12.3 Hospital Outpatient Clinic, Preventive, and Critical Care

Hospital outpatient clinic visits are where COC candidates most often import professional-office habits onto a facility claim. For Original Medicare hospital outpatient department (HOPD) clinic encounters, the facility assessment-and-management service is HCPCS G0463, described as a hospital outpatient clinic visit for assessment and management of a patient. CMS has used G0463 for this purpose since it replaced leveled clinic visit codes, and the calendar year 2026 OPPS final rule continues to treat G0463 as the outpatient clinic visit HCPCS code. CMS still standardizes OPPS relative weights to APC 5012, the APC to which G0463 is assigned.

Do not report CPT 99202-99215 as the Medicare HOPD facility clinic visit on the UB-04. Those codes remain the usual professional office and outpatient E/M series on the CMS-1500. A typical Medicare split is: the hospital reports G0463 with a clinic revenue code (often 0510) on the UB-04; the physician reports 99213 or another supported office/outpatient code on the CMS-1500.

Off-campus provider-based departments add location modifiers. Nonexcepted off-campus departments use modifier PN. Excepted off-campus departments use modifier PO. CMS continues, including for CY 2026, a volume-control policy that pays G0463 in excepted off-campus provider-based departments at a Physician Fee Schedule-equivalent rate (40 percent of the OPPS rate). On-campus HOPD clinic visits are not paid under that 40-percent clinic-visit reduction. Payment chapters cover APC math. This chapter's point is code selection: Medicare facility clinic = G0463, not a leveled CPT office visit.

Commercial and other non-Medicare clinic reporting

Commercial payers, Medicare Advantage plans, and Medicaid agencies write their own facility clinic rules. Some follow Medicare and want G0463. Others still want CPT office and outpatient E/M 99202-99215 on the institutional claim, sometimes with new-versus-established distinctions that Medicare G0463 does not make. When the stem names a commercial payer and gives MDM or time, be ready to apply the 2023 and later office/outpatient E/M framework: select the level by MDM or by total time on the date of the encounter, using the CPT E/M guidelines in your book. When the stem names Medicare HOPD facility clinic, G0463 is the facility code whether the professional service would have been 99212 or 99215.

G0463 is not an ED code, not observation, and not critical care. If the patient is in a Type A ED, use 99281-99285. If the patient is in observation under a physician order, add G0378 as taught in section 12.2. If the documentation supports critical care, use 99291-99292, not G0463.

Office and outpatient CPT E/M (99202-99215) still matter on the COC exam because AAPC tests CPT E/M proficiency and because some facility claims are not Medicare OPPS clinic visits. The 2023 revisions let you select those levels by MDM or by time. MDM still uses problems, data, and risk; read the official table in the CPT E/M guidelines rather than a reproduced grid. Time, when used, is total time on the date of the encounter by the physician or QHP, not the patient's waiting-room clock and not nursing facility time unless the book says otherwise.

Preventive services: CPT 99381-99397 versus Medicare G-codes

CPT preventive medicine E/M codes 99381-99387 (new patient) and 99391-99397 (established patient) describe age-based comprehensive preventive evaluations. Commercial plans often pay this series for an annual physical.

Original Medicare does not use 99381-99397 to pay the Medicare wellness benefit. CMS instructs providers not to bill those CPT preventive codes for the Medicare Initial Preventive Physical Examination (IPPE) or Annual Wellness Visit (AWV). The Medicare codes are:

A hospital outpatient department that furnishes these services reports the applicable G-code on the facility claim when it is the billing provider for that encounter, following CMS billing instructions. Problem-oriented E/M may be separately reportable on the same day when a significant, separately identifiable problem is documented; professional claims commonly append modifier 25 to the problem-oriented E/M. Do not treat a Medicare AWV as if it were a CPT 99397 physical, and do not treat a commercial age-based physical as if it were G0439.

Other Medicare preventive HCPCS codes (for example, certain screening pelvic, depression, or alcohol-screening G-codes) may appear with clinic encounters. Report them when documentation and frequency rules are met. They do not automatically replace G0463 when a hospital clinic assessment-and-management visit also occurred, unless a specific CMS instruction packages or substitutes the service.

Outpatient critical care: 99291 and 99292

Critical care is reported with CPT 99291 (first 30-74 minutes) and add-on 99292 (each additional 30 minutes) when the patient is critically ill or injured and the clinician provides the time-based critical-care service defined in the CPT E/M guidelines. Location does not have to be an intensive care unit. Critical care may be provided in the ED or in other outpatient hospital settings when the definition is met. Time of less than 30 minutes is not 99291; report the appropriate non-critical E/M instead.

99291 is reported once per date for the first 30-74 minutes. 99292 is an add-on and is never standalone. CMS and CPT have differed on when the first 99292 unit is allowed: CPT counting begins the additional 30-minute code at 75 total minutes, while Medicare has required a full additional 30 minutes (104 total minutes) before 99292. On a Medicare facility item, follow CMS time math. If the stem is purely a CPT-book question, follow the critical-care instructions in your CPT Professional. In either case, document the total critical-care time and the organ-system failure or injury that made the care critical. An intensive-care bed or a cardiac monitor alone does not create critical care.

Facility claims may report 99291-99292 when the hospital record supports critical care as a facility service. Do not downcode documented critical care to G0463 or to an ED level because the patient later stabilizes. Conversely, do not upcode a clinic blood-pressure recheck to 99291.

If a patient is seen in the ED and later becomes critical, CPT allows both ED E/M and critical care on the same date when the ED E/M occurred before the patient was critically ill and the services are separately documented; modifier 25 is applied to the ED E/M on professional claims when required. Read the CPT critical-care and ED notes rather than assuming the two families always bundle.

Scenario

A Medicare patient is seen in an on-campus hospital cardiology clinic for medication review. The hospital reports G0463, not 99214. The cardiologist reports 99214 on the CMS-1500 if MDM or time supports that professional level. The next week, a commercially insured 54-year-old established patient presents to the same clinic for a periodic physical and is not on Original Medicare: reporting follows the commercial contract, which commonly uses CPT 99396 rather than G0439. That evening, a different patient arrives in the Type A ED in respiratory failure and receives 55 minutes of documented critical care: the facility reports 99291 (not G0463, and not 99285 as a substitute for documented critical care). Keep the setting, the payer, and the service definition in that order and the COC clinic-versus-ED-versus-critical-care traps lose most of their force.