Off-Campus Hospital Outpatient Department Reporting Requirements

Increasingly, hospitals operate an off-campus, outpatient, provider-based department of a hospital. In some cases, these additional locations are in a different payment locality than the main provider. For Medicare Physician Fee Schedule (MPFS) and outpatient prospective payment system (OPPS) payments to be accurate, CMS uses the service facility address of the off-campus, outpatient, provider-based department of a hospital facility to determine the locality in these cases.

Under Section 1833(t)(21) of the Social Security Act, providers must identify non-excepted services at an off-campus, outpatient, provider-based department of a hospital. Non-excepted services provided at these locations of a hospital are paid under the MPFS rates, not the OPPS.

Validation Edits

On August 1, 2023, systematic validation edits were set within Noridian jurisdictions E and F to enforce requirements for hospitals with multiple locations to include off-campus provider-based departments. Changes to editing for appropriate reporting of off-campus outpatient department locations impact all providers. Payment amounts related to this reporting will only impact those providers paid under the OPPS.

The requirements by CMS for the correct reporting have been in place since 2017, however, they had not been enforced until the activation of edits. There are six edits that Noridian activated. These require the exact, correct reporting on the claim of (1) the practice location address where the service was performed; and (2) whether the service was excepted (grandfathered) or non-excepted from payment on the MPFS, or if it was performed in a provider-based, off-campus, dedicated emergency department.

These edits are set to Return-To-Provider (RTP), and are as follows:

34977 - Claim service facility address does not exactly match the provider practice file address.
34978 - Off-campus provider claim line containing a HCPCS is missing either a PN, PO, or ER modifier.
34984 - Modifier ER is not present on the claim and practice location reported is a dedicated emergency department (ED).
34985 - Modifier PO is not present on the claim and a practice location is reported that has an effective date on or before 11/1/2015. Refer to SE18002.
34986 - Modifier PN is not present on the claim and a practice location is reported that has a practice effective date on or after 11/2/15. Refer to SE18002.
34987 - Condition code A7 is present on the claim and the location reported is not a Mobile Facility and/or Portable Units.

Enrollment Information

Hospital providers are required to include all practice locations on the CMS 855A enrollment. If a hospital claim is submitted with a service facility location not included, or if the location reported does not exactly match the information, it will RTP with reason code 34977. When edits reveal errors between the enrollment and claim addresses, providers can correct the service facility address on the claim to match the official postal address in PECOS, using the MAP171F screen for DDE submitters.

Providers should ensure that their enrollment information is up to date, and that it is USPS verified. Also, ensure that claim submissions reflect the practice location exactly as it appears from the practice location address screen in PECOS and viewed in the DDE under Option 1D - Provider Practice Address Query. Additionally, providers should ensure that the practice locations are linked to the NPI that is being reported on the claim submission. If the NPI is not linked, the enrollment record will need to be updated. Requirements for correct provider practice location reporting began in 2017, however, systematic edits were not put in place at that time.

Providers who need to add a new (or correct an existing) practice location address will need to submit an 855A (change of information) application either by hardcopy or using the online PECOS system. For more information, visit Noridian’s Provider Enrollment Website.

Non-OPPS Providers

Non-OPPS hospital provider types include Maryland Waiver hospitals, Indian Health Service (IHS), Critical Access Hospital (CAH), Outpatient Rehabilitation Facility (ORF), Comprehensive Outpatient Rehabilitation Facility (CORF), Skilled Nursing Facility (SNF), End Stage Renal Disease (ESRD) Facility, and Home Health Agency (HHA). These provider types are not bound by the modifier billing requirements.

Non-OPPS providers are exempt from reporting the modifiers PN, PO, or ER, as payments will not change due to off-campus practice locations. Non-OPPS providers only must ensure the off-campus location is reported correctly.

OPPS Providers: Billing Requirements

OPPS providers are required to report one of the appropriate modifiers, PN, PO or ER, when reporting an off-campus practice location.

Modifier PO: Services, procedures and/or surgeries provided at off-campus provider-based outpatient departments. This is used 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 PN: Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital. Used to identify and pay non-excepted items and services billed on an institutional claim.
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. The use of modifier PN will trigger a payment rate under the Medicare Physician Fee Schedule (MPFS).

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 reporting a practice location without a modifier) will result in a claim RTP with reason code 34978.

Reporting the Provider Practice Location

Providers will report the service facility location for an off-campus, outpatient, provider-based department of a hospital as follows on the claim ensuring it is an exact match to what is in PECOS. This includes abbreviations, special characters, punctuation, spaces, and 5- or 9-digit ZIP code. Failure on these elements will result in RTP reason code 34977.

For electronic claims, report using the 2310E loop of the 837 institutional claim transaction.
For DDE, report in MAP171F: To extend Claim Page 3, press F11 twice.
For paper submissions on the UB-04, report this information in Form Locator (FL) 01.

When all the services rendered on the claim are from the billing provider address (main campus location), providers are to report the billing provider address only in the billing provider information. No practice facility location should be submitted, or the claim will RTP with reason code 34977. Complete information about appropriate location reporting is available in the CMS Special Edition (SE) articles listed in the Reference section below.

References

Last Updated Apr 03 , 2024