POS code and Description
21 Inpatient Hospital A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
22 On Campus-Outpatient Hospital A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. (Description change effective January 1, 2016)
23 Emergency Room – Hospital A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.
Reporting Guidelines
• The POS is a required field, entered in the 2400 Place of Service Code loop (segment SV105) of the 837P electronic claim or Item 24B on the CMS-1500 paper claim
• The name, address and ZIP code of where the service(s) were actually performed is required for all POS codes, and is entered in Item 32 on the CMS 1500 claim form or in the corresponding loop on its electronic equivalent
• Must specify the correct location where the service(s) is performed and billed on the claim, since both the POS and the locality address are components of the MPFS
• If the POS is missing, invalid or inconsistent with procedure code on claim form it will be returned as unprocessable (RUC)
• For example, POS 21 (inpatient hospital) is not compatible with procedure code 99211 (Establish patient office or other outpatient visit)
• If a provider specialty other than “69” (Clinical laboratory-billing independently) bills a claim with a POS 81 (Independent laboratory) it will be denied with a claim adjustment reason code (CARC) CO5, refer to Washington Publishing Company (WPC) website http://www.wpc-edi.com/reference/ external link.
Using of POS 23 with modifier 26
Modifier 26 is only appropriate in one of the following places of service:
* Hospital inpatient (place of service 21).
* Hospital outpatient (place of service 22).
* Emergency Room (place of service 23).
* Use of Modifier 26 is not appropriate in conjunction with any other place of service code.
The place of service indicated on the radiologist’s claim, in this case, reflects the location where the CT was performed, not the location where the radiologist actually reviewed the film. If the radiologist indicated a place of service of 11 (office), the service 70450 appended with modifier 26 would be denied for an ineligible place of service. Please note the above also applies to the technical component (TC). Only place of service 21, 22 & 23 are appropriate for TC and PC component. If services are rendered in a freestanding radiology/imaging center then the center would bill globally. In addition, if a specialty physician is over-reading or interpreting the procedure as a consultation in the office (POS 11) the service will not be reimbursed separately from the global component.
The radiologist will submit a claim for the reading and interpreting of the results (the professional component PC) of that diagnostic service with the following claim elements:
CPT Code 70450 Modifier 26
POS 23
The place of service indicated on the radiologist’s claim, in this case, reflects the location where the CT was performed, not the location where the radiologist actually reviewed the film. If the radiologist indicated a place of service of 11 (office), the service 70450 appended with modifier 26 would be denied for an ineligible place of service. Please note the above also applies to the technical component (TC). Only place of service 21, 22 & 23 are appropriate for TC and PC component. If services are rendered in a freestanding radiology/imaging center then the center would bill globally. In addition, if a specialty physician is over-reading or interpreting the procedure as a consultation in the office (POS 11) the service will not be reimbursed separately from the global component.
Will Oxford reimburse the same physician for both an injection (96372-96379) and an Evaluation and Management (E/M) service code on the same date of service if each is performed in a different place of service?
A: Yes, Oxford will separately reimburse the same physician for both an injection procedure and E/M service on the same date of service if each is performed in a different place of service (POS) and the injection was provided in a POS other than 19, 21, 22, 23, 24, 26, 51, 52, and 61. For example, if the patient only receives an injection at a physician’s office (POS 11) and later that day the patient is admitted to the hospital (POS 21), both services, the injection service performed at the physician’s office and the E/M performed later that day at the hospital, would be separately reimbursed because the injection service and E/M service were performed in different locations by the same physician on the same date of service. Injection services are not reimbursable when provided in POS 19, 21, 22, 23, 24, 26, 51, 52, and 61.
Reporting outpatient hospital POS code 19 or 22 is a minimum requirement to trigger the facility payment amount under the Physician Fee Schedule (PFS) when services are provided to a registered outpatient. Therefore, you should use POS code 19 or POS code 22 when you furnish services to a hospital outpatient regardless of where the face-to-face encounter occurs.
The payment policies that currently apply to POS 22 will continue to apply to this POS, and will now also apply to POS 19 unless otherwise stated in Change Request (CR) 9231.
POS 22 – Update on Campus outpatient hospital
This Change Request revises the description of Place of Service (POS) code 22 to On Campus-Outpatient Hospital, and creates a new POS code for Off Campus-Outpatient Hospital.
As an entity covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Medicare must comply with standards and their implementation guides adopted by regulation under this statute. The currently adopted professional implementation guide for the ASC X12N 837 standard requires that each electronic claim transaction include a Place of Service (POS) code from the POS code set maintained by the Centers for Medicare and Medicaid Services (CMS). As a payer, Medicare must be able to recognize as valid any valid code from the POS code set that appears on the HIPAA standard claim transaction.
The POS code set provides setting information necessary to appropriately pay Medicare and Medicaid claims. At times, Medicaid has had a greater need for specificity than has Medicare, and many of the new codes developed over the past few years have been to meet Medicaid’s needs. While Medicare does not always need this greater specificity in order to appropriately pay claims, it nevertheless adjudicates claims with the new codes to ease coordination of benefits and to give Medicaid and other payers the setting information they require.
This Change Request (CR) updates the current POS code set by adding new POS code 19 for “Off CampusOutpatient Hospital” and revising POS code 22 from “Outpatient Hospital” to “On Campus-Outpatient Hospital.” Also, this CR will implement the systems and local contractor level changes needed for Medicare to adjudicate claims with the new and revised codes. Local contractors shall develop policies as needed to adjudicate claims containing new POS code 19 and revised POS code 22 in accordance with Medicare national policy. Contractor editing shall treat POS 19 and POS 22 in the same way. See Title 42 CFR 413.65(a)(2) for a definition of “campus.”
Payments for services provided to outpatients who are later admitted as inpatients within 3 days (or, in the case of non-IPPS hospitals, 1 day) are bundled when the patient is seen in a wholly owned or wholly operated physician practice. The 3-day payment window applies to diagnostic and nondiagnostic services that are clinically related to the reason for the patient’s inpatient admission regardless of whether the inpatient and outpatient diagnoses are the same. The 3-day payment rule will also apply to services billed with POS code 19.
As discussed in the CY 2015 Physician Fee Schedule (PFS) final rule with comment period published on November 13, 2014 (79 FR 67572), in order to differentiate between on-campus and offcampus provider-based hospital departments, CMS is creating a new POS code (POS 19) and revising the current POS code description for outpatient hospital (POS 22) as follows:
POS 19: Off Campus-Outpatient Hospital Descriptor: A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
POS 22: On Campus-Outpatient Hospital
Descriptor: A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
Unless prohibited by national policy to the contrary, Medicare not only recognizes valid POS codes from the POS code set but also adjudicates claims having these codes. Although the Medicare program does not always have the same need for setting specificity as other payers, including Medicaid, adjudicating the claims eases the coordination of benefits for Medicaid and other payers who may need the specificity afforded by the entire POS code set.
Claims for covered services rendered in an Off Campus-Outpatient Hospital setting, or in an On CampusOutpatient Hospital setting, if payable by Medicare, shall be paid at the facility rate. The payment policies that currently apply to POS 22 will continue to apply and will now also apply to POS19 unless otherwise stated.
9231.2 Effective for claims processed on or after January 1, 2016, contractors shall recognize the revised description for place of service (POS) code 22 from “Outpatient Hospital” to “On Campus-Outpatient Hospital”
9231.8 Contractors shall educate physicians/practitioners and other suppliers to use, at a minimum, POS code 19 (Off Campus-Outpatient Hospital) or POS code 22 (On Campus-Outpatient Hospital) when they furnish services to an outpatient of a hospital, irrespective of where the face-to-face encounter occurs. (As discussed under “Special Considerations for Outpatient Hospital Departments”
9231.10 Until notified otherwise by CMS, for claims processed on or after January 1, 2016, contractors shall make any necessary systems changes to process procedure codes submitted with the revised POS code 22 and the new POS code 19 in the same way as they did for claims with 2015 dates of service submitted with POS 22.
Under the Medicare Physician Fee schedule (MPFS), some procedures have separate rates for physicians’ services when provided in facility and nonfacility settings. The CMS furnishes both rates in the MPFSDB update.
Special Considerations for Outpatient Hospital Departments
The place of service (POS) code for “Outpatient Hospital” has been expanded. The description of POS 22 has been revised from “Outpatient Hospital” to “On Campus-Outpatient Hospital” and POS 19 has been created for the “Off Campus-Outpatient Hospital” setting. Throughout this Internet Only Manual (IOM) you may find references to “Outpatient Hospital” that do not differentiate between the “On Campus” or “Off Campus” setting; however, any reference to POS 22 (formerly “Outpatient Hospital”) found anywhere within the IOM is now defined as “On CampusOutpatient Hospital.” In addition, POS 19 will also apply in the majority of situations describing an outpatient hospital setting.
When a physician/practitioner furnishes services to an outpatient of a hospital, payment is made under the PFS at the facility rate. Physicians/practitioners who furnish services to a hospital outpatient, including in a hospital outpatient department (including in a provider-based department of that hospital) or under arrangement to a hospital shall, at a minimum, report the off campusoutpatient hospital POS code 19 or on campus-outpatient hospital POS code 22 irrespective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the outpatient hospital POS code 19 or 22 is a minimum requirement for purposes of triggering the facility payment amount under the PFS when services are provided to a registered outpatient. If the physician/practitioner is aware of the exact setting where the beneficiary is a registered hospital outpatient, the appropriate outpatient facility POS code may be reported consistent with the code list annotated in this section (instead of POS 19 or 22). For example, physicians/practitioners may use POS code 23 for services furnished to a patient registered in the emergency room, POS 24 for patients registered in an ambulatory surgical center, and POS 56 for patients registered in a psychiatric residential treatment center.
NOTE: Physicians/practitioners who perform services in a hospital outpatient department shall use, at a minimum, POS code 19 (Off Campus-Outpatient Hospital) or POS code 22 (On Campus-Outpatient Hospital). Code 19 or 22 (or other appropriate outpatient department POS code as described above) shall be used unless the physician maintains separate office space in the hospital or on the hospital campus and that physician office space is not considered a provider-based department of the hospital as defined in 42. C.F.R. 413.65. Physicians shall use POS code 11 (office) when services are performed in a separately maintained physician office space in the hospital or on the hospital campus and that physician office space is not considered a provider-based department of the hospital. Use of POS code 11(office) in the hospital outpatient department or on hospital campus is subject to the physician self-referral provisions set forth in 42 C.F.R 411.353 through 411.357.
