Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.17-013 - Prosthetics 2-16; Section V 7-16

Current through Register Vol. 49, No. 6, June, 2024
Section
			 II Prosthetics
242.191
			 Wheelchairs and Wheelchair Seating Systems for Individuals Ages 5-1-17
Two Through Adult
Arkansas Medicaid covers wheelchairs and wheelchair seating
				systems for individuals ages two through adult.
For any item to be covered by Arkansas Medicaid, the
				beneficiary must be eligible for a defined Medicaid Aid Category. Coverage is
				subject to the requirement that the equipment must be medically necessary for
				the diagnosis or treatment of an illness or injury to improve the functioning
				of an affected body part, and must meet all other Medicaid statutory and
				regulatory requirements and established criteria.
The beneficiary's diagnosis must warrant the type of equipment
				being purchased. Items may not be covered in every instance.
Providers are cautioned that an approved prior authorization
				does not guarantee payment. Reimbursement is contingent upon eligibility of
				both the beneficiary and the provider at the time service is provided and
				submission of an accurate and complete request. The DME provider is responsible
				for verifying the eligibility of the beneficiary at the time service is
				provided.
Specialized wheelchairs and wheelchair seating systems must be
				ordered by a physician.
When a request is submitted for a power wheelchair,
				Power-Operated Vehicle (POV) or specialized manual wheelchair, the following
				Medicaid requirements must be met:
A.
			 A Prescription & Prior Authorization Request for Medical Equipment form
			 (DMS-679) must be completed and submitted. This form must not be altered by the
			 provider.
View or print form DMS-679 and instructions
for
completion.
B.
			 The DMS-679 must be signed and dated by the beneficiary's PCP or the ordering
			 physician. The signature must be original. Stamp signatures are not acceptable.
			 Medicaid will accept electronic signatures provided the electronic signatures
			 comply with Arkansas Code § 25-31-103etseq.
C. Correct Medicaid procedure codes and
			 modifiers must be utilized. Requested items will be denied if correct
			 procedures codes and modifiers are not used.
D. All requests for prior authorization must
			 be legible (felt pens must not be used).
E. Medicaid requires the submission of the
			 original request.
F. Medical
			 documentation from the beneficiary's PCP or ordering physician which included a
			 detailed face-to-face medical examination must be submitted to establish
			 medical necessity.
G. An Evaluation
			 for Wheelchair and Wheelchair Seating form (DMS-0843) must be submitted. This
			 evaluation will be completed in three parts:
1. Part A-to be completed by the DME
			 provider.
2. Part B-to be completed
			 by the assistive technology practitioner or can be completed by a physical
			 therapist or occupational therapist or seating specialist for Group 1 (one) and
			 Group 2 (two) power wheelchairs with no power options.
3. Part C-to be completed by the
			 beneficiary's PCP or the ordering physician.
4. An Evaluation for Wheelchair and
			 Wheelchair Seating form (DMS-0843) must be completed for all specialized
			 wheelchairs except for rental wheelchairs.
View or print form
			 DMS-0843 and instructions for completion.
Wheelchairs and Wheelchair Seating Systems for
				Individuals Ages Two Through Aduit (Section 242.191)
Procedure Code
M1
M2
Description
PA
Payment Method
E0700
NU EP
U1 U1
Safety equipment, e.g., belt, harness
or
vest
N****
Purchase
E0700
NU
EP
U2
U2
***(Travel restraint auto safe harness, E-Z on vest, no
						  known comparable product) Safety equipment, e.g., belt, harness or vest
N****
Purchase
E0950
NU
EP
***(Tray for W/C)
W/C
accessory, tray,
						  each
Y
Purchase
E0950
NU
EP
U2
U2
***(ABS tray, 4-SM 5-LG)
W/C
accessory,
tray, each
Y
Purchase
£0950
NU
EP
U3 U3
***(W/C Tray, Custom) W/C accessory, tray,
each
Y
Purchase
E0950
NU EP
U4 U4
***(Tray,
customized) W/C
accessory,
tray, each
N
Purchase
E0950
NU
EP
U5 U5
***(Clear upper Ex support system)
W/C
accessory, tray, each
Y
Purchase
E0950
NU
EP
U6 U6
***(Lap Tray Switch Array) Wheelchair accessory, tray,
						  each
Y
Purchase
E0950
NU
EP
U7
U7
Wheelchair accessory, tray, each
Y
Purchase
E0950
NU
EP
UE
U7 U7
***(Removable Hinged Overlay for Tray) W/C accessory,
						  tray, each
v****
Purchase
E0950
NU EP
U8
U8
***(Lap Tray for Switch Array) Wheelchair
accessory, tray, each
Y
Purchase
E0951
NU
EP
Heel loop/holder, with or without ankle strap,
						  each
N****
Purchase
E0952
NU EP
Toe loop/holder, each
N****
Purchase
E0955
NU
EP
Wheelchair
accessory, headrest, cushioned,
						  any type, including fixed mounting hardware, each
N
Purchase
E0956
NU EP
***(Trunk supports for any W/C, other
than
travel, with hardware) Wheelchair accessory, lateral trunk or hip
						  support, any type, including fixed mounting
hardware, each
N****
Purchase
E0956
NU
EP
U1
U1
***(Lateral
trunk
supports, swing-away,
						  each) Wheelchair accessory, lateral
trunk or hip support,
any
						  type, including
fixed mounting hardware, each
N****
Purchase
E0970
NU EP
No. 2 footplates, except for elevating leg rest
N****
Purchase
E0971
NU
EP
Anti-tipping device W/C
N****
Purchase
E0973
NU EP
W/C accessory, adjustable height, detachable armrest,
						  complete assembly, each
N****
Purchase
E0973
NU EP
U1 U1
***(Height Adj. Arms, replacement) W/C accessory,
						  adjustable height, detachable armrest, complete assembly, each
N****
Purchase
E0974
NU
EP
Manual wheelchair accessory, anti-rollback device (/*
						  grade aids), each
N****
Purchase
E0978
NU EP
Wheelchair accessory, positioning belt/safety
						  belt/pelvic strap, each
N**«
Purchase
E0978
NU
EP
U1 U1
/*(Belt, safety or chest, w/pad) Wheelchair accessory,
						  positioning belt/safety belt/ pelvic strap, each
N
Purchase
E0978
NU
EP
U2
U2
Wheelchair accessory, positioning belt/safety
						  belt/pelvic strap, each
N*«*
Purchase
E0980
NU
EP
/*(Chest panel, 21-SM 22-LG) Safety vest,
						  wheelchair
N**«
Purchase
E0980
NU
EP
U1 U1
*'*(Shoulder retractors) Safety vest, W/C
N****
Purchase
E0981
NU EP
W/C accessory, seat upholstery, replacement only,
						  each
N
Purchase
E0982
NU EP
W/C accessory, back upholstery, replacement only,
						  each
N****
Purchase
E0982
NU EP
U1 U1
/*(Standard back upholstery replacement) W/C accessory,
						  back upholstery, replacement only, each
N*"*
Purchase
E0990
NU
EP
/*(Elevating foot, leg rest) W/C accessory, elevating
						  legrest, complete assembly, each
N****
Purchase
E0990
NU
EP
U1
U1
/*(Elevating legrest 90 Degree, 12" -16" Width) W/C
						  accessory, elevating legrest, complete assembly, each
N"**
Purchase
E0992
NU EP
/* (Manual wheelchair accessory, solid seat)
N****
Purchase
E0992
NU EP
U1 U1
/*Manual w/c accessory, solid seat insert (Large
						  adjustable solid seat w/hardware)
N****
Purchase
E0992
NU EP
U2
U2
/*(Foam and Plywood Flat Side Manual wheelchair
						  accessory, solid seat)
N****
Purchase
E1084*
NU EP
Hemi-W/C; detachable arms, desk or full-length,
						  swing-away, detachable, elevating leg rests
N****
Purchase
E1086*
NU EP
Hemi W/C; detachable arms, desk or full-length,
						  swing-away, detachable footrests
N"**
Purchase
E1086*
NU EP
U1
U1
Hemi W/C, detachable arms, desk or full-length,
						  swing-away detachable footrests
Y
Purchase
E1088*
NU EP
High strength lightweight W/C; detachable arms, desk or
						  full-length, swing-away, detachable, elevating leg rests
Y*
Purchase
E1090
NU EP
High-strength lightweight W/C; detachable arms, desk or
						  full-length, swing-away,
detachable
footrests
N****
Purchase
E1092*
NU EP
Wide, heavy-duty W/C; detachable arms, desk or
						  full-length, swing-away, detachable, elevating legrests
Y4
Purchase
E1093*
NU EP
Wide, heavy-duty W/C; detachable arms, desk or
						  full-length arms, swing-away, detachable footrests
Y*
Purchase
E1110*
NU EP
Semi-reclining W/C; detachable arms, desk or
						  full-length, elevating legrests
Y4
Purchase
E1161
NU EP
Manual adult size W/C, includes tilt in space
Y*
Purchase
E1170*
NU EP
Amputee W/C; fixed full-length arms, swing-away,
						  detachable, elevating legrests
N****
Purchase
E1172*
NU EP
Amputee W/C; detachable arms, desk or full-length,
						  without footrests or legrests
Y4
Purchase
E1180*
NU EP
Amputee W/C; detachable arms, desk or full-length,
						  swing-away, detachable footrests
Y*
Purchase
E1200*
NU EP
Amputee W/C; fixed full-length arms, swing-away,
						  detachable footrests
jyj****
Purchase
E1220*
NU EP
W/C, specially sized or constructed
(indicate
						  brand name, model number, if any, and justification)
Y
Manually Priced
E1225
NU EP
***(Folding Backrest, 8 Degree Bend, Low, 15" -16")
						  Manual W/C accessory, semi-reclining back, (recline greater than 15 degrees,
						  but less than 80 degrees),
each
N"**
Purchase
E1228
NU EP
***(Folding Backrest, Tall, 19" - 20") Special back
						  height for W/C
N****
Purchase
E2201
NU
EP
***(Seat
Width 20") Manual w/c
accessory,
						  nonstandard seat frame width [GREATER THAN]
than or
equal to 20
						  inches and [LESS THAN] 24 inches
N****
Purchase
E2201
NU EP
U1
U1
***(Frame Width 14"-15") Manual w/c
accessory, nonstandard seat frame width [GREATER THAN]
than or
equal to 20 inches and [LESS THAN] 24
inches
N****
Purchase
E2201
NU
EP
U2
U2
***(Frame Width 19"-20") Manual
w/c
accessory, nonstandard
seat frame width [GREATER THAN] than or
						  equal to 20 inches and [LESS THAN] 24 inches
N*"*
Purchase
E2201
NU EP
U3
U3
Manual w/c accessory, nonstandard seat frame width
						  [GREATER THAN] than or equal to 20 inches and [LESS THAN] 24 inches
N****
Manually Priced
E2203
NU
EP
***(Seat Depth 15") Manual w/c accessory,
						  nonstandard
seat frame depth,
20 to less than 22
						  inches
N****
Purchase
E2203
NU
EP
U1 U1
***(Seat Depth 17° -18") Manual w/c
						  accessory, nonstandard
seat frame depth, 20 to less
than 22
						  inches
(\|****
Purchase
E2203
NU
EP
U2 U2
***(Frame, Long; 16",
17"3,
18", 19"3, 20"
						  Depth) Manual w/c accessory, nonstandard seat frame depth,
20
to
						  less than
22 inches
N****
Purchase
E2203
NU
EP
U3
U3
***(Seat Depth 19" - 20") Manual
w/c
accessory,
nonstandard seat frame depth, 20 to
less than
22
						  inches
N"**
Purchase
E2203
NU EP
U4 U4
Manual w/c accessory, nonstandard seat frame depth, 20
						  to less than 22 inches
N
Manually Priced
E2206
NU
EP
Manual
wheelchair accessory, wheel lock
						  assembly, complete, each
N
Purchase
E2207
NU EP
Wheelchair
accessory, crutch and cane
						  holder, each
jg****
Purchase
E2208
NU
EP
Wheelchair accessory,
cylinder tank
carrier, each
N
Purchase
E2209
NU
EP
Wheelchair accessory, arm trough, each
N
Purchase
E2210
NU
EP
Wheelchair accessory, bearings,
any
type,
replacement only, each
N
Purchase
E2211
NU
EP
Manual wheelchair
accessory, pneumatic
						  propulsion tire, any size, each
N
Purchase
E2212
NU
EP
Manual wheelchair accessory,
tube for
pneumatic propulsion tire, any size, each
N
Purchase
E2311
NU EP
Power w/c accessory, electronic connection between
						  wheelchair controller and two or more power seating system motors, including
						  all related electronics, indicator feature, mechanical function selection
						  switch, and fixed mounting hardware
Y
Purchase
E2322
NU EP
Power w/c accessory, hand control interface, multiple
						  mechanical switches, nonproportional, including all related electronics,
						  mechanical stop switch, and fixed mounting hardware
Y
Purchase
E2323
NU EP
Power w/c accessory, specialty joystick handle for hand
						  control interface,
prefabricated
Y
Purchase
E2324
NU EP
Power w/c accessory, chin cup for chin control
						  interface
Y
Purchase
E2325
NU EP
Power w/c accessory, sip & puff interface
						  nonproportional, including ail related electronics, mechanical stop switch, and
						  manual swing-away mounting hardware
Y
Purchase
E2326
NU EP
Power wheelchair accessory, breath tube kit for sip and
						  puff interface *** {replacement only)
Y
Purchase
E2327
NU EP
Power w/c accessory, head control interface,
						  mechanical, proportional, including all related electronics, mechanical
						  direction change switch, and fixed mounting hardware
Y
Purchase
E2359
NU EP
Power w/c accessory, group 34 sealed lead acid battery,
						  each
N
Purchase
E2360
NU EP
Power w/c accessory, 22 NF non-sealed lead acid
						  battery, each
N
Purchase
E2361
NU EP
Power w/c accessory, 22 NF sealed lead acid battery,
						  each, (e.g., gel cell, absorbed glassmat)
N
Purchase
E2363
NU EP
Power w/c accessory, group 24 sealed lead acid battery,
						  each (e.g., gel cell, absorbed glassmat)
N
Purchase
E2363
NU EP
U1 U1
Power w/c accessory, group 24 sealed lead acid battery,
						  each (e.g., gel cell, absorbed glassmat)
N
Purchase
E2365
NU EP
***(U-1 gel cell battery, each) Power wheelchair
						  accessory, U-1 sealed lead acid battery, each, (e.g., gel cell, absorbed
						  glassmat)
N
Purchase
E2383
NU
EP
Power wheelchair accessory,
insert for
pneumatic drive wheel tire (removable), any type, any size, replacement only,
						  each
Y
Purchase
E2384
NU EP
Power
wheelchair
accessory, pneumatic
						  caster tire, any size, replacement only, each
Y
Purchase
E2385
NU EP
Power wheelchair accessory, tube for pneumatic caster
tire, any
size, replacement
only, each
Y
Purchase
E2386
NU
EP
Power wheelchair accessory, foam filled
drive
						  wheel
tire, any size, replacement only, each
						  t
Y
Purchase
E2387
NU EP
Power wheelchair accessory, foam caster
tire, any
						  size,
replacement only, each
Y
Purchase
E2601
NU EP UE
General
use
wheelchair
seat
						  cushion,
width less than 22 in., any depth
N****
Purchase
E2602
ZUJD
General use wheelchair seat cushion,
width 22 in.
						  or
greater, any depth
N
Purchase
E2611
NU EP UE
General use wheelchair back
cushion, width
less than
22
in.,
any height,
including any
						  type
mounting
hardware
N
Purchase
E2612
NU EP UE
General use wheelchair back cushion, width
22 in.
or greater, any height,
including
any type mounting
						  hardware
N
Purchase
E2619
NU EP
Replacement cover for wheelchair seat
cushion or
						  back cushion, each
N
Purchase
E2622
NU EP UE
Skin protection
wheelchair seat cushion,
adjustable, width less than 22 inches, any depth
N
Purchase
E2623
NU
EP UE
Skin protection wheelchair seat cushion, adjustable,
						  width 22 inches or greater, any depth
N
Purchase
E2624
NU EP UE
Skin protection and positioning wheelchair seat
						  cushion, adjustable width
less than 22 inches, any depth
N
Purchase
E2625
NU EP UE
Skin
protection and positioning wheelchair
						  seat cushion, adjustable width
22 inches or greater, any depth
N
Purchase
E2626
NU EP
Wheelchair accessory, shoulder elbow,
mobile arm
						  support
attached to wheelchair, balanced, adjustable
Y
Purchase
K0011
NU
EP
U1 U1
*"*(Motorized, power base or conventional frame w/c
						  DA/swing-away footrests, programmable electronics and custom options)
						  Standard-weight frame motorized/power, W/C with programmable control parameters
						  for speed adjustment, tremor dampening, acceleration control and braking
Y*
Purchase
K0012
NU EP
A(Motorized folding frame, DA, swing-away footrests)
						  Lightweight portable motorized/power W/C
Y*
Purchase
K0012
NU EP
U1 U1
A(Motorized folding frame, DA, swing-away ELR)
						  Lightweight portable motorized/power W/C
Y*
Purchase
K001412
NU EP
Other motorized/power W/C base
Y*
Purchase
K001412
NU EP
U1 U1
A (Center Drive power base) Other motorized/ power W/C
						  base
Y*
Purchase
K001412
NU EP
U3 U3
A (Motorized, Power Base or conventional frame W/C
						  DA/swtng-away foot rests, programmable electronics and custom options) Other
						  motorized/power W/C base
Y*
Purchase
K00141"2
NU EP
U4 U4
A (Motorized, Power Base or conventional frame W/C
						  DA/swtng-away elevated foot rests, programmable electronics and custom options)
						  Other motorized/power W/C base
Y*
Purchase
K0017
NU EP
A (Receiver for height adjustable arms) Detachable,
						  adjustable height armrest, base,each
N"**
Purchase
K0017
NU EP
U1 U1
A(Dual post and adjustable height DA) Detachable,
						  adjustable height armrest, base,each
KJ****
Purchase
K0019
NU EP
Arm pad,each
N
Purchase
K0020
NU EP
Fixed, adjustable height armrest, pair
N"**
Purchase
K0038**
EP
U1
A (Knee strap) Leg strap, each
N
Purchase
K0038
NU EP
A(Single leg strap, each) Leg strap, each
N****
Purchase
K0038
NU EP
U2 U2
A(Foot straps, pair) Leg strap, each
hi****
Purchase
K0108
NU EP
A(W/C miscellaneous equipment; applicable pages from
						  the manufacturer's catalog must be attached to the claim form.) Other
						  accessories
[U****
Manually Priced
K0739
NU EP
U1 U1
***(Labor only, Repair or non-routine service for
						  durable medical equipment requiring the skill of a technician, labor component,
						  per 15 minutes. A maximum of twenty units per date of service is allowable, 20
						  units = 5 hours of labor)
Y
Purchase
S1002
EP
***(Wheelchair, custom molded seating system only)
						  Customized item, list in addition to code for basic item
N""
Manually Priced
S1002
NU EP
U1 U1
+**(Foam-in-place seat, Pindot quick foam contour
						  system) Customized item, list in addition to code for basic item
K|*#*t
Purchase
The following procedure codes may be billed only on
				paper.
Wheelchairs and Wheelchair Seating Systems for
				Individuals Ages Two Through Adult (Section 242.191)
No
National
Code
M1 M2
Local Code
Description
PA
Payment Method
Bill on paper
NU EP
Z1613
One-piece footboard (each)
N'*"
Purchase
Bill on paper
NU EP
Z1793
Custom foot platform
hi****
Purchase
Bill on paper
EP
Z1824**
PC Car Seat/Snug Seat
Y
Purchase
Bill on paper
NU
EP
Z2137
Adjustable Rem. Abductor w/hardware (ea)
N*"*
Purchase
Bill on paper
NU EP
Z2138
Adjustable Flip Down Abductor w/hardware (ea)
K]****
Purchase
Bill on paper
NU
EP
Z2139
Lateral Hip/Thigh support w/hardware (ea)
K|****
Purchase
Bill on paper
NU
EP
Z2140
Adductor - no hardware
hi****
Purchase
Bill on paper
NU
EP
Z2141
Abductor - no hardware
hi****
Purchase
Bill on paper
NU EP
Z2582
Quick Release Axle
N**«
Purchase
Bill on paper
NU EP
Z2585
Growing Seat Pan
N****
Purchase
Bill on paper
NU EP
Z2586
Growing Back Upholstery
N****
Purchase
Bill on paper
NU
EP
Z2588
Deep Contour Back 20" Width
N****
Purchase
Bill on paper
NU EP
Z2589
Adjustable Contour Lateral Pelvic Support
N****
Purchase
Bill on paper
NU
EP
Z2592
Remote Joystick Module
N****
Purchase
Bill on paper
NU EP
Z2599
Transit Option
N****
Purchase
Bill on paper
NU EP
Z2604
Adjustable Back Upholstery
N****
Purchase
Bill on paper
NU EP
Z2616
Swing-away Mount (Joystick)
N****
Purchase
Required Documentation
Face-to-Face
Examination
In order for Medicaid to provide reimbursement for a
				Power/motorized Wheelchair (PWC), Power Operated Vehicle (POV) (scooter) or
				specialized manual wheelchair, the following requirements must be
				met.
A. A
			 face-to-face physician examination must be performed.
B. The physician must perform a medical
			 examination for the specific purpose of assessing the beneficiary's mobility
			 limitation and needs, The results of this exam must be recorded in the
			 patient's medical record.
C. The
			 prescription must be written only after the face-to-face physician examination
			 and assessment of mobility limitations have occurred and the medical history
			 and physical examination is completed.
D. The prescription and the medical records
			 documenting the in-person visit and examination report must be sent to the
			 equipment supplier within forty-five (45) days of completion of the
			 examination.
E. The physician may
			 refer the beneficiary to a licensed/certified professional, a Physical
			 Therapist (PT) or Occupational Therapist (OT) to perform a wheelchair
			 assessment.
If the beneficiary is referred to a physical/occupational
				therapist before the physician completes the face-to-face examination, the
				physician must review the physical/occupational therapist's written report and
				perform the final examination. The forty-five (45)-day period begins on
				the
E. Strollers and
			 stroller-like chairs of any kind are not covered by Arkansas Medicaid. A
			 stroller is a four-wheeled, often collapsible, chair-like carriage. They are
			 helpful to caregivers and are typically used for transportation. Although
			 stroller and stroller-like chairs may be used to transport individuals with
			 medical conditions, such items do not serve a medical purpose. Strollers and
			 stroller-like chairs have no positioning components for medical use, cannot be
			 modified for growth and accommodate changes in medical or physical condition,
			 and cannot be self-propelled by the individual.
F. Prior authorization is required even when
			 insurance pays primary to Medicaid. Explanation of benefits (EOB) of the other
			 insurance must be submitted with the request.
G. All wheelchair requests require a
			 manufacturer's brand and the model name of the base.
H. In the event a wheelchair is stolen,
			 damaged in the home, or by vehicle or fire, a police/fire report, copy of the
			 home owners/auto insurance coverage and detailed documentation of events
			 leading to the loss/damage are required.
I. Mobility bases for car seats are not
			 covered by Medicaid.
J. Options,
			 accessories, and replacement parts that are medically necessary for wheelchairs
			 that do not have specific HCPCS codes should be coded K0108 (other
			 accessories). The manufacturer's suggested retail price (MSRP) must be listed
			 for each item coded K0108, and the MSRP quote to the DME provider must be
			 included. The MSRP quote must not be altered by the DME provider. If the MSRP
			 is altered in anyway, the request will be denied.
K. In the event a beneficiary wishes to
			 change services from one DME provider to another DME provider, an affidavit
			 signed and dated by the beneficiary must be submitted with the request from the
			 new DME provider.
L. The existence
			 of a procedure code does not necessarily indicate coverage by Arkansas
			 Medicaid.
M. The allowed amount of
			 a POV includes all options and accessories that are provided at the time of
			 initial issue. This includes but is not limited to batteries, battery chargers,
			 seating systems, etc. All options and accessories provided at the initial issue
			 of a Power-Operated Vehicle (POV) are included and should not be billed
			 separately.
N. If coverage criteria
			 is not met for a specific item requested, and Arkansas Medicaid determines that
			 another item Is more appropriate and meets medical necessity, that item will be
			 authorized.
O. The wheelchair will
			 significantly improve the beneficiary's ability to participate in Mobility
			 Related Activities of Daily Living (MRADL) and the individual will use the
			 wheelchair on a regular basis in the home.
P. The individual's home will provide
			 adequate access between rooms, maneuvering space and surface for use of the
			 requested wheelchair.
Non-Covered Items for Specialized Wheelchairs and Wheelchair
				Systems
A. Items that are
			 deluxe in nature. Deluxe items are items of convenience that are not medically
			 necessary. Deluxe items are often used for social purposes or convenience.
			 Deluxe items include deluxe accessories which increase the cost of purchase or
			 operation. Deluxe items and deluxe accessories are not covered by Arkansas
			 Medicaid.
B. Items for use in
			 hospitals, nursing home or other institutions.
C. Items for the beneficiary's comfort or the
			 caregiver's convenience.
D. Two
			 pieces of equipment that serve the same purpose.
Specialized Rehabilitative Equipment, All Ages (Section
				242.192)
Procedure Code
M1
M2
Description
PA
Payment Method
E0149
NU
EP
***(4 Wheel Reverse Walker) Walker, heavy-duty,
						  wheeled, rigid
or
folding, any type
N
Purchase
E0163
EP NU
U1
U1
***(Potty Chair - Small) Commode chair,
stationary, with fixed arms
Y
Purchase
E0168
EP
***(Rehab Shower/Commode Chair) Commode chair, extra
						  wide and/or heavy-duty, stationary or mobile,
with or
without
						  arms, any type, each
Y4
Purchase
E0168
EP
UB
A (Adaptive Commode Chair) Commode chair, extra wide
						  and/or heavy-duty, stationary or mobile, with or without arms,
any type,
						  each
N
Purchase
E0168
NU
***(Adaptive Commode Chair) Commode chair, extra wide
						  and/or
heavy-duty, stationary or mobile, with
or without arms,
any
type, each
N
Purchase
E0168
NU
U1
***(Rehab Shower/Commode Chair) Commode
chair,
extra wide and/or heavy-duty, stationary or mobile, with
or
without arms, any type, each
Yt
Purchase
E0241
NU
EP
***(Bolt-on Sm.
Grab
Bar) Bathroom wall
						  rail, each
N
Purchase
E0241
NU EP
U1 U1
***(Bolt-on Lg. Grab Bar) Bathroom wall
rail,
each
N
Purchase
E0241
NU EP
U2
U2
***(Bolt-on
Med. Grab Bar) Bathroom wall
						  rail, each
N
Purchase
E0245
NU EP
***(Adj. Bath Chair w/Back) Tub stool or bench
N
Purchase
E0245
NU
EP
U2 U2
***(Padded Tub Transfer Bench)
Tub
stool
or bench
N
Purchase
E0245
NU EP
U3 U3
***(30" Bath
Chair) Tub stool or bench
N
Purchase
E0245
NU EP
U4 U4
***(38" Bath Chair) Tub stool
or bench
N
Purchase
E0245
NU
EP
U5 U5
***(47n Bath Chair) Tub
						  stool
or bench
N
Purchase
E0245
NU EP
U6
U6
***(56" Bath Chair) Tub
stool or
						  bench
N
Purchase
E0245
NU EP
UB UB
***(Non-padded tub transfer bench) Tub stool or
						  bench
N
Purchase
E0246
NU EP
***(Clamp-on Tub Grab Bar) Transfer
tub rail
attachment
N
Purchase
E1035**
EP
U2
A(Carrie Seat -
Jr.) Multi-positional
patient transfer system, with integrated seat, operated by care giver
Y
Purchase
E1035
NU EP
U3
U3
***(Carrie Seat - Sm. Adult) Multi-positional patient
						  transfer system, with integrated seat, operated by care giver
Y*
Purchase
E8000
EP
&(14") Gait trainer, pediatric
size,
						  posterior support, includes all accessories and components
Y
Manually Priced
E8000
EP
U1
***(19") Gait trainer, pediatric
size,
						  posterior support, includes all accessories and
components
Y
Manually
Priced
E8000
EP
U2
**(Intermediate) Gait trainer, pediatric
size,
posterior support, includes all accessories and
						  components
Y
Manually
Priced
E8001
EP
***(14") Gait
trainer, pediatric size,
						  upright support, includes alt accessories and
components
Y
Manually
Priced
E8001
EP
U1
***(19") Gait trainer, pediatric size, upright support,
includes
all accessories and components
Y
Manually
Priced
E8001
EP
U2
***(Intermediate) Gait trainer, pediatric
size,
						  upright support,
includes all accessories and
components
Y
Manually Priced
E8002
EP
*%(14") Gait trainer,
pediatric size,
						  anterior
support, includes all
accessories and
components
Y
Manually
Priced
E8002
EP
U1
***(19") Gait trainer, pediatric
size,
						  anterior support, includes all accessories and
components
Y
Manually Priced
E8002
EP
U2
***(Intermediate) Gait trainer,
pediatric
						  size, anterior support, includes all
accessories and components
Y
Manually
Priced
The
following
list of codes may only be
billed on paper.
Specialized Rehabilitative Equipment, All Ages (Section
				242.192)
No
National Code
M1
Local Code
Description
PA
Payment Method
Bill on
paper
NU EP
Z1996
Sm. 51" Supine Stander
Y*
Purchase
Bill
on paper
NU
EP
Z1997
Lg.
71"
Supine Stander
Y*
Purchase
Bill on paper
EP
Z1998**
27" Prone Stander
Y
Purchase
Bill on
paper
EP
22021**
Mobile Floor Sitter Med/Lg.
N
Purchase
Bill on
paper
EP
Z2038**
Therapy Ball
-
Sm,
N
Purchase
Bill on
paper
EP
Z2039**
Therapy Ball - Med.
N
Purchase
Bill on
paper
EP
Z2040**
Therapy Ball - Lg,
N
Purchase
Bill on paper
EP
Z2043"
Seat & Back Pad for Toddler Chairs
Y
Purchase
Bill on
paper
EP
Z2044**
Tray for Toddler Chair
Y
Purchase
Bill on paper
EP
Z2045**
14" T&S High Back w/Support Activity
Chair
Y
Purchase
Bill
on
paper
EP
Z2046**
16" T&S High Back w/Support
Activity
						  Chair
Y
Purchase
Bill on paper
NU
EP
Z2047
Orthopedic Car Seat
Y
Purchase
Bill on
paper
NU EP
Z2072
Lg. Wrap Around Bath Support
N
Purchase
Bill on paper
NU
EP
Z2073
Sm. Wrap Around Back Support
N
Purchase
Bill on
paper
NU
EP
Z2074
Lg. Toilet Support w/Hi Back
N
Purchase
Bill on
paper
NU EP
Z2075
Sm.
Toilet Support w/Hi Back
N
Purchase
Bill on paper
NU
EP
Z2077
Flexible Shower Hose
N
Purchase
Bill
on paper
NU EP
Z2089
Toilet Seat Reducer Ring (Padded)
N
Purchase
Bill on
paper
NU EP
Z2093
Adult
Gait Trainer
Y*
Purchase
Bill on
paper
EP
Z2094**
Tyke Strider Walker w/2 Wheels
N
Purchase
Bill
on paper
EP
Z2095**
Tweener Strider Walker
w/2 Wheels
N
Purchase
Bill on
paper
EP
Z2096**
Middle Strider Walker w/2
Wheels
N
Purchase
Bill
on
paper
NU EP
Z2097
Adult Strider
Walker w/2 Wheels
N
Purchase
E.
			 Requests for replacement where malicious damage, neglect or misuse of the
			 equipment may have occurred may be investigated by Arkansas Medicaid. Requests
			 may be denied if such circumstances are confirmed.
F. If a wheelchair is stolen or damaged by
			 vehicle, fire or in the home, the beneficiary must provide the following with
			 the request:
1. A police or fire
			 report.
2. Copy of the homeowner's
			 or auto insurance coverage.
3.
			 Detailed documentation of events leading to the loss and damage.
If Arkansas Medicaid denies a repair or replacement in a case
				of malicious damage or misuse, payment of repairs is the responsibility of the
				beneficiary or caregiver.