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Official Description

Prosthetic sheath, above knee, each
Short Descr Sheath above knee
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 2133
BETOS D1F – Prosthetic/Orthotic devices
TOS Code(s) P – Lump sum purchase of DME, prosthetics, orthotics
Added Date 1/1/1982
APC Status Indicator Service Paid under Fee Schedule or Payment System other than OPPS
MUE 0
MUE 12
IOM 100-02, 15, 200
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)
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.
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.
KX Requirements specified in the medical policy have been met
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.
K1 Lower extremity prosthesis functional level 1 - has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. typical of the limited and unlimited household ambulator.
AY Item or service furnished to an esrd patient that is not for the treatment of esrd
GW Service not related to the hospice patient's terminal condition
Date
Action
Notes
1982-01-01 Added Code added 1/1/1982
Code
Description
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