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Official Description

Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
Short Descr Pwc gp2 std sing pow opt s/b
Coverage Carrier Priced
Pricing Indicator(s) 36 – Supplies And Surgical Dressings - Capped rental 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 10/1/2006
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
BP The beneficiary has been informed of the purchase and rental options and has elected to purchase the item
RR Rental (use the 'rr' modifier when dme is to be rented)
KJ Dmepos item, parenteral enteral nutrition (pen) pump or capped rental, months four to fifteen
KH Dmepos item, initial claim, purchase or first month rental
GL Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no advance beneficiary notice (abn)
KX Requirements specified in the medical policy have been met
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
GK Reasonable and necessary item/service associated with a ga or gz modifier
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
KI Dmepos item, second or third month rental
Date
Action
Notes
2006-10-01 Added Code added 10/1/2006
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