Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/dma MASSHEALTH TRANSMITTAL LETTER DME-24 January 2004 TO: Durable Medical Equipment Providers Participating in MassHealth FROM: Beth Waldman, Director, Office of Medicaid RE: Durable Medical Equipment Manual (Revised Service Codes) This letter transmits a substantially revised Subchapter 6, including covered service codes, for the Durable Medical Equipment Manual. The revised Subchapter 6 is effective for dates of service on and after January 1, 2004. MassHealth local codes including miscellaneous codes have been replaced with codes that are compliant with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Subchapter 6 now lists all covered service codes in alphanumeric order. Descriptions of codes are no longer included. Providers should refer to www.cms.hhs.gov for code descriptions. Subchapter 6 is organized as follows: 601 Definitions 602 Covered Services 603 Modifiers 604 Place-of-Service (POS) Codes 605 Payment Categories 606 Direct Service Component Codes 607 Wheelchair Base Codes with Options/Accessories 608 Enteral Product Classification List 609 Absorbent Product Classification List Section 602 of Subchapter 6 identifies the payment category, whether prior authorization (PA) is required, and specifies other requirements and limits for each code. The limits were developed in consultation with clinical experts and are based on generally accepted clinical practice guidelines. Providers may submit a PA request for all members for coverage of additional units, if additional units are medically necessary. The request should be submitted before the additional units are provided, and must be supported by medical documentation. Section 602 of Subchapter 6 identifies covered place-of-service codes for each HCPCS code. Please refer to Section 604 in Subchapter 6 to determine the appropriate place-of-service codes if billing claims electronically. Providers are reminded that the place of service is where the product is used (e.g., member’s home, nursing facility, or rest home). The PA, if applicable, and the claim must reflect the accurate place of service. MASSHEALTH TRANSMITTAL LETTER DME-24 January 2004 Page 2 Revised Fee Schedule In December 2003, the Division of Health Care Finance and Policy (DHCFP) issued revised regulations certifying new fees and payment methodologies for the services and products in Subchapter 6 of the Durable Medical Equipment Manual. The new fees and methodologies are effective for dates of service on and after January 1, 2004. The DHCFP regulations, including the fee schedule, are available on the DHCFP Web site at www.mass.gov/dhcfp. If you wish to obtain a paper copy of the fee schedule, you may purchase the schedule from either the Massachusetts State Bookstore or from DHCFP (see addresses and telephone numbers below). You must contact them first to find out the price of the regulation. DHCFP 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 Division of Health Care Finance and Policy State House, Room 116 Two Boylston Street Boston, MA 02133 Boston, MA 02116 Telephone: 617-727-2834 Telephone: 617-988-3100 www.mass.gov/sec/spr www.mass.gov/dhcfp MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site at www.mass.gov/dma. Billing Guidelines Effective for dates of service on and after January 1, 2004, providers can bill for services provided to MassHealth members using only the HCPCS specified in the attached Subchapter 6. PAs and claims submitted with codes not included in Subchapter 6 will be denied. You must also use a modifier with certain codes to accurately reflect the service provided and ensure the appropriate payment. All claims submitted on paper with an explanation of benefits (EOB) from another insurer must be submitted to MassHealth with the same HCPCS code that was billed to the other insurer. MassHealth will deny all claims billed using service code A9270. Effective for dates of service on and after January 1, 2004, ICD-9-CM codes are required on all claims. The ICD-9-CM codes must be directly related to the service billed on the claim. Enteral Formulas To correspond to the new HIPAA-compliant codes, MassHealth has revised the way in which units are counted when billing enteral formulas. Effective for dates of service on and after January 1, 2004, enteral formulas that are used in conjunction with parenteral enteral (PEN) services require the BA modifier. MASSHEALTH TRANSMITTAL LETTER DME-24 January 2004 Page 3 Enteral formulas that are used orally require the BO modifier. For PEN services, one unit equals 100 calories. For oral supplements, one unit equals one can. The following is an example of the codes, modifiers, and units: B4150 BA 1 unit = 100 calories B4150 BO 1 unit = each B4151 BA 1 unit =100 calories B4151 BO 1 unit = each MassHealth has also revised the way in which units are counted when billing for food thickener. Effective for dates of service on and after January 1, 2004, one unit equals one ounce. Specialized Custom Mobility Systems Providers submitting PA requests for custom mobility products must include newly created direct service component codes in their supply list under code K0108. The new codes (RE-1 through RE-23) represent time in hours, along with the level of complexity involved in customizing the requested mobility system. The direct service component codes replace local code X1790, can only be used for custom mobility systems, and require PA. Direct service component codes are for use only on PA requests, and should not be included on claims. Effective for dates of service on and after January 1, 2004, repairs for mobility systems require the RP modifier and do not require a PA. Direct service component codes cannot be used with this modifier. Noncovered Services Providers are reminded that air conditioners, HEPA filters, and light boxes are not covered under MassHealth. Prior Authorization Effective for dates of service on and after January 1, 2004, all requests for PA must be submitted using the codes appearing in this new Subchapter 6. Providers who have already received PAs using now obsolete local codes must request adjustments to those PAs for unused units. When requesting an adjustment, please include the number of units already billed, the new code, any remaining units needed (not to exceed the units on the original decision), and a date-of-service change, if applicable. PA requests require an ICD-9-CM code that directly relates to the equipment or supplies being requested, along with a description of the diagnosis. Case Management for Complex-Care Members Beginning August 1, 2003, the Home Health Agency Manual was revised to include a new initiative for MassHealth members under the age of 22 who require a nurse encounter of more than two continuous hours. MASSHEALTH TRANSMITTAL LETTER DME-24 January 2004 Page 4 MassHealth refers to these members as complex-care members. The new initiative, called Community Case Management (CCM), assigns each complex-care member a case manager who performs a comprehensive needs assessment, and authorizes all medically necessary home health and other community services, including durable medical equipment, for these members. The Recipient Eligibility Verification System (REVS) identifies complex-care members enrolled in CCM. All requests for prior authorization for members enrolled in CCM will be reviewed and authorized by the case manager assigned to the member. PA requests received from providers will automatically be forwarded to the appropriate case manager for review. Providers must continue to follow the PA process as outlined in Subchapter 4 of the Durable Medical Equipment Manual. The case manager will be responsible for direct interaction with the prescriber to ensure proper documentation is received. Questions Providers with questions about this information 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 and 6-1 through 6-66 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Durable Medical Equipment Manual Pages vi and 6-1 through 6-32 . transmitted by Transmittal Letter DME-23 • 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-24 DATE 01/01/04 6. SERVICE CODES 601 Definitions ............................................................................................................................ 6-1 602 Covered Services................................................................................................................... 6-2 603 Modifiers.............................................................................................................................. 6-40 604 Place-of-Service Codes ........................................................................................................ 6-41 605 Payment Categories.............................................................................................................. 6-41 606 Direct Service Component Codes ........................................................................................ 6-42 607 Wheelchair Base Codes with Options/Accessories .............................................................. 6-47 608 Enteral Product Classification List....................................................................................... 6-52 609 Absorbent Product Classification List.................................................................................. 6-61 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 SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-1 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 601 Definitions Briefs – Disposable absorbent products that come in a variety of shapes, sizes, and styles, available to fit children, adolescents, adults, have an outer waterproof cover, and are held in place with its own belted straps (tape, tab-less). Diapers – Disposable absorbent products that come in a variety of shapes, sizes, and styles, available to fit children, adolescents, adults, have an outer plastic cover with leg gathers, and have self-adhesive tape tabs (beltless). Direct Service Component Codes – The new codes (RE-1 through RE-23) represent time, in hours, along with the level of complexity involved in customizing the requested mobility system. Incontinence Absorbent Products – Products that are specifically designed to absorb urine and control odor. Liners/shield – Rectangular absorbent products with a waterproof cover available with or without adhesive strips to hold in place. Underpad – Flat pads with absorbent filler and waterproof backing, designed to protect bedding, wheelchairs, and furniture, and available in various sizes and absorbencies. Underpads can be disposable or reusable. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-2 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Providers may submit a prior-authorization request for all members for coverage of additional units, if additional units are medically necessary. The request should be submitted before the additional units are provided, and must be supported by medical documentation. Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits A4214 OS No 02 07 1 unit = each, 31 per month A4216 OS NU No 02 07 1 unit = each, 100 per month A4217 OS NU No 02 07 1 unit = each, 31 per month A4220 OS NU No 02 07 1 unit = each, 10 per month A4221 SU No 02 07 1 unit = per week, 5 per month (includes dressings, cannulas, needles, and infusion supplies) A4222 SU KO KP KQ No 02 07 1 unit = 1 dose of drug (for intermittent infusions, one bag or cassette for each drug dose). A4232 No 02 07 1 unit = each, 60 per month A4244 IN No 02 07 1 unit = each, 1 per month A4253 IN KS No 02 07 1 unit =1 box (50), 2 units per month A4254 IN NU RR UE No 02 07 1 unit = each, 2 per 12 months A4255 SU KS No 02 07 1 unit = 1 box (50), 2 per month A4256 SU KS No 02 07 1 unit = each, 3 per month (to be used with E0607, E2100, and E2101) A4258 SU KS No 02 07 1 unit = each, 1 per 6 months (to be used with E0607, E2100, and E2101) A4259 SU KS No 02 07 1 unit = 1 box (100), 1 per month (to be used with E0607, E2100, and E21001) A4265 SU No 02 07 1 unit = 1 pound, 1 per 3 months A4310 OS No 02 07 1 unit = 1 tray, 3 per month A4311 OS No 02 07 1 unit = 1 tray, 3 per month A4312 OS No 02 07 1 unit = 1 tray, 3 per month A4313 OS No 02 07 1 unit = 1 tray, 3 per month A4314 OS No 02 07 1 unit = 1 tray, 3 per month (A4331 is included in this code and cannot be billed separately.) A4315 OS No 02 07 1 unit = 1 tray, 3 per month (A4331 is included in A4315 and cannot be billed separately.) A4316 OS No 02 07 1 unit = 1 tray, 3 per month (A4331 is included in A4316 and cannot be billed separately.) A4319 OS No 02 07 1 unit = 1000 ml, 6 per month A4320 OS No 02 07 1 unit = each, 4 per month Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-3 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits A4321 OS No 02 07 1 unit = each, 4 per month A4322 OS No 02 07 1 unit = each, 1 per 3 months A4323 OS No 02 07 1 unit = each, 4 per month A4324 OS No 02 07 1 unit = each, 31 per month A4325 OS No 02 07 1 unit = each, 31 per month A4326 OS No 02 07 1 unit = each, 4 per month A4327 OS No 02 07 1 unit = each, 1 per month A4328 OS No 02 07 1 unit = each, 31 per month A4330 OS No 02 07 1 unit = each, 31 per month A4331 OS No 02 07 1 unit = each, 3 per month A4332 OS No 02 07 1 unit = each, 1000 per month A4333 OS No 02 07 1 unit = each, 4 per month A4334 OS No 02 07 1 unit = each, 1 per month A4338 OS No 02 07 1 unit = each, 3 per month A4340 OS No 02 07 1 unit = each, 3 per month A4344 OS No 02 07 1 unit = each, 3 per month A4346 OS No 02 07 1 unit = each, 3 per month A4347 OS No 02 07 1 unit = 1 dozen, 3 per month A4348 OS No 02 07 1 unit = each, 6 per month A4351 OS No 02 07 1 unit = each, 180 per month A4352 OS No 02 07 1 unit = each, 180 per month A4353 OS No 02 07 1 unit = each, 180 per month A4354 OS No 02 07 1 unit = each, 3 per month A4355 OS No 02 07 1 unit = each, 1 per month A4356 OS No 02 07 1 unit = each, 1 per 3 months A4357 OS No 02 07 1 unit = each, 3 per month (A4331 is included in this code.) A4358 OS No 02 07 1 unit = each, 3 per month (A4331, A4358, and A5112 are included in A4358 and cannot be billed separately.) A4359 OS No 02 07 1 unit = each, 1 per 6 months A4361 OS No 02 07 1 unit = each, 10 per month A4362 OS No 02 07 1 unit = each, 20 per month A4364 OS No 02 07 1 unit = 1 fluid ounce, 4 ounces per month A4365 OS No 02 07 1 unit = 1 box (50), 1 per month (only for use with ostomy supplies) A4366 OS NU No 02 07 1 unit = each, 1 per 3 months A4367 OS No 02 07 1 unit = each, 1 per month A4368 OS No 02 07 1 unit = each, 4 per month A4369 OS No 02 07 1 unit = 1 fluid ounce, 2 per month A4371 OS No 02 07 1 unit = 1 fluid ounce, 6 per 6 months Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-4 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits A4372 OS No 02 07 1 unit = each, 20 per month A4373 OS No 02 07 1 unit = each, 20 per month A4375 OS No 02 07 1 unit = each, 20 per month (A4361 and A4377 are included in A4375 and cannot be billed separately.) A4376 OS No 02 07 1 unit = each, 20 per month (A4361 and A4378 are included in A4376 and cannot be billed separately.) A4377 OS No 02 07 1 unit = each, 20 per month A4378 OS No 02 07 1 unit = each, 20 per month A4379 OS No 02 07 1 unit = each, 20 per month (A4361, A4381, and A4382 are included in A4379 and cannot be billed separately.) A4380 OS No 02 07 1 unit = each, 20 per month (A4361 and A4383 are included in A4380 and cannot be billed separately.) A4381 OS No 02 07 1 unit = each, 20 per month A4382 OS No 02 07 1 unit = each, 20 per month A4383 OS No 02 07 1 unit = each, 20 per month A4384 OS No 02 07 1 unit = each, 20 per month A4385 OS No 02 07 1 unit = each, 20 per month A4387 OS No 02 07 1 unit = each, 20 per month A4388 OS No 02 07 1 unit = each, 20 per month A4389 OS No 02 07 1 unit = each, 20 per month A4390 OS No 02 07 1 unit = each, 20 per month A4391 OS No 02 07 1 unit = each, 20 per month A4392 OS No 02 07 1 unit = each, 20 per month A4393 OS No 02 07 1 unit = each, 20 per month A4394 OS No 02 07 1 unit = 1 fluid ounce, 20 per month A4395 OS No 02 07 1 unit = tablet, 20 per month A4396 OS No 02 07 1 unit = each, 20 per month A4397 OS No 02 07 1 unit = each, 20 per month A4398 OS No 02 07 1 unit = each, 2 per 6 months A4399 OS No 02 07 1 unit = each, 2 per 6 months A4400 OS No 02 07 1 unit = each, 1 per 3 months A4402 OS No 02 07 1 unit = 1 ounce, 4 ounces per month A4404 OS No 02 07 1 unit = each, 10 per month A4405 OS No 02 07 1 unit = 1 ounce 4 ounces per month A4406 OS No 02 07 1 unit = 1 ounce, 5 ounces per month A4407 OS No 02 07 1 unit = each, 20 per month A4408 OS No 02 07 1 unit = each, 20 per month Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-5 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits A4409 OS No 02 07 1 unit = each, 20 per month A4410 OS No 02 07 1 unit = each, 20 per month A4413 OS No 02 07 1 unit = 1 piece system, 20 per month A4414 OS No 02 07 1 unit = each, 20 per month A4415 OS No 02 07 1 unit = each, 10 per month A4422 OS No 02 07 1 unit = each, 20 per month A4423 OS NU No 02 07 1 unit = each, 10 per month A4427 OS NU No 02 07 1 unit = each, 10 per month A4450 OS No 02 07 1 unit = 18 sq. inches, 720 per month A4452 OS No 02 07 1 unit = 18 sq. inches, 10 per month A4455 SD No 02 07 1 unit = 1 once, 16 ounces per 6 months (for use with ostomy supplies) A4462 SD No 02 07 1 unit = each, 1 per 6 months A4521 IN Yes 02 07 1 unit = each, 248 per month A4522 IN Yes 02 07 1 unit = each, 248 per month A4523 IN Yes 02 07 1 unit = each, 248 per month A4524 IN Yes 02 07 1 unit = each, 248 per month A4525 IN Yes 02 07 1 unit = each, 248 per month A4526 IN Yes 02 07 1 unit = each, 248 per month A4527 IN Yes 02 07 1 unit = each, 248 per month A4528 IN Yes 02 07 1 unit = each, 248 per month A4529 IN Yes 02 07 1 unit = each, 248 per month A4530 IN Yes 02 07 1 unit = each, 248 per month A4531 IN Yes 02 07 1 unit = each, 248 per month A4532 IN Yes 02 07 1 unit = each, 248 per month A4533 IN Yes 02 07 1 unit = each, 248 per month A4534 IN Yes 02 07 1 unit = each, 248 per month A4535 IN Yes 02 07 1 unit = each, 248 per month A4537 IN Yes 02 07 1 unit = each, 2 per month A4554 IN Yes 02 07 1 unit = each, 248 per month A4595 SU No 02 07 1 unit = 1 pair, 2 per month (A4595 is included in purchase of E0720 and E0730 and cannot be billed separately.) A4614 IN No 02 07 1 unit = each, 1 per 3 months A4630 IN No 02 07 1 unit = each, 12 per 12 months (used for replacement of patient-owned equipment) A4631 IN NU RR UE No 02 07 1 unit = each, 1 per 12 months (used for replacement of patient-owned equipment) A4632 IN NU RR UE No 02 07 1 unit = each, 1 per 12 months (used for replacement of patient-owned equipment) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-6 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits A4635 IN NU RR UE No 02 07 1 unit = each, 2 per 6 months (used for replacement of patient-owned equipment) A4636 IN NU RR UE No 02 07 1 unit = each, 2 per 12 months A4637 IN NU RR UE No 02 07 1 unit = each, 4 per 12 months (used for replacement of patient-owned equipment) A4640 IN NU RR UE No 02 07 1 unit = each, 1 per 12 months (used for replacement of patient-owned equipment) A4640 is included in initial purchase of E0180 and E0181. A4927 IN No 02 07 1 unit = 1 box (100), 4 per month A4930 IN No 02 07 1 unit = 1 pair, 31 per month A5051 OS No 02 07 1 unit = 1 piece, 20 per month A5052 OS No 02 07 1 unit = 1 piece, 20 per month A5053 OS No 02 07 1 unit = each, 20 per month A5054 OS No 02 07 1 unit = 2 pieces, 20 per month A5055 OS No 02 07 1 unit = each, 20 per month A5061 OS No 02 07 1 unit = each, 20 per month A5062 OS No 02 07 1 unit = each, 20 per month A5063 OS No 02 07 1 unit = each, 20 per month A5071 OS No 02 07 1 unit = each, 20 per month A5072 OS No 02 07 1 unit = each, 20 per month A5073 OS No 02 07 1 unit = each, 20 per month A5081 OS No 02 07 1 unit = each, 20 per month A5082 OS No 02 07 1 unit = each, 20 per month A5093 OS No 02 07 1 unit = each, 20 per month A5102 OS No 02 07 1 unit = each, 1 per month A5105 OS No 02 07 1 unit = each, 2 per 3 months A5112 OS No 02 07 1 unit = each, 1 per month (A4358 is included in A5112 and cannot be billed separately.) A5113 OS No 02 07 1 unit = per set, 2 per 3 months A5114 OS No 02 07 1 unit = per set, 2 per 3 months A5119 OS No 02 07 1 unit = 1 box (50), 3 per 6 months A5121 OS No 02 07 1 unit = each, 20 per month A5122 OS No 02 07 1 unit = each, 20 per month A5126 OS No 02 07 1 unit = each, 20 per month A5131 OS No 02 07 1 unit = 16 ounces, 1 per month A5200 OS No 02 07 1 unit = each, 2 per month A6010 SD A1 A2 A3 No 02 07 1 unit = each (per gram), 45 per month A4 A5 A6 A7 A8 A9 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-7 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 602 Covered Services (cont.) Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits A6011 SD A1 A2 A3 No 02 07 1 unit = each (per gram), 45 per month A4 A5 A6 A7 A8 A9 A6021 SD A1 A2 A3 No 02 07 1 unit = each, 31 per month A4 A5 A6 A7 A8 A9 A6022 SD A1 A2 A3 No 02 07 1 unit = each, 31 per month A4 A5 A6 A7 A8 A9 A6023 SD A1 A2 A3 No 02 07 1 unit = each, 31 per month A4 A5 A6 A7 A8 A9 A6024 SD A1 A2 A3 No 02 07 1 unit = per 6 inches, 31 per month A4 A5 A6 A7 A8 A9 A6154 SD A1 A2 A3 No 02 07 1 unit = each, 4 per month A4 A5 A6 A7 A8 A9 A6196 SD A1 A2 A3 No 02 07 1 unit = 6 inches, 31 per month A4 A5 A6 A7 A8 A9 A6197 SD A1 A2 A3 No 02 07 1 unit = 6 inches, 31 per month A4 A5 A6 A7 A8 A9 A6198 SD A1 A2 A3 No 02 07 1 unit = 6 inches, 31 per month A4 A5 A6 A7 A8 A9 A6199 SD A1 A2 A3 No 02 07 1 unit = 6 inches, 31 per month A4 A5 A6 A7 A8 A9 A6200 SD A1 A2 A3 No 02 07 1 unit = each, 3 per week A4 A5 A6 A7 A8 A9 A6201 SD A1 A2 A3 No 02 07 1 unit = each, 3 per week A4 A5 A6 A7 A8 A9 A6202 SD A1 A2 A3 No 02 07 1 unit = each, 3 per week A4 A5 A6 A7 A8 A9 A6203 SD A1 A2 A3 No 02 07 1 unit = each, 3 per week A4 A5 A6 A7 A8 A9 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-8 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required A6204 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6205 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6206 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6207 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6208 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6209 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6210 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6211 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6212 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6213 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6214 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6215 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6216 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6217 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 Requirements and Limits 1 unit = each, 3 per week 1 unit = each, 3 per week 1 unit = each, 1 per week 1 unit = each, 1 per week 1 unit = each, 1 per week 1 unit = each, 3 per week 1 unit = each, 3 per week 1 unit = each, 3 per week 1 unit = each, 3 per week 1 unit = each, 3 per week 1 unit = each, 3 per week 1 unit = each, 3 per week 1 unit = each, 100 per month 1 unit = each, 60 per month Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-9 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required A6218 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6219 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6220 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6221 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6222 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6223 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6224 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6228 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6229 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6230 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6231 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6232 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6233 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6234 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 Requirements and Limits 1 unit = each, 60 per month 1 unit = each, 60 per month 1 unit = each, 60 per month 1 unit = each, 60 per month 1 unit = each, 100 per month 1 unit = each, 100 per 3 months 1 unit = each, 100 per 3 months 1 unit = each, 100 per 3 months 1 unit = each, 100 per 3 months 1 unit = each, 100 per 3 months 1 unit = each, 100 per 3 months 1 unit = each, 12 per month 1 unit = each, 12 per month 1 unit = each, 12 per month Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-10 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 602 Covered Services (cont.) Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits A6235 SD A1 A2 A3 No 02 07 1 unit = each, 12 per month A4 A5 A6 A7 A8 A9 A6236 SD A1 A2 A3 No 02 07 1 unit = each, 12 per month A4 A5 A6 A7 A8 A9 A6237 SD A1 A2 A3 No 02 07 1 unit = each, 12 per month A4 A5 A6 A7 A8 A9 A6238 SD A1 A2 A3 No 02 07 1 unit = each, 12 per month A4 A5 A6 A7 A8 A9 A6239 SD A1 A2 A3 No 02 07 1 unit = each, 12 per month A4 A5 A6 A7 A8 A9 A6240 SD A1 A2 A3 No 02 07 1 fluid ounce = 12 per month A4 A5 A6 A7 A8 A9 A6241 SD A1 A2 A3 No 02 07 1 unit = 1 gram, 45 per month A4 A5 A6 A7 A8 A9 A6242 SD A1 A2 A3 No 02 07 1 unit = each, 31 per month A4 A5 A6 A7 A8 A9 A6243 SD A1 A2 A3 No 02 07 1 unit = each, 10 per month A4 A5 A6 A7 A8 A9 A6244 SD A1 A2 A3 No 02 07 1 unit = each, 10 per month A4 A5 A6 A7 A8 A9 A6245 SD A1 A2 A3 No 02 07 1 unit = each, 12 per month A4 A5 A6 A7 A8 A9 A6246 SD A1 A2 A3 No 02 07 1 unit = each, 12 per month A4 A5 A6 A7 A8 A9 A6247 SD A1 A2 A3 No 02 07 1 unit = each, 12 per month A4 A5 A6 A7 A8 A9 A6248 SD A1 A2 A3 No 02 07 1 unit = 1 fluid ounce, 3 per month A4 A5 A6 A7 A8 A9 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-11 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required A6251 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6252 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6253 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6254 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6255 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6256 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6257 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6258 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6259 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6260 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6266 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6402 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6403 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6404 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 Requirements and Limits 1 unit = each, 31 per month 1 unit = each, 31 per month 1 unit = each, 31 per month 1 unit = each, 31 per month 1 unit = each, 31 per month 1 unit = each, 31 per month 1 unit = each, 31 per month 1 unit = each, 31 per month 1 unit = each, 31 per month 1 unit = 16 ounces, 31 per month 1 unit = 1 linear yard, 4 per month 1 unit = each, 100 per month 1 unit = each, 100 per month 1 unit = each, 100 per month Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-12 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required A6407 SD NU No 02 07 A6410 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6411 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6421 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6422 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6424 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6426 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6428 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 A6430 SD A1 A2 A3 Yes 02 07 A4 A5 A6 A7 A8 A9 A6432 SD A1 A2 A3 Yes 02 07 A4 A5 A6 A7 A8 A9 A6434 SD A1 A2 A3 Yes 02 07 A4 A5 A6 A7 A8 A9 A6436 SD A1 A2 A3 Yes 02 07 A4 A5 A6 A7 A8 A9 A6438 SD A1 A2 A3 Yes 02 07 A4 A5 A6 A7 A8 A9 A6440 SD A1 A2 A3 No 02 07 A4 A5 A6 A7 A8 A9 Requirements and Limits 1 unit = each, 30 per month 1 unit = each, 31 per month 1 unit = each, 31 per month 1 unit = 1 roll, 31 per month 1 unit = 1 roll, 31 per month 1 unit = 1 roll, 31 per month 1 unit = 1 roll, 31 per month 1 unit = 1 roll, 31 per month 1 unit = 1 roll, 31 per month 1 unit = 1 roll, 31 per month 1 unit = 1 roll, 10 per month 1 unit = 1 roll, 10 per month 1 unit = 1 roll, 31 per month 1 unit = 1 roll, 10 per month A6441 SD NU No 02 07 1 unit = each, 10 per month A6442 SD NU No 02 07 1 unit = 1 yard, 31 per month Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-13 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits A6443 SD NU No 02 07 1 unit = 1 yard, 31 per month A6444 SD NU No 02 07 1 unit = 1 yard, 31 per month A6445 SD NU No 02 07 1 unit = 1 yard, 31 per month A6446 SD NU No 02 07 1 unit = 1 yard, 31 per month A6447 SD NU No 02 07 1 unit = 1 yard, 31 per month A6448 SD NU No 02 07 1 unit = 1 yard, 10 per month A6449 SD NU No 02 07 1 unit = 1 yard, 10 per month A6450 SD NU No 02 07 1 unit = 1 yard, 10 per month A6451 SD NU No 02 07 1 unit = 1 yard, 10 per month A6452 SD NU No 02 07 1 unit = 1 yard, 10 per month A6453 SD NU No 02 07 1 unit = 1 yard, 31 per month A6454 SD NU No 02 07 1 unit = 1 yard, 31 per month A6455 SD NU No 02 07 1 unit = 1 yard, 31 per month A6456 SD NU No 02 07 1 unit = 1 yard, 31 per month A6501 SD Yes 02 07 1 unit = each, 2 per 12 months. ICD-9-CM 949.0, 701.4, and 754.89 A6502 SD Yes 02 07 1 unit = each, 2 per 12 months. ICD-9-CM 949.0, 701.4, and 754.89 A6503 SD Yes 02 07 1 unit = each, 2 per 12 months. ICD-9-CM 949.0, 701.4, and 941.0 A6504 SD Yes 02 07 1 unit = each, 4 per 12 months. ICD-9-CM 949.0, 701.4, and 941.0 A6505 SD Yes 02 07 1 unit = each, 4 per 12 months. ICD-9-CM 949.0, 701.4, and 941.0 A6506 SD Yes 02 07 1 unit = each, 4 per 12 months. ICD-9-CM 949.0, 701.4, and 941.0 A6507 SD Yes 02 07 1 unit = each, 4 per 12 months. ICD-9-CM 949.0, 701.4, and 941.0 A6508 SD Yes 02 07 1 unit = each, 4 per 12 months. ICD-9-CM 949.0, 701.4, and 941.0 A6509 SD Yes 02 07 1 unit = each, 2 per 12 months. ICD-9-CM 949.0, 701.4, and 941.0 A6510 SD Yes 02 07 1 unit = each, 2 per 12 months. ICD-9-CM 949.0, 701.4, and 941.0 A6511 SD Yes 02 07 1 unit = each, 2 per 12 months. ICD-9-CM 949.0, 701.4, and 941.0 A7000 IN No 02 07 1 unit = each, 1 per month (A7000 can be billed separately if patient owns E2000; otherwise included in monthly rental.) A7001 IN No 02 07 1 unit = each, 1 per month (A7001 can be billed separately if patient owns E2000; otherwise included in monthly rental.) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-14 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits A7002 IN No 02 07 1 unit = each, 1 per month (A7002 can be billed separately if patient owns E2000 but not if it is included in A7001; otherwise included in monthly rental.) B4034 IN No 02 07 1 unit = 1 each, 1 per day (A5200 included in B4034). All supplies (including dressings) other than the feeding tube itself included. B4035 IN No 02 07 1 unit = each, 30 per month (A5200 included in B4035). All supplies (including dressings) other than the feeding tube itself included. B4036 IN No 02 07 1 unit = each, 1 per day (A5200 included in B4036). All supplies (including dressings) other than the feeding tube itself included. B4081 IN No 02 07 1 unit = each, 6 per 3 months B4082 IN No 02 07 1 unit = each, 6 per 3 months B4083 IN No 02 07 1 unit = each, 6 per 3 months B4086 IN Yes 02 07 1 unit = each, 6 per 3 months B4100 IN BO Yes 02 07 1 unit = 30 ounces B4150 IN BA BO Yes 02 07 1 unit = 100 calories (BA); 1 unit = each (BO) 6 per day B4151 IN BA BO Yes 02 07 1 unit = 100 calories (BA); 1 unit = each (BO) 6 per day B4152 IN BA BO Yes 02 07 1 unit = 100 calories (BA); 1 unit = each (BO) 6 per day B4153 IN BA BO Yes 02 07 1 unit = 100 calories (BA); 1 unit = each (BO) 6 per day B4154 IN BA BO Yes 02 07 1 unit = 100 calories (BA); 1 unit = each (BO) 6 per day B4155 IN BA BO Yes 02 07 1 unit = 100 calories (BA); 1 unit = each (BO) 6 per day B4156 IN BA BO Yes 02 07 1 unit = 100 calories (BA); 1 unit = each (BO) 6 per day B4164 IN No 02 07 1 unit = 500 ml (included in this code are B4164, B4180, B4168 - B4178). Codes B4216, B4184, B4186 can be billed separately. B4168 IN No 02 07 1 unit = 500 ml (included in this code are B4164, B4180, B4168 - B4178). Codes B4216, B4184, B4186 can be billed separately. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-15 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits B4172 IN No 02 07 1 unit = 500 ml (included in this code are B4164, B4180, B4168 - B4178). Codes B4216, B4184, B4186 can be billed separately. B4176 IN No 02 07 1 unit = 500 ml (included in this code are B4164, B4180, B4168 - B4178). Codes B4216, B4184, B4186 can be billed separately. B4178 IN No 02 07 1 unit = 500 ml (included in this code are B4164, B4180, B4168 - B4178). Codes B4216, B4184, B4186 can be billed separately. B4180 IN No 02 07 1 unit = 500 ml (included in this code are B4164, B4180, B4168 - B4178). Codes B4216, B4184, B4186 can be billed separately. B4184 IN No 02 07 1 unit = 500 ml B4186 IN No 02 07 1 unit = 500 ml B4189 IN No 02 07 1 unit = 10-51 grams of protein included in; B4164, B4180, B4168 - B4178, B4216. B4184 and B4186 can be billed separately. B4193 IN No 02 07 1 unit = 52 to 73 grams of protein B4197 IN No 02 07 1 unit = 74 to 100 grams of protein B4199 IN No 02 07 1 unit = over 100 grams of protein B4216 IN No 02 07 1 unit = 1 per day B4220 IN No 02 07 1 unit = 1 per day B4222 IN No 02 07 1 unit = 1 per day B4224 IN No 02 07 1 unit = 1 per day B5000 No 02 07 1 unit = 1 gram (included in code are B4164, B4180, B4168 - B4178, B4216). B4184 and B4186 can be billed separately B5100 No 02 07 1 unit = 1 gram (included in code are B4164, B4180, B4168 - B4178, B4216). B4184 and B4186 can be billed separately. B5200 No 02 07 1 unit = 1 gram (included in codes are B4164, B4180, B4168 - B4178, B4216). B4184 and B4186 can be billed separately. B9000 NU RR UE No 02 07 1 per 3 years B9002 NU RR UE No 02 07 1 per 3 years B9004 NU RR UE No 02 07 1 per 3 years B9006 NU RR UE No 02 07 1 per 3 years E0100 IN NU RR UE No 02 07 1 per 3 years Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-16 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits E0105 IN NU RR UE No 02 07 1 per 3 years E0110 IN NU RR UE No 02 07 1 per 3 years E0111 IN NU RR UE No 02 07 1 per 3 years E0112 IN NU RR UE No 02 07 1 per 3 years E0113 IN NU RR UE No 02 07 1 per 3 years E0114 IN NU RR UE No 02 07 1 per 3 years E0116 IN NU RR UE No 02 07 1 per 3 years E0117 IN NU RR UE No 02 07 1 per 3 years E0130 IN NU RR UE No 02 07 1 per 3 years (A4636 and A4637 are included in E0130 on initial purchase.) E0135 IN NU RR UE No 02 07 1 per 3 years (A4636 and A4637 are included in E0135 on initial purchase.) E0137 CR KH KI KJ BP Yes 02 07 NU UE E0138 CR KH KI KJ BP Yes 02 07 NU UE E0140 IN NU RR UE Yes 02 07 1 per 5 years; gait trainers and pediatric walkers E0141 IN NU RR UE No 02 07 1 per 3 years (A4636, A4637, E0155, and E0159 are included in E0141.) E0142 IN NU RR UE No 02 07 1 per 3 years E0143 IN NU RR UE No 02 07 A4636, A4637, E0155, and E0159 are included in E0143 on initial purchase. E0144 IN NU RR UE Yes 02 07 A4636, A4637, E0155, E0156, and E0159 are included in E0145 on initial purchase. E0145 CR KH KI KJ BP Yes 02 07 1 per 3 years NU UE E0146 CR KH KI KJ BP Yes 02 07 A4636, E0155, and E0159 are included in NU UE E0146 on initial purchase. E0147 IN NU RR UE Yes 02 07 A4636, E0155, and E0159 are included in initial purchase of E0147 (for patients who weigh over 350 pounds). E0148 IN NU RR UE No 02 07 A4636, A4637 are included in the initial purchase of E0148 (for patients who weigh over 300 pounds). E0149 IN NU RR UE No 02 07 A4636, A4637, E0155, E0156, and E0159 are included in initial purchase of E0149 (for patients who weigh over 300 pounds). E0153 IN NU RR UE No 02 07 2 per 3 years E0154 IN NU RR UE No 02 07 2 per 3 years E0155 IN NU RR UE No 02 07 2 per 3 years E0156 IN NU RR UE No 02 07 1 per 3 years Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-17 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits E0157 IN NU RR UE No 02 07 1 per 3 years E0158 IN NU RR UE No 02 07 1 per 3 years (covered for patients six feet tall or more) E0159 IN NU RR UE No 02 07 1 per 12 months E0160 IN NU RR UE No 02 07 1 per 12 months E0161 IN NU RR UE No 02 07 1 per 12 months E0162 IN NU RR UE No 02 07 1 per 3 years E0163 IN NU RR UE No 02 07 1 per 3 years (E0167 is included in initial purchase of E0163.) E0164 IN NU RR UE No 02 07 1 per 3 years (E0167 is included in initial purchase E0164.) E0165 CR KH KI KJ BP No 02 07 1 per 3 years (E0167 is included initial NU UE purchase of E0165.) E0166 CR KH KI KJ BP No 02 07 1 per 3 years (E0167 is included in initial NU UE purchase of E0166.) E0167 IN NU RR UE No 02 07 1 per 3 years (E0167 is included in initial purchase of E0168, E0166, E0165, E0164, and E0163.) E0168 IN NU RR UE No 02 07 1 per 3 years (E0167 is included in initial purchase of E0168) (for patients who weigh over 300 pounds) E0169 CR KH KI KJ BP Yes 02 07 1 per 5 years NU UE E0175 IN NU RR UE No 02 07 1 per 12 months E0176 IN NU RR UE No 02 07 1 per 12 months E0177 IN NU RR UE No 02 07 1 per 12 months E0178 IN NU RR UE No 02 07 1 per 12 months E0179 IN NU RR UE No 02 07 1 per 12 months E0180 CR KH KI KJ BP Yes 02 07 A4640 and E0182 included NU UE E0181 CR KH KI KJ BP Yes 02 07 A4640 and E0182 are included in E0181. NU UE E0182 CR KH KI KJ BP Yes 02 07 Replacement to an already purchased pressure NU UE pad with pump. E0184 IN NU RR UE No 02 07 1 per 12 months E0185 IN NU RR UE No 02 07 1 per 12 months E0186 CR KH KI KJ BP Yes 02 07 1 per 12 months NU UE E0187 CR KH KI KJ BP Yes 02 07 1 per 12 months NU UE E0188 IN NU RR UE No 02 07 1 per 12 months E0189 IN NU RR UE No 02 07 2 per 6 months Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-18 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits E0190 IN. NU RR UE Yes 02 07 1 unit = each, 2 per 6 months E0191 IN NU RR UE No 02 07 1 per 12 months E0192 IN NU RR UE No 02 06 07 1 per 12 months E0193 CR KH KI KJ BR Yes 02 06 07 E0277, E0371, E0372, and E0373 cannot be used with E0193. PA renewal every 30 days. E0194 CR KH KI KJ BR Yes 02 06 07 E0277, E0371, E0372, and E0373 cannot be used with E0194. PA renewal every 30 days. E0196 CR KH KI KJ BP Yes 02 07 1 per 5 years NU UE E0197 IN NU RR UE No 02 07 1 per 3 years E0198 IN NU RR UE No 02 07 1 per 3 years E0199 IN NU RR UE No 02 07 1 per 3 years E0202 CP No 02 07 14 days maximum, per episode E0210 IN NU RR UE No 02 07 1 per 12 months E0215 IN NU RR UE No 02 07 1 per 12 months E0220 IN NU RR UE No 02 07 1 per 12 months E0230 IN NU RR UE No 02 07 1 per 12 months E0235 CR KH KI KJ BP Yes 02 07 1 per 5 years NU UE E0238 IN NU RR UE No 02 07 1 per 12 months E0240 IN NU RR UE Yes 02 07 1 per 5 years; specialty shower commodes E0241 IN No 02 07 1 per 3 years E0242 IN No 02 07 1 per 12 months E0243 IN No 02 07 1 per 12 months E0244 IN No 02 07 1 per 12 months E0245 IN No 02 07 1 per 12 months E0246 IN No 02 07 1 per 12 months E0247 IN. NU RR UE Yes 02 07 1 per 5 years; specialty transfer bench E0248 IN NU RR UE Yes 02 07 1 per 5 years; specialty transfer bench/commode E0250 CR KH KI KJ BP Yes 02 07 E0271, E0272, E0305, E0310, are included in NU UE E0250. E0251 CR KH KI KJ BP Yes 02 07 E0305, E0310 are included in E0251. Code NU UE E0277 and E0372 can be used with this code. E0255 CR KH KI KJ BP Yes 02 07 E0271, E0272, E0305, E0310 are included in NU UE E0255. E0256 CR KH KI KJ BP Yes 02 07 E0305, E0310 are included in E0256. Code NU UE E0277 and E0372 can be used with this code. E0260 CR KH KI KJ BP Yes 02 07 E0271, E0272, E0305, E0310 are included in NU UE E0260. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-19 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 602 Covered Services (cont.) Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits E0261 CR KH KI KJ BP Yes 02 07 E0305, E0310 are included in E0261. Code NU UE E0277 or E0372 can be used with this code. E0265 CR KH KI KJ BP Yes 02 07 E0271, E0272, E0305, E0310 are included in NU UE E0265. E0266 CR KH KI KJ BP Yes 02 07 E0305, E0310 are included in E0266. Code NU UE E0277 or E0372 can be used with this code. E0271 IN NU RR UE Yes 02 07 1 per 5 years (replacement for an owned hospital bed) E0272 IN NU RR UE Yes 02 07 1 per 5 years (replacement for an owned hospital bed) E0274 IN NU RR UE Yes 02 07 1 per 5 years E0275 IN NU RR UE No 02 07 1 per 6 months E0276 IN NU RR UE No 02 07 1 per 6 months E0277 CR KH KI KJ BP Yes 02 06 07 E0277 is not to be used with E0193, E0371, NU UE E0372, or E0373. E0280 IN NU RR UE Yes 02 07 1 per 5 years (to prevent contact with bed coverings) E0290 CR KH KI KJ BP Yes 02 07 E0271, E0272 are included in E0290. Codes NU UE E0371 and E0372 can be used with E0290. E0291 CR KH KI KJ BP Yes 02 07 E0277 can be used with E0291. NU UE E0292 CR KH KI KJ BP Yes 02 07 E0271, E0272 are included in E0292. Codes NU UE E0371 and E0372 can be used with E0292. E0293 CR KH KI KJ BP Yes 02 07 E0277 can be used with E0293. NU UE E0294 CR KH KI KJ BP Yes 02 07 E0305, E0310, E0271, and E0272 are NU UE included in E0294. Codes E0371 and E0372 can be used with E0294. E0295 CR KH KI KJ BP Yes 02 07 E0277 can be used with this E0295. NU UE E0296 CR KH KI KJ BP Yes 02 07 E0271, E0272 are included in E0296. Codes NU UE E0371 and E0372 can be used with E0296. E0297 CR KH KI KJ BP Yes 02 07 E0305, E0310, E0277 can be used with NU UE E0297. E0300 IN NU RR UE Yes 02 07 1 per 5 years E0301 CR KH KI KJ BP Yes 02 07 E0305, E0310 are included in E0302 and NU UE cannot be billed separately. Code E0277 or E0372 can be used with this code. E0302 CR KH KI KJ BP Yes 02 07 E0305, E0310 are included in E0302 and NU UE cannot be billed separately. Code E0277 or E0372 can be used with this code. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-20 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits E0305 CR KH KI KJ Yes 02 07 E0305 can be used with E0290, E0291, BP NU E0292, E0293, E0294, E0295, E0296, E0297 (not with E0310). E0310 IN NU RR UE Yes 02 07 E0310 can be used with E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297 (not with E0305). E0315 IN NU RR UE Yes 02 07 1 per 5 years E0316 CR KH KI KJ BP Yes 02 07 NU UE RR UE E0325 IN NU RR UE No 02 07 1 unit = each, 1 per 3 months E0326 IN NU RR UE No 02 07 1 unit = each, 1 per 3 months E0371 CR KH KI KJ BP Yes 02 07 1 per 5 years NU UE E0372 CR KH KI KJ BP Yes 02 07 1 per 5 years NU UE E0373 CR KH KI KJ BP Yes 02 07 E0277 can be used with E0372. NU UE E0602 IN NU Yes 02 07 1 = each, 1 only per female (only for separation) E0603 IN NU Yes 02 07 1 = each, 1 only per adult female (only for separation) E0604 RR Yes 02 07 1 unit = 1 month rental (only for separation) E0605 IN NU RR UE No 02 07 1 unit = each, one per 24 months E0606 CR KH KI KJ BP Yes 02 07 NU UE E0607 IN NU RR UE Yes 02 07 1 per 2 years E0610 IN NU RR UE Yes 02 07 1 per 3 years E0621 IN NU RR UE Yes 02 07 1 per 12 months E0625 CR KH KI KJ BP Yes 02 07 NU UE E0627 IN NU RR UE Yes 02 07 1 per 5 years (E0621 is included in the initial purchase of E0627.) E0628 IN NU RR UE Yes 02 07 1 per 5 years (E0621 is included in the initial purchase of E0628.) E0629 IN NU RR UE Yes 02 07 1 per 5 years (E0621 is included in the initial purchase of E0629.) E0630 CR KH KI KJ BP Yes 02 07 1 per 3 years (Transfer between bed, chair, NU UE wheelchair, commode, and requires the assistance of more than one person. E0621 included in E0630.) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-21 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits E0635 CR KH KI KJ BP Yes 02 07 1 per 3 years (Transfer between bed, chair, NU UE wheelchair, commode, and requires the assistance of more than one person. E0621 included in E0635.) E0636 CR KH KI KJ BP Yes 02 07 1 per 3 years (Transfer between bed, chair, NU UE wheelchair, commode and requires the assistance of more than one person. E0621 included in E0636.) E0637 IN NU RR UE Yes 02 07 1 per 5 years E0638 IN NU RR UE Yes 02 07 1 per 5 years; small, medium, or large Prone or Supine Stander E0650 IN NU RR UE Yes 02 07 E0650 can be used with E0671 - E0673. E0651 IN NU RR UE Yes 02 07 E0651 can be used with E0667 - E0669. E0652 IN NU RR UE Yes 02 07 E0652 can be used with E0667 - E0669. E0655 IN NU RR UE Yes 02 07 E0655 can be used with E0650. E0660 IN NU RR UE Yes 02 07 E0660 can be used with E0650. E0665 IN NU RR UE Yes 02 07 E0665 can be used with E0650. E0666 IN NU RR UE Yes 02 07 E0666 can be used with E0650. E0667 IN NU RR UE Yes 02 07 E0667 can be used with E0651 or E0652. E0668 IN NU RR UE Yes 02 07 E0668 can be used with E0651 or E0652. E0669 IN NU RR UE Yes 02 07 E0669 can be used with E0651 or E0652. E0671 IN NU RR UE Yes 02 07 E0671 can be used with E0650. E0672 IN NU RR UE Yes 02 07 E0672 can be used with E0650. E0673 IN NU RR UE Yes 02 07 E0673 can be used with E0650. E0675 CR KH KI KJ BP Yes 02 07 1 per 5 years NU UE E0700 IN No 02 07 E0701 IN NU RR UE No 02 07 E0710 IN No 02 07 E0720 TE Yes 02 07 1 per 3 years E0730 TE Yes 02 07 1 per 3 years E0731 TE Yes 02 07 1 per 3 years E0747 IN NU RR UE Yes 02 07 1 per 5 years (ICD-9-CM codes: 733.83, 755.8, 810.00-810.13, 812.00 - 813.93, 815.00-815.19, 820.00-821.39, 823.00-824.9, 825.25, 825.35, V45.4) E0748 IN NU RR UE Yes 02 07 1 per 5 years (ICD-9-CM V45.4) E0760 IN NU RR UE Yes 02 07 1 per 5 years (ICD-9-CM codes: 733.83, 807.00-807.3, 808.10-816.13, 820.00-826.1) E0776 IN NU RR UE Yes 02 07 1 per 5 years Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-22 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits E0779 CR KH KI KJ BP Yes 02 07 E0776 cannot be provided with E0779. NU UE Supplies used with E0779 are A4221, A4222, or K0552. E0780 IN NU Yes 02 07 1 per 5 years (E0776 cannot be provided with E0780. Supplies used with E0779 are A4221, A4222, or K0553.) E0781 CR KH KI KJ BP Yes 02 07 E0776 cannot be provided. Supplies used NU UE with E0779 are A4221, A4222, or K0554. E0784 CR KH KI KJ BP Yes 02 07 E0776 cannot be provided with E0784. NU UE E0791 CR KH KI KJ BP Yes 02 07 E0776 can be supplied separately when using NU UE E0791. E0840 IN NU RR UE Yes 02 07 1 per 5 years E0850 IN NU RR UE Yes 02 07 1 per 5 years E0855 IN NU RR UE Yes 02 07 1 per 5 years E0860 IN NU RR UE Yes 02 07 1 per 5 years E0870 IN NU RR UE Yes 02 07 1 per 5 years E0880 IN NU RR UE Yes 02 07 1 per 5 years E0890 IN NU RR UE Yes 02 07 1 per 5 years E0900 IN NU RR UE Yes 02 07 1 per 5 years E0910 CR KH KI KJ BP Yes 02 07 1 unit = each, allowed for patient to sit up for NU UE respiratory condition, change in body position, or to get in or out of bed. E0920 CR KH KI KJ BP Yes 02 07 1 per 5 years NU UE E0930 CR KH KI KJ BP Yes 02 07 1 per 5 years NU UE E0935 FS RR Yes 02 07 1 month maximum (per episode) E0940 CR KH KI KJ BP Yes 02 07 1 per 5 years NU UE E0941 CR KH KI KJ BP Yes 02 07 1 per 5 years NU UE E0942 IN NU RR UE No 02 07 1 per 5 years E0943 IN NU RR UE No 02 07 1 per 5 years E0944 IN NU RR UE No 02 07 1 per 5 years E0945 IN NU RR UE No 02 07 1 per 5 years E0946 CR KH KI KJ BP Yes 02 07 2 per 5 years NU UE E0947 IN NU RR UE Yes 02 07 1 per 5 years E0948 IN NU RR UE Yes 02 07 1 per 5 years E0951 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months E0955 IN NU RR UE Yes 02 06 07 1 per 5 years Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-23 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits E0956 IN NU RR UE Yes 02 06 07 1 per 5 years E0957 IN NU RR UE Yes 02 06 07 1 per 5 years E0958 CR KH KI KJ BP Yes 02 06 07 1 per 5 years NU UE E0960 IN NU RR UE Yes 02 06 07 1 per 5 years E0962 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Replacement for wheelchair purchased. E0963 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Replacement for wheelchair purchased. E0964 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Replacement for wheelchair purchased. E0965 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Replacement for wheelchair purchased. E0967 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Replacement for wheelchair purchased. E0968 CR KH KI KJ BP No 02 07 1 unit = each, 1 per 12 months NU UE E0969 IN NU RR UE No 02 07 1 unit = each, 1 per 12 months E0971 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Replacement for wheelchair purchased. E0977 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months E0980 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 12 months E0985 IN NU RR UE Yes 02 06 07 1 per 5 years E0986 IN NU RR UE Yes 02 06 07 1 per 5 years E0994 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Replacement for wheelchair purchased. E0997 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Replacement for wheelchair purchased. E0998 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Replacement for wheelchair purchased. E0999 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Replacement for wheelchair purchased. E1001 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Replacement for wheelchair purchased. E1002 IN NU RR UE Yes 02 06 07 1 per 5 years E1003 IN NU RR UE Yes 02 06 07 1 per 5 years E1004 IN NU RR UE Yes 02 06 07 1 per 5 years E1005 IN NU RR UE Yes 02 06 07 1 per 5 years E1006 IN NU RR UE Yes 02 06 07 1 per 5 years E1007 IN NU RR UE Yes 02 06 07 1 per 5 years E1008 IN NU RR UE Yes 02 06 07 1 per 5 years E1009 IN NU RR UE Yes 02 06 07 1 per 5 years Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-24 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits E1010 IN NU RR UE Yes 02 06 07 1 per 5 years E1011 IN NU RR UE Yes 02 06 07 1 per 5 years E1012 IN NU RR UE Yes 02 06 07 1 per 5 years E1013 IN NU RR UE Yes 02 06 07 1 per 5 years E1014 IN NU RR UE Yes 02 06 07 1 per 5 years E1015 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Replacement for wheelchair purchased. E1016 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Replacement for wheelchair purchased. E1017 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Replacement for wheelchair purchased. E1018 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Replacement for wheelchair purchased. E1019 IN NU RR UE Yes 02 06 07 1 per 5 years E1020 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Replacement for wheelchair purchased. E1021 IN NU RR UE Yes 02 06 07 1 per 5 years E1025 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Replacement for wheelchair purchased. E1026 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Replacement for wheelchair purchased. E1027 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Replacement for wheelchair purchased. E1028 IN NU RR UE Yes 02 06 07 1 per 5 years E1029 IN NU RR UE Yes 02 06 07 1 per 5 years E1030 IN NU RR UE Yes 02 06 07 1 per 5 years E1031 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 12 months. Replacement NU UE for wheelchair purchased. E1035 CR KH KI KJ BP Yes 02 07 1 per 5 years NU UE E1037 CR KH KI KJ BP Yes 02 07 Specialty products included in this code are NU UE pediatric strollers. E1038 CR KH KI KJ BP Yes 02 07 1 per 5 years NU UE E1050 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1060 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1065 IN NU RR UE Yes 02 06 07 1 unit = each E1070 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-25 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 602 Covered Services (cont.) Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits E1083 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1084 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1087 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1088 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1091 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1092 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1093 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1100 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1110 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1150 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1160 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1161 IN NU RR UE Yes 02 06 07 1 unit = each. Refer to Section 607. E1170 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1171 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1172 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1180 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1190 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1195 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1200 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1210 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1211 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-26 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 602 Covered Services (cont.) Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits E1220 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1221 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1222 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1223 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1224 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1225 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1227 IN NU RR UE Yes 02 06 07 1 unit = each E1228 CR KH KI KJ BP Yes 02 06 07 1 unit = each NU UE E1230 IN NU RR UE Yes 02 07 1 unit = each. Refer to Section 607. E1231 IN NU UE Yes 02 06 07 1 unit = each. Refer to Section 607. E1232 IN NU UE Yes 02 06 07 1 unit = each. Refer to Section 607. E1233 IN NU UE Yes 02 06 07 1 unit = each. Refer to Section 607. E1234 IN NU UE Yes 02 06 07 1 unit = each. Refer to Section 607. E1235 IN NU UE Yes 02 06 07 1 unit = each. Refer to Section 607. E1236 IN NU UE Yes 02 06 07 1 unit = each. Refer to Section 607. E1237 IN NU UE Yes 02 06 07 1 unit = each. Refer to Section 607. E1238 IN NU UE Yes 02 06 07 1 unit = each. Refer to Section 607. E1240 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1270 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1280 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1295 CR KH KI KJ BP Yes 02 07 1 unit = each NU UE E1296 IN NU RR UE Yes 02 06 07 1 unit = each E1297 IN NU RR UE Yes 02 06 07 1 unit = each E1298 IN NU RR UE Yes 02 06 07 1 unit = each E1340 RP No 02 06 07 PA required for repair of equipment purchased for member in skilled nursing facility. E1800 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 3 years NU UE E1801 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 3 years NU UE Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-27 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 602 Covered Services (cont.) Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits E1802 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 3 years NU UE E1805 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 3 years NU UE E1806 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 3 years NU UE E1810 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 3 years NU UE E1811 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 3 years NU UE E1815 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 3 years NU UE E1816 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 3 years NU UE E1818 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 3 years NU UE E1820 CR NU RR UE Yes 02 07 1 unit = each, 1 per 3 years E1821 CR NU RR UE Yes 02 07 1 unit = each, 1 per 3 years E1825 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 3 years NU UE E1830 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 3 years NU UE E1840 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 3 years NU UE E1902 IC NU RRUE Yes 02 07 1 unit = each, 1 per 3 years E2000 CR KH KI KJ BP Yes 02 07 1 unit = each, 1 per 3 years NU UE E2100 IN NU RR UE Yes 02 07 Visual impairment (e.g., best corrected visual acuity of 20/200 or worse) E2101 IN NU RR UE Yes 02 07 Manual dexterity impairments E2201 IN NU RR UE Yes 02 06 07 1 per 5 years E2202 IN NU RR UE Yes 02 06 07 1 per 5 years E2203 IN NU RR UE Yes 02 06 07 1 per 5 years E2204 IN NU RR UE Yes 02 06 07 1 per 5 years E2310 IN NU RR UE Yes 02 06 07 1 per 5 years E2311 IN NU RR UE Yes 02 06 07 1 per 5 years E2320 IN NU RR UE Yes 02 06 07 1 per 5 years E2321 IN NU RR UE Yes 02 06 07 1 per 5 years E2322 IN NU RR UE Yes 02 06 07 1 per 5 years E2323 IN NU RR UE Yes 02 06 07 1 per 5 years E2324 IN NU RR UE Yes 02 06 07 1 per 5 years E2325 IN NU RR UE Yes 02 06 07 1 per 5 years Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-28 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits E2326 IN NU RR UE Yes 02 06 07 1 per 2 years E2327 IN NU RR UE Yes 02 06 07 1 per 5 years E2328 IN NU RR UE Yes 02 06 07 1 per 5 years E2329 IN NU RR UE Yes 02 06 07 1 per 5 years E2330 IN NU RR UE Yes 02 06 07 1 per 5 years E2340 IN NU RR UE Yes 02 06 07 1 per 5 years E2341 IN NU RR UE Yes 02 06 07 1 per 5 years E2342 IN NU RR UE Yes 02 06 07 1 per 5 years E2343 IN NU RR UE Yes 02 06 07 1 per 5 years E2351 IN NU RR UE Yes 02 06 07 1 per 5 years K0001 CR KH KI KJ BP No 02 07 1 unit = each. Refer to Section 607. NU RR UE 1 per 5 years K0002 CR KH KI KJ BP No 02 07 1 unit = each. Refer to Section 607. NU RR UE 1 per 5 years K0003 CR KH KI KJ BP No 02 07 1 unit = each. Refer to Section 607. NU RRUE 1 per 5 years K0004 CR KH KI KJ BP Yes 02 06 07 1 unit = each. Refer to Section 607. NU RR UE 1 per 5 years K0005 IN NU RR UE Yes 02 06 07 1 unit = each. Refer to Section 607. 1 per 5 years K0006 CR KH KI KJ BP Yes 02 06 07 1 unit = each. Refer to Section 607. NU RR UE 1 per 5 years K0007 CR KH KI KJ BP Yes 02 06 07 Use K0460 for add-on power packs, patients NU RR UE weighing over 300 pounds, 1 per 5 years. K0010 CR KH KI KJ BP Yes 02 06 07 1 unit = each. Refer to Section 607. NU RR UE 1 per 5 years K0011 CR KH KI KJ BP Yes 02 06 07 1 unit = each. Refer to Section 607. NU RR UE 1 per 5 years K0012 CR KH KI KJ BP Yes 02 06 07 1 unit = each. Refer to Section 607. NU RR UE 1 per 5 years K0014 IN NU RR UE Yes 02 06 07 1 unit = each. Refer to Section 607. K0015 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0016 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0017 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0018 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0019 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0020 IN NU RR UE No 02 06 07 1 unit = pair, 1 per 12 months Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-29 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits K0022 IN NU RR UE No 02 06 07 1 unit = each. Refer to Section 607. K0023 IN NU RR UE No 02 06 07 1 unit = each. Refer to Section 607. K0024 IN NU RR UE No 02 06 07 1 unit = each. Refer to Section 607. K0025 IN NU RR UE No 02 06 07 1 unit = each. Refer to Section 607. K0026 IN NU RR UE No 02 06 07 1 unit = each. Refer to Section 607. K0027 IN NU RR UE No 02 06 07 1 unit = each. Refer to Section 607. K0028 IN NU RR UE No 02 06 07 1 unit = each. Refer to Section 607. K0029 IN NU RR UE No 02 06 07 1 unit = each. Refer to Section 607. K0030 IN NU RR UE No 02 06 07 1 unit = each. Refer to Section 607. K0031 IN NU RR UE No 02 06 07 1 unit = each. Refer to Section 607. K0032 IN NU RR UE No 02 06 07 1 = each, 1 per12 months. Refer to Section 607. K0033 IN NU RR UE No 02 06 07 1 = each, 1 per 12 months. Refer to Section 607. K0035 IN NU RR UE No 02 06 07 1 = each, 2 per 12 months. Refer to Section 607. K0036 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months K0037 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months K0038 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0039 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0040 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months K0041 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months K0042 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0043 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0044 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0045 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0046 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0047 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0048 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0049 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0050 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-30 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits K0051 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0052 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0053 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0054 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months K0055 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months K0056 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months K0057 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months K0058 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months K0059 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months K0060 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 606. K0061 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 606. K0062 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months K0063 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months K0064 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months K0065 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months K0066 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0067 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0068 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0069 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0070 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0071 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0072 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0073 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0074 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0075 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0076 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-31 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits K0077 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0078 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0079 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Refer to Section 607. K0080 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Refer to Section 607. K0081 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0082 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0083 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0084 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0085 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0086 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Refer to Section 607. K0087 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Refer to Section 607. K0088 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Refer to Section 607. K0089 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Refer to Section 607. K0090 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0091 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0092 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0093 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0094 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0095 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0096 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0097 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-32 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits K0098 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0099 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. K0100 IN NU RR UE No 02 06 07 1 unit = pair, 1 per 12 months K0102 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months K0103 IN NU RR UE No 02 07 1 unit = each, 1 per 12 months K0104 IN NU RR UE No 02 07 1 unit = each K0105 IN NU RR UE No 02 07 1 unit = each K0106 IN NU RR UE No 02 07 1 unit = each K0107 IN NU RR UE No 02 07 1 unit = each K0108 NU UE Yes 02 06 07 Direct service component codes RE-1 through RE-23 are to be used under this K0108 for RTS providers only. K0108 RP No 02 06 07 Repair to previously purchased wheelchair, include PA # on claim; RE-1 through RE-23 cannot be used with this modifier (requires PA). K0112 PO Yes 02 06 07 1 unit = each, 1 per 12 months K0113 PO Yes 02 06 07 1 unit = each, 1 per 12 months K0114 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 12 months K0115 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 12 months. Refer to Section 607. K0116 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 12 months. Refer to Section 607. K0195 CR KH KI KJ BP Yes 02 06 07 1 unit = each, 1 per 12 months. Refer to NU UE Section 607. K0452 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months. Refer to Section 607. K0455 FS RR Yes 02 07 K0460 CR KH KI KJ BP Yes 02 06 07 1 per 5 years NU UE K0461 IN NU RR UE Yes 02 06 07 1 per 5 years K0541 IN NU RR UE Yes 02 07 Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digital speech output. E0545 included in K0541. K0543 IN NU RR UE Yes 02 07 Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digitized and synthesized output. E0545 is included in this code. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-33 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits K0544 IN NU RR UE Yes 02 07 Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digitized and synthesized output. E0545 is included in this code. K0545 IN NU RR UE Yes 02 07 Speech-generating software program that enables a laptop computer, desktop computer, or personal digital assistant (PDA) to function as a speech generation device. E0545 is included in this code. K0546 IN NU RR UE Yes 02 07 E0545 is included in K0546. K0547 IN NU RR UE Yes 02 07 E0545 is included in K0547. K0549 CR KH KI KJ BP Yes 02 07 Weight is over 350 pounds but does not NU UE exceed 600 pounds. E0271, E0272, E0305, E0310 are included in K0549. K0550 CR KH KI KJ BP Yes 02 07 Weight exceeds 600 pounds. E0271, E0272, NU UE E0305, E0310 are included in K0550. K0552 SU KO KP KQ Yes 02 07 Intermittent infusions, one bag or cassette for each drug dose, and continuous cassettes, bag, or syringe. K0581 IN No 02 07 1 unit = each, 3 per month K0582 IN No 02 07 1 unit = each, 3 per month K0583 IN No 02 07 1 unit = each, 3 per month K0584 IN No 02 07 1 unit = each, 3 per month K0587 IN No 02 07 1 unit = each, 3 per month K0588 IN No 02 07 1 unit = each, 3 per month K0589 IN No 02 07 1 unit = each, 3 per month K0590 IN No 02 07 1 unit = each, 3 per month K0591 IN No 02 07 1 unit = each, 3 per month K0592 IN No 02 07 1 unit = each, 3 per month K0593 IN No 02 07 1 unit = each, 3 per month K0594 IN No 02 07 1 unit = each, 3 per month K0595 IN No 02 07 1 unit = each, 3 per month K0596 IN No 02 07 1 unit = each, 3 per month K0597 IN No 02 07 1 unit = each, 3 per month K0601 IN NU No 02 07 Replacement for already purchased equipment K0602 IN NU No 02 07 Replacement for already purchased equipment K0603 IN NU No 02 07 Replacement for already purchased equipment K0604 IN NU No 02 07 Replacement for already purchased equipment K0605 IN NU No 02 07 Replacement for already purchased equipment Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-34 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits K0615 IN NU RR UE Yes 02 07 Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digital speech output. E0545 is included in this code. K0616 IN NU RR UE Yes 02 07 Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digital speech output. E0545 is included in this code. K0617 IN NU RR UE Yes 02 07 Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digital speech output. E0545 is included in this code. K0620 SD A1 A2 A3 No 02 07 1 unit = 1 linear yard, 3 per month A4 A5 A6 A7 A8 A9 K0621 SD A1 A2 A3 No 02 07 1 unit = 1 linear yard, 3 per month A4 A5 A6 A7 A8 A9 K0622 SD A1 A2 A3 No 02 07 1 unit = 1 roll, 3 per month (roll gauze type, A4 A5 A6 short stretch bandages, does not contain A7 A8 A9 elastic fibers) K0623 SD A1 A2 A3 No 02 07 1 unit = 1 roll, 3 per month (roll gauze type, A4 A5 A6 short stretch bandages, does not contain A7 A8 A9 elastic fibers) K0624 SD No 02 07 1 unit = 1 roll, 3 per month (Ace type bandages) K0625 SD No 02 07 1 unit = 1 roll, 3 per month K0626 SD No 02 07 1 unit = 1 roll, 3 per month L8501 PO No 02 07 1 unit = each, 1 per 3 months S5160 Yes 02 07 1 unit = 1 installation per RID number (per episode) S5161 RR Yes 02 07 1 unit = 1 month rental S5162 IN NU Yes 02 07 1 unit = 1 time purchase per RID every 3 years. S5497 PD No 02 07 1 unit = 1 day, 31 per month S5498 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-35 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits S5501 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S5502 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S5517 PD No 02 07 1 unit = 1 day, 31 per month (month is DOS driven and cannot cross fiscal year. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S5518 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S5520 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S5521 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S8100 IN No 02 07 1 unit = each, 1 per 3 months S8101 IN No 02 07 1 unit = each, 1 per 3 months S8265 No 02 07 1 unit = each, 4 per 3 months S8420 IN No 02 07 1 unit = each, 2 per 6 months (required ICD 9-CM: 457.0, 457.1, 757.0, 997.99) S8421 IN No 02 07 1 unit = each, 2 per 6 months (required ICD 9-CM: 457.0, 457.1, 757.0, 997.99) S8422 IN No 02 07 1 unit = each, 2 per 6 months (required ICD 9-CM: 457.0, 457.1, 757.0, 997.99) S8423 IN No 02 07 1 unit = each, 2 per 6 months (required ICD 9-CM: 457.0, 457.1, 757.0, 997.100) S8424 IN No 02 07 1 unit = each, 2 per 6 months (required ICD 9-CM: 457.0, 457.1, 757.0, 997.100) S8425 IN No 02 07 1 unit = each, 2 per 6 months (required ICD 9-CM: 457.0, 457.1, 757.0, 997.100) S8426 IN No 02 07 1 unit = each, 2 per 6 months (required ICD 9-CM: 457.0, 457.1, 757.0, 997.100) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-36 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits S8427 IN No 02 07 1 unit = each, 2 per 6 months (required ICD 9-CM: 457.0, 457.1, 757.0, 997.101) S8428 IN No 02 07 1 unit = each, 2 per 6 months (required ICD 9-CM: 457.0, 457.1, 757.0, 997.102) S8429 IN No 02 07 1 unit = each, 2 per 6 months (required ICD 9-CM: 457.0, 457.1, 757.0, 997.101) S8430 IN No 02 07 1 unit = each, 2 per 6 months (required ICD 9-CM: 457.0, 457.1, 757.0, 997.101) S9325 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9326 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9327 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9328 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9329 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9330 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9331 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9336 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-37 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits S9338 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9339 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9340 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill B9998, B99999, B9006, B4034, B4035, B4036, B4081, B4082, B4083, B4086 (B4086 can be billed separately for 21 and under), B9000, B9002, B9004, E0776). S9341 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill B9998, B99999, B9006, B4034, B4035, B4036, B4081, B4082, B4083, B4086 (B4086 can be billed separately for 21 and under), B9000, B9002, B9004, E0776). S9342 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill B9998, B99999, B9006, B4034, B4035, B4036, B4081, B4082, B4083, B4086 (B4086 can be billed separately for 21 and under), B9000, B9002, B9004, E0776). S9343 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill B9998, B99999, B9006, B4034, B4035, B4036, B4081, B4082, B4083, B4086 (B4086 can be billed separately for 21 and under), B9000, B9002, B9004, E0776). S9345 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9346 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-38 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits S9347 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9348 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9349 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9351 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9353 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9355 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9357 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9359 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9361 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9363 PD No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9364 PD No 02 07 1 unit = 1 day, 31 per month S9365 PD No 02 07 1 unit = 1 day, 31 per month Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-39 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 602 Covered Services (cont.) Service Payment Modifiers PA POS Code Category Required Required? Required Requirements and Limits S9366 PD No 02 07 1 unit = 1 day, 31 per month S9367 PD No 02 07 1 unit = 1 day, 31 per month S9368 PD No 02 07 1 unit = 1 day, 31 per month S9370 PD No 02 07 1 unit = 1 day, 31 per month S9372 PD No 02 07 1 unit = 1 day, 31 per month S9373 PD No 02 07 1 unit = 1 day, 31 per month S9374 PD No 02 07 1 unit = 1 day, 31 per month S9375 PD No 02 07 1 unit = 1 day, 31 per month S9376 PD No 02 07 1 unit = 1 day, 31 per month S9377 PD No 02 07 1 unit = 1 day, 31 per month S9434 IN No 02 07 1 unit = each S9435 IN No 02 07 1 unit = each S9490 PD No 02 07 1 unit = 1 day, 31 per month S9494 PD No 02 07 1 unit = 1 day, 31 per month S9497 PD No 02 07 1 unit = 1 day, 31 per month S9500 PD No 02 07 1 unit = 1 day, 31 per month S9501 PD No 02 07 1 unit = 1 day, 31 per month S9502 PD No 02 07 1 unit = 1 day, 31 per month S9503 PD No 02 07 1 unit = 1 day, 31 per month S9504 PD No 02 07 1 unit = 1 day, 31 per month S9537 PD No 02 07 1 unit = 1 day, 31 per month S9538 PD No 02 07 1 unit = 1 day, 31 per month S9542 PD No 02 07 1 unit = 1 day, 31 per month S9558 No 02 07 1 unit = 1 day, 31 per month S9559 No 02 07 1 unit = 1 day, 31 per month S9560 PD No 02 07 1 unit = 1 day, 31 per month S9562 PD No 02 07 1 unit = 1 day, 31 per month S9590 PD No 02 07 1 unit = 1 day, 31 per month T5001 IN NU RR UE Yes 02 07 1 per 3 years Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-40 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Modifiers A1 Dressing for one wound A2 Dressing for two wounds A3 Dressing for three wounds A4 Dressing for four wounds A5 Dressing for five wounds A6 Dressing for six wounds A7 Dressing for seven wounds A8 Dressing for eight wounds A9 Dressing for nine or more wounds BA Item furnished in conjunction with parenteral enteral nutrition (PEN) services BO Orally administered nutrition, not by feeding tube BP The beneficiary has been informed of the purchase and rental options and has elected to purchase the item (For MassHealth members, MassHealth has purchased the item for the member.) (used on the 15th month of rental) BR The beneficiary has been informed of the purchase and rental options and has elected to rent the item (For MassHealth members, member continues to rent, no more claims can be submitted, purchase price has been met. MassHealth will not purchase the item.) (used on the 15th month of rental) KH DME POS item, initial claim, purchase of first month rental (for MassHealth members’ first claim) KI DME POS item, second or third month rental KJ DME POS item, parenteral enteral nutrition (PEN) pump or capped rental, months four to 15 (for MassHealth members months four through 14) KR Rental item, billing for partial month KS Glucose monitor supply for diabetic beneficiary not treated with insulin NR New when rented (Use the 'NR' modifier when DME that was new at the time of the rental is subsequently purchased.) NU New equipment RP Replacement and repair – RP may be used to indicate replacement of DME, orthotic, and prosthetic devices that have been used for some time. The claim shows the code for the part, followed by the RP modifier and the charge for the part. (RE-1 through RE-23 cannot be used with this modifier.) RR Rental (Use the RR modifier when DME is to be rented.) SH Second concurrently administered infusion therapy (For MassHealth members this would be used if a second same-drug therapy is provided in a separate compounded IV bag for infusion over a service period for some of the same days as for the first.) SJ Third or more concurrently administered infusion therapy (for MassHealth members this would be used if a third or more same-drug therapy is provided in a separate compounded IV bag for infusion over a service period for some of the same days as for the first.) UE Used durable medical equipment 604 Place-of-Service Codes Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-41 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 The following are codes and descriptions for paper or electronic submission. Electronic Paper Claim Description Submission Description 02 06 07 Member’s home Nursing home Rest home 12 31, 32 33 Home Skilled nursing facility, nursing facility Custodial care facility 605 Payment Categories Each covered service code is assigned to one of the following payment categories. These categories help providers to identify applicable modifiers, and how MassHealth will pay for the products or services. Category Description CAP Capitated rate (per episode) CR Capped rental FS Frequently serviced items IN Inexpensive and routinely purchased DME OS Ostomy, tracheostomy and urologicals OX Oxygen and oxygen equipment PD Daily per diem PO Prosthetics and orthotics SD Surgical dressings SU Supplies TE TENS Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-42 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Part Number Description RE 1- Specialized Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction, and follow-up (1 hour). RE 2- Specialized Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up (2 hours). RE 3- Specialized Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up (3 hours). RE 4- Specialized Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up (4 hours). RE 5- Specialized Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up (5 hours). RE 6-Intermediate Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, custom fabrication of some parts (6 hours). Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-43 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Part Number Description RE 7-Intermediate Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, custom fabrication of some parts (7 hours). RE 8-Intermediate Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, custom fabrication of some parts (8 hours). RE 9-Intermediate Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, custom fabrication of some parts (9 hours). RE 10-Comprehensive Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, high level of complexity in custom fabrication of some parts and may involve use of components from one or more manufactures (10 hours). RE 11- Comprehensive Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, high level of complexity in custom fabrication of some parts and may involve use of components from one or more manufactures (11 hours). Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-44 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Part Number Description RE 12- Comprehensive Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, high level of complexity in custom fabrication of some parts and may involve use of components from one or more manufactures (12 hours). RE 13- Comprehensive Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, high level of complexity in custom fabrication of some parts and may involve use of components from one or more manufactures (13 hours). RE 14- Comprehensive Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, high level of complexity in custom fabrication of some parts and may involve use of components from one or more manufactures (14 hours). RE 15- Comprehensive Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, high level of complexity in custom fabrication of some parts and may involve use of components from one or more manufactures (15 hours). RE 16- Complex Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, very high level of complexity -may involve extensive time for trails of multiple products or interactions with several professionals- physicians, therapist, teachers. Could include extended amount of custom fabrication (16 hours). Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-45 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Part Number Description RE 17- Complex Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, very high level of complexity -may involve extensive time for trials of multiple products or interactions with several professionals- physicians, therapist, teachers. Could include extended amount of custom fabrication (17 hours). RE 18- Complex Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, very high level of complexity -may involve extensive time for trails of multiple products or interactions with several professionals- physicians, therapist, teachers. Could include extended amount of custom fabrication (18 hours). RE 19- Complex Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, very high level of complexity -may involve extensive time for trails of multiple products or interactions with several professionals- physicians, therapist, teachers. Could include extended amount of custom fabrication (19 hours). RE 20- Complex Custom rehab equipment order requiring the consultation of a Rehab Technology Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, very high level of complexity -may involve extensive time for trails of multiple products or interactions with several professionals- physicians, therapist, teachers. Could include extended amount of custom fabrication (20 hours). Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-46 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Part Number Description RE 21- Complex Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, very high level of complexity -may involve extensive time for trails of multiple products or interactions with several professionals- physicians, therapist, teachers. Could include extended amount of custom fabrication (21 hours). RE 22- Complex Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, very high level of complexity -may involve extensive time for trails of multiple products or interactions with several professionals- physicians, therapist, teachers. Could include extended amount of custom fabrication (22 hours). RE 23- Complex Custom rehab equipment order requiring the consultation of a rehab technology specialist (RTS) with a PT/OT or a wheelchair clinic and utilizing mobility/seating/positioning products with some or all of the following as necessary: evaluation, trial, specification, design, product selection, custom fabrication, fittings, instruction and follow-up. More time and complexity with multiple trials of equipment, very high level of complexity -may involve extensive time for trails of multiple products or interactions with several professionals- physicians, therapist, teachers. Could include extended amount of custom fabrication (23 hours). Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-47 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 E1161 Options included in the rate: K0015, K0017, K0018, K0019, K0022, L0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450 E1230 Not used for a manual wheelchair with an add-on tiller control power pack. Ordered by physician with the following specialties only: physical medicine, orthopedic surgery, neurology, or rheumatology E1231 Options included in the rate when provided at the same time: K0015, K0017, K0018, K0019, K0022, K0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450 E1232 Options included in the rate when provided at the same time: K0015, K0017, K0018, K0019, K0022, K0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450 E1233 Options included in the rate when provided at the same time: K0015, K0017, K0018, K0019, K0022, K0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450 E1234 Options included in the rate when provided at the same time: K0015, K0017, K0018, K0019, K0022, K0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450 E1235 Options included in the rate when provided at the same time: K0015, K0017, K0018, K0019, K0022, K0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450 E1236 Options included in the rate when provided at the same time: K0015, K0017, K0018, K0019, K0022, K0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450 E1237 Options included in the rate when provided at the same time: K0015, K0017, K0018, K0019, K0022, K0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450 E1238 Options included in the rate when provided at the same time: K0015, K0017, K0018, K0019, K0022, K0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450 K0001 Options included in the rate when provided at the same time: K0015, K0017, K0018, K0019, K0022, K0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450, can add K0460 for add-on power packs Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-48 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Base Code Options/Accessories K0002 Options included in the rate when provided at the same time: K0015, K0017, K0018, K0019, K0022, K0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450, can add K0460 for add-on power packs K0003 Options included in the rate when provided at the same time: K0015, K0017, K0018, K0019, K0022, K0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450, can add K0460 for add-on power packs K0004 Options included in the rate when provided at the same time: K0015, K0017, K0018, K0019, K0022, K0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450, can add K0460 for add-on power packs K0006 Options included in the rate when provided at the same time: K0015, K0017, K0018, K0019, K0022, K0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450, can add K0460 for add-on power packs K0007 Used to add K0460 for add-on power packs, patient weighs over 300 pounds K0010 Options included in allowance when provided at the same time: E0971, K0015, K0017, K0018, K0019, K0029, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0051, K0052, K0081, K0088, K0089, K0090, K0092, K0094, K0096, K0098, K0099, K0452, not used for manual wheelchairs with add-on power packs K0011 Options included in allowance when provided at the same time: E0971, K0015, K0017, K0018, K0019, K0029, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0051, K0052, K0081, K0088, K0089, K0090, K0092, K0094, K0096, K0098, K0099, K0452, not used for manual wheelchairs with add-on power packs K0012 Included in allowance when provided at the same time: E0971, K0015, K0017, K0018, K0019, K0029, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0051, K0052, K0081, K0088, K0089, K0090, K0092, K0094, K0096, K0098, K0099, K0452, not used for manual wheelchairs with add-on power packs K0014 Included in allowance when provided at the same time: E0971, K0015, K0017, K0018, K0019, K0029, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0051, K0052, K0081, K0088, K0089, K0090, K0092, K0094, K0096, K0098, K0099, K0452, not used for manual wheelchairs with add-on power packs K0015 Included in allowance when provided at the same time: K0010, K0011, K0012, K0014 K0016 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0017, K0018, K0019 K0017 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014, K0016 K0018 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014, K0016 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-49 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Base Code Options/Accessories K0019 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014, K0016 K0022 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009 K0026 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009 K0027 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009 K0028 Included in the rate when provided at the same time: K0015, K0017, K0018, K0019, K0022, K0026, K0027, K0029, K0032, K0033, K0042, K0043, K0044, K0045, K0046, K0047, K0049, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450, can add K0460 for add-on power packs annually, reclining back only K0029 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014 K0032 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009 K0033 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009 K0035 Allowance includes when provided at the same time: E0951 K0038 Included in allowance for K0039 K0039 Included in allowance for K0038 K0042 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014 K0043 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014, K0045, K0048 K0044 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014, K0045, K004, K0048 K0045 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014, K0043, K0044,K0048 K0046 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014, K0043, K0048 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-50 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Base Code Options/Accessories K0047 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014, K0044, K0048 K0048 Included in allowance when provided at the same time: K0043, K0044, K0045, K0046, K0047, K0049, K0053, used with a wheelchair that has been purchased, per leg set K0049 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014, K0048 K0050 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014 K0051 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014 K0052 Included in allowance when provided at the same time: K0010, K0011, K0012, K0014 K0053 Included in allowance when provided at the same time: K0048 K0060 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009 K0061 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009 K0066 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0069 K0067 Included in allowance when provided at the same time: K0070 K0068 Included in allowance when provided at the same time: K0070 K0069 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0066 K0070 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0067, K0068 K0071 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0074, K0075 K0072 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0075 K0074 Included in allowance for K0071 K0075 Included in allowance for K0071, K0072 K0076 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0077 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-51 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Base Code Options/Accessories K0077 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0076 K0081 Included in allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014 K0088 Included in allowance when provided at the same time: K0010, K0011, K0012, K0014 K0089 Included in allowance when provided at the same time: K0010, K0011, K0012, K0014 K0090 Included in allowance when provided at the same time: K0010, K0011, K0012, K0014, K009, K0092 K0091 Included in allowance when provided at the same time: K0090, K0092 K0092 Included in allowance when provided at the same time: K0010, K0011, K0012, K0014, K0090 K0094 Included in allowance when provided at the same time: K0010, K0011, K0012, K0014, K0096 K0095 Included in allowance when provided at the same time: K0096 K0096 Included in allowance when provided at the same time: K0010, K0011, K0012, K0014, K0094, K0095 K0098 Included in allowance when provided at the same time: K0010, K0011, K0012, K0014 K0099 Included in allowance when provided at the same time: K0010, K0011, K0012, K0014 K0115 For use with custom fabricated seating components that are incorporated into a wheelchair base. This is not used for seating components that are ready made but subsequently modified to fit an individual patient. K0116 Used for either a one piece system or when there are separate back and seat components. For use with custom fabricated seating components that are incorporated into a wheelchair base. This is not used for seating components that are ready made but subsequently modified to fit an individual patient. K0195 Included in the allowance when provided at the same time: K0043, K0044, K0045, K0046, K0047. Use only for capped rental wheelchair base, per pair. K0452 Included in the allowance when provided at the same time: E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-52 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Code Product Name B4100 Thick-It, Thick-It 2, Thicken Up, Thick & Easy, Thicken Right B4150 AMTF B4150 AMTF Diabetic B4150 AMTF High Protein B4150 AMTF Pediatric B4150 Balanced - The Total Nutritional Drink (Instant Meal Replacement Drink) B4150 Balanced - The Total Nutritional Drink (Ready-to-Drink Meal) B4150 Boost B4150 Boost High Protein B4150 Boost with Fiber B4150 Enfamil B4150 Enfamil A.R. B4150 Enfamil EnfaCare B4150 Enfamil Kindercal TF B4150 Enfamil LactoFree B4150 Ensure B4150 Ensure Fiber with FOS B4150 Ensure High Calcium B4150 Ensure HN B4150 Ensure HP B4150 Ensure Powder B4150 Ensure with Fiber B4150 Entera B4150 Entera Isotonic B4150 Entera Isotonic Fiber B4150 Enteralife HN B4150 Enterallfe HN Fiber B4150 Enteralife HN-2 B4150 Entrition HN B4150 Fiberlan B4150 Fibersource B4150 Fibersource HN B4150 Fortison B4150 Glytrol B4150 Hearty Balanace B4150 Introlite B4150 Isocal B4150 IsocalHN B4150 Isocal HN Plus B4150 Isocal II Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-53 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Code Product Name B4150 Isofiber B4150 Isolan B4150 Isomil B4150 Isomil Advance Soy Formula with Iron B4150 Isosource B4150 Isosource HN B4150 Jevity B4150 Jevity 1 Cal B4150 Jevity 1.2 Cal B4150 Jevity Plus B4150 Jevity RTH B4150 Kindercal B4150 Meritene B4150 Naturite B4150 Newtrition (Flavors) B4150 Newtrition HN B4150 Newtrition Isofiber B4150 Newtrition Isotonic B4150 Nitrolan (Nitro-Pro) B4150 Nitro-Pro (Nitrolan) B4150 NuBasics B4150 NuBasics VHP B4150 NuBasics with Fiber B4150 Nutramigen B4150 Nutrapak B4150 Nutren 1.0 B4150 Nutren 1.0 with Fiber B4150 Nutren Junior B4150 Nutren Junior with Fiber B4150 Nutren VHP B4150 Nutri-Drink B4150 NutriHeal Complete Nutrition for Healing Support B4150 Nutrilan B4150 Nutrition B4150 NutriVir B4150 NutriVir - NSA (No Sugar Added) B4150 Osmolite B4150 Osmolite 1 Cal B4150 Osmolite 1.2 Cal B4150 Osmolite HN Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-54 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Code Product Name B4150 Osmolite HN Plus B4150 PediaSure B4150 Pediasure Enteral Formula B4150 Pediasure with Fiber Enteral Formula B4150 Portagen B4150 ProBalance B4150 Promote B4150 Promote with Fiber B4150 Resource B4150 Resource Diabetic B4150 Resource for Kids B4150 Resource Just for Kids with Fiber B4150 Similac NeoSure B4150 Similac NeoSure Advance B4150 Similac with Iron B4150 Susta II B4150 Sustacal B4150 Sustacal Basic B4150 Sustacal Fiber B4151 Compleat-B B4151 Compleat-B Modified B4151 Complete Pediatric B4151 KetoCal B4151 ProSobee B4152 AMTF High Cal 2.0 B4152 AMTF Pulmonary B4152 AMTF Renal 2.0 B4152 Boost Plus B4152 Comply B4152 Deliver 2.0 B4152 Ensure Plus B4152 Ensure Plus HN B4152 Ensure Plus HN Ready-to-Hang B4152 Entrition 1.5 B4152 Hormel Solutions Balanced Fortified Nutrition B4152 IsoSource 1.5 B4152 Isotera Isotonic B4152 Jevity 1.5 Cal B4152 Magnacal B4152 Naturite Plus Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-55 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Code Product Name B4152 Nestle VHC 2.25 Complete Very High Calorie Liquid Nutrition B4152 Newtrition 1.5 B4152 Novasource 2.0 B4152 NovaSource Pulmonary B4152 NuBasics 2.0 Complete B4152 NuBasics Plus B4152 Nutren 1.5 B4152 Nutren 2.0 B4152 NutriAssist 1.5 B4152 Nutri-Drink Plus B4152 Nutrition Plus B4152 Prosurgex B4152 Resource Plus B4152 Respalor B4152 Sustacal HC B4152 Sustacal Plus B4152 Twocal HN B4153 Accupepha B4153 Alimentum Protein Hydrolysate Formula with Iron B4153 CriticareHN B4153 Crucial Complete Elemental Diet B4153 Cyclinex-1 B4153 Cyclinex-2 B4153 EleCare B4153 F.A.A. (Free Amino Acid Diet) B4153 Glutarex-1 B4153 Glutarex-2 B4153 Glutasorb B4153 Hominex-1 B4153 Hominex-2 B4153 IMPACT Glutamine B4153 IntensiCal Ready-to-Hang B4153 Isotein B4153 I-Valex-1 B4153 l-Valex-2 B4153 Ketonex-1 B4153 Ketonex-2 B4153 L-Emental B4153 L-Emental Pediatric B4153 Neocate Infant Formula Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-56 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Code Product Name B4153 Neocate Junior B4153 Neocate One + Liquid B4153 Neocate One + Powder B4153 Optimental B4153 Pediatric Peptinex DT B4153 Pediatric Peptinex DT with Fiber B4153 PepditeOne+ B4153 Peptamen 1.5 B4153 Peptamen Complete Elemental Diet with FOS/Inulin B4153 Peptamen Complete Elemental Diet with Prebio1 B4153 Peptamen Junior Complete Elemental Diet for Children B4153 Peptamen Junior Complete Elemental Diet for Children - Powder B4153 Peptical B4153 Peptinex DT B4153 Phenex-1 B4153 Phenex-2 B4153 Phenex-2, Vanilla B4153 PKU-Gel B4153 Precision HN B4153 Precision Isotera B4153 Propimex-1 B4153 Propimex-2 B4153 Reabilan B4153 Subdue B4153 Subdue Plus B4153 Subdue Ready-to-Hang B4153 Travasorb HN B4154 Acerflex B4154 Advera B4154 Alitrag B4154 AminAid B4154 AMTF Renal B4154 AMTF Trauma B4154 Analog Formulas XR B4154 MSUD B4154 XPHEN, TYR B4154 XPTM B4154 XMTVI B4154 XMET B4154 XLYS, TRY Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-57 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Code Product Name B4154 XLEU B4154 BCAD 2 B4154 Calcilo XD B4154 Choice DM B4154 Citrotein B4154 Diabetisource B4154 Diabetisource AC B4154 Entera OPD B4154 Fulfil B4154 Glucerna B4154 Gluco-Pro B4154 Hepatic-Aid B4154 Immun-Aid B4154 Impact B4154 Impact 1.5 B4154 Impact with Fiber B4154 Isosource VHN B4154 L-Emental Hepatic B4154 L-Emental Plus B4154 Lipisorb B4154 Magnacal Renal B4154 Maxamaid Formulas XP B4154 MSUD B4154 XPHEN, TYR B4154 XMTVI B4154 XMET B4154 XLYS, TRY B4154 XLEU B4154 Maxamum Formulas XP B4154 MSUD B4154 XMTVI B4154 XMET B4154 XLYS, TRY B4154 XLEU B4154 Modulen IBD B4154 Nepro B4154 Novasource Renal B4154 Nutrifocus B4154 NutriHep B4154 NutriRenal Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-58 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Service Code Product Name B4154 Nutrivent B4154 Oxepa B4154 Peptamen B4154 Peptamen Junior B4154 Peptamen VHP B4154 Perative B4154 Periflex B4154 Phenyl-Free 1 B4154 Phenyl-Free 2 B4154 Phenyl-Free 2 HP B4154 Pregestimil B4154 Pro-Peptide B4154 Pro-Peptide for Kids B4154 Pro-Petide VHN B4154 Protain XL B4154 Provide B4154 Pulmocare B4154 Reabilan HN B4154 Renalcal B4154 Replete B4154 Replete with Fiber B4154 SandoSource Peptide B4154 Similac PM 60/40 B4154 SLD (Surgical Liquid Diet) B4154 Stresstein B4154 Suplena (Replena) B4154 Tarvil B4154 Traumacal B4154 Travasorb Hepatic B4154 Travasorb MCT B4154 Travasorb Renal B4155 ArgiMent B4155 Boost Breeze B4155 Casec B4155 Duocal (Super Soluble) B4155 Egg/Pro Powder B4155 Elementra B4155 EMF (Enzymatic Modular Food) B4155 Enlive B4155 EPULOR Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-59 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Code Product Name B4155 Essential ProPlus B4155 Essential Protein B4155 Fibrad B4155 Hi ProCal B4155 Immunocal B4155 Juven with Arginine, Glutamine and HMB B4155 MCT Oil B4155 Microlipid B4155 Moducal B4155 Nestle Additions Calorie and Protein Food Enhancer B4155 NutriMod Protein Supplement B4155 Peptinex B4155 PhenylAde MTE Amino Acid Blend B4155 Phlexy-lO Drink Mix B4155 PKU-Express B4155 Polycose B4155 Procare B4155 ProCell Protein Supplement B4155 Promix B4155 ProMod B4155 Propac Plus B4155 ProPass Protein Supplement B4155 Pro-Phree B4155 ProSource Protein Supplement B4155 Pro-Stat B4155 Pro-Stat 101 B4155 ProSure B4155 ProViMin B4155 RCF (Ross Carbohydrate Free) B4155 Resource Arginaid B4155 Resource Arginaid Extra B4155 Resource Benecalorie B4155 Resource Beneprotein Instant Protein Powder B4155 Resource Fruit Beverage (Novartis Nutrition) B4155 Resource GlutaSolve B4155 Resource Instant Protein Powder B4155 Restore-X B4155 Resurgex B4155 SoyPro B4155 Sumacal Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-60 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 Code Product Name B4155 Sysco Classic Lactose Free ProCal B4156 Precision LR Powder B4156 Tolerex B4156 Travasorb STD Powder Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-61 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 HCPCS Description A4521 All Through the Night A4521 Ambese A4521 At Ease Premium Plus Adult Brief A4521 Attends A4521 Comfort Touch Fitted Brief A4521 Confidence Premium Full Fit A4521 Cuties A4521 Depend A4521 Dignity A4521 Driflo A4521 Dry Comfort A4521 Duro-Med A4521 First Quality A4521 GEPCO A4521 Griffin A4521 Hartmann Moliform A4521 MaxiCare A4521 Molicare A4521 Prevail A4521 Promise A4521 Protection Plus A4521 Reassure A4521 Secure A4521 Select A4521 SIMPLICITY A4521 Slimline A4521 Stanford A4521 SureCare A4521 SuretyS A4521 Tena A4521 Tranquililty A4521 UltraShield A4521 UltraSure A4521 Unigard A4521 Wings A4521 Woodbury A4522 All Through the Night A4522 At Ease Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-62 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 HCPCS Description A4522 Attends A4522 Comfort Touch A4522 Confidence A4522 CVS A4522 Depend A4522 Dignity A4522 Driflo A4522 Dry Comfort A4522 Duro-Med A4522 Entrust+ A4522 First Quality A4522 Hartmann Moliform A4522 Kendall A4522 MaxiCare A4522 Molicare A4522 Nightingale A4522 Prevail A4522 Promise A4522 Protection Plus A4522 Reassure A4522 Secure A4522 Select A4522 Serenity A4522 SIMPLICITY A4522 Slimline A4522 Stanford A4522 SureCare A4522 SuretyS A4522 Tena A4522 Tranquililty A4522 Trim Line A4522 Ultra A4522 UltraShield A4522 UltraSure Plus A4522 Wings A4522 Woodbury A4523 All Through the Night A4523 At Ease Premium Plus Adult Brief Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-63 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 HCPCS Description A4523 Attends A4523 Classic Plus A4523 Comfort Touch Fitted Brief A4523 Confidence Premium Full Fit A4523 Depend A4523 Dignity A4523 Driflo A4523 Dry Comfort A4523 Duro-Med A4523 Entrust+ A4523 First Quality A4523 Hartmann Moliform A4523 Kendall A4523 LDR A4523 MaxiCare A4523 Molicare A4523 Nightingale A4523 Prevail A4523 Protection Plus A4523 Reassure A4523 Secure A4523 Select A4523 SIMPLICITY A4523 Slimline A4523 Stanford A4523 SureCare A4523 SuretyS A4523 Tena A4523 Tena Plus A4523 Tranquililty A4523 Trim Line A4523 UltraShield A4523 UltraSure Plus A4523 Wings A4523 Woodbury A4524 All Through the Night A4524 At Ease A4524 Attends Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-64 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 HCPCS Description A4524 Comfort Touch Fitted Brief A4524 Confidence Premium Full Fit A4524 CVS A4524 Depend A4524 Dignity A4524 Driflo A4524 Dry Comfort A4524 Duro-Med A4524 Entrust+ A4524 First Quality A4524 Hartmann Moliform A4524 MaxiCare A4524 Molicare A4524 Prevail A4524 Promise A4524 Protection Plus A4524 Reassure A4524 Secure A4524 Select A4524 SIMPLICITY A4524 Slimline A4524 Stanford A4524 SureCare A4524 SuretyS A4524 Tena A4524 Tranquility A4524 Ultra A4524 UltraShield A4524 UltraSure Plus A4524 Wings A4524 Woodbury A4529 Huggies Supreme, size 1 A4529 Huggies Supreme, size 2 A4529 Huggies Supreme, size 3 A4529 Huggies Ultratrim, size 2 A4529 Huggies Ultraslim, size 3 A4529 Huggies Overnight, size 3 A4529 Pampers Swaddlers, size 2 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-65 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 HCPCS Description A4529 Pampers Cruisers, size 3 A4529 Pampers Baby Dry, size 2 A4529 Pampers Baby Dry, size 3 A4529 Luvs, size 2 A4529 Luvs, size 3 A4529 Walgreens, size small A4529 Walgreens, size medium A4529 CVS, small A4529 CVS, medium A4530 Huggies Overnites, size 4 A4530 Huggies Overnites, size 5 A4530 Huggies Supreme, size 4 A4530 Huggies Supreme, size 5 A4530 Huggies Supreme, size 6 A4530 Huggies Ultratrim, size 4 A4530 Huggies Ultraslim, size 5 A4530 Pampers Cruisers, size 4 A4530 Luvs, size 4 A4530 Luvs, size 5 A4530 Luvs, size 6 A4530 Walgreens, size large A4530 Walgreens, size extra large A4530 CVS, small A4530 CVS, medium Huggies Girls’ Pull-ups, size A4531 medium Huggies Boys’ Pull-ups, size A4531 medium Trim Fit Good Night Pull-ups, A4531 Size medium A4532 Trim Fit Good Night Pull-ups, size large A4532 Trim Fit Good Night Pull-ups, size extra-large A4532 Huggies Boys’ Pull-Ups, size large A4532 Huggies Boys’ Pull-Ups, size extra-large A4532 Huggies Girls’ Pull-Ups, size large A4532 Huggies Girls’ Pull-Ups, size extra large A4532 Goodnight Pull-Ups, large A4532 Goodnight Pull-Ups, extra large A4533 Attends Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-66 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 HCPCS Description A4533 First Quality A4533 Paper Pack A4533 Wings A4533 Tena A4533 Provide A4534 Attends Belted A4534 First Quality A4534 Provide A4534 Tena A4534 Paper Pack A4554 Conquest A4554 Surety A4554 Maxima A4554 Duro-Med A4554 Priva A4554 Americare A4554 Terndersorb A4554 UltraShield A4554 Wings A4554 Polyguard A4554 Maicare A4554 Durasorb A4535 Aqua-Gel A4535 At Ease A4535 Attends A4535 Briefmate A4535 Comfort Touch A4535 Companion A4535 Confidence A4535 Coveen A4535 CVS A4535 Depend A4535 Dignity A4535 DURA TEX A4535 Duro-Med A4535 First Quality A4535 Flush Safe A4535 Free & Active Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-67 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 HCPCS Description A4535 Free & Active A4535 HadiCare A4535 Harmonie A4535 Hartmann Moliform A4535 ManHood A4535 Maxishield A4535 Minigard A4535 Molimed A4535 Poise A4535 Prefer A4535 Premeir A4535 Presence A4535 Prevail A4535 Primcare A4535 Protection Plus A4535 Reassure A4535 Safe & Dry A4535 Sani-Pad A4535 Secure A4535 Select A4535 Serenity A4535 Stanford A4535 Surecare A4535 SuretyS A4535 Tena A4535 Tena A4535 Tranquility A4535 Unigard A4535 Woodbury Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-68 DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-24 DATE 01/01/04 This page is reserved.