Payment adjustment flag
0 – No payment adjustment
1 – Paid standard amount for pass-through drug or biological (status
indicator G) (discontinued effective October 2016, v17.3)
2 – Payment based on charge adjusted to cost (status indicator H) (discontinued effective October 2016, v17.3)
4 – Deductible not applicable (specific list of HCPCS codes) or condition code “MA” is present on the claim
5 – Blood/blood product used in blood deductible calculation
6 – Blood processing/storage not subject to blood deductible
7 – Item provided without cost to provider (deactivated 01/01/2014, v.15.0)
8 – Item provided with partial credit to provider (deactivated 01/01/2014, v.15.0)
9 – Deductible/co-insurance not applicable
10 – Co-insurance not applicable
11 – Multiple service units reduced to one by IOCE processing; payment based on single payment rate
12 – Offset for device pass-through
13 – Offset for additional device pass-through
14 – PAMA Section 218 reduction on CT scan
15 – Reserved for future use
16 – Terminated procedure with pass-through device
17 – Condition for device credit present
18 – Offset for first pass-through drug or biological
19 – Offset for second pass-through drug or biological
20 – Offset for third pass-through drug or biological
21 – CAA Section 502(b) reduction on film X-ray
22 – CAA Section 502(b) reduction on computed radiography technology
23 – Co-insurance deductible n/a, as well as subject to a reduction due to
film x-ray (CAA Section 502b)
24 – Co-insurance deductible n/a, as well as subject to a reduction due to
computed radiography technology (CAA Section 502b)
25 – Deductible not applicable and Coinsurance reduced
Payment method flag
0 – OPPS pricer determines payment for service
1 – Service not paid based on coverage or billing rules
2 – Service is not subject to OPPS
3 – Service is not subject to OPPS and has an OCE line item denial or rejection
4 – Line item is denied or rejected by MAC; OCE not applied to line item
5 – Payment for service determined under FQHC PPS
6 – CMHC outlier limitation reached
7 – Section 603 service with no reduction in OPPS Pricer
8 – Section 603 service with PFS reduction applied in OPPS Pricer
A – Payment reduction for off-campus clinic visit
B – Payer only testing
C – Payment made by FQHC PPS and coinsurance is n/a (COVID-19)
V – Contractor bypass applied to FQHC PPS service and coinsurance is n/a (COVID-19)
W – Contractor bypass applied to off-campus clinic visit for payment reduction
X – Contractor bypass applied to Section 603 service with no reduction applied in OPPS Pricer
Y – Contractor bypass applied to Section 603 service with reduction applied in OPPS Pricer
Z – Contractor bypass determines payment for services
