HCPCS Code L4361

Official Description

Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf

Short Descr	Pneuma/vac walk boot 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	1/1/2014
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
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)
GZ	Item or service expected to be denied as not reasonable and necessary
GA	Waiver of liability statement issued as required by payer policy, individual case
KV	Dmepos item subject to dmepos competitive bidding program that is furnished as part of a professional service
EY	No physician or other licensed health care provider order for this item or 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
ST	Related to trauma or injury
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.
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.
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.
79	Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
A1	Dressing for one wound
AT	Acute treatment (this modifier should be used when reporting service 98940, 98941, 98942)
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)
CG	Policy criteria applied
FA	Left hand, thumb
GC	This service has been performed in part by a resident under the direction of a teaching physician
GK	Reasonable and necessary item/service associated with a ga or gz modifier
GL	Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no advance beneficiary notice (abn)
GP	Services delivered under an outpatient physical therapy plan of care
GS	Dosage of erythropoietin stimulating agent has been reduced and maintained in response to hematocrit or hemoglobin level
GT	Via interactive audio and video telecommunication systems
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
K2	Lower extremity prosthesis functional level 2 - has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. typical of the limited community ambulator.
KA	Add on option/accessory for wheelchair
KK	Dmepos item subject to dmepos competitive bidding program number 2
KT	Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item
KW	Dmepos item subject to dmepos competitive bidding program number 4
KY	Dmepos item subject to dmepos competitive bidding program number 5
NU	New equipment
P1	A normal healthy patient
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
RA	Replacement of a dme, orthotic or prosthetic item
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
UD	Medicaid level of care 13, as defined by each state
XS	Separate structure, a service that is distinct because it was performed on a separate organ/structure