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Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
MA00.037n

Policy

PROFESSIONAL PROVIDERS

When a professional provider who performs a service that is considered by the Company to be an office-based service (e.g., office visit, outpatient consultation, professional interpretation and report) in an office-based setting located within a hospital, a hospital facility campus, hospital affiliate, or hospital or hospital affiliate-owned site, division, or other location (e.g., clinic, treatment room), the professional provider must submit a CMS-1500 claim form or the electronic equivalent 837p for the office-based service. In such cases, the office-based service fee is inclusive of the professional provider service performed, as well as the office-based overhead (i.e., practice expense).

FACILITIES

When a professional provider who performs a service that is considered by the Company to be an office-based service (e.g., office visit, outpatient consultation, professional interpretation and report) in an office-based setting located within a hospital, a hospital facility campus, hospital affiliate, or hospital or hospital affiliate-owned site, division, or other location (e.g., clinic, treatment room), the facility is not eligible to receive reimbursement for the professional provider office-based services (i.e., room charge) and any item or service included in the payment to the professional provider. If a UB04 claim form or the electronic equivalent 837i is received from the facility for the office-based services, reimbursement will not be made to the facility.

The facility is eligible to receive reimbursement for any covered ancillary service (e.g., laboratory test, radiologic study) related to the office visit or consultation according to their contract.
  • Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) products require that the member obtain capitated services at the primary care provider's (PCP's) designated capitated site. Capitated services obtained from providers other than the member's PCP must be pre-approved by the Company.
BILLING SCENARIO

A professional provider (e.g., physician specialist) completes an initial outpatient evaluation and management (E & M) service in their office or clinic that is located within a facility or on a facility campus.
  • Reimbursement to the professional provider for an E & M service includes payment for the E & M services and any costs associated with office-based overhead to the professional provider.
  • The facility is not eligible to receive reimbursement for a facility component for the outpatient E & M service performed by the consulting professional provider because payment to the professional provider is inclusive of the office-based overhead (i.e., practice expense).
REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

For Preferred Provider Organization (PPO) members to receive the highest level of benefits, diagnostic services should always be performed by a participating professional provider. Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) require that the member obtain capitated services at the primary care physician's (PCP's) designated capitated site.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, professional provider services performed in certain outpatient settings are covered under the medical benefits of the Company's Medicare Advantage products.

Description

Professional providers may perform outpatient office-based services (e.g., office visit, outpatient consultation, professional interpretation and report) in a variety of settings. These settings include, but are not limited to:
  • A freestanding office
  • An office or outpatient clinic located within a hospital, on or within a hospital facility campus, hospital affiliate, hospital or hospital affiliate-owned site, division, or other location (e.g., clinic, treatment room)
As used in this policy:
  • Professional provider refers to the professional provider who performs the health care service, as well as to any professional provider in the same provider group practice.
  • Facility refers to a hospital, a hospital facility campus, hospital affiliate, or hospital or hospital affiliate--owned site, division, or other location (e.g., clinic, treatment room).
  • Office-based service refers to office visits, outpatient consultations, minor office procedures, and any related items or services included in the payment of these services.
  • Capitation is the reimbursement that a participating facility, ancillary provider (e.g., freestanding outpatient radiology site), or professional provider receives in advance of services for a Health Maintenance Organization (HMO) member or for a Health Maintenance Organization Point-of-Service (HMO-POS) member who utilizes their referred benefit.

References

Company Hospital Manuals.

Company Provider Manuals.

Coding

CPT Procedure Code Number(s)
See Attachment A.
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
See Attachment A.
Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

1/1/2026
1/6/2026
MA00.037
Claim Payment Policy Bulletin
Medicare Advantage
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No