G0463 Has No Appeal Rights

CMS has provided direction to the Medicare Administrative Contractors (MACs) to dismiss requests appealing the reimbursement of HCPCS G0463. No further appeal rights will be granted at subsequent levels due to the statutory guidance supporting the pricing of this HCPCS code.

Per the 2019 Outpatient Prospective Payment System (OPPS) Final Rule, as summarized in the Medicare Learning Network (MLN) Matters (MM)11099, under the authority of 42 United States Code (U.S.C.) § 1395l(t), the payment amount of G0463 will be 70% of the OPPS rate for calendar year (CY) 2019. MM11099 states:

"For CY 2019, CMS is finalizing a policy to use its authority under section 1833(t)(2)(F) of the Act to apply an amount equal to the site-specific Physician Fee Schedule (PFS) payment rate for nonexcepted items and services furnished by a nonexcepted off-campus Provider-Based Department (PBD) (the PFS payment rate) for the clinic visit service, as described by HCPCS code G0463, when provided at an off-campus PBD excepted from section 1833(t)(21) of the Act (departments that bill the modifier "PO" on claim lines).

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. CMS is 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."

Last Updated Mar 22, 2019