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Official Description

Mattress, foam rubber
Short Descr Mattress foam rubber
Coverage Special coverage instructions apply
Pricing Indicator(s) 32 – Supplies And Surgical Dressings - Inexpensive & routinely purchased DME (price subject to floors and ceilings)
MPI A – Not applicable, as HCPCS priced under one methodology
CIM 60-18
BETOS D1B – Hospital beds
TOS Code(s) A – Used durable medical equipment (DME)
Added Date 1/1/1986
APC Status Indicator Non-Implantable Durable Medical Equipment
MUE 0
MUE 1
IOM 100-03, 4, 280.1
OTS Orthotic No
CCS Clinical Classification 243 - DME and supplies
KX Requirements specified in the medical policy have been met
RR Rental (use the 'rr' modifier when dme is to be rented)
NU New equipment
BP The beneficiary has been informed of the purchase and rental options and has elected to purchase the item
RB Replacement of a part of a dme, orthotic or prosthetic item furnished as part of a repair
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
GA Waiver of liability statement issued as required by payer policy, individual case
GL Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no advance beneficiary notice (abn)
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
GK Reasonable and necessary item/service associated with a ga or gz modifier
GW Service not related to the hospice patient's terminal condition
GZ Item or service expected to be denied as not reasonable and necessary
KH Dmepos item, initial claim, purchase or first month rental
KJ Dmepos item, parenteral enteral nutrition (pen) pump or capped rental, months four to fifteen
KT Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item
RA Replacement of a dme, orthotic or prosthetic item
UE Used durable medical equipment
Date
Action
Notes
1986-01-01 Added Code added 1/1/1986
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