This instruction establishes that for all services – with two (2) exceptions -- paid under the MPFS that the POS
code to be used by the physician and other supplier shall be assigned as the same setting in which the
beneficiary received the face-to-face service. Because a face-to-face encounter with a physician/practitioner is
required for nearly all services paid under the MPFS and anesthesia services, this rule will apply to the
overwhelming majority of PFS services. In cases where the face-to-face requirement is obviated such as those
when a physician/practitioner provides the professional component (PC)/interpretation of a diagnostic test, from
a distant site, the POS code assigned by the physician /practitioner shall be the setting in which the beneficiary
received the technical component (TC) service. For 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
shall 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 (2) exceptions to this face-to-face provision/rule in which the physician always uses the POS
code where the beneficiary is receiving care as a registered inpatient or an outpatient of a hospital, regardless of
where the beneficiary encounters the face-to-face service. The correct POS code assignment shall be for that
setting in which the beneficiary is receiving inpatient care or outpatient care from a hospital including the
inpatient hospital (POS code 21) or the outpatient hospital (POS code 22) In other words, reporting the
inpatient hospital POS code 21 or the outpatient hospital POS code 22, is a minimum requirement for purposes
of triggering the facility payment under the PFS when services are provided to a registered inpatient or an
outpatient of a hospital respectively. If the physician/practitioner is aware of the exact setting the beneficiary is
a registered inpatient (or hospital outpatient), the appropriate inpatient POS code (or appropriate outpatient POS
code) may be reported consistent with the code list annotated in Pub. 100-04, Medicare Claims Processing
Manual, chapter 26, section 10.5. However, it is more important that the physician/practitioner report the POS
consistent with the patient’s general inpatient or outpatient hospital status than the precise inpatient/ outpatient
POS code (in order to trigger the facility payment rate under the PFS). Pub. 100-04, Medicare Claims
Processing Manual, chapter 26, already requires this for physician services (and for certain independent
laboratory services) provided to beneficiaries in the inpatient hospital and this CR clarifies this exception and
extends it to beneficiaries of the outpatient hospital, as well.