Understanding How Place of Service Codes Work
The Place of service (POS) codes are used by CMS, Medicaid, and other private insurance to indicate where medically related items and services are sold or dispensed for a patient. POS codes are used for professional billing and are required to be reported on each claim submitted on a CMS-1500 or its electronic equivalent. Type of service (TOS) codes are used on hospital and facility claims, also indicating the place of service along with additional information reported on a UB-04. CMS currently maintains the POS codes used to describe the site of service.
It is essential to report the correct POS code to avoid denials and incorrect payments. Different sites may pay a different rate if the services are provided in a facility versus a non-facility setting. This is called a payment differential. When the service is rendered to a patient registered as an inpatient in a hospital (POS code 21) or an outpatient of a hospital (POS codes 19 or 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred.
When billing the professional component (PC), the rates are the same and do not depend on the clam's POS code.
Differential pay is included in Facility Settings
POS where the physician rate is paid at the facility rate:
• Telehealth (POS 02)
• Outpatient Hospital-Off campus (POS code 19)
• Inpatient Hospital (POS code 21)
• Outpatient Hospital-On campus (POS code 22)
• Emergency Room-Hospital (POS code 23)
• Medicare-participating ambulatory surgical center (ASC) for a HCPCS code included on the
ASC approved list of procedures (POS code 24)
• Medicare-participating ASC for a procedure not on the ASC list of approved procedures with
dates of service on or after January 1, 2008. (POS code 24)
• Military Treatment Facility (POS Code 26)
• Skilled Nursing Facility (SNF) for a Part A resident (POS code 31)
• Hospice – for inpatient care (POS code 34)
• Ambulance – Land (POS code 41)
• Ambulance – Air or Water (POS code 42)
• Inpatient Psychiatric Facility (POS code 51)
• Psychiatric Facility -- Partial Hospitalization (POS code 52)
• Community Mental Health Center (POS code 53)
• Psychiatric Residential Treatment Center (POS code 56)
• Comprehensive Inpatient Rehabilitation Facility (POS code 61)
NO differential is applied in other settings
Physicians' services are paid at non-facility rates for procedures furnished in the following settings:
• Pharmacy (POS code 01)
• School (POS code 03)
• Homeless Shelter (POS code 04)
• Prison/Correctional Facility (POS code 09)
• Office (POS code 11)
• Home or Private Residence of Patient (POS code 12)
• Assisted Living Facility (POS code 13)
• Group Home (POS code 14)
• Mobile Unit (POS code 15)
• Temporary Lodging (POS code 16)
• Walk-in Retail Health Clinic (POS code 17)
• Urgent Care Facility (POS code 20)
• Birthing Center (POS code 25)
• Nursing Facility and SNFs to Part B residents (POS code 32)
• Custodial Care Facility (POS code 33)
• Independent Clinic (POS code 49)
• Federally Qualified Health Center (POS code 50)
• Intermediate Health Care Facility/Individuals with Intellectual Disabilities (POS code 54)
• Residential Substance Abuse Treatment Facility (POS code 55)
• Non-Residential Substance Abuse Treatment Facility (POS code 57)
• Mass Immunization Center (POS code 60)
• Comprehensive Outpatient Rehabilitation Facility (POS code 62)
• End-Stage Renal Disease Treatment Facility (POS code 65)
• State or Local Health Clinic (POS code 71)
• Rural Health Clinic (POS code 72)
• Independent Laboratory (POS code 81)
• Other Place of Service (POS code 99)
Paid the same regardless of the setting
Some services are paid under non-facility regardless of where the services were provided; for example, The following are all paid as non-facility if a patient is inpatient and received physical therapy, occupational therapy, and speech-language pathology, or comprehensive outpatient rehabilitative facility (CORF) services.
NOTE: It is essential to mention that this does not include POS 61- Comprehensive Inpatient rehab, which is paid at the facility rate.
For additional detailed Place of Service Codes (POS) and Definitions, see the PUB-100 – Place of service Codes
A Homeless shelter-04 is considered a home-11 when providing durable medical equipment in a homeless shelter and must be reported using POS 11.
When providing services for an inpatient hospital patient bill under POS-21, however, if the patient is registered in a setting that has a more detailed site, it must be used, such as a physician/practitioner may use POS 31, for a patient in an 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.
Outpatient hospital vs. on campus-outpatient hospital; POS 22 has been revised from "Outpatient Hospital" to "On Campus-Outpatient Hospital," and POS 19 was created for the "Off-Campus- Outpatient Hospital" setting. According to CMS, reporting the outpatient hospital POS code 19 or 22 is a minimum requirement to trigger the facility payment amount under the PFS when services are provided to a registered outpatient. If the physician/practitioner knows the exact setting where the beneficiary is a registered hospital outpatient. In that case, the appropriate outpatient facility POS code should be reported consistent with the code list annotated in this section (instead of POS 19 or 22).
Hospice: if a patient is in an "inpatient" respite or general "inpatient" care stay, the POS code 34 (hospice) is used.
Pathology and Radiology Billing Requirements
Pathology and radiology can include different components such as the Technical and professional components; often, these are furnished in different settings and must be billed accordingly. The determining factor is where the provider rendering the service is located. For example, a biopsy that is done in an outpatient hospital must be billed with the Hospital place of service (POS 19, 22) regardless of the location (hospital vs. pathology practice) of the technical and/or professional component.
Biopsies that are performed in the Physician's office (e.g., dermatology) or an Ambulatory Surgical Center (ASC) and referred out for professional and technical pathology services must be billed as an Independent Laboratory under the place of service 81.
As a general policy, the POS code assigned by the physician/practitioner for the PC of a diagnostic service shall be the setting in which the beneficiary received the TC service.
The appropriate POS code for the interpretation (or PC) is where the beneficiary received the TC service. Suppose the interpretation is performed in the Physician's office and the patient received the TC service in the provider-based outpatient hospital setting. In that case, the Physician assigns POS code 22, for outpatient hospital, on the claim for the interpretation or PC.
Global billing Includes both components, TC and PC, according to CMS; when the global diagnostic service code is billed, for example, chest x-ray as described by HCPCS code 71010 (no modifier TC and no modifier -26), the locality is determined by the ZIP code applicable to the testing facility, i.e., where the TC of the chest x-ray was furnished.
Be sure to enter the address and Zip code of the location where the service took place. This information is entered in Item 32 on the paper claim Form CMS 1500 (or its electronic equivalent).
Billing for the Professional Interpretation only
In a CMS transmittal Medicare states; 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.