(Medicare Claims Processing Manual)

A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician. NF 72 Rural Health Clinic   A certified facility which is located in  a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician.  NF 73-80 Unassigned  -- 81 Independent Laboratory   A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office.  NF 82-98 Unassigned  -- 99 Other Place of Service   Other place of service not identified above.  NF  The Medicare contractor can provide guidance regarding which code applies in cases where the appropriate POS code may be unclear.    Special Considerations for Telehealth Claims (Codes 02, 10)   Note that while the modification of POS Code 02 and the creation of POS Code 10 are effective in the National POS code set effective January 1, 2022, Medicare contractors received instructions regarding how to process claims with these codes starting April  4, 2022, so that Medicare would align with existing Telehealth claims processing policy, as well as be considered HIPAA compliant.   Special Considerations for Homeless Shelter (Code 04)  Note that for the purposes of receiving durable medical equipment (DME), a homeless shelter is considered the beneficiarys home. Because DME is payable in the beneficiarys home, the crosswalk for Homeless Shelter (code 04) to Office (code 11) that was mandated effective January 1, 2003, may need to be adjusted or local policy developed so that HCPCS codes for DME are covered when other conditions are met and the beneficiary is in a homeless shelter. If desired, local contractors are permitted to work wi th their medical directors to determine a new crosswalk such as from Homeless Shelter (code 04) to Home (code 12) or Custodial Care Facility (code 33) for DME provided in a homeless shelter setting. If a local contractor is currently paying claims correctl y, however, it is not necessary to change the current crosswalk.    Special Considerations for Indian Health Service (Codes 05, 06) and Tribal 638 Settings (Codes 07, 08)  Medicare does not currently use the POS codes designated for these settings. Follow the instructions you have received regarding how to process claims for services rendered in IHS and Tribal 638 settings. If you receive claims with these codes, you must initially accept them in terms of HIPAA compliance. However, follow your return as unprocessable procedures after this initial compliance check. Follow your return as unprocessable" procedures when you receive paper claims with these codes. (Note that whi le these codes became part of the National POS code set effective January 1, 2003, Medicare contractors received instructions regarding how to process claims with these codes effective October 1, 2003, so that Medicare could be HIPAA compliant by October 16, 2003).   Special Considerations for Mobile Unit Settings (Code  15)  When services are furnished in a mobile unit, they are often provided to serve an entity for which another POS code exists. For example, a mobile unit may be sent to a physicians office or a skilled nursing facility. If the mobile unit is serving an entit y 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 which could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15. Apply the nonfacility rate to payments for services designated as being furnished in POS code 15; apply the appropriate facility or nonfacility rate for the POS code designated when a code other than the mobile unit code is indicated.   A physician or practitioner's office, even if mobile, qualifies to serve as a telehealth originating site. Assuming such an office also fulfills the requirement that it be located in either a rural health professional shortage area as defined under section 332(a)(1)(A) of the Public Health Service Act (42 U.S.C.  254e(a)(1)(A)) or in a county that is not included in a Metropolitan Statistical Area as defined in section 1886(d)(2)(D) of the Act, the originating physician's office should use POS code 11 (Office) in order to ensure appropriate payment for services on the list of Medicare Telehealth  Services.    Special Considerations for Prison/Correctional Facility Settings (Code  09)  The addition of code 09 to the POS code set and Medicare claims processing reflects Medicares compliance with HIPAA laws and regulations. Local contractors must continue to comply with CMS current policy that does not allow payment for Medicare services i n a penal institution in most cases. The addition of a POS code for a prison/correctional facility setting does not supersede this policy.  (See Pub. 100- 04, Medicare Claims Processing, section 10.4, chapter 1.)    Special Considerations for Walk -In Retail Health Clinic (Code 17)  (Effective no later than May 1,  2010)   It should be noted that, while some entities in the industry may elect to use POS code 17 to track the setting of immunizations, Medicare continues to require its billing rules for immunizations claims, which are found in chapter 18, section 10 of this manual. Contractors are to instruct providers and suppliers of immunizations to continue to follow these Medicare billing rules. However, Medicare contractors are to accept and adjudicate claims containing POS code 17, even if its presence on a claim is contrary to these billing instructions.   Special Considerations for Services Furnished to Registered  Inpatients   When a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face- to-face encounter. In other words, reporting the inpatient hospital POS code 21 is a minimum requirement for purposes of triggering the f acility payment under the PFS when services are provided to a registered inpatient. If the physician/practitioner is aware of the exact setting the beneficiary is a registered inpatient, the appropriate inpatient POS code may be reported consistent with th e code list annotated in this section (instead of POS 21). For example, a physician/practitioner may use POS 31, for a patient in a SNF receiving inpatient skilled nursing care, POS 51, for a patient registered in a Psychiatric Inpatient Facility, and POS 61 for patients registered in a Comprehensive Inpatient Rehabilitation Facility.    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 Campus -Outpatient 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 facilit y 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  campus -outpatient 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.   Special Consideration for Ambulatory Surgical Centers (Code 24)  When a physician/practitioner furnishes services to a patient in a Medicare - participating ambulatory surgical center (ASC), the POS code 24 (ASC) shall be used.   NOTE: Physicians/practitioners who perform services in an ASC shall use POS code 24 (ASC). Physicians/practitioners are not to use POS code 11 (office) for ASC based services unless the physician has an office at the same physical location of the ASC, which meets all other requirements for operating as a physician office at the same physical loc ation as the ASC  including meeting the distinct entity criteria defined in the ASC State Operations Manual that precludes the ASC and an adjacent physician offic e from being open at the same time --  and the physician service was actually performed in the office suite portion of the facility.   See Pub 100- 07, Medicare State Operations Manual, Appendix L -  Guidance for Surveyors: Ambulatory Surgical Centers for a complete set of applicable ASC definitions, basic requirements, and conditions of coverage. It is available at the following link: http://www.cms.gov/manuals/Downloads/som107ap_l_ambulatory.pdf    Special Considerations for Hospice (Code 34)  When a physician/practitioner furnishes services to a patient under the hospice benefit, use the following guidelines to identify the appropriate POS.   When a beneficiary is in an inpatient respite or general inpatient care stay, the POS code 34 (hospice) shall be used. When a beneficiary who has elected coverage under the Hospice benefit is receiving inpatient hospice care in a hospital, SNF , or hospice inpatient facility, POS code 34 (Hospice) shall be used to designate the POS on the claim.  For services provided to a hospice beneficiary in an outpatient setting, such as the physician/nonphysician practitioners office (POS 11); the beneficiarys home (POS 12), i.e., not operated by the hospice; or other outpatient setting (e.g., off campus -outpatient hospital (POS 19) or on campus -outpatient hospital (POS 22)), the patients physician or nonphysician practitioner or hospice independent attending physician or nurse practitioner, shall assign the POS code that represents that setting, as appropr iate.  There may be use of nursing homes as the hospice patients home, where the patient resides in the facility but is receiving a home level of care. In addition, hospices are also operating houses or hospice residential entities where hospice patients rec eive a home level of care. In these cases, physicians and nonphysician practitioners, including the patients independent attending physician or nurse practitioner, shall use the appropriate POS code representing the particular setting, e.g., POS code 32 f or nursing home, POS code 13 for an assisted living facility, or POS code 14 for group home.   Special Considerations for Non -residential Opioid Treatment Facility (Code  58)  NOTE: OUD treatment services furnished at Opioid Treatment Programs are not considered physician services and are separately paid under the bundled payment established under sections 1833(a)(1)(CC) and 1834(w) of the Social Security Act.   Paper Claims   Adjudicate paper claims with codes from the National POS code set as you would for electronic claims.  10.6 - A/B Medicare Administrative Contractor (MAC) (B) Instructions for Place of Service (POS) Codes  (Rev. 3490, Issued: 04- 01-16, Effective: 04 -25-16, Implementation: 04- 25-16)