HCPCS Code A4221

Official Description

Supplies for maintenance of non-insulin drug infusion catheter, per week (list drugs separately)

Short Descr	Supp non-insulin inf cath/wk
Coverage	Carrier Priced
Pricing Indicator(s)	34 – Supplies And Surgical Dressings - DME supplies (price subject to floors and ceilings)
MPI	A – Not applicable, as HCPCS priced under one methodology
BETOS	D1E – Other DME
TOS Code(s)	P – Lump sum purchase of DME, prosthetics, orthotics
Added Date	1/1/1997
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	4
OTS Orthotic	No
CCS Clinical Classification	243 - DME and supplies

KX	Requirements specified in the medical policy have been met
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
JB	Administered subcutaneously
GA	Waiver of liability statement issued as required by payer policy, individual case
GX	Notice of liability issued, voluntary under payer policy
GZ	Item or service expected to be denied as not reasonable and necessary
SH	Second concurrently administered infusion therapy
SC	Medically necessary service or supply
CR	Catastrophe/disaster related
EY	No physician or other licensed health care provider order for this item or service
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
GW	Service not related to the hospice patient's terminal condition
BO	Orally administered nutrition, not by feeding tube
SQ	Item ordered by home health
76	Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
77	Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
A1	Dressing for one wound
CA	Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission
GP	Services delivered under an outpatient physical therapy plan of care
GU	Waiver of liability statement issued as required by payer policy, routine notice
JW	Drug amount discarded/not administered to any patient
JZ	Zero drug amount discarded/not administered to any patient
KS	Glucose monitor supply for diabetic beneficiary not treated with insulin
KY	Dmepos item subject to dmepos competitive bidding program number 5
PA	Surgical or other invasive procedure on wrong body part
RC	Right coronary artery
SJ	Third or more concurrently administered infusion therapy
SS	Home infusion services provided in the infusion suite of the iv therapy provider
SU	Procedure performed in physician's office (to denote use of facility and equipment)
TF	Intermediate level of care
UB	Medicaid level of care 11, as defined by each state