CurrentquartzPolicy RP02

Reimbursement of Hospital Outpatient Facility Clinic Visits

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Defines reimbursement rules for facility charges for hospital outpatient clinic visits (G0463) billed on the UB-04 (CMS-1450) for Quartz Commercial and Level Funded lines of business.

Policy Summary

Payerquartz

PolicyReimbursement of Hospital Outpatient Facility Clinic Visits

Policy CodePolicy RP02

Change TypeNo material change

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionDo not bill G0463 with revenue code 051X when there is a corresponding professional E&M billed for the same episode of care; both will be denied as provider liability.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

G0463Primary HCPCS code addressed

051XRevenue code involved in denial rule

Commercial, Level FundedLines of business this policy applies to

3/1/2026Policy effective date / creation date

Coverage Criteria

G0463 and 051X billing criteria

Reimbursement condition for facility clinic visits billed on UB-04:

Claims for hospital outpatient facility clinic visits billed on the CMS-1450 (UB-04) form must meet the following reimbursement condition:

ALL of the following

G0463 reported with revenue code 051X is not eligible for reimbursement when there is a corresponding professional E&M billed for the same episode of care.
When a 051X revenue code is submitted with G0463 and there is a corresponding professional E&M for the same episode of care, both the 051X revenue code and G0463 will be denied as provider liability.

Claims may be subject to denial as provider liability and should be supported with appropriate documentation if requested during review.

Coding and Billing Details

Facility clinic visit codingHCPCS | RevenueCovered

G0463	Hospital outpatient clinic visit for assessment and management of a patient (facility fee)
051X	Revenue code 051X (facility clinic charge) referenced in denial rule

Concurrent professional E&M billing prohibition — G0463 + 051X

RuleG0463 billed with revenue code 051X is not eligible for reimbursement when there is a corresponding professional E&M billed for the same episode of care.

ConsequenceWhen submitted together, the 051X revenue code and G0463 will be denied as provider liability.

Audit expectationClaims may be subject to post-payment review; providers must submit supporting documentation if requested.

Provider Actions and Billing Restrictions

Billing Rule

Avoid billing G0463 with revenue code 051X when professional E&M is billed

Do not bill G0463 with revenue code 051X when there is a corresponding professional E&M billed for the same episode of care. When submitted together the 051X revenue code and G0463 will be denied as provider liability; be prepared to provide supporting documentation if requested during post‑payment review.

Both G0463 and revenue code 051X will be denied as provider liability when a professional E&M for the same episode is billed (deny both).
Quartz may conduct post‑payment review; providers must submit supporting documentation if requested.
Misuse of codes or modifiers or exceeding service limits may result in recoupment or other corrective action.

Definitions

G0463 — Hospital outpatient clinic visit (facility fee)

HCPCS codeG0463 — Hospital outpatient clinic visit for assessment and management of a patient (facility fee)

Typical billing formReported on the CMS-1450 (UB-04) or its electronic equivalent for facility charges.

Applicable lines of businessQuartz Commercial and Level Funded plans.

Revenue code 051X — clinic charge (facility revenue code)

Revenue code051X — facility clinic charge (referenced as the clinic revenue code in this policy)

Policy roleWhen reported with G0463 and a corresponding professional E&M is billed, 051X triggers denial of both codes as provider liability.

Form locatorUsed on the UB-04 (CMS-1450) to indicate facility clinic charges.

Policy Summary

Payerquartz

PolicyReimbursement of Hospital Outpatient Facility Clinic Visits

Policy CodePolicy RP02

Change TypeNo material change

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionDo not bill G0463 with revenue code 051X when there is a corresponding professional E&M billed for the same episode of care; both will be denied as provider liability.

SourceLink

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CurrentquartzPolicy RP02

Reimbursement of Hospital Outpatient Facility Clinic Visits

Customize your policy alerts

Sign up for quartz Policy RP02 alerts

Get alerted when Policy RP02 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines reimbursement rules for facility charges for hospital outpatient clinic visits (G0463) billed on the UB-04 (CMS-1450) for Quartz Commercial and Level Funded lines of business.

Policy Summary

Payerquartz

PolicyReimbursement of Hospital Outpatient Facility Clinic Visits

Policy CodePolicy RP02

Change TypeNo material change

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionDo not bill G0463 with revenue code 051X when there is a corresponding professional E&M billed for the same episode of care; both will be denied as provider liability.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

G0463Primary HCPCS code addressed

051XRevenue code involved in denial rule

Commercial, Level FundedLines of business this policy applies to

3/1/2026Policy effective date / creation date

Coverage Criteria

G0463 and 051X billing criteria

Reimbursement condition for facility clinic visits billed on UB-04:

Claims for hospital outpatient facility clinic visits billed on the CMS-1450 (UB-04) form must meet the following reimbursement condition:

ALL of the following

G0463 reported with revenue code 051X is not eligible for reimbursement when there is a corresponding professional E&M billed for the same episode of care.
When a 051X revenue code is submitted with G0463 and there is a corresponding professional E&M for the same episode of care, both the 051X revenue code and G0463 will be denied as provider liability.

Claims may be subject to denial as provider liability and should be supported with appropriate documentation if requested during review.

Coding and Billing Details

Facility clinic visit codingHCPCS | RevenueCovered

G0463	Hospital outpatient clinic visit for assessment and management of a patient (facility fee)
051X	Revenue code 051X (facility clinic charge) referenced in denial rule

Concurrent professional E&M billing prohibition — G0463 + 051X

RuleG0463 billed with revenue code 051X is not eligible for reimbursement when there is a corresponding professional E&M billed for the same episode of care.

ConsequenceWhen submitted together, the 051X revenue code and G0463 will be denied as provider liability.

Audit expectationClaims may be subject to post-payment review; providers must submit supporting documentation if requested.

Provider Actions and Billing Restrictions

Billing Rule

Avoid billing G0463 with revenue code 051X when professional E&M is billed

Both G0463 and revenue code 051X will be denied as provider liability when a professional E&M for the same episode is billed (deny both).
Quartz may conduct post‑payment review; providers must submit supporting documentation if requested.
Misuse of codes or modifiers or exceeding service limits may result in recoupment or other corrective action.

Definitions

G0463 — Hospital outpatient clinic visit (facility fee)

HCPCS codeG0463 — Hospital outpatient clinic visit for assessment and management of a patient (facility fee)

Typical billing formReported on the CMS-1450 (UB-04) or its electronic equivalent for facility charges.

Applicable lines of businessQuartz Commercial and Level Funded plans.

Revenue code 051X — clinic charge (facility revenue code)

Revenue code051X — facility clinic charge (referenced as the clinic revenue code in this policy)

Policy roleWhen reported with G0463 and a corresponding professional E&M is billed, 051X triggers denial of both codes as provider liability.

Form locatorUsed on the UB-04 (CMS-1450) to indicate facility clinic charges.

Policy Summary

Payerquartz

PolicyReimbursement of Hospital Outpatient Facility Clinic Visits

Policy CodePolicy RP02

Change TypeNo material change

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionDo not bill G0463 with revenue code 051X when there is a corresponding professional E&M billed for the same episode of care; both will be denied as provider liability.

SourceLink

On This Page