![]() Table A includes some miscellaneous additions and changes such as a temporary new C-code, some status indicator changes, and the reassignment of a skin substitute. The first T procedure on a claim is paid at 100%, but subsequent T procedures on the same claim are paid at 50% of the OPPS payment rate.īelow are tables of the code additions and changes from the July 2019 OPPS Updates. SI “T” are procedures and services paid under OPPS but to which a reduction applies for multiple procedures. All S services on a claim are paid at 100% of the OPPS payment rate. SI “S” are procedures and service paid under OPPS similar to SI “T” but to which a payment reduction for multiple procedures/services does not apply. Most clinical lab services have been conditionally packaged since 2014 and have this status indicator. These lab services are only paid separately if they are the only type of services provided on the claim. SI “Q4” is for laboratory services with packaged payment. It defaults to the status indicator of its APC when paid separately. If the Q1 service does not meet packaging criteria (no S, T, or V code on the claim), it is separately paid. ![]() Q1 services are packaged if they appear on the same claim with services with an SI of S, T, or V (visit). SI “Q1” is a conditionally packaged service which means the payment for this service is packaged in certain circumstances. Even though these services are not paid separately, it is important to report the codes so CMS can know all of the components of a primary service. This means there is no separate payment made for this HCPCS code. SI “N” indicates services for which the payment for the service is packaged into the payment of other services. ![]() Notice in the tables below that these services say “provided by physician” or “interpretation and report” meaning they are professional (physician or other qualified health care professional) services and not to be billed by the hospital. SI “M” are services that are not billable to the MAC and are not paid under OPPS. They are paid at reasonable cost and are not subject to deductibles and co-insurance SI “L” are for flu and pneumonia vaccines. SI “K” are drugs and biologicals eligible for separate payment under OPPS because they exceed the per day cost threshold for separately payable drugs. The payment for all adjunctive services on the claim with the J1 service is packaged into the payment for the primary J1 service, with only a few exceptions. ![]() SI “J1” indicates the primary procedure of a comprehensive APC. SI “G” indicates drugs and biologicals that receive pass-through payment. SI “E2” are not paid under OPPS because pricing information and claims data are not yet available. They are services that are not an outpatient benefit, are statutorily excluded, or are not medically necessary for outpatients. SI “E1” are services that are not covered for outpatients and will not be paid when submitted on an outpatient claim. For inpatient only procedures, the patient should be admitted as an inpatient. These codes will not be paid when billed on an outpatient claim with limited exceptions. Another common type of service with this SI is therapy services (PT, OT and SLP services). For example, you see this code in the tables below for laboratory services that are paid under the Clinical Laboratory Fee Schedule (CLFS). SI “A” means the service is paid under a fee schedule or payment system other than OPPS. CMS provides a table of the definitions of the status indicators in Addendum D1 of the OPPS Final Rule each year – the 2019 addenda can be found here.īelow are descriptions of the status indicators that appear in the July 2019 OPPS Update. The status indicators (SI’s) describe how particular HCPCS codes and APCs are paid (or not paid) under OPPS, so it is important for providers to understand what the various status indicators mean. These updates sometimes include policy changes, but generally consist mainly of coding updates, such as new HCPCS codes and revised OPPS status indicator assignments. status indicators.Įach quarter, CMS issues an update for the Outpatient Prospective Payment System (OPPS). There is no summer break from learning in real life and if you work with Medicare outpatient claims, you have to learn your A, C, E1, E2, G, J1, etc. School is out for the summer and my youngest grandchild graduated from pre-school, where she learned her ABC’s.
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