Place of Service

Description

A place of service code is a two-digit numeric character that is used on a professional claim to report where a service(s) was provided. The place of service code set list is maintained by The Centers for Medicare & Medicaid Services (CMS) and can be located in the CMS Place of Service List as cited in the Reference section of this policy.

Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) descriptions and coding guidelines may denote the most appropriate place of service (POS). In some cases, the descriptions or guidelines may define when a POS is considered inappropriate when reported by a physician or other health care professional. All claims with procedure codes are required to indicate a place of service on the claim line. According to the CPT manual, POS should be specified and match the procedure code’s description and/or guidelines for use.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will reimburse places of service according to the criteria outlined in this policy. 

Reimbursement Guidelines

Blue Cross NC requires the appropriate place of service to be reported for a claim to be eligible for reimbursement and can often be found within the CPT® or HCPCS code description or coding guidelines.

Blue Cross NC aligns with the CMS place of service code set listing and will maintain systems to remain up to date with any changes.

Blue Cross NC follows the instruction and guidance of code issuers, including but not limited to CPT®, HCPCS Level II, and ICD-10-CM.

For purposes of this policy, Blue Cross NC will not provide reimbursement for procedures codes reported with inappropriate places of service.

Clinical Social Work Services While Inpatient

Social worker services are included in the facility payment when performed on a member who is registered in an inpatient status and will not be eligible for separate reimbursement.

Durable Medical Equipment (DME)

DME must be billed in the place of service where the member intends to use it, not where it is dispensed.

Evaluation and Management (E/M) Services

Most E/M codes include the place where a service is to be rendered included within the code description. The E/M service will not be eligible for reimbursement if it is reported in a place of service that conflicts with the location included in the code description.

Home Health/Home Infusion

Home Health/Home Infusion procedures should be limited to the following place of service: School, Homeless shelter, Home, Assisted living facility, Group home, Temporary lodging, Custodial care facility, Intermediate care facility/individuals with intellectual disabilities and Residential substance abuse treatment facility. If performed in a home infusion therapy in infusion suite, the claim must be reported wth a modifier representing this. Additionally, home infusion/home therapy services are not eligible for separate reimbursement when a member is in an inpatient status, such as an inpatient hospital or skilled nursing facility.

Hyperbaric Oxygen Therapy

Hyperbaric Oxygen Therapy procedures are eligible for reimbursement when provided in any of the following: Office, Outpatient hospital-off-campus, Inpatient hospital, Outpatient hospital-on-campus, Independent clinic, Hospital inpatient, Hospital outpatient, Critical access hospital.

Immunizations

Hepatitis A/B vaccines, Influenza vaccines or Pneumococcal pneumonia vaccines will not be eligible for reimbursement when provided in an outpatient rehabilitation facility.

Laboratory Services Billed by Physicians

The technical and professional components of a laboratory test are included in the payment to the facility in which the services were rendered, therefore, physicians will not be reimbursed separately except when the professional component is billed by a provider in one of the following specialities: dermatology, genetics, hematology, laboratory, or pathology

Typically, the interpretation of a blood smear should be completed by a physician in an inpatient hospital or an independent laboratory. However, the interpretation of a blood smear in an office setting is only reimbursable for a hematology-oncology physician.

Moderate Sedation

Moderate sedation services performed by a second qualified provider, other than the provider performing the diagnostic or therapeutic service that the sedation supports, is only reimbursable in a facility place of service.

Mutually Exclusive Places of Service

The place of service code used should indicate the setting in which the patient received a face -to-face encounter or where the technical component of a service was rendered in the case of an interpretation. In the event the member is registered as inpatient status, then the physician/practitioner/supplier providing the service needs to indicates as such, irregardless of where the actual face-to-face encounter occurred.

Services While Inpatient

Professional services billed in a Facility setting other than inpatient while a member is registered as an inpatient, are not reimbursable.

Supplies and DME in the Facility Setting

Medical and surgical supplies and DME are not reimbursable as professional services in the facility setting.

Rationale

According to code description and available coding guidelines, some codes should not be filed in some places of service. 

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please the Blue Cross NC web site at www.bcbsnc.com .

Related policy

ASC

Bundling Guidelines

Evaluation and Management Services

Outpatient Code Editor (OCE) Edits

Pricing & Adjudication Principles

Status Codes

Supplies and Equipment

Telehealth

References

Healthcare Common Procedure Coding System

American Medical Association, Current Procedural Terminology (CPT®)

Centers for Medicare and Medicaid Services, National Physician Fee Schedule (NPFS)

Centers for Medicare & Medicaid Services, CMS Manual System, Medicare Claims Processing Manual 100-04 100-04 | CMS, OPPS CMS OPPS, OCE CMS OCE, and other CMS publications

CMS Place of Service List CMS POS List

Provider Blue Book

History

6/1/22 New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

12/31/2022 Routine policy review. Alphabetized Reimbursement Guidelines section and added language for DME billing requirement for place of service. Medical Director approved. (ckb)

11/1/2023 Added Hyperbaric Oxygen Therapy to Reimbursement Guidelines. Medical Director approved. Notification on 11/1/2023 for effective date 1/1/2024. (tlc)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.