Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.08-005 - ARKids First B Provider Manual Update Transmittal # 71

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