December 3, 2013 - amerihealthcaritaspa.com · December 3, 2013 . Dear DME Provider, Revised Maximum Units of Service Policy . ... A4557 Lead wires, (e.g., apnea monitor), per pair

December 3, 2013

Dear DME Provider,

Revised Maximum Units of Service Policy

The Maximum Units of Service policy is updated on a regular basis and is subject to change. The unit(s) assigned on the attached list is not a guarantee of payment

The attached is an updated list of HCPCS codes that have been assigned a maximum number of units that may be billed for a 30-day period (unless otherwise noted) by the same provider. Some units and time frames have changed, so please review carefully. When you bill a number of units that exceeds the assigned maximum allowable for a given HCPCS code without prior-authorization, the total number of units will be adjusted to the assigned maximum allowed amount and the excess units will be denied. These billing limits will be in effect for dates of serve February 1, 2014 and after.

If you need to exceed the maximum number of allowable units, you must request prior authorization of the services from AmeriHealth Caritas Pennsylvania. Requests should be faxed to 1-866-755-9841.

If your claim is denied for exceeding the maximum allowable limits, you may appeal the claim denial. Clinical documentation to support units administered in excess of the maximum limits and medical necessity can be submitted through the provider appeals process. For more information on the AmeriHealth Caritas Pennsylvania appeal process, please visit our website at www.amerihealthcaritaspa.com

If you have any questions or concerns, please contact your Ancillary Account Executive or Provider Services at 1-800-521-6007.

Sincerely,

Jill Blessington Manager, Ancillary Contracting

http://www.amerihealthcaritaspa.com/

DME QUANTITY LIMITATIONS Effective February 1, 2013

1 Revised February 2013

HCPC Code

Procedure Description

Units Allowed

Definition of Units (30 day supply

unless otherwise noted)

Additional

Information/Time Limits

A4206 Syringe with needle, sterile 1 cc, each 150 each A4207 Syringe with needle, sterile 2CC, each 150 each A4208 Syringe with needle, sterile 3 cc, each 150 each A4209 Syringe with needle, sterile 5 cc or greater, each 150 each

A4212

Non-coring needle or stylet with or without cathet

5

each

Not covered - members

A4213 Syringe, sterile, 20 cc or greater, each 150 each A4215 Needle, sterile, any size, each 150 each A4216 Sterile water, saline and/or dextrose (diluent), 1 60 each A4217 Sterile water/saline, 500 ml 5 each A4218 Sterile saline or water, metered dose dispenser, 1 56 each A4221 Supplies for maintenance of drug infusion catheter 4 each A4222 Infusion supplies for external drug infusion pump, 12 each A4230 Infusion set for external insulin pump, non needle 16 each A4231 Infusion set for external insulin pump, needle typ 16 each

A4232

Syringe with needle for external insulin pump, sterile, 3cc

16

each

A4233 Replacement battery, alkaline (other than J cell), 4 each A4234 Replacement battery, alkaline, J cell, for use wit 4 each A4235 Replacement battery, lithium, for use with medical 1 each A4236 Replacement battery, silver oxide, for use with me 1 each A4244 Alcohol or peroxide, per pint 7 each

A4245

Alcohol wipes, per box

2

each


A4246

Betadine or pHisoHex solution, per pint

3

each


A4247

Ostomy Pouch, Drainable, With Extended Wear Barrier Attached, (1 Piece), Each

4

box


A4253 Blood glucose test or reagent strips for home bloo 4 box 50 strips per box A4257 Replacement lens shield cartridge for use with las 3 each A4258 Spring-powered device for lancet, each 2 each Per 365 Days A4259 Lancets, per box of 100 2 box 100 per box A4281 Tubing for breast pump, replacement 2 each Per 365 Days A4282 Adapter for breast pump, replacement 2 each Per 365 Days A4283 Cap for breast pump bottle, replacement 2 each Per 365 Days A4284 Breast shield and splash protector for use with br 2 each Per 365 Days A4285 Polycarbonate bottle for use with breast pump, rep 2 each Per 365 Days A4286 Locking ring for breast pump, replacement 2 each Per 365 Days A4310 Insertion tray without drainage bag and without ca 30 each A4311 Insertion tray without drainage bag with indwellin 2 each A4312 Insertion tray without drainage bag with indwellin 2 each

A4313

Insertion Tray without drainage bag, with indwelling cath. Foley type 3- way

2

each

Per 30 days

A4314 Insertion tray with drainage bag with indwelling c 2 each A4315 Insertion tray with drainage bag with indwelling c 2 each A4320 Irrigation tray with bulb or piston syringe, any p 6 each A4322 Irrigation syringe, bulb or piston, each 31 each A4324 Male external catheter, with adhesive coating, eac 90 each A4326 Male external catheter specialty type with integra 30 each

A4326

Male external catheter specialty type with integral collection chamber, each

30

each



HCPC Code


Units Allowed



Additional


A4327

Female external urinary collection device; meatal cup, each

5

each

A4328 Female external urinary collection device; pouch, each 31 each A4331 Extension drainage tubing, any type, any length, w 31 each A4332 Lubricant, individual sterile packet, each 300 each A4333 Urinary catheter anchoring device, adhesive skin a 15 each

A4333

Urinary catheter anchoring device, adhesive skin attachment, each

15

each

A4334 Urinary catheter anchoring device, leg strap, each 5 each A4334 Urinary catheter anchoring device, leg strap, each 5 each A4338 Indwelling catheter; Foley type, two-way latex wit 2 each A4340 Indwelling catheter; specialty type, (e.g., coude, 2 each A4344 Indwelling catheter, Foley type, two-way, all sili 2 each A4347 Male external catheter with or without adhesive, w 12 each A4349 Male external catheter, with or without adhesive, 100 each A4351 Intermittent urinary catheter; straight tip, with 200 each A4352 Intermittent urinary catheter; coude (curved) tip, 200 each A4353 Intermittent urinary catheter, with insertion supp 180 each A4354 Insertion tray with drainage bag but without cathe 2 each A4355 Irrigation tubing set for continuous bladder irrig 2 each A4357 Bedside drainage bag, day or night, with or withou 2 each A4358 Urinary drainage bag, leg or abdomen, vinyl, with 4 each A4361 Ostomy faceplate, each 4 each A4362 Skin barrier; solid, four by four or equivalent; e 60 each A4363 Ostomy clamp, any type, replacement only, each 1 each A4364 Adhesive, liquid or equal, any type, per oz 12 each A4365 Adhesive remover wipes, any type, per 50 2 box 50 per box A4367 Ostomy belt, each 2 each A4368 Ostomy filter, any type, each 30 each A4371 Ostomy skin barrier, powder, per oz 20 ounce A4373 Ostomy skin barrier, with flange (solid, flexible 30 each A4374 Ostomy skin barrier w/flange (solid/flexible/accor 20 each A4375 Ostomy pouch, drainable, with faceplate attached, 20 each A4376 Ostomy pouch, drainable, with faceplate attached, 45 each A4377 Ostomy pouch, drainable, for use on faceplate, pla 30 each A4380 Ostomy pouch, urinary, with faceplate attached, ru 60 each A4383 Ostomy pouch, urinary, for use on faceplate, rubbe 30 each A4384 Ostomy faceplate equivalent, silicone ring, each 10 each A4385 Ostomy skin barrier, solid 4x4 or equivalent, exte 100 each A4387 Ostomy pouch, closed, with barrier attached, with 105 each

A4388

Ostomy Pouch, Drainable, With Barrier Attached, With Built- In Convexity (1 Piece), Each

45

each

A4389

Ostomy Skin Barrier, With Flange (Solid, Flexible Or Accordion), Without Built-In Convexity, 4 X 4 Inches Or Smaller, Each

60

each

A4390 Ostomy pouch, drainable, with extended wear barrie 31 each A4397 Irrigation supply; sleeve, each 12 each A4400 Ostomy irrigation set 6 each A4402 Lubricant, per ounce 30 ounce A4404 Ostomy ring, each 12 each A4405 Ostomy skin barrier, non-pectin based, paste, per 12 ounce A4406 Ostomy skin barrier, pectin-based, paste, per ounc 12 ounce



HCPC Code


Units Allowed



Additional


A4407 Ostomy skin barrier, with flange (solid, flexible, 80 each A4408 Ostomy skin barrier, with flange (solid, flexible 60 each A4410 Ostomy skin barrier, with flange (solid, flexible 30 each A4411 Ostomy skin barrier, solid 4x4 or equivalent, exte 18 each Per 90 Days A4412 Ostomy pouch, drainable, high output, for use on a 60 each Per 60 Days A4413 Ostomy pouch, drainable, high output, for use on a 30 each

A4414

Ostomy Pouch, Closed, With Barrier Attached, With Filter (1 Piece), Each

60

each

A4416

Ostomy Pouch, Drainable, With Barrier Attached, With Filter (1 Piece), Each

180

each

A4419 Ostomy pouch, closed; for use on barrier with non- 60 each

A4424 Ostomy Pouch, Drainable; For Use On Barrier With Non- Locking Flange, With Filter (2 Piece System), Each

60

each

A4425

Conductive Gel Or Paste, For Use With Electrical Device (E.G., Tens, Nmes), Per Oz

60

each

A4426 Ostomy pouch, drainable; for use on barrier with l 20 each A4428 Ostomy pouch, urinary, with extended wear barrier 30 each A4430 Ostomy pouch, urinary, with extended wear barrier 30 each A4455 Adhesive remover or solvent (for tape, cement or o 16 ounce A4461 Surgical dressing holder, non-reusable, each 10 each A4463 Surgical dressing holder, reusable, each 2 each A4500 Surgical stockings below knee length, each 4 each A4510 Surgical stocking full-length, each 4 each A4554 Disposable underpads, all sizes, (e.g., ChuxOs) 300 each A4556 Electrodes, (e.g., apnea monitor), per pair 30 pairs A4557 Lead wires, (e.g., apnea monitor), per pair 4 pairs

A4558

Housing And Integrated Adhesive, For Use In A Tracheostoma Heat And Moisture Exchange System And/Or With A Tracheostoma Valve, Each

1

ounce

A4580 Cast supplies (e.g. plaster) 2 each A4600 Sleeve for intermittent limb compression device, r 4 each A4604 Tubing with integrated heating element for use wit 1 each Per 90 Days A4605 Tracheal suction catheter, closed system, each 45 each A4606 Oxygen probe for use with oximeter device, replace 6 each A4608 Transtracheal oxygen catheter, each 8 each A4614 Peak expiratory flow rate meter, hand held 1 unit 1 every 5 years A4615 Cannula, nasal 4 each A4617 Mouth piece 30 each A4618 Breathing circuits 1 per unit A4620 Variable concentration mask 2 each A4623 Tracheostomy, inner cannula 35 each A4624 Tracheal suction catheter, any type other than clo 300 each A4625 Tracheostomy care kit for new tracheostomy 30 each A4627 Spacer, bag or reservoir, with or without mask, fo 2 each Per 365 Days A4628 Oropharyngeal suction catheter, each 31 each A4629 Tracheostomy care kit for established tracheostomy 30 each A4635 Underarm pad, crutch, replacement, each 2 each A4636 Replacement, handgrip, cane, crutch, or walker, ea 2 each A4637 Replacement, tip, cane, crutch, walker, each 4 each A4657 Syringe, with or without needle, each 5 each A4660 Sphygmomanometer/blood pressure apparatus with cuf 1 each A4927 Gloves, non-sterile, per 100 5 box 100 per box



HCPC Code


Units Allowed



Additional


A4930 Gloves, sterile, per pair 100 pair A4931 Oral thermometer, reusable, any type, each 1 each A4932 Rectal thermometer, reusable, any type, each 1 each A5054 Ostomy pouch, closed; for use on barrier with flan 31 each A5061 Ostomy pouch, drainable; with barrier attached, (1 31 each A5062 Ostomy pouch, drainable; without barrier attached 20 each A5063 Ostomy pouch, drainable; for use on barrier with f 31 each A5081 Continent device; plug for continent stoma 180 each Per 90 Days A5105 Urinary suspensory; with leg bag, with or without 31 each A5112 Urinary leg bag; latex 4 each A5119 Skin barrier, wipes or swabs, per box 50 2 box 50 per box A5120 Skin barrier, wipes or swabs, each 300 each

A5500

For diabetics only, fitting (including follow-up) custom preparation and supply of off-the-shelf depth-inlay shoe manufa

2

shoe

Per 365 Days

A5512

For diabetics only, multiple density insert, direc

2

each

4 each (2 pairs) per 3- years for 21 and over. 16 each (8 pairs) per 3- years for 0 to 20 yrs of age

A5513

For diabetics only, multiple density insert, custo

2

each

4 each (2 pairs) per 3- years for 21 and over. 16 each (8 pairs) per 3- years for 0 to 20 yrs of age

A6011 Collagen based wound filler, gel/paste, per gram o 27 gram A6022 Collagen dressing, pad size more than 16 sq. in. b 10 each A6023 Collagen dressing, pad size more than 48 sq. in., 5 each A6206 Contact layer, 16 sq. in. or less, each dressing 120 each A6207 Contact layer, more than 16 sq. in. but less than 120 each A6208 Contact layer, more than 48 sq. in., each dressing 120 each A6224 Gauze, impregnated with other than water, normal s 60 each A6228 Gauze, impregnated, water or normal saline, pad si 60 each A6229 Gauze, impregnated, water or normal saline, pad si 60 each A6246 Hydrogel dressing, wound cover, pad size more than 30 each A6247 Hydrogel dressing, wound cover, pad size more than 30 each A6410 Eye pad, sterile, each 90 each A6442 Conforming bandage, non-elastic, knitted/woven, no 300 yard A6443 Conforming bandage, non-elastic, knitted/woven, no 300 yard A6444 Conforming bandage, non-elastic, knitted/woven, no 300 yard A6445 Conforming bandage, non-elastic, knitted/woven, st 300 yard A6446 Conforming bandage, non-elastic, knitted/woven, st 300 yard A6447 Conforming bandage, non-elastic, knitted/woven, st 300 yard A6448 Light compression bandage, elastic, knitted/woven, 300 yard A6449 Light compression bandage, elastic, knitted/woven, 300 yard A6450 Light compression bandage, elastic, knitted/woven, 300 yard A6451 Moderate compression bandage, elastic, knitted/wov 160 yard A6452 High compression bandage, elastic, knitted/woven, 160 yard A6453 Self-adherent bandage, elastic, non-knitted/non-wo 300 yard A6454 Self-adherent bandage, elastic, non-knitted/non-wo 300 yard A6455 Self-adherent bandage, elastic, non-knitted/non-wo 300 yard A6456 Zinc paste impregnated bandage, non-elastic, knitt 60 yard



HCPC Code


Units Allowed



Additional


A6457 Tubular dressing with or without elastic, any widt 60 linear yard A6501 Compression burn garment, bodysuit (head to foot), 2 each A6503 Compression burn garment, facial hood, custom fabr 2 each A6504 Compression burn garment, glove to wrist, custom f 2 each Per extremity/ 30 days A6505 Compression burn garment, glove to elbow, custom f 2 each Per extremity/ 30 days A6506 Compression burn garment, glove to axilla, custom 2 each Per extremity/ 30 days A6509 Compression burn garment, upper trunk to waist inc 2 each A6511 Compression burn garment, lower trunk including le 2 each A6512 Compression burn garment, not otherwise classified 1 each A6513 Compression burn mask, face and/or neck, plastic o 2 each A6530 Gradient compression stocking, below knee, 18-30 m 2 each Per 180 Days A6531 Gradient compression stocking, below knee, 30-40 m 2 each Per 180 Days A6532 Gradient compression stocking, below knee, 40-50 m 2 each Per 180 Days A6533 Gradient compression stocking, thigh length, 18-30 2 each Per 180 Days A6534 Gradient compression stocking, thigh length, 30-40 2 each Per 180 Days A6535 Gradient compression stocking, thigh length, 40-50 2 each Per 180 Days A6536 Gradient compression stocking, full length/chap st 2 each Per 180 Days A6537 Gradient compression stocking, full length/chap st 2 each Per 180 Days A6538 Gradient compression stocking, full length/chap st 2 each Per 180 Days A6539 Gradient compression stocking, waist length, 18-30 2 each Per 180 Days A6540 Gradient compression stocking, waist length, 30-40 2 each Per 180 Days A6541 Gradient compression stocking, waist length, 40-50 2 each Per 180 Days A6543 Gradient compression stocking, lymphedema 2 each Per 180 Days A6544 Gradient compression stocking, garter belt 2 each Per 180 Days A6550 Wound care set, for negative pressure wound therap 15 each A7000 Canister, disposable, used with suction pump, each 1 each A7001 Canister, non-disposable, used with suction pump, 1 each Per 180 Days A7002 Tubing, used with suction pump, each 4 each A7003 Administration set ,with small volume nonfiltered 4 each A7006 Administration set ,with small volume filtered pne 4 each A7007 Large volume nebulizer, disposable, unfilled, used 4 each A7009 Reservoir bottle, non-disposable, used with large 1 each Per 180 Days

A7010

Corrugated tubing, disposable, used with large vol

1

box

100 feet per box, 1 box per 60 Days

A7011

Corrugated tubing, non-disposable, used with large

2

box

10 feet per box, Units Per 365 Days

A7012 Water collection device, used with large volume ne 2 each A7013 Filter, disposable, used with aerosol compressor 2 each A7014 Filter, nondisposable, used with aerosol compresso 1 each Per 90 Days A7015 Aerosol mask, used with DME nebulizer 1 each A7016 Dome and mouthpiece, used with small volume ultras 2 each Per 180 Days A7030 Full face mask used with positive airway pressure 1 each Per 180 Days A7032 Cushion for use on nasal mask interface, replaceme 2 each A7033 Pillow for use on nasal cannula type interface, re 2 pair A7034 Nasal interface (mask or cannula type) used with p 1 each A7035 Headgear used with positive airway pressure device 1 each A7036 Chinstrap used with positive airway pressure devic 1 each A7037 Tubing used with positive airway pressure device 2 each Per 90 Days A7038 Filter, disposable, used with positive airway pres 6 each A7039 Filter, non disposable, used with positive airway 1 each A7046 Water chamber for humidifier, used with positive a 1 each Per 180 Days A7503 Filter holder or filter cap, reusable, for use in 31 each



HCPC Code


Units Allowed



Additional


A7505 Housing, reusable without adhesive, for use in a h 31 each A7507 Filter holder and integrated filter without adhesi 31 each

A7508

Tracheo-Esophageal Voice Prosthesis, Inserted By A Licensed Health Care Provider, Any Type

1

each

A7520 Tracheostomy/laryngectomy tube, non-cuffed, polyvi 4 each A7521 Tracheostomy/laryngectomy tube, cuffed, polyvinylc 4 each A7522 Tracheostomy/laryngectomy tube, stainless steel or 2 each A7523 Tracheostomy shower protector, each 1 each A7524 Tracheostoma stent/stud/button, each 4 each A7525 Tracheostomy mask, each 4 each A7526 Tracheostomy tube collar/holder, each 30 each A8000 Helmet, protective, soft, prefabricated, includes 2 each Per 365 Days A8001 Helmet, protective, hard, prefabricated, includes 2 each Per 365 Days A8002 Helmet, protective, soft, custom fabricated, inclu 2 each Per 365 Days A8003 Helmet, protective, hard, custom fabricated, inclu 2 each Per 365 Days A8004 Soft interface for helmet, replacement only 2 each Per 365 Days B4034 Enteral feeding supply kit; syringe, per day 31 each per 31 days B4035 Enteral feeding supply kit; pump fed, per day 31 each per 31 days B4036 Enteral feeding supply kit; gravity fed, per day 31 each per 31 days B4081 Nasogastric tubing with stylet 10 each B4082 Nasogastric tubing without stylet 10 each B4083 Stomach tube OLevine type 31 each B4086 Gastrostomy/jejunostomy tube, any material, any ty 10 each C1820 Generator, neurostimulator (implantable), with rec 1 each C1821 Interspinous process distraction device (implantab 1 each C8918 Magnetic resonance angiography with contrast, pelv 1 each C8957 Intravenous infusion for therapy/diagnosis; initia 1 each C9350 Microporous collagen tube of non-human origin, per 2 each C9351 Acellular dermal tissue matrix of non-humn origin, 2 each C9726 Placement and removal (if performed) of applicator 1 each E0110 Crutches, forearm, includes crutches of various ma 1 pair Per 365 Days E0111 Crutch, forearm, includes crutches of various mate 2 each Per 365 Days E0113 Crutch, underarm, wood, adjustable or fixed, each, 2 each Per 365 Days E0114 Crutches, underarm, other than wood, adjustable or 1 pair Per 365 Days E0116 Crutch, underarm, other than wood, adjustable or f 2 each Per 365 Days E0118 Crutch substitute, lower leg platform, with or wit 2 each Per 365 Days E0141 Walker, rigid, wheeled, adjustable or fixed height 1 each Per 3 calendar years E0143 Walker, folding, wheeled, adjustable or fixed heig 1 each Per 3 calendar years E0144 Walker, enclosed, four sided framed, rigid or fold 1 each Per 3 calendar years E0147 Walker, heavy duty, multiple braking system, varia 1 each Per 3 calendar years E0149 Walker, heavy duty, wheeled, rigid or folding, any 1 each Per 3 calendar years E0153 Platform attachment, forearm crutch, each 2 each Per 3 calendar years E0154 Platform attachment, walker, each 2 each Per 3 calendar years E0155 Wheel attachment, rigid pick-up walker, per pair 2 pair Per 3 calendar years E0159 Brake attachment for wheeled walker, replacement, 2 each Per 3 calendar years E0163 Commode chair, stationary, with fixed arms 1 each Per 3 calendar years E0190 Positioning cushion/pillow/wedge, any shape or siz 2 each Per 365 Days E0240 Bath/shower chair, with or without wheels, any siz 1 each Per 3 calendar years E0241 Bathtub wall rail, each 1 each Per 5 calendar years E0244 Raised toilet seat 1 each Per 3 calendar years E0247 Transfer bench for tub or toilet with or without c 1 each Per 3 calendar years E0248 Transfer bench, heavy duty, for tub or toilet with 1 each Per 3 calendar years



HCPC Code


Units Allowed



Additional


E0305 Bedside rail, half-length 2 each Per 3 calendar years E0310 Bedside rail, full-length 2 each Per 3 calendar years E0315 Bed accessory: board, table, or support device, an 2 each Per 365 Days E0325 Urinal; male, jug-type, any material 1 each Per 365 Days E0555 Humidifier, durable, glass or autoclavable plastic 1 each E0602 Breast pump, manual, any type 1 each Per 365 Days E0603 Breast pump, electric (AC and/or DC), any type 1 each Per Lifetime E0621 Sling or seat, patient lift, canvas or nylon 1 each Per 365 Days E0655 Nonsegmental pneumatic appliance for use with pneu 2 each Per 2 calendar years E0660 Nonsegmental pneumatic appliance for use with pneu 2 each Per 2 calendar years E0665 Nonsegmental pneumatic appliance for use with pneu 2 each Per 2 calendar years E0668 Segmental pneumatic appliance for use with pneumat 2 each Per 2 calendar years E0705 Transfer board or device, any type, each 1 each Per 3-calendar years E0950 Wheelchair accessory, tray, each 1 each E0951 Heel loop/holder, any type, with or without ankle 2 each E1821 Replacement soft interface material/cuffs for bi-d 2 each

K0603

Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each

2

each

K0739

Repair or nonroutine service for durable medical equipment

24

units

Per 15 minutes

L0100 Cranial orthosis (helmet), with or without soft in 2 each Per 365 Days L0110 Cranial orthosis (helmet), with or without soft-in 2 each Per 365 Days L0120 Cervical, flexible, non-adjustable (foam collar) 2 each Per 365 Days L0491 TLSO, sagittal-coronal control, modular segmented 1 each Per 365 Days L0492 TLSO, sagittal-coronal control, modular segmented 1 each Per 365 Days L0621 Sacroiliac orthosis, flexible, provides pelvic-sac 1 each Per 365 Days L0622 Sacroiliac orthosis, flexible, provides pelvic-sac 1 each Per 365 Days L0623 Sacroiliac orthosis, provides pelvic-sacral suppor 1 each Per 365 Days L0624 Sacroiliac orthosis, provides pelvic-sacral suppor 1 each Per 365 Days L0625 Lumbar orthosis, flexible, provides lumbar support 1 each Per 365 Days L0626 Lumbar orthosis, sagittal control, with rigid post 1 each Per 365 Days L0627 Lumbar orthosis, sagittal control, with rigid ante 1 each Per 365 Days L0628 Lumbar-sacral orthosis, flexible, provides lumbo-s 1 each Per 365 Days L0629 Lumbar-sacral orthosis, flexible, provides lumbo-s 1 each Per 365 Days L0630 Lumbar-sacral orthosis, sagittal control, with rig 1 each Per 365 Days L0631 Lumbar-sacral orthosis, sagittal control, with rig 1 each Per 365 Days L0632 Lumbar-sacral orthosis, sagittal control, with rig 1 each Per 365 Days L0633 Lumbar-sacral orthosis, sagittal-coronal control, 1 each Per 365 Days L0634 Lumbar-sacral orthosis, sagittal-coronal control, 1 each Per 365 Days L0635 Lumbar-sacral orthosis, sagittal-coronal control, 1 each Per 365 Days L0976 LSO, full corset 1 each Per 365 Days L1001 Cervical thoracic lumbar sacral orthosis, immobili 1 each Per 365 Days L1120 Addition to CTLSO, scoliosis orthosis, cover for u 4 each Per 365 Days L1280 Addition to TLSO, (low profile), rib gusset (elast 2 each Per 365 Days L1810 Knee orthosis, elastic with joints, prefabricated, 1 each Per 180 Days L2275 Addition to lower extremity, varus/vulgus correcti 2 each Per 180 Days L2387 Addition to lower extremity, polycentric knee join 1 each Per 365 Days L2415 Addition to knee lock with integrated release mech 2 each L2425 Addition to knee joint, disc or dial lock for adju 2 each L2760 Addition to lower extremity orthosis, extension, p 2 each L2770 Addition to lower extremity orthosis, any material 2 each L2820 Addition to lower extremity orthosis, soft interfa 2 each



HCPC Code


Units Allowed



Additional


L2840 Addition to lower extremity orthosis, tibial lengt 4 each L2860 Addition to lower extremity joint, knee or ankle, 2 each L3000 Foot, insert, removable, molded to patient model, 6 each Per 180 Days L3002 Foot, insert, removable, molded to patient model, 4 each Per 180 Days L3020 Foot, insert, removable, molded to patient model, 4 each Per 180 Days

L3040

Foot, arch support, removable, premolded, longitud

4

each

Quantity and age restrictions based on

L3050

Foot, arch support, removable, premolded, metatars

2

each


L3060

Foot, arch support, removable, premolded, longitud

4

each


L3140

Foot, abduction rotation bar, including shoes

1

each


L3201

Orthopedic shoe, oxford with supinator or pronator

2

each


L3202


2

each


L3203


2

each


L3204

Orthopedic shoe, hightop with supinator or pronato

4

each


L3206


4

each


L3207


4

each


L3215

Orthopedic footwear, ladies shoe, oxford, each

4

each




HCPC Code


Units Allowed



Additional


L3216

Orthopedic footwear, ladies shoe, depth inlay, eac

4

each


L3217

Orthopedic footwear, ladies shoe, hightop, depth i

4

each


L3219

Orthopedic footwear, mens shoe, oxford, each

4

each


L3221

Orthopedic footwear, mens shoe, depth inlay, each

4

each


L3222

Orthopedic footwear, mens shoe, hightop, depth inl

4

each


L3224

Orthopedic footwear, womanOs shoe, oxford, used as

4

each


L3225

Orthopedic footwear, manOs shoe, oxford, used as a

4

each


L3230

Orthopedic footwear, custom shoe, depth inlay, eac

4

each


L3250

Orthopedic footwear, custom molded shoe, removable

4

each


L3253

Foot, molded shoe Plastazote (or similar), custom

2

each


L3580

Orthopedic shoe addition, convert instep to Velcro

2

each


L3702 Elbow orthosis, without joints, may include soft i 1 each Per 180 Days L3730 Elbow orthosis, double upright with forearm/arm cu 2 each Per 365 Days L3763 Elbow wrist hand orthosis, rigid, without joints, 1 each Per 180 Days L3765 Elbow wrist hand finger orthosis, rigid, without j 1 each Per 180 Days L3806 Wrist hand finger orthosis, includes one or more n 2 each Per 180 Days L3808 Wrist hand finger orthosis, rigid without joints, 2 each Per 180 Days L3913 Hand finger orthosis, without joints, may include 1 each Per 180 Days L3915 Wrist hand orthosis, includes one or more nontorsi 2 each Per 180 Days



HCPC Code


Units Allowed



Additional


L3919 Hand orthosis, without joints, may include soft in 1 each Per 180 Days L3921 Hand finger orthosis, includes one or more nontors 1 each Per 180 Days L3933 Finger orthosis, without joints, may include soft 1 each Per 180 Days L3935 Finger orthosis, nontorsion joint, may include sof 1 each Per 180 Days L3961 Shoulder elbow wrist hand orthosis, shoulder cap d 1 each Per 180 Days L3964 Shoulder elbow orthosis, mobile arm support attach 2 each L3965 Shoulder elbow orthosis, mobile arm support attach 2 each L3966 Shoulder elbow orthosis, mobile arm support attach 2 each L3968 Should elbow orthosis, mobile arm support attached 2 each L3969 Shoulder elbow orthosis, mobile arm support, monos 2 each Per 180 Days L3970 SEO, addition to mobile arm support, elevating pro 2 each Per 180 Days L3972 SEO, addition to mobile arm support, offset or lat 2 each Per 180 Days L3974 SEO, addition to mobile arm support, supinator 2 each Per 180 Days L4205 Repair of orthotic device, labor component, per 15 40 each L5688 Addition to lower extremity, below knee, waist bel 2 each L5858 Addition to lower extremity prosthesis, endoskelet 2 each L5971 All lower extremity prosthesis, solid ankle cushio 2 each L5993 Addition to lower extremity prosthesis, heavy duty 2 each L5994 Addition to lower extremity prosthesis, heavy duty 2 each L6611 Addition to upper extremity prosthesis, external p 2 each L6621 Upper extremity prosthesis addition, flexion/exten 2 each L6624 Upper extremity addition, flexion/extension and ro 2 each L6639 Upper extremity addition, heavy duty feature, any 2 each L6677 Upper extremity addition, harness, triple control, 1 each L6703 Terminal device, passive hand/mitt, any material, 1 each L6704 Terminal device, sport/recreational/work attachmen 1 each L6706 Terminal device, hook, mechanical, voluntary openi 1 each L6707 Terminal device, hook, mechanical, voluntary closi 1 each L6708 Terminal device, hand, mechanical, voluntary openi 1 each L6709 Terminal device, hand, mechanical, voluntary closi 1 each L6883 Replacement socket, below elbow/wrist disarticulat 2 each L6884 Replacement socket, above elbow disarticulation, m 2 each L6885 Replacement socket, shoulder disarticulation/inter 2 each L7400 Addition to upper extremity prosthesis, below elbo 2 each L7401 Addition to upper extremity prosthesis, above elbo 2 each L7402 Addition to upper extremity prosthesis, shoulder d 2 each L7403 Addition to upper extremity prosthesis, below elbo 2 each L7404 Addition to upper extremity prosthesis, above elbo 2 each L7520 Repair prosthetic device, labor component, per&nbs 40 each L8000 Breast prosthesis, mastectomy bra 4 each Per 365 Days L8020 Breast prosthesis, mastectomy form 2 each Per 365 Days L8030 Breast prosthesis, silicone or equal 2 each Per 365 Days L8400 Prosthetic sheath, below knee, each 12 each L8420 Prosthetic sock, multiple ply, below knee, each 12 each L8480 Stump sock, single ply, fitting, above knee, each 6 each L8500 Artificial larynx, any type 1 each Per 180 Days L8501 Tracheostomy speaking valve 1 each Per 90 Days

L8509

Cleaning Device Used With Tracheoesophageal Voice Prosthesis, Pipet, Brush, Or Equal, Replacement Only, Each

1

each

Per 30 days/ included in kit



HCPC Code


Units Allowed



Additional


L8513

Cleaning Device Used With Tracheoesophageal Voice Prosthesis, Pipet, Brush, Or Equal, Replacement Only, Each

1

each

Per 30 days/ included in kit

L8695 External recharging system for battery (external) 1 each S8424 Gradient pressure aid (sleeve), ready made 2 each Per 180 Days S8428 Gradient pressure aid (gauntlet), ready made 2 each Per 180 Days S8490 Insulin syringes (100 syringes, any size) 3 each Per 60 Days V2020 Frames, purchases 1 each V2100 Sphere, single vision, plano to plus or minus 4.00 2 each V2101 Sphere, single vision, plus or minus 4.12 to plus 2 each V2102 Sphere, single vision, plus or minus 7.12 to plus 2 each V2200 Sphere, bifocal, plano to plus or minus 4.00D, per 2 each V2201 Sphere, bifocal, plus or minus 4.12 to plus or min 2 each V2202 Sphere, bifocal, plus or minus 7.12 to plus or min 2 each V2520 Contact lens, hydrophilic, spherical, per lens 48 each V2521 Contact lens, hydrophilic, toric, or prism ballast 2 each V2522 Contact lens, hydrophilic, bifocal, per lens 2 each V2523 Contact lens, hydrophilic, extended wear, per lens 2 each V2624 Polishing/resurfacing of ocular prosthesis 1 each Per 180 Days V2788 Presbyopia correcting function of intraocular lens 1 each

V5014

Repair/modification of a hearing aid

2

each

1 repair per hearing aid per day

V5160 Dispensing fee, binaural 1 each fee per 2 aids

V5242 Hearing aid, analog, monaural, CIC (completely in

2

each

1 per ear (per 365

V5243

Hearing aid, analog, monaural, ITC (in the canal)

2

each

1 per ear (per 365

V5248 Hearing aid, analog, binaural, CIC 1 each 1 pair (per 365 Days) V5249 Hearing aid, analog, binaural, ITC 1 each 1 pair (per 365 Days)

V5254

Hearing aid, digital, monaural, CIC

2

each

1 per ear (per 365

V5255

Hearing aid, digital, monaural, ITC

2

each

1 per ear (per 365

V5256

Hearing aid, digital, monaural, ITE

2

each

1 per ear (per 365

V5257 Hearing aid, digital, monaural, BTE 2 each 1 pair (per 365 Days) V5258 Hearing aid, digital, binaural, CIC 2 each 1 pair (per 365 Days) V5259 Hearing aid, digital, binaural, ITC 2 each 1 pair (per 365 Days) V5260 Hearing aid, digital, binaural, ITE 2 each 1 pair (per 365 Days) V5261 Hearing aid, digital, binaural, BTE 2 each 1 pair (per 365 Days) V5264 Ear mold/insert, not disposable, any type 2 each Per 90 Days V5265 Ear mold/insert, disposable, any type 2 each Per 90 Days V5266 Battery for use in hearing device 24 each

Documents

December 3, 2013 - amerihealthcaritaspa.com · December 3, 2013 . Dear DME Provider, Revised Maximum Units of Service Policy . ... A4557 Lead wires, (e.g., apnea monitor), per pair