HCPCS Code A4217

Official Description

Sterile water/saline, 500 ml

Short Descr	Sterile water/saline, 500 ml
Related Drugs	SODIUM CHLORIDE
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	2049
BETOS	D1F – Prosthetic/Orthotic devices
TOS Code(s)	1 – Medical care
Added Date	1/1/2004
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	0
MUE	Not applicable/unspecified.
IOM	100-02, 15, 50
OTS Orthotic	No
CCS Clinical Classification	243 - DME and supplies

KX	Requirements specified in the medical policy have been met
AU	Item furnished in conjunction with a urological, ostomy, or tracheostomy supply
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
CR	Catastrophe/disaster related
A1	Dressing for one wound
GA	Waiver of liability statement issued as required by payer policy, individual case
AY	Item or service furnished to an esrd patient that is not for the treatment of esrd
A2	Dressing for two wounds
GZ	Item or service expected to be denied as not reasonable and necessary
GW	Service not related to the hospice patient's terminal condition
BO	Orally administered nutrition, not by feeding tube
CG	Policy criteria applied
EP	Service provided as part of medicaid early periodic screening diagnosis and treatment (epsdt) program
EY	No physician or other licensed health care provider order for this item or service
22	Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
GX	Notice of liability issued, voluntary under payer policy
JA	Administered intravenously
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.
A3	Dressing for three wounds
A4	Dressing for four wounds
A7	Dressing for seven wounds
GV	Attending physician not employed or paid under arrangement by the patient's hospice provider
JW	Drug amount discarded/not administered to any patient
JZ	Zero drug amount discarded/not administered to any patient
LT	Left side (used to identify procedures performed on the left side of the body)
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
RT	Right side (used to identify procedures performed on the right side of the body)
SU	Procedure performed in physician's office (to denote use of facility and equipment)