Division of Medical Services

Transcription

1 Division of Medical Services Program Development & Quality Assurance P.O. Box 1437, Slot S-295 Little Rock, AR Fax: TO: Arkansas Medicaid Health Care Providers Prosthetics DATE: January 1, 2010 SUBJECT: Provider Manual Update Transmittal #135 REMOVE ISERT Section Date Section Date Explanation of Updates Section has been included to change the title of the section. Information has been added to advise that when using a procedure code that has an Arkansas Medicaid description, the product must meet the indicated description. Several procedure codes and modifiers that are included on the Arkansas Medicaid Fee Schedule have been added to the section. Minor text changes have been made that do not affect policy. Section has been revised to add several procedure codes and modifiers that are included on the Arkansas Medicaid Fee Schedule. Information has been added to advise that when using a procedure code with an Arkansas Medicaid description, the product must meet the indicated Arkansas Medicaid description. Information has been added to clarify that when a modifier is used in conjunction with a procedure code, the modifier must be indicated on the billing form. Other changes have been made that do not affect policy. Section has been revised to add several procedure codes and modifiers that are included in the Arkansas Medicaid Fee Schedule. Several new procedure codes, E0194, E0277, E0302, E0304, E0482, E0483 and K0606 are also being added. code K0606 is covered only for beneficiaries age 18 and over. The payment method for two procedure codes, E0747 and E0748, is being changed from purchase to rental only. code E0936 is being removed. Other changes have been made in the current procedure code list for procedure codes and modifiers to comply with information found in the fee schedule. Information has been added to advise that when using a procedure code with an Arkansas Medicaid description, the product must meet the indicated Arkansas Medicaid description. Section has been marked Reserved and the information previously found in the section has been deleted. codes in the section were either duplications of procedure codes found in section or were no longer covered in the Health Care Professional Coding System (HCPCS). Serving more than one million Arkansans each year

2 Arkansas Medicaid Health Care Providers Prosthetics Provider Manual Update Transmittal #135 Page 2 The paper version of this update transmittal includes revised pages that may be filed in your provider manual. See Section I for instructions on updating the paper version of the manual. For electronic versions, these changes have already been incorporated. If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at (Local); , extension (Toll- Free) or to obtain access to these numbers through voice relay, (TT Hearing Impaired). If you have questions regarding this transmittal, please contact the HP Enterprise Services Provider Assistance Center at (Toll-Free) within Arkansas or locally and Out-of-State at (501) Arkansas Medicaid provider manuals (including update transmittals), official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: Thank you for your participation in the Arkansas Medicaid Program. Roy Jeffus, Director

3 SECTIO II - PROSTHETICS COTETS GEERAL IFORMATIO Arkansas Medicaid Participation Requirements for Prosthetics Providers Providers in Arkansas and Bordering States Routine Services Provider Providers in on-bordering States Limited Services Provider The Prosthetics Provider Role in the Child Health Services (SDT) Program Documentation Requirements Documentation in Beneficiary s Case Files RESERVED RESERVED PROGRAM COVERAGE Scope Condition for Provision of Services Physician s Role in the Prosthetics Program Prosthetics Service Provision Prescription and Referral Renewal Service Initiation Delays Termination of Services Exclusions Electronic Filing of Extension of Benefits Services Provided Diapers and Underpads for Individuals Age 3 and Older Durable Medical Equipment (DME), All Ages (DME) Apnea Monitors for Infants Under Age (DME) Augmentative Communication Device (ACD), All Ages (RESERVED) (DME) Electronic Blood Pressure Monitor and Cuff for Beneficiaries of All Ages (DME) Enteral utrition Infusion Pump and Enteral Feeding Pump Supply Kit for Beneficiaries Under Age (DME) Home Blood Glucose Monitor, Pregnant Women, All Ages (DME) Insulin Pump and Supplies, All Ages (RESERVED) (DME) MIC-KE Skin Level Gastrostomy Tube (Mic-Key Button) and Supplies for Beneficiaries Under Age (RESERVED) (RESERVED) (DME) Specialized Rehabilitative Equipment, All Ages (DME) Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (RESERVED) Medical Supplies, All Ages utritional Formulae for Individuals Under Age Food Thickeners, All Ages Orthotic Appliances and Prosthetic Devices, All Ages Oxygen and Oxygen Supplies, All Ages PRIOR AUTHORIZATIO Prosthetics Services Prior Authorization

4 Request for Prior Authorization Filing for Prior Authorization Approvals of Prior Authorization Denial of Prior Authorization Request Reconsideration of Denials Fair Hearing Request REIMBURSEMET Prosthetics Service of Reimbursement Specialized Wheelchair, Seating and Rehabilitative Equipment Reimbursement for Repairs Orthotic and Prosthetic Reimbursement for Repairs Durable Medical Equipment (DME) Reimbursement for Repairs Augmentative Communication Device Reimbursement for Repairs Reimbursement for Repair of the Enteral utrition Pump Rate Appeal Process BILLIG PROCEDURES Introduction to Billing CMS-1500 Billing s HCPCS Codes ology Respiratory and Diabetic Equipment, All Ages Initial of a DME Item for Individuals of All Ages Home Blood Glucose Monitor and Supplies Pregnant Women, All Ages Medical Supplies for Beneficiaries of All Ages Food Thickeners, All Ages Jobst Stocking for Beneficiaries of All Ages Diapers and Underpads for Beneficiaries Ages 3 ears and Older Electronic Blood Pressure Monitor and Cuff, All Ages utritional Formulae for Child Health Services (SDT) Beneficiaries Under 21 ears of Age Pedia-Pop Enteral utrition Infusion Pump and Enteral Feeding Pump Supply Kit MIC-KE Skin Level Gastrostomy Tube (Mic-Key Button) and Supplies for Individuals Under Age asogastric Tubing for Individuals Under Age Durable Medical Equipment, All Ages RESERVED Apnea Monitors for Beneficiaries Under 1 ear of Age Orthotic Appliances for Beneficiaries of All Ages Prosthetic Devices for Beneficiaries of All Ages Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult Specialized Rehabilitative Equipment for Beneficiaries of All Ages Augmentative Communication Device for Beneficiaries of All Ages ational Place of Service and Modifier Codes Billing Instructions - Paper Completion of CMS-1500 Claim Form Special Billing s Completion of Form - Medicare/Medicaid Deductible And Coinsurance Freight Charges, All Ages

5 Respiratory and Diabetic Equipment, All Ages When billed either electronically or on paper, procedure codes found in this section must be billed with certain modifiers. Modifiers in the section are indicated by the headings M1 and M2. When only the modifier is shown in the M1 column, the procedure code may be billed for beneficiaries of all ages. When and are listed together in the M1 column, the modifier must be used when billing for beneficiaries age 21 and over, and the modifier must be used when billing for beneficiaries under age 21. When a modifier is listed in the M2 heading, that modifier must be used in conjunction with either or. Prior authorization requirements are shown under the heading PA..If prior authorization is needed, the information is indicated with a in the column; if not, an is shown. Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. ( ) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. Respiratory and Diabetic Equipment, All Ages (section ) Code M1 M2 Description PA A4230 Infusion set for external insulin pump, nonneedle cannula type A4231 Infusion set for external insulin pump, needle type A4232 Syringe with needle for external insulin pump, sterile, 3 cc A4627 UB (Spacer bag or reservoir without mask, for use with metered dose inhaler) Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler A4627 (Spacer bag or reservoir with mask, for use with metered dose inhaler) Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler A6021 Collagen dressing, pad size 16 sq. in. or less, each A6022 Collagen dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each A6023 Collagen dressing, pad size more than 48 sq. in., each A6024 Collagen dressing wound filler, per 6 in.

6 Respiratory and Diabetic Equipment, All Ages (section ) Code M1 M2 Description PA A7034 RR (CPAP Device asal Continuous Positive Airway Pressure (CPAP) Device; includes necessary accessory items) OTE: Complete medical data pertinent to the request must be submitted with the prior authorization request. OTE: Bill A7034 as the global daily rental service. asal interface (mask or cannula type) used with positive airway pressure device, with or without head strap A7045 Exhalation port with or without swivel used with accessories for positive airway devices, replacement only A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, each A9999 (Unlisted Durable Medical Equipment. The manufacturer s invoice must be attached to the claim form.) Misc. DME supply or accessory, not otherwise specified E0424 Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing E0430 Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula or mask, and tubing E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adapter, contents gauge, cannula or mask, and tubing E0435 Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapter E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing Manually Priced

7 Respiratory and Diabetic Equipment, All Ages (section ) Code M1 M2 Description PA E0441 Oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned), one month s supply = I unit E0442 Oxygen contents, liquid (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned), one month s supply = 1 unit E0443 Portable oxygen contents, gaseous (for use only with portable gaseous systems when no stationary gas or liquid system is used), one month s supply=1 unit E0444 Portable oxygen contents, liquid (for use only with portable liquid systems when no stationary gas or liquid system is used), one month s supply=1 unit E0470 E0471 E0472 E0482 RR RR RR RR RR RR (BIPAP Device, asal Bi-level Positive Airway support system; includes necessary accessory items. OTE: Complete medical data pertinent to the request must be submitted with the prior authorization request.) Respiratory assist device, bi-level pressure capacity, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) Respiratory assist device, bi-level pressure capacity, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) Respiratory assist device, bi-level pressure capacity, with backup rate feature, used with invasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) Cough stimulating device, alternating positive and negative airway pressure E0483 RR (Bronchial Drainage System) Highfrequency chest wall oscillation air-pulse generator system (includes hoses and vest), each

8 Respiratory and Diabetic Equipment, All Ages (section ) Code M1 M2 Description PA E0483 UB (Pulmonary Vest. The manufacturer invoice must be attached to the claim form.) High-frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each E0560 E0561 E0562 E0570 E0575 E0600 Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery Humidifier, non-heated, used w/positive airway pressure device Humidifier, heated, used w/positive airway pressure device ebulizer, with compressor ebulizer, ultrasonic, large volume Respiratory suction pump, home model, portable or stationary, electric E0779 RR (Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home) Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater E0784 External ambulatory infusion pump, insulin E1340 (DME Repair: Parts Repairs will not be approved for more than the allowed purchase price of new equipment. The manufacturer s invoice must be attached to the repair claim for all parts.) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes E1340 U4 (Maintenance for items) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes /A /A

9 Respiratory and Diabetic Equipment, All Ages (section ) Code M1 M2 Description PA E1340 (Labor ; a maximum of twenty (20) units per date of service is allowable. 20 units = 5 hours of labor) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes E1340 (Labor ; a maximum of twenty (20) units per date of service is allowable. 20 units = 5 hours of labor) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes E1390 Oxygen concentrator, single delivery port, capable of delivering 85 % or greater oxygen concentration at the prescribed flow rate E1391 O2 concentrator, dual delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate, each /A /A Initial of a DME Item for Individuals of All Ages codes found in this section may be billed either electronically or on paper. Some procedure codes have been assigned a modifier that affects the billing process. Required modifiers are indicated in the M1 column in the list below. When a modifier is shown in the M1 column, it must be listed along with the procedure code when requesting payment by Arkansas Medicaid. codes shown in the list below are either covered for all ages (), only for individuals under age 21 () or only for individuals age 21 and over (21+). A column in the list below defines the differences. Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. ( ) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.

10 Initial of a DME Item for Individuals of All Ages (section ) Code M1 Description A7034 (CPAP Device asal Continuous Positive Airway Pressure (CPAP) Device; includes necessary accessory items. OTE: For 21+, complete medical data pertinent to the request must be submitted with the prior authorization request. asal interface (mask or cannula type) used with positive airway pressure device, with or without head strap All 21+ E0181 Pressure pad, alternating with pump, heavy duty E0200 Heat lamp, without stand (table model), includes bulb, or infrared element E0205 Heat lamp, with stand includes bulb, or infrared element E0217 Water circulating heat pad with pump E0225 Hydrocollator unit, includes pad E0236 Pump for water circulating pad E0239 Hydrocollator unit, portable E0250 Hospital bed, fixed height, with any type side rails, with mattress E0250 Hospital bed, fixed height, with any type side rails, with mattress E0250 Hospital bed, fixed height, with any type side rails, with mattress E0255 Hospital bed, variable height; hi-lo, with any type side rails, with mattress E0255 KH Hospital bed, variable height; hi-lo, with any type side rails, with mattress E0260 Hospital bed, semi-electric (head and foot adjustment), with any type side rails with mattress E0260 KH Hospital bed, semi-electric (head and foot adjustment), with any type side rails with mattress E0271 Mattress, inner spring E0272 Mattress, foam rubber E0303 Hospital bed, heavy duty, extra wide, with weight capacity > 350 but < or = 600, any type side rails, w/mattress E0424 Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator flowmeter, humidifier, nebulizer cannula or mask, and tubing

11 Initial of a DME Item for Individuals of All Ages (section ) Code M1 Description E0430 E0434 E0435 E0439 E0445 Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula, or mask, and tubing Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapter Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing Oximeter for measuring blood oxygen levels non-invasively. (Pulse oximeter, including 4 disposable probes) All 21+ E0480 Percussor, electric or pneumatic, home model E0565 Compressor, air power source for equipment which is not self-contained or cylinder driven E0575 ebulizer, ultrasonic, large volume E0585 ebulizer, with compressor and heater E0600 Respiratory suction pump, home model, portable or stationary, electric E0606 Vaporizer, room type E0630 Patient lift, hydraulic, with seat or sling E0630 KH Patient lift, hydraulic, with seat or sling 21+ E0650 Pneumatic compressor, nonsegmental home model E0667 E0668 E0691 E0692 E0693 Segmental pneumatic appliance for use with pneumatic compressor, full leg Segmental pneumatic appliance for use with pneumatic compressor, full arm Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or less Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel

12 Initial of a DME Item for Individuals of All Ages (section ) Code M1 Description E0694 Ultraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protection All 21+ E0720 TES, two lead, localized stimulation E0730 Transcutaneous electrical nerve stimulation (TES) device, four or more leads, for multiple nerve stimulation E0730 KH Transcutaneous electrical nerve stimulation (TES) device, four or more leads, for multiple nerve stimulation E0745 euromuscular stimulator, electronic shock unit E0779 E0910 (Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home) Ambulatory infusion device pump, mechanical, reusable, for infusion 8 hours or greater Trapeze bars, also known as Patient Helper, attached to bed, with grab bar E0910 KH Trapeze bars, also known as Patient Helper, attached to bed, with grab bar E0911 Trapeze bar, heavy-duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar E0920 Fracture frame, attached to bed, includes weights E0930 Fracture frame, freestanding, includes weights E0935 Passive motion exercise device E0940 Trapeze bar, freestanding, complete with grab bar E0941 Gravity assisted traction device, any type E1130 Standard wheelchair, fixed full-length arms, fixed or swing away, detachable footrests E1130 KH Standard wheelchair, fixed full-length arms, fixed or swing away, detachable footrests E1224 Wheelchair with detachable arms, elevating legrests E1224 (Footrests wheelchair with detachable arms, elevating leg rests) Wheelchair with detachable arms, elevating legrests E1390 E1391 Oxygen concentrator, single delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each

13 Providers will be reimbursed for a minimum of 30 days of rental when the equipment is used less than 30 days. Initial rental codes must be billed when equipment is used less than 30 days during the first month of rental. Arkansas Medicaid will only reimburse for one initial minimum 30 days of rental per state fiscal year period per beneficiary per procedure code. The provider will not be reimbursed for the same procedure code utilizing another modifier for the same time period Durable Medical Equipment, All Ages codes found in this section must be billed either electronically or on paper with modifier for beneficiaries under 21 years of age or modifier for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either or. Modifier is required when billing for used equipment. Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a in the column; if not, an is shown. * The purchase of wheelchairs for individuals age 21 and older is limited to one per five-year period. *** This procedure code may not be billed for used equipment. Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. ( ) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. 3 This item is a capped rental for 90 days only, and requires PA and a review. A4635 A4636 A4637 E0100 E0105 Underarm pad, crutch, replacement, each Replacement, handgrip, cane, crutch, or walker, each Replacement, tip, cane, crutch, walker, each Cane, includes canes of all materials, adjustable or fixed, with tip Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips

14 E0110 E0111 Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip E0111 Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip E0112 E0113 E0114 E0116 E0130 E0135 E0140 E0141 E0143 E0147 E0153 Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips Crutch, underarm, other than wood, adjustable or fixed, each, with pad, tip and handgrip Walker, rigid (pickup), adjustable or fixed height Walker, folding (pickup), adjustable or fixed height Walker, w/trunk support, adjustable or fixed height, any type Walker, rigid, wheeled, adjustable or fixed height Walker, folding, wheeled, adjustable or fixed height Walker, heavy duty, multiple braking system, variable wheel resistance Platform attachment, forearm crutch, each

15 E0154 E0155 E0156 E0157 E0158 E0159 E0160 E0161 E0163 E0167 E0175 E0181 E0182 E0184 Platform attachment, walker, each Wheel attachment, rigid pick-up walker, per pair seat attachment, walker Seat attachment, walker Crutch attachment, walker, each Leg extensions for walker, per set of four (4) Brake attachment for wheeled walker, replacement, each Sitz type bath or equipment, portable, used with or without commode Sitz type bath or equipment, portable, used with or without commode, with faucet attachment(s) Commode chair, stationary, with fixed arms Pail or pan for use with commode chair Foot rest, for use with commode chair, each Pressure pad, alternating with pump, heavy duty Pump for alternating pressure pad Dry pressure mattress

16 E0185 E0186 E0187 E0189 E0190 Gel or gel-like pressure pad for mattress, standard mattress length and width Air pressure mattress Water pressure mattress Lambswool sheepskin pad, any size shape or size E0190 (Tumble Form Therapy Roll 4 ) shape or size E0190 (Tumble Form Therapy Roll 6 ) shape or size E0190 U2 (Tumble Form Therapy Wedge 4 ) shape or size E0190 U3 (Tumble Form Therapy Roll 8 ) shape or size E0190 U4 (Tumble Form Therapy Wedge 6 ) shape or size E0190 U5 (Floor Sitter Wedge 4 ) Positioning cushion/pillow/wedge, any shape or size E0190 U6 (Tumble Form Therapy Roll 12 ) shape or size E0190 U7 (Deluxe Wedge with strap 4 ) shape or size E0190 U8 (Deluxe Wedge with strap 6 ) shape or size

17 E0190 U9 (Tumble Form Therapy Wedge 10 ) shape or size E0190 KA (Tumble Form Therapy Roll 14 ) shape or size E0190 KA U2 (Tumble Form Therapy Roll 16 ) shape or size E0190 KA U3 (Tumble Form Therapy Wedge 8 ) shape or size E0191 E E0196 E0197 E0198 E0200 E0202 Heel or elbow protector, each (Clinitron Bed) Air fluidized bed Gel pressure mattress Air pressure pad for mattress, standard mattress length and width Water pressure pad for mattress, standard mattress length and width Heat lamp, without stand (table model), includes bulb, or infrared element Phototherapy (bilirubin) light with photometer E0202 U Phototherapy (bilirubin) light with photometer E0205 E0217 E0225 Heat lamp, with stand includes bulb, or infrared element Water circulating heat pad with pump Hydrocollator unit, includes pad

18 E0235 E0236 E0238 E0239 E0240 E0240 E0240 E0240 E0244 E0245*** E0247 E0247 E0248 E0248 E0249 E0250 U2 U2 U3 U3 Paraffin bath unit, portable (see medical supply code A4265 for paraffin) Pump for water circulating pad onelectric heat pad, moist Hydrocollator unit, portable Bath/shower chair w/wo wheels, any size Bath/shower chair w/wo wheels, any size Bath/shower chair w/wo wheels, any size Bath/shower chair w/wo wheels, any size Raised toilet seat (Bath Frame Support, Large) Tub stool or bench Transfer bench, tub/toilet, w/wo commode opening Transfer bench, tub/toilet, w/wo commode opening Transfer bench, heavy duty, tub/toilet w/wo commode opening Transfer bench, heavy duty, tub/toilet w/wo commode opening Pad for water circulating heat unit (Hospital bed, with side rails, fixed height, with mattress, purchase) Hospital bed, fixed height, with any type side rails, with mattress

19 E0250 E0255 E0255 RR RR RR RR Hospital bed, fixed height, with any type side rails, with mattress Hospital bed, variable height; hi-lo, with any type side rails, with mattress Hospital bed, variable height; hi-lo, with any type side rails, with mattress E0255 (Hospital bed, with side rails, variable height; hi-lo, with mattress, purchase) Hospital bed, variable height; hi-lo, with any type side rails, with mattress E0255 Hospital bed, variable height; hi-lo, with any type side rails, with mattress E0260 E0260 E0271 E0272 E0273 E0275 E0276 E E0280 RR RR (Hospital bed, with side rails, semielectric, head and foot adjustments, with mattress, purchase) Hospital bed, semi-electric, head and foot adjustment, with any type side rails with mattress Hospital bed, semi-electric, head and foot adjustment, with any type side rails with mattress Mattress, inner spring Mattress, foam rubber Bed board Bed pan, standard, metal or plastic Bed pan, fracture, metal or plastic (Low Air Loss Mattress) Powered pressure-reducing air mattress Bed cradle, any type

20 E0300 Pediatric crib, hospital grade, fully enclosed E0300 RR Pediatric crib, hospital grade, fully enclosed E0302 Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress E0303 Hospital bed, heavy duty, extra wide, with weight capacity > 350 but < or = 600, any type side rails, w/mattress (Rent to ) E0304 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress E0325 Urinal; male, jug-type, any material E0325 Urinal; male, jug-type, any material E0326 Urinal; female, jug-type, any material E0445*** (Pulse oximeter, including 4 disposable probes) Oximeter for measuring blood oxygen levels noninvasively E0480 Percussor, electric or pneumatic, home model E0565 Compressor, air power source for equipment which is not self-contained or cylinder driven E0570 ebulizer, with compressor E0585 ebulizer, with compressor and heater

21 E0605 E0606 E0607*** Vaporizer, room type Postural drainage board Home blood glucose monitor E0621 Sling or seat, patient lift, canvas or nylon E0630 E0650 E0667 E0668 E0691 E0692 E0693 E0694 E0720 Patient lift, hydraulic, with seat or sling Pneumatic compressor, nonsegmental home model Segmental pneumatic appliance for use with pneumatic compressor, full leg Segmental pneumatic appliance for use with pneumatic compressor, full arm Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or less Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel Ultraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protection TES, two lead, localized stimulation

22 E0730 E0740 E0745 E0747 E0748 E0760 Transcutaneous electrical nerve stimulation (TES) device, four or more leads, for multiple nerve stimulation Incontinence treatment system, pelvic floor stimulator, monitor, sensor and/or trainer euromuscular stimulator, electronic shock unit Osteogenesis stimulator, electrical noninvasive, other than spinal applications Osteogenesis stimulator, electrical noninvasive, spinal applications Osteogenesis stimulator, low intensity ultrasound, noninvasive E0779 RR (Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home) Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater E0840 E0850 E0860 E0870 E0880 Traction frame, attached to headboard, cervical traction Traction stand, freestanding, cervical traction Traction equipment, overdoor, cervical Traction frame, attached to footboard, extremity traction (e.g., Buck s) Traction stand, freestanding, extremity traction (e.g., Buck s)

23 E0890 E0900 E0910 Traction frame, attached to footboard, pelvic traction Traction stand, freestanding, pelvic traction (e.g., Buck s) Trapeze bars, also known as Patient Helper, attached to bed, with grab bar E0910 RR Trapeze bars, also known as Patient Helper, attached to bed, with grab bar E0920 E0930 E0935 E0940 E0941 E0942 E0944 E0945 E0946 E0947 Fracture frame, attached to bed, includes weights Fracture frame, freestanding, includes weights Continuous passive motion exercise device for use on knee only Trapeze bar, freestanding, complete with grab bar Gravity assisted traction device, any type Cervical head harness/halter Pelvic belt/harness/boot Extremity belt/harness Fracture frame, dual with cross bars, attached to bed (e.g., Balken, Four Poster) Fracture frame, attachments for complex pelvic traction

24 E0948 E0950 E1130* Fracture frame, attachments for complex cervical traction Wheelchair accessory, tray, each Standard wheelchair, fixed full-length arms, fixed or swing away, detachable footrests E1130* Standard wheelchair, fixed full-length arms, fixed or swing away, detachable footrests E1140* E1150* E1160* E1224* Wheelchair, detachable arms, desk or full-length, swing away, detachable footrests Wheelchair; detachable arms, desk or full-length, swing away, detachable, elevating legrests Wheelchair; fixed full-length arms, swing away, detachable, elevating legrests Wheelchair with detachable arms, elevating leg rests E1224* (Footrests wheelchair with detachable arms, elevating leg rests) Wheelchair with detachable arms, elevating leg rests E1340 (DME Repairs/Parts Repairs will not be approved for more than the allowed purchase price of new equipment. The manufacturer s invoice must be attached to the repair claim for all parts.) Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes Manually Priced

25 E1340*** (Labor ; a maximum of twenty [20] units [20 units = 5 hours of labor] per date of service is allowable.) Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes E1399 Durable medical equipment, miscellaneous K0105 K0606 S8096*** Z2211 (Bill on Paper) Manually Priced Manually Priced IV hanger, each Automatic external defibrillator, with integrated electrocardiogram analysis, garment type (covered only for beneficiaries ages 18 and over) (Peak flow meter used by asthmatic patients) Portable peak flow meter Power Kit/Batteries codes E0250, E0255 and E0260 must be billed when hospital beds are purchased for Medicaid beneficiaries of all ages. Providers must only provide these purchaseonly services to beneficiaries who are expected to require the bed for a long period of time. Each procedure code for hospital beds listed above may only be billed once every 10 years. codes E0250, E0255 and E0260 must also be used to bill for equipment that does not meet the purchase-only criteria. They are reimbursed on a capped rental basis. The capped rental items must be used until the equipment is no longer repairable or until it is no longer appropriate for the beneficiary as verified by the physician RESERVED