Office Facility Fees
Governs when facility or office facility fees are payable for services provided in an office place of service and clarifies billing requirements for professional providers/private practices operating within or affiliated with hospitals/facilities. Affects facility and other providers billing Blue KC across commercial and Medicare Advantage lines.
Policy updated to add table of revenue codes not eligible for reimbursement.
Policy updated to remove CPT codes; see CPT manual for correct coding.
Policy updated to remove government regulations link and verbiage.
Annual review - added virtual cardiac rehabilitation under investigational.
This policy applies to all commercial lines of business.
Office Facility Fee Coverage
Office Facility Fee Coverage Criteria
Covered when ALL of the following are met:
ALL of the following
- Services performed by private professional providers/private practices in an office place of service are reimbursable only when billed on a Form CMS-1500 with POS code 11.
- Provider-based facilities shall not charge, bill, or collect a facility fee for services rendered in an office setting; patient responsibility for such a charge applies only when Medicare is primary and federal law permits the fee or when Medicaid allows the charge.
- Blue KC does not recognize ownership of a professional provider/private practice by a hospital or use of a hospital/facility TIN for claims submission as converting an office setting into a hospital/facility place of service.
- There are no exemptions or exceptions to this policy.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.