Hospital Off-Campus Outpatient Department Reporting Requirements

July 24, 2019

Changes to editing for appropriate reporting of off-campus outpatient department locations will impact all providers. Payment impacts related to this reporting will only impact those providers paid under the Outpatient Prospective Payment System (OPPS).

Hospital OPPS providers are required to include all practice locations on the CMS 855A enrollment form. If a hospital claim is submitted with a service facility location that was not included on the CMS 855A enrollment form OR if the location reported does not exactly match the information from the CMS 855A, it will be returned to the provider with reason code 34977.

The OPPS providers are required to report one of the appropriate modifiers, PN, PO or ER, when reporting an off-campus practice location. Modifier “PN” (Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital) to identify and pay non-excepted items and services billed on an institutional claim. The use of modifier “PN” will trigger a payment rate under the Medicare Physician Fee Schedule (MPFS) on and after January 1, 2017. For a service to be considered non-excepted, it will be performed in an off-campus practice location with an effective date on or after November 2, 2015. Modifier “PO” (Services, procedures and/or surgeries provided at off-campus provider-based outpatient departments) for all excepted items and services billed on an institutional claim. For a service to be considered excepted, it will be performed in an off-campus practice location with an effective date prior to November 2, 2015. Modifier “ER” (Items and services furnished by a provider-based off-campus emergency department) with every claim line for outpatient hospital services furnished in an off-campus provider-based emergency department.

Inappropriate modifier reporting or if a practice location is reported and no modifier is reported, will result in a claim Returning to Provider (RTP) with reason code 34978.

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