Health Information Management

Q&A: Why are our clinic visit codes rejected by Medicare?

APCs Insider, February 21, 2014

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A: For 2014, CMS has created one HCPCS Level II code for reporting all clinic visits. G0463 (hospital outpatient clinic visit for assessment and management of a patient) replaces all of the CPT® codes for reporting hospital outpatient department visits. CPT codes 99201-99205 and 99211-99215 are no longer recognized for payment under the OPPS. Be sure you discuss this with your non-Medicare payers as they may or may not accept G0463. If they don’t, you will have to set up your chargemaster (CDM) to accommodate both sets of codes to ensure appropriate reporting of the service.
HCPCS code G0463 has been added to the visits appropriate for combining with observation hours to trigger the Extended Assessment and Management (EAM) Composite APC (8009). 
Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.

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