DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES

DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES COVERAGE AND LIMITATIONS

HANDBOOK

UPDATE LOG DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLY SERVICES COVERAGE

AND LIMITATIONS HANDBOOK

How to Use the Update Log Introduction Changes to the handbook will be sent out as handbook updates. An update

can be a change, addition, or correction to policy. It may be either a pen and ink change to the existing handbook pages or replacement pages. It is very important that the provider read the updated material and file it in the handbook as it is the provider’s responsibility to follow correct policy to obtain Medicaid reimbursement.

Explanation of the Update Log

The provider can use the update log to determine if all the updates to the handbook have been received. Update No. is the number that appears on the front of the update. Effective Date is the date that the update is effective.

Instructions 1. Make the pen and ink changes and file new or replacement pages.

2. File the cover page and pen and ink instructions from the update in numerical order after the log.

If an update is missed, write or call the Medicaid fiscal agent at the address given in Appendix C of the Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221.

UPDATE NO. EFFECTIVE DATE Nov1999—Replacement Pages October 1999

May2000—Replacement Pages January 2000

May2000 Errata—Pen-and-Ink Correction January 2000

April2001—Replacement Pages April 2001

April2001—Errata April 2001

Jan2002—Replacement Pages January 2002

March 2003 – Replacement Pages March 2003

DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLY SERVICES

Coverage and Limitations Handbook

Table of Contents

Chapter/Topic Page Introduction Handbook Use and Format ...............................................................................ii Characteristics of the Handbook........................................................................iii Handbook Updates ...........................................................................................iv Chapter 1 – Provider Qualifications and Enrollment Purpose and Definitions .....................................................................................1-1 Provider Qualifications.......................................................................................1-3 Provider Enrollment ...........................................................................................1-5 Provider Responsibilites.....................................................................................1-7 Chapter 2 - Covered Services, Limitations and Exclusions Service Requirements ........................................................................................2-2 Equipment Purchase, Trade, or Rental................................................................2-7 Equipment Maintenance, Repair, and Renovation...............................................2-10 Ambulatory Aids ...............................................................................................2-11 Apnea Monitors ................................................................................................2-12 Augmentative and Alternative Communication Systems.......................................2-14 Bathroom and Toileting Aids..............................................................................2-23 Compressors.....................................................................................................2-23 Cribs (Safety) ....................................................................................................2-24 Glucose Monitors and Blood Lancets.................................................................2-24 Heat Lamps and Pads........................................................................................2-25 Home Enteral Supplies and Equipment ...............................................................2-25 Hospital Beds, Mattress, and Rails .....................................................................2-26 Infusion Pumps..................................................................................................2-28 Lymphedema Pump...........................................................................................2-29 Nebulizer...........................................................................................................2-30 Orthopedic Footwear ........................................................................................2-31 Orthotic Devices................................................................................................2-32 Osteogenesis Stimulator.....................................................................................2-33 Oxygen and Oxygen Related Equipment.............................................................2-33 Passive Motion Device ......................................................................................2-41

Patient Lifts .......................................................................................................2-42 Peak Flow Meter ..............................................................................................2-42 Pediatric Dynamic Splinting Device ....................................................................2-43 Pressure Ulcer Care ..........................................................................................2-43 Phototherapy (Bilirubin) Light with Photometer...................................................2-44 Prosthetic Devices.............................................................................................2-45 Prosthetic Eyes..................................................................................................2-45 Resuscitator Bag................................................................................................2-46 Suction Machines ..............................................................................................2-46 Traction Equipment............................................................................................2-47 Trapeze Equipment............................................................................................2-48 Ventilator and Respiratory Equipment ................................................................2-48 Wheelchairs.......................................................................................................2-53 Appendix A: Summary of Oxygen Coverage .....................................................A-1 Chapter 3 - Procedure Codes and Fees Reimbursement Information................................................................................3-1 How to Read the Fee Schedule..........................................................................3-3 Non-Classified Procedure Codes.......................................................................3-7 By Report (BR).................................................................................................3-8 Appendix B: Procedure Codes and Fee Schedule for

All Medicaid Recipients...................................................................................B-1 Appendix C: Procedure Codes and Fee Schedule for

Recipients Under 21........................................................................................C-1

DME/Medical Supply Services Coverage and Limitations Handbook

May 1996 i

INTRODUCTION TO THE HANDBOOK

Overview

Introduction This chapter introduces the format used to prepare the Medicaid

Reimbursement and Coverage and Limitations Handbooks and tells the reader how to use the handbooks.

Background The Coverage and Limitations Handbook explains covered services, their

limits and who is eligible to receive them. It is to be used with the Reimbursement Handbook which describes how to complete and file claims for reimbursement by Medicaid.

Legal Authority The Medicaid program is authorized by Title XIX of the Social Security Act

and Title 42, Code of Federal Regulations. The Florida Medicaid program is authorized by Chapter 409, Florida Statutes (F.S.) and Chapter 59G, Florida Administrative Code (F.A.C.).

Federal Regulations, Florida Statutes, and the Florida Administrative Code, which deal with the purpose, implementation, and administration of each Medicaid program, are cited for reference in each program Coverage and Limitations Handbook.

In This Chapter This chapter contains: TOPIC PAGE

Handbook Use and Format ii

Characteristics of the Handbook iii

Handbook Updates iv


May 1996 ii

Handbook Use and Format

Purpose The purpose of the Medicaid handbooks is to furnish the Medicaid provider

with the policies and procedures needed to receive reimbursement for covered services provided to eligible Florida Medicaid recipients.

The handbooks provide descriptions and instructions on how and when to complete forms, letters or other documentation.

“Provider” The term “provider” is used to describe any entity, facility, person or group

who is enrolled in the Medicaid program and renders services to Medicaid recipients and bills Medicaid for services.

“Recipient” The term “recipient” is used to describe an individual who is eligible for

Medicaid. Coverage and Limitations Handbook

Each service handbook is named for the service it describes and is referred to as a "Coverage and Limitations Handbook." A provider who furnishes more than one type of service will have more than one coverage and limitations handbook.

Reimbursement Handbook

Each reimbursement handbook is named for the claim form that it describes. A provider who bills on more than one type of claim form will have more than one reimbursement handbook.

Chapter Numbering System

The first page of each chapter designates the chapter number. The chapter number will appear as the first number of the page number at the bottom of each page in the handbook.

Page Numbering Pages are numbered consecutively by chapter. Page numbers follow the

chapter number found at the bottom of each page.


May 1996 iii

Handbook Use and Format, continued

White Space The "white space" throughout a handbook is characteristic of the handbook

format style. It enhances readability and allows space for writing notes during training and for on-the-job reference.

Characteristics of the Handbook

Format The format used in this handbook represents a concise and consistent way of

displaying complex, technical material. Information Block One of the major features of the format is the information block, which

replaces the traditional paragraph. Blocks are separated by horizontal lines.

The block consists of one or more paragraphs or diagrams about a portion of a subject. Each block is identified or named with a label.

Label Labels or names are located in the left margin of each information block.

They describe the content or function of the block.

Labels provide key subject matter identification which facilitates scanning and locating information quickly within a chapter or section within a chapter.

Note Note: is used most frequently to refer the user to material located elsewhere

in a handbook that is pertinent to the subject being addressed within the information block.

Note: also refers the user to other documents or policies contained in other handbooks.


May 1996 iv

Characteristics of the Handbook , continued

Topic Roster Each chapter contains a topic roster which lists the major subject areas

covered in the chapter and gives the page number where the subject can be found. This topic roster serves as a table of contents for major sections within each chapter.

Forms Copies of all the forms discussed in the handbook appear in the section of

the handbook that describes and discusses the particular document.

Handbook Updates

How Changes Are Updated

The Medicaid handbooks will be updated as needed.

Lengthy changes or multiple changes that occur at the same time will be sent on replacement pages.

Brief changes will be sent as pen and ink updates. The pen and ink updates will be incorporated on replacement pages the next time replacement pages are produced.

Update Log A page designated as the log will accompany handbook updates. This log

serves as a reference for the provider to be sure that each update has been received.

An “Update No.” will be indicated in the first column on the update log. The second column is titled the “Update Issued” and indicates the date that the update was issued.

Numbering Update Pages

Updated replacement pages will have the same number as the page they are replacing. If additional pages are required, the new pages will carry the same number as the proceeding replacement page with an alphabetic character in ascending order.


May 1996 v

Handbook Updates, continued

Effective Date of New Material

The month and year that the new material is effective will appear in the bottom left corner of each page. The provider can check this date to ensure that the material being used is the most current and up to date.

If an information block has an effective date that is different from the effective date on the bottom of the page, the effective date for the information block will be included in the label.

Identifying New Information

New material will be indicated by vertical, gray-shaded lines. The following information blocks give examples of how new labels, new information blocks, and new or changed material within an information block will be indicated.

New Label A new label for an existing information block will be indicated by a vertical

line to the left and right of the label only. New Label/New Information Block

A new label and a new information block will be identified by a vertical line to the left of the label and to the right of the information block.

New Material in an Existing Information Block

New or changed material within an existing information block will be indicated by a vertical line to the left and right of the information block.

New or Changed Paragraph

A paragraph within an information block that has new or changed material will be indicated by a vertical line to the left and right of the paragraph.

Paragraph with new material.


April 2001 1-1

CHAPTER 1 DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLY

SERVICES PROVIDER QUALIFICATIONS AND ENROLLMENT

Overview

Introduction This chapter describes the purpose of the durable medical equipment

(DME) and medical supplies program, the legal authority regulating the program, and provider qualifications, enrollment, and responsibilities.

Legal Authority The Medicaid DME and medical supplies program is authorized by Title

XIX of the Social Security Act and Title 42, Code of Federal Regulations (C.F.R.), Part 440.70. The program was implemented through Chapter 409, Florida Statute (F.S.) and the Florida Administrative Code (F.A.C.) Chapter 59G.

In This Chapter This Chapter contains:

TOPIC PAGE

Purpose and Definitions 1-1

Provider Qualifications 1-3

Provider Enrollment 1-5

Provider Responsibilities 1-7

Purpose and Definitions

Purpose The purpose of the DME and medical supplies program is to promote,

maintain, or restore health and minimize the effects of illness, disability, or a disabling condition.


April 2001 1-2

Purpose and Definitions, continued

Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221

This handbook is intended for use by DME and medical suppliers who provide services to Medicaid recipients. It must be used in conjunction with the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, which contains general information about the Medicaid program and procedures for submitting claims for payment.

Durable Medical Equipment (DME)

DME is defined as medically-necessary equipment that can withstand repeated use, serves a medical purpose, and is appropriate for use in the recipient’s home as determined by the Agency for Health Care Administration (AHCA).

Medical Supplies Medicaid reimbursable medical supplies are defined as medically-necessary

medical or surgical items that are consumable, expendable, disposable, or non-durable and appropriate for use in the recipient’s home.

Orthotic Devices Medicaid reimbursable orthotic devices are defined as medically-necessary

devices or appliances that support or correct a weak or deformed body part, or restrict or eliminate motion in a diseased or injured part of the body.

Prosthetic Devices Medicaid reimbursable prosthetic devices are defined as medically-necessary

artificial devices or appliances that replace all or part of a permanently inoperative or missing body part.


April 2001 1-3

Provider Qualifications

Who Can Provide Services

The following entities may enroll in the Medicaid DME and medical supplies program:

• Businesses and pharmacies that supply DME and medical supplies; • Home health agencies; and • Physicians, optometrists, and opticians who supply artificial prosthetic

eyes. Qualification Requirements

To enroll as a Medicaid provider, a DME and medical supply entity must meet the following criteria:

• Be licensed by the local government agency as a business or merchant or provide documentation from the city or county authority that no licensure is required;

• Be licensed by the Department of Health, Medical Quality Assurance, Board of Orthotics and Prosthetics, if providing orthotics and prosthetic devices;

• Be licensed by the Agency for Health Care Administration, Division of Health Quality Assurarnce, in possession of a Home Health Equipment license;

• Be in compliance with all applicable laws relating to qualifications or licensure; and

• Have an in-state business location or be located not more than fifty miles from the Florida state line.

Note: See Chapter 2, Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for additional information on Medicaid provider qualifications.


April 2001 1-4

Provider Qualifications, continued

Medical Oxygen Retailers

To be reimbursed for providing oxygen and oxygen related equipment, the provider must add specialty code 69 (oxygen) to his provider enrollment application and submit a copy of his oxygen retailer permit issued by the Department of Health, Central Pharmacy.

Pharmacy providers who provide DME and bill Medicaid for oxygen must submit copies of their Department of Health pharmacy permits with their Provider Enrollment Applications.

The oxygen provider must have a licensed certified respiratory therapy technician, registered respiratory therapist, or a registered nurse under contract or on staff.

Note: See Chapter 2 for additional information about Oxygen and Oxygen Related Equipment.

Pharmacy Providers

Pharmacy providers automatically receive a durable medical equipment (DME) location code when they first enroll as a pharmacy. To be reimbursed for DME and medical supplies, the pharmacy provider must request activation of the location code by sending a request letter to the Medicaid fiscal agent to request activitation of the DME locator code. The letter must contain an original signature. Faxed letters will not be accepted. Mail the letter to:

ACS Provider Enrollment P.O. 7070 Tallahassee, Florida 32314-7070

When the DME location code is activated, the fiscal agent will send the pharmacy provider a DME and Medical Supply Services Coverage and Limitations Handbook and the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221. All DME billing must be on the HCFA-1500 claim form using the pharmacy’s provider number with the unique DME locator code.

Operational at Time of Enrollment

DME and medical supply entities must meet all the Medicaid provider requirements and qualifications and their businesses must be fully operational before they can be enrolled as Medicaid providers.


April 2001 1-5


April 2001 1-6

Provider Enrollment

General Enrollment Requirements

DME and medical supply providers must meet the general Medicaid provider enrollment requirements that are contained in Chapter 2 of the Medicaid Provider Reimbursement Handbook, HFCA-1500 and Child Health Check-Up 221. In addition, DME and medical supply providers must meet the specific enrollment requirements that are listed in this section.

One Provider Per Location

Medicaid can only enroll one DME and medical supply provider per physical location. If two or more DME and Medicaid supply entities share a physical location, only one can enroll as a Medicaid provider.

Multiple Locations Providers who have offices at more than one location must have a separate

location code for each location. A location code is a physical location identifier that corresponds to the last two digits of the provider’s Medicaid number. Providers must use the location code assigned to the office location when billing for services provided at that location. The provider must submit a Medicaid Provider Enrollment application to enroll an additional location. The application must include an effective date for the new location. Enrollment Applications can be obtained from the Medicaid fiscal agent by calling 800-289-7799 or from its website at http://floridamedicaid.consultec-inc.com. Any closure of a practice location must also be reported to the fiscal agent in writing on office letterhead stationery, along with the effective date of the closure.


April 2001 1-7

Provider Enrollment, continued

Surety Bond Requirement

A surety bond must be submitted as part of the enrollment application by the provider type unless it is owned and operated by government entities. One $50,000 bond is required for each provider location up to a maximum of five (5) bonds statewide or an aggregate bond of $250,000 statewide.

Bond Renewal Durable medical equipment and medical supply providers must renew their

bonds annually unless a continuous bond is on file. Renewal must be made at least 30 days in advance of the termination date to ensure there is no break in services (termination because of an expired bond).

Licenses/Permits Requirements

Durable medical equipment and suppliers must have one of the following to enroll:

• Pharmacy providers should submit a copy of their pharmacy permit acquired from the Department of Health;

• Oxygen providers should submit a copy of their oxygen retailer permit issued from the Department of Health;

• Any required Home Medical Equipment (HME) license, issued by the Agency for Health Care Administration; or

• Orthotics and Prosthetics licenses.


April 2001 1-8

Provider Enrollment, continued

Site Visit Requirement

A DME and medical supply provider must have a site visit before the provider’s enrollment application can be approved. Additional locations must also receive site visits before they can be approved for enrollment. When a provider receives a site visit, it does not mean that the provider will be approved for Medicaid participation. Medicaid reserves the right to contract with a private entity to conduct site visits.

Site visits are not required for the following DME and medical supply providers: • Providers who are associated with pharmacies; • Providers who are associated with rural health clinics; and • Providers who provide only orthotic or prosthetic devices and who

provide copies of their professional licenses from the Department of Health, Medical Quality Assurance, Board of Orthotics and Prosthetics, with their enrollment applications.

Provider Responsibilities

General Requirements

In addition to the general provider requirements and responsibilities that are contained in Chapter 2 of the Medicaid Provider Reimbursement Handbook, HFCA-1500 and Child Health Check-Up 221, DME and medical supply providers are also responsible for the provisions contained in this section.


April 2001 1-9

Provider Responsibilities, continued


A DME and medical supply provider is responsible for furnishing and supervising all aspects of DME and medical supply service provisions. A DME and medical supply provider must honor warranties and maintain and repair equipment.

All products and items must be: • Appropriate; • Used for the purpose for which they were designed; • Reasonable and effective in meeting the medical needs of the recipient;

and • Of equal quality as those furnished to non-Medicaid patients.

Record Keeping Requirements

In addition to the specific documentation that is required for the covered items listed in Chapter 2 of this handbook, DME and medical supply providers must follow the record keeping requirements listed in Chapter 2 of the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221.

Home Medical Equipment (HME)

Title XIX, Chapter 400, Part X of the Florida Statutes contains regulations regarding Home Medical Equipment. According to S.400.93 F.S., any person or entity that holds itself out to the public as providing home medical equipment and services or accepts physician orders for home medical equipment and services, or any person or entity that holds itself out to the public as providing home medical equipment that typically requires home medical services must be licensed by the Agency for Health Care Administration to operate or provide home medical equipment and services in Florida. A separate license is required of all home medical equipment providers operating on separate premises, even if the providers are operated under the same management.


April 2001 1-10

Provider Responsibilities, continued

HME Providers Exempt from Licensure

Providers exempt from an HME license are those operated by the federal government, nursing homes, assisted living facilities, home health agencies, hospices, intermedicate care facilities, hospitals and ambulatory surgical centers, manufacturers and wholesale distributors when not selling directly to suppliers only, suppliers of consumable and disposable items only, and licensed health care practitioners who utilize HME in the course of their practice, but do not sell or rent HME to their patients. Questions regarding HME licensure, may be directed to the Agency’s HME unit at (850) 414-6010.


April 2001 1-11

This page intentionally left blank.


April 1998 2-1

CHAPTER 2 DURABLE MEDICAL EQUIPMENT AND MEDICAL SUPPLY

SERVICES COVERED SERVICES, LIMITATIONS AND EXCLUSIONS

Overview

Introduction This chapter describes durable medical equipment (DME), medical supplies,

orthotic and prosthetic devices, the service requirements, and limitations. In This Chapter This chapter contains: TOPIC PAGE

Service Requirements 2-2 Equipment Purchase, Trade, or Rental 2-7 Equipment Maintenance, Repair, and Renovation 2-10 Ambulatory Aids 2-11 Apnea Monitors 2-12 Augmentative and Alternative Communication Systems 2-14 Bathroom and Toileting Aids 2-23 Compressors 2-23 Cribs (Safety) 2-24 Glucose Monitors and Blood Lancets 2-24 Heat Lamps and Pads 2-25 Home Enteral Supplies and Equipment 2-25 Hospital Beds, Mattress, and Rails 2-26 Infusion Pumps 2-28 Lymphedema Pump 2-29 Nebulizer 2-30 Orthopedic Footwear 2-31 Orthotic Devices 2-32 Osteogenesis Stimulator 2-33 Oxygen and Oxygen Related Equipment 2-33 Passive Motion Device 2-41 Patient Lifts 2-42 Peak Flow Meter 2-42


April 1998 2-2

In This Chapter Pediatric Dynamic Splinting Device 2-43 (continued) Pressure Ulcer Care 2-43 Phototherapy (Bilirubin) Light with Photometer 2-44 Prosthetic Devices 2-45 Prosthetic Eyes 2-45 Resuscitator Bag 2-46 Suction Machines 2-46 Traction Equipment 2-47 Trapeze Equipment 2-48 Ventilator and Respiratory Equipment 2-48 Wheelchairs 2-53 Non-Covered Services and Exclusions 2-56 Appendix A: Summary Of Oxygen Coverage A-1

Service Requirements

Introduction Many DME services are available only to recipients under 21 years of age. To

determine if a service is available to all recipients or just a specific range of recipients see the DME Fee Schedule in Chapter 3 of this handbook, Appendix B: For All Medicaid Recipients and Appendix C: For Recipients Under Age 21.

Prescribers DME/medical supplies, orthotic, or prosthetic devices must be prescribed by

the Medicaid recipient’s attending physician, physician assistant (PA), advanced registered nurse practitioner (ARNP), or podiatrist.

DME/Medical Supplies Provided Through Home Health Agencies

Medicaid reimburses home health agencies for DME/medical supplies furnished by qualified providers in accordance with the physician approved plan of care.

Plan Of Care A plan of care is an individualized written program for a recipient that is

developed by health care professionals including the attending physician. The plan of care is designed to meet the medical, health, and rehabilitative needs of the recipient.


April 1998 2-3


July 1997 2-4

Service Requirements, continued

Medical Necessity Medicaid reimburses for services that are determined medically necessary, do

not duplicate another provider’s service, and are: • individualized, specific, consistent with symptoms or confirmed diagnosis of

the illness or injury under treatment, and not in excess of the patient’s needs;

• not experimental or investigational; • reflective of the level of services that can be safely furnished and for which

no equally effective and more conservative or less costly treatment is available statewide; and

• furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider.

The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods, or services medically necessary or a covered service. Note: See Appendix D, Glossary, in the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for the definition of medically necessary.

Acceptable Medical Necessity Documentation

Medical necessity must be established for each service and documented on a signed and dated: • prescription—prescriptions may be dated by the physician after service has

been initiated, but cannot be dated more than 14 days after initiation; • Certificate of Medical Necessity (CMN)—Medicaid prohibits vendors

from preparing the entire CMN; • established plan of care; or • hospital discharge plan.

Required Information

The documentation must include the following information:

• the recipient’s name, • the attending practitioner’s name and license number, and • Medicaid or Medicare provider number.


April 2001 2-5


Medical Necessity For Medical Supplies

The medical necessity for disposable medical supplies must be redetermined every six months.

Medical Necessity For One Time Purchase

When DME, orthotic, or prosthetic devices are a one time purchase, medical necessity is required with each request.

Medical Necessity For Rental Items

The medical necessity for a rented item is based on the length of time specified in the prescription, CMN, plan of care, or hospital discharge plan. The exceptions to this policy are apnea monitors and oxygen.

Note: See medical necessity renewal under Apnea Monitor and Oxygen and Oxygen Related Equipment in this chapter.

Service Criteria DME/medical supplies, orthotics, and prosthetic devices must be:

• functionally appropriate, • adequate for the intended medical purpose, • for conventional use, and • for the exclusive use of the recipient.

Medical Supplies To be reimbursed by Medicaid, medical supplies must be needed for use with

one of the following: • colostomy, urostomy, ileostomy appliances; • surgical, wound, and burn dressings; • gastric feeding sets and supplies; • urinary catheters, irrigation apparatus, and related items; • tracheostomy and endotracheal care supplies; • disposable items, which if not provided could reasonably cause the

recipient to require emergency treatment, become hospitalized, or be placed in a long term care facility; or

• support of Medicaid covered DME equipment used by the recipient.


July 1997 2-6


Supply Quantities Medical supply quantities must not exceed one month’s usage.

Prescriptions for disposable supplies are effective for only twelve months. After twelve months, a new prescription will be required from the physician.

Place Of Residence DME/medical supplies, orthotic and prosthetic devices are only reimbursed for

an eligible Medicaid recipient who lives in a non-institutional setting. Exception To Place Of Residence

Recipients under 21 years of age who reside in a nursing facility may be eligible for a customized wheelchair, some customized orthotic and prosthetic devices, and AAC devices.

Recipients under 21 years of age who are hospital inpatients may be eligible for customized orthotic and prosthetic devices prior to discharge.

Recipients who reside in an assisted living facility may be eligible for a customized wheelchair and other DME items.

Prior Authorization (PA)

DME procedures that require prior authorization are: • customized wheelchairs, specially sized and constructed (K0008, K0013); • durable medical equipment, miscellaneous (E1399); • substantial repairs or replacement of components or parts for medical

equipment owned by the recipient (W6091); • hospital beds (E0250 and E0255) and new heavy duty hospital beds

(E0298); and • augumentative/alternative communication devices (K codes)

Note: See Chapter 7 in the Medicaid Provider Reimbursement Handbook, HCFA-1500 Child Health Check-Up 221, for information about prior authorization.


April 2001 2-7


PA Documentation Requirements

DME providers must submit the following information with a prior authorization request: • a full description of the item; • the manufacturer’s name and address; • the model and serial number; • a list of parts, components, attachments, or special features; • if new or used equipment, purchased, or rented; • the acquisition cost; • the effective date of the item; • medical documents that justify all unique features and construction; • the diagnosis of the recipient’s condition and diagnosis code using the most

current version of the International Classification of Diseases, Clinical Modification (ICD-9-CM);

• the recipient’s prognosis, if significant; • the recipient’s physical limitations; • the estimated length of time the item will be required; and • documentation that a qualified individual gave instructions to the recipient, if

necessary, regarding the frequency and use of the item. MediPass Authorization

Effective March 1, 1997

All DME and medical supplies must be authorized by the recipient’s MediPass primary care provider, if the recipient is enrolled in MediPass.

Note: See Chapter 1, Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for information on obtaining MediPass authorization.


July 1997 2-8


Exceptions To Service Limits

Service limits can be exceeded only for recipients under 21. If the service limits must be exceeded, the additional services must be: • medically necessary, • meet all program requirements, • be authorized by the recipient’s MediPass provider if the recipient is

enrolled in MediPass, and • documented, with the medical necessity documentation attached to paper

claims and sent to the appropriate local area Medicaid office for processing.

Providers should consult with the area Medicaid office on DME policy.

Note: See Appendix C, Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for the area Medicaid offices telephone numbers and addresses.

Equipment Purchase, Trade, or Rental

Purchasing New Equipment

Medicaid requires that equipment be warranted by the provider or manufacturer for a minimum of one year. No replacement or repairs will be reimbursed for equipment within the first year of service. The Medicaid reimbursement includes: • all elements of the manufacturer’s warranty; • all routine or special equipment servicing to the extent it is provided to non-

Medicaid persons; • all adjustments and modifications needed by the recipient to make the item

useful and functional during the first year; • delivery, set-up and installation of equipment in the home, and if possible,

to the appropriate room in the home, if home delivery is usual and customary for the item;

• training and instruction to the recipient or caregiver in the safe, sanitary, effective, and appropriate use of the item and necessary servicing and maintenance to be done by the user; and

• providing the recipient or caregiver with all manufacturer’s instructions, servicing manuals, and operating guides needed for routine service and operation.


May 1996 2-9

Equipment Purchase, Trade, or Rental, continued

Used Equipment When used equipment is furnished to a recipient, the provider must:

• Obtain a written signed and dated agreement from the recipient, to provide used equipment;

• Ensure that equipment is functionally sound and in good operating condition;

• Ensure that the product or item furnished includes the required “warranty” conditions listed under Purchasing New Equipment;

• Ensure that the used equipment is fully serviced and attractively re-conditioned;

• Ensure that repaired equipment or equipment with replaced parts is equivalent in quality and condition to the manufacturer’s warranty on a similar new item; and

• Furnish all routine or special equipment servicing, to the extent it is provided to individuals who are not Medicaid recipients.

Note: See Used Equipment Billing in Chapter 3 of this handbook for additional information.

Repairs DME, medical supplies, orthotics, and prosthetics coverage includes general

repairs and service of equipment that is owned and used by a recipient. No repair will be reimbursed for equipment within the first year of service for any recipient.


October 1999 2-10


Trade When Medicaid purchased equipment is no longer suitable because of growth,

development, or changes to the recipient’s condition, Medicaid and the provider may negotiate a good faith trade-in of the unneeded item.

The provider must reflect the pro-rated trade-in amount on the claim for the new equipment purchased.

Rental Discontinuation

The provider may not discontinue the rental service unless medical necessity ends, the recipient is no longer eligible for Medicaid, or the rent-to-purchase period has ended.

Rent-to-Purchase Equipment

When equipment is rent-to-purchase, Medicaid’s reimbursement amount is divided over a ten-month period. At the end of the tenth months, the equipment becomes the property of the Medicaid recipient.

Rental Agreement A rental agreement between a provider and recipient may not be discontinued

without the consent of the recipient or caregiver. Provider Responsibilities

When rental equipment is furnished to a recipient, the provider must:

• service the rental equipment, including maintenance, repair, or replacement of all expendable parts or items;

• substitute like equipment at no additional cost when broken or when damaged equipment is being repaired; and

• maintain in his or her files a signed receipt that the recipient received the equipment and was trained on its proper use.


April 2001 2-11


Replacement Equipment

Replacement equipment will not be reimbursed in cases of misuse, abuse, neglect, loss, or wrongful disposition of equipment. If a piece of equipment is stolen, a police or insurance report will be required documentation in order to replace the stolen item. Medicaid may also replace certain items when medical necessity changes.

Equipment Maintenance, Repair, and Renovation

Maintenance Requirements

Medicaid will reimburse maintenance of equipment when the following conditions are met:

• maintenance was performed by an authorized technician; • the equipment is covered by Medicaid; • the equipment is owned by the recipient or the recipient’s family; • the recipient is the sole user of the equipment; • no other source is available to pay for the needed repairs; • the item is still medically necessary; and • the damage is not due to abuse or misuse. Note: Some maintenance requires prior authorization, see Chapter 7 of the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for instructions on how to request a prior authorization.

Routine Maintenance By A Recipient

The recipient or caregiver is responsible to perform routine maintenance as described in the manufacturer’s operating manual. This includes testing, cleaning, regulating, and lubricating the equipment as needed.

Non-Routine Maintenance And Repair

Medicaid may reimburse a provider for non-routine maintenance and repairs (E1340) needed to keep durable medical equipment functional.

Note: This procedure requires a report of approval and pricing. See Chapter 3 of this handbook for information on By Report.


April 2001 2-12

Equipment Maintenance, Repair, and Renovation, continued

Substantial Repair Or Renovation

Providers may request prior authorization for substantial repairs or renovation (W6091) of durable medical equipment. The request for prior authorization must identify the item and detail the proposed repairs. Maintenance requirements listed above also apply to substantial repairs. When repairs or maintenance results in the need to replace equipment with rental equipment temporarily, the rental period must not exceed seven days. Note: See Chapter 7 in the Medicaid Provider Reimbursement Handbook, HCFA-1500 Child Health Check-Up 221, for information on requesting prior authorizations.

Reimbursement Reimbursement for DME equipment maintenance is limited to the amount

necessary to make the item serviceable but not to exceed 75 percent of the cost of an equivalent replacement.

Ambulatory Aids

Description An ambulatory aid is a medically necessary item that is needed because the

recipient has impaired ambulation. Ambulatory aids include canes, crutches, and walkers that are to be complete with tips, pads, and grips.

Pediatric Forearm Crutches

Medicaid may reimburse for pediatric forearm crutches (W9761). The following must be documented in the recipient’s record: height, weight, growth patterns, and expected benefit for ambulating.

Pediatric Postural Control Walker

Pediatric postural control walker may be reimbursed as an ambulating aid. There must be an expected benefit in gait training for the recipient.

Wheeled Walkers Wheeled walkers with a seat and wheel locks may be reimbursed when

prescribed in lieu of a wheelchair.


November 1997 2-13

Apnea Monitors

Description An apnea monitor is a device that meets the Food and Drug Administration’s

510 (k) guidelines and is equivalent to the device marketed in interstate commerce prior to May 28, 1976; or to a device that has been classified into Class I or Class II since the enactment of the medical device amendments of May 28, 1976.

Medicaid approved apnea monitors are:

• Apnea/Bradycardia/Tachycardia (Impedance Monitoring Technique); • Apnea/Bradycardia (Impedance Monitoring Technique); and • Apnea/Bradycardia/Tachycardia (Piezoelectric Transducer Technique).


The provider must:

• obtain documentation that the family or caregiver successfully completed infant Cardio Pulmonary Resuscitation training;

• ensure that the monitor is a prescribed cardiorespiratory monitor; • provide maintenance coverage 24 hours a day, seven days a week; • handle emergency repair requests within six hours or set up a “loaner”

monitor within two hours; • ensure a home visit is completed by a qualified registered nurse (RN),

certified respiratory therapist technician (CRTT), or a registered respiratory therapist (RRT) within five days following a hospital discharge;

• ensure a home visit is completed by a qualified RN, CRTT, or a RRT every 30 days after the initial visit; and

• file a copy of the home visit report within five days of the provision of the home visit to the district Children’s Medical Services (CMS) office responsible for managing the recipient’s care.


November 1997 2-14

Apnea Monitors, continued

Home Visit Documentation Requirements

When an RN, CRTT, or a RRT conducts a home visit, they must determine and document the following in the recipient’s medical record: • the recipient’s family situation, • the recipient’s home environment, • the diagnosis, • any telephone contacts with CMS or the HMO, • a change in the recipient’s address, and • any non-compliance in the use of the monitor.

Provider Equipment Responsibilities

The provider is responsible for ensuring the following equipment is available at set-up:

• monitor, which includes the battery pack, case, and emergency battery; • two sets of electrodes and, if requested, one extra set for replacement; • if disposable electrodes are necessary, at least ninety (90) per month; • two sets of modified safety lead wires; • two electrode belts; • an operator’s manual; • a copy of the infant monitoring handbook; and • a remote alarm when ordered.

Discontinued Service

When service is discontinued, the provider has three days to remove the equipment from the recipient’s home. Medicaid payments will cease upon receiving physician’s orders to discontinue monitoring service.

Event Recording The provider is responsible for initiating an event recording within two weeks

of the verbal order unless otherwise specified in writing by the attending physician. The provider must send the interpretation to the attending practitioner within three days. The interpretation is completed by a regional apnea center.


October 1998 2-15

Apnea Monitors, continued

Event Recording Continuation

The results of the event recording will determine if the practitioner will issue written orders to continue the event recordings for another month, continue regular monitoring, or discontinue the apnea monitoring.

Event Recording Documentation

Event recording documentation must include: • the age of the recipient; • the length of the recording; • the number, type, and duration of the events; and • the results of the event recording.

Medical Necessity Renewal

Medical necessity renewal time frame for apnea monitors is six months.

Augmentative and Alternative Communication Systems

Introduction Augmentative and alternative communication systems (AACs) are reimbursed

through the Medicaid DME/medical supply services program. Evaluations for the system, ongoing training, and therapy are reimbursed through the Medicaid Therapy Services program and the Medicaid Certified School Match program. Note: See the Therapy Services and Certified School Match Coverage and Limitations Handbook for information about therapy services.

Definitions AACs are designed to allow individuals the capability to communicate. As

defined by the American Speech-Language Hearing Association (ASHA), an AAC attempts to compensate for the impairment and disability patterns of individuals with severe, expressive communication disorders, i.e., individuals with severe speech-language and writing impairments. Dedicated systems are designed specifically for a disabled population. Non-dedicated systems are commercially available devices such as lap top computers with special software.


October 1998 2-16

Augmentative and Alternative Communication Systems, continued

Exception to Place of Residence

Recipients under 21 years of age who reside in a nursing facility may be eligible to receive an AAC device.

Who is Eligible to Receive an AAC

For Medicaid to reimburse for an AAC, the recipient must meet the following criteria: • be unable to communicate basic needs without the use of an AAC, and • have the physical, cognitive, and language abilities necessary to use the

AAC. Prior Authorization

AACs must be prior authorized by the Medicaid consultant. Procedure codes used for AAC devices are the K codes noted in the Medicaid fee schedule in Appendix B of this handbook.

Steps for Completion of a Prior Authorization Package

The following steps must be followed to obtain Medicaid authorization for an AAC. The written documentation from each step must be included in the Medicaid prior authorization package: 1. An interdisciplinary team (ID team), led by the speech-language

pathologist (or only the speech-language pathologist for recipients over age 21 and older), evaluates the recipient, recommends an AAC, and writes an individualized plan.

2. If the recipient is in public school, school personnel must concur with the ID team’s written recommended plan.

3. The speech-language pathologist sends the evaluation, which includes the recommended AAC, the individualized action plan, and the speech-language pathologist’s plans for management of the recipient’s communication disorder to the recipient’s physician, ARNP/PA designee, or designated physician specialist.

4. The physician, ARNP/PA designee, or designated physician specialist must review the evaluation and individualized action plan, and if he concurs, sign and date the evaluation and prescribe the AAC.

5. If the recipient is in MediPass, the recipient’s MediPass provider must authorize the AAC. (The DME provider must obtain MediPass authorization in order to be reimbursed for the claim.).


April 2001 2-17


Steps for Completion of a Prior Authorization Package (continued)

6. The ID team forwards the prior authorization package to the DME provider.

7. The DME provider completes the prior authorization package by attaching an invoice, proof of manufacturer’s cost, and a State of Florida/Florida Medicaid Authorization Request form and submitting the package to the Medicaid fiscal agent.

8. The Medicaid consultant reviews the prior authorization package and approves or denies the authorization request.

Each step is described in detail in the following information blocks. Interdisciplinary Team

For recipients under age 21, an interdisciplinary team (ID team) must be formed to evaluate the recipient, recommend an AAC, and write an individualized action plan.

The ID team must consist of at least two members and must include a speech language pathologist who will lead the team. The speech-language pathologist may request the assistance of an occupational therapist and physical therapist. It is expected that most cases will require the need for an occupational therapist to be a part of the ID team. The recipient who will use the AAC should be encouraged to participate on the ID team, as well as the recipient’s caregivers, teachers, social workers, case managers, and any other members deemed necessary.

For recipients age 21 and older, a speech-language pathologist is responsible for the evaluation, recommending an AAC and writing an individualized action plan.

Speech-Language Pathologist’s Evaluation

Once the ID team (or speech-language pathologist for recipients age 21 and older) has evaluated the recipient and recommended an AAC, the speech-language pathologist must document the following information in writing (the first three items are obtained from the recipient’s medical record): • significant medical diagnosis(es); • significant treatment information and medications; • medical prognosis;


April 2001 2-18


Speech-Language Pathologist’s Evaluation (continued)

• motor skills, i.e., posture/positioning, selection abilities, range and accuracy of movement, etc.;

• cognitive skills, i.e., alertness, attention span, vigilance, etc.; • sensory and perceptual abilities, i.e., hearing, vision, etc.; • language comprehension; • expressive language capabilities; • oral motor speech status; • use of communication and present communication abilities; • communication needs including the need to enhance conversation, writing,

and signaling emergency, basic care and related needs; • writing impairments, if any; • environment, i.e., home, work, etc., with a description of communication

barriers; and • AAC recommendation, which may include symbol selection, encoding

method, selection set (physical characteristics of display), type of display, selection technique, message output, literacy assessment, vocabulary selection, and participation patterns.

AAC Evaluations AAC evaluations are valid for six months from the date of the initial evaluation. Individualized Action Plan

The ID team members headed by the speech-language pathologist (or the speech-language pathologist for recipients age 21 and older) are responsible for developing the recipient’s individualized action plan.


April 2001 2-19


Components of the Individualized Action Plan

The recommended individualized action plan must include the following information: • an explanation of any AAC currently being used or owned by the recipient

at home, work, or school; • the current use of the system(s) and its limitations; • the appropriate long and short-term therapy objectives; • the recommended AAC (based on cost-effectiveness and the recipient’s

needs); • the recommended length of a trial period, if applicable; • a description of any AACs that the recipient has previously tried; • the specific benefits of the recommended AAC over other possibilities; • an established plan for mounting, if necessary, repairing, and maintaining

the AAC; • who is responsible to deliver and program the AAC to operate at the level

recommended by the ID team; • who will train the support staff, recipient, and primary caregiver in the

proper use and programming of the AAC; and • documentation of medical necessity.

AAC Selection The ID team must select an AAC that is based on the recipient’s current

medical needs, and projected changes in the recipient’s communication development over at least a 3-year period.

Concurrence by School Personnel

If the recipient is in the public school system, school personnel must be given the opportunity to comment and concur with the ID team’s recommended device. School personnel must agree that the recipient’s teacher and school therapist are knowledgeable in the use of the AAC or will be trained regarding its use.


October 1999 2-20


Physician Approval

The recipient’s physician, ARNP or PA designee, or designated physician specialist must review the evaluation and individualized action plan, and if he or she concurs, sign and date the evaluation and prescribe the AAC. The prescription must include the physician’s, ARNP or PA designee’s, or designated physician specialist’s name; address; telephone number; medical license number; and MediPass authorization number, if applicable. (If the recipient is in MediPass, the AAC must be authorized by the recipient’s MediPass primary care provider.)

The physician, ARNP or PA designee, or designated physician specialist returns the signed and dated evaluation, individualized action plan, and prescription to the speech-language pathologist.

Conflict of Interest The medical professionals who evaluate the recipient, serve on the ID team, or

prescribe the AAC must not have a financial relationship with or receive any gain from the AAC manufacturer.

Prior Authorization Requirement

After receiving the prior authorization package, the DME provider must request prior authorization from Medicaid.

For AACs, send prior authorization requests to the Medicaid fiscal agent: ACS State Healthcare P.O. Box 7090 Tallahassee, Florida 32314-7090

Note: See Chapter 7 of the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for the prior authorization procedures.


October 1999 2-21


Prior Authorization Documentation Requirements

The DME provider must complete and submit a prior authorization package to the Medicaid fiscal agent for Medicaid review and approval. The following components must be included in the prior authorization package:

1. The AAC evaluation signed by the ID team members (or speech-language pathologist for recipients age 21 and older) and the recipient’s physician, advanced registered nurse practitioner, or physician’s assistant;

2. The individualized action plan; 3. A prescription for the AAC signed and dated by the recipient’s physician,

advanced registered nurse practitioner, or physician’s assistant that includes the provider’s name, address, telephone number, and medical license number;

4. The MediPass authorization number if the recipient is a MediPass participant;

5. A statement of concurrence from school personnel if the recipient is in the public school system;

6. A completed State of Florida/Florida Medicaid Prior Authorization form; 7. An itemized invoice listing retail costs for the equipment; and 8. Manufacturer’s catalogue information regarding cost and warranty

information.

The speech-language pathologist is responsible for submitting items 1 through 5 to the DME provider. The DME provider is responsible for completing items 6, 7, and 8.

Medicaid Approval

Medicaid’s decision for coverage will be based on a medical rationale for the request of a particular system and on a comparative analysis of equipment tested and the individual recipient’s ability to use the equipment as it relates to a medical need.

Medicaid will not deny an AAC based solely on the fact that the recipient can communicate in writing.


October 1999 2-22


Medicare Approval

Effective January 1, 2001, Medicare began reimbursement of AAC devices.

Providers need to be aware that Medicare’s AAC policy differs from Medicaid AAC policy relative to prior authorization criteria.

Additional Evaluation Requested by Medicaid

Florida Medicaid reserves the right to request an AAC evaluation of a recipient from either another physician or an individual who is board-certified as a neurologist, physiatrist, otolaryngologist, audiologist, optometrist, or ophthalmologist.

Service Components

Medicaid reimbursement for AAC system procedure codes includes the following service components:

• AAC device; • programming needed to custom fit the system to achieve the recipient’s

specific speech-language goals; • modifications to adapt the system to the physical characteristics and

limitations of the recipient, i.e., wheelchair; and • shipping and handling charges.

Trial Period for AACs

The ID team (or speech-language pathologist for recipients age 21 and older) may recommend that the recipient have a trial period with the AAC. The trial period must be prior authorized by Medicaid. All the steps for completion of a prior authorization package and the components of the prior authorization package must be completed for a trial period to be authorized.


October 1998 2-23


Rental-Only AACs

Medicaid reimburses for rental-only AACs for trial periods. Rental-only reimbursements can continue past the trial period when the ID team (or speech-language pathologist for recipients age 21 and older) recommends and Medicaid approves a continued rental-only situation.


Prior to billing for an AAC system, the DME provider is responsible to ensure the properly selected system and all components have been delivered to the recipient and are operational in the recipient’s home.

Reimbursement Limitations

Medicaid will reimburse for one AAC every five years per recipient, and a software upgrade every two years, if needed.

Modifications, which may be in the form of replacing the AAC or upgrading the AAC’s software, may be reimbursed only if the new technology will improve communication significantly.

Medicaid will reimburse for replacement of devices, components, or accessories when there is irreparable failure or damage not caused by willful abuse or neglect.

Videotape Requests

Medicaid may request a videotape to assist with reimbursement status.


April 2001 2-24

Bathroom and Toileting Aids

Description Bathroom and toileting aids are devices available to assist recipients who are

incapable of using regular toilet facilities. Reimbursement Limitations

Bedpans and urinals may be reimbursed when a recipient is confined to a bed.

A commode may be reimbursed if a recipient has limited or no access to toilet facilities.

A detachable or drop arm commode may be reimbursed if a recipient cannot pivot transfer without assistance.

Portable paraffin bath units (E0235) may be reimbursed when a recipient has undergone a successful trial period of paraffin therapy and is expected to receive relief through long term use.

Compressors

Description Compressors are machines that compress air into storage tanks for use by air

driven equipment. Service Requirements

Medicaid may reimburse for an air power source compressor (E0565) when:

• it is used to support medically necessary DME that is not self contained, or • used with a nebulizer that provides at least 50 pounds per square inch

(psi).

Medicaid can reimburse for a pneumatic compressor (E0650 through E0668). The recipient or caregiver must receive instructions for the pressure to be used while operating the machine and the frequency and duration of use.


April 2001 2-25

Cribs (Safety)

Description A safety crib is a stainless steel or aluminum constructed crib that has an

enclosed top. Service Requirements

Medicaid may reimburse for a pediatric safety crib (W9762) when it is prescribed as medically necessary treatment for self-protection.

Documentation Requirements

The following documentation must be included in the recipient record:

• a medical statement that the recipient is confined to bed and will be in the crib at least 18 hours a day;

• proof of medical necessity for continued care in the home; • supporting medical information that without the crib the recipient would be

institutionalized; and • supporting information that the crib will provide effective treatment or

prevent self harm or injury when the recipient bites or chews.

Glucose Monitors and Blood Lancets

Home Glucose Monitor

Home glucose monitors are available through the Medicaid Prescription Drug Program.


April 2001 2-26

Glucose Monitors and Blood Lancets, continued

Blood Lancets Blood lancet devices are used by insulin dependent diabetics. Blood lancets

(A4259) and blood lancet devices (W4165) may be reimbursed only for insulin dependent diabetics.

Heat Lamps and Pads

Description Appliances or equipment used to apply heat. Heat Lamps And Pads

Medicaid may reimburse for heat lamps and heat pads when the application of heat is prescribed for the medical condition.

Home Enteral Supplies and Equipment

Description Enteral nutrition is the provision of nutritional requirements to the stomach or

small bowel via a tube. Service Requirements

Medicaid may reimburse for home enteral supplies and equipment when the recipient qualifies for food supplements under the Medicaid pharmacy program and the recipient has a functioning gastrointestinal tract, but regular oral feeding is impossible.


April 2001 2-27

Home Enteral Supplies and Equipment, continued

Enteral Nutrition Tubes

Enteral therapy must be administered by nasogastric (B4081-B4082) or jejunostomy/gastrostomy (B4084) tube.

Enteral Nutrition Supplies And Equipment

Enteral feeding supply kits must include a one-month supply of the following disposable items:

• feeding syringes, tapes/wipes (B4034); • pump sets, containers, syringes, tapes/wipes (B4035); and • lavage sets, containers, syringes, tapes/wipes (B4036).

Home Enteral Therapy Documentation

The provider must maintain documentation of medical necessity for the use of home enteral therapy. The documentation must specify all items and equipment (including pumps) necessary to support the recipient’s program. The provider must also maintain documentation of training provided to the recipient and caregiver regarding enteral feeding and the required sanitation.

Hospital Beds, Mattress, and Rails

Description A standard hospital bed consists of a modified gatch spring assembly mattress,

bed ends with casters and two manually operated foot end cranks. It is equipped with IV sockets, is capable of accommodating a trapeze bar, side rails, an overhead frame, and other accessories.


April 2001 2-28

Hospital Beds, Mattress, and Rails, continued


Medicaid may reimburse for a hospital bed when the recipient requires repositioning of the body in a way not feasible in an ordinary bed, or attachments for the bed are required that cannot be used with an ordinary bed.

In order to be reimbursed by Medicaid for hospital bed procedure codes E0298, E0250 and E0255, the provider must obtain prior authorization from Medicaid. To obtain prior authorization for hospital beds, the provider submits the prior authorization form and required documentation directly to the Medicaid fiscal agent, not to the area Medicaid office as the provider does for other DME prior authorization requests.

Multi-height Bed Medicaid may reimburse for a multi-height bed when it is medically necessary

to permit transfer from a bed to a wheelchair or permit ambulation. Justification for the multi-height bed must be included with the prior authorization request and other required documentation.

Electric Bed Medicaid may reimburse for an electric bed when the electric bed is medically

necessary. The practitioner must determine that the recipient’s condition requires frequent changes in body position and that the recipient cannot tolerate delays in re-positioning. The recipient must be capable of adjusting the position of the bed by operating the controls.


April 2001 2-29

Hospital Beds, Mattress, and Rails, continued

Hospital Bed Documentation

The provider must submit the following documentation with the prior authorization request and maintain copies in the recipient’s record: • the place of service including address;

• a description of the recipient’s diagnosis and symptoms;

• the length of time the bed will be needed;

• the severity and frequency of the symptoms that necessitate a hospital bed for positioning; and

• the practitioner’s prescription or signed certificate of medical necessity (CMN).

Heavy Duty Extra Wide Hospital Bed

Medicaid may reimburse for a heavy duty, extra wide bed if the recipient weighs over 350 pounds. The recipient’s weight should be documented by the practitioner and submitted with the prior authorization request.

Mattress Replacement

Medicaid may reimburse a mattress replacement after four years.

Hospital Bed Rails Medicaid may reimburse for bed rails replacement after eight years.

Infusion Pumps

Description An infusion pump is a device that is used to deliver solutions containing

parenteral medications at a regulated flow. Infusion Pumps Medicaid may reimburse for infusion pumps (E0781, E0791, B9000, B9002)

if the recipient is not receiving total parenteral nutrition (TPN) under the Medicaid prescribed drug program.


April 1998 2-30

Infusion Pumps, continued

Infusion pump Supplies

An infusion pump (E0781) includes all supplies for the initiation of home infusion therapy, including dressing kits, injection cap, betadine wipes, alcohol wipes, two inch Dermiclear tape, one inch Dermiclear tape, one quart Sharps container, Destruclip box, and other miscellaneous supplies.

Lymphedema Pump

Description A non-segmental lymphedema pump (E0650) is a device that has a single

outflow port on the compressor that produces a set level of pressure. A segmental lymphedema pump (E0651, E0652) is a device that has multiple outflow ports on the compressor that lead to distinct segments on the appliance which inflate sequentially. E0651 creates the same pressure in each segment. E0652 has calibrated gradient pressure and is further characterized by a regulator on each outflow port that delivers a specified pressure to an individual segment.


Medicaid may reimburse for lymphedema pumps if medical necessity indicates this treatment is required for intractable lymphedema of the extremities.

Documentation The following must be included in the recipient’s record:

• indication that the recipient or recipient’s caregiver has been instructed on the operation of the machine and the amount of pressure to be used and

• frequency and duration of use.


April 1998 2-31

Nebulizer

Description A nebulizer is an apparatus for producing a fine spray or mist. Nebulizer Medicaid may reimburse for a nebulizer if the recipient’s ability to breathe is

severely impaired. The documentation of medical necessity must include required medications.

Self-contained, Ultrasonic

When prescribed, Medicaid can reimburse for a self-contained ultrasonic nebulizer (E0575), including a decontamination filter.

Compressor and Heater

Medicaid may reimburse for a compressor and heater nebulizer (E0585) for recipients with tracheostomies.

Supply Kit The supply kit includes the hand held disposable nebulizer, pediatric or adult

size, for use with compressor or regulator with or without tubing, connectors, and filters, with germicide.


April 1998 2-32

Orthopedic Footwear

Description Orthopedic footwear is footwear that corrects or prevents deformities. Orthopedic Footwear

Orthopedic footwear (L3201 through L3595) includes orthopedic shoes, shoe modifications, wedges, heels, and miscellaneous shoe additions. Foot orthosis (W9767) is for congenital forefoot deformities in children who are under 18 months of age, unless determined medically necessary for an older child who is not yet walking.

Exclusions Medicaid does not reimburse orthopedic shoes for:

• flexible flat feet; • toe-in or toe-out problems, except where there is specific foot deformity;

and • torsional problems of the extremities, except when attached to a brace.


Medicaid may reimburse for orthopedic footwear when:

• prescribed by a licensed physician or podiatrist (D.P.M. or D.P.); • there are congenital foot deformities, including clubfoot in children; • when one foot is full size and the other is one and one half times in length

or two full widths larger than the other, and requires a lift of one inch or more;

• there is a rigid foot deformity; • there are severe structural deformities (e.g. rheumatoid arthritis, diabetic

osteopathy or arthropathy, or following trauma); • there are persistent skin breakdowns or ulcerations caused by such

conditions as diabetic neuropathies or degenerative disorders when a total contact system on the sole is expected to promote healing and avoid hospital care and surgical intervention;

• the prescribed shoe is constructed to provide support for a totally or partially missing foot; or

• the prescribed shoe is required in conjunction with an orthotic system.


April 1998 2-33

Orthopedic Footwear, continued

Required Components

Orthopedic footwear must have all the following components:

• strap or lace closure, • long medical counters, • steel shanks, • Goodyear welt construction, • bunion last, • high toe box, and • a Thomas heel.

Billing For Different Foot Sizes

When there is a substantial difference in size between the left and right foot and the recipient needs two pair of orthopedic footwear, the provider may be reimbursed for both pairs. Reimbursement for the smaller pair will not exceed 75 percent of the maximum fee of the larger pair. The claim for the smaller pair must be billed “By Report” using procedure code L3257.

Note: See Chapter 3 of this handbook for information on By Report requirements.

Orthotic Devices

Description Orthotic devices are appliances that support or correct a weak or deformed

body part, or restrict or eliminate motion in a diseased or injured part of the body.


The device must fit properly. The provider is responsible for any modifications, adjustments, or replacements that are needed within six months.


April 1998 2-34

Orthotic Devices, continued


The following information must be documented in the recipient’s record:

• measurements, • fitting, • instructions, • progress of the recipient, and • information provided to the recipient.

Osteogenesis Stimulator

Description An osteogenesis stimulator is a device that provides electrical stimulation to

augment bone repair. Osteogenesis Stimulator

Medicaid may reimburse for an osteogenesis stimulator (E0747) when non-union long bone fractures exceed six months, when there is congenital pseudoarthrosis, or when there is failed fusion.

The physician’s prescription must specify that less costly alternatives were tried and this device is provided in lieu of surgery.

Oxygen and Oxygen Related Equipment

Description Oxygen and oxygen related equipment are provided for recipients with

hypoxia.


April 1998 2-35

Provider Service Requirements

An oxygen provider must meet the following requirements:

• secure a permit through the Department of Health pharmacy services to purchase and possess medical oxygen and oxygen concentrators;

• provide all necessary supplies for the administration of oxygen; • provide all equipment and accessories;

Oxygen and Oxygen Related Equipment, continued

Provider Service Requirements (continued)

• provide all contents for stationary and portable oxygen; • supply and replace disposable items such as tubing, masks, cannulas, and

filters; • be able to serve the geographic area where the recipient lives so

emergency service can be accommodated; • make provisions for oxygen due to equipment failure; and • ensure accurate oxygen flow as low as 110 ml/minute for recipients under

21 years of age. Emergency Service Requirements

The oxygen provider must be able to provide recipients with emergency service. This includes:

• responding to an oxygen failure within two hours or less; • having staff available 24 hours a day, seven days a week; and • providing an emergency supply that will last the duration of the

emergency. Provider Staff Requirements

When oxygen and oxygen-related equipment is placed in the recipient’s home, a certified respiratory therapy technician (CRTT), registered respiratory therapist (RRT), or a registered nurse (RN) who is employed by or under contract with the DME provider must supervise the placement. The CRTT’s, RRT’s, or RN’s employment must be verifiable by a W-4 income tax form. A contractual relationship must be evidenced by a contract that meets the specifications described below.


April 2001 2-36


Contract Requirements

To be considered a valid contract between a durable medical equipment/medical supply services provider and a CRTT, RRT, or RN to provide oxygen services for the purposes of the Medicaid program, the contract must meet the following criteria:

• be a written document; • be dated; • be signed by both parties; • specify the term of contract; • specify the amount of consideration (payment) that will be paid to the

contractor by the DME company; • state that consideration paid to the contractor is the sole responsibility of

the contracting parties; • specify that the CRTT, RRT, or RN will provide services and meet all

requirements of this section in this handbook; and • be accompanied by evidence of current professional licensure of the

CRTT, RRT, or RN who will be providing oxygen services. Provider Staff Responsibilities

Medicaid requires either a CRTT, RRT, or RN be present at the time of oxygen equipment installation.


April 2001 2-37


General Diagnostic Requirements

Medicaid will reimburse for oxygen and oxygen related equipment for recipients who have one of the following conditions:

• emphysema, chronic bronchitis, and bronchiectasis; • chronic interstitial pneumonia; • chronic interstitial pulmonary infiltrate-type pulmonary disease such as

pulmonary fibrosis from extensive tuberculosis, eosinophilia, granuloma, idiopathic fibrosis, and pneumoconiosis;

• pulmonary hypertension; • secondary polycythemia; • terminal lung cancer; or • other diagnoses, as approved.

Diagnostic Requirements For Recipients Under 21

In addition to the general requirements, Medicaid will reimburse oxygen for recipients under 21 who have one of these conditions:

• bronchopulmonary dysplasia (BPD); • cystic fibrosis; • pulmonary fibrosis; • pulmonary insufficiency of prematurity (PIP); • tracheomalacia; • chronic lung disease; • agenesis, hypoplasia, dysplasia of the lung; • chronic cardiopulmonary disease (cor pulmonale); • “P” pulmonale on EKG; or • erythrecytosis: Ø familial polycythemia, Ø hereditary elliptocytosis, or Ø polycythemia, secondary.


April 1998 2-38


Additional Service Criteria For Recipients Under 21

For Medicaid reimbursement of oxygen and oxygen-related equipment for recipients under 21, laboratory results of oximetry or arterial blood gases must show:

• pO2 levels at or below 65mm Hg or • oxygen saturation at or below 90 percent.

The Medicare criteria for arterial blood gases or oximetry do not apply for recipients under 21 years of age.

Evaluation Requirements For Recipients Under 21

An oxygen evaluation is needed for recipients under 21 to determine the amount of oxygen necessary to prevent hypoxia. The evaluation is made over an extended period of time to measure different needs with different activities.

The evaluation must be completed by:

• a qualified pediatrician with a specialty in pulmonology or cardiology; • a neonatologist; or • an intensivist pediatrician.

Ιn cases of prevention of hypoxemia, recipients may demonstrate readings at or above 65mm Hg or oxygen saturation at or above 90 percent depending upon whether they are asleep, awake or exercising. Oxygen services may be covered under these circumstances if associated with symptoms or signs reasonably attributable to hypoxemia, e.g., cor pulmonale, “P” pulmonale on EKG, documented pulmonary hypertension and erythrocytosis.

Practitioner Requirements

The prescribing practitioner is responsible for ordering tests, performing tests or having a laboratory perform the test. The practitioner must prescribe the oxygen within 30 days of the test results. If not, the recipient must be re-examined.


April 1998 2-39


Provider Documentation Requirements

A physician-ordered test for blood oxygen levels must be conducted and the oxygen provider must obtain a copy of the test results and practitioner’s orders related to the recipient’s diagnosis.

The following components must also be documented in relationship to the practitioner’s orders:

• pO2 levels that equal or exceed 65mm Hg or • oxygen saturation level that equals or exceeds 90 percent; AND • the prescribed rates of flow; • concentration level; • frequency, duration of usage; and • circumstances under which oxygen is to be used.

The provider may supply oxygen to recipients 21 and over if the recipient meets Medicare’s criteria for laboratory results, arterial blood gases or oximetry.

Medical Necessity Testing

Testing for medical necessity for oxygen should be done on a yearly basis.

Medical Necessity Renewal

Medical necessity renewal time frame for oxygen service is twelve months.

Renewal Exception When an oxygen service test shows a pO2 level at or above 56mm Hg, or

oxygen saturation at or above 89 percent, a second arterial blood gas or arterial oxygen saturation test must be performed within three months of initiation of oxygen service.


April 2001 2-40



The HCFA-484 form or equivalent may be used to document medical necessity for oxygen therapy.

The following information must be filed in the recipient’s record: • provider’s staff member; • positive test results; • medical necessity documented by arterial blood gas testing, and the

laboratory evidence of pO2 or oxygen saturation by ear or pulse oximetry levels;

• the type of system being used, portable or stationary; • the manufacturer name, model and serial number; and • if a concentrator is in use, the number of hours each month.

Stationary Service Medicaid reimburses for the following types of stationary oxygen services:

• compressed oxygen system (E0424); • liquid oxygen system (E0439); • concentrators (E1390); and • oxygen and water vapor enriching system (E1405 & E1406).

Reimbursement For Stationary Services Only

Each stationary oxygen service is reimbursed as an all-inclusive rental fee. The fee includes the following:

• supplies necessary for the administration of oxygen; • all equipment and accessories; and • oxygen contents.


April 2001 2-41


Reimbursement For Stationary Oxygen Services With Portable Equipment

Medicaid may reimburse additional costs for portable equipment when both portable and stationary services are medically necessary; however, Medicaid will not reimburse for additional oxygen contents. The cost of oxygen contents for both portable and stationary services is included in the fee for the stationary oxygen codes.

If both stationary and portable services are medically necessary, Medicaid may reimburse:

• one stationary oxygen type, and • one portable equipment code (E0431 or E0434).

Portable Oxygen Service Criteria

Medicaid reimburses for portable oxygen when a practitioner prescribes activities requiring portable oxygen. The oxygen provider must document the following information in the recipient’s record:

• the recipient qualifies for oxygen service; • the attending practitioner has ordered a program of exercise or an activity

program for therapeutic purposes; • the recommended exercises or activities cannot be accomplished by the

use of stationary oxygen service; and • the use of a portable oxygen system during the activity or exercise results

in an improvement in the individual’s ability to perform the activities and exercises.

Reimbursement For Portable Oxygen Services Only

Medicaid may reimburse for portable oxygen only when it is medically necessary.

The following procedure codes are reimbursed as an all inclusive fee for portable services:

• equipment codes E0431 or E0434; and • oxygen contents codes E0433 or E0444.


April 1998 2-42


Reimbursement Rental services may be reimbursed in the form of gaseous, liquid, or

concentrated oxygen; however, Medicaid will reimburse for only one form of oxygen.

For reimbursement of a concentrator service, the provider must use the procedure code appropriate to the prescribed flow rate.

Note: See Appendix A in this chapter for a summary of oxygen coverage. Recipient Owned Equipment

Medicaid may reimburse for servicing of recipient owned oxygen equipment when oxygen is medically necessary. When billing Medicaid, the provider must use procedure codes E0441 (oxygen contents, gaseous) and E0442 (oxygen contents, liquid).

Passive Motion Device

Description A passive motion device is a mechanical device that is used to extend and flex

the knee. Passive Motion Device

Medicaid may reimburse for a passive motion device (E0935) for a recipient who has undergone total knee replacement. The coverage must begin within two days following surgery and must not exceed 21 days. Sheepskin pads are included in the reimbursement.


April 1998 2-43

Passive Motion Device, continued


The provider must assemble the passive motion device in the recipient’s home and instruct the recipient or caregiver on the proper use of the device.

Patient Lifts

Description A patient lift is a device used to transfer a recipient between a bed, a chair,

wheelchair, or commode. Patient Lifts Medicaid may reimburse for patient lifts (E0630 and E0635) for use in the

recipient’s home when the assistance of more than one person is necessary, and:

• the recipient’s condition is such that periodic movement is necessary for effective treatment or care ,or

• the device is used to prevent deterioration of a condition where the alternative is bed confinement.

Peak Flow Meter

Description A peak flow meter is used to measure the volume of air exchanged in order to

determine if a person can breathe without a ventilator. Peak Flow Meter A peak flow meter (W9764) may be reimbursed for recipients age five

through 20. Service Requirements

The provider is responsible for training the caregiver in the proper and effective use of the device.


April 1998 2-44


April 1998 2-45

Peak Flow Meter, continued



• the item is prescribed by the attending physician; • the diagnosis shows moderate to severe asthma; and • the item is part of a continuing asthma treatment plan.

Pediatric Dynamic Splinting Device

Description A pediatric dynamic splinting device is a device used to allow independent

leg, hip and knee motion, and incrementally limits rotation of the feet. Pediatric Dynamic Splinting Device

Medicaid may reimburse for a pediatric dynamic splinting device (W9768) for clubfoot and internal tibial torsion.

Reimbursement Reimbursement includes the center bar, hinged and rotational joints, the shoe

assembly, and the shoes.

Pressure Ulcer Care

Description Medical equipment used to treat or prevent pressure ulcers. Pads And Wheelchair Cushions

Medicaid may reimburse for pressure ulcer care pads and wheelchair cushions if the recipient currently has pressure ulcers or is highly susceptible to pressure ulcers.

Alternating Pressure Pads, Mattresses, Pumps

Medicaid may reimburse for alternating pressure pads or mattresses and pumps for beds if a recipient is confined to a bed and the recipient has evidence of pressure ulcers or is highly susceptible to pressure ulcers.


April 1998 2-46

Pressure Ulcer Care, continued

Pressure Ulcer Care Documentation

The following must be included in the recipient record:

• documentation of medical necessity; • a statement that less costly alternatives were ineffective and why they were

not successful; and • documentation of the recipient’s course of treatment.

Phototherapy (Bilirubin) Light with Photometer

Description Phototherapy is the exposure to artificial light for treatment of neonatal

jaundice. Service Requirements

Medicaid may reimburse for a phototherapy light with photometer (E0202) if:

• the attending physician diagnosis is neonatal jaundice; • the treatment is limited to five consecutive days and occurs during the first

30 days of life; and • treatment includes a fiberoptics system with the fiberoptics blanket, covers,

light sources and related supplies. Documentation Requirements

The provider must record the following in the recipient’s record:

• the duration of treatment, • the frequency of use per day, and • the maximum number of days.


April 1998 2-47

Prosthetic Devices

Description Prosthetic devices are artificial devices or appliances that replace all or part of

a permanently inoperative or missing body part. Service Requirements

Reimbursement for prosthetic supplies is limited to supplies related to the medically necessary prosthetic device.


The provider must ensure that the prosthetic device fits properly. For the first six months, the provider is responsible for adjustments, modifications, and replacements.



• measurements, • fitting of the device, • instructions given to the recipient, • progress of the recipient, and • information provided to the recipient.

Prosthetic Eyes

Description Prosthetic eyes are artificial replacements for eyes. Service Requirements

Medicaid reimburses for prosthetic eyes if prescribed by an attending physician or optometrist. When the provider bills Medicaid for the service, the following requirements apply: • a prosthetic eye cannot be billed until it has been fitted; • the date of service entered on the claim must be the date the provider

ordered the eye; and • the fee includes all costs related to measuring, fitting, and dispensing of the

eye.


April 1998 2-48

Prosthetic Eyes, continued

Prosthetic Eye Replacements

Medicaid may replace an artificial eye that is damaged or no longer the appropriate size.


The recipient record must contain an evaluation completed by a physician or optometrist not more than three months prior to the provision of the prosthetic eye.

Resuscitator Bag

Description A resuscitator bag is a manual, hand-held device with a bag attached that

forces air into the lungs when it is squeezed. Resuscitator Bag Medicaid may reimburse for a resuscitator bag (W9763) when prescribed for

recipients who are ventilator dependent. Documentation Requirement

The provider must document in the recipient’s record that the caregiver received training in the correct use of the device and demonstrated effective use.

Suction Machines

Description A suction machine is an electric aspirator designed for upper respiratory and

tracheal suction. Stationary Model Medicaid may reimburse for a suction machine (E0600) if the medical

necessity documentation indicates in-home use is appropriate and use of the machine does not require technical or professional supervision.


April 1998 2-49


April 1998 2-50

Suction Machines, continued

Mobile Model Medicaid may reimburse a mobile suction machine (W9766) in conjunction

with a stationary model if the following conditions are met:

• prescribed because the recipient is subject to secretions that require suctioning during travel;

• the recipient is being transported for prescribed medical treatment, therapy, or rehabilitation services; and

• the recipient is not being transported by an ambulance.

A suction machine (W9766) includes a vacuum regulator and is battery operated. The device includes a rechargeable battery and charger device, vehicle DC adapter cable, canister or bottle, connector, and carrying case.

Traction Equipment

Description Traction equipment is equipment used to draw or pull sections of the body. Traction Equipment Medicaid may reimburse for traction equipment when orthopedic impairment

requires traction equipment that prevents ambulation during the period of use.


April 1998 2-51

Trapeze Equipment

Description Trapeze equipment is equipment that is freestanding or attached to a bed and

helps the recipient move. Trapeze Equipment Medicaid may reimburse for trapeze equipment (E0910 or E0940) when a

recipient is confined and needs help to get in or out of bed, change his body position, or sit up for a respiratory condition. Medicaid may also reimburse trapeze equipment when it is prescribed for exercise to prevent deterioration.

Ventilator and Respiratory Equipment

Description Ventilator and respiratory equipment are used to support the respiratory

system. Ventilators And Respiratory Equipment

Medicaid reimburses for the following ventilators or respiratory equipment: • continuous positive airway pressure device (CPAP) (E0601); • respiratory assist device, bi-level pressure capability, without back-up

rate (K0532), with back-up rate (K0533); • intermittent positive pressure breathing machine (IPPB) (E0500); • volume ventilator (E0450); • negative pressure ventilator (E0460); • intermittent assist device with continuous positive airway pressure device

(E0452); and • therapeutic ventilator (E0453).


July 2001 2-52

Ventilator and Respiratory Equipment, continued

Continuous Positive Airway Pressure Device (CPAP)

Medicaid may reimburse for a CPAP device when there is documentation in the medical record to indicate: • a diagnosis of moderate or severe obstructive sleep apnea syndrome

(OSAS), and • the device is prescribed for six months or less. Medicaid may approve a renewal request in cases that are certified by the attending physician that CPAP is effective and the recipient is compliant.

CPAP Documentation


• that the recipient has at least thirty episodes of obstructive sleep apnea, each lasting a minimum of ten seconds, during six to seven hours of recorded sleep;

• surgery is a likely alternative; • a sleep study was conducted that indicates oxygen saturation on room air,

with a saturation level at 88 percent or below, for more than five percent of total sleep;

• a second sleep study was conducted that indicates an oxygen saturation increase of 15 percent, or more, was experienced by using a CPAP device, and a decrease in the number of airway obstructions per hour;

• any correctable causes of the recipient’s sleep apnea have been considered along with an explanation whether these factors are being treated;

• if there are no corrective causes or if all correctable causes have been resolved; and

• whether the recipient is symptomatic or asymptomatic and identify what impairments are present secondary to the sleep apnea.


April 1998 2-53


Respiratory Assist Devices

A respiratory assist device (K0532, K0533, K0534) used to administer NPPRA therapy is covered for those patients with clinical disorder groups characterized as:

1. restrictive thoracic disorders (i.e., progressive neuromuscular diseases or severe thoracic cage abnormalities);

2. severe chronic obstructive pulmonary disease (COPD);

3. central sleep apnea (CSA); or

4. obstructive sleep apnea (OSA) (K0532 only).

Intermittent Positive Pressure Breathing Machine (IPPB)

Medicaid may reimburse for an IPPB machine if the recipient’s ability to breathe is severely impaired.

IPPB Documentation


• the prescribed pressure settings for the machine; • the frequency and duration of treatment; and • that the recipient or caregiver received instruction on the proper and

effective use of the machine. Volume Ventilator Medicaid may reimburse for a positive and negative pressure volume

ventilator when prescribed.


April 1998 2-54



Medicaid may reimburse for a volume ventilator when the recipient has one of the following diagnoses: • neuromuscular disorder; • thoracic restrictive disease; • congenital pulmonary disorder; • respiratory paralysis; • chronic respiratory failure, consequent to chronic obstructive pulmonary

disease (COPD); • neurological disorder, as with spinal cord injury; or • bronchial pulmonary disease.

Volume Ventilator Documentation

The following must be documented in the recipient’s record:

• home care protocols, • airway stability, • oxygen requirements, and • nutritional intake.

Negative Pressure Ventilator

Medicaid reimburses for a negative pressure ventilator, stationary or portable.

Alternating Positive Airway Pressure and Intermittent Positive Ventilation System

Medicaid reimburses for an alternating positive airway pressure and intermittent positive ventilation system for intermittent respiratory service. Reimbursement includes all connectors, pressure measuring and alarm devices, breathing circuits, in-line thermometers, water traps, connectors, adapters, and training.

For a child with a tracheostomy, an intermittent assist device with continuous positive airway pressure must be used with a CPAP system.

Reimbursement for a therapeutic ventilator is limited to 12 hours or less per day.


April 1998 2-55




• the diagnosis; • the machine setting for inspiratory positive airway pressure; • the setting for expiratory positive airway pressure; • liter flow of oxygen, if appropriate; • the time of day and number of hours a day the device is to be used; and • an estimate of the number of months needed.

Documentation For Obstructive Sleep Apnea Syndrome (OSAS)

When intermittent respiratory service is prescribed for obstructive sleep apnea syndrome (OSAS) and an alternating positive airway pressure system (E0452) is used, the provider must document the following information in the recipient’s record:

• OSAS was diagnosed based on a polysomnographic sleep study; • an ongoing plan of therapy has been ordered; and • CPAP therapy was tried but unsuccessful or the recipient was not able to

tolerate the CPAP. Documentation For Intermittent Positive Ventilatory Support

When intermittent respiratory service is prescribed for OSAS and intermittent positive ventilatory support (E0453) is used, the provider must document the following information in the recipient’s record:

• the recipient’s total ventilatory requirements cannot be met by the intermittent assist device with continuous positive airway pressure device (E0452);

• usage is limited to 12 hours per day or less; • the medical purpose specifies that the device is prescribed for purposes

other than nocturnal ventilatory assistance; and • if the device is used in spontaneous/timed or timed mode, the control

settings are specified by the physician.


July 2001 2-56


Recipient Owned Ventilator

When a recipient owns a ventilator, the provider may use procedure code A4618 to bill for a daily amount of accessories, supplies, and a monthly home visit.

Back-up Ventilator

The back-up ventilator is included in the monthly Medicaid reimbursement.


When service of a recipient owned ventilator is provided, the following must be documented in the recipient’s record:

• the manufacturer name, and • the model and serial number of the ventilator.

Wheelchairs

Description A wheelchair is a chair mounted on wheels used to transport a non-

ambulatory individual. Wheelchair Medicaid may reimburse for a wheelchair when the recipient is non-

ambulatory, has severely limited mobility, or it is necessary to accommodate the recipient’s physical characteristics.


April 2001 2-57

Wheelchairs, continued

Categories Of Wheelchairs

Medicaid may reimburse for a standard wheelchair if the recipient is confined to a bed or chair. Reimbursement may be made for the following:

• a narrow wheelchair required due to narrow doorways in the home; • a lightweight wheelchair required when the recipient cannot propel a

standard wheelchair; • a motorized wheelchair required when medical needs cannot be met by a

less costly alternative; • other models if the features and accessories are medically necessary; and • a customized wheelchair that is specially constructed and not available

from manufacturers.

Customized Wheelchair Documentation

Medicaid may reimburse for a customized wheelchair that is specially constructed (K0008, K0013, K0014). Prior authorization is required. Medicaid will not approve a customized wheelchair or wheelchair upgrade where no medical necessity to accomplish basic ADLs within the home has been established.

For a customized wheelchair, the following information must be submitted with the prior authorization request:

• medical necessity; • written documentation describing the physical status of the recipient with

regard to mobility, self-care status, strength, cognitive abilities, coordination, and activity limitations;

• wheelchair evaluations performed by either a registered physical or occupational therapist or a certified physiatrist;

• what physical improvement(s) can be anticipated; • what physical deterioration can be prevented; • a list of each customized feature required for unique physical status; • specify the medical benefit of each customized feature; • identify the principle places of use;


April 2001 2-58


Customized Wheelchair Documentation (continued)

• an itemized invoice listing actual costs for parts and labor; • list the source(s) of purchased accessories and modifications; and • documentation of home accessibility is required for an oversized, heavy-

duty, or manual customized wheelchair.

Note: See Chapter 7 of the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for the prior authorization procedures.

Motorized Wheelchairs Documentation

Medicaid will not approve a motorized wheelchair or wheelchair upgrade where no medical necessity to accomplish basic ADLs within the home has been established. When a motorized wheelchair is prescribed the documentation must establish that the device is a safe method of mobility. The recipient must meet all of the following conditions:

• documented, severe abnormal upper extremity dysfunction or weakness;

• sufficient eye/hand perceptual capabilities to operate the chair and the cognitive skill to guide it independently;

• capable of some activity to which the motorized chair will provide access;

• an environment conducive to the use of a motorized wheelchair;

• clinical documentation of a power wheelchair trial must accompany any first request for a power wheelchair; and

• documentation of home accessibility is required in a prior authorization request for an oversized, heavy-duty or power customized wheelchair.


April 2001 2-59


Wheelchair Repairs All repairs to custom wheelchairs that include replacement of parts listed in

Appendix B, K0015-K0177 (such as armrests, seatbelt, adjustable angle footplate, tires, casters, caster forks, etc.) should be billed as such, and not included with the prior authorization. Prior authorization requests for repair/modification (K0108) should be reserved for custom replacement and modification, such as custom seating.

Wheelchair Prior Authorization Process

See the Services Requirement section of this chapter for prior authorization requirements. The physical therapist or occupational therapist wheelchair evaluation should be included with the prior authorization request.

Wheelchair Evaluation Wheelchair evaluations are valid for up to six months from the date of initial

evaluation.

Non-Covered Services and Exclusions

Non-Covered Items The following list of items and services are not reimbursed by Medicaid

through the DME program; however, they may be reimbursed through other Medicaid programs:

• audiology services; • clinically unproven equipment; • computers and computer related equipment;

• dentures; • diapers; • disposable supplies customarily provided as part of a nursing or personal

care service or a medical diagnostic or monitoring procedure;


April 2001 2-60

Non-Covered Services and Exclusions, continued

Non-Covered Items (continued)

• emergency and non-emergency alert devices; • environmental control equipment (air conditioners, dehumidifiers, air filters

or purifiers); • equipment designed for use by a physician or trained medical personnel;

• experimental equipment; • facilitated communications (FC); • furniture and other items which do not serve a medical purpose; • hearing and vision systems • institutional type equipment; • investigational equipment; • items used for cosmetic purposes; • personal comfort, convenience or general sanitation items; • personal computers, unless the computer is a dedicated AAC system; • physical fitness equipment; • precautionary-type equipment (e.g. power generators, backup oxygen

equipment unless specifically determined as medically necessary to assure life support);

• printers, unless the printer is a built-in component of a dedicated AAC system;

• printer paper or cables; • routine and first aid items; • services or items provided to recipients out of state; • supplies or equipment covered by Medicaid per diem rates; • televisions, telephones, VCR machines and devices designed to produce

music or provide entertainment; and • training equipment or self-help equipment.


May 1996 A-1

APPENDIX A

SUMMARY OF OXYGEN COVERAGE

Coverage Gaseous Liquid Concentrator

Stationary Only E0424 E0439 E1390

Stationary E0424 E0439 E1390 and plus plus plus

Portable E0431 E0434 E0431 or E0434

Portable Only E0431 E0434 None plus plus

E0443 E0444

Recipient Owned Equipment

E0441 E0442 E0441 or E0442


April 2001 3-1

CHAPTER 3

DURABLE MEDICAL EQUIPMENT/MEDICAL SUPPLY SERVICES

PROCEDURE CODES AND FEES

Overview

Introduction This chapter describes the procedure codes for Medicaid reimbursable

services, special billing requirements, and the requirements for prior and “By Report” (BR) authorizations.

In This Chapter This chapter contains:

TOPIC PAGE

Reimbursement Information 3-1

How to Read the Fee Schedule 3-3

Non-Classified Procedure Codes 3-7

By Report (BR) 3-8

Appendix B: Procedure Codes and Fee Schedule for All Medicaid Recipients

B-1

Appendix C: Procedure Codes and Fee Schedule for Recipients Under 21

C-1

Reimbursement Information

Maximum Fee The Medicaid fee reimbursed for DME/medical supplies includes labor,

travel, delivery, shipping, handling, fees for measuring, casting, fitting, or dispensing items or products. It includes all costs associated with a back-up cylinder or oxygen concentrator or ventilator.


April 2001 3-2

Reimbursement Information, continued

Purchased Equipment Credits

Providers are required to credit any parts or accessories that are removed from the amount charged for the equipment before delivery. Credit must be deducted prior to submitting the claim to Medicaid.

Used Equipment Billing

Reimbursement for the purchase of used equipment is 66 percent of the maximum fee shown in Chapter 3 or 66 percent of the provider's usual and customary fee for new equipment, whichever is less. It is the provider’s responsibility to bill the lesser amount. When the amount billed is less than the fee noted in the fee schedule, the claims system will pay the lesser of the two. Refurbished equipment is equipment that displays new parts. Reimbursement for providing refurbished equipment is 100 percent of the maximum rental fee shown in Chapter 3.

Note: See Appendix B and C of this chapter for a list of Medicaid fees. Rent-To-Purchase Rent-to-purchase is paid in ten monthly installments. Authority for rental

payments terminates when the equipment is no longer medically necessary. The item becomes the property of the recipient after the tenth month. Providers may only receive ten payments per medical event.

Reimbursement fees include all the ancillary items necessary to operate the equipment to ensure the highest level of medical care.


May 1996 3-3

Reimbursement Information, continued

Rental Only Items (RO)

Rental only (RO) items remain the property of the provider.

Reimbursement fees include:

• all ancillary items necessary to operate the equipment to ensure the highest level of medical care, and

• any monthly home visits by the provider’s staff as recommended by the manufacturer to ensure that the patient and family are trained, the equipment is operating optimally, and settings are correctly maintained.

Rental reimbursement continues until there is a change in the medical necessity, the period of authorization terminates, or the recipient is no longer Medicaid eligible.

When a rental period is less than 14 days, the provider must prorate the fee to not more than 50 percent of the monthly rental amount.

How To Read The Fee Schedule

Introduction The DME/medical supplies fee schedule is a table of columns listing the

Centers for Medicare and Medicaid Services Common Procedure Coding System (HCPCS) procedure codes, their descriptors, and other information pertinent to each code. The codes are listed in alpha-numeric order.

Fee Schedule The DME/medical supplies fee schedule is divided into 2 sections, Appendix

B and C. Appendix B is a listing of covered DME/medical supplies for all Medicaid recipients, regardless of age. Appendix C is a listing of covered DME/medical supplies for Medicaid recipients under 21 years of age. The format in both sections is the same.


May 1996 3-4

How To Read The Fee Schedule, continued

Code This column identifies the procedure code.

The DME/medical supplies, orthotics and prosthetics program uses the following sections from the HCPCS coding system: • A codes - Medical and Surgical Supplies and miscellaneous • B codes - Enteral and Parenteral Therapy • E codes - Durable Medical Equipment • L codes - Orthotic and Prosthetic devices • V codes - Vision • W codes - State of Florida Specific

Code Description This column describes the service or procedure associated with the

procedure code.

The provider is responsible for providing specific items when the description shows plural nomenclature such as bilateral or pair.

Max Fee This column is the maximum amount Medicaid will pay for that DME/medical

supply, orthotic, or prosthetic device. The fee listed is the unilateral, single item or each unit, unless otherwise specified in the description.

The maximum fee for ostomy supplies is per stoma or per fistula, unless otherwise specified.

When there is no maximum fee listed, the procedure code is considered “non-classified” and the provider must request prior authorization or submit a By Report claim.

Note: See Chapter 7, Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for prior authorization procedures.

Note: See Chapter 2 of this handbook for prior authorization requirements and documentation.


May 1996 3-5


RO (Rental Only) This column means the equipment will remain the property of the provider

and a monthly fee will be reimbursed during the authorized medically necessary time frame.

Rent To Purchase This column represents items that are reimbursed up to a maximum of ten

monthly rental payments. If the medical condition lasts for ten months the item becomes the property of the Medicaid patient.

Units This column indicates the number of units that may be billed for dates of

service within the same month.

The provider may bill for up to a one month's supply for a single billing date, based on the recipient’s medical need.


April 2001 3-6


BR (By Report) This column identifies a “non-classified” procedure code that requires a

medical review to approve and price the procedure correctly. Medical necessity documentation is submitted with the an invoice directly to Medicaid’s fiscal agent.

PA This column identifies the procedure codes that require prior authorization

before the service is performed.

Note: See Chapter 7 of the Medicaid Provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for prior authorization procedures.

Note: See Chapter 2 of this handbook for specific information and documentation required for prior authorization.

Limits The number in this column shows the maximum limits that apply to a

procedure code.

Note: See Chapter 2 of this handbook for information on how to obtain authorization for services that exceed the limitations for recipients under 21 years of age.


April 1998 3-7

Non-Classified Procedure Codes

Introduction The DME/medical supplies fee schedule has "non-classified" procedure

codes. Non-classified procedure codes allow the provider to request reimbursement from Medicaid when a reimbursable item does not have an established fee identified. Pricing non-classified procedure codes is established either by prior authorization or a By Report.

Note: See Chapter 7 of the Medicaid provider Reimbursement Handbook, HCFA-1500 and Child Health Check-Up 221, for prior authorization procedures.

Note: See Chapter 2 of this handbook for specific information on prior authorization requirements and documentation.

Note: See By Report in this chapter for more information and documentation requirements.

When To Use Non-Classified Procedure Codes

Providers must use a non-classified procedure code when the item is reimbursable, but: • the equipment requested needs to be customized to the physical condition

of the recipient, and • there is no less expensive treatment modality, equipment, or measures

available to meet the recipient’s medical needs. Reimbursement For Non-Classified Codes

A provider may be reimbursed for a non-classified procedure code after the claim is approved and priced.


April 1998 3-8

By Report

Description A detailed and formal account that is submitted with a claim that enables

Medicaid to review and price the procedure. Submitting BR Claims

A By Report claim is submitted directly to the fiscal agent and must include the necessary documentation for Medicaid to complete a medical review and price the procedure.

The following written documentation must be submitted with the claim:

• documentation of medical necessity; • a description of the items or services provided; • name of the manufacturer’s model, style, features, attachments,

modifications, and accessories; • a description of the time, skill, and equipment used; • documentation of any cost incurred, including billing invoices from the

manufacturer; • if for a non-routine service, a description of the item before and after

repair; • if for a repair for service, the manufacturer, duration of the warranty,

model, and serial number; and • the date the item was made available to the recipient.

Documentation Exception

An exception to acceptable forms of medical documentation is that a physical or occupational therapist may provide medical documentation for custom wheelchairs relative to procedure E1340 only.

CODE

DME/Medical Supplies Coverage and Limitations Handbook

DESCRIPTION MAX

APPENDIX BFOR ALL MEDICAID RECIPIENTS

UNITS LIMITSRO RENTBR PA

A4206 SYRINGE WITH NEEDLE, STERILE 1CC, EACH 0.29 60 720 PER YEARA4207 SYRINGE WITH NEEDLE, STERILE 2CC, EACH 0.29 60 720 PER YEARA4208 SYRINGE WITH NEEDLE, STERILE 3CC, EACH 0.29 60 720 PER YEARA4209 SYRINGE WITH NEEDLE, STERILE 5CC OR

GREATER, EACH 0.29 60 720 PER YEAR

A4213 SYRINGE, STERILE, 20 CC OR GREATER, EACH 1.94 31 366 PER YEARA4215 NEEDLES ONLY, STERILE, ANY SIZE, EACH 0.19 100 1200 PER YEARA4230 INFUSION SET FOR EXTERNAL INSULIN PUMP,

NON NEEDLE CANNULA TYPE 155.52 1 12 BOXES PER

YEARA4231 INFUSION SET FOR EXTERNAL INSULIN PUMP,

NEEDLE TYPE 87.12 1 12 BOXES PER

YEARA4232 SYRINGE WITH NEEDLE FOR EXTERNAL INSULIN

PUMP, STERILE, 3CC 57.84 1 12 BOXES PER

YEARA4244 ALCOHOL OR PEROXIDE, PER PINT 0.78 12 144 PER YEARA4245 ALCOHOL WIPES, PER BOX 1.94 2 24 PER YEARA4259 LANCETS, PER BOX OF 100 9.70 2 24 PER YEARA4280 ADHESIVE SKIN SUPPORT ATTACHMENT FOR

USE WITH EXTERNAL BREAST PROSTHESIS,EACH

3.76 1 5 PER MONTH

A4311 INSERTION TRAY WITHOUT DRAINAGE BAGWITH INDWELLING CATHETER, FOLEY TYPE,TWO-WAY LATEX WITH COATING (TEFLON,SILICONE, SILICONE ELASTOMER ORHYDROPHILIC, ETC.)

4.46 3 36 PER YEAR

A4312 INSERTION TRAY WITHOUT DRAINAGE BAGWITH INDWELLING CATHETER, FOLEY TYPE,TWO-WAY, ALL SILICONE

15.81 3 36 PER YEAR

A4313 INSERTION TRAY WITHOUT DRAINAGE BAGWITH INDWELLING CATHETER, FOLEY TYPE,THREE-WAY, FOR CONTINUOUS IRRIGATION

10.39 3 36 PER YEAR

A4324 MALE EXTERNAL CATHETER, WITH ADHESIVECOATING, EACH

1.66 35 35 PER MONTH

A4325 MALE EXTERNAL CATHETER, WITH ADHESIVESTRIP, EACH


A4331 EXTENSION DRAINAGE TUBING, ANY TYPE, ANYLENGTH, WITH CONNECTOR/ADAPTOR, FOR USEWITH URINARY LEG BAG OR UROSTOMY POUCH,EACH

1.68 31 366 PER YEAR

A4332 LUBRICANT, INDIVIDUAL STERILE PACKET, FORINSERTION OF URINARY CATHETER, EACH

0.10 200 200 PER MONTH

A4333 URINARY CATHETER ANCHORING DEVICE,ADHESIVE SKIN ATTACHMENT, EACH


A4347 MALE EXTERNAL CATHETER WITH OR WITHOUTADHESIVE, WITH OR WITHOUT ANTI-REFLUXDEVICE; PER DOZEN

9.22 3 60 PER YEAR

A4348 MALE EXTERNAL CATHETER WITH INTEGRALCOLLECTION COMPARTMENT, EXTENDED WEAR,

21.24 2 2 PER MONTH

March 2003B - 1

CODE


DESCRIPTION MAX



EACH (E.G., 2 PER MONTH)A4350 CATHETER CARE KIT 0.00 0 36 PER YEARA4351 INTERMITTENT URINARY CATHETER; STRAIGHT

TIP, WITH OR WITHOUT COATING (TEFLON,SILICONE, SILICONE ELASTOMER, ORHYDROPHILIC, ETC.), EACH

1.60 200 1800 PER YEAR

A4352 INTERMITTENT URINARY CATHETER; COUDE(CURVED) TIP, WITH OR WITHOUT COATING(TEFLON, SILICONE, SILICONE ELASTOMERIC, ORHYDROPHILIC, ETC.), EACH

1.84 200 2400 PER YEAR

A4353 INTERMITTENT URINARY CATHETER, WITHINSERTION SUPPLIES

5.33 200 2400 PER YEAR

A4357 BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITHOR WITHOUT ANTI-REFLUX DEVICE, WITH ORWITHOUT TUBE, EACH

7.76 2 24 PER YEAR

A4358 URINARY DRAINAGE BAG, LEG OR ABDOMEN,VINYL, WITH OR WITHOUT TUBE, WITH STRAPS,EACH

3.40 5 60 PER YEAR

A4361 OSTOMY FACEPLATE, EACH 17.52 1 12 PER YEARA4362 SKIN BARRIER; SOLID, 4 X 4 OR EQUIVALENT;

EACH 2.91 20 240 PER YEAR

A4364 ADHESIVE, LIQUID OR EQUAL, ANY TYPE, PEROZ

2.13 4 48 PER YEAR

A4365 ADHESIVE REMOVER WIPES, ANY TYPE, PER 50 8.64 2 2 PER MONTHA4367 OSTOMY BELT, EACH 5.61 1 12 PER YEARA4368 OSTOMY FILTER, ANY TYPE, EACH 0.20 200 200 PER MONTHA4369 OSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUSH,

ETC), PER OZ 1.84 12 144 PER YEAR

A4371 OSTOMY SKIN BARRIER, POWDER, PER OZ 2.78 12 144 PER YEARA4372 OSTOMY SKIN BARRIER, SOLID 4X4 OR

EQUIVALENT, WITH BUILT-IN CONVEXITY, EACH 3.18 20 240 PER YEAR

A4373 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,FLEXIBLE OR ACCORDIAN), WITH BUILT-INCONVEXITY, ANY SIZE, EACH

4.79 31 240 PER YEAR

A4375 OSTOMY POUCH, DRAINABLE, WITH FACEPLATEATTACHED, PLASTIC, EACH

13.10 10 10 PER MONTH

A4376 OSTOMY POUCH, DRAINABLE, WITH FACEPLATEATTACHED, RUBBER, EACH


A4377 OSTOMY POUCH, DRAINABLE, FOR USE ONFACEPLATE, PLASTIC, EACH


A4378 OSTOMY POUCH, DRAINABLE, FOR USE ONFACEPLATE, RUBBER, EACH


A4379 OSTOMY POUCH, URINARY, WITH FACEPLATEATTACHED, PLASTIC, EACH

11.46 10 10 PER MONTH

A4380 OSTOMY POUCH, URINARY, WITH FACEPLATEATTACHED, RUBBER, EACH

28.48 20 366 PER YEAR

A4381 OSTOMY POUCH, URINARY, FOR USE ON 3.52 10 10 PER MONTH

March 2003B - 2

CODE


DESCRIPTION MAX



FACEPLATE, PLASTIC, EACHA4382 OSTOMY POUCH, URINARY, FOR USE ON

FACEPLATE, HEAVY PLASTIC, EACH 18.78 10 10 PER MONTH

A4383 OSTOMY POUCH, URINARY, FOR USE ONFACEPLATE, RUBBER, EACH

21.51 10 10 PER MONTH

A4384 OSTOMY FACEPLATE EQUIVALENT, SILICONERING, EACH


A4385 OSTOMY SKIN BARRIER, SOLID 4X4 OREQUIVALENT, EXTENDED WEAR, WITHOUTBUILT-IN CONVEXITY, EACH

3.88 10 10 PER OSTOMY

A4387 OSTOMY POUCH, CLOSED, WITH BARRIERATTACHED, WITH BUILT-IN CONVEXITY (1PIECE), EACH


A4388 OSTOMY POUCH, DRAINABLE, WITH EXTENDEDWEAR BARRIER ATTACHED, (1 PIECE), EACH


A4389 OSTOMY POUCH, DRAINABLE, WITH BARRIERATTACHED, WITH BUILT-IN CONVEXITY (1PIECE), EACH


A4390 OSTOMY POUCH, DRAINABLE, WITH EXTENDEDWEAR BARRIER ATTACHED, WITH BUILT-INCONVEXITY (1 PIECE), EACH


A4391 OSTOMY POUCH, URINARY, WITH EXTENDEDWEAR BARRIER ATTACHED (1 PIECE), EACH


A4392 OSTOMY POUCH, URINARY, WITH STANDARDWEAR BARRIER ATTACHED, WITH BUILT-INCONVEXITY (1 PIECE), EACH


A4393 OSTOMY POUCH, URINARY, WITH EXTENDEDWEAR BARRIER ATTACHED, WITH BUILT-INCONVEXITY (1 PIECE), EACH


A4394 OSTOMY DEODORANT FOR USE IN OSTOMYPOUCH, LIQUID, PER FLUID OUNCE

1.96 10 4 PER MONTH

A4395 OSTOMY DEODORANT FOR USE IN OSTOMYPOUCH, SOLID, PER TABLET


A4396 OSTOMY BELT WITH PERISTOMAL HERNIASUPPORT

30.89 2 2 PER MONTH

A4400 OSTOMY IRRIGATION SET 31.70 1 6 PER YEARA4405 OSTOMY SKIN BARRIER, NON-PECTIN BASED,

PASTE, PER OUNCE 2.18 12 144 PER YEAR

A4406 OSTOMY SKIN BARRIER, PECTIN-BASED, PASTE,PER OUNCE

3.67 12 144 PER YEAR

A4407 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,FLEXIBLE, OR ACCORDION), EXTENDED WEAR,WITH BUILT-IN CONVEXITY, 4 X 4 INCHES ORSMALLER, EACH

5.61 31 366 PER YEAR

A4408 OSTOMY SKIN BARRIER, WTIH FLANGE (SOLID,FLEXIBLE OR ACCORDION), EXTENDED WEAR,WITH BUILT-IN CONVEXITY, LARGER THAN 4 X 4

6.32 31 366 PER YEAR

March 2003B - 3

CODE


DESCRIPTION MAX



INCHES, EACHA4409 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,

FLEXIBLE OR ACCORDION), EXTENDED WEAR,WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES ORSMALLER, EACH

3.98 31 366 PER YEAR

A4410 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,FLEXIBLE OR ACCORDION), EXTENDED WEAR,WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4X 4 INCHES, EACH

5.78 31 366 PER YEAR

A4413 OSTOMY POUCH, DRAINABLE, HIGH OUTPUT,FOR USE ON A BARRIER WITH FLANGE (2 PIECESYSTEM), WITH FILTER, EACH


A4414 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,FLEXIBLE OR ACCORDION), WITHOUT BUILT-INCONVEXITY, 4 X 4 INCHES OR SMALLER, EACH

3.15 31 366 PER YEAR

A4415 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,FLEXIBLE OR ACCORDION), WITHOUT BUILT-INCONVEXITY, LARGER THAN 4X4 INCHES, EACH

3.84 31 366 PER YEAR

A4421 OSTOMY SUPPLY; MISCELLANEOUS 7.76 1 12 PER YEARA4455 ADHESIVE REMOVER OR SOLVENT (FOR TAPE,

CEMENT OR OTHER ADHESIVE), PER OUNCE 1.16 4 48 PER YEAR

A4561 PESSARY, RUBBER, ANY TYPE 13.46 1 10 PER MONTHA4562 PESSARY, NON RUBBER, ANY TYPE 36.46 1 10 PER MONTHA4608 TRANSTRACHEAL OXYGEN CATHETER, EACH 46.66 5 5 PER MONTHA4611 BATTERY, HEAVY DUTY; REPLACEMENT FOR

PATIENT OWNED VENTILATOR 111.55 1 MEDICAL

NECESSITYA4612 BATTERY CABLES; REPLACEMENT FOR

PATIENT-OWNED VENTILATOR 41.23 1 MEDICAL

NECESSITYA4613 BATTERY CHARGER; REPLACEMENT FOR

PATIENT-OWNED VENTILATOR 94.09 1 MEDICAL

NECESSITYA4614 PEAK EXPIRATORY FLOW RATE METER, HAND

HELD 18.14 1 1 PER YEAR

A4616 TUBING (OXYGEN), PER FOOT 0.21 25 250 PER YEARA4618 BREATHING CIRCUITS 5.77 1 MEDICAL

NECESSITYA4621 TRACHEOTOMY MASK OR COLLAR 1.18 4 4 PER MONTHA4622 TRACHEOSTOMY OR LARYNGECTOMY TUBE 52.38 1 MEDICAL

NECESSITYA4623 TRACHEOSTOMY, INNER CANNULA

(REPLACEMENT ONLY) 6.25 5 60 PER YEAR

A4624 TRACHEAL SUCTION CATHETER, ANY TYPEOTHER THAN CLOSED SYSTEM, EACH

0.97 250 3000 PER YEAR

A4625 TRACHEOSTOMY CARE KIT FOR NEWTRACHEOSTOMY

6.61 14 14 PER MEDICALEVENT

A4626 TRACHEOSTOMY CLEANING BRUSH, EACH 1.46 1 12 PER YEARA4627 SPACER, BAG OR RESERVOIR, WITH OR WITHOUT

MASK, FOR USE WITH METERED DOSE INHALER 20.00 1 1 PER YEAR

March 2003B - 4

CODE


DESCRIPTION MAX



A4629 TRACHEOSTOMY CARE KIT FOR ESTABLISHEDTRACHEOSTOMY


A4635 UNDERARM PAD, CRUTCH, REPLACEMENT,EACH

1.79 2 2 PER YEAR

A4636 REPLACEMENT, HANDGRIP, CANE, CRUTCH, ORWALKER, EACH

1.65 2 2 PER YEAR

A4637 REPLACEMENT, TIP, CANE, CRUTCH, WALKER,EACH.

1.21 4 4 PER YEAR

A5051 OSTOMY POUCH, CLOSED; WITH BARRIERATTACHED (1 PIECE), EACH

1.66 31 366 PER YEAR

A5052 OSTOMY POUCH, CLOSED; WITHOUT BARRIERATTACHED (1 PIECE), EACH

1.27 31 366 PER YEAR

A5053 OSTOMY POUCH, CLOSED; FOR USE ONFACEPLATE, EACH

1.28 31 366 PER YEAR

A5054 OSTOMY POUCH, CLOSED; FOR USE ON BARRIERWITH FLANGE (2 PIECE), EACH

1.28 31 366 PER YEAR

A5055 STOMA CAP 1.21 31 31 PER MONTHA5061 OSTOMY POUCH, DRAINABLE; WITH BARRIER

ATTACHED, (1 PIECE), EACH 2.18 31 366 PER YEAR

A5062 OSTOMY POUCH, DRAINABLE; WITHOUTBARRIER ATTACHED (1 PIECE), EACH

1.89 31 366 PER YEAR

A5063 OSTOMY POUCH, DRAINABLE; FOR USE ONBARRIER WITH FLANGE (2 PIECE SYSTEM), EACH

1.89 31 366 PER YEAR

A5071 OSTOMY POUCH, URINARY; WITH BARRIERATTACHED (1 PIECE), EACH

2.82 31 366 PER YEAR

A5072 OSTOMY POUCH, URINARY; WITHOUT BARRIERATTACHED (1 PIECE), EACH

2.29 31 366 PER YEAR

A5073 OSTOMY POUCH, URINARY; FOR USE ONBARRIER WITH FLANGE (2 PIECE), EACH

2.09 31 366 PER YEAR

A5081 CONTINENT DEVICE; PLUG FOR CONTINENTSTOMA

2.51 1 6 PER YEAR

A5082 CONTINENT DEVICE; CATHETER FOR CONTINENTSTOMA

7.71 1 6 PER YEAR

A5093 OSTOMY ACCESSORY; CONVEX INSERT 1.55 10 120 PER YEARA5112 URINARY LEG BAG; LATEX 26.42 1 48 PER YEARA5119 SKIN BARRIER; WIPES, BOX PER 50 8.28 1 12 PER YEARA5121 SKIN BARRIER; SOLID, 6 X 6 OR EQUIVALENT,

EACH 4.84 10 120 PER YEAR

A5122 SKIN BARRIER; SOLID, 8 X 8 OR EQUIVALENT,EACH

9.81 10 120 PER YEAR

A5131 APPLIANCE CLEANER, INCONTINENCE ANDOSTOMY APPLIANCES, PER 16 OZ.

10.28 3 3 PER MONTH

A5500 FOR DIABETICS ONLY, FITTING (INCLUDINGFOLLOW-UP), CUSTOM PREPARATION ANDSUPPLY OF OFF-THE-SHELF DEPTH-INLAY SHOEMANUFACTURED TO ACCOMMODATE MULTI-DENSITY INSERT(S), PER SHOE.


March 2003B - 5

CODE


DESCRIPTION MAX



A5501 FOR DIABETICS ONLY, FITTING (INCLUDINGFOLLOW-UP), CUSTOM PREPARATION ANDSUPPLY OF SHOE MOLDED FROM CAST(S) OFPATIENT'S FOOT (CUSTOM MOLDED SHOE), PERSHOE


A5503 FOR DIABETICS ONLY, MODIFICATION(INCLUDING FITTING) OF OFF-THE-SHELFDEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOEWITH ROLLER OR RIGID ROCKER BOTTOM, PERSHOE

25.60 2 2 PER FOOT PERYEAR

A5504 FOR DIABETICS ONLY, MODIFICATION(INCLUDING FITTING) OF OFF-THE-SHELFDEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOEWITH WEDGE(S), PER SHOE


A5505 FOR DIABETICS ONLY, MODIFICATION(INCLUDING FITTING) OF OFF-THE-SHELFDEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOEWITH METATARSAL BAR, PER SHOE


A5506 FOR DIABETICS ONLY, MODIFICATION(INCLUDING FITTING) OF OFF-THE-SHELFDEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOEWITH OFF-SET HEEL(S), PER SHOE


A5507 FOR DIABETICS ONLY, NOT OTHERWISESPECIFIED MODIFICATION (INCLUDING FITTING)OF OFF-THE-SHELF DEPTH-INLAY SHOE ORCUSTOM-MOLDED SHOE, PER SHOE

0.00 BR 2 2 PER FOOT PERYEAR

A5509 FOR DIABETICS ONLY, DIRECT FORMED,MOLDED TO FOOT WITH EXTERNAL HEATSOURCE (I.E. HEAT GUN) MULTIPLE DENSITYINSERT (S), PREFABRICATED, PER SHOE

26.40 2 2 PER FOOT PERYE

A6022 COLLAGEN DRESSING, PAD SIZE MORE THAN 16SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN.,EACH

16.04 31 31 PER MONTH

A6023 COLLAGEN DRESSING, PAD SIZE MORE THAN 48SQ. IN., EACH

145.21 15 15 PER MONTH

A6024 COLLAGEN DRESSING WOUND FILLER, PER 6INCHES

4.72 1 31 PER MONTH

A6231 GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECTWOUND CONTACT, PAD SIZE 16 SQ. IN. OR LESS,EACH DRESSING


A6232 GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECTWOUND CONTACT, PAD SIZE GREATER THAN 16SQ. IN., BUT LESS THAN OR EQUAL TO 48 SQ. IN.,EACH DRESSING


A6233 GAUZE, IMPREGNATED, HYDROGEL FOR DIRECTWOUND CONTACT, PAD SIZE MORE THAN 48 SQ.IN., EACH DRESSING

14.64 31 31 PER MONTH

A6257 TRANSPARENT FILM, 16 SQ. IN. OR LESS, EACH 1.15 31 31 PER MONTH

March 2003B - 6

CODE


DESCRIPTION MAX



DRESSINGA7000 CANISTER, DISPOSABLE, USED WITH SUCTION

PUMP, EACH 6.94 1 4 PER YEAR

A7001 CANISTER, NON-DISPOSABLE, USED WITHSUCTION PUMP, EACH

21.45 1 1 PER 2 YEARS

A7002 TUBING, USED WITH SUCTION PUMP, EACH 2.48 2 12 PER YEARA7003 ADMINISTRATION SET, WITH SMALL VOLUME

NONFILTERED PNEUMATIC NEBULIZER,DISPOSABLE

1.98 3 36 PER YEAR

A7004 SMALL VOLUME NONFILTERED PNEUMATICNEBULIZER, DISPOSABLE

1.16 1 36 PER YEAR

A7005 ADMINISTRATION SET, WITH SMALL VOLUMENONFILTERED PNEUMATIC NEBULIZER,NON-DISPOSABLE

19.99 1 2 PER YEAR

A7006 ADMINISTRATION SET, WITH SMALL VOLUMEFILTERED PNEUMATIC NEBULIZER

7.24 1 36 PER YEAR

A7007 LARGE VOLUME NEBULIZER, DISPOSABLE,UNFILLED, USED WITH AEROSOL COMPRESSOR

3.16 1 36 PER YEAR

A7008 LARGE VOLUME NEBULIZER, DISPOSABLE,PREFILLED, USED WITH AEROSOL COMPRESSOR

7.13 1 36 PER YEAR

A7009 RESERVOIR BOTTLE, NON-DISPOSABLE, USEDWITH LARGE VOLUME ULTRASONIC NEBULIZER

29.79 1 1 PER YEAR

A7010 CORRUGATED TUBING, DISPOSABLE, USED WITHLARGE VOLUME NEBULIZER, 100 FEET

15.30 1 12 PER YEAR

A7011 CORRUGATED TUBING, NON-DISPOSABLE, USEDWITH LARGE VOLUME NEBULIZER, 10 FEET

1.53 1 1 PER MONTH

A7012 WATER COLLECTION DEVICE, USED WITH LARGEVOLUME NEBULIZER

2.74 1 12 PER YEAR

A7013 FILTER, DISPOSABLE, USED WITH AEROSOLCOMPRESSOR

0.53 1 366 PER YEAR

A7014 FILTER, NONDISPOSABLE, USED WITH AEROSOLCOMPRESSOR OR ULTRASONIC GENERATOR

3.30 1 12 PER YEAR

A7015 AEROSOL MASK, USED WITH DME NEBULIZER 1.43 1 12 PER YEARA7016 DOME AND MOUTHPIECE, USED WITH SMALL

VOLUME ULTRASONIC NEBULIZER 4.97 1 12 PER YEAR

A7017 NEBULIZER, DURABLE, GLASS ORAUTOCLAVABLE PLASTIC, BOTTLE TYPE, NOTUSED WITH OXYGEN

102.28 1 1 PER YEAR

A7501 TRACHEOSTOMA VALVE, INCLUDINGDIAPHRAGM, EACH


A7502 REPLACEMENT DIAPHRAGM/FACEPLATE FORTRACHEOSTOMA VALVE, EACH


A7503 FILTER HOLDER OR FILTER CAP, REUSABLE, FORUSE IN A TRACHEOSTOMA HEAT AND MOISTUREEXCHANGE SYSTEM, EACH

8.65 1 4 PER YEAR

A7504 FILTER FOR USE IN A TRACHEOSTOMA HEATAND MOISTURE EXCHANGE SYSTEM, EACH

0.51 31 366 PER YEAR

March 2003B - 7

CODE


DESCRIPTION MAX



A7505 HOUSING, REUSABLE WITHOUT ADHESIVE, FORUSE IN A HEAT AND MOISTURE EXCHANGESYSTEM AND/OR WITH A TRACHEOSTOMAVALVE, EACH

3.57 1 120 PER YEAR

A7506 ADHESIVE DISC FOR USE IN A HEAT ANDMOISTURE EXCHANGE SYSTEM AND/OR WITHTRACHEOSTOMA VALVE, ANY TYPE EACH


A7507 FILTER HOLDER AND INTEGRATED FILTERWITHOUT ADHESIVE, FOR USE IN ATRACHEOSTOMA HEAT AND MOISTUREEXCHANGE SYSTEM, EACH

1.90 1 4 PER YEAR

A7508 HOUSING AND INTEGRATED ADHESIVE, FOR USEIN A TRACHEOSTOMA HEAT AND MOISTUREEXCHANGE SYSTEM AND/OR WITH ATRACHEOSTOMA VALVE, EACH


A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY,AND/OR SERVICE COMPONENT OF ANOTHERHCPCS CODE

0.00 BR 10 MEDICALNECESSITY

March 2003B - 8

CODE


DESCRIPTION MAX



E0100 CANE, INCLUDES CANES OF ALL MATERIALS,ADJUSTABLE OR FIXED, WITH TIP

15.52 1 1 PER YEAR

E0105 CANE, QUAD OR THREE PRONG, INCLUDESCANES OF ALL MATERIALS, ADJUSTABLE ORFIXED, WITH TIPS

36.38 1 1 PER 3 YEARS

E0112 CRUTCHES UNDERARM, WOOD, ADJUSTABLE ORFIXED, PAIR, WITH PADS, TIPS AND HANDGRIPS

21.34 1 1 PER 2 YEARS

E0113 CRUTCH UNDERARM, WOOD, ADJUSTABLE ORFIXED, EACH, WITH PAD, TIP AND HANDGRIP

10.67 1 1 PER 2 YEARS

E0114 CRUTCHES UNDERARM, OTHER THAN WOOD,ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPSAND HANDGRIPS

24.25 1 1 PER 2 YEARS

E0116 CRUTCH UNDERARM, OTHER THAN WOOD,ADJUSTABLE OR FIXED, EACH, WITH PAD, TIPAND HANDGRIP

12.13 1 1 PER 2 YEARS

E0135 WALKER, FOLDING (PICKUP), ADJUSTABLE ORFIXED HEIGHT

53.35 1 1 PER 3 YEARS

E0143 FOLDING WALKER, WHEELED, WITHOUT SEAT 86.24 1 1 PER 3 YEARSE0149 WALKER, HEAVY DUTY, WHEELED, RIGID OR

FOLDING, ANY TYPE, EACH 170.82 1 1 PER 3 YEARS

E0156 SEAT ATTACHMENT, WALKER 17.14 1 1 PER 3 YEARSE0161 SITZ TYPE BATH OR EQUIPMENT, PORTABLE,

USED WITH OR WITHOUT COMMODE, WITHFAUCET ATTACHMENT/S

24.25 1 1 PER 8 YEARS

E0163 COMMODE CHAIR, STATIONARY, WITH FIXEDARMS

71.78 1 1 PER 8 YEARS

E0168 COMMODE CHAIR, EXTRA WIDE AND/OR HEAVYDUTY, STATIONARY OR MOBILE, WITH ORWITHOUT ARMS, ANY TYPE, EACH

115.50 1 1 PER 3 YEARS

E0169 COMMODE CHAIR WITH SEAT LIFT MECHANISM 199.80 1 1 PER 2 YEARSE0176 AIR PRESSURE PAD OR CUSHION,

NONPOSITIONING 61.11 1 1 PER 2 YEARS

E0177 WATER PRESSURE PAD OR CUSHION,NONPOSITIONING

32.98 1 1 PER 2 YEARS

E0178 GEL OR GEL-LIKE PRESSURE PAD OR CUSHION,NONPOSITIONING

54.32 1 1 PER 2 YEARS

E0179 DRY PRESSURE PAD OR CUSHION,NONPOSITIONING

11.41 1 1 PER 2 YEARS

E0185 GEL OR GEL-LIKE PRESSURE PAD FORMATTRESS, STANDARD MATTRESS LENGTH ANDWIDTH

121.25 1 1 PER 2 YEARS

E0192 LOW PRESSURE AND POSITIONINGEQUALIZATION PAD, FOR WHEELCHAIR

261.90 1 26.19 1 PER 2 YEARS

E0197 AIR PRESSURE PAD FOR MATTRESS, STANDARDMATTRESS LENGTH AND WIDTH

121.25 1 1 PER 2 YEARS

E0198 WATER PRESSURE PAD FOR MATTRESS,STANDARD MATTRESS LENGTH AND WIDTH

121.25 1 1 PER 2 YEARS

March 2003B - 9

CODE


DESCRIPTION MAX



E0199 DRY PRESSURE PAD FOR MATTRESS, STANDARDMATTRESS LENGTH AND WIDTH

22.31 1 1 PER 2 YEARS

E0244 RAISED TOILET SEAT 29.10 1 1 PER 8 YEARSE0245 TUB STOOL OR BENCH 35.00 1 1 PER 8 YEARSE0246 TRANSFER TUB RAIL ATTACHMENT 14.55 1 1 PER 8 YEARSE0250 HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE

SIDE RAILS, WITH MATTRESS 795.40 1 PA 79.54 1 PER 8 YEARS

E0255 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHANY TYPE SIDE RAILS, WITH MATTRESS

853.60 1 PA 85.36 1 PER 8 YEARS

E0271 MATTRESS, INNERSPRING 121.25 1 1 PER 4 YEARSE0272 MATTRESS, FOAM RUBBER 121.25 1 1 PER 4 YEARSE0275 BED PAN, STANDARD, METAL OR PLASTIC 7.76 1 1 PER 4 YEARSE0276 BED PAN, FRACTURE, METAL OR PLASTIC 9.22 1 1 PER 4 YEARSE0316 SAFETY ENCLOSURE FRAME/CANOPY FOR USE

WITH HOSPITAL BED, ANY TYPE 3,500.00 1 1 PER 5 YEARS

E0325 URINAL; MALE, JUG-TYPE, ANY MATERIAL 6.31 1 1 PER 4 YEARSE0326 URINAL; FEMALE, JUG-TYPE, ANY MATERIAL 8.73 1 1 PER 4 YEARSE0424 STATIONARY COMPRESSED GASEOUS OXYGEN

SYSTEM, RENTAL; INCLUDES CONTAINER,CONTENTS, REGULATOR, FLOWMETER,HUMIDIFIER, NEBULIZER, CANNULA OR MASK,AND TUBING

0.00 1RO 213.40 1 PER MONTH

E0431 PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL;INCLUDES PORTABLE CONTAINER, REGULATOR,FLOWMETER, HUMIDIFIER, CANNULA OR MASK,AND TUBING

0.00 1RO 38.53 1 PER MONTH

E0434 PORTABLE LIQUID OXYGEN SYSTEM, RENTAL;INCLUDES PORTABLE CONTAINER, SUPPLYRESERVOIR, HUMIDIFIER, FLOWMETER, REFILLADAPTOR, CONTENTS GAUGE, CANNULA ORMASK, AND TUBING

0.00 1RO 38.53 1 PER MONTH

E0439 STATIONARY LIQUID OXYGEN SYSTEM, RENTAL;INCLUDES CONTAINER, CONTENTS, REGULATOR,FLOWMETER, HUMIDIFIER, NEBULIZER,CANNULA OR MASK, & TUBING

0.00 1RO 213.40 1 PER MONTH

E0441 OXYGEN CONTENTS, GASEOUS (FOR USE WITHOWNED GASEOUS STATIONARY SYSTEMS ORWHEN BOTH A STATIONARY AND PORTABLEGASEOUS SYSTEM ARE OWNED), 1 MONTH'SSUPPLY = 1 UNIT

0.00 1RO 126.10 1 PER MONTH

E0442 OXYGEN CONTENTS, LIQUID (FOR USE WITHOWNED LIQUID STATIONARY SYSTEMS ORWHEN BOTH A STATIONARY AND PORTABLELIQUID SYSTEM ARE OWNED), 1 MONTH'SSUPPLY = 1 UNIT

0.00 1RO 126.10 1 PER MONTH

E0443 PORTABLE OXYGEN CONTENTS, GASEOUS (FORUSE ONLY WITH PORTABLE GASEOUS SYSTEMS

0.00 1RO 19.52 1 PER MONTH

March 2003B - 10

CODE


DESCRIPTION MAX



WHEN NO STATIONARY GAS OR LIQUID SYSTEMIS USED), 1 MONTH'S SUPPLY = 1 UNIT

E0444 PORTABLE OXYGEN CONTENTS, LIQUID (FORUSE ONLY WITH PORTABLE LIQUID SYSTEMSWHEN NO STATIONARY GAS OR LIQUID SYSTEMIS USED), 1 MONTH'S SUPPLY = 1 UNIT

0.00 1RO 19.52 1 PER MONTH

E0450 VOLUME VENTILATOR, STATIONARY ORPORTABLE, WITH BACKUP RATE FEATURE, USEDWITH INVASIVE INTERFACE (E.G.,TRACHEOSTOMY TUBE)

0.00 1RO 756.60 MEDICALNECESSITY

E0457 CHEST SHELL (CUIRASS) 0.00 1RO 36.86 MEDICALNECESSITY

E0459 CHEST WRAP 340.50 1 34.05 MEDICALNECESSITY

E0460 NEGATIVE PRESSURE VENTILATOR; PORTABLEOR STATIONARY


E0480 PERCUSSOR, ELECTRIC OR PNEUMATIC, HOMEMODEL

315.30 1 31.53 1 PER 4 YEARS

E0500 IPPB MACHINE, ALL TYPES, WITH BUILT-INNEBULIZATION; MANUAL OR AUTOMATICVALVES; INTERNAL OR EXTERNAL POWERSOURCE


E0550 HUMIDIFIER, DURABLE FOR EXTENSIVESUPPLEMENTAL HUMIDIFICATION DURING IPPBTREATMENTS OR OXYGEN DELIVERY


E0555 HUMIDIFIER, DURABLE, GLASS ORAUTOCLAVABLE PLASTIC BOTTLE TYPE, FORUSE WITH REGULATOR OR FLOWMETER

31.53 1 1 PER 2 YEARS

E0560 HUMIDIFIER, DURABLE FOR SUPPLEMENTALHUMIDIFICATION DURING IPPB TREATMENT OROXYGEN DELIVERY


E0565 COMPRESSOR, AIR POWER SOURCE FOREQUIPMENT WHICH IS NOT SELF- CONTAINED ORCYLINDER DRIVEN


E0570 NEBULIZER, WITH COMPRESSOR 106.70 1 1 PER 2 YEARSE0571 AEROSOL COMPRESSOR, BATTERY POWERED,

FOR USE WITH SMALL VOLUME NEBULIZER 21.12 1 1 PER 2 YEARS

E0572 AEROSOL COMPRESSOR, ADJUSTABLEPRESSURE, LIGHT DUTY FOR INTERMITTENT USE

26.84 1 1 PER 2 YEARS

E0574 ULTRASONIC/ELECTRONIC AEROSOLGENERATOR WITH SMALL VOLUME NEBULIZER

28.36 1 1 PER 2 YEARS

E0575 NEBULIZER, ULTRASONIC, LARGE VOLUME 315.30 1 31.53 1 PER 2 YEARSE0585 NEBULIZER, WITH COMPRESSOR AND HEATER 150.40 1 15.04 1 PER 2 YEARSE0600 RESPIRATORY SUCTION PUMP, HOME MODEL,

PORTABLE OR STATIONARY, ELECTRIC 228.00 1 22.80 1 PER 2 YEARS

E0601 CONTINUOUS AIRWAY PRESSURE (CPAP) DEVICE 0.00 1RO 80.03 MEDICALNECESSITY

March 2003B - 11

CODE


DESCRIPTION MAX



E0605 VAPORIZER, ROOM TYPE 18.92 1 1 PER 4 YEARSE0606 POSTURAL DRAINAGE BOARD 160.10 1 16.01 1 PER 8 YEARSE0747 OSTEOGENESIS STIMULATOR, ELECTRICAL,

NON-INVASIVE, OTHER THAN SPINALAPPLICATIONS

0.00 1RO 247.35 MAXIMUM 6 MOSRENTAL

E0910 TRAPEZE BARS, A/K/A PATIENT HELPER,ATTACHED TO BED, WITH GRAB BAR

150.40 1 15.04 1 PER LIFETIME

E0940 TRAPEZE BAR, FREE STANDING, COMPLETEWITH GRAB BAR

266.80 1 26.68 1 PER LIFETIME

E0962 1" CUSHION, FOR WHEELCHAIR 42.61 1 2 PER 4 YEARSE0963 2" CUSHION, FOR WHEELCHAIR 55.05 1 2 PER 4 YEARSE0964 3" CUSHION, FOR WHEELCHAIR 61.35 1 2 PER 4 YEARSE0965 4" CUSHION, FOR WHEELCHAIR 66.98 1 2 PER 4 YEARSE0967 WHEELCHAIR HAND RIMS WITH 8 VERTICAL

RUBBER TIPPED PROJECTIONS, PAIR 92.57 1 2 PER 4 YEARS

E0968 COMMODE SEAT, WHEELCHAIR 14.27 1 2 PER 4 YEARSE0969 NARROWING DEVICE, WHEELCHAIR 124.69 1 2 PER 4 YEARSE0977 WEDGE CUSHION, WHEELCHAIR 44.26 1 2 PER 4 YEARSE0980 SAFETY VEST, WHEELCHAIR 22.38 1 2 PER 4 YEARSE0994 ARM REST, EACH 14.03 2 2 PER 4 YEARSE0997 CASTER WITH A FORK 45.00 2 2 PER 4 YEARSE0998 CASTER WITHOUT FORK 30.47 2 2 PER 4 YEARSE0999 PNEUMATIC TIRE WITH WHEEL 91.52 2 2 PER 4 YEARSE1001 WHEEL, SINGLE 78.06 2 2 PER 4 YEARSE1031 ROLLABOUT CHAIR, ANY AND ALL TYPES WITH

CASTORS 5" OR GREATER 341.70 1 34.17 1 PER 5 YEARS

E1050 FULLY-RECLINING WHEELCHAIR, FIXED FULLLENGTH ARMS, SWING AWAY DETACHABLEELEVATING LEG RESTS

689.00 1 68.90 1 PER 5 YEARS

E1060 FULLY-RECLINING WHEELCHAIR, DETACHABLEARMS, DESK OR FULL LENGTH, SWING AWAYDETACHABLE ELEVATING LEGRESTS

853.00 1 85.30 1 PER 5 YEARS

E1065 POWER ATTACHMENT (TO CONVERT ANYWHEELCHAIR TO MOTORIZED WHEELCHAIR,E.G., SOLO)

0.00 1 1 PER 5 YEARS

E1070 FULLY-RECLINING WHEELCHAIR, DETACHABLEARMS (DESK OR FULL LENGTH) SWING AWAYDETACHABLE FOOTREST

741.10 1 74.11 1 PER 5 YEARS

E1083 HEMI-WHEELCHAIR, FIXED FULL LENGTH ARMS,SWING AWAY DETACHABLE ELEVATING LEGREST

532.80 1 53.28 1 PER 5 YEARS

E1084 HEMI-WHEELCHAIR, DETACHABLE ARMS DESKOR FULL LENGTH ARMS, SWING AWAYDETACHABLE ELEVATING LEG RESTS

663.80 1 66.38 1 PER 5 YEARS

E1087 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR,FIXED FULL LENGTH ARMS, SWING AWAYDETACHABLE ELEVATING LEG RESTS

856.00 1 85.60 1 PER 5 YEARS

March 2003B - 12

CODE


DESCRIPTION MAX



E1088 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR,DETACHABLE ARMS DESK OR FULL LENGTH,SWING AWAY DETACHABLE ELEVATING LEGRESTS

1,020.70 1102.07 1 PER 5 YEARS

E1092 WIDE HEAVY DUTY WHEEL CHAIR,DETACHABLE ARMS (DESK OR FULL LENGTH),SWING AWAY DETACHABLE ELEVATING LEGRESTS

869.50 1 86.95 1 PER 5 YEARS

E1093 WIDE HEAVY DUTY WHEELCHAIR, DETACHABLEARMS DESK OR FULL LENGTH ARMS, SWINGAWAY DETACHABLE FOOTRESTS

869.50 1 86.95 1 PER 5 YEARS

E1100 SEMI-RECLINING WHEELCHAIR, FIXED FULLLENGTH ARMS, SWING AWAY DETACHABLEELEVATING LEG RESTS

702.50 1 70.25 1 PER 5 YEARS

E1110 SEMI-RECLINING WHEELCHAIR, DETACHABLEARMS (DESK OR FULL LENGTH) ELEVATING LEGREST

687.80 1 68.78 1 PER 5 YEARS

E1150 WHEELCHAIR, DETACHABLE ARMS, DESK ORFULL LENGTH SWING AWAY DETACHABLEELEVATING LEGRESTS

552.00 1 55.20 1 PER 5 YEARS

E1160 WHEELCHAIR, FIXED FULL LENGTH ARMS,SWING AWAY DETACHABLE ELEVATINGLEGRESTS

426.50 1 42.65 1 PER 5 YEARS

E1170 AMPUTEE WHEELCHAIR, FIXED FULL LENGTHARMS, SWING AWAY DETACHABLE ELEVATINGLEGRESTS

604.30 1 60.43 1 PER 5 YEARS

E1171 AMPUTEE WHEELCHAIR, FIXED FULL LENGTHARMS, WITHOUT FOOTRESTS OR LEGREST

542.40 1 54.24 1 PER 5 YEARS

E1172 AMPUTEE WHEELCHAIR, DETACHABLE ARMS(DESK OR FULL LENGTH) WITHOUT FOOTRESTSOR LEGREST

662.70 1 66.27 1 PER 5 YEARS

E1180 AMPUTEE WHEELCHAIR, DETACHABLE ARMS(DESK OR FULL LENGTH) SWING AWAYDETACHABLE FOOTRESTS

685.60 1 68.56 1 PER 5 YEARS

E1190 AMPUTEE WHEELCHAIR, DETACHABLE ARMS(DESK OR FULL LENGTH) SWING AWAYDETACHABLE ELEVATING LEGRESTS

792.10 1 79.21 1 PER 5 YEARS

E1195 HEAVY DUTY WHEELCHAIR, FIXED FULLLENGTH ARMS, SWING AWAY DETACHABLEELEVATING LEGRESTS

850.00 1 85.00 1 PER 5 YEARS

E1200 AMPUTEE WHEELCHAIR, FIXED FULL LENGTHARMS, SWING AWAY DETACHABLE FOOTREST

588.70 1 58.87 1 PER 5 YEARS

E1210 MOTORIZED WHEELCHAIR, FIXED FULL LENGTHARMS, SWING AWAY DETACHABLE ELEVATINGLEG RESTS

2,780.00 1278.00 1 PER 5 YEARS

E1211 MOTORIZED WHEELCHAIR, DETACHABLE ARMSDESK OR FULL LENGTH SWING AWAY,DETACHABLE ELEVATING LEG REST

2,831.80 1283.18 1 PER 5 YEARS

March 2003B - 13

CODE


DESCRIPTION MAX



E1221 WHEELCHAIR WITH FIXED ARM, FOOTRESTS 321.40 1 32.14 1 PER 5 YEARSE1222 WHEELCHAIR WITH FIXED ARM, ELEVATING

LEGRESTS 458.60 1 45.86 1 PER 5 YEARS

E1223 WHEELCHAIR WITH DETACHABLE ARMS,FOOTRESTS

500.80 1 50.08 1 PER 5 YEARS

E1224 WHEELCHAIR WITH DETACHABLE ARMS,ELEVATING LEGRESTS

549.10 1 54.91 1 PER 5 YEARS

E1225 SEMI-RECLINING BACK FOR CUSTOMIZEDWHEEL CHAIR

305.80 1 30.58 1 PER 5 YEARS

E1227 SPECIAL HEIGHT ARMS FOR WHEELCHAIR 220.90 1 1 PER 5 YEARSE1228 SPECIAL BACK HEIGHT FOR WHEELCHAIR 18.97 1 1 PER 5 YEARSE1230 POWER OPERATED VEHICLE (THREE OR FOUR

WHEEL NONHIGHWAY) SPECIFY BRAND NAMEAND MODEL NUMBER

1,210.39 1 1 PER 5 YEARS

E1240 LIGHTWEIGHT WHEELCHAIR, DETACHABLEARMS, (DESK OR FULL LENGTH) SWING AWAYDETACHABLE, ELEVATING LEGREST

697.00 1 69.70 1 PER 5 YEARS

E1270 LIGHTWEIGHT WHEELCHAIR, FIXED FULLLENGTH ARMS, SWING AWAY DETACHABLEELEVATING LEGRESTS

534.20 1 53.42 1 PER 5 YEARS

E1280 HEAVY DUTY WHEELCHAIR, DETACHABLEARMS (DESK OR FULL LENGTH) ELEVATINGLEGRESTS

888.20 1 88.82 1 PER 5 YEARS

E1295 HEAVY DUTY WHEELCHAIR, FIXED FULLLENGTH ARMS, ELEVATING LEGREST

821.90 1 82.19 1 PER 5 YEARS

E1296 SPECIAL WHEELCHAIR SEAT HEIGHT FROMFLOOR

391.39 1 1 PER 5 YEARS

E1297 SPECIAL WHEELCHAIR SEAT DEPTH, BYUPHOLSTERY

83.27 1 1 PER 5 YEARS

E1298 SPECIAL WHEELCHAIR SEAT DEPTH AND/ORWIDTH, BY CONSTRUCTION

299.29 1 1 PER 5 YEARS

E1340 REPAIR OR NONROUTINE SERVICE FOR DURABLEMEDICAL EQUIPMENT REQUIRING THE SKILL OFA TECHNICIAN, LABOR COMPONENT, PER 15MINUTES

10.00 16 $160.00 PER YEAR

E1390 OXYGEN CONCENTRATOR, CAPABLE OFDELIVERING 85 PERCENT OR GREATER OXYGENCONCENTRATION AT THE PRESCRIBED FLOWRATE

0.00 1RO 170.48 1 PER MONTH

E1399 DURABLE MEDICAL EQUIPMENT,MISCELLANEOUS

0.00 1 PA MEDICALNECESSITY

E1405 OXYGEN AND WATER VAPOR ENRICHINGSYSTEM WITH HEATED DELIVERY

0.00 1RO 253.17 1 PER MONTH

E1406 OXYGEN AND WATER VAPOR ENRICHINGSYSTEM WITHOUT HEATED DELIVERY

0.00 1RO 247.16 1 PER MONTH

E1801 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCHELBOW DEVICE WITH RANGE OF MOTION

73.50 1 2 PER 2 YEARS

March 2003B - 14

CODE


DESCRIPTION MAX



ADJUSTMENT, INCLUDES CUFFSE1806 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH

WRIST DEVICE WITH RANGE OF MOTIONADJUSTMENT, INCLUDES CUFFS

73.50 1 2 PER 2 YEARS

E1811 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCHKNEE DEVICE WITH RANGE OF MOTIONADJUSTMENT, INCLUDES CUFFS

73.50 1 2 PER 2 YEARS

E1816 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCHANKLE DEVICE WITH RANGE OF MOTIONADJUSTMENT, INCLUDES CUFFS

73.50 1 2 PER 2 YEARS

E1818 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCHFOREARM PRONATION / SUPINATION DEVICEWITH RANGE OF MOTION ADJUSTMENT,INCLUDES CUFFS

73.50 1 2 PER 2 YEARS

E1821 REPLACEMENT SOFT INTERFACEMATERIAL/CUFFS FOR BI-DIRECTIONAL STATICPROGRESSIVE STRETCH DEVICE

6.06 8 8 PER YEAR

E1840 DYNAMIC ADJUSTABLE SHOULDER FLEXION /ABDUCTION / ROTATION DEVICE, INCLUDESSOFT INTERFACE MATERIAL

73.50 2 2 PER 2 YEARS

E1902 COMMUNICATION BOARD, NON-ELECTRONICAUGMENTATIVE OR ALTERNATIVECOMMUNICATION DEVICE

0.00 1 PA 1 PER 5 YEARS

E2000 GASTRIC SUCTION PUMP, HOME MODEL,PORTABLE OR STATIONARY, ELECTRIC

22.80 1 1 PER 2 YEARS

March 2003B - 15

CODE


DESCRIPTION MAX



K0001 STANDARD WHEELCHAIR 354.30 1 35.43 1 PER 5 YEARSK0002 STANDARD HEMI (LOW SEAT) WHEELCHAIR 530.70 1 53.07 1 PER 5 YEARSK0003 LIGHTWEIGHT WHEELCHAIR 581.10 1 58.11 1 PER 5 YEARSK0004 HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR 866.80 1 86.68 1 PER 5 YEARSK0005 ULTRALIGHTWEIGHT WHEELCHAIR 1,410.71 1 1 PER 5 YEARSK0006 HEAVY DUTY WHEELCHAIR 813.40 1 81.34 1 PER 5 YEARSK0007 EXTRA HEAVY DUTY WHEELCHAIR 1,263.90 1126.39 1 PER 5 YEARSK0009 OTHER MANUAL WHEELCHAIR/BASE 0.00 1 PA 1 PER 5 YEARSK0010 STANDARD - WEIGHT FRAME

MOTORIZED/POWER WHEELCHAIR 2,763.00 1276.30 1 PER 5 YEARS

K0011 STANDARD - WEIGHT FRAMEMOTORIZED/POWER WHEELCHAIR WITHPROGRAMMABLE CONTROL PARAMETERS FORSPEED ADJUSTMENT, TREMOR DAMPENING,ACCELERATION CONTROL AND BRAKING

3,699.70 1369.97 1 PER 5 YEARS

K0012 LIGHTWEIGHT PORTABLE MOTORIZED/POWERWHEELCHAIR

2,269.40 1226.94 1 PER 5 YEARS

K0014 OTHER MOTORIZED/POWER WHEELCHAIR BASE 0.00 1 PA 1 PER 5 YEARSK0015 DETACHABLE, NON-ADJUSTABLE HEIGHT

ARMREST, EACH 138.65 2 1 PER 5 YEARS

K0016 DETACHABLE, ADJUSTABLE HEIGHT ARMREST,COMPLETE ASSEMBLY, EACH

74.57 2 2 PER 4 YEARS

K0017 DETACHABLE, ADJUSTABLE HEIGHT ARMREST,BASE, EACH

39.00 2 2 PER 4 YEARS

K0018 DETACHABLE, ADJUSTABLE HEIGHT ARMREST,UPPER PORTION, EACH

21.78 2 2 PER 4 YEARS

K0019 ARM PAD, EACH 12.47 2 2 PER 4 YEARSK0020 FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR 35.45 2 2 PER 4 YEARSK0022 REINFORCED BACK UPHOLSTERY 38.32 1 1 PER 5 YEARSK0023 SOLID BACK INSERT, PLANAR BACK, SINGLE

DENSITY FOAM, ATTACHED WITH STRAPS 68.38 1 1 PER 5 YEARS

K0024 SOLID BACK INSERT, PLANAR BACK, SINGLEDENSITY FOAM, WITH ADJUSTABLE HOOK-ONHARDWARE

80.95 1 1 PER 5 YEARS

K0025 HOOK-ON HEADREST EXTENSION 49.91 1 1 PER 5 YEARSK0026 BACK UPHOLSTERY FOR ULTRALIGHTWEIGHT

OR HIGH STRENGTH LIGHTWEIGHTWHEELCHAIR

44.35 1 1 PER 5 YEARS

K0027 BACK UPHOLSTERY FOR WHEELCHAIR TYPEOTHER THAN ULTRALIGHTWEIGHT OR HIGHSTRENGTH LIGHTWEIGHT WHEELCHAIR

35.48 1 1 PER 5 YEARS

K0028 MANUAL, FULLY RECLINING BACK 353.90 1 1 PER 5 YEARSK0029 REINFORCED SEAT UPHOLSTERY 37.96 1 1 PER 5 YEARSK0030 SOLID SEAT INSERT, PLANAR SEAT, SINGLE

DENSITY FOAM 69.46 1 1 PER 5 YEARS

K0031 SAFETY BELT/PELVIC STRAP, EACH 27.70 1 1 PER 5 YEARSK0032 SEAT UPHOLSTERY FOR ULTRALIGHTWEIGHT OR 35.00 1 1 PER 5 YEARS

March 2003B - 16

CODE


DESCRIPTION MAX



HIGH STRENGTH LIGHTWEIGHT WHEELCHAIRK0033 SEAT UPHOLSTERY FOR WHEELCHAIR TYPE

OTHER THAN ULTRALIGHTWEIGHT OR HIGHSTRENGTH LIGHTWEIGHT WHEELCHAIR

35.00 1 1 PER 5 YEARS

K0035 HEEL LOOP WITH ANKLE STRAP, EACH 19.02 2 2 PER YEARK0036 TOE LOOP, EACH 14.38 1 2 PER YEARK0037 HIGH MOUNT FLIP-UP FOOTREST, EACH 36.75 2 2 PER 4 YEARSK0038 LEG STRAP, EACH 18.51 2 2 PER 4 YEARSK0039 LEG STRAP, H STYLE, EACH 41.11 2 2 PER 4 YEARSK0040 ADJUSTABLE ANGLE FOOTPLATE, EACH 56.98 2 2 PER 2 YEARSK0041 LARGE SIZE FOOTPLATE, EACH 40.38 2 2 PER 2 YEARSK0042 STANDARD SIZE FOOTPLATE, EACH 27.79 2 2 PER 2 YEARSK0043 FOOTREST, LOWER EXTENSION TUBE, EACH 14.90 2 2 PER 2 YEARSK0044 FOOTREST, UPPER HANGER BRACKET, EACH 12.97 2 2 PER 2 YEARSK0045 FOOTREST, COMPLETE ASSEMBLY 43.00 2 2 PER 2 YEARSK0046 ELEVATING LEGREST, LOWER EXTENSION TUBE,

EACH 14.90 2 2 PER 4 YEARS

K0047 ELEVATING LEGREST, UPPER HANGER BRACKET,EACH

58.36 2 2 PER 4 YEARS

K0048 ELEVATING LEGREST, COMPLETE ASSEMBLY 89.61 2 2 PER 4 YEARSK0049 CALF PAD, EACH 19.72 2 2 PER 4 YEARSK0050 RATCHET ASSEMBLY 24.80 2 2 PER 4 YEARSK0051 CAM RELEASE ASSEMBLY, FOOTREST OR

LEGREST, EACH 40.14 2 2 PER 4 YEARS

K0052 SWINGAWAY, DETACHABLE FOOTRESTS, EACH 70.54 2 2 PER 4 YEARSK0053 ELEVATING FOOTRESTS, ARTICULATING

(TELESCOPING), EACH 77.84 2 2 PER 4 YEARS

K0054 SEAT WIDTH OF 10", 11", 12", 15", 17", OR 20" FORA HIGH STRENGTH, LIGHTWEIGHT ORULTRALIGHTWEIGHT WHEELCHAIR

79.84 1 1 PER 4 YEARS

K0055 SEAT DEPTH OF 15", 17", OR 18" FOR A HIGHSTRENGTH, LIGHTWEIGHT ORULTRALIGHTWEIGHT WHEELCHAIR

72.57 1 1 PER 4 YEARS

K0056 SEAT HEIGHT LESS THAN 17" OR EQUAL TO ORGREATER THAN 21" FOR A HIGH STRENGTH,LIGHTWEIGHT, OR ULTRALIGHTWEIGHTWHEELCHAIR

72.65 1 1 PER 4 YEARS

K0057 SEAT WIDTH 19" OR 20" FOR HEAVY DUTY OREXTRA HEAVY DUTY CHAIR

94.78 1 1 PER 4 YEARS

K0058 SEAT DEPTH 17" OR 18" FOR MOTORIZED/POWERWHEELCHAIR

46.06 1 1 PER 4 YEARS

K0059 PLASTIC COATED HANDRIM, EACH 24.00 2 1 PER 4 YEARSK0060 STEEL HANDRIM, EACH 21.18 2 1 PER 4 YEARSK0061 ALUMINUM HANDRIM, EACH 30.04 2 1 PER 4 YEARSK0062 HANDRIM WITH 8-10 VERTICAL OR OBLIQUE

PROJECTIONS, EACH 46.53 2 1 PER 4 YEARS

K0063 HANDRIM WITH 12-16 VERTICAL OR OLBIQUE 62.16 2 1 PER 4 YEARS

March 2003B - 17

CODE


DESCRIPTION MAX



PROJECTIONS, EACHK0064 ZERO PRESSURE TUBE (FLAT FREE INSERTS),

ANY SIZE, EACH 23.20 2 1 PER 4 YEARS

K0065 SPOKE PROTECTORS, EACH 33.93 2 1 PER 4 YEARSK0066 SOLID TIRE, ANY SIZE, EACH 21.76 2 1 PER 4 YEARSK0067 PNEUMATIC TIRE, ANY SIZE, EACH 31.22 2 1 PER 4 YEARSK0068 PNEUMATIC TIRE TUBE, EACH 4.49 2 1 PER 4 YEARSK0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH

SOLID TIRE, SPOKES OR MOLDED, EACH 76.24 2 1 PER 4 YEARS

K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITHPNEUMATIC TIRE, SPOKES OR MOLDED, EACH

139.77 2 1 PER 4 YEARS

K0071 FRONT CASTER ASSEMBLY, COMPLETE, WITHPNEUMATIC TIRE, EACH

83.36 2 1 PER 4 YEARS

K0072 FRONT CASTER ASSEMBLY, COMPLETE, WITHSEMI-PNEUMATIC TIRE, EACH

50.18 2 1 PER 4 YEARS

K0073 CASTER PIN LOCK,EACH 25.54 2 1 PER 4 YEARSK0074 PNEUMATIC CASTER TIRE, ANY SIZE, EACH 23.35 2 1 PER 4 YEARSK0075 SEMI-PNEUMATIC CASTER TIRE, ANY SIZE, EACH 27.14 2 1 PER 4 YEARSK0076 SOLID CASTER TIRE, ANY SIZE, EACH 19.50 2 1 PER 4 YEARSK0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH

SOLID TIRE, EACH 44.90 2 1 PER 4 YEARS

K0078 PNEUMATIC CASTER TIRE TUBE, EACH 7.33 2 1 PER 4 YEARSK0079 WHEEL LOCK EXTENSION, PAIR 38.60 1 1 PAIR PER 4

YEARSK0080 ANTI-ROLLBACK DEVICE, PAIR 101.70 1 1 PAIR PER 4

YEARSK0081 WHEEL LOCK ASSEMBLY, COMPLETE, EACH 31.04 2 2 PER 4 YEARSK0082 22 NF NON-SEALED LEAD ACID BATTERY, EACH 85.73 2 4 PER 3 YEARSK0083 22 NF SEALED LEAD ACID BATTERY, EACH (E.G.,

GEL CELL, ABSORBED GLASS MAT) 106.42 2 4 PER 3 YEARS

K0084 GROUP 24 NON-SEALED LEAD ACID BATTERY,EACH

70.26 2 4 PER 3 YEARS

K0085 GROUP 24 SEALED LEAD ACID BATTERY, EACH(E.G., GEL CELL ABSORBED GLASS MAT)

141.94 2 4 PER 3 YEARS

K0086 U-1 NON-SEALED LEAD ACID BATTERY, EACH 85.72 2 4 PER 3 YEARSK0087 U-1 SEALED LEAD ACID BATTERY, EACH (E.G.,

GEL CELL, ABSORBED GLASS MAT) 85.59 2 4 PER 3 YEARS

K0088 BATTERY CHARGER, SINGLE MODE, FOR USEWITH ONLY ONE BATTERY TYPE, SEALED ORNON-SEALED

201.16 1 1 PER LIFETIME

K0089 BATTERY CHARGER, DUAL MODE, FOR USE WITHEITHER BATTERY TYPE, SEALED ORNON-SEALED


K0090 REAR WHEEL TIRE FOR POWER WHEELCHAIR,ANY SIZE, EACH

58.13 2 2 PER 4 YEARS

K0091 REAR WHEEL TIRE TUBE OTHER THAN ZEROPRESSURE FOR POWER WHEELCHAIR, ANY SIZE,

15.85 2 2 PER 4 YEARS

March 2003B - 18

CODE


DESCRIPTION MAX



EACHK0092 REAR WHEEL ASSEMBLY FOR POWER

WHEELCHAIR, COMPLETE, EACH 185.52 2 2 PER 4 YEARS

K0093 REAR WHEEL, ZERO PRESSURE TIRE TUBE (FLATFREE INSERT) FOR POWER WHEELCHAIR, ANYSIZE, EACH

115.90 2 2 PER 4 YEARS

K0094 WHEEL TIRE FOR POWER BASE, ANY SIZE, EACH 37.77 2 2 PER 4 YEARSK0095 WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE

FOR EACH BASE, ANY SIZE, EACH 37.77 2 2 PER 4 YEARS

K0096 WHEEL ASSEMBLY FOR POWER BASE,COMPLETE, EACH

209.30 2 2 PER 4 YEARS

K0097 WHEEL ZERO PRESSURE TIRE TUBE (FLAT FREEINSERT) FOR POWER BASE, ANY SIZE, EACH

46.29 2 2 PER 4 YEARS

K0098 DRIVE BELT FOR POWER WHEELCHAIR 20.15 1 2 PER 4 YEARSK0099 FRONT CASTER FOR POWER WHEELCHAIR, EACH 61.74 2 2 PER 4 YEARSK0100 WHEELCHAIR ADAPTER FOR AMPUTEE, PAIR

(DEVICE USED TO COMPENSATE FOR TRANSFEROF WEIGHT DUE TO LOST LIMBS TO MAINTAINPROPER BALANCE)

57.35 1 1 PER 5 YEARS

K0102 CRUTCH AND CANE HOLDER, EACH 33.08 1 1 PER 5 YEARSK0103 TRANSFER BOARD,<25" 40.75 1 1 PER 4 YEARSK0104 CYLINDER TANK CARRIER, EACH 90.64 1 1 PER 5 YEARSK0105 IV HANGER, EACH 75.87 2 1 PER 5 YEARSK0106 ARM TROUGH, EACH 81.77 2 2 PER 4 YEARSK0107 WHEELCHAIR TRAY 67.42 1 2 PER 4 YEARSK0108 WHEELCHAIR COMPONENT OR ACCESSORY, NOT

OTHERWISE SPECIFIED 0.00 1 PA MEDICAL

NECESSITYK0180 AEROSOL MASK, USED WITH DME NEBULIZER 1.20 1 12 PER YEARK0195 ELEVATING LEG RESTS, PAIR (FOR USE WITH

CAPPED RENTAL WHEELCHAIR BASE) 150.60 1 15.06 2 PER 4 YEARS

K0452 WHEELCHAIR BEARINGS, ANY TYPE 5.00 2 2 PER 4 YEARSK0460 POWER ADD-ON, TO CONVERT MANUAL

WHEELCHAIR TO MOTORIZED WHEELCHAIR,JOYSTICK CONTROL

2,225.04 1 1 PER 5 YEARS

K0461 POWER ADD-ON, TO CONVERT MANUALWHEELCHAIR TO POWER OPERATED VEHICLE,TILLER CONTROL

1,457.89 1 1 PER 5 YEARS

K0532 RESPIRATORY ASSIST DEVICE, BI-LEVELPRESSURE CAPABILITY, WITHOUT BACKUP RATEFEATURE, USED WITH NONINVASIVE INTERFACE,E.G., NASAL OR FACIAL MASK (INTERMITTENTASSIST DEVICE WITH CONTINUOUS POSITIVEAIRWAY PRESSURE DEVICE)

0.00 1RO 177.75 1 PER MONTH

K0533 RESPIRATORY ASSIST DEVICE, BI-LEVELPRESSURE CAPABILITY, WITH BACKUP RATEFEATURE, USED WITH NONINVASIVE INTERFACE,E.G., NASAL OR FACIAL MASK (INTERMITTENT

0.00 1RO 416.51 1 PER MONTH

March 2003B - 19

CODE


DESCRIPTION MAX



ASSIST DEVICE WITH CONTINUOUS POSITIVEAIRWAY PRESSURE DEVICE)

K0541 SPEECH GENERATING DEVICE, DIGITIZEDSPEECH, USING PRE-RECORDED MESSAGES, LESSTHAN OR EQUAL TO 8 MINUTES RECORDINGTIME


K0542 SPEECH GENERATING DEVICE, DIGITIZEDSPEECH, USING PRE-RECORDED MESSAGES,GREATER THAN 8 MINUTES RECORDING TIME


K0543 SPEECH GENERATING DEVICE, SYNTHESIZEDSPEECH, REQUIRING MESSAGE FORMULATIONBY SPELLING AND ACCESS BY PHYSICALCONTACT WITH THE DEVICE


K0544 SPEECH GENERATING DEVICE, SYNTHESIZEDSPEECH, PERMITTING MULTIPLE METHODS OFMESSAGE FORMULATION AND MULTIPLEMETHODS OF DEVICE ACCESS


K0545 SPEECH GENERATING SOFTWARE PROGRAM,FOR PERSONAL COMPUTER OR PERSONALDIGITAL ASSISTANT


K0546 ACCESSORY FOR SPEECH GENERATING DEVICE,MOUNTING SYSTEM


K0547 ACCESSORY FOR SPEECH GENERATING DEVICE,NOT OTHERWISE CLASSIFIED


K0556 ADDITION TO LOWER EXTREMITY, BELOWKNEE/ABOVE KNEE, CUSTOM FABRICATED FROMEXISTING MOLD OR PREFABRICATED, SOCKETINSERT, SILICONE GEL, ELASTOMERIC OREQUAL, FOR USE WITH LOCKING MECHANISM

451.23 2 1 PER ORTHOTSIS

K0557 ADDITION TO LOWER EXTREMITY, BELOWKNEE/ABOVE KNEE, CUSTOM FABRICATED FROMEXISTING MOLD OR PREFABRICATED, SOCKETINSERT, SILICONE GEL, ELASTOMERIC OREQUAL, NOT FOR USE WITH LOCKINGMECHANISM

376.02 2 2 PER YEAR

K0558 ADDITION TO LOWER EXTREMITY, BELOWKNEE/ABOVE KNEE, CUSTOM FABRICATEDSOCKET INSERT FOR CONGENITAL OR ATYPICALTRAUMATIC AMPUTEE, SILICONE GEL,ELASTOMERIC OR EQUAL, FOR USE WITH ORWITHOUT LOCKING MECHANISM, INITIAL ONLY(FOR OTHER THAN IN

799.71 2 2 PER YEAR

K0581 OSTOMY POUCH, CLOSED, WITH BARRIERATTACHED, WITH FILTER (1 PIECE), EACH


K0582 OSTOMY POUCH, CLOSED, WITH BARRIERATTACHED, WITH BUILT-IN CONVEXITY, WITHFILTER (1 PIECE), EACH


K0583 OSTOMY POUCH, CLOSED; WITHOUT BARRIER 1.16 31 10 PER MONTH

March 2003B - 20

CODE


DESCRIPTION MAX



ATTACHED, WITH FILTER (1 PIECE), EACHK0584 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER

WITH FLANGE, WITH FILTER (2 PIECE), EACH 1.11 31 10 PER MONTH

K0585 OSTOMY POUCH, CLOSED; FOR USE ON BARRIERWITH LOCKING FLANGE (2 PIECE), EACH


K0586 OSTOMY POUCH, CLOSED; FOR USE ON BARRIERWITH LOCKING FLANGE, WITH FILTER (2 PIECE),EACH


K0587 OSTOMY POUCH, DRAINABLE, WITH BARRIERATTACHED, WITH FILTER (1 PIECE), EACH


K0588 OSTOMY POUCH, DRAINABLE; FOR USE ONBARRIER WITH FLANGE, WITH FILTER (2 PIECESYSTEM), EACH

2.29 31 366 PER YEAR

K0589 OSTOMY POUCH, DRAINABLE; FOR USE ONBARRIER WITH LOCKING FLANGE (2 PIECESYSTEM), EACH

1.51 31 366 PER YEAR

K0590 OSTOMY POUCH, DRAINABLE; FOR USE ONBARRIER WITH LOCKING FLANGE, WITH FILTER(2 PIECE SYSTEM), EACH

1.89 31 366 PER YEAR

K0591 OSTOMY POUCH, URINARY, WITH EXTENDEDWEAR BARRIER ATTACHED, WITH FAUCET-TYPETAP WITH VALVE (1 PIECE), EACH

4.17 31 366 PER YEAR

K0592 OSTOMY POUCH, URINARY, WITH BARRIERATTACHED, WITH BUILT-IN CONVEXITY, WITHFAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH

4.82 31 366 PER YEAR

K0593 OSTOMY POUCH, URINARY, WITH EXTENDEDWEAR BARRIER ATTACHED, WITH BUILT-INCONVEXITY, WITH FAUCET-TYPE TAP WITHVALVE (1 PIECE), EACH

5.46 31 366 PER YEAR

K0594 OSTOMY POUCH, URINARY; WITH BARRIERATTACHED, WITH FAUCET-TYPE TAP WITHVALVE (1 PIECE), EACH


K0595 OSTOMY POUCH, URINARY; FOR USE ONBARRIER WITH FLANGE, WITH FAUCET-TYPE TAPWITH VALVE (2 PIECE), EACH


K0596 OSTOMY POUCH, URINARY; FOR USE ONBARRIER WITH LOCKING FLANGE (2 PIECE),EACH

2.14 31 366 PER YEAR

K0597 OSTOMY POUCH, URINARY; FOR USE ONBARRIER WITH LOCKING FLANGE, WITHFAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH

2.41 31 366 PER YEAR

March 2003B - 21

CODE


DESCRIPTION MAX



L0100 CRANIAL ORTHOSIS (HELMET), WITH ORWITHOUT SOFT INTERFACE, MOLDED TOPATIENT MODEL


L0110 CRANIAL ORTHOSIS (HELMET), WITH ORWITHOUT SOFT-INTERFACE, NON-MOLDED

72.75 1 1 PER YEAR

L0120 CERVICAL, FLEXIBLE, NON-ADJUSTABLE (FOAMCOLLAR)


L0130 CERVICAL, FLEXIBLE, THERMOPLASTIC COLLAR,MOLDED TO PATIENT


L0140 CERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTICCOLLAR)

38.80 1 1 PER YEAR

L0150 CERVICAL, SEMI-RIGID, ADJUSTABLE MOLDEDCHIN CUP (PLASTIC COLLAR WITHMANDIBULAR/OCCIPITAL PIECE)


L0160 CERVICAL, SEMI-RIGID, WIRE FRAMEOCCIPITAL/MANDIBULAR SUPPORT


L0170 CERVICAL, COLLAR, MOLDED TO PATIENTMODEL


L0172 CERVICAL, COLLAR, SEMI-RIGIDTHERMOPLASTIC FOAM, TWO PIECE


L0174 CERVICAL, COLLAR, SEMI-RIGID,THERMOPLASTIC FOAM, TWO PIECE WITHTHORACIC EXTENSION

52.38 1 1 PER YEAR

L0180 CERVICAL, MULTIPLE POST COLLAR,OCCIPITAL/MANDIBULAR SUPPORTS,ADJUSTABLE


L0190 CERVICAL, MULTIPLE POST COLLAR,OCCIPITAL/MANDIBULAR SUPPORTS,ADJUSTABLE CERVICAL BARS (SOMI, GUILFORD,TAYLOR TYPES)


L0200 CERVICAL, MULTIPLE POST COLLAR,OCCIPITAL/MANDIBULAR SUPPORTS,ADJUSTABLE CERVICAL BARS, AND THORACICEXTENSION


L0210 THORACIC, RIB BELT 27.65 1 1 PER YEARL0220 THORACIC, RIB BELT, CUSTOM FABRICATED 58.20 1 1 PER YEARL0450 TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT,

UPPER THORACIC REGION, PRODUCESINTRACAVITARY PRESSURE TO REDUCE LOADON THE INTEVERTEBRAL DISKS WITH RIGIDSTAYS OR PANEL(S), INCLUDES SHOULDERSTRAPS AND CLOSURES, PREFABRICATED,INCLUDES FITTING AN


L0452 TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT,UPPER THORACIC REGION, PRODUCESINTRACAVITARY PRESSURE TO REDUCE LOADON THE INTERVERTEBRAL DISKS WITH RIGIDSTAYS OR PANEL(S), INCLUDES SHOULDER


March 2003B - 22

CODE


DESCRIPTION MAX



STRAPS AND CLOSURES, CUSTOM FABRICATEDL0500 LUMBAR-SACRAL-ORTHOSIS (LSO), FLEXIBLE,

(LUMBO-SACRAL SUPPORT) 65.48 1 2 PER YEAR

L0510 LSO, FLEXIBLE (LUMBO-SACRAL SUPPORT),CUSTOM FABRICATED

173.63 1 2 PER YEAR

L0515 LSO, ANTERIOR-POSTERIOR CONTROL, WITHRIGID OR SEMI-RIGID POSTERIOR PANEL,PREFABRICATED

71.78 1 2 PER YEAR

L0520 LSO, ANTERIOR-POSTERIOR-LATERAL CONTROL(KNIGHT, WILCOX TYPES), WITH APRON FRONT

261.90 1 1 PER 2 YEARS

L0540 LSO, LUMBAR FLEXION (WILLIAMS FLEXIONTYPE)

237.65 1 1 PER 2 YEARS

L0550 LSO, ANTERIOR-POSTERIOR-LATERAL CONTROL,MOLDED TO PATIENT MODEL


L0560 LSO, ANTERIOR-POSTERIOR-LATERAL CONTROL,MOLDED TO PATIENT MODEL, WITH INTERFACEMATERIAL


L0561 LSO, ANTERIOR-POSTERIOR-LATERAL CONTROL,WITH RIGID OR SEMI-RIGID POSTERIOR PANEL,PREFABRICATED

261.90 2 2 PER 2 YEARS

L0565 LSO, ANTERIOR-POSTERIOR-LATERAL CONTROL,CUSTOM FITTED


L0600 SACROILIAC, FLEXIBLE (SACROILIAC SURGICALSUPPORT),

32.98 1 2 PER YEAR

L0610 SACROILIAC, FLEXIBLE (SACROILIAC SURGICALSUPPORT), CUSTOM FABRICATED


L0620 SACROILIAC, SEMI-RIGID (GOLDTHWAITE,OSGOOD TYPES), WITH APRON FRONT

241.68 1 2 PER YEAR

L0700 CERVICAL-THORACIC-LUMBAR-SACRAL-ORTHOSES (CTLSO), ANTERIOR-POSTERIOR-LATERALCONTROL, MOLDED TO PATIENT MODEL,(MINERVA TYPE)

1,406.50 1 1 PER MEDICALEVENT

L0710 CTLSO,ANTERIOR-POSTERIOR-LATERAL-CONTROL,MOLDED TO PATIENT MODEL, WITH INTERFACEMATERIAL, (MINERVA TYPE)


L0810 HALO PROCEDURE, CERVICAL HALOINCORPORATED INTO JACKET VEST


L0820 HALO PROCEDURE, CERVICAL HALOINCORPORATED INTO PLASTER BODY JACKET


L0830 HALO PROCEDURE, CERVICAL HALOINCORPORATED INTO MILWAUKEE TYPEORTHOSIS


L0860 ADDITION TO HALO PROCEDURES, MAGNETICREASONANCE IMAGE COMPATIBLE SYSTEM


L0960 TORSO SUPPORT, POST SURGICAL SUPPORT,PADS FOR POST SURGICAL SUPPORT

53.35 1 1 PER 2 YEARS

March 2003B - 23

CODE


DESCRIPTION MAX



L0970 TLSO, CORSET FRONT 50.93 1 1 PER 2 YEARSL0972 LSO, CORSET FRONT 48.50 1 1 PER 2 YEARSL0974 TLSO, FULL CORSET 111.55 1 1 PER 2 YEARSL0976 LSO, FULL CORSET 112.52 1 1 PER 2 YEARSL0978 AXILLARY CRUTCH EXTENSION 67.90 1 1 PER 2 YEARSL0980 PERONEAL STRAPS, PAIR 3.88 2 2 PER YEARL0984 PROTECTIVE BODY SOCK, EACH 33.84 2 2 PER YEARL0999 ADDITION TO SPINAL ORTHOSIS, NOT

OTHERWISE SPECIFIED 0.00 BR 1 MEDICAL

NECESSITYL1000 CERVICAL-THORACIC-LUMBAR-SACRAL

ORTHOSIS (CTLSO) (MILWAUKEE), INCLUSIVE OFFURNISHING INITIAL ORTHOSIS, INCLUDINGMODEL

937.02 1 1 PER YEAR

L1005 TENSION BASED SCOLIOSIS ORTHOSIS ANDACCESSORY PADS, INCLUDES FITTING ANDADJUSTMENT

60.00 1 1 PER 2 YEARS

L1010 ADDITION TOCERVICAL-THORACIC-LUMBAR-SACRALORTHOSIS (CTLSO) OR SCOLIOSIS ORTHOSIS,AXILLA SLING

33.95 1 1 PER YEAR

L1020 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,KYPHOSIS PAD

59.66 2 2 PER YEAR

L1025 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,KYPHOSIS PAD, FLOATING

78.57 1 1 PER YEAR

L1030 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,LUMBAR BOLSTER PAD

59.17 2 2 PER YEAR

L1040 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,LUMBAR OR LUMBAR RIB PAD

67.90 2 2 PER YEAR

L1050 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,STERNAL PAD

39.77 1 1 PER YEAR

L1060 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,THORACIC PAD

45.59 2 2 PER YEAR

L1070 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,TRAPEZIUS SLING

33.95 2 2 PER YEAR

L1080 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,OUTRIGGER

43.65 2 2 PER YEAR

L1085 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,OUTRIGGER, BILATERAL WITH VERTICALEXTENSIONS

66.93 1 1 PER YEAR

L1090 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,LUMBAR SLING

43.65 2 2 PER YEAR

L1100 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,RING FLANGE, PLASTIC OR LEATHER

72.75 1 1 PER YEAR

L1110 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS,RING FLANGE, PLASTIC OR LEATHER, MOLDEDTO PATIENT MODEL

121.25 1 1 PER YEAR

L1120 ADDITION TO CTLSO, SCOLIOSIS ORTHOSIS, 21.34 6 6 PER YEAR

March 2003B - 24

CODE


DESCRIPTION MAX



COVER FOR UPRIGHT, EACHL1200 THORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO),

INCLUSIVE OF FURNISHING INITIAL ORTHOSISONLY

679.00 1 1 PER YEAR

L1210 ADDITION TO TLSO, (LOW PROFILE), LATERALTHORACIC EXTENSION

45.59 2 2 PER YEAR

L1220 ADDITION TO TLSO, (LOW PROFILE), ANTERIORTHORACIC EXTENSION

45.59 1 1 PER YEAR

L1230 ADDITION TO TLSO, (LOW PROFILE), MILWAUKEETYPE SUPERSTRUCTURE

266.75 1 1 PER 2 YEARS

L1240 ADDITION TO TLSO, (LOW PROFILE), LUMBARDEROTATION PAD

48.50 2 2 PER YEAR

L1250 ADDITION TO TLSO, (LOW PROFILE), ANTERIORASIS PAD

30.07 2 2 PER YEAR

L1260 ADDITION TO TLSO, (LOW PROFILE), ANTERIORTHORACIC DEROTATION PAD

58.20 2 2 PER YEAR

L1270 ADDITION TO TLSO, (LOW PROFILE), ABDOMINALPAD

50.44 2 2 PER YEAR

L1280 ADDITION TO TLSO, (LOW PROFILE), RIB GUSSET(ELASTIC), EACH

46.56 2 2 PER YEAR

L1290 ADDITION TO TLSO, (LOW PROFILE), LATERALTROCHANTERIC PAD

43.65 2 2 PER YEAR

L1300 OTHER SCOLIOSIS PROCEDURE, BODY JACKETMOLDED TO PATIENT MODEL

727.50 1 1 PER YEAR

L1310 OTHER SCOLIOSIS PROCEDURE,POST-OPERATIVE BODY JACKET


L1499 SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED 0.00 BR 1 MEDICALNECESSITY

L1500 THORACIC-HIP-KNEE-ANKLE ORTHOSIS (THKAO),MOBILITY FRAME (NEWINGTON, PARAPODIUMTYPES)

1,069.56 1 3 PER LIFETIME

L1510 THKAO, STANDING FRAME, WITH OR WITHOUTTRAY AND ACCESSORIES


L1520 THKAO, SWIVEL WALKER 1,607.15 1 3 PER LIFETIMEL1600 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP

JOINTS, FLEXIBLE, FREJKA TYPE WITH COVER,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L1620 HIP ORTHOSIS, ABDUCTION CONTROL OF HIPJOINTS, FLEXIBLE, (PAVLIK HARNESS),PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

43.65 1 1 PER 5 YEARS

L1630 HIP ORTHOSIS, ABDUCTION CONTROL OF HIPJOINTS, SEMI-FLEXIBLE (VON ROSEN TYPE),CUSTOM-FABRICATED


L1640 HIP ORTHOSIS, ABDUCTION CONTROL OF HIPJOINTS, STATIC, PELVIC BAND OR SPREADER

116.40 1 1 PER 5 YEARS

March 2003B - 25

CODE


DESCRIPTION MAX



BAR, THIGH CUFFS, CUSTOM-FABRICATEDL1650 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP

JOINTS, STATIC, ADJUSTABLE, (ILFLED TYPE),PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L1652 HIP ORTHOSIS, BILATERAL THIGH CUFFS WITHADJUSTABLE ABDUCTOR SPREADER BAR,ADULT SIZE, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT, ANY TYPE


L1660 HIP ORTHOSIS, ABDUCTION CONTROL OF HIPJOINTS, STATIC, PLASTIC, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT

29.10 1 1 PER 5 YEARS

L1680 HIP ORTHOSIS, ABDUCTION CONTROL OF HIPJOINTS, DYNAMIC, PELVIC CONTROL,ADJUSTABLE HIP MOTION CONTROL, THIGHCUFFS (RANCHO HIP ACTION TYPE), CUSTOMFABRICATED


L1685 HIP ORTHOSIS, ABDUCTION CONTROL OF HIPJOINT, POSTOPERATIVE HIP ABDUCTION TYPE,CUSTOM FABRICATED


L1686 HIP ORTHOSIS, ABDUCTION CONTROL OF HIPJOINT, POSTOPERATIVE HIP ABDUCTION TYPE,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L1690 COMBINATION, BILATERAL, LUMBO-SACRAL,HIP, FEMUR ORTHOSIS PROVIDING ADDUCTIONAND INTERNAL ROTATION CONTROL,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L1700 LEGG PERTHES ORTHOSIS, (TORONTO TYPE),CUSTOM-FABRICATED


L1710 LEGG PERTHES ORTHOSIS, (NEWINGTON TYPE),CUSTOM FABRICATED


L1720 LEGG PERTHES ORTHOSIS, TRILATERAL,(TACHDIJAN TYPE), CUSTOM-FABRICATED


L1730 LEGG PERTHES ORTHOSIS, (SCOTTISH RITETYPE), CUSTOM-FABRICATED


L1750 LEGG PERTHES ORTHOSIS, LEGG PERTHES SLING(SAM BROWN TYPE), PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT


L1755 LEGG PERTHES ORTHOSIS, (PATTEN BOTTOMTYPE), CUSTOM-FABRICATED


L1800 KNEE ORTHOSIS, ELASTIC WITH STAYS,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

38.80 2 2 PER YEAR

L1810 KNEE ORTHOSIS, ELASTIC WITH JOINTS,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

79.06 2 2 PER YEAR

March 2003B - 26

CODE


DESCRIPTION MAX



L1815 KNEE ORTHOSIS, ELASTIC OR OTHER ELASTICTYPE MATERIAL WITH CONDYLAR PAD(S),PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

39.29 2 2 PER YEAR

L1820 KNEE ORTHOSIS, ELASTIC WITH CONDYLARPADS AND JOINTS, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT

58.20 2 2 PER YEAR

L1825 KNEE ORTHOSIS, ELASTIC KNEE CAP,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

36.86 2 2 PER YEAR

L1830 KNEE ORTHOSIS, IMMOBILIZER, CANVASLONGITUDINAL, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT

48.50 2 2 PER YEAR

L1832 KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS,POSITIONAL ORTHOSIS, RIGID SUPPORT,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

559.32 2 2 PER 2 YEARS

L1834 KNEE ORTHOSIS, WITHOUT KNEE JOINT, RIGID,CUSTOM-FABRICATED

630.50 2 2 PER YEAR

L1836 KNEE ORTHOSIS, RIGID, WITHOUT JOINT(S),INCLUDES SOFT INTERFACE MATERIAL,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

69.12 2 2 PER YEAR

L1840 KNEE ORTHOSIS, DEROTATION,MEDIAL-LATERAL, ANTERIOR CRUCIATELIGAMENT, CUSTOM FABRICATED

582.00 2 2 PER YEAR

L1843 KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH ANDCALF, WITH ADJUSTABLE FLEXION ANDEXTENSION JOINT, MEDIAL-LATERAL ANDROTATION CONTROL, INCLUDES VARUS/VALGUSADJUSTMENT, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT

323.72 2 2 PER 2 YEARS

L1844 KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH ANDCALF, WITH ADJUSTABLE FLEXION ANDEXTENSION JOINT, MEDIAL-LATERAL ANDROTATION CONTROL, INCLUDES VARUS/VALGUSADJUSTMENT, CUSTOM FABRICATED

572.30 1 2 PER 2 YEARS

L1845 KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH ANDCALF, WITH ADJUSTABLE FLEXION ANDEXTENSION JOINT, MEDIAL-LATERAL ANDROTATION CONTROL, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT

572.30 2 2 PER 2 YEARS

L1846 KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH ANDCALF, WITH ADJUSTABLE FLEXION ANDEXTENSION JOINT, MEDIAL-LATERAL ANDROTATION CONTROL, CUSTOM FABRICATED

577.15 2 2 PER YEAR

L1847 KNEE ORTHOSIS, DOUBLE UPRIGHT WITHADJUSTABLE JOINT, WITH INFLATABLE AIR


March 2003B - 27

CODE


DESCRIPTION MAX



SUPPORT CHAMBER(S), PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT

L1850 KNEE ORTHOSIS, SWEDISH TYPE,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

134.83 2 2 PER 2 YEARS

L1855 KNEE ORTHOSIS, MOLDED PLASTIC, THIGH ANDCALF SECTIONS, WITH DOUBLE UPRIGHT KNEEJOINTS, CUSTOM-FABRICATED

665.42 2 2 PER 2 YEARS

L1858 KNEE ORTHOSIS, MOLDED PLASTIC,POLYCENTRIC KNEE JOINTS, PNEUMATIC KNEEPADS (CTI), CUSTOM-FABRICATED

753.69 2 2 PER 2 YEARS

L1860 KNEE ORTHOSIS, MODIFICATION OFSUPRACONDYLAR PROSTHETIC SOCKET,CUSTOM-FABRICATED (SK)

485.00 2 2 PER 2 YEARS

L1870 KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH ANDCALF LACERS WITH KNEE JOINTS,CUSTOM-FABRICATED

727.50 2 2 PER YEAR

L1880 KNEE ORTHOSIS, DOUBLE UPRIGHT,NON-MOLDED THIGH AND CALF CUFFS/LACERSWITH KNEE JOINTS, CUSTOM-FABRICATED

230.86 2 2 PER 2 YEARS

L1885 KNEE ORTHOSIS, SINGLE OR DOUBLE UPRIGHT,THIGH AND CALF, WITH FUNCTIONAL ACTIVERESISTANCE CONTROL, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT

597.00 2 2 PER 3 YEARS

L1900 ANKLE FOOT ORTHOSIS, SPRING WIRE,DORSIFLEXION ASSIST CALF BAND,CUSTOM-FABRICATED

189.15 2 2 PER 2 YEARS

L1901 ANKLE ORTHOSIS, ELASTIC, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT (E.G.NEOPRENE, LYCRA)

9.17 2 2 PER YEAR

L1902 ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

39.29 2 2 PER YEAR

L1904 ANKLE FOOT ORTHOSIS, MOLDED ANKLEGAUNTLET, CUSTOM-FABRICATED

221.65 2 2 PER YEAR

L1906 ANKLE FOOT ORTHOSIS, MULTILIGAMENTUSANKLE SUPPORT, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT


L1910 ANKLE FOOT ORTHOSIS, POSTERIOR, SINGLEBAR, CLASP ATTACHMENT TO SHOE COUNTER,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

137.74 2 2 PER 2 YEARS

L1920 ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITHSTATIC OR ADJUSTABLE STOP (PHELPS ORPERLSTEIN TYPE), CUSTOM-FABRICATED

126.10 2 2 PER YEAR

L1930 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHERMATERIAL, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENT

79.06 2 2 PER YEAR

March 2003B - 28

CODE


DESCRIPTION MAX



L1940 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHERMATERIAL, CUSTOM-FABRICATED

261.90 2 2 PER YEAR

L1945 ANKLE FOOT ORTHOSIS, PLASTIC, RIGIDANTERIOR TIBIAL SECTION (FLOOR REACTION),CUSTOM-FABRICATED

630.50 2 2 PER YEAR

L1950 ANKLE FOOT ORTHOSIS, SPIRAL, (IRM TYPE),PLASTIC, CUSTOM-FABRICATED

215.34 2 2 PER YEAR

L1960 ANKLE FOOT ORTHOSIS, POSTERIOR SOLIDANKLE, PLASTIC, CUSTOM-FABRICATED

251.23 2 2 PER YEAR

L1970 ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLEJOINT, CUSTOM-FABRICATED

363.75 2 2 PER YEAR

L1980 ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREEPLANTAR DORSIFLEXION, SOLID STIRRUP, CALFBAND/CUFF (SINGLE BAR 'BK' ORTHOSIS),CUSTOM-FABRICATED

121.25 2 2 PER 2 YEARS

L1990 ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREEPLANTAR DORSIFLEXION, SOLID STIRRUP, CALFBAND/CUFF (DOUBLE BAR 'BK' ORTHOSIS),CUSTOM-FABRICATED

223.10 2 2 PER 2 YEARS

L2000 KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT,FREE KNEE, FREE ANKLE, SOLID STIRRUP, THIGHAND CALF BANDS/CUFFS (SINGLE BAR 'AK'ORTHOSIS), CUSTOM-FABRICATED

282.27 2 2 PER 2 YEARS

L2010 KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT,FREE ANKLE, SOLID STIRRUP, THIGH AND CALFBANDS/CUFFS (SINGLE BAR 'AK' ORTHOSIS),WITHOUT KNEE JOINT, CUSTOM-FABRICATED

237.65 2 2 PER 2 YEARS

L2020 KNEE ANKLE FOOT ORTHOSIS, DOUBLEUPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGHAND CALF BANDS/CUFFS (DOUBLE BAR 'AK'ORTHOSIS), CUSTOM-FABRICATED

461.72 2 2 PER YEAR

L2030 KNEE ANKLE FOOT ORTHOSIS, DOUBLEUPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGHAND CALF BANDS/CUFFS, (DOUBLE BAR 'AK'ORTHOSIS), WITHOUT KNEE JOINT, CUSTOMFABRICATED

295.85 2 2 PER 2 YEARS

L2036 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC,DOUBLE UPRIGHT, FREE KNEE,CUSTOM-FABRICATED

1,047.60 2 2 PER YEAR

L2037 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC,SINGLE UPRIGHT, FREE KNEE,CUSTOM-FABRICATED

1,067.00 2 2 PER 2 YEARS

L2038 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC,WITH KNEE JOINT, MULTI-AXIS ANKLE, (LIVELYORTHOSIS OR EQUAL), CUSTOM-FABRICATED

582.00 2 2 PER YEAR

L2039 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC,SINGLE UPRIGHT, POLY-AXIAL HINGE, MEDIALLATERAL ROTATION CONTROL,

1,236.00 2 2 PER 2 YEARS

March 2003B - 29

CODE


DESCRIPTION MAX



CUSTOM-FABRICATEDL2040 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION

CONTROL, BILATERAL ROTATION STRAPS,PELVIC BAND/BELT, CUSTOM FABRICATED

97.00 1 1 PER YEAR

L2050 HIP KNEE ANKLE FOOT ORTHOSIS, TORSIONCONTROL, BILATERAL TORSION CABLES, HIPJOINT, PELVIC BAND/BELT,CUSTOM-FABRICATED

232.80 1 1 PER YEAR

L2060 HIP KNEE ANKLE FOOT ORTHOSIS, TORSIONCONTROL, BILATERAL TORSION CABLES, BALLBEARING HIP JOINT, PELVIC BAND/ BELT,CUSTOM-FABRICATED

291.00 1 1 PER YEAR

L2070 HIP KNEE ANKLE FOOT ORTHOSIS, TORSIONCONTROL, UNILATERAL ROTATION STRAPS,PELVIC BAND/BELT, CUSTOM FABRICATED

60.14 1 1 PER YEAR

L2080 HIP KNEE ANKLE FOOT ORTHOSIS, TORSIONCONTROL, UNILATERAL TORSION CABLE, HIPJOINT, PELVIC BAND/BELT,CUSTOM-FABRICATED

189.15 1 1 PER YEAR

L2090 HIP KNEE ANKLE FOOT ORTHOSIS, TORSIONCONTROL, UNILATERAL TORSION CABLE, BALLBEARING HIP JOINT, PELVIC BAND/ BELT,CUSTOM-FABRICATED

262.79 2 1 PER YEAR

L2102 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS,TIBIAL FRACTURE CAST ORTHOSIS, PLASTERTYPE CASTING MATERIAL,CUSTOM-FABRICATED


L2104 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS,TIBIAL FRACTURE CAST ORTHOSIS, SYNTHETICTYPE CASTING MATERIAL,CUSTOM-FABRICATED


L2106 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS,TIBIAL FRACTURE CAST ORTHOSIS,THERMOPLASTIC TYPE CASTING MATERIAL,CUSTOM-FABRICATED


L2108 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS,TIBIAL FRACTURE CAST ORTHOSIS,CUSTOM-FABRICATED


L2112 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS,TIBIAL FRACTURE ORTHOSIS, SOFT,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L2114 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS,TIBIAL FRACTURE ORTHOSIS, SEMI-RIGID,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L2116 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS,TIBIAL FRACTURE ORTHOSIS, RIGID,


March 2003B - 30

CODE


DESCRIPTION MAX



PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

L2122 KNEE ANKLE FOOT ORTHOSIS, FRACTUREORTHOSIS, FEMORAL FRACTURE CASTORTHOSIS, PLASTER TYPE CASTING MATERIAL,CUSTOM-FABRICATED


L2124 KNEE ANKLE FOOT ORTHOSIS, FRACTUREORTHOSIS, FEMORAL FRACTURE CASTORTHOSIS, SYNTHETIC TYPE CASTINGMATERIAL, CUSTOM-FABRICATED


L2126 KNEE ANKLE FOOT ORTHOSIS, FRACTUREORTHOSIS, FEMORAL FRACTURE CASTORTHOSIS, THERMOPLASTIC TYPE CASTINGMATERIAL, CUSTOM-FABRICATED


L2128 KNEE ANKLE FOOT ORTHOSIS, FRACTUREORTHOSIS, FEMORAL FRACTURE CASTORTHOSIS, CUSTOM-FABRICATED


L2132 KAFO, FRACTURE ORTHOSIS, FEMORALFRACTURE CAST ORTHOSIS, SOFT,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L2134 KAFO, FRACTURE ORTHOSIS, FEMORALFRACTURE CAST ORTHOSIS, SEMI-RIGID,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L2136 KAFO, FRACTURE ORTHOSIS, FEMORALFRACTURE CAST ORTHOSIS, RIGID,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L2180 ADDITION TO LOWER EXTREMITY FRACTUREORTHOSIS, PLASTIC SHOE INSERT WITH ANKLEJOINTS


L2182 ADDITION TO LOWER EXTREMITY FRACTUREORTHOSIS, DROP LOCK KNEE JOINT


L2184 ADDITION TO LOWER EXTREMITY FRACTUREORTHOSIS, LIMITED MOTION KNEE JOINT


L2186 ADDITION TO LOWER EXTREMITY FRACTUREORTHOSIS, ADJUSTABLE MOTION KNEE JOINT,LERMAN TYPE


L2188 ADDITION TO LOWER EXTREMITY FRACTUREORTHOSIS, QUADRILATERAL BRIM


L2190 ADDITION TO LOWER EXTREMITY FRACTUREORTHOSIS, WAIST BELT


L2192 ADDITION TO LOWER EXTREMITY FRACTUREORTHOSIS, HIP JOINT, PELVIC BAND, THIGHFLANGE, AND PELVIC BELT


L2200 ADDITION TO LOWER EXTREMITY, LIMITEDANKLE MOTION, EACH JOINT

20.91 4 2 PER ORTHOSIS

March 2003B - 31

CODE


DESCRIPTION MAX



L2210 ADDITION TO LOWER EXTREMITY,DORSIFLEXION ASSIST (PLANTAR FLEXIONRESIST), EACH JOINT


L2220 ADDITION TO LOWER EXTREMITY,DORSIFLEXION AND PLANTAR FLEXIONASSIST/RESIST, EACH JOINT


L2230 ADDITION TO LOWER EXTREMITY, SPLIT FLATCALIPER STIRRUPS AND PLATE ATTACHMENT


L2240 ADDITION TO LOWER EXTREMITY, ROUNDCALIPER AND PLATE ATTACHMENT


L2250 ADDITION TO LOWER EXTREMITY, FOOT PLATE,MOLDED TO PATIENT MODEL, STIRRUPATTACHMENT


L2260 ADDITION TO LOWER EXTREMITY, REINFORCEDSOLID STIRRUP (SCOTT-CRAIG TYPE)


L2265 ADDITION TO LOWER EXTREMITY, LONGTONGUE STIRRUP


L2270 ADDITION TO LOWER EXTREMITY,VARUS/VALGUS CORRECTION ('T') STRAP,PADDED/LINED OR MALLEOLUS PAD


L2275 ADDITION TO LOWER EXTREMITY,VARUS/VALGUS CORRECTION, PLASTICMODIFICATION, PADDED/LINED


L2280 ADDITION TO LOWER EXTREMITY, MOLDEDINNER BOOT

242.50 2 2 PER 3 YEARS

L2300 ADDITION TO LOWER EXTREMITY, ABDUCTIONBAR (BILATERAL HIP INVOLVEMENT), JOINTED,ADJUSTABLE

72.75 1 1 PER 2 YEARS

L2310 ADDITION TO LOWER EXTREMITY, ABDUCTIONBAR-STRAIGHT

43.65 1 1 PER 2 YEARS

L2320 ADDITION TO LOWER EXTREMITY,NON-MOLDED LACER


L2330 ADDITION TO LOWER EXTREMITY, LACERMOLDED TO PATIENT MODEL


L2335 ADDITION TO LOWER EXTREMITY, ANTERIORSWING BAND


L2340 ADDITION TO LOWER EXTREMITY, PRE-TIBIALSHELL, MOLDED TO PATIENT MODEL


L2350 ADDITION TO LOWER EXTREMITY, PROSTHETICTYPE, (BK) SOCKET, MOLDED TO PATIENTMODEL, (USED FOR 'PTB' 'AFO' ORTHOSES)


L2360 ADDITION TO LOWER EXTREMITY, EXTENDEDSTEEL SHANK

29.10 4 4 PER YEAR

L2370 ADDITION TO LOWER EXTREMITY, PATTENBOTTOM


L2375 ADDITION TO LOWER EXTREMITY, TORSIONCONTROL, ANKLE JOINT AND HALF SOLID


March 2003B - 32

CODE


DESCRIPTION MAX



STIRRUPL2380 ADDITION TO LOWER EXTREMITY, TORSION

CONTROL, STRAIGHT KNEE JOINT, EACH JOINT 43.65 4 4 PER ORTHOSIS

L2385 ADDITION TO LOWER EXTREMITY, STRAIGHTKNEE JOINT, HEAVY DUTY, EACH JOINT


L2390 ADDITION TO LOWER EXTREMITY, OFFSET KNEEJOINT, EACH JOINT


L2395 ADDITION TO LOWER EXTREMITY, OFFSET KNEEJOINT, HEAVY DUTY, EACH JOINT


L2397 ADDITION TO LOWER EXTREMITY ORTHOSIS,SUSPENSION SLEEVE


L2405 ADDITION TO KNEE JOINT, DROP LOCK, EACHJOINT


L2415 ADDITION TO KNEE LOCK WITH INTEGRATEDRELEASE MECHANISM ( BAIL, CABLE, OREQUAL), ANY MATERIAL, EACH JOINT


L2425 ADDITION TO KNEE JOINT, DISC OR DIAL LOCKFOR ADJUSTABLE KNEE FLEXION, EACH JOINT


L2430 ADDITION TO KNEE JOINT, RATCHET LOCK FORACTIVE AND PROGRESSIVE KNEE EXTENSION,EACH JOINT


L2435 ADDITION TO KNEE JOINT, POLYCENTRIC JOINT,EACH JOINT


L2492 ADDITION TO KNEE JOINT, LIFT LOOP FOR DROPLOCK RING


L2500 ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING, GLUTEAL/ ISCHIALWEIGHT BEARING, RING


L2510 ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING, QUADRI- LATERALBRIM, MOLDED TO PATIENT MODEL


L2520 ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING, QUADRI- LATERALBRIM, CUSTOM FITTED


L2525 ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING, ISCHIALCONTAINMENT/NARROW M-L BRIM MOLDED TOPATIENT MODEL


L2526 ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING, ISCHIALCONTAINMENT/NARROW M-L BRIM, CUSTOMFITTED


L2530 ADDITION TO LOWER EXTREMITY,THIGH-WEIGHT BEARING, LACER, NON-MOLDED


L2540 ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING, LACER, MOLDED TOPATIENT MODEL


March 2003B - 33

CODE


DESCRIPTION MAX



L2550 ADDITION TO LOWER EXTREMITY,THIGH/WEIGHT BEARING, HIGH ROLL CUFF


L2570 ADDITION TO LOWER EXTREMITY, PELVICCONTROL, HIP JOINT, CLEVIS TYPE TWOPOSITION JOINT, EACH


L2580 ADDITION TO LOWER EXTREMITY, PELVICCONTROL, PELVIC SLING

355.99 1 1 PER 2 YEARS

L2600 ADDITION TO LOWER EXTREMITY, PELVICCONTROL, HIP JOINT, CLEVIS TYPE, OR THRUSTBEARING, FREE, EACH


L2610 ADDITION TO LOWER EXTREMITY, PELVICCONTROL, HIP JOINT, CLEVIS OR THRUSTBEARING, LOCK, EACH


L2620 ADDITION TO LOWER EXTREMITY, PELVICCONTROL, HIP JOINT, HEAVY DUTY, EACH


L2622 ADDITION TO LOWER EXTREMITY, PELVICCONTROL, HIP JOINT, ADJUSTABLE FLEXION,EACH


L2624 ADDITION TO LOWER EXTREMITY, PELVICCONTROL, HIP JOINT, ADJUSTABLE FLEXION,EXTENSION, ABDUCTION CONTROL, EACH


L2627 ADDITION TO LOWER EXTREMITY, PELVICCONTROL, PLASTIC, MOLDED TO PATIENTMODEL, RECIPROCATING HIP JOINT AND CABLES

665.42 1 1 PER 2 YEARS

L2628 ADDITION TO LOWER EXTREMITY, PELVICCONTROL, METAL FRAME, RECIPROCATING HIPJOINT AND CABLES

1,018.50 1 1 PER YEAR

L2630 ADDITION TO LOWER EXTREMITY, PELVICCONTROL, BAND AND BELT, UNILATERAL


L2640 ADDITION TO LOWER EXTREMITY, PELVICCONTROL, BAND AND BELT, BILATERAL

121.25 1 1 PER YEAR

L2650 ADDITION TO LOWER EXTREMITY, PELVIC ANDTHORACIC CONTROL, GLUTEAL PAD, EACH

48.50 1 2 PER YEAR

L2660 ADDITION TO LOWER EXTREMITY, THORACICCONTROL, THORACIC BAND

87.30 1 1 PER 2 YEARS

L2670 ADDITION TO LOWER EXTREMITY, THORACICCONTROL, PARASPINAL UPRIGHTS

67.90 1 1 PER 2 YEARS

L2680 ADDITION TO LOWER EXTREMITY, THORACICCONTROL, LATERAL SUPPORT UPRIGHTS

58.20 2 1 PER YEAR

L2750 ADDITION TO LOWER EXTREMITY ORTHOSIS,PLATING CHROME OR NICKEL, PER BAR


L2755 ADDITION TO LOWER EXTREMITY ORTHOSIS,HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALLHYBRID LAMINATION/PREPREG COMPOSITE, PERSEGMENT


L2760 ADDITION TO LOWER EXTREMITY ORTHOSIS,EXTENSION, PER EXTENSION, PER BAR (FORLINEAL ADJUSTMENT FOR GROWTH)


March 2003B - 34

CODE


DESCRIPTION MAX



L2768 ORTHOTIC SIDE BAR DISCONNECT DEVICE, PERBAR

15.00 2 2 PER 2 YEARS

L2770 ADDITION TO LOWER EXTREMITY ORTHOSIS,ANY MATERIAL - PER BAR OR JOINT

14.55 8 4 PER KAFO

L2780 ADDITION TO LOWER EXTREMITY ORTHOSIS,NON-CORROSIVE FINISH, PER BAR


L2785 ADDITION TO LOWER EXTREMITY ORTHOSIS,DROP LOCK RETAINER, EACH

21.34 4 2 PER KAFO

L2795 ADDITION TO LOWER EXTREMITY ORTHOSIS,KNEE CONTROL, FULL KNEECAP

35.89 2 1 PER KAFO

L2800 ADDITION TO LOWER EXTREMITY ORTHOSIS,KNEE CONTROL, KNEE CAP, MEDIAL ORLATERAL PULL

48.99 2 1 PER KAFO

L2810 ADDITION TO LOWER EXTREMITY ORTHOSIS,KNEE CONTROL, CONDYLAR PAD

48.02 2 2 PER KAFO

L2820 ADDITION TO LOWER EXTREMITY ORTHOSIS,SOFT INTERFACE FOR MOLDED PLASTIC, BELOWKNEE SECTION

30.56 2 1 PER KAFO

L2830 ADDITION TO LOWER EXTREMITY ORTHOSIS,SOFT INTERFACE FOR MOLDED PLASTIC, ABOVEKNEE SECTION

30.56 2 1 PER KAFO

L2840 ADDITION TO LOWER EXTREMITY ORTHOSIS,TIBIAL LENGTH SOCK, FRACTURE OR EQUAL,EACH


L2850 ADDITION TO LOWER EXTREMITY ORTHOSIS,FEMORAL LENGTH SOCK, FRACTURE OR EQUAL,EACH


L2860 ADDITION TO LOWER EXTREMITY JOINT, KNEEOR ANKLE, CONCENTRIC ADJUSTABLE TORSIONSTYLE MECHANISM, EACH

220.19 4 2 PER KAFO

L2999 LOWER EXTREMITY ORTHOSES, NOT OTHERWISESPECIFIED


L3000 FOOT, INSERT, REMOVABLE, MOLDED TOPATIENT MODEL, 'UCB' TYPE, BERKELEY SHELL,EACH


L3001 FOOT, INSERT, REMOVABLE, MOLDED TOPATIENT MODEL, SPENCO, EACH


L3002 FOOT, INSERT, REMOVABLE, MOLDED TOPATIENT MODEL, PLASTAZOTE OR EQUAL, EACH


L3010 FOOT, INSERT, REMOVABLE, MOLDED TOPATIENT MODEL, LONGITUDINAL ARCHSUPPORT, EACH


L3020 FOOT, INSERT, REMOVABLE, MOLDED TOPATIENT MODEL, LONGITUDINAL/ METATARSALSUPPORT, EACH


L3030 FOOT, INSERT, REMOVABLE, FORMED TOPATIENT FOOT, EACH


March 2003B - 35

CODE


DESCRIPTION MAX



L3040 FOOT, ARCH SUPPORT, REMOVABLE,PREMOLDED, LONGITUDINAL, EACH


L3050 FOOT, ARCH SUPPORT, REMOVABLE,PREMOLDED, METATARSAL, EACH


L3060 FOOT, ARCH SUPPORT, REMOVABLE,PREMOLDED, LONGITUDINAL/ METATARSAL,EACH


L3070 FOOT, ARCH SUPPORT, NON-REMOVABLEATTACHED TO SHOE, LONGITUDINAL, EACH


L3080 FOOT, ARCH SUPPORT, NON-REMOVABLEATTACHED TO SHOE, METATARSAL, EACH


L3100 HALLUS-VALGUS NIGHT DYNAMIC SPLINT 24.25 2 2 PER YEARL3140 FOOT, ABDUCTION ROTATION BAR, INCLUDING

SHOES 35.41 1 2 PER YEAR

L3150 FOOT, ABDUCTION ROTATATION BAR, WITHOUTSHOES

28.13 1 2 PER YEAR

L3170 FOOT, PLASTIC HEEL STABILIZER 15.52 2 2 PER FOOT PERYEAR

L3201 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOROR PRONATOR, INFANT

36.38 2 3 PAIR PER YEAR

L3202 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOROR PRONATOR, CHILD


L3203 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOROR PRONATOR, JUNIOR


L3204 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOROR PRONATOR, INFANT


L3206 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOROR PRONATOR, CHILD


L3207 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOROR PRONATOR, JUNIOR


L3208 SURGICAL BOOT, EACH, INFANT 17.46 2 2 PER FOOT PERYEAR

L3209 SURGICAL BOOT, EACH, CHILD 17.46 2 2 PER FOOT PERYEAR

L3211 SURGICAL BOOT, EACH, JUNIOR 19.40 2 2 PER FOOT PERYEAR

L3215 ORTHOPEDIC FOOTWEAR, LADIES SHOES,OXFORD


L3216 ORTHOPEDIC FOOTWEAR, LADIES SHOES, DEPTHINLAY


L3217 ORTHOPEDIC FOOTWEAR, LADIES SHOES,HIGHTOP, DEPTH INLAY


L3219 ORTHOPEDIC FOOTWEAR, MENS SHOES, OXFORD 79.54 2 2 PER FOOT PERYEAR

L3221 ORTHOPEDIC FOOTWEAR, MENS SHOES, DEPTHINLAY


L3222 ORTHOPEDIC FOOTWEAR, MENS SHOES, 96.03 2 2 PER FOOT PER

March 2003B - 36

CODE


DESCRIPTION MAX



HIGHTOP, DEPTH INLAY YEARL3230 ORTHOPEDIC FOOTWEAR, CUSTOM SHOES,

DEPTH INLAY 69.84 2 1 PER FOOT PER

YEARL3251 FOOT, SHOE MOLDED TO PATIENT MODEL,

SILICONE SHOE, EACH 213.44 2 2 PER FOOT PER

YEARL3253 FOOT, MOLDED SHOE PLASTAZOTE (OR SIMILAR)

CUSTOM FITTED, EACH 65.96 2 1 PER FOOT PER

YEARL3254 NON-STANDARD SIZE OR WIDTH 1.99 2 6 PER YEARL3255 NON-STANDARD SIZE OR LENGTH 3.15 2 6 PER YEARL3257 ORTHOPEDIC FOOTWEAR, ADDITIONAL CHARGE

FOR SPLIT SIZE 0.00 BR 1 3 PER YEAR

L3300 LIFT, ELEVATION, HEEL, TAPERED TOMETATARSALS, PER INCH

17.95 3 3 PER YEAR

L3310 LIFT, ELEVATION, HEEL AND SOLE, NEOPRENE,PER INCH

35.41 3 3 PER YEAR

L3320 LIFT, ELEVATION, HEEL AND SOLE, CORK, PERINCH

107.19 3 3 PER YEAR

L3330 LIFT, ELEVATION, METAL EXTENSION (SKATE) 291.84 2 3 PER YEARL3332 LIFT, ELEVATION, INSIDE SHOE, TAPERED, UP TO

ONE-HALF INCH 25.71 3 3 PER YEAR

L3334 LIFT, ELEVATION, HEEL, PER INCH 16.98 3 3 PER YEARL3340 HEEL WEDGE, SACH 48.02 2 4 PER YEARL3350 HEEL WEDGE 12.61 2 4 PER YEARL3360 SOLE WEDGE, OUTSIDE SOLE 19.40 2 4 PER YEARL3370 SOLE WEDGE, BETWEEN SOLE 14.55 2 4 PER YEARL3380 CLUBFOOT WEDGE 15.52 2 4 PER YEARL3390 OUTFLARE WEDGE 22.80 2 4 PER YEARL3400 METATARSAL BAR WEDGE, ROCKER 24.25 2 4 PER YEARL3410 METATARSAL BAR WEDGE, BETWEEN SOLE 11.16 2 4 PER YEARL3420 FULL SOLE AND HEEL WEDGE, BETWEEN SOLE 18.92 2 4 PER YEARL3430 HEEL, COUNTER, PLASTIC REINFORCED 19.89 2 2 PER YEARL3440 HEEL, COUNTER, LEATHER REINFORCED 28.13 2 2 PER YEARL3450 HEEL, SACH CUSHION TYPE 25.71 2 2 PER YEARL3460 HEEL, NEW RUBBER, STANDARD 9.22 2 2 PER YEARL3465 HEEL, THOMAS WITH WEDGE 11.16 2 2 PER YEARL3470 HEEL, THOMAS EXTENDED TO BALL 14.55 2 2 PER YEARL3480 HEEL, PAD AND DEPRESSION FOR SPUR 9.70 2 2 PER FOOT PER

YEARL3570 ORTHOPEDIC SHOE ADDITION, SPECIAL

EXTENSION TO INSTEP (LEATHER WITHEYELETS)

20.37 2 6 PER YEAR

L3580 ORTHOPEDIC SHOE ADDITION, CONVERT INSTEPTO VELCRO CLOSURE

33.69 2 2 PER YEAR

L3590 ORTHOPEDIC SHOE ADDITION, CONVERT FIRMSHOE COUNTER TO SOFT COUNTER

27.74 2 2 PER YEAR

L3595 ORTHOPEDIC SHOE ADDITION, MARCH BAR 20.37 2 MEDICALNECESSITY

March 2003B - 37

CODE


DESCRIPTION MAX



L3600 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TOANOTHER, CALIPER PLATE, EXISTING

32.98 2 3 PER YEAR

L3610 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TOANOTHER, CALIPER PLATE, NEW

52.18 2 3 PER YEAR

L3620 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TOANOTHER, SOLID STIRRUP, EXISTING

32.01 2 3 PER YEAR

L3630 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TOANOTHER, SOLID STIRRUP, NEW

52.18 2 3 PER YEAR

L3640 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TOANOTHER, DENNIS BROWNE SPLINT (RIVETON),BOTH SHOES

22.46 1 3 PER YEAR

L3649 ORTHOPEDIC SHOE, MODIFICATION, ADDITIONOR TRANSFER, NOT OTHERWISE SPECIFIED


L3650 SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGNABDUCTION RESTRAINER, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT


L3651 SHOULDER ORTHOSIS, SINGLE SHOULDER,ELASTIC, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENT (E.G. NEOPRENE, LYCRA)


L3652 SHOULDER ORTHOSIS, DOUBLE SHOULDER,ELASTIC, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENT (E.G. NEOPRENE, LYCRA)


L3660 SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGNABDUCTION RESTRAINER, CANVAS ANDWEBBING, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENT


L3670 SHOULDER ORTHOSIS, ACROMIO/CLAVICULAR(CANVAS AND WEBBING TYPE),PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L3675 SHOULDER ORTHOSIS, VEST TYPE ABDUCTIONRESTRAINER, CANVAS WEBBING TYPE OREQUAL, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENT

96.70 1 1 PER 2 YEARS

L3677 SHOULDER ORTHOSIS, HARD PLASTIC,SHOULDER STABILIZER, PRE-FABRICATED,INCLUDES FITTING AND ADJUSTMENT

144.50 2 2 PER 2 YEARS

L3700 ELBOW ORTHOSIS, ELASTIC WITH STAYS,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

29.79 2 2 PER YEAR

L3701 ELBOW ORTHOSIS, ELASTIC, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT (E.G.NEOPRENE, LYCRA)

9.60 2 2 PER YEAR

L3710 ELBOW ORTHOSIS, ELASTIC WITH METALJOINTS, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENT

79.10 2 2 PER YEAR

L3720 ELBOW ORTHOSIS, DOUBLE UPRIGHT WITHFOREARM/ARM CUFFS, FREE MOTION,

226.01 2 2 PER YEAR

March 2003B - 38

CODE


DESCRIPTION MAX



CUSTOM-FABRICATEDL3730 ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH

FOREARM/ARM CUFFS, EXTENSION/ FLEXIONASSIST, CUSTOM-FABRICATED

376.36 2 2 PER YEAR

L3740 ELBOW ORTHOSIS, DOUBLE UPRIGHT WITHFOREARM/ARM CUFFS, ADJUSTABLE POSITIONLOCK WITH ACTIVE CONTROL,CUSTOM-FABRICATED

443.29 2 2 PER YEAR

L3760 ELBOW ORTHOSIS, WITH ADJUSTABLE POSITIONLOCKING JOINT(S), PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTS, ANY TYPE

268.57 2 PER MEDICALEVENT

L3762 ELBOW ORTHOSIS, RIGID, WITHOUT JOINTS,INCLUDES SOFT INTERFACE MATERIAL,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

50.70 2 2 PER YEAR

L3800 WRIST HAND FINGER ORTHOSIS, SHORTOPPONENS, NO ATTACHMENTS,CUSTOM-FABRICATED

83.91 2 2 PER YEAR

L3805 WRIST HAND FINGER ORTHOSIS, LONGOPPONENS, NO ATTACHMENT,CUSTOM-FABRICATED

183.82 2 2 PER YEAR

L3810 WHFO, ADDITION TO SHORT AND LONGOPPONENS, THUMB ABDUCTION ('C') BAR


L3815 WHFO, ADDITION TO SHORT AND LONGOPPONENS, SECOND M.P. ABDUCTION ASSIST


L3820 WHFO, ADDITION TO SHORT AND LONGOPPONENS, I.P. EXTENSION ASSIST, WITH M.P.EXTENSION STOP

52.38 2 1 PER FINGER

L3825 WHFO, ADDITION TO SHORT AND LONGOPPONENS, M.P. EXTENSION STOP


L3830 WHFO, ADDITION TO SHORT AND LONGOPPONENS, M.P. EXTENSION ASSIST


L3835 WHFO, ADDITION TO SHORT AND LONGOPPONENS, M.P. SPRING EXTENSION ASSIST


L3840 WHFO, ADDITION TO SHORT AND LONGOPPONENS, SPRING SWIVEL THUMB


L3845 WHFO, ADDITION TO SHORT AND LONGOPPONENS, THUMB I.P. EXTENSION ASSIST, WITHM.P. STOP


L3850 WHO, ADDITION TO SHORT AND LONGOPPONENS, ACTION WRIST, WITH DORSIFLEXIONASSIST


L3855 WHFO, ADDITION TO SHORT AND LONGOPPONENS, ADJUSTABLE M.P. FLEXIONCONTROL


L3860 WHFO, ADDITION TO SHORT AND LONGOPPONENS, ADJUSTABLE M.P. FLEXIONCONTROL AND I.P.


March 2003B - 39

CODE


DESCRIPTION MAX



L3890 ADDITION TO UPPER EXTREMITY JOINT, WRISTOR ELBOW, CONCENTRIC ADJUSTABLE TORSIONSTYLE MECHANISM, EACH

220.19 2 2 PER YEAR

L3900 WRIST HAND FINGER ORTHOSIS, DYNAMICFLEXOR HINGE, RECIPROCAL WRIST EXTENSION/FLEXION, FINGER FLEXION/EXTENSION, WRISTOR FINGER DRIVEN, CUSTOM-FABRICATED

887.55 2 2 PER YEAR

L3901 WRIST HAND FINGER ORTHOSIS, DYNAMICFLEXOR HINGE, RECIPROCAL WRIST EXTENSION/FLEXION, FINGER FLEXION/EXTENSION, CABLEDRIVEN, CUSTOM-FABRICATED

909.38 2 2 PER YEAR

L3902 WRIST HAND FINGER ORTHOSIS, EXTERNALPOWERED, COMPRESSED GAS,CUSTOM-FABRICATED

1,407.61 2 1 PER ORTHOSIS

L3904 WRIST HAND FINGER ORTHOSIS, EXTERNALPOWERED, ELECTRIC, CUSTOM-FABRICATED


L3906 WRIST HAND ORTHOSIS, WRIST GAUNTLET,CUSTOM-FABRICATED


L3907 WRIST HAND FINGER ORTHOSIS, WRISTGAUNTLET WITH THUMB SPICA,CUSTOM-FABRICATED


L3908 WRST HAND ORTHOSIS, WRIST EXTENSIONCONTROL COCK-UP, NON MOLDED,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

17.46 2 4 PER YEAR

L3909 WRIST ORTHOSIS, ELASTIC, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT (E.G.NEOPRENE, LYCRA)

6.67 2 2 PER YEAR

L3910 WRIST HAND FINGER ORTHOSIS, SWANSONDESIGN, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENT


L3911 WRIST HAND FINGER ORTHOSIS, ELASTIC,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT (E.G. NEOPRENE, LYCRA)

27.45 2 2 PER YEAR

L3912 HAND FINGER ORTHOSIS, FLEXION GLOVE WITHELASTIC FINGER CONTROL, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT

19.40 2 2 PER 2 YEARS

L3914 WRIST HAND ORTHOSIS, WRIST EXTENSIONCOCK-UP, PREFABRICATED, INCLUDESFITTING/ADJUSTMENT

32.01 2 2 PER YEAR

L3916 WRIST HAND FINGER ORTHOSIS, WRISTEXTENSION COCK-UP WITH OUTRIGGER,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L3918 HAND FINGER ORTHOSIS, KNUCKLE BENDER,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L3920 HAND FINGER ORTHOSIS, KNUCKLE BENDER 48.50 2 2 PER MEDICAL

March 2003B - 40

CODE


DESCRIPTION MAX



WITH OUTRIGGER, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT

EVENT

L3922 HAND FINGER ORTHOSIS, KNUCKLE BENDER,TWO SEGMENT TO FLEX JOINTS,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L3923 HAND FINGER ORTHOSIS, WITHOUT JOINT(S),PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTS, ANY TYPE

21.88 1 PER MEDICALEVENT

L3924 WRIST HAND FINGER ORTHOSIS, OPPENHEIMER,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L3926 WRIST HAND FINGER ORTHOSIS, THOMASSUSPENSION, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT


L3928 HAND FINGER ORTHOSIS, FINGER EXTENSION,WITH CLOCK SPRING, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT


L3930 WRIST HAND FINGER ORTHOSIS, FINGEREXTENSION, WITH WRIST SUPPORT,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L3932 FINGER ORTHOSIS, SAFETY PIN, SPRING WIRE,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

19.40 2 2 PER YEAR

L3934 FINGER ORTHOSIS, SAFETY PIN, MODIFIED,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

19.89 2 2 PER YEAR

L3936 WRIST HAND FINGER ORTHOSIS, PALMER,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L3938 WRIST HAND FINGER ORTHOSIS, DORSAL WRIST,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L3940 WRIST HAND FINGER ORTHOSIS, DORSAL WRIST,WITH OUTRIGGER ATTACHMENT,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L3942 HAND FINGER ORTHOSIS, REVERSE KNUCKLEBENDER, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENT


L3944 HAND FINGER ORTHOSIS, REVERSE KNUCKLEBENDER, WITH OUTRIGGER, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT


L3946 HAND FINGER ORTHOSIS, COMPOSITE ELASTIC,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L3948 FINGER ORTHOSIS, FINGER KNUCKLE BENDER, 28.13 2 2 PER YEAR

March 2003B - 41

CODE


DESCRIPTION MAX



PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT

L3950 WRIST HAND FINGER ORTHOSIS, COMBINATIONOPPENHEIMER, WITH KNUCKLE BENDER ANDTWO ATTACHMENTS, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT


L3952 WRIST HAND FINGER ORTHOSIS, COMBINATIONOPPENHEIMER, WITH REVERSE KNUCKLE ANDTWO ATTACHMENTS, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT


L3954 HAND FINGER ORTHOSIS, SPREADING HAND,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L3960 SHOULDER ELBOW WRIST HAND ORTHOSIS,ABDUCTION POSITIONING, AIRPLANE DESIGN,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L3962 SHOULDER ELBOW WRIST HAND ORTHOSIS,ABDUCTION POSITIONING, ERBS PALSEYDESIGN, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENT

186.24 2 2 PER 2 YEARS

L3963 SHOULDER ELBOW WRIST HAND ORTHOSIS,MOLDED SHOULDER, ARM, FOREARM ANDWRIST, WITH ARTICULATING ELBOW JOINT,CUSTOM-FABRICATED

935.34 2 2 PER 2 YEARS

L3964 SHOULDER ELBOW ORTHOSIS, MOBILE ARMSUPPORT ATTACHED TO WHEELCHAIR,BALANCED, ADJUSTABLE, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT

332.71 2 2 PER 2 YEARS

L3980 UPPER EXTREMITY FRACTURE ORTHOSIS,HUMERAL, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENT


L3982 UPPER EXTREMITY FRACTURE ORTHOSIS,RADIUS/ULNAR, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT


L3984 UPPER EXTREMITY FRACTURE ORTHOSIS, WRIST,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L3985 UPPER EXTREMITY FRACTURE ORTHOSIS,FOREARM, HAND WITH WRIST HINGE,CUSTOM-FABRICATED


L3986 UPPER EXTREMITY FRACTURE ORTHOSIS,COMBINATION OF HUMERAL, RADIUS/ULNAR,WRIST, (EXAMPLE--COLLES' FRACTURE),CUSTOM FABRICATED


L3995 ADDITION TO UPPER EXTREMITY ORTHOSIS,SOCK, FRACTURE OR EQUAL, EACH


L3999 UPPER LIMB ORTHOSIS, NOT OTHERWISE 0.00 BR 2 MEDICAL

March 2003B - 42

CODE


DESCRIPTION MAX



SPECIFIED NECESSITYL4000 REPLACE GIRDLE FOR SPINAL ORTHOSIS (CTLSO

OR SO) 630.50 2 2 PER 2 YEARS

L4010 REPLACE TRILATERAL SOCKET BRIM 174.60 2 2 PER LIFETIMEL4020 REPLACE QUADRILATERAL SOCKET BRIM,

MOLDED TO PATIENT MODEL 334.65 2 2 PER YEAR

L4030 REPLACE QUADRILATERAL SOCKET BRIM,CUSTOM FITTED

174.60 2 2 PER YEAR

L4040 REPLACE MOLDED THIGH LACER 176.54 2 2 PER YEARL4045 REPLACE NON-MOLDED THIGH LACER 177.03 2 2 PER YEARL4050 REPLACE MOLDED CALF LACER 160.05 2 2 PER YEARL4055 REPLACE NON-MOLDED CALF LACER 154.72 2 2 PER YEARL4060 REPLACE HIGH ROLL CUFF 205.64 2 2 PER YEARL4070 REPLACE PROXIMAL AND DISTAL UPRIGHT FOR

KAFO 87.30 4 4 PER YEAR

L4080 REPLACE METAL BANDS KAFO, PROXIMALTHIGH

46.01 2 2 PER YEAR

L4090 REPLACE METAL BANDS KAFO-AFO, CALF ORDISTAL THIGH

41.19 2 2 PER YEAR

L4100 REPLACE LEATHER CUFF KAFO, PROXIMALTHIGH

36.86 2 2 PER YEAR

L4110 REPLACE LEATHER CUFF KAFO-AFO, CALF ORDISTAL THIGH

32.98 2 2 PER YEAR

L4130 REPLACE PRETIBIAL SHELL 290.03 2 2 PER YEARL4205 REPAIR OF ORTHOTIC DEVICE, LABOR

COMPONENT, PER 15 MINUTES 10.00 16 $160.00 PER YEAR

L4210 REPAIR OF ORTHOTIC DEVICE, REPAIR ORREPLACE MINOR PARTS

0.00 BR 1 LIMITED TO $160PER YEAR

L4350 PNEUMATIC ANKLE CONTROL SPLINT,PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT


L4360 PNEUMATIC ANKLE FOOT ORTHOSIS, WITH ORWITHOUT JOINTS, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENT


L4370 PNEUMATIC FULL LEG SPLINT, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT


L4380 PNEUMATIC KNEE SPLINT, PREFABRICATED,INCLUDES FITTING AND ADJUSTMENT


L4392 REPLACEMENT, SOFT INTERFACE MATERIAL,STATIC AFO

13.95 1 2 PER YEAR

L4394 REPLACE SOFT INTERFACE MATERIAL, FOOTDROP SPLINT

10.20 1 2 PER YEAR

L4396 STATIC ANKLE FOOT ORTHOSIS, INCLUDINGSOFT INTERFACE MATERIAL, ADJUSTABLE FORFIT, FOR POSITIONING, PRESSURE REDUCTION,MAY BE USED FOR MINIMAL AMBULATION,PREFABRICATED, INCLUDES FITTING AND

99.60 2 2 PER YEAR

March 2003B - 43

CODE


DESCRIPTION MAX



ADJUSTMENTL4398 FOOT DROP SPLINT, RECUMBENT POSITIONING

DEVICE, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENT

45.80 2 2 PER 2 YEARS

L5000 PARTIAL FOOT, SHOE INSERT WITHLONGITUDINAL ARCH, TOE FILLER

129.98 2 2 PER 2 YEARS

L5010 PARTIAL FOOT, MOLDED SOCKET, ANKLEHEIGHT, WITH TOE FILLER

527.20 2 2 PER 2 YEARS

L5020 PARTIAL FOOT, MOLDED SOCKET, TIBIALTUBERCLE HEIGHT, WITH TOE FILLER

527.20 2 2 PER 2 YEARS

L5050 ANKLE, SYMES, MOLDED SOCKET, SACH FOOT 1,387.59 2 2 PER 2 YEARSL5060 ANKLE, SYMES, METAL FRAME, MOLDED

LEATHER SOCKET, ARTICULATED ANKLE/FOOT 1,251.30 2 2 PER 2 YEARS

L5100 BELOW KNEE, MOLDED SOCKET, SHIN, SACHFOOT

1,377.40 2 2 PER YEAR

L5105 BELOW KNEE, PLASTIC SOCKET, JOINTS ANDTHIGH LACER, SACH FOOT

1,719.81 2 2 PER YEAR

L5150 KNEE DISARTICULATION (OR THROUGH KNEE),MOLDED SOCKET, EXTERNAL KNEE JOINTS,SHIN, SACH FOOT

1,940.00 2 2 PER YEAR

L5160 KNEE DISARTICULATION (OR THROUGH KNEE),MOLDED SOCKET, BENT KNEE CONFIGURATION,EXTERNAL KNEE JOINTS, SHIN, SACH FOOT

2,037.00 2 2 PER YEAR

L5200 ABOVE KNEE, MOLDED SOCKET, SINGLE AXISCONSTANT FRICTION KNEE, SHIN, SACH FOOT

1,713.02 2 2 PER YEAR

L5210 ABOVE KNEE, SHORT PROSTHESIS, NO KNEEJOINT ('STUBBIES'), WITH FOOT BLOCKS, NOANKLE JOINTS, EACH

1,261.00 2 2 PER YEAR

L5220 ABOVE KNEE, SHORT PROSTHESIS, NO KNEEJOINT ('STUBBIES'), WITH ARTICULATEDANKLE/FOOT, DYNAMICALLY ALIGNED, EACH

1,261.00 2 2 PER YEAR

L5230 ABOVE KNEE, FOR PROXIMAL FEMORAL FOCALDEFICIENCY, CONSTANT FRICTION KNEE, SHIN,SACH FOOT

1,746.00 2 2 PER YEAR

L5250 HIP DISARTICULATION, CANADIAN TYPE;MOLDED SOCKET, HIP JOINT, SINGLE AXISCONSTANT FRICTION KNEE, SHIN, SACH FOOT

2,840.16 2 2 PER YEAR

L5280 HEMIPELVECTOMY, CANADIAN TYPE; MOLDEDSOCKET, HIP JOINT, SINGLE AXIS CONSTANTFRICTION KNEE, SHIN, SACH FOOT

3,007.00 2 2 PER YEAR

L5301 BELOW KNEE, MOLDED SOCKET, SHIN, SACHFOOT, ENDOSKELETAL SYSTEM

1,457.05 2 2 PER 2 YEARS

L5311 KNEE DISARTICULATION (OR THROUGH KNEE),MOLDED SOCKET, EXTERNAL KNEE JOINTS,SHIN, SACH FOOT, ENDOSKELETAL SYSTEM

2,498.69 2 2 PER 2 YEARS

L5321 ABOVE KNEE, MOLDED SOCKET, OPEN END,SACH FOOT, ENDOSKELETAL SYSTEM, SINGLE

2,530.27 2 2 PER 2 YEARS

March 2003B - 44

CODE


DESCRIPTION MAX



AXIS KNEEL5331 HIP DISARTICULATION, CANADIAN TYPE,

MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIPJOINT, SINGLE AXIS KNEE, SACH FOOT

3,224.08 2 2 PER 2 YEARS

L5341 HEMIPELVECTOMY, CANADIAN TYPE, MOLDEDSOCKET, ENDOSKELETAL SYSTEM, HIP JOINT,SINGLE AXIS KNEE, SACH FOOT

3,356.28 2 2 PER 2 YEARS

L5400 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF INITIAL RIGID DRESSING,INCLUDING FITTING, ALIGNMENT, SUSPENSION,AND ONE CAST CHANGE, BELOW KNEE

679.00 2 1 PERAMPUTATION

L5410 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF INITIAL RIGID DRESSING,INCLUDING FITTING, ALIGNMENT ANDSUSPENSION, BELOW KNEE, EACH ADDITIONALCAST CHANGE AND REALIGNMENT


L5420 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF INITIAL RIGID DRESSING,INCLUDING FITTING, ALIGNMENT ANDSUSPENSION AND ONE CAST CHANGE 'AK' ORKNEE DISARTICULATION


L5430 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF INITIAL RIGID DRESSING, INCL.FITTING, ALIGNMENT AND SUPENSION, 'AK' ORKNEE DISARTICULATION, EACH ADDITIONALCAST CHANGE AND REALIGNMENT


L5450 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF NON-WEIGHT BEARING RIGIDDRESSING, BELOW KNEE


L5460 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF NON-WEIGHT BEARING RIGIDDRESSING, ABOVE KNEE


L5530 PREPARATORY, BELOW KNEE 'PTB' TYPESOCKET, NON-ALIGNABLE SYSTEM, PYLON, NOCOVER, SACH FOOT, THERMOPLASTIC OREQUAL, MOLDED TO MODEL


L5535 PREPARATORY, BELOW KNEE 'PTB' TYPESOCKET, NON-ALIGNABLE SYSTEM, NO COVER,SACH FOOT, PREFABRICATED, ADJUSTABLEOPEN END SOCKET


L5540 PREPARATORY, BELOW KNEE 'PTB' TYPESOCKET, NON-ALIGNABLE SYSTEM, PYLON, NOCOVER, SACH FOOT, LAMINATED SOCKET,MOLDED TO MODEL


L5560 PREPARATORY, ABOVE KNEE- KNEEDISARTICULATION, ISCHIAL LEVEL SOCKET,NON-ALIGNABLE SYSTEM, PYLON, NO COVER,SACH FOOT, PLASTER SOCKET, MOLDED TO


March 2003B - 45

CODE


DESCRIPTION MAX



MODELL5580 PREPARATORY, ABOVE KNEE - KNEE

DISARTICULATION ISCHIAL LEVEL SOCKET,NON-ALIGNABLE SYSTEM, PYLON, NO COVER,SACH FOOT, THERMOPLASTIC OR EQUAL,MOLDED TO MODEL


L5585 PREPARATORY, ABOVE KNEE - KNEEDISARTICULATION, ISCHIAL LEVEL SOCKET,NON-ALIGNABLE SYSTEM, PYLON, NO COVER,SACH FOOT, PREFABRICATED ADJUSTABLE OPENEND SOCKET


L5590 PREPARATORY, ABOVE KNEE - KNEEDISARTICULATION ISCHIAL LEVEL SOCKET,NON-ALIGNABLE SYSTEM, PYLON NO COVER,SACH FOOT, LAMINATED SOCKET, MOLDED TOMODEL

1,067.97 2 1 PERAMPUTATION

L5595 PREPARATORY, HIPDISARTICULATION-HEMIPELVECTOMY, PYLON,NO COVER, SACH FOOT, THERMOPLASTIC OREQUAL, MOLDED TO PATIENT MODEL


L5600 PREPARATORY, HIPDISARTICULATION-HEMIPELVECTOMY, PYLON,NO COVER, SACH FOOT, LAMINATED SOCKET,MOLDED TO PATIENT MODEL


L5610 ADDITION TO LOWER EXTREMITY,ENDOSKELETAL SYSTEM, ABOVE KNEE,HYDRACADENCE SYSTEM

920.53 2 2 PER 4 YEARS

L5611 ADDITION TO LOWER EXTREMITY,ENDOSKELETAL SYSTEM, ABOVE KNEE - KNEEDISARTICULATION, 4 BAR LINKAGE, WITHFRICTION SWING PHASE CONTROL

921.50 2 2 PER 4 YEARS

L5613 ADDITION TO LOWER EXTREMITY,ENDOSKELETAL SYSTEM, ABOVE KNEE-KNEEDISARTICULATION, 4 BAR LINKAGE, WITHHYDRAULIC SWING PHASE CONTROL

1,697.50 2 2 PER 4 YEARS

L5616 ADDITION TO LOWER EXTREMITY,ENDOSKELETAL SYSTEM, ABOVE KNEE,UNIVERSAL MULTIPLEX SYSTEM, FRICTIONSWING PHASE CONTROL

485.00 2 2 PER 4 YEARS

L5617 ADDITION TO LOWER EXTREMITY, QUICKCHANGE SELF-ALIGNING UNIT, ABOVE KNEE ORBELOW KNEE, EACH

323.00 2 2 PER 3 YEARS

L5618 ADDITION TO LOWER EXTREMITY, TEST SOCKET,SYMES

169.75 2 2 PER 2 YEARS

L5620 ADDITION TO LOWER EXTREMITY, TEST SOCKET,BELOW KNEE

145.50 2 2 PER 2 YEARS

L5622 ADDITION TO LOWER EXTREMITY, TEST SOCKET,KNEE DISARTICULATION

169.75 2 2 PER 2 YEARS

March 2003B - 46

CODE


DESCRIPTION MAX



L5624 ADDITION TO LOWER EXTREMITY, TEST SOCKET,ABOVE KNEE

162.96 2 2 PER 2 YEARS

L5626 ADDITION TO LOWER EXTREMITY, TEST SOCKET,HIP DISARTICULATION

169.75 2 2 PER 2 YEARS

L5628 ADDITION TO LOWER EXTREMITY, TEST SOCKET,HEMIPELVECTOMY

169.75 2 2 PER 2 YEARS

L5629 ADDITION TO LOWER EXTREMITY, BELOW KNEE,ACRYLIC SOCKET

121.25 2 1 PER PROSTHESIS

L5630 ADDITION TO LOWER EXTREMITY, SYMES TYPE,EXPANDABLE WALL SOCKET

242.50 2 2 PER 4 YEARS

L5631 ADDITION TO LOWER EXTREMITY, ABOVE KNEEOR KNEE DISARTICULATION, ACRYLIC SOCKET

194.00 2 2 PER 4 YEARS

L5632 ADDITION TO LOWER EXTREMITY, SYMES TYPE,'PTB' BRIM DESIGN SOCKET

119.83 2 2 PER 4 YEARS

L5634 ADDITION TO LOWER EXTREMITY, SYMES TYPE,POSTERIOR OPENING (CANADIAN) SOCKET

72.75 2 2 PER 4 YEARS

L5636 ADDITION TO LOWER EXTREMITY, SYMES TYPE,MEDIAL OPENING SOCKET

118.77 2 2 PER 4 YEARS

L5637 ADDITION TO LOWER EXTREMITY, BELOW KNEE,TOTAL CONTACT

121.25 2 2 PER 4 YEARS

L5638 ADDITION TO LOWER EXTREMITY, BELOWKNEE, LEATHER SOCKET

169.75 2 2 PER 4 YEARS

L5639 ADDITION TO LOWER EXTREMITY, BELOW KNEE,WOOD SOCKET


L5640 ADDITION TO LOWER EXTREMITY, KNEEDISARTICULATION, LEATHER SOCKET

371.51 2 2 PER 4 YEARS

L5642 ADDITION TO LOWER EXTREMITY, ABOVEKNEE, LEATHER SOCKET

371.51 2 2 PER 4 YEARS

L5643 ADDITION TO LOWER EXTREMITY, HIPDISARTICULATION, FLEXIBLE INNER SOCKET,EXTERNAL FRAME

399.16 2 2 PER 4 YEARS

L5644 ADDITION TO LOWER EXTREMITY, ABOVEKNEE, WOOD SOCKET

97.00 2 2 PER 4 YEARS

L5645 ADDITION TO LOWER EXTREMITY, BELOWKNEE, FLEXIBLE INNER SOCKET, EXTERNALFRAME

132.89 2 2 PER 4 YEARS

L5646 ADDITION TO LOWER EXTREMITY, BELOWKNEE, AIR CUSHION SOCKET

211.46 2 2 PER 4 YEARS

L5647 ADDITION TO LOWER EXTREMITY, BELOW KNEESUCTION SOCKET

266.27 2 2 PER 4 YEARS

L5648 ADDITION TO LOWER EXTREMITY, ABOVEKNEE, AIR CUSHION SOCKET

211.46 2 2 PER 2 YEARS

L5649 ADDITION TO LOWER EXTREMITY, ISCHIALCONTAINMENT/NARROW M-L SOCKET

1,331.33 2 2 PER 2 YEARS

L5650 ADDITIONS TO LOWER EXTREMITY, TOTALCONTACT, ABOVE KNEE OR KNEEDISARTICULATION SOCKET

97.00 2 2 PER 4 YEARS

March 2003B - 47

CODE


DESCRIPTION MAX



L5651 ADDITION TO LOWER EXTREMITY, ABOVEKNEE, FLEXIBLE INNER SOCKET, EXTERNALFRAME

443.29 2 2 PER 2 YEARS

L5652 ADDITION TO LOWER EXTREMITY, SUCTIONSUSPENSION, ABOVE KNEE OR KNEEDISARTICULATION SOCKET

218.25 2 2 PER 2 YEARS

L5653 ADDITION TO LOWER EXTREMITY, KNEEDISARTICULATION, EXPANDABLE WALL SOCKET

242.50 2 2 PER 4 YEARS

L5654 ADDITION TO LOWER EXTREMITY, SOCKETINSERT, SYMES, (KEMBLO, PELITE, ALIPLAST,PLASTAZOTE OR EQUAL)

203.70 2 2 PER YEAR

L5655 ADDITION TO LOWER EXTREMITY, SOCKETINSERT, BELOW KNEE (KEMBLO, PELITE,ALIPLAST, PLASTAZOTE OR EQUAL)

162.96 2 2 PER YEAR

L5656 ADDITION TO LOWER EXTREMITY, SOCKETINSERT, KNEE DISARTICULATION (KEMBLO,PELITE, ALIPLAST, PLASTAZOTE OR EQUAL)

218.25 2 2 PER YEAR

L5658 ADDITION TO LOWER EXTREMITY, SOCKETINSERT, ABOVE KNEE (KEMBLO, PELITE,ALIPLAST, PLASTAZOTE OR EQUAL)

218.25 2 2 PER YEAR

L5661 ADDITION TO LOWER EXTREMITY, SOCKETINSERT, MULTI-DUROMETER SYMES

221.16 2 2 PER YEAR

L5665 ADDITION TO LOWER EXTREMITY, SOCKETINSERT, MULTI-DUROMETER, BELOW KNEE

198.85 2 2 PER YEAR

L5666 ADDITION TO LOWER EXTREMITY, BELOWKNEE, CUFF SUSPENSION

29.10 2 2 PER YEAR

L5668 ADDITION TO LOWER EXTREMITY, BELOWKNEE, MOLDED DISTAL CUSHION

77.60 2 2 PER YEAR

L5670 ADDITION TO LOWER EXTREMITY, BELOWKNEE, MOLDED SUPRACONDYLAR SUSPENSION('PTS' OR SIMILAR)

106.70 2 2 PER 2 YEARS

L5671 ADDITION TO LOWER EXTREMITY, BELOW KNEE/ ABOVE KNEE SUSPENSION LOCKINGMECHANISM (SHUTTLE, LANYARD OR EQUAL),EXCLUDES SOCKET INSERT


L5672 ADDITION TO LOWER EXTREMITY, BELOWKNEE, REMOVABLE MEDIAL BRIM SUSPENSION

93.12 2 2 PER 4 YEARS

L5674 ADDITION TO LOWER EXTREMITY, BELOW KNEE,SUSPENSION SLEEVE, ANY MATERIAL, EACH

33.95 2 6 PER YEAR

L5675 ADDITION TO LOWER EXTREMITY, BELOWKNEE, SUSPENSION SLEEVE, HEAVY DUTY, ANYMATERIAL, EACH

57.23 2 6 PER YEAR

L5676 ADDITIONS TO LOWER EXTREMITY, BELOWKNEE, KNEE JOINTS, SINGLE AXIS, PAIR

214.37 2 2 PER 4 YEARS

L5677 ADDITIONS TO LOWER EXTREMITY, BELOWKNEE, KNEE JOINTS, POLYCENTRIC, PAIR

252.69 2 2 PER 4 YEARS

L5678 ADDITIONS TO LOWER EXTREMITY, BELOWKNEE, JOINT COVERS, PAIR


March 2003B - 48

CODE


DESCRIPTION MAX



L5680 ADDITION TO LOWER EXTREMITY, BELOWKNEE, THIGH LACER, NONMOLDED

184.30 2 2 PER 4 YEARS

L5682 ADDITION TO LOWER EXTREMITY, BELOWKNEE, THIGH LACER, GLUTEAL/ISCHIAL,MOLDED

194.00 2 2 PER 4 YEARS

L5684 ADDITION TO LOWER EXTREMITY, BELOWKNEE, FORK STRAP

14.55 2 2 PER 2 YEARS

L5686 ADDITION TO LOWER EXTREMITY, BELOWKNEE, BACK CHECK (EXTENSION CONTROL)


L5688 ADDITION TO LOWER EXTREMITY, BELOWKNEE, WAIST BELT, WEBBING

34.92 2 2 PER YEAR

L5690 ADDITION TO LOWER EXTREMITY, BELOWKNEE, WAIST BELT, PADDED AND LINED

50.44 2 2 PER YEAR

L5692 ADDITION TO LOWER EXTREMITY, ABOVEKNEE, PELVIC CONTROL BELT, LIGHT

43.65 2 2 PER YEAR

L5694 ADDITION TO LOWER EXTREMITY, ABOVEKNEE, PELVIC CONTROL BELT, PADDED ANDLINED

81.48 2 2 PER YEAR

L5695 ADDITION TO LOWER EXTREMITY, ABOVE KNEE,PELVIC CONTROL, SLEEVE SUSPENSION,NEOPRENE OR EQUAL, EACH

89.73 2 4 PER YEAR

L5696 ADDITION TO LOWER EXTREMITY, ABOVE KNEEOR KNEE DISARTICULATION, PELVIC JOINT

92.15 2 2 PER 2 YEARS

L5697 ADDITION TO LOWER EXTREMITY, ABOVE KNEEOR KNEE DISARTICULATION, PELVIC BAND

48.50 2 1 PER 2 YEARS

L5698 ADDITION TO LOWER EXTREMITY, ABOVE KNEEOR KNEE DISARTICULATION, SILESIANBANDAGE

72.75 2 2 PER YEAR

L5699 ALL LOWER EXTREMITY PROSTHESES,SHOULDER HARNESS

38.80 2 2 PER YEAR

L5700 REPLACEMENT, SOCKET, BELOW KNEE, MOLDEDTO PATIENT MODEL

1,701.79 2 2 PER 4 YEARS

L5701 REPLACEMENT, SOCKET, ABOVE KNEE/KNEEDISARTICULATION, INCLUDING ATTACHMENTPLATE, MOLDED TO PATIENT MODEL

2,043.73 2 2 PER 4 YEARS

L5702 REPLACEMENT, SOCKET, HIP DISARTICULATION,INCLUDING HIP JOINT, MOLDED TO PATIENTMODEL

2,585.62 2 2 PER 4 YEARS

L5704 CUSTOM SHAPED PROTECTIVE COVER, BELOWKNEE

318.36 2 2 PER 4 YEARS

L5705 CUSTOM SHAPED PROTECTIVE COVER, ABOVEKNEE

568.86 2 2 PER 4 YEARS

L5706 CUSTOM SHAPED PROTECTIVE COVER, KNEEDISARTICULATION

557.64 2 2 PER 4 YEARS

L5707 CUSTOM SHAPED PROTECTIVE COVER, HIPDISARTICULATION

735.17 2 2 PER 4 YEARS

L5710 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, 97.00 2 2 PER 4 YEARS

March 2003B - 49

CODE


DESCRIPTION MAX



SINGLE AXIS, MANUAL LOCKL5711 ADDITIONS EXOSKELETAL KNEE-SHIN SYSTEM,

SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHTMATERIAL

88.27 2 2 PER 4 YEARS

L5712 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, FRICTION SWING AND STANCEPHASE CONTROL (SAFETY KNEE)

242.50 2 2 PER 4 YEARS

L5714 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, VARIABLE FRICTION SWING PHASECONTROL

209.87 2 2 PER 4 YEARS

L5716 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,POLYCENTRIC, MECHANICAL STANCE PHASELOCK

242.50 2 2 PER 4 YEARS

L5718 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,POLYCENTRIC, FRICTION SWING AND STANCEPHASE CONTROL

399.16 2 2 PER 4 YEARS

L5722 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, PNEUMATIC SWING, FRICTIONSTANCE PHASE CONTROL

492.76 2 2 PER 4 YEARS

L5724 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, FLUID SWING PHASE CONTROL

650.87 2 2 PER 4 YEARS

L5726 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, EXTERNAL JOINTS FLUID SWINGPHASE CONTROL

643.11 2 2 PER 4 YEARS

L5728 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, FLUID SWING AND STANCE PHASECONTROL

1,070.88 2 2 PER 4 YEARS

L5780 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, PNEUMATIC/HYDRA PNEUMATICSWING PHASE CONTROL

680.02 2 2 PER 4 YEARS

L5785 ADDITION, EXOSKELETAL SYSTEM, BELOWKNEE, ULTRA-LIGHT MATERIAL (TITANIUM,CARBON FIBER OR EQUAL)

309.92 2 2 PER 4 YEARS

L5790 ADDITION, EXOSKELETAL SYSTEM, ABOVEKNEE, ULTRA-LIGHT MATERIAL (TITANIUM,CARBON FIBER OR EQUAL)

528.55 2 2 PER 4 YEARS

L5795 ADDITION, EXOSKELETAL SYSTEM, HIPDISARTICULATION, ULTRA-LIGHT MATERIAL(TITANIUM, CARBON FIBER OR EQUAL)

1,052.35 2 2 PER 4 YEARS

L5810 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, MANUAL LOCK

88.27 2 2 PER 4 YEARS

L5811 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHTMATERIAL

341.97 2 2 PER 4 YEARS

L5812 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, FRICTION SWING AND STANCEPHASE CONTROL (SAFETY KNEE)

315.25 2 2 PER 4 YEARS

L5814 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 2,200.00 2 2 PER 2 YEARS

March 2003B - 50

CODE


DESCRIPTION MAX



POLYCENTRIC, HYDRAULIC SWING PHASECONTROL, MECHANICAL STANCE PHASE LOCK

L5816 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,POLYCENTRIC, MECHANICAL STANCE PHASELOCK

221.16 2 2 PER 4 YEARS

L5818 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,POLYCENTRIC, FRICTION SWING, AND STANCEPHASE CONTROL

398.67 2 2 PER 4 YEARS

L5822 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, PNEUMATIC SWING, FRICTIONSTANCE PHASE CONTROL

451.05 2 2 PER 4 YEARS

L5824 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, FLUID SWING PHASE CONTROL

607.22 2 2 PER 4 YEARS

L5828 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, FLUID SWING AND STANCE PHASECONTROL

1,065.06 2 2 PER 4 YEARS

L5830 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,SINGLE AXIS, PNEUMATIC/ SWING PHASECONTROL

785.70 2 2 PER 4 YEARS

L5840 ADDITION, ENDOSKELETAL KNEE/SHIN SYSTEM,4-BAR LINKAGE OR MULTIAXIAL, PNEUMATICSWING PHASE CONTROL

2,083.91 2 2 PER 4 YEARS

L5845 ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM,STANCE FLEXION FEATURE, ADJUSTABLE

1,066.00 2 2 PER 3 YEARS

L5846 ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM,MICROPROCESSOR CONTROL FEATURE, SWINGPHASE ONLY

3,255.87 2 2 PER 4 YEARS

L5847 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,MICROPROCESSOR CONTROL FEATURE, STANCEPHASE

3,255.87 2 2 PER 2 YEARS

L5850 ADDITION, ENDOSKELETAL SYSTEM, ABOVEKNEE OR HIP DISARTICULATION, KNEEEXTENSION ASSIST

43.65 2 2 PER 4 YEARS

L5855 ADDITION, ENDOSKELETAL SYSTEM, HIPDISARTICULATION, MECHANICAL HIPEXTENSION ASSIST

204.18 2 2 PER 4 YEARS

L5910 ADDITION, ENDOSKELETAL SYSTEM, BELOWKNEE, ALIGNABLE SYSTEM

88.27 2 2 PER 4 YEARS

L5920 ADDITION, ENDOSKELETAL SYSTEM, ABOVEKNEE OR HIP DISARTICULATION, ALIGNABLESYSTEM

177.03 2 2 PER 4 YEARS

L5940 ADDITION, ENDOSKELETAL SYSTEM, BELOWKNEE, ULTRA-LIGHT MATERIAL (TITANIUM,CARBON FIBER OR EQUAL)

340.47 2 2 PER 2 YEARS

L5950 ADDITION, ENDOSKELETAL SYSTEM, ABOVEKNEE, ULTRA-LIGHT MATERIAL (TITANIUM,CARBON FIBER OR EQUAL)

576.54 2 2 PER 2 YEARS

L5960 ADDITION, ENDOSKELETAL SYSTEM, HIP 1,196.98 2 2 PER 4 YEARS

March 2003B - 51

CODE


DESCRIPTION MAX



DISARTICULATION, ULTRA-LIGHT MATERIAL(TITANIUM, CARBON FIBER OR EQUAL)

L5962 ADDITION, ENDOSKELETAL SYSTEM, BELOWKNEE, FLEXIBLE PROTECTIVE OUTER SURFACECOVERING SYSTEM

376.82 2 2 PER 4 YEARS

L5964 ADDITION, ENDOSKELETAL SYSTEM, ABOVEKNEE, FLEXIBLE PROTECTIVE OUTER SURFACECOVERING SYSTEM

556.26 2 2 PER 4 YEARS

L5966 ADDITION, ENDOSKELETAL SYSTEM, HIPDISARTICULATION, FLEXIBLE PROTECTIVEOUTER SURFACE COVERING SYSTEM

708.80 2 2 PER 4 YEARS

L5968 ADDITION TO LOWER LIMB PROSTHESIS,MULTIAXIAL ANKLE WITH SWING PHASE ACTIVEDORSIFLEXION FEATURE

2,204.51 2 2 PER 4 YEARS

L5970 ALL LOWER EXTREMITY PROSTHESES, FOOT,EXTERNAL KEEL, SACH FOOT

48.50 2 2 PER 2 YEARS

L5972 ALL LOWER EXTREMITY PROSTHESES, FLEXIBLEKEEL FOOT (SAFE, STEN, BOCK DYNAMIC OREQUAL)

177.03 2 2 PER 2 YEARS

L5974 ALL LOWER EXTREMITY PROSTHESES, FOOT,SINGLE AXIS ANKLE/FOOT

67.90 2 2 PER 2 YEARS

L5975 ALL LOWER EXTREMITY PROSTHESIS,COMBINATION SINGLE AXIS ANKLE ANDFLEXIBLE KEEL FOOT

281.24 2 2 PER 4 YEARS

L5976 ALL LOWER EXTREMITY PROSTHESES, ENERGYSTORING FOOT (SEATTLE CARBON COPY II OREQUAL)

291.00 2 2 PER 2 YEARS

L5978 ALL LOWER EXTREMITY PROSTHESES, FOOT,MULTIAXIAL ANKLE/FOOT

135.80 2 2 PER 2 YEARS

L5979 ALL LOWER EXTREMITY PROSTHESIS,MULTI-AXIAL ANKLE, DYNAMIC RESPONSEFOOT, ONE PIECE SYSTEM

1,355.26 2 2 PER 2 YEARS

L5980 ALL LOWER EXTREMITY PROSTHESES, FLEXFOOT SYSTEM

2,202.21 2 2 PER 2 YEARS

L5981 ALL LOWER EXTREMITY PROSTHESES,FLEX-WALK SYSTEM OR EQUAL

1,779.08 2 2 PER 2 YEARS

L5982 ALL EXOSKELETAL LOWER EXTREMITYPROSTHESES, AXIAL ROTATION UNIT

204.67 2 2 PER 2 YEARS

L5984 ALL ENDOSKELETAL LOWER EXTREMITYPROSTHESES, AXIAL ROTATION UNIT

243.47 2 2 PER 2 YEARS

L5985 ALL ENDOSKELETAL LOWER EXTREMITYPROTHESES, DYNAMIC PROSTHETIC PYLON

163.00 2 2 PER 3 YEARS

L5986 ALL LOWER EXTREMITY PROSTHESES,MULTI-AXIAL ROTATION UNIT ('MCP' OR EQUAL)

203.70 2 2 PER 2 YEARS

L5987 ALL LOWER EXTREMITY PROSTHESIS, SHANKFOOT SYSTEM WITH VERTICAL LOADING PYLON

4,275.00 2 2 PER 2 YEARS

L5988 ADDITION TO LOWER LIMB PROSTHESIS, 1,211.88 2 2 PER 4 YEARS

March 2003B - 52

CODE


DESCRIPTION MAX



VERTICAL SHOCK REDUCING PYLON FEATUREL5989 ADDITION TO LOWER EXTREMITY PROSTHESIS,

ENDOSKELETAL SYSTEM, PYLON WITHINTEGRATED ELECTRONIC FORCE SENSORS

1,779.08 2 2 PER 2 YEARS

L5990 ADDITION TO LOWER EXTREMITY PROSTHESIS,USER ADJUSTABLE HEEL HEIGHT

39.45 2 2 PER 2 YEARS

L5995 ADDITION TO LOWER EXTREMITY PROSTHESIS,HEAVY DUTY FEATURE (FOR PATIENT WEIGHT >300 LBS)

51.25 2 2 PER ORTHOTSIS

L5999 LOWER EXTREMITY PROSTHESIS, NOTOTHERWISE SPECIFIED


L6000 PARTIAL HAND, ROBIN-AIDS, THUMBREMAINING (OR EQUAL)

638.26 2 2 PER 4 YEARS

L6010 PARTIAL HAND, ROBIN-AIDS, LITTLE AND/ORRING FINGER REMAINING (OR EQUAL)

638.26 2 2 PER 4 YEARS

L6020 PARTIAL HAND, ROBIN-AIDS, NO FINGERREMAINING (OR EQUAL)

638.26 2 2 PER 2 YEARS

L6050 WRIST DISARTICULATION, MOLDED SOCKET,FLEXIBLE ELBOW HINGES, TRICEPS PAD

1,013.65 2 2 PER 2 YEARS

L6055 WRIST DISARTICULATION, MOLDED SOCKETWITH EXPANDABLE INTERFACE, FLEXIBLEELBOW HINGES, TRICEPS PAD

1,237.72 2 2 PER 4 YEARS

L6100 BELOW ELBOW, MOLDED SOCKET, FLEXIBLEELBOW HINGE, TRICEPS PAD

1,009.77 2 2 PER 2 YEARS

L6110 BELOW ELBOW, MOLDED SOCKET, (MUENSTEROR NORTHWESTERN SUSPENSION TYPES)

1,057.30 2 2 PER 2 YEARS

L6120 BELOW ELBOW, MOLDED DOUBLE WALL SPLITSOCKET, STEP-UP HINGES, HALF CUFF

1,231.90 2 2 PER 4 YEARS

L6130 BELOW ELBOW, MOLDED DOUBLE WALL SPLITSOCKET, STUMP ACTIVATED LOCKING HINGE,HALF CUFF

1,231.90 2 2 PER 4 YEARS

L6200 ELBOW DISARTICULATION, MOLDED SOCKET,OUTSIDE LOCKING HINGE, FOREARM

1,421.05 2 2 PER 4 YEARS

L6205 ELBOW DISARTICULATION, MOLDED SOCKETWITH EXPANDABLE INTERFACE, OUTSIDELOCKING HINGES, FOREARM

1,641.24 2 2 PER 4 YEARS

L6250 ABOVE ELBOW, MOLDED DOUBLE WALLSOCKET, INTERNAL LOCKING ELBOW, FOREARM

1,425.90 2 2 PER 2 YEARS

L6300 SHOULDER DISARTICULATION, MOLDEDSOCKET, SHOULDER BULKHEAD, HUMERALSECTION, INTERNAL LOCKING ELBOW, FOREARM

1,891.50 2 2 PER 2 YEARS

L6310 SHOULDER DISARTICULATION, PASSIVERESTORATION (COMPLETE PROSTHESIS)

1,891.50 2 2 PER 4 YEARS

L6320 SHOULDER DISARTICULATION, PASSIVERESTORATION (SHOULDER CAP ONLY)

630.50 2 2 PER 4 YEARS

L6350 INTERSCAPULAR THORACIC, MOLDED SOCKET,SHOULDER BULKHEAD, HUMERAL SECTION,

1,891.50 2 2 PER 2 YEARS

March 2003B - 53

CODE


DESCRIPTION MAX



INTERNAL LOCKING ELBOW, FOREARML6360 INTERSCAPULAR THORACIC, PASSIVE

RESTORATION (COMPLETE PROSTHESIS) 2,085.50 2 2 PER 4 YEARS

L6370 INTERSCAPULAR THORACIC, PASSIVERESTORATION (SHOULDER CAP ONLY)

630.50 2 2 PER 4 YEARS

L6380 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF INITIAL RIGID DRESSING,INCLUDING FITTING ALIGNMENT ANDSUSPENSION OF COMPONENTS, AND ONE CASTCHANGE, WRIST DISARTICULATION OR BELOWELBOW


L6382 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF INITIAL RIGID DRESSINGINCLUDING FITTING ALIGNMENT ANDSUSPENSION OF COMPONENTS, AND ONE CASTCHANGE, ELBOW DISARTICULATION OR ABOVEELBOW


L6384 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF INITIAL RIGID DRESSINGINCLUDING FITTING ALIGNMENT ANDSUSPENSION OF COMPONENTS, AND ONE CASTCHANGE, SHOULDER DISARTICULATION ORINTERSCAPULAR THORACIC


L6386 IMMEDIATE POST SURGICAL OR EARLY FITTING,EACH ADDITIONAL CAST CHANGE ANDREALIGNMENT


L6388 IMMEDIATE POST SURGICAL OR EARLY FITTING,APPLICATION OF RIGID DRESSING ONLY


L6400 BELOW ELBOW, MOLDED SOCKET,ENDOSKELETAL SYSTEM, INCLUDING SOFTPROSTHETIC TISSUE SHAPING

1,261.00 2 2 PER 4 YEARS

L6450 ELBOW DISARTICULATION, MOLDED SOCKET,ENDOSKELETAL SYSTEM, INCLUDING SOFTPROSTHETIC TISSUE SHAPING

1,818.75 2 2 PER 4 YEARS

L6500 ABOVE ELBOW, MOLDED SOCKET,ENDOSKELETAL SYSTEM, INCLUDING SOFTPROSTHETIC TISSUE SHAPING

1,818.75 2 2 PER 4 YEARS

L6550 SHOULDER DISARTICULATION, MOLDEDSOCKET, ENDOSKELETAL SYSTEM, INCLUDINGSOFT PROSTHETIC TISSUE SHAPING

1,891.50 2 2 PER 4 YEARS

L6570 INTERSCAPULAR THORACIC, MOLDED SOCKET,ENDOSKELETAL SYSTEM, INCLUDING SOFTPROSTHETIC TISSUE SHAPING

2,085.50 2 2 PER 4 YEARS

L6580 PREPARATORY, WRIST DISARTICULATION ORBELOW ELBOW, SINGLE WALL PLASTIC SOCKET,FRICTION WRIST, FLEXIBLE ELBOW HINGES,FIGURE OF EIGHT HARNESS, HUMERAL CUFF,BOWDEN CABLE CONTROL, USMC OR EQUAL

992.50 2 2 PER 4 YEARS

March 2003B - 54

CODE


DESCRIPTION MAX



PYLON, NO COVER, MOLDED TO PATIENT MODELL6582 PREPARATORY, WRIST DISARTICULATION OR

BELOW ELBOW, SINGLE WALL SOCKET,FRICTION WRIST, FLEXIBLE ELBOW HINGES,FIGURE OF EIGHT HARNESS, HUMERAL CUFF,BOWDEN CABLE CONTROL, USMC OR EQUALPYLON, NO COVER, DIRECT FORMED

898.93 2 2 PER 4 YEARS

L6584 PREPARATORY, ELBOW DISARTICULATION ORABOVE ELBOW, SINGLE WALL PLASTIC SOCKET,FRICTION WRIST, LOCKING ELBOW, FIGURE OFEIGHT HARNESS, FAIR LEAD CABLE CONTROL,USMC OR EQUAL PYLON, NO COVER, MOLDEDTO PATIENT MODEL

1,409.60 2 2 PER 4 YEARS

L6586 PREPARATORY, ELBOW DISARTICULATION ORABOVE ELBOW, SINGLE WALL SOCKET,FRICTION WRIST, LOCKING ELBOW, FIGURE OFEIGHT HARNESS, FAIR LEAD CABLE CONTROL,USMC OR EQUAL PYLON, NO COVER, DIRECTFORMED

1,319.30 2 2 PER 4 YEARS

L6588 PREPARATORY, SHOULDER DISARTICULATIONOR INTERSCAPULAR THORACIC, SINGLE WALLPLASTIC SOCKET, SHOULDER JOINT, LOCKINGELBOW, FRICTION WRIST, CHEST STRAP, FAIRLEAD CABLE CONTROL, USMC OR EQUAL PYLON,NO COVER, MOLDED TO PATIENT MODEL

2,166.92 2 2 PER 4 YEARS

L6590 PREPARATORY, SHOULDER DISARTICULATIONOR INTERSCAPULAR THORACIC, SINGLE WALLSOCKET, SHOULDER JOINT, LOCKING ELBOW,FRICTION WRIST, CHEST STRAP, FAIR LEADCABLE CONTROL, USMC OR EQUAL PYLON, NOCOVER, DIRECT FORMED

1,646.61 2 2 PER 4 YEARS

L6600 UPPER EXTREMITY ADDITIONS, POLYCENTRICHINGE, PAIR

53.35 2 2 PER 4 YEARS

L6605 UPPER EXTREMITY ADDITIONS, SINGLE PIVOTHINGE, PAIR

53.35 2 2 PER 4 YEARS

L6610 UPPER EXTREMITY ADDITIONS, FLEXIBLEMETAL HINGE, PAIR

53.35 2 2 PER 4 YEARS

L6615 UPPER EXTREMITY ADDITION, DISCONNECTLOCKING WRIST UNIT

128.04 2 2 PER 2 YEARS

L6616 UPPER EXTREMITY ADDITION, ADDITIONALDISCONNECT INSERT FOR LOCKING WRIST UNIT,EACH

43.65 2 6 PER 4 YEARS

L6620 UPPER EXTREMITY ADDITION,FLEXION-FRICTION WRIST UNIT

163.93 2 2 PER 2 YEARS

L6625 UPPER EXTREMITY ADDITION, ROTATION WRISTUNIT WITH CABLE LOCK

145.50 2 2 PER 4 YEARS

L6628 UPPER EXTREMITY ADDITION, QUICKDISCONNECT HOOK ADAPTER, OTTO BOCK OR

284.54 1 2 PER 4 YEARS

March 2003B - 55

CODE


DESCRIPTION MAX



EQUALL6629 UPPER EXTREMITY ADDITION, QUICK

DISCONNECT LAMINATION COLLAR WITHCOUPLING PIECE, OTTO BOCK OR EQUAL

86.90 1 2 PER 4 YEARS

L6630 UPPER EXTREMITY ADDITION, STAINLESSSTEEL, ANY WRIST

102.15 2 2 PER 2 YEARS

L6632 UPPER EXTREMITY ADDITION, LATEXSUSPENSION SLEEVE, EACH

30.56 2 12 PER YEAR

L6635 UPPER EXTREMITY ADDITION, LIFT ASSIST FORELBOW

75.66 2 2 PER 2 YEARS

L6637 UPPER EXTREMITY ADDITION, NUDGE CONTROLELBOW LOCK

223.14 2 2 PER 4 YEARS

L6640 UPPER EXTREMITY ADDITIONS, SHOULDERABDUCTION JOINT, PAIR

156.66 2 2 PER 4 YEARS

L6641 UPPER EXTREMITY ADDITION, EXCURSIONAMPLIFIER, PULLEY TYPE

52.87 2 2 PER 4 YEARS

L6642 UPPER EXTREMITY ADDITION, EXCURSIONAMPLIFIER, LEVER TYPE

66.93 2 2 PER 4 YEARS

L6645 UPPER EXTREMITY ADDITION, SHOULDERFLEXION-ABDUCTION JOINT, EACH

236.20 2 2 PER 4 YEARS

L6650 UPPER EXTREMITY ADDITION, SHOULDERUNIVERSAL JOINT, EACH

249.29 2 2 PER 4 YEARS

L6655 UPPER EXTREMITY ADDITION, STANDARDCONTROL CABLE, EXTRA

19.40 2 2 PER YEAR

L6660 UPPER EXTREMITY ADDITION, HEAVY DUTYCONTROL CABLE

24.25 2 2 PER YEAR

L6665 UPPER EXTREMITY ADDITION, TEFLON, OREQUAL, CABLE LINING

21.15 2 2 PER YEAR

L6670 UPPER EXTREMITY ADDITION, HOOK TO HAND,CABLE ADAPTER

11.64 2 2 PER YEAR

L6672 UPPER EXTREMITY ADDITION, HARNESS, CHESTOR SHOULDER, SADDLE TYPE

38.80 2 2 PER YEAR

L6675 UPPER EXTREMITY ADDITION, HARNESS,FIGURE OF ('8') EIGHT TYPE, FOR SINGLECONTROL

31.04 2 2 PER YEAR

L6676 UPPER EXTREMITY ADDITION, HARNESS,FIGURE OF ('8') EIGHT TYPE, FOR DUAL CONTROL

77.60 2 2 PER YEAR

L6680 UPPER EXTREMITY ADDITION, TEST SOCKET,WRIST DISARTICULATION OR BELOW ELBOW


L6682 UPPER EXTREMITY ADDITION, TEST SOCKET,ELBOW DISARTICULATION OR ABOVE ELBOW


L6684 UPPER EXTREMITY ADDITION, TEST SOCKET,SHOULDER DISARTICULATION ORINTERSCAPULAR THORACIC


L6686 UPPER EXTREMITY ADDITION, SUCTION SOCKET 309.92 2 2 PER 4 YEARSL6687 UPPER EXTREMITY ADDITION, FRAME TYPE

SOCKET, BELOW ELBOW OR WRIST 266.27 2 2 PER 4 YEARS

March 2003B - 56

CODE


DESCRIPTION MAX



DISARTICULATIONL6688 UPPER EXTREMITY ADDITION, FRAME TYPE

SOCKET, ABOVE ELBOW OR ELBOWDISARTICULATION

266.27 2 2 PER 4 YEARS

L6689 UPPER EXTREMITY ADDITION, FRAME TYPESOCKET, SHOULDER DISARTICULATION

398.67 2 2 PER 4 YEARS

L6690 UPPER EXTREMITY ADDITION, FRAME TYPESOCKET, INTERSCAPULAR-THORACIC

398.67 2 2 PER 4 YEARS

L6691 UPPER EXTREMITY ADDITION, REMOVABLEINSERT, EACH

199.34 2 2 PER YEAR

L6692 UPPER EXTREMITY ADDITION, SILICONE GELINSERT OR EQUAL, EACH

363.75 2 2 PER 2 YEARS

L6693 UPPER EXTREMITY ADDITION, LOCKING ELBOW,FOREARM COUNTERBALANCE

1,722.26 2 2 PER 4 YEARS

L6700 TERMINAL DEVICE, HOOK, DORRANCE, OREQUAL, MODEL #3

163.93 2 2 PER 4 YEARS


144.53 2 2 PER 4 YEARS

L6710 TERMINAL DEVICE, HOOK, DORRANCE, OREQUAL, MODEL #5X

163.93 2 2 PER 4 YEARS

L6715 TERMINAL DEVICE, HOOK, DORRANCE, OREQUAL, MODEL #5XA

156.17 2 2 PER 2 YEARS


361.81 2 2 PER 4 YEARS


213.40 2 2 PER 4 YEARS

L6730 TERMINAL DEVICE, HOOK, DORRANCE, OREQUAL, MODEL #7LO

218.25 2 2 PER 4 YEARS


144.53 2 2 PER 4 YEARS


156.17 2 2 PER 4 YEARS


156.17 2 2 PER 4 YEARS

L6750 TERMINAL DEVICE, HOOK, DORRANCE, OREQUAL, MODEL #10P

156.17 2 2 PER 4 YEARS


156.17 2 2 PER 4 YEARS

L6765 TERMINAL DEVICE, HOOK, DORRANCE, OREQUAL, MODEL #12P

156.17 2 2 PER 4 YEARS


156.17 2 2 PER 4 YEARS


164.90 2 2 PER 4 YEARS

L6780 TERMINAL DEVICE, HOOK, DORRANCE, OREQUAL, MODEL #SS555

179.45 2 2 PER 4 YEARS

L6790 TERMINAL DEVICE, HOOK-ACCU HOOK, OR 179.45 2 2 PER 4 YEARS

March 2003B - 57

CODE


DESCRIPTION MAX



EQUALL6795 TERMINAL DEVICE, HOOK-2 LOAD, OR EQUAL 640.20 2 2 PER 4 YEARSL6800 TERMINAL DEVICE, HOOK-APRL VC, OR EQUAL 508.28 2 2 PER 4 YEARSL6805 TERMINAL DEVICE, MODIFIER WRIST FLEXION

UNIT 156.17 2 2 PER 4 YEARS

L6807 TERMINAL DEVICE, HOOK, GRIP I, GRIP II, VC, OREQUAL

774.00 0 2 PER 2 YEARS

L6808 TERMINAL DEVICE, HOOK, TRS ADEPT, INFANTOR CHILD, VC, OR EQUAL

661.00 0 2 PER 2 YEARS

L6810 TERMINAL DEVICE, PINCHER TOOL, OTTO BOCKOR EQUAL

81.48 2 2 PER 4 YEARS

L6825 TERMINAL DEVICE, HAND, DORRANCE, VO 518.95 2 2 PER 4 YEARSL6830 TERMINAL DEVICE, HAND, APRL, VC 557.75 2 2 PER 4 YEARSL6835 TERMINAL DEVICE, HAND, SIERRA, VO 557.75 2 2 PER 4 YEARSL6840 TERMINAL DEVICE, HAND, BECKER IMPERIAL 468.51 2 2 PER 4 YEARSL6845 TERMINAL DEVICE, HAND, BECKER LOCK GRIP 421.95 2 2 PER 4 YEARSL6850 TERMINAL DEVICE, HAND, BECKER PLYLITE 194.00 2 2 PER 4 YEARSL6855 TERMINAL DEVICE, HAND, ROBIN-AIDS, VO 445.23 2 2 PER 4 YEARSL6860 TERMINAL DEVICE, HAND, ROBIN-AIDS, VO SOFT 360.84 2 2 PER 4 YEARSL6865 TERMINAL DEVICE, HAND, PASSIVE HAND 195.94 2 2 PER 4 YEARSL6867 TERMINAL DEVICE, HAND, DETROIT INFANT

HAND (MECHANICAL) 467.83 2 2 PER YEAR

L6868 TERMINAL DEVICE, HAND, PASSIVE INFANTHAND, (STEEPER, HOSMER OR EQUAL)

96.03 2 2 PER YEAR

L6870 TERMINAL DEVICE, HAND, CHILD MITT 118.34 2 2 PER 4 YEARSL6872 TERMINAL DEVICE, HAND, NYU CHILD HAND 492.76 2 2 PER YEARL6873 TERMINAL DEVICE, HAND, MECHANICAL INFANT

HAND, STEEPER OR EQUAL 143.56 2 2 PER YEAR

L6875 TERMINAL DEVICE, HAND, BOCK, VC 393.82 2 2 PER 4 YEARSL6880 TERMINAL DEVICE, HAND, BOCK, VO 217.28 2 2 PER 4 YEARSL6881 AUTOMATIC GRASP FEATURE, ADDITION TO

UPPER LIMB PROSTHETIC TERMINAL DEVICE 500.00 1 2 PER 2 YEARS

L6882 MICROPROCESSOR CONTROL FEATURE,ADDITION TO UPPER LIMB PROSTHETICTERMINAL DEVICE


L6890 TERMINAL DEVICE, GLOVE FOR ABOVE HANDS,PRODUCTION GLOVE

78.09 2 2 PER YEAR

L6900 HAND RESTORATION (CASTS, SHADING ANDMEASUREMENTS INCLUDED), PARTIAL HAND,WITH GLOVE, THUMB OR ONE FINGERREMAINING

526.71 2 2 PER 4 YEARS

L6905 HAND RESTORATION (CASTS, SHADING ANDMEASUREMENTS INCLUDED), PARTIAL HAND,WITH GLOVE, MULTIPLE FINGERS REMAINING

526.71 2 2 PER 4 YEARS

L6910 HAND RESTORATION (CASTS, SHADING ANDMEASUREMENTS INCLUDED), PARTIAL HAND,WITH GLOVE, NO FINGERS REMAINING

526.71 2 2 PER 4 YEARS

March 2003B - 58

CODE


DESCRIPTION MAX



L6915 HAND RESTORATION (SHADING, ANDMEASUREMENTS INCLUDED), REPLACEMENTGLOVE FOR ABOVE

276.45 2 2 PER 4 YEARS

L6920 WRIST DISARTICULATION, EXTERNAL POWER,SELF-SUSPENDED INNER SOCKET, REMOVABLEFOREARM SHELL, OTTO BOCK OR EQUAL,SWITCH, CABLES, TWO BATTERIES AND ONECHARGER, SWITCH CONTROL OF TERMINALDEVICE


L6925 WRIST DISARTICULATION, EXTERNAL POWER,SELF-SUSPENDED INNER SOCKET, REMOVABLEFOREARM SHELL, OTTO BOCK OR EQUALELECTRODES, CABLES, TWO BATTERIES ANDONE CHARGER, MYOELECTRONIC CONTROL OFTERMINAL DEVICE


L6930 BELOW ELBOW, EXTERNAL POWER,SELF-SUSPENDED INNER SOCKET, REMOVABLEFOREARM SHELL, OTTO BOCK OR EQUALSWITCH, CABLES, TWO BATTERIES AND ONECHARGER, SWITCH CONTROL OF TERMINALDEVICE


L6935 BELOW ELBOW, EXTERNAL POWER,SELF-SUSPENDED INNER SOCKET, REMOVABLEFOREARM SHELL, OTTO BOCK OR EQUALELECTRODES, CABLES, TWO BATTERIES ANDONE CHARGER, MYOELECTRONIC CONTROL OFTERMINAL DEVICE


L6940 ELBOW DISARTICULATION, EXTERNAL POWER,MOLDED INNER SOCKET, REMOVABLEHUMERAL SHELL, OUTSIDE LOCKING HINGES,FOREARM, OTTO BOCK OR EQUAL SWITCH,CABLES, TWO BATTERIES AND ONE CHARGER,SWITCH CONTROL OF TERMINAL DEVICE


L6945 ELBOW DISARTICULATION, EXTERNAL POWER,MOLDED INNER SOCKET, REMOVABLEHUMERAL SHELL, OUTSIDE LOCKING HINGES,FOREARM, OTTO BOCK OR EQUAL ELECTRODES,CABLES, TWO BATTERIES AND ONE CHARGER,MYOELECTRONIC CONTROL OF TERMINALDEVICE


L6950 ABOVE ELBOW, EXTERNAL POWER, MOLDEDINNER SOCKET, REMOVABLE HUMERAL SHELL,INTERNAL LOCKING ELBOW, FOREARM, OTTOBOCK OR EQUAL SWITCH, CABLES, TWOBATTERIES AND ONE CHARGER, SWITCHCONTROL OF TERMINAL DEVICE


L6955 ABOVE ELBOW, EXTERNAL POWER, MOLDEDINNER SOCKET, REMOVABLE HUMERAL SHELL,


March 2003B - 59

CODE


DESCRIPTION MAX



INTERNAL LOCKING ELBOW, FOREARM, OTTOBOCK OR EQUAL ELECTRODES, CABLES, TWOBATTERIES AND ONE CHARGER,MYOELECTRONIC CONTROL OF TERMINALDEVICE

L6960 SHOULDER DISARTICULATION, EXTERNALPOWER, MOLDED INNER SOCKET, REMOVABLESHOULDER SHELL, SHOULDER BULKHEAD,HUMERAL SECTION, MECHANICAL ELBOW,FOREARM, OTTO BOCK OR EQUAL SWITCH,CABLES, TWO BATTERIES AND ONE CHARGER,SWITCH CONTROL OF TERM


L6965 SHOULDER DISARTICULATION, EXTERNALPOWER, MOLDED INNER SOCKET, REMOVABLESHOULDER SHELL, SHOULDER BULKHEAD,HUMERAL SECTION, MECHANICAL ELBOW,FOREARM, OTTO BOCK OR EQUAL ELECTRODES,CABLES, TWO BATTERIES AND ONE CHARGER,MYOELECTRONIC CONT


L6970 INTERSCAPULAR-THORACIC, EXTERNAL POWER,MOLDED INNER SOCKET, REMOVABLESHOULDER SHELL, SHOULDER BULKHEAD,HUMERAL SECTION, MECHANICAL ELBOW,FOREARM, OTTO BOCK OR EQUAL SWITCH,CABLES, TWO BATTERIES AND ONE CHARGER,SWITCH CONTROL OF TERMIN


L6975 INTERSCAPULAR-THORACIC, EXTERNAL POWER,MOLDED INNER SOCKET, REMOVABLESHOULDER SHELL, SHOULDER BULKHEAD,HUMERAL SECTION, MECHANICAL ELBOW,FOREARM, OTTO BOCK OR EQUAL ELECTRODES,CABLES, TWO BATTERIES AND ONE CHARGER,MYOELECTRONIC CONTRO


L7010 ELECTRONIC HAND, OTTO BOCK, STEEPER OREQUAL, SWITCH CONTROLLED


L7015 ELECTRONIC HAND, SYSTEM TEKNIK, VARIETYVILLAGE OR EQUAL, SWITCH CONTROLLED


L7020 ELECTRONIC GREIFER, OTTO BOCK OR EQUAL,SWITCH CONTROLLED


L7025 ELECTRONIC HAND, OTTO BOCK OR EQUAL,MYOELECTRONICALLY CONTROLLED


L7030 ELECTRONIC HAND, SYSTEM TEKNIK, VARIETYVILLAGE OR EQUAL, MYOELECTRONICALLYCONTROLLED


L7035 ELECTRONIC GREIFER, OTTO BOCK OR EQUAL,MYOELECTRONICALLY CONTROLLED


L7040 PREHENSILE ACTUATOR, HOSMER OR EQUAL,SWITCH CONTROLLED


March 2003B - 60

CODE


DESCRIPTION MAX



L7045 ELECTRONIC HOOK, CHILD, MICHIGAN OREQUAL, SWITCH CONTROLLED


L7170 ELECTRONIC ELBOW, HOSMER OR EQUAL,SWITCH CONTROLLED


L7185 ELECTRONIC ELBOW, ADOLESCENT, VARIETYVILLAGE OR EQUAL, SWITCH CONTROLLED


L7186 ELECTRONIC ELBOW, CHILD, VARIETY VILLAGEOR EQUAL, SWITCH CONTROLLED


L7260 ELECTRONIC WRIST ROTATOR, OTTO BOCK OREQUAL


L7261 ELECTRONIC WRIST ROTATOR, FOR UTAH ARM 594.61 2 2 PER LIFETIMEL7266 SERVO CONTROL, STEEPER OR EQUAL 788.61 2 2 PER LIFETIMEL7272 ANALOGUE CONTROL, UNB OR EQUAL 788.61 2 2 PER LIFETIMEL7274 PROPORTIONAL CONTROL, 6-12 VOLT, LIBERTY,

UTAH OR EQUAL 2,145.64 2 2 PER LIFETIME

L7360 SIX VOLT BATTERY, OTTO BOCK OR EQUAL,EACH

79.54 2 2 PER 3 YEARS

L7362 BATTERY CHARGER, SIX VOLT, OTTO BOCK OREQUAL


L7364 TWELVE VOLT BATTERY, UTAH OR EQUAL,EACH

121.25 2 2 PER 3 YEARS

L7366 BATTERY CHARGER, TWELVE VOLT, UTAH OREQUAL

249.29 1 1 PER 3 YEARS

L7499 UPPER EXTREMITY PROSTHESIS, NOTOTHERWISE SPECIFIED


L7500 REPAIR OF PROSTHETIC DEVICE, HOURLY RATE(EXCLUDES V5335 REPAIR OF ORAL ORLARYNGEAL PROSTHESIS OR ARTIFICIALLARYNX)

38.80 4 LIMITED TO $160PER YEAR

L7510 REPAIR OF PROSTHETIC DEVICE, REPAIR ORREPLACE MINOR PARTS

0.00 BR 0 LIMITED TO $160PER YEAR

L7520 REPAIR PROSTHETIC DEVICE, LABORCOMPONENT, PER 15 MINUTES

0.00 BR 0

L8000 BREAST PROSTHESIS, MASTECTOMY BRA 26.13 3 3 PER YEARL8001 BREAST PROSTHESIS, MASTECTOMY BRA, WITH

INTEGRATED BREAST PROSTHESIS FORM,UNILATERAL

125.00 2 2 PER 2 YEARS

L8002 BREAST PROSTHESIS, MASTECTOMY BRA, WITHINTEGRATED BREAST PROSTHESIS FORM,BILATERAL

165.00 1 2 PER 2 YEARS

L8010 BREAST PROSTHESIS, MASTECTOMY SLEEVE 37.15 6 6 PER YEARL8015 EXTERNAL BREAST PROSTHESIS GARMENT,

WITH MASTECTOMY FORM, POST MASTECTOMY 34.42 2 2 PER 4 YEARS

L8020 BREAST PROSTHESIS, MASTECTOMY FORM 135.42 2 2 PER YEARL8030 BREAST PROSTHESIS, SILICONE OR EQUAL 146.47 2 2 PER 2 YEARSL8100 GRADIENT COMPRESSION STOCKING, BELOW

KNEE, 18-30 MMHG, EACH 31.04 2 8 PER YEAR

March 2003B - 61

CODE


DESCRIPTION MAX



L8110 GRADIENT COMPRESSION STOCKING, BELOWKNEE, 30-40 MMHG, EACH

31.04 2 8 PER YEAR

L8120 GRADIENT COMPRESSION STOCKING, BELOWKNEE, 40-50 MMHG, EACH

31.04 2 8 PER YEAR

L8130 GRADIENT COMPRESSION STOCKING, THIGHLENGTH, 18-30 MMHG, EACH

40.74 2 8 PER YEAR


40.74 2 8 PER YEAR


40.74 2 8 PER YEAR

L8160 GRADIENT COMPRESSION STOCKING, FULLLENGTH/CHAP STYLE, 18-30 MMHG, EACH

111.55 2 8 PER YEAR


111.55 2 8 PER YEAR


111.55 2 8 PER YEAR

L8190 GRADIENT COMPRESSION STOCKING, WAISTLENGTH, 18-30 MMHG, EACH

111.55 2 8 PER YEAR


111.55 2 8 PER YEAR


111.55 2 8 PER YEAR

L8300 TRUSS, SINGLE WITH STANDARD PAD 63.05 1 2 PER YEARL8310 TRUSS, DOUBLE WITH STANDARD PADS 169.75 1 2 PER YEARL8400 PROSTHETIC SHEATH, BELOW KNEE, EACH 5.82 6 72 PER YEARL8410 PROSTHETIC SHEATH, ABOVE KNEE, EACH 5.82 6 72 PER YEARL8415 PROSTHETIC SHEATH, UPPER LIMB, EACH 8.73 6 72 PER YEARL8417 PROSTHETIC SHEATH/SOCK, INCLUDING A GEL

CUSHION LAYER, BELOW KNEE OR ABOVE KNEE,EACH

44.50 2 6 PER YEAR

L8420 PROSTHETIC SOCK, MULTIPLE PLY, BELOWKNEE, EACH

12.61 6 72 PER YEAR

L8430 PROSTHETIC SOCK, MULTIPLE PLY, ABOVEKNEE, EACH

13.58 6 72 PER YEAR

L8435 PROSTHETIC SOCK, MULTIPLE PLY, UPPER LIMB,EACH

12.61 6 72 PER YEAR

L8440 PROSTHETIC SHRINKER, BELOW KNEE, EACH 29.10 2 4 PER YEARL8460 PROSTHETIC SHRINKER, ABOVE KNEE, EACH 43.17 2 4 PER YEARL8465 PROSTHETIC SHRINKER, UPPER LIMB, EACH 35.41 2 4 PER YEARL8470 PROSTHETIC SOCK, SINGLE PLY, FITTING, BELOW

KNEE, EACH 1.94 6 72 PER YEAR

L8480 PROSTHETIC SOCK, SINGLE PLY, FITTING, ABOVEKNEE, EACH

2.43 6 72 PER YEAR

L8485 PROSTHETIC SOCK, SINGLE PLY, FITTING, UPPERLIMB, EACH

6.60 2 72 PER YEAR

L8490 ADDITION TO PROSTHETIC SHEATH/SOCK, AIRSEAL SUCTION RETENTION SYSTEM

78.92 2 6 PER YEAR

March 2003B - 62

CODE


DESCRIPTION MAX



L8499 UNLISTED PROCEDURE FOR MISCELLANEOUSPROSTHETIC SERVICES


L8500 ARTIFICIAL LARYNX, ANY TYPE 392.00 1 1 PER LIFETIMEL8501 TRACHEOSTOMY SPEAKING VALVE 116.40 1 6 PER YEARL8507 TRACHEO-ESOPHAGEAL VOICE PROSTHESIS,

PATIENT INSERTED, ANY TYPE, EACH 116.40 1 1 PER 5 YEARS

March 2003B - 63

CODE


DESCRIPTION MAX



V2623 PROSTHETIC EYE, PLASTIC, CUSTOM 567.45 2 MEDICALNECESSITY

V2624 POLISHING/RESURFACING OF OCULARPROSTHESIS

38.80 2 1 PER YEAR

V2625 ENLARGEMENT OF OCULAR PROSTHESIS 242.50 2 1 PER PROSTHESISV2626 REDUCTION OF OCULAR PROSTHESIS 155.20 2 1 PER PROSTHESISV2627 SCLERAL COVER SHELL 902.10 2 MEDICAL

NECESSITYV2628 FABRICATION AND FITTING OF OCULAR

CONFORMER 208.55 2 MEDICAL

NECESSITYV5336 REPAIR/MODIFICATION OF AUGMENTATIVE

COMMUNICATIVE SYSTEM OR DEVICE(EXCLUDES ADAPTIVE HEARING AID)


March 2003B - 64

CODE


DESCRIPTION MAX



W4097 EXTENSION TUBING FOR CONNECTINGAPPLIANC

3.88 31 366 PER YEAR

W4098 ADAPTER OR CONNECTOR FOR TUBING 2.43 31 366 PER YEARW9763 RESUSCITATOR BAG, SELF-INFLATING: HAND

HELD; NON- DISPOSABLE PEDIATRIC OR 112.52 1 1 PER 2 YEARS

W9765 NEBULIZER KIT FOR ADMINISTRATION OFAEROSOLIZED MEDICATION, INCLUDES HAND

3.88 3 36 PER YEAR

W9766 SUCTION MACHINE W/VACUUM REGULATOR;BATTERY OPERATED; INCLUDES RECHARGABLE

363.75 1 1 PER 2 YEARS

W9776 AUGMENTATIVE COMMUNICATION DEVICE,RENTAL


March 2003B - 65

CODE


DESCRIPTION MAX

APPENDIX CONLY FOR RECIPIENTS UNDER AGE 21


A4246 BETADINE OR PHISOHEX SOLUTION, PER PINT 4.85 3 36 PER YEARA4247 BETADINE OR IODINE SWABS/WIPES, PER BOX 7.28 2 24 PER YEARA4255 PLATFORMS FOR HOME BLOOD GLUCOSE

MONITOR, 50 PER BOX 2.99 1 2 PER MONTH

A4256 NORMAL, LOW AND HIGH CALIBRATORSOLUTION / CHIPS

8.06 1 4 PER YEAR

A4265 PARAFFIN, PER POUND 3.88 6 24 PER YEARA4310 INSERTION TRAY WITHOUT DRAINAGE BAG AND

WITHOUT CATHETER (ACCESSORIES ONLY) 4.03 2 24 PER YEAR

A4314 INSERTION TRAY WITH DRAINAGE BAG WITHINDWELLING CATHETER, FOLEY TYPE,TWO-WAY LATEX WITH COATING (TEFLON,SILICONE, SILICONE ELASTOMER ORHYDROPHILIC, ETC.)

10.67 2 24 PER YEAR

A4315 INSERTION TRAY WITH DRAINAGE BAG WITHINDWELLING CATHETER, FOLEY TYPE,TWO-WAY, ALL SILICONE

10.67 2 24 PER YEAR

A4316 INSERTION TRAY WITH DRAINAGE BAG WITHINDWELLING CATHETER, FOLEY TYPE,THREE-WAY, FOR CONTINUOUS IRRIGATION

10.67 2 24 PER YEAR

A4320 IRRIGATION TRAY WITH BULB OR PISTONSYRINGE, ANY PURPOSE

4.90 31 366 PER YEAR

A4322 IRRIGATION SYRINGE, BULB OR PISTON, EACH 2.15 31 366 PER YEARA4326 MALE EXTERNAL CATHETER SPECIALTY TYPE,

EG; INFLATABLE, FACEPLATE, ETC., EACH 8.34 31 366 PER YEAR

A4327 FEMALE EXTERNAL URINARY COLLECTIONDEVICE; MEATAL CUP, EACH

16.10 1 1 PER YEAR

A4328 FEMALE EXTERNAL URINARY COLLECTIONDEVICE; POUCH, EACH

5.00 2 24 PER YEAR

A4330 PERIANAL FECAL COLLECTION POUCH WITHADHESIVE, EACH

5.19 31 366 PER YEAR

A4335 INCONTINENCE SUPPLY; MISCELLANEOUS 19.40 1 12 PER YEARA4338 INDWELLING CATHETER; FOLEY TYPE,

TWO-WAY LATEX WITH COATING (TEFLON,SILICONE, SILICONE ELASTOMER, ORHYDROPHILIC, ETC.), EACH

6.16 3 36 PER YEAR

A4340 INDWELLING CATHETER; SPECIALTY TYPE, EG;COUDE, MUSHROOM, WING, ETC.), EACH

6.69 3 36 PER YEAR

A4344 INDWELLING CATHETER, FOLEY TYPE,TWO-WAY, ALL SILICONE, EACH

5.34 3 36 PER YEAR

A4346 INDWELLING CATHETER; FOLEY TYPE, THREEWAY FOR CONTINUOUS IRRIGATION, EACH

8.73 3 36 PER YEAR

A4354 INSERTION TRAY WITH DRAINAGE BAG BUTWITHOUT CATHETER

3.88 3 36 PER YEAR

A4355 IRRIGATION TUBING SET FOR CONTINUOUSBLADDER IRRIGATION THROUGH A THREE-WAYINDWELLING FOLEY CATHETER, EACH

2.52 4 48 PER YEAR

March 2003C - 1

CODE


DESCRIPTION MAX



A4356 EXTERNAL URETHRAL CLAMP OR COMPRESSIONDEVICE (NOT TO BE USED FOR CATHETERCLAMP), EACH

34.92 1 1 PER YEAR

A4359 URINARY SUSPENSORY WITHOUT LEG BAG,EACH

7.76 1 2 PER YEAR

A4397 IRRIGATION SUPPLY; SLEEVE, EACH 3.94 10 120 PER YEARA4398 OSTOMY IRRIGATION SUPPLY; BAG, EACH 23.28 2 24 PER YEARA4399 OSTOMY IRRIGATION SUPPLY; CONE/CATHETER,

INCLUDING BRUSH 5.82 1 2 PER YEAR

A4402 LUBRICANT, PER OUNCE 1.35 4 48 PER YEARA4404 OSTOMY RING, EACH 1.29 31 366 PER YEARA4481 TRACHEOSTOMA FILTER, ANY TYPE, ANY SIZE,

EACH 0.28 31 31 PER MONTH

A4554 DISPOSABLE UNDERPADS, ALL SIZES, (E.G.,CHUX'S)

0.34 150 1800 PER YEAR

A4565 SLINGS 5.34 1 1 PER MEDICALEVENT

A4570 SPLINT 10.67 1 1 PER MEDICALEVENT

A4631 REPLACEMENT, BATTERIES FOR MEDICALLYNECESSARY ELECTRONIC WHEEL CHAIR OWNEDBY PATIENT

83.91 2 2 PER YEAR

A4640 REPLACEMENT PAD FOR USE WITH MEDICALLYNECESSARY ALTERNATING PRESSURE PADOWNED BY PATIENT

33.95 1 1 PER YEAR

A4649 SURGICAL SUPPLY; MISCELLANEOUS 0.00 BR 1 MEDICALNECESSITY

A4927 GLOVES, NON-STERILE, PER 100 0.34 100 1000 PER YEARA4930 GLOVES, STERILE, PER PAIR 0.34 100 1200 PER YEARA4930 GLOVES, STERILE, PER PAIR 0.34 100 1200 PER YEARA5102 BEDSIDE DRAINAGE BOTTLE WITH OR WITHOUT

TUBING, RIGID OR EXPANDABLE, EACH 6.69 1 2 PER YEAR

A5105 URINARY SUSPENSORY; WITH LEG BAG, WITHOR WITHOUT TUBE

14.40 1 2 PER YEAR

A5113 LEG STRAP; LATEX, REPLACEMENT ONLY, PERSET

4.48 1 4 PER YEAR

A5114 LEG STRAP; FOAM OR FABRIC, REPLACEMENTONLY, PER SET

5.53 1 4 PER YEAR

A5126 ADHESIVE OR NON-ADHESIVE; DISK OR FOAMPAD

0.63 20 240 PER YEAR

A5200 PERCUTANEOUS CATHETER/TUBE ANCHORINGDEVICE, ADHESIVE SKIN ATTACHMENT

8.62 3 3 PER MONTH

A6154 WOUND POUCH, EACH 10.64 15 15 PER MONTHA6196 ALGINATE OR OTHER FIBER GELLING DRESSING,

WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS,EACH DRESSING


A6197 ALGINATE OR OTHER FIBER GELLING DRESSING, 12.50 31 31 PER MONTH

March 2003C - 2

CODE


DESCRIPTION MAX



WOUND COVER, PAD SIZE MORE THAN 16 SQ. IN.BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACHDRESSING

A6199 ALGINATE OR OTHER FIBER GELLING DRESSING,WOUND FILLER, PER 6 INCHES


A6200 COMPOSITE DRESSING, PAD SIZE 16 SQ. IN. ORLESS, WITHOUT ADHESIVE BORDER, EACHDRESSING


A6201 COMPOSITE DRESSING, PAD SIZE MORE THAN 16SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN.,WITHOUT ADHESIVE BORDER, EACH DRESSING

15.87 31 31 PER MONTH

A6202 COMPOSITE DRESSING, PAD SIZE MORE THAN 48SQ. IN., WITHOUT ADHESIVE BORDER, EACHDRESSING

26.62 31 31 PER MONTH

A6203 COMPOSITE DRESSING, PAD SIZE 16 SQ. IN. ORLESS, WITH ANY SIZE ADHESIVE BORDER, EACHDRESSING


A6204 COMPOSITE DRESSING, PAD SIZE MORE THAN 16SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN.,WITH ANY SIZE ADHESIVE BORDER, EACHDRESSING


A6207 CONTACT LAYER, MORE THAN 16 SQ. IN. BUTLESS THAN OR EQUAL TO 48 SQ. IN., EACHDRESSING


A6209 FOAM DRESSING, WOUND COVER, PAD SIZE 16SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER,EACH DRESSING


A6210 FOAM DRESSING, WOUND COVER, PAD SIZEMORE THAN 16 SQ. IN. BUT LESS THAN OREQUAL TO 48 SQ. IN., WITHOUT ADHESIVEBORDER, EACH DRESSING

15.20 31 31 PER MONTH

A6211 FOAM DRESSING, WOUND COVER, PAD SIZEMORE THAN 48 SQ. IN., WITHOUT ADHESIVEBORDER, EACH DRESSING

22.40 31 31 PER MONTH

A6212 FOAM DRESSING, WOUND COVER, PAD SIZE 16SQ. IN. OR LESS, WITH ANY SIZE ADHESIVEBORDER, EACH DRESSING


A6214 FOAM DRESSING, WOUND COVER, PAD SIZEMORE THAN 48 SQ. IN., WITH ANY SIZEADHESIVE BORDER, EACH DRESSING


A6216 GAUZE, NON-IMPREGNATED, NON-STERILE, PADSIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVEBORDER, EACH DRESSING

0.04 200 200 PER MONTH

A6219 GAUZE, NON-IMPREGNATED, PAD SIZE 16 SQ. IN.OR LESS, WITH ANY SIZE ADHESIVE BORDER,EACH DRESSING


A6220 GAUZE, NON-IMPREGNATED, PAD SIZE MORETHAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48


March 2003C - 3

CODE


DESCRIPTION MAX



SQ. IN., WITH ANY SIZE ADHESIVE BORDER,EACH DRESSING

A6222 GAUZE, IMPREGNATED WITH OTHER THANWATER, NORMAL SALINE, OR HYDROGEL, PADSIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVEBORDER, EACH DRESSING

1.63 200 31 PER MONTH

A6223 GAUZE, IMPREGNATED WITH OTHER THANWATER, NORMAL SALINE, OR HYDROGEL, PADSIZE MORE THAN 16 SQUARE INCHES, BUT LESSTHAN OR EQUAL TO 48 SQUARE INCHES,WITHOUT ADHESIVE BORDER, EACH DRESSING

1.84 200 31 PER MONTH

A6224 GAUZE, IMPREGNATED WITH OTHER THANWATER, NORMAL SALINE, OR HYDROGEL, PADSIZE MORE THAN 48 SQUARE INCHES, WITHOUTADHESIVE BORDER, EACH DRESSING


A6229 GAUZE, IMPREGNATED, WATER OR NORMALSALINE, PAD SIZE MORE THAT 16 SQ. IN. BUTLESS THAN OR EQUAL TO 48 SQ. IN., WITHOUTADHESIVE BORDER, EACH DRESSING


A6234 HYDROCOLLOID DRESSING, WOUND COVER, PADSIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVEBORDER, EACH DRESSING


A6235 HYDROCOLLOID DRESSING, WOUND COVER, PADSIZE MORE THAN 16 SQ. IN. BUT LESS THAN OREQUAL TO 48 SQ. IN., WITHOUT ADHESIVEBORDER, EACH DRESSING

12.84 31 31 PER MONTH

A6236 HYDROCOLLOID DRESSING, WOUND COVER, PADSIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVEBORDER, EACH DRESSING

20.80 31 31 PER MONTH

A6237 HYDROCOLLOID DRESSING, WOUND COVER, PADSIZE 16 SQ. IN. OR LESS, WITH ANY SIZEADHESIVE BORDER, EACH DRESSING


A6238 HYDROCOLLOID DRESSING, WOUND COVER, PADSIZE MORE THAN 16 SQ. IN. BUT LESS THAN OREQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVEBORDER, EACH DRESSING

17.40 31 31 PER MONTH

A6240 HYDROCOLLOID DRESSING, WOUND FILLER,PASTE, PER FLUID OUNCE


A6241 HYDROCOLLOID DRESSING, WOUND FILLER,DRY FORM, PER GRAM


A6242 HYDROGEL DRESSING, WOUND COVER, PAD SIZE16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER,EACH DRESSING


A6243 HYDROGEL DRESSING, WOUND COVER, PAD SIZEMORE THAN 16 SQ. IN. BUT LESS THAN OREQUAL TO 48 SQ. IN., WITHOUT ADHESIVEBORDER, EACH DRESSING


A6244 HYDROGEL DRESSING, WOUND COVER, PAD SIZE 29.95 31 31 PER MONTH

March 2003C - 4

CODE


DESCRIPTION MAX



MORE THAN 48 SQ. IN., WITHOUT ADHESIVEBORDER, EACH DRESSING

A6245 HYDROGEL DRESSING, WOUND COVER, PAD SIZE16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVEBORDER, EACH DRESSING


A6246 HYDROGEL DRESSING, WOUND COVER, PAD SIZEMORE THAN 16 SQ. IN. BUT LESS THAN OREQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVEBORDER, EACH DRESSING


A6247 HYDROGEL DRESSING, WOUND COVER, PAD SIZEMORE THAN 48 SQ. IN., WITH ANY SIZEADHESIVE BORDER, EACH DRESSING

18.15 31 31 PER MONTH

A6248 HYDROGEL DRESSING, WOUND FILLER, GEL, PERFLUID OUNCE

12.40 15 15 PER MONTH

A6251 SPECIALTY ABSORPTIVE DRESSING, WOUNDCOVER, PAD SIZE 16 SQ. IN. OR LESS, WITHOUTADHESIVE BORDER, EACH DRESSING


A6252 SPECIALTY ABSORPTIVE DRESSING, WOUNDCOVER, PAD SIZE MORE THAN 16 SQ. IN. BUTLESS THAN OR EQUAL TO 48 SQ. IN., WITHOUTADHESIVE BORDER, EACH DRESSING


A6253 SPECIALTY ABSORPTIVE DRESSING, WOUNDCOVER, PAD SIZE MORE THAN 48 SQ. IN.,WITHOUT ADHESIVE BORDER, EACH DRESSING


A6254 SPECIALTY ABSORPTIVE DRESSING, WOUNDCOVER, PAD SIZE 16 SQ. IN. OR LESS, WITH ANYSIZE ADHESIVE BORDER, EACH DRESSING


A6255 SPECIALTY ABSORPTIVE DRESSING, WOUNDCOVER, PAD SIZE MORE THAN 16 SQ. IN. BUTLESS THAN OR EQUAL TO 48 SQ. IN., WITH ANYSIZE ADHESIVE BORDER, EACH DRESSING


A6258 TRANSPARENT FILM, MORE THAN 16 SQ. IN. BUTLESS THAN OR EQUAL TO 48 SQ. IN., EACHDRESSING


A6259 TRANSPARENT FILM, MORE THAN 48 SQ. IN.,EACH DRESSING


A6266 GAUZE, IMPREGNATED, OTHER THAN WATER,NORMAL SALINE, OR ZINC PASTE, ANY WIDTH,PER LINEAR YARD


A6402 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER,EACH DRESSING

0.10 200 200 PER MONTH

A6403 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZEMORE THAN 16 SQ. IN. LESS THAN OR EQUAL TO48 SQ. IN., WITHOUT ADHESIVE BORDER, EACHDRESSING

0.33 200 200 PER MONTH

March 2003C - 5

CODE


DESCRIPTION MAX



B4034 ENTERAL FEEDING SUPPLY KIT; SYRINGE, PERDAY

145.50 1 12 PER YEAR

B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED, PERDAY

266.75 1 12 PER YEAR

B4036 ENTERAL FEEDING SUPPLY KIT; GRAVITY FED,PER DAY

189.15 1 12 PER YEAR

B4081 NASOGASTRIC TUBING WITH STYLET 14.55 8 96 PER YEARB4082 NASOGASTRIC TUBING WITHOUT STYLET 11.64 8 96 PER YEARB4083 STOMACH TUBE - LEVINE TYPE 1.46 15 180 PER YEARB4086 GASTROSTOMY / JEJUNOSTOMY TUBE, ANY

MATERIAL, ANY TYPE, (STANDARD OR LOWPROFILE), EACH

14.55 4 48 PER YEAR

B9000 ENTERAL NUTRITION INFUSION PUMP -WITHOUT ALARM


B9002 ENTERAL NUTRITION INFUSION PUMP - WITHALARM


B9998 NOC FOR ENTERAL SUPPLIES 6.79 1 120 PER YEAR

March 2003C - 6

CODE


DESCRIPTION MAX



E0110 CRUTCHES, FOREARM, INCLUDES CRUTCHES OFVARIOUS MATERIALS, ADJUSTABLE OR FIXED,PAIR, COMPLETE WITH TIPS AND HANDGRIPS

38.80 1 1 PER 2 YEARS

E0111 CRUTCH FOREARM, INCLUDES CRUTCHES OFVARIOUS MATERIALS, ADJUSTABLE OR FIXED,EACH, WITH TIP AND HANDGRIPS

19.40 1 1 PER 2 YEARS

E0130 WALKER, RIGID (PICKUP), ADJUSTABLE ORFIXED HEIGHT

53.35 1 1 PER 3 YEARS

E0141 RIGID WALKER, WHEELED, WITHOUT SEAT 81.48 1 1 PER 3 YEARSE0142 RIGID WALKER, WHEELED, WITH SEAT 81.48 1 1 PER 3 YEARSE0145 WALKER, WHEELED, WITH SEAT AND CRUTCH

ATTACHMENTS 257.10 1 25.71 1 PER 3 YEARS

E0146 FOLDING WALKER, WHEELED, WITH SEAT 81.48 1 1 PER 3 YEARSE0147 HEAVY DUTY, MULTIPLE BREAKING SYSTEM,

VARIABLE WHEEL RESISTANCE WALKER 439.93 1 1 PER 3 YEARS

E0153 PLATFORM ATTACHMENT, FOREARM CRUTCH,EACH

34.44 2 2 PER 3 YEARS

E0154 PLATFORM ATTACHMENT, WALKER, EACH 40.26 2 2 PER 3 YEARSE0155 WHEEL ATTACHMENT, RIGID PICK-UP WALKER,

PER PAIR 27.71 1 1 PER 3 YEARS

E0157 CRUTCH ATTACHMENT, WALKER, EACH 39.77 1 1 PER 3 YEARSE0158 LEG EXTENSIONS FOR WALKER, PER SET OF

FOUR (4) 16.98 4 4 PER 3 YEARS

E0159 BRAKE ATTACHMENT FOR WHEELED WALKER,REPLACEMENT, EACH

13.64 1 2 PER 2 YEARS

E0160 SITZ TYPE BATH OR EQUIPMENT, PORTABLE,USED WITH OR WITHOUT COMMODE


E0165 COMMODE CHAIR, STATIONARY, WITHDETACHABLE ARMS

72.27 1 1 PER 3 YEARS

E0167 PAIL OR PAN FOR USE WITH COMMODE CHAIR 7.28 1 1 PER YEARE0181 PRESSURE PAD, ALTERNATING WITH PUMP,

HEAVY DUTY 150.40 1 15.04 1 PER 3 YEARS

E0184 DRY PRESSURE MATTRESS 276.50 1 27.65 1 PER 3 YEARSE0186 AIR PRESSURE MATTRESS 184.30 1 1 PER 3 YEARSE0187 WATER PRESSURE MATTRESS 184.30 1 1 PER 3 YEARSE0189 LAMBSWOOL SHEEPSKIN PAD, ANY SIZE 77.60 1 1 PER 2 YEARSE0191 HEEL OR ELBOW PROTECTOR, EACH 6.79 2 4 PER YEARE0196 GEL PRESSURE MATTRESS 184.30 1 1 PER 3 YEARSE0202 PHOTOTHERAPY (BILIRUBIN) LIGHT WITH

PHOTOMETER 0.00 5RO 42.68 1 PER MEDICAL

EVENTE0205 HEAT LAMP, WITH STAND, INCLUDES BULB, OR

INFRARED ELEMENT 38.80 1 1 PER LIFETIME

E0215 ELECTRIC HEAT PAD, MOIST 16.49 1 1 PER LIFETIMEE0217 WATER CIRCULATING HEAT PAD WITH PUMP 322.02 1 1 PER 5 YEARSE0235 PARAFFIN BATH UNIT, PORTABLE (SEE MEDICAL

SUPPLY CODE A4265 FOR PARAFFIN) 116.40 1 11.64 1 PER 8 YEARS

E0249 PAD FOR WATER CIRCULATING HEAT UNIT 25.71 1 1 PER YEAR

March 2003C - 7

CODE


DESCRIPTION MAX



E0260 HOSPITAL BED, SEMI-ELECTRIC (HEAD ANDFOOT ADJUSTMENT), WITH ANY TYPE SIDERAILS, WITH MATTRESS

1,071.85 1 1 PER 8 YEARS

E0265 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOTAND HEIGHT ADJUSTMENTS), WITH ANY TYPESIDE RAILS, WITH MATTRESS

1,343.45 1 1 PER 8 YEARS

E0305 BED SIDE RAILS, HALF LENGTH 105.73 1 1 PER 8 YEARSE0310 BED SIDE RAILS, FULL LENGTH 105.73 1 1 PER 8 YEARSE0315 BED ACCESSORY: BOARD, TABLE, OR SUPPORT

DEVICE, ANY TYPE 82.45 1 1 PER 8 YEARS

E0370 AIR PRESSURE ELEVATOR FOR HEEL 19.92 1 2 PER 2 YEARSE0609 BLOOD GLUCOSE MONITOR WITH SPECIAL

FEATURES (EG., VOICE SYNTHESIZERSAUTOMATIC TIMERS, ETC.)

194.00 1 1 PER 2 YEARS

E0618 APNEA MONITOR, WITHOUT RECORDINGFEATURE

0.00 1 MEDICALNECESSITY

E0621 SLING OR SEAT, PATIENT LIFT, CANVAS ORNYLON

58.20 1 1 PER 4 YEARS

E0630 PATIENT LIFT, HYDRAULIC, WITH SEAT OR SLING 664.50 1 66.45 1 PER 8 YEARSE0635 PATIENT LIFT, ELECTRIC WITH SEAT OR SLING 664.50 1 66.45 1 PER 8 YEARSE0650 PNEUMATIC COMPRESSOR, NON-SEGMENTAL

HOME MODEL 485.00 1 48.50 1 PER 8 YEARS

E0651 PNEUMATIC COMPRESSOR, SEGMENTAL HOMEMODEL WITHOUT CALIBRATED GRADIENTPRESSURE

941.90 1 94.19 1 PER 8 YEARS

E0652 PNEUMATIC COMPRESSOR, SEGMENTAL HOMEMODEL WITH CALIBRATED GRADIENT PRESSURE

3,689.90 1368.99 1 PER 8 YEARS

E0655 NON-SEGMENTAL PNEUMATIC APPLIANCE FORUSE WITH PNEUMATIC COMPRESSOR, HALF ARM

73.72 1 2 PER YEAR

E0660 NON-SEGMENTAL PNEUMATIC APPLIANCE FORUSE WITH PNEUMATIC COMPRESSOR, FULL LEG

67.90 1 2 PER YEAR

E0665 NON-SEGMENTAL PNEUMATIC APPLIANCE FORUSE WITH PNEUMATIC COMPRESSOR, FULL ARM

67.90 1 2 PER YEAR

E0666 NON-SEGMENTAL PNEUMATIC APPLIANCE FORUSE WITH PNEUMATIC COMPRESSOR, HALF LEG

101.37 1 2 PER YEAR

E0667 SEGMENTAL PNEUMATIC APPLIANCE FOR USEWITH PNEUMATIC COMPRESSOR, FULL LEG

395.76 1 2 PER YEAR

E0668 SEGMENTAL PNEUMATIC APPLIANCE FOR USEWITH PNEUMATIC COMPRESSOR, FULL ARM

395.76 1 2 PER YEAR

E0744 NEUROMUSCULAR STIMULATOR FOR SCOLIOSIS 810.00 1 81.00 MEDICALNECESSITY

E0745 NEUROMUSCULAR STIMULATOR, ELECTRONICSHOCK UNIT

717.80 1 71.78 MEDICALNECESSITY

E0776 IV POLE 106.70 1 10.67 1 PER 8 YEARSE0779 AMBULATORY INFUSION PUMP, MECHANICAL,

REUSABLE, FOR INFUSION 8 HOURS OR GREATER 0.00 0RO 11.74 MEDICAL

NECESSITYE0780 AMBULATORY INFUSION PUMP, MECHANICAL, 0.00 1RO 7.91 MEDICAL

March 2003C - 8

CODE


DESCRIPTION MAX



REUSABLE, FOR INFUSION LESS THAN 8 HOURS NECESSITYE0781 AMBULATORY INFUSION PUMP, SINGLE OR

MULTIPLE CHANNELS, ELECTRIC OR BATTERYOPERATED, WITH ADMINISTRATIVE EQUIPMENT,WORN BY PATIENT


E0791 PARENTERAL INFUSION PUMP, STATIONARY,SINGLE OR MULTI-CHANNEL


E0840 TRACTION FRAME, ATTACHED TO HEADBOARD,CERVICAL TRACTION


E0850 TRACTION STAND, FREE STANDING, CERVICALTRACTION


E0860 TRACTION EQUIPMENT, OVERDOOR, CERVICAL 24.74 1 1 PER LIFETIMEE0870 TRACTION FRAME, ATTACHED TO FOOTBOARD,

EXTREMITY TRACTION, (E.G. BUCK'S) 63.05 1 1 PER LIFETIME

E0880 TRACTION STAND, FREE STANDING, EXTREMITYTRACTION, (E.G., BUCK'S)


E0890 TRACTION FRAME, ATTACHED TO FOOTBOARD,PELVIC TRACTION


E0900 TRACTION STAND, FREE STANDING, PELVICTRACTION, (E.G., BUCK'S)


E0920 FRACTURE FRAME, ATTACHED TO BED,INCLUDES WEIGHTS

354.10 1 35.41 1 PER LIFETIME

E0930 FRACTURE FRAME, FREE STANDING, INCLUDESWEIGHTS

354.10 1 35.41 1 PER LIFETIME

E0935 PASSIVE MOTION EXERCISE DEVICE 0.00 0RO 13.57 10 DAYS PERMED.EVENT

E0942 CERVICAL HEAD HARNESS/HALTER 15.52 1 1 PER MEDICALEVENT

E0943 CERVICAL PILLOW 26.39 1 1 PER MEDICALEVENT

E0944 PELVIC BELT/HARNESS/BOOT 12.13 1 1 PER MEDICALEVENT

E0945 EXTREMITY BELT/HARNESS 15.04 1 1 PER MEDICALEVENT

E0947 FRACTURE FRAME, ATTACHMENTS FORCOMPLEX PELVIC TRACTION

217.80 1 21.78 1 PER MEDICALEVENT

E0948 FRACTURE FRAME, ATTACHMENTS FORCOMPLEX CERVICAL TRACTION

209.50 1 20.95 1 PER MEDICALEVENT

E0961 BRAKE EXTENSION, FOR WHEELCHAIR 15.52 1 2 PER 2 YEARSE1085 HEMI-WHEELCHAIR, FIXED FULL LENGTH ARMS,

SWING AWAY DETACHABLE FOOT RESTS 489.90 1 48.99 1 PER 5 YEARS

E1091 YOUTH WHEELCHAIR, ANY TYPE 663.60 1 66.36 1 PER 5 YEARSE1800 DYNAMIC ADJUSTABLE ELBOW

EXTENSION/FLEXION DEVICE, INCLUDES SOFTINTERFACE MATERIAL

73.50 2 2 PER 2 YEARS

E1805 DYNAMIC ADJUSTABLE WRIST EXTENSION /FLEXION DEVICE, INCLUDES SOFT INTERFACE

75.50 2 2 PER 2 YEARS

March 2003C - 9

CODE


DESCRIPTION MAX



MATERIALE1810 DYNAMIC ADJUSTABLE KNEE EXTENSION /

FLEXION DEVICE, INCLUDES SOFT INTERFACEMATERIAL

73.60 2 2 PER 2 YEARS

E1815 DYNAMIC ADJUSTABLE ANKLEEXTENSION/FLEXION DEVICE, INCLUDES SOFTINTERFACE MATERIAL

75.50 2 2 PER 2 YEARS

E1820 REPLACEMENT SOFT INTERFACE MATERIAL,DYNAMIC ADJUSTABLE EXTENSION/FLEXIONDEVICE

6.06 8 8 PER YEAR

E1825 DYNAMIC ADJUSTABLE FINGEREXTENSION/FLEXION DEVICE, INCLUDES SOFTINTERFACE MATERIAL

75.50 2 2 PER 2 YEARS

E1830 DYNAMIC ADJUSTABLE TOEEXTENSION/FLEXION DEVICE, INCLUDES SOFTINTERFACE MATERIAL

75.50 2 2 PER 2 YEARS

March 2003C - 10

CODE


DESCRIPTION MAX



W4087 SUPPLY KIT- PORTABLE PUMPW/SUBCUTANEOUS/PERCUTANEOUS LINE(INCLUDES INFUSE

29.10 31 366 PER YEAR

W4088 SUPPLY KIT-PORTABLE PUMP W/IMPLANTEDACCESS DEVICE, PORT-A-CATH, MED-I-

33.95 31 366 PER YEAR

W4090 CATHETER IRRIGATION SOLUTION, 250CC 2.43 1 12 PER YEARW4102 REPLACEMENT FILTERS FOR USE WITH FILTERE 0.49 31 366 PER YEARW4107 OSTOMY SUPPORT BELT 17.46 1 2 PER YEARW4165 BLOOD LANCET DEVICE (AUTOCLIX,

MONOJECTO 8.25 1 1 PER 5 YEARS

W9760 PEDIATRIC POSTURAL CONTROL WALKER, ANYSIZE, ANY TYPE ( E.G. KAYE, STRIDER,

160.05 1 1 PER 2 YEARS

W9761 PEDIATRIC FOREARM CRUTCHES; ALUMINIUM;HAND GRIP HEIGHT ADJUSTABLE UP TO


W9762 PEDIATRIC SAFETY CRIB WITH METAL TUBEENDS AND SIDES WITH ENCLOSURE TOP;


W9767 FOOT ORTHOSIS, FOR CONGENITAL FOREFOOTDEFORMITIES (L.E., METATARSUS


W9768 PEDIATRIC DYNAMIC SPLINTING DEVICE,ALLOWS INDEPENDENT LEG MOTION, ALLOWS


W9769 SPONGE; DRAIN, DRESSING, IV ORTRACHEOSTOMY; STERILE OR NON-STERILE ANYSIZ

0.38 150 1800 PER YEAR

March 2003C - 11

JEB BUSH, GOVERNOR RHONDA M. MEDOWS, MD, FAAFP, SECRETARY

M e d i c a i d C o n t r a c t M a n a g e m e n t 2 3 0 8 K i l l e a r n C e n t e r B l v d . S u i t e B 2 0 0 M a i l S t o p 2 2 T a l l a h a s s e e , F L 3 2 3 0 9

A H C A H e a d q u a r t e r s2 7 2 7 M a h a n D r i v e

T a l l a h a s s e e, F L 3 2 3 0 8www.fdhc.state. f l .us

Dear Medicaid Provider: Enclosed you will find an advance copy of the national standard procedure codes that will replace previously used locally assigned procedure codes. You will receive a copy of the new Florida Medicaid Provider General Handbook, describing general Medicaid policy and a revised Medicaid Provider Reimbursement Handbook, CMS-1500, containing revised reimbursement information at a later time. Changes in the procedure codes, instructions for completing the claim form, Explanation of Benefit (EOB) codes, and the paper remittance voucher are required for Florida Medicaid to be compliant with the Health Insurance Portability and Accountability Act (HIPAA) transactions and code set regulations effective October 16, 2003. These changes will also apply to claims submitted for MediKids recipients. HIPAA INFORMATION Please consult the HIPAA transition time line included with this letter for an outline of important events that will occur as Florida Medicaid implements HIPAA regulations. You should be aware that during the week beginning Monday, October 6, 2003, and ending Sunday, October 12, 2003, the Florida Medicaid Management Information Systems (FMMIS) claims processing system, ACS State Healthcare, including the State Healthcare Clearinghouse (EDI) and all related Fiscal Agent Services business processes will implement the new HIPAA-compliant environment. Electronic claims will still be accepted in ACS EDI; providers will receive responses that their claims were or were not accepted. Starting Monday, October 6, 2003, only the HIPAA X12 electronic transactions will be accepted. Paper claims will also be accepted, batched and scanned. Claims will not be passed along to the FMMIS for processing during the implementation window. Claims received during the week of October 6 will be processed starting the week of October 13. The current version of WINASAP will be upgraded with HIPAA compliant software, WINASAP 2003. ACS field representatives are available to assist you with this upgrade if needed. Please call the EDI help desk at 800-829-0218 for more information regarding this software upgrade. During the week of October 13, 2003, providers will not receive a payment from Medicaid. Claims submitted just prior to and during the week of implementation will be processed for adjudication after the cutover week of October 6 through October 12, 2003.

Page Two HIPAA Advance Handbook Update August 2003 By now, health care providers that bill Medicaid electronically should be completing their software and business changes and moving on to testing activities. If you are ready to test your HIPAA changes, sign up for testing with Florida Medicaid/ACS beginning in August by calling the EDI Helpdesk at 800-829-0218. If you are not yet at this stage of readiness, you should immediately contact your software/practice management vendor, billing agent, or clearinghouse to check on the status of their HIPAA implementation. If you don’t use a billing agent or clearinghouse, you may want to contact a HIPAA vendor for assistance (a list is available on the ACS website at http://floridamedicaid.acs-inc.com/index.jsp - select HIPAA Information and then Submitter Information). You should have already signed up for provider training presented by ACS and Medicaid in August and September. If you haven’t sent in the registration form, you can email ACS at [email protected]. If you missed the training session in your area, please contact your Area Medicaid Office for information regarding changes in Florida Medicaid claims processing. A list of the Area Medicaid Offices is included for your reference. Please carefully read the information in this advance handbook publication. The information is vital for Medicaid providers to be able to appropriately bill the Medicaid program for services rendered to eligible recipients. An official update for your Medicaid Coverage and Limitations Handbook will be sent at a later time, containing this and other important Medicaid policy and information. If you have any questions regarding the information in this letter, please contact the ACS Provider Inquiry unit at 800-289-7799 or your Area Medicaid Office. Thank you for the services that you provide for Florida Medicaid recipients. Sincerely,

Alan Strowd, Chief

Medicaid Contract Management

Key Florida Medicaid HIPAA Implementation and Cutover Events

Event / Activity Primary Date

Cutoff old paper claim forms * 09/29/03

Begin accepting new paper claim forms * 09/29/03

Cutoff for claims processed through the final Payment Cycle 10/03/03**

Cutoff current electronic formats 10/03/03**

Final Payment Cycle preceding implementation 10/04/03

Final Payment to Providers Preceding Implementation 10/08/03

FMMIS shut down 10/05/03

Begin accepting X12N transactions 10/06/03

Begin processing new paper claim forms 10/06/03

Eligibility File (as of 10/05/03) available for inquiry (MEVS and AVRS)

10/06/03

Implementation 10/06/03—10/12/03

HIPAA-compliant FMMIS available 10/13/03

First Payment cycle following implementation 10/18/03

First Payment to Providers Following Implementation 10/22/03 *Paper Claim Forms:

• The paper version of the Non-Institutional, 081; Transportation 131; and, Transportation 131-A have been modified.

• The Child Health Check-Up, 221 claim form will be obsolete and providers will use the CMS-1500 claim form to bill Florida Medicaid.

• The Pharmacy 061 claim form will be replaced with the NCPDP Universal Claim Form.

• The CMS-1500; UB-92; Institutional, 021; Transportation 141; and, Dental 111 paper claims will not change.

**All electronic claims and Nursing Home Turn Around Documents (TADs) received by

noon Friday, 10/3 will be processed in the final payment cycle.

Medicaid Area Office Addresses and Telephone Numbers Areas—Counties Covered Address Phone

Area 1—Escambia, Okaloosa, Santa Rosa, Walton

160 Governmental Center, Room 510 Pensacola, Florida 32502

Escambia and Santa Rosa— (850) 595-5700 Okaloosa and Walton— (800) 303-2422

Area 2A—Bay, Gulf, Franklin, Holmes, Jackson, Washington

651-K West 14 Street Panama City, Florida 32401

(850) 872-7690 (800) 699-7068

Area 2B—Calhoun, Gadsden, Jefferson, Liberty, Leon, Madison, Taylor, Wakulla

2002 Old St. Augustine Road Building D, Room 194 Tallahassee, Florida 32301

(850) 921-8474 (888) 503-5163

Area 3A—Alachua, Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette, Levy, Putnam, Suwannee, Union

14101 N.W. Hwy. 441 Suite 600 Alachua, Florida 32615-5669

(386) 418-5350

Area 3B—Citrus, Hernando, Lake, Marion, and Sumter

2441 Silver Springs Boulevard Ocala, Florida 34475

(352) 732-1349

Area 4—Baker, Clay, Duval, Flagler, Nassau, St. Johns and Volusia

Duval Regional Service Center 921 North Davis Street, Building A, Suite 160 Jacksonville, Florida 32209-6806

(904) 353-2100 (800) 273-5880

Area 5—Pasco and Pinellas 525 Mirror Lake Drive North Suite 510 St. Petersburg, Florida 33701

(727) 552-1191 (800) 299-4844

Area 6—Hardee, Highlands, Hillsborough, Manatee, and Polk

6800 North Dale Mabry Hwy. Suite 220 Tampa, Florida 33614

(813) 871-7600 (800) 226-2316

Area 7—Brevard, Orange, Osceola, and Seminole

400 West Robinson Street Suite 309 – South Tower Orlando, Florida 32801

(407) 317-7851 (877) 254-1055

Area 8—Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota

2295 Victoria Avenue, Room 309 Ft. Myers, Florida 33901 All mail should be addressed to: P. O. Box 60127 Ft. Myers, Florida 33906

(941) 338-2620 (800) 226-6735

Area 9—Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie

1710 East Tiffany Drive, Suite 200 West Palm Beach, Florida 33407

(561) 881-5080 (800) 226-5082

Area 10—Broward 1400 West Commercial Boulevard Suite 110 Ft. Lauderdale, Florida 33309

(954) 202-3200

Area 11—Dade and Monroe Doral Center, Manchester Building 8355 N. W. 53 Street, 2nd Floor Miami, Florida 33166

(305) 499-2000

Advance Update Florida Medicaid Reimbursement Handbook CMS-1500

October 2003 Page 1 of 12

Instructions for completing the CMS-1500 claim form will remain as stated in the May 2001 version of the Medicaid Reimbursement Handbook, HCFA-1500 and Child Health Check-Up, 221, with the exceptions of the fields listed below: Providers will receive a revised reimbursement handbook with complete claim instructions at a later time.

Changes Required for How to Complete the CMS-1500 Claim Form

CLAIM ITEM

TITLE ACTION

21 Diagnosis or Nature of Illness or Injury

Enter the patient's diagnosis/condition. All physician specialties must use an ICD-9-CM code number and code to the highest level of specificity. Enter up to 4 codes in priority order (primary, secondary condition). Child Health Check-Up: Enter the diagnosis code(s) primary, secondary, etc. for each component where an abnormal condition is identified. Codes with an “E” or “M” prefix cannot be used for billing Medicaid. Certain diagnosis codes are identified as emergency diagnosis codes. A copayment is not deducted for services using these diagnosis codes. Independent Laboratories: Enter a diagnosis only for limited coverage procedures. Labs must enter the diagnosis code from the referring provider when filing claims for MediPass exempt services, family planning waiver services, and genetic testing. See the Independent Laboratory Services Coverage and Limitations Handbook for the procedure codes and required diagnosis codes.



Changes Required for How to Complete the CMS-1500 Claim Form, continued

CLAIM ITEM

TITLE ACTION

D Procedures, Services or Supplies: CPT HCPCS Codes and Modifiers

Enter the procedure code from the Procedure Code Fee Schedules in the service-specific Coverage and Limitations Handbook. Modifiers: For certain types of service, a two-digit modifier or modifiers must be entered after the procedure code. Modifiers more fully describe the services performed so that accurate payment may be determined. Florida Medicaid uses the first modifier listed on the claim to determine special pricing. Valid modifiers can be found in the service-specific Coverage and Limitations Handbooks for those programs that use modifiers. If more than two (2) modifiers are needed, enter modifier -99 on the claim line and list the other applicable modifiers on the documentation that is attached to the claim, as described below in By Report. Note: Florida Medicaid accepts standard HCPCS codes. Refer to service-specific Coverage and Limitations Handbooks for a list of covered codes and special instructions for using modifiers or diagnosis codes required to uniquely identify some Medicaid services. Ambulatory surgical centers (ASC) can use modifiers “50” and “51.” The ASC facility claims do not require an attachment for proper pricing. By Report: By report procedures are procedures that must be approved or manually priced. They must be submitted on paper claims with relevant reports attached. Procedure codes with -99 modifiers, procedure codes marked “R” on the Procedure Code Fee Schedules, and other procedures specified in the service-specific Coverage and Limitations Handbooks are approved and priced by report.



Changes Required for How to Complete the CMS-1500 Claim Form, continued

CLAIM ITEM

TITLE ACTION

E Diagnosis Code Enter the diagnosis code reference number as shown in Block 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per line item unless instructed otherwise in the service-specific Coverage and Limitations Handbook. If more than one diagnosis reference is required by the service-specific Coverage and Limitations Handbook, you must use a comma (,) separator between the diagnosis code pointers. When multiple services are performed, enter the primary reference number for each service (either "1", "2", "3", or "4").

H Child Health Check-Up and Family Planning Indicator

Enter an “E” if the patient was referred for the services as a result of a Child Health Check-Up screening. (Child Health Check-Up was formerly named EPSDT.) If the service is a surgery that was referred as a result of a Child Health Check-Up screening, an “E” in this item will indicate to the system that prior authorization was not required.

Child Health Check-Up Referral Code Indicator

If the services provided are for Child Health Check-Up screening services, enter the referral code that identifies the health screening of the child:

U Complete Normal Indicator is used when there are no referrals made.

2 Abnormal, Treatment Initiated Indicator is used when child is currently under treatment for referral diagnostic or corrective health problem.

T Abnormal, Recipient Referred Indicator is used for referrals to another provider for diagnostic or corrective treatments or scheduled for another appointment with check-up provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic check-up (not including dental referrals).

V Patient Refused Referral Indicator is used when the patient refused a referral.



Place of Service Codes (POS)

Code Description

03 School

A school facility where a recipient receives a Medicaid service. This new place of service is effective with HIPAA implementation.

11 Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, intermediate care facility (ICF), or mobile van where the health professional routinely provides health examination, diagnosis and treatment of illness or injury on an ambulatory basis.

12 Patient’s Home

Location, other than a hospital or other facility, where the patient receives care in a private residence.

13 Assisted Living Facility Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services.

14 Group Home Congregate residential foster care setting for children and adolescents in state custody that provides some social, health care, and educational support services and that promotes rehabilitation and reintegration of residents into the community.

21 Inpatient Hospital A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non surgical) and rehabilitation services, by or under the supervision of physicians, to patients admitted for a variety of medical conditions.

22 Outpatient Hospital A portion of a hospital that provides diagnostic, therapeutic (both surgical and non surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

23 Emergency Room - Hospital

A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided on a 24-hour basis.



Place of Service Codes (POS), continued

Code Description

24 Ambulatory Surgical Center

A freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis.

25 Birthing Center A facility, other than a hospital’s maternity facilities or a physician’s office, that provides a setting for labor, delivery and immediate postpartum care as well as immediate care of newborn infants.

31 Skilled Nursing Facility A facility that primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services, but does not provide the level of care or treatment available in a hospital.

32 Nursing Facility A facility that primarily provides residents with skilled nursing care and related services for rehabilitation of an injured, disabled, or sick person; or on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.

33 Custodial Care Facility A facility that provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.

34 Hospice

A facility other than a patient’s home, in which palliative and supportive care for terminally ill patients and their families are provided. Note: This place of service can only be used when the actual service is performed in a hospice facility. If a hospice patient receives services in a setting other than a hospice facility, then the specific location for that service must be used.

49 Independent Clinic A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.




Code Description

51 Inpatient Psychiatric Facility

A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician. This place of service code is only used for Medicare crossover billing.

53 Community Mental Health Center A facility that provides comprehensive mental health services on an ambulatory basis primarily to individuals residing or employed in a defined area.

54 Intermediate Care Facility for the Developmentally Disabled (IFC-DD) A facility that primarily provides health-related care and services above the level of custodial care to developmentally disabled individuals, but does not provide the level of care or treatment available in a hospital or a skilled nursing facility.

55 Residential Substance Abuse Treatment Facility A facility that provides treatment for substance (alcohol and drug) abuse to live -in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.

57 Non-residential Substance Abuse Treatment Facility

A location that provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.

62 Comprehensive Outpatient Rehabilitation Facility

A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities.

65 End Stage Renal Disease Treatment Facility A facility other than a hospital, which provides dialysis treatment, and maintenance or training to patients or caregivers.

71 State or Local Public Health Clinic

A facility maintained by either state or local health departments that provides ambulatory primary care under the general direction of a physician.




Code Description

72 Rural Health Clinic or Federally Qualified Health Center

A certified facility located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician.

A certified facility located in a medically underserved area that provides ambulatory primary medical care under the general direction of a physician.

81 Independent Laboratory A laboratory certified to perform diagnostic or clinical tests independent of an institution or a physician’s office.

99 Other Unlisted Facility Other service facilities not identified above.

How to Read The Remittance Voucher Introduction All of a provider’s claims that are entered in the Florida Medicaid Management

Information System (FMMIS) during the weekly cycle are listed on a remittance voucher. A sample remittance voucher follows on the next page with each item explained on the succeeding pages.



Illustration 3-1. Sample Remittance Voucher

TO: (((NAME))) PHYSICIANS R.V. NO: 999999 CHECK NO.: 999999 DATE PAID: 03/18/XX PROVIDER NUMBER: 999999999 PAGE: 2 **** PATIENT NAME **** RECIPIENT TRANS-CONTROL-NUMBER / BILLED OTHER PAID BY PAT ACT NUM / LAST FIRST MI IDENT NUM LINE-ITEM SVC-DATE PROC/MOD UNITS AMT INS. MCAID PERF. PROV. S * * * CLAIM TYPE: PHYSICIAN * * * CLAIM STATUS: PAID ORIGINAL CLAIMS: LAST FIRST MI 9123456789 0-88060-11-001-0001-00 2100.00 0.00 2100.00 9999999999999 001 01/30/XX 90010 xx xx 11 100.00 0.00 100.00 999999999 G 002 01/30/XX 90010 11 100.00 0.00 100.00 999999999 G 003 01/30/XX 90010 11 100.00 0.00 100.00 999999999 G 004 01/30/XX 90010 11 100.00 0.00 100.00 999999999 G PAID CLAIM LINE CUTBACK REASONS: XXX XXX XXX ADJUSTMENT CLAIMS: LAST FIRST MI 9123456789 0-88060-11-001-0001-00 200.00 0.00 200.00- 9999999999999 001 01/30/XX 90010 11- 100.00- 0.00 100.00- 999999999 G 002 01/30/XX 90010 11- 100.00- 0.00 100.00- 999999999 G LAST FIRST MI 9123456789 0-88060-11-001-0001-00 300.00 0.00 290.00 9999999999999 001 01/30/XX 90010 11 150.00 0.00 150.00 999999999 G 002 01/30/XX 90010 11 150.00 0.00 140.00 999999999 G TCN-TO-CREDIT: 2-87150-11-001-0001-00 NET 100.00 0.00 90.00 * * * CLAIM TYPE: PHYSICIAN * * * CLAIM STATUS: DENIED ORIGINAL CLAIMS: LAST FIRST MI 9123456789 0-88060-11-001-0001-00 200.00 0.00 0.00 9999999999999 001 01/30/XX 90010 11 100.00 0.00 0.00 999999999 K 111 22222 PREVIOUS-DATE-PAID: 01/30/XX CONFLICTING-TCN: 2-87150-11-001-0001-00 LAST FIRST MI 9123456789 0-88060-11-001-0001-00 200.00 0.00 0.00 9999999999999 001 01/30/XX 90010 11 100.00 0.00 0.00 999999999 K REASONS/REMARKS: 111 22222 111 22222 111 22222 111 22222 111 22222 111 22222 111 22222 111 22222 111 22222 111 22222 REASONS/REMARKS: 111 22222 111 22222 111 22222 111 22222 111 22222 111 22222 111 22222 111 22222 111 22222 111 22222 THIS MEDICAID RECIPIENT HAS OTHER COVERAGE BY: 333333 REMITTANCE TOTALS: PAID ORIGINAL CLAIMS: NUMBER OF CLAIMS 2 -------- 2,200.00 2,110.00 PAID ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 2 -------- 100.00 90.00 DENIED ORIGINAL CLAIMS: NUMBER OF CLAIMS 2 -------- 400.00 DENIED ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 0 -------- 0.00 PENDED CLAIMS (IN PROCESS): NUMBER OF CLAIMS 3 -------- 500.00 AMOUNT OF CHECK: CHECK NUMBER 999999 ---------------------- 2,200.00 ---- THE FOLLOWING IS A DESCRIPTION OF THE EXPLANATION OF ADJUSTMENT REASON codes THAT APPEAR ABOVE: COUNT: 111 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx 27 ---- THE FOLLOWING IS A DESCRIPTION OF THE REMARK codes THAT APPEAR ABOVE: 22222 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx 27

1 2 3 5 6 7 8 9 12 11 10

15

14

4

13

13

16

17

18

19

20

21



How to Read The Remittance Voucher, continued

RV ITEM

TITLE WHAT ITEM MEANS

1 Patient Name: Last, First, and MI

The recipient’s name as found on the Florida Medicaid eligibility file. If the recipient is not on file, the first two letters of the last name and the first letter of the first name will appear on the remittance voucher.

2 Recipient Ident Num

The recipient’s Medicaid identification number.

3 Trans Control Number

The unique identifying number assigned to each claim submitted. The TCN is the primary number used to identify the claim in the system. The following chart explains the components that the digits of the TCN represent:

Digit 1 2 – 6 7 – 8 9 – 11 12 – 15 16 – 17

Component Represented Claim input type 0 or 1 = Paper claim

2 = Magnetic tape claim 3 = Electronic claim 4 = ACS generated claim 5 = AHCA handled claim Julian date claim was received For internal use Batch number Document number Line number Line number

4 Line Item This is the line item of the claim assigned by Medicaid.

5 Svc Date The date the service was rendered.

6 Proc Code The procedure code for the service billed and up to two modifiers.

7 Units The units of service for the claim line item. This is the units of service for which the provider is to be paid.

8 Billed Amt The total submitted claim charges from the claim.

9 Other Ins. Any actual or expected payments from an insurance carrier entered by the provider on the claim.

10 Paid By Medicaid The amount paid by Medicaid for the service billed by the provider.

11 Pat Act Num. Perf. Prov.

This is the provider assigned patient account number if entered on the claim. This field will contain up to ten characters. If a treating provider number was entered on the claim for a group practice, it will be shown underneath the patient account number.




RV ITEM


12 S “S” is for the source code and indicates how the system priced each claim. For example, claims priced manually by a peer review consultant have a distinct code. Claims paid according to the Medicaid fee schedule have another code. Below are the definitions of these source codes.

A = Professional Component Base

Anesthesia

B = Billed Charge C = Medicare

Coinsurance/Deductible

D = Medicare Deductible E = EAC Priced F = Fee Schedule

G = SMAC Priced J = MediKids K = Denied

L = HMO/PHP Rate M = Manually Priced N = Provider Charge

P = Prior Authorization Rate Q = Technical Component Rate S = System Parameter Rate

T = Transportation Rate V = Percent of Medicare Allowed

Amount W = Zero Priced X = CPHU Encounter Rate

Y = Rural Health Clinic Encounter Rate

Z = FQHC Encounter Rate

1 = Primary Care Rate 2 = Pediatric Surgery Rate 3 = Fee Schedule Physician

Increased Rate 4 = PC/BA Fee Physician Increase

Rate

5 = Technical Component Physician Increased Rate

7 = Calculated Medicare Coinsurance/ Deductible

13 Claim Type/Claim Status

The same types of claims (i.e. physician, inpatient, hospice, etc.) are grouped together. The claim status indicates if the claim is paid, denied or suspended.

14 Original/Adjustment Original claims are grouped together and separated from previously paid claims for which the provider has requested adjustments.

15 Paid Claim Line Cutback Reasons

The reason code(s) indicate why a claim paid at a rate other than what the provider billed. When Medicaid policy or service limits require the system to “cut-back” the number of units or the amount to be paid, the reason code explains the payment reduction. All codes used on the remittance voucher for that week are translated in the Summary Section.




RV ITEM


16 TCN-to-Credit NET

The transaction control number of the claim that the provider requested an adjustment on is indicated for reference. The net of the positive and negative adjustment amounts are printed to reflect the difference between the original and adjusted claim.

17 Previous Date Paid Conflicting TCN

When a claim is denied for duplicate reason, the paid date and the transaction control number of the originally paid claim is indicated for reference.

18 Reasons/Remarks These codes explain why a service was denied, payment was reduced, or why the claim is suspended. At least one code is printed next to each denied claim line item reported on the remittance voucher. A translation of these codes is included in the final Summary Section of the remittance voucher.

19 This Medicaid Recipient Has Other Coverage By

If a claim is denied because the Medicaid file indicates that there is another payer responsible for the claim, the third party carrier code appears in this section. Note: A list of the carrier codes and carrier billing information can be found in Appendix B of the Florida Medicaid Provider General Handbook or on the fiscal agent Website at http://floridamedicaid.acs-inc.com.

20 Remittance Totals This section name is used to denote the total of all claims for this provider’s remittance voucher.

Paid Original Claims: The number of claims and associated dollars for original claims paid on this remittance voucher.

Paid Adjustment Claims: The number of claims and associated dollars for credits and adjustments paid on this remittance voucher. Gross adjustments are tallied as adjustment claims.

Denied Original Claims: The number of claims and associated dollars for original denied claims on this remittance voucher.

Denied Adjustment Claims: The number of claims and associated dollars for adjustments denied on this remittance voucher.

Pended Claims (in process): The number of claims and associated dollars for original claims and adjustments, which are currently suspended for Medicaid Review.

Amount of Check: The amount of the check that is issued to the provider for this remittance voucher.

Check Number: The warrant number.




RV ITEM


21 The Following is a Description

Any adjustment, remark or reason code that appears on the remittance voucher is defined in this section. Note: See Appendix A in the Florida Medicaid Provider General Handbook for a list of the adjustment reasons and remark codes that are used to report claim processing information.

Advance Copy Florida Medicaid Provider General Handbook

October 2003 A-1

APPENDIX A CLAIM ADJUSTMENT REASON CODES ON REMITTANCE

VOUCHERS

Overview

Introduction This section gives general information regarding the information on the Medicaid

remittance voucher and provides information regarding the claim adjustment reason codes and remark codes used by the Florida Medicaid Program to communicate information about claims. With the implementation of federally mandated standard code sets provided in the Health Insurance Portability and Accountability Act (HIPAA) legislation, Medicaid will discontinue use of Medicaid EOBs (Explanation of Benefits). EOBs will be replaced by the HIPAA standard claim adjustment reason and remark codes.

Remittance Voucher

Each time payment is made to a provider Medicaid sends a paper or electronic remittance voucher (RV) listing the status of any claims Medicaid has paid, denied or pended. This section discusses the paper RV. In the far right column of the RV is a three-digit code. This code is the Claim Adjustment Reason Code that explains Medicaid’s reason for denying or pending a claim payment. In some instances there will also be a Remark Code with the Claim Adjustment Reason Code. The Remark Code communicates specific information about the claim. On the last page of each RV is a summary section that translates the codes into narrative form.

Claim Adjustment Reason Codes

Claim adjustment reason codes communicate why a claim or claim line was denied or paid differently than it was billed. If there is no denial or adjustment to a claim or claim line, then there is no adjustment reason code. Medicaid uses the ASC (American Standard Committee) X12 Claim Adjustment reason codes required by HIPAA to communicate claim or claim line denials or adjustments.

Remark Codes Remark codes are used to communicate additional information about the denial

or adjustment of a claim or claim line that cannot be thoroughly explained by a Claim Adjustment Reason Code. Medicaid uses the standard HIPAA Remark codes that are maintained by the Centers for Medicare and Medicaid Services (CMS) to communicate additional information about claim or claim line denials or adjustments.

Florida Medicaid Provider General Handbook Advance Copy

A-2 October 2003

Overview, continued Claim Adjustment Reason and EOB Crosswalk

With the implementation of HIPAA, Medicaid will discontinue the use of Medicaid EOB codes. As of October 16, 2003, Medicaid will communicate claims information using the HIPAA standard codes. The HIPAA standard claim adjustment reason codes and remark codes have been cross-walked to the Medicaid EOBs. The HIPAA standard codes do not communicate the same level of detail about the claim as the Medicaid EOBs. Note: See page A-8 for the EOB crosswalk.

Corrective Action Required

If a claim is denied, the provider must correct the claim before resubmitting it. Resubmitting a denied claim without taking a corrective action will result in another claim denial.

Medicaid Area Office Assistance

The corrective action for some claims requires that the provider contact the area Medicaid office for assistance. The addresses and telephone numbers of the area Medicaid offices are listed in Appendix C of this handbook.

Fiscal Agent Assistance, Provider Inquiry

The corrective action for some claims requires that the provider contact the Medicaid fiscal agent, Provider Support Department for assistance. The Provider Support Department’s address and phone numbers are: ACS - Florida Medicaid Written Correspondence P.O. Box 7070 Tallahassee, Florida 32314-7070 800-289-7799 (inside Florida) 800-955-7799 (outside Florida)

Correcting Keying and Scanning Errors

If a fiscal agent keying error caused a paper claim to be denied or paid incorrectly, the provider may either: • Call the fiscal agent at the above telephone number and request that the

claim be reprocessed; or • Photocopy the claim, circle the item(s) that was incorrectly keyed, sign and

date the form, and resubmit it to the fiscal agent at:

Adjustments and Voids P.O. Box 7080 Tallahassee, FL 32314-7080

Note: See the Medicaid Provider Reimbursement Handbook for the specific claim form for information on resubmitting denied claims.


October 2003 A-3

Crosswalk of X12 Codes to Former FMMIS EOB Codes

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

004 M78 117 Invalid procedure code modifier

004 282 Invalid modifier for ARNP. Registered nurse anesthetists can provide only anesthesia services - modifier 48 not valid.

004 N29 334 Procedure modifier billed requires manual pricing. Please resubmit with medical report attached.

004 363 Procedure code or modifier conflict.

004 420 Independent laboratory - invalid procedure code modifier

004 N54 504 Prior authorization or procedure code modifier conflict.

004 000 668 Provider or procedure code modifier or place of service conflict. Posts with ASC mod. 73 or 74.

005 M77 310 Prov type or place of service conflict.

005 365 Proc. cannot be performed at place of service indicated on claim (or if 99160 or 99162 billed, service payable only if emergency block checked).

006 230 Therapy not covered for recipient 21 years of age or older.

006 434 Procedure code or age conflict.

006 554 First surgical procedure conflicts with age limitations.

006 705 Drug contraindicated for recipient's age.

007 435 Procedure code or drug or sex conflict.

007 555 First surgical procedure invalid for recipient sex.

007 565 Second surgical procedure invalid for recipient sex.

007 619 5th surgical procedure or sex conflict.

008 284 Procedure not compatible with prov. type, procedure cannot be billed on the claim form used, or new anesth. code conflicts with modifier or DOS.

008 364 Pay-to provider type invalid for procedure code.

008 367 Procedure or provider conflict.

009 N59 323 Diagnosis code incompatible for recipient's age (if you're billing for mother, check to see if you used a newborn-only diag code or vice versa).

009 N30 340 Recipient age less than minimum age for drug.

009 N30 341 Recipient age greater than maximum age for drug.

009 454 Recip. age on our file incompatible with primary diag.-if baby & mother involved, make sure you didn't use baby's diag for mother or vice versa.


A-4 October 2003

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

involved, make sure you didn't use baby's diag for mother or vice versa.

009 464 Recip. age on our file incompatible with 2nd diag. - if baby & mother involved, make sure you didn't use baby's diag for mother or vice versa.

009 474 Third diagnosis code conflicts with age limitations.

009 484 Fourth diagnosis code conflicts with age limitations.

009 494 Fifth diagnosis code conflicts with age limitations.

010 324 Diagnosis incompatible with recipient's sex.

010 455 Recip. sex on our file incompatible with primary diag.-if baby & mother involved, make sure you didn't use baby's diag for mother or vice versa.

010 465 Recip. sex on our file incompatible with 2nd diag. - if baby & mother involved, make sure you didn't use baby's diag for mother or vice versa.

010 475 Third diagnosis code invalid for recipient sex.

010 485 Fourth diagnosis code invalid for recipient sex.

010 495 Fifth diagnosis code invalid for recipient sex.

010 733 Drug - gender alert

011 136 Procedure code incompatible with diagnosis code.

011 285 Procedure code incompatible with diag.

012 283 Diagnosis or provider type conflict

013 216 Service date is after the recipient's date of death.

014 589 The first date of service is before the recipient's date of birth. Tape or ASAP billing - deny.

015 N54 604 No match between prior authorization and procedure on claim.

016 N50 115 Discharge date or action code are missing.

016 M53 118 Invalid anesthesia units of service.

016 N75 119 Invalid tooth surface or mouth quadrant

016 N75 121 Mouth quadrant or tooth surface duplicate

016 M57 122 Invalid provider number.

016 MA31 123 Date billed invalid.

016 M52 124 Invalid date of service

016 M52 124 Invalid date of service

016 MA05 126 Admit or discharge date conflict.


October 2003 A-5

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

016 N31 131 Invalid DPR license number.

016 M54 132 Total or submitted charge missing.

016 MA30 138 Type of bill is invalid.

016 M67 145 EPSDT claim lines 1-6 incomplete. Results of all screening components must be reported with appropriate exam code in Field 24F on claim.

016 M49 147 Invalid nursing home action code.

016 M50 148 Revenue center code is missing.

016 MA100 149 Injury date is missing.

016 M54 150 The sum of the third party payment amounts entered on the line item(s) of your claim is not equal to the amount entered in the TPL total field.

016 N31 151 DPR license number is missing.

016 M119 152 National drug code missing.

016 N57 154 Invalid or missing prescription number.

016 M53 155 Drug quantity is missing or zeros.

016 M44 156 Invalid condition code

016 M46 158 Occur span to date missing

016 M54 160 Submitted charges or total claim charge conflict.

016 N78 162 EPSDT or adult screen performed over 3 mos. from recip. enroll date

016 MA63 163 Diagnosis code missing or incomplete (outpatient hospitals: revenue codes 273 & 279 not payable unless diagnosis is included in range 940.0-949.5).

016 M53 165 Invalid hospice units for revenue code 657.

016 MA40 167 Admission date or action code are missing.

016 M77 170 Place of service is invalid.

016 N34 171 EPSDT procedure code W9881 was incorrectly billed on the HCFA 1500 claim form. Procedure should only be billed on the EPSDT form (221).

016 M67 172 Procedure code missing - outpatient revenue codes in the range 300-319 must be accompanied by 5-digit lab proc. Code in range 80000 - 89999.

016 M67 173 Invalid hospice revenue code or invalid combination of hospice revenue codes.

016 174 Invalid private transportation start time.

016 N58 176 Invalid patient responsibility.

016 MA66 177 This code is no longer applicable to the inpatient claim.

016 M49 181 Invalid nursing home termination code.

016 M49 182 Invalid termination code for action code.


A-6 October 2003

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

016 M44 183 Invalid private transportation stop time.

016 M50 184 Invalid units of service for revenue code 652, 652, 655-657, and 659.

016 MA40 185 Invalid admission day-of-the-week.

016 MA43 188 Invalid patient status for private transportation.

016 MA100 190 First surgery date (field 80) not within "statement covers period" date span (field 6).

016 MA100 191 Second surgery date (field 81) not within "statement covers period" date span (field 6).

016 M100 192 Third surgery date (field 81) not within "statement covers period" date span (field 6).

016 M46 193 Invalid newborn occurrence date

016 M67 194 Invalid or spanned header dates - outpatient bills must contain a single date of service.

016 N37 195 Mouth quadrant required

016 M67 196 First surgery procedure code is missing.

016 M67 197 1st surgical procedure date is missing or zeros.

016 M67 199 3rd surgical procedure date is missing or zeros.

016 N59 200 Contact Provider Services.

016 MA63 202 Diagnosis code not covered for birth center procedure code.

016 M68 203 Referring provider number required

016 N66 206 Modifiers 24,78, and 79 require DCF review.

016 MA31 208 Calculated number of days is not equal to the number of days billed.

016 N78 212 EPSDT data missing

016 MA66 214 Invalid EPSDT examination code.

016 M68 215 Examination code requires referral provider code.

016 N56 219 Revenue code not allowed for dialysis provider

016 MA31 223 Billed date greater than batch date

016 N58 226 Fields 2 and 57 on the ub92 do not match.

016 MA43 227 Patient status missing or invalid.

016 240 Procedure code W9657 cannot be billed independently. It must be billed with procedure code W9654.

016 MA31 256 Svc dates not eligible

016 263 TPL on recipient file, not on claim (pay claim).

016 264 TPL on recipient file, not on claim (pay and list).

016 MA64 265 Recipient has other insurance coverage on Medicaid third party liability file. Please file with other carrier or attach insurance company denial.

016 MA64 266 Third party liability indicated on claim, but coverage not on Medicaid file. Must be filed on paper claim with copy of other carrier's payment.


October 2003 A-7

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

016 MA64 267 TPL is indicated on file, but did not appear on claim. Your claim was denied after DCF review of the claim and its attachment (s).

016 N30 272 Recip ineligible for HMO or PHP

016 M46 273 Inpatient invalid date range. Date of service cannot span past January 10,1992 for inpatient claim when recipient is over 20 yrs. old.

016 N30 274 Recipient is not eligible for Medicaid services, but may be eligible for Medicare. Medicaid prescription services not covered.

016 278 Missing or invalid DCF eligibility form for Medically Needy. Photocopied form 2902's must contain denial TCN in top right when resubmitting.

016 M67 287 Procedure code or provider type of service conflict (waiver program and case management).

016 M68 288 Referring provider number not on file.

016 MA30 296 Invalid keyed claim type for provider

016 M57 300 Provider number not on file

016 N31 302 DPR number is not on file

016 N59 322 Screening required, none indicated.

016 M45 331 Newborn occurrence code missing. When admit and birth dates are equal, and the newborn's length of stay exceeds the mother's use occur. Code 51

016 M45 590 4th surgery date or stay conflict

016 M45 591 5th surgery date or stay conflict

016 M67 710 DUR conflict code missing or invalid or not defined in NCPDP data.

016 M67 711 DUR intervention code missing or invalid or not defined in NCPDP data.

016 M67 712 DUR outcome code missing or invalid, or not defined in NCPDP data.

016 MA38 715 Missing or invalid birth date

016 MA38 716 Non-matched birth date to recipient file

016 M49 723 Missing or invalid ingredient cost

016 MA66 724 Missing or invalid date prescription written

016 M45 730 Missing or invalid other payor date

016 M45 731 Missing or invalid eligibility override code

016 N3 904 Consent form invalid. You may correct any item on the form except signature & date of: patient, person obtaining consent & interpreter.

016 N59 905 Acknowledgment form missing.

016 N59 906 Acknowledgement form invalid or incomplete.

016 N29 914 Paper claim required. Submit with report or attachment if indicated.

018 101 Duplicate. Claim has been previously paid on date indicated or if zeroes printed for previous date paid, another submission paid or pended on this remit.


A-8 October 2003

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

018 102 Possible duplicate. May be a conflict with a claim by another provider. Write P.O. Box 7070, Tallahassee, FL 32314-7070 for information.

018 103 Possible duplicate conflict. May be a conflict with another provider's claim. For more information please call Provider Services at 1-800-289-7799.


018 105 Inpatient claim duplicate of outpatient claim or vice versa. Outpatient services not payable for day before or same day of an inpatient claim.

018 M63 107 Recip. no., prov. no., and Rx no. are the same and current claim DOS is more than 366 days before or after the previous claim DOS.

018 M80 207 A surgical procedure (without a modifier) is billed within the follow-up of a previous surgical procedure.

018 N20 211 Rural health encounter limit - cannot bill multiple rural health encounters for the same service date.

018 N20 220 CPHU encounter limit - cannot bill multiple CPHU encounters for the same service date.

018 N20 222 FQHC encounter limit - cannot bill multiple FQHC encounters for the same service date.

018 224 Duplicate dental resin within three years

018 707 Drug therapeutic duplication.

018 709 Recipient has duplicate Rx filled at another pharmacy - still active.

018 718 Duplicate claim - different prescriber

022 237 Medicare coverage is present

023 221 Medicaid allowed charge equal to zero

028 N30 635 Recipient is SLMB, not eligible for Medicaid services

029 128 Claim exceeds 12 month filing limit.

029 168 Crossover claim exceeds filing limit. Filing limit is 6 months from Medicare EOMB date or 12 mos. from date of service, whichever is later.

029 N59 846 Adjustment exceeds 12 months from date. See provider manual for exception criteria.

031 129 Invalid recipient I.D. number.

031 130 Invalid recipient check digit (10th digit of recipient number)

031 250 Recipient ID no. not on file. Because update may arrive from DCF, Recip. File is rechecked weekly for a match. If number incorrect, resubmit now.


October 2003 A-9

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

031 250 Recipient ID no. not on file. Because update may arrive from DCF, Recip. File is rechecked weekly for a match. If number incorrect, resubmit now.

031 251 Recip ID # not on file-denied after pending 14 days awaiting DCF update. If no. incorrect, resubmit. If correct-contact your DCF district office.

031 252 Recipient is not active

031 270 Recip. inelig. for date of srv. - denied after being pended for 14 days awaiting DCF update. If you have elig proof contact DCF district office.

031 271 Recip. inelig. for date of srv. - will pend for up to 14 days awaiting DCF update. Recip elig rechecked weekly for arrival of DCF update.

031 271 Recip. inelig. for date of srv. - will pend for up to 14 days awaiting DCF update. Recip elig rechecked weekly for arrival of DCF update.

035 003 New patient nursing home visits are limited to one per lifetime per recipient.

035 015 This procedure is limited to one time in a lifetime.

035 016 This procedure is limited to two times in a lifetime.

035 M53 027 Procedure code exceeds units of service limit.

035 050 This procedure limited to $1000.00 per year per client.

035 056 Appendectomy is limited to one in a lifetime. This limit has been previously met.

035 062 Normal newborn care. Limit 1 in lifetime.

035 073 Procedures applicable to this exception are limited to three in a lifetime. This limit has been previously met.

035 M13 079 Initial consultations are limited to one per recipient per provider.

035 084 Hospital beds limited to 10 rental payments in a recipient's lifetime.

035 094 This procedure limited to $500.00 per month per client.

035 650 Benefit cap limit has been exceeded.

036 MA125 396 Co-pay deducted or paid in full.

037 229 Sum of coinsurance and deductible amounts greater than claim charge.

037 503 Medicaid allowed charge equal to zero. (MDs, DOs, DPMs and chiropractor. co-ins. or deductible pit cannot exceed Medicaid's max fee for this proc.)

038 860 Service not authorized by MediPass primary care physician. Referring physician not Medipass primary care physician.

038 861 Claim must be processed through PSN.

038 861 Claim must be processed through PSN.

038 862 Claim must be processed through the PSN.


A-10 October 2003

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

039 501 Prior authorization not approved.

039 514 Prior auth line not approved.

040 N54 314 Out-of-state claim not payable - claim reviewed. Services not prior authorized & non-emergency and are therefore not covered.

040 000 329 File indicates you are enrolled as an in-state, non-particip. provider. Claim was reviewed. Srvs deemed non-emergency and non-covered.

040 M85 397 Elective surgery emergency indicated.

040 400 Emergency treatment under review- dental.

042 N6 166 Medicare deductible greater than allowed deductible.

042 318 Calculated payment equals zero, other ins. Paid more than Medicaid allowable.

042 N45 351 Allow to sub percent diff ex.

042 N45 352 Sub to allow percent diff ex.

042 503 Medicaid allowed charge equal to zero. (MDs, DOs, DPMs and chiroprct. co-ins. or deductible pymt cannot exceed Medicaid's max fee for this proc.)

042 700 Drug dose per day exceeds DUR maximum.

042 701 Prescription refill too early.

042 714 Maximum duration exceeded

042 728 Maximum refills exceeded

042 729 Plan limitations exceeded

042 734 Excessive duration alert

045 N14 339 Quantity greater than maximum allowed on plan file.

047 342 Diagnosis not covered.

047 344 Diagnosis not on file.

047 M81 346 Diagnosis not specific.

047 450 First diagnosis code not on file.

047 451 First diagnosis code not covered.

047 M81 456 Diagnosis not specific enough. Refer to ICD-9 book. See if adding a fourth or fifth digit more clearly defines the patient's condition.

047 460 Second diagnosis code not on file.

047 461 Second diagnosis code not covered.

047 M81 466 Secondary diagnosis code not specific. Refer to ICD-9 book. See if adding a 4th or 5th digit more clearly defines the patient's condition.


October 2003 A-11

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

adding a 4th or 5th digit more clearly defines the patient's condition.

047 471 Third diagnosis code not covered.

047 M81 476 Third diagnosis code not specific.

047 480 Fourth diagnosis code not on file.

047 481 Fourth diagnosis code not covered.

047 M81 486 Fourth diagnosis code not specific.

047 490 Fifth diagnosis code not on file.

047 491 Fifth diagnosis code not covered.

047 M81 496 Fifth diagnosis not specific.

047 M64 605 6th thru 11th diag. code is not found

048 M86 024 These procedures not allowed same date of service.

048 N59 025 Procedure not allowed with anesthesia (00100-01999).

048 N56 026 Procedure not allowed with critical care (99160-99174 and 99291 and 99292).

048 213 Procedure code or diagnosis or drug not covered for family planning.

048 430 Procedure code not on file.

048 431 Procedure code not covered.

052 218 X-over claim type not allowed for provider type

052 721 Prescriber not active.

056 000 702 Drug-drug interaction.

056 000 719 Ingredient duplication alert.

057 000 164 Invalid nursing home level of care.

057 357 Days supply less than drug minimum.

057 358 Days supply greater than drug maximum.

057 359 Unit dose differential not allowed, packaging completed by manufacturer. This limit has previously been met.

057 000 720 Low dose alert

057 N54 953 Home health visits W9611, W9612, W9613 and W9620, are limited to 60 visits unless prior authorized.

062 MA120 140 Invalid certification number.

062 327 First surg. proc. is elective & no prior authoriz. # entered. Non-prior authorized hysterectomies permissible in documented emerg. situations.


A-12 October 2003

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

062 N59 328 First surg proc is elective. Procedure requires prior auth. unless performed as a result of EPSDT screen.

062 000 335 Family planning certification required.

062 000 336 Dialysis certification required.

062 000 337 Procedure requires prior auth.

062 353 Prior authorization number is missing.

062 370 Physicians: refer prov req'd for this proc in field 17a or 19. Therapists, home health & DME suppliers: svc. requires a svc. auth. in field 17A or 19.

062 399 Elective surgery: no prior authorization number on claim.

062 436 Procedure code requires prior authorization.

062 500 PA not on file or not in date.

062 N54 510 Prior authorization or provider conflict.

062 N54 511 Procedure billed not in prior authorization record.

062 N54 512 Procedure performed on date of service after prior authorization expiration date.

062 N54 513 Dental claim filed before prior authorization beginning valid date.

062 N45 515 Prior authorization for procedure code exhausted.

062 516 Prior authorization status is "used".

062 517 Service date 912 days after PA issue.

062 556 First surgical procedure requires prior authorization.

062 M46 588 A claim for inpatient services covers more than 15 days, the recipient is less than 21 years old, and the diagnosis code is 290.00-316.99.

062 N54 603 Prior authorization is used.

062 N54 617 Prior auth line item is used.

062 M62 669 Diagnosis is 290.0-314.9 and PA does not begin 7777 for admit prior to 7/1/98 or 3333 for admit on or after 7/1/98, or, xxxx 895xxx (after 1/1/01)

062 N3 903 Consent form incomplete. You may complete any item on the form except signature & date of: patient, person obtaining consent & interpreter

062 931 Service authoriz. (SA) no. required for service. Enter in field 17 on form 081 or field 17a on HCFA-1500. Contact area Medicaid office for SAs.

062 N54 934 Prior auth (PA) record does not contain this proc. If PA not req'd for this proc., rebill this line on separate form without PA no. in field 4.

062 935 Service authorization (SA) number required for this service. Electronic billers should enter this number in the referring provider number field.

078 M53 186 Hospice total units greater than total days.

096 N18 169 Medicare paid amt. is zero. If Medicaid covers proc., complete Medicaid claim form, attach Medicare denial. Send to your area


October 2003 A-13

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

Medicaid claim form, attach Medicare denial. Send to your area Medicaid office.

096 254 Service not allowed

096 275 Service not covered for recipient.

096 M97 316 Procedure invalid in nursing home

096 317 Provider charge record or HMO PHP record not found.

096 M50 347 Outpatient revenue code not on file or not covered - if rev. code is in the range 960-981 (prof. svs.), it must be billed on the HCFA-1500.

096 348 This drug or item is not covered by the Florida Medicaid program.

096 N39 355 Invalid tooth number or invalid for sealants.

096 N39 356 Invalid alpha tooth number.

096 M119 360 NDC code not found on file.

096 N37 361 Tooth number or letter required.

096 N37 362 Tooth surface or quadrant required.

096 N60 390 NDC not covered for NH recipient.

096 550 First surgical procedure code not on file.

096 551 First surgical procedure not covered.

096 560 Second surgical procedure not on file.

096 561 Second surgical procedure not covered.

096 570 Third surgical procedure not on file.

096 571 Third surgical procedure not covered.

096 M67 621 4th surgical procedure not found.

096 M67 623 6th surgical procedure not found.

096 M67 625 5th surgical procedure not covered.

096 M67 626 6th surgical procedure not covered

097 N59 801 Procedure not allowed to be billed in addition to components (93225-93227).

097 N59 802 Procedure not allowed with component parts (93231-93233).

097 N59 977 Procedure not allowed to be billed with 59410.

097 N59 986 Procedure not allowed with obstetrical panel billing (80055).

097 N59 992 Procedure not allowed with lipid panel billing (80061).

097 N59 996 Procedure not allowed with torch antibody panel billing (80090).

110 M52 113 Admission date or from date conflict.

110 127 Last date of service after billing date.


A-14 October 2003

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

110 144 Last date of service after date received.

118 MA64 581 Invalid combination of RPICC services. There is TPL for this claim.

119 M90 004 Procedure is limited to one time in a one-year period. If you billed for more than one unit on this claim, rebill for one unit only.

119 M90 005 Procedure is limited to three times in one-year period per recipient.

119 006 Procedure is limited to two times in three years. If you billed for more than two units on this claim, rebill for two units only.

119 M90 009 Procedure limited to two times in a one-year period.

119 013 This procedure is limited to one in seven days.

119 017 This procedure is limited to one time in three calendar years.

119 022 Limit five times per lifetime.

119 023 Procedure limited to four times in a lifetime.

119 029 This procedure is limited to two in 300 days.

119 031 Service limit 224 units in 7 days per recipient

119 M67 032 This procedure is limited to 10 in 300 days

119 033 This procedure limited to 14 in 300 days

119 000 034 One visit per recipient per provider per month

119 039 Chiropractic services are limited to twenty-four per calendar year.

119 052 More than one Healthy Start prenatal payment in 365 days.

119 000 055 1 per month

119 000 066 Vaginal deliveries or total OB care is limited to one per recipient in a ten-month period. This limit has been previously met.

119 067 Services applicable to this edit are limited to one in 300 days. This limit has been previously met.

119 000 071 Procedures applicable to this edit are limited to one in three years.

119 M90 072 Denture relinings are limited to one per denture in one year. This limit has been previously met.

119 000 075 Service limited to one in 300 days this limit has been exceeded.

119 M90 082 Walkers are limited to one per year.

119 089 This procedure code is limited to two units per client per month.

119 092 This procedure is limited to four in one week. Limit has been met.

119 000 662 SNU max days exceeded

119 N59 919 Max allowed 20 units per calendar month.

119 N59 924 56 max units of service per calendar month.

119 N59 946 Day treatment not to exceed 192 units perfiscal year.


October 2003 A-15

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

119 N59 947 Treatment plan cannot not exceed one per state fiscal yr.

119 N59 948 W1074 limited to 26 per fiscal year for CMH

119 N59 949 W1075 limited to 52 per fiscal year CMH

119 N59 951 CMH limit W1027 to one per fiscal yr.

119 N59 955 Mental health day treatment limit for CMH

119 M90 963 Procedure limited to one time in a one-year period.

119 N59 965 Procedure limited to one time in six months.

119 N59 966 Nebulizer rental limit exceeded.

119 N59 967 Treatment plan review limited to six times per fiscal years.

120 N42 280 Service is covered by prepaid mental health plan (PMHP).

120 MA43 307 Medikid not enrolled with managed care provider.

120 308 Recipient enrolled in an HMO or pre-paid health plan and this service is covered by the HMO or pre-paid health plan.

125 M46 596 Missing occurrence span code and dates.

125 M46 615 Units billed on revenue codes 100-219 do not match covered date spans.


133 M85 104 Multiple surgery requires medical review.

133 113 Admission date - from date conflict.

133 113 Admission date - from date conflict.

133 257 Recipient is under review. Possible PA for transplant service.

133 258 Transplant recipient under review.

133 279 Alien - claim requires medical review. If you did not attach medical reports to this submission, please do so and resubmit.

133 321 Claim requires AHCA manual review

133 000 333 Compound drug requires manual price.

133 000 343 Diagnosis requires medical review.

133 345 Diagnosis requires med review.

133 N35 411 Provider is under review and cannot submit claims via point of sale.

133 432 Procedure code requires medical review.

133 433 Procedure requires medical review.

133 606 6th diag code requires med review.


A-16 October 2003

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text





133 000 613 Claim has been reviewed. Refer to EOB 901-940 for denial reason.

133 000 614 Claim has been reviewed. Refer to EOB 901-940 for denial reason.

133 N30 656 Recipient cap not found.

133 N36 717 TPL payor amount less than 20%

135 M144 057 Billed service included in global reimbursement package.

141 M46 112 This service cannot be billed with a date span that includes 2 or more months. Rebill with one month of services per claim line.

141 N62 114 Claim spans fiscal year end date of June 30. Split bill June services onto one claim and July services onto another claim.

141 MA32 661 SNU leave days present.

146 470 Third diagnosis code not on file.

148 M57 408 Medicare prov no. for treating prov not on Medicaid’s Cross-ref. File. Notify Prov. Enrollment unit of all group member's Medicare prov. nos.

148 N77 409 Treating provider number missing or invalid. Groups must enter 9-digit prov. number for indiv. treating prov. in block 19 of EPSDT form 221.

148 N77 410 Treating provider no. on claim is missing or invalid. On HCFA-1500 claim form, enter in field 24k. On the 081 Non-instit. form, enter in field 6.

148 M68 415 Treating provider or referring provider number are equal.

A1 N56 036 Procedure not allowed with NICU care (99295-99297)

A1 N56 042 Combination of these procedure codes not allowed

A1 M50 137 Invalid financial class code.

A1 M46 304 Partial approval "mo" dates are not within admit or discharge dates.

A1 N34 313 These services cannot be billed on this claim form or the provider type listed for this provider number cannot file this type of claim.

A1 N109 314 Out-of-state claim not payable - claim reviewed. Services not prior authorized & non-emergency and are therefore not covered.

A1 MA11 325 Trauma or accident claim, the accident indicator on the diagnosis record is "Y" (yes).

A1 326 DESI drug or drug pricing not available on date of service.

A1 MA79 354 Mid-month rate change.

A1 M53 369 Submitted charge is not evenly divisible by units of service.


October 2003 A-17

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

A1 N56 372 Procedure code not covered for claim type.

A1 N60 376 The NDC billed is not under rebate agreement.

A1 M123 377 DER ind per dose form conflict

A1 N34 380 Claim was billed on incorrect claim form.

A1 N77 381 No provider rate for date of service (may have been billed under incorrect provider number)

A1 MA66 382 Procedure being billed for pathology has no technical component segment.

A1 MA66 384 Model waiver provider error. Did not bill proc. W9894 or W9895 or W9900 or W9901

A1 MA51 388 No CLIA registration on file for this provider.

A1 M53 394 Units of service not compatible with date span billed. If only one date of service billed, a date span may be required for no. of units billed.

A1 M46 395 Date span billing not allowed for this procedure code. Bill each date of service on a separate claim line.

A1 N80 401 Elective surgery: no screening on claim.

A1 N111 402 Paid related claim. Charlie MCM 3/11/03

A1 N77 412 Treating provider number not on file.

A1 N109 413 Treating provider's claim denied after DCF.

A1 M77 419 Independent laboratory - invalid place of service.

A1 N109 452 Claim has been reviewed. Refer to EOB codes 901 - 940 for denial reason.


A1 N109 463 Claim has been reviewed. Refer to EOB codes 901-940 for denial reason.

A1 N109 472 Claim has been reviewed. Refer to EOB codes 901-940 for denial reason.




A1 N54 502 Claim recipient number or prior authorization recipient number conflict.







A-18 October 2003

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

reason.


A1 N109 580 This RPICC procedure has been reviewed by DCF.

A1 M15 583 Multiple anesthesia procedure codes (00100 - 01999) for the same recipient, provider, and dates of service are not allowed.

A1 M86 943 These procedures not allowed same date of service.

A1 M86 956 Not allowed with CMH rehab.

B03 667 Covered in per diem.

B07 228 Pay to provider nonparticipating.

B07 228 Pay to provider nonparticipating.

B07 301 Provider ineligible for category of service for this date of service.

B07 306 Prescribing provider Medicaid terminated.

B07 320 Provider not certified for procedure.

B07 366 Procedure restricted to certain specialty(ies). Provider not enrolled for necessary specialty (or treating prov not identified on claim).

B07 421 Treating prov is a group prov.

B07 422 Treating provider not eligible for date of service.

B07 N55 423 Treating provider is not a member of the pay to provider's group.

B07 424 Pay to provider ineligible for date(s) of service.

B07 N55 427 Pay to provider number is not a group.

B07 N95 663 Invalid loc for SNU prov.

B07 N95 664 Pay to provider not authorized for direct payment. Contact Provider Enrollment for instructions.

B07 000 665 Pay to provider's mail is undeliverable. Contact Provider Enrollment for instructions.

B13 108 New patient visit has been previously paid.

B13 M144 109 Surg. srv. includes follow-up hosp. & office visits. If visit claim pays first, surgery will deny. Void visit pymt then resubmit surgery claim.

B14 000 028 Multiple visits same day

B14 M86 088 Procedures not allowed same date of service

B14 090 These procedures not allowed same day.

B14 106 Multiple visits same day.

B14 M67 111 Both visit and surgery not covered on same date of service.


October 2003 A-19

X12 Adj. Code

X12 Remark

Code

MMIS EOB Code

MMIS EOB Text

B18 M50 110 Invalid combination of procedures or revenue codes. This is a fatal EDI edit do not resubmit.

B18 M67 368 Invalid combination of procedure codes for private transportation.

B18 373 Anesthesia services must be billed using 00100 - 01999 range of CPT codes for dates of service 10/1/89 and after.

B18 375 An old anesthesia procedure was billed with a new anesthesia modifier.

B18 378 No rate on procedure file for date of service.

B18 437 Procedure code not covered for date of service.

B18 439 Procedure code not allowed for date of service.

B18 440 Procedure code requires medical review for date of service.

B18 442 Invalid procedure code and modifier

B18 N60 722 NDC obsolete or discontinued by manufacturer.

B18 725 Invalid compound code

B19 N115 627 Claim has been reviewed. Refer to EOB 901-940 for denial reason.

D02 000 338 Quantity less than minimum allowed.

D06 N29 438 Manual price-requires report.

Durable Medical Equipment and Supplies Coverage and Limitations Handbook

Local Code Local Code DescriptionHCPCS/CPT

CodeProcedure Code

Clarification

W4087Supply Kit - Portable Pump w/ Subcutaneous/Percutaneous Line A4221

W4088

Supply Kit - Portable Pump w/ Implanted Access Device, Port-A-Cath A4221

W4090 Catheter Irrigation Solution, 250cc A4323W4097 Adapter for Connector For Tubing A4331

W4097Extension Tubing For Connecting Appliance A5200

W4097 Adapter for Connector For Tubing A7002W4098 Adapter or Connector For Tubing A4222

W4102Replacement Filters For Use With Filters A4481

W4107 Ostomy Support Belt A4396

W4165Blood Lancet Device (Autoclix, Monojecto) A4258

W9760

Pediatric Postural Control Walker, Any Size, Any type (E.G. Kaye, Strider) E0146

W9761

Pediatric Forearm Crutches; Alumumim, Hand Grip Height Adjustable E0110

W9761

Pediatric Forearm Crutches; Alumumim, Hand Grip Height Adjustable E0111

W9762

Pediatric Safety Crib With Metal Tube Ends and Sides with Enclosure Top E0316

W9763Resuscitator Bag, Self-Inflating; Hand Held; Non-Disposable Pediatric S8999

W9765Neulizer Kit for Administration of Aerosolized Medication A7007

W9766

Suction Machine w/ Vacuum Regulator; Battery Operated; Includes Rechargeable E0600

Use this chart to determine the correct procedure code to use for dates of services on or after October 16, 2003. Refer to your Coverage and Limitation Handbook for the complete description and associated filing information for these codes. Any "W" codes listed in the handbook will be obsolete for dates of service on or after October 16, 2003.

Advance Update to Appendices B and C

October 2003 Page 1

Durable Medical Equipment and Supplies Coverage and Limitations Handbook

Local Code Local Code DescriptionHCPCS/CPT

CodeProcedure Code

Clarification

W9767Foot Orthosis, for Congenital Forefoot Deformities L3050

Foot, Arch Support, Removable, Premolded, Metatarsal, Each


Foot, Arch Support, Removable, Premolded, Longitudinal/Metatarsal, Each


Foot, Arch Support, Nonremovable, Attached To Shoe, Longitudinal, Each

W9768Pediatric Dynamic Splinting Device, Allows Independent Leg Motion L4386

W9769

Sponge; Drain, Dressing, IV or Tracheostomy; Sterile or Non-Sterile Any Size A9900

October 2003 Page 2