Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.05-015 - Ventilator Update #50

Procedure Code

Modifier(s)

Description

PA Req'd

Max. Units

Capped Rental, Purchase or Rental Only

A4483

Nasal Prosthesis

No

N/A

Purchase

E02501

Hospital bed, fixed height, with any type side rails, with mattress

Yes*

1 per day (1 day = 1 unit)

Capped Rental

E02551

Hospital bed, variable height, hi-lo, with any type side rails, with mattress

Yes*

1 per day (1 day = 1 unit)

Capped Rental

E02601

Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress

Yes*

1 per day (1 day = 1 unit)

Capped Rental

E04241

Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator flowmeter, humidifier, nebulizer, cannula or mask, and tubing

Yes*

1 per day (1 day = 1 unit)

Rental Only

E04301

Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing

Yes*

1 per day (1 day = 1 unit)

Rental Only

E04351

Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing, and refill adapter

Yes*

1 per day (1 day = 1 unit)

Rental Only

E04391

Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

Yes*

1 per day (1 day = 1 unit)

Rental Only

E0450

Positive Pressure Ventilator and Accessories (New Equipment) - Includes circuits, humidifier, low-pressure alarm, back-up emergency power, resuscitator bag, emergency call, 24 hours/day, 7 day/week availability and in-service training (used with invasive interface, e.g., tracheostomy tube)

Yes

1 per day (1 day = 1 unit)

Rental Only

E04501

UB

Positive Pressure Ventilator Supplies -Includes suction catheter kits, trach kits, trach tubes, sterile water and all respiratory care supplies (used with invasive interface, e.g., tracheostomy tube)

Yes

1 per day (1 day = 1 unit)

Purchase

E0450

UE

Positive Pressure Ventilator and Accessories (Used Equipment) - Includes circuits, humidifier, low pressure alarm, backup emergency power, resuscitator bag, emergency call, 24 hours/day, 7 day/week availability and in-service training (used with invasive interface, e.g., tracheostomy tube)

Yes

1 per day (1 day = 1 unit)

Rental Only

E0500

IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source

Yes

1 per day

Rental Only

E05701

Nebulizer, with compressor

Yes*

1 per day (1 day = 1 unit)

Purchase Only

E06001

Respiratory suction pump, home model, portable or stationary, electric

No

1 per day (1 day = 1 unit)

Rental Only

E06001

U1

Suction pump, home model, portable (Used Equipment)

Yes

1 per day (1 day = 1 unit)

Rental Only

E1390

Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate

Yes*

1 per day

Rental Only

G02372

EP, UA

Respiratory therapy services for ventilator-dependent patients

Yes

Frequency of visits as prescribed

N/A

G02382

EP, UA