Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.09-046 - Prosthetics Provider Manual Update Transmittal #135

Current through Register Vol. 49, No. 6, June, 2024
Section IIProsthetics
242.110
Respiratory and Diabetic
			 Equipment, All Ages 1-1-10
When billed either electronically or on paper, procedure codes
				found in this section must be billed with certain modifiers. Modifiers in the
				section are indicated by the headings M1 and M2. When only the NU modifier is
				shown in the M1 column, the procedure code may be billed for beneficiaries of
				all ages. When NU and EP are listed together in the M1 column, the NU modifier
				must be used when billing for beneficiaries age 21 and over, and the EP
				modifier must be used when billing for beneficiaries under age 21. When a
				modifier is listed in the M2 heading, that modifier must be used in conjunction
				with either NU or EP.
Prior authorization requirements are shown under the heading
				PA. .If prior authorization is needed, the information is indicated with a "Y"
				in the column; if not, an "N" is shown.
* Prior authorization is not required when other insurance pays
				at least 50% of the
Medicaid maximum allowable reimbursement amount.
***(...) This symbol, along with text in parentheses, indicates
				the Arkansas Medicaid description of the product. When using a procedure code
				with this symbol, the product must meet the indicated Arkansas Medicaid
				description.
Respiratory and Diabetic Equipment, All Ages (section
				242.110)
Procedure Code
M1
M2
Description
PA
Payment Method
A4230
NU
Infusion set for external insulin pump, nonneedle
						  cannula type
Y*
Purchase
A4231
NU
Infusion set for external insulin pump, needle
						  type
Y*
Purchase
A4232
NU
Syringe with needle for external insulin pump, sterile,
						  3 cc
Y*
Purchase
A4627
NU
UB
***(Spacer bag or reservoir without mask, for use with
						  metered dose inhaler) Spacer, bag or reservoir, with or without mask, for use
						  with metered dose inhaler
N
Purchase
A4627
NU
***(Spacer bag or reservoir with mask, for use with
						  metered dose inhaler) Spacer, bag or reservoir, with or without mask, for use
						  with metered dose inhaler
N
Purchase
A6021
NU
Collagen dressing, pad size 16 sq. in. or less,
						  each
Y*
Purchase
A6022
NU
Collagen dressing, pad size more than 16 sq. in. but
						  less than or equal to 48 sq. in., each
Y*
Purchase
A6023
NU
Collagen dressing, pad size more than 48 sq. in.,
						  each
Y*
Purchase
A6024
NU
Collagen dressing wound filler, per 6 in.
Y*
Purchase
A7034
NU
RR
***(CPAP Device Nasal Continuous Positive Airway
						  Pressure (CPAP) Device; includes necessary accessory items)
NOTE:
						  Complete medical data pertinent to the request must be submitted with the prior
						  authorization request. NOTE: Bill A7034 as the global daily rental service.
Nasal interface (mask or cannula type) used with positive airway
						  pressure device, with or without head strap
Y*
Rental Only
A7045
NU
Exhalation port with or without swivel used with
						  accessories for positive airway devices, replacement only
N
Purchase
A7046
NU
Water chamber for humidifier, used with positive airway
						  pressure device, replacement, each
N
Purchase
A9999
NU
***(Unlisted Durable Medical Equipment.
The
						  manufacturer's invoice must be attached to the claim form.)
Misc. DME
						  supply or accessory, not otherwise specified
Y
Manually Priced
E0424
NU
Stationary compressed gaseous oxygen system, rental;
						  includes container, contents, regulator, flowmeter, humidifier, nebulizer,
						  cannula or mask, and tubing
Y*
Rental Only
E0430
NU
Portable gaseous oxygen system, purchase, includes
						  regulator, flowmeter, humidifier, cannula or mask, and tubing
Y*
Rental Only
E0434
NU
Portable liquid oxygen system, rental; includes
						  portable container, supply reservoir, humidifier, flowmeter, refill adapter,
						  contents gauge, cannula or mask, and tubing
Y*
Rental Only
E0435
NU
Portable liquid oxygen system, purchase; includes
						  portable container, supply reservoir, flowmeter, humidifier, contents gauge,
						  cannula or mask, tubing and refill adapter
Y*
Rental Only
E0439
NU
Stationary liquid oxygen system, rental; includes
						  container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or
						  mask, and tubing
Y*
Rental Only
E0441
NU
Oxygen contents, gaseous (for use with owned gaseous
						  stationary systems or when both a stationary and portable gaseous system are
						  owned), one month's supply = I unit
Y
Purchase
E0442
NU
Oxygen contents, liquid (for use with owned liquid
						  stationary systems or when both a stationary and portable liquid system are
						  owned), one month's supply = 1 unit
Y
Purchase
E0443
NU
Portable oxygen contents, gaseous (for use only with
						  portable gaseous systems when no stationary gas or liquid system is used), one
						  month's supply=1 unit
Y*
Purchase
E0444
NU
Portable oxygen contents, liquid (for use only with
						  portable liquid systems when no stationary gas or liquid system is used), one
						  month's supply=1 unit
Y*
Purchase
E0470
NU EP
RR RR
***(BIPAP Device, Nasal Bi-level Positive Airway
						  support system; includes necessary accessory items.
NOTE: Complete
						  medical data pertinent to the request must be submitted with the prior
						  authorization request.)
Respiratory assist device, bi-level pressure
						  capacity, without backup rate feature, used with noninvasive interface, e.g.,
						  nasal or facial mask (intermittent assist device with continuous positive
						  airway pressure device)
Y4 Y4
Rental Only
E0471
NU EP
RR RR
Respiratory assist device, bi-level pressure capacity,
						  with backup rate feature, used with noninvasive interface, e.g., nasal or
						  facial mask (intermittent assist device with continuous positive airway
						  pressure device)
Y*
Y4
Rental Only
E0472
NU EP
RR RR
Respiratory assist device, bi-level pressure capacity,
						  with backup rate feature, used with invasive interface, e.g., nasal or facial
						  mask (intermittent assist device with continuous positive airway pressure
						  device)
Y*
Y4
Rental Only
E0482
NU EP
Cough stimulating device, alternating positive and
						  negative airway pressure
Y*
Capped Rental
E0483
NU
RR
***(Bronchial Drainage System) High-frequency chest
						  wall oscillation air-pulse generator system (includes hoses and vest),
						  each
Y*
Capped Rental
E0483
NU
UB
***(Pulmonary Vest.
The manufacturer invoice must
						  be attached to the claim form.)
High-frequency chest wall oscillation
						  air-pulse generator system (includes hoses and vest), each
Y*
Purchase
E0560
NU UE
Humidifier, durable for supplemental humidification
						  during IPPB treatment or oxygen delivery
N
Purchase
E0561
NU EP
Humidifier, non-heated, used w/positive airway pressure
						  device
Y*
Purchase
E0562
NU
Humidifier, heated, used w/positive airway
Y*
Purchase
EP
pressure device
Y*
E0570
NU UE
Nebulizer, with compressor
Y*
Purchase
E0575
NU UE
Nebulizer, ultrasonic, large volume
Y*
Capped Rental
E0600
NU UE
Respiratory suction pump, home model, portable or
						  stationary, electric
N
Rental Only
E0779
NU
RR
***(Ambulatory infusion device, payable only when
						  services are provided to patients receiving chemotherapy, pain management or
						  antibiotic treatment in the home) Ambulatory infusion pump, mechanical,
						  reusable, for infusion 8 hours or greater
Y*
Rental Only
E0784
NU
External ambulatory infusion pump, insulin
Y*
Purchase
E1340
NU
***(DME Repair: Parts Only Repairs will not be approved
						  for more than the allowed purchase price of new equipment.
The
						  manufacturer's invoice must be attached to the repair claim for all parts.)
Repair or non routine service for durable medical equipment requiring
						  the skill of a technician, labor component, per 15 minutes
N
N/A
E1340
NU
U4
/*(Maintenance for Capped Rental items) Repair or non
						  routine service for durable medical equipment requiring the skill of a
						  technician, labor component, per 15 minutes
N
N/A
E1340
NU
U1
***(Labor Only; a maximum of twenty (20) units per date
						  of service is allowable. 20 units = 5 hours of labor) Repair or non routine
						  service for durable medical equipment requiring the skill of a technician,
						  labor component, per 15 minutes
N
N/A
E1340
EP
U1
***(Labor Only; a maximum of twenty (20) units per date
						  of service is allowable. 20 units = 5 hours of labor) Repair or non routine
						  service for durable medical equipment requiring the skill of a technician,
						  labor component, per 15 minutes
N
N/A
E1390
NU
Oxygen concentrator, single delivery port, capable of
						  delivering 85 % or greater oxygen concentration at the prescribed flow
						  rate
Y*
Rental Only
E1391
NU
02 concentrator, dual delivery port, capable of
						  delivering 85% or greater oxygen concentration at the prescribed flow rate,
						  each
Y4
Rental Only
242.111
Initial Rental of a DME Item for Individuals of All Ages 1-1-10
Procedure codes found in this section may be billed either
				electronically or on paper.
Some procedure codes have been assigned a modifier that affects
				the billing process. Required modifiers are indicated in the M1 column in the
				list below. When a modifier is shown in the M1 column, it must be listed along
				with the procedure code when requesting payment by Arkansas Medicaid.
Procedure codes shown in the list below are either covered for
				all ages (AA), only for individuals under age 21 (U21) or only for individuals
				age 21 and over (21+). A column in the list below defines the
				differences.
* Prior authorization is not required when other insurance pays
				at least 50% of the
Medicaid maximum allowable reimbursement amount.
***(...) This symbol, along with text in parentheses, indicates
				the Arkansas Medicaid description of the product. When using a procedure code
				with this symbol, the product must meet the indicated Arkansas Medicaid
				description.
Initial Rental of a DME Item for Individuals of All Ages
				(section 242.111)
Procedure Code
M1
Description
All U21 21
+
A7034*
***(CPAP Device Nasal Continuous Positive Airway
						  Pressure (CPAP) Device; includes necessary accessory items.
NOTE: For
						  21+, complete medical data pertinent to the request must be submitted with the
						  prior authorization request.
Nasal interface (mask or cannula type) used
						  with positive airway pressure device, with or without head strap
AA
E0181
Pressure pad, alternating with pump, heavy
						  duty
U21
E0200
Heat lamp, without stand (table model), includes bulb,
						  or infrared element
U21
E0205
Heat lamp, with stand includes bulb, or infrared
						  element
U21
E0217
Water circulating heat pad with pump
U21
E0225
Hydrocollatorunit, includes pad
U21
E0236
Pump for water circulating pad
U21
E0239
Hydrocollatorunit, portable
U21
E0250*
Hospital bed, fixed height, with any type side rails,
						  with mattress
U21
E0250*
U1
Hospital bed, fixed height, with any type side rails,
						  with mattress
U21
E0250*
UE
Hospital bed, fixed height, with any type side rails,
						  with mattress
21 +
E0255*
Hospital bed, variable height; hi-lo, with any type
						  side rails, with mattress
U21
E0255
KH
Hospital bed, variable height; hi-lo, with any type
						  side rails, with mattress
21 +
E0260*
Hospital bed, semi-electric (head and foot adjustment),
						  with any type side rails with mattress
U21
E0260*
KH
Hospital bed, semi-electric (head and foot adjustment),
						  with any type side rails with mattress
21 +
E0271
Mattress, inner spring
U21
E0272
Mattress, foam rubber
U21
E0303
Hospital bed, heavy duty, extra wide, with weight
						  capacity [GREATER THAN] 350 but [LESS THAN] or = 600, any type side rails,
						  w/mattress
AA
E0424
Stationary compressed gaseous oxygen system, rental;
						  includes container, contents, regulator flowmeter, humidifier, nebulizer
						  cannula or mask, and tubing
AA
E0430*
Portable gaseous oxygen system, purchase, includes
						  regulator, flowmeter, humidifier, cannula, or mask, and tubing
AA
E0434
Portable liquid oxygen system, rental; includes
						  portable container, supply reservoir, humidifier, flowmeter, refill adaptor,
						  contents gauge, cannula or mask, and tubing
AA
E0435*
Portable liquid oxygen system, purchase; includes
						  portable container, supply reservoir, flowmeter, humidifier, contents gauge,
						  cannula or mask, tubing and refill adapter
AA
E0439
Stationary liquid oxygen system, rental; includes
						  container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or
						  mask, and tubing
AA
E0445*
Oximeter for measuring blood oxygen levels
						  non-invasively. *** (Pulse oximeter, including 4 disposable probes)
AA
E0480
Percussor, electric or pneumatic, home
						  model
U21
E0565*
Compressor, air power source for equipment which is not
						  self-contained or cylinder driven
U21
E0575*
Nebulizer, ultrasonic, large volume
AA
E0585
Nebulizer, with compressor and heater
U21
E0600
Respiratory suction pump, home model, portable or
						  stationary, electric
AA
E0606
Vaporizer, room type
U21
E0630*
Patient lift, hydraulic, with seat or sling
U21
E0630
KH
Patient lift, hydraulic, with seat or sling
21 +
E0650*
Pneumatic compressor, nonsegmental home
						  model
U21
E0667*
Segmental pneumatic appliance for use with pneumatic
						  compressor, full leg
U21
E0668*
Segmental pneumatic appliance for use with pneumatic
						  compressor, full arm
U21
E0691
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; treatment area two square feet or
						  less
U21
E0692
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; four foot panel
U21
E0693
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; six foot panel
U21
E0694
Ultraviolet multidirectional light therapy system in
						  six foot cabinet includes bulbs/lamps, timer and eye protection
U21
E0720*
TENS, two lead, localized stimulation
U21
E0730*
Transcutaneous electrical nerve stimulation (TENS)
						  device, four or more leads, for multiple nerve stimulation
AA
E0730*
KH
Transcutaneous electrical nerve stimulation (TENS)
						  device, four or more leads, for multiple nerve stimulation
21 +
E0745*
Neuromuscular stimulator, electronic shock
						  unit
U21
E0779*
***(Ambulatory infusion device, payable only when
						  services are provided to patients receiving chemotherapy, pain management or
						  antibiotic treatment in the home) Ambulatory infusion device pump, mechanical,
						  reusable, for infusion 8 hours or greater
AA
E0910
Trapeze bars, also known as Patient Helper, attached to
						  bed, with grab bar
AA
E0910
KH
Trapeze bars, also known as Patient Helper, attached to
						  bed, with grab bar
21 +
E0911
Trapeze bar, heavy-duty, for patient weight capacity
						  greater than 250 pounds, attached to bed, with grab bar
AA
E0920
Fracture frame, attached to bed, includes
						  weights
U21
E0930
Fracture frame, freestanding, includes
						  weights
U21
E0935*
Passive motion exercise device
U21
E0940
Trapeze bar, freestanding, complete with grab
						  bar
U21
E0941
Gravity assisted traction device, any type
U21
E1130*
Standard wheelchair, fixed full-length arms, fixed or
						  swing-away, detachable footrests
U21
E1130*
KH
Standard wheelchair, fixed full-length arms, fixed or
						  swing-away, detachable footrests
21 +
E1224*
Wheelchair with detachable arms, elevating
						  legrests
AA
E1224*
U1
***(Footrests wheelchair with detachable arms,
						  elevating leg rests) Wheelchair with detachable arms, elevating
						  legrests
21 +
E1390
Oxygen concentrator, single delivery port, capable of
						  delivering 85% or greater oxygen concentration at the prescribed flow
						  rate
AA
E1391
Oxygen concentrator, dual delivery port, capable of
						  delivering 85 percent or greater oxygen concentration at the prescribed flow
						  rate, each
AA
Providers will be reimbursed for a minimum of 30 days of rental
				when the equipment is used less than 30 days. Initial rental codes must be
				billed when equipment is used less than 30 days during the first month of
				rental.
Arkansas Medicaid will only reimburse for one initial minimum
				30 days of rental per state fiscal year period per beneficiary per procedure
				code. The provider will not be reimbursed for the same procedure code utilizing
				another modifier for the same time period.
242.160
Durable Medical Equipment, All
			 Ages 1-1-10
Procedure codes found in this section must be billed either
				electronically or on paper with modifier
EP
for beneficiaries
				under 21 years of age or modifier NU for beneficiaries age 21 and older. When a
				second modifier is listed, that modifier must be used in conjunction with
				either
EP
or NU. Modifier UE is required when billing for used
				equipment.
Modifiers in this section are indicated by the headings M1 and
				M2. Prior authorization requirements are shown under the heading PA. If prior
				authorization is needed, that information is indicated with a "Y" in the
				column; if not, an "N" is shown.
* The purchase of wheelchairs for individuals age 21 and older
				is limited to one per five-year period.
*** This procedure code may not be billed for used
				equipment.
* Prior authorization is not required when other insurance pays
				at least 50% of the Medicaid maximum allowable reimbursement amount.
***(...) This symbol, along with text in parentheses, indicates
				the Arkansas Medicaid description of the product. When using a procedure code
				with this symbol, the product must meet the indicated Arkansas Medicaid
				description. 
				3 This item is a capped rental for 90
				days only, and requires PA and a review.
Durable Medical Equipment, All Ages (section
				242.160)
Procedure Code
M1
M2
M3
PA
Description
Payment Method
A4635
NU EP UE
N
Underarm pad, crutch, replacement, each
Purchase
A4636
NU EP UE
N
Replacement, handgrip, cane, crutch, or walker,
						  each
Purchase
A4637
DQ.UJ ZUJD
N
Replacement, tip, cane, crutch, walker,
						  each
Purchase
E0100
DQ.UJ ZUJD
N
Cane, includes canes of all materials, adjustable or
						  fixed, with tip
Purchase
E0105
3 0_ LU
ZUJD
N
Cane, quad or three-prong, includes canes of all
						  materials, adjustable or fixed, with tips
Purchase
E0110
NU EP UE
N
Crutches, forearm, includes crutches of various
						  materials, adjustable or fixed, pair, complete with tips and
						  handgrips
Purchase
E0111
3 CL LU
ZUJD
N
Crutch, forearm, includes crutches of various
						  materials, adjustable or fixed, each, with tip and handgrip
Purchase
E0111
NU
U1
N
Crutch, forearm, includes crutches of various
						  materials, adjustable or fixed, each, with tip and handgrip
Purchase
E0112
3 CL LU Z LU 3
N
Crutches, underarm, wood, adjustable or fixed, pair,
						  with pads, tips and handgrips
Purchase
E0113
3 CL LLI Z LU 3
N
Crutch, underarm, wood, adjustable or fixed, each, with
						  pad, tip and handgrip
Purchase
E0114
3 CL LU
Z LU 3
N
Crutches, underarm, other than wood, adjustable or
						  fixed, pair, with pads, tips and handgrips
Purchase
E0116
3 CL LU Z LU 3
N
Crutch, underarm, other than wood, adjustable or fixed,
						  each, with pad, tip and handgrip
Purchase
E0130
3 CL LU
Z LU 3
N
Walker, rigid (pickup), adjustable or fixed
						  height
Purchase
E0135
NU EP
UE
N
Walker, folding (pickup), adjustable or fixed
						  height
Purchase
E0140
NU EP
N
Walker, w/trunk support, adjustable or fixed height,
						  any type
Purchase
E0141
3 CL LU Z LU 3
N
Walker, rigid, wheeled, adjustable or fixed
						  height
Purchase
E0143
3 CL LU Z LU 3
N
Walker, folding, wheeled, adjustable or fixed
						  height
Purchase
E0147
3 CL LU Z LU 3
N
Walker, heavy duty, multiple braking system, variable
						  wheel resistance
Purchase
E0153
3 CL LU Z LU 3
N
Platform attachment, forearm crutch, each
Purchase
E0154
NU EP UE
N
Platform attachment, walker, each
Purchase
E0155
3 CL LU
ZUJD
N
Wheel attachment, rigid pick-up walker, per pair seat
						  attachment, walker
Purchase
E0156
NU EP
N
Seat attachment, walker
Purchase
E0157
3 CL LU
Z LLI 3
N
Crutch attachment, walker, each
Purchase
E0158
3 CL LLI Z LU 3
N
Leg extensions for walker, per set of four
						  (4)
Purchase
E0159
NU EP
N
Brake attachment for wheeled walker, replacement,
						  each
Purchase
E0160
3 CL LLI Z LU 3
N
Sitz type bath or equipment, portable, used with or
						  without commode
Purchase
E0161
3 CL LLI Z LU 3
N
Sitz type bath or equipment, portable, used with or
						  without commode, with faucet attachment(s)
Purchase
E0163
3 CL LLI Z LLI 3
N
Commode chair, stationary, with fixed arms
Purchase
E0167
NU EP UE
N
Pail or pan for use with commode chair
Purchase
E0175
3 CL LLI Z LLI 3
N
Foot rest, for use with commode chair, each
Purchase
E0181
3 CL LLI Z LLI 3
N
Pressure pad, alternating with pump, heavy
						  duty
Capped Rental
E0182
3 CL LLI Z LLI 3
N
Pump for alternating pressure pad
Purchase
E0184
3 CL LLI Z LLI 3
N
Dry pressure mattress
Purchase
E0185
NU EP UE
N
Gel or gel-like pressure pad for mattress, standard
						  mattress length and width
Purchase
E0186
NU EP
Y
Air pressure mattress
Purchase
E0187
NU EP
Y
Water pressure mattress
Purchase
E0189
NU EP UE
N
Lambswool sheepskin pad, any size
Purchase
E0190
NU UE
N
Positioning cushion/pillow/wedge, any shape or
						  size
Purchase
E0190
EP
N
*** (Tumble Form Therapy Roll 4") Positioning
						  cushion/pillow/wedge, any shape or size
Purchase
E0190
EP
U1
N
*** (Tumble Form Therapy Roll 6") Positioning
						  cushion/pillow/wedge, any shape or size
Purchase
E0190
EP
U2
N
*** (Tumble Form Therapy Wedge 4") Positioning
						  cushion/pillow/wedge, any shape or size
Purchase
E0190
EP
U3
N
*** (Tumble Form Therapy Roll 8") Positioning
						  cushion/pillow/wedge, any shape or size
Purchase
E0190
EP
U4
N
*** (Tumble Form Therapy Wedge 6") Positioning
						  cushion/pillow/wedge, any shape or size
Purchase
E0190
EP
U5
N
*** (Floor Sitter Wedge 4") Positioning
						  cushion/pillow/wedge, any shape or size
Purchase
E0190
EP
U6
N
*** (Tumble Form Therapy Roll 12") Positioning
						  cushion/pillow/wedge, any shape or size
Purchase
E0190
EP
U7
N
*** (Deluxe Wedge with strap 4") Positioning
						  cushion/pillow/wedge, any shape or size
Purchase
E0190
EP
U8
N
*** (Deluxe Wedge with strap 6") Positioning
						  cushion/pillow/wedge, any shape or size
Purchase
E0190
EP
U9
N
A (Tumble Form Therapy Wedge 10") Positioning
						  cushion/pillow/wedge, any shape or size
Purchase
E0190
EP
KA
U1
N
A (Tumble Form Therapy Roll 14") Positioning
						  cushion/pillow/wedge, any shape or size
Purchase
E0190
EP
KA
U2
N
(Tumble Form Therapy Roll 16") Positioning
						  cushion/pillow/wedge, any shape or size A
Purchase
E0190
EP
KA
U3
N
A (Tumble Form Therapy Wedge 8") Positioning
						  cushion/pillow/wedge, any shape or size
Purchase
E0191
NU EP UE
N
Heel or elbow protector, each
Purchase
E01943
NU EP
Y
A(Clinitron Bed) Airfluidized bed
Capped Rental
E0196
NU EP
N
Gel pressure mattress
Purchase
E0197
NU EP UE
N
Air pressure pad for mattress, standard mattress length
						  and width
Purchase
E0198
NU EP
Y
Water pressure pad for mattress, standard mattress
						  length and width
Purchase
E0200
NU EP UE
N
Heat lamp, without stand (table model), includes bulb,
						  or infrared element
Capped Rental
E0202
NU EP UE
N
Phototherapy (bilirubin) light with
						  photometer
Rental Only
E0202
U
U1
N
Phototherapy (bilirubin) light with
						  photometer
Capped Rental
E0205
NU EP UE
N
Heat lamp, with stand includes bulb, or infrared
						  element
Capped Rental
E0217
NU EP UE
N
Water circulating heat pad with pump
Capped Rental
E0225
NU EP UE
N
Hydrocollatorunit, includes pad
Capped Rental
E0235
NU EP UE
N
Paraffin bath unit, portable (see medical supply code
						  A4265 for paraffin)
Purchase
E0236
NU EP UE
N
Pump for water circulating pad
Capped Rental
E0238
3 CL LU
ZUJD
N
Nonelectric heat pad, moist
Purchase
E0239
3 CL LU Z LLI 3
N
Hydrocollatorunit, portable
Capped Rental
E0240
NU EP
N
Bath/shower chair w/wo wheels, any size
Purchase
E0240
NU EP
U1 U1
N
Bath/shower chair w/wo wheels, any size
Purchase
E0240
NU EP
U2 U2
N
Bath/shower chair w/wo wheels, any size
Purchase
E0240
NU EP
U3 U3
N
Bath/shower chair w/wo wheels, any size
Purchase
E0244
NU EP
N
Raised toilet seat
Purchase
E0245***
NU EP
U1 U1
N
***(Bath Frame Support, Large) Tub stool or
						  bench
Purchase
E0247
NU EP
N
Transfer bench, tub/toilet, w/wo commode
						  opening
Purchase
E0247
NU EP
U1 U1
N
Transfer bench, tub/toilet, w/wo commode
						  opening
Purchase
E0248
NU EP
N
Transfer bench, heavy duty, tub/toilet w/wo commode
						  opening
Purchase
E0248
NU EP
U1 U1
N
Transfer bench, heavy duty, tub/toilet w/wo commode
						  opening
Purchase
E0249
3 CL LLI Z LU 3
N
Pad for water circulating heat unit
Purchase
E0250
NU EP
Y*
***(Hospital bed, with side rails, fixed height, with
						  mattress, purchase) Hospital bed, fixed height, with any type side rails, with
						  mattress
Purchase
E0250
NU EP
RR RR
Y*
Hospital bed, fixed height, with any type side rails,
						  with mattress
Capped Rental
E0255
NU EP
Y*
Hospital bed, variable height; hi-lo, with any type
						  side rails, with mattress
Purchase
E0255
NU EP
RR RR
Y*
Hospital bed, variable height; hi-lo, with any type
						  side rails, with mattress
Capped Rental
E0255
NU
U1
Y*
***(Hospital bed, with side rails, variable height;
						  hi-lo, with mattress, purchase) Hospital bed, variable height; hi-lo, with any
						  type side rails, with mattress
Purchase
E0255
UE
Y*
Hospital bed, variable height; hi-lo, with any type
						  side rails, with mattress
Capped Rental
E0260
3 CL LU
ZUJD
Y*
***(Hospital bed, with side rails, semi-electric, head
						  and foot adjustments, with mattress, purchase) Hospital bed, semi-electric,
						  head and foot adjustment, with any type side rails with mattress
Purchase
E0260
NU EP
RR RR
Y*
Hospital bed, semi-electric, head and foot adjustment,
						  with any type side rails with mattress
Capped Rental
E0271
3 CL LU
Z LLI 3
N
Mattress, inner spring
Capped Rental
E0272
3 CL LLI Z LU 3
N
Mattress, foam rubber
Capped Rental
E0273
3 CL LLI Z LU 3
N
Bed board
Purchase
E0275
3 CL LLI Z LU 3
N
Bed pan, standard, metal or plastic
Purchase
E0276
NU EP UE
N
Bed pan, fracture, metal or plastic
Purchase
E02773
NU EP
Y
***(Low Air Loss Mattress) Powered pressure-reducing
						  air mattress
Capped Rental
E0280
NU EP UE
N
Bed cradle, any type
Purchase
E0300
EP
Y
Pediatric crib, hospital grade, fully
						  enclosed
Purchase
E0300
EP
RR
Y
Pediatric crib, hospital grade, fully
						  enclosed
Rental Only
E0302
NU EP
Y
Hospital bed, heavy duty, extra wide, with weight
						  capacity greater than 350 pounds, but less than or equal to 600 pounds, with
						  any type side rails, with mattress
Capped Rental
E0303
NU EP UE
Y Y Y
Hospital bed, heavy duty, extra wide, with weight
						  capacity [GREATER THAN] 350 but [LESS THAN] or = 600, any type side rails,
						  w/mattress
Rental Only (Rent to Purchase)
E0304
NU EP
J
Hospital bed, extra heavy duty, extra wide, with weight
						  capacity greater than 600 pounds, with any type side rails, with
						  mattress
Capped Rental
E0325
3 0_ LU
ZUJD
N
Urinal; male, jug-type, any material
Purchase
E0325
NU EP UE
U1 U1 U1
N
Urinal; male, jug-type, any material
Purchase
E0326
NU EP UE
N
Urinal; female, jug-type, any material
Purchase
E0445***
NU EP
Y*
***(Pulse oximeter, including 4 disposable probes)
						  Oximeter for measuring blood oxygen levels non-invasively
Rental Only
E0480
NU EP UE
N
Percussor, electric or pneumatic, home
						  model
Capped Rental
E0565
NU EP UE
Y*
Compressor, air power source for equipment which is not
						  self-contained or cylinder driven
Capped Rental
E0570
NU UE
Y
Nebulizer, with compressor
Purchase
E0585
NU EP UE
N
Nebulizer, with compressor and heater
Capped Rental
E0605
NU EP UE
N
Vaporizer, room type
Purchase
E0606
NU EP UE
N
Postural drainage board
Capped Rental
E0607***
NU EP
N
Home blood glucose monitor
Purchase
E0621
NU
N
Sling or seat, patient lift, canvas or
						  nylon
Purchase
E0630
NU EP UE
Y*
Patient lift, hydraulic, with seat or sling
Capped Rental
E0650
NU EP UE
Y*
Pneumatic compressor, nonsegmental home
						  model
Capped Rental
E0667
NU EP
Y*
Segmental pneumatic appliance for use with pneumatic
						  compressor, full leg
Capped Rental
E0668
NU EP
Y*
Segmental pneumatic appliance for use with pneumatic
						  compressor, full arm
Capped Rental
E0691
NU EP
N
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; treatment area two square feet or
						  less
Rental Only
E0692
NU EP
N
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; four foot panel
Rental Only
E0693
NU EP
N
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; six foot panel
Rental Only
E0694
NU EP
N
Ultraviolet multidirectional light therapy system in
						  six foot cabinet includes bulbs/lamps, timer and eye protection
Rental Only
E0720
NU EP UE
Y*
TENS, two lead, localized stimulation
Capped Rental
E0730
NU EP UE
Y*
Transcutaneous electrical nerve stimulation (TENS)
						  device, four or more leads, for multiple nerve stimulation
Capped Rental
E0740
NU EP UE
N
Incontinence treatment system, pelvic floor stimulator,
						  monitor, sensor and/or trainer
Purchase
E0745
NU EP UE
Y*
Neuromuscular stimulator, electronic shock
						  unit
Capped Rental
E0747
NU EP UE
Y*
Osteogenesis stimulator, electrical noninvasive, other
						  than spinal applications
Rental Only
E0748
NU EP
Y
Osteogenesis stimulator, electrical noninvasive, spinal
						  applications
Rental Only
E0760
NU EP
Y
Osteogenesis stimulator, low intensity ultrasound,
						  noninvasive
Rental Only
E0779
NU
RR
Y*
***(Ambulatory infusion device, payable only when
						  services are provided to patients receiving chemotherapy, pain management or
						  antibiotic treatment in the home) Ambulatory infusion pump, mechanical,
						  reusable, for infusion 8 hours or greater
Rental Only
E0840
NU EP UE
N
Traction frame, attached to headboard, cervical
						  traction
Purchase
E0850
3 CL LU
ZUJD
N
Traction stand, freestanding, cervical
						  traction
Purchase
E0860
3 CL LU
Z LLI 3
N
Traction equipment, overdoor, cervical
Purchase
E0870
3 CL LLI Z LU 3
N
Traction frame, attached to footboard, extremity
						  traction (e.g., Buck's)
Purchase
E0880
3 CL LLI Z LU 3
N
Traction stand, freestanding, extremity traction (e.g.,
						  Buck's)
Purchase
E0890
NU EP UE
N
Traction frame, attached to footboard, pelvic
						  traction
Purchase
E0900
NU EP UE
N
Traction stand, freestanding, pelvic traction (e.g.,
						  Buck's)
Purchase
E0910
NU EP UE
N
Trapeze bars, also known as Patient Helper, attached to
						  bed, with grab bar
Capped Rental
E0910
NU
RR
N
Trapeze bars, also known as Patient Helper, attached to
						  bed, with grab bar
Capped Rental
E0920
NU EP UE
N
Fracture frame, attached to bed, includes
						  weights
Capped Rental
E0930
NU EP UE
N
Fracture frame, freestanding, includes
						  weights
Capped Rental
E0935
NU EP UE
Y*
Continuous passive motion exercise device for use on
						  knee only
Capped Rental
E0940
NU EP UE
N
Trapeze bar, freestanding, complete with grab
						  bar
Capped Rental
E0941
NU EP UE
N
Gravity assisted traction device, any type
Capped Rental
E0942
NU EP UE
N
Cervical head harness/halter
Purchase
E0944
NU EP UE
N
Pelvic belt/harness/boot
Purchase
E0945
NU EP UE
N
Extremity belt/harness
Purchase
E0946
NU EP UE
N
Fracture frame, dual with cross bars, attached to bed
						  (e.g., Balken, Four Poster)
Purchase
E0947
NU EP UE
N
Fracture frame, attachments for complex pelvic
						  traction
Purchase
E0948
NU EP UE
N
Fracture frame, attachments for complex cervical
						  traction
Purchase
E0950
NU EP UE
N
Wheelchair accessory, tray, each
Purchase
E1130*
NU EP UE
Y*
Standard wheelchair, fixed full-length arms, fixed or
						  swing-away, detachable footrests
Capped Rental
E1130*
NU
U1
Y*
Standard wheelchair, fixed full-length arms, fixed or
						  swing-away, detachable footrests
Rental Only
E1140*
NU EP
Y*
Wheelchair, detachable arms, desk or full-length,
						  swing-away, detachable footrests
Capped Rental
E1150*
NU EP
Y*
Wheelchair; detachable arms, desk or full-length,
						  swing-away, detachable, elevating legrests
Capped Rental
E1160*
NU EP
Y*
Wheelchair; fixed full-length arms, swing-away,
						  detachable, elevating legrests
Capped Rental
E1224*
NU EP UE
Y*
Wheelchair with detachable arms, elevating leg
						  rests
Capped Rental
E1224*
NU
U1
Y*
***(Footrests wheelchair with detachable arms,
						  elevating leg rests) Wheelchair with detachable arms, elevating leg
						  rests
Rental Only
E1340
NU
N
***(DME Repairs/Parts Only Repairs will not be approved
						  for more than the allowed purchase price of new equipment.
The
						  manufacturer's invoice must be attached to the repair claim for all parts.)
Repair or nonroutine service for durable medical equipment requiring the
						  skill of a technician, labor component, per 15 minutes
Manually Priced
E1340***
NU EP
U1 U1
N
***(Labor Only; a maximum of twenty [20] units [20
						  units = 5 hours of labor] per date of service is allowable.) Repair or
						  non-routine service for durable medical equipment requiring the skill of a
						  technician, labor component, per 15 minutes
Manually Priced
E1399
NU
N
Durable medical equipment, miscellaneous
Manually Priced
K0105
NU EP
N
IV hanger, each
Purchase
K0606
NU EP
Y
Automatic external defibrillator, with integrated
						  electrocardiogram analysis, garment type (covered only for beneficiaries ages
						  18 and over)
Capped Rental
S8096***
NU EP
N
***(Peak flow meter used by asthmatic patients)
						  Portable peak flow meter
Purchase
Z2211 (Bill on Paper)
NU EP
Y
Power Kit/Batteries
Purchase
Procedure codes
E0250*, E0255*
and
E0260*
must be billed when hospital beds are purchased for Medicaid
				beneficiaries of all ages. Providers must only provide these purchase-only
				services to beneficiaries who are expected to require the bed for a long period
				of time.
Each procedure code for hospital beds listed above may only be
				billed once every 10 years.
Procedure codes
E0250*, E0255*
and
E0260*
must also be used to bill for equipment that does not meet the
				purchase-only criteria. They are reimbursed on a capped rental basis. The
				capped rental items must be used until the equipment is no longer repairable or
				until it is no longer appropriate for the beneficiary as verified by the
				physician.
242.161
RESERVED 1-1-10