POS 19 in Medical Billing: Off-Campus Outpatient Hospital

POS 19 is the two-digit place of service code for an off-campus outpatient hospital department. CMS defines it as a portion of an off-campus hospital provider-based department that provides diagnostic, therapeutic, and rehabilitation services to patients who do not require hospitalization.

Before 2016, all hospital outpatient services used POS 22 (“Outpatient Hospital”). On January 1, 2016, CMS split the code into two categories: POS 22 for on-campus outpatient hospitals and POS 19 for off-campus outpatient hospitals.

CMS introduced the split to better track and reimburse services delivered at hospital-owned provider-based outpatient departments as hospitals acquired more physician practices.

POS 19 is part of the CMS place of service code set, which includes more than 40 active codes. Providers report POS codes on professional claims (CMS-1500), while institutional UB-04 claims use revenue codes and Type of Bill instead.

This guide explains what POS 19 means, when to use it, how it affects reimbursement, and the common billing errors that lead to denials.

When Should You Use POS 19?

Use POS 19 when a physician treats a hospital outpatient at a provider-based site that is more than 250 yards from the main hospital buildings or a remote hospital location. The location must be officially registered as a provider-based department on the hospital’s CMS-855A enrollment form.

Common settings that qualify for POS 19:

• A hospital-owned cardiology clinic in a strip mall a mile from the main hospital
• An orthopedic outpatient department housed in a separate office building
• A satellite primary care office acquired by a health system
• A hospital-owned diagnostic imaging center across town
• A behavioral health outpatient clinic in a different ZIP code from the hospital

Do not use POS 19 in these cases:

• The clinic sits within 250 yards of the main hospital (use POS 22)
• The location is a free-standing physician office not registered as provider-based (use POS 11)
• The patient is admitted as an inpatient (use POS 21)
• The service happens in a dedicated emergency department (use POS 23 with modifier ER)
• The site is an ambulatory surgical center (use POS 24)

CMS instructs physicians to report POS 19 or 22 whenever the patient is registered as a hospital outpatient, even if the face-to-face encounter happens elsewhere. This rule triggers the facility payment rate under the Medicare Physician Fee Schedule (MPFS).

POS 19 vs POS 22: What’s the Difference?

The only difference between POS 19 and POS 22 is the location relative to the main hospital campus. POS 22 covers on-campus outpatient services. POS 19 covers off-campus outpatient services. Both pay at the same facility rate under the MPFS.

CMS measures the 250-yard rule in a straight line from any point of the main hospital building to any point of the outpatient department. Hospitals must keep surveyor reports or similar documentation to prove the measurement.

The big payment story is not between POS 19 and POS 22 themselves. It is between either of these facility codes and POS 11 (office), which pays at the higher non-facility rate.

How Does POS 19 Affect Reimbursement?

POS 19 triggers the facility payment rate under the Medicare Physician Fee Schedule, which is lower than the non-facility office rate used for POS 11. Physicians get less because the hospital, not the physician, pays for the staff, supplies, and overhead at that location.

Each CPT code on the MPFS has two payment values: a facility rate and a non-facility rate. The non-facility rate uses a higher practice expense relative value unit (peRVU) to cover overhead. The facility rate uses a lower peRVU because the facility absorbs those costs.

Section 603 of the Bipartisan Budget Act of 2015 added a second layer of payment rules. Section 603 stops the hospital’s facility claim from getting the higher Outpatient Prospective Payment System (OPPS) rate at off-campus sites that started billing on or after November 2, 2015. These “non-excepted” sites get paid under the MPFS instead. Off-campus sites that were already billing before that date are “excepted” or grandfathered and still get OPPS rates.

Two modifiers track this on the institutional UB-04 claim:

• Modifier PO: Excepted (grandfathered) services at an off-campus provider-based department. Required since January 1, 2016.
• Modifier PN: Non-excepted services at an off-campus provider-based department. Required since January 1, 2017. Triggers MPFS-based payment instead of OPPS.

Note: PO and PN are hospital institutional claim modifiers. They are not appended to the physician’s CMS-1500 professional claim alongside POS 19. The physician simply reports POS 19. The hospital reports the modifier on its facility claim.

Medicaid programs and commercial payers handle POS 19 differently. Many commercial plans pay POS 19 the same as POS 22. Some state Medicaid programs follow Medicare’s site-neutral logic. Always check the specific payer policy.

Who Is Eligible to Bill POS 19?

Only hospitals with a CMS-approved provider-based status for the specific location can bill POS 19. The site must meet the provider-based requirements in 42 CFR 413.65, including operating under the same license as the main hospital, sharing the same medical director reporting structure, and being held out to the public as part of the hospital.

To qualify a location for POS 19, hospitals must:

• Register the off-campus address on the CMS-855A hospital enrollment form
• Get the address verified in the Provider Enrollment Chain and Ownership System (PECOS)
• Make sure the claim service facility address matches PECOS exactly, character for character
• Track which sites are excepted (pre-November 2, 2015) and which are non-excepted

Documentation that supports POS 19 includes the provider-based attestation letter, CMS approval, the PECOS service location, the date of service, and the original date the location began billing under the hospital.

What Happens When POS 19 Is Coded Incorrectly?

Wrong POS 19 coding causes denials, payment recoupments, and audit exposure under the False Claims Act. The most common error is using POS 11 (office) for an off-campus hospital-owned clinic, which overpays the physician and underpays no one but still creates a compliance problem.

Real denial scenarios:

• The hospital’s institutional claim has POS 19 but no PO or PN modifier. Noridian’s edit 34978 returns the claim to the provider.
• The service facility address on the claim does not match the PECOS file by even one character (Rd vs Road, Ste vs Suite). Noridian edit 34977 returns the claim.
• A non-excepted site fails to add the modifier PN. Noridian edit 34986 returns the claim.

The Office of Inspector General has flagged POS misuse as a top audit target for years. Recovery Audit Contractors actively review claims where the POS code does not match the actual service location. When errors are found, Medicare can recoup payments, often with interest, and can refer repeated patterns for further investigation.

Real-world example: same procedure, two POS codes, two outcomes.

A primary care doctor performs CPT 99214 (established patient office visit, moderate complexity) at a hospital-owned clinic five miles from the main hospital.

• Scenario A: Biller uses POS 11. Medicare pays the higher non-facility rate. The hospital also bills a separate facility fee. Medicare overpays. On audit, the carrier recoups the difference between the non-facility and facility rate from the physician.
• Scenario B: Biller uses POS 19. Medicare pays the lower facility rate. The hospital correctly bills its facility fee with the right modifier. Total payment is split correctly between the physician and the hospital. No audit risk.

The dollar gap on a single 99214 visit is small, but multiplied across thousands of visits per year, the recoupment can run into hundreds of thousands of dollars.

POS 19 in Practice: Billing Examples

Example 1: E/M visit at an off-campus hospital clinic

Dr. Patel sees an established Medicare patient for hypertension follow-up at Memorial Hospital’s off-campus internal medicine clinic, located four miles from the main hospital.

• Physician CMS-1500: CPT 99213, POS 19, diagnosis I10 (essential hypertension)
• Hospital UB-04: Facility fee with modifier PN (the clinic opened in 2019, so it is non-excepted)
• Result: Physician paid at facility rate. Hospital paid under MPFS-based site-neutral rate.

Example 2: Minor procedure at a satellite outpatient department

Dr. Kim removes a benign skin lesion at a hospital-owned dermatology clinic across the city from the main hospital.

• Physician CMS-1500: CPT 11402 (excision benign lesion 1.1 to 2.0 cm), POS 19
• Hospital UB-04: Facility fee with modifier PO (the clinic was billing in 2014, making it excepted)
• Result: Physician paid at facility rate. Hospital paid at full OPPS rate because the clinic is grandfathered.

Example 3: When to switch from POS 19 to POS 22 (and vice versa)

A health system runs two cardiology clinics. Clinic A is in a medical office building 80 yards from the main hospital. Clinic B is in a strip mall 1.2 miles away.

• Cardiology visit at Clinic A: POS 22 (within 250 yards)
• Same cardiology visit at Clinic B: POS 19 (more than 250 yards)
• If Clinic B relocates to the medical office building next to the main hospital, the code changes to POS 22 going forward, but the relocation may also kill the OPPS-excepted status under Section 603 unless an extraordinary-circumstances exception applies.

How to Stay Compliant When Billing POS 19

Compliance starts at registration and ends at the audit log. The front desk, the coder, and the biller all need the same information about each location.

A pre-billing checklist for POS 19:

1. Confirm the address on the CMS-855A and in PECOS
2. Verify the location is more than 250 yards from the main hospital and any remote hospital location
3. Check whether the site is excepted (pre-November 2, 2015) or non-excepted
4. Match the claim’s service facility address to PECOS character for character
5. On the institutional claim, append modifier PO for excepted sites and PN for non-excepted sites
6. On the professional claim, report POS 19 in Box 24B
7. Make sure the EHR does not default to POS 11 for hospital-owned clinics

Audit your POS 19 claims at least quarterly. Pull a random sample of 25 claims per location, verify the POS matches the rendering site, and confirm modifier use on the matching UB-04 claims. Train front-desk staff to flag location changes immediately, since a relocation can cancel excepted status.

POS 19 vs Other Common POS Codes

POS 19 only fits one specific scenario: a registered hospital outpatient at an off-campus provider-based department. Picking between POS 19 and other POS codes comes down to who owns the site, where the site sits, and whether the patient is registered as a hospital outpatient.

Final Words

POS 19 looks like a small two-digit code, but it controls how Medicare splits payment between the physician and the hospital, and it tells auditors whether your facility setup is what you say it is. Picking the right code protects revenue on both sides of the claim and keeps the practice clear of False Claims Act exposure.

If you bill any off-campus hospital outpatient services, run a quick audit this week. Pull 20 claims, check that POS 19 matches the actual service location, confirm the address ties to PECOS, and verify the matching hospital claim carried PO or PN. Fix the EHR defaults that push staff toward POS 11 by accident. The work takes a few hours. The downside of skipping it can run into six figures.