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Official Description

Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each
Short Descr Drive wheel excludes tire
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
Processing Note NCD MANUAL 280.1.
BETOS D1D – Wheelchairs
TOS Code(s) A – Used durable medical equipment (DME)
Added Date 1/1/2007
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
RB Replacement of a part of a dme, orthotic or prosthetic item furnished as part of a repair
KU Dmepos item subject to dmepos competitive bidding program number 3
LT Left side (used to identify procedures performed on the left side of the body)
KX Requirements specified in the medical policy have been met
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
RT Right side (used to identify procedures performed on the right side of the body)
UE Used durable medical equipment
BP The beneficiary has been informed of the purchase and rental options and has elected to purchase the item
BR The beneficiary has been informed of the purchase and rental options and has elected to rent the item
EY No physician or other licensed health care provider order for this item or service
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
KY Dmepos item subject to dmepos competitive bidding program number 5
Date
Action
Notes
2007-01-01 Added Code added 1/1/2007
Code
Description
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