CurrentWellpoint New Jersey MedicaidPolicy G-26002

Modifiers PN and PO: Off-Campus Provider-Based Hospital Outpatient

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This reimbursement policy governs reporting and payment of modifiers PN and PO on outpatient institutional claims for services furnished in off-campus provider-based hospital departments under Wellpoint New Jersey Medicaid.

Policy Summary

PayerWellpoint New Jersey Medicaid

PolicyModifiers PN and PO: Off-Campus Provider-Based Hospital Outpatient

Policy CodePolicy G-26002

Change TypeNo material change

Effective DateJanuary 1, 2027

Next Review DateNot specified

Key ActionReport modifier PN or PO, as applicable, on the outpatient institutional claim for qualifying off-campus provider-based department services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

40%Reimbursement for applicable outpatient facility claims

PN and POModifiers addressed by the policy

4Listed circumstances in which PN and PO are not allowed

250 yardsDistance defining an off-campus provider-based department

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CurrentWellpoint New Jersey MedicaidPolicy G-26002

Modifiers PN and PO: Off-Campus Provider-Based Hospital Outpatient

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Get alerted when Policy G-26002 changes without checking for updates manually.

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Policy Summary

PayerWellpoint New Jersey Medicaid

PolicyModifiers PN and PO: Off-Campus Provider-Based Hospital Outpatient

Policy CodePolicy G-26002

Change TypeNo material change

Effective DateJanuary 1, 2027

Next Review DateNot specified

Key ActionReport modifier PN or PO, as applicable, on the outpatient institutional claim for qualifying off-campus provider-based department services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

40%Reimbursement for applicable outpatient facility claims

PN and POModifiers addressed by the policy

4Listed circumstances in which PN and PO are not allowed

250 yardsDistance defining an off-campus provider-based department

When PN and PO Apply

When modifiers PN and PO are allowed

Modifiers PN and PO may be reported and reimbursed when all of the following conditions are met:

ALL of the following

ALL of the following
- Service is furnished in an off-campus provider-based department of a hospital.
- Service is reported on an outpatient institutional claim.
ONE of
- Modifier PN is applicable to a non-excepted service.
- Modifier PO is applicable to an excepted service.
ALL of the following
- Claim is not a professional claim billed on a CMS-1500.
- Service is not furnished in a licensed, dedicated emergency department or critical access hospital (CAH).
- Facility meets provider-based status requirements.
- Service is not furnished in an on-campus hospital department.

40% reimbursement limitation

The outpatient facility claim is reimbursed at 40% of the allowable amount when all of the following conditions are met:

ALL of the following

Service is provided in an off-campus provider-based department and billed on a UB-04.
ONE of
- HCPCS G0463 is billed.
- E/M code 99202-99215 is billed.
ONE of
- Modifier PN is reported.

Modifiers, Service Codes, and Reimbursement

Modifiers for off-campus provider-based hospital outpatient servicesModifierCovered

PN	Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital
PO	Excepted service provided at an off-campus, outpatient, provider-based department of a hospital

Hospital outpatient clinic visitHCPCSCovered

G0463

Hospital outpatient clinic visit for assessment and management of a patient

Outpatient evaluation and management codesCPTCovered

99202-99205	Office or other outpatient visit for evaluation and management of a new patient
99211-99215	Office or other outpatient visit for evaluation and management of an established patient

Corresponding professional claim place of servicemixed

POS 19

Place of service associated with a corresponding professional claim for an off-campus provider-based department

Reimbursement Limitation

Facility claim reimbursement limitation40% of the allowable amount

Location Threshold

Off-campus location distanceMore than 250 yards from the main hospital campus or a remote hospital location

Billing Actions and Avoidance Rules

Billing Rule

Report PN or PO on Qualifying Institutional Claims

Report modifier PN or PO, as applicable, on the outpatient institutional claim for services rendered in an off-campus, outpatient provider-based department (PBD), unless provider, state, federal, CMS contract, or other applicable requirements indicate otherwise.

PN: Non-excepted service provided at an off-campus, outpatient PBD of a hospital.
PO: Excepted service provided at an off-campus, outpatient PBD of a hospital.

Billing Rule

Apply the 40% Reimbursement Limitation

Apply a 40% reimbursement limitation to the outpatient facility claim when the services are provided in an off-campus PBD, billed on a UB-04 with modifier PN or PO, and include HCPCS G0463 or E/M codes 99202-99215. The limitation applies when a corresponding professional claim is submitted for the same date of service with Place of Service (POS) 19.

G0463: Hospital outpatient clinic visit for assessment and management of a patient.
99202-99205: New-patient office or other outpatient E/M visits.
99211-99215: Established-patient office or other outpatient E/M visits.
Facility reimbursement for these qualifying services is limited to 40% of the allowable amount.

Denial Risk

Avoid Nonreimbursable Uses of PN and PO

Do not report modifiers PN or PO, or expect reimbursement for their use, in excluded settings or on excluded claim types.

Do not use PN or PO on professional claims billed on a CMS-1500 claim form.
Do not use PN or PO for services furnished in a licensed, dedicated emergency department or critical access hospital (CAH).
Do not use PN or PO for services furnished in facilities that do not meet provider-based status requirements, including non-provider-based facilities.
Do not use PN or PO for services furnished in on-campus hospital departments.

Key Terms

Definitions

ExceptedA service furnished in an off-campus provider-based department that qualifies for CMS Medicare excepted (grandfathered) payment status based on applicable CMS Medicare requirements.

Definitions

NonexceptedA service furnished in an off-campus, outpatient, provider-based department of a hospital that does not qualify for CMS Medicare excepted payment status and is subject to applicable site-neutral payment methodologies.

Definitions

Provider-Based DepartmentA department of a hospital that meets CMS Medicare provider-based requirements and bills as part of the hospital under the hospital's CMS Medicare certification.

Definitions

Off-Campus Provider-Based DepartmentA provider-based department located more than 250 yards from the main hospital campus or a remote hospital location, as defined by CMS Medicare.

Policy Summary

PayerWellpoint New Jersey Medicaid

PolicyModifiers PN and PO: Off-Campus Provider-Based Hospital Outpatient

Policy CodePolicy G-26002

Change TypeNo material change

Effective DateJanuary 1, 2027

Next Review DateNot specified

Key ActionReport modifier PN or PO, as applicable, on the outpatient institutional claim for qualifying off-campus provider-based department services.

SourceLink

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