HCPCS Code L8000

Official Description

Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type

Short Descr	Mastectomy bra
Coverage	Special coverage instructions apply
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
MCM	2130 A
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	6
IOM	100-02, 15, 120
OTS Orthotic	No
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
CR	Catastrophe/disaster related
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
GW	Service not related to the hospice patient's terminal condition
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).
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.
AB	Audiology service furnished personally by an audiologist without a physician/npp order for non-acute hearing assessment unrelated to disequilibrium, or hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids; service may be performed once every 12 months, per beneficiary
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
GK	Reasonable and necessary item/service associated with a ga or gz modifier
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
GZ	Item or service expected to be denied as not reasonable and necessary
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.
KT	Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item
LR	Laboratory round trip
M2	Medicare secondary payer (msp)
PO	Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
RA	Replacement of a dme, orthotic or prosthetic item
SC	Medically necessary service or supply