Addendum A and B Instructions

Facilities paid under OPPS utilize Addendum A and B to determine payments.

Addendum A and B are posted quarterly to the OPPS website. Information will include Healthcare Common Procedure Coding System (HCPCS) codes and their status indicators, Ambulatory Payment Classifications (APC) groups, and OPPS payment rates, which are in effect at the beginning of each quarter. The quarterly updates of the Addendum's reflect the OPPS Pricer changes that are part of the quarterly OPPS recurring update notification transmittals from CMS.

Addendum A and B

Note: APC information can be viewed in Addendum A.

Using Addendum B

Addendum B has nine separate columns, which is indicated below:

Addendum B displaying nine separate columns.

Column A lists the HCPCS codes paid under OPPS in numerical order, including codes that have been discontinued for the year. Column B lists a short description of the HCPCS code listed in Column A. The OPPS payment status indicators (SI) can be found in Column C.

Column D lists the APC associated with the HCPCS code listed in column A, if the HCPCS code is paid under a separate APC payment. If the HCPCS code is paid on an APC, Column E will list the Relative Weight of the APC and Column F will list the Payment Rate of the APC. Column G will list the National Unadjusted Copayment if applicable and Column H will list the Minimum Unadjusted Copayment if applicable.

Finally, Column I indicates if a change has been made to any cell in the specific row. This will be indicated by the symbol *.

Providers that have access to Direct Data Entry (DDE) can view the status indicator, APC, or payment rate (if applicable) for an APC for a specific line on a claim after a claim is selected. Once the claim is selected type 02 in the CLAIM PAGE field and press F11 once. The status indicator will be located under the OCE FLAGS field number 1. The APC is located in the PAY/HCPC APC CD field, and the payment rate is located in the PRICER AMT field. This is indicated below in the screen image of Page 2 in DDE.

Screenshot displaying the above information.

Below is a list of the SI, a description of the SI, OPPS payment status:

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:
  • Ambulance
  • Clinical Diagnostic Lab
  • Non-Implantable Prosthetic/Orthotics devices
  • EP0 for ESRD patients
  • PT/OT/SLP
  • Routine Dialysis for ESRD patients provided in a certified dialysis unit of a hospital
  • Screening/Diagnostic Mammography
Not paid under OPPS. Paid by fiscal intermediaries/MAC under a fee schedule or payment system other than OPPS
B Codes that are not recognized by OPPS when submitted on an 12x or 13x TOB - there may be an alternative code or alternate type of bill Not paid under OPPS.

May be paid by intermediaries when submitted on a different bill type, for example, 75x (CORF), but not paid under OPPS.
An alternated code that is recognized by OPPS when submitted on an outpatient hospital Part B bill type (12X and 13x) may be available.
C Inpatient only procedures, not paid under OPPS-denied beneficiary liable 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 Medicare based on statutory exclusion, or there may be an alternate code for the same service or separate payment is not provided by Medicare 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.
G Pass-through Drugs and Biologicals; separate APC payment Paid under OPPS; separate APC payment
H Pass-through Device Categories; separate cost-based pass-through payment, not subject to copayment Separate cost-based pass through payment, not subject to copayment
K Non pass-through drugs and non-implantable biologicals, including therapeutic radiopharmaceuticals; Paid under OPPS, separate APC payment Paid under OPPS; separate APC payment
L Flu/PPV vaccines-not paid under OPPS, paid at reasonable cost, not subject to deductible or coinsurance Not paid under OPPS. Paid at reasonable code; not subject to deductible or coinsurance
M Service not billable to the FI or MAC Not paid under OPPS
N Items or 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 service Paid under OPPS; per diem APC payment
Q1 STVX-Packaged Codes -. . Paid under OPPS; Addendum B displays APC assignments when services are separately payable.
  • Packaged APC payment if billed on same date of service as a HCPCS assigned status indicator S, T, V or X
  • 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.
  • Packaged APC payment if billed on same date of service as a HCPCS assigned status indicator T.
  • In all other circumstances, payment is made through a separate APC payment
Q3 Codes that may be paid through a composite APC. Composite APC payment based on OPPS composite-specific payment criteria. Payment packaged into a single payment for specific combination of service. . In all other circumstances, payment is made through a separate APC or packaged into payment for other services. OPPS Final Rule Addendum M lists composite APC assignments. 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.
  • Composite APC payment based on OPPS composite-specific payment criteria. Payment is packaged into a single payment for specific combinations of service
  • 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 subject to multiple procedure discounting Paid under OPPS; separate APC payment
T Significant procedure, subject to multiple procedure discounting 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 service 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

 

Last Updated Fri, 28 Feb 2020 13:31:31 +0000