ADDENDUM D1.—PROPOSED OPPS PAYMENT STATUS INDICATORS
 

FOR CY 2013
 

ADDENDUM D1.—PROPOSED PPS 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. 
 

 

 

 

 

 

 

 

 

 

 

 

 

ADDENDUM D1.—PROPOSED PPS PAYMENT STATUS INDICATORS FOR CY 2013 

Indicator Item/Code/Service OPPS Payment Status 

● 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. 

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. 
ADDENDUM D1.—PROPOSED PPS PAYMENT STATUS INDICATORS FOR CY 2013 

Indicator Item/Code/Service OPPS Payment Status 

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. 

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. 
 

ADDENDUM D1.—PROPOSED PPS PAYMENT STATUS INDICATORS FOR CY 2013 

Indicator Item/Code/Service OPPS Payment Status 

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. 

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. 
 

ADDENDUM D1.—PROPOSED PPS PAYMENT STATUS INDICATORS FOR CY 2013 

Indicator Item/Code/Service OPPS Payment Status 

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.