Knowledge Base Article

Over the past several years, there has been a trend for hospitals to acquire and operate more off-campus, outpatient provider-based departments (PBDs). As this shift in place of service has occurred, CMS has made several adjustments to promote site-neutral payments and gather data on the number of such entities and the services they provide. We have seen a transition to a different payment system for new off-campus PBDs at 40% of the usual OPPS rates, modifiers for services provided in new and existing off-campus PBDs, and new edits enforcing requirements for reporting the address of the service location on the claim. The good news for this last requirement is that Medicare continues to give hospitals one more chance to get it right before turning on the edits.

MLN Matters Article SE19007 describes the claim requirements related to the service location address and gives a new implementation date of July 2019. Basically, the requirement is that “Medicare outpatient service providers report the service facility location for an off-campus, outpatient, provider-based department of a hospital in the 2310E loop of the 837 institutional claim transaction. Direct Data Entry (DDE) submitters also must report the service facility location for an off-campus, outpatient, provider-based department of a hospital.” The hard part is that the reported addresses must be an exact match to the information on the Medicare enrollment Form CMS-855A submitted by the provider and entered into the Provider Enrollment, Chain and Ownership System (PECOS). In CMS testing to date, many providers are not reporting the correct service facility location on the claim that produces an exact match with the Medicare enrolled location as based on the information entered into the PECOS. Most of the discrepancies have to do with spelling variations, such as “Road” versus “Rd.”

The MLN article gives specific examples of the required claim reporting for different scenarios based on where the services were provided as seen in the table below:

These are not new requirements but were discussed in CRs 9613 and 9907, both of which were effective on January 1, 2017. CMS released MLN Matters Article SE18023 in October 2018 and originally planned to turn on the edits that would reject claims if the addresses were not an exact match in April 2019. As stated above, this latest MLN SE Article delays the implementation until at least July 2019 with additional testing prior to that date.  Another positive is that in the April 2019 system update, the FISS maintainer, at the direction of CMS, has made the practice location address screen available to providers in DDE. This will allow providers to ensure the service location address they are reporting is an exact match to the PECOS address. Another helpful resource is a list of Questions and Answers published by CGS, the Medicare Administrative Contractor (MAC) for Jurisdiction 15.

SE19007 also discusses the use of modifiers PO and PN. Modifier PO is reported on line items for all excepted items provided at an off-campus PBD and modifier PN is reported on line items for all non-excepted items provided at an off-campus PBD. As a reminder, non-excepted off-campus PBDs are those off-campus provider-based departments of a hospital that were not furnishing or billing for services before November 2, 2015. Non-excepted off-campus PBDs are paid under the physician fee schedule (PFS) instead of under OPPS at a rate equal to 40% of the OPPS. Non-excepted services are reported with the PN modifier to trigger the reduced payment. Excepted off-campus PBDs report modifier PO to allow CMS to gather data and monitor billing patterns but, at this time most services continue to be paid under OPPS at regular OPPS payment rates. Beginning in 2019, there is a 30% reduction in payment for clinic visit services (HCPCS G0463) from the regular OPPS rates when provided at excepted off-campus PBDs. This reduction increases to a 60% reduction for 2020 which will equal the 40% of OPPS payment rate received by the non-excepted off-campus PBDs but again, at this time, only for clinic visits for the excepted off-campus PBDs.

Once the edits are turned on, be that July or later, claims submitted with service location addresses that are not an exact match to PECOS will Return to the Provider (RTP). Facilities should take advantage of this implementation delay, the new DDE screen showing the PECOS address, and the expanded reporting instructions to make sure you have it right.