Place of Service is one of the most important concepts to understand for claims as well as benefit configuration.
Place of Service : Where the service was rendered by healthcare provider. e.g. in Provider office, Patient Home, Home healthcare facility , Hospice center, Nursing Facility etc.
Please note that this healthcare provider is Professional Providers like physician , Nurse Practioner, specialists etc. and submitting CMS-1500 forms for reimbursement and not the Facility Providers.
e.g. 1. we went to doctor office for treatment then doctor will submit the claims with Place of service -11( Office)
e.g. 2. doctor come to patient home then doctor will submit claims with place of service -12( Home)
e.g.3. Patient is admitted to the hospital for treatment in a facility and physician who is not employed by Facility also called to see the patient then Facility will submit the UB-04 claims but this Physician will submit CMS-1500 forms for re-imbursement with correct place of service i.e. 21 - Hospital Inpatient.
Place of service is applicable to both Inpatient and Outpatient setting e.g. Place of service -21 means Inpatient Hospital , Place of Service 22 means Outpatient Hospital. So when Physician see a patient that is admitted in hospital i.e. patient is hospitalized ( Inpatient setting) , Physician will file the claim with Place of service - 21 however if physician see the patient in outpatient department ( Outpatient setting) then he will file the claim with place of service 22 ( Hospital Outpatient)
Place of Service is applicable to both Facility and Non-Facility.
Keeping everything simple, Place of service apply for Facility , for Non -Facility, for Inpatient , for Outpatient.
It is required by the law to report correct Place of Service.
Place of service is applicable to both Inpatient and Outpatient setting e.g. Place of service -21 means Inpatient Hospital , Place of Service 22 means Outpatient Hospital. So when Physician see a patient that is admitted in hospital i.e. patient is hospitalized ( Inpatient setting) , Physician will file the claim with Place of service - 21 however if physician see the patient in outpatient department ( Outpatient setting) then he will file the claim with place of service 22 ( Hospital Outpatient)
Place of Service is applicable to both Facility and Non-Facility.
Keeping everything simple, Place of service apply for Facility , for Non -Facility, for Inpatient , for Outpatient.
It is required by the law to report correct Place of Service.
Why it is important : Claims can be denied if provider is not submitting correct place of service. If provider has a contract to treat patient in Outpatient setting but he submits a claims with Inpatient place of service (21) that claim will be denied.
Based on place of service provider can get more or less payments e.g Place of service 23( Emergency visit) may get more re-imbursement then office visit.
provider may get less re-imbursement for all Facility place of service than Non- Facility place of service.( Because provider will be getting all the infrastructure from facility like office rent, equipment's, tools, electricity etc so his re-imbursement will be less)
Same service performed on different place of service will get different re-imbursement. CM Physician fee schedules are based on Facility and non-Facility setting.
If provider is not suppose to treat Urgent care or emergency visit and if submits such claims will be denied.
Also some of the services can not be rendered in all the place of services and that claims will be denied. eg. Pregnancy can not be delivered in Office ( POS-11) setting and that claims will be denied by the system edits.
Also some of the service will have the limitation ( like 2 or 3 units in a year for office visits ) and that limitation is reached then its patient responsibility to pay the amount .
If provider is suppose to treat only in Office then he can submit only the claims with Place of service 11 and all others claims will be denied.
Who Maintain POS : CMS
Please see all the POS with description and where it is applied ( Facility or Non-Facility) . This has been taken from CMS website. see that link below
https://www1d.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf
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
| |
02 Unassigned
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--
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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 instructions 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 instructions below.)
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Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA
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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 instructions 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 instructions 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 instructions 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 instructions below.)
|
NF
|
10 Unassigned
| |
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
|
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
|
POS Code and Name (effective date)
Description
|
Payment Rate
Facility=F
Nonfacility=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.
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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.
|
Not applicable for adjudication of Medicare claims; systems must recognize for HIPAA
|
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
|
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 Outpatient Hospital
A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
|
F
|
POS Code and Name (effective date)
Description
|
Payment Rate
Facility=F
Nonfacility=NF
|
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
|
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
|
27-30 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 mentally retarded individuals.
|
NF
|
33 Custodial Care Facility
A facility which provides room, board and other personal assistance services, generally on a longterm basis, and which does not include a medical component.
|
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
|
--
|
POS Code and Name (effective date)
Description
|
Payment Rate
Facility=F
Nonfacility=NF
|
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
|
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
|
F
|
POS Code and Name (effective date)
Description
|
Payment Rate
Facility=F
Nonfacility=NF
|
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.
| |
54 Intermediate Care Facility/Mentally Retarded
A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded 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
|
58-59 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
|
F
|
POS Code and Name (effective date)
Description
|
Payment Rate
Facility=F
Nonfacility=NF
|
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.
| |
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
|
66-70 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
|
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