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Official Description

Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
Short Descr Ewhf s/d uprt micro sensor
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 1/1/2019
APC Status Indicator Service Paid under Fee Schedule or Payment System other than OPPS
MUE 0
MUE 1
OTS Orthotic No
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
GA Waiver of liability statement issued as required by payer policy, individual case
KH Dmepos item, initial claim, purchase or first month rental
KI Dmepos item, second or third month rental
KJ Dmepos item, parenteral enteral nutrition (pen) pump or capped rental, months four to fifteen
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)
NU New equipment
RR Rental (use the 'rr' modifier when dme is to be rented)
RT Right side (used to identify procedures performed on the right side of the body)
Date
Action
Notes
2024-01-01 Note Payment change (MOG, pricing indicator codes, anesthesia base units, Ambulatory Surgical Centers)
2020-10-01 Changed Long description changed.
2019-01-01 Added Code added.
Code
Description
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