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APC Assistant
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Procedure Table Headings and Descriptions
Proc Code: HCPCS procedure code.
Start Date: The starting date for this version of the code in the OCE. A code may have multiple start dates if changes have been made to any characteristic of the code (not only the characteristics listed in the procedure table).
End Date: The last day a particular version of a code is effective. If this column is blank within the results tables, then the code is current for this version of the OCE.
Code Description: Description of procedure code.
Min Age: Minimum allowable age of patient for this procedure code.

    0 = Minimum age does not apply for this code.
Max Age: Maximum allowable age of patient for this procedure code.

    124 = Maximum age does not apply for this code.
Pay Stat: Assigned payment status indicator.

A= Services not paid under OPPS; paid under fee schedule or other payment system (effective 1/1/2023 - includes unclassified drugs and biologicals reportable under HCPCS code C9399)
B= Service not allowed under OPPS on hospital outpatient claim
C= Inpatient service, not paid under OPPS
E1= Non-allowed item or service
E2= Items and services for which pricing information and claims data are not available
F= Corneal tissue acquisition; certain CRNA services
G= Drug/biological pass-through
H= Pass-through device categories
H1= Non-opioid medical devices for post-surgical pain relief
J1= Hospital Part B services paid through a Comprehensive APC
J2= Hospital Part B services that may be paid through a Comprehensive APC
K= Non-pass-through drugs and non-implantable biologicals, including therapeutic radiopharmaceuticals
K1= Non-opioid drugs and biologicals for post-surgical pain relief
L= Influenza vaccine; pneumococcal pneumonia vaccine; Hepatitis B vaccines; COVID-19 vaccine; monoclonal antibody therapy product
M= Service not billable to the FI/MAC
N= Packaged/incidental service
P= Service paid only in Partial Hospitalization Program or Intensive Outpatient Program
Q1= STV-packaged services
Q2= T-packaged services
Q3= Services that may be paid through a Composite APC
Q4= Conditionally packaged laboratory services
R= Blood and blood products
S= Procedure or service, not discounted when multiple
T= Procedure or service, multiple reduction applies
U= Brachytherapy sources
V= Clinic or emergency department visit
Y= Non-implantable DME
..= Payment status indicator not available for service
APC: Assigned APC number.
APC Rate: Assigned rate for this APC.
Max Unit: The maximum allowable units for this procedure (see edit 15).
Bil Ind: The bilateral indicator for this procedure.

Cnd = Conditional; Procedure is bilateral if the modifier 50 is present. See "Criteria" for a description of exclusively bilateral procedures.
Inh = Inherent; Procedure in and of itself is bilateral.
Ind = Independent; Procedure is bilateral if the modifier 50 is present, however full payment should be made for each procedure.
N/A = Non-bilateral; Bilateral indicators are not applicable to this code. The results within the table will display, "..." indicating Non-bilateral.
Criteria: Indicates specific procedure categories. These procedure categories are used in the processing of OCE edits. Please refer to the "OCE Edit List" in OCE Expert™ for a description of the OCE edits.

CriteriaExplanationFurther Information
009-Non-Covered Services that are not covered under any Medicare outpatient benefit, for reasons other than statutory exclusion Edit 009
012-Questionable Services that are only covered by Medicare under certain medical circumstances Edit 012
013-Not Sep Pay Services with payment status "E2" which are not reportable to Medicare on any outpatient claim Edit 013
018-Inpatient Only Procedures that can only be performed in an inpatient setting Edit 018
028-Unacceptable Procedure codes that are not acceptable to Medicare on OPPS claims; An alternative code may be available Edit 028
035-MH Ed/Train Mental health education and training services that cannot be billed without other outpatient services Edit 035
043-Blood Product Blood or blood product codes, one of which must be reported if blood transfusion is billed Edit 043
043-Blood Transfusion Blood transfusion codes, which must be billed with blood or blood products Edit 043
044-Observation Observation room procedure codes that must be billed with an observation revenue code Edit 044
045-Inpt Sep Proc Inpatient-only separate procedures are assigned OCE 045 if there is a paystat T or J1 on the same day. Edit 045
050-Non-Cov Stat Excl Services that are not covered under the Medicare outpatient benefit based on statute Edit 050
055-OPPS Specific Proc Procedure codes that are only allowed on OPPS outpatient claims Edit 055
061-DME Durable medical equipment codes with payment status "Y" that should be billed separately to the regional carrier (DMERC) Edit 061
062-Not Recognized Procedure codes that are not recognized by Medicare on OPPS claims; An alternate code may be available Edit 062
066-Unclassified Drug/Bio Procedure code used for billing drugs or biologicals after FDA approval date but before a specific HCPCS code has been assigned Edit 066
067-FDA Approval Procedure codes that can be billed only after their FDA approval date. Edit 067
068-NCD Coverage Date Procedure codes that can be billed only after their NCD coverage date. Edit 068
069-Approval Range Procedure codes that can be billed only during a limited approval period Edit 069
072-Not Billable Procedure codes with payment status "M" that cannot be billed on a hospital outpatient claim Edit 072
073-Blood Product Blood or blood product codes that must be billed as two identical lines of HCPCS code, units and modifier BL where one line has revenue code 038x and the other with revenue code 039x. Edit 073
076-Trauma Response Trauma response critical care service subject to special billing rules Edit 076
079-Packed RBC Revenue Code 381 can only be billed with one of the packed red blood cell procedure codes Edit 079
079-Whole Blood Revenue Code 382 can only be billed with one of the whole blood procedure codes Edit 079
080-Not PHP Approved Mental health services that are not approved for the Partial Hospitalization Program Edit 080
081-Only PHP Approved Mental health services that are only approved for the Partial Hospitalization Program Edit 081
082-Charge > $1.00 If an eligible procedure code is billed with charges greater than $1.00, the claim line will receive Edit 082. Edit 082
083-NCD Non-Cov Date Procedure codes that cannot be billed on or after the effective date of NCD non-coverage Edit 083
087-High Cost Skin Proc High cost skin substitute procedure that requires an applicable high cost skin substitute product Edit 087
087-High Cost Skin Prod High cost skin substitute product is required when a high cost skin substitute procedure is billed Edit 087
087-Low Cost Skin Proc Low cost skin substitute procedure that requires an applicable low cost skin substitute product Edit 087
087-Low Cost Skin Prod Low cost skin substitute product is required when a low cost skin substitute procedure is billed Edit 087
088/089-FQHC Pay Code FQHC required payment codes & associated qualifying visit codes Edit 088, Edit 089
091-FQHC/RHC Non-Covered Services not covered on an FQHC or RHC claim Edit 091
092-Device Required Device-intensive procedure codes that require an associated device Edit 092
093-Corneal Proc Corneal transplant procedure codes that satisfy billing requirement when corneal tissue processing is billed Edit 093
095-PHP Hours Partial Hospitalization Program (PHP) procedure codes where the units count toward the 20+ hours of services required per 7-day span on a PHP claim. Edit 095
098-OPPS Proc Required Services assigned to Payment Status Indicator “H1” must be billed with an appropriate surgical procedure or an OPPS payable procedure on the same day Edit 098
098-Pass-Thru Device Pass-through devices that require a device-intensive procedure code Edit 098
099-Excluded Drug/Bio Drugs or biologicals that are excluded from edit 99 and can be billed without an OPPS payable service Edit 099
104-All-Inc Rate Not Elig Procedure codes that are not eligible for all-inclusive rate and are not allowed to be billed on a Rural Health Center (RHC) claim with modifier CG Edit 104
105-Device FDA Date Procedure codes for pass-through devices that cannot be billed before the FDA approval date. Edit 105
106-Drug Admin Add-on Drug administration procedure codes that require a primary code to be billed on the claim. Edit 106
106-RMH Add-on Remote Mental Health (RMH) procedure codes that require a primary code to be billed on the day. Edit 106
106-SaaS Add-on Software as a Service (SaaS) procedure codes that require a primary code to be billed on the claim. Edit 106
106-Type I Add-on Procedure codes that require a primary code to be billed on the same day or day before the procedure code. Edit 106
110-Marketing Date Procedure codes that cannot be billed before the initial marketing date. Edit 110
111-Duplicative Bio Service Procedure codes that are used in manufacturing a drug or biological cannot be paid separately. Edit 111
112-Information Only Procedure codes that are non-covered and are for reporting purposes only. Edit 112
115-COVID-19 Lab Add-on COVID-19 lab procedure codes that require a primary code to be billed on the same day. Edit 115
116-Opioid Treatment Program Opioid Treatment Program procedure codes that are only allowed on bill types approved for an Opioid Treatment Program Provider. Edit 116
120-Colorectal Proc Colorectal procedure that is required on the same day with modifier PT. Edit 120
124-CMS Term Date Procedure codes that can only be billed before CMS termination date Edit 124
125-IMRT Planning Services that cannot be billed with the Intensity-Modulated Radiotherapy (IMRT) planning code. Edit 125
128-IOP Service At least three units of mental health services must be provided on each day of an Intensive Outpatient Program claim. Edit 128
129-IOP Hours Intensive Outpatient Program (IOP) procedure codes where the units count toward the 9+ hours of services required per 7-day span on an IOP claim. Edit 129
131-PHP Service At least three units of mental health services must be provided on each day of a Partial Hospitalization claim. Edit 131
132-Not IOP Approved Mental health procedure codes that are not approved for the Intensive Outpatient Program. Edit 132
133-Only IOP Approved Mental health procedure codes that are only approved for the Intensive Outpatient Program. Edit 133
134-CMS Approval Period Procedure codes that can only be billed during the approval period set by CMS. Edit 134
135-Device-Intensive Proc Device-intensive procedures that must be billed with an appropriate device on the same day. Edit 135
190-IOP Non-Primary Procedure codes that are designated as non-primary services for the Intensive Outpatient Program. OCE 190 may be applied when a non-primary IOP service is present on a day without an IOP primary. Edit 190
191-PHP Non-Primary Procedure codes that are designated as non-primary services for the Partial Hospitalization Program. OCE 191 may be applied when a non-primary PHP service is present on a day without a PHP primary. Edit 191
Antigens Procedure codes classified as antigens that may be reimbursed by Medicare under specific care settings.
Casts Procedure codes classified as casts that may be reimbursed by Medicare under specific care settings.
Coins Waived With Mod CS These procedure codes are eligible for a coinsurance waiver and allowed to be reported with Modifier CS. Procedure codes assigned to this criteria do not receive OCE 114 when reported with Modifier CS. All procedure codes not assigned to this criteria receive OCE 114 when reported with Modifier CS. Edit 114
Comp APC Exclusions Procedure codes excluded from comprehensive APC packaging Comprehensive APC Packaging
Complexity Adjustment Procedure codes that may contribute to comprehensive APC complexity adjustment Comprehensive APC Processing
Comprehensive APC Procedure codes that may be assigned to a comprehensive APC Comprehensive APC Processing
Cond APC Procedure codes that contribute to conditional APC assignment Conditional APCs
Information Pending Procedure codes that are covered under Medicare with editing and/or grouping information pending
IOP/PHP Reportable Procedure codes that may be billed on IOP/PHP claims but do not count toward IOP/PHP Composite APC assignment and are packaged with payment status "N" on these claims.
Part B Inpat Allowed Procedure codes that may be reported on a Part B Inpatient claim. Any service not identified as “Part B Inpat Allowed” that is billed with a revenue code that is not allowed on a Part B Inpatient claim receives Edit 127 on a UB-04 012X claim. Edit 127
Radiation Radiation treatment delivery when billed with modifier PN will be assigned special payment rules
Sometimes Therapy Sometimes therapy procedure codes that may be paid under the MPFS when billed with a therapy modifier or revenue code and otherwise are subject to standard processing rules. Sometimes Therapy
Splints Procedure codes classified as splints that may be reimbursed by Medicare under specific care settings.
STV-Packaged Procedure codes that can be packaged under a procedure code with payment status "S", "T", or "V" Conditional Packaging
T-Packaged Procedure codes that can be packaged when billed with a procedure code with payment status "T" Conditional Packaging
Telehealth Procedure codes that may be billed with a telehealth modifier. Edit 126
Vaccine Admin Procedure codes classified as vaccines that may be reimbursed by Medicare under specific care settings.