POS Coding Must Match Setting Where Service Was Provided

When assigning a place-of-service (POS) code for your Medicare claims, be sure that the POS matches the setting in which the patient received the service (for face-to-face services), or the setting in which the technical portion of the service was delivered (for non face-to-face services, such as interpretation of diagnostic test results).

There are two exceptions to the rule:

1. 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 regardless of the setting where the patient actually receives the face-to-face encounter.

2. 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 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 a 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 above guidelines were recently clarified by Centers for Medicare and Medicaid Services (CMS) CR Transmittal # R2407CP (https://www.cms.gov/transmittals/downloads/R2407CP.pdf), and MLN Matters® Number: MM7631 (http://www.cms.gov/MLNMattersArticles/Downloads/MM7631.pdf), the latter of which 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.”


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13 Responses to “POS Coding Must Match Setting Where Service Was Provided”

  1. Sue Stein says:

    I believe CMS clarified the POS issue. What they have not clarified is what DOS one should use when an interpretation DOS is different than the date the procedure/diagnostic test was performed. What DOS does one utilize, the date of the procedure or the date of the interpretation? We have mixed opinions. Thanks!

  2. Carol Freeman says:

    It is my understanding that if you are not the admitting physician, you can bill the POS your physician provided the face to face. ie….consult in the ER. As long as my doc is not the admitting doc, we can charge out place of service of ER. If my doc was the admitting doc, than that face to face would be charged as inpatient even if provided in the ER.

  3. CANDY says:

    DOS= Date of Service, not date of interpretation.

  4. Michael Miscoe says:

    CR 2407 was rescinded and replaced with CR 2345 (which I looked at and dealt with influenza fees). R2563CP is the most current transmittal that addresses this issue. Questions are already arising regarding reporting physician services (e.g. outpatient E/Ms) performed on patient’s transported to physician office. As the patients are still “in-patients” the physician must report services using POS 21. The problem is that currently, when reporting the outpatient E/M with POS 21, some coders are reporting that services are being denied. To resolve, some have raised the question as to whether they should report an subsequent in-patient E/M to avoid the denial.

    I would suggest not as nothing in the transmittal suggests or implies that outpatient providers, performing outpatient E/M services at their office on a patient who is still an in-patient at a facility and who will be returned to that facility, should report the outpatient E/M as an in-patient service. Instead, it indicates that the service or procedure provided (and presumably correctly coded) should be reported with POS 21. The MCPM instructions to MACs at Pub 100-4, Ch. 26 §10.6 as follows:

    10.6 – Carrier Instructions for Place of Service (POS) Codes
    (Rev.2563, Issued: 10-11-12, Effective: 04-01-13, Implementation: 04-01-13)
    For purposes of payment under the Medicare Physician Fee Schedule (MPFS), the POS code is generally used to reflect the actual setting where the beneficiary receives the face-to-face service. For example, if the physician’s face-to-face encounter with a patient occurs in the office, the correct POS code on the claim, in general, reflects the 2-digit POS code 11 for office. In these instances, the 2-digit POS code (Item 24B on the claim Form CMS-1500) will match the address and ZIP entered in the service location (Item 32 on the 1500 Form) – the physical/geographical location of the physician. However, there are two exceptions to this general rule – these are for a service rendered to a patient who is a registered inpatient or an outpatient of a hospital. In these cases, the correct POS code — regardless of where the face-to-face service occurs — is that of the appropriate inpatient POS code (at a minimum POS code 21) or that of the appropriate outpatient hospital POS code (at a minimum POS code 22) as discussed in section 10.5 of this chapter. So, if in the above example, the patient seen in the physician’s office is actually an inpatient of the hospital, POS code 21, for inpatient hospital, is correct. In this example, the POS code reflects a different setting than the address and ZIP code of the practice location (the physician’s office).

    Medicare Claims Processing Manual, IOM Pub 100-4, Chapter 26, Section 10.6

    To the extent that MAC payment systems are not up to speed with this revision and are denying outpatient E/Ms (e.g. 99211-5) with POS 21 contrary to this instruction, give them time to get their payment systems sorted out. In the interim, appeal the denials citing the revisions to the MCPM cited above. I would not recommend that you attempt to avoid the problem by misreporting the service provided using an incorrect CPT code. Doing so will likely create an overpayment, which under the reverse false claims provisions of the FCA you are obligated to disclose and refund within 60 days or face FCA liability and the associated sanctions.

  5. Denise Atchley says:

    Can someone clarify how we would bill for remote ICD and pacemaker services when the patient is at home and telephonically sends the data to the EP lab of a facility – the facility will bill the TC portion on a UB-04, as an outpatient service. What POS would the physician report on the CMS1500 for his interpretation?

  6. Martha Tracy says:

    Denise, our Medicare contractor, WPS states that the POS for remote ICD and pacemaker services should be POS 12, patient home. If you email me directly at mtracy@mac.md I will forward you that information from WPS.

  7. Rajkumar says:

    Can someone clarify for this what DOS one should use when an interpretation DOS is different than the date the procedure/diagnostic test was performed. What DOS does one utilize, the date of the procedure or the date of the interpretation?

  8. Mary DeFrancisco says:

    I can’t seem to find clarification on the following scenario and I am hoping someone could help.
    What if the patient is seen at 9 am in the ER by the consulting physician and is then admitted at 7 pm by the attending. Do you code the consulting physician’s POS as 23 (Emergency room) or 21 (inpatient)?

    Thank you

  9. Bob Bartlett says:

    When we code EKG’s we always use the date the test was performed as our DOS for billing.

  10. Peggy says:

    According to the IOM we are to use the DOS when the provider performs the service which is not always the same day the EKG technical portion is performed.

    180.6 – Emergency Room (ER) Services That Span Multiple Service Dates
    (Rev. 2361, Issued: 11-25-11, Effective: 01-01-12 and 04-01-12, Implementation; 04-02-12)

    • For all other services related to the ER encounter (i.e., lab, radiology, etc) the line item date of service reported is the date the service was actually rendered

  11. Sarah Kneefel says:

    Can someone please help me find the Place of Service code requirements for CPT’s? They used to be available on the Trailblazer website but now they are gone. I’m trying to find out if a procedure is allowed to be performed in an office setting with a POS 11. We had a claim denied stating that it is not allowed.

    Please help!

  12. Judy says:

    Our Dr. ENT performed an inpatient (21) consult. The procedure code we are using is being denied because our DOS does not match “admission and discharge date”. Suggestions?

  13. ASaiz says:

    Thank you for your comment. You’ll find a lot of suggestions and better answers to your question in the Member Forums.

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