CMS Revises, Clarifies POS Coding
The Centers for Medicare & Medicaid Services (CMS) Transmittal 2407, effective April 1, 2012, requires the place of service (POS) code for all physicians paid under the Medicare Physician Fee Schedule (MFPS) to match the setting in which the beneficiary receives the face-to-face service.
Billable, non face-to-face services (such as when a physician interprets diagnostic test results) are billed to the POS in which the beneficiary received the technical portion of the service. MLN Matters® MM7631 provides the following example:
A beneficiary receives an MRI at an outpatient hospital near his/her home. The hospital submits a claim that would correspond to the TC portion of the MRI. The physician furnishes the PC portion of the beneficiary’s MRI from his/her office location – POS code 22 [outpatient hospital] will be used on the physician’s claim for the PC to indicate that the beneficiary received the face-to-face portion of the MRI, the TC, at the outpatient hospital.
There are two exceptions to the rule that says the physician should always use the POS code where the beneficiary is receiving care as a hospital inpatient or outpatient, regardless of where the beneficiary encounters the face-to-face service. The exceptions are:
- When a physician/practitioner/supplier provides services to a patient who is an inpatient of a hospital, the inpatient hospital POS code 21 will be used irrespective of the setting where the patient actually receives the face-to-face encounter.
- Physicians/practitioners who perform services in a hospital outpatient department will use POS code 22 (Outpatient Hospital) 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 will use POS code 11 (Office) when services are performed in a separately maintained physician office space in the hospital or on hospital campus and that physician office space is not considered a provider-based department of the hospital as defined in 42.C.F.R. 413.6. 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.
The list of settings where physician’s services are paid at the facility rate include:
- Inpatient Hospital (POS 21):
- Outpatient Hospital (POS 22):
- Emergency Room-Hospital (POS 23)
- Ambulatory Surgical Center (POS 24): Physicians should not use POS code 11 (office) for ASC services unless the physician has an office at the same physical location of the ASC that meets all other requirements for operating as a physician office at the same physical location as the ASC—including meeting the “distinct entity” criteria defined in the ASC State Operations Manual—and the service was performed in the office suite portion of the facility.
- Skilled Nursing Facility (SNF) for a Part A resident (POS 31)
- Hospice, for inpatient care (POS 34): For services provided to a hospice beneficiary in an outpatient setting, such as the physician/nonphysician practitioner’s office (POS 11); the beneficiary’s home (POS 12), i.e., not operated by the hospice; or other outpatient setting (e.g., outpatient hospital (POS 22)), the patient’s physician or nonphysician practitioner or hospice independent attending physician or nurse practitioner, will assign the POS that represents that setting, as appropriate.
- Ambulance – Land (POS 41)
- Ambulance – Air or Water (POS 42)
- Inpatient Psychiatric Facility (POS 51)
- Psychiatric Facility – Partial Hospitalization (POS 52)
- Community Mental Health Center (POS 53)
- Psychiatric Residential Treatment Center (POS 56)
- Comprehensive Inpatient Rehabilitation Facility (POS 61)
Settings where physician services are paid at non-facility rates include:
- Pharmacy (POS 01)
- School (POS 03)
- Homeless Shelter (POS 04)
- Prison/Correctional Facility (POS 09)
- Office (POS 11)
- Home or Private Residence of Patient (POS 12)
- Assisted Living Facility (POS 13)
- Group Home (POS 14)
- Mobile Unit (POS 15): If the mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity; however, if the mobile unit is not serving an entity that could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15. Medicare will apply the non-facility rate to payments for services designated as being furnished in POS code 15 and apply the appropriate facility or non-facility rate for the POS code designated when a code other than the mobile unit code is indicated.
- Temporary Lodging (POS 16)
- Walk-in Retail Health Clinic (POS 17)
- Urgent Care Facility (POS 20)
- Birthing Center (POS 25)
- Nursing Facility and Skilled Nursing Facilities (SNFs) to Part B residents (POS
- Custodial Care Facility (POS 33)
- Independent Clinic (POS 49)
- Federally Qualified Health Center (POS 50)
- Intermediate Health Care Facility/Mentally Retarded (POS 54)
- Residential Substance Abuse Treatment Facility (POS 55)
- Non-residential Substance Abuse Treatment Facility (POS 57)
- Mass Immunization Center (POS 60)
- Comprehensive Outpatient Rehabilitation Facility (POS 62)
- End-stage Renal Disease Treatment Facility (POS 65)
- State or Local Health Clinic (POS 71)
- Rural Health Clinic (POS 72)
- Independent Laboratory (POS 81)
- Other Place of Service (POS 99)