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Durable Medical Equipment Equipment and Prostheses ONLY - Listed Alphabetically HCPCS <strong>Description</strong> COS K0043 w E0948 E0947 E0920 E0930 E8000 E8002 E8001 A6501 A6502 A6503 A6508 A6506 A6505 A6504 A6511 A6512 A6510 A6509 A4466 A6507 E2000 E2602 w E2601 w E2611 w E2612 w A6536 A6537 A6533 A6530 A6531 Prior Purch. Appr. LTC PartB Price Updated as of: 8/21/2012 Rent MaxQty/Days FOOTREST, LOWER EXTENSION TUBE, EACH 41 Y N Y 0.00 0.00 N / A FRACTURE FRAME; ATTACHMENTS FOR COMPLEX CERVICAL TRACTION 41 B N Y 434.97 43.48 N / A FRACTURE FRAME; ATTACHMENTS FOR COMPLEX PELVIC TRACTION 41 B N Y 449.70 44.96 N / A FRACTURE FRAME;ATTACHED TO BED,INCLUDES WEIGHTS 41 B N Y 352.67 35.26 N / A FRACTURE FRAME;FREE STANDING, INCLUDES WEIGHTS 41 B N Y 365.75 36.58 N / A GAIT TRAINER PEDS SIZE POSTERISUPPORT INC ALL ACCESS/COMPONT 41 Y N N 0.00 0.00 N / A GAIT TRAINER,PEDS SIZE,ANT SUPPORT, INC ALL ACCESS AND COMPO 41 Y N N 0.00 0.00 N / A GAIT TRAINER,PEDS SIZE,UPRIGHTSUPPORT,INCLUDS ALL ACCES/COMP 41 Y N N 0.00 0.00 N / A GARMENT BURN COMPRESSION BODY SUIT (HEAD TO FOOT) CUSTOM 41 Y Y Y 0.00 0.00 N / A GARMENT BURN COMPRESSION CHIN STRAP CUSTOM FABRICATED 41 Y Y Y 0.00 0.00 N / A GARMENT BURN COMPRESSION FACIAL HOOD, CUSTOM FABRICATED 41 Y Y Y 0.00 0.00 N / A GARMENT BURN COMPRESSION FOOT TO THIGH LENGTH CUSTOM FARBRI 41 Y Y Y 0.00 0.00 N / A GARMENT BURN COMPRESSION GLOVE TO AXILLA CUSTOM FABRICATED 41 Y Y Y 0.00 0.00 N / A GARMENT BURN COMPRESSION GLOVE TO ELBOW CUSTOM FABRICATED 41 Y Y Y 0.00 0.00 N / A GARMENT BURN COMPRESSION GLOVE TO WRIST CUSTOM FABRICATION 41 Y Y Y 0.00 0.00 N / A GARMENT BURN COMPRESSION LOWER TRUNK/LEGS (PANTY) CAST FABRI 41 Y Y Y 0.00 0.00 N / A GARMENT BURN COMPRESSION NOT OTHERWISE CLASSIFIED 41 Y Y Y 0.00 0.00 N / A GARMENT BURN COMPRESSION TRUNK/ARMS DOWN TO LEGS (LEOTARD)CF 41 Y Y Y 0.00 0.00 N / A GARMENT BURN COMPRESSION UPPER TRUNK TO WAIST/ARM OPEN/VEST 41 Y Y Y 0.00 0.00 N / A GARMENT,BELT,SLEEVE, OR OTHER COVERING ELAS OR SIMILAR STRET 41 Y N N 0.00 0.00 N / A GARMENT,BURN COMPRESSION FOOT TO KNEE LENGTH CUST FABRICATED 41 Y Y Y 0.00 0.00 N / A GASTRIC SUCTION PUMP,HOME-MOD,PORTABLE OR STATIONARY,ELECTRI 41 R N Y 0.00 27.65 N / A GEN USE W/C SEAT CUSHION WIDTH 22 INS OR >, ANY DEPTH 41 Y N N 0.00 0.00 N / A GEN USE W/C SEAT CUSHION WIDTH< THAN 22 INS,ANY DEPTH 41 Y N N 0.00 0.00 N / A GENERAL USE W/C BACK CUSHION WIDTH < THAN 22 INS ANY HT,HDW 41 Y N N 0.00 0.00 N / A GENERAL USE W/C BACK CUSHION WIDTH 22 INS OR >ANY HT HARDWA 41 Y N N 0.00 0.00 N / A GRADIENT COMP STOCK; FULL LENGTH/CHAP STYLE 18-30 MMHG, EACH 41 N N N 27.04 0.00 4. / 182. GRADIENT COMP STOCK; FULL LENGTH/CHAP, STYLE30-40 MMHG, EACH 41 N N N 23.88 0.00 4. / 182. GRADIENT COMP STOCKING THIGH LENGTH 18-30 MMHG EACH 41 N N N 24.38 0.00 4. / 182. GRADIENT COMP STOCKING, BELOW KNEE 18-30 MMHG, EACH 41 N N N 16.83 0.00 4. / 182. GRADIENT COMP STOCKING, BELOW KNEE 30-40 MMHG EACH 41 N N N 18.50 0.00 4. / 182. NOTE: For "w" definition, refer to Wheelchair Pricing Schedule. For "nr", the 2.7% reduction doesn't apply to this code. Page 10 of 44
Durable Medical Equipment Equipment and Prostheses ONLY - Listed Alphabetically HCPCS <strong>Description</strong> COS A6532 A6535 A6534 A6538 A6539 A6540 A6541 A6549 A6544 A6545 S8426 S8427 S8421 S8420 S8423 S8422 S8425 S8424 S8428 L3100 L3929 L3917 L6905 L6910 L6900 L6915 L8615 Prior Purch. Appr. LTC PartB Price Updated as of: 8/21/2012 Rent MaxQty/Days GRADIENT COMP STOCKING, BELOW KNEE, 40-50 MMHG EACH 41 N N N 24.64 0.00 4. / 182. GRADIENT COMP STOCKING, THIGH LENGTH 40-50 MMHG, EACH 41 N N N 39.43 0.00 4. / 182. GRADIENT COMP STOCKING, THIGH LENGTH, 30-40 MMHG EACH 41 N N N 27.26 0.00 4. / 182. GRADIENT COMP STOCKING; FULL LENGTH/CHAP, 40-50 MMHG, EACH 41 N N N 26.64 0.00 4. / 182. GRADIENT COMP STOCKING; WAIST LENGTH, 18-30 MMHG, EACH 41 N N N 29.06 0.00 4. / 182. GRADIENT COMP STOCKING; WAIST LENGTH, 30-40 MMHG, EACH 41 N N N 37.54 0.00 4. / 182. GRADIENT COMP STOCKING; WAIST LENGTH, 40-50 MMHG, EACH 41 N N N 51.05 0.00 4. / 182. GRADIENT COMPRESSION STOCKING/ SLEEVE, NOS 41 Y Y N 0.00 0.00 N / A GRADIENT COMPRESSION STOCKING: GARTER BELT 41 N N N 23.33 0.00 1. / 60. GRADIENT COMPRESSION WRAP, NON-ELAS BELOW KNEE 30-40 MMHG EA 41 N N N 81.81 0.00 4. / 365. GRADIENT PRESSURE AID (GLOVE) HEAVY WEIGHT, CUSTOM MADE 41 Y Y N 0.00 0.00 N / A GRADIENT PRESSURE AID (GLOVE) READY MADE 41 N N N 28.52 0.00 2. / 180. GRADIENT PRESSURE AID (SLEEVE AND GLOVE COMBINAT) READY MADE 41 N N N 66.80 0.00 2. / 180. GRADIENT PRESSURE AID (SLEEVE AND GLOVE COMBINATION) CUSTOM 41 Y Y N 0.00 0.00 N / A GRADIENT PRESSURE AID (SLEEVE) CUSTOM MADE, HEAVY WEIGHT 41 Y Y N 0.00 0.00 N / A GRADIENT PRESSURE AID (SLEEVE) CUSTOM MADE, MEDIUM WEIGHT 41 Y Y N 0.00 0.00 N / A GRADIENT PRESSURE AID (SLEEVE) MEDIUM WEIGHT, CUSTOM MADE 41 Y Y N 0.00 0.00 N / A GRADIENT PRESSURE AID (SLEEVE) READY MADE 41 N N N 44.63 0.00 2. / 180. GRADIENT PRESSURE AID GAUNTLET READY MADE 41 N N N 44.47 0.00 2. / 180. HALLUS-VALGUS NIGHT DYNAMIC SPLINT 41 N N N 14.75 0.00 2. / 365. HAND FING/ORT, INC ONE OR MORE JTS, BUCKL,BOS,SAG,INC F/A 41 N N Y 65.56 0.00 1. / 365. HAND ORTHOSIS METACARPAL FX, ORTHHOSIS PRE-FAB, INCLUDE F/A 41 N N Y 70.76 0.00 1. / 365. HAND RESTORATION PARTIAL HAND; W/GLOVE, MULTIPLE FINGER REMA 41 Y Y Y 1,337.27 0.00 N / A HAND RESTORATION PARTIAL HAND; W/GLOVE, NO FINGERS REMAIN 41 Y Y Y 1,314.62 0.00 N / A HAND RESTORATION PARTIAL HAND;W/GLOVE,THUMB/FINGER REMAINING 41 Y Y Y 1,351.17 0.00 N / A HAND RESTORATION; REPLACEMENT GLOVE FOR ABOVE HANDS 41 Y Y Y 564.85 0.00 N / A HEADSET/HEADPIECE FOR USE WITH COCHLEAR IMPL DEVICE,REPLAC 41 N N N 332.74 0.00 1. / 120. V5261 nr HEARING AID DIGITAL, BIN, BTE 41 N Y N 752.00 0.00 1. / 1095. V5258 nr HEARING AID DIGITAL, BIN, CIC 41 N Y N 752.00 0.00 1. / 1095. V5259 nr HEARING AID DIGITAL, BIN, ITC 41 N Y N 752.00 0.00 1. / 1095. V5260 nr HEARING AID DIGITAL, BIN, ITE 41 N Y N 752.00 0.00 1. / 1095. NOTE: For "w" definition, refer to Wheelchair Pricing Schedule. For "nr", the 2.7% reduction doesn't apply to this code. Page 11 of 44
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