ADDENDUM D1.—PROPOSED OPPS PAYMENT STATUS INDICATORS

FOR CY 2012

ADDENDUM D1.—PROPOSED OPPS PAYMENT STATUS INDICATORS FOR CY 2012

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 and 

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.
ADDENDUM D1.—PROPOSED OPPS PAYMENT STATUS INDICATORS FOR CY 2012

Indicator Item/Code/Service OPPS Payment Status

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.

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:

● 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.

Not paid by Medicare when submitted on 

outpatient claims (any outpatient bill type).

F Corneal Tissue Acquisition; Certain CRNA 

Services and Hepatitis B Vaccines

Not paid under OPPS. Paid at reasonable 

cost.
ADDENDUM D1.—PROPOSED OPPS PAYMENT STATUS INDICATORS FOR CY 2012

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 OPPS PAYMENT STATUS INDICATORS FOR CY 2012

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.
ADDENDUM D1.—PROPOSED OPPS PAYMENT STATUS INDICATORS FOR CY 2012

Indicator Item/Code/Service OPPS Payment Status

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.