Updated on: August 6, 2020

CMS Opens Door to G0463 Billing for Remote Physician Visits

Original story posted on: August 5, 2020

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.

Ronald Hirsch, MD

Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP 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).

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