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.
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.
Modifier usage
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.
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.
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.
Modifier usage
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.