| Code | Description | Comment | Version |
| 1 | No payment adjustment | | added v2.4 |
| 2 | Designated current drug or biological payment adjustment applies to APC (status indicator G) | | added v2.4 |
| 3 | Designated new device payment adjustment applies to APC (status indicator H) | | added v2.4 |
| 4 | Designated new drug or new biological payment adjustment applies to APC (status indicator J) | | added v2.4 |
| 5 | Deductible not applicable (specific list of HCPCS codes) | | added v2.4 |