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Official Description

Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service
Short Descr Non-adju cgm supply allow
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) 9 – Other medical items or services
Added Date 1/1/2023
Status Code Bundled/Excluded Code
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 Non-Implantable Durable Medical Equipment
MUE Not applicable/unspecified.
MUE 3
OTS Orthotic No
KX Requirements specified in the medical policy have been met
CG Policy criteria applied
KF Item designated by fda as class iii device
KS Glucose monitor supply for diabetic beneficiary not treated with insulin
CR Catastrophe/disaster related
U8 Medicaid level of care 8, as defined by each state
GW Service not related to the hospice patient's terminal condition
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
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.
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CF Amcc test has been ordered by an esrd facility or mcp physician that is not part of the composite rate and is separately billable
CH 0 percent impaired, limited or restricted
CS Cost-sharing waived for specified covid-19 testing-related services that result in and order for or administration of a covid-19 test and/or used for cost-sharing waived preventive services furnished via telehealth in rural health clinics and federally qualified health centers during the covid-19 public health emergency
CT Computed tomography services furnished using equipment that does not meet each of the attributes of the national electrical manufacturers association (nema) xr-29-2013 standard
GA Waiver of liability statement issued as required by payer policy, individual case
GC This service has been performed in part by a resident under the direction of a teaching physician
GG Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day
GL Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no advance beneficiary notice (abn)
KG Dmepos item subject to dmepos competitive bidding program number 1
KK Dmepos item subject to dmepos competitive bidding program number 2
KR Rental item, billing for partial month
KU Dmepos item subject to dmepos competitive bidding program number 3
KY Dmepos item subject to dmepos competitive bidding program number 5
NU New equipment
RA Replacement of a dme, orthotic or prosthetic item
RT Right side (used to identify procedures performed on the right side of the body)
SG Ambulatory surgical center (asc) facility service
Date
Action
Notes
2023-01-01 Added Code added.
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