Medicare Hospital Outpatient Payment Rate Lookup by Code and Hospital
Medicare pays a hospital outpatient department on its own schedule, not the physician fee schedule and not the surgery center’s. Type a code, a date of service and the hospital. It returns the national rate and that hospital’s own rate, from the CMS release in force that day. Free for 5 codes a day.
The hospital’s rate, per date of service and hospital
Results
99284. New York, date of service Oct 1, 2026.
The release behind these figures
Every amount above is computed from the CMS file below, held in a pinned archive so a number printed in a report can be produced again later, unchanged. The date of service chooses the file. Archive last rebuilt Oct 5, 2026.
- Release
- pfs-2026-10
- CMS file
- 2026 October (quarterly MPFSDB update, CR 14588)
- Prices dates of service
- Oct 1, 2026 onward
- Conversion factor
- $33.40
All 17 CMS physician releases in this archive
Source & method
- Amounts: CMS’s quarterly hospital outpatient Addendum B (code to status indicator, APC and national unadjusted payment rate) and Addendum A (APC to group title and rate), every release from January 2020 to July 2026. A date of service is priced under the release CMS had in force that day. The figures on this page come from the 2026 July OPPS addenda, read from 2026 July Web Addendum B.07.14.26.xlsx (sha256 85baa6b3be8c92a2), and checked field by field against CMS’s own 508 text copy on every build.
- The status indicator gates everything, and it runs last. Fifteen of CMS’s 29 indicators never carry a payment rate. A restated price or a retroactive transmittal can leave an earlier document’s dollar standing beside one of them, so the gate sits after both and nothing can route around it. 11,793 of the 19,153 rows in the current release publish no payable amount, and each renders as CMS’s own Addendum D1 definition instead of a figure.
- Wage adjustment: 60 percent of the rate, at the wage index of the hospital being paid. Pub. 100-04 ch. 4 s10.8: “It is estimated that 60 percent of the group payment represents labor-related costs and are subject to the geographic adjustment”, using the inpatient PPS wage index post-reclassification and post-floor. The index comes from CMS’s CY 2026 OPPS Hospital Impact File, cross-checked against IPPS FY2026 Table 2 (F), and a hospital CMS publishes no index for gets the national figure and the reason, never a neighboring hospital’s.
- The hospital’s own status moves the figure. CMS’s Outpatient Provider Specific File supplies each hospital’s kind and quality-reporting status on the actual date of service, since a record can change mid-year. 668 of the 4,281 hospitals in CY 2026 are excluded from OPPS by 42 CFR 419.20(b), and 105 cancer and children’s hospitals are paid under OPPS but absent from the impact file. Each gets CMS’s regulation, not a number.
- Live source to verify: CMS hospital outpatient quarterly addenda updates.
Medicare hospital outpatient payment, explained
Who is paid what when a service happens in a hospital outpatient department
Two separate payments come out of one hospital outpatient visit, and this page is one of them. The doctor is paid a professional fee under the Physician Fee Schedule. The hospital is paid a separate amount for the room, the staff, the supplies and the equipment, and that payment comes from the hospital outpatient prospective payment system. Those are different parties’ money, so a facility charge tested against the doctor’s fee is tested against the wrong one.
Two other schedules are confused with this one often enough to name. When the same procedure happens in a freestanding surgery center, the facility is paid under the ambulatory surgical center schedule instead, which is a different file at a different rate. When the patient is admitted, Medicare pays one MS-DRG for the whole stay, which is not a per-code amount at all and is not carried on this site. The 2026 July OPPS addenda carry 19,153 codes.
Why the same code pays a different amount at two hospitals
Sixty percent of the rate moves with local wages, and the index is the hospital’s own. CMS states the split plainly in Pub. 100-04 ch. 4 s10.8: “Adjustments for differences in wages across geographical areas are made using inpatient hospital PPS wage index (post-reclassification, post-floor). It is estimated that 60 percent of the group payment represents labor-related costs and are subject to the geographic adjustment.” So the arithmetic is the national rate times 0.60 times the wage index, plus the national rate times 0.40, rounded half up to the cent once at the end.
Two details decide whether a figure is right. The share is 60 percent here and 50 percent on the surgery center schedule, so one reader cannot serve both. And the index is per hospital, not per area: CMS’s CY 2026 impact file states one for 3,439 hospitals, running from 0.5426 to 1.7328, and a reclassified hospital’s figure differs from its neighbors’.
Why a J1 rate is not a price for one billed line
A comprehensive APC pays for the whole claim. CMS’s own words are that all covered Part B services on the claim are packaged with the primary J1 service, except the exclusions in its most recent Addendum J. So the rate beside a J1 code is what Medicare pays for everything on that claim together, and setting it against one line on a bill overstates the charge while looking entirely reasonable. 3,450 of the 19,153 codes in the 2026 July OPPS addenda carry J1.
Three more indicators have the same shape for a different reason. Q1, Q2 and Q3 carry a rate whose payment is decided by the rest of the claim: a Q1 code is packaged whenever a line with indicator S, T or V is billed on the same claim, and paid separately only when none is. 1,101 rows carry one of the three. This tool prints CMS’s condition with the dollar rather than under it.
Which hospitals get no figure, and why
42 CFR 419.20(b) excludes five kinds of hospital from OPPS, and only five: Maryland waiver hospitals, critical access hospitals, hospitals outside the 50 States, DC and Puerto Rico, Indian Health Service hospitals, and rural emergency hospitals. In CMS’s CY 2026 files that is 668 of 4,281 hospitals. Each gets the regulation and CMS’s own reason instead of a number, because a critical access hospital is paid at 101 percent of reasonable cost off its own cost report, which is not a published fee schedule amount at all.
Cancer and children’s hospitals are the case most often got wrong in the other direction. They are absent from that list and they ARE paid under OPPS, 105 of them in CY 2026. CMS leaves them out of the impact file because they are held harmless under section 1833(t)(7)(D)(ii), so it publishes no per-hospital index for them there and the national amount stands with that stated. Community mental health centers, which CMS pays under OPPS per diem for partial hospitalization and lists in the same impact file, are not in this picker: it holds hospitals only.
What the OPPS status indicators mean
Every row of the CMS addenda carries a status indicator, and it decides whether there is a figure at all. This page publishes no code descriptions, so the indicator is what tells a reader what kind of thing a code is and why it does or does not carry an amount. The definitions below are CMS’s own, read from the CY 2026 Addendum D1 published with CMS-1834-FC, with the number of codes in the 2026 July OPPS addenda carrying each and what CMS’s own Pricer source proves about its wage treatment.
| Indicator | CMS’s definition | Codes | With a rate | Wage adjusted |
|---|---|---|---|---|
| J1 | Hospital Part B Services 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 the Comprehensive APC payment policy exclusions found in the most recent Addendum J. | 3,450 | 3,450 | Yes |
| N | Items and Services Packaged into APC Rates. Paid under OPPS; payment is packaged into payment for other services. Therefore, there is no separate APC payment. | 2,086 | none | No amount |
| A | Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS,* for example: ● Ambulance Services ● Separately Payable Clinical Diagnostic Laboratory Services ● Separately Payable Non-Implantable Prosthetics and Orthotics ● Physical, Occupational, and Speech Therapy ● Diagnostic Mammography ● Screening Mammography Unclassified drugs and biologicals reportable under HCPCS code C9399 and not otherwise classified FDA-approved prescription drugs for HIV PrEP reported under HCPCS code J0799. Not paid under OPPS. Paid by MACs under a fee schedule or payment system other than OPPS. Services are subject to deductible or coinsurance unless indicated otherwise. Not subject to deductible or coinsurance. Not subject to deductible or coinsurance. Contractor priced at 95 percent of drug or biological’s average wholesale price (AWP) using Red Book or an equivalent recognized compendium and paid under OPPS. | 2,046 | none | No amount |
| M | Items and Services Not Billable to the MAC. Not paid under OPPS. | 1,494 | none | No amount |
| E1 | Items, Codes, and Services: ● Not covered by any Medicare outpatient benefit category ● Statutorily excluded by Medicare ● Not reasonable and necessary. Not paid by Medicare when submitted on outpatient claims (any outpatient bill type). | 1,442 | none | No amount |
| C | Inpatient Procedures. Not paid under OPPS. Admit patient. Bill as inpatient. | 1,441 | none | No amount |
| Q4 | Conditionally Packaged Laboratory Tests. Paid under OPPS or CLFS. (1) Packaged APC payment if billed on the same claim as a HCPCS code assigned published status indicator “J1",“J2”, “S”, “T” ,“V”, “Q1” ,“Q2”, or “Q3”. (2) In other circumstances, laboratory tests should have a status indicator of "A" and payment is made under the CLFS. | 1,355 | none | No amount |
| T | Procedure or Service, Multiple Procedure Reduction Applies. Paid under OPPS; separate APC payment. | 1,052 | 1,052 | Yes |
| B | Codes that are not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x).. Not paid under OPPS. ● May be paid by MACs when submitted on a different bill type, for example, 75x (CORF), but not paid under OPPS. ● An alternate code that is recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x) may be available. | 1,008 | none | No amount |
| Y | Non-Implantable Durable Medical Equipment * Note -- Payments "under a fee schedule or payment system other than OPPS" may be contractor priced.. Not paid under OPPS. All institutional providers other than home health agencies bill to a DME MAC. | 779 | none | No amount |
| Q1 | STV-Packaged Codes. Paid under OPPS; Addendum B displays APC assignments when services are separately payable. (1) Packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator “S”, “T”, or “V". (2) Composite APC payment if billed with specific combinations of services based on OPPS composite-specific payment criteria. Payment is packaged into a single payment for specific combinations of services. (3) In other circumstances, payment is made through a separate APC payment. | 739 | 739 | Not proven |
| S | Procedure or Service, Not Discounted When Multiple. Paid under OPPS; separate APC payment. | 686 | 686 | Yes |
| K | Nonpass-Through Drugs and Nonimplantable Biologicals, Including Radiopharmaceuticals. Paid under OPPS; separate APC payment. | 539 | 539 | No |
| S1 | Skin substitute product paid separately. Paid under OPPS; separate APC payment. Subject to payment based on FDA regulatory pathway. | 322 | 322 | Not proven |
| Q3 | Codes That May Be Paid Through a Composite APC. Paid under OPPS; Addendum B displays APC assignments when services are separately payable. Addendum M displays composite APC assignments when codes are paid through a composite APC. (1) Composite APC payment based on OPPS composite-specific payment criteria. Payment is packaged into a single payment for specific combinations of services. (2) In other circumstances, payment is made through a separate APC payment or packaged into payment for other services. | 183 | 183 | Not proven |
| Q2 | T-Packaged Codes. Paid under OPPS; Addendum B displays APC assignments when services are separately payable. (1) Packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator “T”. (2) In other circumstances, payment is made through a separate APC payment. | 179 | 179 | Not proven |
| G | Pass-Through Drugs and Biologicals. Paid under OPPS; separate APC payment. | 109 | 109 | No |
| E2 | Items, Codes, and Services: For which pricing information and claims data are not available. Not paid by Medicare when submitted on outpatient claims (any outpatient bill type). | 53 | none | No amount |
| L | Influenza Vaccine; Pneumococcal Pneumonia Vaccine; Hepatitis B Vaccines; Covid-19 Vaccine; Monoclonal Antibody Therapy Product. Not paid under OPPS. Paid at reasonable cost; not subject to deductible or coinsurance. | 50 | none | No amount |
| R | Blood and Blood Products. Paid under OPPS; separate APC payment. | 41 | 41 | No |
| V | Clinic or Emergency Department Visit. Paid under OPPS; separate APC payment. | 23 | 23 | Yes |
| H | Pass-Through Device Categories. Separate cost-based pass‑through payment; not subject to copayment. | 21 | none | No amount |
| U | Brachytherapy Sources. Paid under OPPS; separate APC payment. | 17 | 17 | No |
| H1 | Non-opioid Medical Devices For Post-Surgical Pain Relief. Separate payment based on hospital’s charges adjusted to cost. Subject to criteria and payment limitation under Section 4135 of the CAA, 2023. | 13 | none | No amount |
| J2 | Hospital Part B Services That May Be Paid Through a Comprehensive APC. Paid under OPPS; Addendum B displays APC assignments when services are separately payable. (1) Comprehensive APC payment based on OPPS comprehensive-specific payment criteria. Payment for all covered Part B services on the claim is packaged into a single payment for specific combinations of services, except the Comprehensive APC payment policy exclusions found in the most recent Addendum J. (2) Packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator “J1". (3) In other circumstances, payment is made through a separate APC payment or packaged into payment for other services. | 13 | 13 | Yes |
| K1 | Non-Opioid Drugs and Biologicals For Post-Surgical Pain Relief. Paid under OPPS; separate APC payment. Subject to criteria and payment limitation under Section 4135 of the CAA, 2023. | 7 | 7 | No |
| P | Partial Hospitalization or Intensive Outpatient Program. Paid under OPPS; per diem APC payment. | 4 | none | No amount |
| F | Corneal Tissue Acquisition; Certain CRNA Services. Not paid under OPPS. Paid at reasonable cost. | 1 | none | No amount |
| D | Discontinued Codes. Not paid under OPPS or any other Medicare payment system. | none | none | No amount |
Source: the CY 2026 Addendum D1, member 2026 NFRM Addendum D1.11.20.2025.xlsx. Of the 7,360 rows that carry a payable amount, CMS’s Pricer source proves it wage adjusts 5,224 and does not adjust 713. For the remaining 1,423 the newest Pricer source CMS publishes predates the indicator, so the tool states both readings and publishes neither alone.
Why the date of service decides the file, down to the day
CMS reissues the hospital outpatient addenda every quarter, and a year is not an answer: codes join and leave the schedule mid-year, and rates move with them. Three further instruments change what a date is worth after the addendum is published. CMS restates drug and biological prices on its own correction pages. It creates and reprices codes retroactively in the narrative of its quarterly transmittals, where an addendum reader never looks. And it re-posts whole releases.
That last one is easy to miss. 6 of the 27 releases here, January 2020 to July 2026, are CMS corrections that replace the original file for the whole quarter rather than starting a new window. This archive pins both the correction and the bytes it superseded, each by sha256, so a figure printed in a report can be produced again later unchanged even after CMS rewrites the file at that address. The earliest date this tool prices is Jan 1, 2020.
Key terms in a hospital outpatient rate lookup
- Addendum A and Addendum B
- The two lists CMS publishes each quarter. Addendum B maps a HCPCS code to a status indicator, an APC and a national unadjusted payment rate. Addendum A maps an APC to its group title and rate. The 2026 July OPPS addenda carry 19,153 codes and 1,051 APCs.
- APC
- Ambulatory Payment Classification, the group CMS pays by. Codes in one APC share a rate, and the group title is CMS’s own description of what the group covers.
- Status indicator
- CMS’s one or two character code on every row, deciding how a service is paid and whether a figure exists at all. The 2026 July OPPS addenda define 29 of them.
- Comprehensive APC (J1)
- One payment for the whole claim. Everything else covered on the claim is packaged into it, except CMS’s Addendum J exclusions, so the rate is not a price for a single line.
- CCN
- The CMS Certification Number, six digits, that identifies a hospital to Medicare. It is the unit the wage index is published at, which is why this tool asks for a hospital rather than a state.
- Post-reclassification wage index
- The inpatient PPS wage index after a hospital’s own geographic reclassification and the rural floor. It adjusts 60 percent of an OPPS payment, and it is not the pre-floor index the ASC schedule uses.
How bill reviewers use hospital outpatient rates
A medical billing expert reads the code off the UB-04, prices it under the release CMS had in force on the date of service, picks the hospital that billed it, and sets that hospital’s figure beside the billed facility charge. Because each figure traces to an archived CMS file rather than to a link that may be retired, it can be produced again later unchanged. For the doctor’s fee on the same visit, use the Medicare rate lookup.
For the same procedure in a freestanding surgery center, use the ASC fee schedule lookup. For implants and supplies billed separately, see the DMEPOS fee schedule lookup; for drugs given during the visit, the Part B drug payment limits; for lab work, the clinical lab fee schedule. New Jersey no-fault claims have their own hospital outpatient surgical facility fees in Exhibit 7 of the NJ PIP fee schedule. For the whole workflow from a stack of bills to a signed report, see Desk.
Medicare hospital outpatient rates, answered
What is the Medicare OPPS payment rate?
It is what Medicare pays a hospital for an outpatient service: the hospital's own money for the facility side of the visit, from CMS's quarterly Addendum B and Addendum A. It is not the doctor's fee for the same code, it is not the surgery center's facility payment, and it is not an inpatient stay, which Medicare pays as one MS-DRG for the whole admission. The 2026 July OPPS addenda carry 19,153 HCPCS codes across 29 status indicators. 7,360 of those rows carry a payable amount and 11,793 do not. CMS reissues the addenda every quarter and this archive holds all 27 releases, January 2020 to July 2026.
Why does the same code pay a different amount at two hospitals?
Because CMS adjusts 60 percent of the rate by the wage index of the hospital being paid. Pub. 100-04 ch. 4 s10.8 puts the labor-related share at 60 percent and uses the inpatient PPS wage index, post-reclassification and post-floor. That is a different share and a different index from the ambulatory surgical center schedule, which uses 50 percent and the pre-floor, pre-reclassified index. CMS's CY 2026 OPPS Hospital Impact File states a wage index for 3,439 hospitals, and they run from 0.5426 to 1.7328. On 99284, whose national rate is $426.30, that range is $309.31 at the bottom and $613.74 at the top.
What does status indicator J1 mean, and why does it matter?
J1 is a comprehensive APC, and it is the most expensive misreading on a hospital outpatient bill. CMS pays that one rate for the WHOLE claim: all covered Part B services on the claim are packaged with the primary J1 service, except the exclusions in CMS's most recent Addendum J. So printing a J1 rate beside a single billed line overstates the bill while looking entirely reasonable. 3,450 of the 19,153 codes in the 2026 July OPPS addenda carry J1, and 3,463 carry J1 or J2 between them. A further 1,101 carry Q1, Q2 or Q3, where a rate exists and the rest of the claim decides whether it is paid. This tool prints the condition with the dollar, every time.
Why does an OPPS code show no dollar amount at all?
Because for 11,793 of the 19,153 rows in the 2026 July OPPS addenda CMS publishes no payable amount, and that is an answer rather than a gap. Fifteen of CMS's status indicators never carry a rate. Some services are paid under a different Medicare payment system entirely. Some are packaged into the other services on the claim. Some are inpatient-only procedures CMS says to admit the patient for. A published 0.00 is not a price either, and neither is a rate sitting beside an indicator that pays nothing. This tool shows CMS's own Addendum D1 definition and CMS's own reason in place of a figure, and never prints $0.00 for a service Medicare pays for.
Which hospitals get no per-hospital figure, and why?
42 CFR 419.20(b) excludes exactly five kinds from OPPS: Maryland waiver hospitals, critical access hospitals, hospitals outside the 50 States, DC and Puerto Rico, Indian Health Service hospitals, and rural emergency hospitals. In CMS's CY 2026 files that is 668 of 4,281 hospitals, and each one gets the regulation rather than a number. Cancer and children's hospitals are a separate case: they ARE paid under OPPS, 105 of them here, but CMS leaves them out of the impact file because they are held harmless under section 1833(t)(7)(D)(ii), so CMS publishes no per-hospital wage index for them there and the national amount stands, with that stated.
Does the OPPS rate change during the year?
Yes, and in a way a year filter cannot express. CMS reissues the addenda every quarter, restates drug and biological prices after publishing them, and creates and reprices codes retroactively in the narrative of its quarterly transmittals. It also re-posts a release outright: 6 of the 27 releases here, January 2020 to July 2026, are CMS corrections that replace the original file for the whole quarter. This archive pins every one of them with its own sha256, so a date of service is priced under the file CMS had in force that day rather than under whichever version is on the CMS website now. The earliest date this tool can price is Jan 1, 2020.
Why can this lookup not search by procedure description?
Because it publishes no code descriptions at all, on purpose. For a CPT code the short descriptor is text the American Medical Association licenses, and these files are served publicly to anyone, so the build reads the column, checks it against CMS's own 508 text copy and does not ship it. The cost is real: you have to arrive with the code. What the page publishes instead is CMS's own material, including the definition of all 29 status indicators in the table above and CMS's own Addendum A group title for the APC a code maps to. If you have a half-remembered code, the Medicare rate lookup can find it by word for HCPCS Level II codes, which carry CMS's own names.
How do bill reviewers use OPPS rates in an expert report?
They read the code off the UB-04, price it under the CMS release in force on the date of service, pick the hospital that billed it, and set that hospital's figure beside the billed facility charge. Because every amount traces to an archived CMS file rather than to a link, the figure can be produced again later unchanged. Two things have to travel with it. A comprehensive or conditionally packaged rate carries CMS's condition, because it is not a price for one line. And CY 2026 applies a ratio of 0.9951 to non-drug items and services at every hospital that is not excepted. This tool applies it as its own visible step where CMS's own Addendum R to the CY 2026 OPPS/ASC final rule, the list of providers subject to the reduction, names the hospital, and says in words when a figure leaves it out.