Browse HCPCS Level II 2020 Edition

HCPCS Level II Table of Contents

A4361 - A4435  Ostomy Supplies

A4361
Ostomy faceplate, each
shortOstomy face plate
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.03 Date of Service Edit: ClinicalClinical: Data
DME2.03 Date of Service Edit: ClinicalPublished Contractor Policy
A4362
Skin barrier; solid, 4 x 4 or equivalent; each
shortSolid skin barrier
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.03 Date of Service Edit: ClinicalClinical: Data
A4363
Ostomy clamp, any type, replacement only, each
shortOstomy clamp, replacement
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: Data
OPH0.03 Date of Service Edit: ClinicalCMS Policy
DME6.03 Date of Service Edit: ClinicalClinical: Data
A4364
Adhesive, liquid or equal, any type, per oz
shortAdhesive, liquid or equal
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.03 Date of Service Edit: ClinicalClinical: Data
A4366
Ostomy vent, any type, each
shortOstomy vent
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4367
Ostomy belt, each
shortOstomy belt
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.03 Date of Service Edit: ClinicalClinical: Data
DME3.03 Date of Service Edit: ClinicalPublished Contractor Policy
A4368
Ostomy filter, any type, each
shortOstomy filter
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: Data
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4369
Ostomy skin barrier, liquid (spray, brush, etc.), per oz
shortSkin barrier liquid per oz
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: Data
OPH1.03 Date of Service Edit: ClinicalClinical: Data
A4371
Ostomy skin barrier, powder, per oz
shortSkin barrier powder per oz
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4372
Ostomy skin barrier, solid 4 x 4 or equivalent, standard wear, with built-in convexity, each
shortSkin barrier solid 4x4 equiv
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4373
Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, any size, each
shortSkin barrier with flange
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4375
Ostomy pouch, drainable, with faceplate attached, plastic, each
shortDrainable plastic pch w fcpl
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4376
Ostomy pouch, drainable, with faceplate attached, rubber, each
shortDrainable rubber pch w fcplt
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4377
Ostomy pouch, drainable, for use on faceplate, plastic, each
shortDrainable plstic pch w/o fp
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4378
Ostomy pouch, drainable, for use on faceplate, rubber, each
shortDrainable rubber pch w/o fp
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4379
Ostomy pouch, urinary, with faceplate attached, plastic, each
shortUrinary plastic pouch w fcpl
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4380
Ostomy pouch, urinary, with faceplate attached, rubber, each
shortUrinary rubber pouch w fcplt
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4381
Ostomy pouch, urinary, for use on faceplate, plastic, each
shortUrinary plastic pouch w/o fp
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4382
Ostomy pouch, urinary, for use on faceplate, heavy plastic, each
shortUrinary hvy plstc pch w/o fp
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4383
Ostomy pouch, urinary, for use on faceplate, rubber, each
shortUrinary rubber pouch w/o fp
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4384
Ostomy faceplate equivalent, silicone ring, each
shortOstomy faceplt/silicone ring
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
DME4.03 Date of Service Edit: ClinicalClinical: Data
A4385
Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each
shortOst skn barrier sld ext wear
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4387
Ostomy pouch, closed, with barrier attached, with built-in convexity (1 piece), each
shortOst clsd pouch w att st barr
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: Data
OPH1.03 Date of Service Edit: ClinicalClinical: Data
A4388
Ostomy pouch, drainable, with extended wear barrier attached, (1 piece), each
shortDrainable pch w ex wear barr
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4389
Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 piece), each
shortDrainable pch w st wear barr
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4390
Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each
shortDrainable pch ex wear convex
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4391
Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each
shortUrinary pouch w ex wear barr
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4392
Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (1 piece), each
shortUrinary pouch w st wear barr
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4393
Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (1 piece), each
shortUrine pch w ex wear bar conv
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4394
Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce
shortOstomy pouch liq deodorant
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4395
Ostomy deodorant for use in ostomy pouch, solid, per tablet
shortOstomy pouch solid deodorant
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA3.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH3.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4396
Ostomy belt with peristomal hernia support
shortPeristomal hernia supprt blt
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
DME3.03 Date of Service Edit: ClinicalClinical: Data
A4397
Irrigation supply; sleeve, each
shortIrrigation supply sleeve
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.03 Date of Service Edit: ClinicalClinical: Data
A4398
Ostomy irrigation supply; bag, each
shortOstomy irrigation bag
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
DME1.03 Date of Service Edit: ClinicalPublished Contractor Policy
A4399
Ostomy irrigation supply; cone/catheter, with or without brush
shortOstomy irrig cone/cath w brs
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.03 Date of Service Edit: ClinicalClinical: Data
DME1.03 Date of Service Edit: ClinicalPublished Contractor Policy
A4400
Ostomy irrigation set
shortOstomy irrigation set
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
DME0.03 Date of Service Edit: ClinicalPublished Contractor Policy
A4402
Lubricant, per ounce
shortLubricant per ounce
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.03 Date of Service Edit: ClinicalClinical: Data
A4404
Ostomy ring, each
shortOstomy ring each
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA0.03 Date of Service Edit: ClinicalCMS Policy
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4405
Ostomy skin barrier, non-pectin based, paste, per ounce
shortNonpectin based ostomy paste
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4406
Ostomy skin barrier, pectin-based, paste, per ounce
shortPectin based ostomy paste
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4407
Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 x 4 inches or smaller, each
shortExt wear ost skn barr <=4sq"
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4408
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, larger than 4 x 4 inches, each
shortExt wear ost skn barr >4sq"
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4409
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 x 4 inches or smaller, each
shortOst skn barr convex <=4 sq i
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4410
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4 x 4 inches, each
shortOst skn barr extnd >4 sq
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4411
Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, with built-in convexity, each
shortOst skn barr extnd =4sq
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4412
Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), without filter, each
shortOst pouch drain high output
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4413
Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), with filter, each
short2 pc drainable ost pouch
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4414
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each
shortOst sknbar w/o conv<=4 sq in
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4415
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4 x 4 inches, each
shortOst skn barr w/o conv >4 sqi
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4416
Ostomy pouch, closed, with barrier attached, with filter (1 piece), each
shortOst pch clsd w barrier/filtr
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4417
Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each
shortOst pch w bar/bltinconv/fltr
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4418
Ostomy pouch, closed; without barrier attached, with filter (1 piece), each
shortOst pch clsd w/o bar w filtr
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4419
Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each
shortOst pch for bar w flange/flt
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4420
Ostomy pouch, closed; for use on barrier with locking flange (2 piece), each
shortOst pch clsd for bar w lk fl
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4421
Ostomy supply; miscellaneous
shortOstomy supply misc
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
A4422
Ostomy absorbent material (sheet/pad/crystal packet) for use in ostomy pouch to thicken liquid stomal output, each
shortOst pouch absorbent material
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA7.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4423
Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 piece), each
shortOst pch for bar w lk fl/fltr
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4424
Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each
shortOst pch drain w bar & filter
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4425
Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each
shortOst pch drain for barrier fl
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4426
Ostomy pouch, drainable; for use on barrier with locking flange (2 piece system), each
shortOst pch drain 2 piece system
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4427
Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece system), each
shortOst pch drain/barr lk flng/f
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4428
Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve (1 piece), each
shortUrine ost pouch w faucet/tap
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4429
Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each
shortUrine ost pouch w bltinconv
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4430
Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each
shortOst urine pch w b/bltin conv
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4431
Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (1 piece), each
shortOst pch urine w barrier/tapv
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4432
Ostomy pouch, urinary; for use on barrier with non-locking flange, with faucet-type tap with valve (2 piece), each
shortOs pch urine w bar/fange/tap
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4433
Ostomy pouch, urinary; for use on barrier with locking flange (2 piece), each
shortUrine ost pch bar w lock fln
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4434
Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap with valve (2 piece), each
shortOst pch urine w lock flng/ft
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH1.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
A4435
Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), with or without filter, each
short1pc ost pch drain hgh output
RVU
CPT ModifierPhysician ComponentFacility PracticeNonfacility PracticeProfessional Liability InsuranceTotal FacilityTotal NonfacilityGlobal Period
0.00.00.00.00.00.0XXX
MUE
LocationValueAjudication IndicatorRationale
PRA2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup
OPH2.03 Date of Service Edit: ClinicalClinical: CMS Workgroup