Site of Care

Key facts

Professional claim field

Place of service (POS) code, maintained by CMS

Common POS codes

11 office, 12 home, 19 and 22 outpatient hospital, 21 inpatient hospital, 24 ASC

Institutional claim field

Type of bill, such as 11x for inpatient and 13x for hospital outpatient

Site-neutral statute

Section 603 of the Bipartisan Budget Act of 2015

What is site of care?

Many services can be delivered in more than one setting. A biologic infusion can take place in a hospital outpatient department, an independent infusion center, a physician office or at home. A knee replacement can be performed as an inpatient procedure, a hospital outpatient procedure or in an ambulatory surgery center. Site of care describes which of these settings was used.

Claims record the site. Professional claims carry a two-digit place of service code, and institutional claims carry a type of bill code that distinguishes inpatient, outpatient, skilled nursing and other facility services.

How payment differs by site of care

Medicare and commercial payers pay each setting under different rules:

• Inpatient hospital: a bundled payment per stay, under the Inpatient Prospective Payment System in Medicare.
• Hospital outpatient department: a facility fee under the Outpatient Prospective Payment System, plus a separate physician fee.
• Ambulatory surgery center: a facility fee generally lower than the hospital outpatient rate, plus the physician fee.
• Physician office: a single Physician Fee Schedule payment that includes practice expenses, often the lowest total cost.
• Home: payment through home health, home infusion or pharmacy benefits, depending on the service.

Why site of care matters

Commercial payers increasingly use site-of-care policies that require eligible patients to receive specialty infusions or elective procedures in lower-cost settings. Site-neutral payment pushes in the same direction: Congress applied it to newer off-campus hospital outpatient departments in 2015, CMS extended it to clinic visits at older off-campus departments starting in 2019, and further expansion remains under debate.

• Market access teams track where infused and injected drugs are administered, because site shifts change buy-and-bill economics, 340B exposure and patient cost sharing.
• Medtech and surgery center strategy teams follow procedure migration from inpatient to outpatient and ASC settings as CMS expands the ASC Covered Procedures List.
• Price comparisons are only valid within the same site of care, since the same billing code can pay substantially more in one setting than another.
• Payer benefit teams design tiered cost sharing that rewards patients for choosing lower-cost sites.