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Official Description

Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing
Short Descr Portable liquid 02
Coverage Special coverage instructions apply
Pricing Indicator(s) 33 – Supplies And Surgical Dressings - Oxygen and oxygen equipment (price subject to floors and ceilings)
MPI A – Not applicable, as HCPCS priced under one methodology
CIM 60-4
MCM 4107.9
BETOS D1C – Oxygen and supplies
TOS Code(s) R – Rental of DME
Added Date 1/1/1993
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
RR Rental (use the 'rr' modifier when dme is to be rented)
KX Requirements specified in the medical policy have been met
N1 Group 1 oxygen coverage criteria met
QF Prescribed amount of stationary oxygen while at rest exceeds 4 liters per minute (lpm) and portable oxygen is prescribed
GA Waiver of liability statement issued as required by payer policy, individual case
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
KT Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item
N3 Group 3 oxygen coverage criteria met
QB Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts exceeds 4 liters per minute (lpm) and portable oxygen is prescribed
N2 Group 2 oxygen coverage criteria met
CR Catastrophe/disaster related
KY Dmepos item subject to dmepos competitive bidding program number 5
NU New equipment
RA Replacement of a dme, orthotic or prosthetic item
Date
Action
Notes
1993-01-01 Added Code added 1/1/1993
Code
Description
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