Clarification of Clinic Billing for Critical Access Hospitals

Janet Hodgdon, Director, and Margaret Fortin, Senior Manager, Healthcare Consulting Practice
January 2014

BNN recently helped clarify a coding dilemma on behalf of several clients who provide health care services.

The Centers for Medicare and Medicaid Services (CMS) recently issued the 2014 final rule for outpatient prospective payment services. Part of that rule finalized a proposal to “collapse” the existing five clinic visit levels into one level for payment purposes. G - code G0463 was developed for this purpose. BNN has received many questions regarding the applicability of this G - code and visit leveling to critical access hospitals. We reached out to CMS for clarification. CMS responded to our request and stated the following:

“CAHs may bill the new G-code for clinic visits (facility service) but they are not required to. CMS has no edits that would prevent CAHs from being paid if they billed CPT® codes 99201 – 99205 and 99211 – 99215 for the facility service of the clinic visit. Their payment would also not be affected as they are paid at reasonable cost. For physician services rendered in a Method II CAH during a clinic visit, the MPFS coding (which are the CPT codes) should be used.”

If you have any questions about the final rule or its clarification, have a desire to receive a copy of the ruling or would like assistance in assessing the financial impact of the clarification please contact Maggie Fortin.

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