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Official Description

Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material
Short Descr Add ue prost b/e acrylic
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 1/1/2006
APC Status Indicator Service Paid under Fee Schedule or Payment System other than OPPS
MUE 0
MUE 2
OTS Orthotic No
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)
GZ Item or service expected to be denied as not reasonable and necessary
K3 Lower extremity prosthesis functional level 3 - has the ability or potential for ambulation with variable cadence. typical of the community ambulator who has the ability to transverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.
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.
KX Requirements specified in the medical policy have been met
RB Replacement of a part of a dme, orthotic or prosthetic item furnished as part of a repair
Date
Action
Notes
2006-01-01 Added Code added 1/1/2006
Code
Description
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