Knowledge Base Article

Q:

At the August 18th Hospital Open Door Forum, the CMS representative who answered questions about the “PO” modifier stated that the modifier applied to all outpatient services “paid under OPPS.” The instructions for the “PO” modifier from the July 2015 OPPS Update state that, “This modifier is to be reported with every HCPCS code for all outpatient hospital items and services furnished in an off-campus provider-based department of a hospital.” From reading of the 2015 OPPS Final Rule it appears the intent of this modifier is mainly to gather information on off-campus physician offices and clinics operating as hospital provider-based departments.

Based on differences in the above descriptions of the use of the “PO” modifier, to which types of outpatient services provided in off-campus provider-based departments (PBDs) should the PO modifier be appended?

A:

Medical Management Plus posed this question to CMS through the Hospital Open Door Forum email. The answer we received from Tiffany Swygert with CMS is that, “It applies to all services paid under the OPPS that are furnished in an off-campus provider based department of a hospital except for remote locations, satellite facilities and EDs. If the specific services are not paid under the OPPS, then no modifier is required under this policy.”

Ms. Swygert went on to clarify specifically that rehabilitative therapy services (PT, OT and Speech therapy) paid under the Medicare Physician’s Fee Schedule in accordance with an OPPS Status Indicator of “A” do not require a PO modifier when furnished in an off-campus PBD since they are not paid under the OPPS. Another common outpatient service not paid under OPPS is laboratory services when they are non-patient services or the only outpatient services performed. In this situation, most clinical lab services are paid under the Clinical Laboratory Fee Schedule (CLFS) and based on the same logic would not require a PO modifier. However, lab services furnished with other outpatient services are packaged services which means they are “paid under OPPS” although there is no separate payment. Therefore these lab services would require a PO modifier.

The use of the PO modifier is voluntary for 2015, but will be required on claims for off-campus provider-based departments beginning in 2016.

Hospitals should refer to the OPPS Addendum B to find a service’s status indicator and to Addendum D1 for the descriptions of the status indicators to determine which services are paid under OPPS and which are not.