This policy defines the required reporting of Place of Service (POS) coding on the CMS-1500 claim form for professional claims for commercial members of Blue Cross Blue Shield - Maine. Providers must bill the appropriate two-digit POS code to be eligible for reimbursement unless superseded by provider, state, or federal requirements. The appropriate setting for a procedure or service is determined by the CPT® or HCPCS Level II code description and applicable CPT coding guidelines.
All procedures and services performed by a professional provider in an office setting are only eligible for reimbursement when reported with POS 11 (Office) on the CMS-1500. Services reported with POS 03 (School) will be eligible for non-office reimbursement when the CPT/HCPCS code description supports that setting. Provider Based Clinics that function primarily to see community patients daily are considered to be provided in an office setting.
This policy describes criteria that qualify a physical site as an office place of service (for example, locations outside a hospital or facility without state-licensed inpatient beds, an emergency department, continuous 24/7 onsite acute care staff, or ambulatory surgery center licensure). It also clarifies that office space within a hospital or hospital-owned off-campus building can be treated as office POS when the office operates under a separate TIN/NPI, is a separately identifiable part of the hospital used solely as the provider's office, or when equipment located in the rented space is used for the office services.
Certain items and charges billed on professional claims with a facility place of service are included in facility reimbursement and are not separately reimbursable when reported with a facility POS. Examples include medications (even if reported with an unspecified code), vaccine and vaccine administration, specified injections and radiotherapeutic materials, and HCPCS 'B' and 'E' coded enteral/parenteral therapy supplies. Separate facility fees billed with professional services rendered in a private practice with an office POS are not eligible for reimbursement.
Services must be supported by appropriate medical record documentation and billed using correct, industry-standard CPT/HCPCS coding. Failure to follow the coding and billing requirements in this policy may result in claim rejection, denial, or recovery of payment.