DME MAC JURISDICTION C - CGS

SUPPLIERDME MAC JURISDICTION CMANUAL

Table of ContentsTable of Contents1. Introduction2. Provider Enrollment3. Supplier Documentation4. Certificates of Medical Necessity (CMNs)5. DMEPOS Fee Schedule6. Claim Submission7. Crossover Claims8. Electronic Data Interchange (EDI)9. Coverage and Medical Policy10. Pricing11. Coordination of Benefits (COB)12. Overpayments13. Inquiries and Appeals14. Fraud and Abuse15. Resources16. Coding17. System Outputs18 Acronyms and AbbreviationsDME MAC Jurisdiction C Supplier Manual Page 1

Chapter One √Introduction

Introduction Chapter 1birthday, so an individual born on August 1st reaches age 65 on July 31st, and hospital insurance iseffective July 1st.Some aged individuals do not qualify for premium-free hospital insurance due to insufficient SocialSecurity Quarters of Coverage, but may purchase Medicare Part A coverage. The individual must bea United States resident and either a citizen or an alien lawfully admitted for permanent residencewho has lived in the United States continuously for five years. This person must also enroll (oralready be enrolled) in Supplementary Medical Insurance (SMI). This type of enrollee must pay amonthly premium for both Medicare Part A and Medicare Part B Medicare coverage. If the premiumis not paid within a specified period, coverage is terminated.Under Age 65 with Permanent Kidney Failure (End Stage Renal Disease)Eligibility for coverage of a permanent kidney failure patient begins the third month after the month inwhich a course of renal dialysis begins, unless the individual receives a kidney transplant on orbefore the third month. In that case, eligibility begins the month the individual is admitted as aninpatient to a hospital for procedures, in preparation for, or in anticipation of, a kidney transplant,provided the transplant surgery takes place within the following two months. When the transplant isdelayed more than two months after the preparatory hospitalization, eligibility begins with the secondmonth prior to the month of transplant.Also, Medicare entitlement can begin in the first month of a course of dialysis if the individualparticipates in a self-dialysis training program in a Medicare-approved facility prior to the third monthafter the course of dialysis. The individual is expected to complete the training and self-dialyzethereafter. If a beneficiary is entitled to Medicare only because of permanent kidney failure, Medicareprotection will end 12 months after dialysis ends or 36 months after the month of a kidney transplant.If the transplant fails during or after that 36-month period and the beneficiary again resumesmaintenance dialysis or receives another transplant, Medicare coverage will continue or bereinstated immediately without any waiting period.Under Age 65 and Permanently DisabledMedicare entitlement for the disabled begins with the 25th month after an individual has been eligiblefor Social Security Disability benefits for 24 consecutive months. Generally, Medicare coverage willcontinue for one calendar month after the beneficiary has been sent notice that he or she is nolonger entitled to Social Security disability payments.Medicare Health Insurance Claim (HIC) NumberThe HIC number, or HICN, serves as the beneficiary’s Medicare identification number. This HICnumber is shown on his or her Medicare card.The format of the Social Security Administration (SSA) issued Medicare number is 000-00-0000preceded or followed by a suffix.NOTE: The HIC number may be different than the beneficiary’s Social Security number.The HIC number is probably the most important piece of information you can have about yourMedicare patient. Your claims cannot be paid if the HIC number is missing or incorrect.The Medicare CardDME MAC Jurisdiction C Supplier Manual Page 3

Introduction Chapter 1A Medicare card is issued to every person who is entitled to Medicare benefits. This card identifiesthe Medicare beneficiary and includes the following information:• Name (exactly as it appears on the social security records)• Medicare Health Insurance Claim (HIC) number• Beginning date of Medicare entitlement for hospital and/or medical insurance• Sex• A place for beneficiary's signatureThe following is an example of a Medicare card:Note: More recent cards issued by CMS show the 1-800-Medicare number (see example below). Ifthe beneficiary has a card that shows something different (such as the example above), it is still validand can be used to get medical care.We recommend a copy of the Medicare card be obtained and incorporated in the patient’s file foraccuracy of claim submissions.DME MAC Jurisdiction C Supplier Manual Page 4

Introduction Chapter 1The purpose of the Privacy Act and HIPAA Privacy Rules are to provide safeguards for individualsagainst an invasion of privacy. Federal agencies are required to permit individuals to:1. Determine what records pertaining to him/her are collected, used, or disseminated by suchagencies.2. Prevent records pertaining to him/her from being used for another purpose without theirconsent.3. Gain access to information pertaining to him/her in federal agency records, and to correctsuch records when appropriate.Disclosure of information about a named beneficiary is prohibited except to the beneficiary (orhis/her legal guardian), without the beneficiary's (or legal guardian's) explicit written authorization.This authorization may be in any form, but it must:• Include the beneficiary's name, and HICN;• Specify the individual, organizational unit, class of individuals or organizational units whomay make the disclosure;• Specify the individual, organizational unit, class of individuals or organizational units to whichthe information may be disclosed;• Specify the records, information, or types of information that may be disclosed;• A description of the purpose of the requested use or disclosure (if the beneficiary does notwant to provide a statement of the purpose, he/she can describe the use as “at the requestof the individual”);• Indicate whether the authorization is for a one-time disclosure, or give an expiration date orevent that relates to the individual or the purpose of the use or disclosure (e.g., for theduration of the beneficiary’s enrollment in the health plan);• Be signed and dated by the beneficiary or his/her authorized representative. If signed by therepresentative, a description of the representative’s authority to act for the individual mustalso be provided;• A statement describing the individual’s right to revoke the authorization along with adescription of the process to revoke the authorization;• A statement describing the inability to condition treatment, payment, enrollment or eligibilityfor benefits on whether or not the beneficiary signs the authorization;• A statement informing the beneficiary that information disclosed pursuant to the authorizationmay be redisclosed by the recipient and may no longer be protected.Blanket consents to disclose all of the beneficiary's records to unspecified individuals ororganizations will not be honored. The consent must specify the item/service for which the disclosureis requested and should only include those items/services prescribed by the beneficiary’s physician.DME MAC Jurisdiction C Supplier Manual Page 6

Introduction Chapter 1Freedom of Information Act (FOIA)The Freedom of Information Act (FOIA) requires that most records in custody of CMS (and itscontractors) be made available to the general public when requested. The Act does not apply tomaterials specifically prepared for public distribution or sale, e.g., press releases, speeches, factsheets, listings (names and business addresses) of Medicaid and/or Medicare providers, informationbrochures, and any publication which has been assigned a CMS, Health and Human Services,Government Printing Office, or National Technical Information Service (NTIS) publication number,etc.The FOIA covers records (paper or electronic/tape) only. It does not cover information which may berequested and imparted orally or in writing. For example, requests for dates, addresses, figures suchas the Medicare enrollment for a state, which need not be responded to with the production of adocument are not FOIA requests. Such requests should be directed to the proper public inquiriesoffice.FOIA examples:• Existing records (handwritten, printed, or electronic)• Excerpts from the Medicare manuals, Code of Federal Regulations, supplier manuals, andnewsletters• Supplier name lists• Fee schedules• Coding reports and letters• Claim data reportsNon-FOIA examples:• Requests for dates• Addresses• Figures (i.e., Medicare enrollment for a state)• General questions about coverage or policy interpretation• HCPCS coding informationAll FOIA requests are subject to fees for search, review, and copy/duplication. Before submittingyour request, you may want to see if the information can be obtained from our Web site,www.cignagovernmentservices.com. FOIA requests must be submitted in writing and should providedetails that will help us identify and find the records being requested. If there is insufficientinformation, we will ask you for more. Include your name and telephone number(s) to help us reachyou if we have questions.DME MAC Jurisdiction C Supplier Manual Page 7

Chapter Two √Supplier Enrollment

Supplier Enrollment Chapter 2OverviewThis chapter outlines the enrollment requirements that a DMEPOS supplier must meet in order toreceive payment in the Medicare program.All DMEPOS suppliers who serve Medicare beneficiaries and meet the supplier standards listed inthis chapter must enroll and obtain a supplier number with the National Supplier Clearinghouse(NSC). The Centers for Medicare & Medicaid Services (CMS) has contracted with the NSC todistribute applications, verify data, and maintain a national DMEPOS supplier file. The NSC does notprocess or maintain information on claims.Before enrolling with the NSC, suppliers must obtain a National Provider Identifier (NPI). Applying foran NPI is a separate process from enrollment with the NSC.As of May 23, 2007, all claims filed to Medicare must include the supplier’s NPI. Legacy suppliernumbers issued by the NSC are no longer required in the claim filing process.National Provider Identifier (NPI)The Administrative Simplification provisions of the Health Insurance Portability and AccountabilityAct of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers,as well as the adoption of standard unique identifiers for health plans. For health care providers, theNational Provider Identifier (NPI) is the standard unique identifier. The Centers for Medicare &Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System(NPPES) to assign these unique identifiers.. To obtain an NPI you may apply online athttps://NPPES.cms.hhs.gov. For more information about NPI enumeration, visitwww.cms.hhs.gov/NationalProvIdentStand.CIGNA Government Services is currently accepting the NPI number and/or the NSC (NationalSuppliers Clearinghouse) number for claims submission.Please note, each enrolled supplier of DMEPOS that is a covered entity under HIPAA mustdesignate each practice location (if it has more than one) as a subpart and ensure that each subpartobtains its own unique NPI. Federal regulations require that each location of a Medicare DMEPOSsupplier have its own unique billing number. In order to comply with that regulation, each locationmust have its own unique NPI.National Supplier Clearinghouse (NSC)Obtaining and Retaining a Medicare Supplier NumberUnder the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) regionalizedprocessing, every supplier of Durable Medical Equipment, Prosthetics, Orthotics and Supplies(DMEPOS) services must obtain a Medicare supplier number.A supplier is an entity or individual, which provides, sells, or rents durable medical equipment,prosthetics, orthotics and supplies to Medicare beneficiaries. The Center for Medicare and MedicaidServices (CMS) contracted the National Supplier Clearinghouse (NSC) to distribute supplier numberapplications (Provider/Supplier Enrollment Application or CMS 855S form), verify the data, issuesupplier numbers to approved suppliers and maintain a national DMEPOS supplier file. The NSCDME MAC Jurisdiction C Supplier Manual Page 1

Supplier Enrollment Chapter 2must process supplier data and issue a new supplier number before a supplier may start submittingclaims to Medicare for payment. The NSC will verify all information submitted.In order to bill Medicare for DMEPOS, suppliers should complete the CMS 855S application if:• Enrolling in Medicare for the first time as a DMEPOS supplier.• Currently enrolled in Medicare as a DMEPOS supplier and need to report changes toyour business, other than enrolling a new business location (e.g., you are adding,deleting, or changing existing information under this Medicare supplier billing number).Changes must be reported within 30 days of the effective date of the change.• Currently enrolled in Medicare as a DMEPOS supplier but need to enroll a new businesslocation. This is to add a new location to an organization with a tax identification numberalready listed with the NSC. (This differs from changing information on an alreadyexisting location.)Note: 42 C.F.R. 424.57(b)(1) requires suppliers to enroll separate physical locations,other than warehouses or repair facilities.• Currently enrolled in Medicare as a DMEPOS supplier and have been asked to reenrollin order to verify or update your information. This includes situations where you havebeen asked to attest your organization is still eligible to receive Medicare payments.• Reactivating your Medicare DMEPOS supplier billing number (e.g., your Medicaresupplier billing number was deactivated because of non-billing, and you wish to receivepayment from Medicare for future claims).• Voluntarily terminating your Medicare DMEPOS supplier billing number.Instructions on how to obtain and complete the CMS 855S may be found under the “SupplierEnrollment” section of the NSC Web site (www.PalmettoGBA.com/NSC).The supplier is accountable for the accuracy of the information on the CMS 855S form. Anydeliberate misrepresentation or concealment of material information may subject the supplier toliability under civil and criminal laws.The NSC will contact a supplier if a CMS 855S form is incomplete or has inconsistent information.Further, all suppliers are subject to a site visit in order to determine compliance with the supplierstandards. Suppliers found in noncompliance with the supplier standards are subject to denial orrevocation of their NSC issued supplier number. The denial/revocation notification outlines theappeals process available to suppliers, including instructions on requesting an appeal.NOTE: According to Pub 100-8, Chapter 10, Section 6.2, a supplier that is denied enrollment in theMedicare program cannot submit a new enrollment application until the following has occurred:• If the denial was not appealed, the provider or supplier may reapply after its appeal rightshave lapsed.• If the denial was appealed, the provider or supplier may reapply after it receivednotification the determination was upheld.Further, 42 C.F.R 424.530 (published in April 2006) requires the NSC to return any applicationreceived 30 days prior to the date the business was established (Section 4A of the CMS 855S) andto deny any application where the supplier is not operational. 42 C.F.R. 424.502 defines operationalas follows:“Operational means the provider or supplier has a qualified physical practice location, is open to thepublic for the purpose of providing health care related services, is prepared to submit valid Medicareclaims, and is properly staffed, equipped and stocked to furnish these items or services.”DME MAC Jurisdiction C Supplier Manual Page 2

Supplier Enrollment Chapter 2Each DMEPOS supplier applying for a Medicare supplier number must disclose ownership on theCMS 855S form in accordance with Section 1124A of the Social Security Act and Section 4313 ofthe Balanced Budget Act of 1997, by including:• The names and social security numbers of the owners, managing employees, those withcontrolling interest of 5% or more, and/or authorized representatives/members of theboard of directors (including non-profit corporations) as well as any partnershipregardless of the percentage of ownership.• The names of all owners, managing employees and/or authorizedrepresentatives/members of the board of directors who have received penalties, beensanctioned, or excluded by the Medicare, Medicaid and/or other federal and stateauthorities or programs.The term managing employee is defined as any individual, including a general manager, businessmanager, or administrator, who exercises operational or managerial control over the DMEPOSsupplier, or who conducts the day-to-day operations of the DMEPOS supplier. For Medicareenrollment purposes, “managing employee” also includes individuals who are not actual employeesof the DMEPOS supplier but, either under contract or through some other arrangement, manage theday-to-day operations of the DMEPOS supplier.An authorized official must be an owner, general partner, chairman of the board, chief financialofficer, chief executive officer, or president, OR must hold a position of similar status and authoritywithin the supplier's organization. This individual must have the authorization to legally bind theorganization to a contract. The authorized official has the authority to sign the initial CMS 855Sapplication on behalf of the supplier and to notify the NSC of any change or that the supplier numberis no longer valid due to sale of the entity. Only the authorized official can add, change, or deletedelegated officials or sign off on the change of the authorized official.Adding delegated officials is an option and is not required. Delegated officials may be either amanaging employee of the supplier, or hold a 5% direct ownership interest or partnership interest inthe supplier. Managing employees include general managers, business managers, or administrators- individuals who exercise operational or managerial control over the supplier, or who conduct theday-to-day operations of the supplier. A delegated official must be an employee of the supplier, andproof, such as a W-2 form, may be requested.Delegated officials may not delegate their authority to any other individual. Once a delegated officialhas been designated, he/she may make any changes and/or updates to the provider status includingenrolling additional locations, re- enrolling the supplier, reactivating the supplier, or adding new partowners.Suppliers may have as many authorized and delegated officials as desired as long as the individualmeets the respective definition. These officials are not location specific, but rather are supplierspecific. For example, if a supplier has multiple locations under one tax id number, the authorizedand delegated officials appointed will be the authorized signers for all locations.The CMS 855S FormOn May 1, 2006, the Centers for Medicare & Medicaid Services (CMS) issued the revised CMS 855Medicare enrollment applications. Listed below are changes and enhancements made specifically tothe CMS 855S. DMEPOS suppliers should review and become familiar with this information.• Requires the submission of the National Provider Identifier (NPI) and a copy of the NPInotification furnished by the National Plan and Provider Enumeration System (NPPES).Suppliers should provide their NPI where requested and submit a copy of the notificationDME MAC Jurisdiction C Supplier Manual Page 3

Supplier Enrollment Chapter 2verifying the NPI. If you are unable to locate your NPI notification you may contact the NPPES at(800)-465-3203 or send an e-mail to customerservice@npienumerator.com.Applying for the NPI is a process separate from Medicare enrollment. To obtain an NPI, you mayapply online at https://NPPES.cms.hhs.gov. For more information about NPI enumeration, visitwww.cms.hhs.gov/NationalProvidentStand.Note: Each enrolled supplier of DMEPOS that is a covered entity under HIPAA must designate eachpractice location (if it has more than one) as a subpart and ensure that each subpart obtains its ownunique NPI. Federal regulations require that each location of a Medicare DMEPOS supplier have itsown unique billing number. In order to comply with that regulation, each location must have its ownunique NPI.In addition, the address listed on the NPI notification must match the address listed on the CMS855S. CMS requires a copy of the notification to be submitted with all enrollment documentation,which includes initial applications, changes of information, reenrollments and reactivations.• Requires suppliers complete and submit the most current version of the Authorization Agreementfor Electronic Funds Transfer (CMS 588). With regards to DMEPOS enrollment, suppliers shouldsubmit the EFT when initially enrolling or submitting an application for an additional location.Suppliers must list the proper Medicare contractor and ensure the form has the original signatureof the authorized or delegated official. Also, suppliers should submit a separate form for eachMedicare contractor where it submits claims.Along with each completed form, suppliers must include one of the following verifying the accountinformation:• Voided check• Deposit slip• Notification on bank letterhead verifying the account informationThe NSC's role is to simply verify the form is complete, the correct contractor has been indicated,based on the information the supplier has provided on the CMS 855S and to ensure the agreementis signed properly. Once verified, the NSC will send the agreements to the appropriate DMEcontractor for processing.Again, suppliers should only submit the CMS 588 to the NSC when submitting the CMS 855S forinitial enrollment or when enrolling an additional location. The NSC does not enroll suppliers into theEFT program. Any changes to existing EFT information should be submitted to the followingaddress:CIGNA Government ServicesAttn: EFT-DMEP.O. Box 20010Nashville, TN 37202Note: If a re-enrolling supplier is not already enrolled to receive payments through electronic fundtransfer, the supplier should submit the CMS 588 form.• A new section was added for suppliers to provide a specific address of where the NSC shouldmail their re-enrollment packages. If a supplier would like to receive their reenrollment at anaddress other than the address where correspondences are received, the supplier should listthis address in section 2.A.3. This enhancement was made to provide all suppliers, especiallyDME MAC Jurisdiction C Supplier Manual Page 4

Supplier Enrollment Chapter 2those suppliers with multiple locations, a single address where they would like their reenrollmentpackages mailed.• Requires suppliers to provide the name and phone number of the insurance underwriter. TheNSC is required by CMS to contact the insurance underwriter to verify coverage and not theinsurance agent. Section 2.D requires suppliers to provide identifying information for both theinsurance agent and the underwriter. Providing this information will assist in facilitating theverification process.• A new section was added for suppliers to provide information concerning accreditation. CMS hastasked the NSC with collecting and storing this information. However, CMS has yet to issue afinal rule regarding accreditation. Therefore, until required, suppliers are not required to completethis section.• Requires suppliers list the state(s) where items or services are being provided. Section 4 iswhere suppliers will indicate what jurisdiction the majority of claims will be submitted and list theindividual states where items and services are provided. This information is being collected inorder to ensure suppliers are properly licensed in the states where they provide Medicarecovereditems to beneficiaries.Change of InformationAny changes or updates to information provided on the CMS 855S form must be reported to theNSC within 30 days after such changes have taken place (Supplier Standard #2).Updated information should be submitted on the CMS 855S form. Failure to provide the updatedinformation is grounds for denial or revocation of the Medicare supplier number.In order to timely receive information from the DME MACs, the NSC must have your correct address.The NSC maintains your correspondence address information and transmits this information to theDME MACs.Suppliers who are changing their correspondence or special payment address should be aware thatany mail returned as undeliverable might result in a “Do Not Forward” (DNF).When a DME MAC receives mail returned from the United States Postal Service, the contractor willstop payments and notify the NSC of the situation. The NSC will then notify the other DME MACs ofthe DNF issue and these contractors will also stop payments until the issue has been resolved withthe NSC.Be sure to attach all location specific licenses to any Change of Information form that includes achange of physical location. This will be required before any changes can be made to your supplierfile. This will serve as notice you should apply for any new location specific licenses from the specificlicensing board (such as Board of Pharmacy, business license offices, etc.) as quickly as possible toensure compliance with supplier standard #1.Further instructions on how to complete a change of information for various reasons may be found inthe “Supplier Enrollment/Change of Information” section of the NSC Website(www.PalmettoGBA.com/NSC).All CMS 855S forms and changes to previously submitted information must be sent to:Regular Mail AddressNational Supplier ClearinghouseAG-495P.O. Box 100142Columbia, SC 29202-3142DME MAC Jurisdiction C Supplier Manual Page 5

Supplier Enrollment Chapter 2Overnight Mail AddressNational Supplier ClearinghouseAG-4952300 Springdale Dr., Bldg 1Camden, SC 29020Participating/NonparticipatingA Medicare participating supplier is one who voluntarily enters into an agreement to acceptassignment for all services furnished to Medicare beneficiaries during a 12-month period, beginningJanuary 1 of each year. Suppliers who choose not to sign the participation contract are referred to asnonparticipating suppliers. Nonparticipating suppliers may choose to accept assignment on a claimby-claimbasis except where CMS regulations require mandatory assignment (i.e., Medicare covereddrugs, home dialysis equipment and supplies, Indian Health Services). Accepting assignment meansaccepting the Medicare approved amount as payment in full. Participation status is part of theenrollment process through the National Supplier Clearinghouse.Open enrollment forms (CMS-460, Medicare Participating DMEPOS Supplier Agreement) are mailedto all suppliers every November. If an existing nonparticipating supplier wants to becomeparticipating, then the agreement form must be received during open enrollment and postmarkedbefore December 31st of that year.If a participating supplier wants to become nonparticipating, they can request to becomenonparticipating by sending the request to the NSC on their company letterhead. The request mustbe postmarked and received before December 31st of that year to become nonparticipating effectiveJanuary 1st of the next year.New legislation each year provides incentives for suppliers to participate. These incentives areoutlined in the participation enrollment letter sent to all suppliers each year, along with other valuableinformation.Site VisitsSite Visits:• Are a tool used by the NSC to assist in making a determination as to whether or not asupplier is in compliance with the twenty-one supplier standards• Are conducted in all fifty states and territories• Are completed for initial applications, reenrollments and reactivations• Can and will be conducted at anytime if deemed necessaryThe site visit along with the application and supporting documentation are considered in making adetermination to issue, deny or revoke a supplier’s billing privileges. Refer to the NSC Web site foradditional information regarding site visits.DME MAC Jurisdiction C Supplier Manual Page 6

Supplier Enrollment Chapter 2Do Not ForwardThe DME MAC uses “return service requested” envelopes for all hardcopy checks and MedicareRemittance Notices (MRNs), allowing the U.S. Postal Service to return undeliverable mail. When thepost office returns checks or MRNs, the DME MAC will notify the NSC and cease generatingpayments to the supplier (whether the supplier is enrolled for Electronic Funds Transfer or receiveshardcopy checks) until the supplier furnishes a new address and that address is verified by the NSC.Directory of Medicare SuppliersCMS is responsible for producing a directory of all Medicare Suppliers. Please note, this directorywill not include any physicians or ambulatory surgical centers, but does include optometrists. Thedirectory of Medicare suppliers can be found online at http://www.medicare.gov/Supplier/Home.asp.Supplier StandardsMedicare regulations have defined standards a supplier must meet to receive and maintain asupplier number. These standards can be found on the NSC Web site atwww.PalmettoGBA.com/NSC under “Supplier Enrollment/Standards & Compliance/21 supplierStandards” and are listed below. The 21 supplier standards were finalized and became effectiveDecember 11, 2000.(a) Definitions. As used in this section, the following definitions apply:DMEPOS stands for durable medical equipment, prosthetics, orthotics and supplies.DMEPOS supplier means an entity or individual, including a physician or a Part A provider,which sells or rents Part B covered items to Medicare beneficiaries and which meets thestandards in paragraph (c) of this section. Medicare covered items means medical equipmentand supplies as defined in section 1834(j)(5) of the Act.(b) General rule. A DMEPOS supplier must meet the following conditions in order to be eligible toreceive payment for a Medicare-covered item:1. The supplier has submitted a completed application to CMS to furnish Medicare-covereditems including required enrollment forms. (The supplier must enroll separate physicallocations it uses to furnish Medicare-covered DMEPOS, with the exception of locations that ituses solely as warehouses or repair facilities.)2. The item was furnished on or after the date CMS issued to the supplier a DMEPOS suppliernumber conveying billing privileges. (The CMS issues only one supplier number for eachlocation.) This requirement does not apply to items furnished incident to a physician'sservice.3. The CMS has not revoked or excluded the DMEPOS supplier's privileges during the periodwhich the item was furnished has not been revoked or excluded.4. A supplier that furnishes a drug used as a Medicare-covered supply with durable medicalequipment or prosthetic devices must be licensed by the State to dispense drugs (A supplierof drugs must bill and receive payment for the drug in its own name. A physician, who isenrolled as a DMEPOS supplier, may dispense, and bill for, drugs under this standard ifauthorized by the State as part of the physician's license.)5. The supplier has furnished to CMS all information or documentation required to process theclaim.DME MAC Jurisdiction C Supplier Manual Page 7

Supplier Enrollment Chapter 2(c) Application certification standards. The supplier must meet and must certify in its applicationfor billing privileges that it meets and will continue to meet the following standards:1. Operates its business and furnishes Medicare-covered items in compliance with allapplicable Federal and State licensure and regulatory requirements;2. Has not made, or caused to be made, any false statement or misrepresentation of a materialfact on its application for billing privileges. (The supplier must provide complete and accurateinformation in response to questions on its application for billing privileges. The supplier mustreport to CMS any changes in information supplied on the application within 30 days of thechange.);3. Must have the application for billing privileges signed by an individual whose signature bindsa supplier;4. Fills orders, fabricates, or fits items from its own inventory or by contracting with othercompanies for the purchase of items necessary to fill the order. If it does, it must provide,upon request, copies of contracts or other documentation showing compliance with thisstandard. A supplier may not contract with any entity that is currently excluded from theMedicare program, any State health care programs, or from any other Federal GovernmentExecutive Branch procurement or non-procurement program or activity;5. Advises beneficiaries that they may either rent or purchase inexpensive or routinelypurchased durable medical equipment, and of the purchase option for capped rental durablemedical equipment, as defined in § 414.220(a) of this subchapter. (The supplier mustprovide, upon request, documentation that it has provided beneficiaries with this information,in the form of copies of letters, logs, or signed notices.);6. Honors all warranties expressed and implied under applicable State law. A supplier must notcharge the beneficiary or the Medicare program for the repair or replacement of Medicarecovered items or for services covered under warranty. This standard applies to all purchasedand rented items, including capped rental items, as described in Section 414.229 of thissubchapter. The supplier must provide, upon request, documentation that it has providedbeneficiaries with information about Medicare covered items covered under warranty, in theform of copies of letters, logs, or signed notices;7. Maintains a physical facility on an appropriate site. The physical facility must contain spacefor storing business records including the supplier's delivery, maintenance, and beneficiarycommunication records. For purposes of this standard, a post office box or commercialmailbox is not considered a physical facility. In the case of a multi-site supplier, records maybe maintained at a centralized location;8. Permits CMS, or its agents to conduct on-site inspections to ascertain supplier compliancewith the requirements of this section. The supplier location must be accessible duringreasonable business hours to beneficiaries and to CMS, and must maintain a visible signand posted hours of operation;9. Maintains a primary business telephone listed under the name of the business locally or tollfreefor beneficiaries. The supplier must furnish information to beneficiaries at the time ofdelivery of items on how the beneficiary can contact the supplier by telephone. The exclusiveuse of a beeper number, answering service, pager, facsimile machine, car phone, or anDME MAC Jurisdiction C Supplier Manual Page 8

Supplier Enrollment Chapter 2answering machine may not be used as the primary business telephone for purposes of thisregulation;10. Has a comprehensive liability insurance policy in the amount of at least $300,000 that coversboth the supplier's place of business and all customers and employees of the supplier. In thecase of a supplier that manufactures its own items, this insurance must also cover productliability and completed operations. Failure to maintain required insurance at all times willresult in revocation of the supplier's billing privileges retroactive to the date the insurancelapsed;11. Must agree not to contact a beneficiary by telephone when supplying a Medicare-covereditem unless one of the following applies:i. The individual has given written permission to the supplier to contact them bytelephone concerning the furnishing of a Medicare-covered item that is to be rentedor purchased.ii.iii.The supplier has furnished a Medicare-covered item to the individual and the supplieris contacting the individual to coordinate the delivery of the item.If the contact concerns the furnishing of a Medicare-covered item other than acovered item already furnished to the individual, the supplier has furnished at leastone covered item to the individual during the 15-month period preceding the date onwhich the supplier makes such contact.12. Must be responsible for the delivery of Medicare covered items to beneficiaries and maintainproof of delivery. (The supplier must document that it or another qualified party has at anappropriate time, provided beneficiaries with necessary information and instructions on howto use Medicare-covered items safely and effectively.);13. Must answer questions and respond to complaints a beneficiary has about the Medicarecovereditem that was sold or rented. A supplier must refer beneficiaries with Medicarequestions to the appropriate carrier. A supplier must maintain documentation of contacts withbeneficiaries regarding complaints or questions;14. Must maintain and replace at no charge or repair directly, or through a service contract withanother company, Medicare-covered items it has rented to beneficiaries. The item mustfunction as required and intended after being repaired or replaced;15. Must accept returns from beneficiaries of substandard (less than full quality for the particularitem or unsuitable items, inappropriate for the beneficiary at the time it was fitted and rentedor sold);16. Must disclose these supplier standards to each beneficiary to whom it supplies a Medicarecovereditem;17. Must comply with the disclosure provisions in § 420.206 of this subchapter;18. Must not convey or reassign a supplier number;19. Must have a complaint resolution protocol to address beneficiary complaints that relate tosupplier standards in paragraph (c) of this section and keep written complaints, relatedcorrespondence and any notes of actions taken in response to written and oral complaints.DME MAC Jurisdiction C Supplier Manual Page 9

Supplier Enrollment Chapter 2• Helpful hints for completing the CMS 855S• Numerous FAQs regarding the enrollment process• “The NSC Top Ten” – the top ten reoccurring issues that delay processing• Information regarding the NSC site visit process• Licensure information• A checklist to ensure the CMS 855S was completed properly and that all requireddocumentation has been providedThe NSC Customer Service Line (1-866-238-9652)NSC analysts are available Monday through Friday from 9:00am until 5:00pm (ET) to answerquestions regarding the enrollment process. If you have questions regarding supplier specificinformation, please be sure an individual listed on the supplier file contacts the NSC CustomerService Line. NSC analysts will not be able to give supplier specific information to someone who isnot listed on the supplier file. The NSC also has a voice mailbox available to Spanish suppliers whodo not speak English.NSC Email Address (medicare.NSC@PalmettoGBA.com)If preferred, suppliers can e-mail their questions to this address. Questions received will beanswered within a reasonable time frame. The NSC suggests suppliers do not submit protectedhealthcare information via e-mail.Interactive Voice Response (IVR) UnitThe NSC Interactive Voice Response (IVR) Unit allows suppliers to obtain:• General information regarding the enrollment process• Information on the appeals process• Status of a new application, reenrollment, reactivation or change of information• Instructions on how to obtain a CMS 855S• Contact information for the NSC, DME MACs and CMSThe IVR is available 24 hours a day, seven days a week (except for routine system maintenance)and can be accessed by calling the NSC Customer Service Line at 1-866-238-9652.Participating Supplier SurveyThe NSC conducts annual participating supplier (PAR) enrollment surveys and ensures that allsupplier billing numbers associated with one Employer Identification Number (EIN) have the samePAR selection. In the event that there is a difference of PAR selection within an EIN, the NSC willnegotiate and resolve the discrepancy with the supplier. If there are still mixed PAR selections, thesupplier (and all billing locations) will default to non-PAR status. This annual enrollment survey isalso the supplier's opportunity to change their participation status.DME MAC Jurisdiction C Supplier Manual Page 11

Supplier Enrollment Chapter 2Supplier Audit and Compliance Unit (SACU)The Supplier Audit and Compliance Unit (SACU) is tasked to review new applicants and existingsuppliers to determine if they are in compliance with current supplier standards. Most suppliers andsupplier organizations are interested in fraud and abuse control to protect their industry's image withthe public and Congress. This task is, by its nature, a cooperative effort. It involves somebeneficiaries, state Medicaid agencies, the DME MACs, and federal agencies such as the Centersfor Medicare & Medicaid Services (CMS), the Office of the Inspector General (OIG), the Departmentof Health and Human Services (DHHS), and the United States Attorney's Office (USAO).The SACU has the authority to deny new applicants and to recommend revocation to CMS and/orinactivate existing supplier numbers when it is determined that such suppliers are not in compliancewith the published standards. In addition, the Health Insurance Portability and Accountability Act(HIPAA) of 1996 created criminal and civil penalties for suppliers who submit fraudulent applicationsto a government health care organization. Fully developed cases are submitted for prosecution tothe U. S. Attorney's Office, Columbia, South Carolina. The U. S. Attorney has jurisdiction nationwidebecause all the applications are received, and the supplier numbers issued, by the NSC inColumbia, South Carolina.DME MAC Jurisdiction C Supplier Manual Page 12

Chapter Three √Supplier Documentation

Supplier Documentation Chapter 3General InformationBefore submitting a claim to the DME MAC, the supplier must have on file a dispensing order, thewritten order, the Certificate of Medical Necessity (CMN) (if applicable), the DME MAC InformationForm (DIF) (if applicable), information from the treating physician concerning the patient’sdiagnosis 1 , and any information required for the use of specific modifiers or attestation statements asdefined in certain DME PSC policies. The supplier should also obtain as much documentation fromthe patient's medical record as they determine they need to assure themselves that coveragecriterion for an item has been met. If the information in the patient's medical record does notadequately support the medical necessity for the item, the supplier is liable for the dollar amountinvolved unless a properly executed advance beneficiary notice (ABN) of possible denial has beenobtained.Documentation must be maintained in the supplier's files for seven (7) years.Definition of PhysicianPhysician means any of the following entities legally authorized to practice by a State in whichhe/she performs this function. The services performed by a physician within these definitions aresubject to any limitations posed by the State on the scope of practice.• Doctor of medicine;• Doctor of osteopathy (including osteopathic practitioner) - must be licensed to practice medicineand surgery;• Doctor of dental surgery or dental medicine;• Chiropractor (see below);• Doctor of podiatry (see below) or surgical chiropody, and;• Doctor of optometry.The following practitioners may document the medical necessity of durable medical equipment,prosthetics, orthotics and supplies (DMEPOS) items, including completing orders and Certificates ofMedical Necessity (CMNs), in place of a physician provided that they meet the practitionerrequirements defined in Chapter 15 of the Benefit Policy Manual, the services performed are withintheir scope of practice as defined by their State, and they are treating the beneficiary for thecondition for which the item is needed.• Physician Assistant• Nurse Practitioner• Clinical Nurse SpecialistThe term physician does not include such practitioners as Christian Science practitioner ornaturopath. There is no Medicare benefit for durable medical equipment, prosthetics, orthotics andsupplies (DMEPOS) items ordered by these entities.1 ICD-9 codes are required on all claimsDME MAC Jurisdiction C Supplier Manual Page 1

Supplier Documentation Chapter 3Medicare coverage for all items and services furnished or ordered by chiropractors, with theexception of treatment by means of manual manipulation of the spine to correct a subluxation, isstatutorily excluded. Therefore, all DMEPOS items ordered by chiropractors are denied.Medicare coverage for all items and services furnished or ordered by podiatrists is limited by Statestatutes governing the scope of practice for podiatry. DMEPOS suppliers should be familiar with thelimitations imposed by the statutes of the states in which they operate and dispense DMEPOS items.Claims submitted to the DME MAC, when furnished or ordered by podiatrists practicing outside thelimits of their licensures, will be denied as statutorily non-covered. Podiatrists are excluded bystatute from ordering a power operated vehicle (POV) or power wheelchair.OrdersDISPENSING ORDERSSuppliers must have an order from the treating physician before dispensing a DMEPOS item to abeneficiary. Except for items requiring a written order prior to delivery, the dispensing order may be awritten, fax or verbal order. The dispensing order must include:• A description of the item;• The beneficiary's name;• The name of the physician; and• The date of the order.The supplier must maintain written documentation of the dispensing order and this documentationmust be available upon request. Except for items requiring a written order prior to delivery (seebelow), if the supplier does not have an order from the treating physician before dispensing an item,it will be denied as not medically necessary.Written OrdersWritten orders are acceptable for all transactions involving DMEPOS. Written orders may take theform of a photocopy, facsimile image, electronically maintained, or original "pen-and-ink" document.(Reference: CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3,section 3.4.1.1.B.)All orders must clearly specify the start date of the order.For items that are dispensed based on a verbal order, the supplier must obtain a written order thatmeets the requirements of this section.If the written order is for supplies that will be provided on a periodic basis, the written order shouldinclude appropriate information on the quantity used, frequency of change, and duration of need.(For example, an order for surgical dressings might specify one 4 x 4 hydrocolloid dressing that ischanged 1-2 times per week for 1 month or until the ulcer heals.)The written order must be sufficiently detailed, including all options or additional features that will beseparately billed or that will require an upgraded code. The description can be either a narrativeDME MAC Jurisdiction C Supplier Manual Page 2

Supplier Documentation Chapter 3description (e.g., lightweight wheelchair base) or a brand name/model number.If the order is for a rented item or if the coverage criteria in a policy specify length of need, the ordermust include the length of need.If the supply is a drug, the order must specify the name of the drug, concentration (if applicable),dosage, frequency of administration, and duration of infusion (if applicable).Someone other than the physician may complete the detailed description of the item. However, thetreating physician must review the detailed description and personally sign and date the order toindicate agreement.If a supplier does not have a faxed, photocopied, electronic or pen and ink signed order in theirrecords before they submit a claim to Medicare (i.e., if there is no order or only a verbal order), theclaim will be denied. If the claim is for an item for which an order is required by statute (e.g.,therapeutic shoes for diabetics, oral anticancer drugs, oral antiemetic drugs which are a replacementfor intravenous antiemetic drugs), the claim will be denied as not meeting the benefit category and istherefore not appealable by the supplier (See CMS Manual System, Pub. 100-4, Medicare ClaimsProcessing Manual, Chapter 29, §10, 30.3, 60 for more information on appeals). For all other items,if the supplier does not have an order that has been both signed and dated by the treating physicianbefore billing the Medicare program, the item will be denied as not reasonable and necessary.If an item requires a CMN and if the CMN contains all the information described in this section, itmay serve as the detailed written order.Medical necessity information (e.g., an ICD-9-CM diagnosis code, narrative description of thepatient's condition, abilities, and limitations) is NOT in itself considered to be part of the orderalthough it may be put on the same document as the order.Written Order Prior To DeliveryCertain items require a written order prior to delivery. These items are listed below. For theseitems, the supplier must have received a written order that has been both signed and dated by thetreating physician and meets the requirements for orders before dispensing the item. If a supplierbills for an item without a written order, when the supplier is required to have a written order prior todelivery, the item will be denied as statutorily non-covered.Decubitus CareA4640 Replacement pad for use with medically necessary alternating pressure pad owned by patientE0181 Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy dutyE0182 Pump for alternating pressure pad, for replacement onlyE0184 Dry pressure mattressE0185 Gel or gel-like pressure pad for mattress, standard mattress length and widthE0186 Air pressure mattressE0187 Water pressure mattressE0188 Synthetic sheepskin padE0189 Lambs wool sheepskin pad, any sizeE0193 Powered air flotation bed (low air loss therapy)E0194 Air-fluidized bedDME MAC Jurisdiction C Supplier Manual Page 3

Supplier Documentation Chapter 3E0196 Gel pressure mattressE0197 Air pressure pad for mattress, standard mattress length and widthE0198 Water pressure pad for mattress, standard mattress length and widthE0199 Dry pressure pad for mattress, standard mattress length and widthE0277 Powered pressure-reducing air mattressE0371 Non-powered advanced pressure reducing overlay for mattress, standard mattress length andwidthE0372 Powered air overlay for mattress, standard mattress length and widthE0373 Non-powered pressure mattressSeat Lift MechanismE0172 Seat lift mechanism placed over or on top of toilet, any typeE0627 Seat lift mechanism incorporated into a combination lift-chair mechanismE0628 Separate seat lift mechanism for use with patient owned furniture-electricE0629 Separate seat lift mechanism for use with patient owned furniture-non-electricTranscutaneous Electrical Nerve Stimulator (TENS)E0720 TENS, two-lead, localized stimulationE0730 TENS, four-lead, larger area/multiple nerve stimulationE0731 Form fitting conductive garment for delivery of TENS or NMES (with conductive fibersseparated from the patient's skin by layers of fabric)Power Mobility DevicesK0800 Power operated vehicle, group 1 standard, patient weight capacity up to and including 300poundsK0801 Power operated vehicle, group 1 heavy duty, patient weight capacity, 301 to 450 poundsK0802 Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to 600 poundsK0806 Power operated vehicle, group 2 standard, patient weight capacity up to and including 300poundsK0807 Power operated vehicle, group 2 heavy duty, patient weight capacity 301 to 450 poundsK0808 Power operated vehicle, group 2 very heavy duty, patient weight capacity 451 to 600 poundsK0812 Power operated vehicle, not otherwise classifiedK0813 Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weightcapacity up to and including 300 poundsK0814 Power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to andincluding 300 poundsK0815 Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity upto and including 300 poundsK0816 Power wheelchair, group 1 standard, captains chair, patient weight capacity up to andincluding 300 poundsK0820 Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weightcapacity up to and including 300 poundsK0821 Power wheelchair, group 2 standard, portable, captains chair, patient weight capacity up to andincluding 300 poundsK0822 Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to andincluding 300 poundsK0823 Power wheelchair, group 2 standard, captains chair, patient weight capacity up to andincluding 300 poundsK0824 Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301to 450poundsK0825 Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 451 to 600poundsK0826 Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to600 poundsK0827 Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity 451 to600 poundsDME MAC Jurisdiction C Supplier Manual Page 4

Supplier Documentation Chapter 3K0828 Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601pounds or moreK0829 Power wheelchair, group 2 extra heavy duty, captains chair, patient weight capacity 601poundsor moreK0830 Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weightcapacity up to and including 300 poundsK0831 Power wheelchair, group 2 standard, seat elevator, captain’s chair, patient weightcapacity up to and including 300 poundsK0835 Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weightcapacity up to and including 300 poundsK0836 Power wheelchair, group 2 standard, single power option, captains chair, patient weightcapacity up to and including 300 poundsK0837 Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weightcapacity 301 to 450 poundsK0838 Power wheelchair, group 2 heavy duty, single power option, captains chair, patient weightcapacity 301 to 450 poundsK0839 Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patientweight capacity 451 to 600 poundsK0840 Power wheelchair, group 2 extra heavy duty, single power option, sling/solid seat/back, patientweight capacity 601 pounds or moreK0841 Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weightcapacity up to and including 300 poundsK0842 Power wheelchair, group 2 standard, multiple power option, captains chair, patient weightcapacity up to and including 300 poundsK0843 Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patientweight capacity 301 to 450 poundsK0848 Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to andincluding 300 poundsK0849 Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and Iincluding 300 poundsK0850 Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450poundsK0851 Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to 450poundsK0852 Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to600 poundsK0853 Power wheelchair, group 3 very heavy duty, captains chair, patient weight capacity, 451to 600poundsK0854 Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601pounds or moreK0855 Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601 poundsor moreK0856 Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weightcapacity up to and including 300 poundsK0857 Power wheelchair, group 3 standard, single power option, captains chair, patient weightcapacity up to and including 300 poundsK0858 Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weightcapacity 301 to 450 poundsK0859 Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weightcapacity 301 to 450 poundsK0860 Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patientweight capacity 451 to 600 poundsK0861 Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weightcapacity up to and including 300 poundsK0862 Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patientweight capacity 301 to 450 poundsDME MAC Jurisdiction C Supplier Manual Page 5

Supplier Documentation Chapter 3K0863 Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patientweight capacity 451 to 600 poundsK0864 Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patientweight capacity 601 pounds or moreK0868 Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to andincluding 300 poundsK0869 Power wheelchair, group 4 standard, captains chair, patient weight capacity up to andincluding 300 poundsK0870 Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301to 450poundsK0871 Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to600 poundsK0877 Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weightcapacity up to and including 300 poundsK0878 Power wheelchair, group 4 standard, single power option, captains chair, patient weightcapacity up to and including 300 poundsK0879 Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weightcapacity 301 to 450 poundsK0880 Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patientweight 451 to 600 poundsK0884 Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weightcapacity up to and including 300 poundsK0885 Power wheelchair, group 4 standard, multiple power option, captain’s chair, weightcapacity up to and including 300 poundsK0886 Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patientweight capacity 301 to 450 poundsK0890 Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weightcapacity up to and including 125 poundsK0891 Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weightcapacity up to and including 125 poundsK0898 Power wheelchair, not otherwise classifiedK0899 Power mobility device, not coded by SADMERC or does not meet criteriaE0984 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorizedwheelchair, tiller controlE0986 Manual wheelchair accessory, push activated power assist, eachAll codes for options/accessories for power wheelchairsWheelchair SeatingE0955 Wheelchair accessory, headrest, cushioned, prefabricated, including fixed mountinghardware, eachE0956 Wheelchair accessory, lateral trunk or hip support, prefabricated, including fixed mountinghardware, eachE0957 Wheelchair accessory, medial thigh support, prefabricated, including fixed mountinghardware, eachE0960 Wheelchair accessory, shoulder harness/straps or chest strap, including any typemounting hardwareE0966 Manual wheelchair accessory, headrest extension, eachE0992 Manual wheelchair accessory, solid seat insertE1028 Wheelchair accessory, manual swing-away, retractable or removable mounting hardwarefor joystick, other control interface or positioning accessoryE2291 Back, planar, for pediatric size wheelchair including fixed attaching hardwareE2292 Seat, planar, for pediatric size wheelchair including fixed attaching hardwareE2293 Back, contoured, for pediatric size wheelchair including fixed attaching hardwareE2294 Seat, contoured, for pediatric size wheelchair including fixed attaching hardwareE2601 General use wheelchair seat cushion, width less than 22 inches, any depthE2602 General use wheelchair seat cushion, width 22 inches or greater, any depthDME MAC Jurisdiction C Supplier Manual Page 6

Supplier Documentation Chapter 3E2603 Skin protection wheelchair seat cushion, width less than 22 inches, any depthE2604 Skin protection wheelchair seat cushion, width 22 inches or greater, any depthE2605 Positioning wheelchair seat cushion, width less than 22 inches, any depthE2606 Positioning wheelchair seat cushion, width 22 inches or greater, any depthE2607 Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depthE2608 Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any depthE2609 Custom fabricated wheelchair seat cushion, any sizeE2610 Wheelchair seat cushion, poweredE2611 General use wheelchair back cushion, width less than 22 inches, any height, including anytype mounting hardwareE2612 General use wheelchair back cushion, width 22 inches or greater, any height, including anytype mounting hardwareE2613 Positioning wheelchair back cushion, posterior, width less than 22 inches, any height,including any type mounting hardwareE2614 Positioning wheelchair back cushion, posterior, width 22 inches or greater, any height,including any type mounting hardwareE2615 Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any height,including any type mounting hardwareE2616 Positioning wheelchair back cushion, posterior-lateral, width 22 inches or greater, any height,including any type mounting hardwareE2617 Custom fabricated wheelchair back cushion, any size, including any type mountinghardwareE2618 Wheelchair accessory, solid seat support base (replaces sling seat), for use with manualwheelchair or lightweight power wheelchair, includes any type mounting hardwareE2619 Replacement cover for wheelchair seat cushion or back cushion, eachE2620 Positioning wheelchair back cushion, planar back with lateral supports, width less than 22inches, any height, including any type mounting hardwareE2621 Positioning wheelchair back cushion, planar back with lateral supports, width 22 inches orgreater, any height, including any type mounting hardwareK0734 Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depthK0735 Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depthK0736 Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches,any depthK0737 Skin protection and positioning wheelchair seat cushion, adjustable, width 22 inches or greater,any depthNegative Pressure Wound Therapy (NPWT)E2402 Negative pressure wound therapy electrical pump, stationary or portableRequirement of New OrdersA new order is required:1. When there is a change in the order for the accessory, supply, drug, etc.2. On a regular basis even if there is no change in the order; only if it is so specified in thedocumentation section of a particular medical policy.3. When an item is replaced.4. When there is a change of supplier.5. In cases where two or more suppliers merge, the resultant supplier should make allreasonable attempts to secure copies of all active CMNs or DIFs from the supplier(s)purchased. This document should be kept on file by the resultant supplier for futurepresentation to the DME MAC or DME PSC.DME MAC Jurisdiction C Supplier Manual Page 7

Supplier Documentation Chapter 3A new order is required when an item is being replaced because the item is worn or the patient’scondition has changed. The supplier’s records should also include beneficiary-specific informationregarding the need for the replacement item. This information should be maintained in the supplier’sfiles and be available to the DME MAC or DME PSC on request. Failure to provide the appropriatedocumentation or providing documentation that contains broad, nonspecific explanations will resultin claim(s) denial.A new physician’s order is required before replacing lost, stolen or irreparably damaged items toreaffirm the medical necessity of the item. Proof of loss or damage through documentation such as apolice report, picture, or corroborating statement should be submitted with the claim.For items that require a Certificate of Medical Necessity (CMN), the CMN may serve as the writtenorder if the narrative description in Section C is sufficiently detailed. If the item is one which requiresa written order prior to delivery, and the supplier uses the CMN as the written order, the suppliermust have received the fully completed CMN (original “pen and ink,” electronically maintained,photocopy, or facsimile image) before dispensing the item. For accessories, supplies, and drugsrelated to an item requiring a CMN, the CMN may serve as the written order if the narrativedescription in Section C is sufficiently detailed.Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders andCMNsA nurse practitioner or clinical nurse specialist may give the dispensing order and sign the writtenorder in the following situations:• They are treating the beneficiary for the condition for which the item is needed;• They are practicing independently of a physician;• They bill Medicare for other covered services using their own provider number; and• They are permitted to do all of the above in the State in which the services are rendered.A nurse practitioner or clinical nurse specialist may complete Section B and sign Section D of a CMNif they meet all the criteria described above for signing orders.Physician Assistant Rules Concerning Orders and CMNsPhysician assistants may provide the dispensing order and write and sign the written order if theysatisfy all the following requirements:• They meet the definition of physician assistant found in §1861(aa)(5)(A) of the Act;• They are treating the beneficiary for the condition for which the item is needed;• They are practicing under the supervision of a Doctor of Medicine or Doctor of Osteopathy;• They have their own UPIN; and• They are permitted to perform services in accordance with State law.Physician assistants may complete Section B and sign Section D of a CMN if they meet all thecriteria described above for signing orders.DME MAC Jurisdiction C Supplier Manual Page 8

Supplier Documentation Chapter 3Supply Replacement/Utilization – Evidence of Medical NecessityIf replacement supplies are needed for the therapeutic use of purchased DMEPOS, the treatingphysician must specify on the prescription, or on the CMN, the type of supplies needed and thefrequency with which they must be replaced, used, or consumed. DME PSCs evaluate supplyutilization information as part of the medical necessity determination for DMEPOS. They do notaccept "PRN" or "as needed" utilization estimates for supply replacement, use, or consumption.Absent a State law to the contrary or a supply utilization problem, the prescription or physician'scertification submitted for the DMEPOS may also serve as medical evidence for supply replacementclaims. However, when a prescription for DMEPOS is renewed or revised, supply utilizationinformation must be specified or updated by the physician on the CMN. DME PSCs assess thecontinuing medical necessity.The DME MACs and DME PSCs must establish procedures for monitoring the utilization ofreplacement supplies. DME MACs and DME PSCs must inform suppliers of the need to submitupdated medical information if the patient's condition materially changes the equipment, device, orsupply utilization requirements. Absent such notification, DME MACs and DME PSCs do not allowclaims for unexplained increases in supply utilization above the usage level they previouslydetermined as medically necessary. Suppliers shall provide this information with the claim whereindicated in published policy or to make it available to the DME MACs or DME PSC on request.If necessary or appropriate for a medical necessity determination, the DME PSC must ask thesupplier to obtain documentation from the treating physician, establishing the severity of the patient'scondition and the immediate and long term need for the equipment and the therapeutic benefits thepatient is expected to realize from its use. A claim of therapeutic effectiveness or benefit based onspeculation or theory alone cannot be accepted. When restoration of function is cited as a reason foruse of DMEPOS, the exact nature of the deformity or medical problem should be clear from themedical evidence submitted.Also, the manner in which the equipment or device will restore or improve the bodily function shouldbe explained by the treating physician.If the DME PSC is unsuccessful in obtaining medical information from the supplier for non-assignedclaims, it gives the beneficiary the opportunity to obtain the desired information from the supplier. If,after obtaining the requested information, a question of medical necessity remains, the DME PSCmedical staff must resolve the issue.Acceptability of Faxed Orders and Facsimile or Electronic CMNs or DIFsWhen reviewing claims and orders or auditing CMNs or DIFs for DMEPOS, DME MACs and DMEPSCs may encounter faxed, copied, or electronic orders, CMNs and DIFs in supplier files. Generally,DME MACs and DME PSCs should accept these documents as fulfilling the requirements for thesedocuments.The DME MACs and DME PSCs retain the authority to request additional documentation to supportthe claim. If a DME MAC or DME PSC finds indications of potential fraud or misrepresentation ofDME MAC Jurisdiction C Supplier Manual Page 9

Supplier Documentation Chapter 3these documents, or the claims submitted, they should refer the matter to the DME PSC fordevelopment.Certificates of Medical NecessityInformation on Certificates of Medical Necessity (CMNs) may be found in the chapter entitled"Certificates of Medical Necessity."Documentation in the Patient's Medical RecordFor any DMEPOS item to be covered by Medicare, the patient’s medical record must containsufficient documentation of the patient’s medical condition to substantiate the necessity for the typeand quantity of items ordered and for the frequency of use or replacement (if applicable). Theinformation should include the patient’s diagnosis and other pertinent information including, but notlimited to, duration of the patient’s condition, clinical course (worsening or improving), prognosis,nature and extent of functional limitations, other therapeutic interventions and results, pastexperience with related items, etc. If an item requires a CMN or DIF, it is recommended that a copyof the completed CMN or DIF be kept in the patient’s record. However, neither a physician’s order,nor a CMN nor a DIF nor a supplier-prepared statement nor physician attestation by itself providessufficient documentation of medical necessity, even though it is signed by the treating physician orsupplier. There must be information in the patient’s medical record that supports the medicalnecessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable)or information on a supplier-prepared statement or physician attestation (if applicable).The patient’s medical record is not limited to the physician’s office records. It may include hospital,nursing home, or home health agency records and records from other professionals including, butnot limited to, nurses, physical and occupational therapists, prosthetists, and orthotists.The documentation in the patient’s medical record does not need to be routinely sent to the supplieror to the DME MAC or DME PSC. However, the DME MAC or DME PSC may request thisinformation in selected cases. If the DME MAC or DME PSC does not receive the information whenrequested, or if the information in the patient’s medical record does not adequately support themedical necessity for the item, then for assigned claims, the supplier is liable for the dollar amountinvolved unless a properly executed advance beneficiary notice (ABN) of possible denial has beenobtained. See the chapter entitled "Claim Submission," (Limitation on Liability section) for informationon ABNBeneficiary AuthorizationSuppliers may only receive Medicare payment if the beneficiary assigns his or her Medicare benefitsto the supplier. Regulations authorize Medicare to pay for claims submitted by a supplier only if thebeneficiary or the person authorized to request payment on the beneficiary’s behalf assigns theclaims to the supplier and the supplier accepts assignment. For all claims submitted on or afterJanuary 1, 2005 payment shall be made to physicians and suppliers who have not obtained signedassignment of benefits (AOB) forms from beneficiaries when the service can only be paid on anassignment related basis (which includes any mandatory assignment situations and participatingphysician or supplier situations). When a supplier accepts assignment, the supplier must acceptDME MAC Jurisdiction C Supplier Manual Page 10

Supplier Documentation Chapter 3Medicare’s determination of the approved amount as the full fee for the service(s) rendered. Formore information about beneficiary authorization, see the chapter entitled "Claim Submission".Proof of DeliverySupplier Proof of Delivery Documentation RequirementsSuppliers are required to maintain proof of delivery documentation in their files. Documentation mustbe maintained in the supplier’s files for 7 years.Proof of delivery is required in order to verify that the beneficiary received the DMEPOS. Proof ofdelivery is one of the supplier standards as noted in 42 CFR, 424.57(12). For any services, whichdo not have proof of delivery from the supplier, such claimed items and services shall be denied andoverpayments recovered. Suppliers who consistently do not provide documentation to support theirservices may be referred to the OIG for investigation and/or imposition of sanctions.Proof of Delivery and Delivery MethodsFor the purpose of the delivery methods noted below, designee is defined as:“A person who can sign and accept the delivery of durable medical equipment on behalf ofthe beneficiary.”Suppliers, their employees, or anyone else having a financial interest in the delivery of the item areprohibited from signing and accepting an item on behalf of a beneficiary (i.e., acting as a designeeon behalf of the beneficiary). The relationship of the designee to the beneficiary should be noted onthe delivery slip obtained by the supplier (i.e., spouse, neighbor, etc.). The signature of the designeeshould be legible. If the signature of the designee is not legible, the supplier/shipping service shouldnote the name of the designee on the delivery slip.Suppliers may deliver directly to the beneficiary or the designee. An example of proof of delivery to abeneficiary is having a signed delivery slip, and it is recommended that the delivery slip include: 1)The patient’s name; 2) The quantity delivered; 3) A detailed description of the item being delivered;4) The brand name; and 5) The serial number. The date of signature on the delivery slip must be thedate that the DMEPOS item was received by the beneficiary or designee. In instances where thesupplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supplyshall be the date of service on the claim.If the supplier utilizes a shipping service or mail order, an example of proof of delivery would includethe service’s tracking slip, and the supplier’s own shipping invoice. If possible, the supplier’s recordsshould also include the delivery service’s package identification number for that package sent to thebeneficiary. The shipping service’s tracking slip should reference each individual package, thedelivery address, the corresponding package identification number given by the shipping service,and if possible, the date delivered. If a supplier utilizes a shipping service or mail order, suppliersshall use the shipping date as the date of service on the claim.DME MAC Jurisdiction C Supplier Manual Page 11

Supplier Documentation Chapter 3Suppliers may also utilize a return postage-paid delivery invoice from the beneficiary or designee asa form of proof of delivery. The descriptive information concerning the DMEPOS item (i.e., thepatient’s name, the quantity, detailed description, brand name, and serial number) as well as therequired signatures from either the beneficiary or the beneficiary’s designee should be included onthis invoice as well.For DMEPOS products that are supplied as refills to the original order, suppliers must contact thebeneficiary prior to dispensing the refill. This shall be done to ensure that the refilled item isnecessary and to confirm any changes/modifications to the order. Contact with the beneficiary ordesignee regarding refills should take place no sooner than approximately 7 days prior to thedelivery/shipping date. For subsequent deliveries of refills, the supplier should deliver the DMEPOSproduct no sooner than approximately 5 days prior to the end of usage for the current product. Thisis regardless of which delivery method is utilized. DME MACs shall allow for the processing of claimsfor refills delivered/shipped prior to the beneficiary exhausting his/her supply.ExceptionsExceptions to the preceding statements concerning the date(s) of service on the claim occur whenthe items are provided in anticipation of discharge from a hospital or nursing facility. A supplier maydeliver a DMEPOS item to a patient in a hospital or nursing facility for the purpose of fitting ortraining the patient in the proper use of the item. This may be done up to 2 days prior to the patient’santicipated discharge to their home. The supplier shall bill the date of service on the claim as thedate of discharge and shall use the Place of Service (POS) as 12 (Patient’s Home). The item mustbe for subsequent use in the patient’s home. No billing may be made for the item on those days thepatient was receiving training or fitting in the hospital or nursing facility.A supplier may not bill for drugs or other DMEPOS items used by the patient prior to the patient’sdischarge from the hospital or a Medicare Part A nursing facility stay. Billing the DME MAC forsurgical dressings, urological supplies, or ostomy supplies that are provided in the hospital or duringa Medicare Part A nursing facility stay is not allowed. These items are payable to the facility underPart A of Medicare. This prohibition applies even if the item is worn home by the patient from thehospital or nursing facility. Any attempt by the supplier and/or facility to substitute an item that ispayable to the supplier for an item that, under statute, should be provided by the facility, may beconsidered to be fraudulent. These statements apply to durable medical equipment delivered to apatient in hospitals, skilled nursing facilities (Place of Service = 31), or nursing facilities providingskilled services (Place of Service = 32).A supplier may deliver a DMEPOS item to a patient’s home in anticipation of a discharge from ahospital or nursing facility. The supplier may arrange for actual delivery of the item approximately 2days prior to the patient’s anticipated discharge to their home. The supplier shall bill the date ofservice on the claim as the date of discharge and shall use the Place of Service (POS) as 12(Patient’s Home).DME MAC Jurisdiction C Supplier Manual Page 12

Supplier Documentation Chapter 3Miscellaneous Documentation IssuesDelivery and Service ChargesDelivery and service are an integral part of oxygen and durable medical equipment (DME) suppliers’costs of doing business. Such costs are ordinarily assumed to have been taken into account bysuppliers (along with all other overhead expenses) in setting the prices they charge for covereditems and services. As such, these cost have already been accounted for in the calculation of the feeschedules. Therefore, separate delivery and service charges for DMEPOS items will not be allowedexcept in rare and unusual circumstances when the delivery is outside the normal range of asupplier’s sphere of operation. For example, a reasonable delivery charge might be allowed if asupplier had to deliver a DMEPOS item to a beneficiary who lived outside the supplier’s usualcustomer area and who had no access to a supplier located nearer. The supplier should fullydocument these "unusual circumstances" on claims filed for delivery charges.Same/Similar Equipment and Advance Beneficiary Notices (ABN)This concerns ANSI Reason Code M3 - "Equipment is the same or similar to equipment alreadybeing used.”Numerous claims for durable medical equipment are denied because the equipment involved is thesame as or similar to equipment already in the possession of the beneficiary. The statutory basis fordenial of such claims is medical necessity; therefore, the limitation of liability provision under Section1879 of the law applies.Liability is assessed on claims denied based on "same or similar equipment." DME suppliers areexpected to be familiar with DME PSC coverage policies and any additional pertinent informationthat may have an impact on medical necessity determinations. In order to be protected under thelimitation of liability provision, a supplier must provide a proper advance beneficiary notice (ABN) foreach item that it believes is likely to be denied as not medically necessary.There must be a specific, identifiable reason to believe that Medicare may not pay for certain DMEitems (e.g., "same or similar equipment"). This means that suppliers must obtain all the informationfrom beneficiaries possible in order to determine whether "same or similar equipment" has previouslybeen provided to that beneficiary. Suppliers should ask very specific questions when providing itemsto Medicare patients. The supplier should determine information such as:• the beneficiary’s correct Health Insurance Claim Number;• if the beneficiary has employer insurance or is enrolled in a Medicare Advantage Plan;• if the beneficiary currently has or had an identical or similar item in the past;• when the beneficiary received the items and if the items have been returned;• where the item will be used; and• Certificate of Medical Necessity (CMN) information.DME MAC Jurisdiction C Supplier Manual Page 13

Supplier Documentation Chapter 3The supplier should make certain that the beneficiary understands that items such as wheelchairsand power-operated vehicles are considered "similar equipment," and that Medicare will not coverboth items when they are used simultaneously. The supplier should strongly encourage thebeneficiary to inform the supplier if the medical need for the item changes and the beneficiaryrequires a different piece of equipment that serves a similar purpose. The Medicare program willonly allow items that meet the beneficiary’s current needs.For example, if a beneficiary is renting a manual wheelchair and his/her condition worsens to thepoint that only a different wheelchair, such as a power wheelchair, will meet his/her medical need,coverage will be allowed for the power wheelchair and the manual wheelchair will be denied assame or similar equipment.If there is no indication that same or similar equipment has been previously obtained, the supplierwould not have reason to provide an ABN. If the beneficiary or the beneficiary’s authorizedrepresentative is unable to respond fully on the issue of "same or similar equipment," the suppliermay issue an ABN. In situations where the beneficiary is planning to use a piece of equipment as abackup (e.g., an extra wheelchair to keep in the car), the supplier should ALWAYS obtain a signedABN. Please submit a copy of the ABN with each appeal request.Same or similar rules may not necessarily apply to situations where a new device with additionaltechnological features becomes available. The DME PSC must evaluate whether the new feature(s)meet the patient's medical need that is not met by the patient's current equipment. If the new featureor device meets a current medical need that is not met by the current equipment because theappropriate technology was not available at the time the patient obtained the item, even if there hasbeen no change in the beneficiary's condition, the 5-year useful lifetime rules do not apply and thenew item may be provided. However, if the new item is meeting the same medical need as the olditem but in a more efficient manner or is more convenient, AND there is no change in thebeneficiary's condition, Medicare will not reimburse for the new item.The following examples illustrate these instructions.1. The beneficiary receives a power wheelchair without power tilt/recline. Subsequently, it isdetermined that the beneficiary needs a tilt/recline AND he/she has needed it since theprovision of the initial power wheelchair. Often, the old wheelchair base will notaccommodate the new tilt/recline system; therefore, in addition to the tilt/recline, the supplierasks for a wheelchair base to be reimbursed. In this case one of the following options wouldapply:A. If the old wheelchair is rented, allow additional amount for the tilt/recline but not a new rentalperiod for the new wheelchair base.B. If the old wheelchair was purchased, allow only for reimbursement of the tilt/recline and notthe purchase of a new wheelchair base.2. Code E2101 represents a new code for a home glucose monitor that integrates the lancingand application of blood to the glucose testing strip in one machine. The Glucose MonitorsLocal Coverage Determination (LCD) allows payment for these devices for the beneficiarieswith manual dexterity problems. If a beneficiary had manual dexterity problems at the timeDME MAC Jurisdiction C Supplier Manual Page 14

Supplier Documentation Chapter 3that an E0607 monitor was purchased and the technology of monitors coded E2101 was notavailable at the time the beneficiary obtained the E0607, they would be allowed to purchasethe E2101 to address their medical need for a monitor that accommodates their dexterityproblem. No "same or similar" denial would apply. The E0607 did not accommodate theirmedical need and while their medical need did not change, technology changed such thattheir medical need could now be met by the new technology.These rules apply when the new device with advanced features is classified by the sameHCPCS code as the older device, or when described by a different HCPCS code. However, ifthe new device is described by a different code, the patient must also meet the coverage criteriaof the new item.Pick-up SlipsMedicare regulation specifically forbids payments for multiple claims for rental of the same orsimilar equipment from either the same or a different supplier during the same rental month.For purposes of this section, a pick-up slip is written confirmation, provided by a supplier, thatthe supplier has removed an item of DME from the beneficiary’s home. When makingdeterminations, DME PSCs must ascertain not only whether equipment is present in the home,but must determine which equipment is actually being used by the patient. Therefore, it isinappropriate to determine, solely based on lack of a pick up slip that a piece of equipment maystill be in use. Likewise, it is inappropriate for DME PSCs to deny claims solely based on lack ofa pick up slip. DME PSCs should develop theseclaims to determine which piece of equipment is medically necessary.Starting a New Capped Rental PeriodThis defines two major reasons a new rental period would begin for a similar (same code) or related(different code) item of durable medical equipment (DME) that is in the Capped Rental paymentcategory. These statements reflect current national policy and are provided as a clarification inresponse to inquiries from suppliers.1. For an item described by the same code, a new capped rental period would begin ifthere has been an interruption in the medical necessity for the item and thatinterruption lasted for 60-plus consecutive days.If there is an interruption in the billing of a capped rental DME item to the DME MAC becausethe patient is in a hospital and/or nursing facility or enrolls in a Medicare Advantage Plan orhospice program, a new capped rental period does not automatically begin if/when billing tothe DME MAC resumes. If the billing is for the same item, or for a similar item using thesame code, a new capped rental period would begin if there has been an interruption in themedical necessity for the item and that interruption lasted for 60-plus consecutive days.CMS defines a 60-plus consecutive day interruption as a period including two full rentalmonths plus whatever days are remaining in the rental month during which the need ends.An interruption in medical necessity is defined as a resolution of the condition that createdDME MAC Jurisdiction C Supplier Manual Page 15

Supplier Documentation Chapter 3the first period of medical necessity and the subsequent development of a second event thatcreates a new period of medical necessity.For example, a patient has a wheelchair following a major injury to his legs. Rental starts onJanuary 15 and rentals are billed on the 15th of the subsequent months (e.g., February andMarch). The patient recovers and does not need the wheelchair anymore, and returns thewheelchair on March 25. The patient subsequently has another injury and again needs asimilar wheelchair (same code). A new capped rental period would begin if the wheelchair isprovided in the home on or after June 15. This is an interruption of two full rental months,April and May, plus the remainder of the month of discontinuation, March 25 through April14. Note: In this example, if a similar wheelchair (same code) is needed and is provided inthe home prior to June 15, a new capped rental period would not start because there is not a60-plus consecutive day interruption of medical necessity.A new capped rental period does not start just because there is an interruption in billing tothe DME MAC. For example, if the patient is in the middle of a capped rental period for awheelchair that was needed because of permanent hemiplegia from a stroke, and isadmitted to a hospital and/or nursing facility for 60-plus days, or enrolls in a hospice programfor 60-plus days, the capped rental period for the wheelchair resumes where it left off oncethe patient returns home or disenrolls from the hospice program, even if it is from a differentsupplier. Even though billing to the DME MAC was interrupted, there was no interruption inthe medical necessity for the wheelchair. For purposes of this instruction, CMS hasinterpreted an end to medical necessity to include enrollment in an Medicare Advantage Planfor 60 or more days.2. For an item described by a different code, a new capped rental period would begin ifthere is a substantive change in the patient’s condition that necessitates asignificantly different item.For example, a patient has a K0001 wheelchair for short-term use following an injury. Thepatient then has a stroke, which results in a dense hemiplegia and, after a one month stay ina hospital and skilled nursing facility, it is determined that a K0004 wheelchair is needed. Anew capped rental period would begin for the K0004 wheelchair because there had been asubstantive change in the patient’s condition and a significantly different item was provided.In another example, a patient who meets the criteria for a group II support surface isprovided a powered mattress overlay (E0372). After three months, the pressure ulcers healand the patient is switched to a group I mattress (e.g., E0186). A new capped rental periodwould begin for the group I mattress because there has been a substantive change in thepatient’s condition and a significantly different item was provided.Note: The following groups of support surfaces will be considered "significantly different" forpurposes of starting a new capped rental period: group 1 overlays, group 1 mattresses,group 2 overlays, group 2 mattresses and beds, group 3 beds.If the patient again develops a Stage IV pressure ulcer, restarts the powered mattressoverlay (E0372), and meets the criteria for a group II support surface, the capped rentalDME MAC Jurisdiction C Supplier Manual Page 16

Supplier Documentation Chapter 3period would restart at the month in which it had been discontinued. If a significantly differentitem (e.g., E0277) in group II was started, a new capped rental period would begin.For support surfaces, a new capped rental period does not start just because an item withanother code was provided, if that item is not significantly different from the prior item (seegroupings above). An example would be a patient who has a Stage IV pressure ulcer, meetscoverage criteria for a group II support surface, and is furnished with a powered mattressoverlay (E0372). If the ulcer worsens and the patient is switched to a non-powered group IIoverlay (E0371), a new capped rental period does not start, even if it is a different supplier.This is because even though the patient’s condition changed, the new item is not significantlydifferent from the previous item. However, if the patient had been switched to a group IImattress (e.g., E0277) a new capped rental period would start because there had been asubstantive change in the patient’s condition and a significantly different item was provided.The following guidelines pertain to claim submission for both situations 1 and 2 above. If asupplier is billing for a new capped rental period, the code must have the KH modifier and, ifa Certificate of Medical Necessity (CMN) is required for the code, an initial CMN mustaccompany the claim. When the DME MAC receives a claim for a capped rental code thathas been previously approved and there has been any interruption of billing to the DMEMAC, the presumption is that there has been no interruption in medical necessity for theitem, unless it is clearly documented. Therefore, if there is a 60-plus day interruption of billingfor a code and the supplier thinks that starting a new capped rental period is justified,narrative documentation must accompany the claim. The documentation must include, but isnot limited to:1. a description of the patient’s prior medical condition that necessitated the previousitem,2. a statement explaining when and why the medical necessity for the previous itemended, and3. a statement explaining the patient’s new or changed medical condition and when thenew need began.This information must be entered in the HA0 record of an electronic claim, or attached to apaper claim.Though suppliers should always try to determine whether a beneficiary has had the same orrelated equipment before, there are situations in which a supplier may submit an initial claimfor a capped rental item not knowing that another supplier has previously been approved forthe same or related code. Since in this situation additional narrative documentation justifyingthe start of a new capped rental period will not have been sent with the claim, the DME MACwill presume that there has been no substantial change in the medical necessity for the item.If coverage criteria for the item are met and the code is approved, the modifier will bechanged from a KH to a KI or KJ as appropriate to indicate that it is being processed andpaid as a continuation of a previous capped rental situation. If the new supplier disagreeswith this determination, they can obtain the information described in the previous paragraphand submit the claim as an appeal.DME MAC Jurisdiction C Supplier Manual Page 17

Supplier Documentation Chapter 3Backup EquipmentBackup medical equipment is defined as an identical or similar device that is used to meet the samemedical need for the patient but is provided for precautionary reasons to deal with an emergency inwhich the primary piece of equipment malfunctions. Medicare does not pay separately or make anadditional payment for backup equipment.When a determination is made that if a particular piece of equipment breaks down or malfunctions itwill result in immediate life-threatening consequences for the patient, Medicare will place that item inthe frequent and substantial servicing payment category. For items in this payment category, thesupplier receives monthly rental payments for as long as the equipment is medically necessary.However, the supplier is responsible for ensuring that there is an appropriate and acceptablecontingency plan to address any emergency situations or mechanical failures of the equipment.The expectation is that an acceptable plan would involve input from the patient and the treatingphysician, and would take into account the severity of the patient’s condition and time restraints inproviding emergency support. This means that the supplier is responsible for ensuring that thepatient’s medical needs for the use of this equipment will be met on a continuous and ongoing basisand that there is a plan to deal with any interruptions in the use of the equipment that would be lifethreateningto the patient. The plan may be as simple as the supplier furnishing backup equipment;however, Medicare will not pay separately and/or make any additional payment for the backupequipment. The payment for the primary piece of equipment would include the cost of that piece ofequipment and the frequent and substantial servicing plan that the supplier must provide to ensurethat the patient always has a piece of equipment that is in working order. If the backup equipment isbilled, it will be denied as not being reasonable and necessary.Backup equipment must be distinguished from multiple medically necessary items that are definedas identical or similar devices, each of which meets a different medical need for the patient. AlthoughMedicare does not pay separately for backup equipment, Medicare will make separate payment for asecond piece of equipment if it is required to serve a different purpose that is determined by thepatient’s medical needs.Examples (not all-inclusive) of situations in which multiple items may be covered are:1. A patient requires one type of ventilator (e.g., a negative pressure ventilator with a chestshell) for part of the day and needs a different type of device (e.g., positive pressurerespiratory assist device with a nasal mask) during the rest of the day.2. A patient who is confined to a wheelchair requires a ventilator mounted on the wheelchair foruse during the day and needs another ventilator of the same type for use while in bed.Without both pieces of equipment the patient may be prone to certain medical complications,may not be able to achieve certain appropriate medical outcomes, or may not be able to usethe medical equipment effectively.3. A patient requires one type of infusion pump for a particular drug (e.g., a pump with patientcontrol features for parenteral morphine) and needs a different type of pump for another drug(e.g., continuous infusion chemotherapy).DME MAC Jurisdiction C Supplier Manual Page 18

Supplier Documentation Chapter 3Examples (not all-inclusive) of situations in which a second or other multiple piece of equipmentwould be considered a backup and therefore would not be covered are:1. A ventilator-dependent patient is confined to bed and a second ventilator of the same orsimilar type is provided at the bedside as a precaution in case of malfunction of the primaryventilator.2. The drug epoprostenol (Flolan®) is administered using an ambulatory infusion pump, and asecond infusion pump is provided and billed as a precaution in case of malfunction of theprimary pump. Because interruption of a continuous infusion of this drug results in immediatelife-threatening consequences, a unique code, K0455, has been established for an infusionpump used to administer this drug, and the code is in the frequent and substantial servicingpayment category.Medicare Advantage Plan Beneficiaries Transferring to Fee-For-Service MedicareAs explained in the "Documentation" chapter, a beneficiary who was previously enrolled in aMedicare Advantage Plan, returning to traditional Fee-For-Service (FFS) Medicare, is subject to thesame benefits, rules, requirements, and coverage criteria as a beneficiary who has always beenenrolled in FFS Medicare. When a beneficiary returns to FFS Medicare, it is as though he or she hasbecome eligible for Medicare for the first time. Therefore, if a beneficiary received any items orservices from their Medicare Advantage Plan, they may only continue to receive such items andservices if they would be entitled to them under FFS Medicare coverage criteria and documentationrequirements.For example, a beneficiary who has obtained a capped rental item (e.g., hospital bed) through anMedicare Advantage Plan must, under traditional FFS Medicare, obtain a Certificate of MedicalNecessity (CMN) if applicable and meet FFS Medicare criteria for the item before a new cappedrental period would begin.There is an exception to this rule when a beneficiary was previously enrolled in FFS and received acapped rental item, then enrolled in a Medicare Advantage Plan, stayed with the MedicareAdvantage Plan for 60 or fewer days, then returned to FFS. Enrollment in a Medicare AdvantagePlan for 60 or more days would be considered an end to medical necessity.Another partial exception to this rule involves home oxygen claims. If a beneficiary begins takingoxygen while under a Medicare Advantage Plan, the supplier must obtain an initial CMN and submitit to the DME MAC at the time that FFS coverage begins. However, the beneficiary does not have toobtain the blood gas study on the CMN within 30 days prior to the date on the CMN, but the testmust be the most recent study the patient obtained while in the Medicare Advantage Plan, under theguidelines specified in DME PSC policy. It is important to note, just because a beneficiary qualifiedfor oxygen under a Medicare Advantage Plan, it does not necessarily follow that s/he will qualify foroxygen under FFS. These instructions apply whether a beneficiary voluntarily returns to FFS, or ifs/he involuntarily returns to FFS because their Medicare Advantage Plan no longer participates inthe Medicare+Choice program.DME MAC Jurisdiction C Supplier Manual Page 19

Supplier Documentation Chapter 3Suppliers should maintain open communication with beneficiaries and determine, prior to delivery ofan item or continued rental, whether there has been a change in enrollment from a MedicareAdvantage Plan to FFS Medicare.Comprehensive Error Rate Testing (CERT)The Centers for Medicare & Medicaid Services (CMS) developed the CERT program to producenational, contractor-specific, and service-specific claim error rates. The program has independentreviewers who periodically review representative random samples of Medicare claims. Theindependent reviewers medically review claims that are paid and claims that are denied to ensurethe decision was appropriate. CERT was implemented in order to achieve goals of the GovernmentPerformance and Results Act of 1993, which sets performance measurements for Federal agencies.Each month, the CERT contractor selects a random sample of claims processed by each Medicarecontractor. They then request medical records, Certificates of Medical Necessities, and supportingdocumentation from the provider of the service to verify services billed were delivered, medicallynecessary, and the appropriateness of claims processing procedures. If contacted, you will beprovided with the details regarding the needed information and how to submit it.When no medical records or supporting documentation are received, a denial decision is madewhich ultimately results in a request for refund from the provider if the claim had been paid originally.These claims may be appealed through normal channels at the DME MAC.When records/documentation is received, the CERT contractor’s medical review staff (includesnurses, physicians, and other qualified healthcare practitioners) then performs a complete review ofthe claims. If documentation fails to support the item(s) billed, an error is called. A refund will berequested from the provider. Documentation that supports the medical need will result in no furtheraction needed by the provider.Additional information about CERT may be found at the CMS Web site, www.cms.hhs.gov/cert orthrough our Web site, www.cignagovernmentservices.com.DME MAC Jurisdiction C Supplier Manual Page 20

Chapter Four √Certificates of Medical Necessity (CMNs)

CMNs Chapter 4Certificates of Medical Necessity (CMNs) and DME MAC InformationForms (DIFs)A Certificate of Medical Necessity (CMN) or DME Information Form (DIF) is required to helpdocument the medical necessity and other coverage criteria for selected durable medical equipment,prosthetics, orthotics and supplies (DMEPOS) items. The Documentation section of the medicalpolicy shows which items require one of these forms. CMNs contain four sections, A through D.Sections A and C are completed by the supplier and Sections B and D are completed by thephysician. A DIF is completed and signed by the supplier. It does not require a narrative descriptionof equipment and cost or a physician signature.For certain items or services billed to a DME MAC, the supplier must receive a signed CMN from thetreating physician. A supplier must have a faxed, photocopied, original signed order or an electronicCMN in their records before they can submit a claim for payment to Medicare. CMNs and DIFs arereferred to by their CMS form numbers. The CMS form number is located in the bottom left corner ofthe form. DME MAC form numbers identify the CMN on electronic claims submitted to the DMEMAC.A faxed, photocopied, original signed order, or an electronic signed CMN/DIF must be maintained bythe supplier and be available to the DME MAC or DME PSC on request. When hardcopy CMNs/DIFsare submitted to the DME MAC or DME PSC, the supplier must include a copy of the front side.When CMNs are submitted electronically to the DME MAC or DME PSC, information from sections Aand B are required.In 2006, the Centers for Medicare and Medicaid Services (CMS) developed new and improvedCertificates of Medical Necessity (CMNs) and DME MAC Information Forms (DIFs). These changesare indicated below.The new CMN/DIF forms must be used for CMN/DIFs received on or after July 1, 2007. The oldCMN forms are no longer valid.Newly Revised FormsThe following table indicates the newly revised DME MAC CMN forms.Note: The title of the CMS form 484 for Home Oxygen Therapy changed to Oxygen. In addition, thetitle of CMS form 846 was changed from Lymphedma Pumps to Pneumatic Compression Devices.DME MAC FORM CMS FORM ITEMS ADDRESSED484.03 484 Oxygen04.04B 846 Pneumatic CompressionDevices04.04C 847 Osteogenesis Stimulators06.03B 848 Transcutaneous ElectricalNerve Stimulators (TENS)07.03A 849 Seat Lift Mechanisms11.02 854 Section C Continuation FormDME MAC Jurisdiction C Supplier Manual Page 1

CMNs Chapter 4Suppliers and physicians may choose to utilize electronic CMNs (e-CMNs) or electronic DIFs (e-DIFs). E-CMNs or e-DIFs must adhere to all privacy, security, and electronic signature rules andregulations promulgated by CMS and DHHS. Additionally, e-CMNs or e-DIFs must contain identicalquestions/wording to the CMS forms, in the same sequence, with the same pagination, and identicalinstructions/definitions as printed on the back of the hardcopy form.When a DME PSC is investigating potentially fraudulent behavior by a supplier, it will be thesupplier's responsibility to prove the authenticity/validity of the claim(s) under investigation. A DMEPSC may require the supplier to prove the authenticity/validity of the signature on the CMN, DIF,order, or any other questionable portion of the claim(s) under investigation.Changes to a Completed CMNIf there is a change made to any section of the CMN after the physician has signed theCMN, the physician must line through the correction and initial and date the correction; orthe supplier may choose to have the physician complete a new CMN.Physicians Charging for CMN CompletionCharging suppliers a fee for completing Medicare required CMNs may be considered a potentialfelony by the Office of Inspector General (OIG). When physicians bill for their services, includingexamination, diagnosis, and treatment, any costs associated with paperwork are considered part ofthe charges made for their professional services. If a physician’s patient genuinely needs an item ofdurable medical equipment, the completion of a CMN is a service to the physician’s patient ratherthan the supplier.CMNs as Orders and Claim SubmissionThe CMN can serve as the physician's order if the narrative description in section C is sufficientlydetailed. This would include quantities needed and frequency of replacement on accessories,supplies, nutrients, and drugs. For items requiring a written order prior to delivery (pressure reducingpads, mattress overlays, mattresses and beds, seat lift mechanisms, TENS units, and poweroperated vehicles) suppliers may utilize a completed and physician-signed CMN for this purpose.Otherwise, a separate order in addition to a subsequently completed and signed CMN is necessary.The supplier may not complete the information in section B of the CMN. A supplier who knowinglyand willfully completes section B of the form is subject to a civil monetary penalty up to $1,000 foreach form or document so distributed.The fee schedule amount, narrative description of the items furnished, and the supplier's charge forthe medical equipment or supplies being furnished must be completed on the form by the supplierprior to it being furnished to the physician. A supplier who knowingly and willfully fails to include thisinformation may be subject to a civil monetary penalty up to $1,000 for each form or document sodistributed.If an item requires a CMN or a DIF and the supplier does not have a faxed, photocopied, or originalDME MAC Jurisdiction C Supplier Manual Page 4

CMNs Chapter 4hardcopy, or an electronic signed CMN or DIF in their records before they submit a claim toMedicare, the claim will be denied. If the CMN or DIF is used to verify that statutory benefitrequirements have been met, then the claim will be denied as not meeting the benefit category.In cases where two or more suppliers merge, the resultant supplier should make all reasonableattempts to secure copies of all active CMNs or DIFs from the supplier(s) purchased. This documentshould be kept on file by the resultant supplier for future presentation to the DME MAC or DME PSC.When reviewing claims where the medical record contains a copied, faxed, or electronicallymaintained CMN or DIF (any CMN or DIF created, modified, and stored via electronic means suchas commercially available software packages and servers), the DME MAC and DME PSC mustaccept the copied, faxed, or electronic document as fulfilling the requirements for these documents.Upon request by the DME MAC and DME PSC, suppliers must provide the CMN or DIF, in a formatthat the DME MAC and DME PSC can accept, in a timely manner. Upon medical review, the DMEMAC and DME PSC should not deny claims solely because the CMN or DIF is faxed, copied, orelectronic. The DME MAC or DME PSC may request the supplier to download and print a hard copyof an electronic order, CMN, or DIF if the DME MAC or DME PSC cannot access it electronically.For items that require a CMN, and for accessories, supplies, and drugs related to an item requiring aCMN, the CMN may serve as the written order if the narrative description in Section C is sufficientlydetailed (as described above). This applies to both hard copy and electronic orders or CMNs. A DIFdoes not contain a section for a narrative description and thus is not applicable.A supplier must have a hard copied, faxed, or electronic order, CMN, or DIF in their records beforethey can submit a claim for payment to Medicare. Suppliers must ensure the security and integrity ofelectronically maintained CMNs or DIFs are in accordance with any regulations published by CMS.The DME MACs or DME PSCs need not make any shared system changes to electronically accepte-CMNs or DIFs as CMS views e-CMNs or DIFs as a transaction between the physician andsuppliers. Suppliers must continue to use current systems for transmitting claim information to theDME MAC or DME PSC.Supporting Medical DocumentationInformation on supporting medical documentation may be found in the chapter entitled"Documentation Requirements."DME MAC Jurisdiction C Supplier Manual Page 5

CMNs Chapter 4Evidence of Medical Necessity: Wheelchair and Power OperatedVehicle (POV) ClaimsThe use of the Certificates of Medical Necessity (CMNs) for motorized wheelchairs, manualwheelchairs and power operated vehicles was phased out for claims with dates of service (DOS) onor after May 5, 2005.For claims with dates of service before May 5, 2005, claims shall be submitted and processed usingthe fully completed and signed CMNs (CMS-843 for motorized wheelchairs, CMS-844 for manualwheelchairs, CMS-850 for power operated vehicles, and CMS-854 Section C Continuation Form).Since MMA §302 allows physicians, physician assistants, nurse practitioners, or clinical nursespecialists to prescribe power mobility devices, it is no longer necessary to require a specialist inphysical medicine, orthopedic surgery, neurology or rheumatology to provide a written prescriptionfor POVs.The physician or treating practitioner (a physician assistant, nurse practitioner or clinical nursespecialist) must conduct a face-to-face examination of the beneficiary and write a written prescriptionfor the power mobility device (PMD).The written prescription must include the beneficiary’s name; the date of the face-to-faceexamination; the diagnoses and conditions that the PMD is expected to modify; a description of theitem; the length of need; the physician or treating practitioner’s signature; and the date theprescription is written.The written prescription for the PMD must be in writing and signed and dated by the physician ortreating practitioner (a physician assistant, nurse practitioner, or clinical nurse specialist) whoperformed the face-to-face examination. The face-to-face examination requirement does not applywhen only accessories for power mobility devices are being ordered.The physician or treating practitioner must submit a written prescription for the PMD to the supplier.This written prescription for the PMD must be received by the supplier within 30 days after the faceto-faceexamination. For those instances of a recently hospitalized beneficiary, the writtenprescription must be received by the supplier within 30 days after the date of discharge from thehospital.Prior to dispensing a PMD, the DME supplier must obtain from the physician or treating practitionerwho performed the face-to-face examination the written prescription accompanied by supportingdocumentation of the beneficiary’s need for the PMD in the home. Pertinent parts from thedocumentation of the beneficiary’s PMD evaluation may include the history, physical examination,diagnostic tests, summary of findings, diagnoses, and treatment plans. The physician or treatingpractitioner should select only those parts of the medical record that clearly demonstrate medicalnecessity for the PMD. The parts of the medical record selected should be sufficient to delineate thehistory of events that led to the request for the PMD; identify the mobility deficits to be corrected bythe PMD; and document that other treatments do not obviate the need for the PMD, that thebeneficiary lives in an environment that supports the use of the PMD and that the beneficiary orcaregiver is capable of operating the PMD.DME MAC Jurisdiction C Supplier Manual Page 6

CMNs Chapter 4In most cases, the information recorded at the face-to-face examination will be sufficient. However,there may be some cases where the physician or treating practitioner has treated a patient for anextended period of time and the information recorded at the face-to-face examination refers toprevious notes in the medical record. In this instance, those previous notes would also be needed.The physician, treating practitioner, or supplier that is a HIPAA covered entity should make sure toremove or edit any materials that may be contained within the medical record that are not necessaryto support the prescription. For example, a gynecologic report would not be needed in the recordssubmitted for a beneficiary whose clinical need for a PMD is based solely on disability secondary toa stroke.As defined in the CMS Manual System (Pub. 100-8, Medicare Program Integrity Manual), chapter 3,if data analysis indicates potentially aberrant billing, contractors shall continue to follow the guidanceas defined when performing medical review on claims with dates of service on or after May 5, 2005.Evidence of Medical Necessity for the Oxygen CMNIf DME PSCs learn that the physician of record is no longer the treating physician, the supplier shallobtain from the physician currently responsible for the patient's pulmonary condition a current fullycompletedoxygen CMN. After review of this oxygen CMN, DME MACs continue monthly payments ifthe evidence establishes medical necessity. Their records must be updated to identify the newtreating physician.For more information concerning coverage and claim submission for oxygen therapy, refer toChapter 9.Initial CertificationsFor the situations that require an initial oxygen CMN, refer to the local coverage determination (LCD)entitled "Oxygen and Oxygen Equipment." In determining coverage, the dates of treatment andtesting are critical. For example, the initial date of need for home oxygen coverage cannot precedethe date of the order or the date of the test(s), the results of which are used to determine if thecoverage criteria are met. Once coverage is established, the estimated length of need, along withthe circumstances and results of testing that established the medical necessity at the start of homeoxygen therapy, will determine when recertification is necessary.Qualifying tests must be conducted by the treating physician or a provider certified to conduct suchtests. Because of the potential for conflict of interest, however, the results of oximetry testsconducted by a DME supplier cannot be accepted to establish the need for home oxygen therapyservices, either in initial claims or when accompanying recertification CMNs. This prohibition doesnot extend to the results of tests conducted by a hospital that is a certified provider of such servicesthat may also be furnishing home oxygen therapy to the patient.The date of oxygen testing must be within 30 days prior to the date of initial certification. Therefore,for initial oxygen certifications, the CMN may by completed by the physician no more than 30 daysprior to initial coverage of oxygen. An exception to this is if a beneficiary begins taking oxygen whileunder a Medicare Advantage Plan, the supplier must obtain an initial CMN and submit it to the DMEMAC at the time that FFS coverage begins. However, the beneficiary does not have to obtain theDME MAC Jurisdiction C Supplier Manual Page 7

CMNs Chapter 4blood gas study on the CMN within 30 days prior to the date on the CMN. In this situation the testmust be the most recent study the patient obtained while in the Medicare Advantage Plan, under theguidelines specified in the medical policy. It is important to note that, just because a beneficiaryqualified for oxygen under a Medicare Advantage Plan, it does not necessarily follow that he/she willqualify for oxygen under FFS. These instructions apply whether a beneficiary voluntarily returns toFFS, or if he or she involuntarily returns to FFS because their Medicare Advantage Plan no longerparticipates in the Medicare + Choice program.When both arterial blood gas (ABG) and oxygen saturation (oximetry) tests have recently beenperformed, greater weight is given to the ABG result. That test is generally acknowledged as themore reliable indicator of hypoxemia. In an review situation, if documentation in the medical recordcontains the result of an ABG performed on the same day as an oximetry saturation recorded on theCMN, and they are the most recent tests taken on or before the certification date on the CMN, theABG will be used to determine oxygen coverage for that certification. If the ABG does notsubstantiate the need for oxygen therapy, the claim(s) will be denied as not reasonable andnecessary.There are no professionally accepted formulas for converting the results of tests taken while thepatient is on oxygen to what the same patient would have shown had he or she been breathing roomair. Coverage may not be established by use of any suggested formula to convert this information.Where PO2 levels exceed 59 mm Hg or the arterial blood oxygen saturation exceeds 89 percent atrest, a rebuttable presumption of noncoverage exists. Form CMS-484 certification must besupplemented by additional documentation from the attending physician designed to overcome thispresumption and justify the oxygen order, including a summary of other, more conservative therapythat has not relieved the patient’s condition.CMS stipulates that claims may be denied without development if:• The only qualifying test results came from oximetry tests conducted by a supplier of DMEother than a hospital;• The claim lacks information necessary to justify coverage in accordance with guidelines insection 240.2 of the Medicare National Coverage Determinations Manual;• Hardcopy claims where Form CMS-484 lacks the certifying physician’s original signature; or• Electronic claims where Form CMS-484 fails to indicate that the attending physician’shandwritten signature is on file in the supplier’s office.Treating Physician IdentificationForm CMS-484 must be personally signed and dated by the treating physician, nurse practitioner,physician assistant, or clinical nurse specialist. The physician's identification number must be theUnique Physician Identification Number (UPIN).DME MAC Jurisdiction C Supplier Manual Page 8

CMNs Chapter 4Revised CertificationsNew medical documentation written by the patient’s treating physician must be submitted to theContractor in support of revised oxygen requirements when there has been a change in the patient’scondition and need for oxygen therapy; therefore, physicians are encouraged to file a revised FormCMS-484 as soon as possible when the order for oxygen changes. A revised certification isappropriate under the circumstances described in the "Oxygen and Oxygen Equipment" LCD.Scheduling and Documenting Recertifications of Oxygen CMNsRecertification scheduling and documentation requirements depend on the date when home oxygentherapy began. See policy "Oxygen and Oxygen Equipment" for situations requiring a recertification.The following information is needed on all recertifications:• Date and results of the most recent arterial blood gas or oximetry tests conducted prior to therecertification date;• Name of the provider conducting the most recent ABG or oximetry tests prior to therecertification date;• The conditions under which these tests were conducted;• Estimated length of need for oxygen (in section B of Form CMS-484);• Date of the current oxygen order;• Details of the current oxygen order.Additionally, for beneficiaries who initially qualify for oxygen coverage with Group II blood gases, arepeat blood gas study must be performed between the 61st and 90th day of home oxygen therapy.For those whose physician’s estimated length of need is less than lifetime, repeat blood gasdeterminations must be performed within thirty days prior to recertification.The schedule for recertifying the need of oxygen for patients beginning home oxygen therapy isestablished in accordance with the requirements below.First Recertification Required at 3 Months. OBRA 1990 requires earlier recertification andretesting of oxygen patients based on test results that do not meet the presumed coverage levels(i.e., an ABG result of 55 or less or an arterial oxygen saturation of 88 percent or less). Paymentmay be made for the fourth month of service only upon presentation of test results that meetpresumed coverage levels. The recertification at three months must reflect the results of an arterialblood gas or oxygen saturation test conducted between the 61st and 90th day of home oxygentherapy. If the patient no longer requires home oxygen therapy after three months, retesting is notnecessary.Recertifications at three months should be completed in full. If the order has already beendiscontinued, the physician should write the date that it was stopped.DME MAC Jurisdiction C Supplier Manual Page 9

CMNs Chapter 4The request for recertification to the physician will be made through the supplier of oxygen. Thephysician should be instructed to complete the recertification CMN and return it to the supplier. Thesupplier must then forward a copy of this information with a hardcopy claim or transcribe it exactly asit appears into the GU0 record of an electronic claim for the fourth monthly payment for oxygentherapy. The physician should be encouraged to retain a copy of this recertification CMN. Thesupplier or physician must retain a copy of the completed CMN (photocopy, facsimile image,electronically maintained, or original "pen and ink" document) Form CMS-484. No payment will bemade for the fourth or later months of oxygen service unless the recertification CMN and retestresults establish continuing medical necessity.Recertification for Long Term Therapy. Other than those patients for whom early recertification isrequired, recertification will be requested by our office after the patient has been receiving oxygentherapy for nine months. This will allow up to 90 days for the physician to submit a recertificationCMN.If additional tests have been conducted since the prior certification, these results and other pertinentinformation must be recorded on the recertification. Additional testing will not be requested forpatients with established chronic pulmonary problems.All recertification requests will be routed to the current supplier of oxygen. The supplier will thenforward these requests to the attending physician for completion. The supplier should emphasizethat the completed Form CMS-484 is to be returned to the supplier in all cases. To reducemisrouting problems, the supplier may want to provide self-addressed, return envelopes. Thesupplier must forward a copy of the completed Form CMS-484 with its next claim for monthly rentalof oxygen equipment. It is advisable for the physician to retain a copy of the completed Form CMS-484 with other records for the patient. The supplier or physician must retain a copy of the completedCMN (photocopy, facsimile image, electronically maintained or original "pen and ink" document)Form CMS-484.While the recertification is being obtained, payments will continue through the 12th month of service,based on the estimated length of need for oxygen therapy in the initial certification. Payment will besuspended for the 13th or later months if a satisfactory recertification CMN, including any test resultsthat may be required, has not been received by the time the payment would otherwise beauthorized.Subsequent Recertifications. Most all patients who require home oxygen therapy beyond a fewmonths require it lifelong. Therefore, once a Form CMS-484 recertification establishes that themedical necessity continues, subsequent recertifications are not routinely required. However, theymay be requested in conjunction with quality control sampling, or if there is an indication ofsignificant change in the patient’s status, e.g., large, unexplained variations in the use of oxygen orevidence of confinement to a hospital or skilled nursing facility (SNF) throughout an equipment rentalperiod. Because orders have a fixed, prospective life and payments can only be made pursuant to acurrently valid order, physicians must keep orders current at all times. They must also be retained bythe supplier so as to be immediately available should they be requested during medical reviewaudits or for other purposes.DME MAC Jurisdiction C Supplier Manual Page 10

CMNs Chapter 4Treating Physician of Record No Longer Involved With PatientIf the physician of record is no longer the treating physician, the supplier should obtain a revisedCMN from the treating physician currently responsible for the patient’s pulmonary condition. No newtesting is required. This CMN is not routinely submitted to the DME MAC or DME PSC, but must beavailable on request. Further details on oxygen CMNs is available in the "Oxygen and OxygenEquipment" LCD.Certificates of Medical Necessity - Common ScenariosSuppliers frequently approach the DME MACs or DME PSCs with questions about what CMN typeshould be submitted for a given situation. All CMN requirements detailed below are based onassumptions about what are the most common scenarios seen by the DME MACs. The facts of anyindividual supplier's claim may result in an alternate requirement. Suppliers should use thisinformation only as general guidance and should consult with the appropriate contractor asnecessary.# Oxygen Certification NotesRequiredComments1 Break in service > 60 days(change in medical condition)initial 1, 22 Break in service > 60 days ( nochange in medical condition)none 1, 23 Break in service < 60 days(change in medical condition)none 1, 24 Break in service < 60 days ( nochange in medical condition)none 1, 25 Change in supplier (no break inservice)revised insupplier's files1, 3 In an acquisition, the originalmay be used if it is available.1 The initial date should be thepatient retested and nowdate of the qualifying testqualifies6 Initial CMN did not qualify, initial7 Group II patient not retestedwithin 61-90th dayinitial 1 The initial date should be thedate of the qualifying test8 Group I patient with a length ofneed less than or equal to 12months (but not lifetime) and notretested 30 days prior to revision9 Group I patient with lifetimelength of need, not seen andevaluated by the physicianwithin 90 days prior to the 12month recert but subsequentlyseen10 Change in supplier due toacquisition. Previous supplier didnot file recert when it was due.All requirements for recert weremet when it was due.11 Change in supplier due toacquisition. Previous supplier didnot file recert when it was due.initialrecertification 1The initial date should be thedate of the qualifying testThe recertification dateshould be the date of thephysician visit.recertification 1,3 Recert date would be 12 or 3months after initial datedepending on whether initialcert was group 1 or group 2.initial 1,3 The initial date would be thedate of the qualifying test.DME MAC Jurisdiction C Supplier Manual Page 11

CMNs Chapter 4Not all requirements for recertwere met when it was due.12 Portable was added afterstationaryrevised13 Stationary was added afterportablerevised14 Change in modality none15 Changed billing assignment(non-assigned to assigned)none16 Change in doctor revised insupplier's files17 Change in liter flow revised ifchange inpaymentcategory, e.g.,from 4 lpm to 5lpm. None ifpaymentcategory doesnot change18 Change from Medicaresecondary to Medicare primarynone19 Change from non-Medicareinsurance to MedicareinitialThe initial date should be thedate of Medicare eligibility ifthe patient has a Medicarequalifying test within 30 daysbefore their eligibility. If theydo not get the qualifying testuntil after they becomeMedicare eligible, then theinitial date should be the dateof the qualifying test.Capped Rental Equipment20 Break in service > 60 days(change in medical condition)No change in HCPCS21 Break in service > 60 days ( nochange in medical condition)No change in HCPCS22 Break in service < 60 days(change in medical condition)No change in HCPCS23 Break in service < 60 days ( nochange in medical condition)Certification NotesRequiredinitial 2none 2none 2none 2No change in HCPCSDME MAC Jurisdiction C Supplier Manual Page 12

CMNs Chapter 424 Break in service > 60 days(change in medical condition)Change in HCPCS (e.g., K1 toK3 or K3 to K1)25 Break in service > 60 days ( nochange in medical condition)Change in HCPCS (e.g., K1 toK3 or K3 to K1)26 Break in service < 60 days(change in medical condition)Change in HCPCS (e.g., K1 toK3 or K3 to K1)27 Break in service < 60 days ( nochange in medical condition)initial 2, 4initial 2, 4initial 2, 4initial 2, 4Change in HCPCS (e.g., K1 toK3 or K3 to K1)28 Change in supplier (no break in revised inservice, no change in HCPCS) supplier's files2, 329 Change in supplier (no break in initial 2, 3, 4service, HCPCS changed e.g.,K1 to K3)30 Initial CMN did not qualify, initialpatient re-evaluated and nowqualifies31 Change in doctor revised insupplier's files32 Added elevating leg rests afterwheelchair providednone33 Changed billing assignment(non-assigned to assigned)none34 Change from Medicaresecondary to Medicare primarynone35 Change from non-Medicareinsurance to MedicareinitialNotes:1 Assumes lifetime length of need. If the length of need is less than lifetime, different guidelinesmay apply.2. "Break in service", for the purpose of this table, is defined as break in monthly billing."Change in medical condition" means that the patient’s condition changed to the point that theyno longer needed the original device. The patient’s condition then changed again and the patientneeded to resume using the original item. It could be for the same or different diagnosis."No change in medical condition" means that there is a break in billing but the patient still neededthe same equipment. For example, the patient was in a SNF, hospital, Medicare AdvantageDME MAC Jurisdiction C Supplier Manual Page 13

CMNs Chapter 4Plan, or hospice and the DME MAC was not being billed during this time. This could also includesituations in which the patient continued to need the equipment, but it was removed from thepatient’s home.3. Requirement is for the new supplier.4. Submission of a new Initial CMN does not guarantee that a new capped rental period will bestarted.DME MAC Jurisdiction C Supplier Manual Page 14

Chapter Five √DMEPOS Fee Schedule

DMEPOS Fee Schedule Chapter 5DMEPOS Fee Schedule CategoriesReimbursement for most durable medical equipment, prosthetics, orthotics and supplies (DMEPOS)is established by fee schedules. Payment is limited to the lower of the actual charge or the feeschedule amount.The fee schedule classifies most DMEPOS into one of six categories explained below:• Inexpensive or other routinely purchased DME• Items requiring frequent and substantial servicing• Customized items• Other prosthetic and orthotic devices• Capped rental items• Oxygen and oxygen equipmentInexpensive or Other Routinely Purchased DMEPayment for this type of equipment is for rental or lump sum purchase. The total payment amountmay not exceed the actual charge or the fee for a purchase.• Inexpensive DMEThis category is defined as equipment whose purchase price does not exceed $150.• Other Routinely Purchased DMEThis category consists of equipment that is purchased at least 75 percent of the time.Transcutaneous Electrical Nerve Stimulator (TENS)Up to two months rental is allowed in order to permit an attending physician time to determinewhether the purchase of a TENS is medically appropriate for a particular patient. The purchase priceis determined under the same rules as any other frequently purchased item, except that there is noreduction in the allowed amount for purchase due to the two months rental.Modifiers used in this category are as follows: *RR RentalNU Purchase of new equipment. Only use if new equipment was delivered.UE Purchase of used equipment. Used equipment is any equipment that has been purchasedor rented by someone before the current purchase transaction. Used equipment alsoincludes equipment that has been used under circumstances where there has been nocommercial transaction (e.g., equipment used for trial periods or as a demonstrator).*These modifiers are not all-inclusive.DME MAC Jurisdiction C Supplier Manual Page 1

DMEPOS Fee Schedule Chapter 5Items Requiring Frequent and Substantial ServicingEquipment in this category is paid on a rental basis only. Payment is based on the monthly feeschedule amounts until the medical necessity ends. No payment is made for the purchase ofequipment, maintenance and servicing, or for replacement of items in this category.Supplies and accessories are not allowed separately.Certain Customized ItemsCoverage and allowable amounts for custom equipment will be decided by individual evaluationbased on medical indication.The beneficiary's physician must prescribe the customized equipment and provide informationregarding the patient's physical and medical status to warrant the need for the equipment.Payment with respect to a covered item that is uniquely constructed or substantially modified to meetthe specific needs of an individual patient should be made in a lump-sum amount. The paymentamount for the purchase of a customized item is based upon the Contractor's individualconsideration for that item.The following items are needed for coverage to be considered:1. Detailed description of the item2. Description of feature(s) that make this item unique3. Acquisition or production cost of the item (i.e., line item cost of materials and/or labor)The date of service for custom-made equipment is the actual date the beneficiary receives the item.Do not use the date the item was ordered when billing Medicare.Other Prosthetic and Orthotic DevicesThese items consist of all prosthetic and orthotic devices excluding:• Items requiring frequent and substantial servicing;• Certain customized items;• Parenteral/enteral nutritional supplies and equipment; and,• Intraocular lenses.Other than these exceptions, prosthetic and orthotic devices will be paid on a lump-sum purchasebasis.The date of service for custom-made equipment is the actual date the beneficiary receives theitem. Do not use the date the item was ordered when billing Medicare.DME MAC Jurisdiction C Supplier Manual Page 2

DMEPOS Fee Schedule Chapter 5Artificial Limbs, Braces, and Other Custom Made Items Ordered ButNot FurnishedIf a custom-made item was ordered but not furnished to a beneficiary because the individual died orbecause the order was canceled by the beneficiary or because the beneficiary’s condition changedand the item was no longer reasonable and necessary or appropriate, payment can be made basedon the supplier’s expenses. In such cases, the expense is considered incurred on the date thebeneficiary died or the date the supplier learned of the cancellation or that the item was no longerreasonable and necessary or appropriate for the beneficiary’s condition. If the beneficiary died or thebeneficiary’s condition changed and the item was no longer reasonable and necessary orappropriate, payment can be made on either an assigned or unassigned claim. If the beneficiary, forany other reason, canceled the order, payment can be made to the supplier only.The allowed amount is based on the services furnished and materials used, up to the date thesupplier learned of the beneficiary’s death or of the cancellation of the order or that the item was nolonger reasonable and necessary or appropriate. The Contractor determines the services performedand the allowable amount appropriate in the particular situation. It takes into account any salvagevalue of the device to the supplier. Where a supplier breaches an agreement to make a prosthesis,brace, or other custom made device for a Medicare beneficiary, e.g., an unexcused failure to providethe article within the time specified in the contract, payment may not be made for any work ormaterial expended on the item. Whether a particular supplier has lived up to its agreement, ofcourse, depends on the facts in the individual case.Capped Rental ItemsItems in this category are paid on a monthly rental basis not to exceed a period of continuous use of13 months with rentals beginning on or after January 1, 2006. Prior to January 1, 2006 the monthlyrentals are not to exceed a period of continuous use of 15 months or on a purchase option basis notto exceed a period of continuous use of 13 months.Rental Fee ScheduleFor the first three rental months, the rental fee schedule is calculated so as to limit the monthly rentalof ten percent of the average of allowed purchase prices on assigned claims for new equipmentduring a base period, updated to account for inflation. For each of the remaining months, themonthly rental is limited to 7.5 percent of the average allowed purchase price. After paying the rentalfee schedule amount for 15 months, no further payment may be made except for payments formaintenance and servicing.Modifiers used in this category are as follows:RR RentalKH First rental monthKIKJSecond and third rental monthsFourth to the fifteenth monthsDME MAC Jurisdiction C Supplier Manual Page 3

DMEPOS Fee Schedule Chapter 5BR Beneficiary has elected to rentBP Beneficiary has elected to purchaseBU Beneficiary has not informed supplier of decision after 30 daysMS Maintenance and ServicingNU New EquipmentUE Used EquipmentDeficit Reduction Act (DRA) of 2005Recent legislative changes mandated by sections 5101(a) and 5101(b) of the Deficit Reduction Act(DRA) of 2005 require changes to the way Medicare makes payment for certain items of DME. TheDRA provisions and associated regulations will begin to impact capped rental claims as of February2007.Payments During a Period of Continuous UseInitial rental month on or after January 2006:Section 5101(a) revises the payment rules described above for capped rental DME. In accordancewith the DRA, after 13 months, the beneficiary owns the capped rental DME item, and after thattime, Medicare pays for reasonable and necessary maintenance and servicing (i.e., for parts andlabor not covered by a supplier’s or manufacturer’s warranty) of the item. The beneficiary may not,as in years past, choose to continue to rent the item and leave the supplier with the title to the item.The supplier must follow applicable state and federal laws when transferring title for the item to thebeneficiary. This transfer must occur on the first day after the last rental month.This provision does not affect parenteral nutrition (PEN) pumps, because PEN is not considered tobe capped rental DME, but rather is covered under the prosthetic benefit.Capped rental items furnished to beneficiaries prior to January 1, 2006:Payment for items in this category may not exceed a period of continuous use longer than 15months. After 15 months of rental have been paid, the supplier must continue to provide the itemwithout charge (other than maintenance and servicing fees) until the medical necessity ends orMedicare coverage ceases (e.g., the patient enrolls in a Medicare Advantage Plan).A period of continuous use allows for temporary interruptions in the use of equipment. Interruptionsmust exceed 60 consecutive days plus the days remaining in the rental month in which the useceases (not calendar month, but the 30-day rental period) in order for a new 15-month rental periodto begin. When an interruption continues beyond the end of the rental month in which use ceases,no additional payment will be made until the use of the item resumes. A new date of service will beestablished when use resumes. Unreimbursed months of interruption will not apply toward the 15-month limit.DME MAC Jurisdiction C Supplier Manual Page 4

DMEPOS Fee Schedule Chapter 5A new 15-month period may begin, even though the original 15-month capped rental has beenexhausted. In these situations, suppliers must obtain from the ordering physician a new prescription,a new Certificate of Medical Necessity (CMN) and a statement describing the reasons for theinterruption. Please be thorough, the documentation will be reviewed very carefully.Change of AddressIf the beneficiary moves during or after the rental period, either permanently or temporarily, it doesnot result in a new rental episode.Modification or Substitutions of EquipmentIf equipment is changed to different but similar equipment, and the beneficiary's condition hassubstantially changed to support the medical necessity for the new item, a new rental period willbegin. Otherwise, the rental will continue to count against the current rental period and payment willbe based on the least expensive medically appropriate equipment. If the rental period has alreadyexpired, no additional rental payment will be made for modified or substituted equipment in theabsence of substantial change in medical need.If modification is added to existing equipment and there is a substantial change in medical need, therental period for the original equipment continues and a new rental period begins for the addedequipment.Change in SuppliersIf the beneficiary changes suppliers during the rental period, a new rental period will not begin. Thesupplier providing the item in the 15th month of the rental period is responsible for supplying theequipment and for maintenance and servicing after the 15-month period.Maintenance and ServiceFor capped rental periods beginning prior to January 1, 2006DMEPOS suppliers must not submit claims for maintenance and servicing until all claims for rentalhave been paid and six months have passed from the end of the final paid rental month.Furthermore, DMEPOS suppliers must not bill for maintenance and servicing codes on the sameclaim as codes for the rental itself.Maintenance and servicing for an item billed on the same claim with the rental of the same item willbe denied. A claim must be resubmitted for the maintenance and servicing fee only.In order for maintenance and servicing fees to be paid, the equipment must be medically necessaryas of the date such payment is claimed.Maintenance and servicing fee may be paid once every six months when either the 15-month rentalcap has been reached and six months have passed from the end of the final paid rental month, orwhen the item is no longer covered under the supplier's or manufacturer's warranty, whichever isDME MAC Jurisdiction C Supplier Manual Page 5

DMEPOS Fee Schedule Chapter 5later. Medicare payment may be made whether or not the equipment is actually serviced during thesix-month period.The modifier used in this category is as follows:MS Maintenance and servicing (six-month maintenance and servicing fee for reasonable andnecessary parts and labor that are not covered under any manufacturers or supplier warranty).Purchase Options of Capped Rental ItemsFor capped rental periods beginning prior to January 1, 2006Medicare payment is made on a monthly rental basis not to exceed a period of continuous use of 15months or on a purchase option basis (not to exceed a period of continuous use of 13 months) or ona purchase basis for electric wheelchairs. For the first three rental months, the rental fee schedule iscalculated to limit the monthly rental to 10 percent of the average allowed purchase price onassigned claims for new equipment during a base period, updated to account for inflation. For eachof the remaining months, the monthly rental is limited to 7.5 percent of the average allowed purchaseprice.Electric WheelchairsSuppliers must give beneficiaries entitled to electric wheelchairs the option of purchasing at the timethe supplier first furnishes the item. No rental payment will be made for the first month until thesupplier notifies the Contractor that the beneficiary has been given the option to either purchase orrent. If the beneficiary chooses to purchase, payment will be made on a lump sum purchase basis. Ifthe beneficiary declines the purchase in the first month, payment will be made on a rental basis.For capped rental periods beginning prior to January 1, 2006, the supplier must give the beneficiarythe option of converting the rental equipment to purchase during the tenth continuous rental month.No payment can be made after the 11th month until the supplier indicates that the beneficiary hasbeen given this option. Beneficiaries have one month from the date the supplier makes the offer toaccept the option.If the beneficiary declines purchase, rental payments will continue through the 15th month. If thebeneficiary accepts purchase option, rental payments will continue until a total of 13 continuousrental months have been paid. No additional rental payments beyond the 13th month will be made.On the first day after 13 continuous rental months have been paid, the supplier must transfer title ofequipment to the beneficiary.All Other Capped Rental ItemsCapped rental items furnished to beneficiaries prior to January 1, 2006, suppliers must givebeneficiaries the option of converting their rental equipment to purchase during the tenth continuousrental month. No further rental payments may be made after the 11th rental month for capped rentalDME MAC Jurisdiction C Supplier Manual Page 6

DMEPOS Fee Schedule Chapter 5items until the supplier notifies the Contractor that the beneficiary has been given the purchaseoption.Beneficiaries have one month from the date the supplier makes the offer to accept the option. If thebeneficiary declines purchase, rental payments will continue through the 15th month. If thebeneficiary accepts the purchase option, rental payments will continue until a total of 13 continuousrental months have been paid. No additional payment beyond the 13th month will be made. On thefirst day after 13 continuous months have been paid, the supplier must transfer title of the equipmentto the beneficiary.Modifiers used for the rent/purchase option are as follows:BR Beneficiary has elected to rentBP Beneficiary has elected to purchaseBU Beneficiary has not informed supplier of decision after 30 daysSuppliers must use one of these modifiers to notify the Contractor of the beneficiary's decision.Since HCPCS modifiers are used, it is not necessary for a supplier to submit documentation signedby the beneficiary that he/she has been offered the rent/purchase option. However, the suppliershould maintain documentation in the files supporting the HCPCS modifier entered on the claimform.The following is an example of the beneficiary's notification of the rent/purchase option:The Rent/Purchase OptionYou have been renting your (specify the item(s) or equipment) for 10 continuous rental months.Medicare requires (specify name of supplier) to give you the option of converting your rentalagreement to a purchase agreement. This means that if you accept this option, you would own themedical equipment. If you accept the purchase option, Medicare continues making rental paymentsfor your equipment for 3 additional rental months. You are responsible for the 20% coinsuranceamounts and, for unassigned claims, the balance between the Medicare allowed amount and thesupplier's charge. After making these additional rental payments, title to the equipment is transferredto you. You have until (specify the date one month from the date the supplier notifies the patient ofthis option) to elect the purchase option.If you decide not to elect the purchase option, Medicare continues making rental payments for anadditional 5 rental months, a total of 15 months. You are responsible for the 20% coinsuranceamounts and, for unassigned claims, the balance between the Medicare allowed amount and thesupplier's charge. After a total of 15 months have been paid, title to the equipment remains with themedical equipment supplier; however, the supplier may not charge you any additional rentalamounts.In making your decision to rent or purchase the equipment, you should know that for purchasedequipment, you are responsible for 20% of the service charge each time your equipment is actuallyDME MAC Jurisdiction C Supplier Manual Page 7

DMEPOS Fee Schedule Chapter 5serviced and, for unassigned claims, the balance between the Medicare allowed amount and thesupplier's charge. However, for equipment that is rented for 15 months, your responsibility for suchservice is limited to 20% coinsurance on a maintenance and servicing fee payable twice per yearwhether or not the equipment is actually serviced.Oxygen and Oxygen EquipmentReimbursement for oxygen equipment will be made on a rental basis only. No payment will be madefor equipment purchased on or after June 1, 1989, or for accessories used with equipmentpurchased after this date.Recent legislative changes mandated by sections 5101(b) of the Deficit Reduction Act (DRA) of2005 require changes to the way Medicare makes payment for certain items of DME. Before theenactment of the DRA, monthly payments for oxygen equipment continued for the duration of use ofthe equipment, regardless of the number of months the equipment was in use, provided thatMedicare Part B coverage and eligibility criteria were met. However, DRA Section 5101(b) limits thetotal number of continuous rental months for which Medicare will pay for oxygen equipment to 36months.After the 36th month, the supplier must transfer title to the oxygen equipment so that the beneficiarywill own it. The supplier must follow applicable state and federal laws when transferring title for theitem to the beneficiary. This transfer must occur on the first day after the last rental month.Section 5101(b) of the DRA specifically provides that Medicare will continue to pay for oxygencontents (i.e., oxygen, regardless of modality) for beneficiary-owned stationary or portable gaseousor liquid systems. Payment for oxygen contents will continue to be made as long as the oxygenremains medically necessary.The DRA further stipulates that payment for reasonable and necessary maintenance and servicingof beneficiary-owned oxygen equipment will be made for parts and labor that are not covered by asupplier's or manufacturer's warranty.This provision is effective January 1, 2006. For beneficiaries receiving oxygen equipment onDecember 31, 2005, the 36-month rental period begins on January 1, 2006, regardless of how manymonths rental has been paid prior to January 1, 2006.Fee schedule payments for stationary oxygen system rentals are all-inclusive and represent amonthly allowance per beneficiary. This allowance includes payment for the equipment, contents,and accessories furnished during a rental month.ModifiersThe monthly payment amount for stationary oxygen is subject to adjustment depending on theamount of oxygen prescribed (liters per minute, or LPM) and whether or not portable oxygen is alsoprescribed.DME MAC Jurisdiction C Supplier Manual Page 8

DMEPOS Fee Schedule Chapter 5QE Use if the prescribed amount of oxygen is less than 1 LPM.QFUse if the prescribed amount of oxygen exceeds 4 LPM and portable oxygen is prescribed.QG Use if the prescribed amount of oxygen is greater than 4 LPM.QH Use if an oxygen conserving device is being used with an oxygen delivery system.Oxygen Contents/UnitsWhen a stationary oxygen system is being rented, the monthly allowance includes payment for allrequired contents. It would be considered “unbundling” if the supplier billed the beneficiaryseparately for contents in this scenario. If the beneficiary owns an oxygen stationary system otherthan an oxygen concentrator or uses a portable system only, payment may be made for contents.For claims with dates of service on or after January 1, 2007, if a patient owns both a stationarygaseous or liquid system and a portable gaseous or liquid system, bill two codes – one for thestationary contents (E0441, E0442) and one for the portable contents (E0443, E0444).This is also a monthly allowance so contents should only be billed once a month, not daily orweekly. For dates of service before January 1, 2007, the portable contents fee is never payablein addition to the stationary contents fee.Oxygen Equipment and Contents Billing Chart:The following chart indicates what oxygen fee schedule component is billable/payable under varioustransaction scenarios.Situation: Beneficiary Uses a Stationary System Only1. RentalType of SystemStationary ContentsCodePortable SystemCodePortable ContentsCodeConcentrator No No NoGaseous No* No NoLiquid No* No No2. PurchaseType of SystemStationary ContentsCodePortable SystemCodePortable ContentsCodeConcentrator No No NoGaseous E0441 No NoDME MAC Jurisdiction C Supplier Manual Page 9

DMEPOS Fee Schedule Chapter 5Liquid E0442 No NoSituation: Beneficiary Uses Both a Stationary and Portable System1. Rents Stationary/Rents PortableType of SystemStationary ContentsCodePortable SystemCodePortable ContentsCodeConcentrator No E1392 NoGaseous No* E0431 No*Liquid No* E0434 No** Contents are included in the allowance for rented oxygen stationary system2. Rents Stationary/Owns PortableType of SystemStationary ContentsCodePortable SystemCodePortable ContentsCodeConcentrator No No NoGaseous No* No No*Liquid No* No No** Contents are included in the allowance for rented oxygen stationary system3. Owns Stationary/Owns PortableType of SystemStationary ContentsCodePortable SystemCodePortable ContentsCodeConcentrator No No NoGaseous E0441 No E0443*Liquid E0442 No E0444** Effective with dates of service on or after January 1, 2007 both stationary andportable contents are billable. Prior to January 1, 2007 the allowance for the stationarycontents included payment for the portable oxygen contents.DME MAC Jurisdiction C Supplier Manual Page 10

DMEPOS Fee Schedule Chapter 54. Owns Stationary/Rents PortableType of SystemStationary ContentsCodePortable SystemCodePortable ContentsCodeConcentrator No E1392 NoGaseous E0441 E0431 E0443**Liquid E0442 E0434 E0444**** Effective with dates of service on or after January 1, 2007 both stationary andportable contents are billable. Prior to January 1, 2007 the portable contents reimbursementis included in the reimbursement for the stationary contents.Situation: Beneficiary Uses a Portable System Only1. Rents Portable SystemType of SystemStationary ContentsCodePortable SystemCodePortable ContentsCodeConcentrator No E1392 NoGaseous No E0431 E0443Liquid No E0434 E04442. Owns Portable SystemType of SystemStationary ContentsCodePortable SystemCodePortable ContentsCodeConcentrator No No NoGaseous No No E0443Liquid No No E0444Repairs, Maintenance, and ReplacementUnder the circumstances specified below, payment may be made for repair, maintenance, andreplacement of medically required DME, including equipment which had been in use before theuser enrolled in Part B of the program. In addition, payments for repair and maintenance maynot include payment for parts and labor covered under a manufacturer’s or supplier’s warranty.A - RepairsTo repair means to fix or mend and to put the equipment back in good condition after damage orwear. Repairs to equipment which a beneficiary owns are covered when necessary to make theDME MAC Jurisdiction C Supplier Manual Page 11

DMEPOS Fee Schedule Chapter 5equipment serviceable. If the expense for repairs exceeds the estimated expense of purchasingor renting another item of equipment for the remaining period of medical need, no payment canbe made for the amount of the excess.Repairs of rented equipment are not covered. This includes items in the frequent andsubstantial servicing, oxygen equipment, capped rental and inexpensive or routinely purchasedpayment categories which are being rented.A new Certificate of Medical Necessity (CMN) and/or physician's order is not needed for repairs.B - MaintenanceRoutine periodic servicing, such as testing, cleaning, regulating, and checking of thebeneficiary’s equipment, is not covered. The beneficiary is expected to perform such routinemaintenance rather than the supplier or some other person who charges the beneficiary.Normally, purchasers of DME are given operating manuals which describe the type of servicingan owner may perform to properly maintain the equipment. It is reasonable to expect thatbeneficiaries will perform this maintenance. Thus, hiring a third party to do such work is for theconvenience of the beneficiary and is not covered.However, more extensive maintenance which, based on the manufacturers’ recommendations,is to be performed by authorized technicians, is covered as repairs for medically necessaryequipment which a beneficiary owns. This might include, for example, breaking down sealedcomponents and performing tests which require specialized testing equipment not available tothe beneficiary.Maintenance of purchased items that require frequent and substantial servicing is not covered.Maintenance of rented equipment other than the maintenance and servicing fee established forcapped rental items is not covered. Effective January 1, 2006 oxygen equipment is rented for a36 month cap at which time ownership is given to the beneficiary. Maintenance and servicingmay be billed every six months. This maintenance coverage will not begin before July 1, 2009.For capped rental periods beginning prior to January 1, 2006 which have reached the 15-monthrental cap, contractors pay claims for maintenance and servicing fees after 6 months havepassed from the end of the final paid rental month or from the end of the period the item is nolonger covered under the supplier’s or manufacturer’s warranty, whichever is later.A new CMN and/or physician's order is not needed for covered maintenance.C - ReplacementReplacement refers to the provision of an identical or nearly identical item. Equipment which thebeneficiary owns or is a capped rental item may be replaced in cases of loss or irreparabledamage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire,flood, etc.).Irreparable wear refers to deterioration sustained from day-to-day usage over time and aspecific event cannot be identified. Replacement of equipment due to irreparable wear takesinto consideration the reasonable useful lifetime of the equipment. If the equipment has been incontinuous use by the patient on either a rental or purchase basis for the equipment’s usefulDME MAC Jurisdiction C Supplier Manual Page 12

DMEPOS Fee Schedule Chapter 5lifetime, the beneficiary may elect to obtain a new piece of equipment.The reasonable useful lifetime of durable medical equipment is determined through programinstructions. In the absence of program instructions, Contractors may determine the reasonableuseful lifetime of equipment, but in no case can it be less than 5 years.Computation of the useful lifetime is based on when the equipment is delivered to thebeneficiary, not the age of the equipment. Replacement due to wear is not covered during thereasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicaredoes cover repair up to the cost of replacement (but not actual replacement) for medicallynecessary equipment owned by the beneficiary.For a replacement to be covered, a new physician order and/or new CMN, when required, isneeded to reaffirm the medical necessity of the item.Cases suggesting malicious damage, culpable neglect, or wrongful disposition of equipment willbe investigated and denied where the DME MAC determines that it is unreasonable to makeprogram payment under the circumstances.The following documentation is required when filing a Medicare claim for replacement:• Reason for replacement• New CMN when requiredParenteral/Enteral Nutrition TherapyParenteral/Enteral Pump Rental/PurchaseParenteral/enteral pumps can be either rented or purchased. When rented, they are processed likecapped rental items with two notable exceptions. First, they are not subject to the 25% reductionpayment for the fourth rental month and after. Second, a beneficiary may elect to purchase aparenteral/enteral pump at any time, but must be offered the opportunity to do so by the tenth monthif he/she has not already done so. If the beneficiary decides to purchase the pump once rentals havebeen paid, the purchase allowance will consist of the used purchase allowance less the amountallowed to date for rentals.Additional rental payments after the 15-month limit has been reached or after the pump has beenpurchased will only be considered if the attending physician changes the prescription betweenparenteral and enteral nutrients.A change in suppliers during the 15-month rental period does not begin a new 15-month rentalperiod. The new supplier is entitled to the balance remaining on the 15-month rental period.The supplier that collects the last month of rental (i.e., the 15th month) is responsible for ensuringthat the patient has a pump for as long as it is medically necessary, and for maintenance andservicing of the pump during the period of medical necessity.DME MAC Jurisdiction C Supplier Manual Page 13

DMEPOS Fee Schedule Chapter 5Maintenance and ServicingNecessary maintenance and servicing of parenteral/enteral pumps after the 15-month rental limit isreached may include repairs and extensive maintenance that involve the breaking down of sealedcomponents, or performing tests that require specialized testing equipment not available to thebeneficiary or nursing home. Payment will only be made for actual incidents of maintenance,servicing or replacement. For enteral pumps, maintenance and servicing may be considered forpayment every six months, beginning six months after the last rental payment for the pump. Forparenteral pumps, maintenance and servicing may be considered for payment every three months,beginning three months after the last rental payment for the pump. Claims for replacement ofparenteral/enteral pumps purchased more than eight years ago will be considered for payment.The modifier used in this category is as follows:MS Maintenance and servicingConsolidated BillingSkilled Nursing Facility (SNF) ResidentsSection 4432(b) of the Balanced Budget Act (BBA) requires Consolidated Billing for the SNF. TheCB requirement essentially confers on the SNF itself the Medicare billing responsibility for the entirepackage of care that its residents receive, except for a limited number of specifically excludedservices.For services and supplies furnished to a SNF resident covered under the Part A benefit, SNFs willno longer be able to unbundle services to an outside provider of services or supplies that can thensubmit a separate bill directly to the Medicare Contractor. Instead, the SNF must furnish theservices or supplies either directly or under an arrangement with an outside provider. The SNF,rather than the provider of the service or supplies, bills Medicare. Medicare does not pay amountsthat are due a provider of the services or supplies to any other entity under assignment, power ofattorney, or any other direct payment arrangement. (See 42 CFR 424.73.) As a result, the outsideprovider of the service or supplies must look to the SNF, rather than to the beneficiary or theMedicare Contractor, for payment. The SNF may collect any applicable deductible or coinsurancefrom the beneficiary. Most covered services and supplies billed by the SNF, including thosefurnished under arrangement with an outside provider, for a resident of a SNF in a covered Part Astay are included in the SNF’s bill to the Fiscal Intermediary (FI).It is the supplier’s responsibility to check with the facility to see if their patient is a resident in acovered Part A stay. If so, all services must be billed to Medicare by the SNF except for theexcluded items. A complete list of excluded items may be found athttp://www.cms.hhs.gov/SNFConsolidatedBilling/ on the CMS web site.SNF Consolidated Billing - Capped Rental DMEMedicare pays for durable medical equipment (DME) when it is medically necessary for use in apatient’s home.DME MAC Jurisdiction C Supplier Manual Page 14

DMEPOS Fee Schedule Chapter 5For capped rental items of DME where the supplier submits a monthly bill, the date of delivery on thefirst claim must be the “from” or anniversary date on all subsequent claims for the item.The DME benefit is only meant for items a beneficiary is using in his or her home. For a beneficiaryin a Part A stay, a SNF is not defined as a beneficiary’s home. Medicare does not make separatepayment for DME when a beneficiary is in a SNF. The SNF is expected to provide all medicallynecessary DMEPOS during a beneficiary’s covered Part A stay.However, in accordance with DMEPOS payment policy, Medicare will make a separate payment fora full month of rental for DME items, provided the beneficiary was in the home on the “from” date oranniversary date defined above. Medicare will make payment for the entire month, even if the “from”date is the date of discharge from the SNF.If a beneficiary using DME is in a covered Part A stay in a SNF for a full month, Medicare will notmake payment for the DME for that month.If the beneficiary is in a Part A covered stay, but not for the entire month, the discharge datebecomes the new anniversary date for subsequent claims. In this situation, the supplier must submita new claim using the date of discharge as the “from” date. Suppliers should note in the HAO record(field 19 for paper claims) that the patient was in a SNF, resulting in the need to establish a newanniversary date.Scheduled maintenance and servicing claims should be allowed once 15 rental months have beenpaid, regardless of whether the patient is in a covered Part A stay in the SNF on the date of serviceof the maintenance and servicing claim.Home Health Prospective Payment System (PPS)The Balanced Budget Act of 1997 requires consolidated billing of all home health services while abeneficiary is under a home health plan of care authorized by a physician. Consequently, billing forall such items and services will be made to a single home health agency (HHA) overseeing that plan.The law states that payment will be made to the primary HHA whether or not the item or service wasfurnished by the agency, by others under arrangement to the primary agency, or when any othercontracting or consulting arrangements existed with the primary agency, or “otherwise.” Payment forall items is scheduled in the home health PPS episode payment that the primary HHA receives.Types of services that are subject to the home health consolidated billing provision include:• Skilled nursing care;• Home health aide services;• Physical therapy;• Speech-language pathology;• Occupational therapy;• Medical social services;• Routine and non-routine medical supplies;• Medical services provided by an intern or resident-in-training of a hospital, under anapproved teaching program of the hospital, in the case of a HHA that is affiliated or undercommon control with that hospital; and• Care for homebound patients involving equipment too cumbersome to take to the home.DME MAC Jurisdiction C Supplier Manual Page 15

DMEPOS Fee Schedule Chapter 5Non-Routine Medical SuppliesWhen a beneficiary is in a 60-day episode, these items are included in the PPS episode payment.HHAs must bill for all supplies provided during the 60-day episode including those not related to thePlan of Care because of the consolidated billing requirements. The codes listed below werepublished in the Federal Register.Home Health Consolidated Billing Master Code List will be updated on a quarterly basis and is alsoavailable on the CMS Web site at http://www.cms.hhs.gov/HomeHealthPPS/03_coding&billing.asp.DMEPOS and an Inpatient StayPre-Discharge Delivery of DMEPOS for Fitting and TrainingThe following are CMS policy and billing procedures regarding the circumstances under which asupplier may deliver durable medical equipment, prosthetics, and orthotics-but not supplies-to abeneficiary who is in an inpatient facility that does not qualify as the beneficiary's home.Conditions That Must Be Met:In some cases, it would be appropriate for a supplier to deliver a medically necessary item ofdurable medical equipment (DME), a prosthetic, or an orthotic—but not supplies—to abeneficiary who is an inpatient in a facility that does not qualify as the beneficiary’s home. TheCMS will presume that the pre-discharge delivery of DME, a prosthetic, or an orthotic (hereafter“item”) is appropriate when all the following conditions are met:The item is medically necessary for use by the beneficiary in the beneficiary's home.1. The item is medically necessary on the date of discharge, i.e., there is a physician's orderwith a stated initial date of need that is no later than the date of discharge for home use.2. The supplier delivers the item to the beneficiary in the facility solely for the purpose of fittingthe beneficiary for the item, or training the beneficiary in the use of the item, and the item isfor subsequent use in the beneficiary's home.3. The supplier delivers the item to the beneficiary no earlier than two days before the day thefacility discharges the beneficiary.4. The supplier ensures that the beneficiary takes the item home, or the supplier picks up theitem at the facility and delivers it to the beneficiary's home on the date of discharge.5. The reason the supplier furnishes the item is not for the purpose of eliminating the facility'sresponsibility to provide an item that is medically necessary for the beneficiary's use ortreatment while the beneficiary is in the facility. Such items are included in the DiagnosticRelated Group (DRG) or Prospective Payment System (PPS) rates.6. The supplier does not claim payment for the item for any day prior to the date of discharge.7. The supplier does not claim payment for additional costs that the supplier incurs in ensuringthat the item is delivered to the beneficiary's home on the date of discharge. The suppliercannot bill the beneficiary for redelivery.DME MAC Jurisdiction C Supplier Manual Page 16

DMEPOS Fee Schedule Chapter 58. The beneficiary's discharge must be to a qualified place of service, e.g., home, custodial orfacility, but not to another facility (e.g., inpatient or skilled nursing.) that does not qualify asthe beneficiary's home.Date of Service for Pre-Discharge Delivery of DMEPOS:For DMEPOS, the general rule is that the date of service is equal to the date of delivery.However, pre-discharge delivery of items intended for use upon discharge is consideredprovided on the date of discharge.DMEPOS and HospiceWhen hospice coverage is elected, the beneficiary waives all rights to Medicare Part B paymentsfor services that are related to the treatment and management of his/her terminal illness.During any period in which the hospice benefit election is in force, all items related to thetreatment and management of his/her terminal illness are paid by the intermediary. If theitems are not related to the terminal illness, the supplier should submit the claim to the DMEMAC.DME MAC Jurisdiction C Supplier Manual Page 17

Chapter Six √Claim Submission

Claim Submission Chapter 6Mandatory Claim FilingCenters for Medicare & Medicaid Services (CMS) Claims Filing Policy• For services furnished on or after September 1, 1990, physicians and suppliers mustcomplete and submit both assigned and nonassigned Part B claims for beneficiaries.• The claims filing requirement applies to all suppliers who provide covered services toMedicare beneficiaries.• Suppliers are not required to take assignment of Medicare benefits unless they are enrolledin the Medicare Participating Supplier Program or except where CMS regulations requiremandatory assignment (i.e., Medicare covered drugs).• Suppliers may not charge the beneficiary for preparing and filing a Medicare claim. Thebeneficiary may also not be charged for the completion of a Certificate of Medical Necessity(CMN) form.• The Contractor will monitor supplier compliance with the Medicare claims filing requirement.• Suppliers who do not submit Medicare claims for Medicare beneficiaries may be subject to acivil monetary penalty of up to $2,000 for each violation.• Medicare assigned claims must be filed within one year from the service date or the paymentwill be reduced by 10 percent.• The Administrative Simplification Compliance Act (ASCA) mandates the submission ofelectronic claims to Medicare unless the supplier meets certain “exceptions” described withinthe law• If an exception is met a Medicare paper claims must be submitted on the Health InsuranceClaim Form [CMS-1500 (08-05)] and no superbills can be accepted.• If the supplier determines that the beneficiary has other insurance which may pay primary toMedicare, they may file a claim with the primary insurer on the beneficiary's behalf. However,suppliers are not required by law to submit claims to other payers. If the supplier receives adetermination on the claim directly from the primary payer, they are responsible forsubmitting a claim to Medicare for secondary payment. If the beneficiary files a claim to theprimary insurer, they may forward the primary payer information to the supplier to submit theMedicare Secondary Payer (MSP) claim. The supplier must submit the secondary claim toMedicare for the beneficiary in accordance with the mandatory claims filing requirements.Mandatory Claim Filing Does Not Affect The Following:• Supplier/Beneficiary Payment Arrangements - Suppliers who do not accept assignment maycontinue to request payment in full at the time that the service is provided if the claim for thisservice is unassigned. We encourage you to file the claims about the same time you requestpayment. This will reduce a potential financial hardship for the patient and reduce futureinquiries you may receive regarding the status of the claim.• Providing Suppliers Information on Non-assigned Claims - By not accepting assignment ofMedicare benefits, suppliers are not a party to the Medicare payment transaction betweenDME MAC Jurisdiction C Supplier Manual Page 1

Claim Submission Chapter 6Medicare and the Medicare beneficiary. The transaction is covered by the Privacy Act. Ouroffice can only give limited information on non-assigned claims. The Contractor cannotdisclose payment amounts.• Non-Covered Medicare Services - Suppliers are not required to file claims on behalf ofMedicare beneficiaries for non-covered benefits or for other health insurance benefits.However, if the beneficiary (or his/her representative) believes that a service may be coveredor desires a formal Medicare determination, the supplier must file a claim for that service toeffectuate the beneficiary's right to a determination. Suppliers should note on the claim theirbelief that the service is noncovered and that it is being submitted at the beneficiary'sinsistence. The documentation should state the beneficiary-specific reason the item isconsidered by the supplier to be noncovered, and the modifier GY should be appended tothe HCPCS code(s) on the claim. Use of this modifier does not generate an automatic denialof the service. Coverage decisions are made based on the item billed and other pertinentinformation on the claim without regard to the presence or absence of this modifier.Assignment AgreementAn assignment agreement is between a supplier of services and a Medicare beneficiary. The optionof accepting assignment belongs solely to the supplier. Participating suppliers have signed acontract agreeing to accept assignment on all services rendered to Medicare patients.Nonparticipating suppliers have the option of accepting assignment on a claim-by-claim basis exceptwhere CMS regulations require mandatory assignment (i.e., Medicare covered drugs).Once entered into, the assignment agreement may not be rescinded by nonparticipating suppliersunless done so by mutual written agreement of the supplier and beneficiary. This agreement mustbe communicated to the Contractor before the Contractor has made, and sent notice of, the claimdetermination. Participating suppliers may not rescind the assignment agreement during the periodof their participation contract.When the supplier accepts assignment, he/she is bound by law to accept the Contractor'sdetermination of the approved amount as the full fee for the service rendered. He/she may not bill, oraccept payment for, the amount of the reduced charges. However, an attempt must be made tocollect (1) twenty percent of the approved charge (coinsurance), (2) any amount applied to thedeductible and (3) any noncovered charges subject to the Limitation of Liability provisions.Example of Assigned Claim:Submitted fee $25.00Approved charge (paid at 80% assuming that the $100 deductible has been met) $20.00Allowable charge reduction which cannot be collected from any source (submitted feeminus approved charge)$5.00Payment (80% of the approved charge) $16.00Coinsurance (20% of approved charge) $4.00DME MAC Jurisdiction C Supplier Manual Page 2

Claim Submission Chapter 6Suppliers who repeatedly violate the assignment agreement could be charged and found guilty of amisdemeanor, punishable by a maximum fine of $2,000, up to six months imprisonment, or both.Mandatory Assignment for Covered Drugs Billed to MedicareSection 114 of the Benefits Improvement and Protection Act of 2000 (BIPA) states, in part, "Paymentfor a charge for any drug or biological for which payment may be made under this part may be madeonly on an assignment-related basis." Mandatory assignment applies only to those drugs "for whichpayment may be made" - i.e., Medicare-covered drugs. Drugs that would never be paid (e.g., nobenefit category, never medically necessary) are not subject to mandatory assignment.A supplier may not render a charge or bill to anyone for these drugs and biologicals for any amountother than the Medicare Part B deductible and coinsurance.If a supplier submits an unassigned claim for a drug or biological with a date of service on or afterFebruary 1, 2001, the DME MAC will process the claim as though the supplier accepted assignment.If the patient already paid for the billed services, enter the amount paid for covered services,coinsurance and deductible in block 29 of the CMS-1500 claim form.The DME MAC will reimburse the beneficiary any amount they paid over the patient responsibilityamount shown on the Medicare Remittance Notice (MRN). The supplier must issue the beneficiary arefund within 30 days of the date of the MRN for the difference between the beneficiary's payment tothe supplier and the total of the amount shown as the patient responsibility and as paid to thebeneficiary on the MRN.ADVANCE BENEFICIARY NOTICEAdvanced Beneficiary NoticeAdvance Beneficiary Notice (ABN) is a written notice the supplier gives to a Medicare beneficiarybefore providing items and/or services that are expected to be denied by Medicare based on one ofthe following statutory exclusions:- Lack of medical necessity- Prohibited, unsolicited telephone contacts- No supplier number- Denial of an Advanced Determination of Medicare Coverage (ADMC) requestSuppliers must use the OMB-approved ABN form CMS-R-131 (ABN-G), which can be found onlineat http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp. For an ABN to be acceptable, it must:• Be on the approved CMS-R-131 form,• Clearly identify the particular item and/or service,• State that the supplier believes Medicare is likely (or Certain) to deny payment for theparticular item and/or service, and• Give the supplier’s reason(s) for their belief that Medicare is likely (or certain) to denypayment for the item and/or service.DME MAC Jurisdiction C Supplier Manual Page 3

Claim Submission Chapter 6The purpose of an ABN is to inform the beneficiary that Medicare will probably not pay for a certainitem or service in a specific situation, even if Medicare might pay for the item or service underdifferent circumstances.This allows the beneficiary to make an informed consumer decision about whether or not to receivethe item or service for which they may have to pay out of pocket or through other insurance.ABNs apply to assigned and nonassigned claims, as there are financial liability provisions underMedicare law:Limitation of liability (LOL) applies to assigned claims for DMEPOS services disallowed becauseof medical necessity, due to prohibition on unsolicited telephone calls, no supplier number, or noADMC. Under LOL, a beneficiary can be held liable for a service denied due to reasons cited on theABN.Refund requirements (RR) apply to assigned and non-assigned claims for DMEPOS servicesdisallowed because of medical necessity, due to prohibition on unsolicited telephone calls, nosupplier number, or no ADMC. RR state that suppliers must make refunds of any amounts collectedif the beneficiary was not properly notified of possible disallowed Medicare claims. The RRprovisions require that the beneficiary is notified and agrees to be financially liable.If a supplier renders a service to a patient which Medicare considers not medically necessary, thesupplier should notify the patient in writing, before rendering the service, that Medicare is likely todeny the claim and that the patient will be responsible for payment. Modifier "GA" should beindicated on the Medicare claim with the appropriate HCPCS code when it is filed.The following statements are examples of reasons for your belief that Medicare is likely to denypayment.- Medicare does not usually pay for this many treatments or services;- Medicare usually does not pay for this service;- Medicare does not pay for this because it is a treatment that has yet to be provedeffective (experimental);- Medicare does not pay for this many services within this period of time;- Medicare does not pay for such an extensive treatment;General statements such as "I never know if Medicare will deny payment" are not acceptable.The Medicare Part B beneficiary or his or her representative has the right to appeal a claim decisionif there is dissatisfaction with the amount of payment, denial of coverage for services or supplies, orif the original claim was not acted upon within a reasonable time. The supplier has the right to appeala claim decision when he or she accepts assignment.As a supplier providing items and services to Medicare beneficiaries, you may appeal an initialdetermination if:- You accepted assignment on the claim or- You are acting as the duly authorized representative of the beneficiary.ABNs for UpgradesAn upgrade is an item with features that go beyond what is medically necessary. An upgrade mayinclude an excess component. An excess component may be an item feature or service, which is inDME MAC Jurisdiction C Supplier Manual Page 4

Claim Submission Chapter 6addition to, or is more extensive and/or more expensive than the item that is reasonable andnecessary under Medicare’s coverage requirements. When a DMEPOS supplier knows or believesthat the DMEPOS item does or may not meet Medicare’s reasonable and necessary rules underspecific circumstances, it is the responsibility of the supplier to notify the beneficiary in writing via anABN if the supplier wants to collect money from a beneficiary if an item is denied.When a supplier furnishes an upgraded item of DMEPOS and the supplier expects Medicare toreduce the level of payment based on a medical necessity partial denial of coverage for additionalexpenses attributable to the upgrade, the supplier must give an ABN to the beneficiary for signaturefor holding the beneficiary liable for the additional expense.General Instructions for the Use of ABNs for Upgrading DMEPOS Items1. An upgrade may be from one item to another within a single Heath Insurance Common ProcedureCoding System (HCPCS) code, or may be from one HCPCS code to another. When an upgrade iswithin a single code the upgraded item must include features that exceed the official code descriptorfor that item.2. The upgrade must be within the range of items or services that are medically appropriate for thebeneficiary’s medical condition and the purpose of the physician’s order. ABNs may not be used tosubstitute a different item or service that is not medically appropriate for the beneficiary’s medicalcondition for the original item or service. The upgraded item must still meet the intended medicalpurpose of the item the physician ordered.3. Use of an ABN to furnish an upgraded item or service, with the beneficiary being personallyresponsible for the difference between the costs of the standard and upgraded item or service, doesnot change coverage or payment rules, statutory provisions, or manual instructions for the particularbenefit involved.4. In cases where the DMERCs would make payment for the item the physician ordered on a rentalbasis, the supplier must furnish the upgrade on a rental basis.5. A supplier furnishing an upgrade and using an ABN must submit a claim and include informationon the claim that identifies the upgrade features. Suppliers must submit a claim for upgraded itemsand services using the GA modifier on the upgraded line item to indicate that the beneficiary signedan ABN. Suppliers must list upgrade features in Item 19 or as an attachment to the claim for paperclaims. For electronic claims, suppliers must use the NTE segment/line note on the 837 electronicclaim format.6. Denials should be based on medical necessity.B. Billing Instructions:Suppliers must bill 2 line items for upgraded DMEPOS items where the beneficiary requests anupgrade. Suppliers must bill both lines on the same claim in the following order:Line 1: Bill the appropriate HCPCS code for the upgraded item the supplier actually provided to thebeneficiary with the dollar amount of the upgraded item. If the supplier has a properly obtained ABNon file signed by the beneficiary, use the GA modifier. If the supplier did not properly obtain an ABNsigned by the beneficiary, use the GZ modifier.Line 2: Bill the appropriate HCPCS code for the reasonable and necessary item with the actualcharge for the item. Use the GK modifier.DME MAC Jurisdiction C Supplier Manual Page 5

Claim Submission Chapter 6Suppliers should bill their full submitted charge on the claim line for the upgraded item (Line 1) andthe full amount for the reasonable and necessary item (Line 2). If the upgrade is within a code,suppliers still bill 2 line items, using the same code on both lines, but Line 1 would have the higherdollar amount. Suppliers must bill both lines on the same claim in sequential order. Line 1 and theassociated Line 2 should follow each other.Claims that have invalid ABN upgrade information will be returned as unprocessable.Definitions of Modifiers that May be Associated with ABNsGA - Waiver of Liability (expected to be denied as not reasonable and necessary, ABN on file)GZ - Item or Service not Reasonable and Necessary (expected to be denied as not reasonable andnecessary, no ABN on file)GK - Reasonable and necessary item/service associated with GA or GZ modifierProviding Upgrades of DMEPOS without Any Extra ChargeInstead of using ABNs and charging beneficiaries for upgraded items, suppliers in certaincircumstances may decide to furnish beneficiaries with upgraded equipment but charge theMedicare program and the beneficiary the same price they would charge for a nonupgraded item.The reason for this may be that a supplier prefers to carry only higher level models of medicalequipment in order to reduce the costs of maintaining an inventory that includes a wide variety ofdifferent models and products. Also, a supplier may be able to reduce its costs for replacementparts and repairs if it includes in its inventory only certain product lines. The supplier may alsobe accommodating a physician order for an upgrade.PolicySuppliers are permitted to furnish upgraded DMEPOS items and to charge the same price toMedicare and the beneficiary that they would charge for a non-upgraded item. This policy allowssuppliers to furnish to beneficiaries, at no extra costs to the Medicare program or the beneficiary,a DMEPOS item that exceeds what the non-upgraded item that Medicare considers to bemedically necessary. Therefore, even though the beneficiary received an upgraded DMEPOSitem, Medicare’s payment and the beneficiary’s coinsurance would be based on the Medicareallowed amount for a nonupgraded item that does not include features that exceed thebeneficiary’s medical needs.Billing InstructionsWhen a supplier decides to furnish an upgraded DMEPOS item but to charge Medicare and thebeneficiary for the non-upgraded item, the supplier must bill for the nonupgraded item ratherthan the item the supplier actually furnished. The claim must include only the charge andHCPCS code for the non-upgraded item. The HCPCS code for the non-upgraded item must beaccompanied by the following modifier:GL - Medically Unnecessary Upgrade Provided Instead of Non-upgraded Item, No Charge, NoABNIn Item 19 of a paper claim, or as an attachment, the supplier must specify the make and modelof the item actually furnished, that is, the upgraded item, and describe why this item is anDME MAC Jurisdiction C Supplier Manual Page 6

Claim Submission Chapter 6upgrade. For electronic claims, suppliers must use the NTE segment/line note on the 837electronic claim format.Contractors are to pay based on Medicare’s payment amount for the non-upgraded item if itmeets Medicare’s coverage and payment requirements. A certificate of medical necessity, ifapplicable, must be completed for the HCPCS code that identifies the nonupgraded item but notfor the upgraded item.Claim Filing JurisdictionUnlike other Medicare claims, DMEPOS claim jurisdiction is based on the beneficiary’s address onfile with the Social Security Administration. A DMEPOS claim should be sent to the DME MACjurisdiction for the state in which the beneficiary resides.Jurisdiction A:The Jurisdiction A DME MAC contract was awarded to National Heritage Insurance Company(NHIC). The states included in DME MAC Jurisdiction A are: Connecticut, Delaware, District ofColumbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania,Rhode Island, and Vermont.DME - Drug ClaimsP.O. Box 9145Hingham, MA 02043-9145DME - Oxygen ClaimsP.O. Box 9148Hingham, MA 02043-9148DME - PEN ClaimsP.O. Box 9149Hingham, MA 02043-9149DME - Specialty ClaimsP.O. Box 9165Hingham, MA 02043-9165DME - ADSP.O. Box 9170Hingham, MA 02043-9170Jurisdiction B:The Jurisdiction B DME MAC contract was awarded to National Government Services (NGS). Thestates included in DME MAC Jurisdiction B are: Illinois, Indiana, Kentucky, Michigan, Minnesota,Ohio and Wisconsin.DMEPOS AssignedP.O. Box 7027Indianapolis, Indiana 46207-7027DMEPOS NonassignedP.O. Box 7031Indianapolis, Indiana 46207-7031DME MAC Jurisdiction C Supplier Manual Page 7

Claim Submission Chapter 6Oxygen AssignedP.O. Box 7048Indianapolis, Indiana 46207-7048Oxygen NonassignedP.O. Box 7052Indianapolis, Indiana 46207-7052DMEPOS Additional Documentation Requests (ADRs)P.O. Box 7061Indianapolis, Indiana 46207-7061Jurisdiction C:The Jurisdiction C DME MAC contract was awarded to CIGNA Government Services (CGS). Thestates included in Jurisdiction C are: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana,Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee,Texas, U.S. Virgin Islands, Virginia, and West Virginia.Mailing AddressCIGNA Government ServicesP. O. Box 20010Nashville, TN 37202Jurisdiction D:The Jurisdiction D DME MAC contract was awarded to Noridian Administrative Services (NAS). Thestates included in DME MAC Jurisdiction D are: Alaska, American Samoa, Arizona, California,Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, NorthernMariana Islands, Oregon, South Dakota, Utah, Washington, and Wyoming.Mailing AddressNoridian Administrative ServicesP.O. Box 6727Fargo, ND 58108-6727Place of ServiceCoverage for any DMEPOS items will be considered if the place of service is:01 Pharmacy04 Homeless Shelter09 Prison/Correctional Facility12 Home13 Assisted Living Facility14 Group Home33 Custodial Care FacilityDME MAC Jurisdiction C Supplier Manual Page 8

Claim Submission Chapter 654 Intermediate Care Facility/Mentally Retarded55 Residential Substance Abuse Treatment Facility56 Psychiatric Residential Treatment Center65 End Stage Renal Disease Treatment Facility (valid POS for Parenteral Nutritional TherapyCoverage consideration for DMEPOS items in a Skilled Nursing Facility (31), unless the beneficiaryis in a covered Part A stay, or a Nursing Facility (32) is limited to the following:• Prosthetics, orthotics and related supplies• Urinary incontinence supplies• Ostomy supplies• Surgical dressings• Oral anticancer drugs• Oral antiemetic drugs• Therapeutic shoes for Diabetics• Parenteral/enteral nutrition (including E0776BA, the IV pole used to administerparenteral/enteral nutrition)• ESRD - dialysis supplies only• Immunosuppressive drugsFor a complete list of place of service codes visit:http://www.cms.hhs.gov/MedHCPCSGenInfo/Downloads/Place_of_Service.pdfCMS-1500 (08-05) Claim FormIn July 2006, the Form CMS-1500 (12-90) was revised by the National Uniform Claim Committee(NUCC) predominantly for the purpose of accommodating the National Provider Identifier.Beginning January 1, 2007 either the new form CMS-1500 (08-05) or the previous form CMS-1500(12-90) may be used to submit paper claims. Effective July 2, 2007 only the new form can be usedto submit paper claims.The CMS-1500 (08-05) answers the needs of many health insurers. It is the basic form prescribedby CMS for Medicare claims from suppliers. It has also been adopted by CHAMPUS and hasreceived the approval of the American Medical Association (AMA) Council on Medical Services.Complete instructions for the CMS-1500 (08-05) claim form are provided in this section.DME MAC Jurisdiction C Supplier Manual Page 9

Claim Submission Chapter 6Guidelines For Filing Paper Claims** Failure to follow these guidelines could cause a delay in processing, denial of the claim, or affectpayment accuracy. **The Administrative Simplification Compliance Act (ASCA) mandates the submission of electronicclaims to Medicare unless you meet certain “exceptions” described within the law. If you believe youmeet the exception criteria and will be submitting your claims on paper, please adhere to thefollowing guidelines.1. Do not submit black CMS-1500 forms. This includes submitting copies or carbon copies. Alwayssubmit a RED CMS-1500 form.2. Do not write or stamp information in RED ink. Information inred will not show up on the image and will not be available during processing.3. Do not use light print or a Dot Matrix printer which causes broken lines. Check to make sure theink is dark. Also, laser or inkjet printers are preferred.4. Do not use small font type and size. For best processing results we recommend font type LucidaConsole and size 10.5. Do not use handwriting. It may be too light or simply unrecognizable.6. Do not highlight items on the CMS-1500 form or attachments. This will cause the claim to beillegible which slows down the processing of the claim.7. Do not use stamps or stickers within the body of the claim. If you must use a stamp or sticker,put it at the top of the claim within the blank area.8. Do not leave block 11 blank. If no primary insurance exists, put NONE in the field.9. Do not use extra verbiage within the body of the claim. If you must put extra verbiage on theclaim, use block 19 or an attachment.10. Do not put a description next to the diagnosis code in block 21. All that is needed is the ICD-9alpha/numeric diagnosis code.11. Do not submit more than four diagnosis codes within block 21.12. Do not submit more than one diagnosis pointer in block 24e. Only the first pointer will be usedfor processing.13. Do not submit more than six service lines within block 24.14. Do not put a description of the procedure codes or times/units underneath the line item in blocks24a – 24j. It is not needed and may cause processing errors.15. Do not place the number of units/days in block 24g too close to the charges in 24f. This maycause the units/days to be read as a part of the submitted charges and the number of units/daysDME MAC Jurisdiction C Supplier Manual Page 10

Claim Submission Chapter 6to default to 1. Right justifying the days/units in block 24g will give more space between the twofields.16. Do not put a phone number on the first line of block 33. Submit the phone number below theprovider’s name and address.17. Do not omit the zip code in block 33. This block is used as the mailing address when a claim isreturned.18. Do not change the size of EOBs or copy them across to two pages. This may cause your EOBto be illegible.19. Submit claims to P.O. Box 20010 only.Ordering the FormContractors, physicians, and suppliers are responsible for purchasing their own Form CMS-1500. This form can be bought in single, multi-part snap-out sets or in continuous pin-feed format.Medicare accepts any version. Forms can be obtained from local printers or printed in-house as longas it follows the CMS approved specifications developed by the American Medical Association.The claim forms may also be ordered from the Superintendent of Documents or negatives may bepurchased from the Government Printing Office.U S Government Printing OfficeSuperintendent of DocumentsWashington, DC 20402Or, you may order by phone and charge your order to MasterCard, Visa, or SUPDOCS DepositAccount. Call 202.512.1800 between 8:00 AM and 4:00 PM Eastern time.QUANTITY DISCOUNT: On any order for 100 packages or more to be shipped to one address, youmay apply a 25% discount to the prices shown above.Claim Completion InstructionsHealth Insurance Claim Form CMS-1500The Form CMS-1500 (Health Insurance Claim Form) is sometimes referred to as theAMA (American Medical Association) form. The Form CMS-1500 is the prescribed form for claimsprepared and submitted by physicians or suppliers (except for ambulance suppliers), whether or notthe claims are assigned.Legend DescriptionMM Month (e.g., December = 12)DD Day (e.g., Dec15 = 15)YY 2 position Year (e.g., 1998 = 98)CCYY 4 position Year (e.g., 1998 = 1998)DME MAC Jurisdiction C Supplier Manual Page 11

Claim Submission Chapter 6(MM | DD | YY) or (MM | DD | CCYY) A space must be reported between month, day, and year (e.g.,12 | 15 | 98 or 12 | 15 |1998). This space is delineated by a dotted vertical line on the Form CMS-1500)(MMDDYY) or (MMDDCCYY) No space must be reported between month, day, and year (e.g.,121598 or 12151998). The date must be recorded as one continuous number.Claims that are Incomplete or Contain Invalid InformationIf a claim is submitted with incomplete or invalid information, it will be returned to the submitter asunprocessable.Items 1-11 - Patient and Insured InformationItem 1 - Show the type of health insurance coverage applicable to this claim by checking theappropriate box, e.g., if a Medicare claim is being filed, check the Medicare box.Item 1a - Enter the patient's Medicare Health Insurance Claim Number (HICN) whether Medicare isthe primary or secondary payer. This is a required field.Item 2 - Enter the patient's last name, first name, and middle initial, if any, as shown on the patient'sMedicare card. This is a required field.Item 3 - Enter the patient's 8-digit birth date (MM | DD | CCYY) and sex.Item 4 - If there is insurance primary to Medicare, either through the patient's or spouse'semployment or any other source, list the name of the insured here. When the insured and the patientare the same, enter the word SAME. If Medicare is primary, leave blank.Item 5 - Enter the patient's mailing address and telephone number. On the first line enter the streetaddress; the second line, the city and state; the third line, the ZIP code and phone number.Item 6 - Check the appropriate box for patient's relationship to insured when item 4 is completed.Item 7 - Enter the insured's address and telephone number. When the address is the same as thepatient's, enter the word SAME. Complete this item only when items 4, 6, and 11 are completed.Item 8 - Check the appropriate box for the patient's marital status and whether employed or astudent.Item 9 - Enter the last name, first name, and middle initial of the enrollee in a Medigap policy if it isdifferent from that shown in item 2. Otherwise, enter the word SAME. If no Medigap benefits areassigned, leave blank. This field may be used in the future for supplemental insurance plans.NOTE: Only Participating Physicians and Suppliers are to complete item 9 and its subdivisions andonly when the Beneficiary wishes to assign his/her benefits under a MEDIGAP policy to theParticipating Physician or Supplier. Participating physicians and suppliers must enter informationrequired in item 9 and its subdivisions if requested by the beneficiary. Participatingphysicians/suppliers sign an agreement with Medicare to accept assignment of Medicare benefits forall Medicare patients. A claim for which a beneficiary elects to assign his/her benefits under aMedigap policy to a participating physician/supplier is called a mandated Medigap transfer.Medigap - Medigap policy meets the statutory definition of a "Medicare supplemental policy"contained in §1882(g)(1) of title XVIII of the Social Security Act (the Act) and the definition containedDME MAC Jurisdiction C Supplier Manual Page 12

Claim Submission Chapter 6in the NAIC Model Regulation that is incorporated by reference to the statute. It is a health insurancepolicy or other health benefit plan offered by a private entity to those persons entitled to Medicarebenefits and is specifically designed to supplement Medicare benefits. It fills in some of the "gaps" inMedicare coverage by providing payment for some of the charges for which Medicare does not haveresponsibility due to the applicability of deductibles, coinsurance amounts, or other limitationsimposed by Medicare. It does not include limited benefit coverage available to Medicarebeneficiaries such as "specified disease" or "hospital indemnity" coverage.Also, it explicitly excludes a policy or plan offered by an employer to employees or formeremployees, as well as that offered by a labor organization to members or former members.Do not list other supplemental coverage in item 9 and its subdivisions at the time a Medicare claim isfiled. Other supplemental claims are forwarded automatically to the private insurer if the privateinsurer contracts with the Contractor to send Medicare claim information electronically. If there is nosuch contract, the beneficiary must file his/her own supplemental claim.Item 9a - Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP,MG, or MGAP.NOTE: Item 9d must be completed if the provider enters a policy and/or group number in item 9a.Item 9b - Enter the Medigap insured's 8-digit birth date (MM | DD | CCYY) and sex.Item 9c - Leave blank if a Medigap PayerID is entered in item 9d. Otherwise, enter the claimsprocessing address of the Medigap insurer. Use an abbreviated street address, two-letter postalcode, and ZIP code copied from the Medigap insured's Medigap identification card. For example:1257 Anywhere StreetBaltimore, MD 21204 is shown as "1257 Anywhere St. MD 21204."Item 9d - Enter the 9-digit PAYERID number of the Medigap insurer. If no PAYERID number exists,then enter the Medigap insurance program or plan name.If the beneficiary wants Medicare payment data forwarded to a Medigap insurer under a mandatedMedigap transfer, the participating provider of service or supplier must accurately complete all of theinformation in items 9, 9a, 9b, and 9d. Otherwise, the Medicare Contractor cannot forward the claiminformation to the Medigap insurer.Items 10a through 10c - Check "YES" or "NO" to indicate whether employment, auto liability, orother accident involvement applies to one or more of the services described in item 24. Enter theState postal code. Any item checked "YES" indicates there may be other insurance primary toMedicare. Identify primary insurance information in item 11.Item 10d - Use this item exclusively for Medicaid (MCD) information. If the patient is entitled toMedicaid, enter the patient's Medicaid number preceded by MCD.Item 11 - THIS ITEM MUST BE COMPLETED, IT IS A REQUIRED FIELD. BY COMPLETING THISITEM, THE PHYSICIAN/SUPPLIER ACKNOWLEDGES HAVING MADE A GOOD FAITH EFFORTTO DETERMINE WHETHER MEDICARE IS THE PRIMARY OR SECONDARY PAYER.If there is insurance primary to Medicare, enter the insured's policy or group number and proceed toitems 11a - 11c. Items 4, 6, and 7 must also be completed.DME MAC Jurisdiction C Supplier Manual Page 13

Claim Submission Chapter 6NOTE: Enter the appropriate information in item 11c if insurance primary to Medicare is indicated initem 11. If there is no insurance primary to Medicare, enter the word "NONE" and proceed to item12. If the insured reports a terminating event with regard to insurance which had been primary toMedicare (e.g., insured retired), enter the word "NONE" and proceed to item 11b. If a lab hascollected previously and retained MSP information for a beneficiary, the lab may use that informationfor billing purposes of the non-face-to-face lab service. If the lab has no MSP information for thebeneficiary, the lab will enter the word “None” in Block 11 of Form CMS-1500, when submitting aclaim for payment of a reference lab service. Where there has been no face-to-face encounter withthe beneficiary, the claim will then follow the normal claims process. When a lab has a face-to-faceencounter with a beneficiary, the lab is expected to collect the MSP information and bill accordingly.Insurance Primary to Medicare - Circumstances under which Medicare payment may besecondary to other insurance include:• Group Health Plan Coverage• Working Aged;• Disability (Large Group Health Plan); and• End Stage Renal Disease;• No Fault and/or Other Liability; and• Work-Related Illness/Injury:• Workers' Compensation;• Black Lung; and• Veterans Benefits.NOTE: For a paper claim to be considered for Medicare secondary payer benefits, a copy of theprimary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form.Items 11a - 13 - Patient and Insured InformationItem 11a - Enter the insured's 8-digit birth date (MM | DD | CCYY) and sex if different from item 3.Item 11b - Enter employer's name, if applicable. If there is a change in the insured's insurancestatus, e.g., retired, enter either a 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) retirement datepreceded by the word "RETIRED."Item 11c - Enter the 9-digit PAYERID number of the primary insurer. If no PAYERID number exists,then enter the complete primary payer's program or plan name. If the primary payer's EOB does notcontain the claims processing address, record the primary payer's claims processing addressdirectly on the EOB. This is required if there is insurance primary to Medicare that is indicated in item11.Item 11d - Leave blank. Not required by Medicare.Item 12 - The patient or authorized representative must sign and enter either a 6-digit date (MM | DD| YY), 8-digit date (MM | DD | CCYY), or an alpha-numeric date (e.g., January 1, 1998) unless thesignature is on file. In lieu of signing the claim, the patient may sign a statement to be retained in theprovider, physician, or supplier file. If the patient is physically or mentally unable to sign, arepresentative may sign on the patient's behalf. In this event, the statement's signature line mustindicate the patient's name followed by “by” the representative's name, address, relationship to thepatient, and the reason the patient cannot sign. The authorization is effective indefinitely unlesspatient or the patient's representative revokes this arrangement.DME MAC Jurisdiction C Supplier Manual Page 14

Claim Submission Chapter 6NOTE: This can be "Signature on File" and/or a computer generated signature. The patient'ssignature authorizes release of medical information necessary to process the claim. It alsoauthorizes payment of benefits to the provider of service or supplier when the provider of service orsupplier accepts assignment on the claim.Signature by Mark (X) - When an illiterate or physically handicapped enrollee signs by mark, awitness must enter his/her name and address next to the mark.Item 13 - The signature in this item authorizes payment of mandated Medigap benefits to theparticipating physician or supplier if required Medigap information is included in item 9 and itssubdivisions. The patient or his/her authorized representative signs this item or the signature mustbe on file as a separate Medigap authorization. The Medigap assignment on file in the participatingprovider of service/supplier's office must be insurer specific. It may state that the authorizationapplies to all occasions of service until it is revoked.NOTE: This can be "Signature on File" signature and/or a computer generated signature.Items 14-33 - Provider of Service or Supplier InformationReminder: For date fields other than date of birth, all fields shall be one or the other format, 6-digit:(MM | DD | YY) or 8-digit: (MM | DD | CCYY). Intermixing the two formats on the claim is not allowed.Item 14 - Enter either an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date of current illness,injury, or pregnancy. For chiropractic services, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD| YY) date of the initiation of the course of treatment and enter an 8-digit (MM | DD | CCYY) or 6-digit(MM | DD | YY) date in item 19.Item 15 - Leave blank. Not required by Medicare.Item 16 - If the patient is employed and is unable to work in his/her current occupation, enter an 8-digit (MM | DD | CCYY) or 6-digit (MM | DD | YY) date when patient is unable to work. An entry inthis field may indicate employment related insurance coverage.Item 17 - Enter the name of the referring or ordering physician if the service or item was ordered orreferred by a physician.The term "physician" when used within the meaning of §1861(r) of the Act and used in connectionwith performing any function or action refers to:1. A doctor of medicine or osteopathy legally authorized to practice medicine and surgery bythe State in which he/she performs such function or action;2. A doctor of dental surgery or dental medicine who is legally authorized to practice dentistryby the State in which he/she performs such functions and who is acting within the scope ofhis/her license when performing such functions;3. A doctor of podiatric medicine for purposes of §§(k), (m), (p)(1), and (s) and §§1814(a),1832(a)(2)(F)(ii), and 1835 of the Act, but only with respect to functions which he/she islegally authorized to perform as such by the State in which he/she performs them;4. A doctor of optometry, but only with respect to the provision of items or services described in§1861(s) of the Act which he/she is legally authorized to perform as a doctor of optometry bythe State in which he/she performs them; or5. A chiropractor who is licensed as such by a State (or in a State which does not licensechiropractors as such), and is legally authorized to perform the services of a chiropractor inthe jurisdiction in which he/she performs such services, and who meets uniform minimumstandards specified by the Secretary, but only for purposes of §§1861(s)(1) andDME MAC Jurisdiction C Supplier Manual Page 15

Claim Submission Chapter 61861(s)(2)(A) of the Act, and only with respect to treatment by means of manualmanipulation of the spine (to correct a subluxation). For the purposes of §1862(a)(4) of theAct and subject to the limitations and conditions provided above, chiropractor includes adoctor of one of the arts specified in the statute and legally authorized to practice such art inthe country in which the inpatient hospital services (referred to in §1862(a)(4) of the Act) arefurnished.Referring physician - is a physician who requests an item or service for the beneficiary for whichpayment may be made under the Medicare program.Ordering physician - is a physician or, when appropriate, a non-physician practitioner who ordersnon-physician services for the patient. Examples of services that might be ordered include diagnosticlaboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, andservices incident to that physician’s or non-physician practitioner’s service.The ordering/referring requirement became effective January 1, 1992, and is required by §1833(q) ofthe Act. All claims for Medicare covered services and items that are the result of a physician's orderor referral shall include the ordering/referring physician's name. See Items 17a and 17b below forfurther guidance on reporting the referring/ordering provider’s UPIN and/or NPI. The followingservices/situations require the submission of the referring/ordering provider information:• Medicare covered services and items that are the result of a physician's order or referral;• Parenteral and enteral nutrition;• Immunosuppressive drug claims;• Hepatitis B claims;• Diagnostic laboratory services;• Diagnostic radiology services;• Portable x-ray services;• Consultative services;• Durable medical equipment;• When the ordering physician is also the performing physician (as often is the case with inofficeclinical laboratory tests);• When a service is incident to the service of a physician or non-physician practitioner, thename of the physician or non-physician practitioner who performs the initial service andorders the non-physician service must appear in item 17;• When a physician extender or other limited licensed practitioner refers a patient forconsultative service, submit the name of the physician who is supervising the limited licensedpractitioner;Item 17a – Enter the CMS assigned UPIN of the referring/ordering physician listed in item 17. TheUPIN may be reported on the Form CMS-1500 until May 22, 2007, and MUST be reported if an NPIis not available.NOTE: Field 17a and/or 17b is required when a service was ordered or referred by a physician.Effective May 23, 2007, and later, 17a is not to be reported but 17b MUST be reported when aservice was ordered or referred by a physician. When a claim involves multiple referring and/orordering physicians, a separate Form CMS-1500 shall be used for each ordering/referring physician.All physicians who order or refer Medicare beneficiaries or services must report either an NPI orUPIN or both prior to May 23, 2007. After that date, an NPI (but not a UPIN) must be reported eventhough they may never bill Medicare directly. A physician who has not been assigned a UPIN shallcontact the Medicare Contractor.DME MAC Jurisdiction C Supplier Manual Page 16

Claim Submission Chapter 6Item 17b Form CMS-1500 (08-05) – Enter the NPI of the referring/ordering physician listed in item17 as soon as it is available. The NPI may be reported on the Form CMS-1500 (08-05) as early asJanuary 1, 2007.NOTE: Field 17a and/or 17b is required when a service was ordered or referred by a physician.Effective May 23, 2007, and later, 17a is not to be reported but 17b MUST be reported when aservice was ordered or referred by a physician.Item 18 - Enter either an 8-digit (MM | DD | CCYY) or a 6-digit (MM | DD | YY) date when a medicalservice is furnished as a result of, or subsequent to, a related hospitalization.Item 19 – Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) date patient was lastseen and the UPIN (NPI when it becomes effective) of his/her attending physician when a physicianproviding routine foot care submits claims.For physical therapy, occupational therapy or speech-language pathology services, effective forclaims with dates of service on or after June 6, 2005, the date last seen and the UPIN/NPI of anordering/referring/attending/certifying physician or non-physician practitioner are not required. If thisinformation is submitted voluntarily, it must be correct or it will cause rejection or denial of the claim.However, when the therapy service is provided incident to the services of a physician or nonphysicianpractitioner, then incident to policies continue to apply. For example, for identification ofthe ordering physician who provided the initial service, see Item 17 and 17a, and for the identificationof the supervisor, see item 24K of this section.Enter either a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) x-ray date for chiropractorservices (if an x-ray, rather than a physical examination was the method used to demonstrate thesubluxation). By entering an x-ray date and the initiation date for course of chiropractic treatment initem 14, the chiropractor is certifying that all the relevant information requirements (including level ofsubluxation) of Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, are on file, along with theappropriate x-ray and all are available for Contractor review.Enter the drug's name and dosage when submitting a claim for Not Otherwise Classified (NOC)drugs.Enter a concise description of an "unlisted procedure code" or an NOC code if one can be givenwithin the confines of this box. Otherwise an attachment shall be submitted with the claim.Enter all applicable modifiers when modifier -99 (multiple modifiers) is entered in item 24d. If modifier-99 is entered on multiple line items of a single claim form, all applicable modifiers for each line itemcontaining a -99 modifier should be listed as follows: 1=(mod), where the number 1 represents theline item and "mod" represents all modifiers applicable to the referenced line item.Enter the statement "Homebound" when an independent laboratory renders an EKG tracing orobtains a specimen from a homebound or institutionalized patient. (See Pub. 100-02, MedicareBenefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," and Pub. 100-04,Medicare Claims Processing Manual, Chapter 16, "Laboratory Services From Independent Labs,Physicians and Providers," and Pub. 100- 01, Medicare General Information, Eligibility, andEntitlement Manual, Chapter 5, "Definitions," respectively for the definition of "homebound" and amore complete definition of a medically necessary laboratory service to a homebound or aninstitutional patient.)Enter the statement, "Patient refuses to assign benefits" when the beneficiary absolutely refuses toassign benefits to a non-participating physician/supplier who accepts assignment on a claim. In thiscase, payment can only be made directly to the beneficiary.DME MAC Jurisdiction C Supplier Manual Page 17

Claim Submission Chapter 6Enter the statement, "Testing for hearing aid" when billing services involving the testing of a hearingaid(s) is used to obtain intentional denials when other payers are involved.When dental examinations are billed, enter the specific surgery for which the exam is beingperformed.Enter the specific name and dosage amount when low osmolar contrast material is billed, but only ifHCPCS codes do not cover them.Enter a 6-digit (MM | DD | YY) or an 8-digit (MM | DD | CCYY) assumed and/or relinquished date fora global surgery claim when providers share post-operative care.Enter demonstration ID number "30" for all national emphysema treatment trial claims.Enter the PIN (or NPI when effective) of the physician who is performing a purchased interpretationof a diagnostic test. (See Pub. 100-04, Chapter 1, Section 30.2.9.1 for additional information.)Method II suppliers shall enter the most current HCT value for the injection of Aranesp for ESRDbeneficiaries on dialysis. (See Pub. 100-04, Chapter 8, Section 60.7.2.)Item 20 - Complete this item when billing for diagnostic tests subject to purchase price limitations.Enter the purchase price under charges if the "yes" block is checked. A "yes" check indicates that anentity other than the entity billing for the service performed the diagnostic test. A "no" check indicates"no purchased tests are included on the claim." When "yes" is annotated, item 32 shall becompleted. When billing for multiple purchased diagnostic tests, each test shall be submitted on aseparate claim Form CMS- 1500. Multiple purchased tests may be submitted on the ASC X12 837electronic format as long as appropriate line level information is submitted when services arerendered at different service facility locations.NOTE: This is a required field when billing for diagnostic tests subject to purchase price limitations.Item 21 - Enter the patient's diagnosis/condition. With the exception of claims submitted byambulance suppliers (specialty type 59), all physician and non-physician specialties (i.e., PA, NP,CNS, CRNA) use an ICD-9-CM code number and code to the highest level of specificity for the dateof service. Enter up to four diagnoses in priority order. All narrative diagnoses for non-physicianspecialties shall be submitted on an attachment.Item 22 - Leave blank. Not required by Medicare.Item 23 - Enter the Quality Improvement Organization (QIO) prior authorization number forprocedures requiring QIO prior approval.thoseEnter the Investigational Device Exemption (IDE) number when an investigational device is used inan FDA-approved clinical trial. Post Market Approval number should also be placed here whenapplicable.For physicians performing care plan oversight services, enter the 6-digit Medicare providernumber (or NPI when effective) of the home health agency (HHA) or hospice when CPT codeG0181 (HH) or G0182 (Hospice) is billed.Enter the 10-digit Clinical Laboratory Improvement Act (CLIA) certification number for laboratoryservices billed by an entity performing CLIA covered procedures.DME MAC Jurisdiction C Supplier Manual Page 18

Claim Submission Chapter 6When a physician provides services to a beneficiary residing in a SNF and the services wererendered to a SNF beneficiary outside of the SNF, the physician shall enter the Medicare facilityprovider number of the SNF in item 23.NOTE: Item 23 can contain only one condition. Any additional conditions should be reported on aseparate Form CMS-1500.Item 24 (Form CMS-1500 (08-05) – The six service lines in section 24 have been dividedhorizontally to accommodate submission of both the NPI and legacy identifier during the NPItransition and to accommodate the submission of supplemental information to support the billedservice. The top portion in each of the six service lines is shaded and is the location for reportingsupplemental information. It is not intended to allow the billing of 12 service lines. At this time, theshaded area in 24a through 24h is not used by Medicare. Future guidance will be provided on whenand how to use this shaded area for the submission of Medicare claims.Item 24A - Enter a 6-digit or 8-digit (MMDDCCYY) date for each procedure, service, or supply.When "from" and "to" dates are shown for a series of identical services, enter the number of days orunits in column G. This is a required field. Return as unprocessable if a date of service extends morethan 1 day and a valid "to" date is not present.Item 24B - Enter the appropriate place of service code(s). Identify the location, using a place ofservice code, for each item used or service performed. This is a required field.NOTE: When a service is rendered to a hospital inpatient, use the “inpatient hospital” code.Item 24C - Medicare providers are not required to complete this item.Item 24D - Enter the procedures, services, or supplies using the CMS Healthcare CommonProcedure Coding System (HCPCS) code. When applicable, show HCPCS code modifiers with theHCPCS code. The Form CMS-1500 (08-05) has the ability to capture up to four modifiers.Enter the specific procedure code without a narrative description. However, when reporting an"unlisted procedure code" or a "not otherwise classified" (NOC) code, include a narrative descriptionin item 19 if a coherent description can be given within the confines of that box. Otherwise, anattachment shall be submitted with the claim. This is a required field.Return as unprocessable if an "unlisted procedure code" or an (NOC) code is indicated in item 24d,but an accompanying narrative is not present in item 19 or on an attachment.Item 24E - Enter the diagnosis code reference number as shown in item 21 to relate the date ofservice and the procedures performed to the primary diagnosis. Enter only one reference numberper line item. When multiple services are performed, enter the primary reference number for eachservice, either a 1, or a 2, or a 3, or a 4. This is a required field.If a situation arises where two or more diagnoses are required for a procedure code (e.g., papsmears), the provider shall reference only one of the diagnoses in item 21.Item 24F- Enter the charge for each listed service.Item 24G - Enter the number of days or units. This field is most commonly used for multiple visits,units of supplies, anesthesia minutes, or oxygen volume. If only one service is performed, thenumeral 1 must be entered.DME MAC Jurisdiction C Supplier Manual Page 19

Claim Submission Chapter 6Some services require that the actual number or quantity billed be clearly indicated on the claimform (e.g., multiple ostomy or urinary supplies, medication dosages, or allergy testing procedures).When multiple services are provided, enter the actual number provided.For anesthesia, show the elapsed time (minutes) in item 24g. Convert hours into minutes and enterthe total minutes required for this procedure.For instructions on submitting units for oxygen claims, see chapter 20, section 130.6 of this manual.NOTE: This field should contain at least 1day or unit. The Contractor should program their system toautomatically default "1" unit when the information in this field is missing to avoid returning asunprocessable.Item 24H - Leave blank. Not required by Medicare.Item 24I Form CMS-1500 (08-05) – Enter the ID qualifier 1C in the shaded portion.Item 24J Form CMS-1500 (08-05) – Prior to May 23, 2007, enter the rendering provider’s PIN in theshaded portion. In the case of a service provided incident to the service of a physician or nonphysicianpractitioner, when the person who ordered the service is not supervising, enter the PIN ofthe supervisor in the shaded portion.Effective May 23, 2007 and later, do not use the shaded portion. Beginning no earlier than January1, 2007, enter the rendering provider’s NPI number in the lower portion. In the case of a serviceprovided incident to the service of a physician or non- physician practitioner, when the person whoordered the service is not supervising, enter the NPI of the supervisor in the lower portion.Item 24K Form CMS-1500 (08-05) – There is no Item 24K on this version.Item 25 - Enter the provider of service or supplier Federal Tax ID (Employer Identification Number)or Social Security Number. The participating provider of service or supplier Federal Tax ID number isrequired for a mandated Medigap transfer.Item 26 - Enter the patient's account number assigned by the provider's of service or supplier'saccounting system. This field is optional to assist the provider in patient identification. As a service,any account numbers entered here will be returned to the provider.Item 27 - Check the appropriate block to indicate whether the provider of service or supplier acceptsassignment of Medicare benefits. If Medigap is indicated in item 9 and Medigap paymentauthorization is given in item 13, the provider of service or supplier shall also be a Medicareparticipating provider of service or supplier and accept assignment of Medicare benefits for allcovered charges for all patients.The following providers of service/suppliers and claims can only be paid on an assignment basis:• Clinical diagnostic laboratory services;• Physician services to individuals dually entitled to Medicare and Medicaid;• Participating physician/supplier services;• Services of physician assistants, nurse practitioners, clinical nurse specialists, nursemidwives, certified registered nurse anesthetists, clinical psychologists, and clinicalsocial workers;• Ambulatory surgical center services for covered ASC procedures;• Home dialysis supplies and equipment paid under Method II;• Ambulance services;• Drugs and biologicals; andDME MAC Jurisdiction C Supplier Manual Page 20

Claim Submission Chapter 6• Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine.Item 28 - Enter total charges for the services (i.e., total of all charges in item 24f).Item 29 - Enter the total amount the patient paid on the covered services only.Item 30 - Leave blank. Not required by Medicare.Item 31 - Enter the signature of provider of service or supplier, or his/her representative, and eitherthe 6-digit date (MM | DD | YY), 8-digit date (MM | DD | CCYY), or alphanumeric date (e.g., January1, 1998) the form was signed.In the case of a service that is provided incident to the service of a physician or nonphysicianpractitioner, when the ordering physician or non-physician practitioner is directly supervising theservice as in 42 CFR 410.32, the signature of the ordering physician or non-physician practitionershall be entered in item 31. When the ordering physician or non-physician practitioner is notsupervising the service, then enter the signature of the physician or non-physician practitionerproviding the direct supervision in item 31.NOTE: This is a required field; however the claim can be processed if the following is true. If aphysician, supplier, or authorized person's signature is missing, but the signature is on file; or if anyauthorization is attached to the claim or if the signature field has "Signature on File" and/or acomputer generated signature..Item 32 Form CMS-1500 (08-05) - Enter the name and address, and ZIP code of the facility if theservices were furnished in a hospital, clinic, laboratory, or facility other than the patient's home orphysician's office. Effective for claims received on or after April 1, 2004, enter the name, address,and zip code of the service location for all services other than those furnished in place of servicehome – 12. Effective for claims received on or after April 1, 2004, on the Form CMS-1500, only onename, address and zip code may be entered in the block. If additional entries are needed, separateclaim forms shall be submitted.Providers of service (namely physicians) shall identify the supplier's name, address, and ZIP codewhen billing for purchased diagnostic tests. When more than one supplier is used, a separate FormCMS-1500 shall be used to bill for each supplier.For foreign claims, only the enrollee can file for Part B benefits rendered outside of the UnitedStates. These claims will not include a valid ZIP code. When a claim is received for these serviceson a beneficiary submitted Form CMS-1490S, before the claim is entered in the system, it should bedetermined if it is a foreign claim. If it is a foreign claim, follow instructions in chapter 1 for dispositionof the claim. The Contractor processing the foreign claim will have to make necessaryaccommodations to verify that the claim is not returned as unprocessable due to the lack of a ZIPcode.For durable medical, orthotic, and prosthetic claims, the name and address of the location where theorder was accepted must be entered. This field is required. When more than one supplier is used, aseparate Form CMS-1500 shall be used to bill for each supplier. This item is completed whether thesupplier's personnel performs the work at the physician's office or at another location.If a modifier is billed, indicating the service was rendered in a Health Professional Shortage Area(HPSA) or Physician Scarcity Area (PSA), the physical location where the service was renderedshall be entered if other than home.DME MAC Jurisdiction C Supplier Manual Page 21

Claim Submission Chapter 6If the supplier is a certified mammography screening center, enter the 6-digit FDA approvedcertification number.Complete this item for all laboratory work performed outside a physician's office. If an independentlaboratory is billing, enter the place where the test was performed.Item 32a Form CMS-1500 (08-05) – If required by Medicare claims processing policy,enter the NPI of the service facility.Item 32b Form CMS-1500 (08-05) - If required by Medicare claims processing policy,enter the PIN of the service facility. Be sure to precede the PIN with the ID qualifier of1C. There should be one blank space between the qualifier and the PIN.Providers of service (namely physicians) shall identify the supplier's PIN when billing for purchaseddiagnostic tests.For durable medical, orthotic, and prosthetic claims, enter the PIN (of the location where the orderwas accepted) if the name and address was not provided in item 32 (DME MAC only).Item 33 - Enter the provider of service/supplier's billing name, address, ZIP code, and telephonenumber. This is a required field.Item 33a Form CMS-1500 (08-05) - Effective May 23, 2007, and later, you MUST enter the NPI ofthe billing provider or group. The NPI may be reported on the Form CMS-1500 (08-05) as early asJanuary 1, 2007. This is a required field.Item 33b Form CMS-1500 (08-05) - Enter the ID qualifier 1C followed by one blank space and thenthe PIN of the billing provider or group. Effective May 23, 2007, and later, 33b is not to be reported.Suppliers billing the DME MAC will use the National Supplier Clearinghouse (NSC) number in thisitem.Supplier Signature Requirements (CMS-1500 (08-05), Item 31)The rules below apply to both assigned and unassigned claims unless otherwise indicated.1. On claims for services furnished by a provider/supplier, the provider/supplier may:a. Sign item 31 of Form CMS-1500.b. Sign one time certification letter for machine-prepared claims submitted on other thanpaper vehicles.c. Authorize an employee (e.g., nurse, secretary) to enter the provider/supplier signature initem 31 of the Form CMS-1500 (manually, by stamp-facsimile or block letters, or bycomputer).d. Authorize a non-employee agent, e.g., billing service or association, to enter as in c.above, the provider/supplier signature in item 31 of the Form CMS-1500, followed by theagent’s name, title, and organization (e.g., a billing agent might enter by stamp “Dr. TomJones by Robert Smith, Secretary, Ajax Billing Service”). Alternatively, the agent maysimply enter the provider/supplier signature.DME MAC Jurisdiction C Supplier Manual Page 22

Claim Submission Chapter 6Beneficiary Signature Requirements(CMS-1500 (08-05), Items 12 & 13)A request for payment signed by the beneficiary must be filed on or with each claim for charge basisreimbursement except as provided below. All rules apply to both assigned and unassigned claimsunless otherwise indicated.1. When no enrollee signature required:a. Claim submitted for diagnostic tests or test interpretations performed in a medical facilitywhich has no contact with enrollee.b. Unassigned claim submitted by a public welfare agency on a bill which is paid.c. Enrollee deceased, bill unpaid and the physician or supplier agrees to accept Medicareapproved amount as the full charge.2. When signature by mark is permitted: The enrollee is unable to sign his name because ofilliteracy or physical handicap.3. When another person may sign on behalf of the enrollee:a. Enrollee who is resident of a nonprofit retirement home gives power of attorney to theadministrator of the home.b. Enrollee physically or mentally unable to transact business: The request may be signedby a representative payee, legal representative, relative, friend, representative of aninstitution providing the enrollee care or support, or of a governmental agency providinghim/her assistance.c. Enrollee physically or mentally unable to transact business and full documentation issupplied that the enrollee has no one else to sign on his behalf: The physician, supplier,or clinic may sign.d. Enrollee deceased and bill paid or liability assumed: Person claiming payment shouldsign. If Form CMS-1500 was signed before the enrollee dies, claimant should signseparate request for underpayment.4. When request retained in file may cover extended future period:a. Assignment in files of welfare agency covers all services furnished during the periodwhen the enrollee is on medical assistance.b. Authorization in files of organization approved under the indirect payment procedure(CMS Pub. 100-4, Chapter 1, § 30.2.8.3) covers all services paid for by that organization.c. Assignment in the files of group practice prepayment plan covers services furnished bythe plan during the period of the enrollee’s membership.d. Assignment in the files of a participating provider (hospital, SNF, home health agency,outpatient physical or speech therapy provider or comprehensive rehabilitation facility) orESRD facility covers physician services for which the provider or facility is authorized tobill, and may cover the physician services furnished in the provider or facility as follows:• Inpatient services - effective for period of confinement.• Outpatient services - effective indefinitely.e. Assignment in files of individual physician, supplier (except in the case of unassignedclaims for rental of durable medical equipment) or qualified reassignee under CMS Pub.100-4, Chapter 1, § 30.2 - Assignment of Provider’s Right to Payment, is effectiveindefinitely.DME MAC Jurisdiction C Supplier Manual Page 23

Claim Submission Chapter 6Suppliers may obtain and retain in their files a one-time payment authorization from a patient (or thepatient's representative) applicable to any current and future services. The supplier should have thepatient sign a brief statement such as:Name of BeneficiaryHICNI request that payment of authorized Medicare benefits be made either to me or on mybehalf to (supplier)___________________ for any services furnished me by that supplier.I authorize any holder of medical information about me to release to the Centers forMedicare & Medicaid Services and its agents any information needed to determine thesebenefits or the benefits payable for related services.Signature______________________Date__________________________Once the supplier has obtained the patient's one-time authorization, later claims for those sameservices can be filed without obtaining an additional signature from the patient. These claims may beon an assigned or non-assigned basis with the exception of durable medical equipment rentals. Theone-time authorization for DME rental claims is limited to assigned claims.Responsibility for Accurate ClaimsThe supplier is ultimately responsible for the accuracy of claims filed for his/her services. Werecommend that your office set a policy to ensure that all necessary information is included on theinitial claim submission and that the information is correct. You may refer to the CMS-1500 (08-05)instructions for guidance on completing the claim form.Clean Claims - Payments/InterestA "clean" claim is one that does not require investigation or development outside the DME MACoperation on a prepayment basis.A "paper claim" is one that is submitted on paper.An "electronic claim" is one that is received by the Contractor via tape, diskette, modem, etc.The Medicare statute provides for claims payment "floors" and "ceilings." A floor is the minimumamount of time a claim must be held before payment can be released. A ceiling is the maximum timeallowed for processing a "clean" claim before Medicare owes interest to a supplier of services.Suppliers who file paper claims will not be paid before the 29th day after the date of receipt of theirclaims (i.e., a 28-day payment floor). However, clean claims filed electronically can be paid as earlyas 14 days after receipt (i.e., a 13-day payment floor).On October 1, 1993, changes were also made to the provisions for paying interest on clean claimsnot processed timely. For suppliers, interest payments will begin on the 31st day after the date ofreceipt for clean electronic and paper claims that are not yet paid.DME MAC Jurisdiction C Supplier Manual Page 24

Claim Submission Chapter 6The difference in payment floors is further incentive for suppliers to consider use of electronic claimssubmission to improve their cash flow, record keeping, and claim status tracking ability.Electronic Funds TransferElectronic Funds Transfer (EFT) is the process through which payment on Medicare claims iselectronically transferred directly to the supplier's bank account. This process eliminates mail anddeposit time and is available to all suppliers. As your Medicare contractor, we can deposit yourMedicare payments directly into your bank account via Electronic Funds Transfer. EFT benefits usas well as other taxpayers because it reduces Medicare administrative spending by eliminating theprocess of issuing paper checks and the postage costs for mailing.Other benefits to the Electronic Funds Transfer process are:• Quicker payment• Increased convenience• Assurance of timely payment in the bank• Elimination of multi-handling risks• Prevention of lost or delayed checks• Easier bank reconciliation• Administration efficiencyThere are no charges for EFT and you do not have to file your claims electronically to receive yourpayments sent by direct deposit.To sign up for EFT, the supplier or authorized representative must complete the Authorizationfor Electronic Funds Transfer agreement form at the end of this chapter. The form can also bedownloaded from our Web site at www.cignagovernmentservices.com and CMS’ Web site atwww.cms.hhs.gov/forms/cms588.pdf.An authorized representative is an appointed official of the entity (including, but not limited to, officer,director, manager, general partner, etc.) who has been given the legal authority by the entity to enrollit in the Medicare DMEPOS supplier program, to make changes and/or updates to the entities statusin the DMEPOS program and to commit the entity to fully abide by the laws, rules and regulations ofthe Medicare DMEPOS program. A written appointment or delegation of authority is required to beon file with NSC for all other than officers of the company and general partners. The person(s)granted the authority of authorized representative must sign the appointment as well to ensure thattheir signature is on file with NSC.Once we receive the request, we will conduct testing with your bank. During the testing process, abank transaction with a payment will be initiated and forwarded to the routing and account numberprovided on the authorization agreement received by CIGNA Medicare. The testing process normallytakes ten business days to complete. Once the testing process is successful, the account will beactivated for Electronic Funds Transfer. Deposits made to the supplier's account will transpire withinDME MAC Jurisdiction C Supplier Manual Page 25

Claim Submission Chapter 648 hours after the claim has been through the adjudication process and has reached the mandatedpayment floor.Any questions regarding EFT may be directed to the customer service line at 866.270.4909Time Limit for Filing ClaimsMedicare claims must be submitted within the following time limits:For services provided between:The claim must be submitted by:October 1, 2003 and September 30, 2004 December 31, 2005October 1, 2004 and September 30, 2005 December 31, 2006October 1, 2005 and September 30, 2006 December 31, 2007October 1, 2006 and September 30, 2007 December 31, 2008Effects of Time LimitationsWhere a supplier accepts assignment within the time limit for filing and then delays submission ofthe claim until no payment can be made to the supplier or the beneficiary, the supplier cannot chargethe beneficiary for the services shown on the bill except for the 20 percent coinsurance and anyunmet part of the deductible.DME MAC Jurisdiction C Supplier Manual Page 26

Chapter Seven √Crossover Claims

Crossover Claims Chapter 7Crossover ClaimsCrossover is the transfer of processed claim data from Medicare operations to other insurancecompanies that sell supplemental insurance benefits to Medicare beneficiaries and to the Medicaid(or state) agencies. The Centers for Medicare & Medicaid Services (CMS) Coordination of Benefits(COB) program identifies the health benefits available to a Medicare beneficiary and coordinates thepayment process to ensure appropriate payment of Medicare benefits. There are two ways thatMedicare claim information is crossed over to the beneficiary’s supplemental insurance company:• Medigap claim-based crossovers• Coordination of Benefits Agreement (COBA) crossovers.MedigapSection 4081 of the Omnibus Budget Reconciliation Act (OBRA) of 1987 carries a provision that isintended to speed payment of Medicare supplemental insurance benefits to participating suppliersby automatic transfer of claims information to Medigap insurers. This provision does not apply tononparticipating suppliers.A Medicare supplemental ("Medigap") policy is a health insurance policy or other health benefit planoffered by a private company to those entitled to Medicare benefits. It provides reimbursement forMedicare charges not reimbursable because of the applicability of deductibles, coinsurance amountsor other Medicare imposed limitations. A policy or plan offered by an employer to employees orformer employees, as well as that offered by a labor organization to members or former members, isnot considered part of the Medigap provision.Medigap ProceduresMedicare beneficiaries initiate the automatic transmittal of claims information by exercising theirright to assign payment of Medigap, as well as Medicare benefits, for the services of participatingsuppliers.It is recommended that the beneficiaries show you their Medigap enrollment card (supplied by theinsurer) to ensure actual coverage is available. The card should clearly indicate that the policy isdesignated as Medicare supplemental coverage. Always try to maintain a copy of the card in yourpatient's file. Medicare will recognize only one supplemental policy per Medicare claim for transfer ofclaim information.Medicare beneficiaries may have more than one policy and you may choose to help them file claimsfor the additional policies. If multiple Medigap coverage is indicated on the claim form, no automatictransmittal will occur since the contractor will be unable to determine which insurer the beneficiary isauthorizing to issue benefits to the supplier.The Medigap policy information should be shown in items 9-9d of the CMS-1500 (08-05) claim form:DME MAC Jurisdiction C Supplier Manual Page 1

Crossover Claims Chapter 7• The word “Medigap” (or an abbreviation of the word; e.g., MG) and individual Medigap policynumber must be present on the claim in item 9a of the CMS-1500 form.• The OCNA (Other Contractor Name and Address) number must be present on the claim initem 9d on the CMS-1500 form.Refer to CMS-1500 (08-05) claim completion instructions for items 9a, 9c, and 9d for situationswhere more than one insurance company is involved.NOTE: The Centers for Medicare & Medicaid Services (CMS) has given approval for the DME MACsto use the Other Contractor Name/Address (OCNA) number in lieu of writing in the Medigap nameand address in items 9d and 9c. Item 9a must still be updated with the word Medigap and the policynumber. The OCNA number may be entered in item 9d.It should be noted that no development for missing or incomplete information will be done by thecontractor. When any of the required information is missing or incomplete, no transfer of claiminformation will occur.Medicare beneficiaries must indicate that they have assigned their Medigap benefits to the supplierby signing item 13 of the CMS 1500 (08-05) claim form. This authorization is in addition to theirassignment of Medicare benefits as indicated by their signature in item12. Separate signaturesauthorizing Medigap assignment must be retained in files when signature on file is authorized.Suggested wording for the Medigap assignment agreement authorization follows.Patient's Assignment Authorization (CMS-1500, Item 13):NAME OF BENEFICIARY, HEALTH INSURANCE CLAIM NUMBER (HICN), MEDIGAP POLICYNUMBER“I request that payment of authorized Medigap benefits be made on my behalfto_______________________for any services furnished me by that supplier. I authorize any holderof medical information about me to release to (Name of Medigap insurer) any information needed todetermine these benefits.”Signature______________________ Date________________Missing signature or the lack of an indication of signature on file is reason for the contractor not totransfer claim information to the Medigap insurer.Your Medicare Remittance Notice (MRN) and the beneficiary's Medicare Summary Notice (MSN) willindicate that data was transferred to the Medigap insurer. You will also be notified via your MRNwhen Medigap information was not transferred because it was incomplete or unclear. You will haveto file a separate claim to the Medigap insurer with a copy of the MRN. Claim data will be transferredto Medigap insurers on a monthly basis. Within a reasonable time, if you have not heard from theMedigap insurer, it will be necessary for you to follow up with the Medigap insurer.The DME MAC's responsibility ends once we have transferred the Medicare payment data to theMedigap insurer, thus we would be unable to furnish you any information about Medigap benefits.DME MAC Jurisdiction C Supplier Manual Page 2

Crossover Claims Chapter 7The law states that the Medigap insurer must treat the Medicare claim data as a request for paymentwhen the supplier is participating in the Medicare program.ANSI (American National Standard Identification) codes associated with Medigap crossover areMA18 and MA19. The appropriate code(s) and explanation(s) will appear on the supplier's MRN.When submitting claims under this procedure, suppliers agree:1. To complete and submit promptly the appropriate Medicare billing form for all servicescovered by the request for payment.2. To incorporate, by stamp or otherwise, the following information on any bills they send toMedicare patients: "Do not use this bill for claiming Medicare benefits. A claim has been orwill be submitted to Medicare on your behalf." This requirement is necessary to preventpatients from submitting duplicate claims.3. To cancel the authorization on request by patient.4. To make the patient signature files available for contractor inspection upon request.Coordination of Benefits Agreement CrossoversThe Coordination of Benefits Agreement (COBA) program establishes a nationally standard contractbetween the CMS Coordination of Benefits Contractor (COBC) and supplemental insurers andMedicaid agencies. This process consolidates the activities that support the collection, management,and reporting of other insurance coverage for Medicare beneficiaries.For COBA crossovers, insurers and Medicaid agencies supply the COBC with their eligibility file andindicate the types of claims they would like to receive and which states. This information is stored ateach contractor’s CWF host site and is used to flag Medicare claims for crossover as they are sentto CWF for processing. The claims that have been flagged for crossovers are then stored and oncethe claims have completed the processing cycle; the contractor sends the claims to the COBC. TheCOBC will then combine all the claims for a particular insurer and send them to that insurer followingthe terms of the COBA that insurer has on file with the COBC. When claims are crossed to theCOBC, the MA18 (supplemental insurance) and MA07 (Medicaid) codes will be reported on theremittance advice.If a claim did not cross to the COBC, the supplier will need to submit a crossover claim to thebeneficiary’s crossover company manually.DME MAC Jurisdiction C Supplier Manual Page 3

Chapter Eight √Electronic Data Interchange (EDI)

Electronic Data Interchange (EDI) Chapter 8IntroductionElectronic Data Interchange (EDI) is the computer-to-computer electronic exchange of businessdocuments using standard format. One method of EDI is the ability for suppliers to transmitElectronic Media Claims (EMC) to Medicare in the Health Insurance Portability and AccountabilityAct (HIPAA) compliant format. The EDI services for submitters in Jurisdiction C is provided byPalmetto GBA.The following pages describe the benefits of billing electronically and additional electronic optionsavailable. Details and instructions on what you will need to do to begin billing electronically can befound on the Jurisdiction C’s EDI Web site at www.palmettogba.com/jcedi. The Web site containsvaluable information including technical information, manuals, and enrollment materials.If you require additional EDI information, please contact the Jurisdiction C EDI Technology SupportCenter toll-free at 888.613.9271,Note: The acceptable HIPAA compliant format is the American National Standards Institute (ANSI)X12N Version 4010A1 837 transaction and the National Council for Prescription Drug Programs(NCPDP) Telecommunications Standard Version 5.1 and Batch Standard 1.1.BenefitsElectronic Data Interchange (EDI) will simplify time-consuming, labor-intensive jobs, and ultimatelyenable suppliers to increase their productivity. The following are a few of the benefits experienced byutilizing the EDI options offered by Medicare.• Increased cash flow• Ease of billing electronically (support is available)• More efficient and accurate claims filing; data is received precisely as input by the supplier’soffice, eliminating the chance of processing errors• Electronic Receipt Listing—a confirmation that can be downloaded via modem within 48-hours of transmission. This report verifies the acceptance of claims and Certificates ofMedical Necessity (CMNs).• Online or batch version Claim Status Inquiry (CSI)• Availability of electronic remittance advice (ERA) for faster payment posting• Availability of electronic funds transfer (EFT)• Lower administrative, postage and handling costs• Ability to submit claims and CMNs seven days a week, including holidays• Online beneficiary eligibilityAdministrative Simplification Compliance ActSection 3 of the Administrative Simplification Compliance Act (ASCA), Public Law (PL) 107-105, andthe implementing regulation at 42 CFR 424.32 require that all initial claims for reimbursementunder Medicare (except from small providers) be submitted electronically as of October 16, 2003,with limited exceptions. Initial claims are those claims submitted to a Medicare fee-for-servicecontractor, durable medical equipment Medicare administrative contractor (DME MAC), or fiscalintermediary for the first time, including:DME MAC Jurisdiction C Supplier Manual Page 1

Electronic Data Interchange (EDI) Chapter 8• Resubmitted previously rejected claims• Claims with paper attachments• Demand claims• Claims where Medicare is secondary and there is only one primary payer• Nonpayment claimsMedicare will not cover claims submitted on paper that do not meet the limited exception criteria.Claims denied for this reason will not contain claim adjustment reason code 96 (Noncoveredcharge[s]) and remark code M117 (Not covered unless submitted via electronic claim).Further details on the ASCA provision, exception criteria and how to apply for a waiver can be foundon the CIGNA Government Services Web site at: www.CIGNAGovernmentServices.com, selectJurisdiction C DME MAC.Transmitting Claims to Other DME MACsIf a claim is transmitted electronically for a beneficiary who resides in another region, the claimwill automatically be transferred to the appropriate DME MAC based on the beneficiary'saddress noted on the claim.Note: The claim will not be processed unless the supplier has a signed EDI Enrollment Form onfile with the other DME MAC prior to transmitting the claims. If not, the claim will be transferredbut not processed.CMN REJECT ListingThe CMN Reject Listing is attached to the Electronic Receipt Listing. This report lists any CMNs thatwere rejected after the claim was accepted into our system. The rejection codes are as follows:CodeDefinition/Explanation3030 An initial certification is already on file for this procedure code with the same dates. Theclaim will be processed against certification that is on file. If the original certification wascompleted correctly, the claim will pay. If the submitter was trying to send a corrected initialcertification, they cannot do this. The submitter will have to file a reopening on that claimthat had the original initial certification.3031 We already have an initial certification for this procedure and the initial date of thecertification just submitted is less than the end date of the previous initial certification. Theclaim will be processed against certification that is on file. If the original certification wascompleted correctly, the claim will pay. However, the submitter may want to verify that theywere trying to submit a revision certification rather than an initial. If the submitter was tryingto resend a corrected initial certification, they cannot do this. The submitter will have to filea reopening on the claim that had the original initial certification.3032 This edit could mean one of two things:1) This certification is a duplicate of a previous revision/recertification sent in on apreviously received claim.DME MAC Jurisdiction C Supplier Manual Page 2

Electronic Data Interchange (EDI) Chapter 82) The recertification date on the latest CMN is earlier than the revision/recertificationdate on a previously received claim. If the previous certification was completedcorrectly, the claims will pay. The submitter will have to file a reopening on the claimthat had the original revision/recertification.3047 The recertification or revised CMN transmitted electronically has an initial date that is notthe same as the initial date on the initial CMN currently on file for the same procedurecode.3048 The recertification or revised CMN transmitted electronically cannot be accepted for thisprocedure code. The initial CMN on file for this procedure code has been discontinued.Any CMN in a discontinued status cannot be recertified or revised.3052 A revised CMN has been submitted for an initial CMN that has been closed. Any CMN in aclosed status cannot be revised.Additional information on these codes can be found in the Front-End Edit Error Manual for ANSI 837v4010A1 Claims on the JCEDI Web site.Additional Electronic OptionsThere are additional electronic options available which will increase your business’ productivity.These options include Claim Status Inquiry, Electronic Remittance Notices, and BeneficiaryEligibility. To apply for these options, complete the JCEDI Application which is available on theJCEDI Web site.Claim Status Inquiry (CSI)Claim Status Inquiry (CSI) allows you to electronically check the status of production claims afterthey have passed the front-end edits and received Claim Control Numbers (CCNs).At least three working days after you successfully file an electronic claim, you will be able to locateyour claim in the processing cycle. Through CSI, you will know if your claim has been paid, denied,or still pending. If you are checking the status of pending claims, there are additional screensavailable which contain more detailed status information. CSI is available for both electronic andpaper claims.Electronic Remittance Notices (ERNs)An Electronic Remittance Notice (ERN) is an electronic data file that shows claims that have beenpaid and the dollar amounts for each, and also shows claims denied with the reason for denial. Thisdocument contains the same information as the paper Medicare Remittance Notices suppliersreceive through the mail.When the ERN file has been downloaded, it must be run through ERN reader software to allowbillers to view and print out the document in a readable format. ERN reader software may bepurchased from a software vendor. CMS has developed a free software called Medicare Remit EasyDME MAC Jurisdiction C Supplier Manual Page 3

Electronic Data Interchange (EDI) Chapter 8Print (MREP) that enables suppliers to view and print ERNs. This software is available through theJCEDI Web site.Beneficiary EligibilityBeneficiary Eligibility allows suppliers to request eligibility information on specific beneficiaries.There are two versions of beneficiary eligibility to choose from the online method or the Real-Timemode.With the online option, users input requests one at a time and then receive an instant response. WithReal-Time mode you will build a file for each request using separate software. Visit the CMS Website for additional information on the real-time version.More InformationIf you would like more information about electronic billing, please visit our Web site atwww.palmettogba.com/jcedi or contact us by phone at 888.613.9271 Monday – Friday between thehours of 8:00 A.M and 5:00 P.M. EST.DME MAC Jurisdiction C Supplier Manual Page 4

Chapter Nine √Coverage and Medical Policy

Coverage and Medical Policy Chapter 9DMEPOS Benefit CategoriesMedicare Part B covered services processed by the DME MAC fall into the following benefitcategories specified in the Social Security Act (§1861(s)):1. Durable medical equipment (DME)2. Prosthetic devices3. Leg, arm, back and neck braces (orthoses) and artificial leg, arm and eyes, includingreplacement (prostheses)4. Home dialysis supplies and equipment5. Surgical dressings6. Immunosuppressive drugs7. Erythropoietin for home dialysis patients8. Therapeutic shoes for diabetics9. Oral anticancer drugs10. Oral antiemetic drugs (replacement for intravenous antiemetics)11. Intravenous immune globulinGeneral definitions and coverage issues relating to the preceding categories are listed below.Durable Medical Equipment (DME):Durable medical equipment is equipment which (a) can withstand repeated use, and (b) is primarilyand customarily used to serve a medical purpose, and (c) generally is not useful to a person in theabsence of an illness or injury, and (d) is appropriate for use in the home.Supplies and accessories that are necessary for the effective use of medically necessary DME arecovered. Supplies may include drugs and biologicals that must be put directly into the equipment inorder to achieve the therapeutic benefit of the DME or to assure the proper functioning of theequipment.Repairs, skilled maintenance and replacement of medically necessary DME are covered.Prosthetic Devices:Prosthetic devices are items which replace all or part of an internal body organ or replace all or partof the function of a permanently inoperative or malfunctioning internal body organ. The test ofpermanence is considered met if the medical record, including the judgment of the attendingphysician, indicates that the condition is of long and indefinite duration.In addition to artificial arms and legs, coverage under this benefit includes, but is not limited to,breast prostheses, eye prostheses, parenteral and enteral nutrition, ostomy supplies, urologicalDME MAC Jurisdiction C Supplier Manual Page 1

Coverage and Medical Policy Chapter 9supplies in patients with permanent urinary incontinence, and glasses or contact lenses in patientswith aphakia or pseudophakia.Supplies that are necessary for the effective use of a medically necessary prosthetic device arecovered. Equipment, accessories and supplies (including nutrients) which are used directly with anenteral or parenteral nutrition device to achieve the therapeutic benefit of the prosthesis or to assurethe proper functioning of the device are covered.Repairs, adjustments and replacement of medically necessary prosthetic devices are covered.Dental prostheses (i.e., dentures) are excluded from coverage. Claims for internal prostheses (e.g.,intraocular lens, joint implants, etc.) are not processed by the DME MAC.Braces (Orthotics):A brace is a rigid or semi-rigid device that is used for the purpose of supporting a weak or deformedbody member or restricting or eliminating motion in a diseased or injured part of the body.Repairs, adjustments and replacement of medically necessary braces are covered.Home Dialysis Supplies and Equipment:Dialysis supplies and equipment used by patients with end stage renal disease who are beingdialyzed at home under the supervision of a Medicare-approved dialysis facility are covered. DurableMedical Equipment Medicare Administrative Contractors (DME MACs) have jurisdiction for paymentof dialysis supplies and equipment for Method II dialysis patients only.Surgical Dressings:Surgical dressings are therapeutic and protective coverings applied to surgical wounds or debridedwounds. Surgical dressings include primary and secondary dressings.Immunosuppressive Drugs:Immunosuppressive drugs used in patients who have received a Medicare-covered organ transplantare covered. Immunosuppressive drugs used for indications other than transplantation are not DMEMAC jurisdiction.Supplies used in conjunction with parenterally administered immunosuppressive drugs are notcovered under this benefit category.Erythropoietin:Claims for erythropoietin administered in the home to home dialysis patients will be processed by theDME MAC.Supplies necessary for the administration of medically necessary erythropoietin are covered.DME MAC Jurisdiction C Supplier Manual Page 2

Coverage and Medical Policy Chapter 9Therapeutic Shoes for Diabetics:Custom molded or extra-depth shoes and inserts for use by patients with diabetes are coveredunder this benefit.Oral Anticancer Drugs:Certain oral cancer drugs are covered if they have the same chemical composition and indicationsas the parenteral form of the drug.Oral Antiemetics (used as full replacement for IV form)Certain oral antiemetic drugs are covered when used as full replacement for the intravenous (IV)form of the same drug during chemotherapy treatment.Intravenous Immune GlobulinIntravenous immune globulin is covered when it is administered in the home to treat primaryimmunodeficiency. Infusion pumps and other administration supplies are not covered under thisbenefit.Medical Review ProgramThe goal of the medical review program is to reduce payment errors by identifying and addressingbilling errors concerning coverage and coding made by providers. The medical review staff atCIGNA Government Services (CGS) consists of a medical director (physician), clinical staff(registered nurses and other allied health professionals) and experienced support personnel.Medical Review Responsibilities• Develop Local Coverage Determinations (coverage policies);• Analyze claim data;• Perform probe reviews and audits to validate if problems exist;• Perform corrective actions to reduce errors, including prepay review of claims with clinicalstaff;• Advance Determination of Medicare Coverage (ADMC);• Develop strategies to address the Comprehensive Error Rate Testing (CERT) results; and• Partner with the Communications Department to offer provider outreach and education.NERAL INFORMATIONMedical PoliciesGeneral InformationMedical policies may be either national or local.DME MAC Jurisdiction C Supplier Manual Page 3

Coverage and Medical Policy Chapter 9National medical policies are established by the Centers for Medicare and Medicaid Services (CMS).These policies are found on the CMS Web site in the Medicare National Coverage DeterminationsManual and in the Medicare Benefit Policy Manual. Both manuals can be viewed atwww.cms.hhs.gov/Manuals/IOM/list.asp. Suppliers can search for National CoverageDeterminations (NCDs) using the Medicare Coverage Database atwww.cms.hhs.gov/MCD/search.asp. The DME Medicare Administrative Contractors (MACs) andProgram Safeguard Contractors (PSCs) follow national policy when it exists.Local medical policies are developed by the DME Medicare Administrative Contractors (MACs). TheDME contractors have the authority and responsibility to establish local policies when there is nonational policy on a subject or when there is a need to further define a national policy. The DMEMACs’ medical directors jointly develop local medical policies. The medical policies are identical forall DME MACs.Local medical policies consist of two separate, though closely related, documents: a Local CoverageDetermination (LCD) and a Policy Article. A link to the Jurisdiction C LCDs and Policy Articles can befound on the Medical Review page of CGS’s DME MAC Web sitewww.cignagovernmentservices.com. The link is to the CMS Medicare Coverage Database.Major sections of an LCD:• Indications and Limitations of Coverage and/or Medical NecessityDefines coverage criteria based on a determination of whether an item is reasonable andnecessary. It includes information from National Coverage Determinations, when applicable.When an item does not meet these criteria, it will be denied as “not medically necessary” orpaid comparable to the least costly medically appropriate alternative, when applicable.• HCPCS Codes and ModifiersThe presence of a code in this section does not necessarily indicate coverage.• ICD-9 Codes and Diagnoses that Support Medical NecessityThese are ICD-9 codes that relate to coverage criteria described in the Indications andLimitations of Coverage and/or Medical Necessity section• Documentation RequirementsRevision History• AttachmentsCMN or DIF, if applicableOther suggested forms, if applicableMajor sections of a Policy Article:• Non-Medical Necessity Coverage and Payment RulesIdentifies situations in which an item does not meet the statutory definition of a benefit category(e.g., durable medical equipment, prosthetic devices, etc.) or when it doesn’t meet otherrequirements specified in regulations. It also identifies situations in which an item is statutorilyexcluded from coverage for reasons other than medical necessity. In these situations, termused to describe the denial is “noncovered”. This section may also include statements definingwhen an item will be denied as “not separately payable” or situations in which claim processingfor the item is not DME MAC jurisdiction.• Coding Guidelines• ICD-9 Codes that are coveredThese are ICD-9 codes that relate to statutory or regulatory coverage issues, as described inthe Non-Medical Necessity Coverage and Payment Rules section.• Revision HistoryDME MAC Jurisdiction C Supplier Manual Page 4

Coverage and Medical Policy Chapter 9At the end of each LCD, there is a link to the related Policy Article and at the end of each PolicyArticle there is a link to the related LCD. New or revised policies are generally released on aquarterly basis: March, June, September and December. Posting of new and revised policies will beannounced in a listserv message from CIGNA Government Services (CGS) and on the CGS Website at www.cignagovernmentservices.com.Most new or revised policies have a future effective date at the time of posting. The link on the CGSDME MAC Web site to the list of Jurisdiction C LCDs or Policy Articles is to the Current/Activepolicies. On this page, there is a link titled “Display Future Effective Documents” which allows accessto policies with future effective dates.Development of Local Coverage DeterminationsDEVELOPMENT OF LOCAL COVERAGE DETERMINATIONSThe development of Local Coverage Determinations (LCDs) is a collaborative effort led by themedical directors of the DME MACs. The intent of the policy development process is to provide theopportunity for input from the supplier and medical community to assure that the final policy isconsistent with sound medical practice.The initial stage of the process is the development of a draft policy. This stage is based on a reviewof the medical literature and the contractor’s knowledge of medical practice relating to the item. Themedical directors seek input from various individuals and groups during the drafting phase of policydevelopment.Drafts of new medical policies or revised policies that propose more restrictive medical necessitycoverage criteria are sent for comment to a wide spectrum of national and regional organizationsrepresenting manufacturers, suppliers, physicians and other healthcare professionals. These draftmedical policies are announced in a listserv message from CGS and a posting on the CGS Web siteat www.cignagovernmentservices.com. The DME MAC Web site lists both a mailaddress and an e-mail address to which comments may be sent. There are 45 days allowed forcomments to draft policies. The Web site lists the start date and end date of the comment period.The DME MAC encourages written comments to its draft policies. If commenters disagree with anyaspects of the policy, they should offer specific alternative wording and support their suggestionswith references from the published medical literature.The DME MAC also holds an open meeting to hear public comments on each draft policy that is sentfor comment. The meeting is scheduled during the comment period for a draft policy. Notice of themeeting is placed on the Draft Medical Policy Information page on the DME MAC Web site. Thenotice includes the date, time and location of the meeting and instructions for those who wish tomake a presentation at the meeting. Interested parties may present scientific, evidence-basedinformation, professional consensus opinions or any other relevant information. The meeting is ledby the DME MAC Medical Director.After the close of the comment period, the DME MAC medical directors review all of the commentsthat have been received and revise the policy as appropriate. The medical directors summarize thecomments and provide a response to each indicating whether or not they agree with the suggestion.If they do not agree, they give reasons for the decision. This “Response to Comments” document isfound as an LCD attachment link at the end of the LCD. Following adoption, final medical policiesare posted on the DME MAC Web site.DME MAC Jurisdiction C Supplier Manual Page 5

Coverage and Medical Policy Chapter 9LCD Reconsideration ProcessLCD RECONSIDERATION PROCESSThere is a formal process for requesting revision of a LCD. Information can be found on the MedicalPolicy page of the DME MAC Web site www.cignagovernmentservices.com.Special Circumstances/Individual ConsiderationSPECIAL CIRCUMSTANCES/INDIVIDUAL CONSIDERATIONMedical policies are constructed to address the rule, not the exception. Unless there is a NationalCoverage Determination which provides absolute limits of coverage, special circumstances may beconsidered. These situations require detailed documentation from the ordering physician andsupplier supporting the medical necessity of the item in the individual case. Types of information (notall-inclusive) that may be pertinent are diagnosis relating to the need for the item, complicatingmedical conditions, functional abilities and limitations, duration of the condition, overall course(improving or worsening), rehabilitation potential (including recent prior functional level), prognosis,description of and response to prior treatment, experience with similar items, physical examinationfindings, test results, etc.Claim Determination in the Absence of Medical PolicyCLAIM DETERMINATION IN THE ABSENCE OF MEDICAL POLICYThe DME MACs and PSCs have the authority to review any claim even if there is no formal nationalor local policy. In those situations, the contractor first determines whether the item falls within astatutory benefit category that is within its jurisdiction. If it is, then the reviewer determines whetherthe item is reasonable and necessary for the individual patient. This may include a review ofpertinent medical literature. It also includes review of detailed documentation from the orderingphysician and supplier supporting the medical necessity of the item in the individual case, asdescribed in the preceding section on “Individual Consideration.”Advance Determination of Medicare Coverage for WheelchairsAdvance Determination of Medicare Coverage (ADMC) is a process by which the DME MACprovides the supplier and beneficiary with a coverage decision prior to delivery of an item. An ADMCis available as an option only for the following wheelchair base HCPCS codes and related optionsand accessories:HCPCSCODE RELATED OPTIONS AND ACCESSORIESE1161E1231-E1234K0005K0009K0835-K0843K0848-K0855 Only if an alternative drive control interface will be provided at the time of initial issueK0856-K0864K0868-K0871 Only if an alternative drive control interface will be provided at the time of initial issueK0877-K0891When a particular wheelchair base is eligible for ADMC, all wheelchair options and accessoriesordered by the physician for that patient along with the base HCPCS code will be eligible for ADMC.All requests for Advance Determination of Medicare Coverage should be submitted to CIGNAGovernment Services (CGS). Clearly indicate “ADMC” on the first page of all requests. ADMCrequests may be faxed to (615) 782-4647 or mailed to:DME MAC Jurisdiction C Supplier Manual Page 6

Coverage and Medical Policy Chapter 9CIGNA Government ServicesAttn: ADMCP.O. Box 20010Nashville, TN 37202ADMC requests cannot be submitted electronically.The first page of the ADMC request must contain all of the following demographic information:• Beneficiary information• Name• HICN• Address• Date of birth• Place of service• ICD-9 diagnosis code (narrative description is not sufficient)• Supplier information• Name• NSC number• Address• Phone number• Physician’s information• Name• UPIN• Address• Phone numberIf the information listed above is not present, the request will be rejected and the supplier will receivewritten notification.Power Wheelchair DocumentationInclude all of the following items:1. The order that the supplier received within 45 days following the completion of the face-tofaceexamination. This order must contain the following elements:• Beneficiary name• Description of the item. This may be general – e.g., “power wheelchair” or “powermobility device” – or may be more specific.• Date of the face-to-face examination. If the evaluation involved multiple visits, enterthe date of the last visit. Refer to the Power Wheelchairs policy for additionalinformation.• Pertinent diagnoses/conditions that relate to the need for the power wheelchair.• Length of need• Physician’s signature• Date of physician signatureThere must be a date stamp or equivalent on the order to indicate when it was received bythe supplier.2. A detailed product description signed and dated by the physician that lists the specificwheelchair base and all options and accessories that will be separately billed. For each itemDME MAC Jurisdiction C Supplier Manual Page 7

Coverage and Medical Policy Chapter 9there must be a HCPCS code and either a narrative description of the item or themanufacturer name/model. The detailed product description must also list the supplier’scharge and the Medicare fee schedule allowance for each item.(If there is no fee schedule allowance, the supplier must enter “not applicable”.)If the manufacturer name/model for the wheelchair base is not included on the detailedproduct description, the supplier must provide this information.3. Reports of the face-to-face examination and specialty evaluation by the physician and otherlicensed/certified medical professionals (LCMPs), such as a physical therapist (PT) oroccupational therapist (OT). There must be a date stamp or equivalent on the reports toindicate when they were received by the supplier. Reports of LCMPs must include anattestation statement from the supplier indicating that the LCMP has no financial relationshipwith the supplier. Refer to the Documentation Requirements section of the Power MobilityDevices LCD for guidance about the type of information to be included in the face-to- faceexamination and specialty evaluation.4. A report of the on-site home assessment which establishes that the beneficiary is able to usethe wheelchair ordered to assist with ADLs in the home.Manual Wheelchair DocumentationInclude all of the following items:1. Detailed written order that lists the specific wheelchair base that is to be provided and eachoption/accessory that will be separately billed. The order must also specify which HCPCScode is associated with each item on the order. This information may be entered by thesupplier but the order must be signed and dated by the physician.2. Information from the patient’s medical record that documents that the coverage criteriadefined in the medical policy on Manual Wheelchairs have been met.3. A home assessment which establishes that the beneficiary or caregiver is able to use thewheelchair ordered to assist with ADLs in the home.Additional Guidance on DocumentationAny information that is provided that explains the medical necessity for separately billed options andaccessories must use the same short description for the item that is used in the detailed productdescription or detailed written order.If the patient’s weight and/or height are needed to support the medical necessity for items that areordered, that information should be included on the first page of the ADMC request.Even if the majority of the face-to-examination is performed by an LCMP, the ADMC request mustalso include the report of the face-to-face examination with the physician.For wheelchair cushions, include the manufacturer, the product name, the model number, and thewidth of wheelchair cushion(s) that are provided. Make certain that the product is listed on theSADMERC Product Classification List and that the HCPCS code on the ADMC is the one specifiedby the SADMERC.DME MAC Jurisdiction C Supplier Manual Page 8

Coverage and Medical Policy Chapter 9If the patient currently has a wheelchair or a power operated vehicle (POV), the ADMC request mustindicate the reason why it is being replaced.ADMC ProcessADMC PROCESSUpon receipt of an ADMC request, the DME MAC will make a determination within 30 calendar days.The DME MAC will provide the supplier and beneficiary with its determination, either affirmative ornegative, in writing. If it is a negative determination, the letter will indicate why the request wasdenied - e.g., not medically necessary, insufficient information submitted to determine coverage,statutorily non-covered.If a wheelchair base receives a negative determination, all accessories will also receive a negativedetermination. If a wheelchair base receives an affirmative determination, each accessory willreceive an individual determination.An affirmative determination only relates to whether the item is reasonable and necessary based onthe information submitted. An affirmative determination does not provide assurance that thebeneficiary meets Medicare eligibility requirements nor does it provide assurance that any otherMedicare requirements (e.g., place of service, Medicare Secondary Payer) have been met. Onlyupon submission of a complete claim can the DME MAC make a full and complete determination.An affirmative determination does not extend to the price that Medicare will pay for the item.Finally, the DME MAC may review selected claims on a pre-payment or post-payment basis andmay deny a claim or request an overpayment if it determines that an affirmative determination wasmade based on incorrect information.An affirmative ADMC is only valid for items delivered within six months following the date of thedetermination. If the wheelchair is not delivered within that time, the supplier has the option of eithersubmitting a new ADMC request (prior to providing the item) or filing a claim (after providing theitem).If any of the items on the ADMC request were described by HCPCS code K0108 and if those itemswere provided, the supplier must ensure that the narrative description used on the claim matches thenarrative description used on the ADMC determination letter.If a wheelchair base receives an affirmative determination, the supplier may not submit a separateADMC request for additional accessories. If options or accessories are provided that were not listedon the ADMC request, the supplier must obtain a product description for these items and whateverinformation is appropriate to document the medical necessity for the additional item(s).A negative ADMC may not be appealed because it does not meet the regulatory definition of aninitial determination since no request for payment is being made. However, if the ADMC request forthe wheelchair base is denied and if the supplier obtains additional medical documentation, anADMC request may be resubmitted. ADMC requests may only be resubmitted once during the sixmonthperiod following a negative determination. If the wheelchair base is approved, but one ormore accessories are denied, an ADMC request may not be resubmitted for those accessories. If asupplier provides a wheelchair and/or accessories following a negative determination, a claim for theitem should be submitted. If new information is provided with the claim, coverage will be considered.If the claim is denied, it may be appealed through the usual process.DME MAC Jurisdiction C Supplier Manual Page 9

Chapter Ten √Pricing

Pricing Chapter 10PricingThe Medicare Pricing Department is responsible for the accurate and appropriate calculation andimplementation of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) prices.Note: The beneficiary's permanent address, rather than the location of the DMEPOS supplier, willdetermine the amount allowed by Medicare for a particular service.There are three DMEPOS payment methodologies:• Fee Schedules - applies to the allowed amount for inexpensive items, those items thatrequire frequent and substantial servicing, other prosthetic and orthotic devices, cappedrental items, oxygen and oxygen supplies, parenteral and enteral nutrition (PEN) andtherapeutic shoe claims. Fee schedule amounts are updated annually.Note: Fee schedules can change as the result of CMS revisions and/or through theapplication of inherent reasonableness, which is a review to determine if the existing pricesare appropriate. The factors used to determine inherent reasonableness include, but are notlimited to, price markup, differences in charges, costs and utilization.• Reasonable charge - applies to the allowed amount for certain dialysis equipment andsupplies. Reasonable charge amounts are updated annually.• Drug Pricing - applies to the allowed amount for immunotherapy, bronchodilator, and otherdrugs submitted to DME MAC. Most fees determined under drug pricing are subject toquarterly updates.Fee SchedulesMost payments of durable medical equipment (DME) are based on a fee schedule. A standard fee isestablished for each DMEPOS item by state. Payment is calculated using either the fee scheduleamount or the actual charge submitted on the claim, whichever is lower. The fee scheduleallowances include the application of national floors and ceilings.The DME fee schedules include items of DME as well as supplies needed to use the DME and aredivided into the following categories:• Inexpensive or other routinely purchased DME• Items requiring frequent and substantial servicing• Customized items• Other prosthetic and orthotic devices• Capped rental items• Oxygen and oxygen equipment• Surgical DressingsDME MAC Jurisdiction C Supplier Manual Page 1

Pricing Chapter 10For each class of equipment, payment is based on fees established effective January 1, 1989, andthese fees are indexed annually. After application of the annual fee update for all categories of DMEexcept prosthetics and orthotics, the national floor and ceiling payment limits are applied. Paymentfor surgical dressing fees is an exception, and is calculated using a 1992 base period. The BalancedBudget Act of 1997 § 4315 authorized the Secretary to implement a fee schedule for parenteral andenteral nutrition (PEN) items and services. These items were previously paid on a reasonablecharge basis. The new PEN fee schedule is effective for claims with dates of service on or afterJanuary 1, 2002.Gap FillingThe fee schedule for items for which charge data is not available is calculated based on:• Fee schedule amounts for comparable equipment• Fee schedule amounts of other DME MACs• Supplier price listsWhere supplier price lists are used, efforts are made to obtain prices in effect during the base year(1986-1987). Mail order catalogs are often used as sources of price information. A deflation factor isapplied if the price information is from a period other than the base period. This is done in order toapproximate the base year price for gap filling purposes.Reasonable ChargesThe manner in which reasonable charge allowances by Medicare are determined is stipulated byMedicare law and not left to the discretion of the Medicare contractor. Medicare law specificallystates that the amount allowed by Medicare must be the lowest of:• The actual charge;• The supplier's customary charge or the 50th percentile of arrayed and weighted customarycharges in the absence of a customary charge for the specific service rendered;• The prevailing charge; or• The Inflation-Indexed Charge (IIC)Data regarding suppliers' fees is obtained by compiling information from claims that have beensubmitted. Records of all charges are kept on each claim processed during a calendar year. Thisinformation identifies the supplier, the type of service, the area in which the service was rendered,and the charge for that service. Effective with the 1995 reasonable charge updates, the data will becompiled using beneficiaries' state of residency, rather than the area from which the service wasrendered.Beginning January of each year, the data accumulated from July 1st of the second preceding yearthrough June 30th of the preceding year is arrayed to develop the current year's Annual PricingUpdate of Medicare allowances. For example, data accumulated from July 1, 2005, to June 30,DME MAC Jurisdiction C Supplier Manual Page 2

Pricing Chapter 102006, is arrayed to develop the Annual Pricing Update of Medicare allowances for 2007. The annualupdate reflects the changes in the fees most frequently charged by suppliers for a particular service,within a specific locality, during the 12-month period ending June 30th of the previous year. This timeframe is referred to as the base year. The customary and reasonable charge effective for the newannual pricing update does not necessarily reflect the fees currently being charged.Customary ChargesThe customary charge is the charge that best represents the most frequently charged amount by asupplier for a particular service. In order to determine the customary charges for each individualsupplier, the actual charges the supplier has submitted for services rendered during the year endingJune 30th immediately preceding the start of the Annual Pricing Update (January of each year) for agiven service, are arrayed in ascending order and the median charge is calculated. If you do nothave at least three charges for a procedure code, then the 50th percentile of all other suppliers’customary charges weighted by frequency will be used as the customary charge.The lowest actual charge, which is high enough to include the median of the arrayed charge data, isthen selected as the suppliers' customary charge for the service. For example, if ABC suppliercharges $12.00 for a particular service 75 times during a calendar year and $15.00 twelve times forthe same service, $12.00 would best represent the actual charge made by that supplier.The following is an example of how charges for a supplier would be arrayed in order to determinethe customary charge.Charge Frequency Billed Cumulative Frequency$10.00$12.50$14.00$15.0020 times40 times35 times5 times206095100Based on the cumulative frequency of 100 submitted charges, the median charge would be the 50thcharge. In this example, the median charge submitted is $12.50. There must be at least three (3)billed charges for the same procedure by the same supplier to establish a customary for thatprocedure within the base year.Prevailing ChargesThe prevailing charge is the 75th percentile of all suppliers' customary charges, within thebeneficiary state for a specific service or procedure, weighted by frequency. Prevailing charges arecalculated in much the same way as customary charges. The customary charge for each procedureis arrayed in ascending order, and weighted by how often the supplier rendered the services asreflected by the data used to calculate the customary charge. The prevailing charge is established atDME MAC Jurisdiction C Supplier Manual Page 3

Pricing Chapter 10the 75th percentile of these cumulative services. There must be at least four customary charges fora given procedure to establish a prevailing charge for that service.The proper procedure for establishing prevailing charges is illustrated in the following example:Customary Charge$5.00$6.00$7.00$8.00TOTALNumber of Supplies Rendered by Supplierswith Customary Charges as Indicated27302518100Cumulative Services275782100In this example, 75 percent of the total of 100 supplies falls at the 75th supply. The 75th supply fallswithin the cumulative frequency of 82 submitted supplies, therefore $7.00 becomes the prevailingcharge.Inflation-Indexed Charge (IIC) for Non-Physician ServicesThe IIC is the lowest of the reasonable charges for the previous Annual Pricing Update year updatedby an inflation index factor. [The inflation index factor is based on the change in the Consumer PriceIndex (CPI).] The reasonable charges include the prevailing charge, customary charge, lowestcharge level (if applicable), and the IIC. The IIC calculation does not take into account anyreasonable charge limitation resulting from the application of comparability, inherent reasonablenessor the 50th percentile in the absence of a customary charge.Drug PricingEffective January 1, 2005, the vast majority of drugs and biologicals not paid on a cost orprospective payment basis will be paid based on the average sales price (ASP) methodology.Pricing for compounded drugs is performed by the local contractor. The ASP methodology isbased on quarterly data submitted to CMS by manufacturers. CMS will supply contractors withthe ASP drug pricing files for Medicare Part B/DME MAC drugs on a quarterly basis.Beginning January 1, 2005, the payment allowance limits for Medicare Part B/DME MAC drugsand biologicals that are not paid on a cost or prospective payment basis are 106 percent of theASP. CMS will update the payment allowance limits quarterly. There are exceptions to thisgeneral rule and those that impact the DME MAC are summarized below.• The payment allowance limits for infusion drugs furnished through a covered item ofdurable medical equipment on or after January 1, 2005 will continue to be 95 percent ofthe AWP reflected in the published compendia as of October 1, 2003, unless the drug iscompounded. The payment allowance limits will not be updated in 2007. The paymentallowance limits for infusion drugs furnished through a covered item of durable medicalDME MAC Jurisdiction C Supplier Manual Page 4

Pricing Chapter 10equipment that were not listed in the published compendia as of October 1, 2003, (i.e.,new drugs) are 95 percent of the first published AWP unless the drug is compounded.• The payment allowance limits for drugs that are not included in the ASP Medicare Part BDrug Pricing File or Not Otherwise Classified (NOC) Pricing file, other than new drugsthat are produced or distributed under a new drug application approved by the Food andDrug Administration (FDA), are based on the published wholesale acquisition cost(WAC) or invoice pricing.• The payment allowance limits for new drugs that are produced or distributed under a newdrug application approved by the FDA and that are not included in the ASP Medicare Part BDrug Pricing File or NOC pricing File are based on 106 percent of the WAC, or invoicepricing if the WAC is not published. This policy applies only to new drugs that were first soldon or after January 1, 2005.Individual ConsiderationUnusual services and items are generally reported to the contractor with miscellaneous HCPCScodes. It will be necessary in these situations for the supplier to furnish documentation describingthe service or item, manufacturer name, product name and number and the suggested retail price.When necessary, consultants' advice will be obtained.Inherent ReasonablenessWhere a review of customary and prevailing fees indicates excessive or deficient amounts, applyinginherent reasonableness may be appropriate. We will always publish notice of proposed inherentreasonableness charges and provide a minimum of a 30-day comment period. This notice willinclude the HCPCS code, the current prevailing charge and the proposed charge. We will alsoinclude source documentation that supports the proposed charge. After comments are reviewed, wewill publish a final decision and responses to the issues raised in the comments.DME MAC Jurisdiction C Supplier Manual Page 5

Chapter Eleven √Coordination of Benefits (COB)

Coordination of Benefits Chapter 11Coordination of Benefits (COB)COB Contractor Fact Sheet for ProvidersThe Centers for Medicare & Medicaid Services (CMS) has embarked on an important initiative tofurther expand its campaign against Medicare waste, fraud and abuse under the Medicare IntegrityProgram. CMS awarded the Coordination of Benefits (COB) contract to consolidate the activities thatsupport the collection, management, and reporting of other insurance coverage of Medicarebeneficiaries.The awarding of the COB contract provides many benefits for employers, providers, suppliers, thirdparty payers, attorneys, beneficiaries, and Federal and State insurance programs. All MedicareSecondary Payer (MSP) claims investigations are initiated from, and researched at the COBcontractor. This is no longer the function of your local Medicare intermediary or carrier. Implementingthis single-source development approach will greatly reduce the amount of duplicate MSPinvestigations. This will also offer a centralized, one-stop customer service approach, for all MSPrelatedinquiries, including those seeking general MSP information, but not those related to specificclaims or recoveries that serve to protect the Medicare Trust Funds. The COB Contractor providescustomer service to all callers from any source, including but not limited to beneficiaries,attorneys/other beneficiary representatives, employers, insurers, providers, and suppliers.Information GatheringMedicare generally uses the term Medicare Secondary Payer or "MSP" when the Medicare programis not responsible for paying a claim first. The COB contractor will use a variety of methods andprograms to identify situations in which Medicare beneficiaries have other health insurance that isprimary to Medicare. In such situations, the other health plan has the legal obligation to meet thebeneficiary's health care expenses first before Medicare. The table below describes a few of thesemethods and programs.Method/ProgramInitial EnrollmentQuestionnaire (IEQ)IRS/SSA/CMS DataMatchMSP ClaimsInvestigationVoluntary MSP DataMatch AgreementsDescriptionBeneficiaries are sent a questionnaire about other insurance coverageapproximately three (3) months before they are entitled to Medicare.Under the Omnibus Budget Reconciliation Act of 1989, employers arerequired to complete a questionnaire that requests Group Health Plan(GHP) information on identified workers who are either entitled to Medicareor married to a Medicare beneficiary.This activity involves the collection of data on other health insurance thatmay be primary to Medicare based on information submitted on a medicalclaim or from other sources.Voluntary Agreements allow for the electronic data exchange of GHPeligibility and Medicare information between CMS and employers or variousinsurers.DME MAC Jurisdiction C Supplier Manual Page 1

Coordination of Benefits Chapter 11Provider Requests and Questions Regarding Claims PaymentIntermediaries and carriers will continue to process claims submitted for primary or secondarypayment. Claims processing will not be a function of the COB contractor. Questions concerning howto bill for payment (e.g., value codes, occurrence codes) should continue to be directed to your localintermediary or carrier. In addition, continue to return inappropriate Medicare payments to the localMedicare contractor. Checks should not be sent to the COB Contractor. Questions regardingMedicare claim or service denials and adjustments should continue to be directed to your localintermediary and carrier. If a provider submits a claim on behalf of a beneficiary and there is anindication of MSP, but not sufficient information to disprove the existence of MSP, the claim will beinvestigated by the COB Contractor. This investigation will be performed with the provider or supplierthat submitted the claim. MSP investigations will no longer be a function of your local intermediary orcarrier. The goal of MSP information gathering and investigation is to identify MSP situations quicklyand accurately, thus ensuring correct primary and secondary payments by the responsible party.Providers, physicians, and other suppliers benefit not only from lower administrative claims costs,but also through enhanced customer service to their Medicare patients.Medicare Secondary Payer Auxiliary Records in CMS's DatabaseThe COB Contractor is the sole authority to ensure the accuracy and integrity of the MSPinformation contained in CMS's database (i.e., Common Working File). Information received as aresult of MSP gathering and investigation is stored on the CWF in an MSP auxiliary file. The MSPauxiliary file allows for the entry of several auxiliary records, where necessary. MSP data may beupdated, as necessary, based on additional information received from external parties (e.g.,beneficiaries, providers, attorneys, third party payers). Beneficiary, spouse and/or family memberchanges in employment, reporting of an accident, illness, or injury, Federal program coveragechanges, or any other insurance coverage information should be reported directly to the COBContractor. CMS also relies on providers and suppliers to ask their Medicare patients about thepresence of other primary health care coverage, and to report this information when filing claims withthe Medicare program.Termination and Deletion of MSP Auxiliary Records in CMS's DatabaseIntermediaries and carriers will continue to terminate records on the CWF where the provider hasreceived information that MSP no longer applies (e.g. succession of employment, exhaustion ofbenefits). Termination requests should continue to be directed to your local intermediary or carrier.MSP records on the CWF that you identify as invalid should be reported to the COB Contractor forinvestigation and deletion.Contacting the COB ContractorEffective January 1, 2001, refer all MSP inquiries; including, the reporting of potential MSPsituations, invalid MSP auxiliary files, and general MSP questions/concerns to the COB contractor.Continue to call your local intermediary and/or carrier regarding claims-related and recoveryquestions. The COB Contractor's Customer Call Center toll free number is 1-800-999-1118 orTDD/TYY 1-800-318-8782. Customer service representatives are available to assist you from 8 a.m.DME MAC Jurisdiction C Supplier Manual Page 2

Coordination of Benefits Chapter 11to 8 p.m., Monday through Friday, eastern standard time, except holidays. Clip and post this sectionin a handy place for access by your office and billing staff.MSP ClassificationsUntil 1980, when Congress mandated that Medicare pay only secondary benefits in certainsituations, the program had generally assumed a position of primary payer responsibility for itsbeneficiaries. Since 1980 there have been other changes in the Medicare Law that have added newcircumstances under which Medicare is a secondary payer. Medicare Secondary Payer (MSP) isessentially the Medicare program's coordination of benefits with other insurers including thefollowing:• Employer Group Health Plans• Accident/Injury Insurance• Other Government Sponsored Health PlansEmployer Sponsored Group Health Plan CoverageWorking AgedMedicare is secondary for beneficiaries 65 years or older who have Employer Group Health Plan(EGHP) coverage through their own current employment or the current employment of a spouse. AnEGHP is a health insurance or benefit plan that is offered through an employer of 20 or moreemployees. The "20 or more employees" threshold is met when an employer has 20 or more fulland/or part-time employees for each working day in each of 20 or more calendar weeks in thecurrent or preceding year. The 20 calendar weeks do not have to be consecutive.DisabilityMedicare is secondary for beneficiaries under age 65 who are entitled to Medicare on the basis ofpermanent disability who have health insurance coverage under a Large Group Health Plan (LGHP)either through their own current employment or the current employment of a family member. AnLGHP is a health insurance or benefit plan that is offered through an employer who has 100 or moreemployees or is part of a multi-employer trust or association which has at least one employer of 100or more employees. The "100 or more employees" threshold is met when an employer has 100 ormore full and/or part-time employees on 50 percent or more of its business days during the previouscalendar year.End Stage Renal Disease (ESRD)Medicare is secondary for beneficiaries under age 65 who are entitled to Medicare solely on thebasis of ESRD who have health insurance coverage under an employer sponsored Group HealthPlan (GHP) as a result of the current or former employment of the beneficiary or a family memberregardless of the size of the employer.DME MAC Jurisdiction C Supplier Manual Page 3

Coordination of Benefits Chapter 11Medicare is secondary payer to GHPs for individuals eligible for or entitled to Medicare benefitsbased on ESRD for the following coordination of benefit (COB) periods:Date of Medicare EligibilityOctober 1, 1981 - January 31, 1990COB Period12 monthsFebruary 1, 1990 - February 29, 1996 18 monthsMarch 1, 1996 - Present30 monthsDually Entitled BeneficiariesWhen an individual is eligible for or entitled to Medicare based on ESRD and also entitled on thebasis of age or disability they are considered dually entitled to Medicare and other provisions apply.Effective August 10, 1993, GHPs are subject to the ESRD COB period for any plan enrollee eligiblefor or entitled to Medicare based on ESRD, regardless of whether that individual also is entitled toMedicare on the basis of age or disability. However, if Medicare is primary for an individual who isalready entitled on the basis of age or disability when he/she becomes eligible on the basis ofESRD, the ESRD COB period would not apply.Accident/Injury InsuranceWorkers' CompensationMedicare payment may not be made for covered items or services to the extent that payment hasbeen made or can reasonably be expected to be made under a workers' compensation (WC) law orplan. However, Medicare secondary, primary, or conditional payments may be made in certainsituations.Secondary payment may be made by Medicare if the WC plan does not pay the supplier's fullcharge. However, if the supplier accepts or is required under the WC law to accept the WC paymentas payment in full, Medicare secondary payment is not allowed. When submitting claims to Medicarefor secondary payment, suppliers should attach a copy of the WC explanation of benefits (EOB).Generally speaking, Medicare primary payment may be made for services not covered under WC,assuming the services are otherwise covered by Medicare. Primary payment may also be made byMedicare for services that are clearly unrelated to the injuries covered under WC.Conditional Medicare payments may be made when a WC claim is contested. The statute furtherauthorizes Medicare to make payment if the WC insurer will not pay or will not pay promptly (120days). This is allowed in order to avoid imposing a hardship on the Medicare beneficiary since along delay may occur between the occurrence of an injury or illness and the final decision regardingthe case by the WC agency. Conditional payments issued by Medicare are subject to recovery byMedicare when the WC case is settled.DME MAC Jurisdiction C Supplier Manual Page 4

Coordination of Benefits Chapter 11No-FaultMedicare is secondary to both automobile and non-automobile no-fault insurance. No-fault insuranceis insurance that pays for medical expenses due to injuries sustained on the property or premises ofthe insured, or in the use, occupancy, or operation of an automobile regardless of who may havebeen responsible for causing the accident. It is sometimes called "medical payments coverage,""personal injury protection" or "medical expense coverage." Services covered under no-faultinsurance must be billed to the no-fault insurer first. If the charges are not paid in full, a claim maybe submitted to Medicare for possible secondary benefits. Claims for services covered under nofaultinsurance should be submitted with an explanation of benefits from the no-fault insurer orevidence that the no-fault insurance benefits have been exhausted.Under certain circumstances, Medicare may make conditional payments if the no-fault insurance willnot pay or will not pay promptly (i.e., 120 days after receipt of the claim). Conditional payments areconditioned on reimbursement to the Medicare program to the extent that payment with respect tothe same items or services has been made, or could be made, under no-fault insurance.LiabilityMedicare is secondary to any liability insurance (e.g., automobile liability insurance and malpracticeinsurance). When a supplier has reason to believe that it provided covered services to a Medicarebeneficiary for which payment under liability insurance may be available, the supplier should bill onlythe liability insurer, unless it has evidence that the liability insurer will not pay within the 120 daypromptly period. If it has such evidence, it may bill Medicare for conditional payment, provided itsupplies documentation to support the fact that payment will not be made promptly. After the 120day promptly period has ended, the supplier may (but is not required to) bill Medicare for conditionalpayment if the liability insurance claim is not finally resolved.If the supplier chooses to bill Medicare, it must withdraw claims against the liability insurer or a lienplaced on the beneficiary's settlement. If it chooses to continue its claim against the liabilityinsurance settlement, it may not also bill Medicare. The supplier may not collect payment from thebeneficiary until after the proceeds of liability insurance are available to the beneficiary.Other Government-Sponsored Health PlansBlack LungMedicare is secondary payer for beneficiaries entitled to benefits under the Federal Black LungProgram for items and services provided for certain respiratory conditions. Claims with black lungdiagnoses should have an EOB or payment determination from the Federal Black Lung Program inorder for Medicare to consider payment.Send claims related to Black Lung Disease to:Federal Black Lung ProgramPO Box 828Lanham-Seabrook, MD 20703-0828 (Phone: 800.638.7072)DME MAC Jurisdiction C Supplier Manual Page 5

Coordination of Benefits Chapter 11Veteran's Administration (VA)Veterans who are also entitled to Medicare can choose which program will be responsible forpayment when services are covered by both programs. However, Medicare cannot pay for servicesreceived from the VA hospital or other VA facilities, except for certain emergency hospital servicesand generally cannot pay if the VA pays for VA authorized services provided in a non-VA hospital orfrom a non-VA physician.You do not have to submit claims involving a veteran to the VA for denial before submitting the claimto Medicare. Claims for services for which the veteran elects Medicare coverage should besubmitted to Medicare in the normal manner. Claims cannot be submitted at the same time to bothprograms for the same dates and type of treatment. If a veteran elects Medicare coverage, a claimshould not be submitted to the VA for the Medicare deductible or coinsurance.Medicare and the VA will perform periodic computer data matches to assure that instances ofduplicate payment are identified. When duplicate payments are found, Medicare will pursue recoveryof its payment and will develop information for potential referral to the Internal Revenue Service orthe Office of Inspector General.Federal Public HealthMedicare will not make payment for services authorized and eligible under another federal program,such as Federal Public Health.Claims for services authorized or guaranteed under other federal programs should be submitted tothat program for payment. No claim should be submitted to Medicare until after the authorizingagency has processed the claim.If a claim is filed to Medicare because of a denial or a balance owed after the other program pays, acopy of the denial notice or explanation of benefits from the other program should be submitted withthe Medicare claim.MSP Payment CalculationMedicare secondary payments are based on the higher allowable charge between the primaryinsurer and Medicare unless the supplier is obligated to accept the primary insurer's allowable aspayment in full. At no time will Medicare pay more secondary benefits than it would have paid asprimary payer and all claims are subject to Medicare coverage criteria. The MSP paymentcalculation applies to assigned and non-assigned claims.Secondary payments are calculated as follows:1. The Medicare primary payment is determined in the usual manner (i.e., as if there were noother coverage).2. The higher of the Medicare allowable charge or the primary insurer's allowable charge isdetermined.DME MAC Jurisdiction C Supplier Manual Page 6

Coordination of Benefits Chapter 113. The amount paid by the primary insurer is subtracted from the amount determined in Step 2above.4. Medicare pays the lower of Step 1 or 3.The following are examples of Medicare secondary payment calculations:Example 1:Submitted Charge $500Unmet Medicare Deductible 0Medicare Allowable $375Primary Allowable $500Primary Paid $4001. Medicare primary payment is $375 x 80%= $3002. Primary allowed of $500 is the higher allowed amount3. Primary allowed minus primary paid is $500 - $400 = $1004. The lower of Step 1 or 3 is $100. (This claim will pay $100)Example 2:Submitted Charge $300Unmet Medicare Deductible 0Medicare Allowed $250Primary Allowed $200Primary Paid $1601. Medicare primary payment is $250 x 80%= $2002. Medicare allowed of $250 is the higher allowed amount3. Medicare allowed minus primary paid is $250 - $160 = $904. The lower of Step 1 or 3 is $90. (This claim will pay $90)DME MAC Jurisdiction C Supplier Manual Page 7

Coordination of Benefits Chapter 11MSP and DeductibleExample 1:Submitted Charge $150Unmet Medicare Deductible (this amount does not reflect current deductibleamount)$100Medicare Allowed $120Primary Allowed $150Primary Paid $1201. Medicare primary payment is $120 - $100 (deductible) x 80%= $162. Primary allowed of $150 is the higher allowed amount3. Primary allowed minus primary paid is $150 - $120 = $304. The lower of Step 1 or 3 is $16. (This claim will pay $16)If the claim is filed assigned the patient responsibility would be the differencebetween the Medicare allowed amount and the total amount paid. The patientresponsibility is 0 for this claim. The Medicare deductible is satisfied by thisclaim.Example 2:Submitted Charge $200Unmet Medicare Deductible 0Medicare Allowed $120Unmet Primary Deductible $150Primary Allowable $150Primary Paid 01. Medicare primary payment is $120 x 80% = $962. Primary allowed of $150 is the higher allowed amount3. Primary allowed minus primary paid is $150 - 0 = $1504. The lower of Step 1 or 3 is $96. (This claim will pay $96)If the claim is filed assigned the patient responsibility would be the differenceDME MAC Jurisdiction C Supplier Manual Page 8

Coordination of Benefits Chapter 11between the Medicare allowed amount and the total amount paid. The patientresponsibility is $24 for this claim. The Medicare deductible is satisfied by thisclaim.Obligated to Accept"Obligated to Accept" is a term used when a supplier has a contractual agreement with the primaryinsurer to accept the primary insurer's allowed amount as payment in full. When the supplier isobligated to accept, the secondary payment is based solely on the primary insurer's allowed amount.Example 1:Submitted Charge $300Unmet Medicare Deductible 0Medicare Allowed $300Primary Allowed $250Primary Payment $200Supplier is obligated to accept the primary allowed as payment in full.1. Medicare primary payment is $300 x 80%= $2402. Primary allowed of $250 is the higher allowed amount3. Primary allowed minus primary paid is $250 - $200 = $504. The lower of Step 1 or 3 is $50. (This claim will pay $50)MSP Overpayment RefundsIt is the supplier's responsibility to refund overpayments on MSP claims. To expedite the refundprocess, please include the following:1. Explanation of benefits from the third party payer;2. Type of primary insurance (i.e., EGHP, liability, workers compensation, no fault);3. Medicare Explanation of Benefits; and4. Check in the amount of the original Medicare payment.The claim will then be adjusted according to the MSP guidelines and any additional benefits will beissued at that time.All refunds should be made payable to CIGNA Government Services (CGS) and sent to:DME MAC Jurisdiction C Supplier Manual Page 9

Coordination of Benefits Chapter 11CIGNA Government ServicesJC DME MACPO Box 30629New York, NY 10087-0629Medicare Secondary Claim Filing Tips• A claim should be submitted to the primary insurer first.• An explanation of benefits (EOB) or payment determination from the primary insurer mustaccompany each claim submitted to Medicare.• If Medicare is secondary to a GHP, item 11, 11a, 11b and 11c of the CMS-1500 must becompleted.• If the claim is due to an accident, item10a, 10b, and 10c should be completed.• Do not enter the primary insurer's payment amount in item 29 of the CMS-1500. Completethe field only if payment is received from the beneficiary.• The claim should be submitted for the total charge, not the difference between your usualcharge and the primary insurer's payment (i.e., co-pay). The total charge should not bereduced to reflect the Medicare or primary insurer's allowed amounts.• Refer to the patient responsibility (PT RESP) field on the Medicare Remittance Notice (MRN)to determine how much to bill the beneficiary. The coinsurance (COINS) and deductible(DEDUCT) fields are calculated based on the Medicare primary payment and do not apply toa secondary claim.Identifying Beneficiary Insurance CoveragesThe reporting of Medicare Secondary Payer (MSP) has been mandated by the Centers for Medicare& Medicaid Services (CMS). Prior to billing Medicare, suppliers must take an active role in theidentification of MSP claims/cases.Information obtained at the time of contact with the beneficiary is essential in making the Medicareprimary or secondary payer determination. After a Medicare beneficiary leaves your office, it is oftendifficult for pertinent information to be obtained for billing purposes.A recommended Medicare Secondary Payer Questionnaire to be completed by the beneficiary orregistration personnel is included in this chapter. When providing services to a Medicare beneficiary,use of this form should facilitate the identification and proper billing of MSP cases. This will helpmaximize your reimbursement and shorten claim-processing time.Medicare Secondary Payer Questionnaire (35K) Acrobat 4.0DME MAC Jurisdiction C Supplier Manual Page 10

Coordination of Benefits Chapter 11Miscellaneous IssuesMedicare Secondary Payer on Capped Rental ItemsCapped rental items, other than electric wheelchairs, are rented for a continuous 13 months andthen ownership transferred to the beneficiary. When Medicare is the secondary payer we will makesecondary payments for these rental months if all guidelines are met and we could have made aprimary payment. A copy of the primary payer's explanation of benefits must be attached to eachMedicare claim.The primary insurance does not have to honor the purchase option if it is not consistent with theirpolicy requirements. However, a claim must be submitted to the primary insurance first.Medicare as secondary payer can, under no circumstances, pay more than we would have paid as aprimary payer. If the primary insurance pays for the lump sum purchase of a capped rental item(except electric wheelchair), Medicare cannot make a secondary payment. Medicare would notmake a primary payment; therefore, we could not make a secondary payment for the lump sumpurchase of a capped rental item.Electric wheelchairs are the only exception to capped rental guidelines. Medicare as primary payercould pay for purchase or rental. When Medicare is secondary payer, the primary insurance must befiled first and Medicare would process the claim secondary.Medicare may not pay secondary benefits when the primary payer pays the supplier's charges in full,or when the supplier is either obligated to accept, or voluntarily accepts, the primary payer's paymentas payment in full.Medicare Secondary Payer (MSP) with One or Multiple Primary Payers1. When Medicare is the Secondary Payer Following One Primary PayerThere are situations where one primary payer pays on a Medicare Part B claim and Medicare maymake a secondary payment on the claim. Physicians and suppliers must comply with Section 1.4.2,titled “Coordination of Benefits,” found in the 837 version 4010 Professional Implementation Guide(IG) regarding the submission of Medicare beneficiary MSP claims (The IG can be found athttp://www.wpc-edi.com.) Providers must follow model 1 in section 1.4.2.1 that discusses theprovider-to-payer-to-provider methodology of submitting electronic claims. Providers must use theappropriate loops and segments to identify the other payer paid amount, allowed amount, and theobligated to accept payment in full amount on the 837.Primary Payer Paid Amount:For line level services, physicians and suppliers must indicate the primary payer paid amount for thatservice line in loop ID 2430 SVD02 of the 837.For claim level information, physicians and suppliers must indicate the other payer paid amount forthat claim in loop ID 2320 AMT02 AMT01=D of the 837.DME MAC Jurisdiction C Supplier Manual Page 11

Coordination of Benefits Chapter 11Primary Payer Allowed Amount:For line level services, physicians and suppliers must indicate the primary payer allowed amount forthat service line in the Approved Amount field, loop ID 2400 AMT02 segment with AAE as thequalifier in the 2400 AMT01 segment of the 837.For claim level information, physicians and suppliers must indicate the primary payer allowedamount in the Allowed Amount field, Loop ID 2320 AMT02 AMT01 = B6.Obligated to Accept as Payment in Full Amount (OTAF):For line level services, physicians and suppliers must indicate the OTAF amount for that service linein loop 2400 CN102 CN 101 = 09. The OTAF amount must be greater than zero.For claim level information, physicians and suppliers must indicate the OTAF amount in loop 2300CN102 CN101 = 09. The OTAF amount must be greater than zero.2. When Medicare is the Secondary Payer Following Two Primary PayersSubmission of Hardcopy MSP Claims with Multiple Primary PayersThere may be situations where more than one primary insurer to Medicare makes payment on aclaim; for example, an employer group health plan makes a primary payment for a service and,subsequently, another group health plan also makes a primary payment for the same service.Claims with multiple primary payers cannot be sent electronically to Medicare. A hardcopy claimmust be submitted on Form CMS-1500. Physicians and suppliers must attach the other payers’EOB, or remittance advice, to the claim when sending it to Medicare for processing.Medicare Secondary Payer Fact SheetsFour new fact sheets on the subject of Medicare Secondary Payer are now available on the Centersfor Medicare & Medicaid Services (CMS) Medlearn Web page at:http://www.cms.hhs.gov/medlearn/pubs.asp.These fact sheets should prove to be very useful in explaining provider/billing clerk responsibilities.The fact sheets are titled as follows:• Collecting, Submitting, and Updating Beneficiary Insurance Information For Clinical Laboratories• Complying with Medicare Secondary Payer Requirements• Collecting, Submitting, and Updating Beneficiary Insurance Information to Medicare• When Medicare is the Primary PayerDME MAC Jurisdiction C Supplier Manual Page 12

Chapter Twelve √Overpayments

Overpayments and Refunds Chapter 12Overpayments and RefundsThe Centers for Medicare & Medicaid Services (CMS) requires the contractor to request refunds onnon-MSP overpayments of $10 or more. If a supplier owes several small overpayments, each ofwhich is less than $10, the total amount owed will be considered in the decision to request therefund. Refunds will be requested for overpayments totaling $10 or more. Although not requested bythe contractor, refunds of less than $10 will be accepted. If a lump sum refund would cause a severefinancial hardship, repayment may be accepted over an extended period. The supplier must submitspecific documentation to support the request. The $10 tolerance does not apply to MSPoverpayments.It is the supplier's responsibility to refund overpayments. You should respond to the request forrefund according to the instructions provided in the request. When submitting voluntary refundchecks to the DME MAC, the Voluntary Overpayment Refund form (located at the end of thischapter) must be completed and returned to ensure proper recording and receipt of the check. Thiswill allow for the timely processing of your refund.Refund checks should be made payable to CIGNA Government Services (CGS) and mailed to:Overpayment OffsetsCIGNA GOVERNMENT SERVICESJC DME MACPO Box 30629New York, NY 10087-0629Suppliers are notified by letter when an overpayment has been identified and a refund is requested.A second request is made in 30 days if no response has been received and interest is assessed onthe principal balance. If, after 10 additional days, the supplier has not contacted our office regardingthe overpayment, offset withholdings are initiated.Although the recommended solution for any overpayment is to send a refund, suppliers can requestan overpayment be placed into immediate offset. If the principal amount is offset prior to 30 daysfrom the date of the letter no interest will be assessed. If a balance remains after 30 days, interestwill be assessed on the principal balance. Suppliers can also request an immediate offset, if desired.Please include the FCN number located on the demand letter on this request or any othercorrespondence sent to this office in reference to the overpayment.Offset withholdings sometimes create a difficulty in bookkeeping for a supplier's office.Understanding the offset information on a Medicare Remittance Notice (MRN) may alleviate some ofthe confusion. The Offset Details indicates if the claim was offset (OF) or adjusted (AJ). Other detailscan be found in the Glossary listed below the Offset Details on the MRN. If the claim is offset, anumber will be listed in the Financial Control Number (FCN) column. This number is used to matchthe MRN to the corresponding overpayment letter previously received. The FCN is located in thelower right hand corner of the overpayment letter. The amount field details the dollars offset oradjusted depending on the indicator in the Offset Details column. If the claim is offset, the amount isDME MAC Jurisdiction C Supplier Manual Page 1

Overpayments and Refunds Chapter 12the difference between the Total Provider Paid column and the Amount of Check column minus anyadjustments involved.Referral of Delinquent DebtIf the overpayment amount has not been refunded in full (principal plus interest), by the time theoverpayment is 180 days delinquent, the debt will be referred to the Department of Treasury’s DebtCollection Center (DCC) for cross servicing and offset of federal overpayments. The Department ofTreasury can use various tools to attempt collection of the debt from the supplier, including theinvolvement of a private collection agency and the Treasury Offset Program (TOP). Types ofpayments that can be offset may include tax refunds, vendor payments and benefit payments; withcertain restrictions. Extended Repayment Agreements for debts that have been referred may bediscussed and negotiated with the Department of Treasury.Voluntary Overpayment Refund Form (36K) Acrobat 4.0Extended Repayment PlanA debtor is expected to repay any overpayment as quickly as possible. If it cannot refund the totaloverpayment within 30 days after receiving the first demand letter, it should request an extendedrepayment plan (ERP) immediately. However, an ERP request may be received and shall bereviewed at any time the overpayment is outstanding. The provider must explain and document itsneed for an extended (beyond 30 days) repayment plan. A repayment plan may be established torecover all or part of an overpayment. Any approved ERP will run from the date of the initial demandletter.A written request must be submitted that refers to the specific overpayment for which an extendedrepayment is being requested. This request must detail the number of months requested, indicatethe approximate monthly payment amount (principal and interest, if possible), and include the firstpayment.Please provide the following when requesting an ERP:If sole proprietor:• Complete form CMS – 379 (copy included in the back of this chapter)• Attach income tax statements from the most recent calendar yearIf entity other than a sole proprietor:• Amortization Schedule- this schedule shall contain the proposed repayment schedule,including length of schedule, dates of payment, and payment amount broken down betweenprincipal and interest for the life of the schedule.• Balance sheets - the most current balance sheet and the one for the last complete Medicarecost reporting period or the most recent fiscal year (preferably prepared and certified by theprovider's accountant).DME MAC Jurisdiction C Supplier Manual Page 2

Overpayments and Refunds Chapter 12NOTE: If the time period between the two balance sheets is less than 6 months (or the providercannot submit balance sheets prepared by its accountant), it must submit balance sheets for the lasttwo complete Medicare reporting periods (providers that file a cost report) or last two complete fiscalyears.• Income statements - related to the balance sheets (preferably prepared by the provider'saccountant).CMS suggests that both the balance sheets and income statements include the followingstatements:MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED INTHIS BALANCE SHEET OR INCOME STATEMENT MAY BE PUNISHABLE BY FINEAND/OR IMPRISONMENT UNDER FEDERAL LAW.CERTIFICATION BY OFFICER OF ADMINISTRATOROF PROVIDER(S)(For physicians/suppliers, “CERTIFICATION BY OFFICER/OWNER OF DEBTOR(S))I HEREBY CERTIFY that I have examined the balance sheet and income statement prepared by__________and that to the best of my knowledge and belief, it is a true, correct, and completestatement from the books and records of the provider.SignedOfficer or Administrator ofProvider(s)TitleDate(For physicians/suppliers:SignedOfficer or Owner ofDebtor(s)Title)• Statement of Sources and Application of Funds - for the periods covered by the incomestatements (see CMS Manual System, Pub. 100-8, Medicare Program Integrity Manual,Chapter 4, Section 50.3, Exhibit 2 for recommended format).• Cash flow statements - for the periods covered by the balance sheets (see CMS ManualSystem, Pub. 100-8, Medicare Program Integrity Manual, Chapter 4, Section 50.3, Exhibit 3for recommended format). If the date of the request for an extended repayment schedule ismore than 3 months after the date of the most recent balance sheet, a cash flow statementshould be provided for all months between that date and the date of the request.DME MAC Jurisdiction C Supplier Manual Page 3

Overpayments and Refunds Chapter 12In addition, whether or not the date of the request is more than 3 months after that of themost recent balance sheet, a projected cash flow statement should be included for the 6months following the date of the request.• Projected cash flow statement - covering the remainder of the current fiscal year. If fewerthan 6 months remain, a projected cash flow statement for the following year should beincluded. (See CMS Manual System, Pub. 100-8, Medicare Program Integrity Manual,Chapter 4, Section 50.3, Exhibit 3 for recommended format.)• List of restricted cash funds - by amount as of the date of request and the purpose for whicheach fund is to be used.• List of investments - by type (stock, bond, etc.), amount, and current market value as of thedate of the report.• List of notes and mortgages payable - by amounts as of the date of the report, and their duedates.• Schedule showing amounts - due to and from related companies or individuals included inthe balance sheets. The schedule should show the names of related organizations orpersons and show where the amounts appear on the balance sheet--such as AccountsReceivable, Notes Receivable, etc.• Schedule showing types - and amounts of expenses (included in the income statements)paid to related organizations. The names of the related organizations should be shown.• Loan Applications - Requests for extended repayment of 12 months or more. Have thedebtor include at least one letter from a financial institution denying the debtor’s loan requestfor the amount of the overpayment. Also, include a copy of the loan application with thedenial letter from the bank.All financial records must be for the business participating in the program. They should not be forthe owner if the business is a partnership or a corporation. If the financial aspects of the businessare managed by an outside facility, the provider’s individual financial records must still be submittedas well as the financial records of the outside facility.If a debtor is unable to furnish some of the documentation, it should fully explain why it is unable to.DME MAC Jurisdiction C Supplier Manual Page 4

Chapter Thirteen √Inquiries and Appeals

Inquiries and Appeals Chapter 13Telephone InquiriesA toll-free telephone number has been designated for the exclusive use of suppliers. The number is1-866-238-9650. This number will be answered by an Interactive Voice Response (IVR) system thatis capable of responding to a variety of supplier inquiries and requests including claim status, totalnumber of claims in process, allowable amounts, outstanding check information, offset information,duplicate remittance, beneficiary deductible and beneficiary eligibility which includes Part A and Bentitlement dates, Medicare Advantage Plan enrollment, Home Health and Medicare SecondaryPayer information. When the system cannot answer your questions or provide the assistance youneed, you may disconnect from the IVR and call 1-866-270-4909 to speak to a Customer ServiceRepresentative (CSR). When accessing the IVR, suppliers will not be able to transfer to a CustomerService Representative.To speak to a Customer Service Representative, suppliers will be required to disconnect from theIVR and call 1-866-270-4909. CSRs are trained to answer supplier questions and resolve problems.They should be your first contact with our office when you need assistance.When calling, please have your Medicare supplier number and name, and, if appropriate, thepatient’s name and Health Insurance Claim Number (HICN) available. So that we may assist asmany callers as possible, suppliers are limited to three separate beneficiary inquiries per phone call.Lengthy requests should be submitted in writing.Customer Service Representatives are available Monday – Friday, 8:00 am to 4:00 pm local time ineach time zone which falls in Jurisdiction C. The IVR is available outside normal business hours aslong as the mainframe system is functional.Customer Service Representatives are able to:• Clarify the denial reason associated with a claim.• Provide general information regarding Medicare coverage.• Explain terminology and information published in issues of your DME MAC newsletters andthis Supplier Manual.• Provide status of a Redetermination case.• Assist with other complex issues.Customer Service Representatives are not able to:• Provide claim status, beneficiary eligibility, or other information which is available through theIVR.• Give preauthorization of beneficiary entitlement for specific DME.• Adjust a claim, unless the claim was processed incorrectly by the Contractor.Written InquiriesCIGNA Government Services is committed to providing the highest level of service to our Medicaresuppliers. It is our goal to handle all written inquiries in a timely and efficient manner. When writing,please state your question or concern as clearly as possible including all pertinent information, i.e.,your supplier number and, if appropriate, the patient’s name and HICN. This will allow us to respondmore specifically to your inquiry. Please also include your name and phone number.DME MAC Jurisdiction C Supplier Manual Page 1

Inquiries and Appeals Chapter 13Please send all general written inquiries to:CIGNA Government ServicesDMAC Jurisdiction CPO Box 20010Nashville, TN 37202ATTN: Correspondence DepartmentE-mail inquiries may be submitted through our Website at http://www.cignagovernmentservices.com.Information that is personal/private (e.g., HICN, supplier number, financial information, etc.) must notbe included in the inquiry. A response will be returned via e-mail. Responses that requirepersonal/private information will be returned by phone or in writing.Provider Outreach and Education (POE) DepartmentCIGNA Government Services offers several different methods of educational training. Each methodoffers providers the latest and most up-to-date Medicare information. Provider Relationsrepresentatives are available for training and educational seminars, online education, andworkshops. Visit our Web site at www.cignagovernmentservices.com for a complete listing ofseminars, online training and workshops.Reopenings for Minor Errors and OmissionsSuppliers should be aware there is no need to request a redetermination if the supplier has made aminor error or omission in filing the claim, which, in turn, caused the claim to be denied. In the casewhere a minor error or omission is involved, the supplier can request Medicare to reopen the claimso the error or omission can be corrected, rather than having to go through the appeal process. Youcan request a reopening for minor errors or omissions either by telephone or in writing. Suppliershave one year to request a reopening from the date on the remittance advice.Examples of minor errors or omissions include:• Mathematical or computational mistakes;• Transposed procedure or diagnostic codes;• Inaccurate data entry;• Misapplication of a fee schedule;• Computer errors; or,• Denial of claims as duplicates which the party believes were incorrectly identified as aduplicate.• Incorrect data items, such as provider number, use of a modifier or date of service.Because some issues are more complicated than others, and may require more research orconsulting medical staff, the DME MAC reserves the right to decline the clerical error reopening andrequest the supplier submit a written redetermination request.DME MAC Jurisdiction C Supplier Manual Page 2

Inquiries and Appeals Chapter 13In situations where a provider, supplier or beneficiary requests a redetermination and the issueinvolves a minor error or omission, irrespective of the request for a redetermination, the durablemedical equipment Medicare administrative contractor (DME MAC) will treat the request as arequest for a clerical error reopening.Suppliers can request a reopening either by telephone or by sending in a written request for areopening. Detailed instructions are provided below:Telephone ReopeningsThe DME MAC telephone reopening number is 1-866-813-7878.1) Use the telephone reopening process to resolve minor errors or omissions involving:• Units of service• Service dates• Healthcare Common Procedure Code System (HCPCS) coding• Diagnosis codes and diagnosis reference• Modifiers• Place of service• Claim incorrectly denied as duplicate charges2) Wait to call the telephone reopening line until you receive your Medicare remittance notice.No action can be taken until a final claim determination is issued.3) Callers should consult the Jurisdiction C DME MAC Supplier Manual and applicable medicalpolicy guidelines before calling. Failure to have appropriate information available when youcall the telephone reopening line may result in an unfavorable decision.4) Questions about the status of a claim, or general Medicare payment and coding questions,should not be directed through the telephone reopening line. Suppliers can obtain a claimstatus report through the Interactive Voice Response (IVR) Unit or by using Claim StatusInquiry (CSI).5) Suppliers must have the following information on-hand before placing the call for a telephonereopening:• Your supplier number• The Medicare Claim Control Number (CCN) and reason for denial• Beneficiary name and Medicare health insurance claim number (HICN)• Any additional information to support why you believe the decision is not correct. Thisincludes having the correct procedure code(s), modifier(s), diagnoses, units of service, etc.All medical information provided to the DME MAC must be documented in the patient’s file andavailable to the DME MAC should an audit be required.If a previous reopening decision has been issued, a redetermination must be made in writing. If aprevious redetermination decision has been issued, a reconsideration must be filed.To effectively service all callers, each call is limited to three claim issues.DME MAC Jurisdiction C Supplier Manual Page 3

Inquiries and Appeals Chapter 13Written ReopeningsWritten requests for reopenings should be mailed to:CIGNA Government ServicesDME MAC Jurisdiction CPO Box 20010Nashville, TN 37202ATTN: Clerical Error Reopening DepartmentWritten Reopening requests should be made using the Medicare Reopening Request form. If youwish to send a written request instead of using the Medicare Reopening Request form, be sure toinclude the following information with your reopening request:• The beneficiary’s name• The Medicare health insurance claim number of the beneficiary• The specific services(s) and/or item(s) for which the reopening is being requested and thespecific date(s) of service, and• The name and signature of the person filing the requestAppealsThe Medicare program offers suppliers and beneficiaries the right to appeal claim determinationsmade by the contractor. The purpose of the appeals process is to ensure the correct adjudication ofclaims.Suppliers who provide services to Medicare Part B beneficiaries may appeal an initial claimreimbursement determination. Beneficiaries also have the right to appeal any claim determination.The Medicare law consists of five levels of appeal. The appellant must begin at the first level afterreceiving an initial determination. Each level, after the initial determination, has procedural steps thatmust be taken before an appeal may be taken to the next level. The following table lists the types ofappeal, the order in which appeals must be followed and the filing requirements for each.Appeal Level Time Limit for FilingRequestWhere to File an AppealMonetaryThresholdRedetermination 120 days from the date CIGNA Government Services Noneof receipt of the initialdetermination oroverpayment demandletterJurisdiction C DME MACReconsideration 180 days from the date RiverTrust Solutions, Inc.Noneof receipt of theredetermination noticeAdministrative LawJudge (ALJ)60 days from the date ofreceipt of thereconsideration noticeHHS Office of Medicare Hearingsand Appeals (OMHA) field officeAt least $120remains incontroversyDepartmental 60 days from the date of DAB or ALJ Hearing Office NoneAppeals Board(DAB) Reviewreceipt of the ALJdecision/dismissalFederal Court 60 days from the date of On or afterDME MAC Jurisdiction C Supplier Manual Page 4

Inquiries and Appeals Chapter 13(Judicial) Reviewreceipt of the DABdecision or declinationof review by DABJanuary 1,2007 at least$1130remains incontroversyOn or afterJanuary 1,2008 at least$1180remains incontroversyParties to an AppealAn appeal request must be submitted by someone who is considered a party to the appeal. Theappeal will be dismissed if the person requesting is not a proper party. Any of the following areconsidered proper parties to an appeal:• A beneficiary;• A participating supplier;• A non-participating supplier taking assignment for a specific item or service;• A non-participating supplier of DME potentially responsible for making a refund to thebeneficiary under Section 1834(a)(18) of the Act;• A supplier of medical equipment and supplies not taking assignment and is responsible formaking a refund to the beneficiary under Section 1834(j)(4) of the Act;• A Medicaid State agency or party authorized to act on behalf of the State; or• Any individual whose rights may be affected by the claim being reviewed.Appointment of RepresentativeA person/supplier/physician who files an appeal request on behalf of a beneficiary is not, by virtue offiling the appeal, a representative. To act as the beneficiary’s representative, aperson/supplier/physician must submit a properly executed appointment of representative form(Form CMS-1696). However, an appointment of representative form is not necessary. A writtenstatement containing all the required elements is also acceptable as a valid appointment ofrepresentative. The following information must be included on a written statement:• The name, address and phone number of the individual.• The individual’s Medicare number when the party making the appointment is the beneficiary.• A specific individual must be named as the representative. An organization or entity may notbe named as the representative, but rather a specific member of that organization or entitymust be named. The representative must sign and date the form and list his/her name,address and phone number. A statement that he/she accepts the appointment needs to beincluded.• Representatives must sign the appointment within 30 calendar days of the party’s signature.• A statement that the party authorizes the representative to act on her or his behalf for theclaims at issue and a statement authorizing disclosure of individually identifying informationto the representative.• Signature of the party making the appointment and the date signed.DME MAC Jurisdiction C Supplier Manual Page 5

Inquiries and Appeals Chapter 13The appointment of representative is valid for one year from either: (1) The date signed by the partymaking the appointment, or (2) The date the appointment is accepted by the representative—whichever is later.The appointment remains valid for any subsequent levels of appeal on the claim/service in questionunless the beneficiary specifically withdraws the representative's authority. However, if during anappeal the appointment of representative expires, a new form is necessary.Redeterminations – First Level of AppealThe first step in the appeals process is the redetermination which is conducted by the DME MAC.The redetermination process provides a complete re-examination of all information submitted withthe original claim. Any new information or medical evidence should be submitted with the request forredetermination and will be evaluated fully in accordance with the Medicare law regulating theredetermination process. Every effort will be made by the redetermination specialist to clarify anyquestions that may arise in the course of the redetermination, (e.g., calling the beneficiary or his/herrepresentative or the physician who prescribed the equipment). The redetermination specialist issomeone who did not participate in the original decision. The opinion of medical consultantsspecializing in the services being reviewed may also be requested.The denial on a duplicate line item is not a denial of service. There are no appeal rights on theduplicate submission. Appeal requests on duplicate claim denials will be treated as inquiries and notas appeals for this reason. Suppliers who wish to request an appeal must request the appeal on theoriginal denial.The time limit for requesting a redetermination is 120 days from the date of issuance of theremittance notice or the date of the overpayment demand letter. The DME MAC redeterminationstaff will determine if the request was filed timely or if good cause was established for a request notfiled timely. The DME MAC redetermination staff has 60 days to complete a redetermination.Redetermination RequestsThe payee, (i.e., the beneficiary or his/her representative), or the supplier of an assigned claim maycomplete a request for redetermination, CMS-20027 (05/05) form, which may be obtained online athttp://www.cms.hhs.gov/forms/CMS20027.pdf. (A supply of the CMS-20027 form can be ordered bywriting to Superintendent of Documents, United States Government Printing Office, Washington, DC,20402.)You may also request a redetermination by submitting a completed Jurisdiction C MedicareRedetermination Request Form. If you wish to send a written request instead of using the MedicareRedetermination Request or CMS-20027 form, your written request must contain the following:• The beneficiary’s name;• The Medicare health insurance claim number of the beneficiary;• The specific service(s) and/or item(s) for which the redetermination is being requested andthe specific date(s) of service; and• The name and signature of the person filing the request.Incomplete requests will be dismissed with an explanation of the missing information. Suppliers willbe instructed to resubmit the request with all of the missing information. Incomplete requests that areresubmitted for appeal must be submitted within the 120 day timely filing limit. Incomplete requeststhat are resubmitted past the 120 day timely filing limit will be dismissed.DME MAC Jurisdiction C Supplier Manual Page 6

Inquiries and Appeals Chapter 13Additional information that the supplier wishes to be considered during the redetermination shouldbe mailed with the written redetermination request. Redetermination requests should be mailed to:Redetermination DecisionsCIGNA Government ServicesDME MAC Jurisdiction CP. O. Box 20009Nashville, TN 37202The redetermination decision will result in one of three dispositions:AffirmationThe redetermination specialist may find the original claim disposition to be accurate and affirm theoriginal disposition. A letter will be sent to the appellant explaining the decision and the grounds onwhich the affirmation is based. A carbon copy of all decisions will be sent to the beneficiary if theappellant, on an assigned claim, is the supplier.ReversalThe redetermination specialist may find in favor of the appellant and will take action to reverse theoriginal decision. A fully favorable reversal will result in an adjusted claim with the MedicareSummary Notice (MSN) to the beneficiary and, if assigned, the Remittance Advice to the supplier,serving as notice of the decision. A partially favorable decision will result in an adjusted claim with anaccompanying MSN, and (if assigned) Remittance Advice, serving as notice of the decision as wellas a letter to the appellant explaining the reason for the partially favorable decision.DismissalThe redetermination specialist may determine the request was not submitted timely. Theredetermination specialist will dismiss the request and send a letter to the appellant explaining thedismissal.Appeal Rights for DismissalsParties to the redetermination have the right to appeal a dismissal of a redetermination request tothe Qualified Independent Contractor (QIC). A party to the redetermination may appeal the dismissalif they believe the dismissal is incorrect.The reconsideration request must be filed at the QIC within 60 days of the date of the dismissalletter. When the QIC performs its reconsideration of the dismissal, it will decide if the dismissal wascorrect. If it determines that the DME MAC incorrectly dismissed the redetermination, it will vacatethe dismissal and remand the case to the DME MAC for reopening. It is mandatory for the DMEMAC to reopen any case that is remanded to it and issue a new decision. The QIC's reconsiderationof a DME MAC's dismissal of a redetermination request is final and not subject to further review.Reconsideration – Second Level of AppealThe second level in the appeals process is a reconsideration. The reconsideration is conducted bythe Qualified Independent Contractor (QIC). A redetermination must be issued on the claim(s) indispute before requesting a reconsideration.The reconsideration process provides a complete reexamination of the information contained in theredetermination case file. Any new information or medical evidence must be submitted with therequest for reconsideration and will be evaluated fully in accordance with the Medicare lawregulating the reconsideration process.DME MAC Jurisdiction C Supplier Manual Page 7

Inquiries and Appeals Chapter 13The adjudicator performing the reconsideration is an independent reviewer of the appeal. Requestson claims that were denied due to medical necessity will be reviewed by a panel of physicians andother health professionals.The QIC adjudication staff has 60 days to complete a reconsideration decision.Reconsideration RequestsTo exercise your right to a reconsideration, you must file a request in writing within 180 days ofreceiving the redetermination letter. You may request the reconsideration one of three ways:• Complete the Reconsideration Request form included with the Redetermination letter;• Complete CMS 20033 Medicare Reconsideration Request Form located athttp://www.cms.hhs.gov/CMSForms; or• Submit a written request containing all of the following information:- The beneficiary's name;- The beneficiary's Medicare health insurance claim number;- The specific service(s) and item(s) for which the reconsideration is requested, and thespecific date(s) of service;- The name and signature of the party or representative of the party; and- The name of the contractor that made the redetermination.Your request for reconsideration should be mailed to:RiverTrust Solutions, Inc.Qualified Independent Contractor (QIC)P.O. Box 180208Chattanooga, TN 37401-7208Administrative Law Judge (ALJ) Hearing Officer – Third Level of AppealIf the appellant remains dissatisfied following the QIC reconsideration and the remaining amount incontroversy is $110.00 or more, the appellant has the right to a hearing before an AdministrativeLaw Judge (ALJ). The request for ALJ hearing must be in writing and must be received within 60days from the date of the reconsideration. The ALJ hearing may be requested by submitting awritten request or by using Form CMS-5011A/B located online at http://www.cms.hhs.gov/forms.Requests for ALJ hearings must be filed to the Office of Medicare Hearings and Appeals (OMHA) atthe following locations depending on the place of service (for DMEPOS claims, the place of serviceis defined as the beneficiary’s address of record):OMHA Field Office LocationsArlington, Virginia1700 N. Moore St., Suite 1600Arlington, VA 22209Phone: 866-231-3087DME MAC Jurisdiction C Supplier Manual Page 8

Inquiries and Appeals Chapter 13Cleveland, OhioBP Tower, Suite 1300200 Public SquareCleveland, OH 44114-2316Phone: 866-236-5089Irvine, California27 Technology Drive, Suite 100Irvine, CA 92618-2364Phone: 866-495-7414Miami, Florida100 SE 2 nd Street, Suite 1700Miami, FL 33131-2100Phone: 866-622-0382Field Office JurisdictionsField OfficeMiami, FL Field OfficeCleveland, OH Field OfficeIrvine, CA Field OfficeArlington, VA Field OfficeStatesAlabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, NewMexico, North Carolina, Oklahoma, Puerto Rico, South Carolina andTennessee, Texas, and Virgin IslandsConnecticut, Delaware, Illinois, Indiana, Kentucky, Maine,Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey,New York, Ohio, Pennsylvania, Puerto Rico, Rhode Island, Vermont,Virgin Islands, Wisconsin, and West VirginiaAlaska, Arizona, California, Colorado, Guam, Hawaii, Idaho, Iowa,Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota,Oregon, South Dakota, Utah, Washington, Wyoming, Trust Territoryof the Pacific, and American SamoaDistrict of Columbia, Maryland, VirginiaDepartmental Appeals Board ReviewIf the appellant remains dissatisfied following the Administrative Law Judge’s (ALJ) decision ordismissal, you may file an appeal requesting the Departmental Appeals Board to review it. To file anappeal, you must request the Departmental Appeals Board to review the order in writing within 60days from the date you receive the ALJ decision. Your ALJ decision letter outlines the properprocess for requesting a Departmental Appeals Board review.When the Departmental Appeals Board has rendered its final decision, a copy will be sent to theappellant and the case file will be returned to the contractor for completion. Favorable or partiallyfavorable decisions will be adjusted for payment within 60 days of receiving the case file from theDepartmental Appeals Board.Federal Court ReviewIf the appellant remains dissatisfied following the Departmental Appeals Board decision, you, youmay request a court review of the decision. The complaint must be filed with a United States DistrictCourt.DME MAC Jurisdiction C Supplier Manual Page 9

Inquiries and Appeals Chapter 13Documentation in the Appeals ProcessOften original claim denials are upheld at the redetermination or reconsideration level of appeal dueto the lack of documentation supporting the medical necessity of services rendered. Beforerequesting a redetermination or reconsideration, consult the Jurisdiction C DME MAC SupplierManual and/or supplier bulletins. These resources contain all applicable medical policy anddocumentation guidelines for each piece of equipment/supply. Failure to include all appropriatedocumentation with the appeal may result in an unfavorable appeal decision.DME MAC Jurisdiction C Supplier Manual Page 10

Chapter Fourteen √Fraud and Abuse

Fraud and Abuse Chapter 14Medicare Fraud and AbuseThe Medicare program provides reimbursement for health care services for millions of beneficiariesand provides payment to tens of thousands of providers and suppliers of services. Numerous publicand private organizations are involved in the program’s administration. Within a program of suchcomplexity and magnitude, the opportunities for fraud, abuse and waste are considerable. Thequality control effort to eliminate fraud, abuse and waste is necessarily a cooperative effort involvingthe beneficiaries, contractors, Quality Improvement Organizations, state Medicaid agencies, andfederal agencies such as the Centers for Medicare & Medicaid Services (CMS), the Office of theInspector General (OIG) and the Department of Health and Human Services (DHHS). As well, mostsuppliers and supplier organizations are interested in fraud and abuse control to protect theirindustry’s image with the public and Congress.Program Safeguard ContractorsMedicare administrative contractor Benefit Integrity Units (BIUs) have historically performedMedicare fraud and abuse detection and case referral and provided assistance to law enforcement.As permitted by Congress in the Health Insurance Portability and Accountability Act of 1996(HIPAA), the Centers for Medicare & Medicaid Services (CMS) has moved Medicare benefit integritywork from the administrative contractors to entities known as Program Safeguard Contractors(PSCs). PSCs are independent organizations that specialize in benefit integrity work. Because thesole purpose of the PSCs who perform benefit integrity work is identifying Medicare fraud andabuse, the PSCs can maximize their effectiveness.With the addition of PSCs, the administrative contractors place greater focus on claims processingand customer service, while the PSCs concentrate on benefit integrity issues, including fraud andabuse detection and deterrence. PSCs have a duty to identify cases of suspected fraud and to makereferrals of all such cases to the OIG, regardless of dollar thresholds or subject matter.PSCs use a variety of tools including data analysis, fraud complaints and referrals. They alsodevelop innovative tools and techniques to identify potential Medicare fraud and abuse. Theseapproaches are used in building and referring cases to law enforcement involving those who aresuspected of perpetrating Medicare fraud.TrustSolutions, LLCTrustSolutions began operations as a PSC on October 1, 2002. TrustSolutions’ responsibilitiesinclude DME benefit integrity functions and data analysis for Jurisdiction C which includes Alabama,Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina,Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, the U.S. Virgin Islands, Virginia, andWest Virginia.In addition to Jurisdiction C, TrustSolutions’ other contracts include the Medicare jurisdictions forPart A and Part B in four (4) states, Medicare Part A only in nine (9) states and U.S. territories,Medicare Part B only in one (1) state, home health/hospice in eighteen (18) states and U.S.territories, Medi-Medi in one state, and Federally Qualified Health Centers in many states and U.S.territories.PSC Responsibilities• Investigate allegations of fraud made by beneficiaries, providers, suppliers, CMS, Office ofInspector General (OIG) and other sources, including proactive data analysis results andDME MAC Jurisdiction C Supplier Manual Page 1

Fraud and Abuse Chapter 14pre- and post-pay medical review for benefit integrity. Explore all available sources of fraudleads in its jurisdictions.• Refer investigations to the Office of Inspector General/Office of Investigations (OIG/OI) forconsideration of civil and criminal prosecution and/or application of administrative sanctions.• Support law enforcement in requests for information, including but not limited to data anddata analysis, cost report data and medical review.• Recommend administrative actions to CMS, such as Medicare payment suspensions,identifying and recouping overpayments, pursuing civil monetary penalties, andrecommending program exclusions.• Prevent fraud by identifying program vulnerabilities to CMS.• Work cooperatively with law enforcement and other partners, including CMS, affiliatedcontractors (Fiscal Intermediaries, Contractors and Medicare Administrative Contractors orMACs), Harkin Grantees, providers, suppliers, and other PSCs to fight fraud and abuse• Initiate and maintain networking, education and outreach activities to ensure effectiveinteraction and exchange of information with internal components as well as outside groups,suppliers, providers and beneficiaries.Defining Fraud and AbuseFraud is intentional deception or misrepresentation that the individual makes, knowing it to be falseand that it could result in some unauthorized benefit to them.Abuse describes incidents or practices of providers, physicians or suppliers, or services andequipment which, although not usually fraudulent, are inconsistent with accepted sound medical,business or fiscal practices. These practices may, directly or indirectly, result in unnecessary coststo the program, improper payment, or payment for services which fail to meet professionallyrecognized standards of care, or which are medically unnecessary.Defining a Complaint of Fraud and AbuseA complaint is a statement, oral or written, alleging that a provider, supplier, or beneficiary received aMedicare benefit of monetary value, directly or indirectly, overtly or covertly, in cash or in kind, towhich they are not entitled under current Medicare law, regulations, and/or program policy. Includedare allegations of misrepresentation and violations of Medicare requirements applicable to personsor entities that bill for Medicare-covered items and services.Examples of complaints include:• Allegations that items or services are not received;• Allegations that the services received are inconsistent with the services billed (as indicatedon the Medicare Summary Notice (MSN);• Allegations that a supplier has billed both the beneficiary and Medicare for the same item orservice;• Allegations regarding the waiver of coinsurance or deductibles;• Allegations that a supplier has misrepresented itself as having an affiliation with an agency ordepartment of state, local, or federal government, whether expressed or implied; and/or• Beneficiary inquiries concerning payment for an item or service, which in his or her opinion,may far exceed a reasonable payment for the service which they received, (i.e., the supplieror physician has “upcoded” to receive a higher payment).DME MAC Jurisdiction C Supplier Manual Page 2

Fraud and Abuse Chapter 14The following are not fraud and abuse complaints:• Complaints (or inquiries) regarding Medicare coverage policy;• Complaints (or inquiries) regarding the status of claims;• Requests for claims appeal, complaints regarding the appeals process; and/or• Complaints concerning suppliers (other than those complaints meeting the criteriaestablished), which are general in nature and are policy- or program-oriented.FraudThe most frequent type of fraud arises from a false statement or misrepresentation which is materialto entitlement or payment under the Medicare program. The violator may be a supplier of durablemedical equipment, a beneficiary, or some other person or business entity (e.g., a prescribingphysician).Fraud in the Medicare program takes such forms as, but is not limited to:• Billing for services or supplies that were not provided;• Supplier claim forms which have been altered to obtain a higher payment amount (i.e.,falsifying a beneficiary’s address to a DME MAC jurisdiction with higher fee scheduleamounts; or using a beneficiary’s home address when in fact the beneficiary is in a nursinghome);• Supplier’s deliberate application for duplicate payment (i.e., billing both Medicare and thebeneficiary for the same service, or billing both Medicare and another insurer in an attempt toget paid twice);• Soliciting, offering, receiving or giving a kickback, bribe, or rebate, in exchange for referring apatient or arranging for referral of a patient;• Physician signing of Certificates of Medical Necessity (CMNs) for patients not personally andprofessionally known to the physician;• False representation with respect to the nature of services rendered, amounts charged forservices rendered, identity of the person receiving the services, dates of services, etc.;• Claims for non-covered services billed as covered services;• Claims involving collusion between a provider and a beneficiary, or between a supplier and aprovider resulting in unwarranted or higher costs or charges to the Medicare program;• Use of another person’s Medicare card in obtaining medical services;• Repeated violations of the participation agreement, or the assignment agreement;• Unbundled or fragmented charges; for example, billing for parts of an ostomy bag;• Falsification of CMNs (e.g., misrepresenting the diagnosis for the patient to justify theservices or equipment furnished, indicating a patient cannot swallow - when in fact he or shecan - to justify enteral nutrition);• Falsification of qualifying tests (e.g., exercising a patient before oximetry or ABG testing).AbuseThe type of abuse to which Medicare is most vulnerable is over-utilization of medical and health careservices.DME MAC Jurisdiction C Supplier Manual Page 3

Fraud and Abuse Chapter 14Abuse takes such forms as, but is not limited to:• Breaches of assignment agreements, which result in beneficiaries being billed for disallowedamounts on the basis that such charges exceeded the reasonable charge criteria (unlessAdvance Beneficiary Notice applies);• Claims for services not medically necessary, or not medically necessary to the extentrendered, (e.g., an electric hospital bed is supplied where a manual bed would be medicallysufficient);• Routine waiver of coinsurance and/or deductibles;• Excessive charges for services or supplies;• Improper billing practices which include:o Supplier failure to file non-assigned claims,o Provider billing Medicare at a higher and different fee schedule rate than for non-Medicare beneficiary,o Submission of bills to Medicare instead of third-party payers which are primaryinsurers for Medicare beneficiaries, and/oro Unbundled or fragmented charges;• Supplier violations of Medicare participation agreements or supplier standards.Although these types of practices may initially be categorized as abusive in nature, under certaincircumstances they may develop into fraud.Other Illegal Activities• Prohibited completion of CMN by suppliers.• A supplier misrepresenting itself as having an affiliation with any agency or department ofstate, local or federal government, whether expressed or implied.Bribes, Kickbacks, and RebatesUnder federal law, Section 1877 (b) and 1909 (b) of the Social Security Act [42 USC 1395 nn (b) and42 USC 1396h (b)], it is a felony for anyone to knowingly and willfully offer, pay, solicit or receive anypayment in return for referring an individual to another person for the furnishing, or arranging for thefurnishing, of any item or service that may be paid for by the Medicare or Medicaid program.Individuals convicted under these felony provisions may be fined up to $25,000 or imprisoned up tofive years, or both.Anyone who accepts or solicits any payment for referring patients to any practitioner, durablemedical equipment supplier, home health agency, laboratory, or any other health provider or facilitywhich furnishes items or services that may be paid for by Medicare or Medicaid may be subject toprosecution.The criminal statute applies regardless of whether the payment for referral is made directly orindirectly, overtly or covertly, in cash or in kind.The following are examples of potential violations of federal law if the services are covered under theMedicare or Medicaid programs:DME MAC Jurisdiction C Supplier Manual Page 4

Fraud and Abuse Chapter 14• Physicians who are offered percentages of Medicare payment either acting in the capacity ofa consultant, attending physician, etc., if they refer patients needing DMEPOS services tospecific DMEPOS suppliers.• Skilled Nursing Facilities or Nursing Homes who are offered at no charge Durable MedicalEquipment (DME), formula for non-Medicare-eligible beneficiaries (i.e., Medicaid-eligiblebeneficiaries), or computers and/or billing services, or a rebate on the 20 percentcoinsurance as an inducement to refer patients needing Parenteral or Enteral Nutrition (PEN)to a specific PEN supplier.• Hospital social workers or discharge planners who receive payment from DME suppliers forreferring hospital patients who will need home medical equipment, once they are dischargedfrom the hospital.In the listed examples, the unlawful activity is not the referral but the solicitation, receipt, offering orgiving of payment or free items/services. A referral of a patient that does not involve a solicitation oroffer, or result in the receipt of a gift of any payment or free items would not be considered aviolation of the statute. Furthermore, these examples are not all-inclusive of the types of kickbackarrangements that are violations of the law.Procedures for Handling Fraud and Abuse SituationsSuppliers can contact TrustSolutions in writing, using the contact information that follows. Or youmay call the OIG at their fraud hotline at 1-800-HHS-TIPS. Please be specific about the potentialfraud you suspect. You may remain anonymous. However, calls from known entities will receivepriority.TrustSolutions, LLCP.O. Box 50218Indianapolis, IN 46250Fax: (317) 863-3755DocumentationUnsubstantiated allegations from suppliers will be accepted and recorded in Benefit Integrity Unitfiles. However, investigative action will not be initiated until some verification of the allegation isreceived. This not only will preserve limited investigative resources, but will protect innocentsuppliers from false or vindictive allegations by unfriendly competitors.PenaltiesProviders may be subject to up to $25,000 fine and a five-year imprisonment term, or both perviolation, under the applicable federal law and suspended from the Medicare program. Civil penaltiesinclude $2,000 fines plus double damages per violation and exclusion. Administrative remedies forabuse include revocation of assignment privileges, withholding of payments, recovery ofoverpayments, educational contacts and/or warnings, as well as exclusion from the Medicareprogram.Keep in mind that the suspects in Medicare fraud and abuse are seldom beneficiaries. Most oftenthe suspects are suppliers or physicians. Many times the beneficiaries are witnesses in suspectedfraud and abuse cases.DME MAC Jurisdiction C Supplier Manual Page 5

Fraud and Abuse Chapter 14Protect Yourself from FraudWhat you can do as a Medicare Supplier to protect yourself from fraud:• Be informed -It is important to understand Medicare eligibility criteria, coverage guidelines, billing and costreport requirements. Seek clarification from your DME MAC as necessary and attend trainingopportunities by CMS and Medicare contractors.• Be an educator -Keep beneficiaries (patients) properly informed and educated about the care or supplies youare providing, and ensure the physician is actively involved in the planning and delivery ofyour service to the patient. Many recent OIG hotline reports by beneficiaries relate to billingand service issues. A supplier can prevent inappropriate referrals about them frombeneficiaries if they have informed patients and family members. Always provide completeand accurate information to beneficiaries according to your participation agreement.• Be in compliance -If your agency does not have a compliance program in place, development of one should beconsidered. The OIG has developed a number of model compliance programs for providersand suppliers to use as guidance in developing individual agency programs. Theseprograms, along with other pertinent information can be found on the OIG Internet site athttp://oig.hhs.gov, or by contacting the OIG directly.• Be a responsible employer -Every supplier should be aware of and use the Office of Inspector General’s Sanction List.This list identifies Medicare providers who have been restricted from participation ingovernment programs. For a supplier’s protection, the list should be checked prior to hiringnew employees to ensure the government has not sanctioned the prospective employee.The OIG Sanction List can be accessed via the OIG Internet address identified above.• Be a Medicare Anti-Fraud Team member -You can contact TrustSolutions by calling or writing, using the contact information thatfollows. Or you may call the OIG at their fraud hotline at (1-800-HHS-TIPS). Please bespecific about the potential fraud you suspect, and you may remain anonymous.TrustSolutions, LLCP.O. Box 50218Indianapolis, IN 46250Fax: (317) 863-3755You may contact Adele Culpepper, Medicare Outreach Liaison, directly at (214) 231-2464.For more on TrustSolutions, visit their Web site at http://www.trustsolutionsllc.com/.DME MAC Jurisdiction C Supplier Manual Page 6

Chapter Fifteen √Resources

Resources Chapter 15ResourcesThe following addresses and telephone numbers are provided so that you will know where to obtainthe information/materials you need or where to send inquiries.Durable Medical Equipment Medicare Administrative Contractors(DME MACs)Jurisdiction AConnecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire,New Jersey, New York, Pennsylvania, Rhode Island, VermontNational Heritage Insurance CompanyP.O. Box 9146Hingham, MA 02043-9146Phone/IVR: 866.419.9458Website: www.medicarenhic.comJurisdiction BIllinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, WisconsinNational Government ServicesPO Box 240Indianapolis, IN 46207-0240Phone/IVR: 877.299.7900Website: www.adminastar.comJurisdiction CAlabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina,Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia, WestVirginiaCIGNA Government ServicesPO Box 20010Nashville, TN 37202-0010Phone: 866.270.4909IVR: 866.238.9650Telephone Reopenings: 866-813-7878Website: www.cignagovernmentservices.comJurisdiction DAlaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Mariana Islands,Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington,WyomingNoridian Administrative Services901 40th Ave. S., Suite 1Fargo, ND 58103-2146Phone: 866.243.7272IVR: 877.320.0390Website: www.noridianmedicare.comDME MAC Jurisdiction C Supplier Manual Page 1

Resources Chapter 15Jurisdiction C ResourcesJurisdiction C Electronic Data Interchange (EDI)Jurisdiction C EDI OperationsPO Box 100170Columbia, SC 29202Phone: 888-613-9271Website: www.palmettogba.com/jcediProvider Outreach and Education(POE)CIGNA Government ServicesDME MAC Jurisdiction CPO Box 20010Nashville, TN 37202ATTN: POE DepartmentFraud and AbuseTrustSolutions, LLCPO Box 50218Indianapolis, IN 46250Phone: 214-231-2464Fax: 317-863-3755Refund ChecksCIGNA Government ServicesJurisdiction C DME MACPO Box 30629New York, NY 10087-0629Publications (DME MAC Jurisdiction CSupplier Manual and updates, DME MACInsider, Fee Schedules)Send publication orders with payments to:Connecticut General Life Insurance CompanyAttn: DME MAC Publication Fulfillment CenterP. O. Box 30629New York, New York 10087-0629If your order does not require a payment, send thecompleted order form to:CIGNA Government ServicesATTN: DME MAC PublicationsCIGNA Government ServicesPO Box 20010Nashville, TN 37202Send requests for status of an order to:ATTN: DME MAC PublicationsCIGNA Government ServicesPO Box 20010Nashville, TN 37202DME MAC Jurisdiction C Supplier Manual Page 2

Resources Chapter 15Advance Determination of Medicare Coverage (ADMC)CIGNA Government ServicesAttn: ADMCP.O. Box 20010Nashville, TN 37202FAX: 615-782-4647CorrespondenceCIGNA Government ServicesDME MAC Jurisdiction CPO Box 20010Nashville, TN 37202Clerical Error ReopeningsCIGNA Government ServicesDME MAC Jurisdiction CPO Box 20010Nashville, TN 37202Telephone Reopenings: 866-813-7878RedeterminationsCIGNA Government ServicesATTN: Redetermination DepartmentPO Box 20009Nashville, TN 37202ReconsiderationsRiverTrust Solutions, IncPO Box 180208Chattanooga, TN 37401-7208Overnight:RiverTrust Solutions, Inc801 Pine St.Chattanooga, TN 37402Administrative Law Judge (ALJ)Requests for ALJ hearings must be filed to the Office of Medicare Hearings and Appeals (OMHA) atthe following locations depending on the place of service (for DMEPOS claims, the place of serviceis defined as the beneficiary’s address of record):OMHA Field Office LocationsArlington, Virginia(Mid-Atlantic Field Office and Headquarters)1700 N. Moore St., Suite 1600Arlington, VA 22209Phone: 866-231-3087Cleveland, Ohio(Mid-West Field Office)BP Tower, Suite 1300200 Public SquareDME MAC Jurisdiction C Supplier Manual Page 3

Resources Chapter 15Cleveland, OH 44114-2316Phone: 866-236-5089Irvine, California(Western Field Office)27 Technology Drive, Suite 100Irvine, CA 92618-2364Phone: 866-495-7414Miami, Florida(Southern Field Office)100 SE 2 nd Street, Suite 1700Miami, FL 33131-2100Phone: 866-622-0382Field Office JurisdictionsField Office Jurisdiction StatesMid-Atlantic Field Office The Mid-Atlantic Field Office provides overflow capacity to processappeals from any of the other three offices.Southern Field Office HHS Region 4 Alabama, Florida, Georgia, Kentucky, Mississippi,North Carolina, South Carolina and TennesseeHHS Region 6 Arkansas, Louisiana, New Mexico, Oklahoma andTexasMid-west Field Office HHS Region 1 Connecticut, Maine, Massachusetts, NewHampshire, Rhode Island and VermontHHS Region 2 New York, New Jersey, Puerto Rico and VirginIslandsHHS Region 3 Delaware, Maryland, Pennsylvania, Virginia, WestVirginia and District of ColumbiaHHS Region 5 Illinois, Indiana, Ohio, Michigan, Minnesota andWisconsinWestern Field Office HHS Region 7 Iowa, Kansas, Missouri and NebraskaHHS Region 8 Colorado, Montana, North Dakota, South Dakota,Utah and WyomingHHS Region 9 Arizona, California, Hawaii, Nevada, Guam, TrustTerritory of the Pacific and American SamoaHHS Region 10 Alaska, Idaho, Oregon and WashingtonAdditional ResourcesSupplier Enrollment/InquiriesNational Supplier Clearinghouse (NSC)AG-495PO Box 100142Columbia, SC 29202-3142Phone: 866.238.9652Web site: www.palmettogba.com/nscDME MAC Jurisdiction C Supplier Manual Page 4

Resources Chapter 15The supplier enrollment form, CMS 855S, is available atwww.cms.hhs.gov/providers/enrollment/forms.Coding AssistanceStatistical Analysis DMERC (SADMERC)Palmetto Government Benefits AdministratorsMedicare SADMERC OperationsPO Box 100143Columbia, SC 29202-3143Phone: 877.735.1326Web site: www.palmettogba.com/sadmercSocial Security Administration (SSA)Contact your local SSA office or call 800.772.1213.CMS-1500 (12/90) Claim FormU. S. Government Printing OfficeSuperintendent of DocumentsWashington, DC 20402Phone: 202.512.1800UPIN DirectoriesComplete UPIN directories are now available on CD-ROM from the U. S. Government PrintingOffice. For current prices and ordering information, call 202.512.1800.UPIN information is also available at: www.upinregistry.comICD-9-CM (Three Volume Set)The most recent version may be obtained through the following sources:• Ingenix – 800.999.4600• American Medical Association (AMA) – 800.621.8335 or www.ama-assn.org• National Center for Health Statistics (NCHS) - www.cdc.gov/nchs/icd9.htmUnited Mine Workers Association (UMWA)U.M.W.A. Health and Retirement FundsPO Box 619099Dallas TX 75261-9741Phone: 1-888-865-5290DME MAC Jurisdiction C Supplier Manual Page 5

Resources Chapter 15Web ResourcesDME MAC Jurisdiction C Web site at www.cignagovernmentservices.com (select DME MAC).From the Web site, you can access and download the Jurisdiction C DME MAC newsletters, DMEMAC Jurisdiction C Supplier Manual, and DME MAC Jurisdiction C Fee Schedules. The Web sitealso provides links to the other DME MACs, NSC, MEDPARD, and SADMERC.To access the DME MAC Jurisdiction C resources go to www.cignagovernmentservices.com; selectDME MAC. Frequently Asked Questions, forms and other publications can be accessed there. Youcan also e-mail DME MAC Jurisdiction C through the Web site. Please do not include sensitiveinformation such as your supplier number, beneficiary's Medicare number or financial information inyour e-mail inquiry.Centers for Medicare & Medicaid Services (CMS) - www.cms.hhs.govCMS Manual System - www.cms.hhs.gov/manualsBeginning October 1, 2003, CMS transitioned from a paper-based manual system to a Web-basedsystem. The transition included streamlining, updating, and consolidating various CMS programinstructions into an electronic Web-based manual system for all users. The new online CMS ManualSystem is organized by functional area, (e.g., eligibility, entitlement, claims processing, benefitpolicy, program integrity). The manuals are listed below.Pub. 100-01 — Medicare General Information, Eligibility, and EntitlementPub. 100-02 — Medicare Benefit PolicyPub. 100-03 — Medicare National Coverage DeterminationsPub. 100-04 — Medicare Claims ProcessingPub. 100-05 — Medicare Secondary PayerPub. 100-06 — Medicare Financial ManagementPub. 100-07 — State OperationsPub. 100-08 — Medicare Program IntegrityPub. 100-09 — Medicare Contractor Beneficiary and Provider CommunicationsPub. 100-10 — Quality Improvement OrganizationPub. 100-11 — ReservedPub. 100-12 — State MedicaidPub. 100-13 — Medicaid State Children’s Health Insurance ProgramPub. 100-14 — Medicare End Stage Renal Disease Network OrganizationPub. 100-15 — State Buy-InPub. 100-16 — Medicare Managed CarePub. 100-17 — CMS/Business Partners Systems SecurityPub. 100-18 — ReservedPub. 100-19 — DemonstrationsPub. 100-20 — One-Time NotificationPub. 100-21 — Recurring Update NotificationCMS Quarterly Provider Update - www.cms.hhs.gov/providerupdateIssues are released the first business day of each subsequent calendar quarter. The updateprovides a single source for national Medicare provider/supplier information and givesproviders/suppliers advance notice on upcoming instructions and regulations.DME MAC Jurisdiction C Supplier Manual Page 6

Resources Chapter 15Medicare Coverage Homepage - www.cms.hhs.gov/coverageThis site includes National Coverage Determinations, National Coverage Analyses, and LocalMedical Review Policies.CMS Forms - http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp#TopOfPageCIGNA Government Services does not review or control the content and accuracy of Web sitesreferenced in this manual, except the CIGNA Government Services Web site, and is therefore notresponsible for their content or accuracy.Attachment: DME MAC Jurisdiction C Publication Order Form (PDF)Publication Form.pdf(151 KB)Attachment: Suggested Intake Form (PDF)Suggested Intake Form.pdfDME MAC Jurisdiction C Supplier Manual Page 7

Chapter Sixteen √Coding

Coding Chapter 16The Statistical Analysis Durable Medical Equipment RegionalContractor (SADMERC)Palmetto Government Benefits Administrators, is contracted by the Centers for Medicare & MedicaidServices (CMS) to serve as the SADMERC. The SADMERC assists suppliers and manufacturers in theproper use of the Healthcare Common Procedure Coding System (HCPCS). The HCPCS is used toidentify items of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) forpurposes of Medicare billing.The SADMERC plays a key role in the regionalization of DMEPOS claim processing. Some of theirresponsibilities include:• coordinating the creation/revision and interpretation of the Level II HCPCS codes/modifiers• analyzing DMEPOS claim data• establishing and distributing to the DME MACs national pricing files for parenteral/enteralnutrition, durable medical equipment, and prosthetics and orthotics in accordance with CMSdirectives• conducting postpayment reviews of national suppliersThe SADMERC also operates a HCPCS help line to provide DMEPOS coding advice. The help linetelephone number is 877.735.1326. The hours of operation are Monday through Friday, 9:00 a.m. to 4:00p.m. EST, with extended hours, 9:00 a.m. to 6 p.m. EST, on Wednesday.You can also reach the SADMERC at their website: http://www.palmettogba.com/Or by mail:SADMERC/HCPCS UnitP.O. Box 100143Columbia, South Carolina 29202-3143DMECS – Online Coding Assistance from the SADMERCThe DMECS (Durable Medical Equipment Coding System) is an online application that will provideHealthcare Common Procedure Coding System (HCPCS) coding assistance and national pricinginformation 24 hours a day. DMECS is designed to help Medicare providers and suppliers quicklyclassify durable medical equipment, prosthetics/orthotics, and supplies (DMEPOS) by combininginformation from a variety of sources to make HCPCS coding determinations for claim submission to theDME MACs easier. Currently, DMECS has four interactive components that work together to provideHCPCS coding information. The four components are Search by HCPCS information, Search forModifier, Search for Fee Schedule and Search DMEPOS Product Classification List.DMECS is available on the SADMERC Web site at http://www3.palmettogba.com/dmecs/jsp/index.jsp.DME MAC Jurisdiction C Supplier Manual Page 1

Coding Chapter 16Level II HCPCS CodesLevel II HCPCS codes are CMS assigned and consist of an alpha followed by four numerics. The Level IIHCPCS listed in this chapter are provided as a guide for identifying items that are processed by the DMEMACs. The appearance of a code in this chapter does not necessarily indicate coverage.Coding Jurisdiction2006 Jurisdiction ListA spreadsheet containing an updated list of the HCPCS for Durable Medical Equipment RegionalContractor (DMERC) and Part B local contractor jurisdictions is updated annually to reflect codesthat have been added or discontinued (deleted) each year. The jurisdiction list is an Excel file andwill be located at http://www.cms.hhs.gov/center/dme.aspModifiersModifiers can be alphas, numerics or a combination of both, but will always be two digits forMedicare purposes. Some modifiers cause automated pricing changes, while others are used toconvey information only.Below is a list of modifiers used with procedure codes for DMEPOS:99 Modifier overflow. (Effective date 7/1/2003)A1 Dressing for one wound. (Effective date 1/1/2003)A2 Dressing for two wounds. (Effective date 1/1/2003)A3 Dressing for three wounds. (Effective date 1/1/2003)A4 Dressing for four wounds. (Effective date 1/1/2003)A5 Dressing for five wounds. (Effective date 1/1/2003)A6 Dressing for six wounds. (Effective date 1/1/2003)A7 Dressing for seven wounds. (Effective date 1/1/2003)A8 Dressing for eight wounds. (Effective date 1/1/2003)A9 Dressing for nine or more wounds. (Effective date 1/1/2003)AUAVItem furnished in conjunction with a urological, ostomy, or tracheostomy supply. (Effective date1/1/2003)Item furnished in conjunction with a prosthetic device, prosthetic or orthotic. (Effective date1/1/2003)AW Item furnished in conjunction with a surgical dressing. (Effective date 1/1/2003)AX Item furnished in conjunction with dialysis services. (Effective date 1/1/2003)BAItem furnished in conjunction with parenteral enteral nutrition (PEN) services. (Effective dateDME MAC Jurisdiction C Supplier Manual Page 2

Coding Chapter 161/1/2003)BO Orally administered nutrition, not by feeding tube. (Effective date 1/1/2003)BPBRBUCCEAEBECEDEEEJEMEYFBThe beneficiary has been informed of the purchase and rental options and has elected topurchase the item.The beneficiary has been informed of the purchase and rental options and has elected to rent theitem.The beneficiary has been informed of the purchase and rental options and after 30 days has notinformed the supplier of his/her decision.Procedure code change (use 'CC' when the procedure code submitted was changed either foradministrative reasons or because an incorrect code was filed). (Suppliers should not submitmodifier CC.)ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA DUETO ANTI-CANCER CHEMOTHERAPY (Effective date 1/1/2008)ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA DUETO ANTI-CANCER RADIOTHERAPY (Effective date 1/1/2008)ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA NOTDUE TO ANTI-CANCER RADIOTHERAPY OR ANTI-CANCER CHEMOTHERAPY (Effectivedate 1/1/2008)HEMATOCRIT LEVEL HAS EXCEEDED 39% (OR HEMOGLOBIN LEVEL HAS EXCEEDED13.0 G/DL) FOR 3 OR MORE CONSECUTIVE BILLING CYCLES IMMEDIATELY PRIOR TOAND INCLUDING THE CURRENT CYCLE (Effective date 1/1/2008)HEMATOCRIT LEVEL HAS NOT EXCEEDED 39% (OR HEMOGLOBIN LEVEL HAS NOTEXCEEDED 13.0 G/DL) FOR 3 OR MORE CONSECUTIVE BILLING CYCLES IMMEDIATELYPRIOR TO AND INCLUDING THE CURRENT CYCLE (Effective date 1/1/2008)Subsequent claims for a defined course of therapy, E.G., EPO, Sodium Hyaluronate, Inflaximab.Emergency reserve supply (for ESRD benefit only).No physician or other licensed health care provider order for this item or service. (Effective date1/1/2003)ITEM PROVIDED WITHOUT COST TO PROVIDER, SUPPLIER OR PRACTITIONER, OR FULLCREDIT RECEIVED FOR REPLACED DEVICE (EXAMPLES, BUT NOT LIMITED TO,COVERED UNDER WARRANTY, REPLACED DUE TO DEFECT, FREE SAMPLES) (Updated1/1/2008)FC PARTIAL CREDIT RECEIVED FOR REPLACED DEVICE (Effective date 1/1/2008)GAGDGKGLWaiver of Liability statement on file.UNITS OF SERVICE EXCEEDS MEDICALLY UNLIKELY EDIT VALUE AND REPRESENTSREASONABLE AND NECESSARY SERVICES (Effective date 1/1/2008)REASONABLE AND NECESSARY ITEM/SERVICE ASSOCIATED WITH A GA OR GZMODIFIER (Updated 1/1/2008)MEDICALLY UNNECESSARY UPGRADE PROVIDED INSTEAD OF NON-UPGRADED ITEM,DME MAC Jurisdiction C Supplier Manual Page 3

Coding Chapter 16NO CHARGE, NO ADVANCE BENEFICIARY NOTICE (ABN) (Updated 1/1/2008)GW Service not related to the hospice patient's terminal condition. (used for Medicare AdvantagePlans claims)GX Service not covered by Medicare. (Deleted effective 12/31/2001)GYITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANYMEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CONTRACT BENEFIT(Updated 1/1/2008)GZ Item or service expected to be denied as not reasonable or necessary. (Effective 1/1/2002)K0K1K2K3K4KBLower extremity prosthesis functional level 0 - Does not have the ability or potential to ambulateor transfer safely with or without assistance and a prosthesis does not enhance their quality of lifeor mobility.Lower extremity prosthesis functional level 1 - Has the ability or potential to use a prosthesis fortransfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimitedhousehold ambulator.Lower extremity prosthesis functional level 2 - Has the ability or potential for ambulation with theability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces.Typical of the limited community ambulator.Lower extremity prosthesis functional level 3 - Has the ability or potential for ambulation withvariable cadence. Typical of the community ambulator who has the ability to transverse mostenvironmental barriers and may have vocational, therapeutic or exercise activity that demandsprosthetic utilization beyond simple locomotion.Lower prosthesis functional level 4 - Has the ability or potential for prosthetic ambulation thatexceeds the basic ambulation skills, exhibiting high impact, stress, or energy levels, typical of theprosthetic demands of the child, active adult, or athlete.Beneficiary requested upgrade for ABN, more than 4 modifiers identified on claim. (Effective date1/1/2003)KC Replacement of special power wheelchair interface. (Effective date 01/01/05)KD Drug or biological infused though DME. (Effective date 01/01/04)KF Item designated by FDA as Class III Devices. (Effective date 04/01/04)KG DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 1(Effective date 07/01/2007)KHKIKJDMEPOS item, initial claim, purchase or first month rentalDMEPOS item, second or third month rentalDMEPOS item, parenteral enteral nutrition (PEN) pump or capped rental, months four to fifteenKK DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 2(Effective date 07/01/2007)KL DMEPOS ITEM DELIVERED VIA MAIL (Effective date 07/01/2007)KMReplacement of facial prosthesis including new impression/moulageDME MAC Jurisdiction C Supplier Manual Page 4

Coding Chapter 16KNKOKPKQKRKSKTReplacement of facial prosthesis using previous master modelSingle drug unit dose formulationFirst drug of a multiple drug unit dose formulationSecond or subsequent drug of a multiple drug unit dose formulationRental item, billing for partial month.Glucose monitor supply for diabetic beneficiary not treated with insulinBENEFICIARY RESIDES IN A COMPETITIVE BIDDING AREA AND TRAVELS TO A NON-COMPETITIVE BIDDING AREA AND RECEIVES ITEM FROM A NON-CONTRACT SUPPLIER(Effective date 07/01/2007)KU DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 3(Effective date 07/01/2007)KVDMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM THAT ISFURNISHED AS PART OF A PROFESSIONAL SERVICE (Effective date 1/1/2008)KW DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 4(Effective date 1/1/2008)KX Specific required documentation on file. (Effective date 7/1/2002)KY DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 5(Effective date 1/1/2008)LTMSNUQ0Q1Left side. (Used to identify item provided for the left side of the body.)Six month maintenance and servicing fee for reasonable and necessary parts and labor whichare not covered under any manufacturer or supplier warrantyNew durable medical equipment purchase.INVESTIGATIONAL CLINICAL SERVICE PROVIDED IN A CLINICAL RESEARCH STUDYTHAT IS IN AN APPROVED CLINICAL RESEARCH STUDY (Effective date 1/1/2008)ROUTINE CLINICAL SERVICE PROVIDED IN A CLINICAL RESEARCH STUDY THAT IS IN ANAPPROVED CLINICAL RESEARCH STUDY (Effective date 1/1/2008)QA FDA investigational device exemption (Ends 12/31/2007)QEQFQGQHQJQQPrescribed amount of oxygen is less than 1 liter per minute (LPM).Prescribed amount of oxygen exceeds 4 LPM and portable oxygen is prescribed.Prescribed amount of oxygen is greater than 4 liters per minute (LPM).Oxygen conserving device is being used with an oxygen delivery system.Service/items provided to a prisoner or patient in state or local custody, however the state orlocal government, as applicable, meets the requirement in 42 CFR 411.1(B). (Effective date1/1/2003)Claim submitted with a written statement of intentDME MAC Jurisdiction C Supplier Manual Page 5

Coding Chapter 16QR Item/service in Medicare study – oxygen (Ends 12/31/2007)QV Item or service provided as routine care in a Medicare qualifying clinical trail (Ends 12/31/2007)RPRRRTUEReplacement and repair. RP may be used to indicate replacement of DME, orthotic andprosthetic devices, which have been in use for sometime. The claim shows the code for the part,followed by the 'RP' modifier and the charge for the part.Rental. (Use this 'R' modifier when DME is to be rented).Right Side (Used to identify procedures performed on the right side of the body).Used durable medical equipment purchase.DME MAC Jurisdiction C Supplier Manual Page 6

Chapter Seventeen √Symptoms Outputs

System Outputs Chapter 17Claim Development ProceduresWhen a Medicare claim requires additional information, the contractor will send a development letterrequesting information on an incomplete or inaccurate claim. These are not denial letters. The claimsthey refer to are pending in the computer system, waiting for a response.A supplier may receive several letters asking the same questions if several claims submitted werelacking the same information. Each letter with the response must be returned so it can be matchedto the corresponding claim. The requested information may be written directly on the developmentletter or documentation may be attached to the letter. Be sure to respond to each question asked.Responses to development letters should be returned immediately to avoid processing delays. If theresponse is delayed and the claim is subsequently denied, the claim will either need to be refiled oran appeal requested, depending on the denial code.Medicare Summary Notice (MSN)A Medicare Summary Notice (MSN) is sent to Medicare beneficiaries for each claim that isprocessed. The MSN explains which claim is involved, the type of services, the supplier, and otheridentifying information. Statements explain the basis for the payment and/or denial. It also includesinformation that can affect future reimbursement, such as explaining that a Certificate of MedicalNecessity (CMN) has expired. Remind your clients to review each MSN carefully and report anysuspected errors as soon as possible. This information is provided to the supplier on the MedicareRemittance Notice for assigned claims only.Medicare Remittance Notice (MRN)Suppliers are notified of the claim determinations on all assigned claims. The notification is providedby issuance of a Medicare Remittance Notice (MRN) which includes information on one or moreclaims. The notices are mailed daily; therefore, you should receive notification shortly after yourclaims are processed.All original MRNs should be kept in your records as they provide valuable facts regarding yourclaims. There may be occasions in the future when you will need to refer to an earlier MRN.The claims will be listed in alphabetical order by the patient's last name. On the same line as thepatient's name, you will find the HICN and internal control number (ICN), also referred to as a claimcontrol number. The ICN number will be different for every claim. These numbers are importantwhen calling or writing regarding a claim.Special attention should be made to the claim remarks and ANSI codes (AC). The claim remarks arelisted at the end of the first line in the MOA field and an explanation of each code at the bottom ofDME MAC Jurisdiction C Supplier Manual Page 1

System Outputs Chapter 17the remit. The ANSI codes are listed at the end of each line item prefaced by group code (CO, PR orOA). Explanations for the ANSI code and the Group code will be listed at the bottom of the MRN.The codes will explain the basis for payment, reason(s) for denial, and other pertinent claiminformation.When you look at an MRN, do not just look at the “PAY PROV” column. The other information givenis very important in helping you understand the way a claim was processed. As an example, the“PAY PROV” column may show “00.” This does not mean the claim was denied. There may havebeen approved charges that applied to the patient's deductible, resulting in no payment.The supplier of service will also receive an MRN on nonassigned claims. The patient will be issued aMedicare Summary Notice (MSN) on both assigned and nonassigned claims. The MSN will explainthe claim decision to the patient. Even though the supplier may have received an MRN, the patientmay not have received their MSN.Sample Medicare Remittance NoticeBiller Purged Claim Report - Error Message ExplanationsThe Biller Purged Claim Report represents electronic claims that have been deleted from our systembecause they cannot be processed due to some error on the claim.In most cases, the reason for the deletion is indicated on the printout of the claim data. Errormessages are found on the bottom left-hand corner of the claim data printout. If you receive a reportwith no message at the bottom or if the message is not listed in the error message descriptions,verify that all information on the claim was correct including the beneficiary’s name and HICN(Medicare number). The beneficiary’s name and HICN should match the information on theirMedicare card.Claims on a Biller Purged Claim Report have been deleted. All tracking records are lost when claimsare purged, which means it will appear as if the claims were never submitted. It is imperative thatyou update or correct the claim appropriately. The claim may then be resubmitted electronically.If there is a problem with your software that may be causing these errors, you may want to contactyour software vendor or programmer for assistance.DME MAC Jurisdiction C Supplier Manual Page 2

System Outputs Chapter 17Biller Purged Claim Report - Error Message ExplanationsFollowing is a list of the reasons a claim may be purged and the appropriate steps to take. Your firststep should always be to check your source documents to be sure the beneficiary's account was setup correctly.MessageExplanation and Action0001 HICN SUFFIX, SEX The suffix used for the Medicare number does notmatch the sex indicated for this beneficiary, or anincorrect Medicare number was submitted. Verify andresubmit the claim.0005 INVALID HICN The transmitted Medicare number was invalid (e.g., toomany numbers, not enough numbers, no suffix, invalidsuffix, etc.). Correct Medicare number as shown on thebeneficiary’s red, white, and blue Medicare card andresubmit the claim.0007 BENE REC CLOSED The master record for this Medicare number was closedbecause a previous claim was submitted withinappropriate patient information for the Medicarenumber. Verify that the patient’s name and Medicarenumber is the same as it appears on their Medicarecard (it is helpful to obtain a copy). If different, resubmitthe claim with the correct information. If the informationseems to be correct, the patient may need to contacthis/her Social Security office. If you are still unable todetermine the reason the claim has been purged,contact the Jurisdiction C DMERC office. Suppliers mayalso get this error if the beneficiary’s Medicare benefitshave expired.0047 NAME-KEY MISMATCH (REJECT 52) The beneficiary’s name does not match the name on filefor this Medicare number. Verify name and Medicarenumber as shown on the patient’s Medicare card (it ishelpful to obtain a copy to show exact spelling) andresubmit the claim. Do not use nicknames,abbreviations or middle names unless printed on thebeneficiary’s Medicare card.0049 SEX-KEY MISMATCH The sex indicated on the claim does not match the sexon file for this Medicare number. Resubmit the claimwith the correct information. If the information is alreadycorrect, contact the Jurisdiction C DMERC office.0058 RESPONSE REVIEW An incorrect Medicare number for the beneficiary wassubmitted. Verify the Medicare number or name(including spelling) as it appears on the patient’sMedicare card (it is helpful to obtain a copy). Also,check to make sure the Medicare number is notassigned to the beneficiary’s spouse. Resubmit theclaim with the correct information.DME MAC Jurisdiction C Supplier Manual Page 3

System Outputs Chapter 171003 INV PROC CODE The procedure code entered is invalid or the field isblank. Verify the procedure code and resubmit theclaim.1014 INVALID FROM An invalid date of service was submitted. Verify thedates and resubmit the claim.1015 INVALID TO An invalid date of service was submitted. Verify thedates and resubmit the claim.1019 INVALID NO SERV The number of services is equal to zero, is blank, or isinvalid. Verify the number of services and resubmit theclaim.Remember . . . DO NOT return Biller Purged Claim Reports. Changes must be submitted as a newclaim.ANSI CodesANSI (American National Standard Institute) codes are used to explain the adjudication of a claim.The complete listing of Claim Adjustment Reason Codes and Remittance Advice Remark Codes canbe found at http://www.wpc-edi.com.Group Codes must be entered with all reason code(s) to establish financial liability for theamount of the adjustment or to identify a post-initial-adjudication adjustment. Group codesare not used with Medicare REF or MIA/MOA remarks code entries.PRPatient responsibility. This signifies the amount that may be billed to the beneficiary or to anotherpayer on the beneficiary’s behalf. For example, PR would be used with the reason code for:• Patient’s deductible or coinsurance,• The patient assumed financial responsibility for a service not considered reasonable andnecessary,• Cost of therapy or psychiatric services after the coverage limit had been reached,• A charge denied as a result of the patient’s failure to supply primary payer or other information,• Where a patient is responsible for payment of excess non-assigned physician charges.Charges that have not been paid by Medicare and/or are not included in a PR groupare:• Late filing penalty (reason code B4),• Excess charges on an assigned claim (reason code 42),• Excess charges attributable to rebundled services (reason code B15),• Charges denied as a result of the failure to submit necessary information by a provider whoaccepts assignment,• Services that are not reasonable and necessary for care (reason code 50 or 57) for which thereDME MAC Jurisdiction C Supplier Manual Page 4

System Outputs Chapter 17are no indemnification agreements are the liability of the provider.Providers may be subject to penalties if they bill a patient for charges not identifiedwith the PR group code.CO Contractual obligations. This includes any amounts for which the provider is financially liable,such as:• Participation agreement violations,• Assignment amount violations,• Excess charges by a managed care plan provider,• Late filing penalties,• Gramm-Rudman reductions,• Medical necessity denials/reductions.The patient may not be billed for these amounts.OA Other adjustment. This would only be used if neither PR nor CO applied. At least one PR, CO orOA group must appear on each remittance advice. For example, OA would be used when a claimis paid in full at initial adjudication with reason code 93 and a zero amount Neither the patient northe provider can be held responsible for any amount classified as an OA adjustmentCR Correction to or reversal of a prior decision. This group applies whenever there is a change to apreviously adjudicated claim. CR explains the reason for the correction; PR, CO and/or OA mustalways be used in tandem with CR to show the revised information. Separate reason code entriesmust be used in the NSF for the CR group entry and any other groups that apply to thereadjudicated claim.At least one reason code is always used with a group code in the NSF. We always enter thereason code(s) and that amount from the initial remittance advice for the service being correctedwith the CR, and include any additional reason code that may apply to the subsequentadjustment. If the change does not involve a prior denial/reduction reason code reason code 93 isused.DME MAC Jurisdiction C Supplier Manual Page 5

Chapter Eighteen √Acronyms and Abbreviations

Acronyms and Abbreviations Chapter 18Acronyms and AbbreviationsABN Advance Beneficiary Notice HO Hearing OfficerALJ Administrative Law Judge IOL Intraocular lensAMA American Medical Association IPPB Intermittent Positive PressureBreathingANSIAmerican National StandardIdentificationIVIntravenousASCAAdministrative SimplificationCompliance ActIVRInteractive Voice ResponseAWP Average Wholesale Pricing LCD Local Coverage DeterminationBBA Balanced Budget Act LCL Lowest Charge LevelCCN Claim Control Number LGHP Large Group Health PlanCFR Code of Federal Regulations LSO Lumbar Sacral OrthosisCGLICConnecticut General Life InsuranceCompanyMEDPARDMedicare Participating SuppliersDirectoryCMN Certificate of Medical Necessity MMA Medicare Modernization Act (of 1999)COB Coordination of Benefits MRN Medicare Remittance NoticeCPAPContinuous Positive AirwayPressureMSMaintenance and ServicingCPI Consumer Price Index MSN Medicare Summary NoticeCSI Claim Status Inquiry MSP Medicare Secondary PayerCWF Common Working File NCD National Coverage DeterminationDCN Document Control Number NDC National Drug CodeDHHSDepartment of Health and HumanServicesNSCNational Supplier ClearinghouseDIF DMERC Information Form NSF National Standard FormatDME Durable Medical Equipment OBRA Omnibus Budget Reconciliation ActDMEMACDurable Medical EquipmentMedicare Administrative ContractorOCNAOther Carrier Name/AddressDMEPOSDurable Medical Equipment,Prosthetics, Orthotics, and SuppliesOIGOffice of the Inspector GeneralDMERCDurable Medical EquipmentRegional Carrier (as of June 2007,there are no DMERCs)OMBOffice of Management and BudgetDO Doctor of Osteopathy OMHA Office of Medicare Hearings andAppealsDME MAC Jurisdiction C Supplier Manual Page 1

Acronyms and Abbreviations Chapter 18DPM Doctor of Podiatric Medicine PA Policy ArticleEDI Electronic Data Interchange PAR Participating SupplierEFT Electronic Funds Transfer PCA Progressive Corrective Actione.g. For example PIM Program Integrity ManualEGHP Employer Group Health Plan PM Program MemorandumEIN Employer Identification Number POE Provider Outreach and EducationEMC Electronic Media Claims PSC Program Safeguard ContractorEOB Explanation of Benefits QIC Qualified Independent ContractorEOMB Explanation of Medicare Benefits RRB Railroad Retirement BoardERL Electronic Receipt Listing SACU Supplier Audit and Compliance UnitERN Electronic Remittance Notice SADMERC Statistical Analysis DMERCESRD End Stage Renal Disease SLM Seat Lift MechanismFCN Financial Control Number SNF Skilled Nursing FacilityFDA Food and Drug Administration SSA Social Security AdministrationFed Reg Federal Register TENS Transcutaneous Electrical NerveStimulatorFFS Fee-for-Service TLSO Thoracic-Lumbar-Sacral OrthosisFOIA Freedom of Information Act UMWA United Mine Workers AssociationGHP Group Health Plan UPIN Unique Physicians IdentificationNumberHCPCSHealthcare Common ProcedureCoding SystemUSCUnited States CodeHICN Health Insurance Claim Number VA Veteran’s AdministrationHIPAAHealth Insurance Portability andAccountability ActWCWorkers’ CompensationHMOHealth Maintenance OrganizationDME MAC Jurisdiction C Supplier Manual Page 2

Appendix A √HCPCS

HCPCSAppendix ALevel II HCPCS CodesFollowing is a list of Level II HCPCS codes which includes the code descriptions, payment category,and DMERC Certificate of Medical Necessity (CMN) or DMERC Information Form (DIF) numberrequired where applicable.(Note: Although, a CMN may not be required for certain supplies, a CMN for the related equipmentmay be required. Please refer to the Documentation Requirements in the Regional Medical ReviewPolicies for more information regarding CMN requirements.)Below is a chart with the description for the category numbers listed with the HCPCS codes.HCPCS APayment Category1 Capped Rental 8 Parenteral/Enteral Supplies and Kits 15 Nebulizer Drugs2 Freq. & Substantial Serv. DME 9 Parenteral/Enteral Pumps 16 Therapeutic Shoes for Diabetics3 Customized DMEPOS 10 Immunosuppressive Drugs 17 Individual Consideration4 Prosthetics/Orthotics 11 Ostomy, Trach., & Urologicals 18 Epoetin (EPO)5 Inexp. & Routinely Purch. DME 12 Surgical Dressings 19 Dialysis Supplies & Equipment6 Oxygen and Oxygen Equipment 13 Supplies 20 Oral Antiemetic Drugs7 Parenteral/Enteral Nutrients 14 Not Otherwise ClassifiedCode Description Category CMN/DIFRequiredA4190 Transparent film, each (Deleted eff. 12/31/1996) 12A4200 Gauze pads, medicated or non-medicated, each (Deleted eff.12/31/1996)12A4202 Gauze, elastic, all types, per roll (Deleted eff. 12/31/1996) 12A4203 Gauze, non-elastic, per roll (Deleted eff. 12/31/1996) 12A4204 Absorptive dressing (e.g. hydrocolloid), adhesive or non-adhesive,each (Deleted eff. 12/31/1996)A4205 Non-absorptive dressing (e.g. hydrogel), adhesive or non-adhesive,each (Deleted eff. 12/31/1996)1212A4206 SYRINGE WITH NEEDLE, STERILE, 1 CC OR LESS, EACH(Deleted eff. 3/31/1999) (Updated Description 1/1/2008)A4207 Syringe with needle, sterile 2cc, each (Deleted eff. 3/31/1999)DME MAC Jurisdiction C Supplier Manual Page 1

HCPCSAppendix AA4208 Syringe with needle, sterile 3cc, each (Deleted eff. 3/31/1999)A4209 Syringe with needle, sterile 5cc or greater, each (Deleted eff.3/31/1999)A4210 Needle-free injection device, eachA4211 Supplies for self-administered injectionsA4212 Non-coring needle or stylet with or without catheterA4213 Syringe, sterile, 20 cc or greater, each (not valid for Medicare)A4214 Sterile saline or water, 30 cc vial (Deleted eff. 12/31/2003) 11A4215 Needle, Sterile, any size, eachA4216 Sterile water, saline and/or dextrose, diluent/flush, 10 ml (Eff. date1/1/2004)13A4217 Sterile water/saline 500 ml (Eff. Date 1/1/2004) 13A4218 Sterile saline or water, meter dose dispenser, 10 ml (Eff. Date1/1/2006)15A4220 Refill kit for implantable infusion pumpA4221 Supplies for maintenance of drug infusion catheter, per week (listdrug separately)A4222 Infusion supplies for external drug infusion pump, per cassette orbag (list drugs separately)1313A4223 Infusion supplies not used with external infusion pump, per cassetteor bag (list drugs separately) (Eff. Date 1/1/2005)A4230 Infusion set for external insulin pump, non needle cannula type (notvalid for Medicare as of 1/1/2000)A4231 Infusion set for external insulin pump, needle type (not valid forMedicare as of 1/1/2000)A4232 Syringe with needle for external insulin pump, sterile, 3cc (Deletedeff. 3/31/2003)A4233 Replacement battery, alkaline (other than J cell), for use withmedicallynecessary home blood glucose monitor owned by patient, each(Eff. Date 1/1/2006)A4234 Replacement battery, alkaline, J cell, for use with medicallynecessaryhome blood glucose monitor owned by patient, each (Eff. Date1/1/2006)A4235 Replacement battery, lithium, for use with medically necessary homeblood glucose monitor owned by patient, each (Eff. Date 1/1/2006)131313050505DME MAC Jurisdiction C Supplier Manual Page 2

HCPCSAppendix AA4236 Replacement battery, silver oxide, for use with medically necessaryhome blood glucose monitor owned by patient, each (Eff. Date1/1/2006)05A4244 Alcohol or peroxide, per pint 13A4245 Alcohol wipes, per boxA4246 Betadine or phisohex solution, per pintA4247 Betadine or iodine swabs/wipes, per boxA4248 Chlorhexidine containing antiseptic, 1 ml (Eff. Date 1/1/2004) 19A4250 Urine test or reagent strips or tablets (100 tablets or strips)A4252 BLOOD KETONE TEST OR REAGENT STRIP, EACH (Eff. Dt1/1/2008)A4253 Blood glucose test or reagent strips for home blood glucose monitor,per 50 stripsA4254 Replacement battery, any type, for use with medically necessaryhome blood glucose monitor owned by patient, each (Deleted eff.12/31/2005)0505A4255 Platforms for home blood glucose monitor, 50 per box 13A4256 Normal, low and high calibrator solution/chips 13A4257 Replacement lens shield cartridge for use with laser skin piercingdevice, each (Eff. Date 1/1/2002)13A4258 Spring-powered device for lancet, each 13A4259 Lancets, per box of 100 05A4260 Levonorgestrel (contraceptive) implants system, including implantsand suppliesA4261 Cervical cap for contraceptive useA4262 Temporary, absorbable lacrimal duct implant, eachA4263 Permanent, long term, non-dissolvable lacrimal duct implant, eachA4265 Paraffin, per pound 13A4270 Disposable endoscope sheath, eachA4280 Adhesive skin support attachment for use with external breastprosthesis, each implantable access catheter (venous, arterial,epidural or peritoneal), external access, (Eff. Date 1/1/2000)04A4301 Implantable access total system; catheter, port/reservoir (venous,arterial or epidural), percutaneous accessA4305 Disposable drug delivery system, flow rate of 50 ml or greater perhourDME MAC Jurisdiction C Supplier Manual Page 3

HCPCSAppendix AA4306 Disposable drug delivery system, flow rate less than 50 ml per hourA4310 Insertion tray without drainage bag and without catheter (accessoriesonly)A4311 Insertion tray without drainage bag with indwelling catheter, foleytype, two-way latex with coating (teflon, silicone, silicone elastomeror hydrophilic, etc.)A4312 Insertion tray without drainage bag with indwelling catheter, foleytype, two-way, all siliconeA4313 Insertion tray without drainage bag with indwelling catheter, foleytype, three-way, for continuous irrigationA4314 Insertion tray with drainage bag with indwelling catheter, foley type,two-way latex with coating (teflon, silicone, silicone elastomer orhydrophilic, etc.)A4315 Insertion tray with drainage bag with indwelling catheter, foley type,two-way, all siliconeA4316 Insertion tray with drainage bag with indwelling catheter, foley type,three-way, for continuous irrigation11111111111111A4319 Sterile water irrigation solution, 1000 ml (Deleted eff. 12/31/2003)A4320 Irrigation tray with bulb or piston syringe, any purpose 11A4321 Therapeutic agent for urinary catheter irrigation 11A4322 Irrigation syringe, bulb or piston, each 11A4323 Sterile saline irrigation solution, 1000 ml. (Deleted eff. 12/31/2003) 11A4324 Male external catheter, with adhesive coating, each (Eff. Date1/1/2001) (Deleted eff. 12/31/2004)A4325 Male external catheter, with adhesive strip, each (Eff. Date 1/1/2001)(Deleted eff. 12/31/2004)A4326 Male external catheter with integral collection chamber, any type,each111111A4327 Female external urinary collection device; metal cup, each 11A4328 Female external urinary collection device; pouch, each 11A4329 External catheter starter set, male/female, includes catheters/urinarycollection device, bag/pouch and accessories (tubing, clamps, etc.),7 day supply (Deleted eff. 12/31/2001)11A4330 Perianal fecal collection pouch with adhesive, each 11A4331 Extension drainage tubing, any type, any length, withconnector/adaptor, for use with urinary leg bag or urostomy pouch,each (Eff. Date 1/1/2001)11DME MAC Jurisdiction C Supplier Manual Page 4

HCPCSAppendix AA4332 Lubricant, individual sterile packet, each (Eff. Date 1/1/2001) 11A4333 Urinary catheter anchoring device, adhesive skin attachment, each(Eff. Date 1/1/2001)A4334 Urinary catheter anchoring device, leg strap, each (Eff. Date1/1/2001)1111A4335 Incontinence supply; miscellaneous 14A4338 Indwelling catheter; foley type, two-way latex with coating (teflon,silicone, silicone elastomer, or hydrophilic, etc.), eachA4340 Indwelling catheter; specialty type, eg; coude, mushroom, wing,etc.), each1111A4344 Indwelling catheter, foley type, two-way, all silicone, each 11A4346 Indwelling catheter; foley type, three way for continuous irrigation,eachA4347 Male external catheter with or without adhesive, with or without antirefluxdevice; per dozen (Deleted eff. 9/30/1994) (Deleted eff.12/31/2004)A4348 Male external catheter with integral collection compartment,extended wear, each (e.g., 2 per month) (Eff. Date 1/1/2001)(deleted 12/31/06)A4349 Male external catheter, with or without adhesive, disposable, each(Eff. Date 1/1/2005)A4351 Intermittent urinary catheter; straight tip, with or without coating(teflon, silicone, silicone elastomer, or hydrophilic, etc.), eachA4352 Intermittent urinary catheter; coude (curved) tip, with or withoutcoating (teflon, silicone, silicone elastomeric, or hydrophilic, etc.),each111111111111A4353 Intermittent urinary catheter, with insertion supplies 11A4354 Insertion tray with drainage bag but without catheter 11A4355 Irrigation tubing set for continuous bladder irrigation through a threewayindwelling foley catheter, eachA4356 External urethral clamp or compression device (not to be used forcatheter clamp), each (Deleted eff. 12/31/2005)A4357 Bedside drainage bag, day or night, with or without anti-refluxdevice, with or without tube, eachA4358 Urinary drainage bag, leg or abdomen, vinyl, with or without tube,with straps, each11111111A4359 Urinary suspensory without leg bag, each (deleted 12/31/06) 11A4360 Adult incontinence garment (e.g. brief, diaper), each (Deleted eff.DME MAC Jurisdiction C Supplier Manual Page 5

HCPCSAppendix A12/31/2002)A4361 Ostomy faceplate, each 11A4362 Skin barrier; solid, 4 x 4 or equivalent; each 11A4363 Ostomy clamp, any type, replacement only, each (Eff. Date1/1/2006)11A4364 Adhesive liquid or equal, any type, per oz. 11A4365 Adhesive remover wipes, any types, per 50 11A4366 Ostomy vent, any type, each (Eff. Date 1/1/2004) 11A4367 Ostomy belt, each 11A4368 Ostomy filter, any type, each 11A4369 Ostomy skin barrier, liquid (spray, brush, etc), per oz (Eff. Date1/1/2000)11A4370 Ostomy skin barrier, paste, per oz (Deleted eff. 3/31/2002) 11A4371 Ostomy skin barrier, powder, per oz (Eff. Date 1/1/2000) 11A4372 Ostomy skin barrier, solid 4X4 or equivalent, standard wear, withbuilt-in convexity, each (Eff. Date 1/1/2000)A4373 Ostomy skin barrier, with flange (solid, flexible or accordion), withbuilt-in convexity, any size, each (Eff. Date 1/1/2000)A4374 Ostomy skin barrier, with flange (solid, flexible or accordion),extended wear, with built-in convexity, any size, each (Deleted eff.04/01/2002)A4375 Ostomy pouch, drainable, with faceplate attached, plastic, each (Eff.Date 1/1/2000)A4376 Ostomy pouch, drainable, with faceplate attached, rubber, each (Eff.Date 1/1/2000)A4377 Ostomy pouch, drainable, for use on faceplate, plastic, each (Eff.Date 1/1/2000)A4378 Ostomy pouch, drainable, for use on faceplate, rubber, each (Eff.Date 1/1/2000)A4379 Ostomy pouch, urinary, with faceplate attached, plastic, each (Eff.Date 1/1/2000)A4380 Ostomy pouch, urinary, with faceplate attached, rubber, each (Eff.Date 1/1/2000)A4381 Ostomy pouch, urinary, for use on faceplate, plastic, each (Eff. Date1/1/2000)11111111111111111111A4382 Ostomy pouch, urinary, for use on faceplate, heavy plastic, each 11DME MAC Jurisdiction C Supplier Manual Page 6

HCPCSAppendix A(Eff. Date 1/1/2000)A4383 Ostomy pouch, urinary, for use on faceplate, rubber, each (Eff. Date1/1/2000)11A4384 Ostomy faceplate equivalent, silicone ring, each (Eff. Date 1/1/2000) 11A4385 Ostomy skin barrier, solid 4x4 or equivalent, extended wear, withoutbuilt-in convexity, each (Eff. Date 1/1/2000)A4386 Ostomy skin barrier, with flange (solid, flexible or accordion),extended wear, without built-in convexity, any size, each (Eff. Date1/1/2000)A4387 Ostomy pouch closed, with barrier attached, with built-in convexity (1piece), each (Eff. Date 1/1/2000)A4388 Ostomy pouch, drainable, with extended wear barrier attached, (1piece) (Eff. Date 1/1/2000)A4389 Ostomy pouch, drainable, with barrier attached, with built-inconvexity (1 piece), each (Eff. Date 1/1/2000)A4390 Ostomy pouch, drainable, with extended wear barrier attached, withbuilt-in convexity (1 piece), each (Eff. Date 1/1/2000)A4391 Ostomy pouch, urinary, with extended wear barrier attached, (1piece), each (Eff. Date 1/1/2000)A4392 Ostomy pouch, urinary, with standard wear barrier attached, withbuilt-in convexity (1 piece), each (Eff. Date 1/1/2000)A4393 Ostomy pouch, urinary, with extended wear barrier attached, withbuilt-in convexity (1 piece), each (Eff. Date 1/1/2000)A4394 Ostomy deodorant, with or without lubricant, for use in ostomypouch, per fluid ounceA4395 Ostomy deodorant for use in ostomy pouch, solid, per tablet (Eff.Date 1/1/2000)1111111111111111111111A4396 Ostomy belt with peristomal hernia support (Eff. Date 1/1/2001) 11A4397 Irrigation supply; sleeve, each 11A4398 Ostomy irrigation supply; bag, each 11A4399 Ostomy irrigation supply; cone/catheter, including brush 11A4400 Ostomy irrigation set (not valid for Medicare as of 9/30/1993) 11A4402 Lubricant, per ounce 11A4404 Ostomy ring, each 11A4405 Ostomy skin barrier, non-pectin based, paste, per ounce (Eff. Date1/1/2003)04DME MAC Jurisdiction C Supplier Manual Page 7

HCPCSAppendix AA4406 Ostomy skin barrier, pectin based, paste, per ounce (Eff. Date1/1/2003)A4407 Ostomy skin barrier, with flange (solid, flexible, or accordion),extended wear, with built-in convexity, 4 x 4 inches or smaller, each(Eff. Date 1/1/2003)A4408 Ostomy skin barrier, with flange (solid, flexible, or accordion),extended wear, with built-in convexity, larger than 4 x 4 inches, each(Eff. Date 1/1/2003)A4409 Ostomy skin barrier, with flange (solid, flexible, or accordion),extended wear, without built-in convexity, 4 x 4 inches or smaller,each (Eff. Date 1/1/2003)A4410 Ostomy skin barrier, with flange (solid, flexible, or accordion),extended wear, without built-in convexity, larger than 4 x 4 inches,each (Eff. Date 1/1/2003)A4411 Ostomy skin barrier, solid 4 X 4 or equivalent, extended wear, withbuilt-inconvexity, each (Eff. Date 1/1/2006)A4412 Ostomy pouch, drainable, high output, for use on a barrier withflange(2 piece system), without filter, each (Eff. Date 1/1/2006)A4413 Ostomy pouch, drainable, high output, for use on a barrier withflange (2 piece system), with filter, each (Eff. Date 1/1/2003)A4414 Ostomy skin barrier, with flange (solid, flexible, or accordion),without built-in convexity, 4 x 4 inches or smaller, each (Eff. Date1/1/2003)A4415 Ostomy skin barrier, with flange (solid, flexible, or accordion),without built-in convexity, larger than4 x 4 inches, each (Eff. Date1/1/2003)A4416 Ostomy pouch, closed, with barrier attached, with filter (1 piece),each (Eff. Date 1/1/2004)A4417 Ostomy pouch, closed, with barrier attached, with built-in convexity,with filter (1 piece), each (Eff. Date 1/1/2004)A4418 Ostomy pouch, closed; without barrier attached, with filter (1 piece),each (Eff. Date 1/1/2004)A4419 Ostomy pouch, closed; for use on barrier with non-locking flange,with filter (2 piece), each (Eff. Date 1/1/2004)A4420 Ostomy pouch, closed; for use on barrier with locking flange (2piece), each (Eff. Date 1/1/2004)111111111111111111111111111111A4421 Ostomy supply; miscellaneous 14A4422 Ostomy absorbent material (sheet/pad/crystal packet) for use inostomy pouch to thicken liquid stomal output, each (Eff. Date1/1/2003)11DME MAC Jurisdiction C Supplier Manual Page 8

HCPCSAppendix AA4423 Ostomy pouch, closed; for use on barrier with locking flange, withfilter (2 piece), each (Eff. Date 1/1/2004)A4424 Ostomy pouch, drainable, with barrier attached, with filter (1 piece),each (Eff. Date 1/1/2004)A4425 Ostomy pouch, drainable; for use on barrier with non-locking flange,with filter (2 piece system), each (Eff. Date 1/1/2004)A4426 Ostomy pouch, drainable; for use on barrier with locking flange (2piece system), each (Eff. Date 1/1/2004)A4427 Ostomy pouch, drainable; for use on barrier with locking flange, withfilter (2 piece system), each (Eff. Date 1/1/2004)A4428 Ostomy pouch, urinary, with extended wear barrier attached, withfaucet-type tap with valve (1 piece), each (Eff. Date 1/1/2004)A4429 Ostomy pouch, urinary, with barrier attached, with built-in convexity,with faucet-type tap with valve (1 piece), each (Eff. Date 1/1/2004)A4430 Ostomy pouch, urinary, with extended wear barrier attached, withbuilt-in convexity, with faucet-type tap with valve (1 piece), each (Eff.Date 1/1/2004)A4431 Ostomy pouch, urinary; with barrier attached, with faucet-type tapwith valve (1 piece), each (Eff. Date 1/1/2004)A4432 Ostomy pouch, urinary; for use on barrier with non locking flange,with faucet-type tap with valve (2 piece), each (Eff. Date 1/1/2004)A4433 Ostomy pouch, urinary; for use on barrier with locking flange (2piece), each (Eff. Date 1/1/2004)A4434 Ostomy pouch, urinary; for use on barrier with locking flange, withfaucet-type tap with valve (2 piece), each (Eff. Date 1/1/2004)111111111111111111111111A4450 Tape, non-waterproof, per 18 square inches (Eff. Date 1/1/2003) 11A4452 Tape, waterproof, per 18 square inches (Eff. Date 1/1/2003) 11A4454 Tape, all types, all sizes (Deleted eff. 3/31/1994) 11A4455 Adhesive remover or solvent (for tape, cement or other adhesive),per ounce11A4458 Enema bag with tubing, reusable (Eff. Date 1/1/2003) 11A4460 Elastic bandage, per roll (e.g. compression bandage) (Deletedeff.12/31/2002)12A4461 Surgical dressing holder, non-reusable, each (Eff date 01/01/2007) 12A4462 Abdominal dressing holder, each (deleted 12/31/2006) 12A4463 Surgical dressing holder, reusable, each (Eff date 01/01/2007) 12A4464 Joint supportive device/garment, elastic or equal, each (DeletedDME MAC Jurisdiction C Supplier Manual Page 9

HCPCSAppendix Aeff.12/31/2002)A4465 Non-elastic binder for extremityA4470 Gravlee jet washerA4480 Vabra aspiratorA4481 Tracheostoma filter, any type, any size, each 11A4483 Moisture exchanger, disposable, for use with invasive mechanicalventilation11A4490 Surgical stockings above knee length, eachA4495 Surgical stockings thigh length, eachA4500 Surgical stockings below knee length, eachA4510 Surgical stockings full length, eachA4520 Incontinence Garment, any type, (e.g, brief, diaper), each (Eff. Date1/1/2005)A4521 Adult-sized incontinence product, diaper, small size, each (Eff. Date1/1/2003) (Deleted eff. 12/31/2004)A4522 Adult-sized incontinence product, diaper, medium size, each (Eff.Date 1/1/2003) (Deleted eff. 12/31/2004)A4523 Adult-sized incontinence product, diaper, large size, each (Eff. Date1/1/2003) (Deleted eff. 12/31/2004)A4524 Adult-sized incontinence product, diaper, extra large size, each (Eff.Date 1/1/2003) (Deleted eff. 12/31/2004)A4525 Adult-sized incontinence product, brief, small size, each (Eff. Date1/1/2003) (Deleted eff. 12/31/2004)A4526 Adult-sized incontinence product, brief, medium size, each (Eff. Date1/1/2003) (Deleted eff. 12/31/2004)A4527 Adult-sized incontinence product, brief, large size, each (Eff. Date1/1/2003) (Deleted eff. 12/31/2004)A4528 Adult-sized incontinence product, brief, extra-large size, each (Eff.Date 1/1/2003) (Deleted eff. 12/31/2004)A4529 Child-sized incontinence product, diaper, small/medium size, each(Eff. Date 1/1/2003) (Deleted eff. 12/31/2004)A4530 Child-sized incontinence product, diaper, large size, each (Eff. Date1/1/2003) (Deleted eff. 12/31/2004)A4531 Child-sized incontinence product, brief, small/medium size, each(Eff. Date 1/1/2003) (Deleted eff. 12/31/2004)A4532 Child-sized incontinence product, brief, large size, each (Eff. DateDME MAC Jurisdiction C Supplier Manual Page 10

HCPCSAppendix A1/1/2003) (Deleted eff. 12/31/2004)A4533 Youth-sized incontinence product, diaper, each (Eff. Date 1/1/2003)(Deleted eff. 12/31/2004)A4534 Youth-sized incontinence product, brief, each (Eff. Date 1/1/2003)(Deleted eff. 12/31/2004)A4535 Disposable liner/shield for incontinence, each (Eff. Date 1/1/2003)(Deleted eff. 12/31/2004)A4536 Protective underwear, washable, any size, each (Eff. Date 1/1/2003)(Deleted eff. 12/31/2004)A4537 Under pad, reusable/washable, any size, each (Eff. Date 1/1/2003)(Deleted eff. 12/31/2004)A4538 Diaper, reusable, provided by a diaper service, each diaper (Eff.Date 1/1/2003) (Deleted eff. 12/31/2004)A4550 Surgical traysA4554 Disposable underpads, all sizesA4556 Electrodes, (e.g., apnea monitor), per pair (not valid for Medicare asof 11/1/1996)13A4557 Lead wires, (e.g., apnea monitor), per pair 13A4558 Conductive paste or gel (not valid for Medicare as of 11/1/1996) 13A4559 Coupling gel or paste, for use with ultrasound device, per oz (Effdate 01/01/2007)A4560 Pessary (Deleted eff. 12/31/2000) 04A4561 Pessary, rubber, any type (Deleted eff. 12/31/2001) 04A4562 Pessary, non rubber, any type (Deleted eff. 12/31/2001) 04A4565 Slings (Deleted eff. 3/1/1998) (Eff. Date 3/1/1998 changed to localcarrier jurisdiction)A4570 Splint (Deleted eff. 7/1/2001)A4572 Rib belt (Deleted eff.12/31/2002)A4575 Topical hyperbaric oxygen chamber, disposableA4580 Cast supplies (e.g. plaster)A4581 Supplies risser jacket (Deleted eff. 12/31/1996)A4590 Special casting material (e.g. fiberglass)A4595 Electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) 13A4600 Sleeve for intermittent limb compression device, replacement only,each05DME MAC Jurisdiction C Supplier Manual Page 11

HCPCSAppendix AA4601 Lithium ion battery for non-prosthetic use, replacement 05A4604 Tubing with integrated heating element for use with positive airwaypressure device (Eff. Date 1/1/2006)05A4605 Tracheal suction catheter, closed system, each (Eff. Date 1/1/2005) 05A4606 Oxygen probe for use with oximeter device, replacement (Eff. Date1/1/2003)17A4608 Transtracheal oxygen catheter, each (Eff. Date 1/1/2001) 05A4609 Tracheal suction catheter, closed system, for less than 72 hours ofuse, each (Eff. Date 1/1/2003) (Deleted eff. 12/31/2004)A4610 Tracheal suction catheter, closed system, for 72 or more hours ofuse, each (Eff. Date 1/1/2003) (Deleted eff. 12/31/2004)0505A4611 Battery, heavy duty; replacement for patient owned ventilator 05A4612 Battery cables; replacement for patient-owned ventilator 05A4613 Battery charger; replacement for patient-owned ventilator 05A4614 Peak expiratory flow rate meter, hand heldA4615 Cannula, nasal 06A4616 Tubing (oxygen), per foot 06A4617 Mouth piece 06A4618 Breathing circuits 05A4619 Face tent 06A4620 Variable concentration mask 06A4621 Tracheotomy mask or collar (Deleted eff. 12/31/2003) 06A4622 Tracheostomy or laryngectomy tube (Deleted eff. 12/31/2003) 11A4623 Tracheostomy, inner cannula 11A4624 Tracheal suction catheter, any type other than closed system, each 05A4625 Tracheostomy care kit for new tracheostomy 11A4626 Tracheostomy cleaning brush, each 11A4627 Spacer, bag or reservoir, with or without mask, for use with metereddose inhalerA4628 Oropharyngeal suction catheter, each 05A4629 Tracheostomy care kit for established tracheostomy 11A4630 Replacement, batteries, medically necessary, transcutaneouselectrical stimulator, owned by patient (not valid for Medicare as of05DME MAC Jurisdiction C Supplier Manual Page 12

HCPCSAppendix A11/1/1996)A4631 Replacement, batteries for medically necessary electronic wheelchair owned by patient (not valid for Medicare as of 1/1/1994)(Deleted eff. 12/31/2003)A4632 Replacement battery for external infusion pump, any type, each(Deleted eff. 3/31/2003)A4633 Replacement bulb/lamp for ultraviolet light therapy system, each (Eff.Date 1/1/2003)A4634 Replacement bulb for therapeutic light box, tabletop model (Eff. Date1/1/2003)05050505A4635 Underarm pad, crutch, replacement, each 05A4636 Replacement, handgrip, cane, crutch, or walker, each 05A4637 Replacement tip, cane, crutch, walker, each. 05A4638 Replacement battery for patient-owned ear pulse generator, each(Eff. Date 1/1/2004)A4639 Replacement pad for infrared heating pad system, each (Eff. Date1/1/2003)A4640 Replacement pad for use with medically necessary alternatingpressure pad owned by patient130505A4641 Supply of radiopharmaceutical diagnostic imaging agent, nototherwise classifiedA4642 Supply of satumomab pendetide, radiopharmaceutical diagnosticimaging agent, per doseA4643 Supply of additional high dose contrast material(s) during magneticresonance imaging, e.g., gadoteridol injectionA4644 Supply of low osmolar contrast material (100-199 mgs of iodine)A4645 Supply of low osmolar contrast material (200-299 mgs of iodine)A4646 Supply of low osmolar contrast material (300-399 mgs of iodine)A4647 Supply of paramagnetic contrast material, eg., gadoliniumA4649 Surgical supply; miscellaneous 14A4650 Centrifuge (includes calibrated microcapillary tubes and sealease)(Deleted eff. 12/31/2001)19A4651 Calibrated microcapillary tube, each (Eff. Date 1/1/2002) 19A4652 Microcapillary tube sealant (Eff. Date 1/1/2002) 19A4653 Peritoneal dialysis catheter anchoring device, belt, each (Eff. Date1/1/2003)19DME MAC Jurisdiction C Supplier Manual Page 13

HCPCSAppendix AA4655 Needles and syringes for dialysis (Deleted eff. 12/31/2001) 19A4656 Needle, any size, each (Eff. Date 1/1/2002) 19A4657 Syringe, with or without needle, each (Eff. Date 1/1/2002) 19A4660 Sphygmomanometer/blood pressure apparatus with cuff andstethoscope19A4663 Blood pressure cuff only 19A4670 Automatic blood pressure monitorA4671 Disposable cycler set used with cycler dialysis machine, each (Eff.Date 1/1/2004)A4672 Drainage extension line, sterile, for dialysis, each (Eff. Date1/1/2004)A4673 Extension line with easy lock connectors, used with dialysis (Eff.Date 1/1/2004)A4674 Chemicals/antiseptics solution used to clean/sterilize dialysisequipment, per 8 ounces (Eff. Date 1/1/2004)19191919A4680 Activated carbon filter for hemodialysis, each 19A4690 Dialyzer (artificial kidneys), all types, all sizes, for hemodialysis, each 19A4700 Standard dialysate solution, each (Deleted eff. 12/31/2001) 19A4705 Bicarbonate dialysate solution, each (Deleted eff. 12/31/2001) 19A4706 Bicarbonate concentrate, solution, for hemodialysis, per gallon (Eff.Date 1/1/2002)A4707 Bicarbonate concentrate, powder, for hemodialysis, per packet (Eff.Date 1/1/2002)A4708 Acetate concentrate solution, for hemodialysis, per gallon (Eff. Date1/1/2002)A4709 Acid concentrate, solution, for hemodialysis, per gallon (Eff. Date1/1/2002)19191919A4712 Water, sterile, for injection, per 10 ml (Deleted eff. 12/31/2003) 19A4714 Treated water (deionized, distilled, or reverse osmosis) for peritonealdialysis, per gallon19A4719 Y set tubing for peritoneal dialysis (Eff. Date 1/1/2002) 19A4720 Dialysate solution, any concentration of dextrose, fluid volumegreater than 249cc, but less than or equal to 999cc, for peritonealdialysis (Eff. Date 1/1/2002)A4721 Dialysate solution, any concentration of dextrose, fluid volumegreater than 999cc, but less than or equal to 1999cc, for peritoneal1919DME MAC Jurisdiction C Supplier Manual Page 14

HCPCSAppendix Adialysis (Eff. Date 1/1/2002)A4722 Dialysate solution, any concentration of dextrose, fluid volumegreater than 1999cc, but less than or equal to 2999cc, for peritonealdialysis (Eff. Date 1/1/2002)A4723 Dialysate solution, any concentration of dextrose, fluid volumegreater than 2999cc, but less than or equal to 3999cc, for peritonealdialysis (Eff. Date 1/1/2002)A4724 Dialysate solution, any concentration of dextrose, fluid volumegreater than 3999cc, but less than or equal to 4999cc, for peritonealdialysis (Eff. Date 1/1/2002)A4725 Dialysate solution, any concentration of dextrose, fluid volumegreater than 4999cc, but less than or equal to 5999cc, for peritonealdialysis (Eff. Date 1/1/2002)A4726 Dialysate solution, any concentration of dextrose, fluid volumegreater than 5999cc, for peritoneal dialysis (Eff. Date 1/1/2002)A4728 Dialysate solution, non-dextrose containing, 500 ml (Eff. Date1/1/2004)191919191919A4730 Fistula cannulation set for hemodialysis, each 19A4735 Local/topical anesthetics for dialysis only (Deleted eff. 12/31/2001) 19A4736 Topical anesthetic, for dialysis, per gram (Eff. Date 1/1/2002) 19A4737 Injectable anesthetic, for dialysis, per 10 ml (Eff. Date 1/1/2002) 19A4740 Shunt accessory, for hemodialysis, any type, each 19A4750 Blood tubing, arterial or venous, for hemodialysis, each 19A4755 Blood tubing, arterial and venous combined, for hemodialysis, each 19A4760 Dialysate solution test kit, for peritoneal dialysis, any type, each 19A4765 Dialysate concentrate, powder, additive for peritoneal dialysis, perpacketA4766 Dialysate concentrate, solution, additive for peritoneal dialysis, per10 ml (Eff. Date 1/1/2002)1919A4770 Blood collection tube, vacuum, for dialysis, per 50 19A4771 Serum clotting time tube, for dialysis, per 50 19A4772 Blood glucose test strips, for dialysis, per 50 19A4773 Occult blood test strips, for dialysis, per 50 19A4774 Ammonia test strips, for dialysis, per 50A4780 Sterilizing agent for dialysis equipment, per gallon (Deleted eff.12/31/2001)19DME MAC Jurisdiction C Supplier Manual Page 15

HCPCSAppendix AA4790 Cleansing agents for equipment for dialysis only (Deleted eff.12/31/2001)A4800 Heparin for dialysis and antidote, any strength, porcine or beef, up to1000 units, 10-30 ml (for parenteral use see b4216) (Deleted eff.12/31/2001)A4801 Heparin, any type for hemodialysis, per 1000 units (Deletedeff.12/31/2002)191919A4802 Protamine sulfate, for hemodialysis, per 50 mg (Eff. Date 1/1/2002) 19A4820 Hemodialysis kit supplies (Deleted eff. 12/31/2001) 19A4850 Hemostats with rubber tips for dialysis (Deleted eff. 12/31/2001) 19A4860 Disposable catheter tips for peritoneal dialysis, per 10 19A4870 Plumbing and/or electrical work for home hemodialysis equipment 19A4880 Storage tanks utilized in connection with water purification system,replacement tanks for dialysis (Deleted eff. 12/31/2001)19A4890 Contracts, repair and maintenance, for hemodialysis equipmentA4900 Continuous ambulatory peritoneal dialysis (CAPD) supply kit(Deleted eff. 12/31/2001)A4901 Continuous cycling peritoneal dialysis (CCPD) supply kit (Deletedeff. 12/31/2001)A4905 Intermittent peritoneal dialysis (IPD) supply kit (Deleted eff.12/31/2001)A4910 Non-medical supplies for dialysis, (i.e., scale, scissors, stopwatch,etc.) (Deleted eff. 12/31/2001)19191919A4911 Drain bag/bottle, for dialysis, each (Eff. Date 1/1/2002) 19A4912 Gomco drain bottle (Deleted eff. 12/31/2001) 19A4913 Miscellaneous dialysis supplies, not otherwise specified 19A4914 Preparation kits (Deleted eff. 12/31/2001) 19A4918 Venous pressure clamp, for hemodialysis, each 19A4919 Dialyzer holder, each (Deleted eff. 12/31/2001) 19A4920 Harvard pressure clamp, each (Deleted eff. 12/31/2001) 19A4921 Measuring cylinder, any size, each (Deleted eff. 12/31/2001) 19A4927 Gloves, non-sterile, per 100 19A4928 Surgical mask, per 20 (Eff. Date 1/1/2002) 19A4929 Tourniquet for dialysis, each (Eff. Date 1/1/2002) 19DME MAC Jurisdiction C Supplier Manual Page 16

HCPCSAppendix AA4930 Gloves, sterile, per pair (Eff. Date 1/1/2003) 19A4931 Oral thermometer, reusable, any type, each (Eff. Date 1/1/2003) 19A4932 Rectal thermometer, reusable, any type, each (Eff. Date 1/1/2003) 17A5051 Ostomy pouch, closed; with barrier attached (1 piece), each 11A5052 Ostomy pouch, closed; without barrier attached (1 piece), each 11A5053 Ostomy pouch, closed; for use on faceplate, each 11A5054 Ostomy pouch, closed; for use on barrier with flange (2 piece), each 11A5055 Stoma cap 11A5061 Pouch, drainable; with barrier attached (1 piece), each 11A5062 Ostomy pouch, drainable; without barrier attached (1 piece), each 11A5063 Ostomy pouch, drainable; for use on barrier with flange (2 piecesystem), eachA5064 Pouch, drainable, with faceplate attached; plastic or rubber (Deletedeff. 12/31/2001)A5065 Pouch, drainable, for use on faceplate; plastic or rubber (Deleted eff.12/31/1996)111111A5071 Ostomy pouch, urinary; with barrier attached (1 piece), each 11A5072 Ostomy pouch, urinary; without barrier attached (1 piece), each 11A5073 Ostomy pouch, urinary; for use on barrier with flange (2 piece), each 11A5074 Pouch, urinary, w/faceplate attach; plastic/rubber (Deleted eff.12/31/2001)A5075 Pouch, urinary, for use on faceplate; plastic/rubber (Deleted eff.12/31/2001)1111A5081 Continent device; plug for continent stoma 11A5082 Continent device; catheter for continent stoma 11A5083 CONTINENT DEVICE, STOMA ABSORPTIVE COVER FORCONTINENT STOMA (Eff. Dt 1/1/2008)11A5093 Ostomy accessory; convex insert 11A5102 Bedside drainage bottle with or without tubing, rigid or expandable,eachA5105 URINARY SUSPENSORY WITH LEG BAG, WITH OR WITHOUTTUBE, EACH (Updated Description 1/1/2008)1111A5112 Urinary leg bag; latex 11A5113 Leg strap; latex, replacement only, per set 11DME MAC Jurisdiction C Supplier Manual Page 17

HCPCSAppendix AA5114 Leg strap; foam or fabric, replacement only, per set 11A5119 Skin Barrier, wipes or swabs, per box 50 (Deleted eff. 12/31/2005) 11A5120 Skin Barrier, wipes or swabs, each (Eff. Date 1/1/2006) 11A5121 Skin barrier; solid, 6 x 6 or equivalent, each 11A5122 Skin barrier; solid, 8 x 8 or equivalent, each 11A5123 Skin barrier; with flange (solid, flexible or accordion), any size(Deleted eff. 3/31/2002)11A5126 Adhesive or non-adhesive; disk or foam pad 11A5131 Appliance cleaner, incontinence and ostomy appliances, per 16 oz. 11A5149 Incontinence/ostomy supply; miscellaneous (Deleted eff.12/31/2000)A5200 Percutaneous catheter/tube anchoring device, adhesive skinattachmentA5500 For diabetics only, fitting (including follow-up), custom preparationand supply of off-the-shelf depth-inlay shoe manufactured toaccommodate multi-density insert(s), per shoe.A5501 For diabetics only, fitting (including follow-up), custom preparationand supply of shoe molded from cast(s) of patient's foot (custommolded shoe), per shoeA5502 For diabetics only, multiple density insert(s), per shoe (Deleted eff.12/31/2001)A5503 For diabetics only, modification (including fitting) of off-the-shelfdepth-inlay shoe or custom-molded shoe with roller or rigid rockerbottom, per shoeA5504 For diabetics only, modification (including fitting) of off-the-shelfdepth-inlay shoe or custom-molded shoe with wedge(s), per shoeA5505 For diabetics only, modification (including fitting) of off-the-shelfdepth-inlay shoe or custom-molded shoe with metatarsal bar, pershoeA5506 For diabetics only, modification (including fitting) of off-the-shelfdepth-inlay shoe or custom-molded shoe with off-set heel(s), pershoeA5507 For diabetics only, not otherwise specified modification (includingfitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, pershoeA5508 For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe orcustom-molded shoe, per shoe (Eff. Date 1/1/2000)A5509 For diabetics only, direct formed, molded to foot with external heatsource (i.e. heat gun) multiple density insert(s), prefabricated, per141116161616161616161616DME MAC Jurisdiction C Supplier Manual Page 18

HCPCSAppendix Ashoe (Eff. Date 1/1/2002) (Deleted eff. 03/31/2004)A5510 For diabetics only, direct formed, compression molded to patient’sfoot without external heat source, multiple-density insert(s)prefabricated, per shoe (Eff. Date 1/1/2002)A5511 For diabetics only, custom-molded from model of patient’s foot,multiple density insert(s), custom-fabricated, per shoe (Eff. Date1/1/2002) (Deleted eff. 03/31/2004)A5512 For diabetics only, multiple density insert, direct formed, molded tofoot after external heat source of 230 degrees fahrenheit or higher,total contract with patient's foot, including arch, base layer minimumof 1/4 inch material of shore a 35 durometer or 3/16 inch material ofshore a 40 durometer (or higher), prefabricated, each(Eff. Date 1/1/2006)A5513 For diabetic only, multiple density insert, custom molded from modelofpatient's foot, total contact with patient's foot, including arch, baselayerminimum of 1/4 inch material of shore a 35 durometer or 3/16 inchmaterial of shore a 40 durometer (or higher), includes arch filler andother shaping material, custom fabricated, each (Eff. Date 1/1/2006)A6000 Non-contact wound warming wound cover for use with the noncontactwound warming device and warming card (Eff. Date1/1/2002)A6010 Collagen based wound filler, dry form, per gram of collagen (Eff.Date 1/1/2002)A6011 Collagen based wound filler, gel/paste, per gram of collagen (Eff.Date 1/1/2003)A6020 Collagen based wound dressing, each dressing (Deleted eff.12/31/2000)A6021 Collagen dressing, pad size 16 sq. in., or less, each (Eff. Date1/1/2001)A6022 Collagen dressing, pad size more than 16sq. in. but less than orequal to 48 sq. inc., each (Eff. Date 1/1/2001)A6023 Collagen dressing, pad size more than 48 sq. in., each (Eff. Date1/1/2001)1616161613121212121212A6024 Collagen dressing wound filler, per 6 inches (Eff. Date 1/1/2001) 12A6025 Gel sheet for dermal or epidermal application, (e.g., silicone,hydrogel, other), each (not valid for Medicare)A6154 Wound pouch, each 12A6196 Alginate or other fiber gelling dressing, wound cover, pad size 16 sq.in. or less, each dressing12A6197 Alginate or other fiber gelling dressing, wound cover, pad size more 12DME MAC Jurisdiction C Supplier Manual Page 19

HCPCSAppendix Athan 16 sq. in. but less than or equal to 48 sq. in., each dressingA6198 Alginate or other fiber gelling dressing, wound cover, pad size morethan 48 sq. in., each dressing17A6199 Alginate or other fiber gelling dressing, wound filler, per 6 inches 12A6200 Composite dressing, pad size 16 sq. in. or less, without adhesiveborder, each dressingA6201 Composite dressing, pad size more than 16 sq. in. but less than orequal to 48 sq. in., without adhesive border, each dressingA6202 Composite dressing, pad size more than 48 sq. in., without adhesiveborder, each dressingA6203 Composite dressing, pad size 16 sq. in. or less, with any sizeadhesive border, each dressingA6204 Composite dressing, pad size more than 16 sq. in. but less than orequal to 48 sq. in., with any size adhesive border, each dressingA6205 Composite dressing, pad size more than 48 sq. in., with any sizeadhesive border, each dressing121217121217A6206 Contact layer, 16 sq. in. or less, each dressing 17A6207 Contact layer, more than 16 sq. in. but less than or equal to 48 sq.in., each dressing12A6208 Contact layer, more than 48 sq. in., each dressing 17A6209 Foam dressing, wound cover, pad size 16 sq. in. or less, withoutadhesive border, each dressingA6210 Foam dressing, wound cover, pad size more than 16 sq. in. but lessthan or equal to 48 sq. in., without adhesive border, each dressingA6211 Foam dressing, wound cover, pad size more than 48 sq. in., withoutadhesive border, each dressingA6212 Foam dressing, wound cover, pad size 16 sq. in. or less, with anysize adhesive border, each dressingA6213 Foam dressing, wound cover, pad size more than 16 sq. in. but lessthan or equal to 48 sq. in., with any size adhesive border, eachdressingA6214 Foam dressing, wound cover, pad size more than 48 sq. in., with anysize adhesive border, each dressing121212121712A6215 Foam dressing, wound filler, per gram 17A6216 Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less,without adhesive border, each dressingA6217 Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in.but less than or equal to 48 sq. in., without adhesive border, each1212DME MAC Jurisdiction C Supplier Manual Page 20

HCPCSAppendix AdressingA6218 Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in.,without adhesive border, each dressingA6219 Gauze, non-impregnated, pad size 16 sq. in. or less, with any sizeadhesive border, each dressingA6220 Gauze, non-impregnated, pad size more than 16 sq. in. but less thanor equal to 48 sq. in., with any size adhesive border, each dressingA6221 Gauze, non-impregnated, pad size more than 48 sq. in., with anysize adhesive border, each dressingA6222 Gauze, impregnated, other than water or normal saline, or hydrogel,pad size 16 sq. in. or less, without adhesive border, each dressingA6223 Gauze, impregnated, other than water or normal saline, or hydrogel,pad Size more than 16 sq. in. but less than or equal to 48 sq. in.,without adhesive border, each dressingA6224 Gauze, impregnated, other than water or normal saline, or hydrogel,pad size more than 48 sq. in., without adhesive border, eachdressingA6228 Gauze, impregnated, water or normal saline, pad size 16 sq. in. orless, without adhesive border, each dressingA6229 Gauze, impregnated, water or normal saline, pad size more that 16sq. in. but less than or equal to 48 sq. in., without adhesive border,each dressingA6230 Gauze, impregnated, water or normal saline, pad size more than 48sq. in., without adhesive border, each dressingA6231 Gauze, impregnated, hydrogel, for direct wound contact, pad size 16sq. in. or less, without adhesive border, each dressing (Eff. Date1/1/2001)A6232 Gauze, impregnated, hydrogel, for direct wound contact, pad sizemore than 16 sq. in. but less than or equal to 48 sq. in., withoutadhesive border, each dressing (Eff. Date 1/1/2001)A6233 Gauze, impregnated, hydrogel, for direct wound contact, pad sizemore than 48 sq. in., without adhesive border, each dressing (Eff.Date 1/1/2001)A6234 Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less,without adhesive border, each dressingA6235 Hydrocolloid dressing, wound cover, pad size more than 16 sq. in.but less than or equal to 48 sq. in., without adhesive border, eachdressingA6236 Hydrocolloid dressing, wound cover, pad size more than 48 sq. in.,without adhesive border, each dressing17121217121212171217121212121212A6237 Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with 12DME MAC Jurisdiction C Supplier Manual Page 21

HCPCSAppendix Aany size adhesive border, each dressingA6238 Hydrocolloid dressing, wound cover, pad size more than 16 sq. in.but less than or equal to 48 sq. in., with any size adhesive border,each dressingA6239 Hydrocolloid dressing, wound cover, pad size more than 48 sq. in.,with any size adhesive border, each dressing1217A6240 Hydrocolloid dressing, wound filler, paste, per fluid ounce 12A6241 Hydrocolloid dressing, wound filler, dry form, per gram 12A6242 Hydrogel dressing, wound cover, pad size 16 sq. in. or less, withoutadhesive border, each dressingA6243 Hydrogel dressing, wound cover, pad size more than 16 sq. in. butless than or equal to 48 sq. in., without adhesive border, eachdressingA6244 Hydrogel dressing, wound cover, pad size more than 48 sq. in.,without adhesive border, each dressingA6245 Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with anysize adhesive border, each dressingA6246 Hydrogel dressing, wound cover, pad size more than 16 sq. in. butless than or equal to 48 sq. in., with any size adhesive border, eachdressingA6247 Hydrogel dressing, wound cover, pad size more than 48 sq. in., withany size adhesive border, each dressing121212121212A6248 Hydrogel dressing, wound filler, gel, per fluid ounce 12A6250 Skin sealants, protectants, moisturizers, ointments, any type, anysizeA6251 Specialty absorptive dressing, wound cover, pad size 16 sq. in. orless, without adhesive border, each dressingA6252 Specialty absorptive dressing, wound cover, pad size more than 16sq. in. but less than or equal to 48 sq. in., without adhesive border,each dressingA6253 Specialty absorptive dressing, wound cover, pad size more than 48sq. in., without adhesive border, each dressingA6254 Specialty absorptive dressing, wound cover, pad size 16 sq. in. orless, with any size adhesive border, each dressingA6255 Specialty absorptive dressing, wound cover, pad size more than 16sq. in. but less than or equal to 48 sq. in., with any size adhesiveborder, each dressingA6256 Specialty absorptive dressing, wound cover, pad size more than 48sq. in., with any size adhesive border, each dressing12121212121217DME MAC Jurisdiction C Supplier Manual Page 22

HCPCSAppendix AA6257 Transparent film, 16 sq. in. or less, each dressing 12A6258 Transparent film, more than 16 sq. in. but less than or equal to 48sq. in., each dressing12A6259 Transparent film, more than 48 sq. in., each dressing 12A6260 Wound cleansers, any type, any size 12A6261 Wound filler, gel/paste, per fluid ounce, not elsewhere classified 14A6262 Wound filler, dry form, per gram, not elsewhere classified 14A6263 Gauze, elastic, non-sterile, all types, per linear yard (Deleted eff.12/31/2002)A6264 Gauze, non-elastic, non-sterile, per linear yard (Deleted eff.12/31/2002)1212A6265 Tape, all types, per 18 square inches (Deleted eff. 3/31/2002) 12A6266 Gauze, impregnated, other than water or normal saline, any width,per linear yardA6402 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, withoutadhesive border, each dressingA6403 Gauze, non-impregnated, sterile, pad size more than 16 sq. in. lessthan or equal to 48 sq. in., without adhesive border, each dressingA6404 Gauze, non-impregnated, sterile, pad size more than 48 sq. in.,without adhesive border, each dressingA6405 Gauze, elastic, sterile, all types, per linear yard (Deleted eff.12/31/2002)A6406 Gauze, non-elastic, sterile, all types, per linear yard (Deleted eff.12/31/2002)A6407 Packing strips, non-impregnated, up to 2 inches width, per linearyard (Eff. Date 1/1/2004)12121212121212A6410 Eye pad, sterile, each (Eff. Date 1/1/2003) 12A6411 Eye pad, non-sterile, each (Eff. Date 1/1/2003) 12A6412 Eye patch, occlusive, each (Eff. Date 1/1/2003) 12A6413 ADHESIVE BANDAGE, FIRST-AID TYPE, ANY SIZE, EACH (Eff.Date 1/1/2008)A6421 Padding bandage, non-elastic, non-woven/non-knitted, width greaterthan or equal to 3 inches and less than 5 inches, per roll (at least 3yards, unstretched) (Deleted eff. 12/31/2003)A6422 Conforming bandage, non-elastic, knitted/woven, non-sterile, widthgreater than or equal to 3 inches and less than 5 inches, per roll (atleast 3 yards, unstretched) (Deleted eff. 12/31/2003)1212DME MAC Jurisdiction C Supplier Manual Page 23

HCPCSAppendix AA6424 Conforming bandage, non-elastic, knitted/woven, non-sterile, widthgreater than or equal to 5 inches, per roll (at least 3 yards,unstretched) (Deleted eff. 12/31/2003)A6426 Conforming bandage, non-elastic, knitted/woven, sterile, widthgreater than or equal to 3 inches and less than 5 inches, per roll (atleast 3 yards, unstretched) (Deleted eff. 12/31/2003)A6428 Conforming bandage, non-elastic, knitted/woven, sterile, widthgreater than or equal to 5 inches, per roll (at least 3 yards,unstretched) (Deleted eff. 12/31/2003)A6430 Light compression bandage, elastic, knitted/woven, load resistanceless than 1.25 foot pounds at 50% maximum stretch, width greaterthan or equal to 3 inches and less than 5 inches, per roll (at least 3yards, unstretched) (Deleted eff. 12/31/2003)A6432 Light compression bandage, elastic, knitted/woven, load resistanceless than 1.25 foot pounds at 50% maximum stretch, width greaterthan or equal to 5 inches, per roll (at least 3 yards, unstretched) (Eff.Date 1/1/2003) (Deleted eff. 12/31/2003)A6434 Moderate compression bandage, elastic, knitted/woven, loadresistance of 1.25 to 1.34 foot pounds at 50% maximum stretch ,width greater than or equal to 3 inches or less than 5 inches, per roll( at least 3 yards, unstretched) (Eff. Date 1/1/2003) (Deleted eff.12/31/2003)A6436 High compression bandage, elastic, knitted/woven, load resistancegreater than 1.35 foot pounds at 50% maximum stretch, widthgreater than or equal to 3 inches and less than 5 inches, per roll (atleast 3 yards, unstretched) (Deleted eff. 12/31/2003)A6438 Self-adherent bandage, elastic, non-knitted/non-woven, loadresistance greater than or equal to 0.55 foot pounds at 50%maximum stretch, width greater than or equal to 3 inches and lessthan 5 inches, per roll (at least 3 yards, unstretched ) (Deleted eff.12/31/2003)A6440 Zinc paste impregnated bandage, non-elastic, knitted/woven, widthgreater than or equal to 3 inches and less than 5 inches, per roll (atleast 10 yards, unstretched) (Deleted eff. 12/31/2003)A6441 Padding bandage, non-elastic, non-woven/non-knitted, width greaterthan or equal to three inches and less than five inches, per yard (Eff.Date 1/1/2004)A6442 Conforming bandage, non-elastic, knitted/woven, non-sterile, widthless than three inches, per yard (Eff. Date 1/1/2004)A6443 Conforming bandage, non-elastic, knitted/woven, non-sterile, widthgreater than or equal to three inches and less than five inches, peryard (Eff. Date 1/1/2004)A6444 Conforming bandage, non-elastic, knitted/woven, non-sterile, widthgreater than 5 inches, per yard (Eff. Date 1/1/2004)12121212121212121212121212DME MAC Jurisdiction C Supplier Manual Page 24

HCPCSAppendix AA6445 Conforming bandage, non-elastic, knitted/woven, sterile, width lessthan three inches, per yard (Eff. Date 1/1/2004)A6446 Conforming bandage, non-elastic, knitted/woven, sterile, widthgreater than or equal to three inches and less than five inches, peryard (Eff. Date 1/1/2004)A6447 Conforming bandage, non-elastic, knitted/woven, sterile, widthgreater than or equal to five inches, per yard (Eff. Date 1/1/2004)A6448 Light compression bandage, elastic, knitted/woven, width less thanthree inches, per yard (Eff. Date 1/1/2004)A6449 Light compression bandage, elastic, knitted/woven, width greaterthan or equal to three inches and less than five inches, per yard (Eff.Date 1/1/2004)A6450 Light compression bandage, elastic, knitted/woven, width greaterthan or equal to five inches, per yard (Eff. Date 1/1/2004)A6451 Moderate compression bandage, elastic, knitted/woven, loadresistance of 1.25 to 1.34 foot pounds at 50% maximum stretch,width greater than or equal to three inches or less than five inches,per yard (Eff. Date 1/1/2004)A6452 High compression bandage, elastic, knitted/woven, load resistancegreater than or equal to 1.35 foot pounds at 50% maximum stretch,width greater than or equal to three inches and less than five inchesper yard (Eff. Date 1/1/2004)A6453 Self-adherent bandage, elastic, non-knitted/non-woven, less thanthree inches, per yard (Eff. Date 1/1/2004)A6454 Self-adherent bandage, elastic, non-knitted/non-woven, widthgreater than or equal to three inches and less than five inches, peryard (Eff. Date 1/1/2004)A6455 Self-adherent bandage, elastic, non-knitted/non-woven, widthgreater than or equal to five inches, per yard (Eff. Date 1/1/2004)A6456 Zinc paste impregnated bandage, non-elastic, knitted/woven, widthgreater than or equal to three inches and less than five inches, peryard (Eff. Date 1/1/2004)A6457 Tubular dressing with or without elastic, any width, per linear yard(Eff. Date 1/1/2006)A6501 Compression Burn garment, bodysuit (head to foot), customfabricated (Eff. Date 1/1/2003)A6502 Compression Burn garment, chin strap , custom fabricated (Eff. Date1/1/2003)A6503 Compression Burn garment, facial hood, custom fabricated (Eff.Date 1/1/2003)A6504 Compression Burn garment, glove to wrist, custom fabricated (Eff.Date 1/1/2003)1212121212121212121212121212121212DME MAC Jurisdiction C Supplier Manual Page 25

HCPCSAppendix AA6505 Compression Burn garment, glove to elbow, custom fabricated (Eff.Date 1/1/2003)A6506 Compression Burn garment, glove to axilla, custom fabricated (Eff.Date 1/1/2003)A6507 Compression Burn garment, foot to knee length, custom fabricated(Eff. Date 1/1/2003)A6508 Compression Burn garment, foot to thigh length, custom fabricated(Eff. Date 1/1/2003)A6509 Compression Burn garment, upper trunk to waist including armopenings (vest), custom fabricated (Eff. Date 1/1/2003)A6510 Compression Burn garment, trunk, including arms down to legopenings (leotard), custom fabricated (Eff. Date 1/1/2003)A6511 Compression Burn garment, lower trunk including leg openings(panty), custom fabricated (Eff. Date 1/1/2003)A6512 Compression Burn garment, not otherwise classified (Eff. Date1/1/2003)A6513 Compression burn mask, face and/or neck, plastic or equal, customfabricated (Eff. Date 1/1/2006)A6530 Gradient compression stocking, below knee, 18-30 MMHG,each (Eff. Date 1/1/2006)A6531 Gradient compression stocking, below knee, 30-40 MMHG, each(Eff. Date 1/1/2006)A6532 Gradient compression stocking, below knee, 40-50 MMHG, each(Eff. Date 1/1/2006)A6533 Gradient compression stocking, thigh length, 18-30 MMHG, each(Eff. Date 1/1/2006)A6534 Gradient compression stocking, thigh length, 30-40 MMHG, each(Eff. Date 1/1/2006)A6535 Gradient compression stocking, thigh length, 40-50 MMHG, each(Eff. Date 1/1/2006)A6536 Gradient compression stocking, full length/chap style, 18-30 MMHG,each (Eff. Date 1/1/2006)A6537 Gradient compression stocking, full length/chap style, 30-40 MMHG,each (Eff. Date 1/1/2006)A6538 Gradient compression stocking, full length/chap style, 40-50 MMHG,each (Eff. Date 1/1/2006)A6539 Gradient compression stocking, waist length, 18-30 MMHG, each(Eff. Date 1/1/2006)12121212121212121212121212121212121212A6540 Gradient compression stocking, waist length, 30-40 MMHG, each 12DME MAC Jurisdiction C Supplier Manual Page 26

HCPCSAppendix A(Eff. Date 1/1/2006)A6541 Gradient compression stocking, waist length, 40-50 MMHG, each(Eff. Date 1/1/2006)12A6542 Gradient compression stocking, custom made (Eff. Date 1/1/2006) 12A6543 Gradient compression stocking, lymphedema (Eff. Date 1/1/2006) 12A6544 Gradient compression stocking, garter belt (Eff. Date 1/1/2006) 12A6549 Gradient compression stocking, not otherwise specified(Eff. Date 1/1/2006)A6550 Wound care set, for negative pressure wound therapy electricalpump, includes all supplies and accessories (Eff. Date 1/1/2004)A6551 Canister set for negative pressure wound therapy electrical pump,stationary or portable, each (Eff. Date 1/1/2004) (Deleted eff.12/31/2005)A7000 Canister, disposable, used with suction pump, each (Eff. Date1/1/2000)A7001 Canister, non-disposable, used with suction pump, each (Eff. Date1/1/2000)1213120505A7002 Tubing, used with suction pump, each (Eff. Date 1/1/2000) 05A7003 Administration set, with small volume nonfiltered pneumaticnebulizer, disposable (Eff. Date 1/1/2000)A7004 Small volume nonfiltered pneumatic nebulizer, disposable (Eff. Date1/1/2000)A7005 Administration set, with small volume nonfiltered pneumaticnebulizer, non-disposable (Eff. Date 1/1/2000)A7006 Administration set, with small volume filtered pneumatic nebulizer(Eff. Date 1/1/2000)A7007 Large volume nebulizer, disposable, unfilled, used with aerosolcompressor (Eff. Date 1/1/2000)A7008 Large volume nebulizer, disposable, prefilled, used with aerosolcompressor (Eff. Date 1/1/2000)A7009 Reservoir bottle, non-disposable, used with large volume ultrasonicnebulizer (Eff. Date 1/1/2000)A7010 Corrugated tubing, disposable, used with large volume nebulizer,100 feet (Eff. Date 1/1/2000)A7011 Corrugated tubing, non-disposable, used with large volumenebulizer, 10 feet (Eff. Date 1/1/2000)A7012 Water collection device, used with large volume nebulizer (Eff. Date1/1/2000)05050505050505051705DME MAC Jurisdiction C Supplier Manual Page 27

HCPCSAppendix AA7013 Filter, disposable, used with aerosol compressor (Eff. Date 1/1/2000) 05A7014 Filter, nondisposable, used with aerosol compressor or ultrasonicgenerator (Eff. Date 1/1/2000)05A7015 Aerosol mask, used with DME nebulizer (Eff. Date 1/1/2000) 05A7016 Dome and mouthpiece, used with small volume ultrasonic nebulizer(Eff. Date 1/1/2000)A7017 Nebulizer, durable, glass or autoclavable plastic, bottle type, notused with oxygen (Eff. Date 1/1/2000)A7018 Water, distilled, used with large volume nebulizer, 1000 ml (Eff. Date1/1/2001)A7019 Saline solution, per 10 ml, metered dose dispenser, for use withinhalation drugs (Deleted eff. 12/31/2003)A7020 Sterile water or sterile saline, 1000 ml, used with large volumenebulizer (Deleted eff. 12/31/2003)A7025 High frequency chest wall oscillation system vest, replacement foruse with patient owned equipment, each (Eff. Date 1/1/2003)A7026 High frequency chess wall oscillation system hose, replacement foruse with patient owned equipment, each (Eff. Date 1/1/2003)05051313150505A7027 COMBINATION ORAL/NASAL MASK, USED WITH CONTINUOUSPOSITIVE AIRWAY PRESSURE DEVICE, EACH (Eff. Date1/1/2008) 05A7028 ORAL CUSHION FOR COMBINATION ORAL/NASAL MASK,REPLACEMENT ONLY, EACH (Eff. Date 1/1/2008) 05A7029 NASAL PILLOWS FOR COMBINATION ORAL/NASAL MASK,REPLACEMENT ONLY, PAIR (Eff. Date 1/1/2008) 05A7030 Full face mask used with positive airway pressure device, each (Eff.Date 1/1/2003)A7031 Face mask interface, replacement for full face mask, each (Eff. Date1/1/2003)A7032 Cushion for use on nasal mask interface, replacement only, each(Eff. Date 1/1/2003)A7033 Pillow for use on nasal cannula type interface, replacement only,each (Eff. Date 1/1/2003)A7034 Nasal interface (mask or cannula type) used with positive airwaypressure device, with or without head strap (Eff. Date 1/1/2003)A7035 Headgear used with positive airway pressure device (Eff. Date1/1/2003)A7036 Chinstrap used with positive airway pressure device (Eff. Date1/1/2003)05050505050505DME MAC Jurisdiction C Supplier Manual Page 28

HCPCSAppendix AA7037 Tubing used with positive airway pressure device (Eff. Date1/1/2003)A7038 Filter, disposable, used with positive airway pressure device (Eff.Date 1/1/2003)A7039 Filter, non disposable, used with positive airway pressure device(Eff. Date 1/1/2003)A7044 Oral interface used with positive airway pressure device, each (Eff.Date 1/1/2003)A7045 Exhalation port with or without swivel used with accessories forpositive airway devices, replacement only (Eff. Date 1/1/2005)A7046 Water chamber for humidifier, used with positive airway pressuredevice, replacement, each (Eff. Date 1/1/2004)050505050505A7501 Tracheostoma valve, including diaphragm, each (Eff. Date 1/1/2001) 11A7502 Replacement diaphragm/faceplate for tracheostoma valve, each (Eff.Date 1/1/2001)A7503 Filter holder or filter cap, reusable, for use in a trachostoma heat andmoisture exchange, each (Eff. Date 1/1/2001)A7504 Filter for use in a tracheostoma heat and moisture exchange system,each (Eff. Date 1/1/2001)A7505 Housing, reusable without adhesive, for use in a heat and moistureexchange system and/or with a tracheostoma valve, each (Eff. Date1/1/2001)A7506 Adhesive disc for use in a heat and moisture exchange systemand/or with trachostoma valve, any type each (Eff. Date 1/1/2001)A7507 Filter holder and integrated filter without adhesive, for use in atrachostoma heat and moisture exchange system, each (Eff. Date1/1/2001)A7508 Housing and integrated adhesive, for use in a trachestoma heat andmoisture exchange system and/or with a tracheostma valve, each(Eff. Date 1/1/2001)A7509 Filter holder and integrated filter housing, and adhesive, for use as atracheostoma heat and moisture exchange system, each (Eff. Date1/1/2001)A7520 Tracheostomy/laryngectomy tube, non-cuffed, polyvinylchloride(PVC), silicone or equal, each (Eff. Date 1/1/2004)A7521 Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC),silicone or equal, each (Eff. Date 1/1/2004)A7522 Tracheostomy/laryngectomy tube, stainless steel or equal(sterilizable and reusable), each (Eff. Date 1/1/2004)1111111111111111111111A7523 Tracheostomy shower protector, each (Eff. Date 1/1/2004) 11DME MAC Jurisdiction C Supplier Manual Page 29

HCPCSAppendix AA7524 Tracheostoma stent/stud/button, each (Eff. Date 1/1/2004) 11A7525 Tracheostomy mask, each (Eff. Date 1/1/2004) 11A7526 Tracheostomy tube collar/holder, each (Eff. Date 1/1/2004) 11A7527 Tracheostomy/laryngectomy tube plug/stop, each (Eff. Date1/1/2005)A8000 Helmet, protective, soft, prefabricated, includes all components andaccessories (effective 01/01/2007)A8001 Helmet, protective, hard, prefabricated, includes all components andaccessories (effective 01/01/2007A8002 Helmet, protective, soft, custom fabricated, includes all componentsand accessories (effective 01/01/2007A8003 Helmet, protective, hard, custom fabricated, includes all componentsand accessories (effective 01/01/20071105050505A8004 Soft onterface for helmet, replacement only (effective 01/01/2007 05A9150 Non-prescription drugsA9160 Non-covered svc. by podiatristA9170 Non-covered svc. by chiropractorA9190 Personal comfort item (Deleted eff. 12/31/2001)A9270 Non-covered item or serviceA9274 EXTERNAL AMBULATORY INSULIN DELIVERY SYSTEM,DISPOSABLE, EACH, INCLUDES ALL SUPPLIES ANDACCESSORIES (Eff. Date 1/1/2008)A9275 Home Blood Glucose disposable monitor, includes test strips(Eff. Date 1/1/2006)A9276 SENSOR; INVASIVE (E.G. SUBCUTANEOUS), DISPOSABLE, FORUSE WITH INTERSTITIAL CONTINUOUS GLUCOSEMONITORING SYSTEM, ONE UNIT = 1 DAY SUPPLY (Eff. Date1/1/2008)A9277 TRANSMITTER; EXTERNAL, FOR USE WITH INTERSTITIALCONTINUOUS GLUCOSE MONITORING SYSTEM (Eff. Date1/1/2008)A9278 RECEIVER (MONITOR); EXTERNAL, FOR USE WITHINTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM(Eff. Date 1/1/2008)A9279 Monitoring feature/device, stand-alone or integrated, any type,includes all accessories, components and electromics, not otherwiseclassified (effective 01/01/2007)A9280 Alert or alarm device, not otherwise specified (Eff. Date 1/1/2004) 14DME MAC Jurisdiction C Supplier Manual Page 30

HCPCSAppendix A(Deleted eff. 12/31/2003)A9281 Reaching/grabbing device, any type, any length, each(Eff. Date 1/1/2006)A9282 Wig, any type, each (Eff. Date 1/1/2006)A9283 FOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANYTYPE, EACH (Eff. Date 1/1/2008)A9300 Exercise equipmentA9500 Supply of radiopharmaceutical diagnostic imaging agent, technetiumtc 99m sestamibi, per doseA9502 Supply of radiopharmaceutical diagnostic imaging agent, technetiumtc 99m tetrofosmin, per unit doseA9503 Supply of radiopharmaceutical diagnostic imaging agent, technetiumtc 99m, medronate, up to 30 mciA9504 Supply of radiopharmaceutical diagnostic imaging agent, technetiumtc 99m apcitide (Eff. Date 1/1/2000)A9505 Supply of radiopharmaceutical diagnostic imaging agent, thallouschloride tl 201, per mciA9507 Supply of radiopharmaceutical diagnostic imaging agent, indium in111 capromab pendetide, per doseA9600 Supply of therapeutic radiopharmaceutical, strontium-89 chloride,per mciA9605 Supply of therapeutic radiopharmaceutical, samarium sm 153lexidronamm, 50 mciA9900 Miscellaneous DME supply, accessory, and/or service of anotherHCPCS code (Eff. Date 1/1/2000)17A9901 DME delivery, set up, and/or dispensing service component ofHCPCS code (Eff. Date 1/1/2000)anotherA9999 Miscellaneous DME supply or accessory, not otherwise specified(Eff. Date 1/1/2004)14DME MAC Jurisdiction C Supplier Manual Page 31

HCPCSAppendix AHCPCS BPayment Category1 Capped Rental 8 Parenteral/Enteral Supplies and Kits 15 Nebulizer Drugs2 Freq. & Substantial Serv. DME 9 Parenteral/Enteral Pumps 16 Therapeutic Shoes for Diabetics3 Customized DMEPOS 10 Immunosuppressive Drugs 17 Individual Consideration4 Prosthetics/Orthotics 11 Ostomy, Trach., & Urologicals 18 Epoetin (EPO)5 Inexp. & Routinely Purch. DME 12 Surgical Dressings 19 Dialysis Supplies & Equipment6 Oxygen and Oxygen Equipment 13 Supplies 20 Oral Antiemetic Drugs7 Parenteral/Enteral Nutrients 14 Not Otherwise ClassifiedCode Description Category CMN/DIFRequiredB4034 ENTERAL FEEDING SUPPLY KIT; SYRINGE FED, PER DAY 1.01MCI (NIST), PER SOURCE (Updated Description 1/1/2008)08B4035 Enteral feeding supply kit; pump fed, per day 08B4036 Enteral feeding supply kit; gravity fed, per day 08B4081 Nasogastric tubing with stylet 08B4082 Nasogastric tubing without stylet 08B4083 Stomach tube - levine type 08B4084 Gastrostomy/jejunostomy tubing (Deleted eff. 12/31/2001) 08B4085 Gastrostomy tube, silicone with sliding ring, each (Deleted eff.12/31/2001)B4086 Gastrostomy/jejunostomy tube, any material, any type (standard orlow profile), each (Deleted eff. 12/31/2007)07B4087 GASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD, ANYMATERIAL, ANY TYPE, EACH (Eff. Date 1/1/2008)B4088 GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFILE, ANYMATERIAL, ANY TYPE, EACH (Eff. Date 1/1/2008)B4100 Food thickener, administered orally, per ounce (Eff. Date 1/1/2003)B4102 Enteral Formula, for adults, used to replace fluids and electrolytes(e.g. clear liquids), 500 ml = 1 unit (Eff. Date 1/1/2005)B4103 Enteral Formula, for pediatrics, used to replace fluids and electrolytes(e.g. clear liquids), 500 ml = 1 unit (Eff. Date 1/1/2005)07 10.03B07 10.03BDME MAC Jurisdiction C Supplier Manual Page 32

HCPCSAppendix AB4104 Additive for enteral formula (e.g. fiber) (Eff. Date 1/1/2005) 07B4149 Enteral formula, manufactured blenderized natural foods with intactnutrients, includes proteins, fats, carbohydrates, vitamins andminerals, may include fiber, administered through an enteral feedingtube, 100 calories = 100 unit (Eff. Date 1/1/2005)B4150 Enteral Formula, nutritionally complete with intact nutrients, includesproteins, fats, carbohydrates, vitamins and minerals, may includefiber, administered through an enteral feeding tube, 100 calories = 1unitB4151 Enteral formulae; category I: natural intact protein/protein isolates,administered through an external feeding tube,100 calories = 1 unit(Deleted eff. 12/31/2004)B4152 Enteral formula, nutritionally complete, calorically dense (equal to orgreater than 1.5 KCL/ML) with intact nutrients, includes proteins, fats,carbohydrates, vitamins and minerals, may include fiber,administered through an enteral feeding tube, 100 calories = 1 unitB4153 Enteral Formula, nutritionally complete, hydrolyzed proteins (aminoacids and peptide chain) includes fats, carbohydrates, vitamins andminerals, may include fiber, administered through an enteral feedingtube, 100 calories = 1 unitB4154 Enteral Formula, nutritionally complete, for special metabolic needs,excludes inherited disease of metabolism, includes alteredcomposition of proteins, fats, carbohydrates, vitamins and/ orminerals, may include fiber, administered through an enteral feedingtube, 100 calories = 1 unitB4155 Enteral Formula, nutritionally incomplete/modular nutrients, includesspecific nutrients, carbohydrates (e.g. glucose polymers),proteins/amino acids (e.g.glutamine, arginine), fat (e.g. medium chaintriglycerides) or combination, administered through an enteralfeeding tube, 100 calories = 1 unitB4156 Enteral formulae; category VI: standardized nutrients, administeredthrough an external feeding tube,100 calories = 1 unit (Deleted eff.12/31/2004)B4157 Enteral Formula, nutritionally complete, for special metabolic needsfor inherited disease of metabolism, includes proteins, fats,carbohydrates, vitamins and minerals, may include fiber,administered through an enteral feeding tube, 100 calories = 1 unit(Eff. Date 1/1/2005)B4158 Enteral Formula, for pediatrics, nutritionally complete with intactnutrients includes proteins, fats, carbohydrates, vitamins andminerals, may include fiber and/or iron, administered through anenteral feeding tube, 100 calories = 1 unit (Eff. Date 1/1/2005)B4159 Enteral Formula, for pediatrics, nutritionally complete soy based withintact nutrients includes proteins, fats, carbohydrates, vitamins andminerals, may include fiber and/or iron, administered through anenteral feeding tube, 100 calories = 1 unit (Eff. Date 1/1/2005)07 10.03B07 10.03B07 10.03B07 10.03B07 10.03B07 10.03B07 10.03B07 10.03B07 10.03B07 10.03B07 10.03BDME MAC Jurisdiction C Supplier Manual Page 33

HCPCSAppendix AB4160 Enteral Formula, for pediatrics, nutritionally complete caloricallydense (equal to or greater than 0.7 KCAL/ ml) with intact nutrientsincludes proteins, fats, carbohydrates, vitamins and minerals, mayinclude fiber, administered through an enteral feeding tube, 100calories = 1 unit (Eff. Date 1/1/2005)B4161 Enteral Formula, for pediatrics, hydrolyzed/amino acids and peptidechain proteins, includes fats, carbohydrates, vitamins and minerals,may include fiber, administered through an enteral feeding tube, 100calories = 1 unit (Eff. Date 1/1/2005)B4162 Enteral Formula, for pediatrics, special metabolic needs for inheriteddisease of metabolism, includes proteins, fats, carbohydrates,vitamins and minerals, may include fiber, administered through anenteral feeding tube, 100 calories = 1 unit (Eff. Date 1/1/2005)B4164 Parenteral nutrition solution: carbohydrates (dextrose), 50% or less(500 ml=1 unit) - homemixB4168 Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) -homemixB4172 Parenteral nutrition solution; amino acid, 5.5% through 7%, (500ml=1 unit) - homemixB4176 Parenteral nutrition solution; amino acid, 7% through 8.5%, (500ml=1 unit) - homemixB4178 Parenteral nutrition solution: amino acid, greater than 8.5% (500ml=1 unit) - homemixB4180 Parenteral nutrition solution; carbohydrates (dextrose), greater than50% (500 ml=1 unit) - homemixB4184 Parenteral nutrition solution; lipids, 10% with administration set (500ml = 1 unit) (Deleted eff. 12/31/2005)07 10.03B07 10.03B07 10.03B07 10.03A07 10.03A07 10.03A07 10.03A07 10.03A07 10.03A07 10.03AB4185 Parenteral nutrition solution, per 10 grams lipids (Eff. Date 1/1/2006) 07 10.03AB4186 Parenteral nutrition solution, lipids, 20% with administration set (500ml = 1 unit) (Deleted eff. 12/31/2005)B4189 Parenteral nutrition solution; compounded amino acid andcarbohydrates with electrolytes, trace elements, and vitamins,including preparation, any strength, 10 to 51 grams of protein -premixB4193 Parenteral nutrition solution; compounded amino acid andcarbohydrates with electrolytes, trace elements, and vitamins,including preparation, any strength, 52 to 73 grams of protein -premixB4197 Parenteral nutrition solution; compounded amino acid andcarbohydrates with electrolytes, trace elements and vitamins,including preparation, any strength, 74 to 100 grams of protein -premix07 10.03A07 10.03A07 10.03A07 10.03ADME MAC Jurisdiction C Supplier Manual Page 34

HCPCSAppendix AB4199 Parenteral nutrition solution; compounded amino acid andcarbohydrates with electrolytes, trace elements and vitamins,including preparation, any strength, over 100 grams of protein -premixB4216 Parenteral nutrition; additives (vitamins, trace elements, heparin,electrolytes) homemix per day07 10.03A07 10.03AB4220 Parenteral nutrition supply kit; premix, per day 08B4222 Parenteral nutrition supply kit; home mix, per day 08B4224 Parenteral nutrition administration kit, per day 08B5000 Parenteral nutrition solution: compounded amino acid andcarbohydrates with electrolytes, trace elements, and vitamins,including preparation, any strength, renal - amirosyn rf, nephramine,renamine - premixB5100 Parenteral nutrition solution: compounded amino acid andcarbohydrates with electrolytes, trace elements, and vitamins,including preparation, any strength, hepatic - freamine hbc,hepatamine - premixB5200 Parenteral nutrition solution: compounded amino acid andcarbohydrates with electrolytes, trace elements, and vitamins,including preparation, any strength, stress - branch chain aminoacids - premix07 10.03A07 10.03A07 10.03AB9000 Enteral nutrition infusion pump - without alarm 09 10.03BB9002 Enteral nutrition infusion pump - with alarm 09 10.03BB9004 Parenteral nutrition infusion pump, portable 09 10.03AB9006 Parenteral nutrition infusion pump, stationary 09 10.03AB9998 NOC for enteral supplies 08B9999 NOC for parenteral supplies 08DME MAC Jurisdiction C Supplier Manual Page 35

HCPCSAppendix AHCPCS EPayment Category1 Capped Rental 8 Parenteral/Enteral Supplies and Kits 15 Nebulizer Drugs2 Freq. & Substantial Serv. DME 9 Parenteral/Enteral Pumps 16 Therapeutic Shoes for Diabetics3 Customized DMEPOS 10 Immunosuppressive Drugs 17 Individual Consideration4 Prosthetics/Orthotics 11 Ostomy, Trach., & Urologicals 18 Epoetin (EPO)5 Inexp. & Routinely Purch. DME 12 Surgical Dressings 19 Dialysis Supplies & Equipment6 Oxygen and Oxygen Equipment 13 Supplies 20 Oral Antiemetic Drugs7 Parenteral/Enteral Nutrients 14 Not Otherwise ClassifiedCode Description Category CMN/DIFRequiredE0100 Cane, includes canes of all materials, adjustable or fixed, with tip 05E0105 Cane, quad or three prong, includes canes of all materials,adjustable or fixed, with tipsE0110 Crutches, forearm, includes crutches of various materials, adjustableor fixed, pair, complete with tips and handgripsE0111 Crutch forearm, includes crutches of various materials, adjustable orfixed, each, with tip and handgripE0112 Crutches underarm, wood, adjustable or fixed, pair, with pads, tipsand handgripsE0113 Crutch underarm, wood, adjustable or fixed, each, with pad, tip andhandgripE0114 Crutches underarm, other than wood, adjustable or fixed, pair, withpads, tips and handgripsE0116 Crutch, underarm, other than wood, adjustable or fixed, with pad, tip,handgrip, with or without shock absorber, eachE0117 Crutch, underarm, articulating, spring assisted, each (Eff. Date1/1/2003)E0118 Crutch substitute, lower leg platform, with or without wheels, each(Eff. Date 1/1/2004)050505050505050505E0130 Walker, rigid (pickup), adjustable or fixed height 05E0135 Walker, folding (pickup), adjustable or fixed height 05E0140 Walker, with trunk support, adjustable or fixed height, any type (Eff. 05DME MAC Jurisdiction C Supplier Manual Page 36

HCPCSAppendix ADate 1/1/2004)E0141 Walker, rigid, wheeled, adjustable or fixed height 05E0142 Rigid walker, wheeled, with seat (not valid for Medicare as of5/1/1999) (Deleted eff. 12/31/2003)05E0143 Walker, folding, wheeled, adjustable or fixed height 05E0144 Walker, enclosed, four-sided framed, rigid or folding, wheeled withposterior seat (Eff. Date 1/1/2000)E0145 Walker, wheeled, with seat and crutch attachments (not valid forMedicare as of 5/1/1999) (Deleted eff. 12/31/2003)0501E0146 Folding walker, wheeled, with seat (Deleted eff. 12/31/2003) 01E0147 Walker, heavy duty, multiple braking system, variable wheelresistanceE0148 Walker, heavy duty, without wheels, rigid or folding, any type, each(Eff. Date 1/1/2001)E0149 Walker, heavy duty, wheeled, rigid or folding, any type (Eff. Date1/1/2001)050505E0153 Platform attachment, forearm crutch, each 05E0154 Platform attachment, walker, each 05E0155 Wheel attachment, rigid pick-up walker, per pair 05E0156 Seat attachment, walker 05E0157 Crutch attachment, walker, each 05E0158 Leg extensions for walker, per set of four (4) 05E0159 Brake attachment for wheeled walker, replacement, each 05E0160 Sitz type bath or equipment, portable, used with or without commode 05E0161 Sitz type bath or equipment, portable, used with or withoutcommode, with faucet attachment/s05E0162 Sitz bath chair 05E0163 Commode chair, stationary, with fixed arms 05E0164 Commode chair, mobile, with fixed arms 05E0165 Commode chair, stationary, with detachable arms 01E0166 Commode chair, mobile, with detachable arms 01E0167 Pail or pan for use with commode chair 05E0168 Commode chair, extra wide and/or heavy duty, stationary or mobile,with or without arms, any type, each (Eff. Date 1/1/2001)05DME MAC Jurisdiction C Supplier Manual Page 37

HCPCSAppendix AE0169 Commode chair with seat lift mechanism (Eff. Date 1/1/2002)(Deleted eff. 12/31/2005)E0170 Commode chair with integrated seat lift mechanism, electric, anytype(Eff. Date 1/1/2006)E0171 Commode chair with integrated seat lift mechanism, non-electric,any type(Eff. Date 1/1/2006)010101E0172 Seat lift mechanism placed over or on top of toilet, any type(Eff. Date 1/1/2006)E0175 Foot rest, for use with commode chair, each 05E0176 Air pressure pad or cushion, nonpositioning (Deleted Eff. 06/30/04) 05E0177 Water pressure pad or cushion, nonpositioning (Deleted Eff.06/30/04)E0178 Gel or gel-like pressure pad or cushion, nonpositioning (Deleted Eff.06/30/04)0505E0179 Dry pressure pad or cushion, nonpositioning (Deleted Eff. 06/30/04) 05E0180 Pressure pad, alternating with pump (deleted 12/31/06) 01E0181 Powered pressure reducing mattress overlay/pad, alternating, withpump, includes heavy duty01E0182 Pump for alternating pressure pad, for replacement only 01E0184 Dry pressure mattress 05E0185 Gel or gel-like pressure pad for mattress, standard mattress lengthand width05E0186 Air pressure mattress 01E0187 Water pressure mattress 01E0188 Synthetic sheepskin pad 05E0189 Lambswool sheepskin pad, any size 05E0190 Positioning cushion/pillow/wedge, any shape or size, includes allcomponents and accessories (Eff. Date 1/1/2004)05E0191 Heel or elbow protector, each 05E0192 Low pressure and positioning equalization pad, for wheelchair(Deleted Eff. 06/30/04)05E0193 Powered air flotation bed (low air loss therapy) 01E0194 Air fluidized bed 01E0196 Gel pressure mattress 01DME MAC Jurisdiction C Supplier Manual Page 38

HCPCSAppendix AE0197 Air pressure pad for mattress, standard mattress length and width 05E0198 Water pressure pad for mattress, standard mattress length and width 05E0199 Dry pressure pad for mattress, standard mattress length and width 05E0200 Heat lamp, without stand (table model), includes bulb, or infraredelement05E0202 Phototherapy (bilirubin) light with photometer 01E0203 Therapeutic lightbox, minimum 10,000 LUX, table top model (Eff.Date 1/1/2003)05E0205 Heat lamp, with stand, includes bulb, or infrared element 05E0210 Electric heat pad, standard 05E0215 Electric heat pad, moist 05E0217 Water circulating heat pad with pump 05E0218 Water circulating cold pad with pump 01E0220 Hot water bottle 05E0221 Infrared heating pad system (Eff. Date 1/1/2002) 05E0225 Hydrocollator unit, includes pads 05E0230 Ice cap or collar 05E0231 Non-contact wound warming device (temperature control unit, ACadapter and power cord) for use with warming card and wound cover(Eff. Date 1/1/2002)E0232 Warming card for use with the non-contact wound warming deviceand non-contact wound warming wound cover (Eff. Date 1/1/2002)E0235 Paraffin bath unit, portable (see medical supply code A4265 forparaffin)011301E0236 Pump for water circulating pad 01E0237 Water circulating heat/cold pad with pump (Deleted eff. 12/31/1996) 05E0238 Non-electric heat pad, moist 05E0239 Hydrocollator unit, portable 05E0240 Bath/shower chair, with or without wheels, any size (Eff. Date1/1/2004)E0241 Bath tub wall rail, eachE0242 Bath tub rail, floor baseE0243 Toilet rail, eachDME MAC Jurisdiction C Supplier Manual Page 39

HCPCSAppendix AE0244 Raised toilet seatE0245 Tub stool or benchE0246 Transfer tub rail attachmentE0247 Transfer bench for tub or toilet with or without commode opening(Eff. Date 1/1/2004)E0248 Transfer bench, heavy duty, for tub or toilet with or without commodeopening (Eff. Date 1/1/2004)0505E0249 Pad for water circulating heat unit 05E0250 Hospital bed, fixed height, with any type side rails, with mattress 01E0251 Hospital bed, fixed height, with any type side rails, without mattress 01E0255 Hospital bed, variable height, hi-lo, with any type side rails, withmattressE0256 Hospital bed, variable height, hi-lo, with any type side rails, withoutmattressE0260 Hospital bed, semi-electric (head and foot adjustment), with any typeside rails, with mattressE0261 Hospital bed, semi-electric (head and foot adjustment), with any typeside rails, without mattressE0265 Hospital bed, total electric (head, foot and height adjustments), withany type rails, with mattressE0266 Hospital bed, total electric (head, foot and height adjustments), withany type side rails, without mattress010101010101E0270 Hospital bed, institutional type includes: oscillating, circulating andstryker frame, with mattressE0271 Mattress, innerspring 05E0272 Mattress, foam rubber 05E0273 Bed boardE0274 Over-bed tableE0275 Bed pan, standard, metal or plastic 05E0276 Bed pan, fracture, metal or plastic 05E0277 Powered pressure-reducing air mattress 01E0280 Bed cradle, any type 05E0290 Hospital bed, fixed height, without side rails, with mattress 01E0291 Hospital bed, fixed height, without side rails, without mattress 01DME MAC Jurisdiction C Supplier Manual Page 40

HCPCSAppendix AE0292 Hospital bed, variable height, hi-lo, without side rails, with mattress 01E0293 Hospital bed, variable height, hi-lo, without side rails, withoutmattressE0294 Hospital bed, semi-electric (head and foot adjustment), without siderails, with mattressE0295 Hospital bed, semi-electric (head and foot adjustment), without siderails, without mattressE0296 Hospital bed, total electric (head, foot and height adjustments).without side rails, with mattressE0297 Hospital bed, total electric (head, foot and height adjustments),without side rails, without mattressE0298 Hospital bed, heavy duty, extra wide, with any type side rails, withmattress (Deleted eff. 6/30/2001)010101010101E0300 Pediatric crib, hospital grade, fully enclosed (Eff. Date 1/1/2004) 05E0301 Hospital bed, heavy duty, extra wide, with weight capacity greaterthan 350 pounds, but less than or equal to 600 pounds, with anytype side rails, without mattress (Eff. Date 1/1/2004)E0302 Hospital bed, extra heavy duty, extra wide, with weight capacitygreater than 600 pounds, with any type side rails, without mattress(Eff. Date 1/1/2004)E0303 Hospital bed, heavy duty, extra wide, with weight capacity greaterthan 350 pounds, but less than or equal to 600 pounds, with anytype side rails, with mattress(Eff. Date 1/1/2004)E0304 Hospital bed, extra heavy duty, extra wide, with weight capacitygreater than 600 pounds, with any type side rails, with mattress (Eff.Date 1/1/2004)01010101E0305 Bed side rails, half length 01E0310 Bed side rails, full length 05E0315 Bed accessory: board, table, or support device, any typeE0316 Safety enclosure frame/canopy for use with hospital bed, any type(Eff. Date 1/1/2002)01E0325 Urinal; male, jug-type, any material 05E0326 Urinal; female, jug-type, any material 05E0328 HOSPITAL BED, PEDIATRIC, MANUAL, 360 DEGREE SIDEENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDERAILS UP TO 24 INCHES ABOVE THE SPRING, INCLUDESMATTRESS (Eff. Date 1/1/2008)01E0329 HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 01DME MAC Jurisdiction C Supplier Manual Page 41

HCPCSAppendix A360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD,FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THESPRING, INCLUDES MATTRESS (Eff. Date 1/1/2008)E0350 Control unit for electronic bowel irrigation/evacuation systemE0352 Disposable pack (water reservoir bag, speculum, valving mechanismand collection bag/box) for use with the electronic bowelirrigation/evacuation systemE0370 Air pressure elevator for heel 05E0371 Nonpowered advanced pressure reducing overlay for mattress,standard mattress length and widthE0372 Powered air overlay for mattress, standard mattress length andwidth0101E0373 Nonpowered advanced pressure reducing mattress 01E0424 Stationary compressed gaseous oxygen system, rental; includescontents, regulator, flowmeter, humidifier, nebulizer, cannula ormask, & tubingE0425 Stationary compressed gas system, purchase; includes regulator,flowmeter, humidifier, nebulizer, cannula or mask, and tubingE0430 Portable gaseous oxygen system, purchase; includes regulator,flowmeter, humidifier, cannula or mask, and tubingE0431 Portable gaseous oxygen system, rental; includes portablecontainer, regulator, flowmeter, humidifier, cannula or mask, andtubingE0434 Portable liquid oxygen system, rental; includes portable container,supply reservoir, humidifier, flowmeter, refill adaptor, contentsgauge, cannula or mask, and tubingE0435 Portable liquid oxygen system, purchase; includes portablecontainer, supply reservoir, flowmeter, humidifier, contents gauge,cannula or mask, tubing and refill adaptorE0439 Stationary liquid oxygen system, rental; includes use of reservoir,contents, regulator, flowmeter, humidifier, nebulizer, cannula ormask, & tubingE0440 Stationary liquid oxygen system, purchase; includes use of reservoir,contents indicator, regulator, flowmeter, humidifier, nebulizer,cannula or mask, and tubingE0441 Oxygen contents, gaseous, (for use with owned gaseous stationarysystems or when both a stationary and portable gaseous system areowned), 1 monthly's supply = 1 unitE0442 Oxygen contents, liquid, (for use with owned liquid stationarysystems or when both a stationary and portable liquid system areowned), 1 month's supply = 1 unit06 484.3060606 484.306 484.30606 484.30606 484.306 484.3DME MAC Jurisdiction C Supplier Manual Page 42

HCPCSAppendix AE0443 Portable oxygen contents, gaseous, (for use only with portablegaseous systems when no stationary gas or liquid system is used), 1month's supply = 1 unitE0444 Portable oxygen contents, liquid, (for use only with portable liquidsystems when no stationary gas or liquid system is used), 1month'ssupply = 1 unitE0445 Oximeter device for measuring blood oxygen levels non-invasively(Eff. Date 1/1/2003)E0450 Volume control ventilator, without pressure support mode, mayinclude pressure control mode, used with invasive interface (e.g.,tracheostomy tube)E0452 Intermittent assist device with continuous positive airway pressuredevice (CPAP) (Deleted eff. 12/31/1999)E0453 Therapeutic ventilator; suitable for use 12 hours or less per day(Deleted eff. 12/31/1999)E0454 Pressure ventilator with pressure control, pressure support and flowtriggering features (Eff. Date 1/1/2003) (Deleted eff. 12/31/2004)06 484.306 484.30602010202E0455 Oxygen tent, excluding croup or pediatric tents 06E0457 Chest shell (cuirass) 02E0459 Chest wrap 01E0460 Negative pressure ventilator; portable or stationary 02E0461 Volume control ventilator, without pressure support mode, mayinclude pressure control mode, used with non-invasive interface (e.g.mask) (Eff. Date 1/1/2003)02E0462 Rocking bed with or without side rails 01E0463 Pressure support ventilator with volume control mode, may includepressure control mode, used with invasive interface (e.g.tracheostomy tube) (Eff. Date 1/1/2005)E0464 Pressure support ventilator, with volume control mode, may includepressure control mode, used with non-invasive interface (e.g. mask)(Eff. Date 1/1/2005)E0470 Respiratory assist device, bi-level pressure capability, withoutbackup rate feature, used with noninvasive interface, e.g. nasal orfacial mask (intermittent assist device with continuous positiveairway pressure device) (Eff. Date 1/1/2004)E0471 Respiratory assist device, bi-level pressure capability, with backuprate feature, used with noninvasive interface, e.g. nasal or facialmask (intermittent assist device with continuous positive airwaypressure device) (Eff. Date 1/1/2004)E0472 Respiratory assist device, bi-level pressure capability, with backuprate feature, used with invasive interface, e.g. tracheostomy tube0202010101DME MAC Jurisdiction C Supplier Manual Page 43

HCPCSAppendix A(intermittent assist device with continuous positive airway pressuredevice) (Eff. Date 1/1/2004)E0480 Percussor, electric or pneumatic, home model 01E0481 Intrapulmonary percussive ventilation system and relatedaccessories (not valid for Medicare) (Eff. Date 1/1/2002)E0482 Cough stimulating device, alternating positive and negative airwaypressure (Eff. Date 1/1/2002)E0483 High frequency chest wall oscillation air-pulse generator system,(includes hoses and vest), each (Eff. Date 1/1/2003)E0484 Oscillatory positive expiratory pressure device, non-electric, anytype, each (Eff. Date 1/1/2003)E0485 Oral device/appliance used to reduce upper airway collapsibility,adjustable or non-adjustable, prefabricated, includes fitting andadjustment(Eff. Date 1/1/2006)E0486 Oral device/appliance used to reduce upper airway collapsibility,adjustable or non-adjustable, custom fabricated, includes fitting andadjustment (Eff. Date 1/1/2006)E0500 IPPB machine, all types, with built-in nebulization; manual orautomatic valves; internal or external power sourceE0550 Humidifier, durable for extensive supplemental humidification duringIPPB treatments or oxygen deliveryE0555 Humidifier, durable, glass or autoclavable plastic bottle type, for usewith regulator or flowmeterE0560 Humidifier, durable for supplemental humidification during IPPBtreatment or oxygen deliveryE0561 Humidifier, non-heated, used with positive airway pressure device(Eff. Date 1/1/2004)E0562 Humidifier, heated, used with positive airway pressure device (Eff.Date 1/1/2004)E0565 Compressor, air power source for equipment which is not selfcontainedor cylinder driven010105050502010605050501E0570 Nebulizer, with compressor 01E0571 Aerosol compressor, battery powered, for use with small volumenebulizer (Eff. Date 1/1/2001)E0572 Aerosol compressor, adjustment pressure, light duty for intermittentuse (Eff. Date 1/1/2001)E0574 UItrasonic/eletronic generator with small volume nebulizer (Eff. Date1/1/2001)010101DME MAC Jurisdiction C Supplier Manual Page 44

HCPCSAppendix AE0575 Nebulizer; ultrasonic, large volume 02E0580 Nebulizer, durable, glass or autoclavable plastic, bottle type, for usewith regulator or flowmeter06E0585 Nebulizer, with compressor and heater 01E0590 Dispensing fee covered drug administered through DME nebulizer(Eff. Date 1/1/2000) (Deleted eff. 12/31/2004)E0600 Respiratory suction pump, home model, portable or stationary,electric (Eff. Date 1/1/2002)1501E0601 Continuous airway pressure (CPAP) device 01E0602 Breast pump, manual, any type (Eff. Date 1/1/2002)E0603 Breast pump, electric (AC and/or DC), any type (Eff. Date 1/1/2002)E0604 BREAST PUMP, HOSPITAL GRADE, ELECTRIC (AC AND / ORDC), ANY TYPE (Updated Description 1/1/2008)E0605 Vaporizer, room type 05E0606 Postural drainage board 01E0607 Home blood glucose monitor 05E0608 Apnea monitor (Deleted eff.12/31/2002) 01E0609 Blood glucose monitor with special features (eg., voice synthesizersautomatic timers, etc.) (Deleted eff. 12/31/2001)E0610 Pacemaker monitor, self-contained, (checks battery depletion,includes audible and visible check systems)E0615 Pacemaker monitor, self contained, checks battery depletion andother pacemaker components, includes digital/visible check systems050505E0616 Implantable cardiac event recorder with memory, activator andprogrammer (Eff. Date 1/1/2000)E0617 External defibrillator with integrated electrocardiogram analysis (Eff.Date 1/1/2001)E0618 Apnea monitor, without recording feature (Eff. Date 1/1/2003) 01E0619 Apnea monitor, with recording feature (Eff. Date 1/1/2003) 01E0620 Skin piercing device for collection of capillary blood, laser, each (Eff.Date 1/1/2002)05E0621 Sling or seat, patient lift, canvas or nylon 05E0625 Patient lift, bathroom or toilet, not otherwise classified (not payableby Medicare) (Eff. Date 1/1/2005)E0627 Seat lift mechanism incorporated into a combination lift-chairmechanism05 07.03ADME MAC Jurisdiction C Supplier Manual Page 45

HCPCSAppendix AE0628 Separate seat lift mechanism for use with patient owned furnitureelectricE0629 Separate seat lift mechanism for use with patient owned furniturenon-electricE0630 PATIENT LIFT, HYDRAULIC OR MECHANICAL, INCLUDES ANYSEAT, SLING, STRAP(S) OR PAD(S) (Updated Description1/1/2008)05 07.03A05 07.03A01E0635 Patient lift, electric with seat or sling 01E0636 Multipositional patient support system, with integrated lift, patientaccessible controls (Eff. Date 1/1/2003)E0637 Combination sit to stand, any size including pediatric, with seatliftfeature, with or without wheels (Eff. Date 1/1/2004)E0638 Standing frame system, one position (e.g., upright, supine or pronestander) and size including pediatric, with or without wheels (Eff.Date 1/1/2004)010505E0639 Patient lift, moveable from room to room with disassembly andreassembly, includes all components/accessories (Eff. Date1/1/2005)E0640 Patient lift, fixed system, includes all components/accessories (Eff.Date 1/1/2005)E0641 Standing frame system, multi-position (e.g., three-way stander), anysizeincluding pediatric, with or without wheels (Eff. Date 1/1/2006)E0642 Standing frame system, mobile (dynamic stander), any size includingpediatric (Eff. Date 1/1/2006)E0650 Pneumatic compressor, non-segmental home model 05 04.04BE0651 Pneumatic compressor, segmental home model without calibratedgradient pressureE0652 Pneumatic compressor, segmental home model with calibratedgradient pressureE0655 Non-segmental pneumatic appliance for use with pneumaticcompressor, half armE0660 Non-segmental pneumatic appliance for use with pneumaticcompressor, full legE0665 Non-segmental pneumatic appliance for use with pneumaticcompressor, full armE0666 Non-segmental pneumatic appliance for use with pneumaticcompressor, half legE0667 Segmental pneumatic appliance for use with pneumatic compressor,full leg05 04.04B05 04.04B05 04.04B05 04.04B05 04.04B05 04.04B05 04.04BDME MAC Jurisdiction C Supplier Manual Page 46

HCPCSAppendix AE0668 Segmental pneumatic appliance for use with pneumatic compressor,full armE0669 Segmental pneumatic appliance for use with pneumatic compressor,half legE0670 Segmental pneumatic appliance for use with pneumatic compressor,half arm (Deleted eff. 12/31/1994)05 04.04B05 04.04B05 04.04BE0671 Segmental gradient pressure pneumatic appliance, full leg 05 04.04BE0672 Segmental gradient pressure pneumatic appliance, full arm 05 04.04BE0673 Segmental gradient pressure pneumatic appliance, half leg 05 04.04BE0675 Pneumatic compression device, high pressure, rapidinflation/deflation cycle, for arterial insufficiency (unilateral or bilateralsystem) (Eff. Date 1/1/2004)01E0676 Intermittent limb compression device (includes all accessories), nototherwise classified (effective 01/01/2007)E0690 Ultraviolet cabinet, appropriate for home use (Deletedeff.12/31/2002)E0691 Ultraviolet light therapy system panel, includes bulbs/lamps, timerand eye protection; treatment area 2 square feet or less (Eff. Date1/1/2003)E0692 Ultraviolet light therapy system panel, includes bulb/lamps, timer andeye protection; 4 foot panel (Eff. Date 1/1/2003)E0693 Ultraviolet light therapy system panel, includes bulb/lamps, timer andeye protection; 6 foot panel (Eff. Date 1/1/2003)E0694 Ultraviolet multidirectional light therapy system in 6 foot cabinet,,includes bulb/lamps, timer and eye protection (Eff. Date 1/1/2003)0505050505E0700 Safety equipment (e.g., belt, harness or vest) (deleted 01/01/2007)E0701 Helmet with face guard and soft interface material, prefabricated(Eff. Date 1/1/2003)05E0705 TRANSFER DEVICE, ANY TYPE, EACH (Updated Description1/1/2008)E0710 Restraints, any type (body, chest, wrist or ankle)E0720 Transcutaneous Electrical Nerve Stimulation (TENS) device, twolead, localized stimulationE0730 Transcutaneous Electrical Nerve Stimulation (TENS) device, four ormore leads, for multiple nerve stimulationE0731 Form fitting conductive garment for delivery of TENS or NMES (withconductive fibers separated from the patient’s skin by layers offabric)05 06.03B05 06.03B05DME MAC Jurisdiction C Supplier Manual Page 47

HCPCSAppendix AE0740 Incontinence treatment system, pelvic floor stimulator, monitor,sensor and/or trainer05E0744 Neuromuscular stimulator for scoliosis 01E0745 Neuromuscular stimulator, electronic shock unit 01E0746 Electromyography (EMG), biofeedback deviceE0747 Osteogenesis stimulator, electrical, non-invasive, other than spinalapplications05 04.04CE0748 Osteogenesis stimulator, electrical, non-invasive, spinal applications 05 04.04CE0749 Osteogenesis stimulator, electrical, surgically implantedE0751 Implantable neurostimulator pulse generator, or combination ofexternal transmitter with implantable receiver (includes extension)E0753 Implantable neurostimulator electrodes, per group of four (Deletedeff. 12/31/2001)E0755 Electronic salivary reflex stimulator (intra-oral/non-invasive)E0760 Ostogenesis stimulator, low intensity ultrasound, non-invasive 05E0761 Non-thermal pulsed high frequency radiowaves, high peak powerelectromagnetic energy treatment device (Eff. Date 1/1/2003)E0762 Transcutaneous electrical joint stimulation device system, includesallaccessories (Eff. Date 1/1/2006)E0764 Functional neuromuscular stimulator, transcutaneous stimulation ofmuscles of ambulation with computer control, used for walking byspinal cord injured, entire system, after completion of trainingprogram(Eff. Date 1/1/2006)170105E0765 FDA approver nerve stimulator, with replaceable batteries, fortreatment of nausea and vomiting (Eff. Date 1/1/2001)E0769 Electrical stimulation or electromagnetic wound treatment device, nototherwise classified (Eff. Date 1/1/2005)E0776 IV pole 05 09.03E0779 Ambulatory infusion pump, mechanical, reusable, for infusion 8hours or greater (Eff. Date 1/1/2000)E0780 Ambulatory infusion pump, mechanical, reusable, for infusion lessthan 8 hours (Eff. Date 1/1/2000)E0781 Ambulatory infusion pump, single or multiple channels, electric orbattery operated, with administrative equipment, worn by patientE0782 Infusion pump, implantable, non-programmable (includes allcomponents, e.g., pump, catheter, connectors, etc.)01 09.0305 09.0301 09.0305DME MAC Jurisdiction C Supplier Manual Page 48

HCPCSAppendix AE0783 Infusion pump system, implantable, programmable (includes allcomponents, e.g., pump, catheter, connectors, etc.)05E0784 External ambulatory infusion pump, insulin 01 09.03E0785 Implantable intraspinal (epidural/intrathecal) catheter used withimplantable infusion pump, replacementE0791 Parenteral infusion pump, stationary, single or multi-channel 01 09.03E0830 Ambulatory traction device, all types, each (Eff. Date 1/1/2001)E0840 Traction frame, attached to headboard, cervical traction 05E0849 Traction equipment, cervical, free-standing stand/frame, pneumatic,applying traction force to other than mandible (Eff. Date 1/1/2005)05E0850 Traction stand, free standing, cervical traction 05E0855 Cervical traction equipment not requiring additional stand or frame 05E0856 CERVICAL TRACTION DEVICE, CERVICAL COLLAR WITHINFLATABLE AIR BLADDER (Eff. Date 1/1/2008)05E0860 Traction equipment, overdoor, cervical 05E0870 Traction frame, attached to footboard, extremity traction, (e.g.buck’s)05E0880 Traction stand, free standing, extremity traction, (e.g., buck’s) 05E0890 Traction frame, attached to footboard, pelvic traction 05E0900 Traction stand, free standing, pelvic traction, (e.g., buck’s) 05E0910 Trapeze bars, a/k/a patient helper, attached to bed, with grab bar 01E0911 Trapeze bar, heavy duty, for patient weight capacity greater than250pounds, attached to bed, with grab bar (Eff. Date 1/1/2006)E0912 Trapeze bar, heavy duty, for patient weight capacity greater than250pounds, free standing, complete with grab bar (Eff. Date 1/1/2006)0101E0920 Fracture frame, attached to bed, includes weights 01E0930 Fracture frame, free standing, includes weights 01E0935 Continuous passive motion exercise device for use on knee only 02E0936 Continuous passive motion exercise device for use other than knee(effective 01/01/2007)E0940 Trapeze bar, free standing, complete with grab bar 01E0941 Gravity assisted traction device, any type 01E0942 Cervical head harness/halter 05DME MAC Jurisdiction C Supplier Manual Page 49

HCPCSAppendix AE0943 Cervical pillow (Deleted eff. 12/31/2003) 05E0944 Pelvic belt/harness/boot 05E0945 Extremity belt/harness 05E0946 Fracture, frame, dual with cross bars, attached to bed, (e.g. balken,4 poster)01E0947 Fracture frame, attachments for complex pelvic traction 05E0948 Fracture frame, attachments for complex cervical traction 05E0950 Wheelchair accessory, tray, each 05E0951 Heel loop/holder, any type, with or without ankle strap, each 05E0952 Toe loop/holder, any type, each 05E0955 Wheelchair accessory, headrest, cushioned, any type, includingfixed mounting hardware, each (Eff. Date 1/1/2004)E0956 Wheelchair accessory, lateral trunk or hip support, any type,including fixed mounting hardware, each (Eff. Date 1/1/2004)E0957 Wheelchair accessory, medial thigh support, any type, includingfixed mounting hardware, each (Eff. Date 1/1/2004)E0958 Manual wheelchair accessory, one-arm drive attachment, each (Eff.Date 1/1/2003)E0959 Manual wheelchair accessory, adapter for amputee, each (Eff. Date1/1/2004)E0960 Wheelchair accessory, shoulder harness/straps or chest strap,including any type mounting hardware (Eff. Date 1/1/2004)E0961 Manual wheelchair accessory, wheel lock brake extension (handle),each (Eff. Date 1/1/2004)05050501050505E0962 1" cushion, for wheelchair (Deleted Eff. 06/30/04) 05E0963 2" cushion, for wheelchair (Deleted Eff. 06/30/04) 05E0964 3" cushion, for wheelchair (Deleted Eff. 06/30/04) 05E0965 4" cushion, for wheelchair (Deleted Eff. 06/30/04) 05E0966 Manual wheelchair accessory, headrest extension, each (Eff. Date1/1/2004)E0967 Manual wheelchair accessory, hand rim with projections, any type,each (Eff. Date 1/1/2004)0505E0968 Commode seat, wheelchair (Deleted eff. 1/1/1993) 01E0969 Narrowing device, wheelchair (Deleted eff. 1/1/1993) 05E0971 Manual Wheelchair accessory, anti-tipping device, each (Eff. Date 05DME MAC Jurisdiction C Supplier Manual Page 50

HCPCSAppendix A1/1/2003)E0972 Wheelchair accessory, transfer board or device, each (Eff. Date1/1/2004) (Deleted eff. 12/31/2005)E0973 Wheelchair accessory, adjustable height, detachable armrest,complete assembly, each (Eff. Date 1/1/2004)E0974 Manual wheelchair accessory, anti-rollback device, each (Eff. Date1/1/2004)050505E0977 Wedge cushion, wheelchair (Deleted eff. 1/1/1993) 05E0978 Wheelchair accessory, positioning belt/safety belt/pelvic strap, each(Eff. Date 1/1/2004)E0981 Wheelchair accessory, seat upholstery, replacement only, each (Eff.Date 1/1/2004)E0982 Wheelchair accessory, back upholstery, replacement only, each (Eff.Date 1/1/2004)E0983 Manual wheelchair accessory, power add-on to convert manualwheelchair to motorized wheelchair, joystick control (Eff. Date1/1/2004)E0984 Manual wheelchair accessory, power add-on to convert manualwheelchair to motorized wheelchair, tiller control (Eff. Date 1/1/2004)0505050505E0985 Wheelchair accessory, seat lift mechanism (Eff. Date 1/1/2004) 05E0986 Manual wheelchair accessory, push activated power assist, each(Eff. Date 1/1/2004)E0990 Wheelchair accessory, elevating leg rest, complete assembly, each(Eff. Date 1/1/2004)0505E0992 Manual wheelchair accessory, solid seat insert (Eff. Date 1/1/2004) 05E0995 Wheelchair accessory, calf rest/pad, each (Eff. Date 1/1/2004) 05E1002 Wheelchair accessory, power seating system, tilt only (Eff. Date1/1/2004)E1003 Wheelchair accessory, power seating system, recline only, withoutshear reduction (Eff. Date 1/1/2004)E1004 Wheelchair accessory, power seating system, recline only, withmechanical shear reduction (Eff. Date 1/1/2004)E1005 Wheelchair accessory, power seating system, recline only, withpower shear reduction (Eff. Date 1/1/2004)E1006 Wheelchair accessory, power seating system, combination tilt andrecline, without shear reduction (Eff. Date 1/1/2004)E1007 Wheelchair accessory, power seating system, combination tilt andrecline, with mechanical shear reduction (Eff. Date 1/1/2004)050505050505DME MAC Jurisdiction C Supplier Manual Page 51

HCPCSAppendix AE1008 Wheelchair accessory, power seating system, combination tilt andrecline, with power shear reduction (Eff. Date 1/1/2004)E1009 Wheelchair accessory, addition to power seating system,mechanically linked leg elevation system, including pushrod andlegrest, each (Eff. Date 1/1/2004)E1010 Wheelchair accessory, addition to power seating system, power legelevation system, including leg rest, pair (Eff. Date 1/1/2004)E1011 Modification to pediatric size wheelchair, width adjustment package(not to be dispensed with initial chair) (Eff. Date 1/1/2003)E1012 Integrated seating system, planar, for pediatric wheelchair (Eff. Date1/1/2003) (Deleted Eff. 06/30/04)E1013 Integrated seating system, contoured, for pediatric wheelchair (Eff.Date 1/1/2003) (Deleted Eff. 06/30/04)E1014 Reclining back, addition to pediatric size wheelchair (Eff. Date1/1/2003)05050505050505E1015 Shock absorber for manual wheelchair, each (Eff. Date 1/1/2003) 05E1016 Shock absorber for power wheelchair, each (Eff. Date 1/1/2003) 05E1017 Heavy duty shock absorber for heavy duty or extra heavy dutymanual wheelchair, each (Eff. Date 1/1/2003)E1018 Heavy duty shock absorber for heavy duty or extra heavy duty powerwheelchair, each (Eff. Date 1/1/2003)0505E1020 Residual limb support system for wheelchair (Eff. Date 1/1/2003) 05E1025 Lateral thoracic support, non-contoured, for pediatric wheelchair,each (includes hardware) (Eff. Date 1/1/2003) (Deleted eff.12/31/2005)E1026 Lateral thoracic support, contoured, for pediatric wheelchair, each(includes hardware) (Eff. Date 1/1/2003) (Deleted eff. 12/31/2005)E1027 Lateral/anterior support, for pediatric wheelchair, each (includeshardware) (Eff. Date 1/1/2003) (Deleted eff. 12/31/2005)E1028 Wheelchair accessory, manual swingaway, retractable, or removablemounting hardware for joystick, other control interface or positioningaccessory (Eff. Date 1/1/2004)05050505E1029 Wheelchair accessory, ventilator tray, fixed (Eff. Date 1/1/2004) 05E1030 Wheelchair accessory, ventilator tray, gimbaled (Eff. Date 1/1/2004) 05E1031 Rollabout chair, any and all types with castors 5" or greater 01E1035 Multi-positional patient transfer system, with integrated seat,operated by care giver (Eff. Date 1/1/2001)E1037 Transport chair, pediatric size (Eff. Date 1/1/2003) 01DME MAC Jurisdiction C Supplier Manual Page 52

HCPCSAppendix AE1038 Transport chair, adult size, patient weight capacity up to andincluding 300 pounds (Eff. Date 1/1/2003)E1039 Transport chair, adult size, heavy duty, patient weight capacitygreater than 300 pounds (Eff. Date 1/1/2005)E1161 Manual adult size wheelchair, includes tilt in space (Eff. Date1/1/2003)E1225 Wheelchair accessory, manual semi-reclining back, (recline greaterthan 15 degrees, but less than 80 degrees), each (Eff. Date1/1/2004)E1226 Wheelchair accessory, manual fully reclining back, (recline greaterthan 80 degrees), each (Eff. Date 1/1/2004)E1229 Wheelchair pediatric size, not otherwise specified (Eff. Date1/1/2005)E1230 Power operated vehicle (three or four wheel nonhighway) specifybrand name and model numberE1231 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seatingsystem (Eff. Date 1/1/2003)E1232 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, withseating system (Eff. Date 1/1/2003)E1233 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, withoutseating system (Eff. Date 1/1/2003)E1234 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, withoutseating system (Eff. Date 1/1/2003)E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system(Eff. Date 1/1/2003)E1236 Wheelchair, pediatric size, folding, adjustable, with seating system(Eff. Date 1/1/2003)E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system(Eff. Date 1/1/2003)E1238 Wheelchair, pediatric size, folding, adjustable, without seatingsystem (Eff. Date 1/1/2003)E1239 Power wheelchair, pediatric size, not otherwise specified (Eff. Date1/1/2005)01010501050505050505050505050505E1300 Whirlpool, portable (overtub type)E1310 Whirlpool, non-portable (built-in type) 05E1340 Repair or nonroutine service for durable medical equipment requiringthe skill of a technician, labor component, per 15 minutesE1350 Repair or non-routine service (e.g., breaking down sealedcomponents) requiring the skill of a technician (Deleted eff.DME MAC Jurisdiction C Supplier Manual Page 53

HCPCSAppendix A12/31/1996)E1353 Regulator 06 484.3E1355 Stand/rack 06E1372 Immersion external heater for nebulizer 05E1375 Nebulizer portable with small compressor, with limited flow 05E1390 Oxygen concentrator, single delivery port, capable of delivering 85percent or greater concentration at the prescribed flow rate (Eff.Date 1/1/2000)E1391 Oxygen concentrator, dual delivery port, capable of delivering 85percent or greater oxygen concentration at the prescribed flow rate,each (Eff. Date 1/1/2004)06 484.305 484.3E1392 Portable oxygen concentrator, rental (Eff. Date 1/1/2006) 06 484.3E1399 Durable medical equipment, miscellaneous 14E1400 Oxygen concentrator, manufacturer specified maximum flow ratedoes not exceed 2 liters per minute, at 85 percent or greaterconcentration. (Deleted eff. 12/31/1999)E1401 Oxygen concentrator, manufacturer specified maximum flow rategreater than 2 liters per minute, does not exceed 3 liters per minute,at 85 percent or greater concentration (Deleted eff. 12/31/1999)E1402 Oxygen concentrator, manufacturer specified maximum flow rategreater than 3 liters per minute, does not exceed 4 liters per minute,at 85 percent or greater concentration (Deleted eff. 12/31/1999)E1403 Oxygen concentrator, manufacturer specified maximum flow rategreater than 4 liters per minute, does not exceed 5 liters per minute,at 85 percent or greater concentration (Deleted eff. 12/31/1999)E1404 Oxygen concentrator, manufacturer specified maximum flow rategreater than 5 liters per minute, at 85 percent or greaterconcentration (Deleted eff. 12/31/1999)06 484.306 484.306 484.306 484.306 484.3E1405 Oxygen and water vapor enriching system with heated delivery 06 484.3E1406 Oxygen and water vapor enriching system without heated delivery 06 484.3E1500 Centrifuge, for dialysis (Eff. Date 1/1/2002) 19E1510 Kidney, dialysate delivery syst. kidney machine, pump recirculating,air removal syst, flowrate meter, power off, heater and temperaturecontrol with alarm, i.v.poles, pressure gauge, concentrate container19E1520 Heparin infusion pump for hemodialysis 19E1530 Air bubble detector for hemodialysis, each, replacement 19E1540 Pressure alarm for hemodialysis, each, replacement 19DME MAC Jurisdiction C Supplier Manual Page 54

HCPCSAppendix AE1550 Bath conductivity meter for hemodialysis, each 19E1560 Blood leak detector for hemodialysis, each, replacement 19E1570 Adjustable chair, for ESRD patients 19E1575 Transducer protectors/fluid barriers, for hemodialysis, any size, per1019E1580 Unipuncture control system for hemodialysis 19E1590 Hemodialysis machine 19E1592 Automatic intermittent peritioneal dialysis system 19E1594 Cycler dialysis machine for peritoneal dialysis 19E1600 Delivery and/or installation charges for hemodialysis equipment 19E1610 Reverse osmosis water purification system, for hemodialysis 19E1615 Deionizer water purification system, for hemodialysis 19E1620 Blood pump for hemodialysis, replacement 19E1625 Water softening system, for hemodialysis 19E1630 Reciprocating peritoneal dialysis system 19E1632 Wearable artificial kidney, each 19E1634 Peritoneal dialysis clamps, each (Eff. Date 1/1/2004) 19E1635 Compact (portable) travel hemodialyzer system 19E1636 Sorbent cartridges, for hemodialysis, per 10 19E1637 Hemostats, each (Eff. Date 1/1/2002) 19E1638 Heating pad, for peritoneal dialysis, any size, each (Deletedeff.12/31/2002)19E1639 Scale, each (Eff. Date 1/1/2002) 19E1640 Replacement components for hemodialysis and/or peritoneal dialysismachines that are owned or being purchased by the patient (Deletedeff. 12/31/2001)19E1699 Dialysis equipment, not otherwise specified 14E1700 Jaw motion rehabilitation system 05E1701 Replacement cushions for jaw motion rehabilitation system, pkg. of 6 13E1702 Replacement measuring scales for jaw motion rehabilitation system,pkg. of 200E1800 Dynamic adjustable elbow extension/flexion device, includes softinterface material1301DME MAC Jurisdiction C Supplier Manual Page 55

HCPCSAppendix AE1801 STATIC PROGRESSIVE STRETCH ELBOW DEVICE, EXTENSIONAND/OR FLEXION, WITH OR WITHOUT RANGE OF MOTIONADJUSTMENT, INCLUDES ALL COMPONENTS ANDACCESSORIES (Updated Description 1/1/2008)E1802 Dynamic adjustable forearm pronation/supination device, includessoft interface (Eff. Date 1/1/2003)E1805 Dynamic adjustable wrist extension/flexion device, includes softinterface materialE1806 STATIC PROGRESSIVE STRETCH WRIST DEVICE, FLEXIONAND/OR EXTENSION, WITH OR WITHOUT RANGE OF MOTIONADJUSTMENT, INCLUDES ALL COMPONENTS ANDACCESSORIES (Updated Description 1/1/2008)E1810 Dynamic adjustable knee extension/flexion device, includes softinterface materialE1811 STATIC PROGRESSIVE STRETCH KNEE DEVICE, EXTENSIONAND/OR FLEXION, WITH OR WITHOUT RANGE OF MOTIONADJUSTMENT, INCLUDES ALL COMPONENTS ANDACCESSORIES (Updated Description 1/1/2008)E1812 Dynamic knee, extension/flexion device with active resistancecontrol(Eff. Date 1/1/2006)01010101010101E1815 Dynamic adjustable ankle extension/flexion device, or equal 01E1816 STATIC PROGRESSIVE STRETCH ANKLE DEVICE, FLEXIONAND/OR EXTENSION, WITH OR WITHOUT RANGE OF MOTIONADJUSTMENT, INCLUDES ALL COMPONENTS ANDACCESSORIES (Updated Description 1/1/2008)E1818 STATIC PROGRESSIVE STRETCH FOREARM PRONATION /SUPINATION DEVICE, WITH OR WITHOUT RANGE OF MOTIONADJUSTMENT, INCLUDES ALL COMPONENTS ANDACCESSORIES (Updated Description 1/1/2008)E1820 Replacement soft interface material, dynamic adjustableextension/flexion deviceE1821 Replacement soft interface material/cuffs for bi-directional staticprogressive stretch device (Eff. Date 1/1/2002)E1825 Dynamic adjustable finger extension/flexion device, includes softinterface materialE1830 Dynamic adjustable toe extension/flexion device, includes softinterface materialE1840 Dynamic adjustable shoulder flexion/abduction/rotation device,includes soft interface material (Eff. Date 1/1/2002)E1841 STATIC PROGRESSIVE STRETCH SHOULDER DEVICE, WITHOR WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES0101050501010101DME MAC Jurisdiction C Supplier Manual Page 56

HCPCSAppendix AALL COMPONENTS AND ACCESSORIES (Updated Description1/1/2008)E1900 Synthesized Speech Augmentative Comm. device with DynamicDisplay (Deleted eff. 12/31/2001)E1902 Communication board, non-electronic augmentation or alternativecommunication device (Eff. Date 1/1/2002)E2000 Gastric suction pump, home model, portable or stationary, electric(Eff. Date 1/1/2002)E2100 Blood glucose monitor with integrated voice synthesizer (Eff. Date1/1/2002)E2101 Blood glucose monitor with integrated lancing/blood sample (Eff.Date 1/1/2002)E2120 Pulse generator system for the tympanic treatment of inner earendolymphatic fluid (Eff. Date 1/1/2004)E2201 Manual wheelchair accessory, nonstandard seat frame, widthgreater than or equal to 20 inches but less than 24 inches (Eff. Date1/1/2004)E2202 Manual wheelchair accessory, nonstandard seat frame width, 24-27inches (Eff. Date 1/1/2004)E2203 Manual wheelchair accessory, nonstandard seat frame depth, 20 toless than 22 inches (Eff. Date 1/1/2004)E2204 Manual wheelchair accessory, nonstandard seat frame depth, 22 to25 inches (Eff. Date 1/1/2004)E2205 MANUAL WHEELCHAIR ACCESSORY, HANDRIM WITHOUTPROJECTIONS (INCLUDES ERGONOMIC OR CONTOURED),ANY TYPE, REPLACEMENT ONLY, EACH (Updated Description1/1/2008)010505010505050505E2206 Manual wheelchair accessory, wheel lock assembly, complete, each(Eff. Date 1/1/2005)E2207 Wheelchair accessory, crutch and cane holder, each (Eff. Date1/1/2006)E2208 Wheelchair accessory, cylinder tank carrier, each (Eff. Date1/1/2006)E2209 Accessory, arm trough, with or without hand support, each (Eff. Date1/1/2006)E2210 Wheelchair accessory, bearings, any type, replacement only, each(Eff. Date 1/1/2006)E2211 Manual wheelchair accessory, pneumatic propulsion tire, any size,each (Eff. Date 1/1/2006)050505050505DME MAC Jurisdiction C Supplier Manual Page 57

HCPCSAppendix AE2212 Manual wheelchair accessory, tube for pneumatic propulsion tire,any size, each (Eff. Date 1/1/2006)E2213 Manual wheelchair accessory, insert for pneumatic propulsion tire(removable) any type, any size, each (Eff. Date 1/1/2006)E2214 Manual wheelchair accessory, pneumatic caster tire, any size each(Eff. Date 1/1/2006)E2215 Manual wheelchair accessory, tube for pneumatic caster tire, anysize each (Eff. Date 1/1/2006)E2216 Manual wheelchair accessory, foam filled propulsion tire, any size,each (Eff. Date 1/1/2006)E2217 Manual wheelchair accessory, foam filled caster tire, any size, each(Eff. Date 1/1/2006)E2218 Manual wheelchair accessory, foam propulsion tire, any size, each(Eff. Date 1/1/2006)E2219 Manual wheelchair accessory, foam caster tire, any size, each (Eff.Date 1/1/2006)E2220 Manual Wheelchair accessory, solid (rubber/plastic) propulsion tire,any size, each (Eff. Date 1/1/2006)E2221 Manual wheelchair accessory, solid (rubber/plastic) caster tire(removable), any size, each (Eff. Date 1/1/2006)E2222 Manual wheelchair accessory, solid (rubber/plastic) caster tire withintegrated wheel, any size, each (Eff. Date 1/1/2006)E2223 Manual wheelchair accessory, valve, any type, replacement only,each (Eff. Date 1/1/2006)E2224 Manual wheelchair accessory, propulsion wheel excludes tire, anysize, each (Eff. Date 1/1/2006)E2225 Manual wheelchair accessory, caster wheel excludes tire, any size,replacement only, each (Eff. Date 1/1/2006)E2226 Manual wheelchair accessory, caster fork, any size, replacementonly, each (Eff. Date 1/1/2006)E2227 MANUAL WHEELCHAIR ACCESSORY, GEAR REDUCTIONDRIVE WHEEL, EACH (Eff. Date 1/1/2008)E2228 MANUAL WHEELCHAIR ACCESSORY, WHEEL BRAKINGSYSTEM AND LOCK, COMPLETE, EACH (Eff. Date 1/1/2008)E2291 Back, planar, for pediatric size wheelchair including fixed attachinghardware (Eff. Date 1/1/2005)E2292 Seat, planar, for pediatric size wheelchair including fixed attachinghardware (Eff. Date 1/1/2005)05050505050505050505050505050505050505E2293 Back, contoured, for pediatric size wheelchair including fixed 05DME MAC Jurisdiction C Supplier Manual Page 58

HCPCSAppendix Aattaching hardware (Eff. Date 1/1/2005)E2294 Seat, contoured, for pediatric size wheelchair including fixedattaching hardware (Eff. Date 1/1/2005)E2300 Power wheelchair accessory, power seat elevation system (Eff. Date1/1/2004)E2301 Power wheelchair accessory, power standing system (Eff. Date1/1/2004)E2310 Power wheelchair accessory, electronic connection betweenwheelchair controller and one power seating system motor, includingall related electronics, indicator feature, mechanical functionselection switch, and fixed mounting hardware (Eff. Date 1/1/2004)E2311 Power wheelchair accessory, electronic connection betweenwheelchair controller and two or more power seating system motors,including all related electronics, indicator feature, mechanicalfunction selection switch, and fixed mounting hardware (Eff. Date1/1/2004)E2312 POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROLINTERFACE, MINI-PROPORTIONAL REMOTE JOYSTICK,PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWARE(Eff. Date 1/1/2008)E2313 POWER WHEELCHAIR ACCESSORY, HARNESS FOR UPGRADETO EXPANDABLE CONTROLLER, INCLUDING ALL FASTENERS,CONNECTORS AND MOUNTING HARDWARE, EACH (Eff. Date1/1/2008)E2320 Power wheelchair accessory, hand or chin control interface, remotejoystick or touchpad, proportional, including all related electronicsand fixed mounting hardware (Eff. Date 1/1/2004) (delete 12/31/06)E2321 Power wheelchair accessory, hand control interface, remote joystick,nonproportional, including all related electronics, mechanical stopswitch, and fixed mounting hardware (Eff. Date 1/1/2004)E2322 Power wheelchair accessory, hand control interface, multiplemechanical switches, nonproportional, including all relatedelectronics, mechanical stop switch, and fixed mounting hardware(Eff. Date 1/1/2004)E2323 Power wheelchair accessory, specialty joystick handle for handcontrol interface, prefabricated (Eff. Date 1/1/2004)E2324 Power wheelchair accessory, chin cup for chin control interface (Eff.Date 1/1/2004)E2325 Power wheelchair accessory, sip and puff interface, nonproportional,including all related electronics, mechanical stop switch, and manualswingaway mounting hardware (Eff. Date 1/1/2004)E2326 Power wheelchair accessory, breath tube kit for sip and puffinterface (Eff. Date 1/1/2004)0505050505050505050505050505DME MAC Jurisdiction C Supplier Manual Page 59

HCPCSAppendix AE2327 Power wheelchair accessory, head control interface, mechanical,proportional, including all related electronics, mechanical directionchange switch, and fixed mounting hardware (Eff. Date 1/1/2004)E2328 Power wheelchair accessory, head control or extremity controlinterface, electronic, proportional, including all related electronicsand fixed mounting hardware (Eff. Date 1/1/2004)E2329 Power wheelchair accessory, head control interface, contact switchmechanism, nonproportional, including all related electronics,mechanical stop switch, mechanical direction change switch, headarray, and fixed mounting hardware (Eff. Date 1/1/2004)E2330 Power wheelchair accessory, head control interface, proximity switchmechanism, nonproportional, including all related electronics,mechanical stop switch, mechanical direction change switch, headarray, and fixed mounting hardware (Eff. Date 1/1/2004)E2331 Power wheelchair accessory, attendant control, proportional,including all related electronics and fixed mounting hardware (Eff.Date 1/1/2004)E2340 Power wheelchair accessory, nonstandard seat frame width, 20-23inches (Eff. Date 1/1/2004)E2341 Power wheelchair accessory, nonstandard seat frame width, 24-27inches (Eff. Date 1/1/2004)E2342 Power wheelchair accessory, nonstandard seat frame depth, 20 or21 inches (Eff. Date 1/1/2004)E2343 Power wheelchair accessory, nonstandard seat frame depth, 22-25inches (Eff. Date 1/1/2004)E2351 Power wheelchair accessory, electronic interface to operate speechgenerating device using power wheelchair control interface (Eff.Date 1/1/2004)E2360 Power wheelchair accessory, 22 NF non-sealed lead acid battery,each (Eff. Date 1/1/2004)E2361 Power wheelchair accessory, 22 NF sealed lead acid battery, each(e.g., gel cell, absorbed glassmat) (Eff. Date 1/1/2004)E2362 Power wheelchair accessory, Group 24 non-sealed lead acidbattery, each (Eff. Date 1/1/2004)E2363 Power wheelchair accessory, Group 24 sealed lead acid battery,each (e.g., gel cell, absorbed glassmat) (Eff. Date 1/1/2004)E2364 Power wheelchair accessory, U-1 non-sealed lead acid battery, each(Eff. Date 1/1/2004)E2365 Power wheelchair accessory, U-1 sealed lead acid battery, each(e.g., gel cell, absorbed glassmat) (Eff. Date 1/1/2004)E2366 Power wheelchair accessory, battery charger, single mode, for usewith only one battery type, sealed or non-sealed, each (Eff. Date0505050505050505050505050505050505DME MAC Jurisdiction C Supplier Manual Page 60

HCPCSAppendix A1/1/2004)E2367 Power wheelchair accessory, battery charger, dual mode, for usewith either battery type, sealed or non-sealed, each (Eff. Date1/1/2004)E2368 Power wheelchair component, motor, replacement only (Eff. Date1/1/2005)E2369 Power wheelchair component, gear box, replacement only (Eff. Date1/1/2005)E2370 Power wheelchair component, motor and gear box combination,replacement only (Eff. Date 1/1/2005)E2371 Power wheelchair accessory, group 27 sealed lead acid battery,each(e.g. gel cell, absorbed glassmat), each (Eff. Date 1/1/2006)E2372 Power wheelchair accessory, group 27 non-sealed lead acid battery,each (Eff. Date 1/1/2006)E2373 POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROLINTERFACE, COMPACT REMOTE JOYSTICK, PROPORTIONAL,INCLUDING FIXED MOUNTING HARDWARE (Updated Description1/1/2008)E2374 Power Wheelchair Accessory, hand or chin control, interface,stabdard remote joystick (not including controller), proportional,including all related electronics and fixed mounting hardware,replacement onlyE2375 Power Wheelchair Accessory, non-expandable controller, includingall related electronics and mounting hardware, replacement only (Effdate 01/01/2007)E2376 Power Wheelchair Accessory, expandable controller, including allrelated electronics and mounting hardware, replacement only (Effdate 01/01/2007)E2377 Power Wheelchair Accessory, expandable controller, including allrelated electronics and mounting hardware, upgrade provided atintial issue (Eff date 01/01/2007)E2381 Power Wheelchair Accessory, Pneumatic Drive Wheel Tire, anysize, replacement only, each (Eff date 01/01/2007)E2382 Power Wheelchair Accessory, Tube for Pneumatic Drive WheelTire, any size, replacement only, each (Eff date 01/01/2007)E2383 Power Wheelchair Accessory, Insert for Pneumatic Drive Wheel Tire(removable), any type, any size, replacement only, each (Effdate 01/01/2007)E2384 Power Wheelchair Accessory, Pneumatic Caster Tire, any size,replacement only, each (Eff date 01/01/2007)050505050505050505050505050505E2385 Power Wheelchair Accessory, Tube for Pneumatic Caster Tire, any 05DME MAC Jurisdiction C Supplier Manual Page 61

HCPCSAppendix Asize, replacement only, each (Eff date 01/01/2007)E2386 Power Wheelchair Accessory, Foam Filled Drive Wheel Tire, anysize, replacement only, each (Eff date 01/01/2007)E2387 Power Wheelchair Accessory, Foam Filled Caster Tire, any size,replacement only, each (Eff date 01/01/2007)E2388 Power Wheelchair Accessory, Foam Drive Wheel Tire, any size,replacement only, each (Eff date 01/01/2007)E2389 Power Wheelchair Accessory, Foam Caster Tire, any size,replacement only, each (Eff date 01/01/2007)E2390 Power Wheelchair Accessory, Solid (Rubber/Plastic) Drive WheelTire, any size, replacement only, each (Eff date 01/01/2007)E2391 Power Wheelchair Accessory, Solid (Rubber/Plastic) Caster Tire(Removable), any size, replacement only, each (Eff date01/01/2007)E2392 Power Wheelchair Accessory, Solid (Rubber/Plastic) Caster Tire,with intrgrated Wheel, any size, replacement only, each (Eff date01/01/2007)E2393 Power Wheelchair Accessory, Valve for Pneumatic Tire Tube, anytype, replacement only, each (Eff date 01/01/2007)E2394 Power Wheelchair Accessory, Drive Wheel excludes Tire, any size,replacement only, each (Eff date 01/01/2007)E2395 Power Wheelchair Accessory, Caster Wheel excludes Tire, any size,replacement only, each (Eff date 01/01/2007)E2396 Power Wheelchair Accessory, Caster Fork, any size, replacementonly, each (Eff date 01/01/2007)E2397 POWER WHEELCHAIR ACCESSORY, LITHIUM-BASEDBATTERY, EACH (Eff date 01/01/2008)E2399 Power wheelchair accessory, not otherwise classified interface,including all related electronics and any type mounting hardware(Eff. Date 1/1/2004)E2402 Negative pressure wound therapy electrical pump, stationary orportable (Eff. Date 1/1/2004)E2500 Speech generating device, digitized speech, using pre-recordedmessages, less than or equal to 8 minutes recording time (Eff. Date1/1/2004)E2502 Speech generating device, digitized speech, using pre-recordedmessages, greater than 8 minutes but less than or equal to 20minutes recording time (Eff. Date 1/1/2004)E2504 Speech generating device, digitized speech, using pre-recordedmessages, greater than 20 minutes but less than or equal to 40minutes recording time (Eff. Date 1/1/2004)0505050505050505050505050501050505DME MAC Jurisdiction C Supplier Manual Page 62

HCPCSAppendix AE2506 Speech generating device, digitized speech, using pre-recordedmessages, greater than 40 minutes recording time (Eff. Date1/1/2004)E2508 Speech generating device, synthesized speech, requiring messageformulation by spelling and access by physical contact with thedevice (Eff. Date 1/1/2004)E2510 Speech generating device, synthesized speech, permitting multiplemethods of message formulation and multiple methods of deviceaccess (Eff. Date 1/1/2004)E2511 Speech generating software program, for personal computer orpersonal digital assistant (Eff. Date 1/1/2004)E2512 Accessory for speech generating device, mounting system (Eff. Date1/1/2004)E2599 Accessory for speech generating device, not otherwise classified(Eff. Date 1/1/2004)E2601 General use wheelchair seat cushion, width less than 22 inches, anydepth (Eff. Date 1/1/2005)E2602 General use wheelchair seat cushion, width 22 inches or greater,any depth (Eff. Date 1/1/2005)E2603 Skin protection wheelchair seat cushion, width less than 22 inches,any depth (Eff. Date 1/1/2005)E2604 Skin protection wheelchair seat cushion, width 22 inches or greater,any depth (Eff. Date 1/1/2005)E2605 Positioning wheelchair seat cushion, width less than 22 inches, anydepth (Eff. Date 1/1/2005)E2606 Positioning wheelchair seat cushion, width 22 inches or greater, anydepth (Eff. Date 1/1/2005)E2607 Skin protection and positioning wheelchair seat cushion, width lessthan 22 inches, any depth (Eff. Date 1/1/2005)E2608 Skin protection and positioning wheelchair seat cushion, width 22inches or greater, any depth (Eff. Date 1/1/2005)E2609 Custom fabricated wheelchair seat cushion, any size (Eff. Date1/1/2005)050505050505050505050505050505E2610 Wheelchair seat cushion, powered (Eff. Date 1/1/2005) 05E2611 General use wheelchair back cushion, width less than 22 inches,any height, including any type mounting hardware (Eff. Date1/1/2005)E2612 General use wheelchair back cushion, width 22 inches or greater,any height, including any type mounting hardware (Eff. Date1/1/2005)0505DME MAC Jurisdiction C Supplier Manual Page 63

HCPCSAppendix AE2613 Positioning wheelchair back cushion, posterior, width less than 22inches, any height, including any type mounting hardware (Eff. Date1/1/2005)E2614 Positioning wheelchair back cushion, posterior, width 22 inches orgreater, any height, including any type mounting hardware (Eff. Date1/1/2005)E2615 Positioning wheelchair back cushion, posterior-lateral, width lessthan 22 inches, any height, including mounting any type hardware(Eff. Date 1/1/2005)E2616 Positioning wheelchair back cushion, posterior-lateral, width 22inches or greater, any height, including any type mounting hardware(Eff. Date 1/1/2005)E2617 Custom fabricated wheelchair back cushion, any size, including anytype mounting hardware (Eff. Date 1/1/2005)E2618 Wheelchair accessory, solid seat support base (replaces sling seat),for use with manual wheelchair or lightweight power wheelchair,includes any type mounting hardware (Deletion Date 12/31/2007)E2619 Replacement cover for wheelchair seat cushion or back cushion,each (Eff. Date 1/1/2005)E2620 Positioning wheelchair back cushion, planar back with lateralsupports, width less than 22 inches, any height, including any typemounting hardware (Eff. Date 1/1/2005)E2621 Positioning wheelchair back cushion, planar back with lateralsupports, width 22 inches or greater, any height, including any typemounting hardware (Eff. Date 1/1/2005)050505050505050505E8000 Gait trainer, pediatric size, posterior support, includes all accessoriesand components (not payable by Medicare) (Eff. Date 1/1/2005)E8001 Gait trainer, pediatric size, upright support, includes all accessoriesand components (not payable by Medicare) (Eff. Date 1/1/2005)E8002 Gait trainer, pediatric size, anterior support, includes all accessoriesand components (not payable by Medicare) (Eff. Date 1/1/2005)DME MAC Jurisdiction C Supplier Manual Page 64

HCPCSAppendix AHCPCS GPayment Category1 Capped Rental 8 Parenteral/Enteral Supplies and Kits 15 Nebulizer Drugs2 Freq. & Substantial Serv. DME 9 Parenteral/Enteral Pumps 16 Therapeutic Shoes for Diabetics3 Customized DMEPOS 10 Immunosuppressive Drugs 17 Individual Consideration4 Prosthetics/Orthotics 11 Ostomy, Trach., & Urologicals 18 Epoetin (EPO)5 Inexp. & Routinely Purch. DME 12 Surgical Dressings 19 Dialysis Supplies & Equipment6 Oxygen and Oxygen Equipment 13 Supplies 20 Oral Antiemetic Drugs7 Parenteral/Enteral Nutrients 14 Not Otherwise ClassifiedCode Description Category CMN/DIFRequiredG0333 G0333 Pharmacy dispensing fee for inhalation drug(s); per 30-days as a beneficiary (Eff. Date 01/01/2006)G0369 Pharmacy supply fee for initial immunosuppressive drug (s) firstmonth following transplant (Eff. Date 01/01/05) (Deleted eff.12/31/2005)G0370 Pharmacy supply fee for oral anti-cancer, oral anti-emetic orimmunosuppressive drug (s) (Eff. Date 01/01/05) (Deleted eff.12/31/2005)G0371 Pharmacy dispensing fee for inhalation drug (s); per 30-days (Eff.Date 01/01/05) (Deleted eff. 12/31/2005)G0374 Pharmacy dispensing fee for inhalation drug (s); per 90-days (Eff.Date 01/01/05) (Deleted eff. 12/31/2005)DME MAC Jurisdiction C Supplier Manual Page 65

HCPCSAppendix AHCPCS JPayment Category1 Capped Rental 8 Parenteral/Enteral Supplies and Kits 15 Nebulizer Drugs2 Freq. & Substantial Serv. DME 9 Parenteral/Enteral Pumps 16 Therapeutic Shoes for Diabetics3 Customized DMEPOS 10 Immunosuppressive Drugs 17 Individual Consideration4 Prosthetics/Orthotics 11 Ostomy, Trach., & Urologicals 18 Epoetin (EPO)5 Inexp. & Routinely Purch. DME 12 Surgical Dressings 19 Dialysis Supplies & Equipment6 Oxygen and Oxygen Equipment 13 Supplies 20 Oral Antiemetic Drugs7 Parenteral/Enteral Nutrients 14 Not Otherwise ClassifiedCode Description Category CMN/DIFRequiredJ0120 Injection, tetracycline, up to 250 mgJ0128 Injection, abarelix, 10 mg (Eff. Date 1/1/2005)J0129 Injection, abatacept, 10 mg Eff.Date 01/01/2007)J0130 Injection abciximab, 10 mgJ0133 Injection, acyclovir, 5 mg (Eff. Date 1/1/2006)J0135 Injection, adalimumab, 20 mg (Eff. Date 1/1/2005)J0150 Injection, adenosine for therapeutic use, 6 mg (not to be used toreport any adenosine phosphate compounds, instead used A9270)J0151 Injection, adenosine, 90 mg (not to be used to report any adenosinephosphate compounds, instead use A9270) (Deleted eff. 12/31/2003)J0152 Injection, adenosine for diagnostic use, 30 mg (not to be used to report anyadenosine phosphate compounds; instead use A9270)J0170 Injection, adrenalin, epinephrine, up to 1 ml ampuleJ0180 Injection, agalsidase beta, 1 mg (Eff. Date 1/1/2005)J0190 Injection, biperiden lactate, per 5 mgJ0200 Injection, alatrofloxacin mesylate, 100 mg (Eff. Date 1/1/2000)J0205 Injection, alglucerase, per 10 unitsJ0207 Injection, amifostine, 500 mgJ0210 Injection, methyldopate HCL, up to 250 mgDME MAC Jurisdiction C Supplier Manual Page 66

HCPCSAppendix AJ0215 Injection, alefacept, 0.5 mg (Eff. Date 1/1/2004) 10J0220 INJECTION, AGLUCOSIDASE ALFA, 10 MG (Eff. Date 1/1/2008)J0256 Injection, alpha 1 - proteinase inhibitor - human, 10 mgJ0270 Injection, alprostadil, 1.25 mcg (code may be used for Medicarewhen drug administered under the direct supervision of a physician,not for use when drug is self administered)J0275 Alprostadil urethral suppository (code may be used for Medicarewhen drug administered under the direct supervision of a physician,not for use when drug is self administered)J0278 Injection, amikacin sulfate, 100 mg (Eff. Date 1/1/2006)J0280 Injection, aminophyllin, up to 250 mgJ0282 Injection, amiodarone hydrochloride, 30 mg (Eff. Date 1/1/2001)J0285 Injection, amphotericin B 50 mgJ0286 Injection, amphotericin B, any lipid formulation, 50 mg (Deletedeff.12/31/2002)J0287 Injection, amphotericin B lipid complex, 10 mg (Eff. Date 1/1/2003)J0288 Injection, amphotericin B cholesteryl sulfate complex, 10 mg (Eff.Date 1/1/2003)J0289 Injection, amphotericin B liposome, 10 mg (Eff. Date 1/1/2003)J0290 Injection, ampicillin sodium, 500 mgJ0295 Injection, ampicillin sodium/sulbactam sodium, per 1.5 gmJ0300 Injection, amobarbital, up to 125 mgJ0330 Injection, succinylcholine chloride, up to 20 mgJ0340 Injection, nandrolone phenpropionate, up to 50 mg (Deleted eff.12/31/2001)J0348 Injection, anidulafungin, 1 mg (Eff. Date 01/01/2007)J0350 Injection, anistreplase, per 30 unitsJ0360 Injection, hydralazine HCL, up to 20 mgJ0364 njection, Apomorphine Hydrochloride, 1 mg (Eff date 01/01/2007)J0365 Injection, aprotinin, 10, 000 KIU (Eff. Date 1/1/2006)J0380 Injection, metaraminol bitartrate, per 10 mgJ0390 Injection, chloroquine hydrochloride, up to 250 mgJ0395 Injection, arbutamine HCL, 1 mgDME MAC Jurisdiction C Supplier Manual Page 67

HCPCSAppendix AJ0400 INJECTION, ARIPIPRAZOLE, INTRAMUSCULAR, 0.25 MG- (Eff.Date 1/1/2008)J0456 Injection, azithromycin, 500 mg (Eff. Date 1/1/2000)J0460 Injection, atropine sulfate, up to 0.3 mgJ0470 Injection, dimercaprol, per 100 mgJ0475 Injection, baclofen, 10 mgJ0476 Injection, baclofen, 50 mcg for intrathecal trialJ0480 Injection, basiliximab, 20 mg (Eff. Date 1/1/2006)J0500 Injection, dicyclomine HCL, up to 20 mgJ0510 Injection, benzquinamide HCL, up to 50 mg (Deleted eff. 12/31/2001)J0515 Injection, benztropine mesylate, per 1 mgJ0520 Injection, bethanechol chloride, myotonachol or urecholine, up to 5mgJ0530 Injection, penicillin g benzathine and penicillin g procaine, up to600,000 unitsJ0540 Injection, penicillin g benzathine and penicillin g procaine, up to1,200,000 unitsJ0550 Injection, penicillin g benzathine and penicillin g procaine, up to2,400,000 unitsJ0560 Injection, penicillin g benzathine, up to 600,000 unitsJ0570 Injection, penicillin g benzathine, up to 1,200,000 unitsJ0580 Injection, penicillin g benzathine, up to 2,400,000 unitsJ0583 Injection, bivalirudin, 1 mgJ0585 Botulinum toxin type a, per unitJ0587 Botulinum toxin type B, per 100 units (Eff. Date 1/1/2002)J0590 Injection, ethylnorepinephrine HCL, 1 ml (Deleted eff. 12/31/2001)J0592 Injection, buprenorphine hydrochloride, 0.1 mg (Eff. Date 1/1/2003)J0594 Injection, busulfan, 1 mg ( eff. Date 01/01/2007)J0595 Injection, butorphanol, 1 mgJ0600 Injection, edetate calcium disodium, up to 1000 mgJ0610 Injection, calcium gluconate, per 10 mlJ0620 Injection, calcium glycerophosphate and calcium lactate, per 10 mlDME MAC Jurisdiction C Supplier Manual Page 68

HCPCSAppendix AJ0630 Injection, calcitonin salmon, up to 400 unitsJ0635 Injection, calcitriol, 1 mcg amp. (Deleted eff.12/31/2002)J0636 Injection, calcitriol, 0.1 mcg (Eff. Date 1/1/2003)J0637 Injection, caspofungin acetate, 5 mg (Eff. Date 1/1/2003)J0640 Injection, leucovorin calcium, per 50 mgJ0670 Injection, mepivacaine hydrochloride, per 10 mlJ0690 Injection, cefazolin sodium, 500 mgJ0692 Injection, cefepime hydrochloride, 500 mg (Eff. Date 1/1/2002)J0694 Injection, cefoxitin sodium, 1 gmJ0695 Injection, cefonicid sodium, 1 gram (Deleted eff. 12/31/2001)J0696 Injection, ceftriaxone sodium, per 250 mgJ0697 Injection, sterile cefuroxime sodium, per 750 mgJ0698 Injection, cefotaxime sodium, per gmJ0702 INJECTION, BETAMETHASONE ACETATE 3MG ANDBETAMETHASONE SODIUM PHOSPHATE 3MG (Updated01/01/2008)J0704 Injection, betamethasone sodium phosphate, per 4 mgJ0706 Injection, caffeine citrate, 5 mg (Eff. Date 1/1/2002)J0710 Injection, cephapirin sodium, up to 1 gmJ0713 Injection, ceftazidime, per 500 mgJ0715 Injection, ceftizoxime sodium, per 500 mgJ0720 Injection, chloramphenicol sodium succinate, up to 1 gmJ0725 Injection, chorionic gonadotropin, per 1,000 usp unitsJ0730 Injection, chlorpheniramine maleate, per 10 mg (Deleted eff.12/31/2001)J0735 Injection, clonidine hydrochloride, 1 mgJ0740 Injection, cidofovir, 375 mgJ0743 Injection, cilastatin sodium; imipenem, per 250 mgJ0744 Injection, ciprofloxacin for intravenous infusion, 200 mg (Eff. Date1/1/2002)J0745 Injection, codeine phosphate, per 30 mgDME MAC Jurisdiction C Supplier Manual Page 69

HCPCSAppendix AJ0760 Injection, colchicine, per 1mgJ0770 Injection, colistimethate sodium, up to 150 mgJ0780 Injection, prochlorperazine, up to 10 mgJ0795 Injection, corticorelin ovine triflutate, 1 microgram (Eff. Date1/1/2006)J0800 Injection, corticotropin, up to 40 unitsJ0810 Injection, cortisone, up to 50 mg (Deleted eff. 12/31/2001)J0835 Injection, cosyntropin, per 0.25 mgJ0850 Injection, cytomegalovirus immune globulin intravenous (human), pervialJ0878 Injection, daptomycin, 1 mg (Eff. Date 1/1/2005)J0880 Injection, darbepoetin alfa, 5 mcg (Eff. Date 1/1/2003) (Deleted eff.12/31/2005)J0881 Injection, darbepoetin alfa, 1 microgram (non-ESRD use) (Eff. Date1/1/2006)J0882 Injection, darbepoetin alfa, 1 microgram (for ESRD on dialysis) (Eff.Date 1/1/2006)J0885 Injection, epoetin alfa, (for non-ESRD use), 1000 units (Eff. Date1/1/2006)J0886 Injection, epoetin alfa, 1000 units (for ESRD on dialysis) (Eff. Date1/1/2006)J0894 Injection, decitabine, 1 mg (Eff date 01/01/2007)J0895 Injection, deferoxamine mesylate, 500 mg per 5 ccJ0900 Injection, testosterone enanthate and estradiol valerate, up to 1 ccJ0945 Injection, brompheniramine maleate, per 10 mgJ0970 Injection, estradiol valerate, up to 40 mgJ1000 Injection, depo-estradiol cypionate, up to 5 mgJ1020 Injection, methylprednisolone acetate, 20 mgJ1030 Injection, methylprednisolone acetate, 40 mgJ1040 Injection, methylprednisolone acetate, 80 mgJ1050 Injection, medroxyprogesterone acetate, 100 mg (Deletedeff.12/31/2002)J1051 Injection, medroxyprogesterone acetate, 50 mg (Eff. Date 1/1/2003)DME MAC Jurisdiction C Supplier Manual Page 70

HCPCSAppendix AJ1055 Injection, medroxyprogesterone acetate for contraceptive use, 150mgJ1056 Injection, medroxyprogesterone acetate/estradiol cypionate, 5 mg/25mg (Eff. Date 1/1/2002)J1060 Injection, testosterone cypionate and estradiol cypionate, up to 1 mlJ1070 Injection, testosterone cypionate, up to 100 mgJ1080 Injection, testosterone cypionate, 1 cc, 200 mgJ1090 Injection, testosterone cypionate, 1 cc, 50 mg (Deleted eff.12/31/2001)J1094 Injection, dexamethasone acetate, 1 mg (Eff. Date 1/1/2003)J1095 Injection, dexamethasone acetate, per 8 mg (Deleted eff.12/31/2002)J1100 Injection, dexamethosone sodium phosphate, 1 mgJ1110 Injection, dihydroergotamine mesylate, per 1 mgJ1120 Injection, acetazolamide sodium, up to 500 mgJ1160 Injection, digoxin, up to 0.5 mgJ1162 Injection, digoxin immune fab (ovine), per vial (Eff. Date 1/1/2006)J1165 Injection, phenytoin sodium, per 50 mgJ1170 Injection, hydromorphone, up to 4 mgJ1180 Injection, dyphylline, up to 500 mgJ1190 Injection, dexrazoxane hydrochloride, per 250 mgJ1200 Injection, diphenhydramine HCL, up to 50 mgJ1205 Injection, chlorothiazide sodium, per 500 mgJ1212 Injection, dmso, dimethyl sulfoxide, 50%, 50 mlJ1230 Injection, methadone HCL, up to 10 mgJ1240 Injection, dimenhydrinate, up to 50 mgJ1245 Injection, dipyridamole, per 10 mgJ1250 Injection, dobutamine hydrochloride, per 250 mgJ1260 Injection, dolasetron mesylate, 10 mgJ1265 Injection, dopamine HCL, 40 MG (Eff. Date 1/1/2006)J1270 Injection, doxercalciferol, 1 mcg (Eff. Date 1/1/2002)J1300 INJECTION, ECULIZUMAB, 10 MG- (Eff. Date 1/1/2008)DME MAC Jurisdiction C Supplier Manual Page 71

HCPCSAppendix AJ1320 Injection, amitriptyline HCL, up to 20 mgJ1324 Injection, enfuvirtide, 1 mg (Eff date 01/01/2007)J1325 Injection, epoprostenol, 0.5 mgJ1327 Injection, eptifibatide, 5 mg (Eff. Date 1/1/2000)J1330 Injection, ergonovine maleate, up to 0.2 mgJ1335 Injection, ertpenem sodium, 500 mgJ1362 Injection, erythromycin gluceptate, per 250 mg (Deleted eff.12/31/2001)J1364 Injection, erythromycin lactobionate, per 500 mgJ1380 Injection, estradiol valerate, up to 10 mgJ1390 Injection, estradiol valerate, up to 20 mgJ1410 Injection, estrogen conjugated, per 25 mgJ1430 Injection, ethanolamine oleate, 100 MG (Eff. Date 1/1/2006)J1435 Injection, estrone, per 1 mgJ1436 Injection, etidronate disodium, per 300 mgJ1438 Injection, etanercept, 25 mg (code may be used for Medicare whendrug administered under the direct supervision of a physician, not foruse when drug is self administered) (Eff. Date 1/1/2000)J1440 Injection, filgrastim (g-csf), 300 mcgJ1441 Injection, filgrastim (g-csf), 480 mcgJ1450 Injection fluconazole, 200 mg (Eff. Date 1/1/2000)J1451 Injection, fomepizole, 15 mg (Eff. Date 1/1/2006)J1452 Injection, fomivirsen sodium, intraocular, 1.65 mg (Eff. Date 1/1/2001)J1455 Injection, foscarnet sodium, per 1000 mgJ1457 Injection, gallium nitrate, 1 mg (Eff. Date 1/1/2005)J1458 Injection, galsulfase, 1 mg (Eff date 01/01/2007)J1460 Injection, gamma globulin, intramuscular, 1 ccJ1470 Injection, gamma globulin, intramuscular, 2 ccJ1480 Injection, gamma globulin, intramuscular, 3 ccJ1490 Injection, gamma globulin, intramuscular, 4 ccJ1500 Injection, gamma globulin, intramuscular, 5 ccDME MAC Jurisdiction C Supplier Manual Page 72

HCPCSAppendix AJ1510 Injection, gamma globulin, intramuscular, 6 ccJ1520 Injection, gamma globulin, intramuscular, 7 ccJ1530 Injection, gamma globulin, intramuscular, 8 ccJ1540 Injection, gamma globulin, intramuscular, 9 ccJ1550 Injection, gamma globulin, intramuscular, 10 ccJ1560 Injection, gamma globulin, intramuscular, over 10 ccJ1561 INJECTION, IMMUNE GLOBULIN, (GAMUNEX), INTRAVENOUS,NON-LYOPHILIZED (E.G. LIQUID), 500 MG- (Eff. Date 1/1/2008)J1562 INJECTION, IMMUNE GLOBULIN (VIVAGLOBIN), 100 MG (Updated01/01/2008)J1563 Injection, immune globulin, intravenous, 1g (Eff. Date 1/1/2001)(Deleted eff. 03/31/2005)J1564 Injection, immune globulin, intravenous, 10 mg (Eff. Date 1/1/2003)(Deleted eff. 03/31/2005)J1565 Injection, respiratory syncytial virus immune globulin, intravenous, 50mgJ1566 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED(E.G. POWDER), NOT OTHERWISE SPECIFIED, 500 MG (Updated01/01/2008)J1567 Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid),500 mg (Terminated on 6/30/2007)J1568 INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS,NON-LYOPHILIZED (E.G. LIQUID), 500 MG- (Eff. Date 1/1/2008)J1569 INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID),INTRAVENOUS, NON-LYOPHILIZED, (E.G. LIQUID), 500 MG- (Eff.Date 1/1/2008)J1570 Injection, ganciclovir sodium, 500 mgJ1571 INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B),INTRAMUSCULAR, 0.5 ML- (Eff. Date 1/1/2008)J1572 INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA),INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), 500 MG- (Eff.Date 1/1/2008)J1573 INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B),INTRAVENOUS, 0.5 ML- (Eff. Date 1/1/2008)J1580 Injection, garamycin, gentamicin, up to 80 mgJ1590 Injection, gatifloxacin, 10 mg (Eff. Date 1/1/2002)J1595 Injection, glatiramer acetate, 20 mgDME MAC Jurisdiction C Supplier Manual Page 73

HCPCSAppendix AJ1600 Injection, gold sodium thiomalate, up to 50 mgJ1610 Injection, glucagon hydrochloride, per 1 mgJ1620 Injection, gonadorelin hydrochloride, per 100 mcgJ1625 Injection, granisetron hydrochloride, per 1 mg (Deleted eff.12/31/1997)J1626 Injection, granisetron hydrochloride, 100 mcgJ1630 Injection, haloperidol, up to 5 mgJ1631 Injection, haloperidol decanoate, per 50 mgJ1640 Injection, hemin, 1 mg (Eff. Date 1/1/2006)J1642 Injection, heparin sodium, (heparin lock flush), per 10 unitsJ1644 Injection, heparin sodium, per 1000 unitsJ1645 Injection, dalteparin sodium, per 2500 I.U.J1650 Injection, enoxaparin sodium, 10 mgJ1652 Injection, fondaparinux sodium, 0.5mg (Eff. Date 1/1/2003)J1655 Injection, tinzaparin sodium, 1000 IU (Eff. Date 1/1/2002)J1670 Injection, tetanus immune globulin, human, up to 250 unitsJ1675 Injection, histrelin acetate, 10 micrograms (Eff. Date 1/1/2006)J1690 Injection, prednisolone tebutate, up to 20 mg (Deleted eff.12/31/2001)J1700 Injection, hydrocortisone acetate, up to 25 mgJ1710 Injection, hydrocortisone sodium phosphate, up to 50 mgJ1720 Injection, hydrocortisone sodium succinate, up to 100 mgJ1730 Injection, diazoxide, up to 300 mgJ1739 Injection, hydroxyprogesterone caproate 125 mg/ml (Deleted eff.12/31/2001)J1740 Injection, Ibandronate Sodium, 1 mg (Eff date 01/01/2007)J1741 Injection, hydroxyprogesterone caproate, 250 mg/ml (Deleted eff.12/31/2001)J1742 Injection, ibutilide fumarate, 1 mgJ1743 INJECTION, IDURSULFASE, 1 MG- (Eff. Date 1/1/2008)J1745 Injection infliximab, 10 mg (Eff. Date 1/1/2000)DME MAC Jurisdiction C Supplier Manual Page 74

HCPCSAppendix AJ1750 Injection, iron dextran, 50 mg (Eff. Date 1/1/2000) (Deleted eff.12/31/2005)J1751 Injection, iron dextran 165, 50 mg (Eff. Date 1/1/2006)J1752 Injection, iron dextran 267, 50 mg (Eff. Date 1/1/2006)J1755 Injection, iron sucrose, 20 mg (Deleted eff.12/31/2002)J1756 Injection, iron sucrose, 1 mg (Eff. Date 1/1/2003)J1760 Injection, iron dextran, 2 cc (Deleted eff. 12/31/1999)J1770 Injection, iron dextran, 5 cc (Deleted eff. 12/31/1999)J1780 Injection, iron dextran, 10 cc (Deleted eff. 12/31/1999)J1785 Injection, imiglucerase, per unitJ1790 Injection, droperidol, up to 5 mgJ1800 Injection, propranolol HCL, up to 1 mgJ1810 Injection, droperidol and fentanyl citrate, up to 2 ml ampuleJ1815 Injection, insulin, per 5 units (Eff. Date 1/1/2003)J1817 Insulin for administration through DME (i.e., insulin pump) per 50units (Eff. Date 1/1/2003)J1820 Injection, insulin, up to 100 units (Deleted eff.12/31/2002)J1825 Injection, interferon beta-1a, 33 mcg (code may be used for Medicarewhen drug administered under the direct supervision of a physician,not for use when drug is self administered)J1830 Injection interferon beta-1b, 0.25 mg (code may be used for Medicarewhen drug administered under the direct supervision of a physician,not for use when drug is self administered)J1835 Injection, itroconazole, 50 mg (Eff. Date 1/1/2002)J1840 Injection, kanamycin sulfate, up to 500 mgJ1850 Injection, kanamycin sulfate, up to 75 mgJ1885 Injection, ketorolac tromethamine, per 15 mgJ1890 Injection, cephalothin sodium, up to 1 gramJ1910 Injection, kutapressin, up to 2 ml (Deleted eff. 12/31/2003)J1930 Injection, propiomazine HCL, up to 20 mg (Deleted eff. 12/31/2001)J1931 Injection, laronidase, 0.1 mg (Eff. Date 1/1/2005)J1940 Injection, furosemide, up to 20 mgDME MAC Jurisdiction C Supplier Manual Page 75

HCPCSAppendix AJ1945 Injection, lepirudin, 50 mg (Eff. Date 1/1/2006)J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mgJ1955 Injection, levocarnitine, per 1 gmJ1956 Injection, levofloxacin, 250 mgJ1960 Injection, levorphanol tartrate, up to 2 mgJ1970 Injection, methotrimeprazine, up to 20 mg (Deleted eff. 12/31/2001)J1980 Injection, hyoscyamine sulfate, up to 0.25 mgJ1990 Injection, chlordiazepoxide HCL, up to 100 mgJ2000 Injection, lidocaine HCL, 50 cc (Deleted eff. 12/31/2003)J2001 Injection, lidocaine HCL for intravenous infusion, 10 mgJ2010 Injection, lincomycin HCL, up to 300 mgJ2020 Injection, linezolid, 200 mg (Eff. Date 1/1/2002)J2050 Injection, liver, up to 20 mcg (Deleted eff. 12/31/1996)J2060 Injection, lorazepam, 2 mgJ2150 Injection, mannitol, 25% in 50 mlJ2170 Injection, Mecasermin, 1 mg (Eff date 01/01/2007)J2175 Injection, meperidine hydrochloride, per 100 mgJ2180 Injection, meperidine and promethazine HCL, up to 50 mgJ2185 Injection, meropenem, 100 mgJ2210 Injection, methylergonovine maleate, up to 0.2 mgJ2240 Injection, metocurine iodide, up to 2 mg (Deleted eff. 12/31/2001)J2248 Injection, micafungin sodium, 1 mg (Eff date 01/01/2007)J2250 Injection, midazolam hydrochloride, per 1 mgJ2260 Injection, milrinone lactate, 5 mgJ2270 Injection, morphine sulfate, up to 10 mgJ2271 Injection, morphine sulfate, 100mgJ2275 Injection, morphine sulfate (preservative-free sterile solution), per 10mgJ2278 Injection, ziconotide, 1 microgram (Eff. Date 1/1/2006)J2280 Injection, moxifloxacin, 100 mgDME MAC Jurisdiction C Supplier Manual Page 76

HCPCSAppendix AJ2300 Injection, nalbuphine hydrochloride, per 10 mgJ2310 Injection, naloxone hydrochloride, per 1 mgJ2315 Injection, Naltrexone, Depot Foam, 1 mg (EFF date 01/01/2007)J2320 Injection, nandrolone decanoate, up to 50 mgJ2321 Injection, nandrolone decanoate, up to 100 mgJ2322 Injection, nandrolone decanoate, up to 200 mgJ2323 INJECTION, NATALIZUMAB, 1 MG- (Eff. Date 1/1/2008)J2324 Injection, nesiritide, 0.25 mg (Eff. Date 1/1/2003) (Deleted eff.12/31/2005)J2325 Injection, nesiritide, 0.1 mg (Eff. Date 1/1/2006)J2330 Injection, thiothixene, up to 4 mg (Deleted eff. 12/31/2001)J2350 Injection, niacinamide, niacin, up to 100 mg (Deleted eff. 12/31/2001)J2352 Injection, octreotide acetate, 1 mg (Deleted eff. 12/31/2003)J2353 Injection, octreotide, depot form for intramuscular injection, 1 mgJ2354 Injection, octreotide, non-depot form for subcutaneous or intravenousinjection, 20 mcgJ2355 Injection, oprelvekin, 5 mgJ2357 Injection, omalizumab, 5 mg (Eff. Date 1/1/2005)J2360 Injection, orphenadrine citrate, up to 60 mgJ2370 Injection, phenylephrine HCL, up to 1 mlJ2400 Injection, chloroprocaine hydrochloride, per 30 mlJ2405 Injection, ondansetron hydrochloride, per 1 mgJ2410 Injection, oxymorphone HCL, up to 1 mgJ2425 Injection, palifermin, 50 micrograms (Eff. Date 1/1/2006)J2430 Injection, pamidronate disodium, per 30 mgJ2440 Injection, papaverine HCL, up to 60 mgJ2460 Injection, oxytetracycline HCL, up to 50 mgJ2469 Injection, palonosetron HCL, 25 mcg (Eff. Date 1/1/2005)J2480 Injection, hydrochlorides of opium alkaloids, up to 20 mg (Deleted eff.12/31/2001)J2500 Injection, paricalcitol, 5 mcg (Deleted eff.12/31/2002)DME MAC Jurisdiction C Supplier Manual Page 77

HCPCSAppendix AJ2501 Injection, paricalcitol, 1 mcg (Eff. Date 1/1/2003)J2503 Injection, pegaptanib sodium, 0.3 mg (Eff. Date 1/1/2006)J2504 Injection, pegademase bovine, 25 IU (Eff. Date 1/1/2006)J2505 Injection, pegfilgrastim, 6 mgJ2510 Injection, penicillin g procaine, aqueous, up to 600,000 unitsJ2512 Injection, pentagastrin, per 2 ml (Deleted eff. 12/31/2001)J2513 Injection, pentastarch, 10% solutin, 100 ml (Eff. Date 1/1/2006)J2515 Injection, pentobarbital sodium, per 50 mgJ2540 Injection, penicillin g potassium, up to 600,000 unitsJ2543 Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125grams (1.125 grams) (Eff. Date 1/1/2000)J2545 PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300MG (Updated 01/01/2008)15J2550 Injection, promethazine HCL, up to 50 mgJ2560 Injection, phenobarbital sodium, up to 120 mgJ2590 Injection, oxytocin, up to 10 unitsJ2597 Injection, desmopressin acetate, per 1 mcgJ2640 Injection, prednisolone sodium phosphate, to 20 mg (Deleted eff.12/31/2001)J2650 Injection, prednisolone acetate, up to 1 mlJ2670 Injection, tolazoline HCL, up to 25 mgJ2675 Injection, progesterone, per 50 mgJ2680 Injection, fluphenazine decanoate, up to 25 mgJ2690 Injection, procainamide HCL, up to 1 gmJ2700 Injection, oxacillin sodium, up to 250 mgJ2710 Injection, neostigmine methylsulfate, up to 0.5 mgJ2720 Injection, protamine sulfate, per 10 mgJ2724 INJECTION, PROTEIN C CONCENTRATE, INTRAVENOUS,HUMAN, 10 IU- (Eff. Date 1/1/2008)J2725 Injection, protirelin, per 250 mcgDME MAC Jurisdiction C Supplier Manual Page 78

HCPCSAppendix AJ2730 Injection, pralidoxime chloride, up to 1 gmJ2760 Injection, phentolamine mesylate, up to 5 mgJ2765 Injection, metoclopramide HCL, up to 10 mgJ2770 Injection, quinupristin/dalfopristim, 500 mg (150/350) (Eff. Date1/1/2001)J2778 INJECTION, RANIBIZUMAB, 0.1 MG- (Eff. Date 1/1/2008)J2780 Injection, ranitidine hydrochloride, 25 mg (Eff. Date 1/1/2000)J2783 Injection, rasburicase, 0.5mgJ2788 Injection, rho d immune globuline, human, minidose, 50 mcg (Eff.Date 1/1/2003)J2790 Injection, rho d immune globulin, human, full dose, 300mcgJ2791 INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN),(RHOPHYLAC), INTRAMUSCULAR OR INTRAVENOUS, 100 IU-(Eff. Date 1/1/2008)J2792 Injection, rho d immune globulin, intravenous, human, solventdetergent, 100 I.U.J2794 Injection, risperidone, long acting, 0.5 mg (Eff. Date 1/1/2005)J2795 Injection, ropivacaine hydrochloride, 1 mg (Eff. Date 1/1/2001)J2800 Injection, methocarbamol, up to 10 mlJ2805 Injection, sincalide, 5 micrograms (Eff. Date 1/1/2006)J2810 Injection, theophylline, per 40 mgJ2820 Injection, sargramostim (gm-csf), 50 mcgJ2850 Injection, secretin, synthetic, human, 1 microgram (Eff. Date1/1/2006)J2860 Injection, secobarbital sodium, up to 250 mg (Deleted eff.12/31/2001)J2910 Injection, aurothioglucose, up to 50 mgJ2912 Injection, sodium chloride, 0.9%, per 2 mlJ2915 Injection, sodium ferric gluconate complex in sucrose injection, 62.5mg (Deleted eff.12/31/2002)J2916 Injection, sodium ferric gluconate complex in sucrose injection, 12.5mg (Eff. Date 1/1/2003)J2920 Injection, methylprednisolone sodium succinate, up to 40 mg 10DME MAC Jurisdiction C Supplier Manual Page 79

HCPCSAppendix AJ2930 Injection, methylprednisolone sodium succinate, up to 125 mg 10J2940 Injection, somatrem, 1 mg (Eff. Date 1/1/2002)J2941 Injection, somatropin, 1 mg (Eff. Date 1/1/2002)J2950 Injection, promazine HCL, up to 25 mgJ2970 Injection, methicillin sodium, up to 1 gm (Deleted eff. 12/31/2001)J2993 Injection, reteplase, 18.1 mg (Eff. Date 1/1/2001)J2994 Injection reteplase, 37.6 mg (two single use vials)J2995 Injection, streptokinase, per 250,000 I.U.J2996 Injection, alteplase recombinant, per 10 mgJ2997 Injection, alteplase recombinant, 1 mg (Eff. Date 1/1/2001)J3000 Injection, streptomycin, up to 1 gmJ3005 Injection, strontium-89 chloride, per 10 ml (Deleted eff. 12/31/1997)J3010 Injection, fentanyl citrate, 0.1 mgJ3030 Injection, sumatriptan succinate, 6 mg (code may be used forMedicare when drug administered under the direct supervision of aphysician, not for use when drug is self administered)J3070 Injection, pentazocine, 30 mgJ3080 Injection, chlorprothixene, up to 50 mg (Deleted eff. 12/31/2001)J3100 Injection, tenecteplase, 50 mg (Eff. Date 1/1/2002)J3105 Injection, terbutaline sulfate, up to 1 mgJ3110 Injection, teriparatide, 10 mcg (Eff. Date 1/1/2005)J3120 Injection, testosterone enanthate, up to 100 mgJ3130 Injection, testosterone enanthate, up to 200 mgJ3140 Injection, testosterone suspension, up to 50 mgJ3150 Injection, testosterone propionate, up to 100 mgJ3230 Injection, chlorpromazine HCL, up to 50 mgJ3240 Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vialJ3243 Injection, tigecycline, 1 mg (Eff date 01/01/2007)J3245 Injection, tirofiban hydrochloride, 12.5 mg (Eff. Date 1/1/2000)(Deleted eff. 12/31/2004)DME MAC Jurisdiction C Supplier Manual Page 80

HCPCSAppendix AJ3246 Injection, Tirofiban HCL, 0.25 mgJ3250 Injection, trimethobenzamide HCL, up to 200 mgJ3260 Injection, tobramycin sulfate, up to 80 mgJ3265 Injection, torsemide, 10 mg/mlJ3270 Injection, imipramine HCL, up to 25 mg (Deleted eff. 12/31/2001)J3280 Injection, thiethylperazine maleate, up to 10 mgJ3285 Injection, treprostinil, 1 mg (Eff. Date 1/1/2006)J3301 Injection, triamcinolone acetonide, per 10mgJ3302 Injection, triamcinolone diacetate, per 5mgJ3303 Injection, triamcinolone hexacetonide, per 5mgJ3305 Injection, trimetrexate glucuronate, per 25 mgJ3310 Injection, perphenazine, up to 5 mgJ3315 Injection, triptorelin pamoate, 3.75 mg (Eff. Date 1/1/2003)J3320 Injection, spectinomycin dihydrochloride, up to 2 gmJ3350 Injection, urea, up to 40 gmJ3355 Injection, urofollitropin, 75 IU (Eff. Date 1/1/2006)J3360 Injection, diazepam, up to 5 mgJ3364 Injection, urokinase, 5000 iu vialJ3365 Injection, IV, urokinase, 250,000 i.u. vialJ3370 Injection, vancomycin HCL, 500 mgJ3390 Injection, methoxamine HCL, up to 20 mg (Deleted eff. 12/31/2001)J3395 Injection, verteporfin, 15 mg (Eff. Date 1/1/2002) (Deleted eff.12/31/2004)J3396 Injection, verteporfin, 0.1 mg (Eff. Date 1/1/2005)J3400 Injection, triflupromazine HCL, up to 20 mgJ3410 Injection, hydroxyzine HCL, up to 25 mgJ3411 Injection, thiamine HCL, 100 mgJ3415 Injection, pyridoxine HCL, 100 mgJ3420 Injection, vitamin b-12 cyanocobalamin, up to 1000 mcgJ3430 Injection, phytonadione (vitamin k), per 1 mgDME MAC Jurisdiction C Supplier Manual Page 81

HCPCSAppendix AJ3450 Injection, mephentermine sulfate, up to 30 mg (Deleted eff.12/31/2001)J3465 Injection, voriconazole, 10 mgJ3470 Injection, hyaluronidase, up to 150 unitsJ3471 Injection, hyaluronidase, ovine, preservative free, per 1 USP unit (upto 999 USP units) (Eff. Date 1/1/2006)J3472 Injection, hyaluronidase, ovine, preservative free, per 1000 USP units(Eff. Date 1/1/2006)J3473 Injection, Hyaluronidase, Recombinant, 1 USP Unit (Eff date01/01/2007)J3475 Injection, magnesium sulfate, per 500 mgJ3480 Injection, potassium chloride, per 2 meqJ3485 Injection, zidovudine, 10 mg (Eff. Date 1/1/2001)J3486 Injection, ziprasidone mesylate, 10 mgJ3487 INJECTION, ZOLEDRONIC ACID (ZOMETA), 1 MG (Updated01/01/2008)J3488 INJECTION, ZOLEDRONIC ACID (RECLAST), 1 MG- (Eff. Date1/1/2008)J3490 Unclassified drugs 14J3520 Edetate disodium, per 150 mgJ3530 Nasal vaccine inhalationJ3535 Drug administered through a metered dose inhalerJ3570 Laetrile, amygdalin, vitamin b17J3590 Unclassified biologics (Eff. Date 1/1/2003)J7030 Infusion, normal saline solution , 1000 ccJ7040 Infusion, normal saline solution, sterile (500 ml=1 unit)J7042 5% dextrose/normal saline (500 ml = 1 unit)J7050 Infusion, normal saline solution , 250 ccJ7051 Sterile saline or water, up to 5 cc (Deleted eff. 12/31/2005) 15J7060 5% dextrose/water (500 ml = 1 unit)J7070 Infusion, d5w, 1000 ccJ7100 Infusion, dextran 40, 500 mlDME MAC Jurisdiction C Supplier Manual Page 82

HCPCSAppendix AJ7110 Infusion, dextran 75, 500 mlJ7120 Ringers lactate infusion, up to 1000 ccJ7130 Hypertonic saline solution, 50 or 100 meq, 20 cc vialJ7140 Prescription drug, oral, dispensed in physician’s office (Deleted eff.12/31/1996)J7150 Prescription drug, oral chemotherapy for malignant disease (Deletedeff. 12/31/1996)J7187 INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMATE-P), PER IU VWF:RCO (Updated 01/01/2008)J7188 Injection, von willebrand factor complex, human, IU (Eff. Date1/1/2006)J7189 Factor VIIA (antihemophilic factor, recombinant), per 1 microgram(Eff. Date 1/1/2006)J7190 Factor VIII (antihemophilic factor, human) per I.U.J7191 Factor VIII (antihemophilic factor (porcine), per I.U.J7192 Factor VIII (antihemophilic factor, recombinant) per I.U.J7193 Factor IX (antihemophilic factor, purified, non-recombinant) per I.U.(Eff. Date 1/1/2002)J7194 Factor IX, complex, per I.U..J7195 Factor IX (antihemophilic factor, recombinant) per I.U. (Eff. Date1/1/2002)J7196 Other hemophilia clotting factors, (e.g., anti-inhibitors), per I.U.(Deleted eff. 12/31/1999)14J7197 Antithrombin III (human), per I.U.J7198 Anti-inhibitor, per I.U. (Eff. Date 1/1/2000)J7199 Hemophilia clotting factor, not otherwise classified (Eff. Date1/1/2000)J7300 Intrauterine copper contraceptiveJ7302 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg(Eff. Date 1/1/2002)J7303 Contraceptive Supply, Hormone containing vaginal ring, eachJ7304 Contraceptive supply, hormone containing patch, each (Eff. Date1/1/2005)J7306 Levonorgestrel (contraceptive) implant system, including implantsandDME MAC Jurisdiction C Supplier Manual Page 83

HCPCSAppendix Asupplies (Eff. Date 1/1/2006)J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM,INCLUDING IMPLANT AND SUPPLIES- (Eff. Date 1/1/2008)J7308 Aminolevulinic acid HCL for topical administration, 20%, single unitdosage form (354 mg) (Eff. Date 1/1/2002)J7310 Ganciclovir, 4.5 mg, long-acting implantJ7311 Fluocinolone Acetonide, Intravitreal implant Eff date 01/01/2007)J7315 Sodium hyaluronate, 20 mg, for intra articular injection (Deleted eff.12/31/2001)J7316 Sodium hyaluronate, 5 mg for intra-articular injection (Deletedeff.12/31/2002)J7317 Sodium hyaluronate, 20-25 mg dose for intra-articular injection (Eff.Date 1/1/2003) (Deleted eff. 12/31/2005)J7319 Hyaluronan (Sodium Hyaluronate) or Derivative, intra-articularinjection, per injection (Terminated on 3/31/2007)J7320 Hylan g-f 20, 16 mg, for intra articular injection (Deleted eff.12/31/2005)J7321J7322J7323J7324HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FORINTRA-ARTICULAR INJECTION, PER DOSE- (Eff. Date 1/1/2008)HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE- (Eff. Date 1/1/2008)HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJECTION, PER DOSE- (Eff. Date 1/1/2008)HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE- (Eff. Date 1/1/2008)J7340 Dermal and eipdermal, (substitute) tissue of human orgain, with ourwithout bioengineered or processed elements, with matabolicallyactive elements, per square centimeter (Eff. Date 1/1/2002)J7343 Dermal and epidermal, tissue of non-human origin, with or withoutother bioengineered or processed elements, without metabolicallyactive elements, per square centimeter (Eff. Date 1/1/2005)J7344 Dermal tissue, of human origin, with and without other bioengineeredor processed elements, without metabolically active elements, persquare centimeter (Eff. Date 1/1/2005)J7345 Dermal (Substitute) Tissue of non-human origin, with or without otherDME MAC Jurisdiction C Supplier Manual Page 84

HCPCSAppendix ABioengineered or processed elements, without metabolically activeelements, per square centimeter (Terminated Date 12/31/2007)J7346 Dermal (Substitute) Tissue of Human Origin, Injectable, with orwithout other Bioengineered or processed elements, butwithoutmetabolically active elements, 1 cc (Eff date 01/01/2007)J7347 DERMAL (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITHOR WITHOUT OTHER BIOENGINEERED OR PROCESSEDELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS(INTEGRA MATRIX), PER SQUARE CENTIMETER- (Eff. Date1/1/2008)J7348 DERMAL (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITHOR WITHOUT OTHER BIOENGINEERED OR PROCESSEDELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS(TISSUEMEND), PER SQUARE CENTIMETER- (Eff. Date 1/1/2008)J7349 DERMAL (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITHOR WITHOUT OTHER BIOENGINEERED OR PROCESSEDELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS(PRIMATRIX), PER SQUARE CENTIMETER- (Eff. Date 1/1/2008)J7500 Azathioprine, oral, 50 mg 10J7501 Azathioprine, parenteral, 100 mg 10J7502 Cyclosporine, oral, 100 mg (Eff. Date 1/1/2000) 10J7503 Cyclosporine, parenteral, per 50 mg (Deleted eff. 12/31/1999)J7504 Lymphocyte immune globulin, antithymocyte globulin, equine,parenteral, 250 mg10J7505 Muromonab-cd3, parenteral, 5 mg 10J7506 Prednisone, oral, per 5mg 10J7507 Tacrolimus, oral, per 1 mg 10J7508 Tacrolimus, oral, per 5 mg (Deleted eff. 12/31/2003) 10J7509 Methylprednisolone oral, per 4 mg 10J7510 Prednisolone oral, per 5 mg 10J7511 Lymphocyte immune globulin, antithymocyte globulin, rabbit,parenteral 25 mg (Eff. Date 1/1/2002)J7513 Daclizumab, parenteral, 25 mg 10J7515 Cyclosporine, oral, 25 mg (Eff. Date 1/1/2000) 10J7516 Cyclosporin, parenteral, 250 mg (Eff. Date 1/1/2000) 10J7517 Mycophenolate mofetil, oral, 250 mg (Eff. Date 1/1/2000) 10DME MAC Jurisdiction C Supplier Manual Page 85

HCPCSAppendix AJ7518 Mycophenolic acid, oral, 180 mg (Eff. Date 1/1/2005) 10J7520 Sirolimus, oral, 1 mg (Eff. Date 1/1/2001)J7525 Tacrolimus, parenteral, 5 mg (Eff. Date 1/1/2001)J7599 Immunosuppressive drug, not otherwise classified 10J7602 ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATEDISOMERS, INHALATION SOLUTION, FDA-APPROVED FINALPRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGHDME, CONCENTRATED FORM, PER 1 MG (ALBUTEROL) OR PER0.5 MG (LEVALBUTEROL)- (Eff. Date 1/1/2008)J7603 ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATEDISOMERS, INHALATION SOLUTION, FDA-APPROVED FINALPRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGHDME, UNIT DOSE, PER 1 MG (ALBUTEROL) OR PER 0.5 MG(LEVALBUTEROL)- (Eff. Date 1/1/2008)J7604 ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDEDPRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM,PER GRAM- (Eff. Date 1/1/2008)J7605 ARFORMOTEROL, INHALATION SOLUTION, FDA APPROVEDFINAL PRODUCT, NON-COMPOUNDED, ADMINISTEREDTHROUGH DME, UNIT DOSE FORM, 15 MICROGRAMS- (Eff. Date1/1/2008)J7607 Levalbuterol, inhalation solution, compounded product, administeredthrough DME, Concentrated form, 0.5 mg (Eff date 01/01/2007)J7608 ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVEDFINAL PRODUCT, NON-COMPOUNDED, ADMINISTEREDTHROUGH DME, UNIT DOSE FORM, PER GRAM (Updated01/01/2008)J7609 Albuterol, inhalation solution, compounded product, administeredthrough DME, unit dose, 1 mg (Eff date 01/01/2007)J7610 Albuterol, inhalation solution, compounded product, administeredthrough DME, concentrated form, 1 mg (Eff date 01/01/2007)J7611 Albuterol, inhalation solution, FDA-approved final product, noncompounded,administered through DME, concentrated form, 1 mg(Terminated on 6/30/2007)J7612 Levalbuterol, inhalation solution, FDA-approved final product, noncompounded,administered through DME, concentrated form, 0.5 mg(Terminated on 6/30/2007)J7613 Albuterol, inhalation solution, FDA-approved final product, noncompounded,administered through DME, unit dose, 1 mg(Terminated on 6/30/2007)J7614 Levalbuterol, inhalation solution, FDA-approved final product, noncompounded,administered through DME, unit dose, 0.5 mg151515151515151515151515DME MAC Jurisdiction C Supplier Manual Page 86

HCPCSAppendix A(Terminated on 6/30/2007)J7615 Levalbuterol, inhalation solution, compounded product, administeredthrough DME, unit dose, 0.5 mg (Eff date 01/01/2007)J7616 Albuterol, up to 5 mg and ipratropium bromide, up to 1 mg,compounded inhalation solution, administered through DME (Eff.Date 1/1/2005) (Deleted eff. 12/31/2005)J7617 Levalbuterol, up to 2.5 mg and ipratropium bromide, up to 1 mg,compounded inhalation solution, administered through DME (Eff.Date 1/1/2005) (Deleted eff. 12/31/2005)J7618 Albuterol, all formulations including separated isomers, inhalationsolution administered through DME, concentrated form, per 1 mg(albuterol) or per 0.5 mg (levalbuterol) (Eff. Date 1/1/2000) (Deletedeff. 12/31/2004)J7619 Albuterol, all formulations including separated isomers, inhalationsolution administered through DME, unit dose, per 1 mg (albuterol) orper 0.5 mg (levalbuterol) (Eff. Date 1/1/2000) (Deleted eff.12/31/2004)1515151515J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDAapprovedfinal product, non-compounded inhalation solution,administered through DME (Eff. Date 1/1/2006)J7621 Albuterol, all formulations, including separated isomers, up to 5 mg(albuterol) or 2.5mg (levalbuterol) and ipratropium bromide, up to 1mg, compounded inhalation solution, administered through DME (Eff.Date 1/1/2004) (Deleted eff. 12/31/2004)J7622 Beclomethasone, inhalation solution, compounded product,administered through DME, unit dose form, per milligram (Eff. Date1/1/2002)J7624 Betamethasone, inhalation solution, compounded product,administered through DME, unit dose form, per milligram (Eff. Date1/1/2002)J7625 Albuterol sulfate, 0.5%, per ml, inhalation solution administeredthrough DME (Deleted eff. 12/31/2000)J7626 Budesonide inhalation solution, FDA-approved final product,noncompounded,administered through DME, unite dose form, up to 0.5mg (Eff. Date 1/1/2002)J7627 Budesonide, inhalation solution, compounded product, administeredthrough DME, unit dose form, up to 0.5 mg (Eff. Date 1/1/2006)J7628 Bitolterol mesylate, inhalation solution, compounded product,administered through DME, concentrated form, per milligram (Eff.Date 1/1/2000)15151515151515DME MAC Jurisdiction C Supplier Manual Page 87

HCPCSAppendix AJ7629 Bitolterol mesylate, inhalation solution, compounded product,administered through DME, unit dose form, per milligram (Eff. Date1/1/2000)J7630 Cromolyn sodium, per 20 mg, inhalation solution administeredthrough DME (Deleted eff. 12/31/2000)J7631 CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVEDFINAL PRODUCT, NON-COMPOUNDED, ADMINISTEREDTHROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS(Updated 01/01/2008)J7632 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDEDPRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE FORM,PER 10 MILLIGRAMS- (Eff. Date 1/1/2008)J7633 Budesonide, inhalation solution, FDA-approved final product, noncompounded,administered throught DME, concentrated form, per0.25 milligram (Eff. Date 1/1/2003)J7634 Budesonide, inhalation solution, compounded product, administeredthrought DME, concentrated form, per 0.25 milligram (Eff. Date1/1/2007)J7635 Atropine, inhalation solution compounded product, administeredthrough DME, concentrated form, per milligram (Eff. Date 1/1/2000)J7636 Atropine, inhalation solution, compounded product, administeredthrough DME, unit dose form, per milligram (Eff. Date 1/1/2000)J7637 Dexamethasone, inhalation solution, compounded product,administered through DME, concentrated form, per milligram (Eff.Date 1/1/2000)J7638 Dexamethasone, inhalation solution, compounded product,administered through DME, unit dose form, per milligram (Eff. Date1/1/2000)J7639 DORNASE ALPHA, INHALATION SOLUTION, FDA-APPROVEDFINAL PRODUCT, NON-COMPOUNDED, ADMINISTEREDTHROUGH DME, UNIT DOSE FORM, PER MILLIGRAM (Updated01/01/2008)1515151515151515151515J7640 Formorterol, inhalation solution, compounded product, administeredthrough DME, unit dose form, 12 micrograms (Eff. Date 1/1/2006)J7641 Flunisolide, inhalation solution, compounded product, administeredthrough DME, unit dose, per milligram (Eff. Date 1/1/2002)J7642 Glycopyrrolate, inhalation solution, compounded product,administered through DME, concentrated form, per milligram (Eff.Date 1/1/2000)J7643 Glycopyrrolate, inhalation solution, compounded product,administered through DME, unit dose form, per milligram (Eff. Date1/1/2000)1515DME MAC Jurisdiction C Supplier Manual Page 88

HCPCSAppendix AJ7644 Ipratropium bromide, inhalation solution, FDA-approved final product,non-compounded, administered through DME, unit dose form, permilligram (Eff. Date 1/1/2000)J7645 Ipratropium bromide, inhalation solution, compounded product,administered through DME, unit dose form, per milligram (Eff. Date1/1/2007)J7647 Isoetharine HCL, inhalation solution, compounded product,administered through DME, concentrated form, per milligram (Eff.Date 01/01/2007)J7648 Isoetharine HCL, inhalation solution, FDA-approved final product,non-compounded, administered through DME, concentrated form,per milligram (Eff. Date 1/1/2000)J7649 Isoetharine HCL, inhalation solution, FDA-approved final product,non-compounded, administered through DME, unit dose form, permilligram (Eff. Date 1/1/2000)J7650 Isoetharine HCL, inhalation solution, compounded product,administered through DME, unit dose form, per milligram (Eff. Date01/01/2007)151515151515J7651 Isoetharine hydrochloride, 0.125%, per ml, inhalation solutionadministered through DME (Deleted eff. 12/31/2000)J7652 Isoetharine hydrochloride, 0.167%, per ml, inhalation solutionadministered through DME (Deleted eff. 12/31/2000)J7653 Isoetharine hydrochloride, 0.2%, per ml, inhalation solutionadministered through DME (Deleted eff. 12/31/2000)J7654 Isoetharine hydrochloride, 0.25%, per ml, inhalation solutionadministered through DME (Deleted eff. 12/31/2000)J7655 Isoetharine hydrochloride, 1.0%, per ml, inhalation solutionadministered through DME (Deleted eff. 12/31/2000)J7657 Isoproterenol HCL, inhalation solution, compounded product,administered through DME, concentrated form, per milligram (Eff.Date 01/01/2007)J7658 Isoproterenol HCL, inhalation solution, FDA-approved final product,non-compounded, administered through DME, concentrated form,per milligram (Eff. Date 1/1/2000)J7659 Isoproterenol HCL, inhalation solution. FDA-approved, noncompounded,administered through DME, unit dose form, permilligram (Eff. Date 1/1/2000)J7660 Isoproterenol HCL, inhalation solution, compounded product,administered through DME, unit dose form, per milligram (Eff. Date01/01/2007)J7665 Isoproterenol hydrochloride, 1.0%, per ml, inhalation solutionadministered through DME (Deleted eff. 12/31/2000)1515151515DME MAC Jurisdiction C Supplier Manual Page 89

HCPCSAppendix AJ7667 Metaproterenol sulfate, inhalation solution, compounded product,administered through DME, concentrated form, per 10 milligrams (Effdate 01/01/2007)J7668 Metaproterenol sulfate, inhalation solution, FDA-approved, noncompounded,administered through DME, concentrated form, per 10milligrams (Eff. Date 1/1/2000)J7669 Metaproterenol sulfate, inhalation solution, FDA-approved finalproduct, administered through DME, unit dose form, per 10milligrams (Eff. Date 1/1/2000)J7670 Metaproterenol sulfate,inhalation solution, compounded product,administered through DME, unit dose form, per 10 milligram (Eff.Date 01/01/2007)15151515J7672 Metaproterenol sulfate, 0.6%, per 2.5 ml, inhalation solutionadministered through DME (Deleted eff. 12/31/2000)J7674 Methacholine chloride administered as inhalation solution through anebulizer, per 1 mg (Eff. Date 1/1/2005)J7675 Metaproterenol sulfate, 5.0%, per ml, inhalation solution administeredthrough DME (Deleted eff. 12/31/2000)J7676 PENTAMIDINE ISETHIONATE, INHALATION SOLUTION,COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,UNIT DOSE FORM, PER 300 MG- (Eff. Date 1/1/2008)J7680 Terbutaline sulfate, inhalation solution, compounded product,administered through DME, concentrated form, per milligram (Eff.Date 1/1/2000)J7681 Terbutaline sulfate, inhalation solution, compounded product,administered through DME, unit dose form, per milligram (Eff. Date1/1/2000)J7682 Tobramycin, inhalation solution, FDA-approved final product, noncompounded,unit dose form, administered through DME, per 300milligrams (Eff. Date 1/1/2000)J7683 Triamcinolone, inhalation solution, compounded product,administered through DME, concentrated form, per milligram (Eff.Date 1/1/2000)J7684 Triamcinolone, inhalation solution, compounded product,administered through DME, unit dose form, per milligram (Eff. Date1/1/2000)J7685 Tobramycin, inhalation solution, compounded product, administeredthrough DME. Unit dose form, per 300 milligrams (Eff date01/01/2007)15151515151515J7699 NOC drugs, inhalation solution administered through DME 15J7799 NOC drugs, other than inhalation drugs, administered through DME 14DME MAC Jurisdiction C Supplier Manual Page 90

HCPCSAppendix AJ8498 Antiemetic drug, rectal/suppository, not otherwise specified (Eff. Date1/1/2006)J8499 Prescription drug, oral, non chemotherapeutic, NOSJ8501 Aprepitant, oral, 5 mg (Eff. Date 1/1/2005) 20J8510 Busulfan; oral, 2 mg (Eff. Date 1/1/2000)J8515 Cabergoline, oral, 0.25 mg (Eff. Date 1/1/2006)J8520 Capecitabine, oral, 150 mg (Eff. Date 1/1/2000)J8521 Capecitabine, oral, 500 mg (Eff. Date 1/1/2000)J8530 Cyclophosphamide; oral, 25 mg 10J8540 Dexamethasone, oral, 0.25 mg (Eff. Date 1/1/2006)J8560 Etoposide; oral, 50 mgJ8565 Gefitinib, oral, 250 mg (Eff. Date 1/1/2005)J8597 Antiemetic drug, oral, not otherwise specified (Eff. Date 1/1/2006)J8600 Melphalan; oral, 2 mgJ8610 Methotrexate; oral, 2.5 mg 10J8650 Nabilone, oral, 1mg(Eff date 01/01/2007) 20J8999 Prescription drug, oral, chemotherapeutic, NOSJ9000 Doxorubicin HCL, 10 mgJ9001 Doxorubicin hydrochloride, all lipid formulations, 10 mg (Eff. Date1/1/2000)J9010 Alemtuzumab, 10 mg (Eff. Date 1/1/2003)J9015 Aldesleukin, per single use vialJ9017 Arsenic trioxide, 1 mg (Eff. Date 1/1/2002)J9020 Asparaginase, 10,000 unitsJ9025 Injection, azacitidine, 1 mg (Eff. Date 1/1/2006)J9027 Injection, clofarabine, 1 mg (Eff. Date 1/1/2006)J9031 Bcg (intravesical) per instillationJ9035 Injection, bevacizumab, 10 mg (Eff. Date 1/1/2005)J9040 Bleomycin sulfate, 15 unitsJ9041 Injection, bortezomib, 0.1 mg (Eff. Date 1/1/2005)DME MAC Jurisdiction C Supplier Manual Page 91

HCPCSAppendix AJ9045 Carboplatin, 50 mgJ9050 Carmustine, 100 mgJ9055 Injection, cetuximab, 10 mg (Eff. Date 1/1/2005)J9060 Cisplatin, powder or s0lution, per 10 mgJ9062 Cisplatin, 50 mgJ9065 Injection, cladribine, per 1 mgJ9070 Cyclophosphamide, 100 mgJ9080 Cyclophosphamide, 200 mgJ9090 Cyclophosphamide, 500 mgJ9091 Cyclophosphamide, 1.0 gramJ9092 Cyclophosphamide, 2.0 gramJ9093 Cyclophosphamide, lyophilized, 100 mgJ9094 Cyclophosphamide, lyophilized, 200 mgJ9095 Cyclophosphamide, lyophilized, 500 mgJ9096 Cyclophosphamide, lyophilized, 1.0 gramJ9097 Cyclophosphamide, lyophilized, 2.0 gramJ9098 Cytarabine liposome, 10 mgJ9100 Cytarabine, 100 mgJ9110 Cytarabine, 500 mgJ9120 Dactinomycin, 0.5 mgJ9130 Dacarbazine, 100 mgJ9140 Dacarbazine, 200 mgJ9150 Daunorubicin, 10 mgJ9151 Daunorubicin citrate, liposomal formulation, 10 mgJ9165 Diethylstilbestrol diphosphate, 250 mgJ9170 Docetaxel, 20 mgJ9175 Injection, elliotts' B solution, 1 ml (Eff. Date 1/1/2006)J9178 Injection, epirubicin HCL, 2 mgJ9181 Etoposide, 10 mgDME MAC Jurisdiction C Supplier Manual Page 92

HCPCSAppendix AJ9182 Etoposide, 100 mgJ9185 Fludarabine phosphate, 50 mgJ9190 Fluorouracil, 500 mgJ9200 Floxuridine, 500 mgJ9201 Gemcitabine HCL, 200 mgJ9202 Goserelin acetate implant, per 3.6 mgJ9206 Irinotecan, 20 mgJ9208 Ifosfamide, 1 gmJ9209 Mesna, 200 mgJ9211 Idarubicin hydrochloride, 5 mgJ9212 Injection, interferon alfacon-1, recombinant, 1 mcgJ9213 Interferon, alfa-2a, recombinant, 3 million unitsJ9214 Interferon, alfa-2b, recombinant, 1 million unitsJ9215 Interferon, alfa-n3, (human leukocyte derived), 250,000 I.U.J9216 Interferon, gamma 1-b, 3 million unitsJ9217 Leuprolide acetate (for depot suspension), 7.5 mgJ9218 Leuprolide acetate, per 1 mgJ9225 HISTRELIN IMPLANT (VANTAS), 50 MG (Updated 01/01/2008)J9226 HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG- (Eff. Date1/1/2008)J9230 Mechlorethamine hydrochloride, (nitrogen mustard), 10 mgJ9245 Injection, melphalan hydrochloride, 50 mgJ9250 Methotrexate sodium, 5 mgJ9260 Methotrexate sodium, 50 mgJ9261 Injection, nelarabine, 50 mg (Eff date 01/01/2007)J9263 Injection, oxaliplatine, 0.5 mgJ9264 Injection, paclitaxel protein-bound particles, 1 mg (Eff. Date 1/1/2006)J9265 Paclitaxel, 30 mgJ9266 Pegaspargase, per single dose vialJ9268 Pentostatin, per 10 mgDME MAC Jurisdiction C Supplier Manual Page 93

HCPCSAppendix AJ9270 Plicamycin, 2.5 mgJ9280 Mitomycin, 5 mgJ9290 Mitomycin, 20 mgJ9291 Mitomycin, 40 mgJ9293 Injection, mitoxantrone hydrochloride, per 5 mgJ9300 Gemtuzumab ozogamicin, 5 mg (Eff. Date 1/1/2002)J9303 INJECTION, PANITUMUMAB, 10 MG- (Eff. Date 1/1/2008)J9305 Injection, pemetrexed, 10 mg (Eff. Date 1/1/2005)J9310 Rituximab, 100 mgJ9320 Streptozocin, 1 gmJ9340 Thiotepa, 15 mgJ9350 Topotecan, 4 mgJ9355 Trastuzumab, 10 mg (Eff. Date 1/1/2000)J9357 Valrubicin, intravesical, 200 mg (Eff. Date 1/1/2000)J9360 Vinblastine sulfate, 1 mgJ9370 Vincristine sulfate, 1 mgJ9375 Vincristine sulfate, 2 mgJ9380 Vincristine sulfate, 5 mgJ9390 Vinorelbine tartrate, per 10 mgJ9395 Injection, fulvestrant, 25 mgJ9600 Porfimer sodium, 75 mgJ9999 Not otherwise classified, antineoplastic drugs 14DME MAC Jurisdiction C Supplier Manual Page 94

HCPCSAppendix AHCPCS KPayment Category1 Capped Rental 8 Parenteral/Enteral Supplies and Kits 15 Nebulizer Drugs2 Freq. & Substantial Serv. DME 9 Parenteral/Enteral Pumps 16 Therapeutic Shoes for Diabetics3 Customized DMEPOS 10 Immunosuppressive Drugs 17 Individual Consideration4 Prosthetics/Orthotics 11 Ostomy, Trach., & Urologicals 18 Epoetin (EPO)5 Inexp. & Routinely Purch. DME 12 Surgical Dressings 19 Dialysis Supplies & Equipment6 Oxygen and Oxygen Equipment 13 Supplies 20 Oral Antiemetic Drugs7 Parenteral/Enteral Nutrients 14 Not Otherwise ClassifiedCode Description Category CMN/DIFRequiredK0001 Standard wheelchair 01K0002 Standard hemi (low seat) wheelchair 01K0003 Lightweight wheelchair 01K0004 High strength, lightweight wheelchair 01K0005 Ultralightweight wheelchair 05K0006 Heavy duty wheelchair 01K0007 Extra heavy duty wheelchair 01K0008 Custom manual wheelchair/base (Deleted eff. 10/1/01) 03K0009 Other manual wheelchair/base 14K0010 Standard - weight frame motorized/power wheelchair 01K0011 Standard - weight frame motorized/power wheelchair withprogrammable control parameters for speed adjustment, tremordampening, acceleration control and braking01K0012 Lightweight portable motorized/power wheelchair 01K0013 Custom motorized/power wheelchair base (Deleted eff. 10/1/01) 03K0014 Other motorized/power wheelchair base 01/14K0015 Detachable, non-adjustable height armrest, each 05K0016 Detachable, adjustable height armrest, complete assembly, each 05DME MAC Jurisdiction C Supplier Manual Page 95

HCPCSAppendix AK0017 Detachable, adjustable height armrest, base, each 05K0018 Detachable, adjustable height armrest, upper portion, each 05K0019 Arm pad, each 05K0020 Fixed, adjustable height armrest, pair 05K0021 Anti-tipping device, each (Deleted eff.12/31/2002) 05K0022 Reinforced back upholstery (Deleted eff. 12/31/2003) 05K0023 Solid back insert, planar back, single density foam, attached withstraps (Deleted Eff. 06/30/04)K0024 Solid back insert, planar back, single density foam, with adjustablehook-on hardware (Deleted Eff. 06/30/04)0505K0025 Hook-on headrest extension (Deleted eff. 12/31/2003) 05K0026 Back upholstery for ultralightweight or high strength lightweightwheelchair (Deleted eff. 12/31/2003)K0027 Back upholstery for wheelchair type other than ultralightweight orhigh strength lightweight wheelchair (Deleted eff. 12/31/2003)0505K0028 Manual, fully reclining back (Deleted eff. 12/31/2003) 05K0029 Reinforced seat upholstery (Deleted eff. 12/31/2003) 05K0030 Solid seat insert, planar seat, single density foam (Deleted eff.12/31/2003)05K0031 Safety belt/pelvic strap, each (Deleted eff. 12/31/2003) 05K0032 Seat upholstery for ultralightweight or high strength lightweightwheelchair (Deleted eff. 12/31/2003)K0033 Seat upholstery for wheelchair type other than ultralightweight orhigh strength lightweight wheelchair (Deleted eff. 12/31/2003)0505K0034 Heel loop, each (Deleted eff.12/31/2002) 05K0035 Heel loop with ankle strap, each (Deleted eff. 12/31/2003) 05K0036 Toe loop, each (Deleted eff. 12/31/2003) 05K0037 High mount flip-up footrest, each 05K0038 Leg strap, each 05K0039 Leg strap, H style, each 05DME MAC Jurisdiction C Supplier Manual Page 96

HCPCSAppendix AK0040 Adjustable angle footplate, each 05K0041 Large size footplate, each 05K0042 Standard size footplate, each 05K0043 Footrest, lower extension tube, each 05K0044 Footrest, upper hanger bracket, each 05K0045 Footrest, complete assembly 05K0046 Elevating legrest, lower extension tube, each 05K0047 Elevating legrest, upper hanger bracket, each 05K0048 Elevating legrest, complete assembly (Deleted eff. 12/31/2003) 05K0049 Calf pad, each (Deleted eff. 12/31/2003) 05K0050 Ratchet assembly 05K0051 Cam release assembly, footrest or legrest, each 05K0052 Swingaway, detachable footrests, each 05K0053 Elevating footrests, articulating (telescoping), each 05K0054 Seat width of 10", 11", 12", 15", 17", or 20" for a high strength,lightweight or ultralightweight wheelchair (Deleted eff. 12/31/2003)K0055 Seat depth of 15", 17", or 18" for a high strength, lightweight orultralightweight wheelchair (Deleted eff. 12/31/2003)K0056 Seat height less than 17" or equal to or greater than 21" for a highstrength, lightweight, or ultralightweight wheelchairK0057 Seat width 19" or 20" for heavy duty or extra heavy duty chair(Deleted eff. 12/31/2003)K0058 Seat depth 17" or 18" for motorized/power wheelchair (Deleted eff.12/31/2003)0505050505K0059 Plastic coated handrim, each (Deleted eff. 12/31/2004) 05K0060 Steel handrim, each (Deleted eff. 12/31/2004) 05K0061 Aluminum handrim, each (Deleted eff. 12/31/2004) 05K0062 Handrim with 8-10 vertical or oblique projections, each (Deleted eff.12/31/2003)05K0063 Handrim with 12-16 vertical or oblique projections, each (Deleted eff. 05DME MAC Jurisdiction C Supplier Manual Page 97

HCPCSAppendix A12/31/2003)K0064 Zero pressure tube (flat free inserts), any size, each (Deleted eff.12/31/2005)05K0065 Spoke protectors, each 05K0066 Solid tire, any size, each (Deleted eff. 12/31/2005) 05K0067 Pneumatic tire, any size, each (Deleted eff. 12/31/2005) 05K0068 Pneumatic tire tube, each (Deleted eff. 12/31/2005) 05K0069 Rear wheel assembly, complete, with solid tire, spokes or molded,eachK0070 Rear wheel assembly, complete, with pneumatic tire, spokes ormolded, each0505K0071 Front caster assembly, complete, with pneumatic tire, each 05K0072 Front caster assembly, complete, with semi-pneumatic tire, each 05K0073 Caster pin lock, each 05K0074 Pneumatic caster tire, any size, each (Deleted eff. 12/31/2005) 05K0075 Semi-pneumatic caster tire, any size, each (Deleted eff. 12/31/2005) 05K0076 Solid caster tire, any size, each (Deleted eff. 12/31/2005) 05K0077 Front caster assembly, complete, with solid tire, each 05K0078 Pneumatic caster tire tube, each (Deleted eff. 12/31/2005) 05K0079 Wheel lock extension, pair (Deleted eff. 12/31/2003) 05K0080 Anti-rollback device, pair (Deleted eff. 12/31/2003) 05K0081 Wheel lock assembly, complete, each (Deleted eff. 12/31/2004) 05K0082 22 nf non-sealed lead acid battery, each (Deleted eff. 12/31/2003) 05K0083 22 nf sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) (Deleted eff. 12/31/2003)K0084 Group 24 non-sealed lead acid battery, each (Deleted eff.12/31/2003)K0085 Group 24 sealed lead acid battery, each (e.g., gel cell, absorbedglass mat) (Deleted eff. 12/31/2003)050505K0086 U-1 non-sealed lead acid battery, each (Deleted eff. 12/31/2003) 05K0087 U-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) (Deleted eff. 12/31/2003)05DME MAC Jurisdiction C Supplier Manual Page 98

HCPCSAppendix AK0088 Battery charger single mode, for use with only one battery type,sealed or non-sealed (Deleted eff. 12/31/2003)K0089 Battery charger, dual mode, for use with only one battery type,sealed or non-sealed (Deleted eff. 12/31/2003)K0090 Rear wheel tire for power wheelchair, any size, each (delete12/31/06)K0091 Rear wheel tire tube other than zero pressure for power wheelchair,any size, each (delete 12/31/06)K0092 Rear wheel assembly for power wheelchair, complete, each (delete12/31/06)K0093 Rear wheel, zero pressure tire tube (flat free insert) for powerwheelchair, any size, each (delete 12/31/06)050505050505K0094 Wheel tire for power base, any size, each (delete 12/31/06) 05K0095 Wheel tire tube other than zero pressure for each base, any size,each (delete 12/31/06)05K0096 Wheel assembly for power base, complete, each (delete 12/31/06) 05K0097 Wheel zero pressure tire tube (flat free insert) for power base, anysize, each (delete 12/31/06)05K0098 Drive belt for power wheelchair 05K0099 Front caster for power wheelchair, each (delete 12/31/06) 05K0100 Wheelchair adapter for amputee, pair (device used to compensatefor transfer of weight due to lost limbs to maintain proper balance)(Deleted eff. 12/31/2003)05K0101 One-arm drive attachment, each (Deleted eff.12/31/2002) 01K0102 Crutch and cane holder, each (Deleted eff. 12/31/2005) 05K0103 Transfer board,

HCPCSAppendix AK0111 Supplies for external drug infusion pump, per cassette or bag(Deleted eff. 12/31/1996)K0112 Trunk support device, vest type, with inner frame, prefabricated (notvalid for Medicare as of 7/1/2002) (Deleted eff. 12/31/2003)K0113 Trunk support device, vest type, without inner frame, prefabricated(not valid for Medicare as of 7/1/2002) (Deleted eff. 12/31/2003)K0114 Back support system for use with a wheelchair, with inner frame,prefabricated (Deleted Eff. 06/30/04)K0115 Seating system, back module, posterior lateral control, with orwithout lateral supports, custom fabricated for attachment towheelchair base (Deleted eff. 12/31/2004)K0116 Seating system, combined back and seat module, custom fabricatedfor attachment to wheelchair base (Deleted eff. 12/31/2004)050504050505K0117 Unlisted item, orthotic seating, back module (Deleted eff.12/31/1995)K0118 TENS supplies - one month supply for TENS, 2 lead (Deleted eff.12/31/1995)05K0119 Azathioprine - oral, tab, 50 mg (Deleted eff. 12/31/1999) 10K0120 Azathioprine - parenteral, 100 mg (Deleted eff. 12/31/1999) 10K0121 Cyclosporine - oral, 25 mg (Deleted eff. 12/31/1999) 10K0122 Cyclosporine - parenteral, 250 mg (Deleted eff. 12/31/1999) 10K0123 Lymphocyte immune globulin, antithymocyte globulin - parenteral,250 mg (Deleted eff. 12/31/1999)10K0124 Monoclonal antibodies - parenteral, 5 mg (Deleted eff. 12/31/1996) 10K0125 Prednisone - oral, 5 mg (Deleted eff. 12/31/1996) 10K0126 Replace soft interface material, multi-podus type splint (Deleted eff.12/31/1996)K0127 Replace soft interface material, ankle contracture splint (Deleted eff.12/31/1996)K0128 Replace soft interface material, foot drop splint (Deleted eff.12/31/1996)040404K0129 Ankle contracture splint (Deleted eff. 12/31/1996) 04K0130 Foot drop splint, recumbent positioning device (Deleted eff.12/31/1996)04K0131 Spring-powered device for lancet (Deleted eff. 12/31/1995) 05DME MAC Jurisdiction C Supplier Manual Page 100

HCPCSAppendix AK0132 Male external catheter with or without adhesive, with or without antireflux(Deleted eff. 12/31/1995)K0133 Intermittent urinary catheter, disposable; straight tip (Deleted eff.9/30/1995)K0134 Intermittent urinary catheter, disposable; coude (curved) tip (Deletedeff. 9/30/1995)K0135 Intermittent urinary catheter, reusable: straight tip (Deleted eff.9/30/1995)K0136 Intermittent urinary catheter, reusable; coude (curved) tip (Deletedeff. 9/30/1995)K0137 Skin barrier; liquid (spray, brush, etc.), per oz. (Deleted eff.12/31/1999)111111111111K0138 Skin barrier; paste, per oz. (Deleted eff. 12/31/1999) 11K0139 Skin barrier; powder, per oz. (Deleted eff. 12/31/1999) 11K0140 Acetylcysteine, compounded, per mg, inhalation solutionadministered through DME (Deleted eff. 3/31/1997)K0141 Albuterol sulfate, compounded, per mg, inhalation solutionadministered through DME (Deleted eff. 3/31/1997)K0142 Cromolyn sodium, compounded, per mg, inhalation solutionadministered through DME (Deleted eff. 3/31/1997)K0143 Isoetharine hydrochloride, compounded, per mg, inhalation solutionadministered through DME (Deleted eff. 3/31/1997)K0144 Isoproterenol hydrochloride, compounded, per mg, inhalationsolution administered through DME (Deleted eff. 3/31/1997)K0145 Metaproterenol, compounded, per mg, inhalation solutionadministered through DME (Deleted eff. 3/31/1997)K0146 Terbutaline, compounded, per mg, inhalation solution administeredthrough DME (Deleted eff. 3/31/1997)15151515151515K0147 Gastrostomy tube, silicone with sliding ring (Deleted eff. 12/31/1995)K0148 Hydrogel dressing, each (Deleted eff. 3/29/1994) 12K0149 Hydrocolloid dressing, each (Deleted eff. 3/29/1994) 12K0150 Alginate dressing, each (Deleted eff. 3/29/1994) 12K0151 Foam dressing, each (Deleted eff. 3/29/1994) 12K0152 Pastes, powders, granules, beads, contact layers (Deleted eff.12/31/1996)12K0153 Composite dressing, each (Deleted eff. 3/29/1994) 12DME MAC Jurisdiction C Supplier Manual Page 101

HCPCSAppendix AK0154 Wound pouch, each (Deleted eff. 12/31/1996)K0162 Progressive lens, each lens (Deleted eff. 12/31/1995) 04K0163 Vacuum erection system (Deleted eff. 12/31/1996) 04K0164 Oropharyngel suction catheter, each (Deleted eff. 12/31/1995) 05K0165 Tracheostomy care kit for established tracheostomy (Deleted eff.12/31/1995)11K0166 Methylprednicolone - oral, 4 mg (Deleted eff. 12/31/1995) 10K0167 Prednisolone - oral, 5 mg (Deleted eff. 12/31/1995) 10K0168 Administration set, small volume nonfiltered pneumatic nebulizer,disposable (Deleted eff. 12/31/1999)K0169 Small volume nonfiltered pneumatic nebulizer, disposable (Deletedeff. 12/31/1999)K0170 Administration set, small volume nonfiltered pneumatic nebulizer,non-disposable (Deleted eff. 12/31/1999)K0171 Administration set, small volume filtered pneumatic nebulizer(Deleted eff. 12/31/1999)K0172 Large volume nebulizer, disposable, unfilled, used with aerosolcompressor (Deleted eff. 12/31/1999)K0173 Large volume nebulizer, disposable, prefilled, used with aerosolcompressor (Deleted eff. 12/31/1999)K0174 Reservoir bottle, non-disposable, used with large volume ultrasonicnebulizer (Deleted eff. 12/31/1999)K0175 Corrugated tubing, disposable, used with large volume nebulizer,100 feet (Deleted eff. 12/31/1999)K0176 Corrugated tubing, non-disposable, used with large volumenebulizer, 10 feet (Deleted eff. 12/31/1999)K0177 Water collection device, used with large volume nebulizer (Deletedeff. 12/31/1999)K0178 Filter, disposable, used with aerosol compressor (Deleted eff.12/31/1999)K0179 Filter, non-disposable, used with aerosol compressor or ultrasonicgenerator (Deleted eff. 12/31/1999)050505050505050505050505K0180 Aerosol mask, used with DME nebulizer (Deleted eff. 12/31/1999) 05K0181 Dome and mouthpiece, used with small volume ultrasonic nebulizer(Deleted eff. 12/31/1999)05DME MAC Jurisdiction C Supplier Manual Page 102

HCPCSAppendix AK0182 Water, distilled, used with large volume nebulizer, 1000 ml (Deletedeff. 12/31/2000)K0183 Nasal application device used with positive airway pressure device(Deleted eff.12/31/2002)K0184 Nasal single piece interface, replacement for nasal applicationdevice, pair or single piece interface (Deleted eff.12/31/2002)K0185 Headgear used with positive airway pressure device (Deletedeff.12/31/2002)K0186 Chin strap used with positive airway pressure device (Deletedeff.12/31/2002)K0187 Tubing used with positive airway pressure device (Deletedeff.12/31/2002)K0188 Filter, disposable, used with positive airway pressure device (Deletedeff.12/31/2002)K0189 Filter, non disposable, used with positive airway pressure device(Deleted eff.12/31/2002)K0190 Canister, disposable, used with suction pump (Deleted eff.12/31/1999)K0191 Canister, non-disposable, used with suction pump (Deleted eff.12/31/1999)15050505050505050505K0192 Tubing, used with suction pump (Deleted eff. 12/31/1999) 05K0193 Continuous positive airway pressure device, with humidifier (Deletedeff. 9/30/1999)K0194 Intermittent assist device with continuous positive airway pressure,with humidifier (Deleted eff. 9/30/1999)0101K0195 Elevating leg rests, pair (for use with capped rental wheelchair base) 01K0196 Alginate dressing, wound cover, pad size 16 sq. in. or less, eachdressing (Deleted eff. 12/31/1996)K0197 Alginate dressing, wound cover, pad size more than 16 but less thanor equal to 48 sq. in., each dressing (Deleted eff. 12/31/1996)K0198 Alginate dressing, wound cover, pad size more than 48 sq. in., eachdressing (Deleted eff. 12/31/1996)121212K0199 Alginate dressing, wound filler, per 6 inches (Deleted eff. 12/31/1996) 12K0203 Composite dressing, pad size 16 sq. in. or less, with any sizeadhesive border, each dressing (Deleted eff. 12/31/1996)K0204 Composite dressing, pad size more than 16 but less than or equal to48 sq. in., with any size adhesive border, each dressing (Deleted eff.1212DME MAC Jurisdiction C Supplier Manual Page 103

HCPCSAppendix A12/31/1996)K0205 Composite dressing, pad size more than 48 sq. in., with any sizeadhesive border, each dressing (Deleted eff. 12/31/1996)K0206 Contact layer, 16 sq. in. or less, each dressing (Deleted eff.12/31/1996)K0207 Contact layer, more than 16 but less than or equal to 48 sq. in., eachdressing (Deleted eff. 12/31/1996)K0208 Contact layer, more than 48 sq. in., each dressing (Deleted eff.12/31/1996)K0209 Foam dressing, wound cover, pad size 16 sq. in. or less, withoutadhesive border, each dressing (Deleted eff. 12/31/1996)K0210 Foam dressing, wound cover, pad size more than 16 but less than orequal to 48 sq. in., without adhesive border, each dressing (Deletedeff. 12/31/1996)K0211 Foam dressing, wound cover, pad size more than 48 sq. in., withoutadhesive sq. in., border, each dressing (Deleted eff. 12/31/1996)K0212 Foam dressing, wound cover, pad size 16 sq. in. or less, with anysize adhesive border, each dressing (Deleted eff. 12/31/1996)K0213 Foam dressing, wound cover, pad size more than 16 but less than orequal to 48 sq. in., with any size adhesive border, each dressing(Deleted eff. 12/31/1996)K0214 Foam dressing, wound cover, pad size more than 48 sq. in., with anysize adhesive border, each dressing (Deleted eff. 12/31/1996)12121212121212121212K0215 Foam dressing, wound filler, per gram (Deleted eff. 12/31/1996) 12K0216 Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less,without adhesive border, each dressing (Deleted eff. 12/31/1996)K0217 Gauze, non-impregnated, non-sterile, pad size more than 16 but lessthan or equal to 48 sq. in., without adhesive border, each dressing(Deleted eff. 12/31/1996)K0218 Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in.,without adhesive border, each dressing (Deleted eff. 12/31/1996)K0219 Gauze, non-impregnated, pad size 16 sq. in. or less, with any sizeadhesive border, each dressing (Deleted eff. 12/31/1996)K0220 Gauze, non-impregnated, pad size more than 16 but less than orequal to 48 sq. in., with any size adhesive border, each dressing(Deleted eff. 12/31/1996)K0221 Gauze, non-impregnated, pad size more than 48 sq. in., with anysize adhesive border, each dressing (Deleted eff. 12/31/1996)121212121212DME MAC Jurisdiction C Supplier Manual Page 104

HCPCSAppendix AK0222 Gauze, impregnated, other than water or normal saline, pad size 16sq. in. or less, without adhesive border, each dressing (Deleted eff.12/31/1996)K0223 Gauze, impregnated, other than water or normal saline, pad sizemore than 16 but less than or equal to 48 sq. in., without adhesiveborder, each dressing (Deleted eff. 12/31/1996)K0224 Gauze, impregnated, other than water or normal saline, pad sizemore than 48 sq. in., without adhesive border, each dressing(Deleted eff. 12/31/1996)K0228 Gauze, impregnated, water or normal saline, pad size 16 sq. in. orless, without adhesive border, each dressing (Deleted eff.12/31/1996)K0229 Gauze, impregnated, water or normal saline, pad size more than 16but less than or equal to 48 sq. in., without adhesive border, eachdressing (Deleted eff. 12/31/1996)K0230 Gauze, impregnated, water or normal saline, pad size more than 48sq. in., without adhesive border, each dressing (Deleted eff.12/31/1996)K0234 Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less,without adhesive border, each dressing (Deleted eff. 12/31/1996)K0235 Hydrocolloid dressing, wound cover, pad size more than 16 but lessthan or equal to 48 sq. in., without adhesive border, each dressing(Deleted eff. 12/31/1996)K0236 Hydrocolloid dressing, wound cover, pad size more than 48 sq. in.,without equal to 48 sq. in., without adhesive border, each dressingadhesive border, each dressing (Deleted eff. 12/31/1996)K0237 Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, withany size adhesive border, each dressing (Deleted eff. 12/31/1996)K0238 Hydrocolloid dressing, wound cover, pad size more than 16 but lessthan or equal to 48 sq. in., with any size adhesive border, eachdressing (DeletedK0239 Hydrocolloid dressing, wound cover, pad size more than 48 sq. in.,with any size adhesive border, each dressing (Deleted eff.12/31/1996)K0240 Hydrocolloid dressing, wound filler, paste, per fluid ounce (Deletedeff. 12/31/1996)K0241 Hydrocolloid dressing, wound filler, dry form, per gram (Deleted eff.12/31/1996)K0242 Hydrogel dressing, wound cover, pad size 16 sq. in. or less, withoutadhesive border, each dressing (Deleted eff. 12/31/1996)121212121212121212121212121212DME MAC Jurisdiction C Supplier Manual Page 105

HCPCSAppendix AK0243 Hydrogel dressing, wound cover, pad size more than 16 but lessthan or equal to 48 sq. in., without adhesive border, each dressing(Deleted eff. 12/31/1996)K0244 Hydrogel dressing, wound cover, pad size more than 48 sq. in.,without adhesive border, each dressing (Deleted eff. 12/31/1996)K0245 Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with anysize adhesive border, each dressing (Deleted eff. 12/31/1996)K0246 Hydrogel dressing, wound cover, pad size more than 16 but lessthan or equal to 48 sq. in., with any size adhesive border, eachdressing (Deleted eff. 12/31/1996)K0247 Hydrogel dressing, wound cover, pad size more than 48 sq. in., withany size adhesive border, each dressing (Deleted eff. 12/31/1996)K0248 Hydrogel dressing, wound filler, gel, per fluid ounce (Deleted eff.12/31/1996)K0249 Hydrogel dressing, wound filler, dry form, per gram (Deleted eff.12/31/1996)K0250 Skin sealants, protectants, moisturizers, any type, any size (Deletedeff. 12/31/1996)K0251 Specialty absorptive dressing, wound cover, pad size 16 sq. in. orless, without adhesive border, each dressing (Deleted eff.12/31/1996)K0252 Specialty absorptive dressing, wound cover, pad size more than 16but less than or equal to 48 sq. in., without adhesive border, eachdressingK0253 Specialty absorptive dressing, wound cover, pad size more than 48sq. in., without adhesive border, each dressing (Deleted eff.12/31/1996)K0254 Specialty absorptive dressing, wound cover, pad size 16 sq. in. orless, with any size adhesive border, each dressing (Deleted eff.12/31/1996)K0255 Specialty absorptive dressing, wound cover, pad size more than 16but less than or equal to 48 sq. in., with any size adhesive border,each dressing (Deleted eff. 12/31/1996)K0256 Specialty absorptive dressing, wound cover, pad size more than 48sq. in., with any size adhesive border, each dressing (Deleted eff.12/31/1996)K0257 Transparent film, 16 sq. in. or less, each dressing (Deleted eff.12/31/1996)K0258 Transparent film, more than 16 but less than or equal to 48 sq. in.,each dressing (Deleted eff. 12/31/1996)12121212121212121212121212121212K0259 Transparent film, more than 48 sq. in., each dressing (Deleted eff. 12DME MAC Jurisdiction C Supplier Manual Page 106

HCPCSAppendix A12/31/1996)K0260 Wound cleansers, any type, any size (Deleted eff. 12/31/1996) 12K0261 Wound filler, not elsewhere classified, gel/paste, per fluid ounce(Deleted eff. 12/31/1996)K0262 Wound filler, not elsewhere classified, dry form, per gram (Deletedeff. 12/31/1996)K0263 Gauze, elastic, non-sterile, all types, per linear yard (Deleted eff.12/31/1996)K0264 Gauze, non-elastic, non-sterile, per linear yard (Deleted eff.12/31/1996)12121212K0265 Tape, all types, per 18 square inches (Deleted eff. 12/31/1996) 12K0266 Gauze, impregnated, other than water or normal saline, any width,per linear yard (Deleted eff. 12/31/1996)K0267 Replacement battery, any type, for use with medically necessaryhome blood glucose monitor owned by patient, each (Deleted eff.12/31/1995)K0268 Humidifier, non-heated, used with positive airway pressure device(Deleted eff. 12/31/2003)K0269 Aerosol compressor, adjustable pressure, light duty for intermittentuse (Deleted eff. 12/31/2000)K0270 Ultrasonic generator with small volume ultrasonic nebulizer (Deletedeff. 12/31/2000)K0271 Pouch, drainable; with faceplate attached; reusable; rubber or vinyl,each (Deleted eff. 6/30/1996)K0272 Pouch, drainable; without faceplate attached; reusable; rubber orvinyl, each (Deleted eff. 6/30/1996)K0273 Pouch, urinary; with faceplate attached; reusable; rubber or vinyl,each (Deleted eff. 6/30/1996)K0274 Pouch, urinary; without faceplate attached; reusable; rubber or vinyl,each (Deleted eff. 6/30/1996)K0275 Ostomy faceplate; convex; reusable; rubber or vinyl, each (Deletedeff. 6/30/1996)K0276 Ostomy faceplate; convex; custom fitted reusable; rubber or vinyl,each (Deleted eff. 6/30/1996)K0277 Skin barrier; solid 4x4 or equivalent, standard wear, with built-inconvexity, each (Deleted eff. 12/31/1999)K0278 Skin barrier; with flange (solid, flexible or accordion), standard wear,with built-in convexity, any size, each (Deleted eff. 12/31/1999)12050501011111111111111111DME MAC Jurisdiction C Supplier Manual Page 107

HCPCSAppendix AK0279 Skin barrier; with flange (solid, flexible or accordion), extended wear,with built-in convexity, any size, each (Deleted eff. 12/31/1999)K0280 Extension drainage tubing, any type, any length, withconnector/adaptor, for use with urinary leg bag or urostomy pouch,each (Deleted eff. 12/31/2000)K0281 Lubricant, individual sterile packet, for insertion of urinary catheter,each (Deleted eff. 12/31/2000)K0282 Water, distilled, 1000 ml, used with large volume nebulizer (Deletedeff. 12/31/1994)K0283 Saline solution, per 10 ml, metered dose dispenser, for use withinhalation drugs (Deleted eff. 12/31/2000)K0284 External infusion pump, mechanical, reusable, for extended druginfusion (Deleted eff. 12/31/1999)K0285 Repair of prosthetic device, labor component, per 15 minutes(Deleted eff. 12/31/1996)K0400 Adhesive skin support attachment for use with external breastprosthesis, each (Deleted eff. 12/31/1999)K0401 For diabetics only, deluxe feature of off-the shelf depth inlay shoe orcustom molded shoe, per shoe (Deleted eff. 12/31/1999)K0402 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, withoutadhesive border, each dressing (Deleted eff. 12/31/1996)K0403 Gauze, non-impregnated, sterile, pad size more than 16 but lessthan or equal to 48 sq. in., without adhesive border, each dressing(Deleted eff. 12/31/1996)K0404 Gauze, non-impregnated, sterile, pad size more than 48 sq. in.,without adhesive border, each dressing (Deleted eff. 12/31/1996)K0405 Gauze, elastic, sterile, all types, per linear yard (Deleted eff.12/31/1996)111111151501 09.0304041612121212K0406 Gauze, non-elastic, sterile, per linear yard (Deleted eff. 12/31/1996) 12K0407 Urinary catheter anchoring device, adhesive skin attachment(Deleted eff. 12/31/2000)K0408 Urinary catheter anchoring device, leg strap (Deleted eff.12/31/2000)1111K0409 Sterile water irrigation solution, 1000 ml (Deleted eff. 12/31/2000) 11K0410 Male external catheter, with adhesive coating, each (Deleted eff.12/31/2000)K0411 Male external catheter, with adhesive strip, each (Deleted eff.12/31/2000)1111DME MAC Jurisdiction C Supplier Manual Page 108

HCPCSAppendix AK0412 Mycophenolate mofetil, oral, 250 mg (Deleted eff. 12/31/1999) 10K0413 Non-powered, advanced pressure-reducing overlay for mattress,standard mattress length and width (Deleted eff. 12/31/1997)K0414 Powered air overlay for mattress, standard mattress length and width(Deleted eff. 12/31/1997)0101K0415 Prescription anti-emetic drug, oral, per 1 mg, for use in conjunctionwith oral anti-cancer drug, not otherwise specified (Deleted eff.12/31/2005)K0416 Prescription anti-emetic drug, rectal, per 1 mg, for use in conjunctionwith oral anti-cancer drug, not otherwise specified (Deleted eff.12/31/2005)K0417 External infusion pump, mechanical, reusable, for short term druginfusion (Deleted eff. 12/31/1999)05 09.03K0418 Cyclosporin, oral, per 100 mg (Deleted eff. 12/31/1999) 10K0419 Pouch, drainable, with faceplate attached, plastic, each (Deleted eff.12/31/1999)K0420 Pouch, drainable, with faceplate attached, rubber, each (Deleted eff.12/31/1999)K0421 Pouch, drainable, for use on faceplate, plastic, each (Deleted eff.12/31/1999)K0422 Pouch, drainable, for use on faceplate, rubber, each (Deleted eff.12/31/1999)K0423 Pouch, urinary, with faceplate attached, plastic, each (Deleted eff.12/31/1999)K0424 Pouch, urinary, with faceplate attached, rubber, each (Deleted eff.12/31/1999)K0425 Pouch, urinary, for use on faceplate, plastic, each (Deleted eff.12/31/1999)K0426 Pouch, urinary, for use on faceplate, heavy plastic, each (Deleted eff.12/31/1999)K0427 Pouch, urinary, for use on faceplate, rubber, each (Deleted eff.12/31/1999)K0428 Ostomy faceplate equivalent, silicone ring, each (Deleted eff.12/31/1999)K0429 Skin barrier, solid 4x4 or equivalent, extended wear, without built-inconvexity, each (Deleted eff. 12/31/1999)K0430 Skin barrier, with flange (solid, flexible or accordion), extended wear,without built-in convexity, any size, each (Deleted eff. 12/31/1999)111111111111111111111111DME MAC Jurisdiction C Supplier Manual Page 109

HCPCSAppendix AK0431 Pouch, closed; with standard wear barrier attached, with built-inconvexity (1 piece), each (Deleted eff. 12/31/1999)K0432 Pouch, drainable, with extended wear barrier attached, without builtinconvexity (1 piece), each (Deleted eff. 12/31/1999)K0433 Pouch, drainable, with standard wear barrier attached, with built-inconvexity (1 piece), each (Deleted eff. 12/31/1999)K0434 Pouch, drainable, with extended wear barrier attached, with built-inconvexity (1 piece), each (Deleted eff. 12/31/1999)K0435 Pouch, urinary, with extended wear barrier attached, without built-inconvexity (1 piece), each (Deleted eff. 12/31/1999)K0436 Pouch, urinary, with standard wear barrier attached, with built-inconvexity (1 piece), each (Deleted eff. 12/31/1999)K0437 Pouch, urinary, with extended wear barrier attached, with built-inconvexity (1 piece), each (Deleted eff. 12/31/1999)K0438 Ostomy deodorant for use in ostomy pouch, liquid, per fluid ounce(Deleted eff. 12/31/1999)K0439 Ostomy deodorant for use in ostomy pouch, solid, per tablet (Deletedeff. 12/31/1999)K0440 Nasal prosthesis - provided by a non-physician (Deleted eff.12/31/2000)K0441 Midfacial prosthesis - provided by a non-physician (Deleted eff.12/31/2000)K0442 Orbital prosthesis - provided by a non-physician (Deleted eff.12/31/2000)K0443 Upper facial prosthesis - provided by a non-physician (Deleted eff.12/31/2000)K0444 Hemi-facial prosthesis - provided by a non-physician (Deleted eff.12/31/2000)K0445 Auricular prosthesis - provided by a non-physician (Deleted eff.12/31/2000)K0446 Partial facial prosthesis - provided by a non-physician (Deleted eff.12/31/2000)K0447 Nasal septal prosthesis - provided by a non-physician (Deleted eff.12/31/2000)K0448 Unspecified maxillofacial prosthesis, by report - provided by a nonphysician(Deleted eff. 12/31/2000)K0449 Repair or modification of maxillofacial prosthesis, labor component,15 minute increments - provided by a non-physician (Deleted eff.12/31/2000)11111111111111111104040404040404040404DME MAC Jurisdiction C Supplier Manual Page 110

HCPCSAppendix AK0450 Adhesive, liquid, for use with facial prosthesis only, per ounce(Deleted eff. 12/31/2000)K0451 Adhesive remover, wipes, for use with facial prosthesis, per box of50 (Deleted eff. 12/31/2000)0404K0452 Wheelchair bearings, any type (Deleted eff. 12/31/2005)K0453 Injection, amphotericin b, 50 mg (Deleted eff. 12/31/1998) 05K0454 Non-powered, advanced pressure-reducing mattress (Deleted eff.12/31/1997)K0455 Infusion pump used for uninterrupted parenteral administration ofmedication, epoprostenol or treprostinilK0456 Hospital bed, heavy duty, extra wide, with any type side rails, withmattress (Deleted eff. 12/31/2000)K0457 Extra wide/heavy duty commode chair, each (Deleted eff.12/31/2000)0102 09.030105K0458 Heavy duty walker, without wheels, each (Deleted eff. 12/31/2000) 05K0459 Heavy duty wheeled walker, each (Deleted eff. 12/31/2000) 05K0460 Power add-on, to convert manual wheelchair to motorizedwheelchair, joystick control (Deleted eff. 12/31/2003)K0461 Power add-on, to convert manual wheelchair to power operatedvehicle, tiller control (Deleted eff. 12/31/2003)K0462 Temporary replacement for patient owned equipment being repaired,any typeK0501 Aerosol compressor, battery powered, for use with small volumenebulizer (Deleted eff. 12/31/2000)K0503 Acetylcysteine, inhalation solution administered through DME, unitdose form, per gram (Deleted eff. 12/31/1999)K0504 Albuterol, inhalation solution administered through DME,concentrated form, per milligram (Deleted eff. 12/31/1999)K0505 Albuterol, inhalation solution administered through DME, unit doseform, per milligram (Deleted eff. 12/31/1999)K0506 Atropine, inhalation solution administered through DME,concentrated form, per milligram (Deleted eff. 12/31/1999)K0507 Atropine, inhalation solution administered through DME, unit doseform, per milligram (Deleted eff. 12/31/1999)K0508 Bitolterol mesylate, inhalation solution administered through DME,concentrated form, per milligram (Deleted eff. 12/31/1999)01050501151515151515DME MAC Jurisdiction C Supplier Manual Page 111

HCPCSAppendix AK0509 Bitolterol mesylate, inhalation solution administered through DME,unit dose form, per milligram (Deleted eff. 12/31/1999)K0511 Cromolyn sodium, inhalation solution administered through DME,unit dose form, per milligram (Deleted eff. 12/31/1999)K0512 Dexamethasone, inhalation solution administered through DME,concentrated form, per milligram (Deleted eff. 12/31/1999)K0513 Dexamethasone, inhalation solution administered through DME, unitdose form, per milligram (Deleted eff. 12/31/1999)K0514 Dornase alpha, inhalation solution administered through DME, unitdose form, per milligram (Deleted eff. 12/31/1999)K0515 Glycopyrrolate, inhalation solution administered through DME,concentrated form, per milligram (Deleted eff. 12/31/1999)K0516 Glycopyrrolate, inhalation solution administered through DME, unitdose form, per milligram (Deleted eff. 12/31/1999)K0518 Ipratropium bromide, inhalation solution administered through DME,unit dose form, per milligram (Deleted eff. 12/31/1999)K0519 Isoetharine Hcl, inhalation solution administered through DME,concentrated form, per milligram (Deleted eff. 12/31/1999)K0520 Isoetharine Hcl, inhalation solution administered through DME, unitdose form, per milligram (Deleted eff. 12/31/1999)K0521 Isoproterenol Hcl, inhalation solution administered through DME,concentrated form, per milligram (Deleted eff. 12/31/1999)K0522 Isoproterenol Hcl, inhalation solution administered through DME,concentrated form, per milligram (Deleted eff. 12/31/1999)K0523 Metaproterenol sulfate, inhalation solution administered throughDME, concentrated form, per 10 milligrams (Deleted eff. 12/31/1999)K0524 Metaproterenol sulfate, inhalation solution administered throughDME, unit dose form, per 10 milligrams (Deleted eff. 12/31/1999)K0525 Terbutaline sulfate, inhalation solution administered through DME,concentrated form, per milligram (Deleted eff. 12/31/1999)K0526 Terbutaline sulfate, inhalation solution administered through DME,unit dose form, per milligram (Deleted eff. 12/31/1999)K0527 Triamcinolone, inhalation solution administered through DME,concentrated form, per milligram (Deleted eff. 12/31/1999)K0528 Triamcinolone, inhalation solution administered through DME, unitdose form, per milligram (Deleted eff. 12/31/1999)K0529 Sterile water or sterile saline, 1000 ml, used with large volumenebulizer (Deleted eff. 12/31/2000)15151515151515151515151515151515151515DME MAC Jurisdiction C Supplier Manual Page 112

HCPCSAppendix AK0530 Nebulizer, durable, glass , or autoclavable plastic, bottle type, notused with oxygen (Deleted eff. 12/31/1999)K0531 Humidifier, heated, used with positive airway pressure device(Deleted eff. 12/31/2003)K0532 Respiratory assist device, bi-level pressure capability, withoutbackup rate feature, used with noninvasive interface, e.g., nasal orfacial mask (intermittent assist device with continuous positive airwaypressure device) (Deleted eff. 12/31/2003)K0533 Respiratory assist device, bi-level pressure capability, with backuprate feature, used with noninvasive interface, e.g., nasal or facialmask (intermittent assist device with continuous positive airwaypressure device) (Deleted eff. 12/31/2003)K0534 Respiratory assist device, bi-level pressure capacity, with back uprate feature, used with invasive interface, e.g., tracheostomy tube(intermittent assist device with continuous positive airway pressuredevice) (Deleted eff. 12/31/2003)K0535 Gauze, impregnated, hydrogel, for direct wound contact, pad size 16sq. in. or less, without adhesive border, each dressing (Deleted eff.12/31/2000)K0536 Gauze, impregnated, hydrogel, for direct wound contact, pad sizemore than 16 sq. in. but less than or equal to 48 sq. in., withoutadhesive border, each dressing (Deleted eff. 12/31/2000)K0537 Gauze, impregnated, hydrogel, for direct wound contact, pad sizemore than 48 sq. in., without adhesive border, each dressing(Deleted eff. 12/31/2000)K0538 Negative pressure wound therapy electrical pump, stationary orportable (Eff. Date 1/1/2001) (Deleted eff. 12/31/2003)K0539 Dressing set for negative pressure wound therapy electrical pump,stationary or portable, each (Deleted eff. 12/31/2003)K0540 Canister set for negative pressure wound therapy electrical pump,stationary or portable, each (Deleted eff. 12/31/2003)K0541 Speech generating device, digitized speech, using pre-recordedmessages, less than or equal to 8 minutes recording time (Deletedeff. 12/31/2003)K0542 Speech generation device, digitized speech, using pre-recordedmessages, greater than 8 minutes recording time (Deleted eff.12/31/2003)K0543 Speech generative device, synthesized speech, requiring messageformulation by spelling and access by physical contact with thedevice (Deleted eff. 12/31/2003)0505010202121212011313050505DME MAC Jurisdiction C Supplier Manual Page 113

HCPCSAppendix AK0544 Speech generating device, synthesized speech, permitting multiplemethods of message formulation and multiple methods of deviceaccess (Deleted eff. 12/31/2003)K0545 Speech generating software program, for personal computer orpersonal digital assistant (Deleted eff. 12/31/2003)K0546 Accessory for speech generating device, mounting system (Deletedeff. 12/31/2003)K0547 Accessory for speech generating device, not otherwise classified(Deleted eff. 12/31/2003)05050514K0548 Injection, insulin, lispro, up to 50 units (Deleted eff. 12/31/2002)K0549 Hospital bed, heavy duty, extra wide, with weight capacity greaterthan 350 pounds, but less than or equal to 600 pounds, with any typeside rails, with mattress (Deleted eff. 12/31/2003)K0550 Hospital bed, extra heavy duty, extra wide, with weight capacitygreater than 600 pounds, with any type side rails, with mattress(Deleted eff. 12/31/2003)0101K0551 Residual limb support system, solid base with adjustable drop hooks,mounts to wheelchair frame, each (Deleted eff.12/31/2002)K0552 Supplies for external infusion pump, syringe type cartridge, sterile,each (Eff. Date 04/01/2003)K0553 Combination Oral/Nasal Mask, Used With Continuous PositiveAirway Pressure Device, Each (Deleted eff.12/31/2007)K0554 Oral Cushion For Combination Oral/Nasal Mask, Replacement Only,Each (Deleted eff.12/31/2007)K0555 Nasal Pillows For Combination Oral/Nasal Mask, Replacement Only,Pair (Deleted eff.12/31/2007)K0556 Addition to lower extremity, below knee/above knee, customfabricated from existing mold or prefabricated, socket insert, siliconegel, elastomeric or equal, for use with locking mechanism. (Deletedeff. 12/31/2003)K0557 Addition to lower extremity, below knee/above knee, customfabricated from existing mold or prefabricated, socket insert, siliconegel, elastomeric or equal, not for use with locking mechanism.(Deleted eff. 12/31/2003)K0558 Addition to lower extremity, below knee/above knee, customfabricated socket insert for congenital or atypical traumatic amputee,silicone gel, elastomeric or equal, for use with or without lockingmechanism, initial only. (Deleted eff. 12/31/2003)13050505040404DME MAC Jurisdiction C Supplier Manual Page 114

HCPCSAppendix AK0559 Addition to lower extremity, below knee/above knee, customfabricated socket insert for other than congenital or atypical traumaticamputee, silicone gel, elastomeric or equal, for use with or withoutlocking mechanism, initial only. (Deleted eff. 12/31/2003)K0561 Ostomy skin barrier, non-pectin based, paste, per ounce (Deletedeff.12/31/2002)K0562 Ostomy skin barrier, pectin-based, paste, per ounce (Deletedeff.12/31/2002)K0563 Ostomy skin barrier, with flange (solid, flexible, or accordion),extended wear, with built-in convexity, 4 x 4 inches or smaller, each(Deleted eff.12/31/2002)K0564 Ostomy skin barrier, with flange (solid, flexible, or accordion),extended wear, with built-in convexity, larger than 4 x 4 inches, each(Deleted eff.12/31/2002)K0565 Ostomy skin barrier, with flange (solid, flexible, or accordion),extended wear, without built-in convexity, 4 x 4 inches or smaller,each (Deleted eff.12/31/2002)K0566 Ostomy skin barrier, with flange (solid, flexible, or accordion),extended wear, without built-in convexity, larger than 4 x 4 inches,each (Deleted eff.12/31/2002)K0567 Ostomy pouch, drainable, with karaya based barrier attached,without built-in convexity, (1 piece), each (Deleted eff.12/31/2002)K0568 Ostomy pouch, drainable, with standard wear barrier attached,without built-in convexity, (1 piece), each (Deleted eff.12/31/2002)K0569 Ostomy pouch, drainable, high output, for use on a barrier withflange (2 piece system), each (Deleted eff.12/31/2002)K0570 Ostomy skin barrier, with flange (solid, flexible, or accordion), withoutbuilt-in convexity, 4 x 4 inches or smaller, each (Deletedeff.12/31/2002)K0571 Ostomy skin barrier, with flange (solid, flexible, or accordion), withoutbuilt-in convexity, larger than 4 x 4 inches, each (Deletedeff.12/31/2002)040404040404040404040404K0572 Tape, non-waterproof, per 18 square inches (Deleted eff.12/31/2002) 04K0573 Tape, waterproof, per 18 square inches (Deleted eff.12/31/2002) 04K0574 Addition to ostomy pouch, filter, integral or added separately topouch, each (Deleted eff.12/31/2002)K0575 Addition to ostomy pouch, rustle-free material, per pouch (Deletedeff.12/31/2002)K0576 Addition to ostomy pouch, friction and irritant-reducing, absorbent,interface layer (comfort panel), per pouch (Deleted eff.12/31/2002)040404DME MAC Jurisdiction C Supplier Manual Page 115

HCPCSAppendix AK0577 Addition to ostomy pouch, odor barrier, incorporated into pouchlaminate, per pouch (Deleted eff.12/31/2002)K0578 Addition to ostomy pouch , faucet-type tap with valve for drainingurinary pouch, each (Deleted eff.12/31/2002)K0579 Addition to ostomy pouch, absorbent material (sheet/pad/crystalpacket) to thicken liquid stomal output, for use in pouch, each(Deleted eff.12/31/2002)K0580 Addition to ostomy pouch, flange locking mechanism, each (Deletedeff.12/31/2002)04040404K0581 Ostomy pouch, closed, with barrier attached, with filter (1 piece),each (Deleted eff. 12/31/2003)K0582 Ostomy pouch, closed, with barrier attached, with built-in convexity,with filter (1 piece), each (Deleted eff. 12/31/2003)K0583 Ostomy pouch, closed; without barrier attached, with filter (1 piece),each (Deleted eff. 12/31/2003)K0584 Ostomy pouch, closed; for use on barrier with flange, with filter (2piece), each (Deleted eff. 12/31/2003)K0585 Ostomy pouch, closed; for use on barrier with locking flange (2piece), each (Deleted eff. 12/31/2003)K0586 Ostomy pouch, closed; for use on barrier with locking flange, withfilter (2 piece), each (Deleted eff. 12/31/2003)K0587 Ostomy pouch, drainable, with barrier attached, with filter (1 piece),each (Deleted eff. 12/31/2003)K0588 Ostomy pouch, drainable; for use on barrier with flange, with filter (2piece system), each (Deleted eff. 12/31/2003)K0589 Ostomy pouch, drainable; for use on barrier with locking flange (2piece system), each (Deleted eff. 12/31/2003)K0590 Ostomy pouch, drainable; for use on barrier with locking flange, withfilter (2 piece system), each (Deleted eff. 12/31/2003)K0591 Ostomy pouch, urinary, with extended wear barrier attached, withfaucet-type tap with valve (1 piece), each (Deleted eff. 12/31/2003)K0592 Ostomy pouch, urinary, with barrier attached, with built-in convexity,with faucet-type tap with valve (1 piece), each (Deleted eff.12/31/2003)K0593 Ostomy pouch, urinary, with extended wear barrier attached, withbuilt-in convexity, with faucet-type tap with valve (1 piece), each(Deleted eff. 12/31/2003)K0594 Ostomy pouch, urinary, with barrier attached, with faucet-type tapwith valve (1 piece), each (Deleted eff. 12/31/2003)11111111111111111111111111DME MAC Jurisdiction C Supplier Manual Page 116

HCPCSAppendix AK0595 Ostomy pouch, urinary, for use on barrier with flange, with faucettypetap with valve (2 piece), each (Deleted eff. 12/31/2003)K0596 Ostomy pouch, urniary, for use on barrier with locking flange (2piece), each (Deleted eff. 12/31/2003)K0597 Ostomy pouch, urinary, for use on barrier with locking flange, withfaucet-type tap with valve (2 piece), each (Deleted eff. 12/31/2003)K0600 Functional neuromuscular stimulator, transcutaneous stimulation ofmuscles of ambulation with computer control, used for walking byspinal cord injured, entire system, after completion of trainingprogram (Eff. Date 4/1/2003) (Deleted eff. 12/31/2005)K0601 Replacement battery for external infusion pump owned by patient,silver oxide, 1.5 volt, each (Eff. Date 4/1/2003)K0602 Replacement battery for external infusion pump owned by patient,silver oxide, 3 volt, each (Eff. Date 4/1/2003)K0603 Replacement battery for external infusion pump owned by patient,alkaline, 1.5 volt, each (Eff. Date 4/1/2003)K0604 Replacement battery for external infusion pump owned by patient,lithium, 3.6 volt, each (Eff. Date 4/1/2003)K0605 Replacement battery for external infusion pump owned by patient,lithium, 4.5 volt, each (Eff. Date 4/1/2003)K0606 Automatic external defibrillator, with integrated electrocardiogramanalysis, garment type (Eff. Date 7/1/2003)K0607 Replacement battery for automated external defibrillator, garmenttype only, each (Eff. Date 7/1/2003)K0608 Replacement garment for use with automated external defibrillator,each (Eff. Date 7/1/2003)K0609 Replacement electrodes for use with automated external defibrillator,garment type only, each (Eff. Date 7/1/2003)11111105131313131301050513K0610 Peritoneal dialysis clamps, each (Deleted eff. 12/31/2003) 19K0611 Disposable cycler set used with cycler dialysis machine, each(Deleted eff. 12/31/2003)K0612 Drainable extension line, sterile, for dialysis, each (Deleted eff.12/31/2003)K0613 Extension line with easy lock connectors, used with dialysis (Deletedeff. 12/31/2003)K0614 Chemicals/antiseptics solution used to clean/sterilize dialysisequipment, per 8 ounces (Deleted eff. 12/31/2003)19191919DME MAC Jurisdiction C Supplier Manual Page 117

HCPCSAppendix AK0615 Speech generating device, digitized speech, using prerecordedmessage, greater than 8 minutes but less than or equal to 20minutes recording time (Deleted eff. 12/31/2003)K0616 Speech generating device, digitized speech, using prerecordedmessage, greater than 20 minutes but less than or equal to 40minutes recording time (Deleted eff. 12/31/2003)K0617 Speech generating device, digitized speech, using prerecordedmessage, greater than 40 minutes recording time (Deleted eff.12/31/2003)K0618 TLSO, sagittal-coronal control, modular segmented spinal system,two rigid plastic shells, posterior extends from the sacrococcygeljunction and terminates just inferior to the scapular spine, anteriorextends from the symphysis pubis to the xiphoid, soft liner, restrictsgross trunk motion in the sagittal and coronal planes, lateral strengthis provided by overlapping plastic and stabilizing closures, includesstrap and closures, prefabricated, includes fitting and adjustment(Eff. Date 7/1/2003) (Deleted eff. 12/31/2005)K0619 TLSO, sagittal-coronal control, modular segmented spinal system,three rigid plastic shells, posterior extends from the sacrococcygeljunction and terminates just inferior to the scapular spine, anteriorextends from the symphysis pubis to the xiphoid, soft liner, restrictsgross trunk motion in the sagittal and coronal planes, lateral strengthis provided by overlapping plastic and stabilizing closures, includesstrap and closures, prefabricated, includes fitting and adjustment(Eff. Date 7/1/2003) (Deleted eff. 12/31/2005)K0620 Tubular elastic dressing, any width, per linear yard (Eff. Date7/1/2003) (Deleted eff. 12/31/2005)K0621 Gauze, packing strips, non-impregnated, up to 2 inches in width, perlinear yard 12 (Deleted eff. 12/31/2003)K0622 Conforming bandage, non-elastic, knitted/woven, non-sterile widthless than three inches, per roll. (Deleted eff. 12/31/2003)K0623 Conforming bandage, non-elastic, knitted/woven, sterile width lessthan three inches, per roll. (Deleted eff. 12/31/2003)K0624 Light compression bandage, elastic, knitted/woven width less than 3inches, per roll (at least 3 yards unstretched). (Deleted eff.12/31/2003)K0625 Self adherent bandage, elastic, non-knitted/non-woven, loadresistance greater than or equal to 0.55 foot pounds at 50%maximum stretch, width less than 3 inches, per roll. (Deleted eff.12/31/2003)K0626 Self adherent bandage, elastic, non-knitted/non-woven, loadresistance greater than or equal to 0.55 foot pounds at 50%maximum stretch, width greater than or equal to 5 inches, per roll.(Deleted eff. 12/31/2003)050505040412121212121212DME MAC Jurisdiction C Supplier Manual Page 118

HCPCSAppendix AK0627 Traction equipment, cervical, free-standing, pneumatic, applyingtraction force to other than mandible (Eff. Date 04/01/2004) (Deletedeff. 12/31/2004)K0628 For diabetics only, multiple density insert, direct formed, molded tofoot after external heat source of 230 degrees fahrenheit or higher,total contact with patient’s foot, including arch, base layer minimumof ¼ inch material of shore a 35 durometer of 3/16 inch material ofshore a 40 (or higher), prefabricated, each (Eff. Date 04/01/2004)(Deleted eff. 12/31/2005)0516K0629 For diabetics only, multiple density insert, custom molded from modelof patient’s foot, total contact with patient’s foot, including arch, baselayer minimum of 3/16 inch material of shore a 35 durometer orhigher, includes arch filler and other shaping material, customfabricated, each (Eff. Date 04/01/2004) (Deleted eff. 12/31/2005)K0630 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reducesmotion about the sacroiliac joint, includes straps, closures, mayinclude pendulous abdomen design, prefabricated, includes fittingand adjustment (Eff. Date 04/01/2004) (Deleted eff. 12/31/2005)K0631 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reducesmotion about the sacroiliac joint, includes straps, closures, mayinclude pendulous abdomen design, custom fabricated (Eff. Date04/01/2004) (Deleted eff. 12/31/2005)K0632 Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semirigidpanels over the sacrum and abdomen, reduces motion aboutthe sacroiliac joint, includes straps, closures, may include pendulousabdomen design, prefabricated, includes fitting and adjustment (Eff.Date 04/01/2004) (Deleted eff. 12/31/2005)K0633 Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semirigidpanels placed over the sacrum and abdomen, reduces motionabout the sacroiliac joint, includes straps, closures, may includependulous abdomen design, custom fabricated (Eff. Date04/01/2004) (Deleted eff. 12/31/2005)K0634 Lumbar orthosis, flexible, provides lumbar support, posterior extendsfrom L-1 to below L-5 vertebra, produces intracavitary pressure toreduce load on the intervertebral discs, includes straps, closures,may include pendulous abdomen design, shoulder straps, stays,prefabricated, includes fitting and adjustment (Eff. Date 04/01/2004)(Deleted eff. 12/31/2005)K0635 Lumbar orthosis, sagittal control, with rigid posterior panel(s),posterior extends from L-1 to below L-5 vertebrae, producesintracavitary pressure to reduce load on the intervertebral discs,includes straps, closures, may include padding, stays, shoulderstraps, pendulous abdomen design, prefabricated, includes fittingand adjustment (Eff. Date 04/01/2004) (Deleted eff. 12/31/2005)040404040404DME MAC Jurisdiction C Supplier Manual Page 119

HCPCSAppendix AK0636 Lumbar orthosis, sagittal control, with rigid anterior and posteriorpanels, posterior extends from L-1 to below L-5 vertebra, producesintracavitary pressure to reduce load on the intervertebral discs,includes straps, closures, may include padding, shoulder straps,pendulous abdomen design, prefabricated, includes fitting andadjustment (Eff. Date 04/01/2004) (Deleted eff. 12/31/2005)K0637 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support,posterior extends from sacrococcygeal junction to T-9 vertebra,produces intracavitary pressure to reduce load on the intervertebraldiscs, includes straps, closures, may include stays, shoulder straps,pendulous abdomen design, prefabricated, includes fitting andadjustment (Eff. Date 04/01/2004) (Deleted eff. 12/31/2005)K0638 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support,posterior extends from sacrococcygeal junction to T-9 vertebra,produces intracavitary pressure to reduce load on the intervertebraldiscs, includes straps, closures, may include stays, shoulder straps,pendulous abdomen design, custom fabricated (Eff. Date04/01/2004) (Deleted eff. 12/31/2005)K0639 Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s),posterior extends from sacrococcygeal junction to T-9 vertebra,produces intracavitary pressure to reduce load on the intervertebraldiscs, includes straps, closures, may include padding, stays,shoulder straps, pendulous abdomen design, prefabricated, includesfitting and adjustment (Eff. Date 04/01/2004) (Deleted eff.12/31/2005)K0640 Lumbar-sacral orthosis, sagittal control, with rigid anterior andposterior panels, posterior extends from sacrococcygeal junction toT-9 vertebra, produces intracavitary pressure to reduce load on theintervertebral discs, includes straps, closures, may include padding,shoulder straps, pendulous abdomen design, prefabricated, includesfitting and adjustment (Eff. Date 04/01/2004) (Deleted eff.12/31/2005)K0641 Lumbar-sacral orthosis, sagittal control, with rigid anterior andposterior panels, posterior extends from sacrococcygeal junction toT-9 vertebra, produces intracavitary pressure to reduce load on theintervertebral discs, includes straps, closures, may include padding,shoulder straps, pendulous abdomen design, custom fabricated (Eff.Date 04/01/2004) (Deleted eff. 12/31/2005)K0642 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posteriorframe/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels,produces intracavitary pressure to reduce load on intervertebraldiscs, includes straps, closures, may include padding, stays,shoulder straps, pendulous abdomen design, prefabricated, includesfitting and adjustment (Eff. Date 04/01/2004) (Deleted eff.12/31/2005)04040404040404DME MAC Jurisdiction C Supplier Manual Page 120

HCPCSAppendix AK0643 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posteriorframe/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels,produces intracavitary pressure to reduce load on intervertebraldiscs, includes straps, closures, may include padding, stays,shoulder straps, pendulous abdomen design, custom fabricated (Eff.Date 04/01/2004) (Deleted eff. 12/31/2005)K0644 Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigidposterior frame/panels, lateral articulating design to flex the lumbarspine, posterior extends from sacrococcygeal junction to T-9vertebra, lateral strength provided by rigid lateral frame/panels,produces intracavitary pressure to reduce load on intervertebraldiscs, includes straps, closures, may include padding, anterior panel,pendulous abdomen design, prefabricated, includes fitting andadjustment (Eff. Date 04/01/2004) (Deleted eff. 12/31/2005)K0645 Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigidposterior frame/panels, lateral articulating design to flex the lumbarspine, posterior extends from sacrococcygeal junction to T-9vertebra, lateral strength provided by rigid lateral frame/panels,produces intracavitary pressure to reduce load on intervertebraldiscs, includes straps, closures, may include padding, anterior panel,pendulous abdomen design, custom fabricated (Eff. Date04/01/2004) (Deleted eff. 12/31/2005)K0646 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anteriorand posterior frame/panels, posterior extends from sacrococcygealjunction to T-9 vertebra, lateral strength provided by rigid lateralframe/panels, produces intracavitary pressure to reduce load onintervertebral discs, includes straps, closures, may include padding,shoulder straps, pendulous abdomen design, prefabricated, includesfitting and adjustment (Eff. Date 04/01/2004) (Deleted eff.12/31/2005)K0647 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anteriorand posterior frame/panels, posterior extends from sacrococcygealjunction to T-9 vertebra, lateral strength provided by rigid lateralframe/panels, produces intracavitary pressure to reduce load onintervertebral discs, includes straps, closures, may include padding,shoulder straps, pendulous abdomen design, custom fabricated (Eff.Date 04/01/2004) (Deleted eff. 12/31/2005)K0648 Lumbar-sacral orthosis, sagittal-coronal control, rigidshell(s)/panel(s), posterior extends from sacrococcygeal junction toT-9 vertebra, anterior extends from symphysis pubis to xiphoid,produces intracavitary pressure to reduce load on the intervertebraldiscs, overall strength is provided by overlapping rigid plastic andstabilizing closures, includes straps, closures, may include softinterface, pendulous abdomen design, prefabricated, includes fittingand adjustment (Eff. Date 04/01/2004) (Deleted eff. 12/31/2005)040404040404DME MAC Jurisdiction C Supplier Manual Page 121

HCPCSAppendix AK0649 Lumbar-sacral orthosis, sagittal-coronal control, rigidshell(s)/panel(s), posterior extends from sacrococcygeal junction toT-9 vertebra, anterior extends from symphysis pubis to xiphoid,produces intracavitary pressure to reduce load on the intervertebraldiscs, overall strength is provided by overlapping rigid plastic andstabilizing closures, includes straps, closures, may include softinterface, pendulous abdomen design, custom fabricated (Eff. Date04/01/2004) (Deleted eff. 12/31/2005)K0650 General use wheelchair seat cushion, width less than 22 inches, anydepth (Eff. Date 07/01/2004) (Deleted eff. 12/31/2004)K0651 General use wheelchair seat cushion, width 22 inches or greater, anydepth (Eff. Date 07/01/2004) (Deleted eff. 12/31/2004)K0652 Skin protection wheelchair seat cushion, width less than 22 inches,any depth (Eff. Date 07/01/2004) (Deleted eff. 12/31/2004)K0653 Skin protection wheelchair seat cushion, width 22 inches or greater,any depth (Eff. Date 07/01/2004) (Deleted eff. 12/31/2004)K0654 Positioning wheelchair seat cushion, width less than 22 inches, anydepth (Eff. Date 07/01/2004) (Deleted eff. 12/31/2004)K0655 Positioning wheelchair seat cushion, width 22 inches or greater, anydepth (Eff. Date 07/01/2004) (Deleted eff. 12/31/2004)K0656 Skin protection and positioning wheelchair seat cushion, width lessthan 22 inches, any depth (Eff. Date 07/01/2004) (Deleted eff.12/31/2004)K0657 Skin protection and positioning wheelchair seat cushion, width 22inches or greater, any depth (Eff. Date 07/01/2004) (Deleted eff.12/31/2004)K0658 Custom fabricated wheelchair seat cushion, any size (Eff. Date07/01/2004) (Deleted eff. 12/31/2004)K0659 Wheelchair seat cushion powered (Eff. Date 07/01/2004) (Deletedeff. 12/31/2004)K0660 General use wheelchair back cushion, width less than 22 inches, anyheight, including any type mounting hardware (Eff. Date 07/01/2004)(Deleted eff. 12/31/2004)K0661 General use wheelchair back cushion, width 22 inches or greater,any height, including any type mounting hardware (Eff. Date07/01/2004) (Deleted eff. 12/31/2004)K0662 Positioning wheelchair back cushion, posterior, width less than 22inches, any height, including any type mounting hardware (Eff. Date07/01/2004) (Deleted eff. 12/31/2004)K0663 Positioning wheelchair back cushion, posterior, width 22 inches orgreater, any height, including any type mounting hardware (Eff. Date07/01/2004) (Deleted eff. 12/31/2004)0505050505050505050505050505DME MAC Jurisdiction C Supplier Manual Page 122

HCPCSAppendix AK0664 Positioning wheelchair back cushion, posterior lateral, width lessthan 22 inches, any height, including any type mounting hardware(Eff. Date 07/01/2004) (Deleted eff. 12/31/2004)K0665 Positioning wheelchair back cushion, posterior lateral width 22inches or greater, any height, including any type mounting hardware(Eff. Date 07/01/2004) (Deleted eff. 12/31/2004)K0666 Custom fabricated wheelchair back cushion, any size, including anytype mounting hardware (Eff. Date 07/01/2004) (Deleted eff.12/31/2004)050505K0667 Mounting hardware, any type, for seat cushion or seat support baseattached to a manual wheelchair or lightweight power wheelchair, percushion/base (Not valid for Medicare) (Deleted eff. 12/31/2004)K0668 Replacement cover for wheelchair seat cushion or back cushion,each (Eff. Date 07/01/2004) (Deleted eff. 12/31/2004)K0669 Wheelchair accessory, wheelchair seat or back cushion, does notmeet specific code criteria or no written coding verification fromSADMERC (Eff. Date 07/01/2004)K0670 Addition to lower extremity prosthesis, endoskeletal knee shinsystem, microprocessor control feature, stance phase only, includeselectronic sensor (s), any type (Eff. Date 04/01/05) (Deleted eff.12/31/2005)K0671 Portable oxygen concentrator, rental (Eff. Date 04/01/05) (Deletedeff. 12/31/2005)K0730 Controlled dose inhalation drug delivery system (Eff. Date04/01/2005)K0733 Power wheelchair accessory, 12 or 24 amp hour sealed lead acidbattery, each (e.g. gel cell, absorbed glassmat) (Eff. Date 07/01/06)K0734 Skin protection wheelchair seat cushion, adjustable, width less than22 inches, any depth (Eff. Date 07/01/06)K0735 Skin protection wheelchair seat cushion, adjustable, width 22 inchesor greater, any depth (Eff. Date 07/01/06)K0736 Skin protection and positioning wheelchair seat cushion, adjustable,width less than 22 inches, any depth (Eff. Date 07/01/06)K0737 Skin protection and positioning wheelchair seat cushion, adjustablewidth 22 inches or greater, any depth (Eff. Date 07/01/06)K0738 Portable Gaseous Oxygen System, Rental, Home CompressionUsed to fill Poratble Oxygen Cylinders; includes Portable Containers,Regulator, Flowmeter, Humidifier, Cannula or Mask, and Tubing (Effdat 10/01/2006)K0800 Power operated vehicle, group 1 standard, patient weight capacity upto and including 300 pounds (Eff. Date 10/01/2006)0505040605050505050506 484.305DME MAC Jurisdiction C Supplier Manual Page 123

HCPCSAppendix AK0801 Power operated vehicle, group 1 heavy duty, patient weight capacity,301 to 450 pounds (Eff. Date 10/01/2006)K0802 Power operated vehicle, group 1 very heavy duty, patient weightcapacity 451 to 600 pounds (Eff. Date 10/01/2006)K0806 Power operated vehicle, group 2 standard, patient weight capacity upto and including 300 pounds (Eff. Date 10/01/2006)K0807 Power operated vehicle, group 2 heavy duty, patient weight capacity301 to 450 pounds (Eff. Date 10/01/2006)K0808 Power operated vehicle, group 2 very heavy duty, patient weightcapacity 451 to 600 pounds (Eff. Date 10/01/2006)K0812 Power operated vehicle, not otherwise classified (Eff. Date10/01/2006)K0813 Power wheelchair, group 1 standard, portable, sling/solid seat andback, patient weight capacity up to and including 300 pounds (Eff.Date 10/01/2006)K0814 Power wheelchair, group 1 standard, portable, captains chair, patientweight capacity up to and including 300 pounds (Eff. Date10/01/2006)K0815 Power wheelchair, group 1 standard, sling/solid seat and back,patient weight capacity up to and including 300 pounds (Eff. Date10/01/2006)K0816 Power wheelchair, group 1 standard, captains chair, patient weightcapactiy up to and including 300 pounds (Eff. Date 10/01/2006)K0820 Power wheelchair, group 2 standard, portable, sling/solid seat/back,patient weight capacity up to and including 300 pounds (Eff. Date10/01/2006)K0821 Power wheelchair, group 2 standard, portable, captains chair, patientweight capacity up to and including 300 pounds (Eff. Date10/01/2006)K0822 Power wheelchair, group 2 standard, sling/solid seat/back, patientweight capacity up to and including 300 pounds (Eff. Date10/01/2006)K0823 Power wheelchair, group 2 standard, captains chair, patient weightcapacity up to and including 300 pounds (Eff. Date 10/01/2006)K0824 Power wheelchair, group 2 heavy duty, sling/solid seat/back, patientweight capacity 301 to 450 pounds (Eff. Date 10/01/2006)K0825 Power wheelchair, group 2 heavy duty, captains chair, patient weightcapacity 301 to 450 pounds (Eff. Date 10/01/2006)K0826 Power wheelchair, group 2 very heavy duty, sling/solid seat/back,patient weight capacity 451 to 600 pounds (Eff. Date 10/01/2006)0505050505050101010101010101010101DME MAC Jurisdiction C Supplier Manual Page 124

HCPCSAppendix AK0827 Power wheelchair, group 2 very heavy duty, captains chair, patientweight capacity 451 to 600 pounds (Eff. Date 10/01/2006)K0828 Power wheelchair, group 2 extra heavy duty, sling/solid seat/back,patient weight capacity 601 pounds or more (Eff. Date 10/01/2006)K0829 Power wheelchair, group 2 extra heavy duty, captains chair, patientweight capacity 601 pounds or more (Eff. Date 10/01/2006)K0830 Power wheelchair, group 2 standard, seat elevator, sling/solidseat/back, patient weight capacity up to and including 300 pounds(Eff. Date 10/01/2006)K0831 Power wheelchair, group 2 standard, seat elevator, captains chair,patient weight capacity up to and including 300 pounds (Eff. Date10/01/2006)K0835 Power wheelchair, group 2 standard, single power option, sling/solidseat/back, patient weight capacity up to and including 300 pounds(Eff. Date 10/01/2006)K0836 Power wheelchair, group 2 standard, single power option, captainschair, patient weight capacity up to and including 300 pounds (Eff.Date 10/01/2006)K0837 Power wheelchair, group 2 heavy duty, single power option,sling/solid seat/back, patient weight capacity 301 to 450 pounds (Eff.Date 10/01/2006)K0838 Power wheelchair, group 2 heavy duty, single power option, captainschair, patient weight capacity 301 to 450 pounds (Eff. Date10/01/2006)K0839 Power wheelchair, group 2 very heavy duty, single power option,sling/solid seat/back, patient weight capacity 451 to 600 pounds (Eff.Date 10/01/2006)K0840 Power wheelchair, group 2 extra heavy duty, single power option,sling/solid seat/back, patient weight capacity 601 pounds or more(Eff. Date 10/01/2006)K0841 Power wheelchair, group 2 standard, multiple power option,sling/solid seat/back, patient weight capacity up to and including 300pounds (Eff. Date 10/01/2006)K0842 Power wheelchair, group 2 standard, multiple power option, captainschair, patient weight capacity up to and including 300 pounds (Eff.Date 10/01/2006)K0843 Power wheelchair, group 2 heavy duty, multiple power option,sling/solid seat/back, patient weight capacity 301 to 450 pounds (Eff.Date 10/01/2006)K0848 Power wheelchair, group 3 standard, sling/solid seat/back, patientweight capacity up to and including 300 pounds (Eff. Date10/01/2006)010101010101010101010101010101DME MAC Jurisdiction C Supplier Manual Page 125

HCPCSAppendix AK0849 Power wheelchair, group 3 standard, captains chair, patient weightcapacity up to and including 300 pounds (Eff. Date 10/01/2006)K0850 Power wheelchair, group 3 heavy duty, sling/solid seat/back, patientweight capacity 301 to 450 pounds (Eff. Date 10/01/2006)K0851 Power wheelchair, group 3 heavy duty, captains chair, patient weightcapacity 301 to 450 pounds (Eff. Date 10/01/2006)K0852 Power wheelchair, group 3 very heavy duty, sling/solid seat/back,patient weight capacity 451 to 600 pounds (Eff. Date 10/01/2006)K0853 Power wheelchair, group 3 very heavy duty, captains chair, patientweight capacity, 451 to 600 pounds (Eff. Date 10/01/2006)K0854 Power wheelchair, group 3 extra heavy duty, sling/solid seat/back,patient weight capacity 601 pounds or more (Eff. Date 10/01/2006)K0855 Power wheelchair, group 3 extra heavy duty, captains chair, patientweight capacity 601 pounds or more (Eff. Date 10/01/2006)K0856 Power wheelchair, group 3 standard, single power option, sling/solidseat/back, patient weight capacity up to and including 300 pounds(Eff. Date 10/01/2006)K0857 Power wheelchair, group 3 standard, single power option, captainschair, patient weight capacity up to and including 300 pounds (Eff.Date 10/01/2006)K0858 Power wheelchair, group 3 heavy duty, single power option,sling/solid seat/back, patient weight capacity 301 to 450 pounds (Eff.Date 10/01/2006)K0859 Power wheelchair, group 3 heavy duty, single power option, captainschair, patient weight capacity 301 to 450 pounds (Eff. Date10/01/2006)K0860 Power wheelchair, group 3 very heavy duty, single power option,sling/solid seat/back, patient weight capacity 451 to 600 pounds (Eff.Date 10/01/2006)K0861 Power wheelchair, group 3 standard, multiple power option,sling/solid seat/back, patient weight capacity up to and including 300pounds (Eff. Date 10/01/2006)K0862 Power wheelchair, group 3 heavy duty, multiple power option,sling/solid seat/back, patient weight capacity 301 to 450 pounds (Eff.Date 10/01/2006)K0863 Power wheelchair, group 3 very heavy duty, multiple power option,sling/solid seat/back, patient weight capacity 451 to 600 pounds (Eff.Date 10/01/2006)K0864 Power wheelchair, group 3 extra heavy duty, multiple power option,sling/solid seat/back, patient weight capacity 601 pounds or more(Eff. Date 10/01/2006)01010101010101010101010101010101DME MAC Jurisdiction C Supplier Manual Page 126

HCPCSAppendix AK0868 Power wheelchair, group 4 standard, sling/solid seat/back, patientweight capacity up to and including 300 pounds (Eff. Date10/01/2006)K0869 Power wheelchair, group 4 standard, captains chair, patient weightcapacity up to and including 300 pounds (Eff. Date 10/01/2006)K0870 Power wheelchair, group 4 heavy duty, sling/solid seat/back, patientweight capacity 301 to 450 pounds (Eff. Date 10/01/2006)K0871 Power wheelchair, group 4 very heavy duty, sling/solid seat/back,patient weight capacity 451 to 600 pounds (Eff. Date 10/01/2006)K0877 Power wheelchair, group 4 standard, single power option, sling/solidseat/back, patient weight capacity up to and including 300 pounds(Eff. Date 10/01/2006)K0878 Power wheelchair, group 4 standard, single power option, captainschair, patient weight capacity up to and including 300 pounds (Eff.Date 10/01/2006)K0879 Power wheelchair, group 4 heavy duty, single power option,sling/solid seat/back, patient weight capacity 301 to 450 pounds (Eff.Date 10/01/2006)K0880 Power wheelchair, group 4 very heavy duty, single power option,sling/solid seat/back, patient weight 451 to 600 pounds (Eff. Date10/01/2006)K0884 Power wheelchair, group 4 standard, multiple power option,sling/solid seat/back, patient weight capacity up to and including 300pounds (Eff. Date 10/01/2006)K0885 Power wheelchair, group 4 standard, multiple power option, captainschair, weight capacity up to and including 300 pounds (Eff. Date10/01/2006)K0886 Power wheelchair, group 4 heavy duty, multiple power option,sling/solid seat/back, patient weight capacity 301 to 450 pounds (Eff.Date 10/01/2006)K0890 Power wheelchair, group 5 pediatric, single power option, sling/solidseat/back, patient weight capacity up to and including 125 pounds(Eff. Date 10/01/2006)K0891 Power wheelchair, group 5 pediatric, multiple power option,sling/solid seat/back, patient weight capacity up to and including 125pounds (Eff. Date 10/01/2006)01010101010101010101010101K0898 Power wheelchair, not otherwise classified (Eff. Date 10/01/2006) 01K0899 Power mobility device, not coded by SADMERC or does not meetcriteria (Eff. Date 10/01/2006)01DME MAC Jurisdiction C Supplier Manual Page 127

HCPCSAppendix AHCPCS LPayment Category1 Capped Rental 8 Parenteral/Enteral Supplies and Kits 15 Nebulizer Drugs2 Freq. & Substantial Serv. DME 9 Parenteral/Enteral Pumps 16 Therapeutic Shoes for Diabetics3 Customized DMEPOS 10 Immunosuppressive Drugs 17 Individual Consideration4 Prosthetics/Orthotics 11 Ostomy, Trach., & Urologicals 18 Epoetin (EPO)5 Inexp. & Routinely Purch. DME 12 Surgical Dressings 19 Dialysis Supplies & Equipment6 Oxygen and Oxygen Equipment 13 Supplies 20 Oral Antiemetic Drugs7 Parenteral/Enteral Nutrients 14 Not Otherwise ClassifiedCode Description Category CMN/DIFRequiredL0100 Cranial orthosis (helmet), with or without soft interface, molded topatient model ( deleted 12/31/2006)L0110 Cranial orthosis (helmet), with or without soft interface, non-molded(deleted 12/31/06)L0112 Cranial cervical orthosis, congenital torticollis type, with or withoutsoft interface material, adjustable range of motion joint, customfabricated (Eff. Date 1/1/2004)040404L0120 Cervical, flexible, non-adjustable (foam collar) 04L0130 Cervical, flexible, thermoplastic collar, molded to patient 04L0140 Cervical, semi-rigid, adjustable (plastic collar) 04L0150 Cervical, semi-rigid, adjustable molded chin cup (plastic collar withmandibular/occipital piece)04L0160 Cervical, semi-rigid, wire frame occipital/mandibular support 04L0170 Cervical, collar, molded to patient model 04L0172 Cervical, collar, semi-rigid thermoplastic foam, two piece 04L0174 Cervical, collar, semi-rigid, thermoplastic foam, two piece withthoracic extensionL0180 Cervical, multiple post collar, occipital/mandibular supports,adjustableL0190 Cervical, multiple post collar, occipital/mandibular supports,adjustable cervical bars (somi, guilford, taylor types)040404DME MAC Jurisdiction C Supplier Manual Page 128

HCPCSAppendix AL0200 Cervical, multiple post collar, occipital/mandibular supports,adjustable cervical bars, and thoracic extension04L0210 Thoracic, rib belt 04L0220 Thoracic, rib belt, custom fabricatedL0300 Thoracic-lumbar-sacral-orthosis (TLSO), flexible (dorso-lumbarsurgical support)(Deleted eff.12/31/2002)L0310 TLSO, flexible, (dorso-lumbar surgical support), custom fabricated(Deleted eff.12/31/2002)L0315 TLSO, flexible dorso-lumbar surgical support, elastic type, with rigidposterior (Deleted eff. 12/31/2002)L0317 TLSO, flexible dorso-lumbar surgical support, hyperextension, elastictype, with rigid posterior panel (Deleted eff. 12/31/2002)L0320 TLSO, anterior-posterior control (taylor type), with apron front(Deleted eff.12/31/2002)L0321 TLSO, anterior-posterior control, with rigid or semi-rigid posteriorpanel, prefabricated (includes fitting and adjustment) (Deletedeff.12/31/2002)L0330 TLSO, anterior-posterior-lateral control (knight-taylor type), withapron front (Deleted eff.12/31/2002)L0331 TLSO, anterior-posterior-lateral control, with rigid or semi-rigidposterior panel, prefabricated (includes fitting and adjustment)(Deleted eff.12/31/2002)L0340 TLSO, anterior-posterior-lateral-rotary control (arnold, magnuson,steindler types), with apron front (Deleted eff.12/31/2002)L0350 TLSO, anterior-posterior-lateral-rotary control, flexion compressionjacket, custom fitted (Deleted eff.12/31/2002)L0360 TLSO, anterior-posterior-lateral-rotary control, flexion compressionjacket molded to patient model (Deleted eff.12/31/2002)L0370 TLSO, anterior-posterior-lateral-rotary control, hyperextension(jewett, lennox, baker, cash types) (Deleted eff.12/31/2002)L0380 TLSO, anterior-posterior-lateral-rotary control, with extensions(Deleted eff.12/31/2002)L0390 TLSO, anterior-posterior-lateral control molded to patient model(Deleted eff.12/31/2002)L0391 TLSO, anterior-posterior-lateral-rotary control, with rigid or semi-rigidposterior panel, prefabricated (includes fitting and adjustment)(Deleted eff.12/31/2002)L0400 TLSO, anterior-posterior-lateral control molded to patient model, withinterface material (Deleted eff.12/31/2002)04040404040404040404040404040404DME MAC Jurisdiction C Supplier Manual Page 129

HCPCSAppendix AL0410 TLSO, anterior-posterior-lateral control, two-piece construction,molded to patient model (Deleted eff.12/31/2002)L0420 TLSO, anterior-posterior-lateral control, two piece construction,molded to patient model, with interface material (Deletedeff.12/31/2002)L0430 Spinal Orthosis, anterior-posterior-lateral control, with interfacematerial, custom fitted (DeWall Posture Protector only) (Eff. Date1/1/2005)L0440 TLSO, anterior-posterior-lateral control, with overlapping frontsection, spring steel front, custom fitted (Deleted eff.12/31/2002)04040404L0450 TLSO, flexible, provides trunk support, upper thoracic region,produces intracavitary pressure to reduce load on the intervertebraldisks with rigid stays or panel(s), includes shoulder straps andclosures, prefabricated, includes fitting and adjustement (Eff. Date1/1/2003)L0452 TLSO, flexible, provides trunk support, upper thoracic region,produces intracavitary pressures to reduce load on the intervertebraldisks with rigid stays or panel(s), includes shoulder straps andclosures, custom fabricated (Eff. Date 1/1/2003)L0454 TLSO, flexible, provides trunk support, extends from sacrococcygealjunction to above T-9 vertebra, restricts gross trunk motion in thesagittal plane, produces intracavitary pressure to reduce load on theintervertebral disks with rigid stays or panel(s), includes should strapsand closures, prefabricted, includes fitting and adjustment (Eff. Date1/1/2003)L0456 TLSO, flexible, provides trunk support, thoracic region, rigid posteriorpanel and a soft anterior apron, extends from the sacrococcygealjunction and terminates just inferior to the scapular spine, restrictsgross trunk motion in the sagittal plane, produces intraclosures,prefabricated, includes fitting and adjustment (Eff. Date 1/1/2003)L0458 TLSO, triplanar control, modular segmented spinal system, two rigidplastic shells, posterior extends from the sacrococcygeal junction andterminates just inferior to the scapular spine, anterior extends fromthe symphysis pubis to the xiphoid, soft liner, restricts gross trunkmotion in the sagittal, coronal, and transverse planes, lateral strengthis provided by overlapping plastic and stabilizing closures, includesstraps and closures, prefabricated, includes fitting and adjustment(Eff. Date 1/1/2003)L0460 TLSO, triplanar control, modular segmented spinal system, two rigidplastic shells, posterior extends from the sacrococcygeal junction andterminates just inferior to the scapular spine, anterior extends fromthe smphysis pubis to the sternal notch, soft liner, restricts grosstrunk motion in the sagittal, coronal, and transverse planes, lateralstrength is provided by overlapping plastic and stabilizing closures,includes straps and closures prefabricated, includes fitting andadjustment (Eff. Date 1/1/2003)040404040404DME MAC Jurisdiction C Supplier Manual Page 130

HCPCSAppendix AL0462 TLSO, triplanar control, modular segmented spinal system, three rigidplastic shells, posterior extends from the sacrococcygeal junction andterminates just inferior to the scapular spine, anterior extends fromthe symphysis pubis to the sternal notch, soft liner, restricts grosstrunk motion in the sagittal, coronal, and transverse planes, lateralstrength is provided by overlapping plastic and stabilizing closure,includes straps and clsoures, prefabricated, includes fitting andadjustment (Eff. Date 1/1/2003)L0464 TLSO, triplanar control, modular segmented spinal system, four rigidplastic shells, posterior extends from sacrococcygeal junction andterminates just inferior to scapular spine, anterior extends fromsymphysis pubis to the sternal notch, soft liner, restricts gross trunkmotion in sagittal, coronal, and transverse planes, lateral strength isprovided by overlapping plastic and stabilizing closures, includesstraps and closures prefabricated, includes fitting and adjustment(Eff. Date 1/1/2003)L0466 TLSO, sagittal control, rigid posterior frame and flexible soft anteriorapron with straps, closures and padding, restricts gross trunk motionin sagittal plane, produces intracavitary pressure to reduce load onintervertebral disks, includes fitting and shaping the frame,prefabricated, includes fitting and adjustment (Eff. Date 1/1/2003)L0468 TLSO, sagittal-coronal control, rigid posterior frame and flexible softanterior apron with straps, closures and padding, extends fromsacrococcygeal junction over scapulae, lateral strength provided bypelvic, thoracic, and lateral frame pieces, restricts gross trunk motionin sagittal, and coronal planes, produces intracavitary presssure toreduce load on intervertebral disks, includes fitting and shaping theframe, prefabricated, includes fitting and adjustment (Eff. Date1/1/2003)L0470 TLSO, triplanar control, rigid posterior frame and flexible soft anteriorapron with straps, closures and padding, extends fromsacrococcygeal junction to scapula, lateral strength provided bypelvic, thoracic, and lateral frame pieces, rotational strength providedby subclavicular extensions, restricts gross trunk motion in sagittal,coronal, and transverse planes, produces intracavitary pressure toreduce load on the intervertebral disks, includes fitting and shapingthe frame, prefabricated, includes fitting and adjustment (Eff. Date1/1/2003)L0472 TLSO, triplanar control, hyperextension, rigid anterior and lateralframe extends from syphysis pubis to sternal notch with two anteriorcomponents (one pubic and one sternal), posterior and lateral padswith straps and closures, limits spinal flexion, restricts gross trunkmotion in sagittal, coronal, and transverse planes, includes fitting andshaping the frame, prefabricated, includes fitting and adjustment (Eff.Date 1/1/2003)L0476 TLSO, sagittal-coronal control, flexion compression jacket, two rigidplastic shells with soft liner, posterio extends from sacrococcygealjunction and terminates at or before the T-9 vertebra, anteriorextends from symphysis pubis to xiphoid, usually laced together onone side, restricts gross trunk motion in sagittal and coronal planes,04040404040404DME MAC Jurisdiction C Supplier Manual Page 131

HCPCSAppendix Aallows free flexion and compression of the LS region, includes strapsand closures, prefabricated, inludes fitting and adjustment (Eff. Date1/1/2003) (Deleted eff. 03/31/2004)L0478 TLSO, sagittal-coronal control, flexion compression jacket, two rigidplastic shells with soft liner, posterior extends from sacrococcygealjunction and terminates at or before the T-9 vertebra, anteriorextends from symphysis pubis to xiphoid, usually laced together onone side, restricts gross trunk motion in sagittal and coronal planes,allows free flexion and compression of LS region, includes straps andclosures, custom fabricated (Eff. Date 1/1/2003) (Deleted eff.03/31/2004)L0480 TLSO, triplanar control, one piece rigid plastric shell without interfaceliner, with multiple straps and closures, posterior extends fromsacrococcygeal junctuin and terminates just inferior to scapular spine,anterior extends from symphysis pubis to sternal notch, anterior orposterior opening, restricts gross trunk motion in sagittal, coronal,and transverse planes, includes a carved plaster or Cad-Cam model,custom fabricated (Eff. Date 1/1/2003)L0482 TLSO, triplanar control, one piece rigid plastic shell with interfaceliner, multiple straps and closures, posteror extends fromsacrococcygeal junction and terminates just inferior to scapular spine,anterior extends from symphysis pubis to sternal notch, anterior orposterior opening, restricts gross trunk motion in sagittal, coronal,and transverse planes, includes a carved plaster or Cad-Cam model,custom fabricated (Eff. Date 1/1/2003)L0484 TLSO, triplanar control, two piece rigid plastic shell without interfaceliner, with multiple straps and closures, posterior extends fromsacrococcygeal junction and terminates just inferior to scapular spine,anterior extends from symphysis pubis to sternal notch, lateralstrength is enhanced by overlapping plastic, restricts gross trunkmotion in the sagittal, coronal, and transverse planes, includes acarved plaster or Cad-Cam mode, custom fabricated (Eff. Date1/1/2003)L0486 TLSO, triplanar control, two piece rigid plastic shell with interfaceliner, multiple straps and closures, posterior extends fromsacrococcygel junction and terminates just inferior to scapular spine,anterior extends from symphysis pubis to sternal notch, lateralstrength is enhanced by overlapping plastic, restricts gross trunkmotion in the sagittal, coronal, and transverse planes, includes acarved plaster or Cad-Cam model, custom fabricated (Eff. Date1/1/2003)L0488 TLSO, triplanar control, one piece rigid plastic shell with interfaceliner, multiple straps and closures, posterior extends fromscarococcygeal junction and terminates just inferior to scapular spine,anterior extends from symphysis pubis to sternal notch, anterior orposterior opening, restricts gross trunk motion in the sagittal, coronal,and transverse planes, prefabricated, includes fitting and adjustment(Eff. Date 1/1/2003)040404040404DME MAC Jurisdiction C Supplier Manual Page 132

HCPCSAppendix AL0490 TLSO, sagittal-coronal control, one piece rigid plastic shell, withoverlapping reinforced anterior, with multiple straps and closures,posterior extends from sacrococcygeal junction and terminates at orbefore the T-9 vertebra, anterior extends from symphysis pubis toxiphoid, anterior opening, restricts gross trunk motion in sagittal andcoronal planes, prefabricated, includes fitting and adjustment (Eff.Date 1/1/2003)L0491 TLSO, sagittal-coronal control, modular segmented spinal system,two rigidplastic shells, posterior extends from the sacrococcygeal junction andterminates just inferior to the scapular spine, anterior extends fromthe symphysis pubis to the xiphoid, soft liner, restricts gross trunkmotion in the sagittal and coronal planes, lateral strength is providedby overlapping plastic and stabilizing closures, includes straps andclosures, prefabricated includes fitting and adjustment (Eff. Date1/1/2006)L0492 TLSO, sagittal-coronal control., modular segmented spinal system,threerigid plastic shells, posterior extends from the sacrococcygealjunction andterminates just inferior to the scapular spine, anterior extends fromthe symphysis pubis to the xiphoid, soft liner, restricts gross trunkmotion in the sagittal and coronal planes, lateral strength is providedby overlapping plastic and stabilizing closures, includes straps andclosures, prefabricated includes fitting and adjustment (Eff. Date1/1/2006)L0500 Lumbar-sacral-orthosis (LSO), flexible, (lumbo-sacral support)(Deleted eff. 03/31/2004)L0510 LSO, flexible (lumbo-sacral upport), custom fabricated (Deleted eff.03/31/2004)L0515 LSO, anterior-posterior control, with rigid or semi-rigid posteriorpanel, prefabricated (Deleted eff. 03/31/2004)L0520 LSO, anterior-posterior-lateral control (knight, wilcox types), withapron front (Deleted eff. 03/31/2004)L0530 LSO, anterior-posterior control (macausland type), with apron front(Deleted eff. 03/31/2004)0404040404040404L0540 LSO, lumbar flexion (williams flexion type) (Deleted eff. 03/31/2004) 04L0550 LSO, anterior-posterior-lateral control, molded to patient model(Deleted eff. 03/31/2004)L0560 LSO, anterior-posterior-lateral control, molded to patient model, withinterface material (Deleted eff. 03/31/2004)L0561 LSO, anterior-posterior-lateral control, with rigid or semi-rigidposterior panel, prefabricated (Eff. Date 1/1/2002) (Deleted eff.03/31/2004)040404L0565 LSO, anterior-posterior-lateral control, custom fitted (Deleted eff. 04DME MAC Jurisdiction C Supplier Manual Page 133

HCPCSAppendix A03/31/2004)L0600 Sacroiliac, flexible (sacroiliac surgical support) (Deleted eff.03/31/2004)L0610 Sacroiliac, flexible (sacroiliac surgical support), custom fabricated(Deleted eff. 03/31/2004)L0620 Sacroiliac, semi-rigid (goldthwaite, osgood types), with apron front(Deleted eff. 03/31/2004)L0621 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reducesmotionabove the sacroiliac joint, includes straps, closures, may includespendulousabdomen design, prefabricated, includes fitting and adjustment(Eff. Date 1/1/2006)L0622 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reducesmotion above the sacroiliac joint, includes straps, closures, mayincludependulous abdomen design, custom fabricated (Eff. Date 1/1/2006)L0623 Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semirigidpanels over the sacrum and abdomen, reduces motion above thesacroiliacjoint, includes straps, closures, may includes pendulous abdomendesign,prefabricated, includes fitting and adjustment (Eff. Date 1/1/2006)L0624 Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semirigidpanels places over the sacrum and abdomen, reduces motion abovethesacroiliac joint, include straps, closures, may includes pendulousabdomendesign, custom fabricated (Eff. Date 1/1/2006)L0625 Lumbar orthosis, flexible, provides lumbar support, posterior extendsfrom L-1 to below L-5 vertebra, produces intracavitary pressure toreduceload on the intervertebral discs, includes straps, closures, mayincludependulous abdomen design, shoulder straps, stays, prefabricated,includesfitting and adjustment (Eff. Date 1/1/2006)L0626 Lumbar orthosis, sagittal control, with rigid posterior panel(s),posteriorextends from L-1 to below L-5 vertebra, produces intracavitarypressureto reduce load on the intervertebral discs, includes straps, closures,mayinclude padding, stays, shoulder straps, pendulous abdomen design,prefabricated includes fitting and adjustment (Eff. Date 1/1/2006)040404040404040404DME MAC Jurisdiction C Supplier Manual Page 134

HCPCSAppendix AL0627 Lumbar orthosis, sagittal control, with rigid anterior and posteriorpanels,posterior extends from L-1 to below L-5 vertebra, producesintracavitarypressure to reduce load on the intervertebral discs, includes straps,closures,may include padding, shoulder straps, pendulous abdomen design,prefabricated includes fitting and adjustment (Eff. Date 1/1/2006)L0628 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support,posteriorextends from sacococcygeal junction to T-9 vertebra, producesintracavitary pressure to reduce load on the intervertebral discs,includes straps, closures, may include stays, shoulder straps,pendulousabdomen design, prefabricated, includes fitting and adjustment(Eff. Date 1/1/2006)L0629 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support,posteriorextends from sacococcygeal junction to T-9 vertebra, producesintracavitarypressure to reduce load on the intervertebral discs, includes straps,closures,may include stays, shoulder straps, pendulous abdomen design,customprefabricated (Eff. Date 1/1/2006)L0630 Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s),posterior extends from sacrococcygeal juntion to T-9 vertebra,producesintracavitary pressure to reduce load on the intervertebral discs,includesstraps, closures, may include padding, stays, shoulder straps,pendulousabdomen design, prefabricated, includes fitting and adjustment(Eff. Date 1/1/2006)L0631 Lumbar-sacral orthosis, sagittal control, with rigid anterior andposterior panels, posterior extends from sacrococcygeal junction toT-9 vertebra, produces intracavitary pressure to reduce load on theintervertebral discs, includes straps, closures, may include padding,shoulder straps, pendulous abdomen design, prefabricated, includesfitting and adjustment (Eff. Date 1/1/2006)L0632 Lumbar-sacral orthosis, sagittal control, with rigid anterior andposteriorpanels, posterior extends from sacrococcygeal juntion to T-9vertebra,produces intracavitary pressure to reduce load on the intervertebraldiscs,includes straps, closures, may include padding, shoulder straps,pendulousabdomen design, custom fabricated (Eff. Date 1/1/2006)040404040404L0633 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior 04DME MAC Jurisdiction C Supplier Manual Page 135

HCPCSAppendix Aframe/panel(s), posterior extends from sacrococcygeal juntion to T-9vertebra, lateral strength provided by rigid lateral frame/panels,producesintracavitary pressure to reduce load on intervertebral discs, includesstraps,closures, may include padding, stays, shoulder straps, pendulousabdomendesign, prefabricated, includes fitting and adjustment(Eff. Date 1/1/2006)L0634 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posteriorframe/panel(s), posterior extends from sacrococcygeal juntion to T-9vertebra, lateral strength provided by rigid lateral frame/panel(s),produces intracavitary pressure to reduce load on intervertebraldiscs,includes straps, closures, may include padding, stays, shoulderstraps,pendulous abdomen design, custom fabricated (Eff. Date 1/1/2006)L0635 Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigidposterior frame/panel(s), lateral articulating design to flex the lumbarspine, posterior extends from sacrococcygeal juntion to T-9 vertebra,lateral strength provided by rigid lateral frame/panel(s), producesintracavitary pressure to reduce load on intervertebral discs, includesstraps, closures, may include padding, anterior panel, pendulousabdomen design, prefabricated, includes fitting and adjustment (Eff.Date 1/1/2006)L0636 Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigidposterior frame/panels, lateral articulating design to flex the lumbarspine,posterior extends from sacrococcygeal juntion to T-9 vertebra, lateralstrengthprovided by rigid lateral frame/panels, produces intracavitarypressure to reduceload on intervertebral discs, includes straps, closures, may includepadding,anterior panel, pendulous abdomen design, custom fabricated (Eff.Date 1/1/2006)L0637 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anteriorandposterior frame/panels, posterior extends from sacrococcygealjuntion toT-9 vertebra, lateral strength provided by rigid lateral frame/panels,producesintracavitary pressure to reduce load on intervertebral discs, includesstraps,closures, may include padding, shoulder straps, pendulous abdomendesign,prefabricated, includes fitting and adjustment (Eff. Date 1/1/2006)L0638 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anteriorandposterior frame/panels, posterior extends from sacrococcygealjuntion to0404040404DME MAC Jurisdiction C Supplier Manual Page 136

HCPCSAppendix AT-9 vertebra, lateral strength provided by rigid lateral frame/panels,producesintracavitary pressure to reduce load on intervertebral discs, includesstraps,closures, may include padding, shoulder straps, pendulous abdomendesign,custom fabricated (Eff. Date 1/1/2006)L0639 Lumbar-sacral orthosis, sagittal-coronal control, rigidshell(s)/panel(s),posterior extends from sacrococcygeal juntion to T-9 vertebra,anteriorextends from symphysis pubis to xyphoid, produces intracavitarypressure toreduce load on intervertebral discs, overall strength is provided byoverlappingrigid material and stabilizing closures, includes straps, closures, mayincludesoft interface, pendulous abdomen design, prefabricated, includesfitting andadjustment (Eff. Date 1/1/2006)L0640 Lumbar-sacral orthosis, sagittal-coronal control, rigidshell(s)/panel(s), posteriorextends from sacrococcygeal juntion to T-9 vertebra, anterior extendsfromsymphysis pubis to xyphoid, produces intracavitary pressure toreduce load onintervertebral discs, overall strength is provided by overlapping rigidmaterial andstabilizing closures, includes straps, closures, may include softinterface, pendulous abdomen design, custom fabricated (Eff. Date1/1/2006)L0700 Cervical-thoracic-lumbar-sacral-orthoses (CTLSO), anterior-posteriorlateralcontrol, molded to patient model, (minerva type)L0710 CTLSO, anterior-posterior-lateral-control, molded to patient model,with interface material, (minerva type)04040404L0810 Halo procedure, cervical halo incorporated into jacket vest 04L0820 Halo procedure, cervical halo incorporated into plaster body jacket 04L0830 Halo procedure, cervical halo incorporated into milwaukee typeorthosisL0859 Addition to halo procedure, magnetic resonance image compatiblesystems,rings and pins, any material (Eff. Date 1/1/2006)L0860 Addition to halo procedures, magnetic reasonance image compatiblesystem (Deleted eff. 12/31/2005)L0861 Addition to halo procedure, replacement liner/interface material (Eff.Date 1/1/2004)04040404DME MAC Jurisdiction C Supplier Manual Page 137

HCPCSAppendix AL0900 Torso support, ptosis support (Deleted eff.12/31/2002) 04L0910 Torso support, ptosis support, custom fabricated (Deletedeff.12/31/2002)04L0920 Torso support, pendulous abdomen support (Deleted eff.12/31/2002) 04L0930 Torso support, pendulous abdomen support, custom fabricated(Deleted eff.12/31/2002)04L0940 Torso support, postsurgical support (Deleted eff.12/31/2002) 04L0950 Torso support, post surgical support, custom fabricated (Deletedeff.12/31/2002)L0960 Torso support, post surgical support, pads for post surgical support(Deleted eff. 03/31/2004)0404L0970 TLSO, corset front 04L0972 LSO, corset front 04L0974 TLSO, full corset 04L0976 LSO, full corset 04L0978 Axillary crutch extension 04L0980 Peroneal straps, pair 04L0982 Stocking supporter grips, set of four (4) 04L0984 Protective body sock, each 04L0986 Addition to spinal orthosis, rigid or semi-rigid abdominal panel,prefabricated (Deleted eff.12/31/2002)04L0999 Addition to spinal orthosis, not otherwise specified 14L1000 Cervical-thoracic-lumbar-sacral orthosis (CTLSO) (milwaukee),inclusive of furnishing initial orthosis, including modelL1001 Cervical thoracic lumbar sacral orthosis, immobilizer, infant size,prefabricated. Includes fitting and adjustment (Eff date 01/01/2007)L1005 Tension based scoliosis orthosis and accessory pads, includes fittingand adjustment (Eff. Date 1/1/2002)L1010 Addition to cervical-thoracic-lumbar-sacral orthosis (CTLSO) orscoliosis orthosis, axilla sling04040404L1020 Addition to CTLSO or scoliosis orthosis, kyphosis pad 04L1025 Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating 04L1030 Addition to CTLSO or scoliosis orthosis, lumbar bolster pad 04DME MAC Jurisdiction C Supplier Manual Page 138

HCPCSAppendix AL1040 Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad 04L1050 Addition to CTLSO or scoliosis orthosis, sternal pad 04L1060 Addition to CTLSO or scoliosis orthosis, thoracic pad 04L1070 Addition to CTLSO or scoliosis orthosis, trapezius sling 04L1080 Addition to CTLSO or scoliosis orthosis, outrigger 04L1085 Addition to CTLSO or scoliosis orthosis, outrigger, bilateral withvertical extensions04L1090 Addition to CTLSO or scoliosis orthosis, lumbar sling 04L1100 Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather 04L1110 Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather,molded to patient model04L1120 Addition to CTLSO, scoliosis orthosis, cover for upright, each 04L1200 Thoracic-lumbar-sacral-orthosis (TLSO), inclusive of furnishing initialorthosis only04L1210 Addition to TLSO, (low profile), lateral thoracic extension 04L1220 Addition to TLSO, (low profile), anterior thoracic extension 04L1230 Addition to TLSO, (low profile), milwaukee type superstructure 04L1240 Addition to TLSO, (low profile), lumbar derotation pad 04L1250 Addition to TLSO, (low profile), anterior asis pad 04L1260 Addition to TLSO, (low profile), anterior thoracic derotation pad 04L1270 Addition to TLSO, (low profile), abdominal pad 04L1280 Addition to TLSO, (low profile), rib gusset (elastic), each 04L1290 Addition to TLSO, (low profile), lateral trochanteric pad 04L1300 Other scoliosis procedure, body jacket molded to patient model 04L1310 Other scoliosis procedure, post-operative body jacket 04L1499 Spinal orthosis, not otherwise specified 14L1500 Thoracic-hip-knee-ankle orthosis (THKAO), mobility frame(newington, parapodium types)04L1510 THKAO, standing frame, with or without tray and accessories 04L1520 THKAO, swivel walker 04L1600 Hip orthosis (HO), abduction control of hip joints, flexible, frejka type 04DME MAC Jurisdiction C Supplier Manual Page 139

HCPCSAppendix Awith cover, perfabriacted, includes fitting and adjustmentL1610 HO, abduction control of hip joints, flexible, frejka cover only,perfabriacted, includes fitting and adjustmentL1620 HO, abduction control of hip joints, flexible, pavlik harness,perfabriacted, includes fitting and adjustmentL1630 HO, abduction control of hip joints, semi-flexible (von rosen type),custom-fabricatedL1640 HO, abduction control of hip joints, static, pelvic band or spreaderbar, thigh cuffs, custom-fibricatedL1650 HO, abduction control of hip joints, static, adjustable, (ilfled type),perfabriacted, includes fitting and adjustmentL1652 Hip orthosis, bilateral thigh cuffs with adjustable abductor spreaderbar, adult size, prefabricated, includes fitting and adjustment, anytype (Eff. Date 1/1/2003)L1660 HO, abduction control of hip joints, static, plastic, perfabriacted,includes fitting and adjustmentL1680 HO, abduction control of hip joints, dynamic, pelvic control, adjustablehip motion control, thigh cuffs (rancho hip action type), customfabricatedL1685 HO, abduction control of hip joint, post-operative hip abduction type,custom fabricatedL1686 HO, abduction control of hip joint, post-operative hip abduction type,perfabriacted, includes fitting and adjustmentL1690 Combination, bilateral, lumbo-sacral, hip, femur orthosis providingadduction and internal rotation control, perfabriacted, includes fittingand adjustment0404040404040404040404L1700 Legg perthes orthosis, toronto type, custom-fabricated 04L1710 Legg perthes orthosis, newington type, custom-fabricated 04L1720 Legg perthes orthosis, trilateral, (tachdijan type), custom-fabricated 04L1730 Legg perthes orthosis, scottish rite type, custom-fabricated 04L1750 Legg perthes orthosis, legg perthes sling (sam brown type),perfabriacted, includes fitting and adjustment (Deleted eff.12/31/2005)04L1755 Legg perthes orthosis, patten bottom type, custom-fabricated 04L1800 Knee orthosis (KO), elastic with stays, perfabriacted, includes fittingand adjustmentL1810 Knee orthosis, elastic with joints, perfabriacted, includes fitting andadjustment0404DME MAC Jurisdiction C Supplier Manual Page 140

HCPCSAppendix AL1815 Knee orthosis, elastic or other elastic type material with condylarpad(s), perfabriacted, includes fitting and adjustmentL1820 Knee orthosis, elastic with condylar pads and joints, with or withoutpatellar control, prefabricated, includes fitting and adjustmentL1825 Knee orthosis, elastic knee cap, perfabriacted, includes fitting andadjustmentL1830 Knee orthosis, immobilizer, canvas longitudinal, perfabriacted,includes fitting and adjustmentL1831 Knee orthosis, locking knee joint(s), positional orthosis, prefabricated,includes fitting and adjustment (Eff. Date 1/1/2004)L1832 Knee Orthosis, adjustable knee joint (unicentric or polycentric),positional orthosis, rigid support, prefabricated, includes fitting andadjustmentL1834 Knee orthosis, without knee joint, rigid, molded to patient model,custom-fabricatedL1836 Knee orthosis, rigid, without joint(s), includes soft interface material,prefabricated, includes fitting and adjustment (Eff. Date 1/1/2003)L1840 Knee orthosis, derotation, medial-lateral, anterior cruciate ligament,custom-fabricatedL1843 Knee Orthosis, single upright, thigh and calf, with adjustable flexionand extension joint (unicentric or polycentric), medial-lateral androtation control, with or without varus/valgus adjustment,prefabricated including fitting and adjustmentL1844 Knee Orthosis, single upright, thigh and calf, with adjustable flexionand extension joint (unicentric or polycentric), medial-lateral androtation control, with our without varus/valgus adjustment, customfabricatedL1845 Knee Orthosis, double upright, thigh and calf, with adjustable flexionand extension joint, (unicentric or polycentric), medial-lateral androtation control, with or without varus/valgus adjustment,prefabricated, includes fitting and adjustmentL1846 Knee Orthosis, double upright, thigh and calf, with adjustable flexionand extension joint, (unicentric or polycentric), medial-lateral androtation control, with or without varus/valgus adjustment, customfabricatedL1847 Knee orthosis, double upright with adjustable joint, with inflatable airsupport chamber(s), perfabriacted, includes fitting and adjustmentL1850 Knee orthosis, swedish type, perfabriacted, includes fitting andadjustmentL1855 Knee orthosis, molded plastic, thigh and calf sections, with doubleupright knee joints, custom-fabricated (Deleted eff. 12/31/2007)04040404040404040404040404040404DME MAC Jurisdiction C Supplier Manual Page 141

HCPCSAppendix AL1858 Knee orthosis, molded plastic, polycentric knee joints, pneumaticknee pads (CTI), custom-fabricated (Deleted eff. 12/31/2007)L1860 Knee orthosis, modification of supracondylar prosthetic socket,custom-fabricated (SK)L1870 Knee orthosis, double upright, thigh and calf lacers with knee joints,custom-fabricated (Deleted eff. 12/31/2007)L1880 Knee orthosis, double upright, non-molded thigh and calf cuffs/lacerswith knee joints, custom fabricated (Deleted eff. 12/31/2007)L1885 Knee orthosis, single or double upright, thigh and calf, with functionalactive resistance control, perfabriacted, includes fitting andadjustment (Deleted eff. 12/31/2003)L1900 Ankle-foot orthosis (AFO), spring wire, dorsiflexion assist calf band,custom-fabricatedL1901 Ankle orthosis, elastic, prefabricated, includes fitting and adjustment(e.g., neoprene, lyra) (Eff. Date 1/1/2003)L1902 Ankle-foot orthosis, ankle gauntlet, perfabriacted, includes fitting andadjustment0404040404040404L1904 Ankle-foot orthosis, molded ankle gauntlet, custom-fabricated 04L1906 Ankle-foot orthosis, multiligamentus ankle support, perfabriacted,includes fitting and adjustmentL1907 AFO, supramalleolar with straps, with or without interface/pads,custom fabricated (Eff. Date 1/1/2004)L1910 Ankle-foot orthosis, posterior, single bar, clasp attachment to shoecounter, prefabriacted, includes fitting and adjustmentL1920 Ankle-foot orthosis, single upright with static or adjustable stop(phelps or perlstein type), custom-fabricatedL1930 Ankle-foot orthosis, plastic or other material, perfabricated, includesfitting and adjustmentL1932 AFO, rigid anterior tibial section, total carbon fiber or equal material,prefabricated, includes fitting and adjustment (Eff. Date 1/1/2005)040404040404L1940 Ankle-foot orthosis, plastic or other material, custom-fabricated 04L1945 Ankle-foot orthosis, plastic, rigid anterior tibial section (floor reaction),custom-fabricatedL1950 Ankle foot orthosis, spiral, (institute of rehabilitative medicine type),plastic, custom-fabricatedL1951 Ankle foot orthosis, spiral, (institute of rehabilitative medicine type),plastic or other material, prefabricated, includes fitting and adjustment(Eff. Date 1/1/2004)040404L1960 Ankle-foot orthosis, posterior solid ankle, plastic, custom-fabricated 04DME MAC Jurisdiction C Supplier Manual Page 142

HCPCSAppendix AL1970 Ankle-foot orthosis, plastic , with ankle joint, custom-fabricated 04L1971 Ankle foot orthosis, plastic or other material with ankle joint,prefabricated, includes fitting and adjustment (Eff. Date 1/1/2004)L1980 Ankle-foot orthosis, single upright free plantar dorsiflexion, solidstirrup, calf band/cuff (single bar ‘bk’ orthosis), custom-fabricatedL1990 Ankle-foot orthosis, double upright free plantar dorsiflexion, solidstirrup, calf band/cuff (double bar ‘bk’ orthosis), custom-fabricatedL2000 Knee-ankle-foot-orthosis (KAFO), single upright, free knee, freeankle, solid stirrup, thigh and calf bands/cuffs (single bar ‘ak’orthosis), custom-fabricatedL2005 Knee ankle foot orthosis, any material, single or double upright,stance control, automatic lock and swing phase release, mechanicalactivation, includes ankle joint, any type, custom fabricated (Eff. Date1/1/2005)L2010 Knee-ankle-foot-orthosis, single upright, free ankle, solid stirrup, thighand calf bands/cuffs (single bar ‘ak’ orthosis), without knee joint,custom-fabricatedL2020 Knee-ankle-foot-orthosis, double upright, free knee, free ankle, solidstirrup, thigh and calf bands/cuffs (double bar ‘ak’ orthosis), customfabricatedL2030 Knee-ankle-foot-orthosis, double upright, free ankle, solid stirrup,thigh and calf bands/cuffs, (double bar ‘ak’ orthosis), without kneejoint, custom-fabricatedL2034 Knee ankle foot orthosis, full plastic, single upright, with or withoutfreemotion knee, medial lateral rotation control, with our without freemotion ankle,custom fabricated (Eff. Date 1/1/2006)L2035 Knee ankle foot orthosis, full plastic, static (pediatric size), withoutfree motion ankle, prefabricated, includes fitting and adjustmentL2036 Knee ankle foot orthosis, full plastic, dougle upright, with or withoutfree motion knee, with or without free motion ankle, custom fabricatedL2037 Knee ankle foot orthosis, full plastic, single upright, with or withoutfree motion knee, with or without free motion ankle, custom fabricatedL2038 Knee ankle foot orthosis, full plastic with or without free motion kneejoint, multi-axis ankle, custom fabricatedL2039 Knee ankle foot orthosis, full plastic, single upright, poly-axial hinge,medial lateral rotation control, with or without free motion ankle,custom fabricated (Deleted eff. 12/31/2005)L2040 Hip-knee-ankle-foot orthosis (HKAFO) torsion control, bilateralrotation straps, pelvic band/belt, custom-fabricated040404040404040404040404040404DME MAC Jurisdiction C Supplier Manual Page 143

HCPCSAppendix AL2050 Hip-knee-ankle-foot orthosis, torsion control, bilateral torsion cables,hip joint, pelvic band/belt, custom-fabricatedL2060 Hip-knee-ankle-foot-orthosis, torsion control, bilateral torsion cables,ball bearing hip joint, pelvic band/ belt, custom fabricatedL2070 Hip-knee-ankle-foot-orthosis, torsion control, unilateral rotationstraps, pelvic band/belt, custom-fabricatedL2080 Hip-knee-ankle-foot-orthosis, torsion control, unilateral torsion cable,hip joint, pelvic band/belt, custom-fabricatedL2090 Hip-knee-ankle-foot-orthosis, torsion control, unilateral torsion cable,ball bearing hip joint, pelvic band/ belt, custom-fabricatedL2102 Ankle-foot-orthosis (AFO), fracture orthosis, tibial fracture castorthosis, plaster type casting material, custom-fabricated (Not validfor Medicare as of 10/2/2001.)L2104 Ankle-foot-orthosis, fracture orthosis, tibial fracture cast orthosis,synthetic type casting material, custom-fabricated (Not valid forMedicare as of 10/1/2001.)L2106 Ankle-foot-orthosis, fracture orthosis, tibial fracture cast orthosis,thermoplastic type casting material, custom-fabricatedL2108 Ankle-foot-orthosis, fracture orthosis, tibial fracture cast orthosis,custom-fabricatedL2112 Ankle-foot-orthosis, fracture orthosis, tibial fracture orthosis, soft,prefabriacted, includes fitting and adjustmentL2114 Ankle-foot-orthosis, fracture orthosis, tibial fracture orthosis, semirigid,prefabriacted, includes fitting and adjustmentL2116 Ankle-foot-orthosis, fracture orthosis, tibial fracture orthosis, rigid,prefabriacted, includes fitting and adjustmentL2122 Knee-ankle-foot-orthosis, (KAFO), fracture orthosis, femoral fracturecast orthosis, plaster type casting material, custom-fabricated (Notvalid for Medicare as of 10/1/2001.)L2124 Knee-ankle-foot-orthosis, fracture orthosis, femoral fracture castorthosis, synthetic type casting material, custom-fabricated (Not validfor Medicare as of 10/1/2001.)L2126 Knee-ankle-foot-orthosis, fracture orthosis, femoral fracture castorthosis, thermoplastic type casting material, custom-fabricatedL2128 Knee-ankle-foot-orthosis, fracture orthosis, femoral fracture castorthosis, custom-fabricatedL2132 Knee-ankle-foot-orthosis, fracture orthosis, femoral fracture castorthosis, soft, prefabriacted, includes fitting and adjustmentL2134 Knee-ankle-foot-orthosis, fracture orthosis, femoral fracture castorthosis, semi-rigid, perfabriacted, includes fitting and adjustment040404040404040404040404040404040404DME MAC Jurisdiction C Supplier Manual Page 144

HCPCSAppendix AL2136 Knee-ankle-foot-orthosis, fracture orthosis, femoral fracture castorthosis, rigid, perfabriacted, includes fitting and adjustmentL2180 Addition to lower extremity fracture orthosis, plastic shoe insert withankle joints0404L2182 Addition to lower extremity fracture orthosis, drop lock knee joint 04L2184 Addition to lower extremity fracture orthosis, limited motion knee joint 04L2186 Addition to lower extremity fracture orthosis, adjustable motion kneejoint, lerman type04L2188 Addition to lower extremity fracture orthosis, quadrilateral brim 04L2190 Addition to lower extremity fracture orthosis, waist belt 04L2192 Addition to lower extremity fracture orthosis, hip joint, pelvic band,thigh flange, and pelvic belt04L2200 Addition to lower extremity, limited ankle motion, each joint 04L2210 Addition to lower extremity, dorsiflexion assist (plantar flexion resist),each jointL2220 Addition to lower extremity, dorsiflexion and plantar flexionassist/resist, each jointL2230 Addition to lower extremity, split flat caliper stirrups and plateattachmentL2232 Addition to lower extremity orthosis, rocker bottom for total contactankle foot orthosis, for custom fabricated orthosis only (Eff. Date1/1/2005)04040404L2240 Addition to lower extremity, round caliper and plate attachment 04L2250 Addition to lower extremity, foot plate, molded to patient model,stirrup attachment04L2260 Addition to lower extremity, reinforced solid stirrup (scott-craig type) 04L2265 Addition to lower extremity, long tongue stirrup 04L2270 Addition to lower extremity, varus/valgus correction (‘t’) strap,padded/lined or malleolus padL2275 Addition to lower extremity, varus/valgus correction, plasticmodification, padded/lined0404L2280 Addition to lower extremity, molded inner boot 04L2300 Addition to lower extremity, abduction bar (bilateral hip involvement),jointed, adjustable04L2310 Addition to lower extremity, abduction bar-straight 04DME MAC Jurisdiction C Supplier Manual Page 145

HCPCSAppendix AL2320 Addition to lower extremity, non-molded lacer, for custom fabricatedorthosis onlyL2330 Addition to lower extremity, lacer molded to patient model, for customfabricated orthosis only0404L2335 Addition to lower extremity, anterior swing band 04L2340 Addition to lower extremity, pre-tibial shell, molded to patient model 04L2350 Addition to lower extremity, prosthetic type, (bk) socket, molded topatient model, (used for ‘ptb’ ‘AFO’ orthoses)04L2360 Addition to lower extremity, extended steel shank 04L2370 Addition to lower extremity, patten bottom 04L2375 Addition to lower extremity, torsion control, ankle joint and half solidstirrupL2380 Addition to lower extremity, torsion control, straight knee joint, eachjoint0404L2385 Addition to lower extremity, straight knee joint, heavy duty, each joint 04L2387 Addition to lower extremity, polycentric knee joint, for customfabricated kneeankle foot orthosis, each joint (Eff. Date 1/1/2006)04L2390 Addition to lower extremity, offset knee joint, each joint 04L2395 Addition to lower extremity, offset knee joint, heavy duty, each joint 04L2397 Addition to lower extremity orthosis, suspension sleeve 04L2405 Addition to knee joint, drop lock, each 04L2415 Addition to knee lock with integrated release mechanism (bail, cable,or equal), any material, each jointL2425 Addition to knee joint, disc or dial lock for adjustable knee flexion,each jointL2430 Addition to knee joint, ratchet lock for active and progressive kneeextension, each jointL2435 Addition to knee joint, polycentric joint, each joint (Deleted eff.12/31/2004)04040404L2492 Addition to knee joint, lift loop for drop lock ringL2500 Addition to lower extremity, thigh/weight bearing, gluteal/ ischialweight bearing, ringL2510 Addition to lower extremity, thigh/weight bearing, quadri- lateral brim,molded to patient model0404DME MAC Jurisdiction C Supplier Manual Page 146

HCPCSAppendix AL2520 Addition to lower extremity, thigh/weight bearing, quadri- lateral brim,custom fittedL2525 Addition to lower extremity, thigh/weight bearing, ischialcontainment/narrow m-l brim molded to patient modelL2526 Addition to lower extremity, thigh/weight bearing, ischialcontainment/narrow m-l brim, custom fitted040404L2530 Addition to lower extremity, thigh-weight bearing, lacer, non-molded 04L2540 Addition to lower extremity, thigh/weight bearing, lacer, molded topatient model04L2550 Addition to lower extremity, thigh/weight bearing, high roll cuff 04L2570 Addition to lower extremity, pelvic control, hip joint, clevis type twoposition joint, each04L2580 Addition to lower extremity, pelvic control, pelvic sling 04L2600 Addition to lower extremity, pelvic control, hip joint, clevis type, orthrust bearing, free, eachL2610 Addition to lower extremity, pelvic control, hip joint, clevis or thrustbearing, lock, each0404L2620 Addition to lower extremity, pelvic control, hip joint, heavy duty, each 04L2622 Addition to lower extremity, pelvic control, hip joint, adjustable flexion,eachL2624 Addition to lower extremity, pelvic control, hip joint, adjustable flexion,extension, abduction control, eachL2627 Addition to lower extremity, pelvic control, plastic, molded to patientmodel, reciprocating hip joint and cablesL2628 Addition to lower extremity, pelvic control, metal frame, reciprocatinghip joint and cables04040404L2630 Addition to lower extremity, pelvic control, band and belt, unilateral 04L2640 Addition to lower extremity, pelvic control, band and belt, bilateral 04L2650 Addition to lower extremity, pelvic and thoracic control, gluteal pad,each04L2660 Addition to lower extremity, thoracic control, thoracic band 04L2670 Addition to lower extremity, thoracic control, paraspinal uprights 04L2680 Addition to lower extremity, thoracic control, lateral support uprights 04L2750 Addition to lower extremity orthosis, plating chrome or nickel, per bar 04L2755 Addition to lower extremity orthosis, high strength, lightweight 04DME MAC Jurisdiction C Supplier Manual Page 147

HCPCSAppendix Amaterial, all hybrid lamination/prepreg composite, per segment, forcustom fabricated orthosis onlyL2760 Addition to lower extremity orthosis, extension, per extension, per bar(for lineal adjustment for growth)04L2768 Orthotic side bar disconnect device, per bar 04L2770 Addition to lower extremity orthosis, any material - per bar or joint 04L2780 Addition to lower extremity orthosis, non-corrosive finish, per bar 04L2785 Addition to lower extremity orthosis, drop lock retainer, each 04L2795 Addition to lower extremity orthosis, knee control, full kneecap 04L2800 Addition to lower extremity orthosis, knee control, knee cap, medial orlateral pull, for use with custom fabricated orthosis only04L2810 Addition to lower extremity orthosis, knee control, condylar pad 04L2820 Addition to lower extremity orthosis, soft interface for molded plastic,below knee sectionL2830 Addition to lower extremity orthosis, soft interface for molded plastic,above knee sectionL2840 Addition to lower extremity orthosis, tibial length sock, fracture orequal, eachL2850 Addition to lower extremity orthosis, femoral length sock, fracture orequal, eachL2860 Addition to lower extremity joint, knee or ankle, concentric adjustabletorsion style mechanism, each (not valid for Medicare as of11/1/1997)0404040404L2999 Lower extremity orthoses, not otherwise specified 14L3000 Foot, insert, removable, molded to patient model, ‘ucb’ type, berkeleyshell, each04L3001 Foot, insert, removable, molded to patient model, spenco, each 04L3002 Foot, insert, removable, molded to patient model, plastazote or equal,each04L3003 Foot, insert, removable, molded to patient model, silicone gel, each 04L3010 Foot, insert, removable, molded to patient model, longitudinal archsupport, eachL3020 Foot, insert, removable, molded to patient model, longitudinal/metatarsal support, each0404L3030 Foot, insert, removable, formed to patient foot, each 04DME MAC Jurisdiction C Supplier Manual Page 148

HCPCSAppendix AL3031 Foot, insert/plate, removable, addition to lower extremity orthosis,high strength, lightweight material, all hybrid lamination/prepregcomposite, each (Eff. Date 1/1/2004)04L3040 Foot, arch support, removable, premolded, longitudinal, each 04L3050 Foot, arch support, removable, premolded, metatarsal, each 04L3060 Foot, arch support, removable, premolded, longitudinal/ metatarsal,eachL3070 Foot, arch support, non-removable attached to shoe, longitudinal,eachL3080 Foot, arch support, non-removable attached to shoe, metatarsal,eachL3090 Foot, arch support, non-removable attached to shoe,longitudinal/metatarsal, each04040404L3100 Hallus-valgus night dynamic splint 04L3140 Foot, abduction rotation bar, including shoes 04L3150 Foot, abduction rotatation bar, without shoes 04L3160 Foot, adjustable shoe-styled positioning device 04L3170 Foot, plastic, silicone or equal, heel stabilizer, each 04L3201 Orthopedic shoe, oxford with supinator or pronator, infant 04L3202 Orthopedic shoe, oxford with supinator or pronator, child 04L3203 Orthopedic shoe, oxford with supinator or pronator, junior 04L3204 Orthopedic shoe, hightop with supinator or pronator, infant 04L3206 Orthopedic shoe, hightop with supinator or pronator, child 04L3207 Orthopedic shoe, hightop with supinator or pronator, junior 04L3208 Surgical boot, each, infant 04L3209 Surgical boot, each, child 04L3211 Surgical boot, each, junior 04L3212 Benesch boot, pair, infant 04L3213 Benesch boot, pair, child 04L3214 Benesch boot, pair, junior 04L3215 Orthopedic footwear, ladies shoe, oxford, each 04L3216 Orthopedic footwear, ladies shoe, depth inlay, each 04DME MAC Jurisdiction C Supplier Manual Page 149

HCPCSAppendix AL3217 Orthopedic footwear, ladies shoe, hightop, depth inlay, each 04L3218 Orthopedic footwear, ladies surgical boot, each (Deletedeff.12/31/2002)04L3219 Orthopedic footwear, mens shoe, oxford, each 04L3221 Orthopedic footwear, mens shoe, depth inlay, each 04L3222 Orthopedic footwear, mens shoe, hightop, depth inlay, each 04L3223 Orthopedic footwear, mens surgical boot, each (Deletedeff.12/31/2002)L3224 Orthopedic footwear, woman’s shoe, oxford, used as an integral partof a brace (orthosis)L3225 Orthopedic footwear, man’s shoe, oxford, used as an integral part ofa brace (orthosis)040404L3230 Orthopedic footwear, custom shoe, depth inlay, each 04L3250 Orthopedic footwear, custom molded shoe, removable inner mold,prosthetic shoe, each04L3251 Foot, shoe molded to patient model, silicone shoe, each 04L3252 Foot, shoe molded to patient model, plastazote (or similar), customfabricated, each04L3253 Foot, molded shoe plastazote (or similar) custom fitted, each 04L3254 Non-standard size or width 04L3255 Non-standard size or length 04L3257 Orthopedic footwear, additional charge for split size 04L3260 Surgical boot/shoe, each 04L3265 Plastazote sandal, each 04L3300 Lift, elevation, heel, tapered to metatarsals, per inch 04L3310 Lift, elevation, heel and sole, neoprene, per inch 04L3320 Lift, elevation, heel and sole, cork, per inch 04L3330 Lift, elevation, metal extension (skate) 04L3332 Lift, elevation, inside shoe, tapered, up to one-half inch 04L3334 Lift, elevation, heel, per inch 04L3340 Heel wedge, sach 04L3350 Heel wedge 04DME MAC Jurisdiction C Supplier Manual Page 150

HCPCSAppendix AL3360 Sole wedge, outside sole 04L3370 Sole wedge, between sole 04L3380 Clubfoot wedge 04L3390 Outflare wedge 04L3400 Metatarsal bar wedge, rocker 04L3410 Metatarsal bar wedge, between sole 04L3420 Full sole and heel wedge, between sole 04L3430 Heel, counter, plastic reinforced 04L3440 Heel, counter, leather reinforced 04L3450 Heel, sach cushion type 04L3455 Heel, new leather, standard 04L3460 Heel, new rubber, standard 04L3465 Heel, thomas with wedge 04L3470 Heel, thomas extended to ball 04L3480 Heel, pad and depression for spur 04L3485 Heel, pad, removable for spur 04L3500 Orthopedic shoe addition, insole, leather 04L3510 Orthopedic shoe addition, insole, rubber 04L3520 Orthopedic shoe addition, insole, felt covered with leather 04L3530 Orthopedic shoe addition, sole, half 04L3540 Orthopedic shoe addition, sole, full 04L3550 Orthopedic shoe addition, toe tap standard 04L3560 Orthopedic shoe addition, toe tap, horseshoe 04L3570 Orthopedic shoe addition, special extension to instep (leather witheyelets)04L3580 Orthopedic shoe addition, convert instep to velcro closure 04L3590 Orthopedic shoe addition, convert firm shoe counter to soft counter 04L3595 Orthopedic shoe addition, march bar 04L3600 Transfer of an orthosis from one shoe to another, caliper plate, 04DME MAC Jurisdiction C Supplier Manual Page 151

HCPCSAppendix AexistingL3610 Transfer of an orthosis from one shoe to another, caliper plate, new 04L3620 Transfer of an orthosis from one shoe to another, solid stirrup,existing04L3630 Transfer of an orthosis from one shoe to another, solid stirrup, new 04L3640 Transfer of an orthosis from one shoe to another, dennis brownesplint (riveton), both shoesL3649 Orthopedic shoe, modification, addition or transfer, not otherwisespecifiedL3650 Shoulder orthosis, (SO), figure of eight design abduction restrainer,prefabricated, included fitting and adjustmentL3651 Shoulder orthosis, single shoulder, elastic, prefabricatd, includesfitting and adjustment (e.g., neoprene, lycra) (Eff. Date 1/1/2003)L3652 Shoulder orthosis, double shoulder, elastic, prefabricated, includesfitting and adjustment (e.g., neoprene, lycra) (Eff. Date 1/1/2003)L3660 Shoulder orthosis, figure of eight design abduction restrainer, canvasand webbing, prefabricated, included fitting and adjustmentL3670 Shoulder orthosis, acromio/clavicular (canvas and webbing type),prefabricated, included fitting and adjustmentL3671 Shoulder orthosis, shoulder cap design, without joint, may includesoft interface, straps, custom fabricated, includes fitting andadjustment(Eff. Date 1/1/2006)L3672 Shoulder orthosis, abduction positioning (airplane design), thoraciccomponents and support bar, without joints, may include softinterface,straps, custom fabricated, includes fitting and adjustment (Eff. Date1/1/2006)L3673 Shoulder orthosis, abduction positioning (airplane design), thoraciccomponent and support bar, includes nontorsion joint/turnbuckle,mayinclude soft interface, straps, custom fabricated, includes fitting andadjustment (Eff. Date 1/1/2006)L3675 Shoulder orthosis, vest type abduction restrainer, canvas webbingtype, or equa, prefabricated, included fitting and adjustmentL3677 Shoulder orthosis, hard plastic, shoulder stabilizer, pre-fabricated,includes fitting and adjustment (Eff. Date 1/1/2002)L3700 Elbow orthosis (EO), elastic with stays, prefabricated, included fittingand adjustment04140404040404040404040404L3701 Elbow orthosis, elastic, prefabricated, includes fitting and adjustment 04DME MAC Jurisdiction C Supplier Manual Page 152

HCPCSAppendix A(e.g., neoprene, lycra) (Eff. Date 1/1/2003)L3702 Elbow orthosis, without joints, may include soft interface, straps,custom fabricated, includes fitting and adjustment (Eff. Date1/1/2006)L3710 Elbow orthosis, elastic with metal joints, prefabricated, included fittingand adjustmentL3720 Elbow orthosis, double upright with forearm/arm cuffs, free motioncustom-fabricatedL3730 Elbow orthosis, double upright with forearm/arm cuffs, extension/flexion assist, custom-fabricatedL3740 Elbow orthosis, double upright with forearm/arm cuffs, adjustableposition lock with active control, custom-fabricatedL3760 Elbow orthosis, with adjustable position locking joint(s), prefabricated,includes fitting and adjustments, any type (Eff. Date 1/1/2001)L3762 Elbow orthosis, rigid, without joints, includes soft interface material,prefabricated, includes fitting and adjustment (Eff. Date 1/1/2003)L3763 Elbow wrist hand orthosis, rigid, without joints, may include softinterfacematerial, straps, custom fabricated, includes fitting and adjustment(Eff. Date 1/1/2006)L3764 Elbow wrist hand orthosis, includes one or more nontorsion joints,elastic bands, turnbuckles, may include soft interface, straps, customfabricated, includes fitting and adjustment (Eff. Date 1/1/2006)L3765 Elbow wrist hand finger orthosis, without joints, may include softinterface,straps, custom fabricated, includes fitting and adjustment (Eff. Date1/1/2006)L3766 Elbow wrist hand finger orthosis, includes one or more nontorsionjoints,elastic bands, turnbuckles, may include soft interface, straps, customfabricated, includes fitting and adjustment (Eff. Date 1/1/2006)L3800 Wrist-hand-finger-orthosis (WHFO), short opponens, no attachments,custom-fabricated (Deleted eff. 12/31/2007)L3805 Wrist-hand-finger-orthosis, long opponens, no attachment, customfabricated(Deleted eff. 12/31/2007)L3806 WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORENONTORSION JOINT(S), TURNBUCKLES, ELASTICBANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL,STRAPS, CUSTOM FABRICATED, INCLUDES FITTING ANDADJUSTMENT ( Updated 01/01/2008)L3807 Wrist-hand-finger-orthosis, without joint(s), prefabricated, includesfitting and adjustment (Eff. Date 1/1/2000)040404040404040404040404040404DME MAC Jurisdiction C Supplier Manual Page 153

HCPCSAppendix AL3808 Wrist hand finger orthosis, rigid without joints, may include softinterface material, straps, custom fabricated, includes fitting andadjustment (Eff date 01/01/2007)L3810 WHFO, addition to short and long opponens, thumb abduction (‘c’)bar (Deleted eff. 12/31/2007)L3815 WHFO, addition to short and long opponens, second m.p. abductionassist (Deleted eff. 12/31/2007)L3820 WHFO, addition to short and long opponens, i.p. extension assist,with m.p. extension stop (Deleted eff. 12/31/2007)L3825 WHFO, addition to short and long opponens, m.p. extension stop(Deleted eff. 12/31/2007)L3830 WHFO, addition to short and long opponens, m.p. extension assist(Deleted eff. 12/31/2007)L3835 WHFO, addition to short and long opponens, m.p. spring extensionassist (Deleted eff. 12/31/2007)L3840 WHFO, addition to short and long opponens, spring swivel thumb(Deleted eff. 12/31/2007)L3845 WHFO, addition to short and long opponens, thumb i.p. extensionassist, with m.p. stop (Deleted eff. 12/31/2007)L3850 WHO, addition to short and long opponens, action wrist, withdorsiflexion assist (Deleted eff. 12/31/2007)L3855 WHFO, addition to short and long opponens, adjustable m.p. flexioncontrol (Deleted eff. 12/31/2007)L3860 WHFO, addition to short and long opponens, adjustable m.p. flexioncontrol and i.p. (Deleted eff. 12/31/2007)L3890 Addition to upper extremity joint, wrist or elbow, concentric adjustabletorsion style mechanism, eachL3900 Wrist-hand-finger-orthosis, dynamic flexor hinge, reciprocal wristextension/flexion, finger flexion/extension, wrist or finger driven,custom-fabricatedL3901 Wrist-hand-finger-orthosis, dynamic flexor hinge, reciprocal wristextension/flexion, finger flexion/extension, cable driven, customfabricatedL3902 Wrist-hand-finger-orthosis, external powered, compressed gas,custom-fabricated (deleted 12/31/06L3904 Wrist-hand-finger-orthosis, external powered, electric, customfabricatedL3905 Wrist hand orthosis, includes one or more nontorsion joints, elasticbands, turnbuckles, may include soft interface, straps, customfabricated,includes fitting and adjustment (Eff. Date 1/1/2006)040404040404040404040404040404040404DME MAC Jurisdiction C Supplier Manual Page 154

HCPCSAppendix AL3906 Wrist hand orthosis, without joints, may include soft interface, straps,custom fabricated, includes fitting and adjustmentL3907 Wrist-hand-finger-orthosis, wrist gauntlet with thumb spica, customfabricated(Deleted eff. 12/31/2007)L3908 Wrist-hand-finger-orthosis, wrist extension control cock-up, nonmolded, prefabricated, included fitting and adjustmentL3909 Wrist orthosis, elastic, prefabricated, includes fitting and adjustment(e.g., neoprene, lycra) (Eff. Date 1/1/2003)L3910 Wrist hand finger orthosis, swanson design, prefabricated, includedfitting and adjustment (Deleted eff. 12/31/2007)L3911 Wrist Hand Finger orthosis, elastic, prefabricated, includes fitting andadjustment (Eff. Date 1/1/2003)L3912 Hand finger orthosis, flexion glove with elastic finger control,prefabricated, included fitting and adjustmentL3913 Hand finger orthosis, without joint, may include soft interface, straps,custom fabricated, includes fitting and adjustment (Eff. Date1/1/2006)L3914 Wrist hand orthosis, wrist extension cock-up, prefabricated, includedfitting and adjustment (deleted 12/31/06)L3915 Wrist hand finger orthosis, includes one or more nontorsion joint(s),elastic bands, turnbuckles, may include soft interface, straps,prefabricated, includes fitting and adjustment ( Eff date 01/01/2007)L3916 Wrist hand finger orthosis, wrist extension cock-up, with outrigger,prefabricated, included fitting and adjustment (Deleted eff.12/31/2007)L3917 Hand orthosis, metacarpal fracture orthosis, prefabricated, includesfitting and adjustment (Eff. Date 1/1/2004)L3918 Hand finger orthosis, knuckle bender, prefabricated, included fittingand adjustment (Deleted eff. 12/31/2007)L3919 Hand orthosis, without joint, may include soft interface, straps,customfabricated, includes fitting and adjustment (Eff. Date 1/1/2006)L3920 Hand finger orthosis, knuckle bender, with outrigger, prefabricated,included fitting and adjustment (Deleted eff. 12/31/2007)L3921 Hand finger orthosis, includes one or more nontorsion joints, elasticbands, turnbuckles, may include soft interface, straps, customfabricated,includes fitting and adjustment (Eff. Date 1/1/2006)L3922 Hand finger orthosis, knuckle bender, two segment to flex joints,prefabricated, included fitting and adjustment (Deleted eff.12/31/2007)0404040404040404040404040404040404DME MAC Jurisdiction C Supplier Manual Page 155

HCPCSAppendix AL3923 Hand finger orthosis without joint, may include soft interface, straps,prefabricated, includes fitting and adjustment (Eff. Date 1/1/2001)L3924 Wrist hand finger orthosis, oppenheimer, prefabricated, includedfitting and adjustment (Deleted eff. 12/31/2007)L3925 FINGER ORTHOSIS, PROXIMAL INTERPHALANGEAL(PIP)/DISTAL INTERPHALANGEAL (DIP), NON TORSIONJOINT/SPRING, EXTENSION/FLEXION, MAY INCLUDE SOFTINTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENT (Eff. Date 1/1/2008)L3926 Wrist hand finger orthosis, thomas suspension, prefabricated,included fitting and adjustment (Deleted eff. 12/31/2007)L3927 FINGER ORTHOSIS, PROXIMAL INTERPHALANGEAL(PIP)/DISTAL INTERPHALANGEAL (DIP), WITHOUTJOINT/SPRING, EXTENSION/FLEXION (E.G. STATIC OR RINGTYPE), MAY INCLUDE SOFT INTERFACE MATERIAL,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (Eff.Date 1/1/2008)0404040404L3928 Hand finger orthosis, finger extension, with clock spring,prefabricated, included fitting and adjustment (Deleted eff.12/31/2007)L3929 HAND FINGER ORTHOSIS, INCLUDES ONE OR MORENONTORSION JOINT(S), TURNBUCKLES, ELASTICBANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL,STRAPS, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT (Eff. Date 1/1/2008)L3930 Wrist hand finger orthosis, finger extension, with wrist support,prefabricated, included fitting and adjustment (Deleted eff.12/31/2007)L3931 WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORENONTORSION JOINT(S), TURNBUCKLES, ELASTICBANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL,STRAPS, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENT (Eff. Date 1/1/2008)L3932 Finger orthosis, safety pin, spring wire, prefabricated, included fittingand adjustment (Deleted eff. 12/31/2007)L3933 Finger orthosis, without joints, may includes soft interface, customfabricated, includes fitting and adjustment (Eff. Date 1/1/2006)L3934 Finger orthosis, safety pin, modified, prefabricated, included fittingand adjustment (Deleted eff. 12/31/2007)L3935 Finger orthosis, nontorsion joint, may include soft interface, customfabricated, includes fitting and adjustment (Eff. Date 1/1/2006)L3936 Wrist hand finger orthosis, palmer, prefabricated, included fitting andadjustment (Deleted eff. 12/31/2007)040404040404040404DME MAC Jurisdiction C Supplier Manual Page 156

HCPCSAppendix AL3938 Wrist hand finger orthosis, dorsal wrist, prefabricated, included fittingand adjustment (Deleted eff. 12/31/2007)L3940 Wrist hand finger orthosis, dorsal wrist, with outrigger attachment,prefabricated, included fitting and adjustment (Deleted eff.12/31/2007)L3942 Hand finger orthosis, reverse knuckle bender, prefabricated, includedfitting and adjustment (Deleted eff. 12/31/2007)L3944 Hand finger orthosis, reverse knuckle bender, with outrigger,prefabricated, included fitting and adjustment (Deleted eff.12/31/2007)L3946 Hand finger orthosis, composite elastic, prefabricated, included fittingand adjustment (Deleted eff. 12/31/2007)L3948 Finger orthosis, finger knuckle bender, prefabricated, included fittingand adjustment (Deleted eff. 12/31/2007)L3950 Wrist hand finger orthosis, combination oppenheimer, with knucklebender and two attachments, prefabricated, included fitting andadjustment (Deleted eff. 12/31/2007)L3952 Wrist hand finger orthosis, combination oppenheimer, with reverseknuckle and two attachments, prefabricated, included fitting andadjustment (Deleted eff. 12/31/2007)L3954 Hand finger orthosis, spreading hand, prefabricated, included fittingand adjustment (Deleted eff. 12/31/2007)040404040404040404L3956 Addition of joint to upper extremity orthosis, any material; per joint 04L3960 Shoulder-elbow-wrist-hand orthosis, (SEWHO), abductionpositioning, airplane design, prefabricated, included fitting andadjustmentL3961 Shoulder elbow wrist hand orthosis, should cap design, without joints,may include soft interface, straps, custom fabricated, includes fittingandadjustment (Eff. Date 1/1/2006)L3962 Shoulder-elbow-wrist-hand orthosis, abduction positioning, erbspalsey design, prefabricated, included fitting and adjustmentL3963 Shoulder-elbow-wrist-hand orthosis, molded shoulder, arm, forearm,and wrist, with articulating elbow joint, custom-fabricated (Deleted eff.12/31/2005)L3964 Shoulder elbow orthosis, mobile arm support attached to wheelchair,balanced, adjustable, prefabricated, included fitting and adjustmentL3965 Shoulder elbow orthosis, mobile arm support attached to wheelchair,balanced, adjustable rancho type, prefabricated, included fitting andadjustment040404040505L3966 Shoulder elbow orthosis, mobile arm support attached to wheelchair, 05DME MAC Jurisdiction C Supplier Manual Page 157

HCPCSAppendix Abalanced, reclining, prefabricated, included fitting and adjustmentL3967 Shoulder elbow wrist hand orthosis, abduction positioning (airplanedesign),thoracic component and support bar, without joints, may include softinterface,straps, custom fabricated, includes fitting and adjustment(Eff. Date 1/1/2006)L3968 Shoulder elbow orthosis, mobile arm support attached to wheelchair,balanced,friction arm support (friction dampening to proximal anddistal joints), prefabricated, included fitting and adjustmentL3969 Shoulder elbow orthosis, mobile arm support, monosuspension armand hand support, overhead elbow forearm hand sling support, yoketype arm suspension support, prefabricated, included fitting andadjustment040505L3970 SEO, addition to mobile arm support, elevating proximal arm 05L3971 Shoulder elbow wrist hand orthosis, shoulder cap design, includesone ormore nontorsion joints, elastic bands, turnbuckles, may include softinterface, straps, custom fabricated, includes fitting and adjustment(Eff. Date 1/1/2006)L3972 SEO, addition to mobile arm support, offset or lateral rocker arm withelastic balance controlL3973 Shoulder elbow wrist hand orthosis, abduction positioning (airplanedesign)thoracic component and support bar, includes one or morenontorsion joints,elastic bands, turnbuckles, may include soft interface, straps, customfabricated, includes fitting and adjustment (Eff. Date 1/1/2006)040504L3974 SEO, addition to mobile arm support, supinator 05L3975 Shoulder elbow wrist hand orthosis, shoulder cap design, withoutjoints,may include soft interface, straps, custom fabricated, includes fittingandadjustment (Eff. Date 1/1/2006)L3976 Shoulder elbow wrist hand finger orthosis, abduction positioning(airplane design), thoracic component and support bar, without joints,may include soft interface, straps, custom fabricated, includes fittingand adjustment (Eff. Date 1/1/2006)L3977 Shoulder elbow wrist hand finger orthosis, shoulder cap design,includesone or more nontorsion joints, elastic bands, turnbuckles, mayinclude softinterface, straps, custom fabricated, includes fitting and adjustment(Eff. Date 1/1/2006)040404DME MAC Jurisdiction C Supplier Manual Page 158

HCPCSAppendix AL3978 Shoulder elbow wrist hand finger orthosis, abduction positioning(airplanedesign) thoracic component and support bar, includes one or morenontorsionjoints, elastic bands, turnbuckles, may include soft interface, straps,customfabricated, includes fitting and adjustment (Eff. Date 1/1/2006)L3980 Upper extremity fracture orthosis, humeral, prefabricated, includedfitting and adjustmentL3982 Upper extremity fracture orthosis, radius/ulnar, prefabricated,included fitting and adjustmentL3984 Upper extremity fracture orthosis, wrist, prefabricated, included fittingand adjustmentL3985 Upper extremity fracture orthosis, forearm, hand with wrist hinge,custom-fabricated (Deleted eff. 12/31/2007)L3986 Upper extremity fracture orthosis, combination of humeral,radius/ulnar, wrist, (example - colles fracture), custom-fabricated(Deleted eff. 12/31/2007)040404040404L3995 Addition to upper extremity orthosis, sock, fracture or equal, each 04L3999 Upper limb orthosis, not otherwise specified 14L4000 Replace girdle for spinal orthosis (CTLSO or SO) 04L4002 Replacement strap, any orthosis, includes all components, anylength, any type (Eff. Date 1/1/2005)04L4010 Replace trilateral socket brim 04L4020 Replace quadrilateral socket brim, molded to patient model 04L4030 Replace quadrilateral socket brim, custom fitted 04L4040 Replace molded thigh lacer, for custom fabricated orthosis only 04L4045 Replace non-molded thigh lacer, for custom fabricated orthosis only 04L4050 Replace molded calf lacer, for custom fabricated orthosis only 04L4055 Replace non-molded calf lacer, for custom fabricated orthosis only 04L4060 Replace high roll cuff 04L4070 Replace proximal and distal upright for KAFO 04L4080 Replace metal bands KAFO, proximal thigh 04L4090 Replace metal bands KAFO-AFO, calf or distal thigh 04L4100 Replace leather cuff KAFO, proximal thigh 04DME MAC Jurisdiction C Supplier Manual Page 159

HCPCSAppendix AL4110 Replace leather cuff KAFO-AFO, calf or distal thigh 04L4130 Replace pretibial shell 04L4200 Repair of orthotic device, hourly rate (Deleted eff. 12/31/1996) 04L4205 Repair of orthotic device, labor component, per 15 minutes 04L4210 Repair of orthotic device, repair or replace minor parts 04L4310 Multi-podus or equal orthotic preparatory management system forlower extremities (Deleted eff. 12/31/1998)L4320 Addition to AFO, multi-podus (or equal) orthotic preparatorymanagement system for lower extremities, flexible foot positioner withsoft interface for AFO, with velcro closure (Deleted eff. 12/31/1998)L4350 Ankle control orthosis, stirrup style, rigid, includes any type interface(e.g., pneumatic, gel), prefabricated, includes fitting and adjustmentL4360 Walking boot, pneumatic, with or without joints, with or withoutinterface material, prefabricated, includes fitting and adjustmentL4370 Pneumatic full leg splint, prefabricated, included fitting andadjustment0404040404L4380 Pneumatic knee splint, prefabricated, included fitting and adjustment 04L4386 Walking boot, non-pneumatic, with or without joints, with or withoutinterface material, prefabricated, includes fitting and adjustment (Eff.Date 1/1/2003)L4390 Replace soft interface material, multi-podus type splint (Deleted eff.12/31/1998)0404L4392 Replacement soft interface material, static AFO 04L4394 Replace soft interface material, foot drop splint 04L4396 Static ankle foot orthosis, including soft interface material, adjustablefor fit, for positioning, pressure reduction, may be used for minimalambulation, prefabricated, includes fitting and adjustmentL4398 Foot drop splint, recumbent positioning device, prefabricated,included fitting and adjustment0404L5000 Partial foot, shoe insert with longitudinal arch, toe filler 04L5010 Partial foot, molded socket, ankle height, with toe filler 04L5020 Partial foot, molded socket, tibial tubercle height, with toe filler 04L5050 Ankle, symes, molded socket, sach foot 04L5060 Ankle, symes, metal frame, molded leather socket, articulatedankle/foot04DME MAC Jurisdiction C Supplier Manual Page 160

HCPCSAppendix AL5100 Below knee, molded socket, shin, sach foot 04L5105 Below knee, plastic socket, joints and thigh lacer, sach foot 04L5150 Knee disarticulation (or through knee), molded socket, external kneejoints, shin, sach footL5160 Knee disarticulation (or through knee), molded socket, bent kneeconfiguration, external knee joints, shin, sach footL5200 Above knee, molded socket, single axis constant friction knee, shin,sach footL5210 Above knee, short prosthesis, no knee joint (‘stubbies’), with footblocks, no ankle joints, eachL5220 Above knee, short prosthesis, no knee joint (‘stubbies’), witharticulated ankle/foot, dynamically aligned, eachL5230 Above knee, for proximal femoral focal deficiency, constant frictionknee, shin, sach footL5250 Hip disarticulation, canadian type; molded socket, hip joint, singleaxis constant friction knee, shin, sach footL5270 Hip disarticulation, tilt table type; molded socket, locking hip joint,single axis constant friction knee, shin, sach footL5280 Hemipelvectomy, canadian type; molded socket, hip joint, single axisconstant friction knee, shin, sach footL5300 Below knee, molded socket, sach foot, endoskeletal system,including soft cover and finishing (Deleted eff. 12/31/2001)L5301 Below knee, molded socket, shin, sach foot, endoskeletal system(Eff. Date 1/1/2002)L5310 Knee disarticulation (or through knee), molded socket, sach footendoskeletal system, including soft cover and finishing (Deleted eff.12/31/2001)L5311 Knee disarticulation (or through knee), molded socket, external kneejoints, shin, sach foot, endoskeletal system (Eff. Date 1/1/2002)L5320 Above knee, molded socket, open end, sach foot, endoskeletalsystem, single axis knee, including soft cover and finishing (Deletedeff. 12/31/2001)L5321 Above knee, molded socket, open end, sach foot, endoskeletalsystem, single axis knee (Eff. Date 1/1/2002)L5330 Hip disarticulation, canadian type; molded socket, endoskeletalsystem, hip joint, single axis knee, sach foot, including soft cover andfinishing (Deleted eff. 12/31/2001)L5331 Hip disarticulation, canadian type, molded socket, endoskeletalsystem, hip joint, single axis knee, sach foot (Eff. Date 1/1/2002)0404040404040404040404040404040404DME MAC Jurisdiction C Supplier Manual Page 161

HCPCSAppendix AL5340 Hemipelvectomy, canadian type; molded socket, endoskeletalsystem, hip joint, single axis knee, sach foot, including soft cover andfinishing (Deleted eff. 12/31/2001)L5341 Hemipelvectomy, canadian type, molded socket, endoskeletalsystem, hip joint, single axis knee, sach foot (Eff. Date 1/1/2002)L5400 Immediate post surgical or early fitting, application of initial rigiddressing, including fitting, alignment, suspension, and one castchange, below kneeL5410 Immediate post surgical or early fitting, application of initial rigiddressing, including fitting, alignment and suspension, below knee,each additional cast change and realignmentL5420 Immediate post surgical or early fitting, application of initial rigiddressing, including fitting, alignment and suspension and one castchange ‘ak’ or knee disarticulationL5430 Immediate post surgical or early fitting, application of initial rigiddressing, incl. fitting, alignment and supension, ‘ak’ or kneedisarticulation, each additional cast change and realignmentL5450 Immediate post surgical or early fitting, application of non-weightbearing rigid dressing, below kneeL5460 Immediate post surgical or early fitting, application of non-weightbearing rigid dressing, above kneeL5500 Initial, below knee ‘ptb’ type socket, non-alignable system, pylon, nocover, sach foot, plaster socket, direct formedL5505 Initial, above knee - knee disarticulation, ischial level socket, nonalignablesystem, pylon, no cover, sach foot, plaster socket, directformedL5510 Preparatory, below knee ‘ptb’ type socket, non-alignable system,pylon, no cover, sach foot, plaster socket, molded to modelL5520 Preparatory, below knee ‘ptb’ type socket, non-alignable system,pylon, no cover, sach foot, thermoplastic or equal, direct formedL5530 Preparatory, below knee ‘ptb’ type socket, non-alignable system,pylon, no cover, sach foot, thermoplastic or equal, molded to modelL5535 Preparatory, below knee ‘ptb’ type socket, non-alignable system, nocover, sach foot, prefabricated, adjustable open end socketL5540 Preparatory, below knee ‘ptb’ type socket, non-alignable system,pylon, no cover, sach foot, laminated socket, molded to modelL5560 Preparatory, above knee- knee disarticulation, ischial level socket,non-alignable system, pylon, no cover, sach foot, plaster socket,molded to modelL5570 Preparatory, above knee - knee disarticulation, ischial level socket,non-alignable system, pylon, no cover, sach foot, thermoplastic orequal, direct formed0404040404040404040404040404040404DME MAC Jurisdiction C Supplier Manual Page 162

HCPCSAppendix AL5580 Preparatory, above knee - knee disarticulation ischial level socket,non-alignable system, pylon, no cover, sach foot, thermoplastic orequal, molded to modelL5585 Preparatory, above knee - knee disarticulation, ischial level socket,non-alignable system, pylon, no cover, sach foot, prefabricatedadjustable open end socketL5590 Preparatory, above knee - knee disarticulation ischial level socket,non-alignable system, pylon no cover, sach foot, laminated socket,molded to modelL5595 Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover,sach foot, thermoplastic or equal, molded to patient modelL5600 Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover,sach foot, laminated socket, molded to patient modelL5610 Addition to lower extremity, endoskeletal system, above knee,hydracadence systemL5611 Addition to lower extremity, endoskeletal system, above knee - kneedisarticulation, 4 bar linkage, with friction swing phase controlL5613 Addition to lower extremity, endoskeletal system, above knee-kneedisarticulation, 4 bar linkage, with hydraulic swing phase controlL5614 Addition to lower extremity, exoskeletal system, above knee-kneedisarticulation, 4 bar linkage, with pneumatic swing phase controlL5616 Addition to lower extremity, endoskeletal system, above knee,universal multiplex system, friction swing phase controlL5617 Addition to lower extremity, quick change self-aligning unit, aboveknee or below knee, each0404040404040404040404L5618 Addition to lower extremity, test socket, symes 04L5620 Addition to lower extremity, test socket, below knee 04L5622 Addition to lower extremity, test socket, knee disarticulation 04L5624 Addition to lower extremity, test socket, above knee 04L5626 Addition to lower extremity, test socket, hip disarticulation 04L5628 Addition to lower extremity, test socket, hemipelvectomy 04L5629 Addition to lower extremity, below knee, acrylic socket 04L5630 Addition to lower extremity, symes type, expandable wall socket 04L5631 Addition to lower extremity, above knee or knee disarticulation,acrylic socket04L5632 Addition to lower extremity, symes type, ‘ptb’ brim design socket 04DME MAC Jurisdiction C Supplier Manual Page 163

HCPCSAppendix AL5634 Addition to lower extremity, symes type, posterior opening (canadian)socket04L5636 Addition to lower extremity, symes type, medial opening socket 04L5637 Addition to lower extremity, below knee, total contact 04L5638 Addition to lower extremity, below knee, leather socket 04L5639 Addition to lower extremity, below knee, wood socket 04L5640 Addition to lower extremity, knee disarticulation, leather socket 04L5642 Addition to lower extremity, above knee, leather socket 04L5643 Addition to lower extremity, hip disarticulation, flexible inner socket,external frame04L5644 Addition to lower extremity, above knee, wood socket 04L5645 Addition to lower extremity, below knee, flexible inner socket, externalframeL5646 Addition to lower extremity, below knee, air, fluid, gel or equal,cushion socket0404L5647 Addition to lower extremity, below knee suction socket 04L5648 Addition to lower extremity, above knee, air, fluid, gel or equal,cushion socketL5649 Addition to lower extremity, ischial containment/narrow m-l socket 04L5650 Additions to lower extremity, total contact, above knee or kneedisarticulation socketL5651 Addition to lower extremity, above knee, flexible inner socket,external frameL5652 Addition to lower extremity, suction suspension, above knee or kneedisarticulation socketL5653 Addition to lower extremity, knee disarticulation, expandable wallsocketL5654 Addition to lower extremity, socket insert, symes, (kemblo, pelite,aliplast, plastazote or equal)L5655 Addition to lower extremity, socket insert, below knee (kemblo, pelite,aliplast, plastazote or equal)L5656 Addition to lower extremity, socket insert, knee disarticulation(kemblo, pelite, aliplast, plastazote or equal)L5658 Addition to lower extremity, socket insert, above knee (kemblo, pelite,aliplast, plastazote or equal)0404040404040404DME MAC Jurisdiction C Supplier Manual Page 164

HCPCSAppendix AL5660 Addition to lower extremity, socket insert, symes, silicone gel or equal(Deleted eff. 10/01/02)04L5661 Addition to lower extremity, socket insert, multi-durometer symes 04L5662 Addition to lower extremity, socket insert, below knee, silicone gel orequal (Deleted eff. 10/01/02)L5663 Addition to lower extremity, socket insert, knee disarticulation,silicone gel or equal (Deleted eff. 10/01/02)L5664 Addition to lower extremity, socket insert, above knee, silicone gel orequal (Deleted eff. 10/01/02)L5665 Addition to lower extremity, socket insert, multi-durometer, belowknee04040404L5666 Addition to lower extremity, below knee, cuff suspension 04L5667 Addition to lower extremity, below knee/above knee, socket insert,suction suspension with locking mechanism (Deleted eff. 12/31/2001)04L5668 Addition to lower extremity, below knee, molded distal cushion 04L5669 Addition to lower extremity, below knee/above knee, socket insert,suction suspension without locking mechanism (Deleted eff.12/31/2001)L5670 Addition to lower extremity, below knee, molded supracondylarsuspension (‘pts’ or similar)L5671 Addition to lower extremity, below knee/above knee suspensionlocking mechanism (shuttle, lanyard or equal), excludes socket insert(Eff. Date 1/1/2002)L5672 Addition to lower extremity, below knee, removable medial brimsuspensionL5673 Addition to lower extremity, below knee/above knee, customfabricated from existing mold or prefabricated, socket insert, siliconegel, elastomeric or equal, for use with locking mechanism (Eff. Date1/1/2004)L5674 Addition to lower extremity, below knee, suspension sleeve, anymaterial, each (Deleted eff. 12/31/2004)L5675 Addition to lower extremity, below knee, suspension sleeve , heavyduty, any material, each (Deleted eff. 12/31/2004)04040404040404L5676 Additions to lower extremity, below knee, knee joints, single axis, pair 04L5677 Additions to lower extremity, below knee, knee joints, polycentric, pair 04L5678 Additions to lower extremity, below knee, joint covers, pairL5679 Addition to lower extremity, below knee/ above knee, customfabricated from existing mold or prefabricated, socket insert, silicone04DME MAC Jurisdiction C Supplier Manual Page 165

HCPCSAppendix Agel, elastomeric or equal, not for use with locking mechanism (Eff.Date 1/1/2004)L5680 Addition to lower extremity, below knee, thigh lacer, nonmolded 04L5681 Addition to lower extremity, below knee/above knee, customfabricated socket insert for congenital or atypical traumatic amputee,silicone gel, elastomeric or equal, for use with or without lockingmechanism, initial only (for other than initial, use code L5673 orL5679) (Eff. Date 1/1/2004)L5682 Addition to lower extremity, below knee, thigh lacer, gluteal/ischial,moldedL5683 Addition to lower extremity, below knee/above knee, customfabricated socket insert for other than congenital or atypical traumaticamputee, silicone gel, elastomeric or equal, for use with or withoutlocking mechanism, initial only (for other than initial, use code L5673or L5679) (Eff. Date 1/1/2004)040404L5684 Addition to lower extremity, below knee, fork strap 04L5685 Addition to lower extremity prosthesis, below knee,suspension/sealing sleeve, with or without valve, any material, each(Eff. Date 1/1/2005)L5686 Addition to lower extremity, below knee, back check (extensioncontrol)0404L5688 Addition to lower extremity, below knee, waist belt, webbing 04L5690 Addition to lower extremity, below knee, waist belt, padded and lined 04L5692 Addition to lower extremity, above knee, pelvic control belt, light 04L5694 Addition to lower extremity, above knee, pelvic control belt, paddedand linedL5695 Addition to lower extremity, above knee, pelvic control, sleevesuspension, neoprene or equal, eachL5696 Addition to lower extremity, above knee or knee disarticulation, pelvicjointL5697 Addition to lower extremity, above knee or knee disarticulation, pelvicbandL5698 Addition to lower extremity, above knee or knee disarticulation,silesian bandage0404040404L5699 All lower extremity prostheses, shoulder harness 04L5700 Replacement, socket, below knee, molded to patient model 04L5701 Replacement, socket, above knee/knee disarticulation, includingattachment plate, molded to patient model04DME MAC Jurisdiction C Supplier Manual Page 166

HCPCSAppendix AL5702 Replacement, socket, hip disarticulation, including hip joint, molded topatient modelL5703 Ankle, symes, molded to patient model, socket without solid anklecushionheel (sach) foot, replacement only (Eff. Date 1/1/2006)0404L5704 Custom shaped protective cover, below knee 04L5705 Custom shaped protective cover, above knee 04L5706 Custom shaped protective cover, knee disarticulation 04L5707 Custom shaped protective cover, hip disarticulation 04L5710 Addition, exoskeletal knee-shin system, single axis, manual lock 04L5711 Additions exoskeletal knee-shin system, single axis, manual lock,ultra-light materialL5712 Addition, exoskeletal knee-shin system, single axis, friction swing andstance phase control (safety knee)L5714 Addition, exoskeletal knee-shin system, single axis, variable frictionswing phase controlL5716 Addition, exoskeletal knee-shin system, polycentric, mechanicalstance phase lockL5718 Addition, exoskeletal knee-shin system, polycentric, friction swingand stance phase controlL5722 Addition, exoskeletal knee-shin system, single axis, pneumatic swing,friction stance phase controlL5724 Addition, exoskeletal knee-shin system, single axis, fluid swing phasecontrolL5726 Addition, exoskeletal knee-shin system, single axis, external jointsfluid swing phase controlL5728 Addition, exoskeletal knee-shin system, single axis, fluid swing andstance phase controlL5780 Addition, exoskeletal knee-shin system, single axis, pneumatic/hydrapneumatic swing phase controlL5781 Addition to lower limb prosthesis, vacuum pump, residual limbvolume management and moisture evacuation system (Eff. Date1/1/2003)L5782 Addition to lower limb prosthesis, vacuum pump, residual limbvolume management and moisture evacuation system, heavy duty(Eff. Date 1/1/2003)L5785 Addition, exoskeletal system, below knee, ultra-light material(titanium, carbon fiber or equal)04040404040404040404040404DME MAC Jurisdiction C Supplier Manual Page 167

HCPCSAppendix AL5790 Addition, exoskeletal system, above knee, ultra-light material(titanium, carbon fiber or equal)L5795 Addition, exoskeletal system, hip disarticulation, ultra-light material(titanium, carbon fiber or equal)0404L5810 Addition, endoskeletal knee-shin system, single axis, manual lock 04L5811 Addition, endoskeletal knee-shin system, single axis, manual lock,ultra-light materialL5812 Addition, endoskeletal knee-shin system, single axis, friction swingand stance phase control (safety knee)0404L5814 Addition, endoskeletal knee-shin system, polycentric, hydraulic swingphase control, mechanical stance phase lockL5816 Addition, endoskeletal knee-shin system, polycentric, mechanicalstance phase lockL5818 Addition, endoskeletal knee-shin system, polycentric, friction swing,and stance phase controlL5822 Addition, endoskeletal knee-shin system, single axis, pneumaticswing, friction stance phase controlL5824 Addition, endoskeletal knee-shin system, single axis, fluid swingphase controlL5826 Addition, endoskeletal knee-shin system, single axis, hydraulic swingphase control, with miniature high activity frameL5828 Addition, endoskeletal knee-shin system, single axis, fluid swing andstance phase controlL5830 Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase controlL5840 Addition, endoskeletal knee/shin system, 4-bar linkage or multiaxial,pneumatic swing phase controlL5845 Addition, endoskeletal, knee-shin system, stance flexion feature,adjustableL5846 Addition, endoskeletal, knee-shin system, microprocessor controlfeature, swing phase only (Deleted eff. 12/31/2004)L5847 Addition, endoskeletal knee-shin system, microprocessor controlfeature, stance phase (Eff. Date 1/1/2002) (Deleted eff. 12/31/2004)L5848 Addition to endoskeletal, knee-shin system, hydraulic stanceextension, dampening feature, with or without adjustability (Eff. Date1/1/2003)L5850 Addition, endoskeletal system, above knee or hip disarticulation,knee extension assist0404040404040404040404040404DME MAC Jurisdiction C Supplier Manual Page 168

HCPCSAppendix AL5855 Addition, endoskeletal system, hip disarticulation, mechanical hipextension assistL5856 Addition to lower extremity prosthesis, endoskeletal knee-shinsystem, microprocessor control feature, swing and stance phase,includes electronic sensor (s), any type (Eff. Date 1/1/2005)L5857 Addition to lower extremity prosthesis, endoskeletal knee-shinsystem, microprocessor control feature, swing phase only, includeselectronic sensor (s), any type (Eff. Date 1/1/2005)L5858 Addition to lower extremity prosthesis, endoskeletal knee shinsystem,microprocessor control feature, stance phase only, includeselectronicsensor(s), any type (Eff. Date 1/1/2006)04040404L5910 Addition, endoskeletal system, below knee, alignable system 04L5920 Addition, endoskeletal system, above knee or hip disarticulation,alignable systemL5925 Addition, endoskeletal system, above knee, knee disarticulation orhip disarticulation, manual lock0404L5930 Addition, endoskeletal system, high activity knee control frame 04L5940 Addition, endoskeletal system, below knee, ultra-light material(titanium, carbon fiber or equal)L5950 Addition, endoskeletal system, above knee, ultra-light material(titanium, carbon fiber or equal)L5960 Addition, endoskeletal system, hip disarticulation, ultra-light material(titanium, carbon fiber or equal)040404L5962 Addition, endoskeletal system, below knee, flexible protective outersurface covering systemL5964 Addition, endoskeletal system, above knee, flexible protective outersurface covering systemL5966 Addition, endoskeletal system, hip disarticulation, flexible protectiveouter surface covering systemL5968 Addition to lower limb prosthesis, multiaxial ankle with swing phaseactive dorsiflexion feature04040404L5970 All lower extremity prostheses, foot, external keel, sach foot 04L5971 All lower extremity prosthesis, solid ankle cushion heel (sach) foot,replacement only (Eff. Date 1/1/2006)L5972 All lower extremity prostheses, flexible keel foot (safe, sten, bockdynamic or equal)0404DME MAC Jurisdiction C Supplier Manual Page 169

HCPCSAppendix AL5974 All lower extremity prostheses, foot, single axis ankle/foot 04L5975 All lower extremity prosthesis, combination single axis ankle andflexible keel footL5976 All lower extremity prostheses, energy storing foot (seattle carboncopy ii or equal)0404L5978 All lower extremity prostheses, foot, multiaxial ankle/foot 04L5979 All lower extremity prostheses, mult-iaxial ankle, dynamic responsefoot, one piece system04L5980 All lower extremity prostheses, flex foot system 04L5981 All lower extremity prostheses, flex-walk system or equal 04L5982 All exoskeletal lower extremity prostheses, axial rotation unit 04L5984 All endoskeletal lower extremity prosthesis, axial rotation unit, with orwithout adjustability04L5985 All endoskeletal lower extremity protheses, dynamic prosthetic pylon 04L5986 All lower extremity prostheses, multi-axial rotation unit (‘mcp’ orequal)L5987 All lower extremity prosthesis, shank foot system with vertical loadingpylonL5988 Addition to lower limb prosthesis, vertical shock reducing pylonfeatureL5989 Additino to lower extremity prosthesis, endoskeletal system, pylonwith integrated electronic force sensors (Eff. Date 1/1/2002) (Deletedeff. 12/31/2004)L5990 Addition to lower extremity prosthesis, user adjustable heel height(Eff. Date 1/1/2002)L5993 Addition to lower extremity prosthesis, heavy duty feature, foot only,(for patient weight greater than 300 lbs) (Eff date 01/01/2007)L5994 Addition to lower extremity prosthesis, heavy duty feature, knee only,(for patient weight greater than 300 lbs) (Eff date 01/01/2007)L5995 Addition to lower extremity prostheis, heavy duty feature (for patientweight > 300 lbs) (Eff. date 1/1/2003)0404040404040404L5999 Lower extremity prosthesis, not otherwise specified 14L6000 Partial hand, robin-aids, thumb remaining (or equal) 04L6010 Partial hand, robin-aids, little and/or ring finger remaining (or equal) 04L6020 Partial hand, robin-aids, no finger remaining (or equal) 04DME MAC Jurisdiction C Supplier Manual Page 170

HCPCSAppendix AL6025 Transcarpal/metacarpal or partial hand disarticulation prosthesis,external power, self-suspended, inner socket with removable forearmsection, electrodes and cables, two batteries, charger, myoelectriccontrol of terminal device (Eff. Date 1/1/2003)L6050 Wrist disarticulation, molded socket, flexible elbow hinges, tricepspadL6055 Wrist disarticulation, molded socket with expandable interface,flexible elbow hinges, triceps pad040404L6100 Below elbow, molded socket, flexible elbow hinge, triceps pad 04L6110 Below elbow, molded socket, (muenster or northwestern suspensiontypes)L6120 Below elbow, molded double wall split socket, step-up hinges, halfcuffL6130 Below elbow, molded double wall split socket, stump activatedlocking hinge, half cuff040404L6200 Elbow disarticulation, molded socket, outside locking hinge, forearm 04L6205 Elbow disarticulation, molded socket with expandable interface,outside locking hinges, forearmL6250 Above elbow, molded double wall socket, internal locking elbow,forearmL6300 Shoulder disarticulation, molded socket, shoulder bulkhead, humeralsection, internal locking elbow, forearm040404L6310 Shoulder disarticulation, passive restoration (complete prosthesis) 04L6320 Shoulder disarticulation, passive restoration (shoulder cap only) 04L6350 Interscapular thoracic, molded socket, shoulder bulkhead, humeralsection, internal locking elbow, forearm04L6360 Interscapular thoracic, passive restoration (complete prosthesis) 04L6370 Interscapular thoracic, passive restoration (shoulder cap only) 04L6380 Immediate post surgical or early fitting, application of initial rigiddressing, including fitting alignment and suspension of components,and one cast change, wrist disarticulation or below elbowL6382 Immediate post surgical or early fitting, application of initial rigiddressing including fitting alignment and suspension of components,and one cast change, elbow disarticulation or above elbowL6384 Immediate post surgical or early fitting, application of initial rigiddressing including fitting alignment and suspension of components,and one cast change, shoulder disarticulation or interscapularthoracic040404DME MAC Jurisdiction C Supplier Manual Page 171

HCPCSAppendix AL6386 Immediate post surgical or early fitting, each additional cast changeand realignmentL6388 Immediate post surgical or early fitting, application of rigid dressingonly0404L6400 Below elbow, molded socket, endoskeletal system, including softprosthetic tissue shapingL6450 Elbow disarticulation, molded socket, endoskeletal system, includingsoft prosthetic tissue shapingL6500 Above elbow, molded socket, endoskeletal system, including softprosthetic tissue shapingL6550 Shoulder disarticulation, molded socket, endoskeletal system,including soft prosthetic tissue shapingL6570 Interscapular thoracic, molded socket, endoskeletal system, includingsoft prosthetic tissue shapingL6580 Preparatory, wrist disarticulation or below elbow, single wall plasticsocket, friction wrist, flexible elbow hinges, figure of eight harness,humeral cuff, bowden cable control, usmc or equal pylon, no cover,molded to patient modelL6582 Preparatory, wrist disarticulation or below elbow, single wall socket,friction wrist, flexible elbow hinges, figure of eight harness, humeralcuff, bowden cable control, usmc or equal pylon, no cover, directformedL6584 Preparatory, elbow disarticulation or above elbow, single wall plasticsocket, friction wrist, locking elbow, figure of eight harness, fair leadcable control, usmc or equal pylon, no cover, molded to patient modelL6586 Preparatory, elbow disarticulation or above elbow, single wall socket,friction wrist, locking elbow, figure of eight harness, fair lead cablecontrol, usmc or equal pylon, no cover, direct formedL6588 Preparatory, shoulder disarticulation or interscapular thoracic, singlewall plastic socket, shoulder joint, locking elbow, friction wrist, cheststrap, fair lead cable control, usmc or equal pylon, no cover, moldedto patient modelL6590 Preparatory, shoulder disarticulation or interscapular thoracic, singlewall socket, shoulder joint, locking elbow, friction wrist, chest strap,fair lead cable control, usmc or equal pylon, no cover, direct formed04040404040404040404L6600 Upper extremity additions, polycentric hinge, pair 04L6605 Upper extremity additions, single pivot hinge, pair 04L6610 Upper extremity additions, flexible metal hinge, pair 04L6611 Addition to upper extremity prosthesis, external powered, additionalswitch, any type (Eff date 01/01/2007)04DME MAC Jurisdiction C Supplier Manual Page 172

HCPCSAppendix AL6615 Upper extremity addition, disconnect locking wrist unit 04L6616 Upper extremity addition, additional disconnect insert for locking wristunit, eachL6620 Upper extremity addition, flexion/extension wrist unit, with or withoutfrictionL6621 Upper extremity prosthesis addition, flexion/extension wrist with ourwithout friction, for use with external powered terminal device (Eff.Date 1/1/2006)L6623 Upper extremity addition, spring assisted rotational wrist unit withlatch releaseL6624 Upper extremity addition, flexion/extension and rotation wrist unit (Effdate 01/01/2007)0404040404L6625 Upper extremity addition, rotation wrist unit with cable lock 04L6628 Upper extremity addition, quick disconnect hook adapter, otto bock orequalL6629 Upper extremity addition, quick disconnect lamination collar withcoupling piece, otto bock or equal0404L6630 Upper extremity addition, stainless steel, any wrist 04L6632 Upper extremity addition, latex suspension sleeve, each 04L6635 Upper extremity addition, lift assist for elbow 04L6637 Upper extremity addition, nudge control elbow lock 04L6638 Upper extremity addition to prosthesis, electric locking feature, onlyfor use with manually powered elbow (Eff. Date 1/1/2003)L6639 Upper extremity addition, heavy duty feature, any elbow (Eff date01/01/2007)0404L6640 Upper extremity additions, shoulder abduction joint, pair 04L6641 Upper extremity addition, excursion amplifier, pulley type 04L6642 Upper extremity addition, excursion amplifier, lever type 04L6645 Upper extremity addition, shoulder flexion-abduction joint, each 04L6646 Upper extremity addition, shoulder joint, multipositional locking,flexion, adjustable abduction friction control, for use with bodypowered or external powered system (Eff. Date 1/1/2003)L6647 Upper extremity addition, shoulder lock mechanism, body poweredactuator (Eff. Date 1/1/2003)L6648 Upper extremity addition, shoulder lock mechanism, external powredactuator (Eff. Date 1/1/2003)040404DME MAC Jurisdiction C Supplier Manual Page 173

HCPCSAppendix AL6650 Upper extremity addition, shoulder universal joint, each 04L6655 Upper extremity addition, standard control cable, extra 04L6660 Upper extremity addition, heavy duty control cable 04L6665 Upper extremity addition, teflon, or equal, cable lining 04L6670 Upper extremity addition, hook to hand, cable adapter 04L6672 Upper extremity addition, harness, chest or shoulder, saddle type 04L6675 Upper extremity addition, harness, (e.g. figure of eight type), singlecable designL6676 Upper extremity addition, harness, (e.g. figure of eight type), dualcable designL6677 Upper extremity addition, harness, triple control, simultaneousoperationof terminal device and elbow (Eff. Date 1/1/2006)L6680 Upper extremity addition, test socket, wrist disarticulation or belowelbowL6682 Upper extremity addition, test socket, elbow disarticulation or aboveelbowL6684 Upper extremity addition, test socket, shoulder disarticulation orinterscapular thoracic040404040404L6686 Upper extremity addition, suction socket 04L6687 Upper extremity addition, frame type socket, below elbow or wristdisarticulationL6688 Upper extremity addition, frame type socket, above elbow or elbowdisarticulation0404L6689 Upper extremity addition, frame type socket, shoulder disarticulation 04L6690 Upper extremity addition, frame type socket, interscapular-thoracic 04L6691 Upper extremity addition, removable insert, each 04L6692 Upper extremity addition, silicone gel insert or equal, each 04L6693 Upper extremity addition, locking elbow, forearm counterbalance 04L6694 Addition to upper extremity prosthesis, below elbow/above elbow,custom fabricated from existing mold or prefabricated, socket insert,silicone gel, elastomeric or equal, for use with locking mechanism(Eff. Date 1/1/2005)L6695 Addition to upper extremity prosthesis, below elbow/above elbow,custom fabricated from existing mold or prefabricated, socket insert,silicone gel, elastomeric or equal, not for use with locking mechanism0404DME MAC Jurisdiction C Supplier Manual Page 174

HCPCSAppendix A(Eff. Date 1/1/2005)L6696 Addition to upper extremity prosthesis, below elbow/above elbow,custom fabricated socket insert for congenital or atypical traumaticamputee, silicone gel, elastomeric or equal, for use with or withoutlocking mechanism, initial only (for other than initial, use code L6694or L6695) (Eff. Date 1/1/2005)L6697 Addition to upper extremity prosthesis, below elbow/above elbow,custom fabricated socket insert for other than congenital or atypicaltraumatic amputee, silicone gel, elastomeric or equal, for use with orwithout locking mechanism, initial only (for other than initial, use codeL6694 or L6695) (Eff. Date 1/1/2005)L6698 Addition to upper extremity prosthesis, below elbow/above elbow,lock mechanism, excludes socket insert (Eff. Date 1/1/2005)L6700 Terminal device, hook, dorrance, or equal, model #3 (deleted12/31/06)L6703 Terminal device, passive hand/mitt, any material, ant size (Eff date01/01/2007)L6704 Terminal device, sport/recreation/work attachment, anu material, anysize (Eff date 01/01/2007)L6705 Terminal device, hook, dorrance, or equal, model #5 (deleted12/31/06)L6706 Terminal device, hook, mechanical, voluntary opening, any material,any size, lined or unlined (Eff date 01/01/2007)L6707 Terminal device, hook, mechanical, voluntary closing, any material,any size, lined or unlined (Eff date 01/01/2007)L6708 Terminal device, hand, mechanical, voluntary opening, any material,any size (Eff date 01/01/2007)L6709 Terminal device, hand, mechanical, voluntary closing, any material,any size (Eff date 01/01/2007)L6710 Terminal device, hook, dorrance, or equal, model #5x (deleted12/31/06)L6715 Terminal device, hook, dorrance, or equal, model #5x (deleted12/31/06)L6720 Terminal device, hook, dorrance, or equal, model #6 (deleted12/31/06)L6725 Terminal device, hook, dorrance, or equal, model #7 (deleted12/31/06)L6730 Terminal device, hook, dorrance, or equal, model #7lo (deleted12/31/06)L6735 Terminal device, hook, dorrance, or equal, model #8 (deleted12/31/06)0404040404040404040404040404040404DME MAC Jurisdiction C Supplier Manual Page 175

HCPCSAppendix AL6740 Terminal device, hook, dorrance, or equal, model #8x (deleted12/31/06)L6745 Terminal device, hook, dorrance, or equal, model #88x (deleted12/31/06)L6750 Terminal device, hook, dorrance, or equal, model #10p (deleted12/31/06)L6755 Terminal device, hook, dorrance, or equal, model #10x (deleted12/31/06)L6765 Terminal device, hook, dorrance, or equal, model #12p (deleted12/31/06)L6770 Terminal device, hook, dorrance, or equal, model #99x (deleted12/31/06)L6775 Terminal device, hook, dorrance, or equal, model #555 (deleted12/31/06)L6780 Terminal device, hook, dorrance, or equal, model #ss555 (deleted12/31/06)0404040404040404L6790 Terminal device, hook-accu hook, or equal (deleted 12/31/06) 04L6795 Terminal device, hook-2 load, or equal (deleted 12/31/06) 04L6800 Terminal device, hook-aprl vc, or equal (deleted 12/31/06) 04L6805 Addition to terminal device, modifier wrist unit 04L6806 Terminal device, hook, trs grip, grip III, vc, or equal (deleted12/31/06)04L6807 Terminal device, hook, grip I, grip II, vc, or equal (deleted 12/31/06) 04L6808 Terminal device, hook, trs adept, infant or child, vc, or equal (deleted12/31/06)04L6809 Terminal device, hook, trs super sport, passive (deleted 12/31/06) 04L6810 Addition to terminal device, precision pinch device 04L6825 Terminal device, hand, dorrance, vo (deleted 12/31/06) 04L6830 Terminal device, hand, aprl, vc (deleted 12/31/06) 04L6835 Terminal device, hand, sierra, vo (deleted 12/31/06)L6840 Terminal device, hand, becker imperial (deleted 12/31/06) 04L6845 Terminal device, hand, becker lock grip (deleted 12/31/06) 04L6850 Terminal device, hand, becker plylite (deleted 12/31/06) 04L6855 Terminal device, hand, robin-aids, vo (deleted 12/31/06) 04DME MAC Jurisdiction C Supplier Manual Page 176

HCPCSAppendix AL6860 Terminal device, hand, robin-aids, vo soft (deleted 12/31/06) 04L6865 Terminal device, hand, passive hand (deleted 12/31/06) 04L6867 Terminal device, hand, detroit infant hand (mechanical) (deleted12/31/06)L6868 Terminal device, hand, passive infant hand, (steeper, hosmer orequal) (deleted 12/31/06)0404L6870 Terminal device, hand, child mitt (deleted 12/31/06) 04L6872 Terminal device, hand, nyu child hand (deleted 12/31/06) 04L6873 Terminal device, hand, mechanical infant hand, steeper or equal(deleted 12/31/06)04L6875 Terminal device, hand, bock, vc (deleted 12/31/06) 04L6880 Terminal device, hand, bock, vo (deleted 12/31/06) 04L6881 Automatic grasp feature, addition to upper limb electric prostheticterminal device (Eff. Date 1/1/2002)L6882 Microprocessor control feature, addition to upper limb prostheticterminal device (Eff. Date 1/1/2002)L6883 Replacement socket, below elbow/wrist disarticulation, molded topatientmodel, for use with or without external power (Eff. Date 1/1/2006)L6884 Replacement socket, above elbow/elbow disarticulation, molded topatient model, for use with or without external power (Eff. Date1/1/2006)L6885 Replacement socket, shoulder disarticulation/interscapular thoracic,molded to patient model, for use with or without external power (Eff.Date 1/1/2006)L6890 Addition to upper extremity prosthesis, glove for terminal device, anymaterial, prefabricated, includes fitting and adjustmentL6895 Addition to upper extremity prosthesis, glove for terminal device, anymaterial, custom fabricatedL6900 Hand restoration (casts, shading and measurements included),partial hand, with glove, thumb or one finger remainingL6905 Hand restoration (casts, shading and measurements included),partial hand, with glove, multiple fingers remainingL6910 Hand restoration (casts, shading and measurements included),partial hand, with glove, no fingers remainingL6915 Hand restoration (shading, and measurements included),replacement glove for above0404040404040404040404DME MAC Jurisdiction C Supplier Manual Page 177

HCPCSAppendix AL6920 Wrist disarticulation, external power, self-suspended inner socket,removable forearm shell, otto bock or equal, switch, cables, twobatteries and one charger,switch control of terminal deviceL6925 Wrist disarticulation, external power, self-suspended inner socket,removable forearm shell, otto bock or equal electrodes, cables, twobatteries and one charger, myoelectronic control of terminal deviceL6930 Below elbow, external power, self-suspended inner socket,removable forearm shell, otto bock or equal switch, cables, twobatteries and one charger, switch control of terminal deviceL6935 Below elbow, external power, self-suspended inner socket,removable forearm shell, otto bock or equal electrodes, cables, twobatteries and one charger, myoelectronic control of terminal deviceL6940 Elbow disarticulation, external power, molded inner socket,removable humeral shell, outside locking hinges, forearm, otto bockor equal switch, cables, two batteries and one charger, switch controlof terminal deviceL6945 Elbow disarticulation, external power, molded inner socket,removable humeral shell, outside locking hinges, forearm, otto bockor equal electrodes, cables, two batteries and one charger,myoelectronic control of terminal deviceL6950 Above elbow, external power, molded inner socket, removablehumeral shell, internal locking elbow, forearm, otto bock or equalswitch, cables, two batteries and one charger, switch control ofterminal deviceL6955 Above elbow, external power, molded inner socket, removablehumeral shell, internal locking elbow, forearm, otto bock or equalelectrodes, cables, two batteries and one charger, myoelectroniccontrol of terminal deviceL6960 Shoulder disarticulation, external power, molded inner socket,removable shoulder shell, shoulder bulkhead, humeral section,mechanical elbow, forearm, otto bock or equal switch, cables, twobatteries and one charger, switch control of terminal deviceL6965 Shoulder disarticulation, external 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 control of terminalL6970 Interscapular-thoracic, external power, molded inner socket,removable shoulder shell, shoulder bulkhead, humeral section,mechanical elbow, forearm, otto bock or equal switch, cables, twobatteries and one charger, switch control of terminal deviceL6975 Interscapular-thoracic, external 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 control of terminaldevice040404040404040404040404DME MAC Jurisdiction C Supplier Manual Page 178

HCPCSAppendix AL7007 Electric hand, switchor myoelectric controlled, adult (Eff date01/01/2007)L7008 Electric hand, switchor myoelectric controlled, pediatric (Eff date01/01/2007)L7009 Electric hand, switchor myoelectric controlled, adult (Eff date01/01/2007)L7010 Electronic hand, otto bock, steeper or equal, switch controlled(deleted 12/31/06)L7015 Electronic hand, system teknik, variety village or equal, switchcontrolled (deleted 12/31/06)L7020 Electronic greifer, otto bock or equal, switch controlled (deleted12/31/06)L7025 Electronic hand, otto bock or equal, myoelectronically controlled(deleted 12/31/06)L7030 Electronic hand, system teknik, variety village or equal,myoelectronically controlled (deleted 12/31/06)L7035 Electronic greifer, otto bock or equal, myoelectronically controlled(deleted 12/31/06)040404040404040404L7040 Prehensile actuator, switch controlled 04L7045 Electronic hook, switch or myoelectric controlled, pediatric 04L7160 Electronic elbow, boston or equal, switch controlled (Deleted eff.12/31/1996)L7165 Electronic elbow, boston or equal, myoelectronically controlled(Deleted eff. 12/31/1996)0404L7170 Electronic elbow, hosmer or equal, switch controlled 04L7180 Electronic elbow, microprocessor sequential control of elbow andterminal deviceL7181 Electronic elbow, microprocessor simultaneous control of elbow andterminal device (Eff. Date 1/1/2005)L7185 Electronic elbow, adolescent, variety village or equal, switchcontrolled040404L7186 Electronic elbow, child, variety village or equal, switch controlled 04L7190 Electronic elbow, adolescent, variety village or equal,myoelectronically controlledL7191 Electronic elbow, child, variety village or equal, myoelectronicallycontrolled0404L7260 Electronic wrist rotator, otto bock or equal 04DME MAC Jurisdiction C Supplier Manual Page 179

HCPCSAppendix AL7261 Electronic wrist rotator, for Utah arm 04L7266 Servo control, steeper or equal 04L7272 Analogue control, unb or equal 04L7274 Proportional control, 6-12 volt, liberty, Utah or equal 04L7360 SIX VOLT BATTERY, EACH (Updated 1/1/2008) 04L7362 BATTERY CHARGER, SIX VOLT, EACH (Updated 1/1/2008) 04L7364 TWELVE VOLT BATTERY, EACH (Updated 1/1/2008) 04L7366 BATTERY CHARGER, TWELVE VOLT, EACH (Updated 1/1/2008) 04L7367 Lithium ion battery, replacement (Eff. Date 1/1/2003) 04L7368 Lithium ion battery charger (Eff. Date 1/1/2003) 04L7400 Addition to upper extremity prosthesis, below elbow/wristdisarticulationultralight material (titanium, carbon fiber, or equal) (Eff. Date1/1/2006)L7401 Addition to upper extremity prosthesis, above elbow disarticulation,ultralight material (titanium, carbon fiber, or equal) (Eff. Date1/1/2006)L7402 Addition to upper extremity prosthesis, shoulderdisarticulation/interscapularthoracic, ultralight material (titanium, carbon fiber or equal) (Eff. Date1/1/2006)L7403 Addition to upper extremity prosthesis, below elbow/wristdisarticulation,acrylic material (Eff. Date 1/1/2006)L7404 Addition to upper extremity prosthesis, above elbow disarticulation,acrylicmaterial (Eff. Date 1/1/2006)L7405 Addition to upper extremity prosthesis, shoulderdisarticulation/interscapularthoracic, acrylic material (Eff. Date 1/1/2006)040404040404L7499 Upper extremity prosthesis, not otherwise specified 14L7500 Repair of prosthetic device, hourly rate (excludes v5335 repair of oralor laryngeal prosthesis or artificial larynx)04L7510 Repair of prosthetic device, repair or replace minor parts 04L7520 Repair prosthetic device, labor component, per 15 minutes 04L7600 Prosthesis donning sleeve, any material, each (Eff. Date 1/1/2006) 04DME MAC Jurisdiction C Supplier Manual Page 180

HCPCSAppendix AL7611 TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARYOPENING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED,PEDIATRIC (Eff. Date 1/1/2008)L7612 TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARYCLOSING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED,PEDIATRIC (Eff. Date 1/1/2008)L7613 TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARYOPENING, ANY MATERIAL, ANY SIZE, PEDIATRIC (Eff. Date1/1/2008)L7614 TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARYCLOSING, ANY MATERIAL, ANY SIZE, PEDIATRIC (Eff. Date1/1/2008)L7621 TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY,MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANYSIZE, LINED OR UNLINED (Eff. Date 1/1/2008)L7622 TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY,MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANYSIZE, LINED OR UNLINED (Eff. Date 1/1/2008)040404040404L7900 Vacuum erection system 04L8000 Breast prosthesis, mastectomy bra 04L8001 Breast prosthesis, mastectomy bra, with integrated breast prosthesisform, unilateral (Eff. Date 1/1/2002)L8002 Breast prosthesis, mastectomy bra, with integrated breast prosthesisform, bilateral (Eff. Date 1/1/2002)0404L8010 Breast prosthesis, mastectomy sleeve 04L8015 External breast prosthesis garment, with mastectomy form, postmastectomy04L8020 Breast prosthesis, mastectomy form 04L8030 Breast prosthesis, silicone or equal 04L8035 Custom breast prosthesis, post mastectomy, molded to patient model 04L8039 Breast prosthesis, not otherwise specified 14L8040 Nasal prosthesis, provided by a non-physician (Eff. Date 1/1/2001) 04L8041 Midfacial prosthesis, provided by a non-physician (Eff. Date 1/1/2001) 04L8042 Orbital prosthesis, provided by a non-physician (Eff. Date 1/1/2001) 04L8043 Upper facial prosthesis, provided by a non-physician (Eff. Date1/1/2001)04L8044 Hemi-facial prosthesis, provided by a non-physician (Eff. Date 04DME MAC Jurisdiction C Supplier Manual Page 181

HCPCSAppendix A1/1/2001)L8045 Auricular prosthesis, provided by a non-physician (Eff. Date 1/1/2001) 04L8046 Partial facial prosthesis, provided by a non-physician (Eff. Date1/1/2001)L8047 Nasal septal prosthesis, provided by a non-physician (Eff. Date1/1/2001)L8048 Unspecified maxillofacial prothesis, by report, provided by a nonphysician(Eff. Date 1/1/2001)L8049 Repair or modification of maxillofacial prosthesis, labor component,15 minute increments, provided by a non-physician (Eff. Date1/1/2001)L8100 Gradient compression stocking, below knee, 18-30 mmhg, each(Deleted eff. 12/31/2005)L8110 Gradient compression stocking, below knee, 30-40 mmhg, each(Deleted eff. 12/31/2005)L8120 Gradient compression stocking, below knee, 40-50 mmhg, each(Deleted eff. 12/31/2005)L8130 Gradient compression stocking, thigh length, 18-30 mmhg, each(Deleted eff. 12/31/2005)L8140 Gradient compression stocking, thigh length, 30-40 mmhg, each(Deleted eff. 12/31/2005)L8150 Gradient compression stocking, thigh length, 40-50 mmhg, each(Deleted eff. 12/31/2005)L8160 Gradient compression stocking, full length/chap style, 18-30 mmhg,each (Deleted eff. 12/31/2005)L8170 Gradient compression stocking, full length/chap style, 30-40 mmhg,each (Deleted eff. 12/31/2005)L8180 Gradient compression stocking, full length/chap style, 40-50 mmhg,each (Deleted eff. 12/31/2005)L8190 Gradient compression stocking, waist length, 18-30 mmhg, each(Deleted eff. 12/31/2005)L8195 Gradient compression stocking, waist length, 30-40 mmhg, each(Deleted eff. 12/31/2005)L8200 Gradient compression stocking, waist length, 40-50 mmhg, each(Deleted eff. 12/31/2005)L8210 Gradient compression stocking, custom made (Deleted eff.12/31/2005)0404040404040404040404040404040404L8220 Gradient compression stocking, lymphedema (Deleted eff. 04DME MAC Jurisdiction C Supplier Manual Page 182

HCPCSAppendix A12/31/2005)L8230 Gradient compression stocking, garter belt (Deleted eff. 12/31/2005) 04L8239 Gradient compression stocking, not otherwise specified (Deleted eff.12/31/2005)14L8300 Truss, single with standard pad 04L8310 Truss, double with standard pads 04L8320 Truss, addition to standard pad, water pad 04L8330 Truss, addition to standard pad, scrotal pad 04L8400 Prosthetic sheath, below knee, each 04L8410 Prosthetic sheath, above knee, each 04L8415 Prosthetic sheath, upper limb, each 04L8417 Prosthetic sheath/sock, including a gel cushion layer, below knee orabove knee, each04L8420 Prosthetic sock, multiple ply, below knee, each 04L8430 Prosthetic sock, multiple ply, above knee, each 04L8435 Prosthetic sock, multiple ply, upper limb, each 04L8440 Prosthetic shrinker, below knee, each 04L8460 Prosthetic shrinker, above knee, each 04L8465 Prosthetic shrinker, upper limb, each 04L8470 Prosthetic sock, single ply, fitting, below knee, each 04L8480 Prosthetic sock, single ply, fitting, above knee, each 04L8485 Prosthetic sock, single ply, fitting, upper limb, each 04L8490 Addition to prosthetic sheath/sock, air seal suction retention system(Deleted eff. 12/31/2004)04L8499 Unlisted procedure for miscellaneous prosthetic services 14L8500 Artificial larynx, any type 04L8501 Tracheostomy speaking valve 04L8505 Artificial larynx replacement battery/accessory, any type (Eff. Date1/1/2002)L8507 Tracheo-esophageal voice prosthesis, patient inserted, any type,each (Eff. Date 1/1/2002)0404DME MAC Jurisdiction C Supplier Manual Page 183

HCPCSAppendix AL8509 Tracheo-esophageal voice prosthesis, inserted by a licensed healthcare provider, any type (Eff. Date 1/1/2002)04L8510 Voice amplifier (Eff. Date 1/1/2002) 04L8511 Insert for indwelling tracheoesophageal prosthesis, with or withoutvalve, replacement only, each (Eff. Date 1/1/2004)L8512 Gelatin capsules or equivalent, for use with tracheoesophageal voiceprosthesis, replacement only, per 10 (Eff. Date 1/1/2004)L8513 Cleaning device used with tracheoesophageal voice prosthesis,pipet, brush or equal, replacement only, each (Eff. Date 1/1/2004)L8514 Tracheoesophageal puncture dilator, replacement only, each (Eff.Date 1/1/2004)L8515 Gelatin capsule application device for use with tracheoesophagealvoice prosthesis, each (Eff. Date 1/1/2005)0404040404L8600 Implantable breast prosthesis, silicone or equal 04L8603 Collagen implant, urinary tract, per 2.5 cc syringe, includes shippingand necessary supplies04L8605 Tissue expander implant (Deleted eff. 12/31/1997) 04L8609 Artificial Cornea (Eff. Date 1/1/2006) 04L8610 Ocular implant 04L8611 Orbital implant (Deleted eff. 12/31/1997) 04L8612 Aqueous shunt 04L8613 Ossicula implant 04L8614 Cochlear device/system 04L8619 Cochlear implant external speech processor, replacement 04L8623 Distal ulna implant (Deleted eff. 12/31/1997) 04L8624 Distal radius implant (Deleted eff. 12/31/1997) 04L8625 Trapezium implant (Deleted eff. 12/31/1997) 04L8626 Wrist implant (Deleted eff. 12/31/1997) 04L8627 Lunate implant (Deleted eff. 12/31/1997) 04L8628 Carpus implant (Deleted eff. 12/31/1997) 04L8629 Scaphoid implant (Deleted eff. 12/31/1997) 04L8630 Metacarpophalangeal joint implant 04DME MAC Jurisdiction C Supplier Manual Page 184

HCPCSAppendix AL8640 Patella implant (Deleted eff. 12/31/1997) 04L8641 Metatarsal joint implant 04L8642 Hallux implant 04L8655 Flexor tendon in hand or finger, implant (Deleted eff. 12/31/1997) 04L8656 Extensor tendon in hand or finger, implant (Deleted eff. 12/31/1997) 04L8657 Tendon other than hand or finger, implant (Deleted eff. 12/31/1997) 04L8658 Interphalangeal joint spacer, silicone, or equal, each 04L8670 Vascular graft material, synthetic, implant 04L8680 Biliary stent, endoprosthesis (permanent), implant (Deleted eff.12/31/1997)04L8690 Testicle implant (Deleted eff. 12/31/1997) 04L8691 Auditory osseointegrated device, external sound processor,replacement (Eff date 01/01/2007)L8695 External recharging system for battery (external) for use withimplantable neurostimulator (Eff date 01/01/2007)L8699 Prosthetic implant, not otherwise specified 04L9900 Orthotic and prosthetic supply, accessory, and/or service componentof04L9999 Sales tax, orthotic/prosthetic/other (Deleted eff. 12/31/1996) 14DME MAC Jurisdiction C Supplier Manual Page 185

HCPCSAppendix AHCPCS QPayment Category1 Capped Rental 8 Parenteral/Enteral Supplies and Kits 15 Nebulizer Drugs2 Freq. & Substantial Serv. DME 9 Parenteral/Enteral Pumps 16 Therapeutic Shoes for Diabetics3 Customized DMEPOS 10 Immunosuppressive Drugs 17 Individual Consideration4 Prosthetics/Orthotics 11 Ostomy, Trach., & Urologicals 18 Epoetin (EPO)5 Inexp. & Routinely Purch. DME 12 Surgical Dressings 19 Dialysis Supplies & Equipment6 Oxygen and Oxygen Equipment 13 Supplies 20 Oral Antiemetic Drugs7 Parenteral/Enteral Nutrients 14 Not Otherwise ClassifiedCode Description Category CMN/DIFRequiredQ0136 Injection, Epoetin Alpha, (for non ESRD use), per 1000 units(Deleted eff. 12/31/2005)Q0137Injection, Darbepoetin Alfa, 1 MCG (non-ESRD use) (Deleted eff.12/31/2005)18Q0163 Diphenhydramine hydrochloride, 50 mg, oral, FDA approvedprescription anti-emetic, for use as a complete therapeutic substitutefor an IV anti-emetic at time of chemotherapy treatment not toexceed a 48 hour dosage regimenQ0164 Prochlorperazine maleate, 5 mg, oral, FDA approved prescriptionanti-emetic, for use as a complete therapeutic substitute for an IVanti-emetic at the time of chemotherapy treatment, not to exceed a48 hour dosage regimenQ0165 Prochlorperazine maleate, 10 mg, oral, FDA approved prescriptionanti-emetic, for use as a complete therapeutic substitute for an IVanti-emetic at the time of chemotherapy treatment, not to exceed a48 hour dosage regimenQ0166 Granisetron hydrochloride, 1 mg, oral, FDA approved prescriptionanti-emetic, for use as a complete therapeutic substitute for an IVanti-emetic at the time of chemotherapy treatment, not to exceed a24 hour dosage regimenQ0167 Dronabinol, 2.5 mg, oral, FDA approved prescription anti-emetic, foruse as a complete therapeutic substitute for an IV anti-emetic at thetime of chemotherapy treatment, not to exceed a 48 hour dosageregimen2020202020DME MAC Jurisdiction C Supplier Manual Page 186

HCPCSAppendix AQ0168 Dronabinol, 5 mg, oral, FDA approved prescription anti-emetic, foruse as a complete therapeutic substitute for an IV anti-emetic at thetime of chemotherapy treatment, not to exceed a 48 hour dosageregimenQ0169 Promethazine hydrochloride, 12.5 mg, oral, FDA approvedprescription anti-emetic, for use as a complete therapeutic substitutefor an IV anti-emetic at the time of chemotherapy treatment, not toexceed a 48 hour dosage regimenQ0170 Promethazine hydrochloride, 25 mg, oral, FDA approvedprescription anti-emetic, for use as a complete therapeutic substitutefor an IV anti-emetic at the time of chemotherapy treatment, not toexceed a 48 hour dosage regimenQ0171 Chlorpromazine hydrochloride, 10 mg, oral, FDA approvedprescription anti-emetic, for use as a complete therapeutic substitutefor an IV anti-emetic at the time of chemotherapy treatment, not toexceed a 48 hour dosage regimenQ0172 Chlorpromazine hydrochloride, 25 mg, oral, FDA approvedprescription anti-emetic, for use as a complete therapeutic substitutefor an IV anti-emetic at the time of chemotherapy treatment, not toexceed a 48 hour dosage regimenQ0173 Trimethobenzamide hydrochloride, 250 mg, oral, FDA approvedprescription anti-emetic, for use as a complete therapeutic substitutefor an IV anti-emetic at the time of chemotherapy treatment, not toexceed a 48 hour dosage regimenQ0174 Thiethylperazine maleate, 10 mg, oral, FDA approved prescriptionanti-emetic, for use as a complete therapeutic substitute for an IVanti-emetic at the time of chemotherapy treatment, not to exceed a48 hour dosage regimenQ0175 Perphenazine, 4 mg, oral, FDA approved prescription anti-emetic,for use as a complete therapeutic substitute for an IV anti-emetic atthe time of chemotherapy treatment, not to exceed a 48 hour dosageregimenQ0176 Perphenazine, 8mg, oral, FDA approved prescription anti-emetic, foruse as a complete therapeutic substitute for an IV anti-emetic at thetime of chemotherapy treatment, not to exceed a 48 hour dosageregimenQ0177 Hydroxyzine pamoate, 25 mg, oral, FDA approved prescription antiemetic,for use as a complete therapeutic substitute for an IV antiemeticat the time of chemotherapy treatment, not to exceed a 48hour dosage regimenQ0178 Hydroxyzine pamoate, 50 mg, oral, FDA approved prescription antiemetic,for use as a complete therapeutic substitute for an IV antiemeticat the time of chemotherapy treatment, not to exceed a 48hour dosage regimen2020202020202020202020DME MAC Jurisdiction C Supplier Manual Page 187

HCPCSAppendix AQ0179 Ondansetron hydrochloride 8 mg, oral, FDA approved prescriptionanti-emetic, for use as a complete therapeutic substitute for an IVanti-emetic at the time of chemotherapy treatment, not to exceed a48 hour dosage regimenQ0180 Dolasetron mesylate, 100 mg, oral, FDA approved prescription antiemetic,for use as a complete therapeutic substitute for an IV antiemeticat the time of chemotherapy treatment, not to exceed a 24hour dosage regimenQ0181 Unspecified oral dosage form, FDA approved prescription antiemetic,for use as a complete therapeutic substitute for a IV antiemeticat the time of chemotherapy treatment, not to exceed a 48hour dosage regimen202020Q0182 Dermal and epidermal, tissue of non-human origin, with or withoutother bioengineered or processed elements, without metabolicallyactive elements, per square centimeter (Eff. Date 1/1/2004) (Deletedeff. 12/31/2004)Q0183 Dermal tissue, of human origin, with and without otherbioengineered or processed elements, but without metabolicallyactive elements, per square centimeter (Deleted eff. 12/31/2004)Q0184 Dermal tissue, of human origin, with or without other bioengineeredor processed elements, with metabolically active elements, persquare centimeterQ0185 Dermal and epidermal, tissue of human origin, with or withoutbioengineered or processed elements, with metabolically activeelements, per square centimeter (Deleted eff. 12/31/2001)Q0510 Pharmacy Supply fee for initial immunosuppressive drug(s), firstmonthfollowing implant (Eff. Date 1/1/2006)Q0511 Pharmacy Supply fee for oral anti-cancer, oral anti-emetic orimmunosuppressive drug(s); for the first prescription in a 30 -dayperiod(Eff. Date 1/1/2006)Q0512 Pharmacy supply fee for oral anti-cancer, oral anti-emetic orimmunosuppressive drug(s): for a subsequent prescription in a 30-day period (Eff. Date 1/1/2006)Q0513 Pharmacy dispensing fee for inhalation drug(s); per 30 days (Eff.Date 1/1/2006)Q0514 Pharmacy dispensing fee for inhalation drug(s): per 90 days (Eff.Date 1/1/2006)Q4054 Injection, Darbepoetin Alfa, 1 MCG (for ESRD on dialysis) (Deletedeff. 12/31/2005)Q4055 Injection, Epoetin Alfa, 1000 Units (for ESRD on dialysis) (Deletedeff. 12/31/2005)1818DME MAC Jurisdiction C Supplier Manual Page 188

HCPCSAppendix AQ4075 Injection, acyclovid, 5mg (effective 10/01/03) (Deleted eff.12/31/2005)Q4076 Injection, dopamine hydrochloride, 40mg (effective 10/01/03)(Deleted eff. 12/31/2005)Q4077 Injection, treprostinil, 1 mg (effective 10/01/03) (Deleted eff.12/31/2005)Q4079 INJECTION, NATALIZUMAB, 1 MG (Deleted eff. 12/31/2007)Q4080 ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINALPRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGHDME, UNIT DOSE FORM, 20 MICROGRAMS (Updated 01/01/2008)Q4081 Injection, Epoetin alfa, 100 units (for ESRD on Dialysis) (Eff date01/01/2007)18Q4087 INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS,NON-LYOPHILIZED (E.G. LIQUID), 500 MG (Deleted eff.12/31/2007)Q4088 INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID),INTRAVENOUS, NON-LYOPHILIZED, (E.G. LIQUID), 500 MG(Deleted eff. 12/31/2007)Q4089 INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN),(RHOPHYLAC), INTRAMUSCULAR OR INTRAVENOUS, 100 IU(Deleted eff. 12/31/2007)Q4090 INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B),INTRAMUSCULAR, 0.5 ML (Deleted eff. 12/31/2007)Q4091 INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA),INTRAVENOUS, NON-LYOPHILIZED, (E.G. LIQUID), 500 MG(Deleted eff. 12/31/2007)Q4092 INJECTION, IMMUNE GLOBULIN, (GAMUNEX), INTRAVENOUS,NON-LYOPHILIZED (E.G. LIQUID), 500 MG (Deleted eff.12/31/2007)Q4093 ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATEDISOMERS, INHALATION SOLUTION, FDA-APPROVED FINALPRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGHDME, CONCENTRATED FORM, PER 1 MG (ALBUTEROL) ORPER 0.5 MG (LEVALBUTEROL) (Deleted eff. 12/31/2007)Q4094 ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATEDISOMERS, INHALATION SOLUTION, FDA-APPROVED FINALPRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGHDME, UNIT DOSE, PER 1 MG (ALBUTEROL) OR PER 0.5 MG(LEVALBUTEROL) (Deleted eff. 12/31/2007)Q4095 INJECTION, ZOLEDRONIC ACID (RECLAST), 1 MG (Deleted eff.12/31/2007)151514Q9920 Injection of EPO, per 1000 units, at patient HCT of 20 or less 18DME MAC Jurisdiction C Supplier Manual Page 189

HCPCSAppendix AQ9921 Injection of EPO, per 1000 units, at patient HCT of 21 18Q9922 Injection of EPO, per 1000 units, at patient HCT of 22 18Q9923 Injection of EPO, per 1000 units, at patient HCT of 23 18Q9924 Injection of EPO, per 1000 units, at patient HCT of 24 18Q9925 Injection of EPO, per 1000 units, at patient HCT of 25 18Q9926 Injection of EPO, per 1000 units, at patient HCT of 26 18Q9927 Injection of EPO, per 1000 units, at patient HCT of 27 18Q9928 Injection of EPO, per 1000 units, at patient HCT of 28 18Q9929 Injection of EPO, per 1000 units, at patient HCT of 29 18Q9930 Injection of EPO, per 1000 units, at patient HCT of 30 18Q9931 Injection of EPO, per 1000 units, at patient HCT of 31 18Q9932 Injection of EPO, per 1000 units, at patient HCT of 32 18Q9933 Injection of EPO, per 1000 units, at patient HCT of 33 18Q9934 Injection of EPO, per 1000 units, at patient HCT of 34 18Q9935 Injection of EPO, per 1000 units, at patient HCT of 35 18Q9936 Injection of EPO, per 1000 units, at patient HCT of 36 18Q9937 Injection of EPO, per 1000 units, at patient HCT of 37 18Q9938 Injection of EPO, per 1000 units, at patient HCT of 38 18Q9939 Injection of EPO, per 1000 units, at patient HCT of 39 18Q9940 Injection of EPO, per 1000 units, at patient HCT of 40 or above 18Q9941 Injection, Immune globulin, intravenous, lyophilized, 1 G (Eff. Date04/01/05) (Deleted eff. 12/31/2005)Q9942 Injection, Immune globulin, intravenous, lyophilized, 10 MG (Eff.Date 04/01/05) (Deleted eff. 12/31/2005)Q9943 Injection, Immune globulin, intravenous, non-lyophilized, 1 G (Eff.Date 04/01/05) (Deleted eff. 12/31/2005)Q9944 Injection, Immune globulin, intravenous, non-lyophilized, 10 MG (Eff.Date 04/01/05) (Deleted eff. 12/31/2005)DME MAC Jurisdiction C Supplier Manual Page 190

HCPCSAppendix AHCPCS VPayment Category1 Capped Rental 8 Parenteral/Enteral Supplies and Kits 15 Nebulizer Drugs2 Freq. & Substantial Serv. DME 9 Parenteral/Enteral Pumps 16 Therapeutic Shoes for Diabetics3 Customized DMEPOS 10 Immunosuppressive Drugs 17 Individual Consideration4 Prosthetics/Orthotics 11 Ostomy, Trach., & Urologicals 18 Epoetin (EPO)5 Inexp. & Routinely Purch. DME 12 Surgical Dressings 19 Dialysis Supplies & Equipment6 Oxygen and Oxygen Equipment 13 Supplies 20 Oral Antiemetic Drugs7 Parenteral/Enteral Nutrients 14 Not Otherwise ClassifiedCode Description Category CMN/DIFRequiredV2020 Frames, purchases 04V2025 Deluxe frame 04V2100 Sphere, single vision, plano to plus or minus 4.00, per lens 04V2101 Sphere, single vision, plus or minus 4.12 to plus or minus 7.00d,per lensV2102 Sphere, single vision, plus or minus 7.12 to plus or minus 20.00d,per lensV2103 Spherocylinder, single vision, plano to plus or minus 4.00d sphere,.12 to 2.00d cylinder, per lensV2104 Spherocylinder, single vision, plano to plus or minus 4.00d sphere,2.12 to 4.00d cylinder, per lensV2105 Spherocylinder, single vision, plano to plus or minus 4.00d sphere,4.25 to 6.00d cylinder, per lensV2106 Spherocylinder, single vision, plano to plus or minus 4.00d sphere,over 6.00d cylinder, per lensV2107 Spherocylinder, single vision, plus or minus 4.25 to plus or minus7.00 sphere, .12 to 2.00d cylinder, per lensV2108 Spherocylinder, single vision, plus or minus 4.25d to plus or minus7.00d sphere, 2.12 to 4.00d cylinder, per lensV2109 Spherocylinder, single vision, plus or minus 4.25 to plus or minus7.00d sphere, 4.25 to 6.00d cylinder, per lens040404040404040404V2110 Spherocylinder, single vision, plus or minus 4.25 to 7.00d sphere, 04DME MAC Jurisdiction C Supplier Manual Page 191

HCPCSAppendix Aover 6.00d cylinder, per lensV2111 Spherocylinder, single vision, plus or minus 7.25 to plus or minus12.00d sphere, .25 to 2.25d cylinder, per lensV2112 Spherocylinder, single vision, plus or minus 7.25 to plus or minus12.00d sphere, 2.25d to 4.00d cylinder, per lensV2113 Spherocylinder, single vision, plus or minus 7.25 to plus or minus12.00d sphere, 4.25 to 6.00d cylinder, per lensV2114 Spherocylinder, single vision, sphere over plus or minus 12.00d,per lens04040404V2115 Lenticular, (myodisc), per lens, single vision 04V2116 Lenticular lens, nonaspheric, per lens, single vision (Deleted eff.12/31/2003)V2117 Lenticular, aspheric, per lens, single vision (Deleted eff.12/31/2003)0404V2118 Aniseikonic lens, single vision 04V2121 Lenticular lens, per lens, single (Eff. Date 1/1/2004) 04V2199 Not otherwise classified, single vision lens 04V2200 Sphere, bifocal, plano to plus or minus 4.00d, per lens 04V2201 Sphere, bifocal, plus or minus 4.12 to plus or minus 7.00d, per lens 04V2202 Sphere, bifocal, plus or minus 7.12 to plus or minus 20.00d, perlensV2203 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to2.00d cylinder, per lensV2204 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 2.12to 4.00d cylinder, per lensV2205 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 4.25to 6.00d cylinder, per lensV2206 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, over6.00d cylinder, per lensV2207 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00dsphere, .12 to 2.00d cylinder, per lensV2208 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00dsphere, 2.12 to 4.00d cylinder, per lensV2209 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00dsphere, 4.25 to 6.00d cylinder, per lensV2210 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00dsphere, over 6.00d cylinder, per lens040404040404040404DME MAC Jurisdiction C Supplier Manual Page 192

HCPCSAppendix AV2211 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00dsphere, .25 to 2.25d cylinder, per lensV2212 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00dsphere, 2.25 to 4.00d cylinder, per lensV2213 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00dsphere, 4.25 to 6.00d cylinder, per lens040404V2214 Spherocylinder, bifocal, sphere over plus or minus 12.00d, per lens 04V2215 Lenticular (myodisc), per lens, bifocal 04V2216 Lenticular, nonaspheric, per lens, bifocal (Deleted eff. 12/31/2003) 04V2217 Lenticular, aspheric lens, bifocal (Deleted eff. 12/31/2003) 04V2218 Aniseikonic, per lens, bifocal 04V2219 Bifocal seg width over 28mm 04V2220 Bifocal add over 3.25d 04V2221 Lenticular lens, per lens, bifocal (Eff. Date 1/1/2004) 04V2299 Specialty bifocal (by report) 04V2300 Sphere, trifocal, plano to plus or minus 4.00d, per lens 04V2301 Sphere, trifocal, plus or minus 4.12 to plus or minus 7.00d, per lens 04V2302 Sphere, trifocal, plus or minus 7.12 to plus or minus 20.00, per lens 04V2303 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, .12-2.00d cylinder, per lensV2304 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 2.25-4.00d cylinder, per lensV2305 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 4.25to 6.00 cylinder, per lensV2306 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, over6.00d cylinder, per lensV2307 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00dsphere, .12 to 2.00d cylinder, per lensV2308 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00dsphere, 2.12 to 4.00d cylinder, per lensV2309 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00dsphere, 4.25 to 6.00d cylinder, per lensV2310 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00dsphere, over 6.00d cylinder, per lensV2311 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00dsphere, .25 to 2.25d cylinder, per lens040404040404040404DME MAC Jurisdiction C Supplier Manual Page 193

HCPCSAppendix AV2312 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00dsphere, 2.25 to 4.00d cylinder, per lensV2313 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00dsphere, 4.25 to 6.00d cylinder, per lensV2314 Spherocylinder, trifocal, sphere over plus or minus 12 .00d, perlens040404V2315 Lenticular, (myodisc), per lens, trifocal 04V2316 Lenticular nonaspheric, per lens, trifocal (Deleted eff. 12/31/2003) 04V2317 Lenticular, aspheric lens, trifocal (Deleted eff. 12/31/2003) 04V2318 Aniseikonic lens, trifocal 04V2319 Trifocal seg width over 28 mm 04V2320 Trifocal add over 3.25d 04V2321 Lenticular lens, per lens, trifocal (Eff. Date 1/1/2004) 04V2399 Specialty trifocal (by report) 04V2410 Variable asphericity lens, single vision, full field, glass or plastic,per lens04V2430 Variable asphericity lens, bifocal, full field, glass or plastic, per lens 04V2499 Variable sphericity lens, other type 04V2500 Contact lens, PMMA, spherical, per lens 04V2501 Contact lens, PMMA, toric or prism ballast, per lens 04V2502 Contact lens, PMMA, bifocal, per lens 04V2503 Contact lens, PMMA, color vision deficiency, per lens 04V2510 Contact lens, gas permeable, spherical, per lens 04V2511 Contact lens, gas permeable, toric, prism ballast, per lens 04V2512 Contact lens, gas permeable, bifocal, per lens 04V2513 Contact lens, gas permeable, extended wear, per lens 04V2520 Contact lens, hydrophilic, spherical, per lens 04V2521 Contact lens, hydrophilic, toric, or prism ballast, per lens 04V2522 Contact lens, hydrophillic, bifocal, per lens 04V2523 Contact lens, hydrophilic, extended wear, per lens 04V2530 Contact lens, scleral, gas impermeable, per lens (for contact lensmodification, see 92325)04DME MAC Jurisdiction C Supplier Manual Page 194

HCPCSAppendix AV2531 Contact lens, scleral, gas permeable, per lens (for contact lensmodification,see 92325)04V2599 Contact lens, other type 04V2600 Hand held low vision aids and other nonspectacle mounted aids 04V2610 Single lens spectacle mounted low vision aids 04V2615 Telescopic and other compound lens system, including distancevision telescopic, near vision telescopes and compoundmicroscopic lens system04V2623 Prosthetic eye, plastic, custom 04V2624 Polishing/resurfacing of ocular prosthesis 04V2625 Enlargement of ocular prosthesis 04V2626 Reduction of ocular prosthesis 04V2627 Scleral cover shell 04V2628 Fabrication and fitting of ocular conformer 04V2629 Prosthetic eye, other type 04V2630 Anterior chamber intraocular lens 04V2631 Iris supported intraocular lens 04V2632 Posterior chamber intraocular lens 04V2700 Balance lens, per lens 04V2702 Deluxe lens feature (Eff. Date 1/1/2005) 04V2710 Slab off prism, glass or plastic, per lens 04V2715 Prism, per lens 04V2718 Press-on lens, fresnell prism, per lens 04V2730 Special base curve, glass or plastic, per lens 04V2740 Tint, plastic, rose 1 or 2 per lens (Deleted eff. 12/31/2003) 04V2741 Tint, plastic, other than rose 1-2, per lens (Deleted eff. 12/31/2003) 04V2742 Tint, glass rose 1 or 2, per lens (Deleted eff. 12/31/2003) 04V2743 Tint, glass other than rose 1 or 2, per lens (Deleted eff.12/31/2003)04V2744 Tint, photochromatic, per lens 04V2745 Addition to lens; tint, any color, solid, gradient or equal, excludesphotochromatic, any lens material, per lens (Eff. Date 1/1/2004)04DME MAC Jurisdiction C Supplier Manual Page 195

HCPCSAppendix AV2750 Anti-reflective coating, per lens 04V2755 U-V lens, per lens 04V2756 Eye glass case (Eff. Date 1/1/2004) 04V2760 Scratch resistant coating, per lens 04V2761 Mirror coating, any type, solid, gradient or equal, any lens material,per lens (Eff. Date 1/1/2004)04V2762 Polarization, any lens material, per lens (Eff. Date 1/1/2004) 04V2770 Occluder lens, per lens 04V2780 Oversize lens, per lens 04V2781 Progressive lens, per lens 04V2782 Lens index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludespolycarbonate, per lens (Eff. Date 1/1/2004)V2783 Lens index greater than or equal to 1.66 plastic or greater than orequal to 1.80 glass, excludes polycarbonate, per lens (Eff. Date1/1/2004)V2784 Lens, polycarbonate or equal, any index, per lens (Eff. Date1/1/2004)040404V2785 Processing, preserving and transporting corneal tissue 04V2786 Specialty occupational multifocal lens, per lens (Eff. Date 1/1/2004) 04V2787 ASTIGMATISM CORRECTING FUNCTION OF INTRAOCULARLENS (Eff. Date 01/01/2008)V2797 Vision supply, accessory and/or services component of anotherHCPCS vision code (Eff. Date 1/1/2004)04V2799 Vision service, miscellaneous 04V5008 Hearing screening 04V5010 Assessment for hearing aid 04V5011 Fitting/orientation/checking of hearing aid 04V5014 Repair/modification of a hearing aid 04V5020 Conformity evaluation 04V5030 Hearing aid, monaural, body worn, air conduction 04V5040 Hearing aid, monaural, body worn, bone conduction 04V5050 Hearing aid, monaural, in the ear 04V5060 Hearing aid, monaural, behind the ear 04DME MAC Jurisdiction C Supplier Manual Page 196

HCPCSAppendix AV5070 Glasses, air conduction 04V5080 Glasses, bone conduction 04V5090 Dispensing fee, unspecified hearing aid 04V5100 Hearing aid, bilateral, body worn 04V5110 Dispensing fee, bilateral 04V5120 Binaural, body 04V5130 Binaural, in the ear 04V5140 Binaural, behind the ear 04V5150 Binaural, glasses 04V5160 Dispensing fee, binaural 04V5170 Hearing aid, cros, in the ear 04V5180 Hearing aid, cros, behind the ear 04V5190 Hearing aid, cros, glasses 04V5200 Dispensing fee, cros 04V5210 Hearing aid, bicros, in the ear 04V5220 Hearing aid, bicros, behind the ear 04V5230 Hearing aid, bicros, glasses 04V5240 Dispensing fee, bicros 04V5299 Hearing service, miscellaneous 04V5336 Repair/modification of augmentative communicative system ordevice (excludes adaptive hearing aid)14V5362 Speech screening 04V5363 Language screening 04V5364 Dysphagia screening 04DME MAC Jurisdiction C Supplier Manual Page 197