TrailBlazer Health Enterprises

Education Makes the Difference

Part A OPPS Status Indicators

Status indicators are assigned to HCPCS/CPT codes to indicate how the service is processed and/or paid under the Outpatient Prospective Payment System (OPPS). Providers may reference Addendum B to determine the status indicator assigned to a particular code. Addendum B is published quarterly in January, April, July and October and posted on the CMS Web site at http://www.cms.gov/HospitalOutpatientPPS/AU/list.asp. An OPPS Addendum B Search tool is also available on the TrailBlazer Web site at http://www.trailblazerhealth.com/Tools/OPPSAddendumB.aspx. The status indicators and their definitions are listed below. Indicator A Item/Code/Service Services furnished to a hospital outpatient that are paid under a fee schedule/payment system other than Outpatient Prospective Payment System (OPPS), such as: Ambulance services. Clinical diagnostic laboratory services. Non-implantable prosthetic and orthotic devices. Erythropoietin (EPO) for End Stage Renal Disease (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. Explanation Not paid under OPPS. Paid by A/B Medicare Administrative Contractors (MACs) under a fee schedule/payment system other than OPPS.

Published January 2012 AS

2012 TrailBlazer Health Enterprises/TrailBlazer. All rights reserved.

Indicator B

Item/Code/Service Codes that are not recognized by OPPS when submitted on an outpatient hospital Part B Type of Bill (TOB) (12X and 13X)

Explanation Not paid under OPPS: May be paid by A/B MACs when submitted on a different TOB, e.g., 75X (Comprehensive Outpatient Rehabilitation Facility (CORF)), but not paid under OPPS. An alternate code that is recognized by OPPS when submitted on an outpatient hospital Part B TOB (12X and 13X) may be available. Not paid under OPPS. Admit patient. Bill as inpatient. Not paid under OPPS or any other Medicare payment system. Not paid under OPPS or any other Medicare payment system.

C D E

Inpatient procedures Discontinued codes Items, codes and services: That are not covered by Medicare based on statutory exclusion. That are not covered by Medicare for reasons other than statutory exclusion. That are not recognized by Medicare but for which an alternate code for the same item or service may be available. For which separate payment is not provided by Medicare. Corneal tissue acquisition, certain Certified Registered Nurse Anesthetist (CRNA) services and hepatitis B vaccines Pass-through drugs and biologicals

Not paid under OPPS. Paid at reasonable cost.

Paid under OPPS. Separate Ambulatory Payment Classification (APC) payment includes pass-through amount.

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Indicator H K L M N

Item/Code/Service Pass-through device categories Non-pass-through drugs and non-implantable biologicals including therapeutic radiopharmaceuticals Influenza vaccine and Pneumococcal Pneumonia Vaccine (PPV) Items and services not billable to the FI/MAC Items and services packaged into APC rates

Explanation Separate cost-based pass-through payment. Not subject to coinsurance. Paid under OPPS. Separate APC payment. Not paid under OPPS. Paid at reasonable cost. Not subject to deductible or coinsurance. Not paid under OPPS. Paid under OPPS. Payment is packaged into payment for other services, including outliers. Therefore, there is no separate APC payment. Paid under OPPS. Per diem APC payment. Paid under OPPS. This status indicator is only assigned after the claim processes and, therefore, does not appear on Addendum B. Payment is packaged into payment for other services. If billed alone, the service is assigned a different status indicator and payment is made through a separate APC payment. Paid under OPPS. Addendum B displays APC assignments when services are separately payable. Packaged APC payment if billed on the same date of service as a HCPCS code assigned a status indicator of S, T, V or X. In all other circumstances, payment is made through a separate APC payment.

P Q

Partial Hospitalization Program (PHP) Packaged services

Q1

STVX-packaged codes

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Indicator Q2

Item/Code/Service T-packaged codes

Explanation Paid under OPPS. Addendum B displays APC assignments when services are separately payable. Packaged APC payment if billed on the same date of service as a HCPCS code assigned a status indicator of T. In all other circumstances, payment is made through a separate APC payment. 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 services. In all other circumstances, payment is made through a separate APC payment or packaged into payment for other services. Paid under OPPS. Separate APC payment. Paid under OPPS. Separate APC payment. Paid under OPPS. Separate APC payment. Paid under OPPS. Separate APC payment. Paid under OPPS. Separate APC payment.

Q3

Codes that may be paid through a composite APC

R S T U V

Blood and blood products Significant procedure not subject to multiple-procedure discounting Significant procedure subject to multiple-procedure discounting Brachytherapy sources Clinic or emergency department visit

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Indicator W

Item/Code/Service Invalid HCPCS or invalid revenue code with blank HCPCS Ancillary services Non-Implantable Durable Medical Equipment (DME)

Explanation Not paid under OPPS as submitted. This status indicator is only assigned after the claim is received and, therefore, does not appear on Addendum B. Paid under OPPS. Separate APC payment. Not paid under OPPS. All institutional providers other than home health agencies bill to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC). Not paid under OPPS as submitted. This status indicator is only assigned after the claim processes and, therefore, does not appear on Addendum B.

X Y

Valid revenue code with blank HCPCS

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