OPPS Payment Status Indicators - JF Part A
OPPS Payment Status Indicators
| 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/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. |
| E1 | Items, codes, and services not covered by any Medicare outpatient benefit category; statutorily excluded; not reasonable and necessary | Not paid by Medicare when submitted on outpatient claims (any outpatient bill type). |
| E2 | Items, codes, and services for which pricing information and claims data are not available | 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. |
| J1 | Hospital part B services paid through a comprehensive APC | Paid under OPPS; all covered part B services on the claim are packaged with the primary "J1" service for the claim, except services with OPPS status indictor of "F', "G", "H", "L", and "U"; ambulance services, diagnostic and screen mammography, rehabilitation therapy services, services assigned to a new technology services, services assigned to a new technology APC, self-administered drugs, all preventive services, and certain part B inpatient services. |
| J2 | Hospital part B services that may be paid through a comprehensive APC | Paid under OPPS; all covered part B services on the claim are packaged with the primary "J1" service for the claim, except services with OPPS status indictor of "F', "G", "H", "L", and "U"; ambulance services, diagnostic and screen mammography, rehabilitation therapy services, services assigned to a new technology services, services assigned to a new technology APC, self-administered drugs, all preventive services, and certain part B inpatient services. Packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator "J1". In other circumstances, payment is made through a separate APC payment or packaged into payment for other services. |
| K | Nonpass-through drugs and non-implantable biologicals, including therapeutic radiopharmaceuticals | Paid under OPPS; separate APC payment. |
| L | Flu/PPV/COVID-19 vaccine; monoclonal antibody therapy product | Not paid under OPPS. Paid at reasonable code; not subject to deductible or coinsurance. |
| M | Items and services 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 | STV-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". 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 | 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. |
| Q4 | Conditionally packaged laboratory tests | Paid under OPPS or CLFS Packaged APC payment if billed on the same claim as a HCPCS code assigned published status indicator "J1", "J2", "S", "T", "V", "Q1", "Q2", or "Q3". In other circumstances, laboratory tests should have a status indicator of "A" and payment is made under the CLFS. |
| R | Blood and Blood Products | Paid under OPPS; separate APC payment. |
| S | Procedure or service not subject to multiple procedure discounting | Paid under OPPS; separate APC payment. |
| T | Procedure or service 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 (DME) | Not paid under OPPS. All institutional providers other than home health agencies bill to DME MAC. |
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Last Updated Dec 09 , 2023
