Payment reduction for off‑campus provider‑based departments billed with modifier PO (G0463)
Governance of facility reimbursement when HCPCS code G0463 is billed with modifier PO for outpatient hospital items and services in off‑campus provider‑based departments; applies to UnitedHealthcare commercial plans for dates of service on or after September 1, 2025.
UnitedHealthcare will implement a payment reduction aligning with CMS that reimburses HCPCS code G0463 billed with modifier PO at 40% of the allowable amount (a 60% reduction) effective for dates of service on or after September 1, 2025.
UnitedHealthcare requires reporting of modifier PO with outpatient hospital items and services in off‑campus provider‑based departments.
The policy excludes certain facility types from the PO payment reduction (Emergency Department; Critical Access Hospitals; Psychiatric, Rehabilitation, or Long‑Term Care Hospitals or Units; hospitals in Maryland, Puerto Rico or U.S. territories; Rural Sole Community Hospitals; Indian Health Service hospitals).
Payment Application and Exclusions
Payment reduction application and exclusions
Application of the payment reduction and exclusions for HCPCS G0463 when reported with modifier PO:
ALL of the following
Exclusions (one of)
- Services rendered in the Emergency Department.
- Critical Access Hospitals.
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