CMS Pub. 100-04, ch. 26, § 10.5

o HIPAA

o The Health Insurance Portability and Accountability Act of 1996

(HIPAA) became effective October 16, 2003, for all covered entities.

Medicare is a covered entity under HIPAA.

o The final rule, “Health Insurance Reform: Standards for Electronic

Transactions,” published in the Federal Register, August 17, 2000,

adopts the standards to be used under HIPAA and names the

implementation guides to be used for these standards. The ASC X12N

837 professional is the standard to be used for transmitting health care

claims electronically, and its implementation guide requires the use of

POS codes from the National POS code set, currently maintained by

CMS.

o As a covered entity, Medicare must use the POS codes from the

National POS code set for processing its electronically submitted

claims. Medicare must also recognize as valid POS codes from the POS

code set when these codes appear on such a claim.

o Medicare must recognize and accept POS codes from the

national POS code set in terms of HIPAA compliance. Note

special considerations for Homeless Shelter (code 04), Indian

Health Service (codes 05, 06), Tribal 638 (codes 07, 08), and

09 Prison/Correctional Facility settings, describe below.

Where there is no national policy for a given POS code, local

contractors may work with their medical directors to develop

local policy regarding the services payable in a given setting,

and this could include creating a crosswalk to an existing

setting if desired. However, local contractors must pay for the

services at either the facility or the nonfacility rate as

designated below. In addition, local contractors, when

developing policy, must ensure that they continue to pay

appropriate rates for services rendered in the new setting; if

they choose to create a crosswalk from one setting to another,

they must crosswalk a facility rate designated code to another

facility rate designated code, and a nonfacility rate designated

code to another nonfacility rate designated code. For

previously issued POS codes for which a crosswalk was

mandated, and for which no other national Medicare directive

has been issued, local contractors may elect to continue to use

the crosswalk or develop local policy regarding the services

payable in the setting, including another crosswalk, if

appropriate. If a local contractor develops local policy for

these settings, but later receives specific national instructions

for these codes, the local contractors shall defer to and

comply with the newer instructions. (Note: While, effective

January 1, 2003, codes 03 School, 04 Homeless Shelter, and

20 Urgent Care became part of the National POS code set and

were to be crosswalked to 11 Office, this mandate to

crosswalk has since been lifted, as indicated above).

o National policy in the form of “Special Considerations” for

Off Campus- Outpatient Hospital (POS 19), Inpatient

Hospital (POS code 21), On Campus-Outpatient Hospital

(POS code 22), Ambulatory Surgical Center (POS code 24)

and Hospice (POS code 34) are included below.

• The National POS Code Set and Instructions for Using It

The following is the current national POS code set, with facility and

nonfacility designations noted for Medicare payment for services on

the Physician Fee Schedule. As a new POS code is established, the

health care industry is permitted to use this code from the date that it

is posted on the Medicare Place of Service Code Set Web page at

http://www.cms.gov/Medicare/Coding/place-of-service-

codes/Place_of_Service_Code_Set.html which is typically expected to

be some months ahead of the final effective date for Medicare use.

The code set is annotated with the effective dates for this and all

other codes added on and after January 1, 2003. Codes without

effective dates annotated are long-standing and in effect on and

before January 1, 2003.

POS Code and Name (effective date)

Description

Payment Rate

Facility=F

Nonfacility=NF

01 Pharmacy (October 1, 2005)

A facility or location where drugs and other medically related items and

services are sold, dispensed, or otherwise provided directly to patients.

NF

02 Telehealth Provided Other than in Patient’s Home (January 1, 2017)

The location where health services and health related services are provided

or received, through telecommunication technology. Patient is not located in

their home when receiving health services or health related services through

telecommunication technology.

(See “Special Considerations” below.)

F

POS Code and Name (effective date)

Description

Payment Rate

Facility=F

Nonfacility=NF

03 School (January 1, 2003)

A facility whose primary purpose is education.

NF

04 Homeless Shelter (January 1, 2003)

A facility or location whose primary purpose is to provide temporary

housing to homeless individuals (e.g., emergency shelters, individual or

family shelters).

(See “Special Considerations” below.)

NF

05 Indian Health Service Free-standing Facility (January 1, 2003)

A facility or location, owned and operated by the Indian Health Service,

which provides diagnostic, therapeutic (surgical and nonsurgical), and

rehabilitation services to American Indians and Alaska Natives who do not

require hospitalization.

(See “Special Considerations” below.)

Not applicable for

adjudication of

Medicare claims;

systems must

recognize for HIPAA

06 Indian Health Service Provider-based Facility (January 1, 2003)

A facility or location, owned and operated by the Indian Health Service,

which provides diagnostic, therapeutic (surgical and nonsurgical), and

rehabilitation services rendered by, or under the supervision of, physicians

to American Indians and Alaska Natives admitted as inpatients or

outpatients.

(See “Special Considerations” below.)

Not applicable for

adjudication of

Medicare claims;

systems must

recognize for HIPAA

07 Tribal 638 Free-Standing Facility (January 1, 2003)

A facility or location owned and operated by a federally recognized

American Indian or Alaska Native tribe or tribal organization under a 638

agreement, which provides diagnostic, therapeutic (surgical and

nonsurgical), and rehabilitation services to tribal members who do not

require hospitalization.

(See “Special Considerations” below.)

Not applicable for

adjudication of

Medicare claims;

systems must

recognize for HIPAA

POS Code and Name (effective date)

Description

Payment Rate

Facility=F

Nonfacility=NF

08 Tribal 638 Provider-Based Facility (January 1, 2003)

A facility or location owned and operated by a federally recognized

American Indian or Alaska Native tribe or tribal organization under a 638

agreement, which provides diagnostic, therapeutic (surgical and

nonsurgical), and rehabilitation services to tribal members admitted as

inpatients or outpatients.

(See “Special Considerations” below.)

Not applicable for

adjudication of

Medicare claims;

systems must

recognize for HIPAA

09 Prison/Correctional Facility (July 1, 2006)

A prison, jail, reformatory, work farm, detention center, or any other similar

facility maintained by either Federal, State or local authorities for the

purpose of confinement or rehabilitation of adult or juvenile criminal

offenders.

(See “Special Considerations” below.)

NF

10 Telehealth Provided in Patient’s Home (January 1, 2022)

The location where health services and health related services are provided or

received, through telecommunication technology. Patient is located in their

home (which is a location other than a hospital or other facility where the

patient receives care in a private residence) when receiving health services or

health related services through telecommunication technology.

(See “Special Considerations” below.)

NF

11 Office

Location, other than a hospital, skilled nursing facility (SNF), military

treatment facility, community health center, State or local public health

clinic, or intermediate care facility (ICF), where the health professional

routinely provides health examinations, diagnosis, and treatment of illness

or injury on an ambulatory basis.

NF

12 Home

Location, other than a hospital or other facility, where the patient receives

care in a private residence.

NF

POS Code and Name (effective date)

Description

Payment Rate

Facility=F

Nonfacility=NF

13 Assisted Living Facility (October 1, 2003)

Congregate residential facility with self-contained living units providing

assessment of each resident’s needs and on-site support 24 hours a day, 7

days a week, with the capacity to deliver or arrange for services including

some health care and other services.

NF

14 Group Home (Code effective, October 1, 2003; description revised,

effective April 1, 2004)

A residence, with shared living areas, where clients receive supervision and

other services such as social and/or behavioral services, custodial service,

and minimal services (e.g., medication administration).

NF

15 Mobile Unit (January 1, 2003)

A facility/unit that moves from place-to-place equipped to provide

preventive, screening, diagnostic, and/or treatment services.

(See “Special Considerations” below.)

NF

16 Temporary Lodging (April 1, 2008)

A short-term accommodation such as a hotel, camp ground, hostel, cruise

ship or resort where the patient receives care, and which is not identified by

any other POS code.

NF

17 Walk-in Retail Health Clinic (No later than May 1, 2010)

A walk-in health clinic, other than an office, urgent care facility, pharmacy

or independent clinic and not described by any other Place of Service code,

that is located within a retail operation and provides, on an ambulatory

basis, preventive and primary care services.

(See “Special Considerations” below.)

NF

18 Place of Employment/Worksite (No later than May 1, 2013)

A location, not described by any other POS code, owned or operated by a

public or private entity where the patient is employed, and where a health

professional provides on-going or episodic occupational medical, therapeutic

or rehabilitative services to the individual.

Not applicable for

adjudication of

Medicare claims;

systems must

recognize for HIPAA

POS Code and Name (effective date)

Description

Payment Rate

Facility=F

Nonfacility=NF

19 Off Campus-Outpatient Hospital (January 1, 2016)

A portion of an off-campus hospital provider based department which

provides diagnostic, therapeutic (both surgical and nonsurgical), and

rehabilitation services to sick or injured persons who do not require

hospitalization or institutionalization.

(See “Special Considerations” below.)

F

20 Urgent Care Facility (January 1, 2003)

Location, distinct from a hospital emergency room, an office, or a clinic,

whose purpose is to diagnose and treat illness or injury for unscheduled,

ambulatory patients seeking immediate medical attention.

NF

21 Inpatient Hospital

A facility, other than psychiatric, which primarily provides diagnostic,

therapeutic (both surgical and nonsurgical), and rehabilitation services by,

or under, the supervision of physicians to patients admitted for a variety of

medical conditions.

F

22 On Campus-Outpatient Hospital (description revised January 1, 2016)

A portion of a hospital’s main campus which provides diagnostic,

therapeutic (both surgical and nonsurgical), and rehabilitation services to

sick or injured persons who do not require hospitalization or

institutionalization.

(See “Special Considerations” below.)

F

23 Emergency Room-Hospital

A portion of a hospital where emergency diagnosis and treatment of illness

or injury is provided.

F

24 Ambulatory Surgical Center

A freestanding facility, other than a physician's office, where surgical and

diagnostic services are provided on an ambulatory basis.

F

POS Code and Name (effective date)

Description

Payment Rate

Facility=F

Nonfacility=NF

25 Birthing Center

A facility, other than a hospital's maternity facilities or a physician's office,

which provides a setting for labor, delivery, and immediate postpartum care

as well as immediate care of newborn infants.

NF

26 Military Treatment Facility

A medical facility operated by one or more of the Uniformed Services.

Military Treatment Facility (MTF) also refers to certain former U.S. Public

Health Service (USPHS) facilities now designated as Uniformed Service

Treatment Facilities (USTF).

F

27 Outreach Site/Street (October 1, 2023)

A non-permanent location on the street or found environment, not described by

any other POS code, where health professionals provide preventive, screening,

diagnostic, and/or treatment services to unsheltered homeless individuals.

NF

28-30 Unassigned --

31 Skilled Nursing Facility

A facility which primarily provides inpatient skilled nursing care and

related services to patients who require medical, nursing, or rehabilitative

services but does not provide the level of care or treatment available in a

hospital.

F

32 Nursing Facility

A facility which primarily provides to residents skilled nursing care and

related services for the rehabilitation of injured, disabled, or sick persons,

or, on a regular basis, health-related care services above the level of

custodial care to other than individuals with intellectual disabilities.

NF

33 Custodial Care Facility

A facility which provides room, board and other personal assistance

services, generally on a long term basis, and which does not include a

medical component.

NF

POS Code and Name (effective date)

Description

Payment Rate

Facility=F

Nonfacility=NF

34 Hospice

A facility, other than a patient's home, in which palliative and supportive

care for terminally ill patients and their families are provided.

F

35-40 Unassigned --

41 Ambulance—Land

A land vehicle specifically designed, equipped and staffed for lifesaving

and transporting the sick or injured.

F

42 Ambulance—Air or Water

An air or water vehicle specifically designed, equipped and staffed for

lifesaving and transporting the sick or injured.

F

43-48 Unassigned --

49 Independent Clinic (October 1, 2003)

A location, not part of a hospital and not described by any other Place of

Service code, that is organized and operated to provide preventive,

diagnostic, therapeutic, rehabilitative, or palliative services to outpatients

only.

NF

50 Federally Qualified Health Center

A facility located in a medically underserved area that provides Medicare

beneficiaries preventive primary medical care under the general direction of

a physician.

NF

51 Inpatient Psychiatric Facility

A facility that provides inpatient psychiatric services for the diagnosis and

treatment of mental illness on a 24 -hour basis, by or under the supervision

of a physician.

F

52 Psychiatric Facility-Partial Hospitalization

A facility for the diagnosis and treatment of mental illness that provides a

planned therapeutic program for patients who do not require full time

hospitalization, but who need broader programs than are possible from

outpatient visits to a hospital-based or hospital-affiliated facility.

F

POS Code and Name (effective date)

Description

Payment Rate

Facility=F

Nonfacility=NF

53 Community Mental Health Center

A facility that provides the following services: outpatient services, including

specialized outpatient services for children, the elderly, individuals who are

chronically ill, and residents of the CMHC’s mental health services area

who have been discharged from inpatient treatment at a mental health

facility; 24 hour a day emergency care services; day treatment, other partial

hospitalization services, or psychosocial rehabilitation services; screening

for patients being considered for admission to State mental health facilities

to determine the appropriateness of such admission; and consultation and

education services.

F

54 Intermediate Care Facility/Individuals with Intellectual Disabilities

A facility which primarily provides health-related care and services above

the level of custodial care to individuals but does not provide the level of

care or treatment available in a hospital or SNF.

NF

55 Residential Substance Abuse Treatment Facility

A facility which provides treatment for substance (alcohol and drug) abuse to

live-in residents who do not require acute medical care. Services include

individual and group therapy and counseling, family counseling, laboratory

tests, drugs and supplies, psychological testing, and room and board.

NF

56 Psychiatric Residential Treatment Center

A facility or distinct part of a facility for psychiatric care which provides a

total 24-hour therapeutically planned and professionally staffed group living

and learning environment.

F

57 Non-residential Substance Abuse Treatment Facility (October 1,

2003)

A location which provides treatment for substance (alcohol and drug) abuse

on an ambulatory basis. Services include individual and group therapy and

counseling, family counseling, laboratory tests, drugs and supplies, and

psychological testing.

NF

POS Code and Name (effective date)

Description

Payment Rate

Facility=F

Nonfacility=NF

58 Non-residential Opioid Treatment Facility (January 1, 2020)

A location that provides treatment for opioid use disorder on an ambulatory

basis. Services include methadone and other forms of Medication Assisted

Treatment (MAT).

(See “Special Considerations” below.)

NF

59 Unassigned --

60 Mass Immunization Center

A location where providers administer pneumococcal pneumonia and

influenza virus vaccinations and submit these services as electronic media

claims, paper claims, or using the roster billing method. This generally takes

place in a mass immunization setting, such as, a public health center,

pharmacy, or mall but may include a physician office setting.

NF

61 Comprehensive Inpatient Rehabilitation Facility

A facility that provides comprehensive rehabilitation services under the

supervision of a physician to inpatients with physical disabilities. Services

include physical therapy, occupational therapy, speech pathology, social or

psychological services, and orthotics and prosthetics services.

F

62 Comprehensive Outpatient Rehabilitation Facility

A facility that provides comprehensive rehabilitation services under the

supervision of a physician to outpatients with physical disabilities. Services

include physical therapy, occupational therapy, and speech pathology

services.

NF

63-64 Unassigned --

65 End-Stage Renal Disease Treatment Facility

A facility other than a hospital, which provides dialysis treatment,

maintenance, and/or training to patients or caregivers on an ambulatory or

home-care basis.

NF

POS Code and Name (effective date)

Description

Payment Rate

Facility=F

Nonfacility=NF

66 Programs of All-Inclusive Care for the Elderly (PACE) Center

A facility or location providing comprehensive medical and social services as

part of the Programs of All-Inclusive Care for the Elderly (PACE). This

includes, but is not limited to, primary care; social work services; restorative

therapies, including physical and occupational therapy; personal care and

supportive services; nutritional counseling; recreational therapy; and meals

when the individual is enrolled in PACE.

Not applicable for

adjudication of

Medicare claims;

systems must

recognize for HIPAA

67-70 Unassigned --

71 State or Local Public Health Clinic

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)

Beginning in CY 2024, practitioners may receive either the facility or the

non-facility payment rate for an otherwise eligible Medicare telehealth

service, depending on whether the billing practitioner selects POS code 02 or

POS code 10. The only two valid POS codes for Medicare telehealth billing

in CY 2024 are POS 02 and POS 10. As appropriate, POS 02 or POS 10 may

be used and must be paired with the appropriate telehealth modifier (modifier

93 for audio-only and modifier 95 for audio/video). The payment rate for

POS 02 is the facility payment rate (F); the payment rate for POS 10 is the

non-facility rate (NF). Use of audio-only (93) or audio-video (95) does not

change rate of payment, only the POS code determines the non-facility or

facility payment rate.

• Special Considerations for Homeless Shelter (Code 04)

Note that for the purposes of receiving durable medical equipment

(DME), a homeless shelter is considered the beneficiary’s home.

Because DME is payable in the beneficiary’s 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 with 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 correctly, 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 while 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 physician’s office or a skilled nursing facility. 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 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 Medicare’s compliance with HIPAA laws and regulations. Local

contractors must continue to comply with CMS current policy that does not

allow payment for Medicare services in 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 facility 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 the 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 facility 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 location as the ASC – including

meeting the “distinct entity” criteria defined in the ASC State Operations

Manual that precludes the ASC and an adjacent physician office 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 practitioner’s office (POS 11); the beneficiary’s

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 patient’s physician or nonphysician practitioner or hospice

independent attending physician or nurse practitioner, shall assign the POS

code that represents that setting, as appropriate.

There may be use of nursing homes as the hospice patient’s “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 receive a home level of care. In these cases, physicians and

nonphysician practitioners, including the patient’s independent attending

physician or nurse practitioner, shall use the appropriate POS code representing

the particular setting, e.g., POS code 32 for 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.