Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER DME-25 July 2004 TO: Durable Medical Equipment Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director 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. This transmittal letter replaces Transmittal Letter DME-23, issued last April, and Transmittal Letter DME-24. (Please Note: In January 2004, the Division of Health Care Finance and Policy rescinded regulations that had been promulgated the same month, which made TL DME-24 invalid.) The revised Subchapter 6, and the billing and prior authorization (PA) instructions and guidelines appearing below are effective for dates of service on and after July 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 in Subchapter 6. 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 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 Revised Fee Schedule In June 2004, 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 July 1, 2004. The DHCFP regulations, including the fee schedule, are available on the DHCFP Web site at www.mass.gov/dhcfp. Among other methodological changes, the new DHCFP fee schedule no longer includes the so-called third payment methodology for those services for which a fee has been established within the regulation. The established rate for these services is now the provider’s usual and customary charge, or the rate established by DHCFP, whichever is lower. This change means that providers are no longer required to submit an invoice with a PA request or a claim in most instances. Providers must now submit only an invoice for a PA or a claim for services that are priced on an individual consideration (I.C.) basis. These services are listed as I.C. in the DHCFP fee schedule and in Subchapter 6 of the Durable Medical Equipment Manual. 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/masshealth. Impact of Effective Date of Subchapter 6 on Claims Effective for dates of service on and after July 1, 2004, providers must bill for services provided to MassHealth members using only the HCPCS specified in the attached Subchapter 6. In addition to the new codes, providers must also use a modifier with certain codes to accurately reflect the service provided, and ensure the appropriate payment. Claims submitted with codes not included in Subchapter 6 will be denied as not covered. Impact of Effective Date of Subchapter 6 on Prior Authorization Effective for dates of service on and after July 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 codes must request a new PA. When requesting a new PA for services already approved by MassHealth as medically necessary, providers should reference the old PA number. Providers should also indicate the new code, the number of units already billed, any remaining units needed (not to exceed the units on the original PA decision), and provide a copy of the physician’s prescription submitted with the old PA. Providers who have already received PAs with new codes that can be used after July 1, 2004, do not need to request a new PA. Providers are reminded that PA requests require an ICD-9-CM code that directly relates to the service being requested, along with a description of the diagnosis. Service Code Limits Section 602 of Subchapter 6 identifies the payment category, indicates 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 all services (even if a PA is not typically required for the service) for coverage of additional units beyond the specified guidelines, if additional units are medically necessary. The request should be submitted before the additional units are provided, and must be supported by medical documentation. New Billing and PA Requirements Diagnosis Codes 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. Services Provided to Members Aged 21 and Under and for Which No Code Appears in Subchapter 6 Miscellaneous codes have been removed from Subchapter 6 except where noted. If a member is aged 21 or under, and has a medically justified need for a product that is not listed in Subchapter 6, the provider should refer to MassHealth’s Administrative and Billing Regulations at 130 CMR 450.000 for the EPSDT PA process. To receive payment for any service described in 130 CMR 450.144(A)(1) that is not specifically included as a covered service under any MassHealth regulation, service code list, or contract, the requester must submit a request for prior authorization in accordance with 130 CMR 450.303. This request must include, without limitation, a letter and supporting documentation from a MassHealth enrolled physician or nurse practitioner documenting the medical need for the requested service. If MassHealth approves such a request for service for which there is no established payment rate, MassHealth will establish the appropriate payment rate for such service on an individual- consideration basis in accordance with 130 CMR 450.271. Services Purchased as Capped Rental for Members with MassHealth Coverage Only For equipment considered capped rental, modifiers NU (new purchase) and UE (used equipment purchase) can be substituted for the KH, KI, KJ, and BP modifiers accepted by Medicare. If a member is covered by MassHealth only, and there is written medical documentation to justify the ongoing need of the equipment, providers can bill using the NU or UE modifier (whichever is applicable) to purchase the equipment for a MassHealth member. Providers do not have to bill over a 15-month period. If, however, a member has other insurance, a provider must follow the primary insurer’s payment methodology when billing MassHealth. Inexpensive and Routinely Purchased DME Certain HCPCS codes listed in Subchapter 6 require modifiers NU (new), RR (rental), and UE (used equipment). Providers are reminded that the RR modifier is for short-term use only. The rate attached to the RR modifier can never exceed the cost of purchasing the equipment new or used. Breast Pumps MassHealth has added a code that will allow for the purchase of an electric breast pump. The purchase of the product will be approved in situations in which the mother and child are separated for medical reasons. For example, MassHealth will purchase an electric breast pump for a mother who is discharged from the hospital and whose baby must remain hospitalized. Diabetic Supplies The KS modifier must be used for a member that is non-insulin dependant. The KX modifier must be used to identify a member that is insulin dependant. Enteral Formulas To correspond to the new HIPAA-compliant HCPCS codes, MassHealth has revised the way in which units are counted when billing enteral formulas. Enteral formulas that are used in conjunction with parenteral enteral (PEN) services require the BA modifier. 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 are examples of the codes, modifiers, and units: B4150 BA 1 unit = 100 calories B4150 BO 1 unit = each (8 ounce can) B4151 BA 1 unit =100 calories B4151 BO 1 unit = each (8 ounce can) MassHealth has also revised the way in which units are counted when billing for food thickener. One unit equals one ounce. Service Code B4086 (only when product is a Mikey-Tube) can be billed separately for members aged 21 and under when billing Service Codes S9340, S9341, S9342, and S9343. 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 Service 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, and can be used only for custom mobility systems. The direct service component codes require PA and should only be submitted on the PA request; the direct service component codes should not be included on claims. Specialized Rehabilitation Equipment for Children Providers can use Service Code E1399 with a UC modifier for specialized rehab equipment that does not have a HCPCS code. This code and modifier can be billed only by an RTS provider and only for specialty rehabilitation equipment. Power-Operated Vehicles (POV) MassHealth will accept a physician order for a POV only when the physician specializes in physical medicine, orthopedic surgery, neurology, or rheumatology. Repairs Providers of mobility products must use Service Code E1340 with the UB modifier for all repairs of customized mobility systems not under warranty. Direct service component codes cannot be used with this code and modifier. All other providers must use Service Code E1340 RP for the repair of equipment not under warranty. A PA is required for all repairs in all settings when the fee for the repairs will exceed $1000. A prescription is not required for repair of equipment that was previously approved as medically necessary by MassHealth. Claims for repairs must be supported by an itemized bill indicating parts and labor. Payment for repairs will be a lump sum payment that cannot exceed the purchase price of a new item, or the payment that would be necessary to rent a replacement item for the remaining period for which the product has been determined to be medically necessary. Claims submitted for repairs must use Service Code E1340 and the RP and UB modifiers, must be billed in 15-minute increments, and must be supported by the following information: * a description of the repair; * an explanation as to why the repair is medically necessary; * an itemization of parts and labor; and * invoices for all parts. Prescription Requirements for Services Provided to Members Who Are in Nursing Facilities A prescription from a physician on a prescription pad or physician’s letterhead is no longer required when providing services to MassHealth members who are in nursing facilities. Instead, providers are required to submit a copy of the order from the member’s medical record along with any treatment plan (i.e., wound care) written by the facility’s staff. Wound Care Modifiers Modifiers A1-A9 have been established to indicate that a particular item is being used as a primary or secondary dressing on a surgical or debrided wound, and also to indicate the number of wounds on which that dressing is being used. The modifier number must correspond to the number of wounds on which the dressing is being used and not the total number of wounds treated. For example, if the patient has four wounds but a particular dressing is used on only two of them, then the A2 modifier must be used with the applicable HCPCS code. Other Billing Guideline Reminders Place-of-Service Codes Section 602 of Subchapter 6 identifies covered place-of-service codes for each HCPCS code. Please refer to Section 604 in Subchapter 6 for the crosswalk to the appropriate place-of-service codes if billing HIPAA-compliant transactions. This crosswalk is to be referenced only for HIPAA transactions, and should not be used for paper claims. Providers are reminded that the place of service is where the product is used (e.g., member’s home, nursing facility, or rest home). For a member residing in a group home, providers are required to use the code for home. The PA, if applicable, and the claim must reflect the accurate place of service. Providers are reminded that MassHealth does not pay a DME provider for equipment and supplies provided to MassHealth members in institutions licensed as acute, chronic, or rehabilitation hospitals. Individual Consideration (I.C.) Providers must submit an invoice for claims for services that are I.C. Providers are required to enter the acquisition cost, plus the appropriate mark-up, in the “usual fee” data element, and provide a complete description of the service in the “remarks” data element. Billing for DME Equipment for Which Multiple PA Numbers Have Been Issued In certain instances, PAs require multiple lines. MassHealth’s Automated PA System (APAS) can accommodate an unlimited number of HCPCS codes on a PA request. However, in situations where a PA requires more than 5 lines, typically for specialized mobility products situations, providers will receive more than one PA number for the requested equipment. Providers are reminded when billing for the service that the correct PA number must correspond to the appropriate service being billed. IV and Enteral products Effective for dates of services on and after April 1, 2003, providers should not bill the “From” and “Thru” dates on claims for “S” codes IV and Enteral HCPCS products. To ensure that claims are processed appropriately, providers must enter the date the service was furnished in the “From” data element on the claim and leave the “To” data element blank. Claims for Custom-Made Goods Provided to Members Who Become Ineligible As stated in 130 CMR 450.231(B), “the ‘date of service’ is the date on which a medical service is furnished to a member or, if the medical service consists principally of custom-made goods such as durable medical equipment, the date on which the goods are delivered to a member. If a provider delivers medical goods to member, which goods had to be ordered, fitted or altered for the member, and the member ceases to be eligible for such MassHealth services on a date prior to the final delivery of the goods, the Division will reimburse the provider for the goods…” Providers must submit paper claims for these services with all applicable documentation outlined in 130 CMR 450.231(B) to the following address. MassHealth Claims Operations Unit Attention: After Cancel Unit 600 Washington Street Boston, MA 02111 Members with Other Insurance All claims submitted to MassHealth, on which MassHealth is a secondary payer, must be billed to MassHealth with the same HCPCS code as was billed to the other primary insurer. MassHealth will deny all claims for services provided to members with other insurance if those claims are billed using Service Code A9270. If a service code is never covered by a primary insurer, but is covered by MassHealth, an explanation of benefits (EOB) is not required when billing MassHealth. For example, Medicare does not cover diapers. If the member is covered by Medicare, the provider does not have to bill Medicare first, and can bill MassHealth directly. MassHealth will pay up to the MassHealth amount, or the member’s responsibility, whichever is less. If a service code is covered by Medicare, but not in the place of service in which the service was provided, the provider must obtain a letter from CMS, annually, that indicates that the specific code is not covered by Medicare in the specific setting. For example, oxygen is a service that is covered by Medicare, but it is not covered in a nursing facility. If the member is covered by Medicare, the provider must obtain a letter from CMS, annually, to submit in support of each claim. Medical Necessity Documentation Medical necessity determinations are based on specific clinical information and documentation that supports appropriate medical use of the services being requested. When documenting medical necessity, a provider should include at least the following information: * the member’s diagnosis; * a summary of the member’s medical history and physical exam from medical records. Current test results, lab reports, and visiting nurse’s notes are examples of appropriate supporting documentation. * a description of the severity of the medical problem (acute, chronic, stable) and clinical findings to support this; * whether the medical condition is life threatening; and * whether the member’s medical status or condition is permanent or reversible. MassHealth requires medical necessity documentation to demonstrate that the service will contribute to the member’s treatment or recovery process. Noncovered Services Providers are reminded that air conditioners, HEPA filters, light boxes, and disposable washcloths (baby wipes) are not covered by MassHealth. 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 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 the MassHealth regulations 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 6-68 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-24 MASSHEALTH TRANSMITTAL LETTER DME-25 July 2004 Page 2 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE TABLE OF CONTENTS PAGE vi DURABLE MEDICAL EQUIPMENT MANUAL TRANSMITTAL LETTER DME-25 DATE 07/01/04 6. SERVICE CODES 601 Definitions………………………………………………………………………………..… 6-1 602 Covered Services…………………………………………………………………………… 6-2 603 Modifiers…………………………………………………………………………………… 6-39 604 Place of Service Codes……………………………………………………………………... 6-40 605 Payment Categories……………………………………………………………………….... 6-40 606 Direct Service Component Codes………………………………………………………….. 6-41 607 Wheelchair Base Codes with Options/Accessories………………………………………… 6-46 608 Enteral Product Classification List……………………………………………………….… 6-51 609 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 Subchapter 6 contains definitions, service codes, modifiers and descriptions, place-of-service codes, and product classification lists. 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 their own belted straps (tape, tabless). 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/shields – Rectangular absorbent products with a waterproof cover available with or without adhesive strips to hold them 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. 602 Covered Services 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 Code Payment Category Modifiers Required PA Required? POS Required Requirements and Limits 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 KX No 02 07 1 unit = per week, 20 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 IN - - No 02 07 1 unit = each, 60 per month A4244 IN - - No 02 07 1 unit = per pint, 4 per month A4245 IN - - No 02 07 1 unit = per box, 4 per month A4246 IN - - No 02 07 1 unit = per pint, 4 per month A4247 IN - - No 02 07 1unit = per box, 4 per month A4250 IN KX No 02 07 1 unit = each (box of 8, blood ketone), 2 per month A4253 IN KS No 02 07 1 unit =1 box (50), 5 per 3 months A4253 IN KX No 02 07 1 unit =1 box (50), 15 per 3 months A4254 IN NU RR UE No 02 07 1 unit = each, 9 per 3 months A4255 SU KS KX No 02 07 1 unit = 1 box (50), 2 per month A4256 SU KS KX No 02 07 1 unit = 1 each (vial/bottle of 100), 1 per 3 months (to be used with E0607, E2100, and E2101) A4258 SU KS KX 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), 3 per 3 months (to be used with E0607, E2100, and E2101) A4259 SU KX No 02 07 1 unit = 1 box (100), 8 per 3 months (to be used with E0607, E2100, and E2101) A4265 SU - - No 02 07 1 unit = 1 pound, 1 per 3 months A4310 OS - - No 02 07 1 unit = 1 tray, 31 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.) A4315 OS - - No 02 07 1 unit = 1 tray, 3 per month (A4331 is included in A4315.) A4316 OS - - No 02 07 1 unit = 1 tray, 3 per month (A4331 is included in A4316.) A4319 OS - - No 02 07 1 unit = 1000 ml, 6 per month A4320 OS - - No 02 07 1 unit = each, 4 per month A4321 OS - - No 02 07 1 unit = each, 4 per month A4322 OS - - No 02 07 1 unit = each, 3 per month A4324 OS - - No 02 07 1 unit = each, 250 per month A4325 OS - - No 02 07 1 unit = each, 35 per month A4326 OS - - No 02 07 1 unit = each, 35 per month A4327 OS - - No 02 07 1 unit = each, 4 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, 12 per month A4334 OS - - No 02 07 1 unit = each, 1 per month A4338 OS - - No 02 07 1 unit = each, 31 per month A4340 OS - - No 02 07 1 unit = each, 31 per month A4344 OS - - No 02 07 1 unit = each, 31 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, 250 per month A4352 OS - - No 02 07 1 unit = each, 250 per month A4353 OS - - No 02 07 1 unit = each, 250 per month A4354 OS - - No 02 07 1 unit = each, 31 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 6 months A4362 OS - - No 02 07 1 unit = each, 20 per month A4364 OS - - No 02 07 1 unit = 1 fluid ounce, 4 per month A4365 OS - - No 02 07 1 unit = 1 box (50), 1 per month (for use only with ostomy supplies) A4366 OS - - No 02 07 1 unit = each, 20 per month 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, 10 per 6 months 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.) A4376 OS - - No 02 07 1 unit = each, 20 per month (A4361 and A4378 are included in A4376.) 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, 60 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, 31 per month A4396 OS - - No 02 07 1 unit = each, 1 per month A4397 OS - - No 02 07 1 unit = each, 4 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, 18 per month A4404 OS - - No 02 07 1 unit = each, 10 per month A4405 OS - - No 02 07 1 unit = 1 ounce, 4 per month A4406 OS - - No 02 07 1 unit = 1 ounce, 4 per month A4407 OS - - No 02 07 1 unit = each, 20 per month A4408 OS - - No 02 07 1 unit = each, 20 per month 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 = each, 20 per month A4414 OS - - No 02 07 1 unit = each, 20 per month A4415 OS - - No 02 07 1 unit = each, 20 per month A4416 OS - - No 02 07 1 unit = each, 60 per month A4417 OS - - No 02 07 1 unit = each, 60 per month A4418 OS - - No 02 07 1 unit = each, 60 per month A4419 OS - - No 02 07 1 unit = each, 60 per month A4422 OS - - No 02 07 1 unit = each, 120 per month A4423 OS NU No 02 07 1 unit = each, 60 per month A4424 OS - - No 02 07 1 unit = each, 20 per month A4425 OS - - No 02 07 1 unit = each, 20 per month A4426 OS - - No 02 07 1 unit = each, 20 per month A4427 OS - - No 02 07 1 unit = each, 20 per month A4428 OS - - No 02 07 1 unit = each, 20 per month A4429 OS - - No 02 07 1 unit = each, 20 per month A4430 OS - - No 02 07 1 unit = each, 20 per month A4431 OS - - No 02 07 1 unit = each, 20 per month A4432 OS - - No 02 07 1 unit = each, 20 per month A4433 OS - - No 02 07 1 unit = each, 20 per month A4434 OS - - No 02 07 1 unit = each, 20 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, 40 per month A4455 SD - - No 02 07 1 unit = 1 ounce, 16 ounces per 6 months (for use with ostomy supplies) A4462 SD - - No 02 07 1 unit = each, 1 per 6 months A4490 IN NU No 02 07 1 unit = each, 4 per 3 months A4495 IN NU No 02 07 1 unit = each, 4 per 3 months A4500 IN NU No 02 07 1 unit = each, 4 per 3 months A4510 IN NU No 02 07 1 unit = each, 4 per 3 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 A4536 IN - - Yes 02 07 1 unit = each, 7 per 3 months 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.) 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) A4632 IN NU RR UE No 02 07 1 unit = each, 1 per 12 months (used for replacement of patient-owned equipment) 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.) A4660 IN NU No 02 07 1 unit = each, 1 per 3 years A4663 IN NU No 02 07 1 unit = each, 1 per 3 years A4927 IN - - No 02 07 1 unit = 1 box (100), 4 per month A4930 IN - - No 02 07 1 unit = 1 pair, 93 per month A5051 OS - - No 02 07 1 unit = each, 60 per month A5052 OS - - No 02 07 1 unit = each, 60 per month A5053 OS - - No 02 07 1 unit = each, 60 per month A5054 OS - - No 02 07 1 unit = each, 60 per month A5055 OS - - No 02 07 1 unit = each, 31 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, 31 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 6 months 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, 12 per month A6010 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each (per gram), 45 per month, per wound A6011 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each (per gram), 45 per month, per wound A6021 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 31 per month, per wound A6022 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 31 per month, per wound A6023 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 31 per month, per wound A6024 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = per 6 inches, 31 per month, per wound A6154 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6196 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 6 inches, 31 per month, per wound A6197 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 6 inches, 31 per month, per wound A6198 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 6 inches, 31 per month, per wound A6199 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 6 inches, 60 per month, per wound A6200 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6201 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6202 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6203 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6204 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6205 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6206 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 4 per month, per wound A6207 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 4 per month, per wound A6208 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 4 per month, per wound A6209 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6210 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6211 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6212 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6213 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6214 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6215 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 3 per month, per wound A6216 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 200 per month, per wound A6217 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 200 per month, per wound A6218 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 200 per month, per wound A6219 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 100 per month, per wound A6220 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 100 per month, per wound A6221 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 100 per month, per wound A6222 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 100 per month, per wound A6223 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 100 per 3 months, per wound A6224 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 100 per 3 months, per wound A6228 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 100 per 3 months, per wound A6229 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 100 per 3 months, per wound A6230 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 100 per 3 months, per wound A6231 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6232 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6233 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6234 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6235 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6236 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6237 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6238 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6239 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6240 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 fluid ounce, 12 per month, per wound A6241 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 gram, 45 per month, per wound A6242 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 31 per month, per wound A6243 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 31 per month, per wound A6244 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 31 per month, per wound A6245 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6246 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6247 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6248 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 fluid ounce, 3 per month, per wound A6251 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 100 per month, per wound A6252 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 100 per month, per wound A6253 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 100 per month, per wound A6254 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 31 per month, per wound A6255 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 31 per month, per wound A6256 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 31 per month, per wound A6257 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6258 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6259 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 12 per month, per wound A6260 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 16 ounces, 12 per month, per wound A6266 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 linear yard, 60 per month, per wound A6402 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 200 per month, per wound A6403 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 200 per month, per wound A6404 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 100 per month, per wound A6407 SD NU No 02 07 1 unit = each, 30 per month A6410 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 31 per month, per wound A6411 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = each, 31 per month, per wound A6442 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 240 per month, per wound A6443 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 240 per month, per wound A6444 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 240 per month, per wound A6445 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 240 per month, per wound A6446 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 240 per month, per wound A6447 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 240 per month, per wound A6448 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 30 per month, per wound A6449 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 30 per month, per wound A6450 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 30 per month, per wound A6451 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 30 per month, per wound A6452 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 30 per month, per wound A6453 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 30 per month, per wound A6454 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 80 per month, per wound A6455 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 80 per month, per wound A6456 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 yard, 160 per month, per wound 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 E0600 or 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 E0600 or E2000; otherwise included in monthly rental.) A7002 IN - - No 02 07 1 unit = each, 1 per month (A7002 can be billed separately if patient owns E0600 or 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. B4034 included in “S” code. B4035 IN - - No 02 07 1 unit = each, 31 per month (A5200 included in B4035). All supplies (including dressings) other than the feeding tube itself included. B4035 included in “S” code. B4036 IN - - No 02 07 1 unit = each, 31 per month (A5200 included in B4036). All supplies (including dressings) other than the feeding tube itself included. B4036 included in “S” code. 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 - - No 02 07 1 unit = each, 6 per 3 months. This code can be billed separately only for a child (under 21) when "S" codes are being billed. 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. 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 to 51 grams of protein (B4164, B4180, B4168 - B4178, B4216 included in B4189.) 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 (B4164, B4180, B4168 - B4178, B4216 included in B5000.) B5100 - - No 02 07 1 unit = 1 gram (B4164, B4180, B4168 - B4178, B4216 included in B5100.) B5200 - - No 02 07 1 unit = 1 gram (B4164, B4180, B4168 - B4178, B4216 included in B5200.) 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 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 NU UE Yes 02 07 1 per 5 years E0138 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years E0140 IN NU RR UE Yes 02 07 1 per 5 years; E0140 can be used for 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.) 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. 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 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 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 NU UE No 02 07 1 per 3 years (E0167 is included initial purchase of E0165.) E0166 CR KH KI KJ BP NU UE No 02 07 1 per 3 years (E0167 is included in initial 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 NU UE Yes 02 07 1 per 5 years 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 NU UE Yes 02 07 A4640 and E0182 are included in E0180. E0181 CR KH KI KJ BP NU UE Yes 02 07 A4640 and E0182 are included in E0181. E0182 CR KH KI KJ BP NU UE Yes 02 07 Replacement to an already purchased pressure 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 NU UE Yes 02 07 1 per 12 months E0187 CR KH KI KJ BP NU UE Yes 02 07 1 per 12 months E0188 IN NU RR UE No 02 07 1 per 12 months E0189 IN NU RR UE No 02 07 2 per 6 months E0190 IN. NU RR UE Yes 02 07 1 unit = each, 2 per 6 months E0191 IN NU RR UE No 02 07 4 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 NU UE Yes 02 07 1 per 5 years 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 RR 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 NU UE Yes 02 07 1 per 5 years 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 No 02 07 1 per 5 years; specialty transfer bench E0248 IN NU RR UE No 02 07 1 per 5 years; specialty transfer bench/commode E0250 CR KH KI KJ BP NU UE No 02 07 1 per 5 years. E0271, E0272, E0305, E0310, are included in E0250. E0251 CR KH KI KJ BP NU UE No 02 07 1 per 5 years. E0305, E0310 are included in E0251. E0277 and E0372 can be used with this code. E0255 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0271, E0272, E0305, E0310 are included in E0255. E0256 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0305, E0310 are included in E0256. E0277 and E0372 can be used with this code. E0260 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0271, E0272, E0305, E0310 are included in E0260. E0261 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0305, E0310 are included in E0261. E0277 or E0372 can be used with this code. E0265 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0271, E0272, E0305, E0310 are included in E0265. E0266 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0305, E0310 are included in E0266. E0277 or E0372 can be used with this code. E0271 IN NU RR UE No 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 No 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 NU UE Yes 02 06 07 1 per 5 years. E0277 is not to be used with E0193, E0371, 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 NU UE Yes 02 07 1 per 5 years. E0271, E0272 are included in E0290. E0371 and E0372 can be used with E0290. E0291 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0277 can be used with E0291. E0292 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0271, E0272 are included in E0292. E0371 and E0372 can be used with E0292. E0293 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0277 can be used with E0293. E0294 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years, E0305, E0310, E0271, and E0272 are included in E0294. E0371 and E0372 can be used with E0294. E0295 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0277 can be used with this E0295. E0296 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0271, E0272 are included in E0296. E0371 and E0372 can be used with E0296. E0297 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0305, E0310, E0277 can be used with E0297. E0300 IN NU RR UE Yes 02 07 1 per 5 years E0301 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0305, E0310 included in E0301. E0277 or E0372 can be used with E0301. E0302 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0305, E0310 included in E0302. E0277 or E0372 can be used with E0302 E0303 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. Weight is more than 350 pounds, but less than 600 pounds. E0271, E0272, E0305, E0310 included in E0303. E0304 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. Weight exceeds 600 pounds. E0271, E0272, E0305, E0310 included in E0304 E0305 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0305 can be used with E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297 (not with E0310). E0310 IN NU RR UE Yes 02 07 1 per 5 years. 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 NU UE RR Yes 02 07 1 per 5 years 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 NU UE Yes 02 07 1 per 5 years E0372 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years E0373 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0277 can be used with E0372. E0602 IN NU RR UE No 02 07 1 unit = each, 1 per female (mother and child medical separation) E0603 IN NU No 02 07 1 unit = each, 1 per female (mother and child medical separation) E0604 RR Yes 02 07 1 unit = 1 month rental (mother and child medical separation) E0605 IN NU RR UE No 02 07 1 unit = each, one per 24 months E0606 CR KH KI KJ BP NU UE No 02 07 1 per 5 years E0607 IN NU RR UE No 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 IN NU RR UE Yes 02 07 1 per 5 years 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 NU UE Yes 02 07 1 per 3 years (Transfer between bed, chair, wheelchair, commode, and requires the assistance of more than one person. E0621 included in E0630.) E0635 CR KH KI KJ BP NU UE Yes 02 07 1 per 3 years (Transfer between bed, chair, wheelchair, commode, and requires the assistance of more than one person. E0621 included in E0635.) E0636 CR KH KI KJ BP NU UE Yes 02 07 1 per 3 years (Transfer between bed, chair, 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 1 per 5 years. E0650 can be used with E0671 - E0673. E0651 IN NU RR UE Yes 02 07 1 per 5 years. E0651 can be used with E0667 - E0669. E0652 IN NU RR UE Yes 02 07 1 per 5 years. E0652 can be used with E0667 - E0669. E0655 IN NU RR UE Yes 02 07 2 per 3 years. E0655 can be used with E0650. E0660 IN NU RR UE Yes 02 07 2 per 3 years. E0660 can be used with E0650. E0665 IN NU RR UE Yes 02 07 2 per 3 years. E0665 can be used with E0650. E0666 IN NU RR UE Yes 02 07 2 per 3 years. E0666 can be used with E0650. E0667 IN NU RR UE Yes 02 07 2 per 3 years. E0667 can be used with E0651 or E0652. E0668 IN NU RR UE Yes 02 07 2 per 3 years. E0668 can be used with E0651 or E0652. E0669 IN NU RR UE Yes 02 07 2 per 3 years. E0669 can be used with E0651 or E0652. E0671 IN NU RR UE Yes 02 07 2 per 3 years. E0671 can be used with E0650. E0672 IN NU RR UE Yes 02 07 2 per 3 years. E0672 can be used with E0650. E0673 IN NU RR UE Yes 02 07 2 per 3 years. E0673 can be used with E0650. E0675 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years E0700 IN - - No 02 07 1 per 12 months E0701 IN NU RR UE No 02 07 1 per 12 months E0710 IN - - No 02 07 8 per 12 months 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 E0779 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0776 cannot be provided with E0779. Supplies used with E0779 are A4221, A4222, or K0552. E0780 IN - - 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 NU UE Yes 02 07 1 per 5 years. E0776 cannot be provided. Supplies used with E0779 are A4221, A4222, or K0554. E0784 CR KH KI KJ BP NU Yes 02 07 1 per 5 years. E0776 cannot be provided with E0784. E0791 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years. E0776 can be supplied separately when using 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 NU UE Yes 02 07 1 unit = each, 2 per 5 years (allowed for patient to sit up for respiratory condition, change in body position, or to get in or out of bed). E0920 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years E0930 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years E0935 FS RR Yes 02 07 1 month maximum (per episode) E0940 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years E0941 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years E0942 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 NU UE Yes 02 07 2 per 5 years E0947 IN NU RR UE Yes 02 07 1 per 5 years E0948 IN NU RR UE Yes 02 07 1 per 5 years E0950 IN NU RR UE No 02 07 1 unit = each E0951 IN NU RR UE No 02 06 07 1 unit = each E0952 IN NU RR UE No 02 06 07 1 unit = each E0955 IN NU RR UE Yes 02 06 07 1 per 5 years 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 NU UE Yes 02 06 07 1 per 5 years E0959 IN NU RR UE No 02 06 07 1 unit = pair E0960 IN NU RR UE Yes 02 06 07 1 per 5 years E0961 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E0962 IN NU RR UE No 02 06 07 1 unit = each, replacement for wheelchair purchased E0963 IN NU RR UE No 02 06 07 1 unit = each, replacement for wheelchair purchased E0964 IN NU RR UE No 02 06 07 1 unit = each, replacement for wheelchair purchased E0965 IN NU RR UE No 02 06 07 1 unit = each, replacement for wheelchair purchased E0966 IN NU RR UE No 02 06 07 1 unit = each E0967 IN NU RR UE No 02 06 07 1 unit = each, replacement for wheelchair purchased E0968 CR KH KI KJ BP NU UE No 02 07 1 unit = each E0969 IN NU RR UE No 02 07 1 unit = each E0971 IN NU RR UE No 02 06 07 1 unit = each, replacement for wheelchair purchased E0972 IN NU RR UE No 02 07 1 unit = each, 1 per 12 months E0973 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E0974 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E0977 IN NU RR UE No 02 06 07 1 unit = each E0978 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E0980 IN NU RR UE Yes 02 06 07 1 unit = each E0981 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607 E0982 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607 E0983 CR KH KI KJ BP NU UE Yes 02 06 07 1 per 5 years E0984 IN NU RR UE Yes 02 06 07 1 per 5 years 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 E0990 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E0992 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E0994 IN NU RR UE No 02 06 07 1 unit = each, replacement for wheelchair purchased E0995 IN NU RR UE No 02 06 07 1 unit = each, 2 per 12 months. Refer to Section 607. NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E0997 IN NU RR UE No 02 06 07 1 unit = each, replacement for wheelchair purchased E0998 IN NU RR UE No 02 06 07 1 unit = each, replacement for wheelchair purchased E0999 IN NU RR UE No 02 06 07 1 unit = each, replacement for wheelchair purchased E1001 IN NU RR UE No 02 06 07 1 unit = each, 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 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, replacement for wheelchair purchased E1016 IN NU RR UE No 02 06 07 1 unit = each, replacement for wheelchair purchased E1017 IN NU RR UE No 02 06 07 1 unit = each, replacement for wheelchair purchased E1018 IN NU RR UE No 02 06 07 1 unit = each, 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, 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, replacement for wheelchair purchased E1026 IN NU RR UE No 02 06 07 1 unit = each, replacement for wheelchair purchased E1027 IN NU RR UE No 02 06 07 1 unit = each, replacement for wheelchair purchased E1028 IN NU RR UE Yes 02 06 07 - - E1029 IN NU RR UE Yes 02 06 07 - - E1030 IN NU RR UE Yes 02 06 07 - - E1031 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1035 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years E1037 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years, specialty products included in this code are pediatric strollers. E1038 CR KH KI KJ BP NU UE Yes 02 07 1 per 5 years E1050 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1060 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1065 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years E1070 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1083 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1084 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1087 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1088 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1091 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1092 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1093 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1100 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1110 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1150 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1160 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1161 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. E1170 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1171 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1172 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1180 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1190 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1195 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1200 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1210 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1211 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1220 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1221 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1222 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1223 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1224 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1225 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1226 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E1227 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years E1228 CR KH KI KJ BP NU UE Yes 02 06 07 1 unit = each, 1 per 5 years E1230 IN NU RR UE Yes 02 07 1 unit = each, 1 per 5 years, refer to Section 607. E1231 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. E1232 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. E1233 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. E1234 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. E1235 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. E1236 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. E1237 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. E1238 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. E1240 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1270 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1280 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1295 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 5 years E1296 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years E1297 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years E1298 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years E1340 IN RP No 02 06 07 PA required for repair of equipment purchased for member in nursing facility. E1340 IN UB No 02 06 07 Used by RTS providers only. PA required for all repairs over $1000.00 E1399 IN UC Yes 02 07 Use for child pediatric specialty equipment. E1800 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 3 years E1801 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 3 years E1802 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 3 years E1805 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 3 years E1806 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 3 years E1810 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 3 years E1811 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 3 years E1815 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 3 years E1816 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 3 years E1818 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 3 years 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 NU UE Yes 02 07 1 unit = each, 1 per 3 years E1830 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 3 years E1840 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 3 years E1902 IN NU RR UE Yes 02 07 1 unit = each, 1 per 3 years E2000 CR KH KI KJ BP NU UE Yes 02 07 1 unit = each, 1 per 3 years E2100 IN NU RR UE Yes 02 07 1 per 3 years, visual impairment (e.g., best corrected visual acuity of 20/200 or worse) E2101 IN NU RR UE Yes 02 07 1 per 3 years, 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 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 E2331 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 E2360 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E2361 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E2362 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E2363 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E2364 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E2365 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E2366 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E2367 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. E2500 IN NU RR UE Yes 02 06 07 Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digital speech output. E0545 included in E2500. E2502 IN NU RR UE Yes 02 06 07 Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digital speech output. E0545 included in this code E2504 IN NU RR UE Yes 02 06 07 Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digital speech output. E0545 included in this code E2506 IN NU RR UE Yes 02 06 07 Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digital speech output. E0545 included in this code E2508 IN NU RR UE Yes 02 06 07 Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digitized and synthesized output. E0545 included in this code. E2510 IN NU RR UE Yes 02 06 07 Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digitized and synthesized output. E0545 included in this code. E2511 IN NU RR UE Yes 02 06 07 Speech-generating software program that enables a laptop computer, desktop computer or personal digital assistant (PDA) to function as a speech-generating device. E0545 include in this code E2512 IN NU RR UE Yes 02 06 07 E0545 is included in E2512. E2599 IN NU RR UE Yes 02 06 07 E0545 is included in E2599. K0001 CR KH KI KJ BP NU UE No 02 07 1 unit = each, 1 per 5 years, refer to Section 607. K0002 CR KH KI KJ BP NU UE No 02 07 1 unit = each, 1 per 5 years, refer to Section 607. K0003 CR KH KI KJ BP NU UE No 02 07 1 unit = each, 1 per 5 years, refer to Section 607. K0004 CR KH KI KJ BP NU UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. K0005 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. K0006 CR KH KI KJ BP NU UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. K0007 CR KH KI KJ BP NU UE Yes 02 06 07 Use E0983 for add-on power packs, patients weighing over 300 pounds, 1 per 5 years. K0010 CR KH KI KJ BP NU UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. K0011 CR KH KI KJ BP NU UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. K0012 CR KH KI KJ BP NU UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. K0014 IN NU RR UE Yes 02 06 07 1 unit = each, 1 per 5 years, refer to Section 607. K0015 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0017 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0018 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0019 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0020 IN NU RR UE No 02 06 07 1 unit = pair 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. 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, refer to Section 607. K0039 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0040 IN NU RR UE No 02 06 07 1 unit = each K0041 IN NU RR UE No 02 06 07 1 unit = each K0042 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0043 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0044 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0045 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0046 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0047 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0050 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0051 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0052 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0053 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0056 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 K0060 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 606. K0061 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 606. K0064 IN NU RR UE No 02 06 07 1 unit = each K0065 IN NU RR UE No 02 06 07 1 unit = each K0066 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0067 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0068 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0069 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0070 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0071 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0072 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0073 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0074 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0075 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0076 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0077 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0078 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0081 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0090 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0091 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0092 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0093 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0094 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0095 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0096 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0097 IN NU RR UE No 02 06 07 1 unit = each K0098 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0099 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0102 IN NU RR UE No 02 06 07 1 unit = each, 1 per 12 months K0104 IN NU RR UE No 02 07 1 unit = each, 1 per 5 years K0105 IN NU RR UE No 02 07 1 unit = each, 1 per 5 years K0106 IN NU RR UE No 02 07 1 unit = each, 1 per 5 years 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 NU UE Yes 02 06 07 1 unit = each, refer to Section 607. K0452 IN NU RR UE No 02 06 07 1 unit = each, refer to Section 607. K0455 FS RR Yes 02 07 1 per 5 years K0552 SU KO KP KQ KX No 02 07 1 unit = each, 20 per month. Intermittent infusions, one bag or cassette for each drug dose, and continuous cassettes, bag, or syringe. 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 K0620 SD A1 A2 A3 A4 A5 A6 A7 A8 A9 No 02 07 1 unit = 1 linear yard, 3 per month, per wound L8501 PO - - No 02 07 1 unit = each, 1 per 3 months. ICD-9 V44.0 or V55.0 S5160 - - - - Yes 02 07 1 unit = 1 installation per member (per episode) S5161 - - RR Yes 02 07 1 unit = 1 month rental S5162 IN NU Yes 02 07 1 unit = 1 time purchase per member 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 with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S5501 PD - - No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill with 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 with 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 with 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 with 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 with 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 with 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) 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 with 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 with 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 with 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 with 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 with 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 with 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 with 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 with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9338 PD - - No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill with 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 with 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 with B9998, B9999, 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 with 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 with 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 with 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 with 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 with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, E0784.) S9347 PD - - No 02 07 1 unit = 1 day, 31 per month. Included in rate are all equipment and supplies. (Do not bill with 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 with 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 with 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 with 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 with 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 with 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 with 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 with 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 with 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 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 603 Modifiers 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 or 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 KX Specific required documentation on file (For MassHealth members this modifier is required for insulin dependent diabetes management.) NR New when rented (Use the 'NR' modifier when DME that was new at the time of 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.) UB Used with E1340 by mobility “RTS” providers only, for in-home repair and servicing of customized mobility equipment. UC Medicaid level of care 12 (used for child pediatric specialized rehabilitation equipment by RTS providers only) UE Used durable medical equipment 604 Place-of-Service Codes The following are codes and descriptions for paper or electronic submission. Type of Claim Place-of-Service Code Description Paper 02 06 07 Member’s home Nursing home Rest home Electronic 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 explain how MassHealth pays 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 606 Direct Service Component Codes The following are codes and descriptions for customization of specialized mobility systems. 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). 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 manufacturers (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 manufacturers (11 hours). 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 manufacturers (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 manufacturers (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 manufacturers (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 manufacturers (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 professionalsphysicians, therapist, teachers. Could include extended amount of custom fabrication (16 hours). 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 professionalsphysicians, 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 professionalsphysicians, 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 professionalsphysicians, 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 professionalsphysicians, therapist, teachers. Could include extended amount of custom fabrication (20 hours). 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 professionalsphysicians, 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 professionalsphysicians, 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 professionalsphysicians, therapist, teachers. Could include extended amount of custom fabrication (23 hours). 607 Wheelchair Base Codes with Options/Accessories Base Code Options/Accessories E0951 Allowance includes when provided at the same time: E0951 E0973 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 E0973 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 E0981 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 E0990 Included in allowance when provided at the same time: E0995, K0043, K0044, K0045, K0046, K0047, K0053, used with a wheelchair that has been purchased, per leg set E0995 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, E0990 E1161 Options included in the rate: K0015, K0017, K0018, K0019, E0973, E0981, E0982, E0995, K0042, K0043, K0044, K0045, K0046, K0047, 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: E0973, E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0026, K0042, K0043, K0044, K0045, K0046, K0047, 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: E0973, E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0026, K0042, K0043, K0044, K0045, K0046, K0047, 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: E0973, E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0026, K0042, K0043, K0044, K0045, K0046, K0047, 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: E0973, E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0026, K0042, K0043, K0044, K0045, K0046, K0047, 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: E0973, E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0026, K0042, K0043, K0044, K0045, K0046, K0047, 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: E0973, E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0026, K0042, K0043, K0044, K0045, K0046, K0047, 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: E0973, E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0026, K0042, K0043, K0044, K0045, K0046, K0047, 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: E0973, E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0026, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450 E2366 Included in allowance when provided at the same time: K0010, K0011, K0012, K0014 K0001 Options included in the rate when provided at the same time: E0973, E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0026, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450; can add E0983 for add-on power packs. K0002 Options included in the rate when provided at the same time: E0973, E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0026, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450; can add E0983 for add-on power packs. K0003 Options included in the rate when provided at the same time: E0973, E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0026, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450; can add E0983 for add-on power packs. K0004 Options included in the rate when provided at the same time: E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0022, K0026, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450; can add E0983 for add-on power packs. K0006 Options included in the rate when provided at the same time: E0973, E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0026, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0450; can add E0983 for add-on power packs. K0007 Used to add E0983 for add-on power packs, patient weighs over 300 pounds K0010 Options included in allowance when provided at the same time: E0971, E0981, E0995, E2366, K0015, K0017, K0018, K0019, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0081, 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, E0981, E2366, E0995, K0015, K0017, K0018, K0019, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0081, 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, E0981, E0995, E2366, K0015, K0017, K0018, K0019, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0081, 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, E0981, E0995, E2366, K0015, K0017, K0018, K0019, K0042, K0043, K0044, K0045, K0046, K0047 K0050, K0051, K0052, K0081, 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 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, E0973 K0018 Included in allowance when provided at the same time: E0973, E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014 K0019 Included in allowance when provided at the same time: E0973, E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014 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 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: E0990, E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014, K0045 K0044 Included in allowance when provided at the same time: E0990, E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014, K0045, K0047 K0045 Included in allowance when provided at the same time: E0990, E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014, K0043, K0044 K0046 Included in allowance when provided at the same time: E0990, E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014, K0043 K0047 Included in allowance when provided at the same time: E0990, E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0008, K0009, K0010, K0011, K0012, K0014, K0044 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: E0990 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 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 K0089 Included in allowance when provided at the same time: K0010, K0011, K0012, K0014 K0090 Included in allowance when provided at the same time: K0091, K0010, K0011, K0012, K0014, 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 incorporated into a wheelchair base. This is not used for seating components that are ready made and 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 incorporated into a wheelchair base. This is not used for seating components that are ready made and 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 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 Enfacare LIPIL B4150 Enfamil B4150 Enfamil A.R. B4150 Enfamil A.R. LIPIL B4150 Enfamil EnfaCare B4150 Enfamil EnfaCare LIPIL B4150 Enfamil Kindercal TF B4150 Enfamil LactoFree B4150 Enfamil LactoFree LIPIL B4150 Enfamil LactoFree Low Iron B4150 Enfamil LactoFree with Iron B4150 Enfamil Next Step LIPIL B4150 Enfamil Next Step ProSobee LIPIL B4150 Enfamil Next ProSobee B4150 Enfamil Next ProSobee LIPIL 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 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 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 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 Advance with Iron B4150 Similac NeoSure B4150 Similac NeoSure Advance B4150 Similac with Iron B4150 Susta II B4150 Sustacal B4150 Sustacal Basic B4150 Sustacal Fiber B4150 Ultracal B4150 Ultracal HN Plus B4151 Compleat-B B4151 Advantage Plus – 10+ B4151 Advantage Plus – 60+ 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 Hi-Cal B4152 Hormel Solutions Balanced Fortified Nutrition B4152 IsoSource 1.5 B4152 Isotera Isotonic B4152 Jevity 1.5 Cal B4152 Magnacal B4152 Naturite Plus 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 2.0 B4152 Resource just for Kids 1.5 Cal B4152 Resource just for Kids 1.5 Cal with fiber B4152 Resource Plus B4152 Resource Support B4152 Respalor B4152 ScandiShake B4152 Sustacal HC B4152 Sustacal Plus B4152 Twocal HN B4152 Ultralan 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 Entamil Nutramigen B4153 Entamil Nutramigen LIPIL B4153 Entamil Pregestimil 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 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 B4153 Tyrex-1 B4153 Tyrex-2 B4153 Vital HN B4153 Vivonex HN B4153 Vivonex Pediatric B4153 Vivonex RTF B4154 3200AB B4154 3232A B4154 Acerflex B4154 Advera B4154 Alitrag B4154 AminAid B4154 AMTF Renal B4154 AMTF Trauma B4154 Analog Formulas XP B4154 Analog Formulas MSUD B4154 Analog Formulas XPHEN, TYR B4154 Analog Formulas XPTM B4154 Analog Formulas XMTVI B4154 Analog Formulas XMET B4154 Analog Formulas XLYS, TRY B4154 Analog Formulas 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 Glucerna Select B4154 Glucerna Shake B4154 Glucerna Weight Loss Shake B4154 Gluco-Pro B4154 HCY 2 B4154 Hepatic-Aid B4154 Immun-Aid B4154 Impact B4154 Impact 1.5 B4154 Impact Recover 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 Maxamaid Formulas MSUD B4154 Maxamaid Formulas XPHEN, TYR B4154 Maxamaid Formulas XMTVI B4154 Maxamaid Formulas XMET B4154 Maxamaid Formulas XLYS, TRY B4154 Maxamaid Formulas XLEU B4154 Maxamum Formulas XP B4154 Maxamum Formulas MSUD B4154 Maxamum Formulas XMTVI B4154 Maxamum Formulas XMET B4154 Maxamum Formulas XLYS, TRY B4154 Maxamum Formulas XLEU B4154 Modulen IBD B4154 MSUD Diet Powder B4154 Nepro B4154 Novasource Renal B4154 Nutrifocus B4154 NutriHep B4154 NutriRenal B4154 Nutrivent B4154 Oxepa B4154 Peptamen B4154 Peptamen Junior B4154 Peptamen VHP B4154 Perative B4154 Periflex B4154 PhenylAde Drink Mix B4154 PhenylAde 40 Drink Mix 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 B4154 TYROS 2 B4154 Vivonex Plus B4154 Vivonex T.E.N. B4154 WND 2 B4155 80056 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 B4155 Essential ProPlus B4155 Essential Protein B4155 Fibrad B4155 Hi ProCal B4155 Immunocal B4155 Juven with Arginine, Glutamine and HMB B4155 L-Emental Amino Acid Supplement 100% L- Argentine B4155 L-Emental Amino Acid Supplement 100% L- Glutamine B4155 L-Emental Amino Acid Supplement Drink mix B4155 LPS 15/30 B4155 MCT Oil B4155 Microlipid B4155 Moducal B4155 Nestle Additions Calorie and Protein Food Enhancer B4155 NutriMod Protein Supplement B4155 Pedialyte B4155 Peptinex B4155 PFD 2 B4155 PhenylAde Amino Acid Blend 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 64 B4155 ProSure B4155 Proteinex Liquid (8 oz., 16 oz. bottle) 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 Diabeticshield B4155 Resource Fruit Beverage (Novartis Nutrition) B4155 Resource GlutaSolve B4155 Resource Instant Protein Powder B4155 Restore-X B4155 Resurgex B4155 SoyPro B4155 Sumacal B4155 Sysco Classic Lactose Free ProCal B4155 UpCal D B4156 Precision LR Powder B4156 Tolerex B4156 Travasorb STD Powder B4156 Vivonex STD Powder 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 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 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 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 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 A4531 Huggies Girls’ Pull-ups, size medium A4531 Huggies Boys’ Pull-ups, size medium A4531 Trim Fit Good Night Pull-ups, 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 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 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 This page is reserved. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DURABLE MEDICAL EQUIPMENT MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-19 TRANSMITTAL LETTER DME-Draft 10/09/03 DATE 12/01/03 602 Durable Medical Equipment Service Codes (cont.) Service code Payment category Modifier required PA required POS required Requirements and limits Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DURABLE MEDICAL EQUIPMENT MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-1 TRANSMITTAL LETTER DME-25 DATE 07/01/04 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DURABLE MEDICAL EQUIPMENT MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-7 TRANSMITTAL LETTER DME-25 DATE 07/01/04 602 Covered Services (cont.) Service Code Payment Category Modifiers Required PA Required? POS Required Requirements and Limits Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DURABLE MEDICAL EQUIPMENT MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-45 TRANSMITTAL LETTER DME-25 DATE 07/01/04 606 Direct Service Component Codes (cont.) Part Number Description Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DURABLE MEDICAL EQUIPMENT MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-46 TRANSMITTAL LETTER DME-25 DATE 07/01/04 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DURABLE MEDICAL EQUIPMENT MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-50 TRANSMITTAL LETTER DME-25 DATE 07/01/04 607 Wheelchair Base Codes with Options/Accessories (cont.) Base Code Options/Accessories Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DURABLE MEDICAL EQUIPMENT MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-60 TRANSMITTAL LETTER DME-25 DATE 07/01/04 608 Enteral Product Classification List (cont.) Service Code Product Name Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DURABLE MEDICAL EQUIPMENT MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-51 TRANSMITTAL LETTER DME-25 DATE 07/01/04 608 Enteral Product Classification List Service Code Product Name Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DURABLE MEDICAL EQUIPMENT MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-61 TRANSMITTAL LETTER DME-25 DATE 07/01/04 609 Absorbent Product Classification List Service Code Product Name Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series DURABLE MEDICAL EQUIPMENT MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-68 TRANSMITTAL LETTER DME-25 DATE 07/01/04 609 Absorbent Product Classification List (cont.) Service Code Product Name