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Official Description

Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each
Short Descr Integrated filter & holder
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 1/1/2001
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 200
IOM 100-02, 15, 120
OTS Orthotic No
CCS Clinical Classification 243 - DME and supplies
KX Requirements specified in the medical policy have been met
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CR Catastrophe/disaster related
GA Waiver of liability statement issued as required by payer policy, individual case
GW Service not related to the hospice patient's terminal condition
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
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
RA Replacement of a dme, orthotic or prosthetic item
Date
Action
Notes
2001-01-01 Added Code added 1/1/2001
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