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Official Description

Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), with or without filter, each
Short Descr 1pc ost pch drain hgh output
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 1/1/2013
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
A1 Dressing for one wound
Date
Action
Notes
2013-01-01 Added Added
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