CurrentUnitedHealthcarePolicy 2026R5039A

UB04 Policy — G0463 with modifier PO for off‑campus provider‑based outpatient services

Defines UnitedHealthcare's reimbursement requirement that HCPCS code G0463 be reported with modifier PO for services provided in off‑campus provider-based hospital departments and specifies the resulting reimbursement impact for UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyUB04 Policy — G0463 with modifier PO

Policy CodePolicy 2026R5039A

Change TypeNo material change

Effective DateMar 1, 2026

Next Review Date

Key ActionAppend modifier PO to HCPCS code G0463 for services provided in an off‑campus provider‑based hospital department; reimbursement will be reduced to 40% of the allowed amount.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

40%reimbursement paid when G0463 billed with modifier PO

60%reduction vs standard payment

UB04form governed

Commercial & Exchangeplan applicability

>250 yd / ≤35 mioff‑campus definition

G0463 Billing & Reimbursement Rule

G0463 + PO billing and reimbursement rule

Covered when ALL of the following are met:

HCPCS code G0463 is billed (Hospital outpatient clinic visit for assessment and management of a patient).

Service is performed in an off-campus provider-based department of a hospital (facility located more than 250 yards from the main provider and within 35 miles).

Provider appends modifier PO to HCPCS code G0463 (modifier indicating an excepted service provided at an off-campus, outpatient, provider-based department of a hospital).

When G0463 is submitted with modifier PO, reimbursement is set to 40% of the allowed amount (a 60% reduction compared with standard payment).

Codes and Geographic Criteria

Policy Summary

PayerUnitedHealthcare

PolicyUB04 Policy — G0463 with modifier PO

Policy CodePolicy 2026R5039A

Change TypeNo material change

Effective DateMar 1, 2026

Next Review Date

Key ActionAppend modifier PO to HCPCS code G0463 for services provided in an off‑campus provider‑based hospital department; reimbursement will be reduced to 40% of the allowed amount.

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.

Modifier Requirements and Reimbursement Impact

Billing Rule

Append modifier PO to G0463 for off‑campus provider‑based services; reimbursement reduced to 40%

When HCPCS code G0463 is billed for services performed in an off‑campus provider‑based hospital department, append modifier PO to the claim; when G0463 is submitted with modifier PO, reimbursement will be 40% of the allowed amount (a 60% reduction compared with standard payment).

Apply modifier PO when the facility is outside 250 yards from the main provider and within 35 miles (off‑campus).
This requirement aligns with CMS guidance for outpatient items and services and affects UnitedHealthcare Commercial and Individual Exchange plans.
Reimbursement impact: G0463 + PO = 40% of allowed amount (60% reduction).

Key Definitions

Off‑campus provider‑based department

DefinitionA provider-based department is a facility owned and operated by the main provider that is located outside 250 yards from the main provider but within 35 miles

OwnershipProvider-based departments are owned and operated by a single entity known as the main provider

Location scopeCan be located on the same campus as the main provider or off-campus (off-campus defined as >250 yards and within 35 miles)

Modifier PO

Modifier PO meaningModifier indicating an excepted service provided at an off‑campus outpatient provider‑based department of a hospital

Applicable codeWhen appended to HCPCS code G0463, modifier PO must be reported for off‑campus provider‑based outpatient services

Reimbursement impactWhen G0463 is submitted with modifier PO, reimbursement is set to 40% of the allowed amount (a 60% reduction compared with standard payment)

G0463	Hospital outpatient clinic visit for assessment and management of a patient
PO	Excepted service provided at an off-campus, outpatient, provider-based department of a hospital