Provider-Based Clinics Billing Guidelines

POLICY NUMBER

None

DESCRIPTION

None

POLICY

Provider Based Clinic (PBC) is defined as a free-standing or attached facility clinic that is either owned, operated, leased or controlled by a Network Hospital. A PBC can be located inside the hospital, on the hospital campus or remotely off-campus and may utilize the services of that hospital, including hospital-owned equipment located in the PBC.

Effective July 1, 2016, Blue Cross and Blue Shield of Mississippi (BCBSMS) will implement the following billing guidelines for Provider Based Clinics:

Billing Guidelines

When a patient receives services at a PBC, and the PBC utilizes its Network Hospital to perform certain ancillary services as a result of a PBC visit, those Network Hospital services must be billed by the PBC on a professional claim (ANSI 837P electronic claim -- CMS 1500 equivalent). No claim should be filed by the Network Hospital for these services. For a Network Hospital to bill claims to BCBSMS on an institutional claim (ANSI 837I – UB04 equivalent), the member must have physically received services/treatment at the Network Hospital outside of the PBC.

Effective January 1, 2016, BCBSMS will not accept claims from Network Hospitals for facility overhead charges associated with provider-based clinics. These charges are not separately reimbursable and BCBSMS will not accept institutional (UB04) claims billed with revenue codes 510-525, 527-529 or any successor codes from Network Hospitals.

The Place of Service (POS) on the claim should be filed based on the location where the member physically received services.

• • Use POS “11” for face-to-face services rendered in a PBC located on hospital campus or inside the hospital.

  • Use POS “19” for face-to-face services rendered in a PBC located off-campus.

  • Use POS “11” for services originating at a PBC and sent to the Hospital without the member physically receiving services at the hospital. For example, blood drawn in a PBC and sent to a Lab inside the Hospital for testing.

  • Use POS “22” when the member physically receives services in a Hospital outside of the PBC.

Modifiers

The following HCPCS modifiers may be appended to the applicable CPT and HCPCS codes to identify the items and services furnished in an off-campus provider based clinic/department.

POLICY EXCEPTIONS

None.

POLICY GUIDELINES

The coding guidelines outlined in Coding Policy should not be used in lieu of the Member's specific benefits plan language.

POLICY HISTORY

5/23/2016: Policy added.

12/28/18-Added modifiers PN, PO, and ER to the policy.

SOURCE(S)

Centers for Medicare and Medicaid Services (CMS) Medicare Learning Network Bulletin MM7631

Centers for Medicare and Medicaid Services (CMS) Transmittal 3315

CODE REFERENCE

None