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Official Description

Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each
Short Descr Ost pch for bar w flange/flt
Coverage Carrier Priced
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
BETOS D1F – Prosthetic/Orthotic devices
TOS Code(s) P – Lump sum purchase of DME, prosthetics, orthotics
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 2
MUE Not applicable/unspecified.
OTS Orthotic No
CCS Clinical Classification 243 - DME and supplies
KX Requirements specified in the medical policy have been met
GW Service not related to the hospice patient's terminal condition
GA Waiver of liability statement issued as required by payer policy, individual case
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)
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
A1 Dressing for one wound
GK Reasonable and necessary item/service associated with a ga or gz modifier
Date
Action
Notes
2004-01-01 Added Code added 1/1/2004
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