CurrentOptumPolicy N/A

Procedure and Place of Service reimbursement

Governs reimbursement of CPT/HCPCS codes when reported with places of service (POS) for behavioral health benefits administered by Optum; applies to claims submitted on CMS-1500, UB-04 when specified, electronic claim formats and provider portals for applicable commercial, Medicare, and individual exchange products and providers.

Policy Summary

PayerOptum

PolicyProcedure and Place of Service reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims using procedure codes that correctly describe services and the appropriate Place of Service (POS).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500 / 837p/837iclaim form and submission types covered

CMS POS code setcoding standard referenced

11 representative groupsexample CPT groups with POS mappings

Apr 2026most recent history entry

Place of Service Coverage Criteria

Coverage Criteria — Place of Service alignment

Covered when ALL of the following are met:

Service is billed with a Place of Service (POS) code that is appropriate to the CPT/HCPCS code description and CMS POS code set

ALL of the following

Representative examples
- CPT 99202-99205 — acceptable POS: 02-08,10,11,12,15-17,19,20,22,24,26,49,50,53,57,62,65,71,72
- CPT 99211-99215 — acceptable POS: 02-08,10,11,12,15-17,19,20,22,24,26,49,50,53,57,62,65,71,72
- CPT 99221-99223 — acceptable POS: 02,06,08,21,22,23,25,26,34,51,52,53,55,56,61

Policy Summary

PayerOptum

PolicyProcedure and Place of Service reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims using procedure codes that correctly describe services and the appropriate Place of Service (POS).

SourceLink

On This Page

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.

CPT 99231-99233 — acceptable POS: 02,06,08,10,21,22,23,25,26,34,51,52,53,55,56,61

CPT 99234-99236 — acceptable POS: 02,21,22,23,24,25,26,34,51,52,53,56,61

CPT 99238-99239 — acceptable POS: 02,06,08,19,21,22,23,25,26,34,51,52,53,55,56,61

CPT 99281-99285 — acceptable POS: 02,10,23

CPT 99304-99306 — (representative codes) — POS list located in policy code section

CPT 99307-99310 — acceptable POS: 02,10,08,21,31,32,34,51,55,56,57

CPT 99341-99345 — acceptable POS: 02,10,04,09,12,13,14,16,27,31,32,33,54,55,56,61,65

CPT 99347-99350 — acceptable POS: 02,10,04,09,12,13,14,16,27,31,32,33,54,55,56,61,65

Claims submitted on CMS-1500, 837p/837i, or via provider portals for applicable Commercial, Medicare and Individual Exchange products must follow these POS alignments

Optum may use reasonable discretion in interpreting and applying this policy to individual cases

Codes that do not include a POS in their description or are not E/M-related are out of scope for this policy

Codes and Place of Service Requirements

Representative CPT groups with POS mappingsCPTCovered

99202-99205	Representative E/M CPT codes with specified acceptable POS list
99211-99215	Representative E/M CPT codes with specified acceptable POS list
99221-99223	Representative inpatient/observation E/M CPT codes with specified acceptable POS list
99231-99233	Representative inpatient/observation E/M CPT codes with specified acceptable POS list
99234-99236	Representative observation/inpatient E/M CPT codes with specified acceptable POS list
99238-99239	Representative discharge day management E/M CPT codes with specified acceptable POS list
99281-99285	Representative emergency department E/M CPT codes with specified acceptable POS list
99304-99306	Representative nursing facility E/M CPT codes with specified acceptable POS list
99307-99310	Representative nursing facility subsequent care CPT codes with specified acceptable POS list
99341-99345	Representative home visit E/M CPT codes with specified acceptable POS list

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POS alignment requirement

Policy requirementE/M and other CPT/HCPCS services are reimbursed only when reported with an appropriate Place of Service (POS) aligned to the CMS POS Code set and the code's description or coding guidelines.

Referenced standardAligns with The Centers for Medicare & Medicaid Services (CMS) POS Code set (two-digit POS codes).

Provider responsibilitySubmit claims with the POS that corresponds to the CPT/HCPCS code description (Optum maintains a CPT-to-POS mapping list).

Example implicationCPT 99234 (observation/inpatient hospital care) is not appropriate for reporting in an office or home POS per its code description.

Where to find mappingsSee the policy's coding section for Optum's established list of CPT codes and their appropriate POS values.

Provider Responsibilities and Claim Submission

Billing Rule

Claims submission responsibility — accurate procedure codes and POS

Submit accurate claims using procedure codes that correctly describe the services provided and report the appropriate CMS Place of Service (POS) code for each service; Optum may use reasonable discretion in interpreting and applying this policy when adjudicating claims.

Ensure CPT/HCPCS codes reflect the service rendered and align with Optum's CPT-to-POS mapping.
Report the two-digit CMS POS code that corresponds to the setting in which the service was provided.
Claims may be submitted on CMS-1500, UB-04 when specified, electronic 837p/837i formats, or via provider portals as applicable.

Key Definitions

Place of Service

DefinitionPlace of Service (POS) — a two-digit code used on health care professional claims to indicate the setting in which a service was provided.

Claim formsPOS codes are submitted on the CMS-1500 Health Insurance Claim Form or its electronic equivalent (e.g., 837p).

PurposeIndicates the service setting to ensure CPT/HCPCS codes are reported with an appropriate POS per code descriptions and CMS guidance.

Standards alignmentOptum aligns POS usage with the CMS POS Code set when determining reimbursement appropriateness.