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Try CasePilot| Short Descr | Ak 4 bar link hydl swg/stanc | Coverage | Carrier Priced | Pricing Indicator(s) | 38 – Supplies And Surgical Dressings - Orthotics, prosthetics, prosthetic devices & vision services (price subject to floors and ceilings) | MPI | A – Not applicable, as HCPCS priced under one methodology | BETOS | D1F – Prosthetic/Orthotic devices | TOS Code(s) | P – Lump sum purchase of DME, prosthetics, orthotics | Added Date | 4/1/2021 | Termination Date | 12/31/2023 | APC Status Indicator | Non-Implantable Durable Medical Equipment | MUE | Not applicable/unspecified. | MUE | Not applicable/unspecified. | OTS Orthotic | No |
| K3 | Lower extremity prosthesis functional level 3 - has the ability or potential for ambulation with variable cadence. typical of the community ambulator who has the ability to transverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. | K4 | Lower extremity prosthesis functional level 4 - has the ability or potential for prosthetic ambulation that exceeds the basic ambulation skills, exhibiting high impact, stress, or energy levels, typical of the prosthetic demands of the child, active adult, or athlete. | KX | Requirements specified in the medical policy have been met | LT | Left side (used to identify procedures performed on the left side of the body) | NU | New equipment | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2023-12-31 | Deleted | Code deleted, see L5615. |
| 2022-10-01 | Note | Payment change (MOG, pricing indicator codes, anesthesia base units, Ambulatory Surgical Centers) |
| 2021-04-01 | Added | Code added. |
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