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Try CasePilot| Short Descr | Stationary 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 | GA | Waiver of liability statement issued as required by payer policy, individual case | QF | Prescribed amount of stationary oxygen while at rest exceeds 4 liters per minute (lpm) and portable oxygen is prescribed | N3 | Group 3 oxygen coverage criteria met | CR | Catastrophe/disaster related | KT | Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item | GZ | Item or service expected to be denied as not reasonable and necessary | RA | Replacement of a dme, orthotic or prosthetic item | 25 | Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59. | 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 | MS | Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty | N2 | Group 2 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 | QG | Prescribed amount of stationary oxygen while at rest is greater than 4 liters per minute (lpm) |
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| 1993-01-01 | Added | Code added 1/1/1993 |
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