OPPS payment status indicator · CMS Addendum D1
Status indicator A: paid under a fee schedule, not OPPS.
Status indicator A means the hospital outpatient service is paid by the MAC under a fee schedule or payment system other than OPPS. It is a payable code, but no APC sets its price. CMS lists ambulance, separately payable clinical laboratory tests, non-implantable prosthetics and orthotics, therapy and mammography as examples.
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What CMS says status indicator A means
Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS.
CMS's OPPS payment status for A is "Not paid under OPPS. Paid by MACs under a fee schedule or payment system other than OPPS." CMS adds that such payments may be contractor priced, and that services are subject to deductible or coinsurance unless indicated otherwise.
The examples CMS lists
| Example in Addendum D1 | Deductible and coinsurance |
|---|---|
| Ambulance services | Subject, unless indicated otherwise |
| Separately payable clinical diagnostic laboratory services | Not subject |
| Separately payable non-implantable prosthetics and orthotics | Not subject |
| Physical, occupational and speech therapy | Not subject |
| Diagnostic mammography | Not subject |
| Screening mammography | Not subject |
The CMS file lays these out in two blocks. The first block (ambulance) sits under the general rule that deductible or coinsurance applies. Laboratory, prosthetics and orthotics, therapy and diagnostic mammography sit under a "Not subject to deductible or coinsurance" note, and screening mammography carries its own matching note. Read the original file for the exact layout.
The drug rows under A
Addendum D1 also lists unclassified drugs and biologicals reportable under HCPCS code C9399, and FDA-approved prescription drugs for HIV PrEP reported under J0799, under indicator A. CMS says these are contractor priced at 95 percent of the drug or biological's average wholesale price, using Red Book or an equivalent recognized compendium, and paid under OPPS. The CY 2026 final rule notes that the A definition was widened in CY 2023 to cover C9399.
A in the Medicare manual: where Q4 labs end up
Chapter 4 of the Medicare Claims Processing Manual, section 10.1.1, uses A as its example of a service paid under a fee schedule. In section 10.4 it says a Q4 laboratory test not billed with another separately payable service is changed by the Integrated OCE to indicator A, and separate payment is made at the clinical laboratory fee schedule rate.
What to check
- Do not expect an APC on the line. Payment comes from the fee schedule named for that service.
- For a lab test, confirm whether the claim also carries J1, J2, S, T, V, Q1, Q2 or Q3 services. If so, the Q4 packaging rules apply instead.
- Confirm the year. The code's indicator is set annually in Addendum B and can change.
Worked example (hypothetical)
A patient has a blood test billed alone on a hospital outpatient claim. The code is listed with Q4 in the OPPS file, but nothing else on the claim is separately payable, so the Integrated OCE treats it as A and pays it at the clinical laboratory fee schedule rate instead of folding it into an APC.
Other codes in this set
Indicators Q1-Q4, Indicator N, Indicator K, Indicator G, Indicator J1, Indicator T, Indicator S, Indicators E1 and E2, Indicator V.
Sources
- CMS: CY 2026 OPPS/ASC final rule (CMS-1834-FC), Addendum D1, OPPS Payment Status Indicators for CY 2026 — status indicator definitions and payment status (addenda file dated 11.20.2025, retrieved 2026-11-02)
- CMS: Medicare Claims Processing Manual, Chapter 4 (Part B Hospital, including OPPS), Rev. 13799, issued 05-28-26 — read 2026-11-02
The Addendum D1 text and Medicare manual passages above were read on November 2, 2026. The Addendum D1 wording below is CMS's own text for the CY 2026 OPPS (file dated 11.20.2025). CMS republishes Addendum D1 every year, so the indicator on a claim for another year should be checked against that year's file. Causes, checks and examples are general billing practice written for this page, not CMS content. Payers and CMS revise code lists, contracts and policies, so confirm anything that affects a claim or a payment with your Medicare Administrative Contractor.
Frequently asked questions
Does indicator A mean the service is not covered?
No. A means it is paid, but under a fee schedule or another payment system rather than OPPS.
Are A services subject to a deductible?
CMS says services are subject to deductible or coinsurance unless indicated otherwise, and marks several examples, such as laboratory services and mammography, as not subject.
Why did my Q4 lab test become A?
CMS says a Q4 test billed without another separately payable service is changed to indicator A and paid under the clinical laboratory fee schedule.
Not legal, billing or medical advice
This page explains published CMS code definitions and runs a lookup in your browser. It cannot see your claim, your contract or any payer's policy. Confirm with your Medicare Administrative Contractor before you resubmit, appeal or bill a patient.