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Official Description

Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf
Short Descr So 8 abd restraint pre ots
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 1/1/1986
APC Status Indicator Service Paid under Fee Schedule or Payment System other than OPPS
MUE 0
MUE 1
OTS Orthotic Yes
CCS Clinical Classification 243 - DME and supplies
RT Right side (used to identify procedures performed on the right side of the body)
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
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).
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CG Policy criteria applied
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
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
GX Notice of liability issued, voluntary under payer policy
GZ Item or service expected to be denied as not reasonable and necessary
KV Dmepos item subject to dmepos competitive bidding program that is furnished as part of a professional service
NU New equipment
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
ST Related to trauma or injury
Date
Action
Notes
2014-01-01 Changed Description Changed
1986-01-01 Added Code added 1/1/1986
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Description
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