Your SlideShare is downloading. ×
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES

6,096

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
6,096
On Slideshare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
55
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. DURABLE MEDICAL EQUIPMENT/ MEDICAL SUPPLY SERVICES COVERAGE AND LIMITATIONS HANDBOOK
  • 2. 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 The provider can use the update log to determine if all the updates to the Update Log 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
  • 3. 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
  • 4. 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
  • 5. DME/Medical Supply Services Coverage and Limitations Handbook 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 i
  • 6. DME/Medical Supply Services Coverage and Limitations Handbook 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 Each service handbook is named for the service it describes and is referred Limitations to as a "Coverage and Limitations Handbook." A provider who furnishes Handbook more than one type of service will have more than one coverage and limitations handbook. Reimbursement Each reimbursement handbook is named for the claim form that it describes. Handbook A provider who bills on more than one type of claim form will have more than one reimbursement handbook. Chapter Numbering The first page of each chapter designates the chapter number. The chapter System 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 ii
  • 7. DME/Medical Supply Services Coverage and Limitations Handbook 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 iii
  • 8. DME/Medical Supply Services Coverage and Limitations Handbook 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 The Medicaid handbooks will be updated as needed. Updated 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 Updated replacement pages will have the same number as the page they are Pages 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 iv
  • 9. DME/Medical Supply Services Coverage and Limitations Handbook Handbook Updates, continued Effective Date of The month and year that the new material is effective will appear in the New Material 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 New material will be indicated by vertical, gray-shaded lines. The following Information 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 A new label and a new information block will be identified by a vertical line Information Block to the left of the label and to the right of the information block. New Material in an New or changed material within an existing information block will be Existing Information indicated by a vertical line to the left and right of the information block. Block New or Changed A paragraph within an information block that has new or changed material Paragraph will be indicated by a vertical line to the left and right of the paragraph. Paragraph with new material. May 1996 v
  • 10. DME/Medical Supply Services Coverage and Limitations Handbook 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 1-1
  • 11. DME/Medical Supply Services Coverage and Limitations Handbook Purpose and Definitions, continued Medicaid Provider This handbook is intended for use by DME and medical suppliers who Reimbursement provide services to Medicaid recipients. It must be used in conjunction with Handbook, HCFA- the Medicaid Provider Reimbursement Handbook, HCFA-1500 and 1500 and Child Child Health Check-Up 221, which contains general information about the Health Check-Up Medicaid program and procedures for submitting claims for payment. 221 Durable Medical DME is defined as medically-necessary equipment that can withstand Equipment (DME) 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 1-2
  • 12. DME/Medical Supply Services Coverage and Limitations Handbook Provider Qualifications Who Can Provide The following entities may enroll in the Medicaid DME and medical supplies Services program: • Businesses and pharmacies that supply DME and medical supplies; • Home health agencies; and • Physicians, optometrists, and opticians who supply artificial prosthetic eyes. Qualification To enroll as a Medicaid provider, a DME and medical supply entity must Requirements 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 1-3
  • 13. DME/Medical Supply Services Coverage and Limitations Handbook Provider Qualifications, continued Medical Oxygen To be reimbursed for providing oxygen and oxygen related equipment, the Retailers 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 Pharmacy providers automatically receive a durable medical equipment Providers (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 DME and medical supply entities must meet all the Medicaid provider Time of requirements and qualifications and their businesses must be fully operational Enrollment before they can be enrolled as Medicaid providers. April 2001 1-4
  • 14. DME/Medical Supply Services Coverage and Limitations Handbook April 2001 1-5
  • 15. DME/Medical Supply Services Coverage and Limitations Handbook Provider Enrollment General DME and medical supply providers must meet the general Medicaid provider Enrollment enrollment requirements that are contained in Chapter 2 of the Medicaid Requirements 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 Medicaid can only enroll one DME and medical supply provider per physical Location 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 1-6
  • 16. DME/Medical Supply Services Coverage and Limitations Handbook Provider Enrollment, continued Surety Bond A surety bond must be submitted as part of the enrollment application by the Requirement 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 Durable medical equipment and suppliers must have one of the following to Requirements 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 1-7
  • 17. DME/Medical Supply Services Coverage and Limitations Handbook Provider Enrollment, continued Site Visit A DME and medical supply provider must have a site visit before the Requirement 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 In addition to the general provider requirements and responsibilities that are Requirements 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 1-8
  • 18. DME/Medical Supply Services Coverage and Limitations Handbook Provider Responsibilities, continued Provider A DME and medical supply provider is responsible for furnishing and Responsibilities 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 In addition to the specific documentation that is required for the covered items Requirements 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 Title XIX, Chapter 400, Part X of the Florida Statutes contains regulations Equipment regarding Home Medical Equipment. According to S.400.93 F.S., any (HME) 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 1-9
  • 19. DME/Medical Supply Services Coverage and Limitations Handbook Provider Responsibilities, continued HME Providers Providers exempt from an HME license are those operated by the federal Exempt from government, nursing homes, assisted living facilities, home health agencies, Licensure 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 1-10
  • 20. DME/Medical Supply Services Coverage and Limitations Handbook This page intentionally left blank. April 2001 1-11
  • 21. DME/Medical Supply Services Coverage and Limitations Handbook 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 2-1
  • 22. DME/Medical Supply Services Coverage and Limitations Handbook 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 Medicaid reimburses home health agencies for DME/medical supplies Supplies Provided furnished by qualified providers in accordance with the physician approved Through Home plan of care. Health Agencies 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 2-2
  • 23. DME/Medical Supply Services Coverage and Limitations Handbook April 1998 2-3
  • 24. DME/Medical Supply Services Coverage and Limitations Handbook 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 Medical necessity must be established for each service and documented on a Necessity signed and dated: Documentation • 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 The documentation must include the following information: Information • the recipient’s name, • the attending practitioner’s name and license number, and • Medicaid or Medicare provider number. July 1997 2-4
  • 25. DME/Medical Supply Services Coverage and Limitations Handbook Service Requirements, continued Medical Necessity The medical necessity for disposable medical supplies must be redetermined For Medical every six months. Supplies Medical Necessity When DME, orthotic, or prosthetic devices are a one time purchase, medical For One Time necessity is required with each request. Purchase Medical Necessity The medical necessity for a rented item is based on the length of time specified For Rental Items 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. April 2001 2-5
  • 26. DME/Medical Supply Services Coverage and Limitations Handbook Service Requirements, continued 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 Recipients under 21 years of age who reside in a nursing facility may be eligible Of Residence 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 DME procedures that require prior authorization are: (PA) • 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. July 1997 2-6
  • 27. DME/Medical Supply Services Coverage and Limitations Handbook Service Requirements, continued PA Documentation DME providers must submit the following information with a prior authorization Requirements 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 All DME and medical supplies must be authorized by the recipient’s MediPass Authorization primary care provider, if the recipient is enrolled in MediPass. Effective Note: See Chapter 1, Medicaid Provider Reimbursement Handbook, March 1, 1997 HCFA-1500 and Child Health Check-Up 221, for information on obtaining MediPass authorization. April 2001 2-7
  • 28. DME/Medical Supply Services Coverage and Limitations Handbook Service Requirements, continued Exceptions To Service limits can be exceeded only for recipients under 21. If the service Service Limits 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 Medicaid requires that equipment be warranted by the provider or Equipment 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. July 1997 2-8
  • 29. DME/Medical Supply Services Coverage and Limitations Handbook 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. May 1996 2-9
  • 30. DME/Medical Supply Services Coverage and Limitations Handbook Equipment Purchase, Trade, or Rental, continued 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 The provider may not discontinue the rental service unless medical necessity Discontinuation ends, the recipient is no longer eligible for Medicaid, or the rent-to-purchase period has ended. Rent-to-Purchase When equipment is rent-to-purchase, Medicaid’s reimbursement amount is Equipment 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 When rental equipment is furnished to a recipient, the provider must: Responsibilities • 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. October 1999 2-10
  • 31. DME/Medical Supply Services Coverage and Limitations Handbook Equipment Purchase, Trade, or Rental, continued Replacement Replacement equipment will not be reimbursed in cases of misuse, abuse, Equipment 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 Medicaid will reimburse maintenance of equipment when the following Requirements 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 The recipient or caregiver is responsible to perform routine maintenance as Maintenance By A described in the manufacturer’s operating manual. This includes testing, Recipient cleaning, regulating, and lubricating the equipment as needed. Non-Routine Medicaid may reimburse a provider for non-routine maintenance and repairs Maintenance And (E1340) needed to keep durable medical equipment functional. Repair Note: This procedure requires a report of approval and pricing. See Chapter 3 of this handbook for information on By Report. April 2001 2-11
  • 32. DME/Medical Supply Services Coverage and Limitations Handbook Equipment Maintenance, Repair, and Renovation, continued Substantial Repair Providers may request prior authorization for substantial repairs or renovation 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 Medicaid may reimburse for pediatric forearm crutches (W9761). The Crutches following must be documented in the recipient’s record: height, weight, growth patterns, and expected benefit for ambulating. Pediatric Postural Pediatric postural control walker may be reimbursed as an ambulating Control Walker 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. April 2001 2-12
  • 33. DME/Medical Supply Services Coverage and Limitations Handbook 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). Provider The provider must: Responsibilities • 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 2-13
  • 34. DME/Medical Supply Services Coverage and Limitations Handbook Apnea Monitors, continued Home Visit When an RN, CRTT, or a RRT conducts a home visit, they must determine Documentation and document the following in the recipient’s medical record: Requirements • 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 The provider is responsible for ensuring the following equipment is available at Responsibilities 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 When service is discontinued, the provider has three days to remove the Service 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. November 1997 2-14
  • 35. DME/Medical Supply Services Coverage and Limitations Handbook Apnea Monitors, continued Event Recording The results of the event recording will determine if the practitioner will issue Continuation written orders to continue the event recordings for another month, continue regular monitoring, or discontinue the apnea monitoring. Event Recording Event recording documentation must include: Documentation • 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 Medical necessity renewal time frame for apnea monitors is six months. Renewal 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 2-15
  • 36. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Exception to Place Recipients under 21 years of age who reside in a nursing facility may be eligible of Residence to receive an AAC device. Who is Eligible to For Medicaid to reimburse for an AAC, the recipient must meet the following Receive an AAC 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 AACs must be prior authorized by the Medicaid consultant. Procedure codes Authorization used for AAC devices are the K codes noted in the Medicaid fee schedule in Appendix B of this handbook. Steps for The following steps must be followed to obtain Medicaid authorization for an Completion of a AAC. The written documentation from each step must be included in the Prior Medicaid prior authorization package: Authorization 1. An interdisciplinary team (ID team), led by the speech-language Package 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.). October 1998 2-16
  • 37. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Steps for 6. The ID team forwards the prior authorization package to the DME Completion of a provider. Prior 7. The DME provider completes the prior authorization package by attaching Authorization an invoice, proof of manufacturer’s cost, and a State of Florida/Florida Package Medicaid Authorization Request form and submitting the package to the (continued) 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 For recipients under age 21, an interdisciplinary team (ID team) must be Team 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 Once the ID team (or speech-language pathologist for recipients age 21 and Pathologist’s older) has evaluated the recipient and recommended an AAC, the speech- Evaluation 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 2-17
  • 38. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Speech-Language • motor skills, i.e., posture/positioning, selection abilities, range and accuracy Pathologist’s of movement, etc.; Evaluation • cognitive skills, i.e., alertness, attention span, vigilance, etc.; (continued) • 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 The ID team members headed by the speech-language pathologist (or the Action Plan speech-language pathologist for recipients age 21 and older) are responsible for developing the recipient’s individualized action plan. April 2001 2-18
  • 39. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Components of The recommended individualized action plan must include the following the Individualized information: Action Plan • 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 If the recipient is in the public school system, school personnel must be given School Personnel 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. April 2001 2-19
  • 40. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Physician The recipient’s physician, ARNP or PA designee, or designated physician Approval 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 After receiving the prior authorization package, the DME provider must Authorization request prior authorization from Medicaid. Requirement 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 2-20
  • 41. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Prior The DME provider must complete and submit a prior authorization package to Authorization the Medicaid fiscal agent for Medicaid review and approval. The following Documentation components must be included in the prior authorization package: Requirements 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 Medicaid’s decision for coverage will be based on a medical rationale for the Approval 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 2-21
  • 42. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Medicare Effective January 1, 2001, Medicare began reimbursement of AAC devices. Approval Providers need to be aware that Medicare’s AAC policy differs from Medicaid AAC policy relative to prior authorization criteria. Additional Florida Medicaid reserves the right to request an AAC evaluation of a recipient Evaluation from either another physician or an individual who is board-certified as a Requested by neurologist, physiatrist, otolaryngologist, audiologist, optometrist, or Medicaid ophthalmologist. Service Medicaid reimbursement for AAC system procedure codes includes the Components 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 The ID team (or speech-language pathologist for recipients age 21 and older) AACs 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 1999 2-22
  • 43. DME/Medical Supply Services Coverage and Limitations Handbook Augmentative and Alternative Communication Systems, continued Rental-Only Medicaid reimburses for rental-only AACs for trial periods. Rental-only AACs 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. Provider Prior to billing for an AAC system, the DME provider is responsible to ensure Responsibilities the properly selected system and all components have been delivered to the recipient and are operational in the recipient’s home. Reimbursement Medicaid will reimburse for one AAC every five years per recipient, and a Limitations 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 Medicaid may request a videotape to assist with reimbursement status. Requests October 1998 2-23
  • 44. DME/Medical Supply Services Coverage and Limitations Handbook Bathroom and Toileting Aids Description Bathroom and toileting aids are devices available to assist recipients who are incapable of using regular toilet facilities. Reimbursement Bedpans and urinals may be reimbursed when a recipient is confined to a bed. Limitations 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 Medicaid may reimburse for an air power source compressor (E0565) when: Requirements • 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 2-24
  • 45. DME/Medical Supply Services Coverage and Limitations Handbook Cribs (Safety) Description A safety crib is a stainless steel or aluminum constructed crib that has an enclosed top. Service Medicaid may reimburse for a pediatric safety crib (W9762) when it is Requirements prescribed as medically necessary treatment for self-protection. Documentation The following documentation must be included in the recipient record: Requirements • 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 Home glucose monitors are available through the Medicaid Prescription Drug Monitor Program. April 2001 2-25
  • 46. DME/Medical Supply Services Coverage and Limitations Handbook 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 Medicaid may reimburse for heat lamps and heat pads when the application of Pads 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 Medicaid may reimburse for home enteral supplies and equipment when the Requirements 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 2-26
  • 47. DME/Medical Supply Services Coverage and Limitations Handbook Home Enteral Supplies and Equipment, continued Enteral Nutrition Enteral therapy must be administered by nasogastric (B4081-B4082) or Tubes jejunostomy/gastrostomy (B4084) tube. Enteral Nutrition Enteral feeding supply kits must include a one-month supply of the following Supplies And disposable items: Equipment • feeding syringes, tapes/wipes (B4034); • pump sets, containers, syringes, tapes/wipes (B4035); and • lavage sets, containers, syringes, tapes/wipes (B4036). Home Enteral The provider must maintain documentation of medical necessity for the use of Therapy home enteral therapy. The documentation must specify all items and equipment Documentation (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 2-27
  • 48. DME/Medical Supply Services Coverage and Limitations Handbook Hospital Beds, Mattress, and Rails, continued Service Medicaid may reimburse for a hospital bed when the recipient requires Requirements 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 2-28
  • 49. DME/Medical Supply Services Coverage and Limitations Handbook Hospital Beds, Mattress, and Rails, continued Hospital Bed The provider must submit the following documentation with the prior Documentation 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 Medicaid may reimburse for a heavy duty, extra wide bed if the recipient Wide Hospital Bed weighs over 350 pounds. The recipient’s weight should be documented by the practitioner and submitted with the prior authorization request. Mattress Medicaid may reimburse a mattress replacement after four years. Replacement 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 2001 2-29
  • 50. DME/Medical Supply Services Coverage and Limitations Handbook Infusion Pumps, continued Infusion pump An infusion pump (E0781) includes all supplies for the initiation of home Supplies 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. Service Medicaid may reimburse for lymphedema pumps if medical necessity Requirements 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 2-30
  • 51. DME/Medical Supply Services Coverage and Limitations Handbook 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, When prescribed, Medicaid can reimburse for a self-contained ultrasonic Ultrasonic nebulizer (E0575), including a decontamination filter. Compressor and Medicaid may reimburse for a compressor and heater nebulizer (E0585) for Heater 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 2-31
  • 52. DME/Medical Supply Services Coverage and Limitations Handbook Orthopedic Footwear Description Orthopedic footwear is footwear that corrects or prevents deformities. Orthopedic Orthopedic footwear (L3201 through L3595) includes orthopedic shoes, Footwear 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. Service Medicaid may reimburse for orthopedic footwear when: Requirements • 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 2-32
  • 53. DME/Medical Supply Services Coverage and Limitations Handbook Orthopedic Footwear, continued Required Orthopedic footwear must have all the following components: 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 When there is a substantial difference in size between the left and right foot Foot Sizes 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. Service The device must fit properly. The provider is responsible for any Requirements modifications, adjustments, or replacements that are needed within six months. April 1998 2-33
  • 54. DME/Medical Supply Services Coverage and Limitations Handbook Orthotic Devices, continued Documentation The following information must be documented in the recipient’s record: Requirements • 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 Medicaid may reimburse for an osteogenesis stimulator (E0747) when non- Stimulator 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 2-34
  • 55. DME/Medical Supply Services Coverage and Limitations Handbook Provider Service An oxygen provider must meet the following requirements: 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 • provide all contents for stationary and portable oxygen; Requirements • supply and replace disposable items such as tubing, masks, cannulas, and (continued) 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 The oxygen provider must be able to provide recipients with emergency Requirements 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 When oxygen and oxygen-related equipment is placed in the recipient’s Requirements 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 1998 2-35
  • 56. DME/Medical Supply Services Coverage and Limitations Handbook Oxygen and Oxygen Related Equipment, continued Contract To be considered a valid contract between a durable medical Requirements 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 Medicaid requires either a CRTT, RRT, or RN be present at the time of Responsibilities oxygen equipment installation. April 2001 2-36
  • 57. DME/Medical Supply Services Coverage and Limitations Handbook Oxygen and Oxygen Related Equipment, continued General Diagnostic Medicaid will reimburse for oxygen and oxygen related equipment for Requirements 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 In addition to the general requirements, Medicaid will reimburse oxygen for Requirements For recipients under 21 who have one of these conditions: Recipients Under 21 • 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 2001 2-37
  • 58. DME/Medical Supply Services Coverage and Limitations Handbook Oxygen and Oxygen Related Equipment, continued Additional Service For Medicaid reimbursement of oxygen and oxygen-related equipment for Criteria For recipients under 21, laboratory results of oximetry or arterial blood gases Recipients must show: Under 21 • 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 An oxygen evaluation is needed for recipients under 21 to determine the Requirements amount of oxygen necessary to prevent hypoxia. The evaluation is made over For Recipients an extended period of time to measure different needs with different activities. Under 21 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 The prescribing practitioner is responsible for ordering tests, performing tests Requirements 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 2-38
  • 59. DME/Medical Supply Services Coverage and Limitations Handbook Oxygen and Oxygen Related Equipment, continued Provider A physician-ordered test for blood oxygen levels must be conducted and the Documentation oxygen provider must obtain a copy of the test results and practitioner’s Requirements 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 for medical necessity for oxygen should be done on a yearly basis. Testing Medical Necessity Medical necessity renewal time frame for oxygen service is twelve months. Renewal 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 1998 2-39
  • 60. DME/Medical Supply Services Coverage and Limitations Handbook Oxygen and Oxygen Related Equipment, continued Documentation The HCFA-484 form or equivalent may be used to document medical Requirements 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 Each stationary oxygen service is reimbursed as an all-inclusive rental fee. Stationary Services The fee includes the following: Only • supplies necessary for the administration of oxygen; • all equipment and accessories; and • oxygen contents. April 2001 2-40
  • 61. DME/Medical Supply Services Coverage and Limitations Handbook Oxygen and Oxygen Related Equipment, continued Reimbursement For Medicaid may reimburse additional costs for portable equipment when both Stationary Oxygen portable and stationary services are medically necessary; however, Medicaid Services With will not reimburse for additional oxygen contents. The cost of oxygen Portable Equipment 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 Medicaid reimburses for portable oxygen when a practitioner prescribes Service Criteria 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 Medicaid may reimburse for portable oxygen only when it is medically Portable Oxygen necessary. Services Only 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 2001 2-41
  • 62. DME/Medical Supply Services Coverage and Limitations Handbook Oxygen and Oxygen Related Equipment, continued 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 Medicaid may reimburse for servicing of recipient owned oxygen equipment 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 Medicaid may reimburse for a passive motion device (E0935) for a recipient Device 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 2-42
  • 63. DME/Medical Supply Services Coverage and Limitations Handbook Passive Motion Device, continued Service The provider must assemble the passive motion device in the recipient’s home Requirements 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 The provider is responsible for training the caregiver in the proper and Requirements effective use of the device. April 1998 2-43
  • 64. DME/Medical Supply Services Coverage and Limitations Handbook April 1998 2-44
  • 65. DME/Medical Supply Services Coverage and Limitations Handbook Peak Flow Meter, continued Documentation The following information must be documented in the recipient’s record: Requirements • 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 Medicaid may reimburse for a pediatric dynamic splinting device (W9768) Splinting Device 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 Medicaid may reimburse for pressure ulcer care pads and wheelchair Wheelchair cushions if the recipient currently has pressure ulcers or is highly susceptible to Cushions pressure ulcers. Alternating Pressure Medicaid may reimburse for alternating pressure pads or mattresses and Pads, Mattresses, pumps for beds if a recipient is confined to a bed and the recipient has Pumps evidence of pressure ulcers or is highly susceptible to pressure ulcers. April 1998 2-45
  • 66. DME/Medical Supply Services Coverage and Limitations Handbook Pressure Ulcer Care, continued Pressure Ulcer Care The following must be included in the recipient record: Documentation • 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 Medicaid may reimburse for a phototherapy light with photometer (E0202) if: Requirements • 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 The provider must record the following in the recipient’s record: Requirements • the duration of treatment, • the frequency of use per day, and • the maximum number of days. April 1998 2-46
  • 67. DME/Medical Supply Services Coverage and Limitations Handbook Prosthetic Devices Description Prosthetic devices are artificial devices or appliances that replace all or part of a permanently inoperative or missing body part. Service Reimbursement for prosthetic supplies is limited to supplies related to the Requirements medically necessary prosthetic device. Provider The provider must ensure that the prosthetic device fits properly. For the first Responsibilities six months, the provider is responsible for adjustments, modifications, and replacements. Documentation The following information must be documented in the recipient’s record: Requirements • 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 Medicaid reimburses for prosthetic eyes if prescribed by an attending Requirements 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 2-47
  • 68. DME/Medical Supply Services Coverage and Limitations Handbook Prosthetic Eyes, continued Prosthetic Eye Medicaid may replace an artificial eye that is damaged or no longer the Replacements appropriate size. Documentation The recipient record must contain an evaluation completed by a physician or Requirements 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 The provider must document in the recipient’s record that the caregiver Requirement 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 2-48
  • 69. DME/Medical Supply Services Coverage and Limitations Handbook April 1998 2-49
  • 70. DME/Medical Supply Services Coverage and Limitations Handbook 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 2-50
  • 71. DME/Medical Supply Services Coverage and Limitations Handbook 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 Medicaid reimburses for the following ventilators or respiratory equipment: Respiratory • continuous positive airway pressure device (CPAP) (E0601); Equipment • 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). April 1998 2-51
  • 72. DME/Medical Supply Services Coverage and Limitations Handbook Ventilator and Respiratory Equipment, continued Continuous Positive Medicaid may reimburse for a CPAP device when there is documentation in Airway Pressure the medical record to indicate: Device (CPAP) • 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 The following information must be documented in the recipient’s record: 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. July 2001 2-52
  • 73. DME/Medical Supply Services Coverage and Limitations Handbook Ventilator and Respiratory Equipment, continued Respiratory Assist A respiratory assist device (K0532, K0533, K0534) used to administer Devices 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 Medicaid may reimburse for an IPPB machine if the recipient’s ability to Pressure Breathing breathe is severely impaired. Machine (IPPB) IPPB The following information must be documented in the recipient’s record: 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 2-53
  • 74. DME/Medical Supply Services Coverage and Limitations Handbook Ventilator and Respiratory Equipment, continued Service Medicaid may reimburse for a volume ventilator when the recipient has one of Requirements 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 The following must be documented in the recipient’s record: Documentation • home care protocols, • airway stability, • oxygen requirements, and • nutritional intake. Negative Pressure Medicaid reimburses for a negative pressure ventilator, stationary or portable. Ventilator Alternating Positive Medicaid reimburses for an alternating positive airway pressure and Airway Pressure intermittent positive ventilation system for intermittent respiratory service. and Intermittent Reimbursement includes all connectors, pressure measuring and alarm Positive Ventilation devices, breathing circuits, in-line thermometers, water traps, connectors, System 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 2-54
  • 75. DME/Medical Supply Services Coverage and Limitations Handbook Ventilator and Respiratory Equipment, continued Documentation The following information must be documented in the recipient’s record: Requirements • 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 When intermittent respiratory service is prescribed for obstructive sleep Obstructive Sleep apnea syndrome (OSAS) and an alternating positive airway pressure system Apnea Syndrome (E0452) is used, the provider must document the following information in the (OSAS) 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 When intermittent respiratory service is prescribed for OSAS and intermittent Intermittent Positive positive ventilatory support (E0453) is used, the provider must document the Ventilatory Support 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. April 1998 2-55
  • 76. DME/Medical Supply Services Coverage and Limitations Handbook Ventilator and Respiratory Equipment, continued Recipient Owned When a recipient owns a ventilator, the provider may use procedure code Ventilator A4618 to bill for a daily amount of accessories, supplies, and a monthly home visit. Back-up The back-up ventilator is included in the monthly Medicaid reimbursement. Ventilator Documentation When service of a recipient owned ventilator is provided, the following must Requirements 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. July 2001 2-56
  • 77. DME/Medical Supply Services Coverage and Limitations Handbook Wheelchairs, continued Categories Of Medicaid may reimburse for a standard wheelchair if the recipient is confined Wheelchairs 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 Medicaid may reimburse for a customized wheelchair that is specially Wheelchair constructed (K0008, K0013, K0014). Prior authorization is required. Documentation 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 2-57
  • 78. DME/Medical Supply Services Coverage and Limitations Handbook Wheelchairs, continued Customized • an itemized invoice listing actual costs for parts and labor; Wheelchair • list the source(s) of purchased accessories and modifications; and Documentation • documentation of home accessibility is required for an oversized, heavy- (continued) 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 Medicaid will not approve a motorized wheelchair or wheelchair upgrade Wheelchairs where no medical necessity to accomplish basic ADLs within the home has Documentation 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 2-58
  • 79. DME/Medical Supply Services Coverage and Limitations Handbook Wheelchairs, continued 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 See the Services Requirement section of this chapter for prior authorization Authorization Process 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 2-59
  • 80. DME/Medical Supply Services Coverage and Limitations Handbook Non-Covered Services and Exclusions, continued Non-Covered Items • emergency and non-emergency alert devices; (continued) • 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. April 2001 2-60
  • 81. DME/Medical Supply Services Coverage and Limitations Handbook 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 E0441 E0442 E0441 or E0442 Equipment May 1996 A-1
  • 82. DME/Medical Supply Services Coverage and Limitations Handbook 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 B-1 Medicaid Recipients Appendix C: Procedure Codes and Fee Schedule for C-1 Recipients Under 21 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 3-1
  • 83. DME/Medical Supply Services Coverage and Limitations Handbook Reimbursement Information, continued Purchased Providers are required to credit any parts or accessories that are removed Equipment Credits from the amount charged for the equipment before delivery. Credit must be deducted prior to submitting the claim to Medicaid. Used Equipment Reimbursement for the purchase of used equipment is 66 percent of the Billing 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. April 2001 3-2
  • 84. DME/Medical Supply Services Coverage and Limitations Handbook Reimbursement Information, continued Rental Only Items Rental only (RO) items remain the property of the provider. (RO) 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 3-3
  • 85. DME/Medical Supply Services Coverage and Limitations Handbook 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 3-4
  • 86. DME/Medical Supply Services Coverage and Limitations Handbook How To Read The Fee Schedule, continued 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. May 1996 3-5
  • 87. DME/Medical Supply Services Coverage and Limitations Handbook How To Read The Fee Schedule, continued 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 2001 3-6
  • 88. DME/Medical Supply Services Coverage and Limitations Handbook 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- Providers must use a non-classified procedure code when the item is Classified Procedure reimbursable, but: Codes • 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 A provider may be reimbursed for a non-classified procedure code after the Non-Classified claim is approved and priced. Codes April 1998 3-7
  • 89. DME/Medical Supply Services Coverage and Limitations Handbook 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 A By Report claim is submitted directly to the fiscal agent and must include Claims 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 An exception to acceptable forms of medical documentation is that a physical Exception or occupational therapist may provide medical documentation for custom wheelchairs relative to procedure E1340 only. April 1998 3-8
  • 90. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS A4206 SYRINGE WITH NEEDLE, STERILE 1CC, EACH 0.29 60 720 PER YEAR A4207 SYRINGE WITH NEEDLE, STERILE 2CC, EACH 0.29 60 720 PER YEAR A4208 SYRINGE WITH NEEDLE, STERILE 3CC, EACH 0.29 60 720 PER YEAR A4209 SYRINGE WITH NEEDLE, STERILE 5CC OR 0.29 60 720 PER YEAR GREATER, EACH A4213 SYRINGE, STERILE, 20 CC OR GREATER, EACH 1.94 31 366 PER YEAR A4215 NEEDLES ONLY, STERILE, ANY SIZE, EACH 0.19 100 1200 PER YEAR A4230 INFUSION SET FOR EXTERNAL INSULIN PUMP, 155.52 1 12 BOXES PER NON NEEDLE CANNULA TYPE YEAR A4231 INFUSION SET FOR EXTERNAL INSULIN PUMP, 87.12 1 12 BOXES PER NEEDLE TYPE YEAR A4232 SYRINGE WITH NEEDLE FOR EXTERNAL INSULIN 57.84 1 12 BOXES PER PUMP, STERILE, 3CC YEAR A4244 ALCOHOL OR PEROXIDE, PER PINT 0.78 12 144 PER YEAR A4245 ALCOHOL WIPES, PER BOX 1.94 2 24 PER YEAR A4259 LANCETS, PER BOX OF 100 9.70 2 24 PER YEAR A4280 ADHESIVE SKIN SUPPORT ATTACHMENT FOR 3.76 1 5 PER MONTH USE WITH EXTERNAL BREAST PROSTHESIS, EACH A4311 INSERTION TRAY WITHOUT DRAINAGE BAG 4.46 3 36 PER YEAR WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.) A4312 INSERTION TRAY WITHOUT DRAINAGE BAG 15.81 3 36 PER YEAR WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE A4313 INSERTION TRAY WITHOUT DRAINAGE BAG 10.39 3 36 PER YEAR WITH INDWELLING CATHETER, FOLEY TYPE, THREE-WAY, FOR CONTINUOUS IRRIGATION A4324 MALE EXTERNAL CATHETER, WITH ADHESIVE 1.66 35 35 PER MONTH COATING, EACH A4325 MALE EXTERNAL CATHETER, WITH ADHESIVE 1.38 35 35 PER MONTH STRIP, EACH A4331 EXTENSION DRAINAGE TUBING, ANY TYPE, ANY 1.68 31 366 PER YEAR LENGTH, WITH CONNECTOR/ADAPTOR, FOR USE WITH URINARY LEG BAG OR UROSTOMY POUCH, EACH A4332 LUBRICANT, INDIVIDUAL STERILE PACKET, FOR 0.10 200 200 PER MONTH INSERTION OF URINARY CATHETER, EACH A4333 URINARY CATHETER ANCHORING DEVICE, 2.43 31 31 PER MONTH ADHESIVE SKIN ATTACHMENT, EACH A4347 MALE EXTERNAL CATHETER WITH OR WITHOUT 9.22 3 60 PER YEAR ADHESIVE, WITH OR WITHOUT ANTI-REFLUX DEVICE; PER DOZEN A4348 MALE EXTERNAL CATHETER WITH INTEGRAL 21.24 2 2 PER MONTH COLLECTION COMPARTMENT, EXTENDED WEAR, March 2003 B-1
  • 91. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS EACH (E.G., 2 PER MONTH) A4350 CATHETER CARE KIT 0.00 0 36 PER YEAR A4351 INTERMITTENT URINARY CATHETER; STRAIGHT 1.60 200 1800 PER YEAR TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH A4352 INTERMITTENT URINARY CATHETER; COUDE 1.84 200 2400 PER YEAR (CURVED) TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMERIC, OR HYDROPHILIC, ETC.), EACH A4353 INTERMITTENT URINARY CATHETER, WITH 5.33 200 2400 PER YEAR INSERTION SUPPLIES A4357 BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH 7.76 2 24 PER YEAR OR WITHOUT ANTI-REFLUX DEVICE, WITH OR WITHOUT TUBE, EACH A4358 URINARY DRAINAGE BAG, LEG OR ABDOMEN, 3.40 5 60 PER YEAR VINYL, WITH OR WITHOUT TUBE, WITH STRAPS, EACH A4361 OSTOMY FACEPLATE, EACH 17.52 1 12 PER YEAR A4362 SKIN BARRIER; SOLID, 4 X 4 OR EQUIVALENT; 2.91 20 240 PER YEAR EACH A4364 ADHESIVE, LIQUID OR EQUAL, ANY TYPE, PER 2.13 4 48 PER YEAR OZ A4365 ADHESIVE REMOVER WIPES, ANY TYPE, PER 50 8.64 2 2 PER MONTH A4367 OSTOMY BELT, EACH 5.61 1 12 PER YEAR A4368 OSTOMY FILTER, ANY TYPE, EACH 0.20 200 200 PER MONTH A4369 OSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUSH, 1.84 12 144 PER YEAR ETC), PER OZ A4371 OSTOMY SKIN BARRIER, POWDER, PER OZ 2.78 12 144 PER YEAR A4372 OSTOMY SKIN BARRIER, SOLID 4X4 OR 3.18 20 240 PER YEAR EQUIVALENT, WITH BUILT-IN CONVEXITY, EACH A4373 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, 4.79 31 240 PER YEAR FLEXIBLE OR ACCORDIAN), WITH BUILT-IN CONVEXITY, ANY SIZE, EACH A4375 OSTOMY POUCH, DRAINABLE, WITH FACEPLATE 13.10 10 10 PER MONTH ATTACHED, PLASTIC, EACH A4376 OSTOMY POUCH, DRAINABLE, WITH FACEPLATE 36.30 10 2 PER MONTH ATTACHED, RUBBER, EACH A4377 OSTOMY POUCH, DRAINABLE, FOR USE ON 3.27 10 10 PER MONTH FACEPLATE, PLASTIC, EACH A4378 OSTOMY POUCH, DRAINABLE, FOR USE ON 23.46 10 2 PER MONTH FACEPLATE, RUBBER, EACH A4379 OSTOMY POUCH, URINARY, WITH FACEPLATE 11.46 10 10 PER MONTH ATTACHED, PLASTIC, EACH A4380 OSTOMY POUCH, URINARY, WITH FACEPLATE 28.48 20 366 PER YEAR ATTACHED, RUBBER, EACH A4381 OSTOMY POUCH, URINARY, FOR USE ON 3.52 10 10 PER MONTH March 2003 B-2
  • 92. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS FACEPLATE, PLASTIC, EACH A4382 OSTOMY POUCH, URINARY, FOR USE ON 18.78 10 10 PER MONTH FACEPLATE, HEAVY PLASTIC, EACH A4383 OSTOMY POUCH, URINARY, FOR USE ON 21.51 10 10 PER MONTH FACEPLATE, RUBBER, EACH A4384 OSTOMY FACEPLATE EQUIVALENT, SILICONE 7.34 10 10 PER MONTH RING, EACH A4385 OSTOMY SKIN BARRIER, SOLID 4X4 OR 3.88 10 10 PER OSTOMY EQUIVALENT, EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, EACH A4387 OSTOMY POUCH, CLOSED, WITH BARRIER 3.06 10 31 PER MONTH ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH A4388 OSTOMY POUCH, DRAINABLE, WITH EXTENDED 3.32 10 10 PER MONTH WEAR BARRIER ATTACHED, (1 PIECE), EACH A4389 OSTOMY POUCH, DRAINABLE, WITH BARRIER 4.74 10 10 PER MONTH ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH A4390 OSTOMY POUCH, DRAINABLE, WITH EXTENDED 7.33 10 10 PER MONTH WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH A4391 OSTOMY POUCH, URINARY, WITH EXTENDED 5.39 10 10 PER MONTH WEAR BARRIER ATTACHED (1 PIECE), EACH A4392 OSTOMY POUCH, URINARY, WITH STANDARD 5.07 10 10 PER MONTH WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH A4393 OSTOMY POUCH, URINARY, WITH EXTENDED 7.00 10 10 PER MONTH WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH A4394 OSTOMY DEODORANT FOR USE IN OSTOMY 1.96 10 4 PER MONTH POUCH, LIQUID, PER FLUID OUNCE A4395 OSTOMY DEODORANT FOR USE IN OSTOMY 0.04 10 31 PER MONTH POUCH, SOLID, PER TABLET A4396 OSTOMY BELT WITH PERISTOMAL HERNIA 30.89 2 2 PER MONTH SUPPORT A4400 OSTOMY IRRIGATION SET 31.70 1 6 PER YEAR A4405 OSTOMY SKIN BARRIER, NON-PECTIN BASED, 2.18 12 144 PER YEAR PASTE, PER OUNCE A4406 OSTOMY SKIN BARRIER, PECTIN-BASED, PASTE, 3.67 12 144 PER YEAR PER OUNCE A4407 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, 5.61 31 366 PER YEAR FLEXIBLE, OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH A4408 OSTOMY SKIN BARRIER, WTIH FLANGE (SOLID, 6.32 31 366 PER YEAR FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, LARGER THAN 4 X 4 March 2003 B-3
  • 93. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS INCHES, EACH A4409 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, 3.98 31 366 PER YEAR FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH A4410 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, 5.78 31 366 PER YEAR FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH A4413 OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, 3.52 10 10 PER MONTH FOR USE ON A BARRIER WITH FLANGE (2 PIECE SYSTEM), WITH FILTER, EACH A4414 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, 3.15 31 366 PER YEAR FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH A4415 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, 3.84 31 366 PER YEAR FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4X4 INCHES, EACH A4421 OSTOMY SUPPLY; MISCELLANEOUS 7.76 1 12 PER YEAR A4455 ADHESIVE REMOVER OR SOLVENT (FOR TAPE, 1.16 4 48 PER YEAR CEMENT OR OTHER ADHESIVE), PER OUNCE A4561 PESSARY, RUBBER, ANY TYPE 13.46 1 10 PER MONTH A4562 PESSARY, NON RUBBER, ANY TYPE 36.46 1 10 PER MONTH A4608 TRANSTRACHEAL OXYGEN CATHETER, EACH 46.66 5 5 PER MONTH A4611 BATTERY, HEAVY DUTY; REPLACEMENT FOR 111.55 1 MEDICAL PATIENT OWNED VENTILATOR NECESSITY A4612 BATTERY CABLES; REPLACEMENT FOR 41.23 1 MEDICAL PATIENT-OWNED VENTILATOR NECESSITY A4613 BATTERY CHARGER; REPLACEMENT FOR 94.09 1 MEDICAL PATIENT-OWNED VENTILATOR NECESSITY A4614 PEAK EXPIRATORY FLOW RATE METER, HAND 18.14 1 1 PER YEAR HELD A4616 TUBING (OXYGEN), PER FOOT 0.21 25 250 PER YEAR A4618 BREATHING CIRCUITS 5.77 1 MEDICAL NECESSITY A4621 TRACHEOTOMY MASK OR COLLAR 1.18 4 4 PER MONTH A4622 TRACHEOSTOMY OR LARYNGECTOMY TUBE 52.38 1 MEDICAL NECESSITY A4623 TRACHEOSTOMY, INNER CANNULA 6.25 5 60 PER YEAR (REPLACEMENT ONLY) A4624 TRACHEAL SUCTION CATHETER, ANY TYPE 0.97 250 3000 PER YEAR OTHER THAN CLOSED SYSTEM, EACH A4625 TRACHEOSTOMY CARE KIT FOR NEW 6.61 14 14 PER MEDICAL TRACHEOSTOMY EVENT A4626 TRACHEOSTOMY CLEANING BRUSH, EACH 1.46 1 12 PER YEAR A4627 SPACER, BAG OR RESERVOIR, WITH OR WITHOUT 20.00 1 1 PER YEAR MASK, FOR USE WITH METERED DOSE INHALER March 2003 B-4
  • 94. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS A4629 TRACHEOSTOMY CARE KIT FOR ESTABLISHED 3.44 31 31 PER MONTH TRACHEOSTOMY A4635 UNDERARM PAD, CRUTCH, REPLACEMENT, 1.79 2 2 PER YEAR EACH A4636 REPLACEMENT, HANDGRIP, CANE, CRUTCH, OR 1.65 2 2 PER YEAR WALKER, EACH A4637 REPLACEMENT, TIP, CANE, CRUTCH, WALKER, 1.21 4 4 PER YEAR EACH. A5051 OSTOMY POUCH, CLOSED; WITH BARRIER 1.66 31 366 PER YEAR ATTACHED (1 PIECE), EACH A5052 OSTOMY POUCH, CLOSED; WITHOUT BARRIER 1.27 31 366 PER YEAR ATTACHED (1 PIECE), EACH A5053 OSTOMY POUCH, CLOSED; FOR USE ON 1.28 31 366 PER YEAR FACEPLATE, EACH A5054 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER 1.28 31 366 PER YEAR WITH FLANGE (2 PIECE), EACH A5055 STOMA CAP 1.21 31 31 PER MONTH A5061 OSTOMY POUCH, DRAINABLE; WITH BARRIER 2.18 31 366 PER YEAR ATTACHED, (1 PIECE), EACH A5062 OSTOMY POUCH, DRAINABLE; WITHOUT 1.89 31 366 PER YEAR BARRIER ATTACHED (1 PIECE), EACH A5063 OSTOMY POUCH, DRAINABLE; FOR USE ON 1.89 31 366 PER YEAR BARRIER WITH FLANGE (2 PIECE SYSTEM), EACH A5071 OSTOMY POUCH, URINARY; WITH BARRIER 2.82 31 366 PER YEAR ATTACHED (1 PIECE), EACH A5072 OSTOMY POUCH, URINARY; WITHOUT BARRIER 2.29 31 366 PER YEAR ATTACHED (1 PIECE), EACH A5073 OSTOMY POUCH, URINARY; FOR USE ON 2.09 31 366 PER YEAR BARRIER WITH FLANGE (2 PIECE), EACH A5081 CONTINENT DEVICE; PLUG FOR CONTINENT 2.51 1 6 PER YEAR STOMA A5082 CONTINENT DEVICE; CATHETER FOR CONTINENT 7.71 1 6 PER YEAR STOMA A5093 OSTOMY ACCESSORY; CONVEX INSERT 1.55 10 120 PER YEAR A5112 URINARY LEG BAG; LATEX 26.42 1 48 PER YEAR A5119 SKIN BARRIER; WIPES, BOX PER 50 8.28 1 12 PER YEAR A5121 SKIN BARRIER; SOLID, 6 X 6 OR EQUIVALENT, 4.84 10 120 PER YEAR EACH A5122 SKIN BARRIER; SOLID, 8 X 8 OR EQUIVALENT, 9.81 10 120 PER YEAR EACH A5131 APPLIANCE CLEANER, INCONTINENCE AND 10.28 3 3 PER MONTH OSTOMY APPLIANCES, PER 16 OZ. A5500 FOR DIABETICS ONLY, FITTING (INCLUDING 50.40 2 2 PER MEDICAL FOLLOW-UP), CUSTOM PREPARATION AND EVENT SUPPLY OF OFF-THE-SHELF DEPTH-INLAY SHOE MANUFACTURED TO ACCOMMODATE MULTI- DENSITY INSERT(S), PER SHOE. March 2003 B-5
  • 95. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS A5501 FOR DIABETICS ONLY, FITTING (INCLUDING 151.20 2 2 PER MEDICAL FOLLOW-UP), CUSTOM PREPARATION AND EVENT SUPPLY OF SHOE MOLDED FROM CAST(S) OF PATIENT'S FOOT (CUSTOM MOLDED SHOE), PER SHOE A5503 FOR DIABETICS ONLY, MODIFICATION 25.60 2 2 PER FOOT PER (INCLUDING FITTING) OF OFF-THE-SHELF YEAR DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH ROLLER OR RIGID ROCKER BOTTOM, PER SHOE A5504 FOR DIABETICS ONLY, MODIFICATION 25.60 2 2 PER FOOT PER (INCLUDING FITTING) OF OFF-THE-SHELF YEAR DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH WEDGE(S), PER SHOE A5505 FOR DIABETICS ONLY, MODIFICATION 25.60 2 2 PER FOOT PER (INCLUDING FITTING) OF OFF-THE-SHELF YEAR DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH METATARSAL BAR, PER SHOE A5506 FOR DIABETICS ONLY, MODIFICATION 25.60 2 2 PER FOOT PER (INCLUDING FITTING) OF OFF-THE-SHELF YEAR DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH OFF-SET HEEL(S), PER SHOE A5507 FOR DIABETICS ONLY, NOT OTHERWISE 0.00 2 BR 2 PER FOOT PER SPECIFIED MODIFICATION (INCLUDING FITTING) YEAR OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE, PER SHOE A5509 FOR DIABETICS ONLY, DIRECT FORMED, 26.40 2 2 PER FOOT PER MOLDED TO FOOT WITH EXTERNAL HEAT YE SOURCE (I.E. HEAT GUN) MULTIPLE DENSITY INSERT (S), PREFABRICATED, PER SHOE A6022 COLLAGEN DRESSING, PAD SIZE MORE THAN 16 16.04 31 31 PER MONTH SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH A6023 COLLAGEN DRESSING, PAD SIZE MORE THAN 48 145.21 15 15 PER MONTH SQ. IN., EACH A6024 COLLAGEN DRESSING WOUND FILLER, PER 6 4.72 1 31 PER MONTH INCHES A6231 GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT 3.56 31 31 PER MONTH WOUND CONTACT, PAD SIZE 16 SQ. IN. OR LESS, EACH DRESSING A6232 GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT 5.26 31 31 PER MONTH WOUND CONTACT, PAD SIZE GREATER THAN 16 SQ. IN., BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING A6233 GAUZE, IMPREGNATED, HYDROGEL FOR DIRECT 14.64 31 31 PER MONTH WOUND CONTACT, PAD SIZE MORE THAN 48 SQ. IN., EACH DRESSING A6257 TRANSPARENT FILM, 16 SQ. IN. OR LESS, EACH 1.15 31 31 PER MONTH March 2003 B-6
  • 96. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS DRESSING A7000 CANISTER, DISPOSABLE, USED WITH SUCTION 6.94 1 4 PER YEAR PUMP, EACH A7001 CANISTER, NON-DISPOSABLE, USED WITH 21.45 1 1 PER 2 YEARS SUCTION PUMP, EACH A7002 TUBING, USED WITH SUCTION PUMP, EACH 2.48 2 12 PER YEAR A7003 ADMINISTRATION SET, WITH SMALL VOLUME 1.98 3 36 PER YEAR NONFILTERED PNEUMATIC NEBULIZER, DISPOSABLE A7004 SMALL VOLUME NONFILTERED PNEUMATIC 1.16 1 36 PER YEAR NEBULIZER, DISPOSABLE A7005 ADMINISTRATION SET, WITH SMALL VOLUME 19.99 1 2 PER YEAR NONFILTERED PNEUMATIC NEBULIZER, NON-DISPOSABLE A7006 ADMINISTRATION SET, WITH SMALL VOLUME 7.24 1 36 PER YEAR FILTERED PNEUMATIC NEBULIZER A7007 LARGE VOLUME NEBULIZER, DISPOSABLE, 3.16 1 36 PER YEAR UNFILLED, USED WITH AEROSOL COMPRESSOR A7008 LARGE VOLUME NEBULIZER, DISPOSABLE, 7.13 1 36 PER YEAR PREFILLED, USED WITH AEROSOL COMPRESSOR A7009 RESERVOIR BOTTLE, NON-DISPOSABLE, USED 29.79 1 1 PER YEAR WITH LARGE VOLUME ULTRASONIC NEBULIZER A7010 CORRUGATED TUBING, DISPOSABLE, USED WITH 15.30 1 12 PER YEAR LARGE VOLUME NEBULIZER, 100 FEET A7011 CORRUGATED TUBING, NON-DISPOSABLE, USED 1.53 1 1 PER MONTH WITH LARGE VOLUME NEBULIZER, 10 FEET A7012 WATER COLLECTION DEVICE, USED WITH LARGE 2.74 1 12 PER YEAR VOLUME NEBULIZER A7013 FILTER, DISPOSABLE, USED WITH AEROSOL 0.53 1 366 PER YEAR COMPRESSOR A7014 FILTER, NONDISPOSABLE, USED WITH AEROSOL 3.30 1 12 PER YEAR COMPRESSOR OR ULTRASONIC GENERATOR A7015 AEROSOL MASK, USED WITH DME NEBULIZER 1.43 1 12 PER YEAR A7016 DOME AND MOUTHPIECE, USED WITH SMALL 4.97 1 12 PER YEAR VOLUME ULTRASONIC NEBULIZER A7017 NEBULIZER, DURABLE, GLASS OR 102.28 1 1 PER YEAR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, NOT USED WITH OXYGEN A7501 TRACHEOSTOMA VALVE, INCLUDING 80.14 1 31 PER MONTH DIAPHRAGM, EACH A7502 REPLACEMENT DIAPHRAGM/FACEPLATE FOR 38.09 1 10 PER MONTH TRACHEOSTOMA VALVE, EACH A7503 FILTER HOLDER OR FILTER CAP, REUSABLE, FOR 8.65 1 4 PER YEAR USE IN A TRACHEOSTOMA HEAT AND MOISTURE EXCHANGE SYSTEM, EACH A7504 FILTER FOR USE IN A TRACHEOSTOMA HEAT 0.51 31 366 PER YEAR AND MOISTURE EXCHANGE SYSTEM, EACH March 2003 B-7
  • 97. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS A7505 HOUSING, REUSABLE WITHOUT ADHESIVE, FOR 3.57 1 120 PER YEAR USE IN A HEAT AND MOISTURE EXCHANGE SYSTEM AND/OR WITH A TRACHEOSTOMA VALVE, EACH A7506 ADHESIVE DISC FOR USE IN A HEAT AND 0.26 31 10 PER MONTH MOISTURE EXCHANGE SYSTEM AND/OR WITH TRACHEOSTOMA VALVE, ANY TYPE EACH A7507 FILTER HOLDER AND INTEGRATED FILTER 1.90 1 4 PER YEAR WITHOUT ADHESIVE, FOR USE IN A TRACHEOSTOMA HEAT AND MOISTURE EXCHANGE SYSTEM, EACH A7508 HOUSING AND INTEGRATED ADHESIVE, FOR USE 2.19 31 31 PER MONTH IN A TRACHEOSTOMA HEAT AND MOISTURE EXCHANGE SYSTEM AND/OR WITH A TRACHEOSTOMA VALVE, EACH A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY, 0.00 10 BR MEDICAL AND/OR SERVICE COMPONENT OF ANOTHER NECESSITY HCPCS CODE March 2003 B-8
  • 98. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS E0100 CANE, INCLUDES CANES OF ALL MATERIALS, 15.52 1 1 PER YEAR ADJUSTABLE OR FIXED, WITH TIP E0105 CANE, QUAD OR THREE PRONG, INCLUDES 36.38 1 1 PER 3 YEARS CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIPS E0112 CRUTCHES UNDERARM, WOOD, ADJUSTABLE OR 21.34 1 1 PER 2 YEARS FIXED, PAIR, WITH PADS, TIPS AND HANDGRIPS E0113 CRUTCH UNDERARM, WOOD, ADJUSTABLE OR 10.67 1 1 PER 2 YEARS FIXED, EACH, WITH PAD, TIP AND HANDGRIP E0114 CRUTCHES UNDERARM, OTHER THAN WOOD, 24.25 1 1 PER 2 YEARS ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPS AND HANDGRIPS E0116 CRUTCH UNDERARM, OTHER THAN WOOD, 12.13 1 1 PER 2 YEARS ADJUSTABLE OR FIXED, EACH, WITH PAD, TIP AND HANDGRIP E0135 WALKER, FOLDING (PICKUP), ADJUSTABLE OR 53.35 1 1 PER 3 YEARS FIXED HEIGHT E0143 FOLDING WALKER, WHEELED, WITHOUT SEAT 86.24 1 1 PER 3 YEARS E0149 WALKER, HEAVY DUTY, WHEELED, RIGID OR 170.82 1 1 PER 3 YEARS FOLDING, ANY TYPE, EACH E0156 SEAT ATTACHMENT, WALKER 17.14 1 1 PER 3 YEARS E0161 SITZ TYPE BATH OR EQUIPMENT, PORTABLE, 24.25 1 1 PER 8 YEARS USED WITH OR WITHOUT COMMODE, WITH FAUCET ATTACHMENT/S E0163 COMMODE CHAIR, STATIONARY, WITH FIXED 71.78 1 1 PER 8 YEARS ARMS E0168 COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY 115.50 1 1 PER 3 YEARS DUTY, STATIONARY OR MOBILE, WITH OR WITHOUT ARMS, ANY TYPE, EACH E0169 COMMODE CHAIR WITH SEAT LIFT MECHANISM 199.80 1 1 PER 2 YEARS E0176 AIR PRESSURE PAD OR CUSHION, 61.11 1 1 PER 2 YEARS NONPOSITIONING E0177 WATER PRESSURE PAD OR CUSHION, 32.98 1 1 PER 2 YEARS NONPOSITIONING E0178 GEL OR GEL-LIKE PRESSURE PAD OR CUSHION, 54.32 1 1 PER 2 YEARS NONPOSITIONING E0179 DRY PRESSURE PAD OR CUSHION, 11.41 1 1 PER 2 YEARS NONPOSITIONING E0185 GEL OR GEL-LIKE PRESSURE PAD FOR 121.25 1 1 PER 2 YEARS MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH E0192 LOW PRESSURE AND POSITIONING 261.90 26.19 1 1 PER 2 YEARS EQUALIZATION PAD, FOR WHEELCHAIR E0197 AIR PRESSURE PAD FOR MATTRESS, STANDARD 121.25 1 1 PER 2 YEARS MATTRESS LENGTH AND WIDTH E0198 WATER PRESSURE PAD FOR MATTRESS, 121.25 1 1 PER 2 YEARS STANDARD MATTRESS LENGTH AND WIDTH March 2003 B-9
  • 99. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS E0199 DRY PRESSURE PAD FOR MATTRESS, STANDARD 22.31 1 1 PER 2 YEARS MATTRESS LENGTH AND WIDTH E0244 RAISED TOILET SEAT 29.10 1 1 PER 8 YEARS E0245 TUB STOOL OR BENCH 35.00 1 1 PER 8 YEARS E0246 TRANSFER TUB RAIL ATTACHMENT 14.55 1 1 PER 8 YEARS E0250 HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE 795.40 79.54 1 PA 1 PER 8 YEARS SIDE RAILS, WITH MATTRESS E0255 HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH 853.60 85.36 1 PA 1 PER 8 YEARS ANY TYPE SIDE RAILS, WITH MATTRESS E0271 MATTRESS, INNERSPRING 121.25 1 1 PER 4 YEARS E0272 MATTRESS, FOAM RUBBER 121.25 1 1 PER 4 YEARS E0275 BED PAN, STANDARD, METAL OR PLASTIC 7.76 1 1 PER 4 YEARS E0276 BED PAN, FRACTURE, METAL OR PLASTIC 9.22 1 1 PER 4 YEARS E0316 SAFETY ENCLOSURE FRAME/CANOPY FOR USE 3,500.00 1 1 PER 5 YEARS WITH HOSPITAL BED, ANY TYPE E0325 URINAL; MALE, JUG-TYPE, ANY MATERIAL 6.31 1 1 PER 4 YEARS E0326 URINAL; FEMALE, JUG-TYPE, ANY MATERIAL 8.73 1 1 PER 4 YEARS E0424 STATIONARY COMPRESSED GASEOUS OXYGEN 0.00 RO 213.40 1 1 PER MONTH SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING E0431 PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; 0.00 RO 38.53 1 1 PER MONTH INCLUDES PORTABLE CONTAINER, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING E0434 PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; 0.00 RO 38.53 1 1 PER MONTH INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, HUMIDIFIER, FLOWMETER, REFILL ADAPTOR, CONTENTS GAUGE, CANNULA OR MASK, AND TUBING E0439 STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; 0.00 RO 213.40 1 1 PER MONTH INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, & TUBING E0441 OXYGEN CONTENTS, GASEOUS (FOR USE WITH 0.00 RO 126.10 1 1 PER MONTH OWNED GASEOUS STATIONARY SYSTEMS OR WHEN BOTH A STATIONARY AND PORTABLE GASEOUS SYSTEM ARE OWNED), 1 MONTH'S SUPPLY = 1 UNIT E0442 OXYGEN CONTENTS, LIQUID (FOR USE WITH 0.00 RO 126.10 1 1 PER MONTH OWNED LIQUID STATIONARY SYSTEMS OR WHEN BOTH A STATIONARY AND PORTABLE LIQUID SYSTEM ARE OWNED), 1 MONTH'S SUPPLY = 1 UNIT E0443 PORTABLE OXYGEN CONTENTS, GASEOUS (FOR 0.00 RO 19.52 1 1 PER MONTH USE ONLY WITH PORTABLE GASEOUS SYSTEMS March 2003 B - 10
  • 100. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS WHEN NO STATIONARY GAS OR LIQUID SYSTEM IS USED), 1 MONTH'S SUPPLY = 1 UNIT E0444 PORTABLE OXYGEN CONTENTS, LIQUID (FOR 0.00 RO 19.52 1 1 PER MONTH USE ONLY WITH PORTABLE LIQUID SYSTEMS WHEN NO STATIONARY GAS OR LIQUID SYSTEM IS USED), 1 MONTH'S SUPPLY = 1 UNIT E0450 VOLUME VENTILATOR, STATIONARY OR 0.00 RO 756.60 1 MEDICAL PORTABLE, WITH BACKUP RATE FEATURE, USED NECESSITY WITH INVASIVE INTERFACE (E.G., TRACHEOSTOMY TUBE) E0457 CHEST SHELL (CUIRASS) 0.00 RO 36.86 1 MEDICAL NECESSITY E0459 CHEST WRAP 340.50 34.05 1 MEDICAL NECESSITY E0460 NEGATIVE PRESSURE VENTILATOR; PORTABLE 0.00 RO 641.17 1 MEDICAL OR STATIONARY NECESSITY E0480 PERCUSSOR, ELECTRIC OR PNEUMATIC, HOME 315.30 31.53 1 1 PER 4 YEARS MODEL E0500 IPPB MACHINE, ALL TYPES, WITH BUILT-IN 0.00 RO 88.76 1 MEDICAL NEBULIZATION; MANUAL OR AUTOMATIC NECESSITY VALVES; INTERNAL OR EXTERNAL POWER SOURCE E0550 HUMIDIFIER, DURABLE FOR EXTENSIVE 0.00 RO 48.50 1 MEDICAL SUPPLEMENTAL HUMIDIFICATION DURING IPPB NECESSITY TREATMENTS OR OXYGEN DELIVERY E0555 HUMIDIFIER, DURABLE, GLASS OR 31.53 1 1 PER 2 YEARS AUTOCLAVABLE PLASTIC BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER E0560 HUMIDIFIER, DURABLE FOR SUPPLEMENTAL 0.00 RO 14.55 1 MEDICAL HUMIDIFICATION DURING IPPB TREATMENT OR NECESSITY OXYGEN DELIVERY E0565 COMPRESSOR, AIR POWER SOURCE FOR 0.00 RO 29.10 1 MEDICAL EQUIPMENT WHICH IS NOT SELF- CONTAINED OR NECESSITY CYLINDER DRIVEN E0570 NEBULIZER, WITH COMPRESSOR 106.70 1 1 PER 2 YEARS E0571 AEROSOL COMPRESSOR, BATTERY POWERED, 21.12 1 1 PER 2 YEARS FOR USE WITH SMALL VOLUME NEBULIZER E0572 AEROSOL COMPRESSOR, ADJUSTABLE 26.84 1 1 PER 2 YEARS PRESSURE, LIGHT DUTY FOR INTERMITTENT USE E0574 ULTRASONIC/ELECTRONIC AEROSOL 28.36 1 1 PER 2 YEARS GENERATOR WITH SMALL VOLUME NEBULIZER E0575 NEBULIZER, ULTRASONIC, LARGE VOLUME 315.30 31.53 1 1 PER 2 YEARS E0585 NEBULIZER, WITH COMPRESSOR AND HEATER 150.40 15.04 1 1 PER 2 YEARS E0600 RESPIRATORY SUCTION PUMP, HOME MODEL, 228.00 22.80 1 1 PER 2 YEARS PORTABLE OR STATIONARY, ELECTRIC E0601 CONTINUOUS AIRWAY PRESSURE (CPAP) DEVICE 0.00 RO 80.03 1 MEDICAL NECESSITY March 2003 B - 11
  • 101. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS E0605 VAPORIZER, ROOM TYPE 18.92 1 1 PER 4 YEARS E0606 POSTURAL DRAINAGE BOARD 160.10 16.01 1 1 PER 8 YEARS E0747 OSTEOGENESIS STIMULATOR, ELECTRICAL, 0.00 RO 247.35 1 MAXIMUM 6 MOS NON-INVASIVE, OTHER THAN SPINAL RENTAL APPLICATIONS E0910 TRAPEZE BARS, A/K/A PATIENT HELPER, 150.40 15.04 1 1 PER LIFETIME ATTACHED TO BED, WITH GRAB BAR E0940 TRAPEZE BAR, FREE STANDING, COMPLETE 266.80 26.68 1 1 PER LIFETIME WITH GRAB BAR E0962 1" CUSHION, FOR WHEELCHAIR 42.61 1 2 PER 4 YEARS E0963 2" CUSHION, FOR WHEELCHAIR 55.05 1 2 PER 4 YEARS E0964 3" CUSHION, FOR WHEELCHAIR 61.35 1 2 PER 4 YEARS E0965 4" CUSHION, FOR WHEELCHAIR 66.98 1 2 PER 4 YEARS E0967 WHEELCHAIR HAND RIMS WITH 8 VERTICAL 92.57 1 2 PER 4 YEARS RUBBER TIPPED PROJECTIONS, PAIR E0968 COMMODE SEAT, WHEELCHAIR 14.27 1 2 PER 4 YEARS E0969 NARROWING DEVICE, WHEELCHAIR 124.69 1 2 PER 4 YEARS E0977 WEDGE CUSHION, WHEELCHAIR 44.26 1 2 PER 4 YEARS E0980 SAFETY VEST, WHEELCHAIR 22.38 1 2 PER 4 YEARS E0994 ARM REST, EACH 14.03 2 2 PER 4 YEARS E0997 CASTER WITH A FORK 45.00 2 2 PER 4 YEARS E0998 CASTER WITHOUT FORK 30.47 2 2 PER 4 YEARS E0999 PNEUMATIC TIRE WITH WHEEL 91.52 2 2 PER 4 YEARS E1001 WHEEL, SINGLE 78.06 2 2 PER 4 YEARS E1031 ROLLABOUT CHAIR, ANY AND ALL TYPES WITH 341.70 34.17 1 1 PER 5 YEARS CASTORS 5" OR GREATER E1050 FULLY-RECLINING WHEELCHAIR, FIXED FULL 689.00 68.90 1 1 PER 5 YEARS LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEG RESTS E1060 FULLY-RECLINING WHEELCHAIR, DETACHABLE 853.00 85.30 1 1 PER 5 YEARS ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLE ELEVATING LEGRESTS E1065 POWER ATTACHMENT (TO CONVERT ANY 0.00 1 1 PER 5 YEARS WHEELCHAIR TO MOTORIZED WHEELCHAIR, E.G., SOLO) E1070 FULLY-RECLINING WHEELCHAIR, DETACHABLE 741.10 74.11 1 1 PER 5 YEARS ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTREST E1083 HEMI-WHEELCHAIR, FIXED FULL LENGTH ARMS, 532.80 53.28 1 1 PER 5 YEARS SWING AWAY DETACHABLE ELEVATING LEG REST E1084 HEMI-WHEELCHAIR, DETACHABLE ARMS DESK 663.80 66.38 1 1 PER 5 YEARS OR FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEG RESTS E1087 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, 856.00 85.60 1 1 PER 5 YEARS FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEG RESTS March 2003 B - 12
  • 102. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS E1088 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, 1,020.70 102.07 1 1 PER 5 YEARS DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE ELEVATING LEG RESTS E1092 WIDE HEAVY DUTY WHEEL CHAIR, 869.50 86.95 1 1 PER 5 YEARS DETACHABLE ARMS (DESK OR FULL LENGTH), SWING AWAY DETACHABLE ELEVATING LEG RESTS E1093 WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE 869.50 86.95 1 1 PER 5 YEARS ARMS DESK OR FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTRESTS E1100 SEMI-RECLINING WHEELCHAIR, FIXED FULL 702.50 70.25 1 1 PER 5 YEARS LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEG RESTS E1110 SEMI-RECLINING WHEELCHAIR, DETACHABLE 687.80 68.78 1 1 PER 5 YEARS ARMS (DESK OR FULL LENGTH) ELEVATING LEG REST E1150 WHEELCHAIR, DETACHABLE ARMS, DESK OR 552.00 55.20 1 1 PER 5 YEARS FULL LENGTH SWING AWAY DETACHABLE ELEVATING LEGRESTS E1160 WHEELCHAIR, FIXED FULL LENGTH ARMS, 426.50 42.65 1 1 PER 5 YEARS SWING AWAY DETACHABLE ELEVATING LEGRESTS E1170 AMPUTEE WHEELCHAIR, FIXED FULL LENGTH 604.30 60.43 1 1 PER 5 YEARS ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS E1171 AMPUTEE WHEELCHAIR, FIXED FULL LENGTH 542.40 54.24 1 1 PER 5 YEARS ARMS, WITHOUT FOOTRESTS OR LEGREST E1172 AMPUTEE WHEELCHAIR, DETACHABLE ARMS 662.70 66.27 1 1 PER 5 YEARS (DESK OR FULL LENGTH) WITHOUT FOOTRESTS OR LEGREST E1180 AMPUTEE WHEELCHAIR, DETACHABLE ARMS 685.60 68.56 1 1 PER 5 YEARS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE FOOTRESTS E1190 AMPUTEE WHEELCHAIR, DETACHABLE ARMS 792.10 79.21 1 1 PER 5 YEARS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE ELEVATING LEGRESTS E1195 HEAVY DUTY WHEELCHAIR, FIXED FULL 850.00 85.00 1 1 PER 5 YEARS LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS E1200 AMPUTEE WHEELCHAIR, FIXED FULL LENGTH 588.70 58.87 1 1 PER 5 YEARS ARMS, SWING AWAY DETACHABLE FOOTREST E1210 MOTORIZED WHEELCHAIR, FIXED FULL LENGTH 2,780.00 278.00 1 1 PER 5 YEARS ARMS, SWING AWAY DETACHABLE ELEVATING LEG RESTS E1211 MOTORIZED WHEELCHAIR, DETACHABLE ARMS 2,831.80 283.18 1 1 PER 5 YEARS DESK OR FULL LENGTH SWING AWAY, DETACHABLE ELEVATING LEG REST March 2003 B - 13
  • 103. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS E1221 WHEELCHAIR WITH FIXED ARM, FOOTRESTS 321.40 32.14 1 1 PER 5 YEARS E1222 WHEELCHAIR WITH FIXED ARM, ELEVATING 458.60 45.86 1 1 PER 5 YEARS LEGRESTS E1223 WHEELCHAIR WITH DETACHABLE ARMS, 500.80 50.08 1 1 PER 5 YEARS FOOTRESTS E1224 WHEELCHAIR WITH DETACHABLE ARMS, 549.10 54.91 1 1 PER 5 YEARS ELEVATING LEGRESTS E1225 SEMI-RECLINING BACK FOR CUSTOMIZED 305.80 30.58 1 1 PER 5 YEARS WHEEL CHAIR E1227 SPECIAL HEIGHT ARMS FOR WHEELCHAIR 220.90 1 1 PER 5 YEARS E1228 SPECIAL BACK HEIGHT FOR WHEELCHAIR 18.97 1 1 PER 5 YEARS E1230 POWER OPERATED VEHICLE (THREE OR FOUR 1,210.39 1 1 PER 5 YEARS WHEEL NONHIGHWAY) SPECIFY BRAND NAME AND MODEL NUMBER E1240 LIGHTWEIGHT WHEELCHAIR, DETACHABLE 697.00 69.70 1 1 PER 5 YEARS ARMS, (DESK OR FULL LENGTH) SWING AWAY DETACHABLE, ELEVATING LEGREST E1270 LIGHTWEIGHT WHEELCHAIR, FIXED FULL 534.20 53.42 1 1 PER 5 YEARS LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS E1280 HEAVY DUTY WHEELCHAIR, DETACHABLE 888.20 88.82 1 1 PER 5 YEARS ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS E1295 HEAVY DUTY WHEELCHAIR, FIXED FULL 821.90 82.19 1 1 PER 5 YEARS LENGTH ARMS, ELEVATING LEGREST E1296 SPECIAL WHEELCHAIR SEAT HEIGHT FROM 391.39 1 1 PER 5 YEARS FLOOR E1297 SPECIAL WHEELCHAIR SEAT DEPTH, BY 83.27 1 1 PER 5 YEARS UPHOLSTERY E1298 SPECIAL WHEELCHAIR SEAT DEPTH AND/OR 299.29 1 1 PER 5 YEARS WIDTH, BY CONSTRUCTION E1340 REPAIR OR NONROUTINE SERVICE FOR DURABLE 10.00 16 $160.00 PER YEAR MEDICAL EQUIPMENT REQUIRING THE SKILL OF A TECHNICIAN, LABOR COMPONENT, PER 15 MINUTES E1390 OXYGEN CONCENTRATOR, CAPABLE OF 0.00 RO 170.48 1 1 PER MONTH DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE E1399 DURABLE MEDICAL EQUIPMENT, 0.00 1 PA MEDICAL MISCELLANEOUS NECESSITY E1405 OXYGEN AND WATER VAPOR ENRICHING 0.00 RO 253.17 1 1 PER MONTH SYSTEM WITH HEATED DELIVERY E1406 OXYGEN AND WATER VAPOR ENRICHING 0.00 RO 247.16 1 1 PER MONTH SYSTEM WITHOUT HEATED DELIVERY E1801 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH 73.50 1 2 PER 2 YEARS ELBOW DEVICE WITH RANGE OF MOTION March 2003 B - 14
  • 104. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS ADJUSTMENT, INCLUDES CUFFS E1806 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH 73.50 1 2 PER 2 YEARS WRIST DEVICE WITH RANGE OF MOTION ADJUSTMENT, INCLUDES CUFFS E1811 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH 73.50 1 2 PER 2 YEARS KNEE DEVICE WITH RANGE OF MOTION ADJUSTMENT, INCLUDES CUFFS E1816 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH 73.50 1 2 PER 2 YEARS ANKLE DEVICE WITH RANGE OF MOTION ADJUSTMENT, INCLUDES CUFFS E1818 BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH 73.50 1 2 PER 2 YEARS FOREARM PRONATION / SUPINATION DEVICE WITH RANGE OF MOTION ADJUSTMENT, INCLUDES CUFFS E1821 REPLACEMENT SOFT INTERFACE 6.06 8 8 PER YEAR MATERIAL/CUFFS FOR BI-DIRECTIONAL STATIC PROGRESSIVE STRETCH DEVICE E1840 DYNAMIC ADJUSTABLE SHOULDER FLEXION / 73.50 2 2 PER 2 YEARS ABDUCTION / ROTATION DEVICE, INCLUDES SOFT INTERFACE MATERIAL E1902 COMMUNICATION BOARD, NON-ELECTRONIC 0.00 1 PA 1 PER 5 YEARS AUGMENTATIVE OR ALTERNATIVE COMMUNICATION DEVICE E2000 GASTRIC SUCTION PUMP, HOME MODEL, 22.80 1 1 PER 2 YEARS PORTABLE OR STATIONARY, ELECTRIC March 2003 B - 15
  • 105. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS K0001 STANDARD WHEELCHAIR 354.30 35.43 1 1 PER 5 YEARS K0002 STANDARD HEMI (LOW SEAT) WHEELCHAIR 530.70 53.07 1 1 PER 5 YEARS K0003 LIGHTWEIGHT WHEELCHAIR 581.10 58.11 1 1 PER 5 YEARS K0004 HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR 866.80 86.68 1 1 PER 5 YEARS K0005 ULTRALIGHTWEIGHT WHEELCHAIR 1,410.71 1 1 PER 5 YEARS K0006 HEAVY DUTY WHEELCHAIR 813.40 81.34 1 1 PER 5 YEARS K0007 EXTRA HEAVY DUTY WHEELCHAIR 1,263.90 126.39 1 1 PER 5 YEARS K0009 OTHER MANUAL WHEELCHAIR/BASE 0.00 1 PA 1 PER 5 YEARS K0010 STANDARD - WEIGHT FRAME 2,763.00 276.30 1 1 PER 5 YEARS MOTORIZED/POWER WHEELCHAIR K0011 STANDARD - WEIGHT FRAME 3,699.70 369.97 1 1 PER 5 YEARS MOTORIZED/POWER WHEELCHAIR WITH PROGRAMMABLE CONTROL PARAMETERS FOR SPEED ADJUSTMENT, TREMOR DAMPENING, ACCELERATION CONTROL AND BRAKING K0012 LIGHTWEIGHT PORTABLE MOTORIZED/POWER 2,269.40 226.94 1 1 PER 5 YEARS WHEELCHAIR K0014 OTHER MOTORIZED/POWER WHEELCHAIR BASE 0.00 1 PA 1 PER 5 YEARS K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT 138.65 2 1 PER 5 YEARS ARMREST, EACH K0016 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, 74.57 2 2 PER 4 YEARS COMPLETE ASSEMBLY, EACH K0017 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, 39.00 2 2 PER 4 YEARS BASE, EACH K0018 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, 21.78 2 2 PER 4 YEARS UPPER PORTION, EACH K0019 ARM PAD, EACH 12.47 2 2 PER 4 YEARS K0020 FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR 35.45 2 2 PER 4 YEARS K0022 REINFORCED BACK UPHOLSTERY 38.32 1 1 PER 5 YEARS K0023 SOLID BACK INSERT, PLANAR BACK, SINGLE 68.38 1 1 PER 5 YEARS DENSITY FOAM, ATTACHED WITH STRAPS K0024 SOLID BACK INSERT, PLANAR BACK, SINGLE 80.95 1 1 PER 5 YEARS DENSITY FOAM, WITH ADJUSTABLE HOOK-ON HARDWARE K0025 HOOK-ON HEADREST EXTENSION 49.91 1 1 PER 5 YEARS K0026 BACK UPHOLSTERY FOR ULTRALIGHTWEIGHT 44.35 1 1 PER 5 YEARS OR HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR K0027 BACK UPHOLSTERY FOR WHEELCHAIR TYPE 35.48 1 1 PER 5 YEARS OTHER THAN ULTRALIGHTWEIGHT OR HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR K0028 MANUAL, FULLY RECLINING BACK 353.90 1 1 PER 5 YEARS K0029 REINFORCED SEAT UPHOLSTERY 37.96 1 1 PER 5 YEARS K0030 SOLID SEAT INSERT, PLANAR SEAT, SINGLE 69.46 1 1 PER 5 YEARS DENSITY FOAM K0031 SAFETY BELT/PELVIC STRAP, EACH 27.70 1 1 PER 5 YEARS K0032 SEAT UPHOLSTERY FOR ULTRALIGHTWEIGHT OR 35.00 1 1 PER 5 YEARS March 2003 B - 16
  • 106. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR K0033 SEAT UPHOLSTERY FOR WHEELCHAIR TYPE 35.00 1 1 PER 5 YEARS OTHER THAN ULTRALIGHTWEIGHT OR HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR K0035 HEEL LOOP WITH ANKLE STRAP, EACH 19.02 2 2 PER YEAR K0036 TOE LOOP, EACH 14.38 1 2 PER YEAR K0037 HIGH MOUNT FLIP-UP FOOTREST, EACH 36.75 2 2 PER 4 YEARS K0038 LEG STRAP, EACH 18.51 2 2 PER 4 YEARS K0039 LEG STRAP, H STYLE, EACH 41.11 2 2 PER 4 YEARS K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH 56.98 2 2 PER 2 YEARS K0041 LARGE SIZE FOOTPLATE, EACH 40.38 2 2 PER 2 YEARS K0042 STANDARD SIZE FOOTPLATE, EACH 27.79 2 2 PER 2 YEARS K0043 FOOTREST, LOWER EXTENSION TUBE, EACH 14.90 2 2 PER 2 YEARS K0044 FOOTREST, UPPER HANGER BRACKET, EACH 12.97 2 2 PER 2 YEARS K0045 FOOTREST, COMPLETE ASSEMBLY 43.00 2 2 PER 2 YEARS K0046 ELEVATING LEGREST, LOWER EXTENSION TUBE, 14.90 2 2 PER 4 YEARS EACH K0047 ELEVATING LEGREST, UPPER HANGER BRACKET, 58.36 2 2 PER 4 YEARS EACH K0048 ELEVATING LEGREST, COMPLETE ASSEMBLY 89.61 2 2 PER 4 YEARS K0049 CALF PAD, EACH 19.72 2 2 PER 4 YEARS K0050 RATCHET ASSEMBLY 24.80 2 2 PER 4 YEARS K0051 CAM RELEASE ASSEMBLY, FOOTREST OR 40.14 2 2 PER 4 YEARS LEGREST, EACH K0052 SWINGAWAY, DETACHABLE FOOTRESTS, EACH 70.54 2 2 PER 4 YEARS K0053 ELEVATING FOOTRESTS, ARTICULATING 77.84 2 2 PER 4 YEARS (TELESCOPING), EACH K0054 SEAT WIDTH OF 10", 11", 12", 15", 17", OR 20" FOR 79.84 1 1 PER 4 YEARS A HIGH STRENGTH, LIGHTWEIGHT OR ULTRALIGHTWEIGHT WHEELCHAIR K0055 SEAT DEPTH OF 15", 17", OR 18" FOR A HIGH 72.57 1 1 PER 4 YEARS STRENGTH, LIGHTWEIGHT OR ULTRALIGHTWEIGHT WHEELCHAIR K0056 SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR 72.65 1 1 PER 4 YEARS GREATER THAN 21" FOR A HIGH STRENGTH, LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR K0057 SEAT WIDTH 19" OR 20" FOR HEAVY DUTY OR 94.78 1 1 PER 4 YEARS EXTRA HEAVY DUTY CHAIR K0058 SEAT DEPTH 17" OR 18" FOR MOTORIZED/POWER 46.06 1 1 PER 4 YEARS WHEELCHAIR K0059 PLASTIC COATED HANDRIM, EACH 24.00 2 1 PER 4 YEARS K0060 STEEL HANDRIM, EACH 21.18 2 1 PER 4 YEARS K0061 ALUMINUM HANDRIM, EACH 30.04 2 1 PER 4 YEARS K0062 HANDRIM WITH 8-10 VERTICAL OR OBLIQUE 46.53 2 1 PER 4 YEARS PROJECTIONS, EACH K0063 HANDRIM WITH 12-16 VERTICAL OR OLBIQUE 62.16 2 1 PER 4 YEARS March 2003 B - 17
  • 107. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS PROJECTIONS, EACH K0064 ZERO PRESSURE TUBE (FLAT FREE INSERTS), 23.20 2 1 PER 4 YEARS ANY SIZE, EACH K0065 SPOKE PROTECTORS, EACH 33.93 2 1 PER 4 YEARS K0066 SOLID TIRE, ANY SIZE, EACH 21.76 2 1 PER 4 YEARS K0067 PNEUMATIC TIRE, ANY SIZE, EACH 31.22 2 1 PER 4 YEARS K0068 PNEUMATIC TIRE TUBE, EACH 4.49 2 1 PER 4 YEARS K0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH 76.24 2 1 PER 4 YEARS SOLID TIRE, SPOKES OR MOLDED, EACH K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITH 139.77 2 1 PER 4 YEARS PNEUMATIC TIRE, SPOKES OR MOLDED, EACH K0071 FRONT CASTER ASSEMBLY, COMPLETE, WITH 83.36 2 1 PER 4 YEARS PNEUMATIC TIRE, EACH K0072 FRONT CASTER ASSEMBLY, COMPLETE, WITH 50.18 2 1 PER 4 YEARS SEMI-PNEUMATIC TIRE, EACH K0073 CASTER PIN LOCK,EACH 25.54 2 1 PER 4 YEARS K0074 PNEUMATIC CASTER TIRE, ANY SIZE, EACH 23.35 2 1 PER 4 YEARS K0075 SEMI-PNEUMATIC CASTER TIRE, ANY SIZE, EACH 27.14 2 1 PER 4 YEARS K0076 SOLID CASTER TIRE, ANY SIZE, EACH 19.50 2 1 PER 4 YEARS K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH 44.90 2 1 PER 4 YEARS SOLID TIRE, EACH K0078 PNEUMATIC CASTER TIRE TUBE, EACH 7.33 2 1 PER 4 YEARS K0079 WHEEL LOCK EXTENSION, PAIR 38.60 1 1 PAIR PER 4 YEARS K0080 ANTI-ROLLBACK DEVICE, PAIR 101.70 1 1 PAIR PER 4 YEARS K0081 WHEEL LOCK ASSEMBLY, COMPLETE, EACH 31.04 2 2 PER 4 YEARS K0082 22 NF NON-SEALED LEAD ACID BATTERY, EACH 85.73 2 4 PER 3 YEARS K0083 22 NF SEALED LEAD ACID BATTERY, EACH (E.G., 106.42 2 4 PER 3 YEARS GEL CELL, ABSORBED GLASS MAT) K0084 GROUP 24 NON-SEALED LEAD ACID BATTERY, 70.26 2 4 PER 3 YEARS EACH K0085 GROUP 24 SEALED LEAD ACID BATTERY, EACH 141.94 2 4 PER 3 YEARS (E.G., GEL CELL ABSORBED GLASS MAT) K0086 U-1 NON-SEALED LEAD ACID BATTERY, EACH 85.72 2 4 PER 3 YEARS K0087 U-1 SEALED LEAD ACID BATTERY, EACH (E.G., 85.59 2 4 PER 3 YEARS GEL CELL, ABSORBED GLASS MAT) K0088 BATTERY CHARGER, SINGLE MODE, FOR USE 201.16 1 1 PER LIFETIME WITH ONLY ONE BATTERY TYPE, SEALED OR NON-SEALED K0089 BATTERY CHARGER, DUAL MODE, FOR USE WITH 319.78 1 1 PER LIFETIME EITHER BATTERY TYPE, SEALED OR NON-SEALED K0090 REAR WHEEL TIRE FOR POWER WHEELCHAIR, 58.13 2 2 PER 4 YEARS ANY SIZE, EACH K0091 REAR WHEEL TIRE TUBE OTHER THAN ZERO 15.85 2 2 PER 4 YEARS PRESSURE FOR POWER WHEELCHAIR, ANY SIZE, March 2003 B - 18
  • 108. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS EACH K0092 REAR WHEEL ASSEMBLY FOR POWER 185.52 2 2 PER 4 YEARS WHEELCHAIR, COMPLETE, EACH K0093 REAR WHEEL, ZERO PRESSURE TIRE TUBE (FLAT 115.90 2 2 PER 4 YEARS FREE INSERT) FOR POWER WHEELCHAIR, ANY SIZE, EACH K0094 WHEEL TIRE FOR POWER BASE, ANY SIZE, EACH 37.77 2 2 PER 4 YEARS K0095 WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE 37.77 2 2 PER 4 YEARS FOR EACH BASE, ANY SIZE, EACH K0096 WHEEL ASSEMBLY FOR POWER BASE, 209.30 2 2 PER 4 YEARS COMPLETE, EACH K0097 WHEEL ZERO PRESSURE TIRE TUBE (FLAT FREE 46.29 2 2 PER 4 YEARS INSERT) FOR POWER BASE, ANY SIZE, EACH K0098 DRIVE BELT FOR POWER WHEELCHAIR 20.15 1 2 PER 4 YEARS K0099 FRONT CASTER FOR POWER WHEELCHAIR, EACH 61.74 2 2 PER 4 YEARS K0100 WHEELCHAIR ADAPTER FOR AMPUTEE, PAIR 57.35 1 1 PER 5 YEARS (DEVICE USED TO COMPENSATE FOR TRANSFER OF WEIGHT DUE TO LOST LIMBS TO MAINTAIN PROPER BALANCE) K0102 CRUTCH AND CANE HOLDER, EACH 33.08 1 1 PER 5 YEARS K0103 TRANSFER BOARD,<25" 40.75 1 1 PER 4 YEARS K0104 CYLINDER TANK CARRIER, EACH 90.64 1 1 PER 5 YEARS K0105 IV HANGER, EACH 75.87 2 1 PER 5 YEARS K0106 ARM TROUGH, EACH 81.77 2 2 PER 4 YEARS K0107 WHEELCHAIR TRAY 67.42 1 2 PER 4 YEARS K0108 WHEELCHAIR COMPONENT OR ACCESSORY, NOT 0.00 1 PA MEDICAL OTHERWISE SPECIFIED NECESSITY K0180 AEROSOL MASK, USED WITH DME NEBULIZER 1.20 1 12 PER YEAR K0195 ELEVATING LEG RESTS, PAIR (FOR USE WITH 150.60 15.06 1 2 PER 4 YEARS CAPPED RENTAL WHEELCHAIR BASE) K0452 WHEELCHAIR BEARINGS, ANY TYPE 5.00 2 2 PER 4 YEARS K0460 POWER ADD-ON, TO CONVERT MANUAL 2,225.04 1 1 PER 5 YEARS WHEELCHAIR TO MOTORIZED WHEELCHAIR, JOYSTICK CONTROL K0461 POWER ADD-ON, TO CONVERT MANUAL 1,457.89 1 1 PER 5 YEARS WHEELCHAIR TO POWER OPERATED VEHICLE, TILLER CONTROL K0532 RESPIRATORY ASSIST DEVICE, BI-LEVEL 0.00 RO 177.75 1 1 PER MONTH PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE) K0533 RESPIRATORY ASSIST DEVICE, BI-LEVEL 0.00 RO 416.51 1 1 PER MONTH PRESSURE CAPABILITY, WITH BACKUP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT March 2003 B - 19
  • 109. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE) K0541 SPEECH GENERATING DEVICE, DIGITIZED 0.00 1 PA 1 PER 5 YEARS SPEECH, USING PRE-RECORDED MESSAGES, LESS THAN OR EQUAL TO 8 MINUTES RECORDING TIME K0542 SPEECH GENERATING DEVICE, DIGITIZED 0.00 1 PA 1 PER 5 YEARS SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 8 MINUTES RECORDING TIME K0543 SPEECH GENERATING DEVICE, SYNTHESIZED 0.00 1 PA 1 PER 5 YEARS SPEECH, REQUIRING MESSAGE FORMULATION BY SPELLING AND ACCESS BY PHYSICAL CONTACT WITH THE DEVICE K0544 SPEECH GENERATING DEVICE, SYNTHESIZED 0.00 1 PA 1 PER 5 YEARS SPEECH, PERMITTING MULTIPLE METHODS OF MESSAGE FORMULATION AND MULTIPLE METHODS OF DEVICE ACCESS K0545 SPEECH GENERATING SOFTWARE PROGRAM, 0.00 1 PA 1 PER 5 YEARS FOR PERSONAL COMPUTER OR PERSONAL DIGITAL ASSISTANT K0546 ACCESSORY FOR SPEECH GENERATING DEVICE, 0.00 1 PA 1 PER 5 YEARS MOUNTING SYSTEM K0547 ACCESSORY FOR SPEECH GENERATING DEVICE, 0.00 1 PA 1 PER 5 YEARS NOT OTHERWISE CLASSIFIED K0556 ADDITION TO LOWER EXTREMITY, BELOW 451.23 2 1 PER ORTHOTSIS KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH LOCKING MECHANISM K0557 ADDITION TO LOWER EXTREMITY, BELOW 376.02 2 2 PER YEAR KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, NOT FOR USE WITH LOCKING MECHANISM K0558 ADDITION TO LOWER EXTREMITY, BELOW 799.71 2 2 PER YEAR KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER THAN IN K0581 OSTOMY POUCH, CLOSED, WITH BARRIER 1.76 31 10 PER MONTH ATTACHED, WITH FILTER (1 PIECE), EACH K0582 OSTOMY POUCH, CLOSED, WITH BARRIER 2.38 31 10 PER MONTH ATTACHED, WITH BUILT-IN CONVEXITY, WITH FILTER (1 PIECE), EACH K0583 OSTOMY POUCH, CLOSED; WITHOUT BARRIER 1.16 31 10 PER MONTH March 2003 B - 20
  • 110. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS ATTACHED, WITH FILTER (1 PIECE), EACH K0584 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER 1.11 31 10 PER MONTH WITH FLANGE, WITH FILTER (2 PIECE), EACH K0585 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER 1.28 31 10 PER MONTH WITH LOCKING FLANGE (2 PIECE), EACH K0586 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER 1.28 31 10 PER MONTH WITH LOCKING FLANGE, WITH FILTER (2 PIECE), EACH K0587 OSTOMY POUCH, DRAINABLE, WITH BARRIER 3.04 31 10 PER MONTH ATTACHED, WITH FILTER (1 PIECE), EACH K0588 OSTOMY POUCH, DRAINABLE; FOR USE ON 2.29 31 366 PER YEAR BARRIER WITH FLANGE, WITH FILTER (2 PIECE SYSTEM), EACH K0589 OSTOMY POUCH, DRAINABLE; FOR USE ON 1.51 31 366 PER YEAR BARRIER WITH LOCKING FLANGE (2 PIECE SYSTEM), EACH K0590 OSTOMY POUCH, DRAINABLE; FOR USE ON 1.89 31 366 PER YEAR BARRIER WITH LOCKING FLANGE, WITH FILTER (2 PIECE SYSTEM), EACH K0591 OSTOMY POUCH, URINARY, WITH EXTENDED 4.17 31 366 PER YEAR WEAR BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH K0592 OSTOMY POUCH, URINARY, WITH BARRIER 4.82 31 366 PER YEAR ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH K0593 OSTOMY POUCH, URINARY, WITH EXTENDED 5.46 31 366 PER YEAR WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH K0594 OSTOMY POUCH, URINARY; WITH BARRIER 3.25 31 10 PER MONTH ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH K0595 OSTOMY POUCH, URINARY; FOR USE ON 2.30 31 10 PER MONTH BARRIER WITH FLANGE, WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH K0596 OSTOMY POUCH, URINARY; FOR USE ON 2.14 31 366 PER YEAR BARRIER WITH LOCKING FLANGE (2 PIECE), EACH K0597 OSTOMY POUCH, URINARY; FOR USE ON 2.41 31 366 PER YEAR BARRIER WITH LOCKING FLANGE, WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH March 2003 B - 21
  • 111. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L0100 CRANIAL ORTHOSIS (HELMET), WITH OR 247.35 1 1 PER MEDICAL WITHOUT SOFT INTERFACE, MOLDED TO EVENT PATIENT MODEL L0110 CRANIAL ORTHOSIS (HELMET), WITH OR 72.75 1 1 PER YEAR WITHOUT SOFT-INTERFACE, NON-MOLDED L0120 CERVICAL, FLEXIBLE, NON-ADJUSTABLE (FOAM 12.13 1 2 PER MEDICAL COLLAR) EVENT L0130 CERVICAL, FLEXIBLE, THERMOPLASTIC COLLAR, 48.50 1 1 PER MEDICAL MOLDED TO PATIENT EVENT L0140 CERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTIC 38.80 1 1 PER YEAR COLLAR) L0150 CERVICAL, SEMI-RIGID, ADJUSTABLE MOLDED 53.35 1 1 PER MEDICAL CHIN CUP (PLASTIC COLLAR WITH EVENT MANDIBULAR/OCCIPITAL PIECE) L0160 CERVICAL, SEMI-RIGID, WIRE FRAME 87.30 1 1 PER MEDICAL OCCIPITAL/MANDIBULAR SUPPORT EVENT L0170 CERVICAL, COLLAR, MOLDED TO PATIENT 348.93 1 1 PER MEDICAL MODEL EVENT L0172 CERVICAL, COLLAR, SEMI-RIGID 43.17 1 2 PER MEDICAL THERMOPLASTIC FOAM, TWO PIECE EVENT L0174 CERVICAL, COLLAR, SEMI-RIGID, 52.38 1 1 PER YEAR THERMOPLASTIC FOAM, TWO PIECE WITH THORACIC EXTENSION L0180 CERVICAL, MULTIPLE POST COLLAR, 180.42 1 1 PER MEDICAL OCCIPITAL/MANDIBULAR SUPPORTS, EVENT ADJUSTABLE L0190 CERVICAL, MULTIPLE POST COLLAR, 281.30 1 1 PER MEDICAL OCCIPITAL/MANDIBULAR SUPPORTS, EVENT ADJUSTABLE CERVICAL BARS (SOMI, GUILFORD, TAYLOR TYPES) L0200 CERVICAL, MULTIPLE POST COLLAR, 197.88 1 1 PER MEDICAL OCCIPITAL/MANDIBULAR SUPPORTS, EVENT ADJUSTABLE CERVICAL BARS, AND THORACIC EXTENSION L0210 THORACIC, RIB BELT 27.65 1 1 PER YEAR L0220 THORACIC, RIB BELT, CUSTOM FABRICATED 58.20 1 1 PER YEAR L0450 TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, 97.41 1 1 PER MEDICAL UPPER THORACIC REGION, PRODUCES EVENT INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTEVERTEBRAL DISKS WITH RIGID STAYS OR PANEL(S), INCLUDES SHOULDER STRAPS AND CLOSURES, PREFABRICATED, INCLUDES FITTING AN L0452 TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, 182.02 1 1 PER MEDICAL UPPER THORACIC REGION, PRODUCES EVENT INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS WITH RIGID STAYS OR PANEL(S), INCLUDES SHOULDER March 2003 B - 22
  • 112. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS STRAPS AND CLOSURES, CUSTOM FABRICATED L0500 LUMBAR-SACRAL-ORTHOSIS (LSO), FLEXIBLE, 65.48 1 2 PER YEAR (LUMBO-SACRAL SUPPORT) L0510 LSO, FLEXIBLE (LUMBO-SACRAL SUPPORT), 173.63 1 2 PER YEAR CUSTOM FABRICATED L0515 LSO, ANTERIOR-POSTERIOR CONTROL, WITH 71.78 1 2 PER YEAR RIGID OR SEMI-RIGID POSTERIOR PANEL, PREFABRICATED L0520 LSO, ANTERIOR-POSTERIOR-LATERAL CONTROL 261.90 1 1 PER 2 YEARS (KNIGHT, WILCOX TYPES), WITH APRON FRONT L0540 LSO, LUMBAR FLEXION (WILLIAMS FLEXION 237.65 1 1 PER 2 YEARS TYPE) L0550 LSO, ANTERIOR-POSTERIOR-LATERAL CONTROL, 657.66 1 1 PER MEDICAL MOLDED TO PATIENT MODEL EVENT L0560 LSO, ANTERIOR-POSTERIOR-LATERAL CONTROL, 679.00 1 1 PER MEDICAL MOLDED TO PATIENT MODEL, WITH INTERFACE EVENT MATERIAL L0561 LSO, ANTERIOR-POSTERIOR-LATERAL CONTROL, 261.90 2 2 PER 2 YEARS WITH RIGID OR SEMI-RIGID POSTERIOR PANEL, PREFABRICATED L0565 LSO, ANTERIOR-POSTERIOR-LATERAL CONTROL, 243.47 1 1 PER MEDICAL CUSTOM FITTED EVENT L0600 SACROILIAC, FLEXIBLE (SACROILIAC SURGICAL 32.98 1 2 PER YEAR SUPPORT), L0610 SACROILIAC, FLEXIBLE (SACROILIAC SURGICAL 144.94 1 1 PER MEDICAL SUPPORT), CUSTOM FABRICATED EVENT L0620 SACROILIAC, SEMI-RIGID (GOLDTHWAITE, 241.68 1 2 PER YEAR OSGOOD TYPES), WITH APRON FRONT L0700 CERVICAL-THORACIC-LUMBAR-SACRAL-ORTHO 1,406.50 1 1 PER MEDICAL SES (CTLSO), ANTERIOR-POSTERIOR-LATERAL EVENT CONTROL, MOLDED TO PATIENT MODEL, (MINERVA TYPE) L0710 CTLSO, 1,552.00 1 1 PER MEDICAL ANTERIOR-POSTERIOR-LATERAL-CONTROL, EVENT MOLDED TO PATIENT MODEL, WITH INTERFACE MATERIAL, (MINERVA TYPE) L0810 HALO PROCEDURE, CERVICAL HALO 1,552.00 1 1 PER MEDICAL INCORPORATED INTO JACKET VEST EVENT L0820 HALO PROCEDURE, CERVICAL HALO 1,164.00 1 1 PER MEDICAL INCORPORATED INTO PLASTER BODY JACKET EVENT L0830 HALO PROCEDURE, CERVICAL HALO 1,527.75 1 1 PER MEDICAL INCORPORATED INTO MILWAUKEE TYPE EVENT ORTHOSIS L0860 ADDITION TO HALO PROCEDURES, MAGNETIC 679.17 1 1 PER MEDICAL REASONANCE IMAGE COMPATIBLE SYSTEM EVENT L0960 TORSO SUPPORT, POST SURGICAL SUPPORT, 53.35 1 1 PER 2 YEARS PADS FOR POST SURGICAL SUPPORT March 2003 B - 23
  • 113. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L0970 TLSO, CORSET FRONT 50.93 1 1 PER 2 YEARS L0972 LSO, CORSET FRONT 48.50 1 1 PER 2 YEARS L0974 TLSO, FULL CORSET 111.55 1 1 PER 2 YEARS L0976 LSO, FULL CORSET 112.52 1 1 PER 2 YEARS L0978 AXILLARY CRUTCH EXTENSION 67.90 1 1 PER 2 YEARS L0980 PERONEAL STRAPS, PAIR 3.88 2 2 PER YEAR L0984 PROTECTIVE BODY SOCK, EACH 33.84 2 2 PER YEAR L0999 ADDITION TO SPINAL ORTHOSIS, NOT 0.00 1 BR MEDICAL OTHERWISE SPECIFIED NECESSITY L1000 CERVICAL-THORACIC-LUMBAR-SACRAL 937.02 1 1 PER YEAR ORTHOSIS (CTLSO) (MILWAUKEE), INCLUSIVE OF FURNISHING INITIAL ORTHOSIS, INCLUDING MODEL L1005 TENSION BASED SCOLIOSIS ORTHOSIS AND 60.00 1 1 PER 2 YEARS ACCESSORY PADS, INCLUDES FITTING AND ADJUSTMENT L1010 ADDITION TO 33.95 1 1 PER YEAR CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) OR SCOLIOSIS ORTHOSIS, AXILLA SLING L1020 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, 59.66 2 2 PER YEAR KYPHOSIS PAD L1025 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, 78.57 1 1 PER YEAR KYPHOSIS PAD, FLOATING L1030 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, 59.17 2 2 PER YEAR LUMBAR BOLSTER PAD L1040 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, 67.90 2 2 PER YEAR LUMBAR OR LUMBAR RIB PAD L1050 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, 39.77 1 1 PER YEAR STERNAL PAD L1060 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, 45.59 2 2 PER YEAR THORACIC PAD L1070 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, 33.95 2 2 PER YEAR TRAPEZIUS SLING L1080 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, 43.65 2 2 PER YEAR OUTRIGGER L1085 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, 66.93 1 1 PER YEAR OUTRIGGER, BILATERAL WITH VERTICAL EXTENSIONS L1090 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, 43.65 2 2 PER YEAR LUMBAR SLING L1100 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, 72.75 1 1 PER YEAR RING FLANGE, PLASTIC OR LEATHER L1110 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, 121.25 1 1 PER YEAR RING FLANGE, PLASTIC OR LEATHER, MOLDED TO PATIENT MODEL L1120 ADDITION TO CTLSO, SCOLIOSIS ORTHOSIS, 21.34 6 6 PER YEAR March 2003 B - 24
  • 114. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS COVER FOR UPRIGHT, EACH L1200 THORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO), 679.00 1 1 PER YEAR INCLUSIVE OF FURNISHING INITIAL ORTHOSIS ONLY L1210 ADDITION TO TLSO, (LOW PROFILE), LATERAL 45.59 2 2 PER YEAR THORACIC EXTENSION L1220 ADDITION TO TLSO, (LOW PROFILE), ANTERIOR 45.59 1 1 PER YEAR THORACIC EXTENSION L1230 ADDITION TO TLSO, (LOW PROFILE), MILWAUKEE 266.75 1 1 PER 2 YEARS TYPE SUPERSTRUCTURE L1240 ADDITION TO TLSO, (LOW PROFILE), LUMBAR 48.50 2 2 PER YEAR DEROTATION PAD L1250 ADDITION TO TLSO, (LOW PROFILE), ANTERIOR 30.07 2 2 PER YEAR ASIS PAD L1260 ADDITION TO TLSO, (LOW PROFILE), ANTERIOR 58.20 2 2 PER YEAR THORACIC DEROTATION PAD L1270 ADDITION TO TLSO, (LOW PROFILE), ABDOMINAL 50.44 2 2 PER YEAR PAD L1280 ADDITION TO TLSO, (LOW PROFILE), RIB GUSSET 46.56 2 2 PER YEAR (ELASTIC), EACH L1290 ADDITION TO TLSO, (LOW PROFILE), LATERAL 43.65 2 2 PER YEAR TROCHANTERIC PAD L1300 OTHER SCOLIOSIS PROCEDURE, BODY JACKET 727.50 1 1 PER YEAR MOLDED TO PATIENT MODEL L1310 OTHER SCOLIOSIS PROCEDURE, 776.00 1 1 PER MEDICAL POST-OPERATIVE BODY JACKET EVENT L1499 SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED 0.00 1 BR MEDICAL NECESSITY L1500 THORACIC-HIP-KNEE-ANKLE ORTHOSIS (THKAO), 1,069.56 1 3 PER LIFETIME MOBILITY FRAME (NEWINGTON, PARAPODIUM TYPES) L1510 THKAO, STANDING FRAME, WITH OR WITHOUT 676.64 1 3 PER LIFETIME TRAY AND ACCESSORIES L1520 THKAO, SWIVEL WALKER 1,607.15 1 3 PER LIFETIME L1600 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP 53.35 1 1 PER LIFETIME JOINTS, FLEXIBLE, FREJKA TYPE WITH COVER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1620 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP 43.65 1 1 PER 5 YEARS JOINTS, FLEXIBLE, (PAVLIK HARNESS), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1630 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP 53.35 1 1 PER LIFETIME JOINTS, SEMI-FLEXIBLE (VON ROSEN TYPE), CUSTOM-FABRICATED L1640 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP 116.40 1 1 PER 5 YEARS JOINTS, STATIC, PELVIC BAND OR SPREADER March 2003 B - 25
  • 115. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS BAR, THIGH CUFFS, CUSTOM-FABRICATED L1650 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP 116.40 1 1 PER LIFETIME JOINTS, STATIC, ADJUSTABLE, (ILFLED TYPE), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1652 HIP ORTHOSIS, BILATERAL THIGH CUFFS WITH 184.66 1 1 PER MEDICAL ADJUSTABLE ABDUCTOR SPREADER BAR, EVENT ADULT SIZE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT, ANY TYPE L1660 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP 29.10 1 1 PER 5 YEARS JOINTS, STATIC, PLASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1680 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP 460.75 1 1 PER MEDICAL JOINTS, DYNAMIC, PELVIC CONTROL, EVENT ADJUSTABLE HIP MOTION CONTROL, THIGH CUFFS (RANCHO HIP ACTION TYPE), CUSTOM FABRICATED L1685 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP 819.65 1 1 PER MEDICAL JOINT, POSTOPERATIVE HIP ABDUCTION TYPE, EVENT CUSTOM FABRICATED L1686 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP 567.45 1 1 PER MEDICAL JOINT, POSTOPERATIVE HIP ABDUCTION TYPE, EVENT PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1690 COMBINATION, BILATERAL, LUMBO-SACRAL, 1,170.82 2 2 PER MEDICAL HIP, FEMUR ORTHOSIS PROVIDING ADDUCTION EVENT AND INTERNAL ROTATION CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1700 LEGG PERTHES ORTHOSIS, (TORONTO TYPE), 904.04 1 1 PER MEDICAL CUSTOM-FABRICATED EVENT L1710 LEGG PERTHES ORTHOSIS, (NEWINGTON TYPE), 557.75 1 1 PER MEDICAL CUSTOM FABRICATED EVENT L1720 LEGG PERTHES ORTHOSIS, TRILATERAL, 834.20 1 1 PER MEDICAL (TACHDIJAN TYPE), CUSTOM-FABRICATED EVENT L1730 LEGG PERTHES ORTHOSIS, (SCOTTISH RITE 557.75 1 1 PER MEDICAL TYPE), CUSTOM-FABRICATED EVENT L1750 LEGG PERTHES ORTHOSIS, LEGG PERTHES SLING 66.93 1 1 PER MEDICAL (SAM BROWN TYPE), PREFABRICATED, INCLUDES EVENT FITTING AND ADJUSTMENT L1755 LEGG PERTHES ORTHOSIS, (PATTEN BOTTOM 732.35 1 1 PER MEDICAL TYPE), CUSTOM-FABRICATED EVENT L1800 KNEE ORTHOSIS, ELASTIC WITH STAYS, 38.80 2 2 PER YEAR PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1810 KNEE ORTHOSIS, ELASTIC WITH JOINTS, 79.06 2 2 PER YEAR PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT March 2003 B - 26
  • 116. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L1815 KNEE ORTHOSIS, ELASTIC OR OTHER ELASTIC 39.29 2 2 PER YEAR TYPE MATERIAL WITH CONDYLAR PAD(S), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1820 KNEE ORTHOSIS, ELASTIC WITH CONDYLAR 58.20 2 2 PER YEAR PADS AND JOINTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1825 KNEE ORTHOSIS, ELASTIC KNEE CAP, 36.86 2 2 PER YEAR PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1830 KNEE ORTHOSIS, IMMOBILIZER, CANVAS 48.50 2 2 PER YEAR LONGITUDINAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1832 KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS, 559.32 2 2 PER 2 YEARS POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1834 KNEE ORTHOSIS, WITHOUT KNEE JOINT, RIGID, 630.50 2 2 PER YEAR CUSTOM-FABRICATED L1836 KNEE ORTHOSIS, RIGID, WITHOUT JOINT(S), 69.12 2 2 PER YEAR INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1840 KNEE ORTHOSIS, DEROTATION, 582.00 2 2 PER YEAR MEDIAL-LATERAL, ANTERIOR CRUCIATE LIGAMENT, CUSTOM FABRICATED L1843 KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND 323.72 2 2 PER 2 YEARS CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT, MEDIAL-LATERAL AND ROTATION CONTROL, INCLUDES VARUS/VALGUS ADJUSTMENT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1844 KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND 572.30 1 2 PER 2 YEARS CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT, MEDIAL-LATERAL AND ROTATION CONTROL, INCLUDES VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATED L1845 KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND 572.30 2 2 PER 2 YEARS CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT, MEDIAL-LATERAL AND ROTATION CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1846 KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND 577.15 2 2 PER YEAR CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT, MEDIAL-LATERAL AND ROTATION CONTROL, CUSTOM FABRICATED L1847 KNEE ORTHOSIS, DOUBLE UPRIGHT WITH 348.25 2 2 PER MEDICAL ADJUSTABLE JOINT, WITH INFLATABLE AIR EVENT March 2003 B - 27
  • 117. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS SUPPORT CHAMBER(S), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1850 KNEE ORTHOSIS, SWEDISH TYPE, 134.83 2 2 PER 2 YEARS PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1855 KNEE ORTHOSIS, MOLDED PLASTIC, THIGH AND 665.42 2 2 PER 2 YEARS CALF SECTIONS, WITH DOUBLE UPRIGHT KNEE JOINTS, CUSTOM-FABRICATED L1858 KNEE ORTHOSIS, MOLDED PLASTIC, 753.69 2 2 PER 2 YEARS POLYCENTRIC KNEE JOINTS, PNEUMATIC KNEE PADS (CTI), CUSTOM-FABRICATED L1860 KNEE ORTHOSIS, MODIFICATION OF 485.00 2 2 PER 2 YEARS SUPRACONDYLAR PROSTHETIC SOCKET, CUSTOM-FABRICATED (SK) L1870 KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND 727.50 2 2 PER YEAR CALF LACERS WITH KNEE JOINTS, CUSTOM-FABRICATED L1880 KNEE ORTHOSIS, DOUBLE UPRIGHT, 230.86 2 2 PER 2 YEARS NON-MOLDED THIGH AND CALF CUFFS/LACERS WITH KNEE JOINTS, CUSTOM-FABRICATED L1885 KNEE ORTHOSIS, SINGLE OR DOUBLE UPRIGHT, 597.00 2 2 PER 3 YEARS THIGH AND CALF, WITH FUNCTIONAL ACTIVE RESISTANCE CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1900 ANKLE FOOT ORTHOSIS, SPRING WIRE, 189.15 2 2 PER 2 YEARS DORSIFLEXION ASSIST CALF BAND, CUSTOM-FABRICATED L1901 ANKLE ORTHOSIS, ELASTIC, PREFABRICATED, 9.17 2 2 PER YEAR INCLUDES FITTING AND ADJUSTMENT (E.G. NEOPRENE, LYCRA) L1902 ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET, 39.29 2 2 PER YEAR PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1904 ANKLE FOOT ORTHOSIS, MOLDED ANKLE 221.65 2 2 PER YEAR GAUNTLET, CUSTOM-FABRICATED L1906 ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS 83.91 2 2 PER MEDICAL ANKLE SUPPORT, PREFABRICATED, INCLUDES EVENT FITTING AND ADJUSTMENT L1910 ANKLE FOOT ORTHOSIS, POSTERIOR, SINGLE 137.74 2 2 PER 2 YEARS BAR, CLASP ATTACHMENT TO SHOE COUNTER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L1920 ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH 126.10 2 2 PER YEAR STATIC OR ADJUSTABLE STOP (PHELPS OR PERLSTEIN TYPE), CUSTOM-FABRICATED L1930 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER 79.06 2 2 PER YEAR MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT March 2003 B - 28
  • 118. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L1940 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER 261.90 2 2 PER YEAR MATERIAL, CUSTOM-FABRICATED L1945 ANKLE FOOT ORTHOSIS, PLASTIC, RIGID 630.50 2 2 PER YEAR ANTERIOR TIBIAL SECTION (FLOOR REACTION), CUSTOM-FABRICATED L1950 ANKLE FOOT ORTHOSIS, SPIRAL, (IRM TYPE), 215.34 2 2 PER YEAR PLASTIC, CUSTOM-FABRICATED L1960 ANKLE FOOT ORTHOSIS, POSTERIOR SOLID 251.23 2 2 PER YEAR ANKLE, PLASTIC, CUSTOM-FABRICATED L1970 ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE 363.75 2 2 PER YEAR JOINT, CUSTOM-FABRICATED L1980 ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE 121.25 2 2 PER 2 YEARS PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (SINGLE BAR 'BK' ORTHOSIS), CUSTOM-FABRICATED L1990 ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE 223.10 2 2 PER 2 YEARS PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (DOUBLE BAR 'BK' ORTHOSIS), CUSTOM-FABRICATED L2000 KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, 282.27 2 2 PER 2 YEARS FREE KNEE, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (SINGLE BAR 'AK' ORTHOSIS), CUSTOM-FABRICATED L2010 KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, 237.65 2 2 PER 2 YEARS FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (SINGLE BAR 'AK' ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM-FABRICATED L2020 KNEE ANKLE FOOT ORTHOSIS, DOUBLE 461.72 2 2 PER YEAR UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (DOUBLE BAR 'AK' ORTHOSIS), CUSTOM-FABRICATED L2030 KNEE ANKLE FOOT ORTHOSIS, DOUBLE 295.85 2 2 PER 2 YEARS UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS, (DOUBLE BAR 'AK' ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM FABRICATED L2036 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, 1,047.60 2 2 PER YEAR DOUBLE UPRIGHT, FREE KNEE, CUSTOM-FABRICATED L2037 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, 1,067.00 2 2 PER 2 YEARS SINGLE UPRIGHT, FREE KNEE, CUSTOM-FABRICATED L2038 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, 582.00 2 2 PER YEAR WITH KNEE JOINT, MULTI-AXIS ANKLE, (LIVELY ORTHOSIS OR EQUAL), CUSTOM-FABRICATED L2039 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, 1,236.00 2 2 PER 2 YEARS SINGLE UPRIGHT, POLY-AXIAL HINGE, MEDIAL LATERAL ROTATION CONTROL, March 2003 B - 29
  • 119. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS CUSTOM-FABRICATED L2040 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION 97.00 1 1 PER YEAR CONTROL, BILATERAL ROTATION STRAPS, PELVIC BAND/BELT, CUSTOM FABRICATED L2050 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION 232.80 1 1 PER YEAR CONTROL, BILATERAL TORSION CABLES, HIP JOINT, PELVIC BAND/BELT, CUSTOM-FABRICATED L2060 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION 291.00 1 1 PER YEAR CONTROL, BILATERAL TORSION CABLES, BALL BEARING HIP JOINT, PELVIC BAND/ BELT, CUSTOM-FABRICATED L2070 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION 60.14 1 1 PER YEAR CONTROL, UNILATERAL ROTATION STRAPS, PELVIC BAND/BELT, CUSTOM FABRICATED L2080 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION 189.15 1 1 PER YEAR CONTROL, UNILATERAL TORSION CABLE, HIP JOINT, PELVIC BAND/BELT, CUSTOM-FABRICATED L2090 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION 262.79 2 1 PER YEAR CONTROL, UNILATERAL TORSION CABLE, BALL BEARING HIP JOINT, PELVIC BAND/ BELT, CUSTOM-FABRICATED L2102 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, 199.34 2 2 PER MEDICAL TIBIAL FRACTURE CAST ORTHOSIS, PLASTER EVENT TYPE CASTING MATERIAL, CUSTOM-FABRICATED L2104 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, 199.34 2 2 PER MEDICAL TIBIAL FRACTURE CAST ORTHOSIS, SYNTHETIC EVENT TYPE CASTING MATERIAL, CUSTOM-FABRICATED L2106 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, 228.92 2 2 PER MEDICAL TIBIAL FRACTURE CAST ORTHOSIS, EVENT THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED L2108 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, 598.49 2 2 PER MEDICAL TIBIAL FRACTURE CAST ORTHOSIS, EVENT CUSTOM-FABRICATED L2112 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, 331.74 2 2 PER MEDICAL TIBIAL FRACTURE ORTHOSIS, SOFT, EVENT PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L2114 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, 465.60 2 2 PER MEDICAL TIBIAL FRACTURE ORTHOSIS, SEMI-RIGID, EVENT PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L2116 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, 465.60 2 2 PER MEDICAL TIBIAL FRACTURE ORTHOSIS, RIGID, EVENT March 2003 B - 30
  • 120. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L2122 KNEE ANKLE FOOT ORTHOSIS, FRACTURE 383.15 2 2 PER MEDICAL ORTHOSIS, FEMORAL FRACTURE CAST EVENT ORTHOSIS, PLASTER TYPE CASTING MATERIAL, CUSTOM-FABRICATED L2124 KNEE ANKLE FOOT ORTHOSIS, FRACTURE 702.51 2 2 PER MEDICAL ORTHOSIS, FEMORAL FRACTURE CAST EVENT ORTHOSIS, SYNTHETIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED L2126 KNEE ANKLE FOOT ORTHOSIS, FRACTURE 776.49 2 2 PER MEDICAL ORTHOSIS, FEMORAL FRACTURE CAST EVENT ORTHOSIS, THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED L2128 KNEE ANKLE FOOT ORTHOSIS, FRACTURE 976.31 2 2 PER MEDICAL ORTHOSIS, FEMORAL FRACTURE CAST EVENT ORTHOSIS, CUSTOM-FABRICATED L2132 KAFO, FRACTURE ORTHOSIS, FEMORAL 487.91 2 2 PER MEDICAL FRACTURE CAST ORTHOSIS, SOFT, EVENT PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L2134 KAFO, FRACTURE ORTHOSIS, FEMORAL 487.91 2 2 PER MEDICAL FRACTURE CAST ORTHOSIS, SEMI-RIGID, EVENT PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L2136 KAFO, FRACTURE ORTHOSIS, FEMORAL 665.42 2 2 PER MEDICAL FRACTURE CAST ORTHOSIS, RIGID, EVENT PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L2180 ADDITION TO LOWER EXTREMITY FRACTURE 43.65 2 2 PER MEDICAL ORTHOSIS, PLASTIC SHOE INSERT WITH ANKLE EVENT JOINTS L2182 ADDITION TO LOWER EXTREMITY FRACTURE 41.16 2 2 PER MEDICAL ORTHOSIS, DROP LOCK KNEE JOINT EVENT L2184 ADDITION TO LOWER EXTREMITY FRACTURE 74.11 2 2 PER MEDICAL ORTHOSIS, LIMITED MOTION KNEE JOINT EVENT L2186 ADDITION TO LOWER EXTREMITY FRACTURE 43.65 2 2 PER MEDICAL ORTHOSIS, ADJUSTABLE MOTION KNEE JOINT, EVENT LERMAN TYPE L2188 ADDITION TO LOWER EXTREMITY FRACTURE 288.09 2 2 PER MEDICAL ORTHOSIS, QUADRILATERAL BRIM EVENT L2190 ADDITION TO LOWER EXTREMITY FRACTURE 48.02 2 2 PER MEDICAL ORTHOSIS, WAIST BELT EVENT L2192 ADDITION TO LOWER EXTREMITY FRACTURE 150.35 1 1 PER MEDICAL ORTHOSIS, HIP JOINT, PELVIC BAND, THIGH EVENT FLANGE, AND PELVIC BELT L2200 ADDITION TO LOWER EXTREMITY, LIMITED 20.91 4 2 PER ORTHOSIS ANKLE MOTION, EACH JOINT March 2003 B - 31
  • 121. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L2210 ADDITION TO LOWER EXTREMITY, 43.65 4 2 PER ORTHOSIS DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST), EACH JOINT L2220 ADDITION TO LOWER EXTREMITY, 56.26 4 2 PER ORTHOSIS DORSIFLEXION AND PLANTAR FLEXION ASSIST/RESIST, EACH JOINT L2230 ADDITION TO LOWER EXTREMITY, SPLIT FLAT 31.04 2 2 PER ORTHOSIS CALIPER STIRRUPS AND PLATE ATTACHMENT L2240 ADDITION TO LOWER EXTREMITY, ROUND 31.04 2 2 PER ORTHOSIS CALIPER AND PLATE ATTACHMENT L2250 ADDITION TO LOWER EXTREMITY, FOOT PLATE, 179.45 2 2 PER ORTHOSIS MOLDED TO PATIENT MODEL, STIRRUP ATTACHMENT L2260 ADDITION TO LOWER EXTREMITY, REINFORCED 67.90 2 2 PER ORTHOSIS SOLID STIRRUP (SCOTT-CRAIG TYPE) L2265 ADDITION TO LOWER EXTREMITY, LONG 19.40 2 2 PER ORTHOSIS TONGUE STIRRUP L2270 ADDITION TO LOWER EXTREMITY, 31.04 4 1 PER ORTHOSIS VARUS/VALGUS CORRECTION ('T') STRAP, PADDED/LINED OR MALLEOLUS PAD L2275 ADDITION TO LOWER EXTREMITY, 72.85 2 2 PER ORTHOSIS VARUS/VALGUS CORRECTION, PLASTIC MODIFICATION, PADDED/LINED L2280 ADDITION TO LOWER EXTREMITY, MOLDED 242.50 2 2 PER 3 YEARS INNER BOOT L2300 ADDITION TO LOWER EXTREMITY, ABDUCTION 72.75 1 1 PER 2 YEARS BAR (BILATERAL HIP INVOLVEMENT), JOINTED, ADJUSTABLE L2310 ADDITION TO LOWER EXTREMITY, ABDUCTION 43.65 1 1 PER 2 YEARS BAR-STRAIGHT L2320 ADDITION TO LOWER EXTREMITY, 67.90 2 2 PER ORTHOSIS NON-MOLDED LACER L2330 ADDITION TO LOWER EXTREMITY, LACER 161.99 2 2 PER ORTHOSIS MOLDED TO PATIENT MODEL L2335 ADDITION TO LOWER EXTREMITY, ANTERIOR 110.58 2 2 PER ORTHOSIS SWING BAND L2340 ADDITION TO LOWER EXTREMITY, PRE-TIBIAL 290.03 2 2 PER ORTHOSIS SHELL, MOLDED TO PATIENT MODEL L2350 ADDITION TO LOWER EXTREMITY, PROSTHETIC 363.75 4 2 PER ORTHOSIS TYPE, (BK) SOCKET, MOLDED TO PATIENT MODEL, (USED FOR 'PTB' 'AFO' ORTHOSES) L2360 ADDITION TO LOWER EXTREMITY, EXTENDED 29.10 4 4 PER YEAR STEEL SHANK L2370 ADDITION TO LOWER EXTREMITY, PATTEN 65.96 4 2 PER ORTHOSIS BOTTOM L2375 ADDITION TO LOWER EXTREMITY, TORSION 43.65 4 4 PER ORTHOSIS CONTROL, ANKLE JOINT AND HALF SOLID March 2003 B - 32
  • 122. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS STIRRUP L2380 ADDITION TO LOWER EXTREMITY, TORSION 43.65 4 4 PER ORTHOSIS CONTROL, STRAIGHT KNEE JOINT, EACH JOINT L2385 ADDITION TO LOWER EXTREMITY, STRAIGHT 21.83 4 4 PER ORTHOSIS KNEE JOINT, HEAVY DUTY, EACH JOINT L2390 ADDITION TO LOWER EXTREMITY, OFFSET KNEE 42.20 4 4 PER ORTHOSIS JOINT, EACH JOINT L2395 ADDITION TO LOWER EXTREMITY, OFFSET KNEE 73.46 4 4 PER ORTHOSIS JOINT, HEAVY DUTY, EACH JOINT L2397 ADDITION TO LOWER EXTREMITY ORTHOSIS, 65.34 2 4 PER ORTHOSIS SUSPENSION SLEEVE L2405 ADDITION TO KNEE JOINT, DROP LOCK, EACH 21.34 4 4 PER ORTHOSIS JOINT L2415 ADDITION TO KNEE LOCK WITH INTEGRATED 142.11 4 4 PER ORTHOSIS RELEASE MECHANISM ( BAIL, CABLE, OR EQUAL), ANY MATERIAL, EACH JOINT L2425 ADDITION TO KNEE JOINT, DISC OR DIAL LOCK 104.76 4 4 PER ORTHOSIS FOR ADJUSTABLE KNEE FLEXION, EACH JOINT L2430 ADDITION TO KNEE JOINT, RATCHET LOCK FOR 58.30 2 1 PER ORTHOSIS ACTIVE AND PROGRESSIVE KNEE EXTENSION, EACH JOINT L2435 ADDITION TO KNEE JOINT, POLYCENTRIC JOINT, 110.10 4 4 PER ORTHOSIS EACH JOINT L2492 ADDITION TO KNEE JOINT, LIFT LOOP FOR DROP 19.40 4 2 PER ORTHOSIS LOCK RING L2500 ADDITION TO LOWER EXTREMITY, 98.94 2 1 PER ORTHOSIS THIGH/WEIGHT BEARING, GLUTEAL/ ISCHIAL WEIGHT BEARING, RING L2510 ADDITION TO LOWER EXTREMITY, 334.65 2 1 PER ORTHOSIS THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, MOLDED TO PATIENT MODEL L2520 ADDITION TO LOWER EXTREMITY, 174.60 2 1 PER ORTHOSIS THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, CUSTOM FITTED L2525 ADDITION TO LOWER EXTREMITY, 630.50 2 1 PER ORTHOSIS THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L BRIM MOLDED TO PATIENT MODEL L2526 ADDITION TO LOWER EXTREMITY, 436.50 2 1 PER ORTHOSIS THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L BRIM, CUSTOM FITTED L2530 ADDITION TO LOWER EXTREMITY, 87.30 2 1 PER ORTHOSIS THIGH-WEIGHT BEARING, LACER, NON-MOLDED L2540 ADDITION TO LOWER EXTREMITY, 161.99 2 1 PER ORTHOSIS THIGH/WEIGHT BEARING, LACER, MOLDED TO PATIENT MODEL March 2003 B - 33
  • 123. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L2550 ADDITION TO LOWER EXTREMITY, 113.49 2 1 PER ORTHOSIS THIGH/WEIGHT BEARING, HIGH ROLL CUFF L2570 ADDITION TO LOWER EXTREMITY, PELVIC 92.15 2 1 PER ORTHOSIS CONTROL, HIP JOINT, CLEVIS TYPE TWO POSITION JOINT, EACH L2580 ADDITION TO LOWER EXTREMITY, PELVIC 355.99 1 1 PER 2 YEARS CONTROL, PELVIC SLING L2600 ADDITION TO LOWER EXTREMITY, PELVIC 82.45 2 2 PER ORTHOSIS CONTROL, HIP JOINT, CLEVIS TYPE, OR THRUST BEARING, FREE, EACH L2610 ADDITION TO LOWER EXTREMITY, PELVIC 106.94 2 2 PER ORTHOSIS CONTROL, HIP JOINT, CLEVIS OR THRUST BEARING, LOCK, EACH L2620 ADDITION TO LOWER EXTREMITY, PELVIC 117.89 2 1 PER ORTHOSIS CONTROL, HIP JOINT, HEAVY DUTY, EACH L2622 ADDITION TO LOWER EXTREMITY, PELVIC 83.91 2 2 PER ORTHOSIS CONTROL, HIP JOINT, ADJUSTABLE FLEXION, EACH L2624 ADDITION TO LOWER EXTREMITY, PELVIC 266.27 2 1 PER ORTHOSIS CONTROL, HIP JOINT, ADJUSTABLE FLEXION, EXTENSION, ABDUCTION CONTROL, EACH L2627 ADDITION TO LOWER EXTREMITY, PELVIC 665.42 1 1 PER 2 YEARS CONTROL, PLASTIC, MOLDED TO PATIENT MODEL, RECIPROCATING HIP JOINT AND CABLES L2628 ADDITION TO LOWER EXTREMITY, PELVIC 1,018.50 1 1 PER YEAR CONTROL, METAL FRAME, RECIPROCATING HIP JOINT AND CABLES L2630 ADDITION TO LOWER EXTREMITY, PELVIC 82.45 1 1 PER ORTHOSIS CONTROL, BAND AND BELT, UNILATERAL L2640 ADDITION TO LOWER EXTREMITY, PELVIC 121.25 1 1 PER YEAR CONTROL, BAND AND BELT, BILATERAL L2650 ADDITION TO LOWER EXTREMITY, PELVIC AND 48.50 1 2 PER YEAR THORACIC CONTROL, GLUTEAL PAD, EACH L2660 ADDITION TO LOWER EXTREMITY, THORACIC 87.30 1 1 PER 2 YEARS CONTROL, THORACIC BAND L2670 ADDITION TO LOWER EXTREMITY, THORACIC 67.90 1 1 PER 2 YEARS CONTROL, PARASPINAL UPRIGHTS L2680 ADDITION TO LOWER EXTREMITY, THORACIC 58.20 2 1 PER YEAR CONTROL, LATERAL SUPPORT UPRIGHTS L2750 ADDITION TO LOWER EXTREMITY ORTHOSIS, 46.60 2 4 PER ORTHOSIS PLATING CHROME OR NICKEL, PER BAR L2755 ADDITION TO LOWER EXTREMITY ORTHOSIS, 77.50 2 1 PER ORTHOSIS HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, PER SEGMENT L2760 ADDITION TO LOWER EXTREMITY ORTHOSIS, 27.16 8 4 PER ORTHOSIS EXTENSION, PER EXTENSION, PER BAR (FOR LINEAL ADJUSTMENT FOR GROWTH) March 2003 B - 34
  • 124. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L2768 ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER 15.00 2 2 PER 2 YEARS BAR L2770 ADDITION TO LOWER EXTREMITY ORTHOSIS, 14.55 8 4 PER KAFO ANY MATERIAL - PER BAR OR JOINT L2780 ADDITION TO LOWER EXTREMITY ORTHOSIS, 40.06 2 4 PER ORTHOSIS NON-CORROSIVE FINISH, PER BAR L2785 ADDITION TO LOWER EXTREMITY ORTHOSIS, 21.34 4 2 PER KAFO DROP LOCK RETAINER, EACH L2795 ADDITION TO LOWER EXTREMITY ORTHOSIS, 35.89 2 1 PER KAFO KNEE CONTROL, FULL KNEECAP L2800 ADDITION TO LOWER EXTREMITY ORTHOSIS, 48.99 2 1 PER KAFO KNEE CONTROL, KNEE CAP, MEDIAL OR LATERAL PULL L2810 ADDITION TO LOWER EXTREMITY ORTHOSIS, 48.02 2 2 PER KAFO KNEE CONTROL, CONDYLAR PAD L2820 ADDITION TO LOWER EXTREMITY ORTHOSIS, 30.56 2 1 PER KAFO SOFT INTERFACE FOR MOLDED PLASTIC, BELOW KNEE SECTION L2830 ADDITION TO LOWER EXTREMITY ORTHOSIS, 30.56 2 1 PER KAFO SOFT INTERFACE FOR MOLDED PLASTIC, ABOVE KNEE SECTION L2840 ADDITION TO LOWER EXTREMITY ORTHOSIS, 37.60 2 3 PER MEDICAL TIBIAL LENGTH SOCK, FRACTURE OR EQUAL, EVENT EACH L2850 ADDITION TO LOWER EXTREMITY ORTHOSIS, 29.10 2 3 PER MEDICAL FEMORAL LENGTH SOCK, FRACTURE OR EQUAL, EVENT EACH L2860 ADDITION TO LOWER EXTREMITY JOINT, KNEE 220.19 4 2 PER KAFO OR ANKLE, CONCENTRIC ADJUSTABLE TORSION STYLE MECHANISM, EACH L2999 LOWER EXTREMITY ORTHOSES, NOT OTHERWISE 0.00 1 BR MEDICAL SPECIFIED NECESSITY L3000 FOOT, INSERT, REMOVABLE, MOLDED TO 168.78 2 1 PER FOOT PER PATIENT MODEL, 'UCB' TYPE, BERKELEY SHELL, YEAR EACH L3001 FOOT, INSERT, REMOVABLE, MOLDED TO 29.10 2 2 PER FOOT PER PATIENT MODEL, SPENCO, EACH YEAR L3002 FOOT, INSERT, REMOVABLE, MOLDED TO 77.60 2 2 PER FOOT PER PATIENT MODEL, PLASTAZOTE OR EQUAL, EACH YEAR L3010 FOOT, INSERT, REMOVABLE, MOLDED TO 77.60 2 1 PER FOOT PER PATIENT MODEL, LONGITUDINAL ARCH YEAR SUPPORT, EACH L3020 FOOT, INSERT, REMOVABLE, MOLDED TO 77.60 2 1 PER FOOT PER PATIENT MODEL, LONGITUDINAL/ METATARSAL YEAR SUPPORT, EACH L3030 FOOT, INSERT, REMOVABLE, FORMED TO 72.75 2 2 PER FOOT PER PATIENT FOOT, EACH YEAR March 2003 B - 35
  • 125. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L3040 FOOT, ARCH SUPPORT, REMOVABLE, 58.20 2 2 PER FOOT PER PREMOLDED, LONGITUDINAL, EACH YEAR L3050 FOOT, ARCH SUPPORT, REMOVABLE, 58.20 2 2 PER FOOT PER PREMOLDED, METATARSAL, EACH YEAR L3060 FOOT, ARCH SUPPORT, REMOVABLE, 77.60 2 2 PER FOOT PER PREMOLDED, LONGITUDINAL/ METATARSAL, YEAR EACH L3070 FOOT, ARCH SUPPORT, NON-REMOVABLE 8.73 2 1 PER FOOT PER ATTACHED TO SHOE, LONGITUDINAL, EACH YEAR L3080 FOOT, ARCH SUPPORT, NON-REMOVABLE 4.37 2 1 PER FOOT PER ATTACHED TO SHOE, METATARSAL, EACH YEAR L3100 HALLUS-VALGUS NIGHT DYNAMIC SPLINT 24.25 2 2 PER YEAR L3140 FOOT, ABDUCTION ROTATION BAR, INCLUDING 35.41 1 2 PER YEAR SHOES L3150 FOOT, ABDUCTION ROTATATION BAR, WITHOUT 28.13 1 2 PER YEAR SHOES L3170 FOOT, PLASTIC HEEL STABILIZER 15.52 2 2 PER FOOT PER YEAR L3201 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR 36.38 2 3 PAIR PER YEAR OR PRONATOR, INFANT L3202 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR 36.38 2 3 PAIR PER YEAR OR PRONATOR, CHILD L3203 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR 36.38 2 3 PAIR PER YEAR OR PRONATOR, JUNIOR L3204 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR 34.92 2 3 PAIR PER YEAR OR PRONATOR, INFANT L3206 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR 41.71 2 3 PAIR PER YEAR OR PRONATOR, CHILD L3207 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR 52.38 2 3 PAIR PER YEAR OR PRONATOR, JUNIOR L3208 SURGICAL BOOT, EACH, INFANT 17.46 2 2 PER FOOT PER YEAR L3209 SURGICAL BOOT, EACH, CHILD 17.46 2 2 PER FOOT PER YEAR L3211 SURGICAL BOOT, EACH, JUNIOR 19.40 2 2 PER FOOT PER YEAR L3215 ORTHOPEDIC FOOTWEAR, LADIES SHOES, 79.54 2 2 PER FOOT PER OXFORD YEAR L3216 ORTHOPEDIC FOOTWEAR, LADIES SHOES, DEPTH 79.54 2 2 PER FOOT PER INLAY YEAR L3217 ORTHOPEDIC FOOTWEAR, LADIES SHOES, 91.18 2 2 PER FOOT PER HIGHTOP, DEPTH INLAY YEAR L3219 ORTHOPEDIC FOOTWEAR, MENS SHOES, OXFORD 79.54 2 2 PER FOOT PER YEAR L3221 ORTHOPEDIC FOOTWEAR, MENS SHOES, DEPTH 79.54 2 2 PER FOOT PER INLAY YEAR L3222 ORTHOPEDIC FOOTWEAR, MENS SHOES, 96.03 2 2 PER FOOT PER March 2003 B - 36
  • 126. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS HIGHTOP, DEPTH INLAY YEAR L3230 ORTHOPEDIC FOOTWEAR, CUSTOM SHOES, 69.84 2 1 PER FOOT PER DEPTH INLAY YEAR L3251 FOOT, SHOE MOLDED TO PATIENT MODEL, 213.44 2 2 PER FOOT PER SILICONE SHOE, EACH YEAR L3253 FOOT, MOLDED SHOE PLASTAZOTE (OR SIMILAR) 65.96 2 1 PER FOOT PER CUSTOM FITTED, EACH YEAR L3254 NON-STANDARD SIZE OR WIDTH 1.99 2 6 PER YEAR L3255 NON-STANDARD SIZE OR LENGTH 3.15 2 6 PER YEAR L3257 ORTHOPEDIC FOOTWEAR, ADDITIONAL CHARGE 0.00 1 BR 3 PER YEAR FOR SPLIT SIZE L3300 LIFT, ELEVATION, HEEL, TAPERED TO 17.95 3 3 PER YEAR METATARSALS, PER INCH L3310 LIFT, ELEVATION, HEEL AND SOLE, NEOPRENE, 35.41 3 3 PER YEAR PER INCH L3320 LIFT, ELEVATION, HEEL AND SOLE, CORK, PER 107.19 3 3 PER YEAR INCH L3330 LIFT, ELEVATION, METAL EXTENSION (SKATE) 291.84 2 3 PER YEAR L3332 LIFT, ELEVATION, INSIDE SHOE, TAPERED, UP TO 25.71 3 3 PER YEAR ONE-HALF INCH L3334 LIFT, ELEVATION, HEEL, PER INCH 16.98 3 3 PER YEAR L3340 HEEL WEDGE, SACH 48.02 2 4 PER YEAR L3350 HEEL WEDGE 12.61 2 4 PER YEAR L3360 SOLE WEDGE, OUTSIDE SOLE 19.40 2 4 PER YEAR L3370 SOLE WEDGE, BETWEEN SOLE 14.55 2 4 PER YEAR L3380 CLUBFOOT WEDGE 15.52 2 4 PER YEAR L3390 OUTFLARE WEDGE 22.80 2 4 PER YEAR L3400 METATARSAL BAR WEDGE, ROCKER 24.25 2 4 PER YEAR L3410 METATARSAL BAR WEDGE, BETWEEN SOLE 11.16 2 4 PER YEAR L3420 FULL SOLE AND HEEL WEDGE, BETWEEN SOLE 18.92 2 4 PER YEAR L3430 HEEL, COUNTER, PLASTIC REINFORCED 19.89 2 2 PER YEAR L3440 HEEL, COUNTER, LEATHER REINFORCED 28.13 2 2 PER YEAR L3450 HEEL, SACH CUSHION TYPE 25.71 2 2 PER YEAR L3460 HEEL, NEW RUBBER, STANDARD 9.22 2 2 PER YEAR L3465 HEEL, THOMAS WITH WEDGE 11.16 2 2 PER YEAR L3470 HEEL, THOMAS EXTENDED TO BALL 14.55 2 2 PER YEAR L3480 HEEL, PAD AND DEPRESSION FOR SPUR 9.70 2 2 PER FOOT PER YEAR L3570 ORTHOPEDIC SHOE ADDITION, SPECIAL 20.37 2 6 PER YEAR EXTENSION TO INSTEP (LEATHER WITH EYELETS) L3580 ORTHOPEDIC SHOE ADDITION, CONVERT INSTEP 33.69 2 2 PER YEAR TO VELCRO CLOSURE L3590 ORTHOPEDIC SHOE ADDITION, CONVERT FIRM 27.74 2 2 PER YEAR SHOE COUNTER TO SOFT COUNTER L3595 ORTHOPEDIC SHOE ADDITION, MARCH BAR 20.37 2 MEDICAL NECESSITY March 2003 B - 37
  • 127. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L3600 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO 32.98 2 3 PER YEAR ANOTHER, CALIPER PLATE, EXISTING L3610 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO 52.18 2 3 PER YEAR ANOTHER, CALIPER PLATE, NEW L3620 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO 32.01 2 3 PER YEAR ANOTHER, SOLID STIRRUP, EXISTING L3630 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO 52.18 2 3 PER YEAR ANOTHER, SOLID STIRRUP, NEW L3640 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO 22.46 1 3 PER YEAR ANOTHER, DENNIS BROWNE SPLINT (RIVETON), BOTH SHOES L3649 ORTHOPEDIC SHOE, MODIFICATION, ADDITION 0.00 1 BR MEDICAL OR TRANSFER, NOT OTHERWISE SPECIFIED NECESSITY L3650 SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN 27.16 2 2 PER MEDICAL ABDUCTION RESTRAINER, PREFABRICATED, EVENT INCLUDES FITTING AND ADJUSTMENT L3651 SHOULDER ORTHOSIS, SINGLE SHOULDER, 31.18 2 2 PER MEDICAL ELASTIC, PREFABRICATED, INCLUDES FITTING EVENT AND ADJUSTMENT (E.G. NEOPRENE, LYCRA) L3652 SHOULDER ORTHOSIS, DOUBLE SHOULDER, 93.55 2 2 PER MEDICAL ELASTIC, PREFABRICATED, INCLUDES FITTING EVENT AND ADJUSTMENT (E.G. NEOPRENE, LYCRA) L3660 SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN 43.17 2 2 PER MEDICAL ABDUCTION RESTRAINER, CANVAS AND EVENT WEBBING, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3670 SHOULDER ORTHOSIS, ACROMIO/CLAVICULAR 58.20 2 2 PER MEDICAL (CANVAS AND WEBBING TYPE), EVENT PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3675 SHOULDER ORTHOSIS, VEST TYPE ABDUCTION 96.70 1 1 PER 2 YEARS RESTRAINER, CANVAS WEBBING TYPE OR EQUAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3677 SHOULDER ORTHOSIS, HARD PLASTIC, 144.50 2 2 PER 2 YEARS SHOULDER STABILIZER, PRE-FABRICATED, INCLUDES FITTING AND ADJUSTMENT L3700 ELBOW ORTHOSIS, ELASTIC WITH STAYS, 29.79 2 2 PER YEAR PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3701 ELBOW ORTHOSIS, ELASTIC, PREFABRICATED, 9.60 2 2 PER YEAR INCLUDES FITTING AND ADJUSTMENT (E.G. NEOPRENE, LYCRA) L3710 ELBOW ORTHOSIS, ELASTIC WITH METAL 79.10 2 2 PER YEAR JOINTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3720 ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH 226.01 2 2 PER YEAR FOREARM/ARM CUFFS, FREE MOTION, March 2003 B - 38
  • 128. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS CUSTOM-FABRICATED L3730 ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH 376.36 2 2 PER YEAR FOREARM/ARM CUFFS, EXTENSION/ FLEXION ASSIST, CUSTOM-FABRICATED L3740 ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH 443.29 2 2 PER YEAR FOREARM/ARM CUFFS, ADJUSTABLE POSITION LOCK WITH ACTIVE CONTROL, CUSTOM-FABRICATED L3760 ELBOW ORTHOSIS, WITH ADJUSTABLE POSITION 268.57 2 PER MEDICAL LOCKING JOINT(S), PREFABRICATED, INCLUDES EVENT FITTING AND ADJUSTMENTS, ANY TYPE L3762 ELBOW ORTHOSIS, RIGID, WITHOUT JOINTS, 50.70 2 2 PER YEAR INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3800 WRIST HAND FINGER ORTHOSIS, SHORT 83.91 2 2 PER YEAR OPPONENS, NO ATTACHMENTS, CUSTOM-FABRICATED L3805 WRIST HAND FINGER ORTHOSIS, LONG 183.82 2 2 PER YEAR OPPONENS, NO ATTACHMENT, CUSTOM-FABRICATED L3810 WHFO, ADDITION TO SHORT AND LONG 24.25 2 1 PER ORTHOSIS OPPONENS, THUMB ABDUCTION ('C') BAR L3815 WHFO, ADDITION TO SHORT AND LONG 24.25 2 1 PER ORTHOSIS OPPONENS, SECOND M.P. ABDUCTION ASSIST L3820 WHFO, ADDITION TO SHORT AND LONG 52.38 2 1 PER FINGER OPPONENS, I.P. EXTENSION ASSIST, WITH M.P. EXTENSION STOP L3825 WHFO, ADDITION TO SHORT AND LONG 42.68 2 1 PER ORTHOSIS OPPONENS, M.P. EXTENSION STOP L3830 WHFO, ADDITION TO SHORT AND LONG 39.77 2 1 PER FINGER OPPONENS, M.P. EXTENSION ASSIST L3835 WHFO, ADDITION TO SHORT AND LONG 39.77 2 1 PER FINGER OPPONENS, M.P. SPRING EXTENSION ASSIST L3840 WHFO, ADDITION TO SHORT AND LONG 24.25 2 1 PER ORTHOSIS OPPONENS, SPRING SWIVEL THUMB L3845 WHFO, ADDITION TO SHORT AND LONG 36.38 2 1 PER FINGER OPPONENS, THUMB I.P. EXTENSION ASSIST, WITH M.P. STOP L3850 WHO, ADDITION TO SHORT AND LONG 54.32 2 1 PER ORTHOSIS OPPONENS, ACTION WRIST, WITH DORSIFLEXION ASSIST L3855 WHFO, ADDITION TO SHORT AND LONG 49.96 2 1 PER ORTHOSIS OPPONENS, ADJUSTABLE M.P. FLEXION CONTROL L3860 WHFO, ADDITION TO SHORT AND LONG 79.54 2 1 PER ORTHOSIS OPPONENS, ADJUSTABLE M.P. FLEXION CONTROL AND I.P. March 2003 B - 39
  • 129. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L3890 ADDITION TO UPPER EXTREMITY JOINT, WRIST 220.19 2 2 PER YEAR OR ELBOW, CONCENTRIC ADJUSTABLE TORSION STYLE MECHANISM, EACH L3900 WRIST HAND FINGER ORTHOSIS, DYNAMIC 887.55 2 2 PER YEAR FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/ FLEXION, FINGER FLEXION/EXTENSION, WRIST OR FINGER DRIVEN, CUSTOM-FABRICATED L3901 WRIST HAND FINGER ORTHOSIS, DYNAMIC 909.38 2 2 PER YEAR FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/ FLEXION, FINGER FLEXION/EXTENSION, CABLE DRIVEN, CUSTOM-FABRICATED L3902 WRIST HAND FINGER ORTHOSIS, EXTERNAL 1,407.61 2 1 PER ORTHOSIS POWERED, COMPRESSED GAS, CUSTOM-FABRICATED L3904 WRIST HAND FINGER ORTHOSIS, EXTERNAL 1,945.40 2 1 PER ORTHOSIS POWERED, ELECTRIC, CUSTOM-FABRICATED L3906 WRIST HAND ORTHOSIS, WRIST GAUNTLET, 241.53 2 2 PER MEDICAL CUSTOM-FABRICATED EVENT L3907 WRIST HAND FINGER ORTHOSIS, WRIST 288.09 2 2 PER MEDICAL GAUNTLET WITH THUMB SPICA, EVENT CUSTOM-FABRICATED L3908 WRST HAND ORTHOSIS, WRIST EXTENSION 17.46 2 4 PER YEAR CONTROL COCK-UP, NON MOLDED, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3909 WRIST ORTHOSIS, ELASTIC, PREFABRICATED, 6.67 2 2 PER YEAR INCLUDES FITTING AND ADJUSTMENT (E.G. NEOPRENE, LYCRA) L3910 WRIST HAND FINGER ORTHOSIS, SWANSON 314.28 2 2 PER MEDICAL DESIGN, PREFABRICATED, INCLUDES FITTING EVENT AND ADJUSTMENT L3911 WRIST HAND FINGER ORTHOSIS, ELASTIC, 27.45 2 2 PER YEAR PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G. NEOPRENE, LYCRA) L3912 HAND FINGER ORTHOSIS, FLEXION GLOVE WITH 19.40 2 2 PER 2 YEARS ELASTIC FINGER CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3914 WRIST HAND ORTHOSIS, WRIST EXTENSION 32.01 2 2 PER YEAR COCK-UP, PREFABRICATED, INCLUDES FITTING/ADJUSTMENT L3916 WRIST HAND FINGER ORTHOSIS, WRIST 56.75 2 2 PER MEDICAL EXTENSION COCK-UP WITH OUTRIGGER, EVENT PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3918 HAND FINGER ORTHOSIS, KNUCKLE BENDER, 25.71 2 2 PER MEDICAL PREFABRICATED, INCLUDES FITTING AND EVENT ADJUSTMENT L3920 HAND FINGER ORTHOSIS, KNUCKLE BENDER 48.50 2 2 PER MEDICAL March 2003 B - 40
  • 130. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS WITH OUTRIGGER, PREFABRICATED, INCLUDES EVENT FITTING AND ADJUSTMENT L3922 HAND FINGER ORTHOSIS, KNUCKLE BENDER, 33.95 2 2 PER MEDICAL TWO SEGMENT TO FLEX JOINTS, EVENT PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3923 HAND FINGER ORTHOSIS, WITHOUT JOINT(S), 21.88 1 PER MEDICAL PREFABRICATED, INCLUDES FITTING AND EVENT ADJUSTMENTS, ANY TYPE L3924 WRIST HAND FINGER ORTHOSIS, OPPENHEIMER, 59.66 2 2 PER MEDICAL PREFABRICATED, INCLUDES FITTING AND EVENT ADJUSTMENT L3926 WRIST HAND FINGER ORTHOSIS, THOMAS 49.47 2 2 PER MEDICAL SUSPENSION, PREFABRICATED, INCLUDES EVENT FITTING AND ADJUSTMENT L3928 HAND FINGER ORTHOSIS, FINGER EXTENSION, 32.50 2 2 PER MEDICAL WITH CLOCK SPRING, PREFABRICATED, EVENT INCLUDES FITTING AND ADJUSTMENT L3930 WRIST HAND FINGER ORTHOSIS, FINGER 24.25 2 2 PER MEDICAL EXTENSION, WITH WRIST SUPPORT, EVENT PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3932 FINGER ORTHOSIS, SAFETY PIN, SPRING WIRE, 19.40 2 2 PER YEAR PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3934 FINGER ORTHOSIS, SAFETY PIN, MODIFIED, 19.89 2 2 PER YEAR PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3936 WRIST HAND FINGER ORTHOSIS, PALMER, 33.95 2 2 PER MEDICAL PREFABRICATED, INCLUDES FITTING AND EVENT ADJUSTMENT L3938 WRIST HAND FINGER ORTHOSIS, DORSAL WRIST, 14.55 2 2 PER MEDICAL PREFABRICATED, INCLUDES FITTING AND EVENT ADJUSTMENT L3940 WRIST HAND FINGER ORTHOSIS, DORSAL WRIST, 52.38 2 2 PER MEDICAL WITH OUTRIGGER ATTACHMENT, EVENT PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3942 HAND FINGER ORTHOSIS, REVERSE KNUCKLE 30.07 2 2 PER MEDICAL BENDER, PREFABRICATED, INCLUDES FITTING EVENT AND ADJUSTMENT L3944 HAND FINGER ORTHOSIS, REVERSE KNUCKLE 29.10 2 2 PER MEDICAL BENDER, WITH OUTRIGGER, PREFABRICATED, EVENT INCLUDES FITTING AND ADJUSTMENT L3946 HAND FINGER ORTHOSIS, COMPOSITE ELASTIC, 14.55 2 2 PER MEDICAL PREFABRICATED, INCLUDES FITTING AND EVENT ADJUSTMENT L3948 FINGER ORTHOSIS, FINGER KNUCKLE BENDER, 28.13 2 2 PER YEAR March 2003 B - 41
  • 131. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3950 WRIST HAND FINGER ORTHOSIS, COMBINATION 71.30 2 2 PER MEDICAL OPPENHEIMER, WITH KNUCKLE BENDER AND EVENT TWO ATTACHMENTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3952 WRIST HAND FINGER ORTHOSIS, COMBINATION 85.36 2 2 PER MEDICAL OPPENHEIMER, WITH REVERSE KNUCKLE AND EVENT TWO ATTACHMENTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3954 HAND FINGER ORTHOSIS, SPREADING HAND, 44.62 2 2 PER MEDICAL PREFABRICATED, INCLUDES FITTING AND EVENT ADJUSTMENT L3960 SHOULDER ELBOW WRIST HAND ORTHOSIS, 296.34 2 2 PER MEDICAL ABDUCTION POSITIONING, AIRPLANE DESIGN, EVENT PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3962 SHOULDER ELBOW WRIST HAND ORTHOSIS, 186.24 2 2 PER 2 YEARS ABDUCTION POSITIONING, ERBS PALSEY DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3963 SHOULDER ELBOW WRIST HAND ORTHOSIS, 935.34 2 2 PER 2 YEARS MOLDED SHOULDER, ARM, FOREARM AND WRIST, WITH ARTICULATING ELBOW JOINT, CUSTOM-FABRICATED L3964 SHOULDER ELBOW ORTHOSIS, MOBILE ARM 332.71 2 2 PER 2 YEARS SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L3980 UPPER EXTREMITY FRACTURE ORTHOSIS, 121.25 2 2 PER MEDICAL HUMERAL, PREFABRICATED, INCLUDES FITTING EVENT AND ADJUSTMENT L3982 UPPER EXTREMITY FRACTURE ORTHOSIS, 218.25 2 2 PER MEDICAL RADIUS/ULNAR, PREFABRICATED, INCLUDES EVENT FITTING AND ADJUSTMENT L3984 UPPER EXTREMITY FRACTURE ORTHOSIS, WRIST, 244.44 2 2 PER MEDICAL PREFABRICATED, INCLUDES FITTING AND EVENT ADJUSTMENT L3985 UPPER EXTREMITY FRACTURE ORTHOSIS, 288.09 2 2 PER MEDICAL FOREARM, HAND WITH WRIST HINGE, EVENT CUSTOM-FABRICATED L3986 UPPER EXTREMITY FRACTURE ORTHOSIS, 218.25 2 2 PER MEDICAL COMBINATION OF HUMERAL, RADIUS/ULNAR, EVENT WRIST, (EXAMPLE--COLLES' FRACTURE), CUSTOM FABRICATED L3995 ADDITION TO UPPER EXTREMITY ORTHOSIS, 11.64 2 6 PER MEDICAL SOCK, FRACTURE OR EQUAL, EACH EVENT L3999 UPPER LIMB ORTHOSIS, NOT OTHERWISE 0.00 2 BR MEDICAL March 2003 B - 42
  • 132. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS SPECIFIED NECESSITY L4000 REPLACE GIRDLE FOR SPINAL ORTHOSIS (CTLSO 630.50 2 2 PER 2 YEARS OR SO) L4010 REPLACE TRILATERAL SOCKET BRIM 174.60 2 2 PER LIFETIME L4020 REPLACE QUADRILATERAL SOCKET BRIM, 334.65 2 2 PER YEAR MOLDED TO PATIENT MODEL L4030 REPLACE QUADRILATERAL SOCKET BRIM, 174.60 2 2 PER YEAR CUSTOM FITTED L4040 REPLACE MOLDED THIGH LACER 176.54 2 2 PER YEAR L4045 REPLACE NON-MOLDED THIGH LACER 177.03 2 2 PER YEAR L4050 REPLACE MOLDED CALF LACER 160.05 2 2 PER YEAR L4055 REPLACE NON-MOLDED CALF LACER 154.72 2 2 PER YEAR L4060 REPLACE HIGH ROLL CUFF 205.64 2 2 PER YEAR L4070 REPLACE PROXIMAL AND DISTAL UPRIGHT FOR 87.30 4 4 PER YEAR KAFO L4080 REPLACE METAL BANDS KAFO, PROXIMAL 46.01 2 2 PER YEAR THIGH L4090 REPLACE METAL BANDS KAFO-AFO, CALF OR 41.19 2 2 PER YEAR DISTAL THIGH L4100 REPLACE LEATHER CUFF KAFO, PROXIMAL 36.86 2 2 PER YEAR THIGH L4110 REPLACE LEATHER CUFF KAFO-AFO, CALF OR 32.98 2 2 PER YEAR DISTAL THIGH L4130 REPLACE PRETIBIAL SHELL 290.03 2 2 PER YEAR L4205 REPAIR OF ORTHOTIC DEVICE, LABOR 10.00 16 $160.00 PER YEAR COMPONENT, PER 15 MINUTES L4210 REPAIR OF ORTHOTIC DEVICE, REPAIR OR 0.00 1 BR LIMITED TO $160 REPLACE MINOR PARTS PER YEAR L4350 PNEUMATIC ANKLE CONTROL SPLINT, 60.14 2 2 PER MEDICAL PREFABRICATED, INCLUDES FITTING AND EVENT ADJUSTMENT L4360 PNEUMATIC ANKLE FOOT ORTHOSIS, WITH OR 160.05 2 2 PER MEDICAL WITHOUT JOINTS, PREFABRICATED, INCLUDES EVENT FITTING AND ADJUSTMENT L4370 PNEUMATIC FULL LEG SPLINT, PREFABRICATED, 72.75 2 2 PER MEDICAL INCLUDES FITTING AND ADJUSTMENT EVENT L4380 PNEUMATIC KNEE SPLINT, PREFABRICATED, 63.05 2 2 PER MEDICAL INCLUDES FITTING AND ADJUSTMENT EVENT L4392 REPLACEMENT, SOFT INTERFACE MATERIAL, 13.95 1 2 PER YEAR STATIC AFO L4394 REPLACE SOFT INTERFACE MATERIAL, FOOT 10.20 1 2 PER YEAR DROP SPLINT L4396 STATIC ANKLE FOOT ORTHOSIS, INCLUDING 99.60 2 2 PER YEAR SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR POSITIONING, PRESSURE REDUCTION, MAY BE USED FOR MINIMAL AMBULATION, PREFABRICATED, INCLUDES FITTING AND March 2003 B - 43
  • 133. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS ADJUSTMENT L4398 FOOT DROP SPLINT, RECUMBENT POSITIONING 45.80 2 2 PER 2 YEARS DEVICE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT L5000 PARTIAL FOOT, SHOE INSERT WITH 129.98 2 2 PER 2 YEARS LONGITUDINAL ARCH, TOE FILLER L5010 PARTIAL FOOT, MOLDED SOCKET, ANKLE 527.20 2 2 PER 2 YEARS HEIGHT, WITH TOE FILLER L5020 PARTIAL FOOT, MOLDED SOCKET, TIBIAL 527.20 2 2 PER 2 YEARS TUBERCLE HEIGHT, WITH TOE FILLER L5050 ANKLE, SYMES, MOLDED SOCKET, SACH FOOT 1,387.59 2 2 PER 2 YEARS L5060 ANKLE, SYMES, METAL FRAME, MOLDED 1,251.30 2 2 PER 2 YEARS LEATHER SOCKET, ARTICULATED ANKLE/FOOT L5100 BELOW KNEE, MOLDED SOCKET, SHIN, SACH 1,377.40 2 2 PER YEAR FOOT L5105 BELOW KNEE, PLASTIC SOCKET, JOINTS AND 1,719.81 2 2 PER YEAR THIGH LACER, SACH FOOT L5150 KNEE DISARTICULATION (OR THROUGH KNEE), 1,940.00 2 2 PER YEAR MOLDED SOCKET, EXTERNAL KNEE JOINTS, SHIN, SACH FOOT L5160 KNEE DISARTICULATION (OR THROUGH KNEE), 2,037.00 2 2 PER YEAR MOLDED SOCKET, BENT KNEE CONFIGURATION, EXTERNAL KNEE JOINTS, SHIN, SACH FOOT L5200 ABOVE KNEE, MOLDED SOCKET, SINGLE AXIS 1,713.02 2 2 PER YEAR CONSTANT FRICTION KNEE, SHIN, SACH FOOT L5210 ABOVE KNEE, SHORT PROSTHESIS, NO KNEE 1,261.00 2 2 PER YEAR JOINT ('STUBBIES'), WITH FOOT BLOCKS, NO ANKLE JOINTS, EACH L5220 ABOVE KNEE, SHORT PROSTHESIS, NO KNEE 1,261.00 2 2 PER YEAR JOINT ('STUBBIES'), WITH ARTICULATED ANKLE/FOOT, DYNAMICALLY ALIGNED, EACH L5230 ABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL 1,746.00 2 2 PER YEAR DEFICIENCY, CONSTANT FRICTION KNEE, SHIN, SACH FOOT L5250 HIP DISARTICULATION, CANADIAN TYPE; 2,840.16 2 2 PER YEAR MOLDED SOCKET, HIP JOINT, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT L5280 HEMIPELVECTOMY, CANADIAN TYPE; MOLDED 3,007.00 2 2 PER YEAR SOCKET, HIP JOINT, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT L5301 BELOW KNEE, MOLDED SOCKET, SHIN, SACH 1,457.05 2 2 PER 2 YEARS FOOT, ENDOSKELETAL SYSTEM L5311 KNEE DISARTICULATION (OR THROUGH KNEE), 2,498.69 2 2 PER 2 YEARS MOLDED SOCKET, EXTERNAL KNEE JOINTS, SHIN, SACH FOOT, ENDOSKELETAL SYSTEM L5321 ABOVE KNEE, MOLDED SOCKET, OPEN END, 2,530.27 2 2 PER 2 YEARS SACH FOOT, ENDOSKELETAL SYSTEM, SINGLE March 2003 B - 44
  • 134. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS AXIS KNEE L5331 HIP DISARTICULATION, CANADIAN TYPE, 3,224.08 2 2 PER 2 YEARS MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT, SINGLE AXIS KNEE, SACH FOOT L5341 HEMIPELVECTOMY, CANADIAN TYPE, MOLDED 3,356.28 2 2 PER 2 YEARS SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT, SINGLE AXIS KNEE, SACH FOOT L5400 IMMEDIATE POST SURGICAL OR EARLY FITTING, 679.00 2 1 PER APPLICATION OF INITIAL RIGID DRESSING, AMPUTATION INCLUDING FITTING, ALIGNMENT, SUSPENSION, AND ONE CAST CHANGE, BELOW KNEE L5410 IMMEDIATE POST SURGICAL OR EARLY FITTING, 203.70 2 1 PER APPLICATION OF INITIAL RIGID DRESSING, AMPUTATION INCLUDING FITTING, ALIGNMENT AND SUSPENSION, BELOW KNEE, EACH ADDITIONAL CAST CHANGE AND REALIGNMENT L5420 IMMEDIATE POST SURGICAL OR EARLY FITTING, 732.35 2 1 PER APPLICATION OF INITIAL RIGID DRESSING, AMPUTATION INCLUDING FITTING, ALIGNMENT AND SUSPENSION AND ONE CAST CHANGE 'AK' OR KNEE DISARTICULATION L5430 IMMEDIATE POST SURGICAL OR EARLY FITTING, 203.70 1 1 PER APPLICATION OF INITIAL RIGID DRESSING, INCL. AMPUTATION FITTING, ALIGNMENT AND SUPENSION, 'AK' OR KNEE DISARTICULATION, EACH ADDITIONAL CAST CHANGE AND REALIGNMENT L5450 IMMEDIATE POST SURGICAL OR EARLY FITTING, 227.95 2 1 PER APPLICATION OF NON-WEIGHT BEARING RIGID AMPUTATION DRESSING, BELOW KNEE L5460 IMMEDIATE POST SURGICAL OR EARLY FITTING, 378.30 2 1 PER APPLICATION OF NON-WEIGHT BEARING RIGID AMPUTATION DRESSING, ABOVE KNEE L5530 PREPARATORY, BELOW KNEE 'PTB' TYPE 877.85 2 1 PER SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO AMPUTATION COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO MODEL L5535 PREPARATORY, BELOW KNEE 'PTB' TYPE 727.50 2 1 PER SOCKET, NON-ALIGNABLE SYSTEM, NO COVER, AMPUTATION SACH FOOT, PREFABRICATED, ADJUSTABLE OPEN END SOCKET L5540 PREPARATORY, BELOW KNEE 'PTB' TYPE 877.85 2 1 PER SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO AMPUTATION COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL L5560 PREPARATORY, ABOVE KNEE- KNEE 873.00 2 2 PER DISARTICULATION, ISCHIAL LEVEL SOCKET, AMPUTATION NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, MOLDED TO March 2003 B - 45
  • 135. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS MODEL L5580 PREPARATORY, ABOVE KNEE - KNEE 945.75 2 1 PER DISARTICULATION ISCHIAL LEVEL SOCKET, AMPUTATION NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO MODEL L5585 PREPARATORY, ABOVE KNEE - KNEE 803.16 2 1 PER DISARTICULATION, ISCHIAL LEVEL SOCKET, AMPUTATION NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PREFABRICATED ADJUSTABLE OPEN END SOCKET L5590 PREPARATORY, ABOVE KNEE - KNEE 1,067.97 2 1 PER DISARTICULATION ISCHIAL LEVEL SOCKET, AMPUTATION NON-ALIGNABLE SYSTEM, PYLON NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL L5595 PREPARATORY, HIP 2,075.80 2 1 PER DISARTICULATION-HEMIPELVECTOMY, PYLON, AMPUTATION NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO PATIENT MODEL L5600 PREPARATORY, HIP 2,308.60 2 1 PER DISARTICULATION-HEMIPELVECTOMY, PYLON, AMPUTATION NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO PATIENT MODEL L5610 ADDITION TO LOWER EXTREMITY, 920.53 2 2 PER 4 YEARS ENDOSKELETAL SYSTEM, ABOVE KNEE, HYDRACADENCE SYSTEM L5611 ADDITION TO LOWER EXTREMITY, 921.50 2 2 PER 4 YEARS ENDOSKELETAL SYSTEM, ABOVE KNEE - KNEE DISARTICULATION, 4 BAR LINKAGE, WITH FRICTION SWING PHASE CONTROL L5613 ADDITION TO LOWER EXTREMITY, 1,697.50 2 2 PER 4 YEARS ENDOSKELETAL SYSTEM, ABOVE KNEE-KNEE DISARTICULATION, 4 BAR LINKAGE, WITH HYDRAULIC SWING PHASE CONTROL L5616 ADDITION TO LOWER EXTREMITY, 485.00 2 2 PER 4 YEARS ENDOSKELETAL SYSTEM, ABOVE KNEE, UNIVERSAL MULTIPLEX SYSTEM, FRICTION SWING PHASE CONTROL L5617 ADDITION TO LOWER EXTREMITY, QUICK 323.00 2 2 PER 3 YEARS CHANGE SELF-ALIGNING UNIT, ABOVE KNEE OR BELOW KNEE, EACH L5618 ADDITION TO LOWER EXTREMITY, TEST SOCKET, 169.75 2 2 PER 2 YEARS SYMES L5620 ADDITION TO LOWER EXTREMITY, TEST SOCKET, 145.50 2 2 PER 2 YEARS BELOW KNEE L5622 ADDITION TO LOWER EXTREMITY, TEST SOCKET, 169.75 2 2 PER 2 YEARS KNEE DISARTICULATION March 2003 B - 46
  • 136. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L5624 ADDITION TO LOWER EXTREMITY, TEST SOCKET, 162.96 2 2 PER 2 YEARS ABOVE KNEE L5626 ADDITION TO LOWER EXTREMITY, TEST SOCKET, 169.75 2 2 PER 2 YEARS HIP DISARTICULATION L5628 ADDITION TO LOWER EXTREMITY, TEST SOCKET, 169.75 2 2 PER 2 YEARS HEMIPELVECTOMY L5629 ADDITION TO LOWER EXTREMITY, BELOW KNEE, 121.25 2 1 PER PROSTHESIS ACRYLIC SOCKET L5630 ADDITION TO LOWER EXTREMITY, SYMES TYPE, 242.50 2 2 PER 4 YEARS EXPANDABLE WALL SOCKET L5631 ADDITION TO LOWER EXTREMITY, ABOVE KNEE 194.00 2 2 PER 4 YEARS OR KNEE DISARTICULATION, ACRYLIC SOCKET L5632 ADDITION TO LOWER EXTREMITY, SYMES TYPE, 119.83 2 2 PER 4 YEARS 'PTB' BRIM DESIGN SOCKET L5634 ADDITION TO LOWER EXTREMITY, SYMES TYPE, 72.75 2 2 PER 4 YEARS POSTERIOR OPENING (CANADIAN) SOCKET L5636 ADDITION TO LOWER EXTREMITY, SYMES TYPE, 118.77 2 2 PER 4 YEARS MEDIAL OPENING SOCKET L5637 ADDITION TO LOWER EXTREMITY, BELOW KNEE, 121.25 2 2 PER 4 YEARS TOTAL CONTACT L5638 ADDITION TO LOWER EXTREMITY, BELOW 169.75 2 2 PER 4 YEARS KNEE, LEATHER SOCKET L5639 ADDITION TO LOWER EXTREMITY, BELOW KNEE, 563.28 2 1 PER PROSTHESIS WOOD SOCKET L5640 ADDITION TO LOWER EXTREMITY, KNEE 371.51 2 2 PER 4 YEARS DISARTICULATION, LEATHER SOCKET L5642 ADDITION TO LOWER EXTREMITY, ABOVE 371.51 2 2 PER 4 YEARS KNEE, LEATHER SOCKET L5643 ADDITION TO LOWER EXTREMITY, HIP 399.16 2 2 PER 4 YEARS DISARTICULATION, FLEXIBLE INNER SOCKET, EXTERNAL FRAME L5644 ADDITION TO LOWER EXTREMITY, ABOVE 97.00 2 2 PER 4 YEARS KNEE, WOOD SOCKET L5645 ADDITION TO LOWER EXTREMITY, BELOW 132.89 2 2 PER 4 YEARS KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAME L5646 ADDITION TO LOWER EXTREMITY, BELOW 211.46 2 2 PER 4 YEARS KNEE, AIR CUSHION SOCKET L5647 ADDITION TO LOWER EXTREMITY, BELOW KNEE 266.27 2 2 PER 4 YEARS SUCTION SOCKET L5648 ADDITION TO LOWER EXTREMITY, ABOVE 211.46 2 2 PER 2 YEARS KNEE, AIR CUSHION SOCKET L5649 ADDITION TO LOWER EXTREMITY, ISCHIAL 1,331.33 2 2 PER 2 YEARS CONTAINMENT/NARROW M-L SOCKET L5650 ADDITIONS TO LOWER EXTREMITY, TOTAL 97.00 2 2 PER 4 YEARS CONTACT, ABOVE KNEE OR KNEE DISARTICULATION SOCKET March 2003 B - 47
  • 137. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L5651 ADDITION TO LOWER EXTREMITY, ABOVE 443.29 2 2 PER 2 YEARS KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAME L5652 ADDITION TO LOWER EXTREMITY, SUCTION 218.25 2 2 PER 2 YEARS SUSPENSION, ABOVE KNEE OR KNEE DISARTICULATION SOCKET L5653 ADDITION TO LOWER EXTREMITY, KNEE 242.50 2 2 PER 4 YEARS DISARTICULATION, EXPANDABLE WALL SOCKET L5654 ADDITION TO LOWER EXTREMITY, SOCKET 203.70 2 2 PER YEAR INSERT, SYMES, (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) L5655 ADDITION TO LOWER EXTREMITY, SOCKET 162.96 2 2 PER YEAR INSERT, BELOW KNEE (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) L5656 ADDITION TO LOWER EXTREMITY, SOCKET 218.25 2 2 PER YEAR INSERT, KNEE DISARTICULATION (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) L5658 ADDITION TO LOWER EXTREMITY, SOCKET 218.25 2 2 PER YEAR INSERT, ABOVE KNEE (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) L5661 ADDITION TO LOWER EXTREMITY, SOCKET 221.16 2 2 PER YEAR INSERT, MULTI-DUROMETER SYMES L5665 ADDITION TO LOWER EXTREMITY, SOCKET 198.85 2 2 PER YEAR INSERT, MULTI-DUROMETER, BELOW KNEE L5666 ADDITION TO LOWER EXTREMITY, BELOW 29.10 2 2 PER YEAR KNEE, CUFF SUSPENSION L5668 ADDITION TO LOWER EXTREMITY, BELOW 77.60 2 2 PER YEAR KNEE, MOLDED DISTAL CUSHION L5670 ADDITION TO LOWER EXTREMITY, BELOW 106.70 2 2 PER 2 YEARS KNEE, MOLDED SUPRACONDYLAR SUSPENSION ('PTS' OR SIMILAR) L5671 ADDITION TO LOWER EXTREMITY, BELOW KNEE 0.00 2 2 PER 2 YEARS / ABOVE KNEE SUSPENSION LOCKING MECHANISM (SHUTTLE, LANYARD OR EQUAL), EXCLUDES SOCKET INSERT L5672 ADDITION TO LOWER EXTREMITY, BELOW 93.12 2 2 PER 4 YEARS KNEE, REMOVABLE MEDIAL BRIM SUSPENSION L5674 ADDITION TO LOWER EXTREMITY, BELOW KNEE, 33.95 2 6 PER YEAR SUSPENSION SLEEVE, ANY MATERIAL, EACH L5675 ADDITION TO LOWER EXTREMITY, BELOW 57.23 2 6 PER YEAR KNEE, SUSPENSION SLEEVE, HEAVY DUTY, ANY MATERIAL, EACH L5676 ADDITIONS TO LOWER EXTREMITY, BELOW 214.37 2 2 PER 4 YEARS KNEE, KNEE JOINTS, SINGLE AXIS, PAIR L5677 ADDITIONS TO LOWER EXTREMITY, BELOW 252.69 2 2 PER 4 YEARS KNEE, KNEE JOINTS, POLYCENTRIC, PAIR L5678 ADDITIONS TO LOWER EXTREMITY, BELOW 9.70 2 2 PER 2 YEARS KNEE, JOINT COVERS, PAIR March 2003 B - 48
  • 138. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L5680 ADDITION TO LOWER EXTREMITY, BELOW 184.30 2 2 PER 4 YEARS KNEE, THIGH LACER, NONMOLDED L5682 ADDITION TO LOWER EXTREMITY, BELOW 194.00 2 2 PER 4 YEARS KNEE, THIGH LACER, GLUTEAL/ISCHIAL, MOLDED L5684 ADDITION TO LOWER EXTREMITY, BELOW 14.55 2 2 PER 2 YEARS KNEE, FORK STRAP L5686 ADDITION TO LOWER EXTREMITY, BELOW 9.70 2 2 PER 2 YEARS KNEE, BACK CHECK (EXTENSION CONTROL) L5688 ADDITION TO LOWER EXTREMITY, BELOW 34.92 2 2 PER YEAR KNEE, WAIST BELT, WEBBING L5690 ADDITION TO LOWER EXTREMITY, BELOW 50.44 2 2 PER YEAR KNEE, WAIST BELT, PADDED AND LINED L5692 ADDITION TO LOWER EXTREMITY, ABOVE 43.65 2 2 PER YEAR KNEE, PELVIC CONTROL BELT, LIGHT L5694 ADDITION TO LOWER EXTREMITY, ABOVE 81.48 2 2 PER YEAR KNEE, PELVIC CONTROL BELT, PADDED AND LINED L5695 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, 89.73 2 4 PER YEAR PELVIC CONTROL, SLEEVE SUSPENSION, NEOPRENE OR EQUAL, EACH L5696 ADDITION TO LOWER EXTREMITY, ABOVE KNEE 92.15 2 2 PER 2 YEARS OR KNEE DISARTICULATION, PELVIC JOINT L5697 ADDITION TO LOWER EXTREMITY, ABOVE KNEE 48.50 2 1 PER 2 YEARS OR KNEE DISARTICULATION, PELVIC BAND L5698 ADDITION TO LOWER EXTREMITY, ABOVE KNEE 72.75 2 2 PER YEAR OR KNEE DISARTICULATION, SILESIAN BANDAGE L5699 ALL LOWER EXTREMITY PROSTHESES, 38.80 2 2 PER YEAR SHOULDER HARNESS L5700 REPLACEMENT, SOCKET, BELOW KNEE, MOLDED 1,701.79 2 2 PER 4 YEARS TO PATIENT MODEL L5701 REPLACEMENT, SOCKET, ABOVE KNEE/KNEE 2,043.73 2 2 PER 4 YEARS DISARTICULATION, INCLUDING ATTACHMENT PLATE, MOLDED TO PATIENT MODEL L5702 REPLACEMENT, SOCKET, HIP DISARTICULATION, 2,585.62 2 2 PER 4 YEARS INCLUDING HIP JOINT, MOLDED TO PATIENT MODEL L5704 CUSTOM SHAPED PROTECTIVE COVER, BELOW 318.36 2 2 PER 4 YEARS KNEE L5705 CUSTOM SHAPED PROTECTIVE COVER, ABOVE 568.86 2 2 PER 4 YEARS KNEE L5706 CUSTOM SHAPED PROTECTIVE COVER, KNEE 557.64 2 2 PER 4 YEARS DISARTICULATION L5707 CUSTOM SHAPED PROTECTIVE COVER, HIP 735.17 2 2 PER 4 YEARS DISARTICULATION L5710 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, 97.00 2 2 PER 4 YEARS March 2003 B - 49
  • 139. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS SINGLE AXIS, MANUAL LOCK L5711 ADDITIONS EXOSKELETAL KNEE-SHIN SYSTEM, 88.27 2 2 PER 4 YEARS SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHT MATERIAL L5712 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, 242.50 2 2 PER 4 YEARS SINGLE AXIS, FRICTION SWING AND STANCE PHASE CONTROL (SAFETY KNEE) L5714 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, 209.87 2 2 PER 4 YEARS SINGLE AXIS, VARIABLE FRICTION SWING PHASE CONTROL L5716 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, 242.50 2 2 PER 4 YEARS POLYCENTRIC, MECHANICAL STANCE PHASE LOCK L5718 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, 399.16 2 2 PER 4 YEARS POLYCENTRIC, FRICTION SWING AND STANCE PHASE CONTROL L5722 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, 492.76 2 2 PER 4 YEARS SINGLE AXIS, PNEUMATIC SWING, FRICTION STANCE PHASE CONTROL L5724 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, 650.87 2 2 PER 4 YEARS SINGLE AXIS, FLUID SWING PHASE CONTROL L5726 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, 643.11 2 2 PER 4 YEARS SINGLE AXIS, EXTERNAL JOINTS FLUID SWING PHASE CONTROL L5728 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, 1,070.88 2 2 PER 4 YEARS SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL L5780 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, 680.02 2 2 PER 4 YEARS SINGLE AXIS, PNEUMATIC/HYDRA PNEUMATIC SWING PHASE CONTROL L5785 ADDITION, EXOSKELETAL SYSTEM, BELOW 309.92 2 2 PER 4 YEARS KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) L5790 ADDITION, EXOSKELETAL SYSTEM, ABOVE 528.55 2 2 PER 4 YEARS KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) L5795 ADDITION, EXOSKELETAL SYSTEM, HIP 1,052.35 2 2 PER 4 YEARS DISARTICULATION, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) L5810 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 88.27 2 2 PER 4 YEARS SINGLE AXIS, MANUAL LOCK L5811 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 341.97 2 2 PER 4 YEARS SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHT MATERIAL L5812 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 315.25 2 2 PER 4 YEARS SINGLE AXIS, FRICTION SWING AND STANCE PHASE CONTROL (SAFETY KNEE) L5814 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 2,200.00 2 2 PER 2 YEARS March 2003 B - 50
  • 140. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS POLYCENTRIC, HYDRAULIC SWING PHASE CONTROL, MECHANICAL STANCE PHASE LOCK L5816 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 221.16 2 2 PER 4 YEARS POLYCENTRIC, MECHANICAL STANCE PHASE LOCK L5818 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 398.67 2 2 PER 4 YEARS POLYCENTRIC, FRICTION SWING, AND STANCE PHASE CONTROL L5822 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 451.05 2 2 PER 4 YEARS SINGLE AXIS, PNEUMATIC SWING, FRICTION STANCE PHASE CONTROL L5824 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 607.22 2 2 PER 4 YEARS SINGLE AXIS, FLUID SWING PHASE CONTROL L5828 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 1,065.06 2 2 PER 4 YEARS SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL L5830 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 785.70 2 2 PER 4 YEARS SINGLE AXIS, PNEUMATIC/ SWING PHASE CONTROL L5840 ADDITION, ENDOSKELETAL KNEE/SHIN SYSTEM, 2,083.91 2 2 PER 4 YEARS 4-BAR LINKAGE OR MULTIAXIAL, PNEUMATIC SWING PHASE CONTROL L5845 ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, 1,066.00 2 2 PER 3 YEARS STANCE FLEXION FEATURE, ADJUSTABLE L5846 ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, 3,255.87 2 2 PER 4 YEARS MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY L5847 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, 3,255.87 2 2 PER 2 YEARS MICROPROCESSOR CONTROL FEATURE, STANCE PHASE L5850 ADDITION, ENDOSKELETAL SYSTEM, ABOVE 43.65 2 2 PER 4 YEARS KNEE OR HIP DISARTICULATION, KNEE EXTENSION ASSIST L5855 ADDITION, ENDOSKELETAL SYSTEM, HIP 204.18 2 2 PER 4 YEARS DISARTICULATION, MECHANICAL HIP EXTENSION ASSIST L5910 ADDITION, ENDOSKELETAL SYSTEM, BELOW 88.27 2 2 PER 4 YEARS KNEE, ALIGNABLE SYSTEM L5920 ADDITION, ENDOSKELETAL SYSTEM, ABOVE 177.03 2 2 PER 4 YEARS KNEE OR HIP DISARTICULATION, ALIGNABLE SYSTEM L5940 ADDITION, ENDOSKELETAL SYSTEM, BELOW 340.47 2 2 PER 2 YEARS KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) L5950 ADDITION, ENDOSKELETAL SYSTEM, ABOVE 576.54 2 2 PER 2 YEARS KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) L5960 ADDITION, ENDOSKELETAL SYSTEM, HIP 1,196.98 2 2 PER 4 YEARS March 2003 B - 51
  • 141. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS DISARTICULATION, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) L5962 ADDITION, ENDOSKELETAL SYSTEM, BELOW 376.82 2 2 PER 4 YEARS KNEE, FLEXIBLE PROTECTIVE OUTER SURFACE COVERING SYSTEM L5964 ADDITION, ENDOSKELETAL SYSTEM, ABOVE 556.26 2 2 PER 4 YEARS KNEE, FLEXIBLE PROTECTIVE OUTER SURFACE COVERING SYSTEM L5966 ADDITION, ENDOSKELETAL SYSTEM, HIP 708.80 2 2 PER 4 YEARS DISARTICULATION, FLEXIBLE PROTECTIVE OUTER SURFACE COVERING SYSTEM L5968 ADDITION TO LOWER LIMB PROSTHESIS, 2,204.51 2 2 PER 4 YEARS MULTIAXIAL ANKLE WITH SWING PHASE ACTIVE DORSIFLEXION FEATURE L5970 ALL LOWER EXTREMITY PROSTHESES, FOOT, 48.50 2 2 PER 2 YEARS EXTERNAL KEEL, SACH FOOT L5972 ALL LOWER EXTREMITY PROSTHESES, FLEXIBLE 177.03 2 2 PER 2 YEARS KEEL FOOT (SAFE, STEN, BOCK DYNAMIC OR EQUAL) L5974 ALL LOWER EXTREMITY PROSTHESES, FOOT, 67.90 2 2 PER 2 YEARS SINGLE AXIS ANKLE/FOOT L5975 ALL LOWER EXTREMITY PROSTHESIS, 281.24 2 2 PER 4 YEARS COMBINATION SINGLE AXIS ANKLE AND FLEXIBLE KEEL FOOT L5976 ALL LOWER EXTREMITY PROSTHESES, ENERGY 291.00 2 2 PER 2 YEARS STORING FOOT (SEATTLE CARBON COPY II OR EQUAL) L5978 ALL LOWER EXTREMITY PROSTHESES, FOOT, 135.80 2 2 PER 2 YEARS MULTIAXIAL ANKLE/FOOT L5979 ALL LOWER EXTREMITY PROSTHESIS, 1,355.26 2 2 PER 2 YEARS MULTI-AXIAL ANKLE, DYNAMIC RESPONSE FOOT, ONE PIECE SYSTEM L5980 ALL LOWER EXTREMITY PROSTHESES, FLEX 2,202.21 2 2 PER 2 YEARS FOOT SYSTEM L5981 ALL LOWER EXTREMITY PROSTHESES, 1,779.08 2 2 PER 2 YEARS FLEX-WALK SYSTEM OR EQUAL L5982 ALL EXOSKELETAL LOWER EXTREMITY 204.67 2 2 PER 2 YEARS PROSTHESES, AXIAL ROTATION UNIT L5984 ALL ENDOSKELETAL LOWER EXTREMITY 243.47 2 2 PER 2 YEARS PROSTHESES, AXIAL ROTATION UNIT L5985 ALL ENDOSKELETAL LOWER EXTREMITY 163.00 2 2 PER 3 YEARS PROTHESES, DYNAMIC PROSTHETIC PYLON L5986 ALL LOWER EXTREMITY PROSTHESES, 203.70 2 2 PER 2 YEARS MULTI-AXIAL ROTATION UNIT ('MCP' OR EQUAL) L5987 ALL LOWER EXTREMITY PROSTHESIS, SHANK 4,275.00 2 2 PER 2 YEARS FOOT SYSTEM WITH VERTICAL LOADING PYLON L5988 ADDITION TO LOWER LIMB PROSTHESIS, 1,211.88 2 2 PER 4 YEARS March 2003 B - 52
  • 142. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS VERTICAL SHOCK REDUCING PYLON FEATURE L5989 ADDITION TO LOWER EXTREMITY PROSTHESIS, 1,779.08 2 2 PER 2 YEARS ENDOSKELETAL SYSTEM, PYLON WITH INTEGRATED ELECTRONIC FORCE SENSORS L5990 ADDITION TO LOWER EXTREMITY PROSTHESIS, 39.45 2 2 PER 2 YEARS USER ADJUSTABLE HEEL HEIGHT L5995 ADDITION TO LOWER EXTREMITY PROSTHESIS, 51.25 2 2 PER ORTHOTSIS HEAVY DUTY FEATURE (FOR PATIENT WEIGHT > 300 LBS) L5999 LOWER EXTREMITY PROSTHESIS, NOT 0.00 0 BR MEDICAL OTHERWISE SPECIFIED NECESSITY L6000 PARTIAL HAND, ROBIN-AIDS, THUMB 638.26 2 2 PER 4 YEARS REMAINING (OR EQUAL) L6010 PARTIAL HAND, ROBIN-AIDS, LITTLE AND/OR 638.26 2 2 PER 4 YEARS RING FINGER REMAINING (OR EQUAL) L6020 PARTIAL HAND, ROBIN-AIDS, NO FINGER 638.26 2 2 PER 2 YEARS REMAINING (OR EQUAL) L6050 WRIST DISARTICULATION, MOLDED SOCKET, 1,013.65 2 2 PER 2 YEARS FLEXIBLE ELBOW HINGES, TRICEPS PAD L6055 WRIST DISARTICULATION, MOLDED SOCKET 1,237.72 2 2 PER 4 YEARS WITH EXPANDABLE INTERFACE, FLEXIBLE ELBOW HINGES, TRICEPS PAD L6100 BELOW ELBOW, MOLDED SOCKET, FLEXIBLE 1,009.77 2 2 PER 2 YEARS ELBOW HINGE, TRICEPS PAD L6110 BELOW ELBOW, MOLDED SOCKET, (MUENSTER 1,057.30 2 2 PER 2 YEARS OR NORTHWESTERN SUSPENSION TYPES) L6120 BELOW ELBOW, MOLDED DOUBLE WALL SPLIT 1,231.90 2 2 PER 4 YEARS SOCKET, STEP-UP HINGES, HALF CUFF L6130 BELOW ELBOW, MOLDED DOUBLE WALL SPLIT 1,231.90 2 2 PER 4 YEARS SOCKET, STUMP ACTIVATED LOCKING HINGE, HALF CUFF L6200 ELBOW DISARTICULATION, MOLDED SOCKET, 1,421.05 2 2 PER 4 YEARS OUTSIDE LOCKING HINGE, FOREARM L6205 ELBOW DISARTICULATION, MOLDED SOCKET 1,641.24 2 2 PER 4 YEARS WITH EXPANDABLE INTERFACE, OUTSIDE LOCKING HINGES, FOREARM L6250 ABOVE ELBOW, MOLDED DOUBLE WALL 1,425.90 2 2 PER 2 YEARS SOCKET, INTERNAL LOCKING ELBOW, FOREARM L6300 SHOULDER DISARTICULATION, MOLDED 1,891.50 2 2 PER 2 YEARS SOCKET, SHOULDER BULKHEAD, HUMERAL SECTION, INTERNAL LOCKING ELBOW, FOREARM L6310 SHOULDER DISARTICULATION, PASSIVE 1,891.50 2 2 PER 4 YEARS RESTORATION (COMPLETE PROSTHESIS) L6320 SHOULDER DISARTICULATION, PASSIVE 630.50 2 2 PER 4 YEARS RESTORATION (SHOULDER CAP ONLY) L6350 INTERSCAPULAR THORACIC, MOLDED SOCKET, 1,891.50 2 2 PER 2 YEARS SHOULDER BULKHEAD, HUMERAL SECTION, March 2003 B - 53
  • 143. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS INTERNAL LOCKING ELBOW, FOREARM L6360 INTERSCAPULAR THORACIC, PASSIVE 2,085.50 2 2 PER 4 YEARS RESTORATION (COMPLETE PROSTHESIS) L6370 INTERSCAPULAR THORACIC, PASSIVE 630.50 2 2 PER 4 YEARS RESTORATION (SHOULDER CAP ONLY) L6380 IMMEDIATE POST SURGICAL OR EARLY FITTING, 725.48 1 1 PER ORTHOSIS APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE, WRIST DISARTICULATION OR BELOW ELBOW L6382 IMMEDIATE POST SURGICAL OR EARLY FITTING, 1,091.47 1 1 PER ORTHOSIS APPLICATION OF INITIAL RIGID DRESSING INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE, ELBOW DISARTICULATION OR ABOVE ELBOW L6384 IMMEDIATE POST SURGICAL OR EARLY FITTING, 1,509.92 1 1 PER ORTHOSIS APPLICATION OF INITIAL RIGID DRESSING INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC L6386 IMMEDIATE POST SURGICAL OR EARLY FITTING, 238.52 1 1 PER ORTHOSIS EACH ADDITIONAL CAST CHANGE AND REALIGNMENT L6388 IMMEDIATE POST SURGICAL OR EARLY FITTING, 261.12 2 1 PER ORTHOSIS APPLICATION OF RIGID DRESSING ONLY L6400 BELOW ELBOW, MOLDED SOCKET, 1,261.00 2 2 PER 4 YEARS ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING L6450 ELBOW DISARTICULATION, MOLDED SOCKET, 1,818.75 2 2 PER 4 YEARS ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING L6500 ABOVE ELBOW, MOLDED SOCKET, 1,818.75 2 2 PER 4 YEARS ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING L6550 SHOULDER DISARTICULATION, MOLDED 1,891.50 2 2 PER 4 YEARS SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING L6570 INTERSCAPULAR THORACIC, MOLDED SOCKET, 2,085.50 2 2 PER 4 YEARS ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING L6580 PREPARATORY, WRIST DISARTICULATION OR 992.50 2 2 PER 4 YEARS BELOW ELBOW, SINGLE WALL PLASTIC SOCKET, FRICTION WRIST, FLEXIBLE ELBOW HINGES, FIGURE OF EIGHT HARNESS, HUMERAL CUFF, BOWDEN CABLE CONTROL, USMC OR EQUAL March 2003 B - 54
  • 144. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS PYLON, NO COVER, MOLDED TO PATIENT MODEL L6582 PREPARATORY, WRIST DISARTICULATION OR 898.93 2 2 PER 4 YEARS BELOW ELBOW, SINGLE WALL SOCKET, FRICTION WRIST, FLEXIBLE ELBOW HINGES, FIGURE OF EIGHT HARNESS, HUMERAL CUFF, BOWDEN CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMED L6584 PREPARATORY, ELBOW DISARTICULATION OR 1,409.60 2 2 PER 4 YEARS ABOVE ELBOW, SINGLE WALL PLASTIC SOCKET, FRICTION WRIST, LOCKING ELBOW, FIGURE OF EIGHT HARNESS, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODEL L6586 PREPARATORY, ELBOW DISARTICULATION OR 1,319.30 2 2 PER 4 YEARS ABOVE ELBOW, SINGLE WALL SOCKET, FRICTION WRIST, LOCKING ELBOW, FIGURE OF EIGHT HARNESS, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMED L6588 PREPARATORY, SHOULDER DISARTICULATION 2,166.92 2 2 PER 4 YEARS OR INTERSCAPULAR THORACIC, SINGLE WALL PLASTIC SOCKET, SHOULDER JOINT, LOCKING ELBOW, FRICTION WRIST, CHEST STRAP, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODEL L6590 PREPARATORY, SHOULDER DISARTICULATION 1,646.61 2 2 PER 4 YEARS OR INTERSCAPULAR THORACIC, SINGLE WALL SOCKET, SHOULDER JOINT, LOCKING ELBOW, FRICTION WRIST, CHEST STRAP, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMED L6600 UPPER EXTREMITY ADDITIONS, POLYCENTRIC 53.35 2 2 PER 4 YEARS HINGE, PAIR L6605 UPPER EXTREMITY ADDITIONS, SINGLE PIVOT 53.35 2 2 PER 4 YEARS HINGE, PAIR L6610 UPPER EXTREMITY ADDITIONS, FLEXIBLE 53.35 2 2 PER 4 YEARS METAL HINGE, PAIR L6615 UPPER EXTREMITY ADDITION, DISCONNECT 128.04 2 2 PER 2 YEARS LOCKING WRIST UNIT L6616 UPPER EXTREMITY ADDITION, ADDITIONAL 43.65 2 6 PER 4 YEARS DISCONNECT INSERT FOR LOCKING WRIST UNIT, EACH L6620 UPPER EXTREMITY ADDITION, 163.93 2 2 PER 2 YEARS FLEXION-FRICTION WRIST UNIT L6625 UPPER EXTREMITY ADDITION, ROTATION WRIST 145.50 2 2 PER 4 YEARS UNIT WITH CABLE LOCK L6628 UPPER EXTREMITY ADDITION, QUICK 284.54 1 2 PER 4 YEARS DISCONNECT HOOK ADAPTER, OTTO BOCK OR March 2003 B - 55
  • 145. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS EQUAL L6629 UPPER EXTREMITY ADDITION, QUICK 86.90 1 2 PER 4 YEARS DISCONNECT LAMINATION COLLAR WITH COUPLING PIECE, OTTO BOCK OR EQUAL L6630 UPPER EXTREMITY ADDITION, STAINLESS 102.15 2 2 PER 2 YEARS STEEL, ANY WRIST L6632 UPPER EXTREMITY ADDITION, LATEX 30.56 2 12 PER YEAR SUSPENSION SLEEVE, EACH L6635 UPPER EXTREMITY ADDITION, LIFT ASSIST FOR 75.66 2 2 PER 2 YEARS ELBOW L6637 UPPER EXTREMITY ADDITION, NUDGE CONTROL 223.14 2 2 PER 4 YEARS ELBOW LOCK L6640 UPPER EXTREMITY ADDITIONS, SHOULDER 156.66 2 2 PER 4 YEARS ABDUCTION JOINT, PAIR L6641 UPPER EXTREMITY ADDITION, EXCURSION 52.87 2 2 PER 4 YEARS AMPLIFIER, PULLEY TYPE L6642 UPPER EXTREMITY ADDITION, EXCURSION 66.93 2 2 PER 4 YEARS AMPLIFIER, LEVER TYPE L6645 UPPER EXTREMITY ADDITION, SHOULDER 236.20 2 2 PER 4 YEARS FLEXION-ABDUCTION JOINT, EACH L6650 UPPER EXTREMITY ADDITION, SHOULDER 249.29 2 2 PER 4 YEARS UNIVERSAL JOINT, EACH L6655 UPPER EXTREMITY ADDITION, STANDARD 19.40 2 2 PER YEAR CONTROL CABLE, EXTRA L6660 UPPER EXTREMITY ADDITION, HEAVY DUTY 24.25 2 2 PER YEAR CONTROL CABLE L6665 UPPER EXTREMITY ADDITION, TEFLON, OR 21.15 2 2 PER YEAR EQUAL, CABLE LINING L6670 UPPER EXTREMITY ADDITION, HOOK TO HAND, 11.64 2 2 PER YEAR CABLE ADAPTER L6672 UPPER EXTREMITY ADDITION, HARNESS, CHEST 38.80 2 2 PER YEAR OR SHOULDER, SADDLE TYPE L6675 UPPER EXTREMITY ADDITION, HARNESS, 31.04 2 2 PER YEAR FIGURE OF ('8') EIGHT TYPE, FOR SINGLE CONTROL L6676 UPPER EXTREMITY ADDITION, HARNESS, 77.60 2 2 PER YEAR FIGURE OF ('8') EIGHT TYPE, FOR DUAL CONTROL L6680 UPPER EXTREMITY ADDITION, TEST SOCKET, 67.90 2 2 PER PROSTHESIS WRIST DISARTICULATION OR BELOW ELBOW L6682 UPPER EXTREMITY ADDITION, TEST SOCKET, 77.60 2 2 PER PROSTHESIS ELBOW DISARTICULATION OR ABOVE ELBOW L6684 UPPER EXTREMITY ADDITION, TEST SOCKET, 82.45 2 2 PER PROSTHESIS SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC L6686 UPPER EXTREMITY ADDITION, SUCTION SOCKET 309.92 2 2 PER 4 YEARS L6687 UPPER EXTREMITY ADDITION, FRAME TYPE 266.27 2 2 PER 4 YEARS SOCKET, BELOW ELBOW OR WRIST March 2003 B - 56
  • 146. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS DISARTICULATION L6688 UPPER EXTREMITY ADDITION, FRAME TYPE 266.27 2 2 PER 4 YEARS SOCKET, ABOVE ELBOW OR ELBOW DISARTICULATION L6689 UPPER EXTREMITY ADDITION, FRAME TYPE 398.67 2 2 PER 4 YEARS SOCKET, SHOULDER DISARTICULATION L6690 UPPER EXTREMITY ADDITION, FRAME TYPE 398.67 2 2 PER 4 YEARS SOCKET, INTERSCAPULAR-THORACIC L6691 UPPER EXTREMITY ADDITION, REMOVABLE 199.34 2 2 PER YEAR INSERT, EACH L6692 UPPER EXTREMITY ADDITION, SILICONE GEL 363.75 2 2 PER 2 YEARS INSERT OR EQUAL, EACH L6693 UPPER EXTREMITY ADDITION, LOCKING ELBOW, 1,722.26 2 2 PER 4 YEARS FOREARM COUNTERBALANCE L6700 TERMINAL DEVICE, HOOK, DORRANCE, OR 163.93 2 2 PER 4 YEARS EQUAL, MODEL #3 L6705 TERMINAL DEVICE, HOOK, DORRANCE, OR 144.53 2 2 PER 4 YEARS EQUAL, MODEL #5 L6710 TERMINAL DEVICE, HOOK, DORRANCE, OR 163.93 2 2 PER 4 YEARS EQUAL, MODEL #5X L6715 TERMINAL DEVICE, HOOK, DORRANCE, OR 156.17 2 2 PER 2 YEARS EQUAL, MODEL #5XA L6720 TERMINAL DEVICE, HOOK, DORRANCE, OR 361.81 2 2 PER 4 YEARS EQUAL, MODEL #6 L6725 TERMINAL DEVICE, HOOK, DORRANCE, OR 213.40 2 2 PER 4 YEARS EQUAL, MODEL #7 L6730 TERMINAL DEVICE, HOOK, DORRANCE, OR 218.25 2 2 PER 4 YEARS EQUAL, MODEL #7LO L6735 TERMINAL DEVICE, HOOK, DORRANCE, OR 144.53 2 2 PER 4 YEARS EQUAL, MODEL #8 L6740 TERMINAL DEVICE, HOOK, DORRANCE, OR 156.17 2 2 PER 4 YEARS EQUAL, MODEL #8X L6745 TERMINAL DEVICE, HOOK, DORRANCE, OR 156.17 2 2 PER 4 YEARS EQUAL, MODEL #88X L6750 TERMINAL DEVICE, HOOK, DORRANCE, OR 156.17 2 2 PER 4 YEARS EQUAL, MODEL #10P L6755 TERMINAL DEVICE, HOOK, DORRANCE, OR 156.17 2 2 PER 4 YEARS EQUAL, MODEL #10X L6765 TERMINAL DEVICE, HOOK, DORRANCE, OR 156.17 2 2 PER 4 YEARS EQUAL, MODEL #12P L6770 TERMINAL DEVICE, HOOK, DORRANCE, OR 156.17 2 2 PER 4 YEARS EQUAL, MODEL #99X L6775 TERMINAL DEVICE, HOOK, DORRANCE, OR 164.90 2 2 PER 4 YEARS EQUAL, MODEL #555 L6780 TERMINAL DEVICE, HOOK, DORRANCE, OR 179.45 2 2 PER 4 YEARS EQUAL, MODEL #SS555 L6790 TERMINAL DEVICE, HOOK-ACCU HOOK, OR 179.45 2 2 PER 4 YEARS March 2003 B - 57
  • 147. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS EQUAL L6795 TERMINAL DEVICE, HOOK-2 LOAD, OR EQUAL 640.20 2 2 PER 4 YEARS L6800 TERMINAL DEVICE, HOOK-APRL VC, OR EQUAL 508.28 2 2 PER 4 YEARS L6805 TERMINAL DEVICE, MODIFIER WRIST FLEXION 156.17 2 2 PER 4 YEARS UNIT L6807 TERMINAL DEVICE, HOOK, GRIP I, GRIP II, VC, OR 774.00 0 2 PER 2 YEARS EQUAL L6808 TERMINAL DEVICE, HOOK, TRS ADEPT, INFANT 661.00 0 2 PER 2 YEARS OR CHILD, VC, OR EQUAL L6810 TERMINAL DEVICE, PINCHER TOOL, OTTO BOCK 81.48 2 2 PER 4 YEARS OR EQUAL L6825 TERMINAL DEVICE, HAND, DORRANCE, VO 518.95 2 2 PER 4 YEARS L6830 TERMINAL DEVICE, HAND, APRL, VC 557.75 2 2 PER 4 YEARS L6835 TERMINAL DEVICE, HAND, SIERRA, VO 557.75 2 2 PER 4 YEARS L6840 TERMINAL DEVICE, HAND, BECKER IMPERIAL 468.51 2 2 PER 4 YEARS L6845 TERMINAL DEVICE, HAND, BECKER LOCK GRIP 421.95 2 2 PER 4 YEARS L6850 TERMINAL DEVICE, HAND, BECKER PLYLITE 194.00 2 2 PER 4 YEARS L6855 TERMINAL DEVICE, HAND, ROBIN-AIDS, VO 445.23 2 2 PER 4 YEARS L6860 TERMINAL DEVICE, HAND, ROBIN-AIDS, VO SOFT 360.84 2 2 PER 4 YEARS L6865 TERMINAL DEVICE, HAND, PASSIVE HAND 195.94 2 2 PER 4 YEARS L6867 TERMINAL DEVICE, HAND, DETROIT INFANT 467.83 2 2 PER YEAR HAND (MECHANICAL) L6868 TERMINAL DEVICE, HAND, PASSIVE INFANT 96.03 2 2 PER YEAR HAND, (STEEPER, HOSMER OR EQUAL) L6870 TERMINAL DEVICE, HAND, CHILD MITT 118.34 2 2 PER 4 YEARS L6872 TERMINAL DEVICE, HAND, NYU CHILD HAND 492.76 2 2 PER YEAR L6873 TERMINAL DEVICE, HAND, MECHANICAL INFANT 143.56 2 2 PER YEAR HAND, STEEPER OR EQUAL L6875 TERMINAL DEVICE, HAND, BOCK, VC 393.82 2 2 PER 4 YEARS L6880 TERMINAL DEVICE, HAND, BOCK, VO 217.28 2 2 PER 4 YEARS L6881 AUTOMATIC GRASP FEATURE, ADDITION TO 500.00 1 2 PER 2 YEARS UPPER LIMB PROSTHETIC TERMINAL DEVICE L6882 MICROPROCESSOR CONTROL FEATURE, 0.00 1 2 PER 2 YEARS ADDITION TO UPPER LIMB PROSTHETIC TERMINAL DEVICE L6890 TERMINAL DEVICE, GLOVE FOR ABOVE HANDS, 78.09 2 2 PER YEAR PRODUCTION GLOVE L6900 HAND RESTORATION (CASTS, SHADING AND 526.71 2 2 PER 4 YEARS MEASUREMENTS INCLUDED), PARTIAL HAND, WITH GLOVE, THUMB OR ONE FINGER REMAINING L6905 HAND RESTORATION (CASTS, SHADING AND 526.71 2 2 PER 4 YEARS MEASUREMENTS INCLUDED), PARTIAL HAND, WITH GLOVE, MULTIPLE FINGERS REMAINING L6910 HAND RESTORATION (CASTS, SHADING AND 526.71 2 2 PER 4 YEARS MEASUREMENTS INCLUDED), PARTIAL HAND, WITH GLOVE, NO FINGERS REMAINING March 2003 B - 58
  • 148. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L6915 HAND RESTORATION (SHADING, AND 276.45 2 2 PER 4 YEARS MEASUREMENTS INCLUDED), REPLACEMENT GLOVE FOR ABOVE L6920 WRIST DISARTICULATION, EXTERNAL POWER, 2,522.00 2 2 PER LIFETIME SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL, SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE L6925 WRIST DISARTICULATION, EXTERNAL POWER, 3,201.00 2 2 PER LIFETIME SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE L6930 BELOW ELBOW, EXTERNAL POWER, 2,522.00 2 2 PER LIFETIME SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE L6935 BELOW ELBOW, EXTERNAL POWER, 3,201.00 2 2 PER LIFETIME SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE L6940 ELBOW DISARTICULATION, EXTERNAL POWER, 3,622.95 2 2 PER LIFETIME MOLDED INNER SOCKET, REMOVABLE HUMERAL 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, 4,301.95 2 2 PER LIFETIME MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE L6950 ABOVE ELBOW, EXTERNAL POWER, MOLDED 4,186.52 2 2 PER LIFETIME INNER SOCKET, REMOVABLE HUMERAL SHELL, INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE L6955 ABOVE ELBOW, EXTERNAL POWER, MOLDED 4,865.52 2 2 PER LIFETIME INNER SOCKET, REMOVABLE HUMERAL SHELL, March 2003 B - 59
  • 149. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE L6960 SHOULDER DISARTICULATION, EXTERNAL 6,106.15 2 2 PER LIFETIME POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER 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, EXTERNAL 5,427.15 2 2 PER LIFETIME POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER 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, 6,106.15 2 2 PER LIFETIME MOLDED INNER SOCKET, REMOVABLE SHOULDER 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, 6,785.15 2 2 PER LIFETIME MOLDED INNER SOCKET, REMOVABLE SHOULDER 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 OR 1,275.55 2 2 PER LIFETIME EQUAL, SWITCH CONTROLLED L7015 ELECTRONIC HAND, SYSTEM TEKNIK, VARIETY 2,037.00 2 2 PER LIFETIME VILLAGE OR EQUAL, SWITCH CONTROLLED L7020 ELECTRONIC GREIFER, OTTO BOCK OR EQUAL, 1,134.90 2 2 PER LIFETIME SWITCH CONTROLLED L7025 ELECTRONIC HAND, OTTO BOCK OR EQUAL, 1,272.64 2 2 PER LIFETIME MYOELECTRONICALLY CONTROLLED L7030 ELECTRONIC HAND, SYSTEM TEKNIK, VARIETY 2,172.80 2 2 PER LIFETIME VILLAGE OR EQUAL, MYOELECTRONICALLY CONTROLLED L7035 ELECTRONIC GREIFER, OTTO BOCK OR EQUAL, 1,338.60 2 2 PER LIFETIME MYOELECTRONICALLY CONTROLLED L7040 PREHENSILE ACTUATOR, HOSMER OR EQUAL, 985.52 2 2 PER LIFETIME SWITCH CONTROLLED March 2003 B - 60
  • 150. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L7045 ELECTRONIC HOOK, CHILD, MICHIGAN OR 467.54 2 2 PER LIFETIME EQUAL, SWITCH CONTROLLED L7170 ELECTRONIC ELBOW, HOSMER OR EQUAL, 3,415.37 2 2 PER LIFETIME SWITCH CONTROLLED L7185 ELECTRONIC ELBOW, ADOLESCENT, VARIETY 3,415.37 2 2 PER LIFETIME VILLAGE OR EQUAL, SWITCH CONTROLLED L7186 ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE 6,294.33 2 2 PER LIFETIME OR EQUAL, SWITCH CONTROLLED L7260 ELECTRONIC WRIST ROTATOR, OTTO BOCK OR 488.88 2 2 PER LIFETIME EQUAL L7261 ELECTRONIC WRIST ROTATOR, FOR UTAH ARM 594.61 2 2 PER LIFETIME L7266 SERVO CONTROL, STEEPER OR EQUAL 788.61 2 2 PER LIFETIME L7272 ANALOGUE CONTROL, UNB OR EQUAL 788.61 2 2 PER LIFETIME L7274 PROPORTIONAL CONTROL, 6-12 VOLT, LIBERTY, 2,145.64 2 2 PER LIFETIME UTAH OR EQUAL L7360 SIX VOLT BATTERY, OTTO BOCK OR EQUAL, 79.54 2 2 PER 3 YEARS EACH L7362 BATTERY CHARGER, SIX VOLT, OTTO BOCK OR 79.54 2 1 PER LIFETIME EQUAL L7364 TWELVE VOLT BATTERY, UTAH OR EQUAL, 121.25 2 2 PER 3 YEARS EACH L7366 BATTERY CHARGER, TWELVE VOLT, UTAH OR 249.29 1 1 PER 3 YEARS EQUAL L7499 UPPER EXTREMITY PROSTHESIS, NOT 0.00 2 BR MEDICAL OTHERWISE SPECIFIED NECESSITY L7500 REPAIR OF PROSTHETIC DEVICE, HOURLY RATE 38.80 4 LIMITED TO $160 (EXCLUDES V5335 REPAIR OF ORAL OR PER YEAR LARYNGEAL PROSTHESIS OR ARTIFICIAL LARYNX) L7510 REPAIR OF PROSTHETIC DEVICE, REPAIR OR 0.00 0 BR LIMITED TO $160 REPLACE MINOR PARTS PER YEAR L7520 REPAIR PROSTHETIC DEVICE, LABOR 0.00 0 BR COMPONENT, PER 15 MINUTES L8000 BREAST PROSTHESIS, MASTECTOMY BRA 26.13 3 3 PER YEAR L8001 BREAST PROSTHESIS, MASTECTOMY BRA, WITH 125.00 2 2 PER 2 YEARS INTEGRATED BREAST PROSTHESIS FORM, UNILATERAL L8002 BREAST PROSTHESIS, MASTECTOMY BRA, WITH 165.00 1 2 PER 2 YEARS INTEGRATED BREAST PROSTHESIS FORM, BILATERAL L8010 BREAST PROSTHESIS, MASTECTOMY SLEEVE 37.15 6 6 PER YEAR L8015 EXTERNAL BREAST PROSTHESIS GARMENT, 34.42 2 2 PER 4 YEARS WITH MASTECTOMY FORM, POST MASTECTOMY L8020 BREAST PROSTHESIS, MASTECTOMY FORM 135.42 2 2 PER YEAR L8030 BREAST PROSTHESIS, SILICONE OR EQUAL 146.47 2 2 PER 2 YEARS L8100 GRADIENT COMPRESSION STOCKING, BELOW 31.04 2 8 PER YEAR KNEE, 18-30 MMHG, EACH March 2003 B - 61
  • 151. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L8110 GRADIENT COMPRESSION STOCKING, BELOW 31.04 2 8 PER YEAR KNEE, 30-40 MMHG, EACH L8120 GRADIENT COMPRESSION STOCKING, BELOW 31.04 2 8 PER YEAR KNEE, 40-50 MMHG, EACH L8130 GRADIENT COMPRESSION STOCKING, THIGH 40.74 2 8 PER YEAR LENGTH, 18-30 MMHG, EACH L8140 GRADIENT COMPRESSION STOCKING, THIGH 40.74 2 8 PER YEAR LENGTH, 30-40 MMHG, EACH L8150 GRADIENT COMPRESSION STOCKING, THIGH 40.74 2 8 PER YEAR LENGTH, 40-50 MMHG, EACH L8160 GRADIENT COMPRESSION STOCKING, FULL 111.55 2 8 PER YEAR LENGTH/CHAP STYLE, 18-30 MMHG, EACH L8170 GRADIENT COMPRESSION STOCKING, FULL 111.55 2 8 PER YEAR LENGTH/CHAP STYLE, 30-40 MMHG, EACH L8180 GRADIENT COMPRESSION STOCKING, FULL 111.55 2 8 PER YEAR LENGTH/CHAP STYLE, 40-50 MMHG, EACH L8190 GRADIENT COMPRESSION STOCKING, WAIST 111.55 2 8 PER YEAR LENGTH, 18-30 MMHG, EACH L8195 GRADIENT COMPRESSION STOCKING, WAIST 111.55 2 8 PER YEAR LENGTH, 30-40 MMHG, EACH L8200 GRADIENT COMPRESSION STOCKING, WAIST 111.55 2 8 PER YEAR LENGTH, 40-50 MMHG, EACH L8300 TRUSS, SINGLE WITH STANDARD PAD 63.05 1 2 PER YEAR L8310 TRUSS, DOUBLE WITH STANDARD PADS 169.75 1 2 PER YEAR L8400 PROSTHETIC SHEATH, BELOW KNEE, EACH 5.82 6 72 PER YEAR L8410 PROSTHETIC SHEATH, ABOVE KNEE, EACH 5.82 6 72 PER YEAR L8415 PROSTHETIC SHEATH, UPPER LIMB, EACH 8.73 6 72 PER YEAR L8417 PROSTHETIC SHEATH/SOCK, INCLUDING A GEL 44.50 2 6 PER YEAR CUSHION LAYER, BELOW KNEE OR ABOVE KNEE, EACH L8420 PROSTHETIC SOCK, MULTIPLE PLY, BELOW 12.61 6 72 PER YEAR KNEE, EACH L8430 PROSTHETIC SOCK, MULTIPLE PLY, ABOVE 13.58 6 72 PER YEAR KNEE, EACH L8435 PROSTHETIC SOCK, MULTIPLE PLY, UPPER LIMB, 12.61 6 72 PER YEAR EACH L8440 PROSTHETIC SHRINKER, BELOW KNEE, EACH 29.10 2 4 PER YEAR L8460 PROSTHETIC SHRINKER, ABOVE KNEE, EACH 43.17 2 4 PER YEAR L8465 PROSTHETIC SHRINKER, UPPER LIMB, EACH 35.41 2 4 PER YEAR L8470 PROSTHETIC SOCK, SINGLE PLY, FITTING, BELOW 1.94 6 72 PER YEAR KNEE, EACH L8480 PROSTHETIC SOCK, SINGLE PLY, FITTING, ABOVE 2.43 6 72 PER YEAR KNEE, EACH L8485 PROSTHETIC SOCK, SINGLE PLY, FITTING, UPPER 6.60 2 72 PER YEAR LIMB, EACH L8490 ADDITION TO PROSTHETIC SHEATH/SOCK, AIR 78.92 2 6 PER YEAR SEAL SUCTION RETENTION SYSTEM March 2003 B - 62
  • 152. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS L8499 UNLISTED PROCEDURE FOR MISCELLANEOUS 0.00 0 BR MEDICAL PROSTHETIC SERVICES NECESSITY L8500 ARTIFICIAL LARYNX, ANY TYPE 392.00 1 1 PER LIFETIME L8501 TRACHEOSTOMY SPEAKING VALVE 116.40 1 6 PER YEAR L8507 TRACHEO-ESOPHAGEAL VOICE PROSTHESIS, 116.40 1 1 PER 5 YEARS PATIENT INSERTED, ANY TYPE, EACH March 2003 B - 63
  • 153. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS V2623 PROSTHETIC EYE, PLASTIC, CUSTOM 567.45 2 MEDICAL NECESSITY V2624 POLISHING/RESURFACING OF OCULAR 38.80 2 1 PER YEAR PROSTHESIS V2625 ENLARGEMENT OF OCULAR PROSTHESIS 242.50 2 1 PER PROSTHESIS V2626 REDUCTION OF OCULAR PROSTHESIS 155.20 2 1 PER PROSTHESIS V2627 SCLERAL COVER SHELL 902.10 2 MEDICAL NECESSITY V2628 FABRICATION AND FITTING OF OCULAR 208.55 2 MEDICAL CONFORMER NECESSITY V5336 REPAIR/MODIFICATION OF AUGMENTATIVE 0.00 1 PA MEDICAL COMMUNICATIVE SYSTEM OR DEVICE NECESSITY (EXCLUDES ADAPTIVE HEARING AID) March 2003 B - 64
  • 154. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX B FOR ALL MEDICAID RECIPIENTS B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS W4097 EXTENSION TUBING FOR CONNECTING 3.88 31 366 PER YEAR APPLIANC W4098 ADAPTER OR CONNECTOR FOR TUBING 2.43 31 366 PER YEAR W9763 RESUSCITATOR BAG, SELF-INFLATING: HAND 112.52 1 1 PER 2 YEARS HELD; NON- DISPOSABLE PEDIATRIC OR W9765 NEBULIZER KIT FOR ADMINISTRATION OF 3.88 3 36 PER YEAR AEROSOLIZED MEDICATION, INCLUDES HAND W9766 SUCTION MACHINE W/VACUUM REGULATOR; 363.75 1 1 PER 2 YEARS BATTERY OPERATED; INCLUDES RECHARGABLE W9776 AUGMENTATIVE COMMUNICATION DEVICE, 0.00 1 PA MEDICAL RENTAL NECESSITY March 2003 B - 65
  • 155. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX C ONLY FOR RECIPIENTS UNDER AGE 21 B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS A4246 BETADINE OR PHISOHEX SOLUTION, PER PINT 4.85 3 36 PER YEAR A4247 BETADINE OR IODINE SWABS/WIPES, PER BOX 7.28 2 24 PER YEAR A4255 PLATFORMS FOR HOME BLOOD GLUCOSE 2.99 1 2 PER MONTH MONITOR, 50 PER BOX A4256 NORMAL, LOW AND HIGH CALIBRATOR 8.06 1 4 PER YEAR SOLUTION / CHIPS A4265 PARAFFIN, PER POUND 3.88 6 24 PER YEAR A4310 INSERTION TRAY WITHOUT DRAINAGE BAG AND 4.03 2 24 PER YEAR WITHOUT CATHETER (ACCESSORIES ONLY) A4314 INSERTION TRAY WITH DRAINAGE BAG WITH 10.67 2 24 PER YEAR INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.) A4315 INSERTION TRAY WITH DRAINAGE BAG WITH 10.67 2 24 PER YEAR INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE A4316 INSERTION TRAY WITH DRAINAGE BAG WITH 10.67 2 24 PER YEAR INDWELLING CATHETER, FOLEY TYPE, THREE-WAY, FOR CONTINUOUS IRRIGATION A4320 IRRIGATION TRAY WITH BULB OR PISTON 4.90 31 366 PER YEAR SYRINGE, ANY PURPOSE A4322 IRRIGATION SYRINGE, BULB OR PISTON, EACH 2.15 31 366 PER YEAR A4326 MALE EXTERNAL CATHETER SPECIALTY TYPE, 8.34 31 366 PER YEAR EG; INFLATABLE, FACEPLATE, ETC., EACH A4327 FEMALE EXTERNAL URINARY COLLECTION 16.10 1 1 PER YEAR DEVICE; MEATAL CUP, EACH A4328 FEMALE EXTERNAL URINARY COLLECTION 5.00 2 24 PER YEAR DEVICE; POUCH, EACH A4330 PERIANAL FECAL COLLECTION POUCH WITH 5.19 31 366 PER YEAR ADHESIVE, EACH A4335 INCONTINENCE SUPPLY; MISCELLANEOUS 19.40 1 12 PER YEAR A4338 INDWELLING CATHETER; FOLEY TYPE, 6.16 3 36 PER YEAR TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH A4340 INDWELLING CATHETER; SPECIALTY TYPE, EG; 6.69 3 36 PER YEAR COUDE, MUSHROOM, WING, ETC.), EACH A4344 INDWELLING CATHETER, FOLEY TYPE, 5.34 3 36 PER YEAR TWO-WAY, ALL SILICONE, EACH A4346 INDWELLING CATHETER; FOLEY TYPE, THREE 8.73 3 36 PER YEAR WAY FOR CONTINUOUS IRRIGATION, EACH A4354 INSERTION TRAY WITH DRAINAGE BAG BUT 3.88 3 36 PER YEAR WITHOUT CATHETER A4355 IRRIGATION TUBING SET FOR CONTINUOUS 2.52 4 48 PER YEAR BLADDER IRRIGATION THROUGH A THREE-WAY INDWELLING FOLEY CATHETER, EACH March 2003 C-1
  • 156. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX C ONLY FOR RECIPIENTS UNDER AGE 21 B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS A4356 EXTERNAL URETHRAL CLAMP OR COMPRESSION 34.92 1 1 PER YEAR DEVICE (NOT TO BE USED FOR CATHETER CLAMP), EACH A4359 URINARY SUSPENSORY WITHOUT LEG BAG, 7.76 1 2 PER YEAR EACH A4397 IRRIGATION SUPPLY; SLEEVE, EACH 3.94 10 120 PER YEAR A4398 OSTOMY IRRIGATION SUPPLY; BAG, EACH 23.28 2 24 PER YEAR A4399 OSTOMY IRRIGATION SUPPLY; CONE/CATHETER, 5.82 1 2 PER YEAR INCLUDING BRUSH A4402 LUBRICANT, PER OUNCE 1.35 4 48 PER YEAR A4404 OSTOMY RING, EACH 1.29 31 366 PER YEAR A4481 TRACHEOSTOMA FILTER, ANY TYPE, ANY SIZE, 0.28 31 31 PER MONTH EACH A4554 DISPOSABLE UNDERPADS, ALL SIZES, (E.G., 0.34 150 1800 PER YEAR CHUX'S) A4565 SLINGS 5.34 1 1 PER MEDICAL EVENT A4570 SPLINT 10.67 1 1 PER MEDICAL EVENT A4631 REPLACEMENT, BATTERIES FOR MEDICALLY 83.91 2 2 PER YEAR NECESSARY ELECTRONIC WHEEL CHAIR OWNED BY PATIENT A4640 REPLACEMENT PAD FOR USE WITH MEDICALLY 33.95 1 1 PER YEAR NECESSARY ALTERNATING PRESSURE PAD OWNED BY PATIENT A4649 SURGICAL SUPPLY; MISCELLANEOUS 0.00 1 BR MEDICAL NECESSITY A4927 GLOVES, NON-STERILE, PER 100 0.34 100 1000 PER YEAR A4930 GLOVES, STERILE, PER PAIR 0.34 100 1200 PER YEAR A4930 GLOVES, STERILE, PER PAIR 0.34 100 1200 PER YEAR A5102 BEDSIDE DRAINAGE BOTTLE WITH OR WITHOUT 6.69 1 2 PER YEAR TUBING, RIGID OR EXPANDABLE, EACH A5105 URINARY SUSPENSORY; WITH LEG BAG, WITH 14.40 1 2 PER YEAR OR WITHOUT TUBE A5113 LEG STRAP; LATEX, REPLACEMENT ONLY, PER 4.48 1 4 PER YEAR SET A5114 LEG STRAP; FOAM OR FABRIC, REPLACEMENT 5.53 1 4 PER YEAR ONLY, PER SET A5126 ADHESIVE OR NON-ADHESIVE; DISK OR FOAM 0.63 20 240 PER YEAR PAD A5200 PERCUTANEOUS CATHETER/TUBE ANCHORING 8.62 3 3 PER MONTH DEVICE, ADHESIVE SKIN ATTACHMENT A6154 WOUND POUCH, EACH 10.64 15 15 PER MONTH A6196 ALGINATE OR OTHER FIBER GELLING DRESSING, 5.61 31 31 PER MONTH 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 2003 C-2
  • 157. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX C ONLY FOR RECIPIENTS UNDER AGE 21 B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS WOUND COVER, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING A6199 ALGINATE OR OTHER FIBER GELLING DRESSING, 4.04 31 31 PER MONTH WOUND FILLER, PER 6 INCHES A6200 COMPOSITE DRESSING, PAD SIZE 16 SQ. IN. OR 7.25 31 31 PER MONTH LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING A6201 COMPOSITE DRESSING, PAD SIZE MORE THAN 16 15.87 31 31 PER MONTH SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING A6202 COMPOSITE DRESSING, PAD SIZE MORE THAN 48 26.62 31 31 PER MONTH SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING A6203 COMPOSITE DRESSING, PAD SIZE 16 SQ. IN. OR 2.56 31 31 PER MONTH LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6204 COMPOSITE DRESSING, PAD SIZE MORE THAN 16 4.76 31 31 PER MONTH SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6207 CONTACT LAYER, MORE THAN 16 SQ. IN. BUT 5.60 31 31 PER MONTH LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING A6209 FOAM DRESSING, WOUND COVER, PAD SIZE 16 5.72 31 31 PER MONTH SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING A6210 FOAM DRESSING, WOUND COVER, PAD SIZE 15.20 31 31 PER MONTH MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING A6211 FOAM DRESSING, WOUND COVER, PAD SIZE 22.40 31 31 PER MONTH MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING A6212 FOAM DRESSING, WOUND COVER, PAD SIZE 16 7.40 31 31 PER MONTH SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6214 FOAM DRESSING, WOUND COVER, PAD SIZE 7.86 31 31 PER MONTH MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6216 GAUZE, NON-IMPREGNATED, NON-STERILE, PAD 0.04 200 200 PER MONTH SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING A6219 GAUZE, NON-IMPREGNATED, PAD SIZE 16 SQ. IN. 0.73 62 62 PER MONTH OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6220 GAUZE, NON-IMPREGNATED, PAD SIZE MORE 1.97 62 62 PER MONTH THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 March 2003 C-3
  • 158. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX C ONLY FOR RECIPIENTS UNDER AGE 21 B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6222 GAUZE, IMPREGNATED WITH OTHER THAN 1.63 200 31 PER MONTH WATER, NORMAL SALINE, OR HYDROGEL, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING A6223 GAUZE, IMPREGNATED WITH OTHER THAN 1.84 200 31 PER MONTH WATER, NORMAL SALINE, OR HYDROGEL, PAD SIZE MORE THAN 16 SQUARE INCHES, BUT LESS THAN OR EQUAL TO 48 SQUARE INCHES, WITHOUT ADHESIVE BORDER, EACH DRESSING A6224 GAUZE, IMPREGNATED WITH OTHER THAN 2.76 31 31 PER MONTH WATER, NORMAL SALINE, OR HYDROGEL, PAD SIZE MORE THAN 48 SQUARE INCHES, WITHOUT ADHESIVE BORDER, EACH DRESSING A6229 GAUZE, IMPREGNATED, WATER OR NORMAL 2.75 31 31 PER MONTH SALINE, PAD SIZE MORE THAT 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING A6234 HYDROCOLLOID DRESSING, WOUND COVER, PAD 5.00 31 31 PER MONTH SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING A6235 HYDROCOLLOID DRESSING, WOUND COVER, PAD 12.84 31 31 PER MONTH SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING A6236 HYDROCOLLOID DRESSING, WOUND COVER, PAD 20.80 31 31 PER MONTH SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING A6237 HYDROCOLLOID DRESSING, WOUND COVER, PAD 6.04 31 31 PER MONTH SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6238 HYDROCOLLOID DRESSING, WOUND COVER, PAD 17.40 31 31 PER MONTH SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6240 HYDROCOLLOID DRESSING, WOUND FILLER, 9.35 31 31 PER MONTH PASTE, PER FLUID OUNCE A6241 HYDROCOLLOID DRESSING, WOUND FILLER, 1.96 31 31 PER MONTH DRY FORM, PER GRAM A6242 HYDROGEL DRESSING, WOUND COVER, PAD SIZE 4.63 31 31 PER MONTH 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING A6243 HYDROGEL DRESSING, WOUND COVER, PAD SIZE 9.40 31 31 PER MONTH MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING A6244 HYDROGEL DRESSING, WOUND COVER, PAD SIZE 29.95 31 31 PER MONTH March 2003 C-4
  • 159. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX C ONLY FOR RECIPIENTS UNDER AGE 21 B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING A6245 HYDROGEL DRESSING, WOUND COVER, PAD SIZE 5.55 31 31 PER MONTH 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6246 HYDROGEL DRESSING, WOUND COVER, PAD SIZE 7.55 31 31 PER MONTH MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6247 HYDROGEL DRESSING, WOUND COVER, PAD SIZE 18.15 31 31 PER MONTH MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6248 HYDROGEL DRESSING, WOUND FILLER, GEL, PER 12.40 15 15 PER MONTH FLUID OUNCE A6251 SPECIALTY ABSORPTIVE DRESSING, WOUND 1.52 31 31 PER MONTH COVER, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING A6252 SPECIALTY ABSORPTIVE DRESSING, WOUND 2.48 31 31 PER MONTH COVER, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING A6253 SPECIALTY ABSORPTIVE DRESSING, WOUND 4.84 10 31 PER MONTH COVER, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING A6254 SPECIALTY ABSORPTIVE DRESSING, WOUND 0.90 31 31 PER MONTH COVER, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6255 SPECIALTY ABSORPTIVE DRESSING, WOUND 2.32 31 31 PER MONTH COVER, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6258 TRANSPARENT FILM, MORE THAN 16 SQ. IN. BUT 3.28 31 31 PER MONTH LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING A6259 TRANSPARENT FILM, MORE THAN 48 SQ. IN., 8.35 31 31 PER MONTH EACH DRESSING A6266 GAUZE, IMPREGNATED, OTHER THAN WATER, 1.45 31 31 PER MONTH NORMAL SALINE, OR ZINC PASTE, ANY WIDTH, PER LINEAR YARD A6402 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE 0.10 200 200 PER MONTH 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING A6403 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE 0.33 200 200 PER MONTH MORE THAN 16 SQ. IN. LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING March 2003 C-5
  • 160. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX C ONLY FOR RECIPIENTS UNDER AGE 21 B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS B4034 ENTERAL FEEDING SUPPLY KIT; SYRINGE, PER 145.50 1 12 PER YEAR DAY B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED, PER 266.75 1 12 PER YEAR DAY B4036 ENTERAL FEEDING SUPPLY KIT; GRAVITY FED, 189.15 1 12 PER YEAR PER DAY B4081 NASOGASTRIC TUBING WITH STYLET 14.55 8 96 PER YEAR B4082 NASOGASTRIC TUBING WITHOUT STYLET 11.64 8 96 PER YEAR B4083 STOMACH TUBE - LEVINE TYPE 1.46 15 180 PER YEAR B4086 GASTROSTOMY / JEJUNOSTOMY TUBE, ANY 14.55 4 48 PER YEAR MATERIAL, ANY TYPE, (STANDARD OR LOW PROFILE), EACH B9000 ENTERAL NUTRITION INFUSION PUMP - 0.00 RO 82.45 1 MEDICAL WITHOUT ALARM NECESSITY B9002 ENTERAL NUTRITION INFUSION PUMP - WITH 0.00 RO 82.45 1 MEDICAL ALARM NECESSITY B9998 NOC FOR ENTERAL SUPPLIES 6.79 1 120 PER YEAR March 2003 C-6
  • 161. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX C ONLY FOR RECIPIENTS UNDER AGE 21 B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS E0110 CRUTCHES, FOREARM, INCLUDES CRUTCHES OF 38.80 1 1 PER 2 YEARS VARIOUS MATERIALS, ADJUSTABLE OR FIXED, PAIR, COMPLETE WITH TIPS AND HANDGRIPS E0111 CRUTCH FOREARM, INCLUDES CRUTCHES OF 19.40 1 1 PER 2 YEARS VARIOUS MATERIALS, ADJUSTABLE OR FIXED, EACH, WITH TIP AND HANDGRIPS E0130 WALKER, RIGID (PICKUP), ADJUSTABLE OR 53.35 1 1 PER 3 YEARS FIXED HEIGHT E0141 RIGID WALKER, WHEELED, WITHOUT SEAT 81.48 1 1 PER 3 YEARS E0142 RIGID WALKER, WHEELED, WITH SEAT 81.48 1 1 PER 3 YEARS E0145 WALKER, WHEELED, WITH SEAT AND CRUTCH 257.10 25.71 1 1 PER 3 YEARS ATTACHMENTS E0146 FOLDING WALKER, WHEELED, WITH SEAT 81.48 1 1 PER 3 YEARS E0147 HEAVY DUTY, MULTIPLE BREAKING SYSTEM, 439.93 1 1 PER 3 YEARS VARIABLE WHEEL RESISTANCE WALKER E0153 PLATFORM ATTACHMENT, FOREARM CRUTCH, 34.44 2 2 PER 3 YEARS EACH E0154 PLATFORM ATTACHMENT, WALKER, EACH 40.26 2 2 PER 3 YEARS E0155 WHEEL ATTACHMENT, RIGID PICK-UP WALKER, 27.71 1 1 PER 3 YEARS PER PAIR E0157 CRUTCH ATTACHMENT, WALKER, EACH 39.77 1 1 PER 3 YEARS E0158 LEG EXTENSIONS FOR WALKER, PER SET OF 16.98 4 4 PER 3 YEARS FOUR (4) E0159 BRAKE ATTACHMENT FOR WHEELED WALKER, 13.64 1 2 PER 2 YEARS REPLACEMENT, EACH E0160 SITZ TYPE BATH OR EQUIPMENT, PORTABLE, 9.70 1 1 PER 8 YEARS USED WITH OR WITHOUT COMMODE E0165 COMMODE CHAIR, STATIONARY, WITH 72.27 1 1 PER 3 YEARS DETACHABLE ARMS E0167 PAIL OR PAN FOR USE WITH COMMODE CHAIR 7.28 1 1 PER YEAR E0181 PRESSURE PAD, ALTERNATING WITH PUMP, 150.40 15.04 1 1 PER 3 YEARS HEAVY DUTY E0184 DRY PRESSURE MATTRESS 276.50 27.65 1 1 PER 3 YEARS E0186 AIR PRESSURE MATTRESS 184.30 1 1 PER 3 YEARS E0187 WATER PRESSURE MATTRESS 184.30 1 1 PER 3 YEARS E0189 LAMBSWOOL SHEEPSKIN PAD, ANY SIZE 77.60 1 1 PER 2 YEARS E0191 HEEL OR ELBOW PROTECTOR, EACH 6.79 2 4 PER YEAR E0196 GEL PRESSURE MATTRESS 184.30 1 1 PER 3 YEARS E0202 PHOTOTHERAPY (BILIRUBIN) LIGHT WITH 0.00 RO 42.68 5 1 PER MEDICAL PHOTOMETER EVENT E0205 HEAT LAMP, WITH STAND, INCLUDES BULB, OR 38.80 1 1 PER LIFETIME INFRARED ELEMENT E0215 ELECTRIC HEAT PAD, MOIST 16.49 1 1 PER LIFETIME E0217 WATER CIRCULATING HEAT PAD WITH PUMP 322.02 1 1 PER 5 YEARS E0235 PARAFFIN BATH UNIT, PORTABLE (SEE MEDICAL 116.40 11.64 1 1 PER 8 YEARS SUPPLY CODE A4265 FOR PARAFFIN) E0249 PAD FOR WATER CIRCULATING HEAT UNIT 25.71 1 1 PER YEAR March 2003 C-7
  • 162. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX C ONLY FOR RECIPIENTS UNDER AGE 21 B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS E0260 HOSPITAL BED, SEMI-ELECTRIC (HEAD AND 1,071.85 1 1 PER 8 YEARS FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITH MATTRESS E0265 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT 1,343.45 1 1 PER 8 YEARS AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITH MATTRESS E0305 BED SIDE RAILS, HALF LENGTH 105.73 1 1 PER 8 YEARS E0310 BED SIDE RAILS, FULL LENGTH 105.73 1 1 PER 8 YEARS E0315 BED ACCESSORY: BOARD, TABLE, OR SUPPORT 82.45 1 1 PER 8 YEARS DEVICE, ANY TYPE E0370 AIR PRESSURE ELEVATOR FOR HEEL 19.92 1 2 PER 2 YEARS E0609 BLOOD GLUCOSE MONITOR WITH SPECIAL 194.00 1 1 PER 2 YEARS FEATURES (EG., VOICE SYNTHESIZERS AUTOMATIC TIMERS, ETC.) E0618 APNEA MONITOR, WITHOUT RECORDING 0.00 1 MEDICAL FEATURE NECESSITY E0621 SLING OR SEAT, PATIENT LIFT, CANVAS OR 58.20 1 1 PER 4 YEARS NYLON E0630 PATIENT LIFT, HYDRAULIC, WITH SEAT OR SLING 664.50 66.45 1 1 PER 8 YEARS E0635 PATIENT LIFT, ELECTRIC WITH SEAT OR SLING 664.50 66.45 1 1 PER 8 YEARS E0650 PNEUMATIC COMPRESSOR, NON-SEGMENTAL 485.00 48.50 1 1 PER 8 YEARS HOME MODEL E0651 PNEUMATIC COMPRESSOR, SEGMENTAL HOME 941.90 94.19 1 1 PER 8 YEARS MODEL WITHOUT CALIBRATED GRADIENT PRESSURE E0652 PNEUMATIC COMPRESSOR, SEGMENTAL HOME 3,689.90 368.99 1 1 PER 8 YEARS MODEL WITH CALIBRATED GRADIENT PRESSURE E0655 NON-SEGMENTAL PNEUMATIC APPLIANCE FOR 73.72 1 2 PER YEAR USE WITH PNEUMATIC COMPRESSOR, HALF ARM E0660 NON-SEGMENTAL PNEUMATIC APPLIANCE FOR 67.90 1 2 PER YEAR USE WITH PNEUMATIC COMPRESSOR, FULL LEG E0665 NON-SEGMENTAL PNEUMATIC APPLIANCE FOR 67.90 1 2 PER YEAR USE WITH PNEUMATIC COMPRESSOR, FULL ARM E0666 NON-SEGMENTAL PNEUMATIC APPLIANCE FOR 101.37 1 2 PER YEAR USE WITH PNEUMATIC COMPRESSOR, HALF LEG E0667 SEGMENTAL PNEUMATIC APPLIANCE FOR USE 395.76 1 2 PER YEAR WITH PNEUMATIC COMPRESSOR, FULL LEG E0668 SEGMENTAL PNEUMATIC APPLIANCE FOR USE 395.76 1 2 PER YEAR WITH PNEUMATIC COMPRESSOR, FULL ARM E0744 NEUROMUSCULAR STIMULATOR FOR SCOLIOSIS 810.00 81.00 1 MEDICAL NECESSITY E0745 NEUROMUSCULAR STIMULATOR, ELECTRONIC 717.80 71.78 1 MEDICAL SHOCK UNIT NECESSITY E0776 IV POLE 106.70 10.67 1 1 PER 8 YEARS E0779 AMBULATORY INFUSION PUMP, MECHANICAL, 0.00 RO 11.74 0 MEDICAL REUSABLE, FOR INFUSION 8 HOURS OR GREATER NECESSITY E0780 AMBULATORY INFUSION PUMP, MECHANICAL, 0.00 RO 7.91 1 MEDICAL March 2003 C-8
  • 163. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX C ONLY FOR RECIPIENTS UNDER AGE 21 B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS REUSABLE, FOR INFUSION LESS THAN 8 HOURS NECESSITY E0781 AMBULATORY INFUSION PUMP, SINGLE OR 0.00 RO 9.41 1 MEDICAL MULTIPLE CHANNELS, ELECTRIC OR BATTERY NECESSITY OPERATED, WITH ADMINISTRATIVE EQUIPMENT, WORN BY PATIENT E0791 PARENTERAL INFUSION PUMP, STATIONARY, 0.00 RO 5.82 1 MEDICAL SINGLE OR MULTI-CHANNEL NECESSITY E0840 TRACTION FRAME, ATTACHED TO HEADBOARD, 63.05 1 1 PER LIFETIME CERVICAL TRACTION E0850 TRACTION STAND, FREE STANDING, CERVICAL 73.72 1 1 PER LIFETIME TRACTION E0860 TRACTION EQUIPMENT, OVERDOOR, CERVICAL 24.74 1 1 PER LIFETIME E0870 TRACTION FRAME, ATTACHED TO FOOTBOARD, 63.05 1 1 PER LIFETIME EXTREMITY TRACTION, (E.G. BUCK'S) E0880 TRACTION STAND, FREE STANDING, EXTREMITY 70.81 1 1 PER LIFETIME TRACTION, (E.G., BUCK'S) E0890 TRACTION FRAME, ATTACHED TO FOOTBOARD, 44.62 1 1 PER LIFETIME PELVIC TRACTION E0900 TRACTION STAND, FREE STANDING, PELVIC 77.60 1 1 PER LIFETIME TRACTION, (E.G., BUCK'S) E0920 FRACTURE FRAME, ATTACHED TO BED, 354.10 35.41 1 1 PER LIFETIME INCLUDES WEIGHTS E0930 FRACTURE FRAME, FREE STANDING, INCLUDES 354.10 35.41 1 1 PER LIFETIME WEIGHTS E0935 PASSIVE MOTION EXERCISE DEVICE 0.00 RO 13.57 0 10 DAYS PER MED.EVENT E0942 CERVICAL HEAD HARNESS/HALTER 15.52 1 1 PER MEDICAL EVENT E0943 CERVICAL PILLOW 26.39 1 1 PER MEDICAL EVENT E0944 PELVIC BELT/HARNESS/BOOT 12.13 1 1 PER MEDICAL EVENT E0945 EXTREMITY BELT/HARNESS 15.04 1 1 PER MEDICAL EVENT E0947 FRACTURE FRAME, ATTACHMENTS FOR 217.80 21.78 1 1 PER MEDICAL COMPLEX PELVIC TRACTION EVENT E0948 FRACTURE FRAME, ATTACHMENTS FOR 209.50 20.95 1 1 PER MEDICAL COMPLEX CERVICAL TRACTION EVENT E0961 BRAKE EXTENSION, FOR WHEELCHAIR 15.52 1 2 PER 2 YEARS E1085 HEMI-WHEELCHAIR, FIXED FULL LENGTH ARMS, 489.90 48.99 1 1 PER 5 YEARS SWING AWAY DETACHABLE FOOT RESTS E1091 YOUTH WHEELCHAIR, ANY TYPE 663.60 66.36 1 1 PER 5 YEARS E1800 DYNAMIC ADJUSTABLE ELBOW 73.50 2 2 PER 2 YEARS EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL E1805 DYNAMIC ADJUSTABLE WRIST EXTENSION / 75.50 2 2 PER 2 YEARS FLEXION DEVICE, INCLUDES SOFT INTERFACE March 2003 C-9
  • 164. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX C ONLY FOR RECIPIENTS UNDER AGE 21 B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS MATERIAL E1810 DYNAMIC ADJUSTABLE KNEE EXTENSION / 73.60 2 2 PER 2 YEARS FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL E1815 DYNAMIC ADJUSTABLE ANKLE 75.50 2 2 PER 2 YEARS EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL E1820 REPLACEMENT SOFT INTERFACE MATERIAL, 6.06 8 8 PER YEAR DYNAMIC ADJUSTABLE EXTENSION/FLEXION DEVICE E1825 DYNAMIC ADJUSTABLE FINGER 75.50 2 2 PER 2 YEARS EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL E1830 DYNAMIC ADJUSTABLE TOE 75.50 2 2 PER 2 YEARS EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL March 2003 C - 10
  • 165. DME/Medical Supplies Coverage and Limitations Handbook APPENDIX C ONLY FOR RECIPIENTS UNDER AGE 21 B CODE DESCRIPTION MAX RO RENT UNITS R PA LIMITS W4087 SUPPLY KIT- PORTABLE PUMP 29.10 31 366 PER YEAR W/SUBCUTANEOUS/PERCUTANEOUS LINE (INCLUDES INFUSE W4088 SUPPLY KIT-PORTABLE PUMP W/IMPLANTED 33.95 31 366 PER YEAR ACCESS DEVICE, PORT-A-CATH, MED-I- W4090 CATHETER IRRIGATION SOLUTION, 250CC 2.43 1 12 PER YEAR W4102 REPLACEMENT FILTERS FOR USE WITH FILTERE 0.49 31 366 PER YEAR W4107 OSTOMY SUPPORT BELT 17.46 1 2 PER YEAR W4165 BLOOD LANCET DEVICE (AUTOCLIX, 8.25 1 1 PER 5 YEARS MONOJECTO W9760 PEDIATRIC POSTURAL CONTROL WALKER, ANY 160.05 1 1 PER 2 YEARS SIZE, ANY TYPE ( E.G. KAYE, STRIDER, W9761 PEDIATRIC FOREARM CRUTCHES; ALUMINIUM; 82.45 1 1 PER LIFETIME HAND GRIP HEIGHT ADJUSTABLE UP TO W9762 PEDIATRIC SAFETY CRIB WITH METAL TUBE 2,134.00 1 1 PER LIFETIME ENDS AND SIDES WITH ENCLOSURE TOP; W9767 FOOT ORTHOSIS, FOR CONGENITAL FOREFOOT 72.75 2 4 PER LIFETIME DEFORMITIES (L.E., METATARSUS W9768 PEDIATRIC DYNAMIC SPLINTING DEVICE, 197.88 1 2 PER LIFETIME ALLOWS INDEPENDENT LEG MOTION, ALLOWS W9769 SPONGE; DRAIN, DRESSING, IV OR 0.38 150 1800 PER YEAR TRACHEOSTOMY; STERILE OR NON-STERILE ANY SIZ March 2003 C - 11
  • 166. JEB BUSH, GOVERNOR RHONDA M. MEDOWS, MD, FAAFP, SECRETARY 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. Medicaid Contract Management AHCA Headquarters 2308 Killearn Center Blvd. Suite B200 2727 Mahan Drive Mail Stop 22 T a l l a h a s s e e, F L 3 2 3 0 8 www.fdhc.state.fl.us Tallahassee, FL 32309
  • 167. Page Two HIPAA Advance Handbook Update August 2003 By now, health care providers that bill Medic aid 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 hipaa.training@acs- inc.com. 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
  • 168. 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 10/06/03 AVRS) 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.
  • 169. Medicaid Area Office Addresses and Telephone Numbers Areas—Counties Covered Address Phone Area 1—Escambia, Okaloosa, 160 Governmental Center, Escambia and Santa Rosa— Santa Rosa, Walton Room 510 (850) 595-5700 Pensacola, Florida 32502 Okaloosa and Walton— (800) 303-2422 Area 2A —Bay, Gulf, Franklin, 651-K West 14 Street (850) 872-7690 Holmes, Jackson, Washington Panama City, Florida 32401 (800) 699-7068 Area 2B —Calhoun, Gadsden, 2002 Old St. Augustine Road (850) 921-8474 Jefferson, Liberty, Leon, Madison, Building D, Room 194 (888) 503-5163 Taylor, Wakulla Tallahassee, Florida 32301 Area 3A —Alachua, Bradford, 14101 N.W. Hwy. 441 (386) 418-5350 Columbia, Dixie, Gilchrist, Suite 600 Hamilton, Lafayette, Levy, Putnam, Alachua, Florida 32615-5669 Suwannee, Union Area 3B —Citrus, Hernando, Lake, 2441 Silver Springs Boulevard (352) 732-1349 Marion, and Sumter Ocala, Florida 34475 Area 4—Baker, Clay, Duval, Duval Regional Service Center (904) 353-2100 Flagler, Nassau, St. Johns and 921 North Davis Street, (800) 273-5880 Volusia Building A, Suite 160 Jacksonville, Florida 32209-6806 Area 5—Pasco and Pinellas 525 Mirror Lake Drive North (727) 552-1191 Suite 510 (800) 299-4844 St. Petersburg, Florida 33701 Area 6—Hardee, Highlands, 6800 North Dale Mabry Hwy. (813) 871-7600 Hillsborough, Manatee, and Polk Suite 220 (800) 226-2316 Tampa, Florida 33614 Area 7—Brevard, Orange, 400 West Robinson Street (407) 317-7851 Osceola, and Seminole Suite 309 – South Tower (877) 254-1055 Orlando, Florida 32801 Area 8—Charlotte, Collier, DeSoto, 2295 Victoria Avenue, Room 309 (941) 338-2620 Glades, Hendry, Lee, and Ft. Myers, Florida 33901 (800) 226-6735 Sarasota All mail should be addressed to: P. O. Box 60127 Ft. Myers, Florida 33906 Area 9—Indian River, Martin, 1710 East Tiffany Drive, (561) 881-5080 Okeechobee, Palm Beach, and St. Suite 200 (800) 226-5082 Lucie West Palm Beach, Florida 33407 Area 10—Broward 1400 West Commercial Boulevard (954) 202-3200 Suite 110 Ft. Lauderdale, Florida 33309 Area 11—Dade and Monroe Doral Center, Manchester Building (305) 499-2000 nd 8355 N. W. 53 Street, 2 Floor Miami, Florida 33166
  • 170. Advance Update Florida Medicaid Reimbursement Handbook CMS-1500 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 TITLE ACTION ITEM 21 Diagnosis or Nature of Enter the patient's diagnosis/condition. Illness or Injury 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. October 2003 Page 1 of 12
  • 171. Advance Update Florida Medicaid Reimbursement Handbook CMS-1500 Changes Required for How to Complete the CMS-1500 Claim Form, continued CLAIM TITLE ACTION ITEM D Procedures, Services Enter the procedure code from the Procedure Code Fee or Supplies: CPT HCPCS Schedules in the service-specific Coverage and Limitations Codes and Modifiers 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. October 2003 Page 2 of 12
  • 172. Advance Update Florida Medicaid Reimbursement Handbook CMS-1500 Changes Required for How to Complete the CMS-1500 Claim Form, continued CLAIM TITLE ACTION ITEM 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 Enter an “E” if the patient was referred for the services as a Family Planning Indicator 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 If the services provided are for Child Health Check-Up screening Referral Code Indicator 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. October 2003 Page 3 of 12
  • 173. Advance Update Florida Medicaid Reimbursement Handbook CMS-1500 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. October 2003 Page 4 of 12
  • 174. Advance Update Florida Medicaid Reimbursement Handbook CMS-1500 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. October 2003 Page 5 of 12
  • 175. Advance Update Florida Medicaid Reimbursement Handbook CMS-1500 Place of Service Codes (POS), continued 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. October 2003 Page 6 of 12
  • 176. Advance Update Florida Medicaid Reimbursement Handbook CMS-1500 Place of Service Codes (POS), continued 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. October 2003 Page 7 of 12
  • 177. Advance Update Florida Medicaid Reimbursement Handbook CMS-1500 Illustration 3-1. Sample Remittance Voucher 2 3 5 6 7 8 9 10 11 12 1 4 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: 13 14 LAST FIRST MI 9123456789 0-88060-11-001-000 1-00 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 15 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 16 TCN -TO-CREDIT: 2 -87150-11-001-0001-00 NET 100.00 0.00 90.00 * * * CLAIM TYPE: PHYSICIAN * * * CLAIM STATUS: DENIED 13 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 17 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 18 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 19 REMITTANCE TOTALS: PAID ORIGINAL CLAIMS: NUMBER OF CLAIMS 2 -------- 2,200.00 2,110.00 20 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: 21 111 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx 27 ---- THE FOLLOWING IS A DESCRIPTION OF THE REMARK codes THAT APPEAR ABOVE: 22222 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxx 27 October 2003 Page 8 of 12
  • 178. Advance Update Florida Medicaid Reimbursement Handbook CMS-1500 How to Read The Remittance Voucher, continued RV TITLE WHAT ITEM MEANS ITEM 1 Patient Name: Last, The recipient’s name as found on the Florida Medicaid eligibility file. If First, and MI 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 The recipient’s Medicaid identification number. Num 3 Trans Control The unique identifying number assigned to each claim submitted. The Number 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 Component Represented 1 Claim input type 0 or 1 = Paper claim 2 = Magnetic tape claim 3 = Electronic claim 4 = ACS generated claim 5 = AHCA handled claim 2–6 Julian date claim was received 7–8 For internal use 9 – 11 Batch number 12 – 15 Document number 16 – 17 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. This is the provider assigned patient account number if entered on the Perf. Prov. 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. October 2003 Page 9 of 12
  • 179. Advance Update Florida Medicaid Reimbursement Handbook CMS-1500 How to Read The Remittance Voucher, continued RV TITLE WHAT ITEM MEANS 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 T = Transportation Rate Anesthesia V = Percent of Medicare Allowed B = Billed Charge Amount C = Medicare W = Zero Priced Coinsurance/Deductible X = CPHU Encounter Rate D = Medicare Deductible Y = Rural Health Clinic Encounter E = EAC Priced Rate F = Fee Schedule Z = FQHC Encounter Rate G = SMAC Priced 1 = Primary Care Rate J = MediKids 2 = Pediatric Surgery Rate K = Denied 3 = Fee Schedule Physician L = HMO/PHP Rate Increased Rate M = Manually Priced 4 = PC/BA Fee Physician Increase Rate N = Provider Charge 5 = Technical Component P = Prior Authorization Rate Physician Increased Rate Q = Technical Component Rate 7 = Calculated Medicare S = System Parameter Rate Coinsurance/ Deductible 13 Claim Type/Claim The same types of claims (i.e. physician, inpatient, hospice, etc.) are Status 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 The reason code(s) indicate why a claim paid at a rate other than what Cutback Reasons 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. October 2003 Page 10 of 12
  • 180. Advance Update Florida Medicaid Reimbursement Handbook CMS-1500 How to Read The Remittance Voucher, continued RV TITLE WHAT ITEM MEANS ITEM 16 TCN-to-Credit The transaction control number of the claim that the provider NET 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 When a claim is denied for duplicate reason, the paid date and the Conflicting TCN 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 If a claim is denied because the Medicaid file indicates that there is Recipient Has Other another payer responsible for the claim, the third party carrier code Coverage By 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. October 2003 Page 11 of 12
  • 181. Advance Update Florida Medicaid Reimbursement Handbook CMS-1500 How to Read The Remittance Voucher, continued RV TITLE WHAT ITEM MEANS ITEM 21 The Following is a Any adjustment, remark or reason code that appears on the Description 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. October 2003 Page 12 of 12
  • 182. Advance Copy Florida Medicaid Provider General Handbook 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 Each time payment is made to a provider Medicaid sends a paper or electronic Voucher 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 Claim adjustment reason codes communicate why a claim or claim line was Reason Codes 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. October 2003 A-1
  • 183. Florida Medicaid Provider General Handbook Advance Copy Overview, continued Claim Adjustment With the implementation of HIPAA, Medicaid will discontinue the use of Medicaid Reason and EOB EOB codes. As of October 16, 2003, Medicaid will communicate claims Crosswalk 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 If a claim is denied, the provider must correct the claim before resubmitting it. Required Resubmitting a denied claim without taking a corrective action will result in another claim denial. Medicaid Area The corrective action for some claims requires that the provider contact the area Office Assistance Medicaid office for assistance. The addresses and telephone numbers of the area Medicaid offices are listed in Appendix C of this handbook. Fiscal Agent The corrective action for some claims requires that the provider contact the Assistance, Medicaid fiscal agent, Provider Support Department for assistance. The Provider Provider Inquiry 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 If a fiscal agent keying error caused a paper claim to be denied or paid and Scanning incorrectly, the provider may either: Errors • 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. A-2 October 2003
  • 184. Advance Copy Florida Medicaid Provider General Handbook Crosswalk of X12 Codes to Former FMMIS EOB Codes X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code 004 M78 117 Invalid procedure code modifier Invalid modifier for ARNP. Registered nurse anesthetists can provide 004 282 only anesthesia services - modifier 48 not valid. Procedure modifier billed requires manual pricing. Please resubmit 004 N29 334 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. Provider or procedure code modifier or place of service conflict. Posts 004 000 668 with ASC mod. 73 or 74. 005 M77 310 Prov type or place of service conflict. Proc. cannot be performed at place of service indicated on claim (or if 005 365 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. Procedure not compatible with prov. type, procedure cannot be billed 008 284 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. Diagnosis code incompatible for recipient's age (if you're billing for 009 N59 323 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. October 2003 A-3
  • 185. Florida Medicaid Provider General Handbook Advance Copy X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code involved, make sure you didn't use baby's diag for mother or vice versa. Recip. age on our file incompatible with 2nd diag. - if baby & mother 009 464 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. Recip. sex on our file incompatible with primary diag.-if baby & mother 010 455 involved, make sure you didn't use baby's diag for mother or vice versa. Recip. sex on our file incompatible with 2nd diag. - if baby & mother 010 465 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. The first date of service is before the recipient's date of birth. Tape or 014 589 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 servi ce 016 M52 124 Invalid date of service 016 MA05 126 Admit or discharge date conflict. A-4 October 2003
  • 186. Advance Copy Florida Medicaid Provider General Handbook X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code 016 N31 131 Invalid DPR license number. 016 M54 132 Total or submitted charge missing. 016 MA30 138 Type of bill is invalid. EPSDT claim lines 1-6 incomplete. Results of all screening 016 M67 145 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. The sum of the third party payment amounts entered on the line item(s) 016 M54 150 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 Diagnosis code missing or incomplete (outpatient hospitals: revenue 016 MA63 163 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. EPSDT procedure code W9881 was incorrectly billed on the HCFA 016 N34 171 1500 claim form. Procedure should only be billed on the EPSDT form (221). Procedure code missing - outpatient revenue codes in the range 300- 016 M67 172 319 must be accompanied by 5-digit lab proc. Code in range 80000 - 89999. Invalid hospice revenue code or invalid combination of hospice revenue 016 M67 173 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. October 2003 A-5
  • 187. Florida Medicaid Provider General Handbook Advance Copy X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code 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. First surgery date (field 80) not within "statement covers period" date 016 MA100 190 span (field 6). Second surgery date (field 81) not within "statement covers period" 016 MA100 191 date span (field 6). Third surgery date (field 81) not within "statement covers period" date 016 M100 192 span (field 6). 016 M46 193 Invalid newborn occurrence date Invalid or spanned header dates - outpatient bills must contain a single 016 M67 194 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. Procedure code W9657 cannot be billed independently. It must be 016 240 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). Recipient has other insurance coverage on Medicaid third party liability 016 MA64 265 file. Please file with other carrier or attach insurance company denial. Third party liability indicated on claim, but coverage not on Medicaid 016 MA64 266 file. Must be filed on paper claim with copy of other carrier's payment. A-6 October 2003
  • 188. Advance Copy Florida Medicaid Provider General Handbook X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code TPL is indicated on file, but did not appear on claim. Your claim was 016 MA64 267 denied after DCF review of the claim and its attachment (s). 016 N30 272 Recip ineligible for HMO or PHP Inpatient invalid date range. Date of service cannot span past January 016 M46 273 10,1992 for inpatient claim when recipient is over 20 yrs. old. Recipient is not eligible for Medicaid services, but may be eligible for 016 N30 274 Medicare. Medicaid prescription services not covered. Missing or invalid DCF eligibility form for Medically Needy. Photocopied 016 278 form 2902's must contain denial TCN in top right when resubmitting. Procedure code or provider type of service conflict (waiver program and 016 M67 287 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. Newborn occurrence code missing. When admit and birth dates are 016 M45 331 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 Consent form invalid. You may correct any item on the form except 016 N3 904 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. Duplicate. Claim has been previously paid on date indicated or if 018 101 zeroes printed for previous date paid, another submission paid or pended on this remit. October 2003 A-7
  • 189. Florida Medicaid Provider General Handbook Advance Copy X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code Possible duplicate. May be a conflict with a claim by another provider. 018 102 Write P.O. Box 7070, Tallahassee, FL 32314-7070 for information. Possible duplicate conflict. May be a conflict with another provider's 018 103 claim. For more information please call Provider Services at 1-800-289- 7799. Possible duplicate conflict. May be a conflict with another provider's 018 103 claim. For more information please call Provider Services at 1-800-289- 7799. Inpatient claim duplicate of outpatient claim or vice versa. Outpatient 018 105 services not payable for day before or same day of an inpatient claim. Recip. no., prov. no., and Rx no. are the same and current claim DOS 018 M63 107 is more than 366 days before or after the previous claim DOS. A surgical procedure (without a modifier) is billed within the follow-up of 018 M80 207 a previous surgical procedure. Rural health encounter limit - cannot bill multiple rural health 018 N20 211 encounters for the same service date. CPHU encounter limit - cannot bill multiple CPHU encounters for the 018 N20 220 same service date. FQHC encounter limit - cannot bill multiple FQHC encounters for the 018 N20 222 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. Crossover claim exceeds filing limit. Filing limit is 6 months from 029 168 Medicare EOMB date or 12 mos. from date of service, whichever is later. Adjustment exceeds 12 months from date. See provider manual for 029 N59 846 exception criteria. 031 129 Invalid recipient I.D. number. 031 130 Invalid recipient check digit (10th digit of recipient number) Recipient ID no. not on file. Because update may arrive from DCF, 031 250 Recip. File is rechecked weekly for a match. If number incorrect, resubmit now. A-8 October 2003
  • 190. Advance Copy Florida Medicaid Provider General Handbook X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code Recipient ID no. not on file. Because update may arrive from DCF, 031 250 Recip. File is rechecked weekly for a match. If number incorrect, resubmit now. Recip ID # not on file-denied after pending 14 days awaiting DCF 031 251 update. If no. incorrect, resubmit. If correct-contact your DCF district office. 031 252 Recipient is not active Recip. inelig. for date of srv. - denied after being pended for 14 days 031 270 awaiting DCF update. If you have elig proof contact DCF district office. Recip. inelig. for date of srv. - will pend for up to 14 days awaiting DCF 031 271 update. Recip elig rechecked weekly for arrival of DCF update. Recip. inelig. for date of srv. - will pend for up to 14 days awaiting DCF 031 271 update. Recip elig rechecked weekly for arrival of DCF update. New patient nursing home visits are limited to one per lifetime per 035 003 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. Appendectomy is limited to one in a lifetime. This limit has been 035 056 previously met. 035 062 Normal newborn care. Limit 1 in lifetime. Procedures applicable to this exception are limited to three in a 035 073 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. Medicaid allowed charge equal to zero. (MDs, DOs, DPMs and 037 503 chiropractor. co-ins. or deductible pit cannot exceed Medicaid's max fee for this proc.) Service not authorized by MediPass primary care physician. Referring 038 860 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. October 2003 A-9
  • 191. Florida Medicaid Provider General Handbook Advance Copy X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code 039 501 Prior authorization not approved. 039 514 Prior auth line not approved. Out-of-state claim not payable - claim reviewed. Services not prior 040 N54 314 authorized & non-emergency and are therefore not covered. File indicates you are enrolled as an in-state, non-particip. provider. 040 000 329 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. Calculated payment equals zero, other ins. Paid more than Medicaid 042 318 allowable. 042 N45 351 Allow to sub percent diff ex. 042 N45 352 Sub to allow percent diff ex. Medicaid allowed charge equal to zero. (MDs, DOs, DPMs and 042 503 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. Diagnosis not specific enough. Refer to ICD-9 book. See if adding a 047 M81 456 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. A-10 October 2003
  • 192. Advance Copy Florida Medicaid Provider General Handbook X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code 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). Procedure not allowed with critical care (99160-99174 and 99291 and 048 N56 026 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. Unit dose differential not allowed, packaging completed by 057 359 manufacturer. This limit has previously been met. 057 000 720 Low dose alert Home health visits W9611, W9612, W9613 and W9620, are limited to 057 N54 953 60 visits unless prior authorized. 062 MA120 140 Invalid certification number. First surg. proc. is elective & no prior authoriz. # entered. Non-prior 062 327 authorized hysterectomies permissible in documented emerg. situations. October 2003 A-11
  • 193. Florida Medicaid Provider General Handbook Advance Copy X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code First surg proc is elective. Procedure requires prior auth. unless 062 N59 328 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. Physicians: refer prov req'd for this proc in field 17a or 19. Therapists, 062 370 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. Procedure performed on date of service after prior authorization 062 N54 512 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. A claim for inpatient services covers more than 15 days, the recipient is 062 M46 588 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. Diagnosis is 290.0-314.9 and PA does not begin 7777 for admit prior to 062 M62 669 7/1/98 or 3333 for admit on or after 7/1/98, or, xxxx 895xxx (after 1/1/01) Consent form incomplete. You may complete any item on the form 062 N3 903 except signature & date of: patient, person obtaining consent & interpreter Service authoriz. (SA) no. required for service. Enter in field 17 on form 062 931 081 or field 17a on HCFA-1500. Contact area Medicaid office for SAs. Prior auth (PA) record does not contain this proc. If PA not req'd for this 062 N54 934 proc., rebill this line on separate form without PA no. in field 4. Service authorization (SA) number required for this service. Electronic 062 935 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 A-12 October 2003
  • 194. Advance Copy Florida Medicaid Provider General Handbook X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code 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. Outpatient revenue code not on file or not covered - if rev. code is in the 096 M50 347 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 Procedure not allowed to be billed in addition to components (93225- 097 N59 801 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. October 2003 A-13
  • 195. Florida Medicaid Provider General Handbook Advance Copy X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code 110 144 Last date of service after date received. 118 MA64 581 Invalid combination of RPICC services. There is TPL for this claim. Procedure is limited to one time in a one-year period. If you billed for 119 M90 004 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. Procedure is limited to two times in three years. If you billed for more 119 006 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 Vaginal deliveries or total OB care is limited to one per recipient in a 119 000 066 ten-month period. This limit has been previously met. Services applicable to this edit are limited to one in 300 days. This limit 119 067 has been previously met. 119 000 071 Procedures applicable to this edit are limited to one in three years. Denture relinings are limited to one per denture in one year. This limit 119 M90 072 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. A-14 October 2003
  • 196. Advance Copy Florida Medicaid Provider General Handbook X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code 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. Recipient enrolled in an HMO or pre-paid health plan and this service is 120 308 covered by the HMO or pre-paid health plan. 125 M46 596 Missing occurrence span code and dates. Units billed on revenue codes 100-219 do not match covered date 125 M46 615 spans. Possible duplicate conflict. May be a conflict with another provider's 133 103 claim. For more information please call Provider Services at 1-800-289- 7799. 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. Alien - claim requires medical review. If you did not attach medical 133 279 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. October 2003 A-15
  • 197. Florida Medicaid Provider General Handbook Advance Copy X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code 133 607 7th diag code requires med review. 133 608 8th diag code requires med review. 133 610 10th diag code requires med review. 133 611 11th diag code requires med review. 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. This service cannot be billed with a date span that includes 2 or more 141 M46 112 months. Rebill with one month of services per claim line. Claim spans fiscal year end date of June 30. Split bill June services 141 N62 114 onto one claim and July services onto another claim. 141 MA32 661 SNU leave days present. 146 470 Third diagnosis code not on file. Medicare prov no. for treating prov not on Medicaid’s Cross-ref. File. 148 M57 408 Notify Prov. Enrollment unit of all group member's Medicare prov. nos. Treating provider number missing or invalid. Groups must enter 9-digit 148 N77 409 prov. number for indiv. treating prov. in block 19 of EPSDT form 221. Treating provider no. on claim is missing or invalid. On HCFA-1500 148 N77 410 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. These services cannot be billed on this claim form or the provider type A1 N34 313 listed for this provider number cannot file this type of claim. Out-of-state claim not payable - claim reviewed. Services not prior A1 N109 314 authorized & non-emergency and are therefore not covered. Trauma or accident claim, the accident indicator on the diagnosis A1 MA11 325 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. A-16 October 2003
  • 198. Advance Copy Florida Medicaid Provider General Handbook X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code 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. No provider rate for date of service (may have been billed under A1 N77 381 incorrect provider number) Procedure being billed for pathology has no technical component A1 MA66 382 segment. Model waiver provider error. Did not bill proc. W9894 or W9895 or A1 MA66 384 W9900 or W9901 A1 MA51 388 No CLIA registration on file for this provider. Units of service not compatible with date span billed. If only one date A1 M53 394 of service billed, a date span may be required for no. of units billed. Date span billing not allowed for this procedure code. Bill each date of A1 M46 395 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. Claim has been reviewed. Refer to EOB codes 901 - 940 for denial A1 N109 452 reason. Claim has been reviewed. Refer to EOB codes 901 - 940 for denial A1 N109 453 reason. Claim has been reviewed. Refer to EOB codes 901-940 for denial A1 N109 463 reason. Claim has been reviewed. Refer to EOB codes 901-940 for denial A1 N109 472 reason. Claim has been reviewed. Refer to EOB codes 901 - 940 for denial A1 N109 473 reason. Claim has been reviewed. Refer to EOB codes 901 - 940 for denial A1 N109 483 reason. Claim has been reviewed. Refer to EOB codes 901 - 940 for denial A1 N109 493 reason. A1 N54 502 Claim recipient number or prior authorization recipient number conflict. Claim has been reviewed. Refer to EOB codes 901 - 940 for denial A1 N109 552 reason. Claim has been reviewed. Refer to EOB codes 901 - 940 for denial A1 N109 553 reason. Claim has been reviewed. Refer to EOB codes 901 - 940 for denial A1 N109 562 reason. Claim has been reviewed. Refer to EOB codes 901 - 940 for denial A1 N109 563 reason. A1 N109 572 Claim has been reviewed. Refer to EOB codes 901 - 940 for denial reason. October 2003 A-17
  • 199. Florida Medicaid Provider General Handbook Advance Copy X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code reason. Claim has been reviewed. Refer to EOB codes 901 - 940 for denial A1 N109 573 reason. A1 N109 580 This RPICC procedure has been reviewed by DCF. Multiple anesthesia procedure codes (00100 - 01999) for the same A1 M15 583 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. Procedure restricted to certain specialty(ies). Provider not enrolled for B07 366 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. Pay to provider not authorized for direct payment. Contact Provider B07 N95 664 Enrollment for instructions. Pay to provider's mail is undeliverable. Contact Provider Enrollment for B07 000 665 instructions. B13 108 New patient visit has been previously paid. Surg. srv. includes follow-up hosp. & office visits. If visit claim pays B13 M144 109 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. A-18 October 2003
  • 200. Advance Copy Florida Medicaid Provider General Handbook X12 MMIS X12 Adj. Remark EOB MMIS EOB Text Code Code Code Invalid combination of procedures or revenue codes. This is a fatal EDI B18 M50 110 edit do not resubmit. B18 M67 368 Invalid combination of procedure codes for private transportation. Anesthesia services must be billed using 00100 - 01999 range of CPT B18 373 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. October 2003 A-19
  • 201. Durable Medical Equipment and Supplies Coverage and Limitations Handbook Advance Update to Appendices B and C 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. HCPCS/CPT Procedure Code Local Code Local Code Description Code Clarification Supply Kit - Portable Pump w/ W4087 Subcutaneous/Percutaneous Line A4221 Supply Kit - Portable Pump w/ Implanted Access Device, Port-A- W4088 Cath A4221 W4090 Catheter Irrigation Solution, 250cc A4323 W4097 Adapter for Connector For Tubing A4331 Extension Tubing For Connecting W4097 Appliance A5200 W4097 Adapter for Connector For Tubing A7002 W4098 Adapter or Connector For Tubing A4222 Replacement Filters For Use With W4102 Filters A4481 W4107 Ostomy Support Belt A4396 Blood Lancet Device (Autoclix, W4165 Monojecto) A4258 Pediatric Postural Control Walker, Any Size, Any type (E.G. Kaye, W9760 Strider) E0146 Pediatric Forearm Crutches; Alumumim, Hand Grip Height W9761 Adjustable E0110 Pediatric Forearm Crutches; Alumumim, Hand Grip Height W9761 Adjustable E0111 Pediatric Safety Crib With Metal Tube Ends and Sides with Enclosure W9762 Top E0316 Resuscitator Bag, Self-Inflating; W9763 Hand Held; Non-Disposable Pediatric S8999 Neulizer Kit for Administration of W9765 Aerosolized Medication A7007 Suction Machine w/ Vacuum Regulator; Battery Operated; W9766 Includes Rechargeable E0600 October 2003 Page 1
  • 202. Durable Medical Equipment and Supplies Coverage and Limitations Handbook HCPCS/CPT Procedure Code Local Code Local Code Description Code Clarification Foot, Arch Support, Foot Orthosis, for Congenital Removable, Premolded, W9767 Forefoot Deformities L3050 Metatarsal, Each Foot, Arch Support, Foot Orthosis, for Congenital Removable, Premolded, W9767 Forefoot Deformities L3060 Longitudinal/Metatarsal, Each Foot, Arch Support, Foot Orthosis, for Congenital Nonremovable, Attached To W9767 Forefoot Deformities L3070 Shoe, Longitudinal, Each Pediatric Dynamic Splinting Device, W9768 Allows Independent Leg Motion L4386 Sponge; Drain, Dressing, IV or Tracheostomy; Sterile or Non-Sterile W9769 Any Size A9900 October 2003 Page 2

×