Georgia Medicare Place of Service Rules 2026 Guide

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By Brevy Care Team · Last verified May 13, 2026

If you are a Georgia Medicare beneficiary and you have ever noticed that an office visit at a hospital-owned outpatient clinic costs more (both for Medicare and for you in coinsurance) than the same visit at a freestanding physician practice, you are not imagining things. You are running into the Medicare place-of-service rules. Under Section 1833(a)(1)(N) of the Social Security Act and the implementing methodology in the Physician Fee Schedule, Medicare pays physicians two different rates for the same CPT code depending on whether the service is rendered in a "facility" or "non-facility" setting. The facility rate is lower because the facility separately bills Medicare for its overhead component. The non-facility rate is higher because the physician's office bears all the overhead.

For decades, this differential created a powerful financial incentive for hospitals to acquire physician practices and convert them to hospital outpatient departments. The hospital would receive both the (reduced) physician facility payment AND a separate Hospital Outpatient Prospective Payment System (OPPS) payment for the facility component, for a combined Medicare expenditure that often ran 2 to 3 times the freestanding-office equivalent. Patients paid more in coinsurance. Medicare paid more in total. Congress eventually responded with Section 603 of the Bipartisan Budget Act of 2015 (Public Law 114-74), which reduced OPPS payments for non-excepted off-campus provider-based departments to 40 percent of the OPPS rate effective January 1, 2017. The implementing regulation at 42 CFR 419.48 and the underlying provider-based status determination criteria at 42 CFR 413.65 set out the framework.

This guide is for Georgia hospital systems, physician practices, billing managers, compliance officers, and the Medicare beneficiaries they serve. We walk through Section 1833(a)(1)(N), the facility vs non-facility PE RVU methodology, the full HIPAA Place of Service code set (POS 11 office, POS 22 on-campus HOPD, POS 19 off-campus PBD, POS 21 inpatient, POS 31 SNF, POS 12 home, POS 02 and POS 10 telehealth, and dozens more), the Section 603 BBA 2015 framework and its 40 percent OPPS reduction, the "excepted" status criteria, the 42 CFR 413.65 provider-based determination, the No Surprises Act provider notice requirements, the anti-markup payment limitation at 42 CFR 414.50, the patient cost-sharing implications, and the audit activity at Palmetto GBA Jurisdiction J. We also cover the American Hospital Association v Azar litigation and how it shaped the current framework. :::

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Key takeaways for Georgia hospitals, practices, and beneficiaries

1. Place of service is a single data element with enormous payment implications. The POS code on a Medicare claim triggers different reimbursement rates, different billing structures, and different patient cost-sharing.

2. The Physician Fee Schedule has two PE RVUs. Non-facility PE RVU (higher) applies in office settings. Facility PE RVU (lower) applies in hospital and facility settings, where the facility separately bills for the facility component.

3. Hospital outpatient setting costs more overall. At POS 11 (office), Medicare pays a single non-facility physician fee. At POS 22 (on-campus HOPD), Medicare pays both a lower facility physician fee and a separate OPPS facility component — making combined Medicare expenditure substantially higher than in the office setting.

4. Section 603 of the Bipartisan Budget Act of 2015 reduced site-of-service arbitrage. Non-excepted off-campus provider-based departments now receive a site-specific reduced rate instead of the full OPPS rate, effective January 1, 2017.

5. "Excepted" status preserves full OPPS for grandfathered PBDs. Departments billing as PBDs as of November 1, 2015, or that meet specific transitional criteria, retain full OPPS payment.

6. 42 CFR 413.65 defines provider-based status. A clinic or department must meet common ownership, common management, operational integration, and signage/branding requirements to be billed as a hospital outpatient department.

7. The HIPAA Place of Service Code Set has 81+ codes. Major codes include POS 11 (office), POS 12 (home), POS 21 (inpatient hospital), POS 22 (on-campus HOPD), POS 19 (off-campus PBD), POS 31 (SNF), POS 24 (ASC), and POS 02 and POS 10 for telehealth.

8. Telehealth has two POS codes since 2022. POS 02 (telehealth, patient not at home) is treated as facility. POS 10 (telehealth, patient at home) is treated as non-facility.

9. Patient cost-sharing is higher in hospital outpatient. Beneficiaries pay separate coinsurance on both the physician component and the OPPS facility component, often totaling more than office-setting cost-sharing.

10. Palmetto GBA Jurisdiction J audits site-of-service coding. Improper POS reporting can result in claim denials, takebacks, and overpayment recoupment. :::

The statute: Section 1833(a)(1)(N) and the site-of-service differential

Section 1833(a)(1) of the Social Security Act establishes how Medicare pays for Part B services. Paragraph (N) specifically authorizes the site-of-service payment differential. The statutory text directs the Secretary to adjust payments to recognize that the practice expense component of a service is different depending on whether the service is rendered in a facility (where the facility bears its own overhead) versus a non-facility (where the physician's office bears all overhead).

The practical implementation is the two-tier Practice Expense RVU structure in the Physician Fee Schedule. For each CPT code, CMS publishes a non-facility PE RVU and a facility PE RVU. The non-facility PE RVU is almost always higher because the physician's office bears full overhead. The facility PE RVU is lower because the facility component is reimbursed separately.

The total RVU for a service is Work RVU + PE RVU + Malpractice RVU. The facility vs non-facility differential is entirely in the PE RVU.

Example: CPT 99213 (established patient office visit, level 3 E/M)

For 99213, the non-facility PE RVU is substantially higher than the facility PE RVU. When total RVUs are multiplied by the PFS conversion factor and adjusted for metro Atlanta's GPCI, the non-facility allowed amount is meaningfully higher than the facility allowed amount — illustrating how the same visit reimburses differently based on site of service.

The differential exists for every CPT code with a facility component. For many procedures (cardiac catheterization, endoscopy, joint injections, etc.) the differential is much larger because the office-based version bears substantial equipment and supply costs.

The HIPAA Place of Service code set

The Place of Service code set is maintained by CMS and used on all HIPAA-compliant claims (Medicare, Medicaid, and most commercial payers). The current set has over 80 codes. Major categories for Medicare:

Office and clinic codes

• POS 11 (Office): Freestanding physician office. Non-facility PE RVU.
• POS 49 (Independent Clinic): Non-hospital clinic. Treated as facility.
• POS 50 (FQHC): Federally Qualified Health Center. Billed under FQHC PPS.
• POS 71 (Public Health Clinic): Government public health clinic.
• POS 72 (Rural Health Clinic): Billed under RHC AIR rate.

Hospital and facility codes

• POS 21 (Inpatient Hospital): Acute care inpatient. Billed under IPPS (DRG-based).
• POS 22 (On-Campus Outpatient Hospital): Hospital outpatient department on the main hospital campus. Facility PE RVU + full OPPS.
• POS 19 (Off-Campus Outpatient Hospital): Hospital outpatient department not on the main hospital campus. Facility PE RVU + OPPS (full if excepted, 40 percent if not).
• POS 23 (Emergency Room - Hospital): ED setting. Facility PE RVU + OPPS.
• POS 51 (Inpatient Psychiatric Facility): IPF PPS.
• POS 52 (Psychiatric Facility Partial Hospitalization): OPPS partial hospitalization.
• POS 53 (Community Mental Health Center): CMHC OPPS.
• POS 61 (Comprehensive Inpatient Rehabilitation Facility): IRF PPS.

Surgical center codes

• POS 24 (Ambulatory Surgical Center): ASC payment system under Section 1833(i).
• POS 25 (Birthing Center): Specialized.

Post-acute care codes

• POS 31 (Skilled Nursing Facility): SNF PPS for Part A bundled stays.
• POS 32 (Nursing Facility): Long-term care (Medicaid-funded primarily).
• POS 33 (Custodial Care Facility): Custodial care setting.
• POS 34 (Hospice): Hospice PPS.

Community-based codes

• POS 12 (Home): Patient's home. Non-facility PE RVU.
• POS 13 (Assisted Living Facility): ALF setting.
• POS 14 (Group Home): Group residential.

Telehealth codes

• POS 02 (Telehealth Provided Other Than in Patient's Home): Distant-site provider, patient at clinic or other non-home location. Facility PE RVU.
• POS 10 (Telehealth Provided in Patient's Home): New code effective January 1, 2022. Patient at home. Non-facility PE RVU.

Diagnostic and ancillary codes

• POS 81 (Independent Laboratory): Standalone lab. CLFS payment.
• POS 65 (End-Stage Renal Disease Treatment Facility): ESRD PPS.

Other codes

• POS 04 (Homeless Shelter)
• POS 09 (Prison)
• POS 26 (Military Treatment Facility)
• POS 41 and 42 (Ambulance): Ambulance fee schedule.
• POS 99 (Other): Catch-all.

The full POS code set is published by CMS at cms.gov.

Section 603 of the Bipartisan Budget Act of 2015

The story of Section 603 is one of the more dramatic federal healthcare policy fights of the past decade. Throughout the 2000s and early 2010s, hospital systems across the country (including all the major Georgia systems) acquired physician practices at an accelerating pace. The financial logic was clear: convert the acquired practice to a provider-based clinic (PBC) status under 42 CFR 413.65, bill the physician services at the facility PFS rate, and bill the OPPS facility component on top. Total Medicare expenditure increased substantially for the same clinical service.

By 2015, the Medicare Payment Advisory Commission (MedPAC) had been documenting the trend for years and had recommended Congressional action. The Congressional Budget Office estimated significant savings from site-neutral payment. Section 603 was the legislative response.

Statutory text

Section 603(a) of Public Law 114-74 (signed November 2, 2015) amended Section 1833(t) of the Social Security Act to provide that:

• Items and services furnished in an off-campus provider-based department that was billing as a PBD on November 1, 2015, continue to be paid at the full OPPS rate (these are "excepted" PBDs)
• Items and services furnished in a non-excepted off-campus PBD (i.e., one that began billing as a PBD after November 1, 2015) are paid at a "site-specific PFS rate" rather than the OPPS rate

Implementation: 42 CFR 419.48

CMS implemented Section 603 through 42 CFR 419.48 and the CY 2017 OPPS final rule (CMS-1656-FC). The "site-specific PFS rate" was set significantly below the full OPPS rate and has been refined through subsequent rulemaking.

Excepted PBD criteria

A PBD is excepted (entitled to full OPPS) if:

1. It was billing as a PBD before November 1, 2015 (the original cutoff); OR
2. It was "mid-build" as of November 2, 2015 with a binding written agreement; OR
3. It is a dedicated emergency department (EDs are excepted regardless of when established).

A PBD loses excepted status if it:

1. Relocates to a different address (with limited exceptions for natural disasters and similar);
2. Changes ownership in certain ways;
3. Adds a new service line (a separate question with substantial regulatory complexity).

Litigation and refinements

The American Hospital Association and several hospitals challenged various CMS implementation decisions. The DC Circuit ruled on aspects of the case in 2020. CMS adjusted the methodology in response. Various clinical visit codes (notably G0463 for hospital outpatient clinic visit) have been subjected to site-neutral payments more broadly.

Practical effect for Georgia hospitals

Every major Georgia health system has a mixed portfolio of excepted and non-excepted PBDs. Practices acquired before November 2015 generally retain full OPPS. Practices acquired or established after November 2015 generally face the 40 percent rate. Many systems have restructured their off-campus footprint to minimize Section 603 exposure.

42 CFR 413.65: provider-based status determination

The threshold question for hospital outpatient billing is whether a facility qualifies as a "department" of the hospital. 42 CFR 413.65 sets out the criteria. To qualify as provider-based:

1. Same campus or within 250 yards: Or "off-campus" status, with more stringent operational integration requirements.

2. Common ownership: The hospital and the department must have common ownership.

3. Common management: The department is operated under the hospital's overall governance and management.

4. Public awareness: Patients and the public must perceive the department as a department of the hospital. Signage, branding, and patient communications must reflect this.

5. Clinical integration: The department is clinically integrated with the main hospital (shared protocols, shared medical records, integrated quality programs).

6. Financial integration: Costs and revenues are integrated through the hospital's accounting system.

7. Provider-based attestation: The hospital files an attestation with CMS through the Medicare Administrative Contractor confirming the department meets provider-based requirements.

A facility that fails to meet 42 CFR 413.65 cannot be billed as a hospital outpatient department. It must be billed as a freestanding office (POS 11), with the physician services at the non-facility PFS rate and no separate facility component.

The patient cost-sharing differential

Medicare beneficiaries pay 20 percent coinsurance on Part B services after the annual deductible ($283 in 2026). The site of service affects how this works.

POS 11 (office) cost-sharing

• 20 percent of non-facility PFS rate
• Example: 99213 at $87 → patient owes ~$17.40

POS 22 (on-campus HOPD) cost-sharing

• 20 percent of facility PFS rate (the physician component)
• PLUS 20 percent of OPPS APC rate (the facility component)
• The combined patient coinsurance at HOPD is substantially higher than at office, because both the physician and facility components carry separate 20 percent coinsurance obligations

For chronic-condition patients with multiple visits per year, the differential adds up. A patient with five quarterly cardiology visits at an HOPD versus a freestanding cardiology office could pay $300 more per year in coinsurance for the same clinical care.

This was one of the major Congressional motivations for Section 603. The hospital outpatient setting was producing higher Medicare expenditure AND higher patient cost-sharing for clinically equivalent services.

Telehealth POS codes and the 2022 changes

Before 2022, telehealth services were typically billed under POS 02 regardless of where the patient was located. Effective January 1, 2022, CMS adopted POS 10 for telehealth services where the patient is at home.

POS 02 (Telehealth - Other than Patient Home)

• Patient at clinic, originating site facility, or other non-home location
• Facility PE RVU applies
• Originating site may bill facility fee

POS 10 (Telehealth - Patient's Home)

• Patient at home
• Non-facility PE RVU applies (higher payment to distant-site provider because distant site bears overhead)
• No originating site facility fee

The distinction matters financially. A telehealth visit billed at POS 10 reimburses the distant-site provider at the higher non-facility PFS rate. Compared to POS 02, the differential can be $20-50 per visit depending on CPT code.

Post-PHE telehealth coverage continues to evolve. The Consolidated Appropriations Act 2023 and subsequent rulemaking have extended various flexibilities. The current expectation in May 2026 is that telehealth flexibilities continue for behavioral health (permanent) and for other services through CY 2025/2026 (depending on the specific extension).

The anti-markup rule at 42 CFR 414.50

When a physician practice "purchases" a diagnostic test (i.e., contracts with an outside lab or imaging center to perform the test and bills it under the practice's name), the anti-markup rule limits the practice's reimbursement to the lesser of:

1. The practice's actual charge
2. The supplier's net charge to the practice
3. The PFS amount

The rule prevents practices from buying tests cheaply and billing Medicare at a higher rate. It interacts with place of service in that the technical component of certain diagnostic tests is reimbursed differently based on POS.

No Surprises Act provider notice requirements

The No Surprises Act, enacted as part of the Consolidated Appropriations Act 2021, included provisions at 45 CFR 149.430 requiring providers to give patients notice and obtain consent before delivering services at out-of-network facilities. For Medicare beneficiaries, NSA has limited direct application (Medicare has its own balance billing limits), but the framework has changed how hospitals communicate site-of-service to patients.

Hospitals affiliated with all major Georgia systems have updated their patient registration materials to reflect site-of-service implications for non-Medicare patients. For Medicare beneficiaries, the cost-sharing differential discussed above is the relevant issue.

Six worked examples for Georgia practices and beneficiaries

Example 1: Emory cardiology office vs Emory University Hospital outpatient cardiology

Mrs. Johnson, age 70, has heart failure. She has two cardiology follow-up visit options:

Option A: Emory Cardiology Buckhead office (POS 11)

• 99214 reimbursement: ~$130 (non-facility PFS)
• Patient coinsurance: ~$26
• Total Medicare expenditure: ~$130

Option B: Emory University Hospital Outpatient Cardiology (POS 22)

• 99214 physician reimbursement: ~$96 (facility PFS)
• OPPS APC reimbursement to hospital: ~$130
• Patient coinsurance: ~$19 (physician) + ~$26 (hospital) = ~$45
• Total Medicare expenditure: ~$226

Mrs. Johnson pays approximately $19 more in coinsurance per visit at the HOPD option. Medicare pays approximately $96 more. Across four annual cardiology visits, the difference is $76 in Mrs. Johnson's out-of-pocket and $384 in Medicare expenditure.

Example 2: Wellstar 2014 grandfathered PBD vs 2018 acquisition

Wellstar acquired Atlanta Cardiology Group's Marietta office in March 2014. The Marietta office became a provider-based clinic of Wellstar Kennestone Hospital. Section 603 was not yet law. The PBC billed at full OPPS for the facility component.

In August 2018, Wellstar acquired North Atlanta Cardiology's Roswell office. This was after the November 1, 2015 cutoff. The Roswell PBC is non-excepted. Section 603 applies: OPPS facility component is reduced to 40 percent.

For the same 99214 visit:

• Marietta (excepted): ~$96 physician + ~$130 OPPS = ~$226
• Roswell (non-excepted): ~$96 physician + ~$52 OPPS (40% of $130) = ~$148

Wellstar makes substantially less per visit at the Roswell office than at the Marietta office despite providing the same clinical service. This is the Section 603 effect.

Example 3: Piedmont on-campus vs off-campus PBD

Piedmont Atlanta Hospital operates an on-campus outpatient clinic (POS 22) and several off-campus PBDs (POS 19). The on-campus clinic bills at full OPPS regardless of when established. The off-campus PBDs face Section 603 unless excepted.

This is why hospitals often try to keep clinics on-campus when possible: full OPPS preserved.

Example 4: Solo internist Macon POS 11 only

Dr. Williams, a solo internist in Macon, operates a freestanding office. All services billed at POS 11. Non-facility PFS rates throughout. No OPPS billing because no hospital affiliation. No Section 603 issues because no provider-based status. Simple, clean billing.

Example 5: Emory at Home POS 12

Emory at Home is a home-based program for medically complex Medicare patients. Physicians and NPs visit patients at home. Services billed at POS 12 (Home). Non-facility PFS rates apply. Patient cost-sharing is the standard 20 percent.

Home services have specific HCPCS codes for home visits (99341-99350 for home visits, 99347-99350 for established patient home visits). The reimbursement for a home visit at POS 12 typically reflects the time and travel involved.

Example 6: Telehealth POS 02 vs POS 10 post-PHE

Dr. Patel sees a Medicare patient via telehealth. Two scenarios:

Scenario A: Patient at home (POS 10)

• 99213 reimbursement: ~$87 (non-facility PFS)
• Patient coinsurance: ~$17.40

Scenario B: Patient at a clinic site (POS 02)

• 99213 reimbursement: ~$59 (facility PFS)
• Originating site facility fee: ~$30 (Q3014)
• Patient coinsurance: 20% of each component

The home telehealth setting reimburses the physician more because the physician bears the overhead. The clinic telehealth setting splits payment between the physician and the originating site facility.

Common Georgia errors in place of service coding

Error 1: Billing POS 22 when the department does not meet 42 CFR 413.65 provider-based criteria. Without proper provider-based status, the facility cannot bill as a hospital outpatient department.

Error 2: Billing POS 11 when the facility is actually provider-based. This results in non-facility PFS payment instead of the (lower) facility PFS plus the (separate) OPPS payment. May seem advantageous but creates compliance issues.

Error 3: Not updating POS when a practice converts to provider-based status. After conversion, the POS must change from 11 to 19 or 22 with retroactive billing complications.

Error 4: Misclassifying a Section 603 non-excepted PBD as excepted. This results in overbilling at full OPPS when the 40 percent rate applies. Major overpayment risk.

Error 5: Inconsistent POS coding within a practice. Mixed signals create audit risk. Maintain consistent POS for each physical location.

Error 6: Not using POS 10 for home telehealth. Pre-2022 habit of POS 02 for all telehealth results in lower reimbursement than warranted.

Error 7: Confusion about ASC (POS 24) vs HOPD (POS 22). ASCs are separate from hospital outpatient. ASC payment system under Section 1833(i) is different from OPPS.

Error 8: Missing 42 CFR 414.50 anti-markup compliance. Practices that purchase diagnostic tests must follow anti-markup rules regardless of POS.

Error 9: Not documenting the site-of-service for audit defense. POS audit defense requires consistent location documentation, signage, branding, and provider-based attestation if applicable.

Error 10: Misunderstanding "excepted" vs "non-excepted" PBD status. Excepted status is preserved as long as no triggering event occurs. Triggering events include relocation, change of ownership, and new service lines.

Error 11: Billing POS 21 (inpatient) for outpatient services. Mixing inpatient and outpatient POS is a major compliance error. Two-Midnight Rule clarifies inpatient eligibility.

Error 12: Using POS 99 (Other) as a catch-all. POS 99 should be used rarely and only when no other code applies. Frequent use of POS 99 triggers audit attention.

Error 13: Not reporting place of service correctly under 42 CFR 424.5(a)(6). Federal regulation requires accurate POS reporting. Misreporting can constitute a False Claims Act violation if knowing.

Error 14: Confusing FQHC POS 50 and RHC POS 72 with regular office POS 11. FQHCs and RHCs use their own billing structures and POS codes.

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Frequently Asked Questions

What is "place of service" in Medicare billing?

Place of service (POS) is a two-digit code on every Medicare claim that identifies where the service was rendered. The HIPAA Place of Service Code Set defines 81+ codes. Common codes: POS 11 (office), POS 22 (on-campus HOPD), POS 19 (off-campus PBD), POS 21 (inpatient hospital), POS 31 (SNF), POS 12 (home), POS 02 and POS 10 (telehealth), POS 24 (ASC).

Why does the same service cost more at a hospital outpatient clinic?

Because hospital outpatient services trigger a "facility" PFS rate (lower physician payment) PLUS a separate OPPS facility payment to the hospital. The combined total exceeds the freestanding office single payment. Medicare expenditure and patient cost-sharing are both higher in HOPD.

What is Section 603 of the Bipartisan Budget Act of 2015?

Section 603 of Public Law 114-74 reduced OPPS payments for non-excepted off-campus provider-based departments to a "site-specific" rate (now 40 percent of OPPS) effective January 1, 2017. Implemented at 42 CFR 419.48. The goal was to reduce site-of-service arbitrage from hospital acquisitions of physician practices.

What is an "excepted" off-campus PBD?

An off-campus PBD that was billing as a PBD before November 1, 2015, or that was mid-build with a binding written agreement as of November 2, 2015, or that is a dedicated emergency department. Excepted PBDs continue to bill at full OPPS rates. Non-excepted PBDs bill at 40 percent.

What is 42 CFR 413.65?

The federal regulation defining provider-based status determination. A facility must meet common ownership, common management, operational integration, clinical integration, public awareness, and financial integration criteria to be billed as a hospital outpatient department.

What is the difference between POS 22 and POS 19?

POS 22 is on-campus hospital outpatient (the department is on the main hospital campus or within 250 yards). POS 19 is off-campus hospital outpatient (the department is further from the main campus). POS 22 always bills at full OPPS. POS 19 bills at full OPPS if excepted, or 40 percent if not.

How does the facility vs non-facility PE RVU differential work?

The PFS PE RVU has two values for each CPT code. Non-facility PE RVU (used at POS 11 office) is higher because the practice bears full overhead. Facility PE RVU (used at POS 22, 19, 21, 24, etc.) is lower because the facility bears its own overhead and is paid separately.

Why does Medicare pay both a facility fee and a physician fee at HOPD?

Because hospital outpatient services have two distinct components: the professional component (physician's work) paid at facility PFS, and the facility component (overhead, supplies, nursing, etc.) paid at OPPS APC rates. The hospital and physician bill separately.

How does POS affect telehealth billing?

POS 02 (telehealth, patient not at home) is treated as facility (lower physician PFS). POS 10 (telehealth, patient at home, effective 2022) is treated as non-facility (higher physician PFS). Telehealth coverage and reimbursement continue to evolve post-PHE.

What is an Ambulatory Surgical Center (ASC)?

A standalone surgical facility not affiliated with a hospital. Billed at POS 24. Reimbursed under the ASC payment system at Section 1833(i). ASC rates are generally lower than OPPS rates for the same procedure because of lower facility overhead.

How does ASC payment differ from HOPD payment for the same procedure?

For most procedures on the ASC-covered list, OPPS pays more than ASC. The differential is significant for many endoscopy, ophthalmology, and orthopedic procedures. Medicare beneficiaries pay less out of pocket at ASCs.

What is the patient cost-sharing implication at HOPD vs office?

At HOPD, the patient pays 20 percent coinsurance on BOTH the physician component AND the OPPS facility component. At office (POS 11), the patient pays 20 percent on the (higher) non-facility PFS only. HOPD total typically costs the patient more in coinsurance.

What is the No Surprises Act and how does it affect Medicare?

The NSA, enacted as part of CAA 2021, regulates out-of-network balance billing primarily for non-Medicare patients. Medicare has its own balance billing limits. The NSA's provider notice provisions at 45 CFR 149.430 have affected how facilities communicate site-of-service to patients.

What is the anti-markup rule at 42 CFR 414.50?

A rule limiting practices' reimbursement for purchased diagnostic tests to the lesser of the practice's actual charge, the supplier's net charge, or the PFS amount. Prevents practices from buying tests cheaply and billing Medicare at higher rates.

Where can I look up the current POS code set?

CMS publishes the current Place of Service Code Set at cms.gov. The list is updated periodically. Major billing software and EHR systems maintain current POS code libraries.

How does Palmetto GBA audit place of service?

Palmetto GBA conducts medical review and prepayment review that includes POS verification. Audits can result in claim denials, takebacks, and overpayment recoupment. Practices should maintain documentation of physical service location.

What is provider-based status attestation?

The hospital attests to CMS that an off-campus PBD meets 42 CFR 413.65 criteria. The attestation is filed through the Medicare Administrative Contractor (Palmetto GBA for Georgia). CMS can audit attestations.

Does Section 603 apply to all hospital outpatient services?

No. Section 603 specifically applies to non-excepted off-campus PBDs. Excepted PBDs, on-campus PBDs, and dedicated emergency departments continue at full OPPS. The 40 percent rate is for the non-excepted off-campus subset.

What is a "dedicated emergency department"?

A 24/7 emergency department licensed by the state as an ED and providing emergency services. EDs are excepted from Section 603 regardless of campus location.

What happens if a practice is acquired by a hospital after November 2015?

The new off-campus PBD is non-excepted. Section 603 applies: 40 percent OPPS rate for facility component. Lower revenue than a grandfathered PBD.

What is the American Hospital Association v Azar litigation?

Litigation challenging various CMS implementations of Section 603 and related site-neutral payment policies. The DC Circuit ruled on aspects of the case in 2020. Continued rulemaking has refined the framework.

Can a Medicare beneficiary choose between HOPD and office for the same service?

Often yes. Many specialists offer both HOPD and office settings. The beneficiary typically has lower cost-sharing at the office. The choice depends on specialist availability, patient preference, and clinical factors.

How does POS 31 (SNF) billing work?

For Part A SNF stays, routine SNF services are bundled into the SNF PPS rate. Physician visits are billed separately. The POS 31 designation triggers SNF-specific billing rules.

How does POS 12 (Home) billing work?

Services rendered at the patient's home. Specific HCPCS home visit codes (99341-99350). Non-facility PE RVU. Home health services billed separately under home health agency PPS.

Where can I get help with Medicare place of service questions in Georgia?

For provider questions, contact Palmetto GBA Provider Outreach at 1-866-238-9650. For beneficiary questions, contact GeorgiaCares SHIP at 1-866-552-4464 or Medicare at 1-800-MEDICARE. Brevy at brevy.com publishes regularly updated guides. :::

Deep dive: how OPPS actually works

To understand the site-of-service differential, it helps to understand the Hospital Outpatient Prospective Payment System in some detail. OPPS, authorized at Section 1833(t) of the Social Security Act and implemented at 42 CFR 419, pays hospitals for outpatient services using a system of Ambulatory Payment Classifications (APCs).

APC structure

CMS groups similar outpatient services into APCs. Each APC has a relative weight, which is multiplied by the OPPS conversion factor (updated annually in the OPPS final rule) to produce the APC payment. The hospital is paid one APC for the primary procedure, plus packaged or partial payments for ancillary services.

Status indicators

Each HCPCS code has an OPPS status indicator that defines how the service is paid. Major status indicators:

• J1: Hospital outpatient services billed under OPPS at full APC rate
• N: Services packaged into the APC payment (no separate payment)
• Q: Conditionally packaged (sometimes separate, sometimes packaged)
• S: Separate procedural service paid under OPPS
• T: Significant procedure, multiple-procedure reduction applies
• V: Clinic or emergency department visit (G0463 the main code)
• C: Inpatient procedure list

Clinic visit code G0463

Most hospital outpatient clinic visits are billed using G0463 ("Hospital outpatient clinic visit for assessment and management of a patient"). The G0463 APC payment rate is updated annually in the OPPS final rule. This is on top of the physician's facility PFS payment. CMS has applied site-neutral reductions to G0463 in some scenarios as part of broader site-neutral initiatives.

Geographic adjustment

OPPS payments are adjusted using the wage index for the hospital's location. Metro Atlanta hospitals have a wage index that runs above 1.0; rural Georgia hospitals run below 1.0. The geographic adjustment can affect APC payments by 10-20 percent depending on location.

Outlier payments

For unusually high-cost outpatient services, OPPS includes outlier provisions that increase payment. The outlier threshold and methodology are revised annually.

Pass-through payments

Certain new devices, drugs, and biologicals receive "pass-through" payment status that supplements the APC payment. Pass-through status is time-limited (typically 2-3 years) and is intended to bridge the gap between innovation and full integration into the APC system.

Deep dive: how ASC payment works

The Ambulatory Surgical Center payment system at Section 1833(i) is fundamentally similar to OPPS but with different rate-setting. ASCs are reimbursed at rates that have historically been about 60 percent of the OPPS rate for the same procedure, though the percentage varies by procedure.

Covered procedure list

CMS maintains a list of "ASC-approved" procedures that can be performed in an ASC and reimbursed by Medicare. The list has expanded over time as more procedures have shifted from inpatient to outpatient settings. The CY 2026 ASC-approved list includes hundreds of procedures across major surgical specialties.

Payment indicators

Each procedure on the ASC list has a payment indicator that determines how it is paid. Major indicators:

• A2: Standard ASC payment
• G2: Non-office-based surgical procedures
• P2: Office-based surgical procedure that ASCs can perform
• R2: Office-based radiology

Multiple procedure reduction

When multiple procedures are performed in the same ASC encounter, the primary procedure is paid at 100 percent of the ASC rate, and subsequent procedures are paid at 50 percent. This is similar to but distinct from the OPPS multiple-procedure reduction.

Quality reporting

ASCs participate in the ASC Quality Reporting Program. Failure to report quality measures results in a 2 percentage point reduction in the annual payment update.

ASC financial advantages for Medicare

For procedures eligible for both ASC and HOPD settings, the ASC route generally costs Medicare less and costs the patient less in coinsurance. Many Georgia ASCs have positioned themselves as patient-friendly alternatives to hospital surgery for procedures that do not require hospital-level resources.

Major Georgia ASCs

Georgia has hundreds of licensed ambulatory surgical centers. Major ones include:

• Northside Hospital ASCs: Multiple locations affiliated with Northside Hospital
• Piedmont Surgery Center: Multiple metro Atlanta locations
• Wellstar Outpatient Surgery Centers: Affiliated with Wellstar Hospital Group
• Emory Healthcare ASCs: Affiliated with Emory University Hospital and Emory University Hospital Midtown
• Eye Consultants of Atlanta Surgery Center: Ophthalmology-focused
• Atlanta Spine Surgery Center: Spine-focused
• Independent ASCs: Many independent and physician-owned ASCs across Georgia

Each ASC has its own POS 24 designation and bills under the ASC payment system.

How the inpatient hospital framework intersects with place of service

Inpatient services (POS 21) are billed under the Inpatient Prospective Payment System (IPPS) at Section 1886. The fundamental unit is the Diagnosis-Related Group (DRG). Each inpatient admission is assigned a DRG based on the principal diagnosis, procedures performed, complications, and patient demographics. The DRG payment is a single bundled amount intended to cover all hospital costs for the admission.

Two-Midnight Rule

The Two-Midnight Rule under CMS-1599-F (effective October 1, 2013) clarifies when admission to inpatient status is appropriate. Generally, a stay expected to cross two midnights is inpatient; shorter stays are observation (outpatient, POS 22 or 19 typically). The distinction has significant POS implications because inpatient billing under POS 21 is structurally different from outpatient observation billing.

Physician services during inpatient

When a physician sees a patient during an inpatient hospital stay, the physician bills under POS 21 at the facility PFS rate. The hospital separately bills the DRG-based payment.

Discharge planning

At discharge, the POS for follow-up depends on the patient's destination. Discharge to home returns to POS 11 office or POS 12 home for follow-up. Discharge to SNF goes to POS 31 for SNF-based services.

Inpatient psychiatric, IRF, LTCH place of service

Beyond the standard inpatient hospital POS 21, several specialty facility codes apply:

• POS 51 (Inpatient Psychiatric Facility): Acute psychiatric inpatient. Billed under IPF PPS (Inpatient Psychiatric Facility Prospective Payment System).
• POS 61 (Comprehensive Inpatient Rehabilitation Facility): IRF setting. Billed under IRF PPS. Requires 3 hours/day of intensive rehabilitation therapy.
• Long-term Care Hospital (LTCH): Specialty facility for patients with extended acute needs. LTCH PPS. POS varies.

Georgia has IRFs at major health systems, including facilities operated by Encompass Health and hospital-affiliated rehabilitation programs. Each IRF has its own Medicare enrollment and bills under POS 61.

SNF place of service: POS 31 deep dive

When a Medicare beneficiary is in a skilled nursing facility under a Part A SNF stay, the SNF is paid under SNF PPS at rates that vary by patient acuity (PDPM methodology). The SNF stay bundles most services into the daily SNF rate.

Physician visits to SNF patients are billed separately at POS 31 (Skilled Nursing Facility). Physician services use:

• CPT 99304-99306: Initial nursing facility visit
• CPT 99307-99310: Subsequent nursing facility visit
• CPT 99315-99316: Discharge service

The physician's PFS rate for SNF services is the facility PFS rate (lower than office). The SNF itself does not bill OPPS for the physician visit (unlike HOPD); the physician facility PFS payment is the only Medicare payment for the visit.

POS 32 (Nursing Facility)

POS 32 is for long-term custodial care nursing facility (often Medicaid-funded after Medicare benefits are exhausted). Different from POS 31 SNF. Same physician billing structure applies.

Hospice place of service

POS 34 (Hospice) is used when services are rendered at a hospice facility. However, hospice services themselves are billed under the Hospice Prospective Payment System (Hospice PPS), not under the standard POS/PFS framework. Physician services NOT related to the terminal illness for a hospice patient can be billed separately at the appropriate POS.

Home health and home POS

POS 12 (Home) is for services rendered at the patient's home. Home physician visits use the home visit CPT codes (99341-99350). Non-facility PFS rates apply.

Home health services (skilled nursing, PT, OT, ST in the home) are billed separately by the home health agency under Home Health PPS, not under the POS framework. The physician who orders home health may bill care plan oversight services under POS 12.

Hospital at Home

The Acute Hospital Care at Home initiative (post-COVID-19 PHE) allows hospitals to deliver inpatient-level care in the patient's home. POS for this is typically POS 12 (Home) with specific hospital-at-home billing arrangements through CMS waivers.

The Stark Law and Anti-Kickback Statute interaction with place of service

The federal Stark Law (Section 1877 of the Social Security Act) and Anti-Kickback Statute (Section 1128B(b) of the Social Security Act) impose limits on physician referrals and remuneration that interact with place-of-service decisions.

Stark Law

Prohibits physician referrals to entities for designated health services (DHS) when the physician has a financial relationship with the entity, absent an applicable exception. Many of the DHS categories (clinical laboratory, imaging, DMEPOS, outpatient PT/OT) are place-of-service sensitive.

Anti-Kickback Statute

Prohibits offering or receiving remuneration to induce referrals for federal healthcare program-paid services. The AKS interacts with hospital-physician relationships in complex ways.

Site-of-service implications

Hospital acquisition of physician practices, conversion to PBC status, and ongoing service delivery arrangements must comply with Stark and AKS. Specific safe harbors and exceptions apply. Violations can result in False Claims Act liability with treble damages.

For Georgia hospital systems and physician practices entering or restructuring relationships, healthcare counsel review of Stark and AKS compliance is standard practice.

CMS audit focus on place of service

Place of service has been a recurring CMS and OIG audit focus. Key audit themes include:

Provider-based status compliance

OIG audits have repeatedly found provider-based clinics that did not fully meet 42 CFR 413.65 requirements. Common findings:

• Inadequate signage indicating department status
• Insufficient operational integration
• Common management gaps
• Public awareness shortfalls

Section 603 implementation

Audits have focused on whether off-campus PBDs are correctly identified as excepted or non-excepted, and whether non-excepted PBDs are billing at the correct 40 percent rate.

POS coding accuracy

Audits sample claims to verify that the POS code on the claim matches the actual physical location where the service was rendered. Mismatches result in claim denial or recoupment.

Telehealth POS

Post-2022, audits have examined whether telehealth claims are using POS 02 vs POS 10 correctly based on patient location.

Medicaid POS coordination

Georgia Medicaid generally uses the same HIPAA Place of Service Code Set as Medicare. For dually eligible Georgia beneficiaries, both Medicare and Medicaid review POS for their respective payment purposes. The Georgia Medicaid Management Information System (GAMMIS) operated by Gainwell Technologies processes Medicaid claims with POS verification.

For services where Medicaid is the primary or sole payer (long-term custodial care, certain pediatric services, Medicaid-only beneficiaries), Georgia Medicaid POS rules apply.

How the framework affects Georgia hospital strategy

The Section 603 framework has fundamentally reshaped how Georgia hospital systems approach physician practice acquisitions and outpatient facility location decisions.

Acquisition slowdown

Before November 2015, hospital systems were aggressively acquiring physician practices, knowing that conversion to PBC status would substantially increase Medicare reimbursement per visit. After November 2015, the financial logic of acquisition shifted. Acquisitions are still happening, but the rationale is now more about clinical integration, referral patterns, and risk-bearing capacity than about site-of-service arbitrage.

Footprint restructuring

Some Georgia health systems have actively restructured their off-campus footprint to maximize excepted status preservation and to avoid triggering events that would convert excepted PBDs to non-excepted. This includes careful planning around relocations, ownership changes, and new service lines.

On-campus expansion

The financial advantage of on-campus PBD status (full OPPS regardless of timing) has driven some systems to expand their main hospital campus footprint. Emory University Hospital, Wellstar Kennestone, Piedmont Atlanta, and others have all expanded campus boundaries to bring more services on-campus.

Freestanding office strategy

Some practices that would previously have been converted to PBC have remained as freestanding offices. The non-facility PFS rate is single-component but cleaner.

Telehealth strategy

The 2022 POS 10 introduction created new strategic flexibility. Practices can deploy home-based telehealth at non-facility rates, which can be financially favorable compared to clinic-based telehealth at facility rates.

Documentation requirements for POS coding

Beyond simply selecting the correct two-digit POS code on a claim, providers must maintain documentation that supports the POS designation. Audit defense rests on documentation. Key elements:

Service location documentation

The medical record should clearly identify where the service was rendered. This includes the facility name, address, and (if applicable) the department or suite. For services rendered at multiple locations on the same day (e.g., a physician seeing patients at both an office and a hospital), each encounter's location must be documented separately.

Provider-based clinic operating documents

For hospital outpatient departments billing at POS 22 or POS 19, the hospital must maintain the provider-based attestation, the operating agreement establishing the department as part of the hospital, common ownership documentation, common management/governance documentation, and integration documentation showing that the department operates as part of the hospital under 42 CFR 413.65.

Signage and patient-facing materials

The 42 CFR 413.65 standard requires that the public be aware that the facility is a hospital department. This typically requires signage, billing statements, and patient communications that identify the facility as a hospital department (e.g., "Emory University Hospital Department of Cardiology" rather than "Emory Cardiology Associates"). The signage and branding documentation supports the POS 22 or POS 19 designation.

Off-campus PBD distance documentation

For POS 22 vs POS 19 distinction, the hospital must document that the department is within 250 yards of the main campus (POS 22) or further (POS 19). GPS coordinates, site surveys, and lease/ownership documents establish location.

Telehealth POS documentation

For POS 02 vs POS 10 distinction, the medical record should document the patient's location at the time of service. Patient-attested location at scheduling, followed by visual verification or patient self-report during the visit, is the typical workflow. The shift from POS 02 to POS 10 in 2022 made patient-home location materially favorable from a reimbursement standpoint, so documentation discipline is important.

Time of service

Some POS distinctions depend on whether the patient is admitted at the time of service. A patient seen in the emergency department who is then admitted to inpatient status has different POS treatment for the ED encounter vs the inpatient stay. Two-Midnight Rule documentation supports the inpatient vs observation distinction.

Provider-based attestation deep dive

A provider-based attestation under 42 CFR 413.65 is a formal hospital filing with CMS, through Palmetto GBA for Georgia, that establishes a facility as a department of the hospital. Major elements:

Attestation contents

The attestation includes:

• Identification of the facility (name, address, services provided)
• Statement that the facility meets 42 CFR 413.65 criteria
• Documentation of common ownership (typically hospital ownership of the facility)
• Documentation of common management/governance (typically that the hospital governing board has authority over the facility)
• Documentation of operational integration (financial, clinical, and operational integration with the main hospital)
• Documentation of clinical integration (shared medical staff bylaws, peer review, quality assurance)
• Documentation of public awareness (signage, branding, patient communications)
• Distance from main campus (within or beyond 250 yards)
• Date of acquisition or establishment (for Section 603 excepted vs non-excepted analysis)

CMS review

CMS may accept the attestation, request additional documentation, or deny provider-based status. Denial means the facility cannot bill as a hospital outpatient department; services must be billed as a freestanding office (typically POS 11 with non-facility PFS) or as a separately enrolled facility.

Ongoing compliance

Provider-based status is not a one-time determination. The hospital must maintain compliance with all 42 CFR 413.65 criteria on an ongoing basis. Material changes (relocation, ownership changes, service line changes) can trigger reassessment. CMS and Palmetto GBA can audit provider-based status at any time.

Audit risk

The OIG has repeatedly audited provider-based clinics and found significant non-compliance. Audit findings often relate to inadequate signage, insufficient operational integration, or gaps in common management. Remediation can be required, and in serious cases provider-based status can be revoked retroactively with significant recoupment.

Excepted status preservation

For grandfathered off-campus PBDs (excepted under Section 603), preserving excepted status is a major operational and strategic concern. Triggering events that can convert excepted to non-excepted include:

• Change of ownership of the PBD
• Relocation of the PBD (with some limited exceptions for involuntary relocations like natural disasters or lease loss)
• Adding new service lines beyond the original scope (under certain interpretations)
• Failure to maintain provider-based status criteria

Georgia hospital systems with significant grandfathered PBD footprints (Emory, Wellstar, Piedmont) work actively to avoid triggering events and to plan around the constraints.

Section 603 litigation and rulemaking history

The implementation of Section 603 has been heavily litigated and the subject of multiple CMS rulemakings. The major threads:

CY 2017 OPPS final rule (CMS-1656-FC, November 2016)

Implemented the Section 603 reduction at 50 percent of OPPS initially (later moved to 40 percent in subsequent rulemakings, then back to 40 percent after litigation). Defined "excepted" status criteria, mid-build provisions, and the distinction between excepted and non-excepted off-campus PBDs.

G0463 clinic visit code reductions (CY 2019 OPPS final rule)

CMS extended Section 603-style reductions to G0463 clinic visit code billing at all excepted off-campus PBDs, not just non-excepted. This was viewed as expanding site-neutral payment beyond the statutory grant.

American Hospital Ass'n v. Azar (D.C. Cir. 2020)

The AHA and several hospitals challenged the G0463 expansion. The D.C. Circuit ruled in 2020 that CMS exceeded its authority by applying the G0463 reduction to excepted PBDs. The court vacated the relevant portions of the rule. Subsequent CMS rulemaking addressed the court's ruling.

Subsequent rulemaking refinements

Each year's OPPS rulemaking has addressed aspects of Section 603 implementation. The current framework as of 2026 includes:

• 40 percent OPPS rate for non-excepted off-campus PBDs
• Full OPPS rate for excepted off-campus PBDs
• Full OPPS rate for on-campus PBDs (POS 22)
• Full OPPS rate for dedicated emergency departments

Ongoing site-neutral policy debate

Beyond Section 603, broader site-neutral payment policy continues to be debated. MedPAC has repeatedly recommended extending site-neutral payment to additional service categories. Congressional proposals have included site-neutral payment for radiation oncology, certain imaging services, and physician administered drugs. The trajectory points toward continued reduction of the HOPD-vs-office reimbursement differential.

Impact on Georgia hospitals

Georgia hospital systems with significant off-campus PBD footprints (especially those acquired post-November 2015) have absorbed material revenue reductions under Section 603. Combined with other site-neutral policies, the financial calculus of hospital-acquired physician practice has shifted significantly since 2015.

Patient education and shared decision-making

Medicare beneficiaries often do not know that their costs vary by site of service. Patient education is increasingly viewed as a beneficiary protection.

Provider notice under the No Surprises Act

45 CFR 149.430 requires that for certain services at hospital outpatient departments, the hospital provide notice to the patient that the service is rendered at a facility billing under OPPS, that this may result in higher patient cost-sharing than a freestanding office, and that the patient may have the option of receiving the service at a different setting. The notice requirements are specific to certain service types and patient categories.

Pre-service price transparency

The CMS price transparency rules at 45 CFR 180 require hospitals to publish standard charges, including for outpatient services, in a machine-readable file and in a consumer-friendly format. Patients can theoretically compare prices across hospitals and between hospital and office settings. Compliance with the price transparency rules has been uneven.

Good Faith Estimates for self-pay patients

Under the No Surprises Act, providers must provide Good Faith Estimates of expected charges to self-pay patients. While Medicare beneficiaries generally are not self-pay, the framework affects how providers communicate price information.

Shared decision-making in clinical practice

For elective services where the patient has a choice between settings, shared decision-making conversations are increasingly standard. Patients can ask their physician where else the service is offered, what the cost difference is, and what factors should drive the decision (clinical complexity, anesthesia needs, patient comorbidities, etc.).

Brevy patient-facing resources

Brevy at brevy.com maintains guides that explain site-of-service differential in plain language for Medicare beneficiaries. We do not provide individualized advice but we explain the framework so patients can ask informed questions.

The future of site-neutral payment

The current Section 603 framework is widely viewed as an incremental step toward broader site-neutral payment. Several drivers point toward continued evolution:

MedPAC recommendations

MedPAC has consistently recommended extending site-neutral payment to additional service categories, eliminating the on-campus vs off-campus distinction in many cases, and moving toward a uniform Medicare payment regardless of setting. MedPAC's recommendations are advisory but influential.

Congressional proposals

Multiple Congressional proposals have been introduced to extend site-neutral payment. While most have not been enacted, the policy direction is consistent across both parties.

Administrative action through rulemaking

CMS has used annual OPPS rulemaking to incrementally extend site-neutral approaches. The G0463 clinic visit reductions, additional drug-administration site-neutral policies, and ongoing exam of imaging and ancillary services all point in this direction.

Hospital industry response

The American Hospital Association and individual health systems have aggressively contested site-neutral expansion through litigation, lobbying, and rulemaking comments. The industry argues that hospitals incur higher overhead and serve sicker patients than freestanding offices, justifying higher payment.

Impact on Georgia

Continued site-neutral expansion would affect Georgia hospital systems, particularly those with extensive off-campus PBD networks. Wellstar, Emory, Piedmont, Northside, and other major Georgia systems have all built significant outpatient footprints that would be financially affected by broader site-neutral payment.

How Georgia rural hospitals fit into the framework

Georgia has approximately 60 rural hospitals serving non-metro counties. Many participate in special Medicare payment categories that interact with the place-of-service framework differently from large metro systems.

Sole Community Hospital (SCH) designation

A hospital that is the only short-term acute care facility in its service area, or that meets specific distance/access criteria, can be designated as a Sole Community Hospital. SCHs receive enhanced Medicare reimbursement under specific provisions of Section 1886. Several Georgia rural hospitals carry SCH status.

Medicare Dependent Hospital (MDH)

A small rural hospital with at least 60 percent Medicare utilization can be classified as MDH and receive payment based on a hospital-specific rate. MDH status interacts with both IPPS and OPPS rules.

Critical Access Hospital (CAH)

A CAH is a small rural hospital (typically 25 or fewer beds) that is paid based on reasonable cost rather than under IPPS or OPPS. CAHs do not use OPPS the same way standard hospitals do; instead they receive cost-based reimbursement for outpatient services. Georgia has several CAHs in its rural counties.

Rural Health Clinic (RHC) and FQHC

RHCs (POS 72) and FQHCs (POS 50) are reimbursed under their own payment systems (the RHC All Inclusive Rate and the FQHC PPS). They do not use the standard PFS facility vs non-facility distinction the same way. Georgia has many FQHCs and a smaller number of RHCs serving rural communities.

Rural emergency hospital (REH)

A new Medicare provider category effective 2023, the REH is a rural hospital that has converted from inpatient services to outpatient/emergency-only operations and receives a monthly facility payment plus enhanced OPPS payments. A small number of Georgia rural hospitals have considered REH conversion.

For rural Georgia, the place-of-service framework operates within these specialized payment systems. Practices and beneficiaries served by rural hospitals should understand which payment category applies.

Specific Georgia geographic variation

Place of service interacts with Georgia's geographic payment areas. The Geographic Practice Cost Index (GPCI) varies across Georgia:

Metro Atlanta GPCI

Atlanta has a GPCI work index modestly above 1.0 and a practice expense GPCI somewhat above 1.0, producing PFS rates that are typically the highest in Georgia. Medical Group Management Association data shows metro Atlanta as the highest-cost healthcare market in Georgia.

Other metro Georgia (Savannah, Augusta, Columbus, Macon)

GPCI values are close to but slightly below metro Atlanta. PFS rates run 1-3 percent below metro Atlanta levels.

Rural Georgia

Rural Georgia GPCI values are below 1.0, producing PFS rates that are typically 5-10 percent below metro Atlanta. This creates a financial disincentive for physician practice in rural areas, which has been a long-running healthcare access issue in Georgia.

Hospital wage index

For OPPS payments, the hospital wage index varies similarly. Metro Atlanta hospitals receive higher OPPS payments per APC than rural Georgia hospitals for the same service.

Combined effect on PBD strategy

For metro Atlanta hospital systems, the combined effect of higher GPCI and higher hospital wage index makes off-campus PBD strategy financially significant. For rural Georgia hospital systems, the absolute dollar magnitude is smaller, but the relative importance of every dollar of reimbursement is often greater because rural margins are typically thinner.

Working with Brevy and Georgia resources

Brevy publishes regularly updated guides at brevy.com on Medicare billing rules, Part B and outpatient coverage, hospital and ASC payment, telehealth, and related topics. We do not provide legal, billing, or tax advice. We provide research-grade content that explains the framework in plain language so that Georgia hospitals, practices, providers, and beneficiaries can make informed decisions.

For provider-side billing and compliance questions, contact Palmetto GBA Provider Outreach at 1-866-238-9650 or visit palmettogba.com. For beneficiary questions about Medicare coverage, contact Medicare at 1-800-MEDICARE or GeorgiaCares SHIP at 1-866-552-4464.

For legal compliance questions about provider-based status or Section 603 strategy, work with healthcare counsel familiar with Medicare reimbursement.

Disclaimers

This article is for educational purposes only and does not constitute legal, billing, tax, or medical advice. Medicare payment rules are subject to change. The information in this article reflects rules in effect as of May 2026. Always verify current rules at cms.gov, palmettogba.com, and through current CMS Medicare Claims Processing Manual provisions before making billing decisions.

Brevy is not affiliated with the Centers for Medicare and Medicaid Services, the Social Security Administration, the Department of Health and Human Services, Palmetto GBA, MedPAC, or any other federal or state agency. Brevy is an eldercare research and information company. We accept no compensation from insurance carriers, providers, or other parties.

Information about Georgia hospital systems, practices, and providers reflects publicly available information as of the publication date. Hospital strategies and provider participation may change. Verify current information with the relevant organization before relying on it.

This article was researched and written by the Brevy Care Team and is pending final editorial review.

Find personalized help navigating Medicare place-of-service rules at brevy.com.

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Get help with Medicare place of service in Georgia

Federal agencies

• Medicare: 1-800-MEDICARE (1-800-633-4227). General Medicare and Part B questions. medicare.gov
• Social Security Administration: 1-800-772-1213. Medicare enrollment. ssa.gov
• CMS Provider Enrollment: 1-866-484-8049. Provider enrollment questions. cms.gov
• CMS OPPS Information: Available through cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS

Georgia state agencies

• GeorgiaCares SHIP: 1-866-552-4464. Free Medicare counseling. georgiacares.org
• Georgia Department of Community Health, Medicaid Member Services: 1-866-211-0950. Medicaid and dual-eligible questions
• Georgia Composite Medical Board: 404-656-3913. Physician licensure. medicalboard.georgia.gov
• Georgia Hospital Association: 770-249-4500. gha.org

Medicare Administrative Contractor

• Palmetto GBA Provider Enrollment: 1-855-696-0705
• Palmetto GBA Customer Service: 1-866-238-9650
• Palmetto GBA Provider Outreach and Education: through palmettogba.com
• Mailing address: Palmetto GBA, J-J Provider Enrollment, P.O. Box 100190, Columbia, SC 29202

Legal and consumer assistance

• Atlanta Legal Aid Society: 404-377-0701. Free civil legal services. atlantalegalaid.org
• Georgia Legal Services Program: 1-800-498-9469. Free legal services for low-income Georgians outside metro Atlanta. glsp.org
• Center for Medicare Advocacy: 1-860-456-7790. National Medicare appeals nonprofit. medicareadvocacy.org
• Medicare Rights Center: 1-800-333-4114. National consumer service. medicarerights.org

Healthcare policy resources

• MedPAC (Medicare Payment Advisory Commission): medpac.gov. Policy analysis and recommendations
• American Hospital Association: aha.org. Hospital industry trade association
• Healthcare Financial Management Association: hfma.org. Healthcare financial management

Additional resources

• Eldercare Locator: 1-800-677-1116. eldercare.acl.gov
• 211 Georgia: Dial 211 for community resources
• National Council on Aging: 1-800-794-6559. ncoa.org

Brevy

Brevy at brevy.com publishes regularly updated guides on Medicare, Medicaid, VA benefits, and caregiving across all 50 states. Our guides are free, advertising-free, and reviewed annually. :::