Key facts for G0463
- Medicare payment
- $136.02
- OPPS rate, SI J2
- Coverage code
- C
- carrier judgment, so the Medicare contractor decides coverage
- Facility outpatient MUE
- 4
- MAI 3
- NCCI PTP pairs
- 6251
- 4425 hospital outpatient
- LCDs and articles
- 0 / 1
TL;DR
HCPCS Level II G0463 reads "Hospital outpatient clinic visit for assessment and management of a patient" in the October 2026 file; it dates from 2014. Hospital outpatient departments are paid $136.02 for G0463 under status indicator J2, APC 5012 (Clinic Visits and Related Services), minimum unadjusted copayment $27.21 (October 2026 Addendum B). CMS caps G0463 at practitioner 0 (MAI 3, CMS Policy); hospital outpatient 4 (MAI 3, Clinical: Data) units per day in the 2026 Q4 MUE tables. G0463 is a primary code for 13 add-on codes (15853, 15854, 90833, 90836). In the NCCI PTP files v323r0 G0463 appears in 6140 practitioner pairs as column 2 and 111 as column 1 (most often with 00100, 00102, 00103), and in 4312 hospital outpatient pairs as column 2 and 113 as column 1. 1 billing and coding article lists G0463 across 6 states: A53296. HCPCS record: BETOS M1B (office visits - established); pricing indicator 00; type of service 1 (medical care). Nearby codes: G0465, G0460, G0466, G0459.
G0463 descriptor and code status
The October 2026 HCPCS Level II file describes G0463 as “Hospital outpatient clinic visit for assessment and management of a patient”. It sits in the G section (procedures and professional services, temporary), listed with the other G codes. Although searches often call it the "G0463 CPT code", G0463 is a HCPCS Level II code maintained by CMS, not an AMA CPT code; both go in the same procedure-code field on the claim.
| Field | Value |
|---|---|
| Short descriptor | Hospital outpt clinic visit |
| Added to HCPCS | 2014-01-01 |
| Last action | N (no maintenance), effective 2014-01-01 |
| Coverage code | C: carrier judgment, so the Medicare contractor decides coverage |
| Pricing indicator | 00: not separately priced by Part B |
| BETOS category | M1B: office visits - established |
| Type of service | 1: medical care |
Medicare payment for G0463
Hospital outpatient departments are paid $136.02 for G0463 under status indicator J2, APC 5012 (Clinic Visits and Related Services), minimum unadjusted copayment $27.21 (October 2026 Addendum B). The amounts below are national figures from the October 2026 CMS files; the contractor applies the locality, rural or state adjustment and the beneficiary's cost sharing.
Physician fee schedule (RVU26D)
Status X: statutory exclusion: not a physician service under the fee schedule. Global period XXX (global surgery concept does not apply); PC/TC indicator 9 (professional/technical concept does not apply).
Hospital outpatient (OPPS Addendum B)
Status indicator J2 (Hospital Part B services that may be paid through a comprehensive APC), APC 5012 (Clinic Visits and Related Services), national unadjusted payment $136.02 with a minimum unadjusted copayment of $27.21.
Medically Unlikely Edits for G0463
CMS caps G0463 at practitioner 0 (MAI 3, CMS Policy); hospital outpatient 4 (MAI 3, Clinical: Data) units per day in the 2026 Q4 MUE tables. The facility outpatient MUE is a date-of-service clinical edit: units above the limit deny but can be paid on appeal with documentation.
| Setting | MUE (units/DOS) | MAI | CMS rationale |
|---|---|---|---|
| Practitioner services | 0 | 3 Date of Service Edit: Clinical | CMS Policy |
| Facility outpatient hospital | 4 | 3 Date of Service Edit: Clinical | Clinical: Data |
The MUE lookup for G0463 shows every setting next to any other code on the same claim.
NCCI edits and add-on rules
In the practitioner PTP file v323r0, G0463 is the column-2 (bundled) code in 6140 active pairs, 95% of which allow a modifier and the column-1 code in 111 (44% modifier-allowed); 502 earlier pairs have been deleted. CMS's most frequent rationale for the bundled pairs: CPT Manual or CMS manual coding instruction.
| Column-1 code | Pairs |
|---|---|
| 00100 (CPT; descriptor licensed by AMA) | 1 |
| 00102 (CPT; descriptor licensed by AMA) | 1 |
| 00103 (CPT; descriptor licensed by AMA) | 1 |
| 00104 (CPT; descriptor licensed by AMA) | 1 |
| 00120 (CPT; descriptor licensed by AMA) | 1 |
| 00124 (CPT; descriptor licensed by AMA) | 1 |
| 00126 (CPT; descriptor licensed by AMA) | 1 |
| 00140 (CPT; descriptor licensed by AMA) | 1 |
| Column-2 code | Pairs |
|---|---|
| 0912T (CPT; descriptor licensed by AMA) | 1 |
| 0929T (CPT; descriptor licensed by AMA) | 1 |
| 36591 (CPT; descriptor licensed by AMA) | 1 |
| 36592 (CPT; descriptor licensed by AMA) | 1 |
| 43752 (CPT; descriptor licensed by AMA) | 1 |
| 80503 (CPT; descriptor licensed by AMA) | 1 |
| 80504 (CPT; descriptor licensed by AMA) | 1 |
| 80505 (CPT; descriptor licensed by AMA) | 1 |
In the hospital outpatient PTP file v323r0, G0463 is the column-2 (bundled) code in 4312 active pairs, 100% of which allow a modifier and the column-1 code in 113 (76% modifier-allowed); 200 earlier pairs have been deleted. CMS's most frequent rationale for the bundled pairs: CPT Manual or CMS manual coding instruction.
| Column-1 code | Pairs |
|---|---|
| 00100 (CPT; descriptor licensed by AMA) | 1 |
| 00102 (CPT; descriptor licensed by AMA) | 1 |
| 00103 (CPT; descriptor licensed by AMA) | 1 |
| 00104 (CPT; descriptor licensed by AMA) | 1 |
| 00120 (CPT; descriptor licensed by AMA) | 1 |
| 00124 (CPT; descriptor licensed by AMA) | 1 |
| 00126 (CPT; descriptor licensed by AMA) | 1 |
| 00140 (CPT; descriptor licensed by AMA) | 1 |
| Column-2 code | Pairs |
|---|---|
| 0591T (CPT; descriptor licensed by AMA) | 1 |
| 0592T (CPT; descriptor licensed by AMA) | 1 |
| 0593T (CPT; descriptor licensed by AMA) | 1 |
| 0912T (CPT; descriptor licensed by AMA) | 1 |
| 0929T (CPT; descriptor licensed by AMA) | 1 |
| 36591 (CPT; descriptor licensed by AMA) | 1 |
| 36592 (CPT; descriptor licensed by AMA) | 1 |
| 43752 (CPT; descriptor licensed by AMA) | 1 |
G0463 is a designated primary code for 13 add-on codes (15853, 15854, 90833, 90836, 90838, 96160, 96161, 99415).
Pair counts show exposure, not the answer for one claim. Check G0463 against a second code to see whether the pair bundles and whether a modifier can separate the services.
Medicare coverage policies for G0463
0 active Local Coverage Determinations and 1 billing and coding article list G0463. Each applies only in its contractor's jurisdiction, and the article carries the diagnosis codes that support the item or service.
| Article | Title | Contractor(s) | Related LCD |
|---|---|---|---|
| A53296 | Billing and Coding: Wound Care & Debridement – Provided by a Therapist, Physician, NPP or as Incident-to Services | Noridian Healthcare Solutions, LLC | — |
Denials to expect on G0463
the diagnosis or documentation does not meet the LCD or billing article that lists G0463
the modifier reported is inconsistent with the code
the claim lacks information needed to adjudicate the line, such as an order, NPI or required modifier
Where QuickIntell fits for G0463 claims
QuickCode supports qualified coder review of units, modifiers and NCCI pairs for G0463 before the claim leaves, and QuickRCM carries claim readiness and the denial follow-up when an edit or coverage policy is missed.
Frequently asked questions: HCPCS G0463
What does HCPCS code G0463 describe?
"Hospital outpatient clinic visit for assessment and management of a patient" (short descriptor "Hospital outpt clinic visit"), in the G section (procedures and professional services, temporary). Added 2014-01-01.
Is G0463 a CPT code?
It is not. G0463 belongs to the G section (procedures and professional services, temporary) of HCPCS Level II, the CMS code set, not to AMA CPT. "G0463 CPT code" searches refer to it.
What does Medicare pay for G0463?
Hospital outpatient departments are paid $136.02 for G0463 under status indicator J2, APC 5012 (Clinic Visits and Related Services), minimum unadjusted copayment $27.21 (October 2026 Addendum B).
Is G0463 an add-on code?
G0463 is a primary code for 13 add-on codes (15853, 15854, 90833, 90836).
How many units of G0463 can be billed per day?
CMS caps G0463 at practitioner 0 (MAI 3, CMS Policy); hospital outpatient 4 (MAI 3, Clinical: Data) units per day in the 2026 Q4 MUE tables. For the facility outpatient MUE (MAI 3), units above 4 deny for the day but can be paid on appeal with documentation; denials arrive as CARC 151.
Does Medicare cover G0463?
Coverage code C (carrier judgment, so the Medicare contractor decides coverage). 1 billing and coding article lists G0463 across 6 states: A53296.
CMS guidance
The Medicare Learning Network publication that CMS issues on this topic, cited by ICN and publication date:
- Evaluation and Management Services(MLN006764, )Evaluation and management code selection by medical decision making or time, documentation and add-on codes.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- HCPCS Level II alpha-numeric file, October 2026Version October 2026 · effective 2026-10-01 · file HCPC2026_OCT_ANWEB_09232026.txtSHA-256 c25240c63108756d…
- Medicare PFS national relative value file RVU26D (non-QPP), October 2026Version RVU26D, released 2026-08-26 · effective 2026-10-01 · file PPRRVU2026_Oct_nonQPP.csvSHA-256 4d0d3f19bd954ffc…
- Medicare PFS national relative value file RVU26D (qualifying APM participants), October 2026Version RVU26D, released 2026-08-26 · effective 2026-10-01 · file PPRRVU2026_Oct_QPP.csvSHA-256 59d3734704853936…
- OPPS Addendum B, October 2026Version October 2026 · effective 2026-10-01 · file 508-compliant-version-2026_October_Web_Addendum_B.09.28.26.csvSHA-256 6ad7393a318bf1b9…
- Integrated Outpatient Code Editor v27.3 data tables: status and payment indicatorsVersion I/OCE v27.3 (October 2026) · effective 2026-10-01 · file Data_Status_Indicator.txtSHA-256 78f119ef0a435351…
- NCCI MUE table, practitioner services, effective 2026-10-01Version 2026 Q4 · effective 2026-10-01 · file MCR_MUE_PractitionerServices_Eff_10-01-2026.csvSHA-256 ef038efaf902b7bd…
- NCCI MUE table, facility services, effective 2026-10-01Version 2026 Q4 · effective 2026-10-01 · file MCR_MUE_OutpatientHospitalServices_Eff_10-01-2026.csvSHA-256 3af9f4e99cc587e2…
- NCCI MUE table, dme services, effective 2026-10-01Version 2026 Q4 · effective 2026-10-01 · file MCR_MUE_DMESupplierServices_Eff_10-01-2026.csvSHA-256 6fa4fbba852f7b74…
- NCCI PTP edits, practitioner, v323r0 (four files)Version v323r0 (2026 Q4) · effective 2026-10-01 · file ccipra-v323r0-f1.TXTSHA-256 7793c0b6686c1e22…
- NCCI PTP edits, hospital outpatient, v323r0 (four files)Version v323r0 (2026 Q4) · effective 2026-10-01 · file ccioph-v323r0-f1.txtSHA-256 063f41b91ef9faa2…
- NCCI Add-On Code edits, effective 2026-10-01Version 2026 Q4 · effective 2026-10-01 · file AOC_V2026Q4-F-MCR.xlsxSHA-256 eabb519623134549…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-10-08 · effective 2026-10-04 · file article.csvSHA-256 5e95c4a8ac3664be…
Disclaimer
This page is an operational reference compiled from CMS publications: the HCPCS Level II file, the physician, DMEPOS and clinical laboratory fee schedules, OPPS and ASC addenda, NCCI MUE, PTP and add-on edit tables and the Medicare Coverage Database. Amounts are Medicare national figures before locality and state adjustment; Medicaid and commercial payers set their own. CPT codes are shown as numbers only; CPT descriptors are copyright AMA. Nothing here is legal, clinical or billing advice.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.