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Hospital off-campus 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.

On August 1, 2023, systematic validation edits were set to enforce requirements in the Medicare Claims Processing Manual, Pub. 100-04, Chapter 1, section 170, for hospitals with multiple locations to include off-campus provider-based departments. 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 OPPS. 

Providers should ensure that their enrollment information is up to date, and any claim submissions reflect the practice locations exactly as it appears from the practice location address screen which is received from PECOS and viewed in Fiscal Intermediary Shared System (FISS) under Short Cut 1D provider practice address. Additionally, providers should ensure that the practice locations are linked to the NPI that is being reported on the claim submission. Requirements for correct provider practice location reporting was effective back in 2017, however, systematic edits were not put in place at that time.

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 an off-campus, outpatient, provider-based department of a hospital are paid under the MPFS and not the OPPS rates.

The following reason codes are set up to return to provider (RTP):

  • 34977 - A hospital claim is submitted with a service facility location that was not included in PECOS or on the CMS 855A enrollment form or the location reported does not exactly match the information from PECOS or the CMS 855A.
  • 34978 - OPPS providers are required to report one of the appropriate modifiers, PN, PO or ER, when reporting an off-campus practice location.
  • 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.
    • If the address reported was effective prior to November 2, 2015, modifier PO needs to be reported.
  • 34986 - Modifier PN is not present on the claim, and a practice location is reported that has a practice effective date on/after November 2, 2015.
    • If the address reported was effective after November 2, 2015, modifier PN needs to be reported.                         
  • 34987 - Condition code A7 is present on the claim and the location reported is not a mobile facility and/or portable units.
    • Only report CC A7 if the practice location is a mobile facility or portable unit.
  • If the practice location is not a mobile facility or portable unit, do not report CC A7.

Reason code 31131 (Practice location file error) has been created to suspend a claim until the provider enrollment file has been corrected.

  • Provider enrollment will send a development request to the provider to determine what type of offsite practice location is reported.
  • Provider needs to ensure all provider practice locations are reported in PECOS or on the CMS 855A enrollment form. 

Providers can make corrections to their service facility address for a claim submitted and editing reveals the claim has typographical errors that do not match the official postal address in PECOS and in the DDE MAP 171F screen for DDE submitters. If you need to add a new practice location that has not been enrolled or correct an existing practice location address that is changed since initial enrollment, you will still need to submit a new 855A enrollment application in PECOS by using PECOS or by paper application and submitting using the Provider Enrollment Gateway or mail.

Non-OPPS providers

Non-OPPS providers include Maryland (MD) waiver and Indian Health Service (IHS) providers. 

Hospital 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 RTP with reason code 34977. 

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 have to ensure the off-campus location is reported correctly. 

OPPS providers

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.
    • 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 MPFS on and after January 1, 2017.
  • Modifier PO - Services, procedures and/or surgeries provided at off-campus provider-based outpatient departments.
    • 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 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 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.

  • For electronic claims, report in the 2310E loop of the 837 institutional claim transaction.
  • For DDE/FISS, report in MAP171F:
    • Claim page 3 extended, press F11 two times.
    • For paper submitters on the UB-04, report in Form Locator (FL) 01.

Practice location review available in direct data entry (DDE)

In April 2019, the practice location screen became available in DDE: Provider Practice Address Query- Option 1D. Providers with outpatient practice locations may use this screen to verify the information available for the FISS to edit against. For OPPS providers, this screen will also provide the practice effective date in the field “PRAC EFF DT.” This will assist with appropriate modifier reporting as described in the OPPS section above. 

When an address is reported in the practice location segment of a claim, FISS will compare the reported address to the Provider Practice Address Query screen from the following fields: 

  • ADDRESS 1
  • ADDRESS 2
  • CITY
  • STATE
  • ZIP

The information reported on the claim as the practice location must match, word for word, including abbreviations and punctuation, to the information that is in the Provider Practice Address Query screen. 

  • For example: Road vs. Rd, Suite vs. Ste., etc.
  • Include special characters if listed in the address. For example, &, (),+, *, -, etc. 

Example 1:

An address in the practice address screen shows as:
ADDRESS 1: 123 Apple St. #34
ADDRESS 2: 
CITY: Nowheretown STATE: JD ZIP: 12345-1234

In order to not receive reason code 34977 for invalid location, on the claim submission, the word street must be abbreviated as it appears on the screen as “St.” with the appropriate punctuation. The “#34” must also appear in the address 1 field, it cannot be moved to the address 2 line. Address 2 line must remain blank. The ZIP code must be reported with the full five digits plus the additional four exactly as they appear. If any element does not exactly match, the system will not be able to match the exact address and the claim will RTP for reason code 34977. 

Example 2:

An address in the practice address screen shows as:
ADDRESS 1: Going Rd Suite 2C
ADDRESS 2: Clinic of Clinics
CITY: Townstown STATE: JD ZIP:98765-5432

In order to not receive reason code 34977 for invalid location on the claim submission, the practice location information must be filled in with ALL elements of this address. The Address 1 line must be abbreviated as it appears with no punctuation in this example. The Address 2 line must include the name listed under the Address 2 line, “Clinic of Clinics.” The FISS system will automatically capitalize all letters, so capitalization is not something that will cause a claim to receive reason code 34977. 

Complete information about the Provider Practice Address Query screen is available in the reference section below within the DDE manual link. 

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 receive reason code 34977. Complete information about appropriate location reporting is available in the CMS Special Edition (SE) articles listed in the reference section below.

Providers who need to add a new or correct an existing practice location address will need to submit a new 855A enrollment application by using PECOS or by paper application and submitting using the Provider Enrollment Gateway or mail. For more information, review the article Hospital off-campus outpatient enrollment requirements or visit the Enrollment webpage.

 

References