Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.09-046 - Prosthetics Provider Manual Update Transmittal #135
Current through Register Vol. 49, No. 9, September, 2024
Section IIProsthetics
When billed either electronically or on paper, procedure codes found in this section must be billed with certain modifiers. Modifiers in the section are indicated by the headings M1 and M2. When only the NU modifier is shown in the M1 column, the procedure code may be billed for beneficiaries of all ages. When NU and EP are listed together in the M1 column, the NU modifier must be used when billing for beneficiaries age 21 and over, and the EP modifier must be used when billing for beneficiaries under age 21. When a modifier is listed in the M2 heading, that modifier must be used in conjunction with either NU or EP.
Prior authorization requirements are shown under the heading PA. .If prior authorization is needed, the information is indicated with a "Y" in the column; if not, an "N" is shown.
* Prior authorization is not required when other insurance pays at least 50% of the
Medicaid maximum allowable reimbursement amount.
***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.
Respiratory and Diabetic Equipment, All Ages (section 242.110)
|
Procedure Code |
M1 |
M2 |
Description |
PA |
Payment Method |
|
A4230 |
NU |
Infusion set for external insulin pump, nonneedle cannula type |
Y* |
Purchase |
|
|
A4231 |
NU |
Infusion set for external insulin pump, needle type |
Y* |
Purchase |
|
|
A4232 |
NU |
Syringe with needle for external insulin pump, sterile, 3 cc |
Y* |
Purchase |
|
|
A4627 |
NU |
UB |
***(Spacer bag or reservoir without mask, for use with metered dose inhaler) Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler |
N |
Purchase |
|
A4627 |
NU |
***(Spacer bag or reservoir with mask, for use with metered dose inhaler) Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler |
N |
Purchase |
|
|
A6021 |
NU |
Collagen dressing, pad size 16 sq. in. or less, each |
Y* |
Purchase |
|
|
A6022 |
NU |
Collagen dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each |
Y* |
Purchase |
|
|
A6023 |
NU |
Collagen dressing, pad size more than 48 sq. in., each |
Y* |
Purchase |
|
|
A6024 |
NU |
Collagen dressing wound filler, per 6 in. |
Y* |
Purchase |
|
|
A7034 |
NU |
RR |
***(CPAP Device Nasal Continuous Positive Airway Pressure (CPAP) Device; includes necessary accessory items) NOTE: Complete medical data pertinent to the request must be submitted with the prior authorization request. NOTE: Bill A7034 as the global daily rental service. Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap |
Y* |
Rental Only |
|
A7045 |
NU |
Exhalation port with or without swivel used with accessories for positive airway devices, replacement only |
N |
Purchase |
|
|
A7046 |
NU |
Water chamber for humidifier, used with positive airway pressure device, replacement, each |
N |
Purchase |
|
|
A9999 |
NU |
***(Unlisted Durable Medical Equipment. The manufacturer's invoice must be attached to the claim form.) Misc. DME supply or accessory, not otherwise specified |
Y |
Manually Priced |
|
|
E0424 |
NU |
Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing |
Y* |
Rental Only |
|
|
E0430 |
NU |
Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula or mask, and tubing |
Y* |
Rental Only |
|
|
E0434 |
NU |
Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adapter, contents gauge, cannula or mask, and tubing |
Y* |
Rental Only |
|
|
E0435 |
NU |
Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapter |
Y* |
Rental Only |
|
|
E0439 |
NU |
Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing |
Y* |
Rental Only |
|
|
E0441 |
NU |
Oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned), one month's supply = I unit |
Y |
Purchase |
|
|
E0442 |
NU |
Oxygen contents, liquid (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned), one month's supply = 1 unit |
Y |
Purchase |
|
|
E0443 |
NU |
Portable oxygen contents, gaseous (for use only with portable gaseous systems when no stationary gas or liquid system is used), one month's supply=1 unit |
Y* |
Purchase |
|
|
E0444 |
NU |
Portable oxygen contents, liquid (for use only with portable liquid systems when no stationary gas or liquid system is used), one month's supply=1 unit |
Y* |
Purchase |
|
|
E0470 |
NU EP |
RR RR |
***(BIPAP Device, Nasal Bi-level Positive Airway support system; includes necessary accessory items. NOTE: Complete medical data pertinent to the request must be submitted with the prior authorization request.) Respiratory assist device, bi-level pressure capacity, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) |
Y4 Y4 |
Rental Only |
|
E0471 |
NU EP |
RR RR |
Respiratory assist device, bi-level pressure capacity, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) |
Y* Y4 |
Rental Only |
|
E0472 |
NU EP |
RR RR |
Respiratory assist device, bi-level pressure capacity, with backup rate feature, used with invasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) |
Y* Y4 |
Rental Only |
|
E0482 |
NU EP |
Cough stimulating device, alternating positive and negative airway pressure |
Y* |
Capped Rental |
|
|
E0483 |
NU |
RR |
***(Bronchial Drainage System) High-frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each |
Y* |
Capped Rental |
|
E0483 |
NU |
UB |
***(Pulmonary Vest. The manufacturer invoice must be attached to the claim form.) High-frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each |
Y* |
Purchase |
|
E0560 |
NU UE |
Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery |
N |
Purchase |
|
|
E0561 |
NU EP |
Humidifier, non-heated, used w/positive airway pressure device |
Y* |
Purchase |
|
|
E0562 |
NU |
Humidifier, heated, used w/positive airway |
Y* |
Purchase |
|
|
EP |
pressure device |
Y* |
|||
|
E0570 |
NU UE |
Nebulizer, with compressor |
Y* |
Purchase |
|
|
E0575 |
NU UE |
Nebulizer, ultrasonic, large volume |
Y* |
Capped Rental |
|
|
E0600 |
NU UE |
Respiratory suction pump, home model, portable or stationary, electric |
N |
Rental Only |
|
|
E0779 |
NU |
RR |
***(Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home) Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater |
Y* |
Rental Only |
|
E0784 |
NU |
External ambulatory infusion pump, insulin |
Y* |
Purchase |
|
|
E1340 |
NU |
***(DME Repair: Parts Only Repairs will not be approved for more than the allowed purchase price of new equipment. The manufacturer's invoice must be attached to the repair claim for all parts.) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes |
N |
N/A |
|
|
E1340 |
NU |
U4 |
/*(Maintenance for Capped Rental items) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes |
N |
N/A |
|
E1340 |
NU |
U1 |
***(Labor Only; a maximum of twenty (20) units per date of service is allowable. 20 units = 5 hours of labor) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes |
N |
N/A |
|
E1340 |
EP |
U1 |
***(Labor Only; a maximum of twenty (20) units per date of service is allowable. 20 units = 5 hours of labor) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes |
N |
N/A |
|
E1390 |
NU |
Oxygen concentrator, single delivery port, capable of delivering 85 % or greater oxygen concentration at the prescribed flow rate |
Y* |
Rental Only |
|
|
E1391 |
NU |
02 concentrator, dual delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate, each |
Y4 |
Rental Only |
Procedure codes found in this section may be billed either electronically or on paper.
Some procedure codes have been assigned a modifier that affects the billing process. Required modifiers are indicated in the M1 column in the list below. When a modifier is shown in the M1 column, it must be listed along with the procedure code when requesting payment by Arkansas Medicaid.
Procedure codes shown in the list below are either covered for all ages (AA), only for individuals under age 21 (U21) or only for individuals age 21 and over (21+). A column in the list below defines the differences.
* Prior authorization is not required when other insurance pays at least 50% of the
Medicaid maximum allowable reimbursement amount.
***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.
Initial Rental of a DME Item for Individuals of All Ages (section 242.111)
|
Procedure Code |
M1 |
Description |
All U21 21 + |
|
A7034* |
***(CPAP Device Nasal Continuous Positive Airway Pressure (CPAP) Device; includes necessary accessory items. NOTE: For 21+, complete medical data pertinent to the request must be submitted with the prior authorization request. Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap |
AA |
|
|
E0181 |
Pressure pad, alternating with pump, heavy duty |
U21 |
|
|
E0200 |
Heat lamp, without stand (table model), includes bulb, or infrared element |
U21 |
|
|
E0205 |
Heat lamp, with stand includes bulb, or infrared element |
U21 |
|
|
E0217 |
Water circulating heat pad with pump |
U21 |
|
|
E0225 |
Hydrocollatorunit, includes pad |
U21 |
|
|
E0236 |
Pump for water circulating pad |
U21 |
|
|
E0239 |
Hydrocollatorunit, portable |
U21 |
|
|
E0250* |
Hospital bed, fixed height, with any type side rails, with mattress |
U21 |
|
|
E0250* |
U1 |
Hospital bed, fixed height, with any type side rails, with mattress |
U21 |
|
E0250* |
UE |
Hospital bed, fixed height, with any type side rails, with mattress |
21 + |
|
E0255* |
Hospital bed, variable height; hi-lo, with any type side rails, with mattress |
U21 |
|
|
E0255 |
KH |
Hospital bed, variable height; hi-lo, with any type side rails, with mattress |
21 + |
|
E0260* |
Hospital bed, semi-electric (head and foot adjustment), with any type side rails with mattress |
U21 |
|
|
E0260* |
KH |
Hospital bed, semi-electric (head and foot adjustment), with any type side rails with mattress |
21 + |
|
E0271 |
Mattress, inner spring |
U21 |
|
|
E0272 |
Mattress, foam rubber |
U21 |
|
|
E0303 |
Hospital bed, heavy duty, extra wide, with weight capacity [GREATER THAN] 350 but [LESS THAN] or = 600, any type side rails, w/mattress |
AA |
|
|
E0424 |
Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator flowmeter, humidifier, nebulizer cannula or mask, and tubing |
AA |
|
|
E0430* |
Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula, or mask, and tubing |
AA |
|
|
E0434 |
Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing |
AA |
|
|
E0435* |
Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapter |
AA |
|
|
E0439 |
Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing |
AA |
|
|
E0445* |
Oximeter for measuring blood oxygen levels non-invasively. *** (Pulse oximeter, including 4 disposable probes) |
AA |
|
|
E0480 |
Percussor, electric or pneumatic, home model |
U21 |
|
|
E0565* |
Compressor, air power source for equipment which is not self-contained or cylinder driven |
U21 |
|
|
E0575* |
Nebulizer, ultrasonic, large volume |
AA |
|
|
E0585 |
Nebulizer, with compressor and heater |
U21 |
|
|
E0600 |
Respiratory suction pump, home model, portable or stationary, electric |
AA |
|
|
E0606 |
Vaporizer, room type |
U21 |
|
|
E0630* |
Patient lift, hydraulic, with seat or sling |
U21 |
|
|
E0630 |
KH |
Patient lift, hydraulic, with seat or sling |
21 + |
|
E0650* |
Pneumatic compressor, nonsegmental home model |
U21 |
|
|
E0667* |
Segmental pneumatic appliance for use with pneumatic compressor, full leg |
U21 |
|
|
E0668* |
Segmental pneumatic appliance for use with pneumatic compressor, full arm |
U21 |
|
|
E0691 |
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or less |
U21 |
|
|
E0692 |
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel |
U21 |
|
|
E0693 |
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel |
U21 |
|
|
E0694 |
Ultraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protection |
U21 |
|
|
E0720* |
TENS, two lead, localized stimulation |
U21 |
|
|
E0730* |
Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation |
AA |
|
|
E0730* |
KH |
Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation |
21 + |
|
E0745* |
Neuromuscular stimulator, electronic shock unit |
U21 |
|
|
E0779* |
***(Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home) Ambulatory infusion device pump, mechanical, reusable, for infusion 8 hours or greater |
AA |
|
|
E0910 |
Trapeze bars, also known as Patient Helper, attached to bed, with grab bar |
AA |
|
|
E0910 |
KH |
Trapeze bars, also known as Patient Helper, attached to bed, with grab bar |
21 + |
|
E0911 |
Trapeze bar, heavy-duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar |
AA |
|
|
E0920 |
Fracture frame, attached to bed, includes weights |
U21 |
|
|
E0930 |
Fracture frame, freestanding, includes weights |
U21 |
|
|
E0935* |
Passive motion exercise device |
U21 |
|
|
E0940 |
Trapeze bar, freestanding, complete with grab bar |
U21 |
|
|
E0941 |
Gravity assisted traction device, any type |
U21 |
|
|
E1130* |
Standard wheelchair, fixed full-length arms, fixed or swing-away, detachable footrests |
U21 |
|
|
E1130* |
KH |
Standard wheelchair, fixed full-length arms, fixed or swing-away, detachable footrests |
21 + |
|
E1224* |
Wheelchair with detachable arms, elevating legrests |
AA |
|
|
E1224* |
U1 |
***(Footrests wheelchair with detachable arms, elevating leg rests) Wheelchair with detachable arms, elevating legrests |
21 + |
|
E1390 |
Oxygen concentrator, single delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate |
AA |
|
|
E1391 |
Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each |
AA |
Providers will be reimbursed for a minimum of 30 days of rental when the equipment is used less than 30 days. Initial rental codes must be billed when equipment is used less than 30 days during the first month of rental.
Arkansas Medicaid will only reimburse for one initial minimum 30 days of rental per state fiscal year period per beneficiary per procedure code. The provider will not be reimbursed for the same procedure code utilizing another modifier for the same time period.
Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU. Modifier UE is required when billing for used equipment.
Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a "Y" in the column; if not, an "N" is shown.
* The purchase of wheelchairs for individuals age 21 and older is limited to one per five-year period.
*** This procedure code may not be billed for used equipment.
* Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.
***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. 3 This item is a capped rental for 90 days only, and requires PA and a review.
Durable Medical Equipment, All Ages (section 242.160)
|
Procedure Code |
M1 |
M2 |
M3 |
PA |
Description |
Payment Method |
|
A4635 |
NU EP UE |
N |
Underarm pad, crutch, replacement, each |
Purchase |
||
|
A4636 |
NU EP UE |
N |
Replacement, handgrip, cane, crutch, or walker, each |
Purchase |
||
|
A4637 |
DQ.UJ ZUJD |
N |
Replacement, tip, cane, crutch, walker, each |
Purchase |
||
|
E0100 |
DQ.UJ ZUJD |
N |
Cane, includes canes of all materials, adjustable or fixed, with tip |
Purchase |
||
|
E0105 |
3 0_ LU ZUJD |
N |
Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips |
Purchase |
||
|
E0110 |
NU EP UE |
N |
Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips |
Purchase |
||
|
E0111 |
3 CL LU ZUJD |
N |
Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip |
Purchase |
||
|
E0111 |
NU |
U1 |
N |
Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip |
Purchase |
|
|
E0112 |
3 CL LU Z LU 3 |
N |
Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips |
Purchase |
||
|
E0113 |
3 CL LLI Z LU 3 |
N |
Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip |
Purchase |
||
|
E0114 |
3 CL LU Z LU 3 |
N |
Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips |
Purchase |
||
|
E0116 |
3 CL LU Z LU 3 |
N |
Crutch, underarm, other than wood, adjustable or fixed, each, with pad, tip and handgrip |
Purchase |
||
|
E0130 |
3 CL LU Z LU 3 |
N |
Walker, rigid (pickup), adjustable or fixed height |
Purchase |
||
|
E0135 |
NU EP UE |
N |
Walker, folding (pickup), adjustable or fixed height |
Purchase |
||
|
E0140 |
NU EP |
N |
Walker, w/trunk support, adjustable or fixed height, any type |
Purchase |
||
|
E0141 |
3 CL LU Z LU 3 |
N |
Walker, rigid, wheeled, adjustable or fixed height |
Purchase |
||
|
E0143 |
3 CL LU Z LU 3 |
N |
Walker, folding, wheeled, adjustable or fixed height |
Purchase |
||
|
E0147 |
3 CL LU Z LU 3 |
N |
Walker, heavy duty, multiple braking system, variable wheel resistance |
Purchase |
||
|
E0153 |
3 CL LU Z LU 3 |
N |
Platform attachment, forearm crutch, each |
Purchase |
||
|
E0154 |
NU EP UE |
N |
Platform attachment, walker, each |
Purchase |
||
|
E0155 |
3 CL LU ZUJD |
N |
Wheel attachment, rigid pick-up walker, per pair seat attachment, walker |
Purchase |
||
|
E0156 |
NU EP |
N |
Seat attachment, walker |
Purchase |
||
|
E0157 |
3 CL LU Z LLI 3 |
N |
Crutch attachment, walker, each |
Purchase |
||
|
E0158 |
3 CL LLI Z LU 3 |
N |
Leg extensions for walker, per set of four (4) |
Purchase |
||
|
E0159 |
NU EP |
N |
Brake attachment for wheeled walker, replacement, each |
Purchase |
||
|
E0160 |
3 CL LLI Z LU 3 |
N |
Sitz type bath or equipment, portable, used with or without commode |
Purchase |
||
|
E0161 |
3 CL LLI Z LU 3 |
N |
Sitz type bath or equipment, portable, used with or without commode, with faucet attachment(s) |
Purchase |
||
|
E0163 |
3 CL LLI Z LLI 3 |
N |
Commode chair, stationary, with fixed arms |
Purchase |
||
|
E0167 |
NU EP UE |
N |
Pail or pan for use with commode chair |
Purchase |
||
|
E0175 |
3 CL LLI Z LLI 3 |
N |
Foot rest, for use with commode chair, each |
Purchase |
||
|
E0181 |
3 CL LLI Z LLI 3 |
N |
Pressure pad, alternating with pump, heavy duty |
Capped Rental |
||
|
E0182 |
3 CL LLI Z LLI 3 |
N |
Pump for alternating pressure pad |
Purchase |
||
|
E0184 |
3 CL LLI Z LLI 3 |
N |
Dry pressure mattress |
Purchase |
||
|
E0185 |
NU EP UE |
N |
Gel or gel-like pressure pad for mattress, standard mattress length and width |
Purchase |
||
|
E0186 |
NU EP |
Y |
Air pressure mattress |
Purchase |
||
|
E0187 |
NU EP |
Y |
Water pressure mattress |
Purchase |
||
|
E0189 |
NU EP UE |
N |
Lambswool sheepskin pad, any size |
Purchase |
||
|
E0190 |
NU UE |
N |
Positioning cushion/pillow/wedge, any shape or size |
Purchase |
||
|
E0190 |
EP |
N |
*** (Tumble Form Therapy Roll 4") Positioning cushion/pillow/wedge, any shape or size |
Purchase |
||
|
E0190 |
EP |
U1 |
N |
*** (Tumble Form Therapy Roll 6") Positioning cushion/pillow/wedge, any shape or size |
Purchase |
|
|
E0190 |
EP |
U2 |
N |
*** (Tumble Form Therapy Wedge 4") Positioning cushion/pillow/wedge, any shape or size |
Purchase |
|
|
E0190 |
EP |
U3 |
N |
*** (Tumble Form Therapy Roll 8") Positioning cushion/pillow/wedge, any shape or size |
Purchase |
|
|
E0190 |
EP |
U4 |
N |
*** (Tumble Form Therapy Wedge 6") Positioning cushion/pillow/wedge, any shape or size |
Purchase |
|
|
E0190 |
EP |
U5 |
N |
*** (Floor Sitter Wedge 4") Positioning cushion/pillow/wedge, any shape or size |
Purchase |
|
|
E0190 |
EP |
U6 |
N |
*** (Tumble Form Therapy Roll 12") Positioning cushion/pillow/wedge, any shape or size |
Purchase |
|
|
E0190 |
EP |
U7 |
N |
*** (Deluxe Wedge with strap 4") Positioning cushion/pillow/wedge, any shape or size |
Purchase |
|
|
E0190 |
EP |
U8 |
N |
*** (Deluxe Wedge with strap 6") Positioning cushion/pillow/wedge, any shape or size |
Purchase |
|
|
E0190 |
EP |
U9 |
N |
A (Tumble Form Therapy Wedge 10") Positioning cushion/pillow/wedge, any shape or size |
Purchase |
|
|
E0190 |
EP |
KA |
U1 |
N |
A (Tumble Form Therapy Roll 14") Positioning cushion/pillow/wedge, any shape or size |
Purchase |
|
E0190 |
EP |
KA |
U2 |
N |
(Tumble Form Therapy Roll 16") Positioning cushion/pillow/wedge, any shape or size A |
Purchase |
|
E0190 |
EP |
KA |
U3 |
N |
A (Tumble Form Therapy Wedge 8") Positioning cushion/pillow/wedge, any shape or size |
Purchase |
|
E0191 |
NU EP UE |
N |
Heel or elbow protector, each |
Purchase |
||
|
E01943 |
NU EP |
Y |
A(Clinitron Bed) Airfluidized bed |
Capped Rental |
||
|
E0196 |
NU EP |
N |
Gel pressure mattress |
Purchase |
||
|
E0197 |
NU EP UE |
N |
Air pressure pad for mattress, standard mattress length and width |
Purchase |
||
|
E0198 |
NU EP |
Y |
Water pressure pad for mattress, standard mattress length and width |
Purchase |
||
|
E0200 |
NU EP UE |
N |
Heat lamp, without stand (table model), includes bulb, or infrared element |
Capped Rental |
||
|
E0202 |
NU EP UE |
N |
Phototherapy (bilirubin) light with photometer |
Rental Only |
||
|
E0202 |
U |
U1 |
N |
Phototherapy (bilirubin) light with photometer |
Capped Rental |
|
|
E0205 |
NU EP UE |
N |
Heat lamp, with stand includes bulb, or infrared element |
Capped Rental |
||
|
E0217 |
NU EP UE |
N |
Water circulating heat pad with pump |
Capped Rental |
||
|
E0225 |
NU EP UE |
N |
Hydrocollatorunit, includes pad |
Capped Rental |
||
|
E0235 |
NU EP UE |
N |
Paraffin bath unit, portable (see medical supply code A4265 for paraffin) |
Purchase |
||
|
E0236 |
NU EP UE |
N |
Pump for water circulating pad |
Capped Rental |
||
|
E0238 |
3 CL LU ZUJD |
N |
Nonelectric heat pad, moist |
Purchase |
||
|
E0239 |
3 CL LU Z LLI 3 |
N |
Hydrocollatorunit, portable |
Capped Rental |
||
|
E0240 |
NU EP |
N |
Bath/shower chair w/wo wheels, any size |
Purchase |
||
|
E0240 |
NU EP |
U1 U1 |
N |
Bath/shower chair w/wo wheels, any size |
Purchase |
|
|
E0240 |
NU EP |
U2 U2 |
N |
Bath/shower chair w/wo wheels, any size |
Purchase |
|
|
E0240 |
NU EP |
U3 U3 |
N |
Bath/shower chair w/wo wheels, any size |
Purchase |
|
|
E0244 |
NU EP |
N |
Raised toilet seat |
Purchase |
||
|
E0245*** |
NU EP |
U1 U1 |
N |
***(Bath Frame Support, Large) Tub stool or bench |
Purchase |
|
|
E0247 |
NU EP |
N |
Transfer bench, tub/toilet, w/wo commode opening |
Purchase |
||
|
E0247 |
NU EP |
U1 U1 |
N |
Transfer bench, tub/toilet, w/wo commode opening |
Purchase |
|
|
E0248 |
NU EP |
N |
Transfer bench, heavy duty, tub/toilet w/wo commode opening |
Purchase |
||
|
E0248 |
NU EP |
U1 U1 |
N |
Transfer bench, heavy duty, tub/toilet w/wo commode opening |
Purchase |
|
|
E0249 |
3 CL LLI Z LU 3 |
N |
Pad for water circulating heat unit |
Purchase |
||
|
E0250 |
NU EP |
Y* |
***(Hospital bed, with side rails, fixed height, with mattress, purchase) Hospital bed, fixed height, with any type side rails, with mattress |
Purchase |
||
|
E0250 |
NU EP |
RR RR |
Y* |
Hospital bed, fixed height, with any type side rails, with mattress |
Capped Rental |
|
|
E0255 |
NU EP |
Y* |
Hospital bed, variable height; hi-lo, with any type side rails, with mattress |
Purchase |
||
|
E0255 |
NU EP |
RR RR |
Y* |
Hospital bed, variable height; hi-lo, with any type side rails, with mattress |
Capped Rental |
|
|
E0255 |
NU |
U1 |
Y* |
***(Hospital bed, with side rails, variable height; hi-lo, with mattress, purchase) Hospital bed, variable height; hi-lo, with any type side rails, with mattress |
Purchase |
|
|
E0255 |
UE |
Y* |
Hospital bed, variable height; hi-lo, with any type side rails, with mattress |
Capped Rental |
||
|
E0260 |
3 CL LU ZUJD |
Y* |
***(Hospital bed, with side rails, semi-electric, head and foot adjustments, with mattress, purchase) Hospital bed, semi-electric, head and foot adjustment, with any type side rails with mattress |
Purchase |
||
|
E0260 |
NU EP |
RR RR |
Y* |
Hospital bed, semi-electric, head and foot adjustment, with any type side rails with mattress |
Capped Rental |
|
|
E0271 |
3 CL LU Z LLI 3 |
N |
Mattress, inner spring |
Capped Rental |
||
|
E0272 |
3 CL LLI Z LU 3 |
N |
Mattress, foam rubber |
Capped Rental |
||
|
E0273 |
3 CL LLI Z LU 3 |
N |
Bed board |
Purchase |
||
|
E0275 |
3 CL LLI Z LU 3 |
N |
Bed pan, standard, metal or plastic |
Purchase |
||
|
E0276 |
NU EP UE |
N |
Bed pan, fracture, metal or plastic |
Purchase |
||
|
E02773 |
NU EP |
Y |
***(Low Air Loss Mattress) Powered pressure-reducing air mattress |
Capped Rental |
||
|
E0280 |
NU EP UE |
N |
Bed cradle, any type |
Purchase |
||
|
E0300 |
EP |
Y |
Pediatric crib, hospital grade, fully enclosed |
Purchase |
||
|
E0300 |
EP |
RR |
Y |
Pediatric crib, hospital grade, fully enclosed |
Rental Only |
|
|
E0302 |
NU EP |
Y |
Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress |
Capped Rental |
||
|
E0303 |
NU EP UE |
Y Y Y |
Hospital bed, heavy duty, extra wide, with weight capacity [GREATER THAN] 350 but [LESS THAN] or = 600, any type side rails, w/mattress |
Rental Only (Rent to Purchase) |
||
|
E0304 |
NU EP |
J |
Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress |
Capped Rental |
||
|
E0325 |
3 0_ LU ZUJD |
N |
Urinal; male, jug-type, any material |
Purchase |
||
|
E0325 |
NU EP UE |
U1 U1 U1 |
N |
Urinal; male, jug-type, any material |
Purchase |
|
|
E0326 |
NU EP UE |
N |
Urinal; female, jug-type, any material |
Purchase |
||
|
E0445*** |
NU EP |
Y* |
***(Pulse oximeter, including 4 disposable probes) Oximeter for measuring blood oxygen levels non-invasively |
Rental Only |
||
|
E0480 |
NU EP UE |
N |
Percussor, electric or pneumatic, home model |
Capped Rental |
||
|
E0565 |
NU EP UE |
Y* |
Compressor, air power source for equipment which is not self-contained or cylinder driven |
Capped Rental |
||
|
E0570 |
NU UE |
Y |
Nebulizer, with compressor |
Purchase |
||
|
E0585 |
NU EP UE |
N |
Nebulizer, with compressor and heater |
Capped Rental |
||
|
E0605 |
NU EP UE |
N |
Vaporizer, room type |
Purchase |
||
|
E0606 |
NU EP UE |
N |
Postural drainage board |
Capped Rental |
||
|
E0607*** |
NU EP |
N |
Home blood glucose monitor |
Purchase |
||
|
E0621 |
NU |
N |
Sling or seat, patient lift, canvas or nylon |
Purchase |
||
|
E0630 |
NU EP UE |
Y* |
Patient lift, hydraulic, with seat or sling |
Capped Rental |
||
|
E0650 |
NU EP UE |
Y* |
Pneumatic compressor, nonsegmental home model |
Capped Rental |
||
|
E0667 |
NU EP |
Y* |
Segmental pneumatic appliance for use with pneumatic compressor, full leg |
Capped Rental |
||
|
E0668 |
NU EP |
Y* |
Segmental pneumatic appliance for use with pneumatic compressor, full arm |
Capped Rental |
||
|
E0691 |
NU EP |
N |
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or less |
Rental Only |
||
|
E0692 |
NU EP |
N |
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel |
Rental Only |
||
|
E0693 |
NU EP |
N |
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel |
Rental Only |
||
|
E0694 |
NU EP |
N |
Ultraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protection |
Rental Only |
||
|
E0720 |
NU EP UE |
Y* |
TENS, two lead, localized stimulation |
Capped Rental |
||
|
E0730 |
NU EP UE |
Y* |
Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation |
Capped Rental |
||
|
E0740 |
NU EP UE |
N |
Incontinence treatment system, pelvic floor stimulator, monitor, sensor and/or trainer |
Purchase |
||
|
E0745 |
NU EP UE |
Y* |
Neuromuscular stimulator, electronic shock unit |
Capped Rental |
||
|
E0747 |
NU EP UE |
Y* |
Osteogenesis stimulator, electrical noninvasive, other than spinal applications |
Rental Only |
||
|
E0748 |
NU EP |
Y |
Osteogenesis stimulator, electrical noninvasive, spinal applications |
Rental Only |
||
|
E0760 |
NU EP |
Y |
Osteogenesis stimulator, low intensity ultrasound, noninvasive |
Rental Only |
||
|
E0779 |
NU |
RR |
Y* |
***(Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home) Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater |
Rental Only |
|
|
E0840 |
NU EP UE |
N |
Traction frame, attached to headboard, cervical traction |
Purchase |
||
|
E0850 |
3 CL LU ZUJD |
N |
Traction stand, freestanding, cervical traction |
Purchase |
||
|
E0860 |
3 CL LU Z LLI 3 |
N |
Traction equipment, overdoor, cervical |
Purchase |
||
|
E0870 |
3 CL LLI Z LU 3 |
N |
Traction frame, attached to footboard, extremity traction (e.g., Buck's) |
Purchase |
||
|
E0880 |
3 CL LLI Z LU 3 |
N |
Traction stand, freestanding, extremity traction (e.g., Buck's) |
Purchase |
||
|
E0890 |
NU EP UE |
N |
Traction frame, attached to footboard, pelvic traction |
Purchase |
||
|
E0900 |
NU EP UE |
N |
Traction stand, freestanding, pelvic traction (e.g., Buck's) |
Purchase |
||
|
E0910 |
NU EP UE |
N |
Trapeze bars, also known as Patient Helper, attached to bed, with grab bar |
Capped Rental |
||
|
E0910 |
NU |
RR |
N |
Trapeze bars, also known as Patient Helper, attached to bed, with grab bar |
Capped Rental |
|
|
E0920 |
NU EP UE |
N |
Fracture frame, attached to bed, includes weights |
Capped Rental |
||
|
E0930 |
NU EP UE |
N |
Fracture frame, freestanding, includes weights |
Capped Rental |
||
|
E0935 |
NU EP UE |
Y* |
Continuous passive motion exercise device for use on knee only |
Capped Rental |
||
|
E0940 |
NU EP UE |
N |
Trapeze bar, freestanding, complete with grab bar |
Capped Rental |
||
|
E0941 |
NU EP UE |
N |
Gravity assisted traction device, any type |
Capped Rental |
||
|
E0942 |
NU EP UE |
N |
Cervical head harness/halter |
Purchase |
||
|
E0944 |
NU EP UE |
N |
Pelvic belt/harness/boot |
Purchase |
||
|
E0945 |
NU EP UE |
N |
Extremity belt/harness |
Purchase |
||
|
E0946 |
NU EP UE |
N |
Fracture frame, dual with cross bars, attached to bed (e.g., Balken, Four Poster) |
Purchase |
||
|
E0947 |
NU EP UE |
N |
Fracture frame, attachments for complex pelvic traction |
Purchase |
||
|
E0948 |
NU EP UE |
N |
Fracture frame, attachments for complex cervical traction |
Purchase |
||
|
E0950 |
NU EP UE |
N |
Wheelchair accessory, tray, each |
Purchase |
||
|
E1130* |
NU EP UE |
Y* |
Standard wheelchair, fixed full-length arms, fixed or swing-away, detachable footrests |
Capped Rental |
||
|
E1130* |
NU |
U1 |
Y* |
Standard wheelchair, fixed full-length arms, fixed or swing-away, detachable footrests |
Rental Only |
|
|
E1140* |
NU EP |
Y* |
Wheelchair, detachable arms, desk or full-length, swing-away, detachable footrests |
Capped Rental |
||
|
E1150* |
NU EP |
Y* |
Wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests |
Capped Rental |
||
|
E1160* |
NU EP |
Y* |
Wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests |
Capped Rental |
||
|
E1224* |
NU EP UE |
Y* |
Wheelchair with detachable arms, elevating leg rests |
Capped Rental |
||
|
E1224* |
NU |
U1 |
Y* |
***(Footrests wheelchair with detachable arms, elevating leg rests) Wheelchair with detachable arms, elevating leg rests |
Rental Only |
|
|
E1340 |
NU |
N |
***(DME Repairs/Parts Only Repairs will not be approved for more than the allowed purchase price of new equipment. The manufacturer's invoice must be attached to the repair claim for all parts.) Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes |
Manually Priced |
||
|
E1340*** |
NU EP |
U1 U1 |
N |
***(Labor Only; a maximum of twenty [20] units [20 units = 5 hours of labor] per date of service is allowable.) Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes |
Manually Priced |
|
|
E1399 |
NU |
N |
Durable medical equipment, miscellaneous |
Manually Priced |
||
|
K0105 |
NU EP |
N |
IV hanger, each |
Purchase |
||
|
K0606 |
NU EP |
Y |
Automatic external defibrillator, with integrated electrocardiogram analysis, garment type (covered only for beneficiaries ages 18 and over) |
Capped Rental |
||
|
S8096*** |
NU EP |
N |
***(Peak flow meter used by asthmatic patients) Portable peak flow meter |
Purchase |
||
|
Z2211 (Bill on Paper) |
NU EP |
Y |
Power Kit/Batteries |
Purchase |
Procedure codes E0250*, E0255* and E0260* must be billed when hospital beds are purchased for Medicaid beneficiaries of all ages. Providers must only provide these purchase-only services to beneficiaries who are expected to require the bed for a long period of time. Each procedure code for hospital beds listed above may only be billed once every 10 years.
Procedure codes E0250*, E0255* and E0260* must also be used to bill for equipment that does not meet the purchase-only criteria. They are reimbursed on a capped rental basis. The capped rental items must be used until the equipment is no longer repairable or until it is no longer appropriate for the beneficiary as verified by the physician.
