CurrentColorado Rocky Mountain Health PlansPolicy 2026R5039A

UB-04 reporting of HCPCS G0463 with modifier PO

Policy governs use of modifier PO with HCPCS code G0463 for outpatient hospital clinic visits billed on UB04 forms and affects providers billing UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUB-04 reporting of HCPCS G0463 with modifier PO

Policy CodePolicy 2026R5039A

Change TypeNo material change

Effective DateMar 1, 2026

Next Review Date

Key ActionReport HCPCS code G0463 with modifier PO when outpatient hospital items and services are provided in an off-campus provider-based hospital department; reimbursement will be 40% of allowed amount.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60%reduction in reimbursement when PO appended

40%reimbursement when G0463 billed with modifier PO

250y / 35midistance criteria

all productsplan applicability

Reimbursement Adjustment Criteria

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyUB-04 reporting of HCPCS G0463 with modifier PO

Policy CodePolicy 2026R5039A

Change TypeNo material change

Effective DateMar 1, 2026

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

ALL of the following
- Service must be provided in an off-campus provider-based hospital department defined as a facility located more than 250 yards from the main provider but within 35 miles of the main provider.
ALL of the following
- HCPCS code G0463 must be reported with modifier PO when the service is provided in an off-campus provider-based department.
ALL of the following
- When HCPCS code G0463 is submitted with modifier PO, reimbursement will be 40% of the allowed amount (a 60% reduction).

Billing and Reporting Requirements for Providers

Billing Rule

Append modifier PO to G0463 for off‑campus provider‑based services

Report HCPCS code G0463 with modifier PO when outpatient hospital items and services are provided in an off-campus provider-based hospital department; when appended, reimbursement will be 40% of the allowed amount (a 60% reduction).

Off-campus provider-based department: facility located more than 250 yards from the main provider but within 35 miles.
Modifier PO denotes an excepted service provided at an off-campus, outpatient, provider-based department of a hospital.

Key Definitions

Definition — off-campus provider-based department and location criteria

DefinitionProvider-based department of a hospital — a facility owned and operated by the main provider; may be located on‑campus or off‑campus.

Off‑campus criteriaConsidered off‑campus when the facility is located more than 250 yards from the main provider but within 35 miles.

Billing requirementWhen services are provided in an off‑campus provider‑based department, HCPCS code G0463 must be reported with modifier PO.

Definition — HCPCS G0463 (hospital outpatient clinic visit for assessment and management of a patient)

CodeG0463

DescriptionHospital outpatient clinic visit for assessment and management of a patient.

RequirementIn alignment with CMS, G0463 must be reported with modifier PO when provided in an off‑campus provider‑based hospital department.

Definition — Modifier PO (excepted service provided at an off-campus, outpatient, provider-based department of a hospital)

ModifierPO

DescriptionExcepted service provided at an off‑campus, outpatient, provider‑based department of a hospital.

Billing impactWhen PO is appended to G0463 for off‑campus provider‑based services, reimbursement is adjusted (G0463 reimbursed at 40% of allowed amount; 60% reduction).

OpenPayer

UB-04 reporting of HCPCS G0463 with modifier PO

Reimbursement Adjustment Criteria

Required Codes, Modifiers, and Distance Thresholds

Billing and Reporting Requirements for Providers

Key Definitions