based clinic we bill place of service for physician. we have a clinic and it is facilty bases for LSU we bill office visits new and established. Will we have to bill this one code for all of our services?
    For Christus I work for the cancer treatment center and we are also facilty based and bill place of service 22. we have new and established patients. The CPT book has codes for our services that are accurate it seems if we all bill the same G code what are the requirements for the visits going to be?

  8. Portia Anderson Says:

    I have the exact question asked above by Eleanor Norling: “We are also Critical Access. Do we bill G0463 for every facility portion of a split-bill and the usual 99xxx for the provider portion?
    The description indicates “…the spectrum of hospital resources provided during an outpatient hospital clinic visit is appropriately captured and reflected in the single level payment for clinic visits…”. Does this mean that EKG tracings, vaccinations, etc are now included in the one fee?
    Also, has the fee for facility billing been finalized as $212.40?”

  9. Jeanne M. Kerr Says:

    Do you know if the Medicare Advantage products are also adopting this processing rule?

  10. Ivonne B Says:

    Does anyone know if Medicaid will be following suit, since out hospital is for pediatrics?

  11. Heather L. Shaull Says:

    I have the same question as many above. We are a Critical Access Hospital with a provider-based clinic. How are we to bill using this new code? Does it just affect the facility portion of a split charge and the physician remains as a 99-code? Are the Medicare Advantage plans also adopting this rule? Medicaid?

    Thank you.

  12. Lisa Perry Says:

    Is the G0463 code also used for 99024 (global) visits?

  13. Wendy Says:

    The Actual verbage for CMS. This should greatly help as you can see which E/M codes are replaced:

    4. Clinic Visits
    Effective January 1, 2014, CMS will recognize HCPCS code G0463 (Hospital outpatient clinic visit for
    assessment and management of a patient) for payment underthe OPPS for outpatient hospital clinic visits.
    Effective January 1, 2014, CPT codes 99201-99205 and 99211-99215 will no longer be recognized for
    payment under the OPPS.
    5. Extended Assessment and Management (EAM) Composite APC (8009)Effective January 1, 2014 CMS will provide payment for all qualifying extended assessment and
    management encounters through newly created composite APC 8009 (Extended Assessment and
    Management (EAM) Composite). A clinic visit (G0463), a Level 4 (99284) or Level 5 Type A ED visit
    (99285), or Level 5 Type B ED visit (G0384) furnished by a hospital in conjunction with observation
    services of eight or more hours will qualify for payment through APC 8009. Effective January 1, 2014 CMS
    will no longer provide payment for extended assessment and management encounters through APCs 8002
    (Level I Extended Assessment and Management Composite) and 8003 (Level I Extended Assessment and
    Management Composite), which have been deleted.

  14. Katie Says:

    I can’t find any guidance on if we can still put our regular modifiers (when necessary) on G0463 as we normally would attach to our clinic E/M codes. Any feedback on this would be greatly appreciated!!

  15. Katie Says:

    Was the G0463 effective on 1/1/14 as the date of service or all claims sent out starting that day (so including December claims going out in January, etc). We had AARP deny a December claim that would have gone out in January. The regular 99xxx E/M code was used on the claim but should have been fine as I didn’t think the G code would be in effect until DOS was 1/1/14 and on. Thanks!

  16. S.Schilling Says:

    I am new at this so please bear with me.. My question is: the old 99201 et al were billed as a split bill with a portion on a 1500 (physician component charge) and a portion on a UB04 (technical portion). Is the new G0463 also a code with both a professional and a technical component? Or do we bill both the G0463 as the technical portion with modifier, and a 99201 as the professional portion with a modifier? If G0463 alone with split portions, where do I get the split percentage or amounts?

  17. Rosemary Hakenwerth Says:

    Under the final rule, beginning Jan. 1, 2014 all hospital clinic E/M visits—regardless of patient status (new or established) or intensity of service—will be reported using new HCPCS Level code G0463 for facility. Hospital outpatient clinic visit for assessment and management of a patient is assigned to new APC 0634 = $92.53.

    Note that this change affects facility billing only, not coding for physician or professional services.

  18. Elaine Jias Says:

    Using G0463 as a single level for as directed by CMS for Medicare and Medicaid patients is required under the new 2014 rule. Other payers (at least at this point) will continue to recognize the CPT series of 992.. My question deals with fees. How are facilities assigning an appropriate fee to the new G-code? I am getting feedback that all patient fees need to be universal and am struggling that all other carriers are recognizing 5 levels while CMS is only recognizing 1 level …. which brings the question: How can you assign a few that is consistent across all payers when the codes are not consistent? How are others handling this challenge?

  19. Reyna Says:

    Does this rule also apply to Medicaid APG billing methodology?

  20. Ashley Bustamante Says:

    Does this pertain to OP Clinics billing on a CMS 1500 Form? we bill for inpatient visits as well but we also bill on a CMS 1500 claim form will we need to change to G0463? I’m really confused….

  21. pz Says:

    Does anyone know the fee amount paid under this code?

  22. Jan Says:

    G0463 has a fixed payment of $92.53. This change only applies to OPPS. Critical Access Hospitals are not paid under OPPS, and therefore not affected. (Per article printed by Optum )

  23. Kristi Says:

    We do outpatient billing and we have been noticing that the facility bills are being paid by using the 99000 codes and not the G-code. The physician bills are being denied for using the 99000 codes and not the G-code. How exactly should these bills be coded? We do worker’s compensation billing and I know that each state has their own guidelines but this is confusing. Should the G-code only be billed on the facility and not the physician bills or the other way around? Hope someone can clarify this.

  24. Steph Says:

    Hi – doesn anyone know if we put a modifier when appropiate?

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