Correct coding for hospital outpatient clinic visits for Medicaid

To align with correct coding guidelines for HCPCS code G0463, Empire BlueCross BlueShield HealthPlus (Empire) is updating its outpatient facility editing system. For Medicaid claims processed on or after May 1, 2023, when HCPCS code G0463 is billed with an inappropriate revenue code, it will be denied. According to correct coding guidelines, HCPCS code G0463 is for hospital outpatient clinic visits or assessment and management of a patient and should only be billed with revenue codes that support the billing of clinic visits, assessments, and management services including the following:

• Clinic (0510 to 0517, 0519, 0520)
• ER urgent care (0456)
• Treatment room (0761)

For assistance with coding guidelines, please refer to the CPT^® coding guidelines. If you believe you have received a denial in error, please follow the Empire standard claim payment dispute process as outlined in the provider manual.

If you have questions or concerns, please contact Provider Services.