Outpatient Surgical Site of Service (Hospital outpatient POS 22) coverage criteria
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Defines medical necessity review and site-of-service requirements for hospital outpatient (place of service 22) use for knee and shoulder arthroscopy/open procedures and small joint surgery for Providence Health Plan commercial fully insured groups; affects providers requesting prior authorization. Does not apply to Providence Medicare or Providence OHP members.
Medical necessity review of the hospital outpatient site of service (place of service 22) will be applied to specified knee, shoulder, and small joint procedures effective 5/11/2026.
If outpatient site criteria are not met, the service must be performed at an ambulatory surgery center (ASC) for coverage.
Providers without geographically accessible ASC privileges must have a signed attestation on file or indicate on the prior authorization that no ASC is available.
Site-of-Service Coverage Criteria
Hospital outpatient (POS 22) site-of-service coverage criteria
Covered when ALL of the following are met:
If medical policy criteria are not met for the outpatient site of service, the service must be performed at an ambulatory surgery center (ASC) for coverage.
Prospective attestations are encouraged to facilitate future reviews.
This policy does not apply to Providence Medicare and Providence OHP members. It applies to Providence Health Plan commercial fully insured groups only and does not supersede benefit determinations of coverage.
Coverage of a procedure performed in a hospital outpatient setting (Place of Service 22) is contingent on meeting the Plan’s medical policy criteria for the outpatient site of service. If medical policy criteria for the outpatient hospital site are not met, the hospital outpatient site (POS 22) is not considered covered and the service must be performed at an ambulatory surgery center (ASC) for coverage. On the PA request, clearly indicate if the procedure will be performed in POS 22; if no ASC is available, attest on the PA to avoid review delays.
Applicable Procedure Codes (Appendix)
| 29873 | Arthroscopy, knee, surgical; with lateral release. |
| 29874 | Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation). |
| 29875 | Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure). |
| 29876 | Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments. |
| 29879 | Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture. |
| 29880 | Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed. |
| 29881 | Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral) including any meniscal shaving and debridement/shaving of articular cartilage (chondroplasty), when performed. |
| 29882 | Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral). |
| 29884 | Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction (separate procedure). |
| 29888 | Arthroscopically aided anterior cruciate ligament reconstruction. |
Provider Requirements and Prior Authorization
Prior authorization required for procedure and hospital outpatient (POS 22) site
Prior authorization and medical necessity review are required for the procedure and additionally for any planned hospital outpatient (place of service 22) site of service for the listed knee, shoulder, and small joint procedures; if medical policy criteria are not met for the outpatient site, the service must be performed at an ambulatory surgery center (ASC) for coverage.
- Prior authorization continues to be required for the procedure itself.
- Medical necessity review will also be applied to any planned hospital outpatient (POS 22) site-of-service.
ASC availability and attestation — provider responsibilities
If you lack geographically accessible ASC availability or ASC privileges, indicate that on the prior authorization request or have a signed attestation on file with The Plan to avoid delays; prospective attestations are encouraged.
- If no attestation is on file, indicate on the PA request that no ASC is available to prevent delay of prior authorization review.
- Providers anticipating future site-of-service authorization requests are encouraged to submit a prospective attestation now.
PA documentation and attestation requirement for POS 22
On the prior authorization request, clearly indicate if the procedure will be performed in a hospital outpatient setting (place of service 22). If an ASC is not geographically accessible or the provider lacks ASC privileges, either attach a signed attestation on file with The Plan or indicate on the PA that no ASC is available.
- Attach a signed attestation found via The Plan if an ASC is not accessible.
- Indicating 'no ASC available' on the PA will prevent delays in review when an attestation is not yet filed.
Denial risk if POS 22 criteria are not met
If medical policy criteria for the hospital outpatient site of service (place of service 22) are not met, the service will not be covered at that site and must be performed at an ambulatory surgery center (ASC) for coverage.
- Coverage at POS 22 is contingent on meeting the policy's medical necessity criteria; failure to meet criteria triggers noncoverage at POS 22.
Key Definitions
Background and Scope
Background: This policy governs site-of-service review (hospital outpatient versus ASC) for select orthopedic procedures — specifically knee arthroscopy/open procedures, shoulder arthroscopy/open procedures, and small joint surgery. It adds medical necessity review of the planned hospital outpatient site in addition to the existing procedure-level prior authorization requirement, effective 5/11/2026. Providers without a geographically accessible ASC or without ASC privileges must either have a signed attestation on file with the Plan or indicate on the prior authorization that no ASC is available; prospective attestations are encouraged.
Policy Revision History
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