ADDENDUM D1.

— FINAL O PPS PAYMENT STATUS INDICATORS FOR CY 201 3

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 unde r 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 Th erapy

● 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 recognize d 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 alt ernate 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 O PPS PAYMENT STATUS INDICATORS FOR CY 201 3

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 a ny 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 m ay 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 su bject 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

cos t; not subject to deductible or
coinsurance.

M Items and Services Not Billable to the Fiscal Intermediary/MAC Not paid under OPPS.ADDENDUM D1.

— FINAL O PPS PAYMENT STATUS INDICATORS FOR CY 201 3

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.
Therefo re, 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 se rvices 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 O PPS PAYMENT STATUS INDICATORS FOR CY 201 3

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 service s

. (2) In all other circumstances, payment is made through a separate APC payment or packaged into payment for other
service s.

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

paymen t.

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.