Paid at reasonable code not subject to deductible or coinsurance. Nonpass-through drugs and non-implantable biologicals, including therapeutic radiopharmaceuticalsįlu/PPV/COVID-19 vaccine monoclonal antibody therapy product In other circumstances, payment is made through a separate APC payment or packaged into payment for other services. Packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator "J1". 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. Hospital part B services paid through a comprehensive APC Separate cost-based pass-through payment, not subject to copayment.
Pass-through device categories separate cost-based pass-through payment, not subject to copayment Pass-through Drugs and Biologicals separate APC payment Items, codes, and services for which pricing information and claims data are not availableĬorneal tissue acquisition certain CRNA services and Hepatitis B vaccines Not paid by Medicare when submitted on outpatient claims (any outpatient bill type). Items, codes, and services not covered by any Medicare outpatient benefit category statutorily excluded not reasonable and necessary Not paid under OPPS or any other Medicare payment system. Inpatient only procedures, not paid under OPPS-denied beneficiary liable An alternated code that is recognized by OPPS when submitted on an outpatient hospital Part B bill type (12X and 13x) may be available. May be paid by intermediaries when submitted on a different bill type, for example, 75x (CORF), but not paid under OPPS. Paid by fiscal intermediaries/MAC under a fee schedule or payment system other than OPPS.Ĭodes 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 Routine Dialysis for ESRD patients provided in a certified dialysis unit of a hospital.Non-Implantable Prosthetic/Orthotics devices.Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS for example:
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