ADDENDUM D1.—FINAL OPPS PAYMENT STATUS INDICATORS FOR CY 2013

Indicator Item/Code/Service OPPS Payment Status

A Services furnished to a hospital 

outpatient that are paid under a fee 

schedule or payment system other than 

OPPS, for example:

Not paid under OPPS. Paid by fiscal 

intermediaries/MACs under a fee 

schedule or payment system other than 

OPPS.

Services are subject to deductible or 

coinsurance unless indicated otherwise. 

● Ambulance Services

● Clinical Diagnostic Laboratory 

 Services

Not subject to deductible or coinsurance.

● Non-Implantable Prosthetic and 

 Orthotic Devices

● EPO for ESRD Patients

● Physical, Occupational, and Speech

 Therapy

● Routine Dialysis Services for ESRD 

 Patients Provided in a Certified 

 Dialysis Unit of a Hospital

● Diagnostic Mammography

● Screening Mammography Not subject to deductible or coinsurance.

B Codes that are not recognized by OPPS 

when submitted on an outpatient hospital 

Part B bill type (12x and 13x).

Not paid under OPPS.

● May be paid by fiscal 

intermediaries/MACs when submitted on 

a different bill type, for example, 75x 

(CORF), but not paid under OPPS.

● An alternate code that is recognized by 

OPPS when submitted on an outpatient 

hospital Part B bill type (12x and 13x) 

may be available.
ADDENDUM D1.—FINAL OPPS PAYMENT STATUS INDICATORS FOR CY 2013

Indicator Item/Code/Service OPPS Payment Status

C Inpatient Procedures Not paid under OPPS. Admit patient. 

Bill as inpatient.

D Discontinued Codes Not paid under OPPS or any other 

Medicare payment system.

E Items, Codes, and Services:

.

Not paid by Medicare when submitted on 

outpatient claims (any outpatient bill 

type).

● That are not covered by any Medicare 

 outpatient benefit based on statutory 

 exclusion.

● That are not covered by any Medicare 

 outpatient benefit for reasons other 

 than statutory exclusion

● That are not recognized by Medicare 

 for outpatient claims but for which 

 an alternate code for the same item 

 or service may be available.

● For which separate payment is not 

 provided on outpatient claims.

F Corneal Tissue Acquisition; Certain 

CRNA Services and Hepatitis B 

Vaccines

Not paid under OPPS. Paid at reasonable 

cost.

G Pass-Through Drugs and Biologicals Paid under OPPS; separate APC 

payment.

H Pass-Through Device Categories Separate cost-based pass-through 

payment; not subject to copayment.

K Nonpass-Through Drugs and 

Nonimplantable Biologicals, Including 

Therapeutic Radiopharmaceuticals

Paid under OPPS; separate APC 

payment.

L Influenza Vaccine; Pneumococcal 

Pneumonia Vaccine

Not paid under OPPS. Paid at reasonable 

cost; not subject to deductible or 

coinsurance.

M Items and Services Not Billable to the 

Fiscal Intermediary/MAC

Not paid under OPPS.
ADDENDUM D1.—FINAL OPPS PAYMENT STATUS INDICATORS FOR CY 2013

Indicator Item/Code/Service OPPS Payment Status

N Items and Services Packaged into APC 

Rates

Paid under OPPS; payment is packaged 

into payment for other services. 

Therefore, there is no separate APC 

payment.

P Partial Hospitalization Paid under OPPS; per diem APC 

payment.

Q1 STVX-Packaged Codes Paid under OPPS; Addendum B displays 

APC assignments when services are 

separately payable.

(1) Packaged APC payment if billed on 

the same date of service as a HCPCS 

code assigned status indicator “S,” “T,” 

“V,” or “X.”

(2) In all other circumstances, payment 

is made through a separate APC 

payment.

Q2 T-Packaged Codes Paid under OPPS; Addendum B displays 

APC assignments when services are 

separately payable.

(1) Packaged APC payment if billed on 

the same date of service as a HCPCS 

code assigned status indicator “T.”

(2) In all other circumstances, payment 

is made through a separate APC 

payment.
ADDENDUM D1.—FINAL OPPS PAYMENT STATUS INDICATORS FOR CY 2013

Indicator Item/Code/Service OPPS Payment Status

Q3 Codes That May Be Paid Through a 

Composite APC

Paid under OPPS; Addendum B displays 

APC assignments when services are 

separately payable.

Addendum M displays composite APC 

assignments when codes are paid through 

a composite APC. 

(1) Composite APC payment based on 

OPPS composite-specific payment 

criteria. Payment is packaged into a 

single payment for specific combinations 

of services.

(2) In all other circumstances, payment 

is made through a separate APC payment 

or packaged into payment for other 

services.

R Blood and Blood Products Paid under OPPS; separate APC 

payment.

S Significant Procedure, Not Discounted 

When Multiple 

Paid under OPPS; separate APC 

payment.

T Significant Procedure, Multiple 

Reduction Applies

Paid under OPPS; separate APC 

payment.

U Brachytherapy Sources Paid under OPPS; separate APC 

payment.

V Clinic or Emergency Department Visit Paid under OPPS; separate APC 

payment.

X Ancillary Services Paid under OPPS; separate APC 

payment.

Y Non-Implantable Durable Medical 

Equipment

Not paid under OPPS. All institutional 

providers other than home health 

agencies bill to DMERC.