Site of Service Differential

Reimbursement Policy:
Site of Service Differential

Effective Date:
10/20/2014

Last Revised Date:
08/02/2016

Purpose:
To outline Horizon BCBSNJ’s business rules for the application and maintenance of Horizon BCBSNJ’s Site of Service differential reimbursement methodology. This policy applies to professional providers.

Scope:
All products are included, except products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:
Site of Service Differential: Some professional services may be provided either in a facility or a non-facility setting. When a professional service is provided in a facility, the costs of the clinical personnel, equipment, and supplies are incurred by the facility, not the physician practice. For this reason, reimbursement for professional services provided in a facility may be lower than if the services were performed in a non-facility setting. This difference in reimbursement, based on where the professional service is performed, is referred to as a “site of service differential.”

Facility Rate: The rate paid for professional services performed in a facility setting.

Non-Facility Rate: The rate paid for professional services performed in a setting that is not a facility.

Policy:
In accordance with CMS guidelines, professional providers will be reimbursed based on the site of service where the selected procedures are performed. Only CMS’s surgical range (10000-69999) of codes that have a site of service differential are included in Horizon BCBSNJ’s list of applicable procedures for differential reimbursement.

The CPT® codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon uses CMS’s list of procedure codes that offer a site of service reimbursement (in range 10000-69999) that were effective at the time Horizon BCBSNJ’s current fee schedule year was implemented. Horizon BCBSNJ will update the list of site of service procedures with any new codes released in subsequent years that have a site of service differential.

The table below1 includes current national place of service code set information that identifies the facility and non-facility designations for each code.

POS Code POS Name Payment Rate
01 Pharmacy NF (Nonfacility)
03 School NF (Nonfacility)
04 Homeless Shelter NF (Nonfacility)
09 Prison/Correctional Facility NF (Nonfacility)
11 Office NF (Nonfacility)
12 Homeless Shelter NF (Nonfacility)
13 Assisted Living Facility NF (Nonfacility)
14 Group Home NF (Nonfacility)
15 Mobile Unit NF (Nonfacility)
16 Temporary Lodging NF (Nonfacility)
17 Walk-in Retail Health Clinic NF (Nonfacility)
19 Off Campus-Outpatient Hospital F (Facility)
20 Urgent Care Facility NF (Nonfacility)
21 Inpatient Hospital F (Facility)
22 On Campus-Outpatient Hospital F (Facility)
23 Emergency Room-Hospital F (Facility)
24 Ambulatory Surgical Center F (Facility)
25 Birthing Center NF (Nonfacility)
26 Military Treatment Facility F (Facility)
31 Skilled Nursing Facility F (Facility)
32 Nursing Facility NF (Nonfacility)
33 Custodial Care Facility NF (Nonfacility)
34 Hospice F (Facility)
41 Ambulance - Land F (Facility)
42 Ambulance - Air or Water F (Facility)
49 Independent Clinic Nonfacility
50 Federally Qualified Health Center Nonfacility
51 Inpatient Psychiatric Facility F (Facility)
52 Psychiatric Facility - Partial Hospitalization F (Facility)
53 Community Mental Health Center F (Facility)
54 Intermediate Care Facility/Mentally Retarded NF (Nonfacility)
55 Residential Substance Abuse Treatment Facility NF (Nonfacility)
56 Psychiatric Residential Treatment Center F (Facility)
57 Non-residential Substance Abuse Treatment Facility NF (Nonfacility)
60 Mass Immunization Center NF (Nonfacility)
61 Comprehensive Inpatient Rehabilitation Facility F (Facility)
62 Comprehensive Outpatient Rehabilitation Facility NF (Nonfacility)
65 End-Stage Renal Disease Treatment Facility NF (Nonfacility)
71 State or Local Public Health Clinic NF (Nonfacility)
72 Rural Health Clinic NF (Nonfacility)
81 Independent Laboratory NF (Nonfacility)
99 Other Place of Service NF (Nonfacility)

1 This information was accessed on August 2, 2016 within the Medicare Claims Processing Manual, Chapter 26 - Completing and Processing, Form CMS-1500 Data Set.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
2011:             Policy approved
10/2014:        Term ”OPERA” removed throughout documents, definitions added; procedure updated.
11/20/2015:   Added new POS 19; added CPT code nomenclature statement
8/2/2016:       Updated to align with CMS in determining facility and non-facility designation for each place of service code.

CPT® is a registered mark of the American Medical Association

Policy 030_v3.0_08022016