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Durable Medical Equipment Equipment and Prostheses ONLY - Listed Alphabetically HCPCS <strong>Description</strong> COS L7900 E2226 w E2225 w E2205 w E2295 w E2231 w E0986 w E2222 w E2221 w E2215 w E0983 w E0984 w E2224 w E2220 w E2206 w E2202 w E2213 w E2212 w E2217 w E2216 w E2218 w E2219 w E2214 w E2211 w E2204 w E2203 w E2201 w E0971 w E2230 w E0988 E2227 w Prior Purch. Appr. LTC PartB Price Updated as of: 8/21/2012 Rent MaxQty/Days MALE VACUUM ERECTION SYSTEM 41 Y N Y 387.62 0.00 N / A MANUAL W/C ACCES CASTER FORK ANY SIZE REPLACMENT ONLY EACH 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCES CASTER WHEEL EXCLUDE TIRE ANY SIZE PRPLA EA 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCES,HANDRIM W/O PROJECTIONS,ANY TYPE REPLAC,EA 41 Y N N 0.00 0.00 N / A MANUAL W/C ACCES,PEDI SIZE W/C DYNA FRAME,ALLOW MUTI POST FE 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCES,SOLID SEAT SOBASE (REPLAC SLING ST) INC HAW 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESS PUSH-RIM ACTIVATED POWER ASIST, EACH 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESS SOLID (RUB/PLAS) CASTOR TIRE W/INTERG WH 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESS SOLID (RUBBER/PLASTIC) CASTOR TIRE (REMOV) 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESS TUBE FOR PNEU CASTER TIRE, ANY SIZE, EA 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESS, POWER ADD-ON TO CONVERT TO POWER W/C W/JO 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESS, POWER ADD-ON TO CONVERT TO POWER W/C W/TI 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESS, PRO-WHEEL EXCLUDES TIRE ANY SIZE, EACH 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESS, SOLID (RUBBER/PLASTIC) PRO-TIRE, ANY SIZE 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESS,WHEEL LOCK ASSEMBLY,COMPLETE,EACH 41 Y N N 0.00 0.00 N / A MANUAL W/C ACCESSORY , NON-STAND FRAME 24- 27 INCHES 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESSORY INSERT FOR PNEU PRO (REMO) TIRE ANY TY 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESSORY TUBE FOR PNEU PROPULSION TIRE ANY SIZE 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE EACH 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESSORY, FOAM FILLED PRO-TIRE, ANY SIZE, EACH 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESSORY, FOAM PRO-TIRE ANY SIZE EACH 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESSORY, FOAMCASTER TIRE, ANY SIZE, EACH 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESSORY, PNEUMATIC CASTER TIRE ANY SIZE, EACH 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE 41 Y N N 0.00 0.00 N / A MANUAL W/C ACCESSORY,NON-STAND FRAME DEPTH, 22-25 INCHES 41 Y N Y 0.00 0.00 N / A MANUAL W/C ACCESSORY,NON-STAND FRAME DEPTH,20-
Durable Medical Equipment Equipment and Prostheses ONLY - Listed Alphabetically HCPCS <strong>Description</strong> COS E2228 w E0186 E0271 E0185 E0184 E0272 E0196 E0373 E0371 E0372 E0277 E0187 L8616 Q0482 Q0481 L8041 A9900 A9999 Q0505 Q0502 Q0486 Q0485 Q0483 Q0484 E0618 E0619 E0610 E0615 A7029 L8040 L8047 Prior Purch. Appr. LTC PartB Price Updated as of: 8/21/2012 Rent MaxQty/Days MANUEL WHEELCHAIR ACESS,WHEEL BRAKING SYSTM/LOCK COMPLETE EA 41 Y N Y 0.00 0.00 N / A MATTRESS - AIR PRESSURE 41 N N Y 157.86 0.00 1. / 730. MATTRESS INNERSPRING, REPLACEMENT, PT OWNED HOSP. BED 41 N N Y 128.91 0.00 1. / 730. MATTRESS PAD; GEL OR GEL-LIKE PAD, STD SIZE 41 N N Y 110.45 0.00 1. / 730. MATTRESS-DRY PRESSURE 41 N N Y 144.36 0.00 1. / 730. MATTRESS-FOAM RUBBER 41 N N Y 93.65 0.00 1. / 730. MATTRESS-GEL PRESSURE 41 N N Y 284.26 0.00 1. / 730. MATTRESS-NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS 41 B N Y 5,620.07 562.01 N / A MATTRESS-NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY 41 B N Y 1,623.33 162.33 N / A MATTRESS-POWERED AIR OVERLAY FOR MATTRESS 41 B N Y 2,060.46 206.04 N / A MATTRESS-POWERED PRESSURE REDUCING AIR 41 B N Y 2,903.16 290.30 N / A MATTRESS-WATER PRESSURE 41 N N Y 68.24 0.00 1. / 730. MICROPHONE FOR USE WITH COCHLEAR IMPLANT DEVICE REPLACEMENT 41 N N N 77.50 0.00 1. / 120. MICROPROCESSOR CONTROL UNIT FOR USE W ELEC/PNEU VAD REPL 41 Y N Y 3,776.55 0.00 N / A MICROPROCESSOR CONTROL UNIT USE WITH ELEC. VAD DEVICE REPLA 41 Y N Y 12,057.29 0.00 N / A MIDFACIAL PROSTHESIS, BY NONPHYSICIAN 41 Y Y Y 2,479.28 0.00 N / A MISCELLANEOUS DME SUPPLY ACCESSORY COMPONENT OF HCPC CODE 41 R N N 0.00 398.92 N / A MISCELLANEOUS DME SUPPLY OR ACCESSORY, NEC 41 B N Y 276.53 27.65 N / A MISCELLANEOUS SUPPLY OR ACCESSORY FOR USE WITH VAD 41 Y N Y 0.00 0.00 N / A MOBILITY CART FOR PNEUMATIC VAD REPLACEMENT ONLY 41 Y N Y 539.52 0.00 N / A MONITOR CONTROL CABLE FOR USE W ELEC/PNEU VAD REPLACE ONLY 41 N N Y 242.77 0.00 1. / 365. MONITOR CONTROL CABLE FOR USE WITH ELEC VAD REPLAC ONLY 41 N N Y 291.72 0.00 1. / 365. MONITOR/DISPLAY MODULE FOR USE WITH ELEC VAD REPLACEMENT ONL 41 Y N Y 15,557.75 0.00 N / A MONITOR/DISPLAY MODULE FOR USE WITH ELEC/PNEU VAD REPLAC ONL 41 Y N Y 3,021.26 0.00 N / A MONITOR; APNEA WITHOUT RECORDING FEATURE 41 B N Y 2,934.88 244.57 N / A MONITOR;APNEA WITH RECORDING FEATURE 41 B N Y 2,934.88 244.57 N / A MONITOR-PACEMAKER;SELF-CONTAINED,W/AUDIBLE/VISIBLE CHECK SYS 41 B N Y 163.72 16.37 N / A MONITOR-PACEMAKER;SELF-CONTAINED,W/DIGITAL/VISIBLE CHECK SYS 41 B N Y 163.72 16.37 N / A NASAL PILLOWS FOR COMBINATION ORAL/NASAL CPAP MASK REPLA PR 41 N N Y 18.52 0.00 3. / 365. NASAL PROSTHESIS, BY NONPHYSICIAN 41 Y Y Y 2,057.12 0.00 N / A NASAL SEPTAL PROTHESIS BY NONPHYSICIAN 41 Y Y Y 1,142.15 0.00 N / A NOTE: For "w" definition, refer to Wheelchair Pricing Schedule. For "nr", the 2.7% reduction doesn't apply to this code. Page 23 of 44
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