Outpatient PPS Outpatient Code Editor (OCE) Payment Flags

OCE Flags appear on MAP171A (claim line item detail page), and explain the OPPS payment computations applied to HPCPS/CPT codes, such as multiple procedure discounting and packaging.

The claim line item detail contains nine payment flags:

 • Flag 1 – Status Indicator

 • Flag 2 – Payment Indicator

 • Flag 3 – Discounting Formula Number 

 • Flag 4 – Line Item Denial or Rejection 

 • Flag 5 – Packaging 

  • Flag 6 – Payment Adjustment

  • Flag 7 – Payment Method 

 • Flag 8 – Line Item Action 

 • Flag 9 – Composite Adjustment 

Flag 1 - OPPS Payment Status Indicators

Values	Description
A	Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS e.g. Ambulance, lab, PT/OT/SLP, Routine Dialysis for ESRD patients, Screening/Diagnostic Mammography, Non-Implantable Prosthetic/Orthotics devices, EPO for ESRD patients
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
C	Inpatient-only procedures; not paid under OPPS. Admit patient, Bill as inpatient
D	Discontinued Codes
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
F	Corneal Tissue Acquisition; Certain CRNA Services and Hepatitis B Vaccines
G	Pass-through Drugs and Biologicals; separate APC payment; Paid at a reasonable cost
H	Pass-through Device Categories; 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
L	Flu/PPV vaccines-not paid under OPPS, paid at reasonable cost, not subject to deductible or coinsurance
M	Service not billable to the FI or MAC
N	Items or services packaged into APC rates therefore no separate payment is made
P	Partial hospitalization service- per diem APC payment
Q1	STVX-Packaged Codes - Packaged APC payment if billed on same date of service as a HCPCS assigned status indicator S, T, V or X. Otherwise, payment is made through separate APC.
Q2	T-Packaged Codes - Packaged APC payment if billed on same date of service as a HCPCS assigned status indicator T. Otherwise, payment is made through separate APC.
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.
R	Blood and Blood Products; separate APC payment
S	Significant procedure not subject to multiple procedure discounting; Separate APC payment
T	Significant procedure subject to multiple procedure discounting; Separate APC payment
U	Brachytherapy Sources; separate APC payment
V	Clinic or Emergency Department Visit; separate APC payment
X	Ancillary service; Separate APC payment
Y	Non-implantable Durable Medical Equipment; not paid under OPPS, all institutional providers except home health agencies bill to DMERC.

Flag 2 - OPPS Payment Indicator

Values	Description
1	Paid standard hospital OPPS amount (status indicators K, S, T, V, X)
2	Services not paid under OPPS (status indicator A)
3	Not paid (status indicators M, Q1, Q2, Q3, Y), or not paid under OPPS (status indicators B, C, Z)
4	Paid at reasonable cost (status indicators F, L)
5	Paid standard amount for pass-through drug or biological (status indicator G)
6	Payment based on charge adjusted to cost (status indicator H)
8	Paid partial hospitalization per diem (status indicator P)
9	No additional payment, payment included in line items with APCs (status indicator N; or no HCPCS code and certain revenue codes; or HCPCS codes G0176 - activity therapy, G0129 - occupational therapy, or G0177 - patient education and training services