### ADDENDUM D1.

— PROPOSED OPPS PAYMENT STATUS INDICATORS

FOR CY 2013

ADDENDUM D1.

— PROPOSED 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 sche dule 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

● R outine 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 201 3

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 tha t 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 Medica re 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.ADDENDUM D1.

— PROPOSED PPS PAYMENT STATUS INDICATORS FOR CY 201 3

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 copay ment.

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 n o 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 da te 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 201 3

Indicator Item/Code/Service OPPS Payment Status

Q2 T

- Packaged Codes Paid under OPPS; Addendum B displays APC assignments when services are

sep arately 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 c riteria. 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 OPP S; separate APC payment.

V Clinic or Emergency Department Visit Paid under OPPS; separate APC payment.ADDENDUM D1.

— PROPOSED PPS PAYMENT STATUS INDICATORS FOR CY 201 3

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 provid ers other than home health agencies
bill to DMERC.