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-26
May 2005

TO:	Durable Medical Equipment Providers Participating in MassHealth

	FROM:	Beth Waldman, Medicaid Director 

RE:	Durable Medical Equipment Manual (Revised Service Codes and Modifiers)

This letter transmits revisions to Subchapter 6 of the Durable Medical Equipment Manual.  These revisions update service codes and modifiers, and are effective for dates of service on and after April 15, 2005.  In addition, this letter provides clarification of MassHealth policy for certain services and some billing reminders.

A.  HCPCS Codes

A summary of updates to HCPCS codes is provided below.  All of these changes are reflected in the attached revisions to Subchapter 6.

1.  Pediatric Gait Trainers.  The federal government has revised the Healthcare Common Procedure Coding System (HCPCS) codes for 2005.  MassHealth has adopted HCPCS codes E8000-E8002, for pediatric gait trainers, but has not adopted any other new 2005 HCPCS codes at this time.  MassHealth will continue to review the remaining 2005 HCPCS codes (additions and deletions) and will provide additional information to providers at a later date, if necessary.  Information about the codes for pediatric gait trainers is summarized below.  

Service	Payment	Modifiers	PA 	POS	
Code	Category	Required	Required	Required	Requirements/Limits

E8000	CR	BP KH KI	Yes	02 07	1 unit = each, 1 per 5 yrs
	KJ NU UE 

E8001	CR	BP KH KI	Yes	02 07	1 unit = each, 1 per 5 yrs
	KJ NU UE 

E8002	CR	BP KH KI	Yes	02 07	1 unit = each, 1 per 5 yrs
	KJ NU UE 

2.  Prior Authorization (PA) Requirement.  The following service codes no longer require PA.

•	
•	E0955
•	E0956
•	E0957
•	E1028
•	E2320
•	E2321
•	E2324
•	E2326
•	K0004
•	K0005
•	K0112
•	K0113
•	K0114
•	K0115
•	K0116

3.  Place of Service Codes (POS) Permitted.  MassHealth now permits POS code 06 (nursing facility), in addition to POS codes 02 (member’s home) and 07 (rest home), for the following HCPCS codes.

•	E0140
•	E0141
•	E0950

4.  Requirements and Limits.  MassHealth has revised requirements and limits for the following service codes, as indicated below.

HCPCS 		HCPCS	
Code	Revised Requirements and Limits	Code	Revised Requirements and Limits

A6411	1 unit = each, 124 per month
B4100	1 unit = 1 ounce
E0175	2 per 12 months
E0243	2 per 12 months
E2320	--
E2321	--
E2324	--
E2326	--
K0112	1 unit = each.  Refer to Section 607.
K0113	1 unit = each.  Refer to Section 607.
K0114	1 unit = each.  Refer to Section 607.
K0115	1 unit = each.  Refer to Section 607.
K0116	1 unit = each.  Refer to Section 607.
S8420	1 unit = each, 4 per month
S8421	1 unit = each, 4 per month
S8422	1 unit = each, 4 per month
S8423	1 unit = each, 4 per month
S8424	1 unit = each, 4 per month
S8425	1 unit = each, 4 per month
S8426	1 unit = each, 4 per month
S8427	1 unit = each, 4 per month
S8428	1 unit = each, 4 per month
S8430	1 unit = each, 4 per month

5.  Service Codes added to Subchapter 6.  The following service codes were adopted July 1, 2004, but were inadvertently omitted from the Subchapter 6 dated July 1, 2004.  These codes have been included in the accompanying Subchapter 6. 

Service	Payment 	Modifiers	PA  	POS	
Code	Category	Required	Required	Required	Requirements/Limits

A4210	IN	--	No	02 07 	1 unit = each
A4483	IN	--	No	02 07	1 unit = 1 box (50), 3 per month
A9280	IN	--	Yes	02 07	This code is to be used for enuresis alarm only.
K0009	CR	BP KH KI	Yes	02 06 07	1 unit = each.  Refer to Section KJ NU UE				607.
S8210	IN	--	Yes	02 07	1 unit = box (50), 3 per month

B.  Modifiers

1.  Modifiers Added.  MassHealth has added modifiers to the following HCPCS codes as indicated below.  Definitions of these modifiers can be found in Subchapter 6, Section 603.  Please note that modifier UD is new and that UC has a revised definition.    	

HCPCS		HCPCS		HCPCS
Code	Modifiers	Code	Modifiers	Code	Modifiers

E0105	UD
E0110	UD
E0111	UD
E0112	UD
E0113	UD
E0114	UD
E0116	UD
E0117	UD
E0130	UD
E0135	UD
E0140	UC UD
E0141	UC UD
E0143	UC UD
E0144	UC UD
E0147	UC UD
E0148	UD
E0149	UC UD
E0153	UC UD
E0154	UC UD	
E0155	UD
E0156	UD
E0157	UD
E0159	UD
E0163	UD
E0165	UD
E0166	UD
E0167	UD
E0168	UD
E0169	UD
E0240	UC UD
E0244	NU UD
E0245	NU UD
E0300	UC
E0636	UC UD
E0637	UC UD
E0638	UC UD
E0701	UC
E0974	UD
E0981	UC UD
E0990	UD
E1019	UD
E1230	UD
E1399	RP
E2500	UC
E2502	UC
E2504	UC
E2506	UC
E2508	UC
E2510	UC
E2511	UC
E2512	UC
E2599	UC
K0052	UD
K0053	UD
K0070	UC

2.  Modifiers Removed.  MassHealth has removed the following modifiers from use with the indicated HCPCS codes.

HCPCS	Modifiers	HCPCS	Modifiers	HCPCS	Modifiers
Code	Removed 	Code	Removed	Code	Removed

A4216	NU	
A4217	NU
A4220	NU
A4423	NU
A4490	NU	
A4495	NU
A4500	NU
A4510	NU
A4632	NU RR UE
A4660	NU	
A4663	NU
A6410	A1 - A9
A6411	A1 - A9

C.  Clarifications

1.  Specialized Rehabilitation Equipment.  MassHealth uses E1399 UC for specialized pediatric rehabilitation equipment only, and only if there is no specific HCPCS code for the product.  Providers may also use E1399 UC for pediatric equipment that is not found in the Product Classification Lists from the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC).  Providers should refer to the Product Classification List at www.pgba.com/index.html.    

2.  Specialty Pediatric Rehabilitation Equipment.  The following HCPCS code/modifier combinations are for use in billing for specialty pediatric rehabilitation equipment.  

E0140 	UC	Walker with trunk support, adjustable or fixed height, any type (pediatric specialized rehabilitation equipment) (specialized pediatric walkers)
E0240	UC	Bath/shower chair, with or without wheels, any size (pediatric specialized rehabilitation equipment) (specialty pediatric shower commodes, toilet/ shower chairs, toileting and bathing, bath positioning chairs)
E0638	UC	Standing frame system, any size, with or without wheels (pediatric specialized rehabilitation equipment) (small medium or large prone or supine standers)
E1236	NU	Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system (pediatric strollers)
T5001	NU	Positioning seat for persons with special orthopedic needs, for use in vehicles (pediatric car seat)

3.  Adult Gait Trainers and Standers.  Providers must use the following code when billing for adult gait trainers and standers.

E0625 NU	Patient lift, bathroom or toilet, not otherwise classified (includes all accessories and components) (For MassHealth members, providers may use this code for adult gait trainers and standers until a more specific HCPCS code becomes available for this product.)

4.  Repairs.    Providers of mobility products must use E1340 UB (labor) and K0108 RP (parts) 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 E1340 RP for the repair of equipment not under warranty.  Providers must use E1399 RP for parts that do not have a more specific HCPCS code.

PA is required for all repairs, in all settings, when the fee for the repairs will exceed $1000 (labor and parts).  A prescription is not required for repair of equipment that was previously approved as medically necessary by MassHealth.

If the repair is for a wheelchair paid for by a primary insurer (that is, not MassHealth), and the equipment is still medically necessary, MassHealth will pay for the repair.  The provider must include the serial number of the equipment on the claim and, when applicable, on the PA request. 

An itemized bill indicating parts and labor must support claims for repairs.  Payment for repairs is all-inclusive, and must not exceed either the purchase price of a new item, or the cost of renting a replacement item for the remaining period that the product has been determined to be medically necessary.

Claims for labor must use E1340 with RP or UB, as applicable.  Claims for labor 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 labor;
•	an itemization of parts; and
•	invoices for all parts.

If the equipment has been sent to the manufacturer for repair, but cannot be repaired due to age, or because improved technology has made the equipment obsolete, the provider must request a PA for new equipment, as long as the equipment is still deemed medically necessary.  The provider must get a letter from the member’s physician stating that the member has been using the equipment and still needs it.  The provider must submit the PA request with the letter from the physician and enclose a copy of the documentation received from the manufacturer explaining why the repair cannot be done. 

5. E motion power-assist add-on.  RTS providers should use Service Code K0108 for Frank’s Mobility E motion power-assist add-on live anti-tip tubes (electric) and battery packs.

6. Prior Authorization request for increase in 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.  PA was removed from many service codes that had required it prior to July 1, 2004.  This allows providers the ability to supply products without requesting a PA.

Providers may submit a PA request for all members and 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 documentation of medical necessity. 

To request a PA for additional units the provider must document, in Box 11 if submitting on paper, or in the providers comment section if submitting on APAS, that this PA is being requested for additional units beyond the limits listed in Subchapter 6, section 602.

D.  Reminders

1.  Members with Other Insurance.  All claims submitted to MassHealth, where MassHealth is a secondary payer, must be billed to MassHealth with the same HCPCS code as was billed to the other primary insurer.  As stated in DME Bulletin 11 (August 1998), claims that are submitted to MassHealth with an attached explanation of benefits (EOB) showing HCPCS code A9270 will be denied.  

If a service code is not covered by a primary insurer under any circumstances, but is covered by MassHealth, providers must submit the claim to MassHealth directly, and should not attach a copy of the EOB from the primary insurer.  

Example:  Medicare does not cover diapers.  If the member is covered by Medicare, the provider can bill MassHealth without first billing Medicare.  

2.  Reminder to Providers.  The Division of Health Care Finance and Policy periodically publishes coding updates and corrections via informational bulletins.  Providers are reminded, however, that MassHealth must adopt any new codes in order for them to be available for use by MassHealth providers.  MassHealth will notify Providers of additional information, including an updated version of Subchapter 6, when the final review is complete.

NEW MATERIAL
(The pages listed here contain new or revised language.)

Durable Medical Equipment Manual

Pages vi and 6-1 through 6-40

OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)

Durable Medical Equipment Manual

	Pages vi and 6-1 through 6-40 – transmitted by Transmittal Letter DME-25
6.  SERVICE CODES

	601  Definitions………………………………………………………………………………..…	6-1
	602  Covered Services……………………………………………………………………………	6-2
	603  Modifiers……………………………………………………………………………………	6-38
	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, are available to fit children, adolescents, and 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, are available to fit children, adolescents, and 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 must 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	
A4210	IN	--	No	02 07	I unit = each	
A4216	OS	 - -	No	02 07	1 unit = each, 100 per month	
A4217	OS	 - -	No	02 07	1 unit = each, 31 per month	
A4220	OS	 - -	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 	- - 	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	
A4483	IN	- - 	No	02 07	1 unit = 1 box (50), 3 per month 	
A4490	IN	- -	No	02 07 	1 unit = each, 4 per 3 months	
A4495	IN	- -	No	02 07	1 unit = each, 4 per 3 months	
A4500	IN	- -	No	02 07	1 unit = each, 4 per 3 months	
A4510	IN	- -	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	--	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	- -	No	02 07	1 unit = each, 1 per 3 years	
A4663	IN	- -	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	- - 	No	02 07	1 unit = each, 124 per month	
A6411	SD	- - 	No	02 07	1 unit = each, 124 per month	
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.) 	
A9280	IN	- - 	Yes	02 07	This code is to be used for an enuresis 
alarm only.	
B4034	IN	- -	No	02 07	1 unit = 1 each, 1 per day (A5200 is included in B4034).  All supplies (including dressings) other than the feeding tube itself are included. B4034 is included in “S” code.	
B4035	IN	- -	No	02 07	1 unit = each, 31 per month (A5200 is included in B4035).  All supplies (including dressings) other than the feeding tube itself are included. B4035 is included in “S” code.	
B4036	IN	- -	No	02 07	1 unit = each, 31 per month (A5200 is included in B4036).  All supplies (including dressings) other than the feeding tube itself are included. B4036 is 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 = 1 ounce	
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, and B4168-B4178.)  Codes B4216, B4184, B4186 may be billed separately.	
B4168	IN	- -	No	02 07	1 unit = 500 ml (Included in this code are B4164, B4180, and B4168-B4178.)  Codes B4216, B4184, and B4186 may be billed separately.	
B4172	IN	- -	No	02 07	1 unit = 500 ml (Included in this code are B4164, B4180, and B4168-B4178.)  Codes B4216, B4184, and B4186 may be billed separately.	
B4176	IN	- -	No	02 07	1 unit = 500 ml (Included in this code are B4164, B4180, and B4168-B4178.)  Codes B4216, B4184, and B4186 may be billed separately.	
B4178	IN	- -	No	02 07	1 unit = 500 ml (Included in this code are B4164, B4180, and B4168-B4178.)  Codes B4216, B4184, and B4186 may be billed separately.	
B4180	IN	- -	No	02 07	1 unit = 500 ml (Included in this code are B4164, B4180, and B4168-B4178.)  Codes B4216, B4184, and B4186 may 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, and B4216 are 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	IN	- -	No	02 07	1 unit = 1 gram (B4164, B4180, B4168-B4178, and B4216 are included in B5000.)  	
B5100	IN	- -	No	02 07	1 unit = 1 gram (B4164, B4180, B4168-B4178, and B4216 are included in B5100.)  	
B5200	IN	- -	No	02 07	1 unit = 1 gram (B4164, B4180, B4168-B4178, and B4216 are included in B5200.) 	
B9000	IN	NU RR UE	No	02 07	1 per 3 years	
B9002	IN	NU RR UE	No	02 07	1 per 3 years	
B9004	IN	NU RR UE	No	02 07	1 per 3 years	
B9006	IN	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 UD UE 	No	02 07	1 per 3 years 	
E0110	IN	NU RR UD UE 	No	02 07	1 per 3 years 	
E0111	IN	NU RR UD UE 	No	02 07	1 per 3 years 	
E0112	IN	NU RR UD UE 	No	02 07	1 per 3 years 	
E0113	IN	NU RR UD UE 	No	02 07	1 per 3 years 	
E0114	IN	NU RR UD UE 	No	02 07	1 per 3 years 	
E0116	IN	NU RR UD UE 	No	02 07	1 per 3 years 	
E0117	IN	NU RR UD UE 	No	02 07	1 per 3 years 	
E0130	IN	NU RR UD UE 	No	02 07	1 per 3 years (A4636 and A4637 are included in E0130 on initial purchase.) 	
E0135	IN	NU RR UD UE 	No	02 07	1 per 3 years (A4636 and A4637 are included in E0135 on initial purchase.) 	
E0137	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years	
E0138	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years	
E0140	IN	NU RR UC UD UE	Yes	02 06 07	1 per 5 years.  E0140 can be used for pediatric walkers.	
E0141	IN	NU RR UC UD UE 	No	02 06 07	1 per 3 years (A4636, A4637, E0155, and E0159 are included in E0141.) 	
E0143	IN	NU RR UC UD UE	No	02 07	A4636, A4637, E0155, and E0159 are included in E0143 on initial purchase.	
E0144	IN	NU RR UC UD UE	Yes	02 07	A4636, A4637, E0155, E0156, and E0159 
are included in E0145 on initial purchase.	
E0147	IN	NU RR UC UD 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 UD UE 	No	02 07	A4636, A4637 are included in initial 
purchase of E0148 (for patients who weigh 
over 300 pounds).
	
E0149	IN	NU RR UC UD 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 UC UD UE	No	02 07	2 per 3 years	
E0154	IN	NU RR UC UD UE 	No	02 07	2 per 3 years	
E0155	IN	NU RR UD UE	No	02 07	2 per 3 years	
E0156	IN	NU RR UD UE 	No	02 07	1 per 3 years	
E0157	IN	NU RR UD 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 UD 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 UD 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	BP KH KI KJ NU UD UE	No	02 07	1 per 3 years (E0167 is included initial purchase of E0165.) 	
E0166	CR	BP KH KI KJ NU UD UE	No	02 07	1 per 3 years (E0167 is included in initial purchase of E0166.) 	
E0167	IN	NU RR UD 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 UD 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	BP KH KI KJ  NU UD UE	Yes	02 07	1 per 5 years	
E0175	IN	NU RR UE	No	02 07	2 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	BP KH KI KJ NU UE	Yes	02 07	A4640 and E0182 are included in E0180.	
E0181	CR	BP KH KI KJ  NU UE
	Yes	02 07	A4640 and E0182 are included in E0181.	
E0182	CR	BP KH KI KJ 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	BP KH KI KJ NU UE	Yes	02 07	1 per 12 months	
E0187	CR	BP KH KI KJ 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	BR KH KI KJ 	Yes	02 06 07	E0277, E0371, E0372, and E0373 cannot be used with E0193.  PA renewal required every 30 days. 	
E0194	CR	BR KH KI KJ 	Yes	02 06 07	E0277, E0371, E0372, and E0373 cannot be used with E0194.  PA renewal required every 30 days. 	
E0196	CR	BP KH KI KJ 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	BP KH KI KJ 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 UC
UD UE	Yes	02 07	1 per 5 years.  E0240 may be used for specialty shower commodes, toilet/shower chairs, toileting and bathing, and bath positioning chairs.	
E0241	IN	- - 	No	02 07	1 per 3 years	
E0242	IN	- -	No	02 07	1 per 12 months	
E0243	IN	- - 	No	02 07	2 per 12 months	
E0244	IN	NU UD	No	02 07	1 per 12 months	
E0245	IN	NU UD	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.  E0247 may be used for specialty transfer benches.	
E0248	IN 	NU RR UE	No	02 07	1 per 5 years.  E0248 may be used for specialty transfer bench /commodes.	
E0250	CR	BP KH KI KJ NU UE	No	02 07	1 per 5 years.  E0271, E0272, E0305, and
E0310 are included in E0250.	
E0251	CR	BP KH KI KJ NU UE	No	02 07	1 per 5 years.  E0305 and E0310 are included in E0251.  E0277 and E0372 may be used with this code.	
E0255	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0271, E0272, E0305, and E0310 are included in E0255.	
E0256	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0305 and E0310 are included in E0256.  E0277 and E0372 may be used with this code.	
E0260	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0271, E0272, E0305, and E0310 are included in E0260.	
E0261	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0305 and E0310 are included 
in E0261.  E0277 or E0372 may be used 
with this code.	
E0265	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0271, E0272, E0305, and E0310 are included in E0265.	
E0266	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0305 and E0310 are included 
in E0266.  E0277 or E0372 may 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	BP KH KI KJ NU UE	Yes	02 06 07	1 per 5 years.  E0277 may not 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	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0271 and E0272 are included 
in E0290.  E0371 and E0372 may be used 
with E0290.	
E0291	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0277 may be used with E0291.	
E0292	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0271 and E0272 are included in E0292.  E0371 and E0372 may be used with E0292.	
E0293	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0277 may be used with E0293.	
E0294	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0305, E0310, E0271, and E0272 are included in E0294.  E0371 and E0372 may be used with E0294.	
E0295	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0277 may be used with E0295.	
E0296	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0271 and E0272 are included 
in E0296.  E0371 and E0372 may be used 
with E0296.	
E0297	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0305, E0310, and E0277 may be used with E0297.	
E0300	IN 	NU RR UC UE	Yes	02 07	1 per 5 years	
E0301	CR 	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0305 and E0310 are included in E0301.  E0277 or E0372 may be used 
with E0301.	
E0302	CR 	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0305 and E0310 are included in E0302.  E0277 or E0372 may be used 
with E0302. 	
E0303	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  Weight is more than 350 pounds, but less than 600 pounds.  E0271, E0272, E0305, and E0310 are included in E0303.	
E0304	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  Weight exceeds 600 pounds.  E0271, E0272, E0305, and E0310 are included in E0304.	
E0305	CR	BP KH KI KJ
NU UE	Yes	02 07	1 per 5 years.  E0305 may be used with E0290, E0291, E0292, E0293, E0294, E0295, E0296, and E0297 (not with E0310).  	
E0310	IN	NU RR UE	Yes	02 07	1 per 5 years.  E0310 may be used with E0290, E0291, E0292, E0293, E0294, E0295, E0296, and E0297 (not with E0305).  	
E0315	IN	NU RR UE	Yes	02 07	1 per 5 years	

E0316	CR	BP KH KI KJ 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	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years	
E0372	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years	
E0373	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0277 may 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	IN	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	BP KH KI KJ 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.  E0625 may be used for adult gait trainers and standers.	
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	BP KH KI KJ NU UE	Yes	02 07	1 per 3 years (Transfer between bed, chair, wheelchair, and commode that requires the assistance of more than one person.  E0621 is included in E0630.)	
E0635	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 3 years (Transfer between bed, chair, wheelchair, and commode that requires the assistance of more than one person.  E0621 is included in E0635.)	
E0636	CR	BP KH KI KJ NU UC UD UE	Yes	02 07	1 per 3 years (Transfer between bed, chair, wheelchair, and commode that requires the assistance of more than one person.  E0621 is included in E0636.) 	
E0637	IN      	NU RR UC UD UE	Yes	02 07	1 per 5 years	
E0638	IN      	NU RR UC UD
UE	Yes	02 07	1 per 5 years.  E0638 may be used for small, medium, or large prone or supine stander.	
E0650	IN	NU RR UE	Yes	02 07	1 per 5 years.  E0650 may be used with E0671 - E0673.	
E0651	IN	NU RR UE	Yes	02 07	1 per 5 years.  E0651 may be used with E0667 - E0669.	
E0652	IN	NU RR UE	Yes	02 07	1 per 5 years.  E0652 may be used with E0667 - E0669.	
E0655	IN	NU RR UE	Yes	02 07	2 per 3 years.  E0655 may be used with E0650.	
E0660	IN	NU RR UE	Yes	02 07	2 per 3 years.  E0660 may be used with E0650.	
E0665	IN	NU RR UE	Yes	02 07	2 per 3 years.  E0665 may be used with E0650.	
E0666	IN	NU RR UE	Yes	02 07	2 per 3 years.  E0666 may be used with E0650.	
E0667 	IN	NU RR UE	Yes	02 07	2 per 3 years.  E0667 may be used with E0651 or E0652.	
E0668	IN	NU RR UE	Yes	02 07	2 per 3 years.  E0668 may be used with E0651 or E0652.	
E0669	IN	NU RR UE	Yes	02 07	2 per 3 years.  E0669 may be used with E0651 or E0652.	
E0671	IN	NU RR UE	Yes	02 07	2 per 3 years.  E0671 may be used with E0650.	
E0672	IN	NU RR UE	Yes	02 07	2 per 3 years.  E0672 may be used with E0650.	
E0673	IN	NU RR UE	Yes	02 07	2 per 3 years.  E0673 may be used with E0650.	
E0675	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years	
E0700	IN	- -	No	02 07	1 per 12 months	
E0701	IN	NU RR UC 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, and V45.4)	
E0748	IN	NU RR UE	Yes	02 07	1 per 5 years (ICD-9-CM code: 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	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0776 may not be provided with E0779.  Supplies used with E0779 are A4221, A4222, or K0552.
	
E0780	IN	- -	Yes	02 07	1 per 5 years.  E0776 may not be provided with E0780.  Supplies used with E0779 are A4221, A4222, or K0553.	
E0781	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0776 may not be provided.  Supplies used with E0779 are A4221, A4222, or K0554.	
E0784	CR	BP KH KI KJ NU 	Yes	02 07	1 per 5 years.  E0776 may not be provided with E0784.	
E0791	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years.  E0776 may 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	BP KH KI KJ 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	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years	
E0930	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years	
E0935	FS	RR	Yes	02 07	1 month maximum (per episode) 	
E0940	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years	
E0941	CR	BP KH KI KJ 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	BP KH KI KJ 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 06 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	No	02 06 07	1 per 5 years	
E0956	IN 	NU RR UE	No	02 06 07	1 per 5 years	
E0957	IN 	NU RR UE	No	02 06 07	1 per 5 years	
E0958	CR	BP KH KI KJ 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	BP KH KI KJ 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 UD 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 UC
UD 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	BP KH KI KJ 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 UD 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.  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 UD 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	No	02 06 07	- - 	
E1029	IN 	NU RR UE	Yes	02 06 07	- - 	
E1030	IN 	NU RR UE	Yes	02 06 07	- - 	
E1031	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1035	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years	
E1037	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years	
E1038	CR	BP KH KI KJ NU UE	Yes	02 07	1 per 5 years	
E1050	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1060	CR	BP KH KI KJ 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	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years 	
E1083	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years 	
E1084	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1087	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1088	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years 	
E1091	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1092	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1093	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1100	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1110	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years 	
E1150	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1160	CR	BP KH KI KJ 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	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years 	
E1171	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1172	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1180	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1190	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1195	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1200	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1210	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1211	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1220	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1221	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1222	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years 	
E1223	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1224	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1225	CR	BP KH KI KJ 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	BP KH KI KJ NU UE	Yes	02 06 07	1 unit = each, 1 per 5 years	
E1230	IN	NU RR UD 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.  E1236 may be used for pediatric strollers. 	
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	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1270	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1280	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E1295	CR	BP KH KI KJ 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 is required for repair of equipment over $1000, purchased for member in nursing facility.	
E1340	IN	UB	No	02 06 07	Used by RTS providers only.  PA is required 
for all repairs over $1000.	
E1399	IN	RP UC 	Yes	02 07	Modifier UC may be used for child pediatric specialty equipment that currently has no HCPCS code and is not listed on the product classification list.	
E1800	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 3 years	
E1801	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 3 years	
E1802	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 3 years	
E1805	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 3 years	
E1806	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 3 years	
E1810	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 3 years	
E1811	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 3 years	

E1815	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 3 years	
E1816	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 3 years	
E1818	CR	BP KH KI KJ 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	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 3 years	
E1830	CR	BP KH KI KJ NU UE	Yes	02 07	1 unit = each, 1 per 3 years	
E1840	CR	BP KH KI KJ 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	BP KH KI KJ 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	No	02 06 07	- - - - -	
E2321	IN 	NU RR UE	No	02 06 07	- - - - -	
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	No	02 06 07	- - - - -	
E2325	IN 	NU RR UE	Yes	02 06 07	1 per 5 years	
E2326	IN 	NU RR UE	No	02 06 07	- - - - -	
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 UC
UE	Yes	02 06 07	Includes the device, any applicable software, batteries, battery chargers, and AC adapters.  Digital speech output.  E0545 is included in E2500.	
E2502	IN	NU RR UC
UE	Yes	02 06 07	Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digital speech output.  E0545 is included in this code	
E2504	IN	NU RR UC
UE	Yes	02 06 07	Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digital speech output.  E0545 is included in this code	
E2506	IN	NU RR UC
UE	Yes	02 06 07	Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digital speech output.  E0545 is included in this code	
E2508	IN	NU RR UC
UE	Yes	02 06 07	Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digitized and synthesized output.  E0545 is included in this code.	
E2510	IN	NU RR UC
UE	Yes	02 06 07	Includes the device, any applicable software, batteries, battery chargers, and AC adapters. Digitized and synthesized output.  E0545 is included in this code.	
E2511	IN	NU RR UC
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 is included in this code.	
E2512	IN	NU RR UC UE	Yes	02 06 07	E0545 is included in E2512.	
E2599	IN	NU RR UC UE	Yes	02 06 07	E0545 is included in E2599.	
E8000	CR	BP KH KI KJ 
NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E8001	CR	BP KH KI KJ 
NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E8002	CR	BP KH KI KJ 
NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
K0001	CR	BP KH KI KJ NU UE	No	02 07 	1 unit = each, 1 per 5 years.  Refer to Section 607.	
K0002	CR	BP KH KI KJ NU UE	No	02 07	1 unit = each, 1 per 5 years.  Refer to Section 607.	
K0003	CR	BP KH KI KJ NU UE	No	02 07	1 unit = each, 1 per 5 years.  Refer to Section 607.	
K0004	CR	BP KH KI KJ NU UE	No	02 06 07	1 unit = each, 1 per 5 years.  Refer to Section 607.	
K0005	IN	NU RR UE	No	02 06 07	1 unit = each, 1 per 5 years.  Refer to Section 607.	
K0006	CR	BP KH KI KJ NU UE	Yes	02 06 07	1 unit = each, 1 per 5 years.  Refer to Section 607.	
K0007	CR	BP KH KI KJ NU UE	Yes	02 06 07	Use E0983 for add-on power packs, patients weighing over 300 pounds, 1 per 5 years.	
K0009	CR	BP KH KI KJ
NU UE	Yes	02 06 07	1 unit = each.  Refer to Section 607.	
K0010	CR	BP KH KI KJ NU UE	Yes	02 06 07	1 unit = each, 1 per 5 years.  Refer to Section 607.	
K0011	CR	BP KH KI KJ NU UE	Yes	02 06 07	1 unit = each, 1 per 5 years.  Refer to Section 607.	
K0012	CR	BP KH KI KJ 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 UD UE	No	02 06 07	1 unit = each.  Refer to Section 607.	
K0053	IN	NU RR UD 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 607.	
K0061	IN	NU RR UE	No	02 06 07	1 unit = each.  Refer to Section 607.	
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 UC UD 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	IN	NU UE	Yes	02 06 07	Direct service component codes RE-1 through RE-23 must be used under 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 may not be used with this modifier (Requires PA for repairs over $1,000.) 	
K0112	PO	- -	No	02 06 07	1 unit = each.  Refer to Section 607.	
K0113	PO	- -	No	02 06 07	1 unit = each.  Refer to Section 607.	
K0114	IN	NU RR UE	No	02 06 07	1 unit = each.  Refer to Section 607.	
K0115	IN	NU RR UE	No	02 06 07	1 unit = each.  Refer to Section 607.	
K0116	IN	NU RR UE	No	02 06 07	1 unit = each.  Refer to Section 607.	
K0195	CR	BP KH KI KJ 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-CM codes:  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.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S5501	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S5502	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S5517	PD	- -	No	02 07	1 unit = 1 day, 31 per month (Month is date-of-service driven and cannot cross fiscal years.)  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S5518	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S5520	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S5521	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or 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	
S8210	IN	- - 	Yes	02 07	1 unit = box (50), 3 per month	
S8265	- -	- -	No	02 07	1 unit = each, 4 per 3 months	
S8420	IN	- -	No	02 07	1 unit = each, 4 per month (required ICD-9-CM: 457.0, 457.1,757.0, or 997.99) 	
S8421	IN	- -	No	02 07	1 unit = each, 4 per month (required ICD-9-CM: 457.0, 457.1,757.0, or 997.99) 	
S8422	IN	- -	No	02 07	1 unit = each, 4 per month (required ICD-9-CM: 457.0, 457.1,757.0, or 997.99)	
S8423	IN	- -	No	02 07	1 unit = each, 4 per month (required ICD-9-CM: 457.0, 457.1,757.0,or 997.100)	
S8424	IN	- -	No	02 07	1 unit = each, 4 per month (required ICD-9-CM: 457.0, 457.1,757.0, or 997.100)	
S8425	IN	- -	No	02 07	1 unit = each, 4 per month (required ICD-9-CM: 457.0, 457.1,757.0, or 997.100)	
S8426	IN	- -	No	02 07	1 unit = each, 4 per month (required ICD-9-CM: 457.0, 457.1,757.0, or 997.100) 	
S8427	IN	- -	No	02 07	1 unit = each, 4 per month (required ICD-9-CM: 457.0, 457.1,757.0, or 997.101) 	
S8428	IN	- -	No	02 07	1 unit = each, 4 per month (required ICD-9-CM: 457.0, 457.1,757.0, or 997.102) 	
S8429	IN	- -	No	02 07	1 unit = each, 2 per 6 months (required ICD-9-CM: 457.0, 457.1, 757.0, or 997.101) 	
S8430	IN	- -	No	02 07	1 unit = each, 4 per month (required ICD-9-CM: 457.0, 457.1,757.0, or 997.101) 	
S9325	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.) 	
S9326	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.) 	
S9327	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S9328	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.) 	

S9329	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.) 	
S9330	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.) 	
S9331	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.) 	
S9336	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.) 	
S9338	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.) 	
S9339	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.) 	
S9340	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with B4034, B4035, B4036, B4081, B4082, B4083, B4086, B9000, B9002, B9004, B9006, B9998, B9999, or E0776).  (B4086 can be billed separately for members aged 21 and under.)	
S9341	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with B4034, B4035, B4036, B4081, B4082, B4083, B4086, B9000, B9002, B9004, B9006, B9998, B9999, or E0776).  (B4086 can be billed separately for members aged 21 and under.)	
S9342	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with B4034, B4035, B4036, B4081, B4082, B4083, B4086, B9000, B9002, B9004, B9006, B9998, B9999, or E0776).  (B4086 can be billed separately for members aged 21 and under.)	
S9343	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with B4034, B4035, B4036, B4081, B4082, B4083, B4086, B9000, B9002, B9004, B9006, B9998, B9999, or E0776).  (B4086 can be billed separately for members aged 21 and under.)	
S9345	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S9346	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S9347	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)
	
S9348	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S9349	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S9351	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S9353	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S9355	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S9357	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	

S9359	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S9361	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or E0784.)	
S9363	PD	- -	No	02 07	1 unit = 1 day, 31 per month.  This rate includes all equipment and supplies.  (Do not bill with A4221, A4222, A4230, A4231, A4232, A4245, E0776, E0781, or 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	PD	- -	No	02 07	1 unit = 1 day, 31 per month 	
S9559	PD	- -	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

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 in use 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, as defined by each state.  (Used for child pediatric specialized rehabilitation equipment by RTS and speech devices by speech-generating device providers.)
UD	Medicaid level of care 13, as defined by each state.  (Used for bariatric equipment.)
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 facility
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	

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