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Issue Number - Name
0108-Facility vs. Non-Facility Reimbursement
Review Type
Automated
Claim Type
Physician/Non-Physician Practitioner
Region and State
RAC 1-4
All States
Date Approved
09/11/2018

Description

Under the Medicare Physician Fee schedule (MPFS), some procedures have separate rates for physicians’ services when provided in facility and non-facility settings. The rate, facility or non-facility, which a physician service is paid under the MPFS is determined by the place of service (POS) code that is used to identify the setting where the beneficiary received the face-to-face encounter with the physician, non-physician practitioner (NPP) or other supplier. In general, the POS code reflects the actual place where the beneficiary receives the face-to-face service and determines whether the facility or non-facility payment rate is paid.  However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS codes 19 or 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred.

Affected Code(s)

Applicable Policy References

Social Security Act, Section 1833(e)
CMS Pub. 100-04,  Medicare Claims Processing Manual, Chapter 12, Section 20.4.2