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Official Description

Skin barrier, wipes or swabs, each
Short Descr Skin barrier, wipe or swab
Coverage Special coverage instructions apply
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
MCM 2130
BETOS D1F – Prosthetic/Orthotic devices
TOS Code(s) P – Lump sum purchase of DME, prosthetics, orthotics
Added Date 1/1/2006
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 150
MUE 450
IOM 100-02, 15, 120
OTS Orthotic No
CCS Clinical Classification 243 - DME and supplies
AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply
KX Requirements specified in the medical policy have been met
AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic
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
CR Catastrophe/disaster related
GW Service not related to the hospice patient's terminal condition
GZ Item or service expected to be denied as not reasonable and necessary
GA Waiver of liability statement issued as required by payer policy, individual case
EY No physician or other licensed health care provider order for this item or service
A1 Dressing for one wound
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
A2 Dressing for two wounds
A3 Dressing for three wounds
A5 Dressing for five wounds
A8 Dressing for eight wounds
AG Primary physician
CG Policy criteria applied
RT Right side (used to identify procedures performed on the right side of the body)
SC Medically necessary service or supply
Date
Action
Notes
2006-01-01 Added Code added 1/1/2006
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