TO:

Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma
MASSHEALTH
TRANSMITTAL LETTER DME-23
April 2003
Durable Medical Equipment Providers Participating in MassHealth

FROM:      Douglas S. Brown, Acting Commissioner
RE:     Durable Medical Equipment Manual (Revised Service Codes and Descriptions)
This letter transmits revisions to Subchapter 6 (service codes and descriptions) of the Durable Medical Equipment Manual. These revisions are effective for dates of service on and after April 1, 2003.
2003 Healthcare Common Procedure Coding System (HCPCS) codes have been added to replace certain MassHealth local codes. The local codes have been replaced so the Division can continue the process of making its covered service code set compliant with the Health Insurance Portability and Accountability Act (HIPAA). The Division will issue additional updates to other local codes at a later date.
Please note that you must use a modifier with some of the new codes to accurately reflect the service provided. The attached Service Code Crosswalk identifies where modifiers are applicable. The crosswalk also identifies the only methodology by which the Division will pay for each of the covered codes included on the attachment.
The Division of Health Care Finance and Policy (DHCFP) recently issued regulations certifying new fees for the products for which the Division is now updating its codes. These new fees and methodologies are also effective for dates of service on and after April 1, 2003. The DHCFP regulation, including the fee schedule, is available on the DHCFP Web site at www.mass.gov/dhcfp.
Alternatively, if you wish to obtain a hard copy of the fee schedule, you may purchase the schedule from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephones numbers below). You must contact them first to find out the price of the regulation. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation title for Durable Medical Equipment and Oxygen and Respiratory Therapy Equipment is 114 CMR 22.00.

Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr

Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp

MASSHEALTH TRANSMITTAL LETTER DME-23
April 2003 Page 2
DMA Web Site
This transmittal letter and attached pages are available on the Division’s Web site at www.mass.gov/dma.
Capped Rental for Support Surfaces
For Service Codes E0193 (powered air flotation bed (low air loss therapy)) and E0194 (air fluidized bed), the Division will pay a monthly rental fee for up to 15 months as indicated in DHCFP’s regulation. The Division will no longer pay a daily rental fee or consider a provider’s adjusted acquisition cost.
These products remain covered items after the 15 months, but the provider should not bill the Division, as the Division will not pay a monthly rental fee after the 15th month. If the product will be provided for 15 months or more, the provider must indicate the modifier “BR” on the claim for the 15th month to indicate that it is the last claim for a monthly rental fee.
The provider must retain ownership of the product, and continue providing the product without any charge until either the medical necessity for the product ends or the eligibility of the member for MassHealth ends.
The provider may bill for a repair, if needed, during or after the 21st month, to maintain the equipment in proper working condition for the member’s use. The provider must request prior authorization for the repair, and must indicate a complete list of parts and hours of labor needed to complete the repair in the prior-authorization request.
These products continue to require prior authorization. If approved, the authorization to be issued for periods of time of not greater than 30 days. The Division will only accept documentation of medical necessity in support of the prior-authorization request from a physician or a wound care specialist employed directly or indirectly (under contract) by a skilled nursing facility.
Capped Rental for Alternating Pressure Pad and Semi-electric Hospital Bed
For Service Codes E0260 (hospital bed, semi-electric (head and foot adjustment, with any type side rails, with mattress) and E0277 (powered pressure-reducing air mattress), the Division will pay a monthly rental fee for up to 15 months. The Division will no longer consider a provider’s adjusted acquisition cost for these products, and will pay only the monthly rental fee indicated in DHCFP’s regulation.
At the end of the 15 months, the Division will have purchased the equipment. This equipment continues to require prior authorization, and is considered durable medical equipment with a life span of five years.

MASSHEALTH TRANSMITTAL LETTER DME-23
April 2003 Page 3
Home Infusion Therapy
The Division has adopted 2003 HCPCS for home infusion therapy (so-called temporary “S” codes). These HCPCS include home infusion therapies, home enteral therapies, specialty drug therapies, and medical foods for inborn errors of metabolism. The Division has adopted the bundled HCPCS codes and will now pay a bundled per diem fee for these products and services. The per diem fees include all necessary supplies, equipment, and administrative services. These codes do not include nursing visits, drugs, enteral or parental products
Please note that for Masshealth, Service Codes S9364 through S9368 (home infusion therapy, total parenteral nutrition), the fee does not include standard total parenteral nutrition formula, lipids, and specialty amino acids.
A provider can bill the per diem every day the member has access to the therapy because the per diem covers each day that a member is provided access to a prescribed therapy, beginning with the day the therapy is initiated and ending with the day the therapy is permanently discontinued. The term “permanently” should not be construed to infer that a therapy will never again be initiated, but rather that continuation of the therapy is simply not predicted or anticipated at the time of cessation. The expected course and duration of the treatment will be determined by the plan of care as prescribed by the ordering physician.
It is not necessary for the member to receive an actual drug infusion each and every day in order to be considered covered under the per diem, so long as additional infusions are anticipated in the near future as prescribed in the physician plan of care. The fact that the DME provider anticipates continued responsibility for the member and incurs costs related to such responsibilities, remains accountable for the provision of such anticipated care, and is responsible for the acquisition and allocation of resources that will be necessary to meet these obligations, justifies the per diem.
The per diem methodology is applicable for any therapies of a duration up to and including every 72 hours. Therapies provided beyond this range should be billed according to existing HCPCS and fee schedules.
Service Code X5040 (clinician service component) has been obsoleted.
Prior Authorization
Effective for dates of service on and after April 1, 2003, all requests for products specified in the attached crosswalk that require prior authorization (PA) must be submitted using the new national codes. Providers who have already requested and received prior authorization using obsoleted local codes will not have to request adjustments to their PAs, The Division will convert existing PAs with unused units to the new national codes. Providers will receive letters notifying them of the P.A. adjustments.

MASSHEALTH TRANSMITTAL LETTER DME-23
April 2003 Page 4
Billing Guidelines
Effective for dates of service on and after April 1, 2003, providers billing for the services specified in the attached crosswalk only may use the new codes. Claims submitted using miscellaneous or other codes will be denied.
Questions
Providers with questions about the information in this transmittal letter may contact MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Durable Medical Equipment Manual
Pages vi, vii, and 6-1 through 6-32
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Durable Medical Equipment Manual
Pages vii and 6-1 through 6-32 — transmitted by Transmittal Letter DME-20
Page vii-a — transmitted by Transmittal Letter DME-21
Page viii — transmitted by Transmittal Letter DME-17
Pages 6-33 and 6-34 — transmitted by Transmittal Letter DME-22

TL DME-23 Attachment Page 1 Durable Medical Equipment Service Code Crosswalk and New and Obsoleted Codes Effective April 1, 2003

Old code	Description	New code	Modifier	Description	Methodology	
						
X5065	Low pressure
and
positioning
equalization
pad for
wheelchair
(custom)	E0192	NU	Low pressure and positioning equalization pad, for wheelchair	Purchase	
E0277	Powered pressure-reducing air mattress (P.A.)	E0277	KH, KI, KJ ,BP	Powered pressure-reducing air mattress (P.A.)	Capped Rental	
A4370	Ostomy skin barrier, paste, per oz					
A6265	Tape, all types, per 18 sq. in					
		S5035		Home infusion therapy, routine service of infusion device (e.g., pump maintenance)	Per Diem	
		S5036		Home infusion therapy, repair of infusion device (e.g., pump repair)	Per Diem	
		S5497		Home infusion therapy, catheter care/maintenance, not otherwise classified; includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S5498		Home infusion therapy, catheter care/maintenance, simple (single lumen), includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
X5066
E0260
A4386

Powered air flotation bed (step down air loss mattress therapy, per day) (P.A.)
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress (purchase) (P.A.)
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built in
convexity, any size, each

E0193
E0194 E0260
S5501

KH, KI, KJ, BR
KH, KI, KJ, BR KH, KI, KJ ,BP

Powered air flotation bed (low air loss therapy) (P.A.)
Air fluidized bed (P.A.)
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress (P.A.)
Home infusion therapy, catheter care/maintenance, complex (more than one lumen), includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Capped Rental
Capped Rental Capped Rental
Per Diem

TL DME-23 Attachment Page 2 Durable Medical Equipment Service Code Crosswalk and New and Obsoleted Codes Effective April 1, 2003

Old code	Description	New code	Modifier	Description	Methodology	
						
		S5502		Home infusion therapy, catheter care/maintenance, implanted access device, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (use this code for interim maintenance of vascular access not currently in use)	Per Diem	
		S5517		Home infusion therapy, all supplies necessary for restoration of catheter patency or declotting	Per Diem	
		S5518		Home infusion therapy, all supplies necessary for catheter repair	Per Diem	
		S5520		Home infusion therapy, all supplies (including catheter) necessary for peripherally inserted central venous catheter (PICC) line insertion	Daily, Per Diem	
		S5521		Home infusion therapy, all supplies (including catheter) necessary for a midline catheter insertion	Per Diem	
		S9325		Home infusion therapy, pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code with S9326, S9327 or S9328)	Per Diem	
		S9326		Home infusion therapy, continuous pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (24 hours or more)	Per Diem	
		S9327		Home infusion therapy, intermittent pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (less than 24 hours)	Per Diem	
		S9328		Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9329		Home infusion therapy, chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code with S9330 or S9331)	Per Diem	
		S9330		Home infusion therapy, continuous chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (24 hours or more)	Per Diem	
		S9331		Home infusion therapy, intermittent chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (less than 24 hours)	Per Diem	
		S9336		Home infusion therapy, continuous anticoagulant infusion therapy (e.g., heparin), administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9338		Home infusion therapy, immunotherapy therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9339		Home therapy; peritoneal dialysis, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S3940		Home therapy; enteral nutrition; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem	Per Diem	

TL DME-23 Attachment Page 3 Durable Medical Equipment Service Code Crosswalk and New and Obsoleted Codes Effective April 1, 2003

Old code	Description	New code	Modifier	Description	Methodology	
						
		S3941		Home therapy; enteral nutrition via gravity; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem	Per Diem	
		S9342		Home therapy; enteral nutrition via pump; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem	Per Diem	
		S9343		Home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem	Per Diem	
		S9345		Home infusion therapy, anti-hemophilic agent infusion therapy (e.g., factor VIII); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9346		Home infusion therapy, alpha-1 proteinase inhibitor (e.g., Prolastin); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9347		Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or subcutaneous infusion therapy (e.g., epoprostenol); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9348		Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g., Dobutamine); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9349		Home infusion therapy, tocolytic infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9351		Home infusion therapy, continuous anti-emetic infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9353		Home infusion therapy, continuous insulin infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9355		Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9357		Home infusion therapy, enzyme replacement intravenous therapy; (e.g. Imiglucerase); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9359		Home infusion therapy, anti-tumor necrosis factor intravenous therapy; (e.g., Infliximab); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9361		Home infusion therapy, diuretic intravenous therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	

TL DME-23 Attachment Page 4 Durable Medical Equipment Service Code Crosswalk and New and Obsoleted Codes Effective April 1, 2003

Old code	Description	New code	Modifier	Description	Methodology	
						
		S9363		Home infusion therapy, anti-spasmotic intravenous therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9364		Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (includes standard TPN formula; lipids, specialty amino acid formulas, drugs, and nursing visits coded separately), per diem (do not use with home infusion codes S9365-S9368 using daily volume scales) (for MassHealth Members, this does not include standard TPN formula-lipids and specialty amino acid formulas)	Per Diem	
		S9365		Home infusion therapy, total parenteral nutrition (TPN); one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (includes standard TPN formula;lipids, specialty amino acid formulas, drugs, and nursing visits coded separately), per diem (for MassHealth members, this does not include standard TPN formula- lipids and specialty amino acid formulas)	Per Diem	
		S9366		Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (includes standard TPN formula; lipids, specialty amino acid formulas, drugs, and nursing visits coded separately), per diem (for MassHealth members, this does not include standard TPN formula-lipids and specialty amino acid formulas)	Per Diem	
		S9367		Home infusion therapy, total parenteral nutrition (TPN); more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (includes standard TPN formula; lipids, specialty amino acids, drugs, and nursing visits coded separately), per diem (for MassHealth members, this does not include standard TPN formula-lipids and specialty amino acids)	Per Diem	
		S9368		Home infusion therapy, total parenteral nutrition (TPN); more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (includes standard TPN formula; lipids, specialty amino acid formulas, drugs, and nursing visits coded separately), per diem (for MassHealth members, this does not include standard TPN formula-lipids and specialty amino acids)	Per Diem	
		S9370		Home therapy, intermittent anti-emetic injection therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9372		Home therapy; intermittent anticoagulant injection therapy (e.g., heparin); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code for flushing of infusion devices with heparin to maintain patency)	Per Diem	
		S9373		Home infusion therapy, hydration therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use with hydration therapy codes S9374 - S9377 using daily volume scales)	Per Diem	
		S9374		Home infusion therapy, hydration therapy; one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	

TL DME-23 Attachment Page 5 Durable Medical Equipment Service Code Crosswalk and New and Obsoleted Codes Effective April 1, 2003

Old code	Description	New code	Modifier	Description	Methodology	
						
		S9375		Home infusion therapy, hydration therapy; more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9376		Home infusion therapy, hydration therapy; more than two liters but no more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9377		Home infusion therapy, hydration therapy; more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies (drugs and nursing visits coded separately), per diem	Per Diem	
		S9379		Home infusion therapy, infusion therapy, not otherwise classified; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
S9435	Medical foods for inborn errors of metabolism	Per Diem
		S9490		Home infusion therapy, corticosteroid infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9494		Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use with home infusion code for hourly dosing schedules S9497-S9504)	Per Diem	
		S9497		Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every three hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9500		Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9501		Home infusion therapy, antibiotic, antiviral, or antifungal therapy, once every 12 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9502		Home infusion therapy, antibiotic, antiviral, or antifungal therapy, once every eight hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9503		Home infusion therapy, antibiotic, antiviral, or antifungal therapy, once every six hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9504		Home infusion therapy, antibiotic, antiviral, or antifungal; once every four hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	

TL DME-23 Attachment Page 6 Durable Medical Equipment Service Code Crosswalk and New and Obsoleted Codes Effective April 1, 2003

Old code	Description	New code	Modifier	Description	Methodology	
						
		S9537		Home therapy, hematopoietic hormone injection therapy (e.g., Crythropoietin, , G-CSF, GM-CSF); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9538		Home transfusion of blood product(s); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (blood products, drugs and nursing visits coded separately), per diem	Per Diem	
		S9542		Home injectable therapy; not otherwise classified, including administrative services, professional pharmacy services, coordination of care, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9558		Home injectable therapy; growth hormone, including administrative services, professional pharmacy services, coordination of care, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9559		Home injectable therapy; interferon, including administrative services, professional pharmacy services, coordination of care, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9560		Home injectable therapy; hormonal therapy (e.g., leuprolide, goserelin), including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9562		Home injectable therapy, palivizumab, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
		S9590		Home therapy, irrigation therapy (e.g., sterile irrigation of an organ or anatomical cavity); including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem	Per Diem	
Modifier Descriptions
BP	Member to purchase the item (Division purchases item)	
BR	Member to continue rental (no option for purchase)	
KH	Initial claim, purchase or first month rental	
KI	Second or third month rental	
KJ	Months four through fifteen	
NU	New equipment	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
vi	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
6. SERVICE CODES AND DESCRIPTIONS 		6-1
Appendix A. DIRECTORY 		A-1
Appendix B. ENROLLMENT CENTERS 		B-1
Appendix C. THIRD-PARTY-LIABILITY CODES 		C-1
Appendix W. EPSDT SERVICES: MEDICAL PROTOCOL AND PERIODICITY SCHEDULE..	W-1
Appendix X. FAMILY ASSISTANCE COPAYMENTS AND DEDUCTIBLES 		X-1
Appendix Y. REVS CODES/MESSAGES 		Y-1
Appendix Z. EPSDT SERVICES LABORATORY CODES 		Z-1

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
PREFACE	PAGE
vii	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
The regulations and instructions of the Division of Medical Assistance governing provider participation in MassHealth are published in the Provider Manual Series. The Division publishes a separate manual for each provider type.
Each manual in the series contains administrative regulations, billing regulations, program regulations, service codes and descriptions, billing instructions, and general information. The Division's regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. Regulations promulgated by the Division of Medical Assistance are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title.
Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals.
Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For durable medical equipment providers, those matters are covered in 130 CMR Chapter 409.000, reproduced as Subchapter 4 in the Durable Medical Equipment Manual.
Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("pen-and-ink" revisions), and by substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others.
The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead the Division's effort to give each provider a single convenient source for the essential information providers need in their routine interaction with the Division and with MassHealth members.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-1	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and
Service
Code	Service Description
CANES
E0100        Cane, includes canes of all materials, adjustable or fixed, with tip
E0105        Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips
X5060        Cane, platform
CRUTCHES
E0110        Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete
with tips and handgrips E0111        Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and
handgrip E0112        Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips E0113        Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip E0114        Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips E0116        Crutch, underarm, other than wood, adjustable or fixed, each, with pad, tip and handgrip
WALKERS
E0130	Walker, rigid (pickup), adjustable or fixed height
E0135	Walker, folding (pickup), adjustable or fixed height
E0141	Rigid walker, wheeled, without seat
E0142	Rigid walker, wheeled, with seat
E0143	Folding walker, wheeled, without seat
E0145	Walker, wheeled, with seat and crutch attachments
E0146	Folding walker, wheeled, with seat
E0147	Heavy duty, multiple breaking system, variable wheel resistance walker
X5061	Walker, heavy duty
X5062	Walker, child, folding walker with wheels
E0153	Platform attachment, forearm crutch, each
E0154	Platform attachment, walker, each
E0155	Wheel attachment, rigid pick-up walker, per pair seat attachment, walker
ATTACHMENTS
E0156        Seat attachment, walker
E0157        Crutch attachment, walker, each
E0158        Leg extensions for walker, per set of four (4)
COMMODES
E0160        Sitz type bath or equipment, portable, used with or without commode
E0161        Sitz type bath or equipment, portable, used with or without commode, with faucet attachment(s)
E0162        Sitz bath chair

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-2	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
X5063	Bath seat, heavy duty
E0163	Commode chair, stationary, with fixed arms
E0164	Commode chair, mobile, with fixed arms
E0165	Commode chair, stationary, with detachable arms (P.A.)
X5064	Commode, heavy duty (P.A.)
X5436	Shower commode chairs (P.A.)
E0166	Commode chair, mobile, with detachable arms (P.A.)
E0167	Pail or pan for use with commode chair
E0175	Foot rest, for use with commode chair, each
DECUBITUS CARE EQUIPMENT
E0176	Air pressure pad or cushion, nonpositioning
E0177	Water pressure pad or cushion, nonpositioning
E0178	Gel or gel-like pressure pad or cushion, nonpositioning
E0179	Dry pressure pad or cushion, nonpositioning
E0180	Pressure pad, alternating with pump (P.A.)
E0181	Pressure pad, alternating with pump, heavy duty (P.A.)
E0182	Pump for alternating pressure pad (P.A.)
E0184	Dry pressure mattress (P.A.)
E0185	Gel or gel-like pressure pad for mattress, standard mattress length and width (P.A.)
E0186	Air pressure mattress
E0187	Water pressure mattress
E0188	Synthetic sheepskin pad
E0189	Lambswool sheepskin pad, any size
E0191	Heel or elbow protector, each (I.C.)
E0192	Low pressure and positioning equalization pad, for wheelchair
E0193	Powered air flotation bed (low air loss therapy) (P.A.)
E0194	Air fluidized bed (P.A.)
E0196	Gel pressure mattress
E0197	Air pressure pad for mattress, standard mattress length and width
E0198	Water pressure pad for mattress, standard mattress length and width
E0199	Dry pressure pad for mattress, standard mattress length and width (P.A.) (I.C.)
E0371	Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and
width (P.A.)
E0372	Powered air overlay for mattress, standard mattress length and width (P.A.)
HEAT/COLD APPLICATION
E0200	Heat lamp, without stand (table model), includes bulb, or infrared element (P.A.)
E0202	Phototherapy (bilirubin) light with photometer (P.A.)
E0205	Heat lamp, with stand, includes bulb, or infrared element (P.A.)
E0210	Electric heat pad, standard
E0215	Electric heat pad, moist

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
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	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
E0217	Water circulating heat pad with pump (P.A.)
E0220	Hot water bottle
E0225	Hydrocollator unit, includes pads (P.A.)
E0230	Ice cap or collar
E0235	Paraffin bath unit, portable (see medical supply code A4265 for paraffin) (P.A.)
E0236	Pump for water circulating pad (P.A.)
E0238	Nonelectric heat pad, moist
E0239	Hydrocollator unit, portable (P.A.)
BATH AND TOILET AIDS
E0241	Bathtub wall rail, each
E0242	Bathtub rail, floor base
E0243	Toilet rail, each
E0244	Raised toilet seat
E0245	Tub stool or bench (standard)
X5067	Tub stool or bench (intermediate)
X5068	Transfer bench (standard)
X5069	Transfer bench (intermediate)
E0246	Transfer tub rail attachment
E0249	Pad for water circulating heat unit
HOSPITAL BEDS AND ACCESSORIES
E0250        Hospital bed, fixed height, with any type side rails, with mattress (purchase) (P.A.)
X5414        Hospital bed, fixed height, with any type side rails, with mattress (rental, first six months, per
month) (P.A. after three months) E0251        Hospital bed, fixed height, with any type side rails, without mattress (purchase) (P.A.) X5415        Hospital bed, fixed height, with any type side rails, without mattress (rental, first six months, per
month) (P.A. after three months) E0255        Hospital bed, variable height, hi-lo, with any type side rails, with mattress (purchase) (P.A.) X5417        Hospital bed, variable height, hi-lo, with any type side rails, with mattress (rental, first six
months, per month) (P.A. after three months) E0256        Hospital bed, variable height, hi-lo, with any type side rails, without mattress (P.A.) E0260        Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress
(P.A.) X5418        Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress
(rental, first six months, per month) (P.A.) E0261        Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress
(purchase) (P.A.) X5419        Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress
(rental, first six months, per month) (P.A.) E0265        Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with
mattress (purchase) (P.A.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-4	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
X5420        Hospital bed, total electric, (head, foot, and height adjustments), with any type side rails, with
mattress (rental, first six months, per month) (P.A.) E0266        Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without
mattress (purchase) (P.A.) X5421        Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without
mattress (rental, first six months, per month) (P.A.) E0270        Hospital bed, institutional type includes: oscillating, circulating and stryker frame, with mattress
(I.C.) E0271        Mattress, inner spring E0272        Mattress, foam rubber E0273        Bed board E0274        Over-bed table E0275        Bed pan, standard, metal or plastic E0276        Bed pan, fracture, metal or plastic E0277        Powered pressure-reducing air mattress (P.A.) E0280        Bed cradle, any type (P.A.) E0296        Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress
(P.A.) X5070        Bed hand control X5071        Bed junction box X5072        Bed motor kit X5073        PC board X5074        Bed ends X5075        Head springs X5076        Foot springs E0305        Bedside rails, half-length (P.A.) E0310        Bedside rails, full-length (P.A.)
E0315        Bed accessory: board, table, or support device, any type (P.A.) (I.C.) E0325        Urinal; male, jug-type, any material E0326        Urinal; female, jug-type, any material
MONITORING EQUIPMENT
X5077        Blood glucose monitor
E0605        Vaporizer, room type
E0607        Home blood glucose monitor (standard)
X5078        Blood glucose monitor (intermediate)
E0609        Blood glucose monitor with special features (e.g., voice synthesizers, automatic timers, etc.)
(P.A.) A4250        Urine test or reagent strips or tablets (100 tablets or strips) A4253        Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips A4254        Replacement battery, any type, for use with medically necessary home blood glucose monitor
owned by patient, each

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-5	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
A4627	Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler
X5274	Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips (intermediate)
A4660	Sphygmomanometer/blood pressure apparatus with cuff and stethoscope
A4663	Blood pressure cuff only
A4670	Automatic blood pressure monitor (P.A.)
X5354	Stethoscope
X5012	Personal emergency response system (monthly rental) (P.A.)
X5014	Personal emergency response system (installation) (P.A.)
X5050	Peak flow meter
PATIENT LIFTS
E0621	Sling or seat, patient lift, canvas or nylon (P.A.)
E0625	Patient lift, Kartop, bathroom or toilet (P.A.)
E0627	Seat lift mechanism incorporated into a combination lift-chair mechanism (P.A.)
E0628	Separate seat lift mechanism for use with patient owned furniture — electric (P.A.)
E0629	Separate seat lift mechanism for use with patient owned furniture — nonelectric (P.A.)
E0630	Patient lift, hydraulic, with seat or sling (P.A.)
E0635	Patient lift, electric, with seat or sling (P.A.) (I.C.)
PNEUMATIC COMPRESSORS AND APPLIANCES
E0651	Pneumatic compressor, segmental home model without calibrated gradient pressure (P.A.)
E0652	Pneumatic compressor, segmental home model with calibrated gradient pressure (P.A.) (I.C.)
E0655	Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm (P.A.)
E0660	Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg (P.A.)
E0665	Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm (P.A.)
E0666	Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg (P.A.)
E0667	Segmental pneumatic appliance for use with pneumatic compressor, full leg (P.A.)
E0668	Segmental pneumatic appliance for use with pneumatic compressor, full arm (P.A.)
E0669	Segmental pneumatic appliance for use with pneumatic compressor, half leg (P.A.)
E0671	Segmental gradient pressure pneumatic appliance, full leg (P.A.)
E0672	Segmental gradient pressure pneumatic appliance, full arm (P.A.)
E0673	Segmental gradient pressure pneumatic appliance, half leg (P.A.)
SAFETY EQUIPMENT
E0700	Safety equipment (e.g., belt, harness or vest)
X5079	Helmet (P.A.) (I.C.)
RESTRAINTS
E0710	Restraint, any type (body, chest, wrist or ankle)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-6	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
TRANSCUTANEOUS AND/OR NEUROMUSCULAR ELECTRICAL NERVE STIMULATORS (TENS)
E0720        TENS, two lead, localized stimulation (P.A.)
E0730        TENS, four or more leads, for multiple nerve stimulation (P.A.)
E0731        Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers
separated from the patient’s skin by layers of fabric) (P.A.) (I.C.) X5052        Pair replacement electrodes utilized for patient owned TENS unit (P.A.)
TRACTION EQUIPMENT
Traction — Cervical
E0840        Traction frame, attached to headboard, cervical traction E0850        Traction stand, freestanding, cervical traction
Traction — Overdoor
E0860        Traction equipment, overdoor, cervical
Traction — Extremity
E0870        Traction frame, attached to footboard, extremity traction (e.g., Buck's) E0880        Traction stand, freestanding, extremity traction (e.g., Buck's)
Traction — Pelvic
E0890        Traction frame, attached to footboard, pelvic traction E0900        Traction stand, freestanding, pelvic traction (e.g., Buck's)
TRAPEZE EQUIPMENT, FRACTURE FRAME, AND OTHER ORTHOPEDIC DEVICES
E0910	Trapeze bars, also known as Patient Helper, attached to bed, with grab bar (P.A.)
E0920	Fracture frame, attached to bed, includes weights (P.A.)
E0930	Fracture frame, freestanding, includes weights (P.A.)
E0935	Passive motion exercise device (P.A.) (I.C.)
E0940	Trapeze bar, freestanding, complete with grab bar (P.A.)
E0941	Gravity assisted traction device, any type
E0942	Cervical head harness/halter
E0943	Cervical pillow
E0944	Pelvic belt/harness/boot
E0945	Extremity belt/harness
E0946	Fracture frame, dual with cross bars, attached to bed (e.g., Balken, Four Poster) (P.A.)
E0947	Fracture frame, attachments for complex pelvic traction (P.A.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-7	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
E0948	Fracture frame, attachments for complex cervical traction (P.A.)
WHEELCHAIR ACCESSORIES
E0954	Semi-pneumatic caster, each
E0959	Amputee adapter (device used to compensate for transfer of weight due to lost limbs to maintain
proper balance)
E0961	Brake extension, for wheelchair
E0962	One-inch cushion, for wheelchair
E0963	Two-inch cushion, for wheelchair
E0964	Three-inch cushion, for wheelchair
E0965	Four-inch cushion, for wheelchair
E0966	Hook on headrest extension
E0967	Wheelchair hand rims with eight vertical rubber-tipped projections, pair
E0968	Commode seat, wheelchair
E0969	Narrowing device, wheelchair
E0996	Tire, solid, each
E0997	Caster with fork
E0998	Caster without fork
E0999	Pneumatic tire with wheel
E1001	Wheel, single
X5081	Tire, each (8")
X5082	Caster, complete
X5084	Axle
X5085	Quick release axle
X5086	Standard fork
X5087	Suspension fork
X5089	Rubber tip
X5091	Caster plate
X5092	Hub cap
X5093	Axle sleeve
X5094	Plastic stem cap
X5098	Clevis pin
X5101	Footrest bumper
X5103	Footrest roller
X5104	Footrest saddle
X5105	L-bracket
X5106	H-harness
X5108	Hanger bracket
X5109	Shoe holder
X5111	Power leg rest rod
X5112	Drawbolt
X5113	Leg rest adjustment rod
X5116	Roller bar

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-8	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
X5118	Roller bumper
X5119	Side guard
X5120	Arm socket
X5123	Arm lock pin
X5124	Skirt guard
X5125	Retractable arm
X5126	Delrin slide block
X5128	Flotation pad, gel type, for wheelchair
X5129	Cushion cover, for wheelchair
X5130	Cushion repair, for wheelchair
X5131	Lateral support
X5132	Headrest
X5134	Solid hook, in back
X5135	Solid hook, in seat
X5138	Zipper back
X5139	Neck support
X5141	Lumbar pad
X5142	Hip pad
X5144	8 degree back angle
X5145	Push handle, back
X5146	Seat hook
X5148	Custom headrest
X5149	Hip guard
X5150	Adjustable back bracket
X5151	Back adjustment tube
X5153	Upper extremity support tray
X5154	Chest strap
X5155	Tray buckle
X5156	Fastening hardware
X5157	Tray hardware
X5158	Abducter wedge
X5159	Flolite pad
X5160	Modify tilt
X5161	Side frame
X5162	Cross brace
X5163	Back frame
X5164	Caps
X5165	Roll pin
X5166	Knob
X5167	Stroller handle
X5168	Back post
X5169	Y adapter
X5170	Plastic spacer
X5171	Foam grip

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-9	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
X5172	Recliner lock
X5174	Recliner trigger
X5176	Hose clamp
X5177	Seat guide
X5178	Telescoping post
X5179	INBTN rails
X5180	Recliner cable
X5181	Tensioning
X5183	Frame extension
X5184	Spreader bar
X5186	Tire, with wheel (22" power)
X5191	Wheel adapter
X5192	Module (P.A.)
X5193	Motor circuit board
X5194	Circuit board
X5195	Oscillator board
X5196	Mode selector box
X5197	Plug
X5199	Pneumatic switch
X5201	Sip & puff mouthpiece
X5202	Sip & puff control box
X5203	Hand control
X5204	Joystick bracket
X5205	Swivel joystick bracket
X5206	Knob for hand control
X5207	CB shield
X5208	On/off switch
X5209	Sip & puff tube
X5210	Tilt/recline interec series
X5211	Switch
X5212	Gooseneck
X5213	Connector
X5214	Motor
X5215	Motor pulley
X5216	Gear box
X5217	Motor brush
X5218	Motor plug
X5220	Motor cover
X5221	Motor plate
X5222	Brake spring
X5223	Electromagnetic brake
X5224	Brake disc
X5225	Clutch
X5228	Battery terminal

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-10	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
X5229	Battery jumper cable
X5230	Battery wire harness
X5231	Fuse holder
X5232	Fuse
X5233	Charger cable
X5234	Actuator part
X5235	Switch and harness
X5236	Wheelchair mounting switch
X5237	Shroud fastener
X5238	Drive collar
X5239	Recliner switch
X5240	Actuator motor
X5241	Battery box
X5242	Vent tray
X5244	Utility tray with hardware
X5245	Environmental control unit (base) (P.A.)
X5246	Environmental control unit (all accessories) (P.A.)
X5247	Automatic door opener (P.A.)
X5252	Tilt-in space (P.A.)
X5253	Stroller (P.A.)
X5255	Floor sitter (P.A.)
X5256	Child therapeutic equipment (P.A.)
X5257	Contour-u-seating system (includes shell, growth link, cushion, front edge, remake, upholstery
bottom, mounting hardware) (P.A.) (I.C.)
ROLLABOUT CHAIR
E1031        Rollabout chair, any and all types with casters five inches or greater (P.A.) (I.C.)
WHEELCHAIR — FULLY RECLINING
E1050        Fully reclining wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
(P.A.) (I.C.) E1060        Fully reclining wheelchair; detachable arms, desk or full-length, swing-away, detachable,
elevating legrests (purchase) (P.A.) E1065        Power attachment (to convert any wheelchair to motorized wheelchair, e.g., Solo) (P.A.) E1070        Fully reclining wheelchair; detachable arms, desk or full-length, swing-away, detachable
footrests (P.A.) (I.C.) E1083        Hemi-wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests (P.A.) (I.C.) E1084        Hemi-wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating
legrests (purchase) (P.A.) E1085        Hemi-wheelchair; fixed full-length arms, swing-away, detachable footrests (P.A.) (I.C.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-11	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
E1086        Hemi-wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests (P.A.)
(I.C.) E1087        High-strength lightweight wheelchair; fixed full-length arms, swing-away, detachable, elevating
legrests (P.A.) E1088        High-strength lightweight wheelchair; detachable arms, desk or full-length, swing-away,
detachable, elevating legrests (purchase) (P.A.) E1089        High-strength lightweight wheelchair; fixed-length arms, swing-away, detachable footrests
(P.A.) (I.C.) E1090        High-strength lightweight wheelchair; detachable arms, desk or full-length, swing-away,
detachable footrests (P.A.) (I.C.) E1091        Youth wheelchair; any type (P.A.) (I.C.) E1092        Wide, heavy-duty wheelchair; detachable arms, desk or full-length, swing-away, detachable,
elevating legrests (purchase) (P.A.) E1093        Wide, heavy-duty wheelchair; detachable arms, desk or full-length arms, swing-away,
detachable footrests (P.A.)
WHEELCHAIR — SEMI-RECLINING
E1100        Semi-reclining wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
(purchase) (P.A.) E1110        Semi-reclining wheelchair; detachable arms, desk or full-length, elevating legrest
WHEELCHAIR — STANDARD
X5422        Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests (rental,
first six months, per month) (P.A. after three months) E1140        Wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests (purchase)
(P.A.) (I.C.) X5423        Wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests (rental, first
six months, per month) (P.A. after three months) E1150        Wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests
(standard) (purchase) (P.A.) X5424        Wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests
(standard) (rental, first six months, per month) (P.A. after three months) E1160        Wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests (standard)
(purchase) (P.A.) (I.C.) X5425        Wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests (standard) (rental,
first six months, per month) (P.A. after three months) (I.C.)
WHEELCHAIR — AMPUTEE
E1170        Amputee wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
(purchase) (P.A.) E1171        Amputee wheelchair; fixed full-length arms, without footrests or legrests (purchase) (P.A.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-12	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
E1172        Amputee wheelchair; detachable arms, desk or full-length, without footrests or legrests
(purchase) (P.A.) E1180        Amputee wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
(purchase) (P.A.) E1190        Amputee wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating
legrests (purchase) (P.A.) E1195        Heavy duty wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
(purchase) (P.A.) E1200        Amputee wheelchair; fixed full-length arms, swing-away, detachable footrests (purchase) (P.A.)
WHEELCHAIR — POWER
E1210        Motorized wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
(purchase) (P.A.) E1212        Motorized wheelchair; fixed full-length arms, swing-away, detachable footrests (purchase)
(P.A.) E1213        Motorized wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
(purchase) (P.A.)
WHEELCHAIR — SPECIAL SIZE
E1220        Wheelchair; specially sized or constructed (indicate brand name, model number, if any, and
justification) (P.A.) (I.C.) E1221        Wheelchair with fixed arm, footrests (purchase) (P.A.) (I.C.) X5426        Wheelchair with fixed arm, footrests (rental, first six months, per month) (P.A. after three
months) (I.C.) E1222        Wheelchair with fixed arm, elevating legrests (purchase) (P.A.) X5427        Wheelchair with fixed arm, elevating legrests (rental, first six months, per month) (P.A. after
three months) (I.C.) E1223        Wheelchair with detachable arms, footrests (purchase) (P.A.) X5428        Wheelchair with detachable arms, footrests (rental, first six months, per month) (P.A. after three
months) E1224        Wheelchair with detachable arms, elevating legrests (purchase) (P.A.) X5429        Wheelchair with detachable arms, elevating legrests (rental, first six months, per month) (P.A.
after three months) E1225        Semi-reclining back for customized wheelchair (P.A.) E1226        Full reclining back for customized wheelchair (P.A.) E1228        Special back height for wheelchair (P.A.) (I.C.) E1230        Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model
number (purchase) (P.A.)

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Division of Medical Assistance
Provider Manual Series
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6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-13	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
WHEELCHAIR — LIGHTWEIGHT
E1240        Lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating
legrest (purchase) (P.A.) E1250        Lightweight wheelchair; fixed full-length arms, swing-away, detachable footrests (purchase)
(P.A.) E1260        Lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
(purchase) (P.A.) E1270        Lightweight wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
(purchase) (P.A.)
WHEELCHAIR — HEAVY DUTY
E1280        Heavy-duty wheelchair; detachable arms, desk or full-length, elevating legrests (purchase) (P.A.) E1285        Heavy-duty wheelchair; fixed full-length arms, swing-away, detachable footrests (purchase)
(P.A.) E1290        Heavy-duty wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
(purchase) (P.A.) E1295        Heavy-duty wheelchair; fixed full-length arms, elevating legrests (purchase) (P.A.)
WHEELCHAIR AND WHEELCHAIR ACCESSORIES
K0001	Standard wheelchair (P.A.)
K0002	Standard hemi (low seat) wheelchair (P.A.)
K0003	Lightweight wheelchair (P.A.)
K0004	High strength, lightweight wheelchair (P.A.)
K0005	Ultralightweight wheelchair (P.A.)
K0006	Heavy-duty wheelchair (P.A.)
K0007	Extra heavy-duty wheelchair (P.A.)
K0008	Custom manual wheelchair/base (P.A.) (I.C.)
K0009	Other manual wheelchair/base (P.A.) (I.C.)
K0010	Standard-weight frame motorized/power wheelchair (P.A.)
K0011	Standard-weight frame motorized/power wheelchair with programmable control parameters for
speed adjustment, tremor dampening, acceleration control and braking (P.A.)
K0012	Lightweight portable motorized/power wheelchair (P.A.)
K0013	Custom motorized/power wheelchair base (P.A.) (I.C.)
K0014	Other motorized/power wheelchair base (P.A.) (I.C.)
K0015	Detachable, nonadjustable height armrest, each
K0016	Detachable, adjustable height armrest, complete assembly, each
K0017	Detachable, adjustable height armrest, base, each
K0018	Detachable, adjustable height armrest, upper portion, each
K0019	Arm pad, each
K0020	Fixed, adjustable height armrest, pair

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
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	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
K0021	Antitipping device, each
K0022	Reinforced back upholstery
K0023	Solid back insert, planar back, single density foam, attached with straps
K0024	Solid back insert, planar back, single density foam, with adjustable hook-on hardware
K0025	Hook-on headrest extension
K0026	Back upholstery for ultralightweight or high-strength lightweight wheelchair
K0027	Back upholstery for wheelchair type other than ultralightweight or high-strength lightweight
wheelchair
K0028	Manual, fully reclining back
K0029	Reinforced seat upholstery
K0030	Solid seat insert, planar seat, single density foam
K0031	Safety belt/pelvic strap, each
K0032	Seat upholstery for ultralightweight or high-strength lightweight wheelchair
K0033	Seat upholstery for wheelchair type other than ultralightweight or high-strength lightweight
wheelchair
K0034	Heel loop, each
K0035	Heel loop with ankle strap, each
K0036	Toe loop, each
K0037	High mount flip-up footrest, each
K0038	Leg strap, each
K0039	Leg strap, H style, each
K0040	Adjustable angle footplate, each
K0041	Large size footplate, each
K0042	Standard size footplate, each
K0043	Footrest, lower extension tube, each
K0044	Footrest, upper hanger bracket, each
K0045	Footrest, complete assembly
K0046	Elevating legrest, lower extension tube, each
K0047	Elevating legrest, upper hanger bracket, each
K0048	Elevating legrest, complete assembly
K0049	Calf pad, each
K0050	Ratchet assembly
K0051	Cam release assembly, footrest or legrest, each
K0052	Swingaway, detachable footrests, each
K0053	Elevating footrests, articulating (telescoping), each
K0054	Seat width of 10, 11, 12, 15, 17, or 20 inches for a high-strength, lightweight or ultralightweight
wheelchair
K0055	Seat depth of 15, 17, or 18 inches for a high strength, lightweight or ultralightweight wheelchair
K0056	Seat height less than 17 inches or equal to or greater than 21 inches for a high strength,
lightweight, or ultralightweight wheelchair
K0057	Seat width 19 or 20 inches for heavy duty or extra heavy-duty chair
K0058	Seat depth 17 or 18 inches for a motorized/power wheelchair
K0059	Plastic coated handrim, each
K0060	Steel handrim, each

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-15	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
K0061	Aluminum handrim, each
K0062	Handrim with 8 to 10 vertical or oblique projections, each
K0063	Handrim with 12 to 16 vertical or oblique projections, each
K0064	Zero pressure tube (flat free insert), any size, each
K0065	Spoke protectors, each
K0066	Solid tire, any size, each
K0067	Pneumatic tire, any size, each
K0068	Pneumatic tire tube, each
K0069	Rear wheel assembly, complete, with solid tire, spokes or molded, each
K0070	Rear wheel assembly, complete with pneumatic tire, spokes or molded, each
K0071	Front caster assembly, complete, with pneumatic tire, each
K0072	Front caster assembly, complete, with semipneumatic tire, each
K0073	Caster pin lock, each
K0074	Pneumatic caster tire, any size, each
K0075	Semipneumatic caster tire, any size, each
K0076	Solid caster tire, any size, each
K0077	Front caster assembly, complete, with solid tire, each
K0078	Pneumatic caster tire tube, each
K0079	Wheel lock extension, pair
K0080	Antirollback device, pair
K0081	Wheel lock assembly, complete, each (I.C.)
K0082	22 NF non-sealed lead acid battery, each
K0083	22 NF sealed lead acid battery, each (e.g., gel cell, absorbed glass mat)
K0084	Group 24 non-sealed lead acid battery, each
K0085	Group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glass mat)
K0086	U-1 non-sealed lead acid battery, each (e.g., gel cell, absorbed glass mat)
K0087	U-1 sealed lead acid battery, each (e.g., gel cell, absorbed glass mat)
K0088	Battery charger, single mode, for use with only one battery type, sealed or non-sealed
K0089	Battery charger, dual mode, for use with either battery type, sealed or non-sealed
K0090	Rear wheel tire for power wheelchair, any size, each
K0091	Rear wheel tire tube other than zero pressure for power wheelchair, any size, each
K0092	Rear wheel assembly for power wheelchair, compete, each
K0093	Rear wheel zero pressure tire tube (flat free insert) for power wheelchair, any size, each
K0094	Wheel tire for power base, any size, each
K0095	Wheel tire tube other than zero pressure for each base, any size, each
K0096	Wheel assembly for power base, complete, each
K0097	Wheel zero-pressure tire tube (flat free insert) for power base, any size, each
K0098	Drive belt for power wheelchair
K0099	Front caster for power wheelchair
K0100	Wheelchair adapter for amputee, pair
K0101	One-arm drive attachment, each
K0102	Crutch and cane holder, each
K0103	Transfer board, less than 25 inches
K0104	Cylinder tank carrier, each

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-16	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
K0105        IV hanger, each K0106        Arm trough, each K0107        Wheelchair tray K0108        Other accessories (I.C.)
SPINAL ORTHOTICS
K0112        Trunk support device, vest type, with inner frame, prefabricated (I.C.) K0113        Trunk support device, vest type, without inner frame, prefabricated (I.C.) K0114        Back support system for use with a wheelchair, with inner frame, prefabricated (I.C.) K0115        Seating system, back module, posterior-lateral control, with or without lateral supports, custom fabricated for attachment to wheelchair base (I.C.)
REPAIRS, REPLACEMENT PARTS, AND PROFESSIONAL AND LABOR SERVICES
X1790        Nonstandard prescription options (for durable medical equipment) (per hour) (P.A.) X1350        Parts only, for repair or replacement (I.C.) Y9858        Repair (labor only, per hour)
AUGMENTATIVE COMMUNICATION DEVICES
X5056        Augmentative communication device (rental) (P.A.) (I.C.) X5057        Augmentative communication device (purchase) (P.A.) (I.C.)
NOT OTHERWISE CLASSIFIED
E1399        Durable medical equipment, miscellaneous (P.A.) (I.C.)
MISCELLANEOUS SUPPLIES
X5267	Gauze, sterile strip 1/2"
X5268	Gauze, sterile strip 1/4"
X5269	Gauze, sterile strip 1"
X5270	Gauze, sterile strip 2"
X5272	Cotton-tip applicators, sterile (100/box)
X5273	Mask, surgical
A4206	Syringe with needle, sterile 1 cc, each
A4207	Syringe with needle, sterile 2 cc, each
A4208	Syringe with needle, sterile 3 cc, each
A4209	Syringe with needle, sterile 5 cc or greater, each
A4210	Needle-free injection device, each (P.A.) (I.C.)
A4211	Supplies for self-administered injections (P.A.) (I.C.)
A4212	Non coring needle or stylet with or without catheter
A4213	Syringe, sterile, 20 cc or greater, each
A4214	Sterile saline or water, 30 cc vial

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-17	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
A4215	Needles only, sterile, any size, each
A4220	Refill kit for implantable infusion pump
A4221	Supplies for maintenance of drug infusion catheter, per week (list drug separately) (I.C.)
A4222	Supplies for external drug infusion pump, per cassette or bag (list drug separately) (I.C.)
A4230	Infusion set for external insulin pump, nonneedle cannula type (P.A.) (I.C.)
A4231	Infusion set for external insulin pump, needle type (P.A.) (I.C.)
A4232	Syringe with needle for external insulin pump, sterile, 3 cc (I.C.)
A4244	Alcohol or peroxide, per pint
A4245	Alcohol wipes, per box
A4246	Betadine or pHisoHex solution, per pint
A4247	Betadine or iodine swabs/wipes, per box
A4250	Urine test or reagent strips or tablets (100 tablets or strips)
A4253	Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips
A4254	Replacement battery, any type, for use with medically necessary home blood glucose monitor
owned by patient, each
A4256	Normal, low, and high calibrator solution/chips
A4258	Spring-powered device for lancet, each (P.A.)
A4259	Lancets, per box of 100
A4265	Paraffin, per pound
A4927	Gloves, nonsterile, per 100
VASCULAR CATHETERS
A4300        Implantable access catheter (e.g., venous, arterial, epidural subarchnoid, or peritoneal, etc.),
external access (I.C.) A4301        Implantable access total catheter, port/reservoir (e.g., venous, arterial, epidural subarchnoid, or
peritoneal, etc.) (I.C.) A4305        Disposable drug delivery system, flow rate of 50 ml or greater per hour (I.C.) A4306        Disposable drug delivery system, flow rate of 5 ml or less per hour (I.C.)
INCONTINENCE APPLIANCES AND CARE SUPPLIES
A4310        Insertion tray without drainage bag and without catheter (accessories only)
A4311        Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with
coating (Teflon®, silicone, silicone elastomer or hydrophilic, etc.) A4312        Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone A4313        Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for
continuous irrigation A4314        Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating
(Teflon®, silicone, silicone elastomer, or hydrophilic, etc.) A4315        Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all silicone A4316        Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, for continuous
irrigation A4319        Sterile water irrigation solution, 1000 ml

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-18	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
A4320        Irrigation tray with bulb or piston syringe, any purpose
A4322        Irrigation syringe, bulb or piston, each
A4323        Sterile saline irrigation solution, 1000 ml
A4324        Male external catheter, with adhesive coating, each
A4325        Male external catheter, with adhesive strip, each
A4326        Male external catheter specialty type (e.g., inflatable, faceplate, etc.), each
A4328        Female external urinary collection device; pouch, each
A4329        External catheter starter set, male/female, includes catheters/urinary collection device,
bag/pouch, and accessories (tubing, clamps, etc.), seven-day supply A4330        Perianal fecal collection pouch with adhesive, each A4331        Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg
bag or urostomy pouch, each A4332        Lubricant, individual sterile packet, for insertion of urinary catheter, each A4333        Urinary catheter anchoring device, adhesive skin attachment, each A4334        Urinary catheter anchoring device, leg strap, each A4335        Incontinence supply; miscellaneous (P.A.) (I.C.) A4338        Indwelling catheter; Foley type, two-way, latex with coating (Teflon®, silicone, silicone
elastomer, or hydrophilic, etc.), each A4340        Indwelling catheter; specialty type (e.g., coudé, mushroom, wing, etc.), each A4344        Indwelling catheter; Foley type, two-way, all silicone, each A4346        Indwelling catheter; Foley type, three-way for continuous irrigation, each A4347        Male external catheter with or without adhesive, with or without anti-reflux device; per dozen A4351        Intermittent urinary catheter; straight tip with or without coating (Teflon, silicone, slilcone
elastomer, or hydrophilic, etc.), each A4352        Intermittent urinary catheter; coudé (curved) tip with or without coating (Teflon, silicone,
slilcone elastomer, or hydrophilic, etc.), each A4354        Insertion tray with drainage bag but without catheter A4355        Irrigation tubing set for continuous bladder irrigation through a three-way indwelling Foley
catheter, each
EXTERNAL URINARY SUPPLIES
A4356	External urethral clamp or compression device (not to be used for catheter clamp), each
A4357	Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each
A4358	Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each
A4359	Urinary suspensory without leg bag, each
OSTOMY SUPPLIES
A4361	Ostomy faceplate, each
A4362	Skin barrier; solid, four by four or equivalent; each
A4364	Adhesive, liquid, or equal, any type, per ounce
A4365	Adhesive remover wipes, any type, per 50

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-19	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
A4367	Ostomy belt, each
A4368	Ostomy filter, any type, each
A4369	Ostomy skin barrier, liquid (spray, brush, etc.), per oz
A4371	Ostomy skin barrier, powder, per oz
A4372	Ostomy skin barrier, solid 4 x 4 or equivalent, with built-in convexity, each
A4373	Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, any size,
each
A4374	Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in
convexity, any size, each
A4375	Ostomy pouch, drainable, with faceplate attached, plastic; each
A4376	Ostomy pouch, drainable, with faceplate attached, rubber, each
A4377	Ostomy pouch, drainable, for use on faceplate, plastic, each
A4378	Ostomy pouch, drainable, for use on faceplate, rubber, each
A4379	Ostomy pouch, urinary, with faceplate attached, plastic, each
A4380	Ostomy pouch, urinary, with faceplate attached, rubber, each
A4381	Ostomy pouch, urinary, for use on faceplate, plastic, each
A4382	Ostomy pouch, urinary, for use on faceplate, heavy plastic, each
A4383	Ostomy pouch, urinary, for use on faceplate, rubber, each
A4384	Ostomy faceplate equivalent, silicone ring, each
A4385	Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each
A4387	Ostomy pouch, closed, with barrier attached, with built-in convexity (one piece), each
A4388	Ostomy pouch, drainable, with extended wear barrier attached, (one piece), each
A4389	Ostomy pouch, drainable, with barrier attached, with built-in convexity (one piece), each
A4390	Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (one
piece), each
A4391	Ostomy pouch, urinary, with extended wear barrier attached, (one piece), each
A4392	Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (one piece),
each
A4393	Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (one piece),
each
A4394	Ostomy deodorant for use in ostomy pouch, liquid, per fluid ounce
A4395	Ostomy deodorant for use in ostomy pouch, solid, per tablet
A4397	Irrigation supply; sleeve, each
A4398	Ostomy irrigation supply; bag, each
A4399	Ostomy irrigation supply; cone/catheter, including brush
A4400	Ostomy irrigation set
A4402	Lubricant, per ounce
A4404	Ostomy ring, each
A4421	Ostomy supply; miscellaneous (P.A.) (I.C.)
ADDITIONAL MISCELLANEOUS SUPPLIES
A4454        Tape, all types, all sizes
A4455        Adhesive remover or solvent (for tape, cement or other adhesive), per ounce

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Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-20	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
A4460	Elastic bandage, per roll (e.g., compression bandage)
A4465	Nonelastic binder for extremity (I.C.)
A4490	Surgical stocking above knee length, each
A4495	Surgical stocking thigh length, each
A4500	Surgical stocking below knee length, each
A4510	Surgical stocking full-length, each
A4550	Surgical trays
A4554	Disposable underpads, all sizes (e.g., Chux’s) (P.A.)
X5276	Diapers, pediatric (each) (P.A.)
X5277	Diapers, youth (each) (P.A.)
X5278	Diapers, adult (small) (each) (P.A.)
X5279	Diapers, adult (medium) (each) (P.A.)
X5280	Diapers, adult (large) (each) (P.A.)
X5281	Diapers, adult (X-large) (each) (P.A.)
X5282	Liners, standard (each) (P.A.)
X5283	Liners, intermediate (each) (P.A.)
A4561	Pessary, rubber, any type
A4562	Pessary, non rubber, any type
A4565	Slings
A4570	Splint
A4572	Rib belt
A4595	Electrical stimulator supplies, 2 lead, per month (e.g., TENS, NMES)
SUPPLIES FOR OTHER DURABLE MEDICAL EQUIPMENT
A4630	Replacement batteries for medically necessary transcutaneous electrical nerve stimulator (TENS)
owned by patient
A4631	Replacement batteries for medically necessary electronic wheelchair owned by patient
A4635	Underarm pad, crutch, replacement, each
A4636	Replacement, handgrip, cane, crutch, or walker, each
A4637	Replacement, tip, cane, crutch, walker, each
A4640	Replacement pad for use with medically necessary alternating pressure pad owned by patient
A4649	Surgical supply; miscellaneous (P.A.) (I.C.)
X5007	Basal thermometer, each
X5008	Eye patch, cloth, each
X5009	Condoms, per 12
X1059	Female condoms with lubricant, 3 pack
X1060	Female condoms with lubricant, 6 pack
X5010	Eye patch, plastic, each
X5011	Eye cup, glass or plastic, each
X5020	Breast shield, each
X5021	Breast pump, each

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Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-21	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
SUPPLIES FOR ESRD
A4660	Sphygmomanometer/blood pressure apparatus with cuff and stethoscope
A4663	Blood pressure cuff only
X5354	Stethoscope
A4670	Automatic blood pressure monitor (P.A.)
A4712	Water, sterile, for injection, per 10 ml
A4772	Blood glucose test strips, for dialysis, per 50
DRESSINGS
X5284        Primary surgical dressing kit (e.g., sterile dressings, pad, etc.) (standard)
X5285        Primary surgical dressing kit (e.g., sterile dressings, pad, etc.) (extensive)
X5286        Primary surgical dressing kit (e.g., sterile dressings, pad, etc.) (intermediate)
X5340        Dressing gel/paste, Unnapaste bandage (each)
X5343        Skin care Cara Klenz (per ounce)
X5344        Skin care, cata cleansing foam (each)
X5349        Skin care, KY Jelly (per ounce)
X5351        Skin care, mentor skin care kit
X5353        Skin care, Hibiclens (16 ounces)
A6154        Wound pouch, each
A6196        Alginate or other fiber gelling dressing, wound cover, pad size 16 sq. in. or less, each dressing
(I.C.) A6197        Alginate or other fiber gelling dressing, wound cover, pad size more than 16 sq. in. but less than
or equal to 48 sq. in., each dressing (I.C.) A6198        Alginate or other fiber gelling dressing, wound cover, pad size more than 48 sq. in., each
dressing (I.C.) A6199        Alginate or other fiber gelling dressing, wound filler, per 6 inches A6200        Composite dressing, pad size 16 sq. in. or less, without adhesive border, each dressing A6201        Composite dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without
adhesive border, each dressing A6202        Composite dressing, pad size more than 48 sq. in., without adhesive border, each dressing A6203        Composite dressing, pad size 16 sq. in. or less, with any size adhesive border, each dressing A6204        Composite dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any
size adhesive border, each dressing A6205        Composite dressing, pad size more than 48 sq. in., with any size adhesive border, each dressing
(I.C.) A6206        Contact layer, 16 sq. in. or less, each dressing (I.C.)A6207    Contact layer, more than 16 sq. in.
but less than or equal to 48 sq. in., each dressing A6208        Contact layer, more than 48 sq. in., each dressing (I.C.)
A6209        Foam dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing A6210        Foam dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in.,
without adhesive border, each dressing A6211        Foam dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each
dressing

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Division of Medical Assistance
Provider Manual Series
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	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
A6212        Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each
dressing A6213        Foam dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in.,
with any size adhesive border, each dressing A6214        Foam dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each
dressing A6215        Foam dressing, wound filler, per gram (I.C.) A6216        Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each
dressing A6217        Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in. but less than or equal to 48
sq. in., without adhesive border, each dressing A6218        Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in., without adhesive border,
each dressing (I.C.) A6219        Gauze, non-impregnated, pad size 16 sq. in. or less, with any size adhesive border, each dressing A6220        Gauze, non-impregnated, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with
any size adhesive border, each dressing A6221        Gauze, non-impregnated, pad size more than 48 sq. in., with any size adhesive border, each
dressing (I.C.) A6222        Gauze, impregnated with other than water, normal saline, or hydrogel, pad size 16 sq. in. or less,
without adhesive border, each dressing A6223        Gauze, impregnated with other than water, normal saline, or hydrogel, pad size more than 16 sq.
in. but less than or equal to 48 sq. in., without adhesive border, each dressing A6224        Gauze, impregnated with other than water, normal saline, or hydrogel, pad size more than 48 sq.
in., without adhesive border, each dressing A6228        Gauze, impregnated, water or normal saline, pad size 16 sq. in. or less, without adhesive border,
each dressing (I.C.) A6229        Gauze, impregnated, water or normal saline, pad size more than 16 sq. in. but less than or equal
to 48 sq. in., without adhesive border, each dressing (I.C.) A6230        Gauze, impregnated, water or normal saline, pad size more than 48 sq. in., without adhesive
border, each dressing (I.C.) A6234        Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each
dressing A6235        Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48
sq. in., without adhesive border, each dressing A6236        Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border,
each dressing A6237        Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border,
each dressingA6238      Hydrocolloid dressing, wound cover, pad size more than 16 sq. in.
but less than or equal to 48 sq. in., with any size adhesive border, each dressing A6239        Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., with any size adhesive
border, each dressing A6240        Hydrocolloid dressing, wound filler, paste, per fluid ounce A6241        Hydrocolloid dressing, wound filler, dry form, per gram

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Division of Medical Assistance
Provider Manual Series
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6 SERVICE CODES AND DESCRIPTIONS	PAGE
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	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
A6242        Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each
dressing A6243        Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq.
in., without adhesive border, each dressing A6244        Hydrogel dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each
dressing A6245        Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each
dressing A6246        Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq.
in., with any size adhesive border, each dressing A6247        Hydrogel dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border,
each dressing A6248        Hydrogel dressing, wound filler, gel, per fluid ounce
A6250        Skin sealants, protectants, moisturizers, ointments, any type, any size (P.A.) (I.C.) A6251        Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, without adhesive border,
each dressing A6252        Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal
to 48 sq. in., without adhesive border, each dressing A6253        Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., without adhesive
border, each dressing A6254        Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive
border, each dressing A6255        Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal
to 48 sq. in., with any size adhesive border, each dressing A6256        Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., with any size adhesive
border, each dressing A6257        Transparent film, 16 sq. in. or less, each dressing
A6258        Transparent film, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing A6259        Transparent film, more than 48 sq. in., each dressing A6260        Wound cleansers, any type, any size (I.C.)
A6261        Wound filler, gel/paste, per fluid ounce, not elsewhere classified (I.C.) A6262        Wound filler, dry form, per gram, not elsewhere classified A6263        Gauze, elastic, non-sterile, all types, per linear yard A6264        Gauze, non-elastic, non-sterile, per linear yard
A6266        Gauze, impregnated, other than water, normal saline, or zinc paste, any width, per linear yard A6402        Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each
dressing A6403        Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in.,
without adhesive border, each dressing A6404        Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each
dressing A6405        Gauze, elastic, sterile, all types, per linear yard A6406        Gauze, non-elastic, sterile, all types, per linear yard

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-24	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
ADDITIONAL OSTOMY SUPPLIES
A5051	Ostomy pouch, closed; with barrier attached (one piece), each
A5052	Ostomy pouch, closed; without barrier attached (one piece), each
A5053	Ostomy pouch, closed; for use on faceplate, each
A5054	Ostomy pouch, closed; for use on barrier with flange (two piece), each
A5055	Stoma cap
A5061	Ostomy pouch, drainable; with barrier attached (one piece), each
A5062	Ostomy pouch, drainable; without barrier attached (one piece), each
A5063	Ostomy pouch, drainable; for use on barrier with flange (two piece system), each
A5064	Ostomy pouch, drainable; with faceplate attached; plastic or rubber, each
A5071	Ostomy pouch, urinary; with barrier attached (one piece), each
A5072	Ostomy pouch, urinary; without barrier attached (one piece), each
A5073	Ostomy pouch, urinary; for use on barrier with flange (two piece), each
A5074	Ostomy pouch, urinary; with faceplate attached; plastic or rubber
A5075	Ostomy pouch, urinary; for use on faceplate; plastic or rubber
A5081	Continent device; plug for continent stoma
A5082	Continent device; catheter for continent stoma
A5093	Ostomy accessory; convex insert
ADDITIONAL INCONTINENCE APPLIANCES/SUPPLIES
A5102	Bedside drainage bottle, with or without tubing, rigid or expandable, each
A5105	Urinary suspensory; with leg bag, with or without tube
A5112	Urinary leg bag; latex
A5113	Leg strap; latex, replacement only, per set
A5114	Leg strap; foam or fabric, replacement only, per set
SUPPLIES FOR EITHER INCONTINENCE OR OSTOMY APPLIANCES
A5119	Skin barrier; wipes, box per 50
A5121	Skin barrier; solid, 6 x 6 or equivalent, each
A5122	Skin barrier; solid, 8 x 8 or equivalent, each
A5123	Skin barrier; with flange (solid, flexible, or accordion), any size, each
A5126	Adhesive or non-adhesive; disk or foam pad
A5131	Appliance cleaner, incontinence and ostomy appliances, per 16 oz.
PARENTERAL/ENTERAL THERAPY
X5022	Advera®, 8 ounce cans, per can (P.A.)
X5023	Nepro® (P.A.) (I.C.)
X5024	Suplena® (P.A.) (I.C.)
X5025	Pulmocare® (P.A.) (I.C.)
X5026	Vital® HN (P.A.) (I.C.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-25	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
X5027	Perative® (P.A.) (I.C.)
X5028	Alitraq® (P.A.) (I.C.)
X5029	Pediasure® with fiber (P.A.) (I.C.)
X5030	Companion pump and set (P.A.) (I.C.)
X5391	Total parenteral nutrition (I.C.)
X5392	Unlisted enteral solutions (P.A.) (I.C.)
X5393	Ensure®, 8 ounce cans, per can (P.A.)
X5394	Ensure® plus, 8 ounce cans, per can (P.A.)
X5395	Ensure® plus HN, 8 ounce cans, per can (P.A.)
X5396	Enfamil®, 8 ounce cans, per can (P.A.)
X5397	Enrich®, 8 ounce cans, per can (P.A.)
X5398	Glucerna®, 8 ounce cans per can (P.A.)
X5399	Isocal®, 8 ounce cans, per can (P.A.)
X5400	Jevity®, 8 ounce cans, per can (P.A.)
X5401	Magnacal®, 8 ounce cans, per can (P.A.)
X5402	Meritene®, 250 ml. cans, per can (P.A.)
X5403	Nutramigen®, 32 ounce cans, per can (P.A.)
X5404	Osmolite®, 8 ounce cans, per can (P.A.)
X5405	Osmolite® HN, 8 ounce cans, per can (P.A.)
X5406	Pediasure®, 8 ounce cans, per can (P.A.)
X5407	Polycose® powder, 12.3 ounce can (P.A.)
X5408	Portagen® powder, 16 ounce can (P.A.)
X5409	Prosobee®, 8 ounce cans, per can (P.A.)
X5410	Resource®, 8 ounce cans, per can (P.A.)
X5411	Sustacal®, 8 ounce cans, per can (P.A.)
X5412	Two cal. HN, 8 ounce cans, per can (P.A.)
X5413	Enteral bags, each (P.A.)
ENTERAL FORMULAE AND ENTERAL MEDICAL SUPPLIES
B4034	Enteral feeding supply kit; syringe, per day (I.C.)
B4035	Enteral feeding supply kit; pump fed, per day (I.C.)
B4036	Enteral feeding supply kit; gravity fed, per day (I.C.)
B4081	Nasogastric tubing with stylet (I.C.)
B4082	Nasogastric tubing without stylet (I.C.)
B4083	Stomach tube — Levine type (I.C.)
B4084	Gastrostomy/jejunostomy tubing (I.C.)
PARENTERAL NUTRITION SOLUTIONS AND SUPPLIES
B4164	Parenteral nutrition solution; carbohydrates (dextrose), 50% or less (500 ml = 1 unit) — home
mix (I.C.)
B4168	Parenteral nutrition solution; amino acid, 3.5% (500 ml = 1 unit) — home mix (I.C.)
B4172	Parenteral nutrition solution; amino acid, 5.5% through 7% (500 ml = 1 unit) — home mix (I.C.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-26	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
B4176 Parenteral nutrition solution; amino acid, 7% through 8.5% (500 ml = 1 unit) — home mix (I.C.) B4178 Parenteral nutrition solution; amino acid, greater than 8.5% (500 ml = 1 unit) — home mix (I.C.) B4180        Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) —
home mix (I.C.) B4184        Parenteral nutrition solution; lipids, 10% with administration set (500 ml = 1 unit) (I.C.) B4186        Parenteral nutrition solution; lipids, 20% with administration set (500 ml = 1 unit) (I.C.) B4189        Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace
elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein —
premix (I.C.) B4193        Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace
elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein —
premix (I.C.) B4197        Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace
elements and vitamins, including preparation, any strength, 74 to 100 grams of protein —
premix (I.C.) B4199        Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace
elements and vitamins, including preparation, any strength, over 100 grams of protein —
premix (I.C.) B4216        Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes) — home mix, per
day (I.C.) B4220        Parenteral nutrition supply kit; premix, per day (I.C.) B4222        Parenteral nutrition supply kit; home mix, per day (I.C.) B4224        Parenteral nutrition administration kit, per day (I.C.) B5000        Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace
elements, and vitamins, including preparation, any strength, renal — amirosyn RF,
nephramine, renamine — premix (I.C.) B5100        Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace
elements, and vitamins, including preparation, any strength, hepatic — freamine HBC,
hepatamine — premix (I.C.) B5200        Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace
elements, and vitamins, including preparation, any strength, stress — branch chain amino
acids — premix (I.C.)
ENTERAL AND PARENTERAL PUMPS
B9000	Enteral nutrition infusion pump — without alarm (P.A.) (I.C.)
B9002	Enteral nutrition infusion pump — with alarm (P.A.) (I.C.)
B9004	Parenteral nutrition infusion pump, portable (I.C.)
B9006	Parenteral nutrition infusion pump, stationary (I.C.)
B9998	Not otherwise classified for enteral supplies (P.A.) (I.C.)
B9999	Not otherwise classified for parenteral supplies (I.C.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-27	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
INFUSION SUPPLIES
E0776        IV pole (I.C.)
E0779        Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater (P.A.) (I.C.)
E0781        Ambulatory infusion pump, single or multiple channels, electric or battery operated, with
administrative equipment, worn by patient (I.C.) E0782        Infusion pump, implantable, non-programmable (includes all components, e.g., pump, catheter,
connectors, etc.) (P.A.) (I.C.) E0783        Infusion pump system, implantable, programmable (includes all components, e.g., pump,
catheter, connectors, etc.) (P.A.) (I.C.)
E0791        Parenteral infusion pump, stationary, single or multichannel (I.C.)
X5381        Dynasplint system (purchase) (P.A.)
X5382	Dynasplint system (rental) (P.A.)
HOME INFUSION THERAPY (per diem)
 55035	Home infusion therapy, routine service of infusion device (e.g.,pump maintenance)
 55036	Home infusion therapy, repair of infusion device (e.g., pump repair)

 55497	Home infusion therapy, catheter care/maintenance, not otherwise classified; includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
 55498	Home infusion therapy, catheter care/maintenance, simple (single lumen), includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

 55501	Home infusion therapy, catheter care/maintenance, complex (more than one lumen), includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
 55502	Home infusion therapy, catheter care/maintenance, implanted access device, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (use this code for interim maintenance of vascular access not currently in use)

 55517	Home infusion therapy, all supplies necessary for restoration of catheter patency or declotting
 55518	Home infusion therapy, all supplies necessary for catheter repair

 55520	Home infusion therapy, all supplies (including catheter) necessary for peripherally inserted central venous catheter (PICC) line insertion
 55521	Home infusion therapy, all supplies (including catheter) necessary for a midline catheter insertion

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-28	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
59325	Home infusion therapy, pain management infusion; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code with S9326, S9327 or S9328)
59326	Home infusion therapy, continuous pain management infusion; administrative services,
professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (24 hours or more)
59327	Home infusion therapy, intermittent pain management infusion; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (less than 24 hours)
59328	Home infusion therapy, implanted pump pain management infusion; administrative
services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
59329	Home infusion therapy, chemotherapy infusion; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code with S9330 or S9331)
59330	Home infusion therapy, continuous chemotherapy infusion; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (24 hours or more)
59331	Home infusion therapy, intermittent chemotherapy infusion; administrative services,
professional pharmacy services, care coordination,and all necessary supplies and equipment
(drugs and nursing visits coded separately), per diem (less than 24 hours)
S9336	Home infusion therapy, continuous anticoagulant infusion therapy (e.g., heparin),
administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
59338	Home infusion therapy; immunotherapy therapy, administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
59339	Home therapy; peritoneal dialysis, administrative services, professional pharmacy
services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
59340	Home therapy; enteral nutrition, administrative services, professional pharmacy
services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem
59341	Home therapy; enteral nutrition via gravity; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem
59342	Home therapy; enteral nutrition via pump; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-29	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
S9343	Home therapy; enteral nutrition via bolus; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem
59345	Home infusion therapy, anti-hemophilic agent infusion therapy (e.g., factor VIII);
administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
59346	Home infusion therapy, alpha-1 proteinase inhibitor (e.g., Prolastin); administrative
services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
59347	Home infusion therapy, uninterrupted, long-term controlled rate intravenous or
subcutaneous infusion therapy (e.g., epoprostenol); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
59348	Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g.,
Dobutamine); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
59349	Home infusion therapy, tocolytic infusion therapy; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9351	Home infusion therapy, continuous anti-emetic infusion therapy; administrative
services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
S9353	Home infusion therapy, continuous insulin infusion therapy; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9355	Home infusion therapy, chelation therapy; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment
(drugs and nursing visits coded separately), per diem
S9357	Home infusion therapy, enzyme replacement intravenous therapy; (e.g.,
Imiglucerase); administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and nursing visits
coded separately), per diem
S9359	Home infusion therapy, anti-tumor necrosis factor intravenous therapy;
(e.g., Infliximab); administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment (drugs and nursing visits
coded separately), per diem
S9361	Home infusion therapy, diuretic intravenous therapy; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
S9363	Home infusion therapy, anti-spasmotic intravenous therapy; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-30	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
59364	Home infusion therapy, total parenteral nutrition (TPN); administrative services,
professional pharmacy services, care coordination, and all necessary supplies and equipment (includes standard TPN formula; lipids, specialty amino acid formulas, drugs, and nursing visits coded separately), per diem (do not use with home infusion codes S9365-S9368 using daily volume scales) (for MassHealth members, this does not include standard TPN formula-lipids and specialty amino acid formulas)
59365	Home infusion therapy, total parenteral nutrition (TPN); one liter per day,
administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (includes standard TPN formula; lipids, specialty amino acid formulas, drugs, and nursing visits coded separately), per diem (for MassHealth members, this does not include standard TPN formula-lipids and specialty amino acid formulas)
59366	Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no
more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (includes standard TPN formula; lipids, specialty amino acid formulas, drugs, and nursing visits coded separately), per diem (for MassHealth members, this does not include standard TPN formula-lipids and specialty amino acid formulas)
59367	Home infusion therapy, total parenteral nutrition (TPN); more than two liters but no
more than three liters per day, administrative services, professional pharmacy
services, care coordination, and all necessary supplies and equipment (includes
standard TPN formula; lipids, specialty amino acid formulas, drugs, and nursing visits coded
separately), per diem (for MassHealth members, this does not include standard TPN
formula-lipids and specialty amino acids formulas)
59368	Home infusion therapy, total parenteral nutrition (TPN); more than three liters per
day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (includes standard TPN formula; lipids, specialty amino acid formulas, drugs, and nursing visits coded separately), per diem (for MassHealth members, this does not include standard TPN formula-lipids and specialty amino acids formulas)
S9370	Home therapy, intermittent anti-emetic injection therapy; administrative
services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9372        Home therapy, intermittent anticoagulant injection therapy (e.g., heparin); administrative
services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code for flushing of infusion devices with heparin to maintain potency)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-31	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
59373	Home infusion therapy, hydration therapy; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use with hydration therapy codes S9374 - S9377 using daily volume scales)
59374	Home infusion therapy, hydration therapy; one liter per day, administrative services,
professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing supplies coded separately), per diem
59375	Home infusion therapy, hydration therapy; more than one liter but no more than two
liters per day, administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
59376	Home infusion therapy, hydration therapy; more than two liters but no more than
three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
59377	Home infusion therapy, hydration therapy; more than three liters per day,
administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9379	Home infusion therapy, infusion therapy, not otherwise classified; administrative
services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9435	Medical foods for inborn errors of metabolism
S9490	Home infusion therapy, corticosteroid infusion; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9494	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative
services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use with home infusion codes for hourly dosing schedules S9497-S9504)
S9497	Home infusion therapy, antibiotic, antiviral, or antifungal, once every three hours;
administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
59500	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours;
administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
59501	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours;
administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem S9501       Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours;
administrative services, professional services, care coordination, and all necessary supplies and equipment (drugs and nursing vivits coded separately), per diem

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
DURABLE MEDICAL EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-32	

	TRANSMITTAL LETTER
DME-23	DATE
04/01/03	
601 Durable Medical Equipment: Service Codes and Descriptions (cont.)
Service
Code	Service Description
 59502	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every eight hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
 59503	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every six hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
 59504	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every four hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

 59537	Home therapy; hematopoietic hormone injection therapy (e.g., Crythropoietin, G-CSF, GM-CSF); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
 59538	Home transfusion of blood product(s); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (blood products, drugs, and nursing visits coded separately), per diem
S9542	Home injectable therapy; not otherwise classified, including administrative services,
professional pharmacy services, coordination of care, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
 59558	Home injectable therapy; growth hormone, including administrative services, professional pharmacy services, coordination of care, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
 59559	Home injectable therapy; interferon, including administrative services, professional pharmacy services, coordination of care, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
 59560	Home injectable therapy; hormonal therapy (e.g., leuprolide, goserelin), including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9562	Home injectable therapy, palivizumab, including administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
S9590	Home therapy, irrigation therapy (e.g., sterile irrigation of an organ or anatomical
cavity); including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem