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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyWellpoint TN Modifiers PN PO Update | OpenPayer
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    CurrentWellpoint Tennessee MedicaidPolicy G-26002

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

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

    Policy Summary
    PayerWellpoint Tennessee Medicaid
    PolicyModifiers PN and PO: Off-Campus Provider-Based Hospital Outpatient
    Policy CodePolicy G-26002
    Change TypeNo material change
    Effective DateFeb 1, 2027
    Next Review DateN/A
    Key ActionReport modifier PN or PO, as applicable, on an outpatient institutional claim for services rendered in an off-campus provider-based department.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    40%Specified outpatient facility reimbursement
    PN and POModifiers addressed
    250 yardsOff-campus distance threshold
    G0463; 99202-99215Codes subject to reduced reimbursement

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    PN and PO Reporting and Reimbursement Criteria

    PN and PO Reporting Criteria

    PN and PO may be reported on the outpatient institutional claim only when all applicable reporting conditions are met and none of the exclusions apply.

    ALL of the following

    • The service is furnished in an off-campus provider-based department (PBD) of a hospital that meets applicable provider-based status requirements and is located more than 250 yards from the main hospital campus or a remote hospital location, as defined by CMS Medicare.
    • The service is reported on an outpatient institutional claim.

    • Use the applicable modifier

      • Modifier PN — non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital; the service does not qualify for CMS Medicare excepted (grandfathered) payment status and is subject to applicable site-neutral payment methodologies.
      • Modifier PO — excepted service provided at an off-campus, outpatient, provider-based department of a hospital; the service qualifies for CMS Medicare excepted (grandfathered) payment status based on applicable CMS Medicare requirements.

    • The service is not furnished in any excluded setting

      • The claim is not a professional claim billed on a CMS-1500 claim form.
      • The service is not furnished in a licensed, dedicated emergency department or critical access hospital (CAH).
      • The facility meets provider-based status requirements and is not a non-provider-based facility.
      • The service is not furnished in an on-campus hospital department.

    Reduced Reimbursement Criteria

    When all applicable conditions below are met, the outpatient facility claim is reimbursed at 40% of the allowable amount.

    ALL of the following

    • The service is furnished in an off-campus, outpatient provider-based department of a hospital and is reported with modifier PN or PO on an outpatient institutional claim billed on a UB-04.

    • The billed service is one of the following

      • HCPCS G0463 — hospital outpatient clinic visit for assessment and management of a patient.
      • CPT 99202-99205 — office or other outpatient evaluation and management visit for a new patient.
      • CPT 99211-99215 — office or other outpatient evaluation and management visit for an established patient.

    Modifiers, Services, and Reimbursement

    Modifier PNModifier
    PNNon-excepted service provided at an off-campus, outpatient, provider-based department of a hospital
    Modifier POModifier
    POExcepted service provided at an off-campus, outpatient, provider-based department of a hospital
    Hospital outpatient clinic visitHCPCSCovered
    G0463Hospital outpatient clinic visits for assessment and management of a patient
    Office or other outpatient E/M visitsCPTCovered
    99202-99205Office or other outpatient visit for the evaluation and management of a new patient
    99211-99215Office or other outpatient visit for the evaluation and management of an established patient
    Reduced outpatient facility reimbursement
    Reimbursement rate40% of the allowable amount
    Applicable servicesHCPCS G0463 and CPT E/M codes 99202-99215
    Claim requirementsBilled on a UB-04 for services provided in an off-campus provider-based department with modifier PN or PO
    Off-campus location distance
    Distance thresholdMore than 250 yards
    Measured fromThe main hospital campus or a remote hospital location
    Definition basisAs defined by CMS Medicare

    Claim Submission and Documentation Requirements

    Billing Rule

    Report PN or PO on the Institutional Claim

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

    • 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.
    Billing Rule

    Apply 40% Facility Reimbursement

    When the qualifying service is billed on a UB-04 for an off-campus PBD and reported with modifier PN or PO, apply the 40% reimbursement rule to the outpatient facility claim. The facility claim is reimbursed at 40% of the allowable amount for the specified services.

    • HCPCS G0463 (hospital outpatient clinic visit for assessment and management).
    • CPT 99202-99215 (new- and established-patient office or other outpatient E/M visits).
    Billing Rule

    Coordinate the Corresponding Professional Claim

    Submit the corresponding professional claim for the specified service on the same date of service as the outpatient institutional claim. For HCPCS G0463 and CPT 99202-99215, the corresponding professional claim must be submitted with Place of Service (POS) 19 for the facility claim to receive reimbursement at 40% of the allowable amount.

    • Applies to HCPCS G0463 and CPT 99202-99215.
    • Use POS 19 on the corresponding professional claim.
    Denial Risk

    Avoid Nonreimbursable Modifier Circumstances

    Do not report modifiers PN or PO when the service or claim falls outside the off-campus PBD circumstances covered by this policy.

    • Do not use PN or PO on professional claims submitted 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.
    Documentation Required

    Support Billed Services

    Use proper billing and submission guidelines and industry-standard, compliant codes for the services performed. Each billed CPT, HCPCS, and/or revenue code must be fully supported by the medical record and/or office notes; noncompliant or unsupported claims may be rejected, denied, recouped, or adjusted.

    • Maintain documentation supporting the billed services and procedures.
    • Ensure services also satisfy applicable authorization, benefit, and medical-necessity requirements.

    Key Location and Payment Status Terms

    Excepted
    Service statusQualifies for CMS Medicare excepted, or grandfathered, payment status
    LocationFurnished in an off-campus provider-based department
    Qualification standardBased on applicable CMS Medicare requirements
    Nonexcepted
    Service statusDoes not qualify for CMS Medicare excepted payment status
    LocationFurnished in an off-campus, outpatient, provider-based department of a hospital
    Payment methodologySubject to applicable site-neutral payment methodologies
    Provider-Based Department
    Department statusA department of a hospital that meets CMS Medicare provider-based requirements
    Billing relationshipBills as part of the hospital
    Certification basisOperates under the hospital's CMS Medicare certification
    Off-Campus Provider-Based Department
    Department statusA provider-based department
    Location thresholdLocated more than 250 yards from the main hospital campus or a remote hospital location
    Definition basisAs defined by CMS Medicare
    Policy Summary
    PayerWellpoint Tennessee Medicaid
    PolicyModifiers PN and PO: Off-Campus Provider-Based Hospital Outpatient
    Policy CodePolicy G-26002
    Change TypeNo material change
    Effective DateFeb 1, 2027
    Next Review DateN/A
    Key ActionReport modifier PN or PO, as applicable, on an outpatient institutional claim for services rendered in an off-campus provider-based department.
    SourceLink
    On This Page
    PN and PO Reporting and Reimbursement CriteriaModifiers, Services, and ReimbursementClaim Submission and Documentation RequirementsKey Location and Payment Status Terms
    A corresponding professional claim is submitted for the same date of service with Place of Service (POS) 19.