HCPCS Code L3908

Official Description

Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the-shelf

Short Descr	Who cock-up nonmolde 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	2
OTS Orthotic	Yes
CCS Clinical Classification	243 - DME and supplies

LT	Left side (used to identify procedures performed on the left side of the body)
RT	Right side (used to identify procedures performed on the right 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
CG	Policy criteria applied
CR	Catastrophe/disaster related
KV	Dmepos item subject to dmepos competitive bidding program that is furnished as part of a professional service
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).
GO	Services delivered under an outpatient occupational therapy plan of care
ST	Related to trauma or injury
58	Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
GC	This service has been performed in part by a resident under the direction of a teaching physician
GP	Services delivered under an outpatient physical therapy plan of care
RA	Replacement of a dme, orthotic or prosthetic item
25	Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59.
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.
51	Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
52	Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
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.
76	Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
77	Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
80	Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
AG	Primary physician
AQ	Physician providing a service in an unlisted health professional shortage area (hpsa)
AT	Acute treatment (this modifier should be used when reporting service 98940, 98941, 98942)
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CO	Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant
CQ	Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant
ER	Items and services furnished by a provider-based, off-campus emergency department
EY	No physician or other licensed health care provider order for this item or service
F2	Left hand, third digit
F3	Left hand, fourth digit
F5	Right hand, thumb
F7	Right hand, third digit
FA	Left hand, thumb
FX	X-ray taken using film
FY	X-ray taken using computed radiography technology/cassette-based imaging
GK	Reasonable and necessary item/service associated with a ga or gz modifier
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
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
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.
KH	Dmepos item, initial claim, purchase or first month rental
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
KZ	New coverage not implemented by managed care
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
RB	Replacement of a part of a dme, orthotic or prosthetic item furnished as part of a repair
RC	Right coronary artery
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
XU	Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service