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Official Description

Manual wheelchair accessory, foam caster tire, any size, each
Short Descr Foam caster tire any size ea
Coverage Carrier Priced
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
BETOS D1D – Wheelchairs
TOS Code(s) A – Used durable medical equipment (DME)
Added Date 1/1/2006
APC Status Indicator Non-Implantable Durable Medical Equipment
MUE 0
MUE 2
OTS Orthotic No
CCS Clinical Classification 243 - DME and supplies
NU New equipment
KU Dmepos item subject to dmepos competitive bidding program number 3
KX Requirements specified in the medical policy have been met
RR Rental (use the 'rr' modifier when dme is to be rented)
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
RB Replacement of a part of a dme, orthotic or prosthetic item furnished as part of a repair
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
KY Dmepos item subject to dmepos competitive bidding program number 5
BP The beneficiary has been informed of the purchase and rental options and has elected to purchase the item
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
GA Waiver of liability statement issued as required by payer policy, individual case
GZ Item or service expected to be denied as not reasonable and necessary
KE Bid under round one of the dmepos competitive bidding program for use with non-competitive bid base equipment
KT Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item
TW Back-up equipment
UE Used durable medical equipment
Date
Action
Notes
2006-01-01 Added Code added 1/1/2006
Code
Description
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