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Official Description

Elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, off-the-shelf
Short Descr Eo, adj lock joint prefab ot
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 1/1/2018
APC Status Indicator Service Paid under Fee Schedule or Payment System other than OPPS
MUE 0
MUE 2
OTS Orthotic No
KX Requirements specified in the medical policy have been met
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)
RA Replacement of a dme, orthotic or prosthetic item
26 Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
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
CR Catastrophe/disaster related
GA Waiver of liability statement issued as required by payer policy, individual case
GW Service not related to the hospice patient's terminal condition
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
GZ Item or service expected to be denied as not reasonable and necessary
KT Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item
KV Dmepos item subject to dmepos competitive bidding program that is furnished as part of a professional service
QX Crna service: with medical direction by a physician
ST Related to trauma or injury
Date
Action
Notes
2018-01-01 Added Code Added.
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