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Official Description

Custom fabricated wheelchair back cushion, any size, including any type mounting hardware
Short Descr Custom fab w/c back cushion
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 1/1/2005
APC Status Indicator Non-Implantable Durable Medical Equipment
MUE 0
MUE 1
OTS Orthotic No
CCS Clinical Classification 243 - DME and supplies
NU New equipment
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
RB Replacement of a part of a dme, orthotic or prosthetic item furnished as part of a repair
GA Waiver of liability statement issued as required by payer policy, individual case
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)
GW Service not related to the hospice patient's terminal condition
GZ Item or service expected to be denied as not reasonable and necessary
KU Dmepos item subject to dmepos competitive bidding program number 3
RA Replacement of a dme, orthotic or prosthetic item
Date
Action
Notes
2005-01-01 Added Code added 1/1/2005
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