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Official Description

Orthopedic shoe, modification, addition or transfer, not otherwise specified
Short Descr Orthopedic shoe modifica nos
Coverage Special coverage instructions apply
Pricing Indicator(s) 00 – Service not separately priced by part B (e.G., services not covered, bundled, used by part a only, etc.)
MPI 9 – Not applicable, as HCPCS not priced separately by part B (pricing indicator is 00) or value is not established (pricing indicator is '99')
MCM 2323
BETOS D1F – Prosthetic/Orthotic devices
TOS Code(s) P – Lump sum purchase of DME, prosthetics, orthotics
Added Date 1/1/1982
APC Status Indicator Service Paid under Fee Schedule or Payment System other than OPPS
MUE 0
MUE Not applicable/unspecified.
IOM 100-02, 15, 290
OTS Orthotic No
CCS Clinical Classification 243 - DME and supplies
RT Right side (used to identify procedures performed on the right side of the body)
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
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
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
AY Item or service furnished to an esrd patient that is not for the treatment of esrd
GA Waiver of liability statement issued as required by payer policy, individual case
GX Notice of liability issued, voluntary under payer policy
GZ Item or service expected to be denied as not reasonable and necessary
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.
NU New equipment
PN Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital
RB Replacement of a part of a dme, orthotic or prosthetic item furnished as part of a repair
Date
Action
Notes
1982-01-01 Added Code added 1/1/1982
Code
Description
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