Reader Questions: Status Indicators Define the Bottom Line

Question: What is the significance of payment status indicators to the OPPS, and how do they affect payment?

Florida Subscriber

Answer: CMS assigns a payment status indicator to each ambulatory payment classification (APC) category. The payment status indicator tells you if -- and if so, under what conditions -- Medicare will make payment for that particular APC.

Of the 19 status indicator codes, only 10 are significant under the outpatient prospective payment system (OPPS). Eight of the 10 status indicators (G, H, K, P, S, T, V and X) allow for separate APC payment. But CMS assigns indicators N and Q to APC categories for which you will never or only occasionally receive separate payment.

Resource: See the chart on page 16 for a complete list of APC payment indicators for the OPPS setting.

An N status indicator means that the APC is effectively "bundled" into any other APC category you report for the same patient. As a result, you will receive no additional payment. Theoretically, at least, you would never report an N category APC by itself on a claim. The service is always included in something else.

A Q status indicator is similar, but allows for separate payment if the Q-status APC is the only APC you report. In other words, payments for APCs with a Q status indicator are bundled to other APCs you report at the same time. If you don’t report any other APCs at the same time, then -- and only then -- you will receive separate reimbursement for the Q status APC.

-- Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C.