| Short Descr | 1 pc ost pou w built-in conv |
| Coverage | Special coverage instructions apply |
| Pricing Indicator(s) | 37 – Supplies And Surgical Dressings - Ostomy, tracheostomy and urological supplies (price subject to floors and ceilings) |
| MPI | A – Not applicable, as HCPCS priced under one methodology |
| MCM | 2130 |
| BETOS | D1F – Prosthetic/Orthotic devices |
| TOS Code(s) | P – Lump sum purchase of DME, prosthetics, orthotics |
| Added Date | 1/1/2012 |
| Status Code | Statutory Exclusion (from MPFS, may be paid under other methodologies) |
| Global Days | XXX - Global Concept Does Not Apply |
| PC/TC Indicator (26, TC) | 9 - Not Applicable |
| Multiple Procedures (51) | 9 - Concept does not apply. |
| Bilateral Surgery (50) | 9 - Concept does not apply. |
| Physician Supervisions | 09 - Concept does not apply. |
| Assistant Surgeon (80, 82) | 9 - Concept does not apply. |
| Co-Surgeons (62) | 9 - Concept does not apply. |
| Team Surgery (66) | 9 - Concept does not apply. |
| Diagnostic Imaging Family | 99 - Concept Does Not Apply |
| APC Status Indicator | Items and Services Packaged into APC Rates |
| MUE | 90 |
| MUE | 120 |
| IOM | 100-02, 15, 120 |
| OTS Orthotic | No |
| CCS Clinical Classification | 243 - DME and supplies |
| KX | Requirements specified in the medical policy have been met |
| GW | Service not related to the hospice patient's terminal condition |
| EY | No physician or other licensed health care provider order for this item or service |
| CR | Catastrophe/disaster related |
| GA | Waiver of liability statement issued as required by payer policy, individual case |
| SC | Medically necessary service or supply |
| CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) |
| NU | New equipment |
| GZ | Item or service expected to be denied as not reasonable and necessary |
| A1 | Dressing for one wound |
| GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2012-01-01 | Added | Added |