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Official Description

Wound pouch, each
Short Descr Wound pouch each
Coverage Special coverage instructions apply
Pricing Indicator(s) 35 – Supplies And Surgical Dressings - Surgical dressings (price subject to floors and ceilings)
MPI A – Not applicable, as HCPCS priced under one methodology
MCM 2079
BETOS D1A – Medical/surgical supplies
TOS Code(s) S – Surgical dressings or other medical supplies
Added Date 1/1/1997
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 Items and Services Packaged into APC Rates
MUE 0
MUE Not applicable/unspecified.
IOM 100-02, 15, 100
OTS Orthotic No
CCS Clinical Classification 243 - DME and supplies
A1 Dressing for one wound
A2 Dressing for two wounds
A3 Dressing for three wounds
CR Catastrophe/disaster related
KX Requirements specified in the medical policy have been met
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
GA Waiver of liability statement issued as required by payer policy, individual case
A4 Dressing for four wounds
Date
Action
Notes
1997-01-01 Added Code added 1/1/1997
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