G0402/g0463

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We are billing g0402 and g0463 for a patient both with the z00.00 as the primary dx. The g0463 is going out on an ubo4 while the professional side is being billed as the g0402....the tc is leaving a ded. Amount to the patient. Should we be billing the tc of this?

Please help clarify.
 

thomas7331

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I would use G0402 on both the UB and professional claims. It's in the same APC as G0463 but more accurately describes the services. Your payer may be classifying G0463 as an illness-related visit and not applying the correct benefit.
 
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I don't think I worded my initial thread properly- I guess I am wondering why we would be billing the TC at all? Wouldn't we just bill the IPPE for the professional side of things and I assumed everything was included in that one code....
Why would we bill that GO463, because as stated in the thread below it is confusing the payer thus leaving a deduc. for the patient. We should not be billing the patient at all if they are going to the clinic for their IPPE....

Any thoughts or suggestions would be appreciated. Thank you.
 

thomas7331

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You're not billing a technical component (this code doesn't have one) - the UB portion of this service is the facility fee. If this service was done in an office, the payment for the professional claim would be higher because it would include payment for the provider's practice expenses. In a hospital outpatient, your professional claim pays less because it just covers the provider's services - the hospital also bills its UB portion to cover the costs of the staff time and the use of the space.

If the hospital claim is going to the patient's deductive for a preventive service though, then I think that's really a different issue that could be caused by your coding G0463 or could be the payer incorrectly applying benefits.
 
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Thomas,

Thank you for all your help!! you are wonderful.


So we are billing as hospital outpatient. The 1500 form is billing G0402 while the UB is billing G0463.
My thought process is we should not be billing that G0402 on the same DOS that we are billing the G0463 with same dx code. The visit is for the IPPE only. But because we are billing/coding this way, I believe this is why the payer is leaving a patient balance??.....thoughts.
 

espressoguy

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I don't work on the facility side of the house, but I just checked and they are also billing a G0463 when we bill an IPPE or AWV. It also looks like there is a patient balance for the G0463.
 

pineapplelvr

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if the patient complains of any other issues above and beyond the IPPE we charge the G0463 but i wouldn't use the Z00.00 dx (example: oh by the the way doc, I have stomach pain.... and the doc examines them, orders labs, xray) if they have no other dx, then i wouldn't be charging the E/M G0463
 
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