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Official Description

Shoulder orthosis, acromio/clavicular (canvas and webbing type), prefabricated, off-the-shelf
Short Descr So acro/clav can web 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 1/1/1982
APC Status Indicator Service Paid under Fee Schedule or Payment System other than OPPS
MUE Not applicable/unspecified.
MUE Not applicable/unspecified.
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
GA Waiver of liability statement issued as required by payer policy, individual case
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
CR Catastrophe/disaster related
CG Policy criteria applied
J5 Off-the-shelf orthotic subject to dmepos competitive bidding program that is furnished as part of a physical therapist or occupational therapist professional service
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).
95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
AY Item or service furnished to an esrd patient that is not for the treatment of esrd
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)
EY No physician or other licensed health care provider order for this item or service
F2 Left hand, third digit
FY X-ray taken using computed radiography technology/cassette-based imaging
GC This service has been performed in part by a resident under the direction of a teaching physician
GL Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no advance beneficiary notice (abn)
GO Services delivered under an outpatient occupational therapy plan of care
GP Services delivered under an outpatient physical therapy plan of care
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
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
JZ Zero drug amount discarded/not administered to any patient
KR Rental item, billing for partial month
KS Glucose monitor supply for diabetic beneficiary not treated with insulin
KT Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item
KY Dmepos item subject to dmepos competitive bidding program number 5
NU New equipment
RA Replacement of a dme, orthotic or prosthetic item
ST Related to trauma or injury
T1 Left foot, second digit
TC Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
Date
Action
Notes
2014-01-01 Changed Description Changed
2011-01-01 Deleted Deleted
2011-01-01 ReActivated This code was originally scheduled for deletion for January 1, 2011. However, on December 10, 2010, CMS issued a statement saying that it was reinstated.
1982-01-01 Added Added
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Description
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