Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.08-005 - ARKids First B Provider Manual Update Transmittal # 71
Current through Register Vol. 49, No. 9, September, 2024
262.110 Medical Supplies Procedure Codes
The following medical supplies procedure codes may be billed by Medicaid-enrolled Home Health and Prosthetics providers for ARKids First-B participants.
|
Procedure Code |
Required Modifier(s) |
Description |
|
A4206 |
NU |
Syringe with needle, sterile [LESS THAN OR EQUAL TO] 1cc |
|
A4207 |
NU |
Syringe with needle, sterile 2 cc, each |
|
A4209 |
NU |
Syringe with needle, sterile 5 cc or greater, each |
|
A4216 |
NU |
Sterile water/saline, 10 ml |
|
A4217 |
NU |
Sterile water/saline, 500 ml |
|
A4221* |
NU |
Supplies for maintenance of drug infusion catheter per week |
|
A4222* |
NU |
Supplies for external drug infusion pump per cassette or bag |
|
A4253 A4253 |
NU NU, U1 |
Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips Billed for Pregnant Women services only |
|
A4256 |
NU |
Normal, low and high calibrator solution/chips |
|
A4259 A4259 |
NU NU, U2 |
Lancets, per box Billed for Pregnant Women services only |
|
A4265 |
NU |
Paraffin |
|
A4310 |
NU |
Insertion tray without drainage bag and without catheter |
|
A4311 |
NU |
Insertion tray without drainage bag with indwelling catheter |
|
A4312 |
NU |
Insertion tray without drainage bag with indwelling catheter |
|
A4313 |
NU |
Insertion tray without drainage bag with indwelling catheter |
|
A4314 |
NU |
Insertion tray with drainage bag with indwelling catheter |
|
A4315 |
NU |
Insertion tray with drainage bag with indwelling catheter |
|
A4316 |
NU |
Insertion tray with drainage bag with indwelling catheter |
|
A4320 |
NU |
Irrigation tray with bulb or piston syringe, any purpose |
|
A4322 |
NU |
Irrigation syringe, bulb or piston |
|
A4326 |
NU |
Male external catheter specialty type, e.g.; inflatable, |
|
A4327 |
NU |
Female external urinary collection device; metal cup, each |
|
A4328 |
NU |
Female external urinary collection device; pouch, each |
|
A4330 |
NU |
Perianal fecal collection pouch with adhesive |
|
A4331 |
NU |
External drainage tube, any type/length, for urine leg bag/urostomy pouch, ea |
|
A4338 |
NU |
Indwelling catheter; foley type, two-way latex with coating |
|
A4340 |
NU |
Indwelling catheter; specialty type, e.g.; Coude, mushroom |
|
A4344 |
NU |
Indwelling catheter; foley type, two-way, all silicone |
|
A4346 |
NU |
Indwelling catheter; foley type, three way for continuous |
|
A4349 |
NU |
Male external catheter w/integral collection compartment |
|
A4351 A4351 |
NU NU, U1 |
Intermittent urinary catheter, disposable straight tip |
|
A4352 A4352 |
NU NU,U1 |
Intermittent urinary catheter disposable Coude (curved) |
|
A4353 A4353 |
NU NU,U2 |
Urinary intermittent catheter with insertion supplies |
|
A4354 |
NU |
Insertion tray with drainage bag but without catheter |
|
A4355 |
NU |
Irrigation tubing set for continuous bladder irrigation |
|
A4356 |
NU |
External urethral clamp or compression device (not to be used for catheter clamp), each |
|
A4357 |
NU |
Bedside drainage bag, day or night, with or without anti reflux |
|
A4358 |
NU |
Urinary leg bag; vinyl, with or without tube |
|
A4361 |
NU |
Ostomy faceplate |
|
A4362 |
NU |
Skin barrier; solid, 4 x 4 or equivalent, each |
|
A4364 |
NU |
Adhesive for ostomy or catheter; liquid (spray, brush, etc.) |
|
A4365 |
NU |
Adhesive remover wipes, any type, per 50 |
|
A4367 |
NU |
Ostomy belt |
|
A4368 |
NU |
Ostomy filters, any type, each |
|
A4369 |
NU |
Ostomy skin barrier liquid spray, brush, etc. |
|
A4371 |
NU |
Ostomy skin barrier powder, per oz |
|
A4394 |
NU |
Ostomy deodorant, all types, per ounce |
|
A4397 |
NU |
Irrigation supply; sleeve |
|
A4398 |
NU |
Irrigation supply; bags |
|
A4399 |
NU |
Irrigation supply; cone/catheter |
|
A4400 |
NU |
Ostomy irrigation set |
|
A4402 |
NU |
Lubricant |
|
A4404 |
NU |
Ostomy rings |
|
A4405 |
NU |
Ostomy skin barrier, non-pectin based paste, per oz. |
|
A4406 |
NU |
Ostomy skin barrier, non-pectin based paste, per oz. |
|
A4407 |
NU |
Ostomy skin barrier w/flange, ext wear, w/built in convexity 4x4 or[LESS THAN], ea |
|
A4414 |
NU |
Ostomy skin barrier, w/flange (solid, flexible or accordion), w/o built in convexity, 4x4 or[LESS THAN], ea |
|
A4452 |
NU |
Tape non-waterproof per 18 sq in |
|
A4455 |
NU |
Adhesive remover or solvent (for tape, cement or other adhesive), per oz |
|
A4483 |
NU |
Moisture exchanger, disposable, for use with invasive mechanical ventilation |
|
A4558 |
NU |
Conductive paste or gel |
|
A4561 |
NU, U1 |
Pessary, rubber, any type |
|
A4562 |
NU |
Pessary, non-rubber, any type |
|
A4623 |
NU |
Tracheostomy, inner cannula (replacement only) |
|
A4624 |
NU |
Tracheal suction catheter, any type, each |
|
A4625 |
NU |
Tracheostomy care or cleaning starter kit |
|
A4626 |
NU |
Tracheostomy cleaning brush, each |
|
A4628 |
NU |
Oropharyngeal suction catheter each |
|
A4629 |
NU |
Tracheostomy care kit for the established tracheostomy |
|
A4772 |
NU |
Dextrostick or glucose test stripes per box |
|
A4927 |
NU |
Gloves sterile or non-sterile per pair |
|
A5051 |
NU |
Pouch, closed; with barrier attached (1 piece) |
|
A5052 |
NU |
Pouch, closed; with barrier attached (1 piece) |
|
A5053 |
NU |
Pouch, closed; for use on faceplate |
|
A5054 |
NU |
Pouch, closed; for use on barrier with flange (2 piece) |
|
A5055 |
NU |
Stoma cap |
|
A5061 |
NU |
Pouch, drainable; with barrier attached (1 piece) |
|
A5062 |
NU |
Pouch, drainable; without barrier attached (1 piece) |
|
A5063 |
NU |
Pouch, drainable; for use on barrier with flange (2 piece) |
|
A5071 |
NU |
Pouch, urinary; with barrier attached (1 piece) |
|
A5072 |
NU |
Pouch, urinary; without barrier attached (1 piece) |
|
A5073 |
NU |
Pouch, urinary; for use on barrier with flange (2 piece) |
|
A5081 |
NU |
Continent device; plug for continent stoma |
|
A5082 |
NU |
Continent device; catheter for continent stoma |
|
A5093 |
NU |
Ostomy accessory; convex insert |
|
A5102 |
NU |
Bedside drainage bottle; rigid or expandable |
|
A5105 |
NU |
Urinary suspensory; with or w/o leg bag, with or without tube |
|
A5112 |
NU |
Urinary leg bag; latex |
|
A5113 |
NU |
Leg strap; latex, per set |
|
A5114 |
NU |
Leg strap; foam or fabric, per set |
|
A5120 |
NU |
Skin barrier, wipes or swabs, each |
|
A5121 |
NU |
Skin barrier; solid, 6 x 6 or equivalent, each |
|
A5122 |
NU |
Skin barrier; solid, 8 x 8 or equivalent, each |
|
A5126 |
NU |
Adhesive; disc or foam pad |
|
A5131 |
NU |
Appliance cleaner, incontinence and ostomy appliances, 16 oz |
|
A6154 |
NU |
Wound pouch each |
|
A6196 |
NU |
Alginate dressing, each (16 square inches or less) |
|
A6197 |
NU |
Alginate dressing, each (more than 16, but less than 48 square inches) |
|
A6198 |
NU |
Alginate dressing, each (more than 48 square inches) |
|
A6203 |
NU |
Composite dressing, each (16 square inches or less) |
|
A6204 |
NU |
Composite dressing, each (more than 16, but less than 48 square inches) |
|
A6205 |
NU |
Composite dressing, each (more than 48 square ins) |
|
A6209 |
NU |
Foam dressing, each (16 square inches or less) |
|
A6211 |
NU |
Foam dressing, wound cover pad each (more than 48 square inches) |
|
A6212 |
NU |
Foam dressing, wound cover pad each (16 sq in or less) |
|
A6213 |
NU |
Foam dressing, each (more than 16, but less than 48 square inches) |
|
A6216 |
NU |
Gauze non-impregnated, non-sterile, pad size 16 square inches or less) w/o adhesive border |
|
A6219 |
NU |
Gauze, non-impregnated pad size 16 sq in or less with adhesive border |
|
A6220 |
NU |
Gauze, non-impregnated pad size [GREATER THAN]16 sq in but [LESS THAN] 48 sq in |
|
A6221 |
NU |
Gauze, non-impregnated, pad size [GREATER THAN] 48 sq in |
|
A6228 |
NU |
Gauze, impregnated, water or NS pad size 16 sq in or less |
|
A6229 |
NU |
Gauze, impregnated, water or NS, pad size [GREATER THAN] 16 in but [LESS THAN] 48 sq in |
|
A6230 |
NU |
Gauze, impregnated, water or NS, pad size [GREATER THAN] 48 sq in |
|
A6234 |
NU |
Hydrocolloid dressing, each (16 square inches or less) |
|
A6235 |
NU |
Hydrocolloid dressing, each (more than 16, but less than 48 square inches) |
|
A6237 |
NU |
Hydrocolloid dressing, wound cover, pad size 16 sq in or less with adhesive |
|
A6238 |
NU, U1 |
Hydrocolloid dressing, each (more than 48 square inches) |
|
A6241 |
NU |
Hydrocolloid dressing, wound cover, pad size 16 sq in or less w/o adhesive |
|
A6242 |
NU |
Hydrogel dressing, each (16 square inches or less) |
|
A6243 |
NU |
Hydrogel dressing, each (more than 16, but less than 48 square inches) |
|
A6244 |
NU |
Hydrogel dressing, each (more than 48 square inches) |
|
A6245 |
NU |
Hydrogel dressing, each (16 square inches or less) |
|
A6246 |
NU |
Hydrogel dressing, each (more than 16, but less than 48 square inches) |
|
A6247 |
NU |
Hydrogel dressing, each (more than 48 square inches) |
|
A6248 |
NU |
Hydrogel dressing, each (1 ounce), wound filler, gel |
|
A6257 |
NU |
Transparent film, each (16 square inches or less) |
|
A6258 |
NU |
Transparent film, each (more than 16, but less than 48 square inches) |
|
A6259 |
NU |
Transparent film, each (more than 48 square inches) |
|
A6403 |
NU |
Gauze, non-impregnated, sterile, pad size more than 16 sq in but = to or [LESS THAN]48 sq in |
|
A6404 |
NU, |
Gauze, non-impregnated, sterile, pad size = to or [GREATER THAN]48 sq in |
|
A6441 |
NU |
Padding Bandage, non-elastic, width [GREATER THAN] or = I in & [LESS THAN] 5 in per yd |
|
A6442 |
NU |
Conform bandage, non-elastic, non-sterile, width [LESS THAN] 3 in, per yd |
|
A6443 |
NU |
Conform bandage, non-elastic, non-sterile, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per y |
|
A6444 |
NU |
Conform bandage, non-elastic, non-sterile, width [GREATER THAN] or = 5 in, per yd |
|
A6445 |
NU |
Conform bandage, non-elastic, sterile, width [LESS THAN] 3 in, per yd |
|
A6446 |
NU |
Conform bandage, non-elastic, sterile, width [GREATER THAN] or = 3 in and [LESS THAN] 5 in, per yd |
|
A6447 |
NU |
Conform bandage, non-elastic, sterile, width [GREATER THAN] or = 5 in, per yd |
|
A6448 |
NU |
Light compression bandage, elastic, width [LESS THAN] 3 in, per yd |
|
A6449 |
NU |
Gauze elastic, all types, per roll (linear yard) |
|
A6450 |
NU |
Light compression bandage, elastic width [GREATER THAN] or = 5 in, per yd |
|
A6451 |
NU |
Mod compress bandage, elastic, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd |
|
A6452 |
NU |
High compress bandage, elastic, with [GREATER THAN] or = 3 in & [LESS THAN] 5 in per yd |
|
A6453 |
NU |
Self-adherent bandage, elastic, width [LESS THAN] 3 in, per yd |
|
A6454 |
NU |
Self-adherent bandage, elastic, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd |
|
A6455 |
NU |
Self-adherent bandage, elastic, width [GREATER THAN] or = 5 in, per yd |
|
A6549* ** |
NU |
Stocking, gradient compression; not otherwise specified |
|
A7520 |
NU |
Trach/Laryngectomy tube, non-cuffed, PVC, silicone or equal, each |
|
A7521 |
NU |
Trach/Laryngectomy tube, cuffed, PVC, silicone or equal, ea |
|
A7522 |
NU |
Trach/Laryngectomy tube, stainless steel or equal, reusable, ea |
|
B4086 |
NU |
Gastrostomy/jejunostomy tube any material any type |
|
B4100** |
NU |
Food thickener, administered orally, per oz. |
|
E0776 |
NU |
IV pole |
NOTE: *A4221, A4222 and A6549 must be prior authorized. Form AFMC-103 must be used for the request for prior authorization. View or print form AFMC-103 and instructions for completion.
**The costs of B4100 and A6549 are not subject to the $125 medical supplies monthly benefit limit.
262.120 Durable Medical Equipment (DME) Procedure Codes 4-1-08
The following DME HCPCS procedure codes may be billed with appropriate modifiers by Medicaid-enrolled prosthetics providers for ARKids First-B participants.
|
HCPCS code |
Modifiers |
Description |
Payment Method |
|
A4213 |
NU |
Syringes, sterile, 20 cc or greater, each |
Purchase only |
|
A4230 |
NU |
Infusion set for external insulin pump, non-needle cannula type |
Purchase only |
|
A4231* |
NU |
Infusion set for external insulin pump, needle (ea) |
Purchase only |
|
A4232* |
NU |
Syringe w/needle for external insulin pump sterile (ea) |
Purchase only |
|
A4627 |
NU, UB |
Spacer bag or reservoir, with or without mask, for use with metered dose inhaler |
Purchase only |
|
A4627 |
NU |
Spacer bag or reservoir, with mask, for use with metered inhaler |
Purchase only |
|
A4635 |
NU UE |
Underarm pad, crutch, replacement, each |
Purchase only |
|
A4636 |
NU UE |
Replacement, handgrip, cane, crutch or walker, each |
Purchase only |
|
A4637 |
NU UE |
Replacement, tip, cane, crutch or walker, each |
Purchase only |
|
A4670 |
NU |
Electronic blood pressure monitor and cuff |
Rental only |
|
A6021 A6022 A6023 A6024 |
NU NU NU NU |
Polyskin/Collagen dressing 16 sq in or less Polyskin/Collagen dressing [GREATER THAN]16 sq in but [LESS THAN]48 sq in Polyskin/Collagen dressing 48 sq in or [GREATER THAN] Polyskin/Collagen dressing wound filler per 6 in |
Purchase only |
|
A7034* A7034* ^ |
RR |
CPAP (continuous positive airway pressure) device, nasal (includes necessary accessory items) Note: Complete medical data pertinent to the request must be submitted with a prior authorization request. |
Rental only |
|
A7045 |
NU |
Exhalation port w/wo swivel used w/accessories for positive airway device, replacement only |
Purchase only |
|
A7046 |
NU |
Water chamber for humidifier, replacement, each |
Purchase only |
|
A7524 |
NU |
Tracheostoma stent/stud/button, each |
Purchase only |
|
A7525 |
NU |
Tracheostomy mask, each |
Purchase only |
|
E0100 |
NU |
Cane includes canes of all materials, adjustable |
Purchase only |
|
E0105 |
NU UE |
Cane, quad or three prong, includes canes of all materials, adjustable or fixed, with tips |
Purchase only |
|
E0110 |
NU UE |
Crutches, forearm, includes crutches of various materials, complete, pair |
Purchase only |
|
E0111 |
NU UE |
Crutch, forearm, includes crutches of various materials, complete, each |
Purchase only |
|
E0112 |
NU UE |
Crutches, underarm, wood, adjustable or fixed, pair |
Purchase only |
|
E0113 |
NU UE |
Crutches, underarm, wood, adjustable or fixed, each |
Purchase only |
|
E0114 |
NU UE |
Crutches underarm, aluminum, adjustable or fixed, pair |
Purchase only |
|
E0116 |
NU UE |
Crutch, underarm, aluminum, adjustable or fixed, each |
Purchase only |
|
E0130 |
NU UE |
Walker, rigid adjust, or fixed height |
Purchase only |
|
E0135 |
NU UE |
Walker, folding (pickup), adjustable or fixed height |
Purchase only |
|
E0141 |
NU UE |
Walker, wheeled, without seat |
Purchase only |
|
E0143 |
NU UE |
Folding walker, wheeled without seat |
Purchase only |
|
E0147 |
NU UE |
Heavy duty, multiple breaking system, variable |
Purchase only |
|
E0153 |
NU UE |
Platform attachment, forearm crutch, each |
Purchase only |
|
E0154 |
NU UE |
Platform attachment, walker each |
Purchase only |
|
E0155 |
NU UE |
Wheel attachment, rigid pickup walker, per pair |
Purchase only |
|
E0156 |
NU |
Seat attachment, walker |
Purchase only |
|
E0157 |
NU UE |
Crutch attachment, walker |
Purchase only |
|
E0158 |
NU UE |
Leg extensions for a walker |
Purchase only |
|
E0159 |
NU |
Brake attachment for wheeled walker, replacement, each |
Purchase only |
|
E0161 |
NU UE |
Sitz type bath, portable, fits over commode seat |
Purchase only |
|
E0163 |
NU UE |
Commode chair, stationary with fixed arms |
Purchase only |
|
E0167 |
NU UE |
Pail or pan for use with commode chair |
Purchase only |
|
E0175 |
NU UE |
Footrest, for use with commode chair, each |
Purchase only |
|
E0181^ |
NU UE |
Pressure pad, alternating with pump |
Capped rental |
|
E0182 |
NU UE |
Pump for alternating pressure pad |
Purchase only |
|
E0184 |
NU UE |
Floatation mattress, dry |
Purchase only |
|
E0185 |
NU UE |
Decubitus care pad, floatation or gel pad with foam leveling |
Purchase only |
|
E0186* |
NU |
Air pressure mattress |
Purchase only |
|
E0187* |
NU |
Water pressure mattress |
Purchase only |
|
E0189 |
NU UE |
Lambswool sheepskin pad, any size |
Purchase only |
|
E0190 |
NU UE |
Decubitus care mattress |
Purchase only |
|
E0191 |
NU UE |
Heel or elbow protector, each |
Purchase only |
|
E0196 |
NU |
Gel pressure mattress |
Purchase only |
|
E0197 |
NU UE |
Air pressure pad for mattress, standard mattress length and width |
Purchase only |
|
E0198* |
NU |
Water pressure pad for mattress, standard mattress length and width |
Purchase only |
|
E0200^ |
NU UE |
Heat lamp, without stand (table model) |
Capped rental |
|
E0202 |
NU UE |
Phototherapy (bilirubin) light with photometer |
Rental only |
|
E0205^ |
NU UE |
Heat lamp, with stand, includes bulb or infrared |
Capped rental |
|
E0217^ |
NU UE |
Water circulating heat pad with pump |
Capped rental |
|
E0225^ |
NU UE |
Hydrocollator unit, includes pads |
Capped rental |
|
E0235 |
NU UE |
Paraffin bath unit, portable |
Purchase only |
|
E0236^ |
NU UE |
Pump for water circulating pad |
Capped rental |
|
E0238 |
NU UE |
Non-electric heat pad, moist |
Purchase only |
|
E0239^ |
NU UE |
Hydrocollator unit, portable |
Capped rental |
|
E0244 |
NU |
Raised toilet seat (manufacturer?s invoice must be attached to paper claim) |
Purchase only Manually priced |
|
E0249 |
NU UE |
Pad for water circulating heat unit |
Purchase only |
|
E0250^ |
NU |
Hospital bed, with side rails fixed height, w/mattress |
Capped rental |
|
E0255^ |
NU UE |
Hospital bed, with side rails, variable heights, hi-lo, w/mattress |
Capped rental |
|
E0260^ |
RR KH UE |
Hospital bed, semi-electric (head and foot adjustment) with any type side rails,w/mattress |
Capped rental |
|
E0271^ |
NU UE |
Mattress, innerspring |
Capped rental |
|
E0272^ |
NU UE |
Mattress, foam rubber |
Capped rental |
|
E0273 |
NU UE |
Bed board |
Purchase only |
|
E0275 |
NU UE |
Bed pan, standard, metal or plastic |
Purchase only |
|
E0276 |
NU UE |
Bed pan, fracture, metal or plastic |
Purchase only |
|
E0280 |
NU UE |
Bed cradle, any type |
Purchase only |
|
E0325 |
NU UE |
Urinal; male, jug-type, any material |
Purchase only |
|
E0326 |
NU UE |
Urinal; female jug type, any material |
Purchase only |
|
E0424^ |
NU |
Stationary compressed gas system rental includes contents |
Rental only |
|
E0430^ |
NU |
Portable gaseous oxygen system, includes contents |
Rental only |
|
E0435^ |
NU |
Oxygen system, liquid, portable, includes portable container |
Rental only |
|
E0439^ |
NU |
Stationary liquid oxygen system rental includes contents |
Rental only |
|
E0443 |
NU |
Portable oxygen contents gaseous one month's supply |
Purchase only |
|
E0444 |
NU |
Portable oxygen contents liquid one month's supply |
Purchase only |
|
E0445^ |
NU |
Pulse oximeter (including 4 disposable probes) |
Rental only |
|
E0480^ |
NU UE |
Percussor, electric or pneumatic, home model |
Capped rental |
|
E0483 |
UB |
Replacement Pulmonary vest ? vest only The manufacturer?s invoice must be attached to the claim form. |
Purchase only |
|
E0483 |
RR |
High-frequency chest-wall oscillation air-pulse generator system, includes hoses and vest |
Rental only |
|
E0560 |
NU UE |
Cascade humidification |
Purchase only |
|
E0565^ |
NU UE |
Compressor, air power source for equipment which is not self contained or cylinder driven |
Capped rental |
|
E0570 |
NU UE |
Nebulizer with compressor |
Purchase only |
|
E0575 |
NU UE |
Ultrasonic nebulizer |
Capped rental |
|
E0585^ |
NU UE |
Nebulizer, with compressor and heater |
Capped rental |
|
E0600 |
NU UE |
Suction pump |
Rental only |
|
E0605 |
NU UE |
Vaporizer room type |
Purchase only |
|
E0606^ |
NU UE |
Postural drainage board |
Capped rental |
|
E0607 |
NU UE NU, U1 |
Home blood glucose monitor Billed for Pregnant Women services only |
Purchase only |
|
E0630^ |
NU UE |
Patient lift, hydraulic, with seat or sling |
Capped rental |
|
E0650^ |
NU UE |
Pneumatic compressor, non-segmental |
Capped rental |
|
E0667^ |
NU |
Pneumatic appliance (leg) |
Capped rental |
|
E0668^ |
NU |
Pneumatic appliance (arm) |
Capped rental |
|
E0691^ |
NU |
Ultraviolet light therapy system panel, bulbs/lamps/timer/eye protect [LESS THAN] 2sq ft treat area |
Rental only |
|
E0692^ |
NU |
Ultraviolet light therapy panel, bulbs/lamps/timer/eye protection, 4 ft panel |
Rental only |
|
E0693^ |
NU |
Ultraviolet light therapy system panel, bulbs/lamps/timer/eye protection, 6 ft panel |
Rental only |
|
E0694^ |
NU |
Ultraviolet light therapy system panel, bulbs/lamps/timer/eye protection, 6 ft cabinet |
Rental only |
|
E0720^ |
NU UE |
TENS, two leads, localized stimulation |
Capped rental |
|
E0730^ |
NU UE |
TENS, four leads, larger area/multiple nerve stimulation |
Capped rental |
|
E0740 |
NU UE |
Replacement batteries for medically necessary TENS |
Purchase only |
|
E0745^ |
NU UE |
Neuromuscular stimulator, electronic shock unit |
Capped rental |
|
E0747^ |
NU UE |
Osteogenesis stimulator |
Rental only |
|
E0760* |
NU |
Osteogenesis stimulator, low intensity ultrasound, non-invasive |
Rental only |
|
E0779 E0779^ |
RR |
Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home |
Rental only |
|
E0840 |
NU UE |
Traction frame attached to headboard, simple cervical traction |
Purchase only |
|
E0850 |
NU UE |
Traction stand, free standing cervical traction |
Purchase only |
|
E0860 |
NU |
Traction equipment, over door, cervical |
Purchase only |
|
E0870 |
NU UE |
Traction frame attached to footboard, extremity traction |
Purchase only |
|
E0880 |
NU UE |
Traction stand, free standing, extremity, traction |
Purchase only |
|
E0890 |
NU UE |
Traction frame, attached to footboard, pelvic traction |
Purchase only |
|
E0900 |
NU UE |
Traction stand, free standing, pelvic traction |
Purchase only |
|
E0910^ |
NU UE |
Trapeze bars, attached to bed, complete with grab bar |
Capped rental |
|
E0920* ^ |
NU UE |
Fracture frame attached to bed, includes weights |
Capped rental |
|
E0930^ |
NU UE |
Fracture frame, free standing, includes weights |
Capped rental |
|
E0935^ |
NU UE |
Passive motion exercise device |
Capped rental |
|
E0936 Bill on paper |
NU |
Continuous passive motion exercise device for use other than knee |
Capped Rental |
|
E0940^ |
NU UE |
Trapeze bar, free standing, complete with grab bar |
Capped rental |
|
E0941^ |
NU UE |
Gravity assisted traction device, any type |
Capped rental |
|
E0942 |
NU UE |
Cervical head harness/halter |
Purchase only |
|
E0944 |
NU UE |
Pelvic belt/harness/boot |
Purchase only |
|
E0945 |
NU UE |
Extremity belt/harness |
Purchase only |
|
E0946 |
NU UE |
Fracture frame, dual with cross bars, attached |
Purchase only |
|
E0947 |
NU UE |
Fracture frame, attachments for complex pelvic |
Purchase only |
|
E0948 |
NU UE |
Fracture frame, attachments for complex cervical |
Purchase only |
|
E1130^ |
NU UE |
Standard wheelchair, fixed full length arms, fixed or swing away detachable footrests |
Capped rental |
|
E1140 |
NU |
W/chair detachable arms, desk or full length |
Capped rental |
|
E1150 |
NU |
W/chair detachable arms, desk or full length |
Capped rental |
|
E1160 |
NU |
W/chair, fixed full length arms, swing away |
Capped rental |
|
E1224** ^ |
NU UE |
Footrest wheelchair with detachable arm |
Capped rental |
|
E1340 Bill on paper |
NU |
Durable medical equipment parts only. Repairs/parts will not be approved for more than the allowed purchase price of new equipment. The manufacturer?s invoice for all parts must be attached to the repair claim |
Manually priced |
|
E1340 |
NU, U1 |
Labor only (a maximum of 20 units per date of service is allowed) (1 unit = 15 minutes of labor) |
N/A ? Labor charges only |
|
E1340 |
NU, U4 |
Maintenance for capped rental items |
N/A ? Labor charges only |
|
E1390^ |
NU |
Oxygen concentrator manufacturer specified maximum flow rate |
Rental only |
|
E1391* ^ |
NU |
O2 concentrator, dual delivery port, 85% or [GREATER THAN] O2 concentration, each |
Rental only |
|
E2601 |
NU |
General use wheelchair seat cushion, width less than 22 in., any depth |
Purchase only |
|
E2602 |
NU |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
Purchase only |
|
E2611 |
NU |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
Purchase only |
|
E2612 |
NU |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
Purchase only |
|
Z0428 Bill on paper |
NU |
Unlisted durable medical equipment, $500.00 and over. The manufacturer?s invoice must be attached to the claim form. |
Manually priced |
|
Z1825 Bill on paper |
NU |
Unlisted durable medical equipment, under $500.00. The manufacturer?s invoice must be attached to the claim form. |
Manually priced |
|
Z2211 Bill on paper |
NU |
Power kit/batteries |
Purchase only |
NOTES: Codes denoted with an asterisk * (A4231, A4232, A7034, E0186, E0187, E0198, E0760, E0920, and E1391) must be prior authorized. Form AFMC-103 must be used for the request for prior authorization. View or print form AFMC-103 and instructions for completion.
** Code E1224 must be prior authorized through the Division of Medical Services, Utilization Review. Form DMS-679 must be used for the request for prior authorization. View or print form DMS-679 and instructions for completion.
Codes denoted with ^ symbol are approved for special circumstance ?Initial? billing (See Section 242.111 of the Prosthetics Medicaid Provider Manual for details regarding ?initial? billing). These codes must be billed WITHOUT A MODIFIER to indicate the ?Initial? bill circumstance applies ? EXCEPTION - if a modifier KH is specifically indicated, that modifier must be used.
