HCPCS Code A4222

Official Description

Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately)

Short Descr	Infusion supplies with pump
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	Not applicable/unspecified.
OTS Orthotic	No
CCS Clinical Classification	243 - DME and supplies

KX	Requirements specified in the medical policy have been met
GA	Waiver of liability statement issued as required by payer policy, individual case
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
JB	Administered subcutaneously
GX	Notice of liability issued, voluntary under payer policy
CR	Catastrophe/disaster related
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.
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
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
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.
SH	Second concurrently administered infusion therapy
SC	Medically necessary service or supply
JZ	Zero drug amount discarded/not administered to any patient
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.
SQ	Item ordered by home health
SS	Home infusion services provided in the infusion suite of the iv therapy provider
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.
A1	Dressing for one wound
BP	The beneficiary has been informed of the purchase and rental options and has elected to purchase the item
BR	The beneficiary has been informed of the purchase and rental options and has elected to rent the item
BU	The beneficiary has been informed of the purchase and rental options and after 30 days has not informed the supplier of his/her decision
EP	Service provided as part of medicaid early periodic screening diagnosis and treatment (epsdt) program
GC	This service has been performed in part by a resident under the direction of a teaching physician
GK	Reasonable and necessary item/service associated with a ga or gz modifier
JW	Drug amount discarded/not administered to any patient
KD	Drug or biological infused through dme
KY	Dmepos item subject to dmepos competitive bidding program number 5
KZ	New coverage not implemented by managed care
LT	Left side (used to identify procedures performed on the left side of the body)
SJ	Third or more concurrently administered infusion therapy
SU	Procedure performed in physician's office (to denote use of facility and equipment)
SV	Pharmaceuticals delivered to patient's home but not utilized
TF	Intermediate level of care
U8	Medicaid level of care 8, as defined by each state
UB	Medicaid level of care 11, as defined by each state