Reminder: National Government Services Appeals Requesting Reimbursement Change for HCPCS Code G0463

Appeals activities conducted by National Government Services are governed by CMS. Providers and beneficiaries have the right to appeal claim determinations made by NGS. The purpose of the appeals process is to ensure the correct adjudication of claims.

When a service was not reimbursed by Medicare and the provider believes that the service should have been covered, the provider should consider filing an appeal. However, when a service is reimbursed in accordance with Medicare’s national payment policy then the amount paid is final. The method of reimbursement is not an appropriate reason for an appeal.

Any redetermination request received for the purpose of disputing the method of reimbursement will be dismissed. For example, an appeal request based on the reimbursement methodology for HCPCS code G0463 will be dismissed.

Background:

Effective 1/1/2019, CMS finalized a policy in the OPPS that reduces the payment rate for HCPCS code G0463 when furnished in excepted off-campus provider-based departments of hospitals. CMS is phasing this policy in over a two-year period that began in CY 2019. 

Per MLN Matters®: MM11099: January 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS):

“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.”

Posted 12/10/2020