CMS Opens Door to G0463 Billing for Remote Physician Visits

The confusion over what code to use when hospital-employed physicians perform virtual visits with patients has reared its head again in the latest FAQ from Medicare (released on July 28).

Based on this latest iteration, the service billed by the hospital seems to be dependent on where the physician is when they conduct the visit. That means the visit is viewed differently by the Centers for Medicare & Medicaid Services (CMS) if the physician is sitting in their office versus sitting at home. But before I go into the details, allow me to compliment the CMS staff. Throughout this pandemic, CMS has gone to great lengths to finesse the regulations and payment rules to try and help providers of all types, without forcing them to go through the regular rule-change process. For example, phone calls went from “never covered” to “covered with a low payment rate” to “covered and paid at the same rate as an in-person office visit” in two months.

Now, back to these virtual visits. Here is my interpretation of this new guidance. If the physician is in their office – which is a provider-based clinic location – and the patient’s home is designated as a temporary provider-based location of the hospital, then technically both the doctor and the patient are in the clinic, so the charges for the use of the facility get billed as a face-to-face visit. It is not a telehealth visit. That means the hospital can bill their usual facility fee, G0463. But if the doctor is not in their office, and perhaps at home or on the golf course, then it is a telehealth visit, and the hospital can only bill the originating site fee (the Q3014) because only the patient is “in” the clinic.

Prior to this updated guidance, CMS seemed to be saying that if the patient and doctor were not literally in the same physical location, the hospital could only charge the originating site fee, Q3014. It seems that what CMS has done is analogous to the regulatory changes for phone calls I outlined above. The rules went from no coverage for these visits to allowing an originating site fee, which meant that there was payment parity between independent physicians who bill place of service 11 and employed physicians who bill place of service 19 or 22. Allowing G0463 brings the payment rate back to the pre-COVID level. It seems that CMS staff have again come through with a great solution.

This is confusing, and subject to interpretation. As always, read the source documentation and discuss this with your compliance and legal teams. There is a significant amount of revenue at stake here, since thousands of these virtual visits by employed physicians have occurred since the start of the public health emergency.

And if you can figure out where the physician was when they conducted the visit, you may be able to go back and rebill and get a significantly higher payment.

Programming Note: Dr. Ronald Hirsch is a permanent panelist on Monitor Mondays. Listen to his Monday Rounds, 10 a.m. EST.

Addendum: I would like to thank John Settlemeyer, the  Assistant Vice President of Enterprise Revenue Management at Atrium Health, for reminding me to inform readers of two very important points. The physician professional fee claim should not be billed with the -95 modifier since it is not a telehealth visit and the hospital should not go to the time and effort to do a temporary extraordinary circumstances relocation in order to be able to bill with the -PO modifier since G0463 pays the same with the -PO or the -PN modifier. The temporary relocation, which requires notifying the regional CMS office of every address, is only of value when there is a payment differential between a service when billed with -PO rather than -PN.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn
Email
Print

Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

The CMS Two-Midnight Rule and short-stay audits are here to stay, impacting inpatient and outpatient admissions, ASC procedures, and Medicare Parts C & D. New for 2024, the Two-Midnight Rule applies to Medicare Advantage patients, requiring differentiation between Medicare plans affecting Case Managers, Utilization Review, and operational processes and knowledge of a vital distinction between these patients that influences post-discharge medical reviews and compliance risk. Join Michael G. Calahan for a comprehensive webcast covering federal laws for all admission processes. Gain the knowledge needed to navigate audits effectively and optimize patient access points, personnel, and compliance strategies. Learn Two-Midnight Rule essentials, Medicare Advantage implications, and compliance best practices. Discover operational insights for short-stay admissions, outpatient observation, and the ever-changing Inpatient-Only Listing.

Print Friendly, PDF & Email
September 19, 2023
Secondary Diagnosis Coding: A Deep Dive into Guidelines and Best Practices

Secondary Diagnosis Coding: A Deep Dive into Guidelines and Best Practices

Explore comprehensive guidelines and best practices for secondary diagnosis coding in our illuminating webcast. Delve into the intricacies of accurately assigning secondary diagnosis codes to ensure precise medical documentation. Learn how to navigate complex scenarios and adhere to coding regulations while enhancing coding proficiency. Our expert-led webcast covers essential insights, including documentation requirements, sequencing strategies, and industry updates. Elevate your coding skills and stay current with the latest coding advancements so you can determine the correct DRG assignment to optimize reimbursement, support medical decision-making, and maintain compliance.

Print Friendly, PDF & Email
September 20, 2023
Principal Diagnosis Coding: Mastering Selection and Sequencing

Principal Diagnosis Coding: Mastering Selection and Sequencing

Enhance your inpatient coding precision and revenue with Principal Diagnosis Coding: Mastering Selection and Sequencing. Join our expert-led webcast to conquer the challenges of principal diagnosis selection and sequencing. We’ll decode the intricacies of ICD-10-CM guidelines, equipping you with a clear grasp of the rules and the official UHDDS principal diagnosis definition. Uncover the crucial role of coding conventions, master the sequencing of related conditions, and confidently tackle cases with equally valid principal diagnoses.

Print Friendly, PDF & Email
September 14, 2023
2024 IPPS Summit: Final Rule Update with Expert Insights and Analysis

2024 IPPS Summit: Final Rule Update with Expert Insights and Analysis

Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY24 Inpatient Prospective Payment System (IPPS) Final Rule, including new ICD-10-CM/PCS codes, plus insights, analysis and answers to questions from the country’s most respected subject matter experts.

Print Friendly, PDF & Email
2024 IPPS Summit Day 3: MS-DRG Shifts and NTAPs

2024 IPPS Summit Day 3: MS-DRG Shifts and NTAPs

This third session in our 2024 IPPS Summit will feature a review of FY24 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by senior healthcare consultant Laurie Johnson, with bonus insights and analysis from two acclaimed subject matter experts

Print Friendly, PDF & Email
August 17, 2023

Trending News