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Durable Medical Equipment Equipment and Prostheses ONLY - Listed Alphabetically HCPCS <strong>Description</strong> COS E2330 w E2329 w E2327 w E2328 w E2300 w E2364 w E2365 w E2389 w E2386 w E2326 w E2396 w E2395 w E2324 w E2394 w E2377 w E2388 w E2387 w E2322 w E2381 w E2325 w E2391 w E2392 w E2390 w E2323 w E2376 w E2373 w E2374 w E2383 w E2375 w E2384 w E2385 w Prior Purch. Appr. LTC PartB Price Updated as of: 8/21/2012 Rent MaxQty/Days POWER W/C ACCES, HEAD CONT/INTERFACE, SWITCH MECH, COMP 41 Y N Y 0.00 0.00 N / A POWER W/C ACCES, HEAD CONTROL INTERFACE, CONTACT SWITCH COMP 41 Y N Y 0.00 0.00 N / A POWER W/C ACCES, HEAD CONTROL INTERFACE, MECH, PROPORT, COM 41 Y N Y 0.00 0.00 N / A POWER W/C ACCES, HEAD OR EXTREM CONTROL INTERFACE, COMPLETE 41 Y N Y 0.00 0.00 N / A POWER W/C ACCES, POWER SEAT ELEVATION SYSTEM 41 Y N N 0.00 0.00 N / A POWER W/C ACCES, U-1 NON-SEALED LEAD ACID BATTERY, EACH 41 Y N Y 0.00 0.00 N / A POWER W/C ACCES, U-1 SEALED LEA ACID BATTERY, EACH IE GEL 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS FOAM CASTER TIRE, ANY SIZE, EACH 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS FOAM FILLED DRIVE WHEEL, ANY SIZE, EACH 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS, BREATH TUBE KIT FOR SIP AND PUFF INTERFACE 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS, CASTER FORK, ANY SIZE, EACH 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS, CASTER WHEEL EXCLUDES TIRE,ANY SIZE, EACH 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS, CHIN CP FOR CHIN CONTROL INTERFACE 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, EACH 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS, EXPANDABLE CONTROL, ALL HARDW, UPGRADE 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS, FOAM DRIVE WHEEL TIRE, ANY SIZE, EACH 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS, FOAM FILLED CASTER TIRE, ANY SIZE, EACH 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS, HAND CONTROL INTERFACE, MULTI/MECH/SWITCH 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS, PNEU DRIVE WHEEL TIRE, ANY SIZE REPLAC,EA 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS, SIP AND PUFF INTERFACE, COMPLETE 41 Y N N 0.00 0.00 N / A POWER W/C ACCESS, SOLID (R/P) CASTER TIRE EACH 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS, SOLID (R/P) CASTER TIRE W/INTERGRATED WH E 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS, SOLID (R/P) DRIVE TIRE, ANY SIZE, EACH 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS, SPECIALTY JOYSTICK HAND CONTROL, PRE-FAB 41 Y N N 0.00 0.00 N / A POWER W/C ACCESS,EXPANDABLE CONTROL,INCLUD HARDW,REPLACEMENT 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS,HAND OR CHIN CONTROL INTERFACE,MINI PROAORT 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS,HAND OR CHIN CONTROL STAND REMOTE,INC HARDW 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS,INSERT FOR PNEU DRIVE TIRE ANY TYPE SIZE 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS,NON EXPANDABLE CONTROLLER, ALL HARDW 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS,PNEU CASTER TIRE, ANY SIZE,REPLACEMENT,EACH 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESS,TUBE FOR PNEU CASTER TIRE ANY SIZE,EACH 41 Y N Y 0.00 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 28 of 44
Durable Medical Equipment Equipment and Prostheses ONLY - Listed Alphabetically HCPCS <strong>Description</strong> COS E2382 w K0733 w E2342 w E2343 w E2341 w E2340 w E2321 w E2369 w E2370 w E2368 w E2359 w K0898 w E0181 K0899 w L5560 L5570 L5530 L5590 L5585 L5540 L6586 L5595 L6590 L5580 L5520 L5535 L5510 L5600 L6582 E0464 E0197 Prior Purch. Appr. LTC PartB Price Updated as of: 8/21/2012 Rent MaxQty/Days POWER W/C ACCESS,TUBE FOR PNEU DRIVE TIRE,ANY SIZE REPLAC EA 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESSORY, 12 TO 24 AMP SEALED LEAD ACID BATT, EA 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESSORY,NONSTANDARD FRAME DEPTH,20 OR 21 INCHES 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESSORY,NONSTANDARD FRAME DEPTH,22-25 INCHES 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESSORY,NONSTANDARD FRAME WIDTH 24-27 INCHES 41 Y N Y 0.00 0.00 N / A POWER W/C ACCESSORY,NONSTANDARD SEAT FRAME WIDTH,20-23 IN. 41 Y N Y 0.00 0.00 N / A POWER W/C ACES, HAND CONTROL, INTERFACE, REMOTE JOYSTICK, CO 41 Y N Y 0.00 0.00 N / A POWER W/C CMOPLONENT,GEAR BOX, REPLACEMENT ONLY 41 Y N N 0.00 0.00 N / A POWER W/C COMPONENT,MOTOR AND GEAR BOX COMBINATION REPL ONLY 41 Y N N 0.00 0.00 N / A POWER W/C COMPONENT,MOTOR REPLACEMENT ONLY 41 Y N N 0.00 0.00 N / A POWER WHEELCHAIR ACCESSORY GRP34 SEALED LEAD ACID BTTY EA 41 Y N Y 0.00 0.00 N / A POWER WHEELCHAIR NOC 41 Y N Y 0.00 0.00 N / A POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD W/PUMP INC 41 N N Y 124.08 0.00 1. / 1095. POWR MOBLITY DEVICE NOT CODED BY DME PDAC, NOT MEET CRITERIA 41 Y N N 0.00 0.00 N / A PREP;AK-KNEE DISART.PLASTER SOCKET,MOLDED TO PT 41 Y Y Y 1,626.52 0.00 N / A PREP;AK-KNEE DISART.THERMOPLASTIC/EQUAL,DIRECT FORM 41 Y Y Y 1,578.59 0.00 N / A PREP;BK-"PTB" TYPE SOCKET,THERMOPLASTIC/EQUAL,MOLDED 41 Y Y Y 1,445.73 0.00 N / A PREPARATORY; AK-KNEE DISART, LAMINATED SOCKET, MOLDED TO PT. 41 Y Y Y 2,042.73 0.00 N / A PREPARATORY; AK-KNEE DISART, PREFABRICATED ADJUSTABLE 41 Y Y Y 2,294.46 0.00 N / A PREPARATORY; BK "PTB" TYPE SOCKET, LAMINATED SOCKET, MOLDED 41 N Y Y 1,427.46 0.00 1. / 365. PREPARATORY; ELBOW DISART/ABOVE ELBOW 41 Y Y Y 1,558.76 0.00 N / A PREPARATORY; HEMIPELVECTOMY -HIP DISART,THERMOPLASTIC,MOLDED 41 Y Y Y 3,192.25 0.00 N / A PREPARATORY; SHOULDER DISART/INTERSCAPULAR THORACIC, DIRECT 41 Y Y Y 2,163.61 0.00 N / A PREPARATORY;AK-KNEE DISART., THERMOPLASTIC/EQUAL, MOLDED 41 Y Y Y 1,959.24 0.00 N / A PREPARATORY;BK "PTB" TYPE SOCKET, THERMOLASTIC/EQUAL, DIRECT 41 Y Y Y 1,099.80 0.00 N / A PREPARATORY;BK "PTB" TYPE, SOCKET, PREFABRICATED, ADJUSTABLE 41 Y Y Y 1,347.73 0.00 N / A PREPARATORY;BK"PTB"TYPE SOCKET,PLASTER SOCKET, MOLDED TO PT 41 Y Y Y 1,226.94 0.00 N / A PREPARATORY;HEMIPELVECTOMY-HIP DISART,LAMINATED,MOLDED TO PT 41 Y Y Y 3,633.24 0.00 N / A PREPARATORY;WRIST DISART/BELOW ELBOW,FLEXIBLE ELBOW,DIRECT 41 Y Y Y 1,181.40 0.00 N / A PRESSUR SUPPORT VENT,W/VOLUM CONTROL W/NON-INVAS INTERFACE 41 R N Y 0.00 832.70 N / A PRESSURE PAD; AIR, FOR MATTRESS, STANDARD 41 N N Y 98.39 0.00 1. / 730. NOTE: For "w" definition, refer to Wheelchair Pricing Schedule. For "nr", the 2.7% reduction doesn't apply to this code. Page 29 of 44
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