HCPCS Code A4927

Official Description

Gloves, non-sterile, per 100

Short Descr	Non-sterile gloves
Coverage	Special coverage instructions apply
Pricing Indicator(s)	00 – Service not separately priced by part B (e.G., services not covered, bundled, used by part a only, etc.)
MPI	9 – Not applicable, as HCPCS not priced separately by part B (pricing indicator is 00) or value is not established (pricing indicator is '99')
Processing Note	SEE INTERMEDIARY MANUAL SECTION 3170.5 FOR COVERAGE INSTRUCTIONS PERTAINING TO
BETOS	P9B – Dialysis services (non-medicare fee schedule)
TOS Code(s)	L – ESRD supplies
Added Date	1/1/1986
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	0
OTS Orthotic	No
CCS Clinical Classification	243 - DME and supplies

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
GX	Notice of liability issued, voluntary under payer policy
GA	Waiver of liability statement issued as required by payer policy, individual case
CR	Catastrophe/disaster related
KX	Requirements specified in the medical policy have been met
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.
AY	Item or service furnished to an esrd patient that is not for the treatment of esrd
SH	Second concurrently administered infusion therapy
AX	Item furnished in conjunction with dialysis services
GW	Service not related to the hospice patient's terminal condition
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.
A1	Dressing for one wound
A2	Dressing for two wounds
A3	Dressing for three wounds
A4	Dressing for four wounds
A5	Dressing for five wounds
A6	Dressing for six wounds
A7	Dressing for seven wounds
A8	Dressing for eight wounds
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CG	Policy criteria applied
EY	No physician or other licensed health care provider order for this item or service
GO	Services delivered under an outpatient occupational therapy plan of care
GP	Services delivered under an outpatient physical therapy plan of care
GU	Waiver of liability statement issued as required by payer policy, routine notice
LT	Left side (used to identify procedures performed on the left side of the body)
RT	Right side (used to identify procedures performed on the right side of the body)
SC	Medically necessary service or supply
U2	Medicaid level of care 2, as defined by each state
U7	Medicaid level of care 7, as defined by each state
U8	Medicaid level of care 8, as defined by each state
UD	Medicaid level of care 13, as defined by each state