Billing

URGENT: Billing Reminders for OPPS Providers with Multiple Service Locations

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Urgent: Provider Compliance Required Effective 8/1/2023

This Update Impacts Payment for OPPS Facilities

Please note: Do not contact the PCC until all claims submissions have been reviewed to ensure the location address entered matches the location in PECOS exactly, or that needed corrections to the PECOS enrollment have been submitted and approved by Provider Enrollment. The PCC will not be able to assist you until these actions have been completed.

Note: As noted below, the location address on claims submissions must match exactly, this includes abbreviations such as St versus Street, East versus E, Third versus 3rd, etc..

Does your hospital operate an off-campus outpatient provider-based department? If so you will need to ensure your addresses for claims submission software matches EXACTLY with PECOS. If they are not exactly the same you have two choices, update your claims submission software to match PECOS or if the location is not in your PECOS record or is different than your PECOS record (not including abbreviations), submit a CMS855A application to update. We encourage you to review this article including the resources listed in the Additional Information section below to ensure you understand the requirements and avoid issues with claim(s) that may be​​​​ RTP.

Medicare’s off-campus outpatient provider-based department billing requirements have been in place since 1/1/2017. Providers with off-campus outpatient provider-based departments must submit claims to Medicare for services rendered at such locations in accordance with all applicable billing requirements. This includes reporting the location of the off-campus outpatient provider provider-based department (service facility address) and certain modifiers. Therefore, claims for your off-campus outpatient provider-based location must be submitted in accordance with the applicable billing requirements regardless of whether there is specific editing in place.

Systematic validation edits, when activated, will enforce requirements for hospitals with multiple locations including off-campus provider-based departments. Changes to editing for appropriate reporting of off-campus outpatient department locations will impact all providers. Payment impacts related to this reporting will only impact those providers paid under the OPPS.

Providers should prepare by ensuring that their enrollment information is up to date, and any claim submissions reflect the practice locations exactly as it appears from the practice location address screen which is received from PECOS. Additionally, providers should ensure that the practice locations are linked to the NPI that is being reported on the claim submission. Requirements for correct provider practice location reporting was effective back in 2017, however, systematic edits were not put in place at that time.

As noted in SE18002, in order for MPFS and OPPS payments to be accurate, the service facility address of the off-campus, outpatient, provider-based department of a hospital facility is used to determine the locality. That said, editing may be implemented at any time.

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Requirements

Hospital OPPS providers are required to:

  • Include all off-campus outpatient provider-based practice locations on the CMS-855A enrollment form. If a hospital OPPS claim is submitted with a service facility location that was not included on the CMS-855A enrollment form OR the location reported does not exactly match the information in PECOS, it may be returned to the provider with reason code 34977.
  • OPPS providers are required to report one of the following modifiers when reporting services provided at an off-campus outpatient provider-based practice location.
    • PN modifier is reported on claims for non-excepted service provided at an outpatient off-campus provider-based department of a hospital to identify and process non-excepted items and services billed on an institutional claim. The PN modifier triggers payment under the MPFS on/after 1/1/2017.

      For a service to be considered non-excepted, it must be performed in an off-campus outpatient provider-based practice location with an effective date on or after 11/2/2015.
       
    • PO modifier is reported on claims for services, procedures and/or surgeries provided at an off-campus provider-based outpatient department of a hospital to identify and process excepted items and services billed on an institutional claim. The PO modifier triggers payment under OPPS.

      For a service to be considered excepted, it must be performed in an off-campus practice location with an effective date prior to 11/2/2015.
       
    • Modifier ER is reported on each claim line applicable to items and services furnished by an off-campus outpatient provider-based emergency department.

If you submit a claim that includes an inappropriate modifier or you report an off-campus outpatient provider-based practice location without a modifier, your claim will RTP with reason code 34978.

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Claim Filing Requirements

To report the service facility location (address) for an off-campus outpatient provider-based department of a hospital:

  • Electronic claim submitters report the service facility location in 2310E loop of the 837 institutional claim transaction
  • FISS DDE submitters report the service facility location in MAP171F, which can be accessed from claim page (3) and then press the (<F11/PF11>) key twice. SE18023 contains a screen shot of MAP171F.
  • Paper UB-04 claim submitters report the service facility location in Form Locator (FL) “01” on the form. (Note: To submit a paper claim, you must have an approved ASCA waiver on file)

The FISS and the information in the PECOS can validate the service facility location to ensure services are being billed in a Medicare enrolled location.  This must be an exact match based on the information submitted on the CMS-855A application and verified through the USPS database. The USPS verified address will be entered into PECOS.

The Service Facility Location has to be an exact match on what was verified with the USPS database and entered into PECOS.

Pay close attention to spelling variations, for example:

  • In PECOS, the word verified and entered was “Road” as part of their address, but the provider entered “Rd” or “Rd.” as part of their address on the claim submission.
  • In PECOS, the word verified and entered was “STE” as part of their address, but the provider entered “Suite” as part of their address on the claim submission.

Providers can review their practice locations in PECOS to ensure that their service facility address for their off-campus provider department location provided on claims is an exact match.

Providers must ensure that all practice locations are present in PECOS and if any locations are not in PECOS then the provider must submit a revised 855A to add the location(s).

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Final Reminders

  • Reason code 34977 edits when the claim service facility address does not match provider practice file address.
  • Reason code 34978 edits when the off-campus provider claim line that contains an HCPCS does not include the required PN or PO modifier.
  • OPPS providers billing with the PO and/or PN modifier for their off-campus, outpatient provide-based department must bill the correct service facility address as indicated in PECOS. The PECOS verified location (Rd, Road, RD, Dr, Drive, DR, Ste, Ste# Suite, Suite#, St, Street, ST) MUST be an exact match.
  • Ensure all off-campus outpatient provider-based department locations are present in PECOS and if not, submit the CMS-855A application to add the address(es).
  • Review ALL of the CMS instructions included in the Additional Information section below.
  • Ensure you understand reason codes 34977 and 34978 and make all appropriate updates as soon as possible to ensure you are billing your claims correctly. Compliant claims prevent you from experiencing claim processing issues and subsequent delays in claim payments.

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Revised 8/7/2023