| Short Descr | Lens sphere trifocal 4.00d | Coverage | Carrier Priced | Pricing Indicator(s) | 38 – Supplies And Surgical Dressings - Orthotics, prosthetics, prosthetic devices & vision services (price subject to floors and ceilings) | MPI | A – Not applicable, as HCPCS priced under one methodology | BETOS | D1F – Prosthetic/Orthotic devices | TOS Code(s) | Q – Vision items or services | Added Date | 1/1/1985 | 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 | Service Paid under Fee Schedule or Payment System other than OPPS | MUE | 0 | MUE | 2 | OTS Orthotic | No | CCS Clinical Classification | 241 - Visual aids and other optical supplies |
| RT | Right side (used to identify procedures performed on the right side of the body) | LT | Left side (used to identify procedures performed on the left side of the body) | KX | Requirements specified in the medical policy have been met | GA | Waiver of liability statement issued as required by payer policy, individual case | VP | Aphakic patient | 55 | Postoperative management only: when 1 physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | EY | No physician or other licensed health care provider order for this item or service | GK | Reasonable and necessary item/service associated with a ga or gz modifier | GW | Service not related to the hospice patient's terminal condition | GX | Notice of liability issued, voluntary under payer policy | 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 | GZ | Item or service expected to be denied as not reasonable and necessary | KA | Add on option/accessory for wheelchair | KT | Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item | KY | Dmepos item subject to dmepos competitive bidding program number 5 | KZ | New coverage not implemented by managed care | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | RA | Replacement of a dme, orthotic or prosthetic item | SC | Medically necessary service or supply |
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| 1985-01-01 | Added | Code added 1/1/1985 |