Notification

PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services


Notification Issue Date: 02/14/2020



Policy Attachment

Attachment to Policy # MA00.010z


Attachment:A1

Policy #:MA00.010z

Description:DME Network Rules and Limited Circumstances

Title:PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.



DURABLE MEDICAL EQUIPMENT NETWORK RULES AND LIMITED CIRCUMSTANCES

NETWORK RULES PROCEDURE CODE LIST

Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
A4206
Syringe with needle, sterile, 1 cc or less, each
01-01-1985
A4207
Syringe with needle, sterile 2 cc, each
01-01-1985
A4208
Syringe with needle, sterile 3 cc, each
01-01-1985
A4209
Syringe with needle, sterile 5 cc or greater, each
01-01-1985
A4210
Needle-free injection device, each
01-01-1989
A4211
Supplies for self-administered injections
01-01-1993
A4212
Noncoring needle or stylet with or without catheter
01-01-1993
A4213
Syringe, sterile, 20 cc or greater, each
01-01-1985
A4215
Needle, sterile, any size, each
01-01-1985
A4216
Sterile water, saline and/or dextrose, diluent/flush, 10 ml
01-01-2004
A4217
Sterile water/saline, 500 ml
01-01-2004
A4218
Sterile saline or water, metered dose dispenser, 10 ml
01-01-2006
A4220
Refill kit for implantable infusion pump
01-01-1994
A4221
Supplies for maintenance of drug infusion catheter, per week (list drug separately)
01-01-1997
A4222
Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately)
01-01-1997
A4223
Infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately)
01-01-2005
A4224
Supplies for maintenance of insulin infusion catheter, per week
01-01-2017
A4225
Supplies for external insulin infusion pump, syringe type cartridge, sterile, each
01-01-2017
A4226
Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose sensing, per week
01-01-2020
A4230
Infusion set for external insulin pump, nonneedle cannula type
01-01-1996
A4231
Infusion set for external insulin pump, needle type
01-01-1996
A4232
Syringe with needle for external insulin pump, sterile, 3 cc
01-01-1996
A4233
Replacement battery, alkaline (other than j cell), for use with medically necessary home blood glucose monitor owned by patient, each
01-01-2006
A4234
Replacement battery, alkaline, j cell, for use with medically necessary home blood glucose monitor owned by patient, each
01-01-2006
A4235
Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each
01-01-2006
A4236
Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each
01-01-2006
A4244
Alcohol or peroxide, per pint
01-01-1985
A4245
Alcohol wipes, per box
01-01-1985
A4246
Betadine or phisohex solution, per pint
01-01-1985
A4247
Betadine or iodine swabs/wipes, per box
01-01-1985
A4248
Chlorhexidine containing antiseptic, 1 ml
01-01-2004
A4250
Urine test or reagent strips or tablets (100 tablets or strips)
01-01-1990
A4252
Blood ketone test or reagent strip, each
01-01-2008
A4253
Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips
01-01-1986
A4255
Platforms for home blood glucose monitor, 50 per box
01-01-1997
A4256
Normal, low, and high calibrator solution/chips
01-01-1985
A4257
Replacement lens shield cartridge for use with laser skin piercing device, each
01-01-2002
A4258
Spring-powered device for lancet, each
01-01-1996
A4259
Lancets, per box of 100
01-01-1985
A4262
Temporary, absorbable lacrimal duct implant, each
01-01-1994
A4263
Permanent, long-term, nondissolvable lacrimal duct implant, each
01-01-1994
A4265
Paraffin, per lb.
01-01-1986
A4270
Disposable endoscope sheath, each
01-01-1994
A4280
Adhesive skin support attachment for use with external breast prosthesis, each
01-01-2000
A4281
Tubing for breast pump, replacement
01-01-2003
A4282
Adapter for breast pump, replacement
01-01-2003
A4283
Cap for breast pump bottle, replacement
01-01-2003
A4284
Breast shield and splash protector for use with breast pump, replacement
01-01-2003
A4285
Polycarbonate bottle for use with breast pump, replacement
01-01-2003
A4286
Locking ring for breast pump, replacement
01-01-2003
A4290
Sacral nerve stimulation test lead, each
01-01-2001
A4300
Implantable access catheter, (e.g., venous, arterial, epidural subarachnoid, or peritoneal, etc.) external access
01-01-1986
A4301
Implantable access total catheter, port/reservoir (e.g., venous, arterial, epidural, subarachnoid, peritoneal, etc.)
01-01-1996
A4305
Disposable drug delivery system, flow rate of 50 ml or greater per hour
01-01-1993
A4306
Disposable drug delivery system, flow rate of less than 50 ml per hour
01-01-1993
A4310
Insertion tray without drainage bag and without catheter (accessories only)
01-01-1990
A4311
Insertion tray without drainage bag with indwelling catheter, foley type, two-way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.)
01-01-1990
A4312
Insertion tray without drainage bag with indwelling catheter, foley type, two-way, all silicone
01-01-1990
A4313
Insertion tray without drainage bag with indwelling catheter, foley type, three-way, for continuous irrigation
01-01-1990
A4314
Insertion tray with drainage bag with indwelling catheter, foley type, two-way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.)
01-01-1990
A4315
Insertion tray with drainage bag with indwelling catheter, foley type, two-way, all silicone
01-01-1990
A4316
Insertion tray with drainage bag with indwelling catheter, foley type, three-way, for continuous irrigation
01-01-1990
A4320
Irrigation tray with bulb or piston syringe, any purpose
01-01-1990
A4321
Therapeutic agent for urinary catheter irrigation
01-01-1997
A4322
Irrigation syringe, bulb or piston, each
01-01-1990
A4326
Male external catheter with integral collection chamber, any type, each
01-01-1990
A4327
Female external urinary collection device; metal cup, each
01-01-1990
A4328
Female external urinary collection device; pouch, each
01-01-1990
A4330
Perianal fecal collection pouch with adhesive, each
01-01-1990
A4331
Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, each
01-01-2001
A4332
Lubricant, individual sterile packet, each
01-01-2001
A4333
Urinary catheter anchoring device, adhesive skin attachment, each
01-01-2001
A4334
Urinary catheter anchoring device, leg strap, each
01-01-2001
A4335
Incontinence supply; miscellaneous
01-01-1990
A4338
Indwelling catheter; foley type, two-way latex with coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each
01-01-1990
A4340
Indwelling catheter; specialty type, (e.g., coude, mushroom, wing, etc.), each
01-01-1990
A4344
Indwelling catheter, foley type, two-way, all silicone, each
01-01-1983
A4346
Indwelling catheter; foley type, three-way for continuous irrigation, each
01-01-1983
A4349
Male external catheter, with or without adhesive, disposable, each
01-01-2005
A4351
Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each
01-01-1990
A4352
Intermittent urinary catheter; coude (curved) tip, with or without coating (teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each
01-01-1990
A4353
Intermittent urinary catheter, with insertion supplies
01-01-1997
A4354
Insertion tray with drainage bag but without catheter
01-01-1986
A4355
Irrigation tubing set for continuous bladder irrigation through a three-way indwelling foley catheter, each
01-01-1984
A4356
External urethral clamp or compression device (not to be used for catheter clamp), each
01-01-1985
A4357
Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each
01-01-1985
A4358
Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each
01-01-1985
A4361
Ostomy faceplate, each
01-01-1985
A4362
Skin barrier; solid, four by four or equivalent; each
01-01-1985
A4363
Ostomy clamp, any type, replacement only, each
01-01-2006
A4364
Adhesive, liquid, or equal, any type, per oz.
01-01-1985
A4365
Adhesive remover wipes, any type, per 50
01-01-1997
12-31-2009
A4366
Ostomy vent, any type, each
01-01-2004
A4367
Ostomy belt, each
01-01-1985
A4368
Ostomy filter, any type, each
01-01-1997
A4369
Ostomy skin barrier, liquid (spray, brush, etc.), per oz.
01-01-2000
A4371
Ostomy skin barrier, powder, per oz.
01-01-2000
A4372
Ostomy skin barrier, solid 4x4 or equivalent, standard wear, with built-in convexity, each
01-01-2000
A4373
Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, any size, each
01-01-2000
A4375
Ostomy pouch, drainable, with faceplate attached, plastic, each
01-01-2000
A4376
Ostomy pouch, drainable, with faceplate attached, rubber, each
01-01-2000
A4377
Ostomy pouch, drainable, for use on faceplate, plastic, each
01-01-2000
A4378
Ostomy pouch, drainable, for use on faceplate, rubber, each
01-01-2000
A4379
Ostomy pouch, urinary, with faceplate attached, plastic, each
01-01-2000
A4380
Ostomy pouch, urinary, with faceplate attached, rubber, each
01-01-2000
A4381
Ostomy pouch, urinary, for use on faceplate, plastic, each
01-01-2000
A4382
Ostomy pouch, urinary, for use on faceplate, heavy plastic, each
01-01-2000
A4383
Ostomy pouch, urinary, for use on faceplate, rubber, each
01-01-2000
A4384
Ostomy faceplate equivalent, silicone ring, each
01-01-2000
A4385
Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each
01-01-2000
A4387
Ostomy pouch closed, with standard wear barrier attached, with built-in convexity (1 piece), each
01-01-2000
A4388
Ostomy pouch, drainable, with extended wear barrier attached, (one piece), each
01-01-2000
A4389
Ostomy pouch, drainable, with barrier attached, with built-in convexity (one piece), each
01-01-2000
A4390
Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each
01-01-2000
A4391
Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each
01-01-2000
A4392
Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (1 piece), each
01-01-2000
A4393
Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (1 piece), each
01-01-2000
A4394
Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce
01-01-2000
A4395
Ostomy deodorant for use in ostomy pouch, solid, per tablet
01-01-2000
A4396
Ostomy belt with peristomal hernia support
01-01-2001
A4397
Irrigation supply; sleeve, each
01-01-1990
A4398
Ostomy irrigation supply; bag, each
01-01-1989
A4399
Ostomy irrigation supply; cone/catheter, with or without brush
01-01-1989
A4400
Ostomy irrigation set
01-01-1982
A4402
Lubricant, per oz.
01-01-1985
A4404
Ostomy ring, each
01-01-1985
A4405
Ostomy skin barrier, nonpectin-based, paste, per oz.
01-01-2003
A4406
Ostomy skin barrier, pectin-based, paste, per oz.
01-01-2003
A4407
Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 x 4 in. or smaller, each
01-01-2003
A4408
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, larger than 4x4 in., each
01-01-2003
A4409
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 x 4 in. or smaller, each
01-01-2003
A4410
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4 x 4 in., each
01-01-2003
A4411
Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, with built-in convexity, each
01-01-2006
A4412
Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), without filter, each
01-01-2006
A4413
Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), with filter, each
01-01-2003
A4414
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 in. or smaller, each
01-01-2003
A4415
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4 x 4 in., each
01-01-2003
A4416
Ostomy pouch, closed, with barrier attached, with filter (one piece), each
01-01-2004
A4417
Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (one piece), each
01-01-2004
A4418
Ostomy pouch, closed; without barrier attached, with filter (one piece), each
01-01-2004
A4419
Ostomy pouch, closed; for use on barrier with nonlocking flange, with filter (two piece), each
01-01-2004
A4420
Ostomy pouch, closed; for use on barrier with locking flange (two piece), each
01-01-2004
A4421
Ostomy supply; miscellaneous
01-01-1985
A4422
Ostomy absorbent material (sheet/pad/crystal packet) for use in ostomy pouch to thicken liquid stomal output, each
01-01-2003
A4423
Ostomy pouch, closed; for use on barrier with locking flange, with filter (two piece), each
01-01-2004
A4424
Ostomy pouch, drainable, with barrier attached, with filter (one piece), each
01-01-2004
A4425
Ostomy pouch, drainable; for use on barrier with nonlocking flange, with filter (two piece system), each
01-01-2004
A4426
Ostomy pouch, drainable; for use on barrier with locking flange (two piece system), each
01-01-2004
A4427
Ostomy pouch, drainable; for use on barrier with locking flange, with filter (two piece system), each
01-01-2004
A4428
Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve (one piece), each
01-01-2004
A4429
Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (one piece), each
01-01-2004
A4430
Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type tap with valve (one piece), each
01-01-2004
A4431
Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (one piece), each
01-01-2004
A4432
Ostomy pouch, urinary; for use on barrier with nonlocking flange, with faucet-type tap with valve (two piece), each
01-01-2004
A4433
Ostomy pouch, urinary; for use on barrier with locking flange (two piece), each
01-01-2004
A4434
Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap with valve (two piece), each
01-01-2004
A4435
Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), with or without filter, each
01-01-2013
A4437
Incontinence supply, rectal insert, any type, each
01-01-2016
A4450
Tape, nonwaterproof, per 18 sq. in.
01-01-2003
A4452
Tape, waterproof, per 18 sq. in.
01-01-2003
A4455
Adhesive remover or solvent (for tape, cement or other adhesive), per oz.
01-01-1989
A4458
Enema bag with tubing, reusable
01-01-2003
A4459
Manual pump-operated enema system, includes balloon, catheter and all accessories, reusable, any type
01-01-2015
A4461
Surgical dressing holder, non-reusable, each
01-01-2007
A4463
Surgical dressing holder, reusable, each
01-01-2007
A4465
Nonelastic binder for extremity
01-01-1994
A4467
Belt, strap, sleeve, garment, or covering, any type
01-01-2017
A4470
Gravlee jet washer
01-01-1986
A4480
Vabra aspirator
01-01-1986
A4481
Tracheostoma filter, any type, any size, each
01-01-1997
A4483
Moisture exchanger, disposable, for use with invasive mechanical ventilation
01-01-1999
A4490
Surgical stocking above knee length, each
01-01-1986
A4495
Surgical stocking thigh length, each
01-01-1986
A4500
Surgical stocking below knee length, each
01-01-1986
A4510
Surgical stocking full-length, each
01-01-1986
A4520
Incontinence garment, any type, (e.g., brief, diaper), each
01-01-2005
A4550
Surgical trays
01-01-1982
A4553
Non-disposable underpads, all sizes
01-01-2017
A4555
Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only
01-01-2014
A4556
Electrodes (e.g., apnea monitor), per pair
01-01-1984
A4557
Lead wires (e.g., apnea monitor), per pair
01-01-1984
A4558
Conductive gel or paste, for use with electrical device (e.g., tens, nmes), per oz
01-01-1985
A4561
Pessary, rubber, any type
01-01-2001
A4562
Pessary, nonrubber, any type
01-01-2001
A4565
Slings
01-01-1983
A4570
Splint
01-01-1982
A4575
Topical hyperbaric oxygen chamber, disposable
01-01-1996
A4580
Cast supplies (e.g., plaster)
01-01-1982
A4590
Special casting material (e.g., fiberglass)
01-01-1984
A4595
Electrical stimulator supplies, 2 lead, per month, (e.g. tens, nmes)
01-01-1996
A4600
Sleeve for intermittent limb compression device, replacement only, each
01-01-2007
A4601
Lithium ion battery, rechargeable, for non-prosthetic use, replacement
01-01-2007
A4602
Replacement battery for external infusion pump owned by patient, lithium, 1.5 volt, each
01-01-2015
A4604
Tubing with integrated heating element for use with positive airway pressure device
01-01-2006
A4605
Tracheal suction catheter, closed system, each
01-01-2005
A4606
Oxygen probe for use with oximeter device, replacement
01-01-2003
A4608
Transtracheal oxygen catheter, each
01-01-2001
A4611
Battery, heavy duty; replacement for patient-owned ventilator
01-01-1990
A4612
Battery cables; replacement for patient-owned ventilator
01-01-1990
A4613
Battery charger; replacement for patient-owned ventilator
01-01-1990
A4614
Peak expiratory flow rate meter, hand held
01-01-1999
A4615
Cannula, nasal
01-01-1990
A4616
Tubing (oxygen), per foot
01-01-1990
A4617
Mouthpiece
01-01-1990
A4618
Breathing circuits
01-01-1990
A4619
Face tent
01-01-1990
A4620
Variable concentration mask
01-01-1990
A4623
Tracheostomy, inner cannula
01-01-1990
A4624
Tracheal suction catheter, any type other than closed system, each
01-01-1990
A4625
Tracheostomy care kit for new tracheostomy
01-01-1990
A4626
Tracheostomy cleaning brush, each
01-01-1990
A4627
Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler
01-01-1991
A4628
Oropharyngeal suction catheter, each
01-01-1996
A4629
Tracheostomy care kit for established tracheostomy
01-01-1996
A4630
Replacement batteries, medically necessary, transcutaneous electrical stimulator (tens), owned by patient
01-01-1991
A4633
Replacement bulb/lamp for ultraviolet light therapy system, each
01-01-2003
A4634
Replacement bulb for therapeutic light box, tabletop model
01-01-2003
A4635
Underarm pad, crutch, replacement, each
01-01-1991
A4636
Replacement, handgrip, cane, crutch, or walker, each
01-01-1991
A4637
Replacement, tip, cane, crutch, walker, each
01-01-1991
A4638
Replacement battery for patient-owned ear pulse generator, each
01-01-2004
A4639
Replacement pad for infrared heating pad system, each
01-01-2003

Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
A4640
Replacement pad for use with medically necessary alternating pressure pad owned by patient
01-01-1991
A4649
Surgical supply; miscellaneous
01-01-1982
A4651
Calibrated microcapillary tube, each
01-01-2002
A4652
Microcapillary tube sealant
01-01-2002
A4653
Peritoneal dialysis catheter anchoring device, belt, each
01-01-2003
A4657
Syringe, with or without needle, each
01-01-2002
A4660
Sphygmomanometer/blood pressure apparatus with cuff and stethoscope
01-01-1986
A4663
Blood pressure cuff only
01-01-1986
A4670
Automatic blood pressure monitor
01-01-1986
A4671
Disposable cycler set used with cycler dialysis machine, each
01-01-2004
A4672
Drainage extension line, sterile, for dialysis, each
01-01-2004
A4673
Extension line with easy lock connectors, used with dialysis
01-01-2004
A4674
Chemicals/antiseptics solution used to clean/sterilize dialysis equipment, per 8 oz.
01-01-2004
A4680
Activated carbon filter for hemodialysis, each
01-01-1986
A4690
Dialyzer (artificial kidneys), all types, all sizes, for hemodialysis, each
01-01-1986
A4706
Bicarbonate concentrate, solution, for hemodialysis, per gallon
01-01-2002
A4707
Bicarbonate concentrate, powder, for hemodialysis, per packet
01-01-2002
A4708
Acetate concentrate solution, for hemodialysis, per gallon
01-01-2002
A4709
Acid concentrate, solution, for hemodialysis, per gallon
01-01-2002
A4714
Treated water (deionized, distilled, or reverse osmosis) for peritoneal dialysis, per gallon
01-01-1986
A4719
Y set tubing for peritoneal dialysis
01-01-2002
A4720
Dialysate solution, any concentration of dextrose, fluid volume greater than 249 cc, but less than or equal to 999 cc, for peritoneal dialysis
01-01-2002
A4721
Dialysate solution, any concentration of dextrose, fluid volume greater than 999 cc, but less than or equal to 1999 cc, for peritoneal dialysis
01-01-2002
A4722
Dialysate solution, any concentration of dextrose, fluid volume greater than 1999 cc, but less than or equal to 2999 cc, for peritoneal dialysis
01-01-2002
A4723
Dialysate solution, any concentration of dextrose, fluid volume greater than 2999 cc, but less than or equal to 3999 cc, for peritoneal dialysis
01-01-2002
A4724
Dialysate solution, any concentration of dextrose, fluid volume greater than 3999 cc, but less than or equal to 4999 cc, for peritoneal dialysis
01-01-2002
A4725
Dialysate solution, any concentration of dextrose, fluid volume greater than 4999 cc, but less than or equal to 5999 cc, for peritoneal dialysis
01-01-2002
A4726
Dialysate solution, any concentration of dextrose, fluid volume greater than 5999 cc
01-01-2002
A4728
Dialysate solution, nondextrose containing, 500 ml
01-01-2004
A4730
Fistula cannulation set for hemodialysis, each
01-01-1986
A4736
Topical anesthetic, for dialysis, per gm
01-01-2002
A4737
Injectable anesthetic, for dialysis, per 10 ml
01-01-2002
A4740
Shunt accessory, for hemodialysis, any type
01-01-1986
A4750
Blood tubing, arterial or venous, for hemodialysis, each
01-01-1986
A4755
Blood tubing, arterial and venous combined, for hemodialysis, each
01-01-1986
A4760
Dialysate solution test kit, for peritoneal dialysis, any type, each
01-01-1986
A4765
Dialysate concentrate, powder, additive for peritoneal dialysis, per packet
01-01-1986
A4766
Dialysate concentrate, solution, additive for peritoneal dialysis, per 10 ml
01-01-2002
A4770
Blood collection tube, vacuum, for dialysis, per 50
01-01-1986
A4771
Serum clotting time tube, for dialysis, per 50
01-01-1986
A4772
Blood glucose test strips, for dialysis, per 50
01-01-1986
A4773
Occult blood test strips, for dialysis, per 50
01-01-1986
A4774
Ammonia test strips, for dialysis, per 50
01-01-1986
A4802
Protamine sulfate, for hemodialysis, per 50 mg
01-01-2002
A4860
Disposable catheter tips for peritoneal dialysis, per 10
01-01-1986
A4870
Plumbing and/or electrical work for home hemodialysis equipment
01-01-1986
A4890
Contracts, repair and maintenance, for hemodialysis equipment
01-01-1986
A4911
Drain bag/bottle, for dialysis, each
01-01-2002
A4913
Miscellaneous dialysis supplies, not otherwise specified
01-01-1986
A4918
Venous pressure clamp, for hemodialysis, each
01-01-1986
A4927
Gloves, nonsterile, per 100
01-01-1986
A4928
Surgical mask, per 20
01-01-2002
A4929
Tourniquet for dialysis, each
01-01-2002
A4930
Gloves, sterile, per pair
01-01-2003
A4931
Oral thermometer, reusable, any type, each
01-01-2003
A4932
Rectal thermometer, reusable, any type, each
01-01-2003
A5051
Ostomy pouch, closed; with barrier attached (one piece), each
01-01-1990
A5052
Ostomy pouch, closed; without barrier attached (one piece), each
01-01-1990
A5053
Ostomy pouch, closed; for use on faceplate, each
01-01-1990
A5054
Ostomy pouch, closed; for use on barrier with flange (two piece), each
01-01-1990
A5055
Stoma cap
01-01-1990
A5056
Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each
01-01-2012
A5057
Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each
01-01-2012
A5061
Ostomy pouch, drainable; with barrier attached, (one piece), each
01-01-1990
A5062
Ostomy pouch, drainable; without barrier attached (one piece), each
01-01-1990
A5063
Ostomy pouch, drainable; for use on barrier with flange (two piece system), each
01-01-1990
A5071
Ostomy pouch, urinary; with barrier attached (one piece), each
01-01-1990
A5072
Ostomy pouch, urinary; without barrier attached (one piece), each
01-01-1990
A5073
Ostomy pouch, urinary; for use on barrier with flange (two piece), each
01-01-1990
A5081
Stoma plug or seal, any type
01-01-1990
A5082
Continent device; catheter for continent stoma
01-01-1990
A5083
Continent device, stoma absorptive cover for continent stoma
01-01-2008
A5093
Ostomy accessory; convex insert
01-01-1990
A5102
Bedside drainage bottle, with or without tubing, rigid or expandable, each
01-01-1990
A5105
Urinary suspensory with leg bag, with or without tube, each
01-01-1990
A5112
Urinary drainage bag, leg or abdomen, latex, with or without tube, with straps, each
01-01-1990
A5113
Leg strap; latex, replacement only, per set
01-01-1990
A5114
Leg strap; foam or fabric, replacement only, per set
01-01-1990
A5120
Skin barrier, wipes or swabs, each
01-01-2006
A5121
Skin barrier; solid, 6 x 6 or equivalent, each
01-01-1990
A5122
Skin barrier; solid, 8 x 8 or equivalent, each
01-01-1990
A5126
Adhesive or nonadhesive; disk or foam pad
01-01-1990
A5131
Appliance cleaner, incontinence and ostomy appliances, per 16 oz.
01-01-1990
A5200
Percutaneous catheter/tube anchoring device, adhesive skin attachment
01-01-1999
A5500
For diabetics only, fitting (including follow-up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe
01-01-1995
A5501
For diabetics only, fitting (including follow-up) custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe
01-01-1995
A5503
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe
01-01-1995
A5504
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe
01-01-1995
A5505
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe
01-01-1995
A5506
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe
01-01-1995
A5507
For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe
01-01-1995
A5508
For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe
01-01-2000
A5510
For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe
01-01-2002
A6000
Noncontact wound-warming wound cover for use with the noncontact wound-warming device and warming card
01-01-2002
A6010
Collagen based wound filler, dry form, sterile, per gram of collagen
01-01-2002
A6011
Collagen based wound filler, gel/paste, per gram of collagen
01-01-2003
A6021
Collagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 sq. in., each
01-01-2001
A6022
Collagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 sq. in., each
01-01-2001
A6023
Collagen dressing, sterile, size more than 48 sq. in., each
01-01-2001
A6024
Collagen dressing wound filler, sterile, per 6 inches
01-01-2001
A6025
Gel sheet for dermal or epidermal application, (e.g., silicone, hydrogel, other), each
01-01-1997
A6154
Wound pouch, each
01-01-1997
A6196
Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. In. Or less, each dressing
01-01-1997
A6197
Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., each dressing
01-01-1997
A6198
Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 48 sq. In., each dressing
01-01-1997
A6199
Alginate or other fiber gelling dressing, wound filler, sterile, per 6 inches
01-01-1997
A6200
Composite dressing, pad size 16 sq. In. Or less, without adhesive border, each dressing
01-01-1999
12-31-2009
A6201
Composite dressing, pad size more than 16 sq. In. But less than or equal to 48 sq. In., without adhesive border, each dressing
01-01-1999
12-31-2009
A6202
Composite dressing, pad size more than 48 sq. In., without adhesive border, each dressing
01-01-1999
12-31-2009
A6203
Composite dressing, sterile, pad size 16 sq. In. Or less, with any size adhesive border, each dressing
01-01-1997
A6204
Composite dressing, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., with any size adhesive border, each dressing
01-01-1997
A6205
Composite dressing, sterile, pad size more than 48 sq. In., with any size adhesive border, each dressing
01-01-1997
A6206
Contact layer, sterile, 16 sq. In. Or less, each dressing
01-01-1997
A6207
Contact layer, sterile, more than 16 sq. In. But less than or equal to 48 sq. In., each dressing
01-01-1997
A6208
Contact layer, sterile, more than 48 sq. In., each dressing
01-01-1997
A6209
Foam dressing, wound cover, sterile, pad size 16 sq. In. Or less, without adhesive border, each dressing
01-01-1997
A6210
Foam dressing, wound cover, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., without adhesive border, each dressing
01-01-1997
A6211
Foam dressing, wound cover, sterile, pad size more than 48 sq. In., without adhesive border, each dressing
01-01-1997
A6212
Foam dressing, wound cover, sterile, pad size 16 sq. In. Or less, with any size adhesive border, each dressingfoam dressing, wound cover, sterile, pad size 16 sq. In. Or less, with any size adhesive border, each dressing
01-01-1997
A6213
Foam dressing, wound cover, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., with any size adhesive border, each dressing
01-01-1997
A6214
Foam dressing, wound cover, sterile, pad size more than 48 sq. In., with any size adhesive border, each dressing
01-01-1997
A6215
Foam dressing, wound filler, sterile, per gram
01-01-1997
A6216
Gauze, nonimpregnated, nonsterile, pad size 16 sq. In. Or less, without adhesive border, each dressing
01-01-1997
A6217
Gauze, nonimpregnated, nonsterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., without adhesive border, each dressing
01-01-1997
A6218
Gauze, nonimpregnated, nonsterile, pad size more than 48 sq. In., without adhesive border, each dressing
01-01-1997
A6219
Gauze, non-impregnated, sterile, pad size 16 sq. In. Or less, with any size adhesive border, each dressing
01-01-1997
A6220
Gauze, non-impregnated, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., with any size adhesive border, each dressing
01-01-1997
A6221
Gauze, non-impregnated, sterile, pad size more than 48 sq. In., with any size adhesive border, each dressing
01-01-1997
A6222
Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. In. Or less, without adhesive border, each dressing
01-01-1997
A6223
Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 16 sq. In., but less than or equal to 48 sq. In., without adhesive border, each dressing
01-01-1997
A6224
Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 48 sq. In., without adhesive border, each dressing
01-01-1997
A6228
Gauze, impregnated, water or normal saline, sterile, pad size 16 sq. In. Or less, without adhesive border, each dressing
01-01-1997
A6229
Gauze, impregnated, water or normal saline, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., without adhesive border, each dressing
01-01-1997
A6230
Gauze, impregnated, water or normal saline, sterile, pad size more than 48 sq. In., without adhesive border, each dressing
01-01-1997
A6231
Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size 16 sq. In. Or less, each dressing
01-01-2001
A6232
Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size greater than 16 sq. In., but less than or equal to 48 sq. In., each dressing
01-01-2001
A6233
Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size more than 48 sq. In., each dressing
01-01-2001
A6234
Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. In. Or less, without adhesive border, each dressing
01-01-1997
A6235
Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., without adhesive border, each dressing
01-01-1997
A6236
Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. In., without adhesive border, each dressing
01-01-1997
A6237
Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. In. Or less, with any size adhesive border, each dressing
01-01-1997
A6238
Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., with any size adhesive border, each dressing
01-01-1997
A6239
Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. In., with any size adhesive border, each dressing
01-01-1997
A6240
Hydrocolloid dressing, wound filler, paste, sterile, per ounce
01-01-1997
A6241
Hydrocolloid dressing, wound filler, dry form, sterile, per gram
01-01-1997
A6242
Hydrogel dressing, wound cover, sterile, pad size 16 sq. In. Or less, without adhesive border, each dressing
01-01-1997
A6243
Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., without adhesive border, each dressing
01-01-1997
A6244
Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. In., without adhesive border, each dressing
01-01-1997
A6245
Hydrogel dressing, wound cover, sterile, pad size 16 sq. In. Or less, with any size adhesive border, each dressing
01-01-1997
A6246
Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., with any size adhesive border, each dressing
01-01-1997
A6247
Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. In., with any size adhesive border, each dressing
01-01-1997
A6248
Hydrogel dressing, wound filler, gel, per fluid ounce
01-01-1997
A6250
Skin sealants, protectants, moisturizers, ointments, any type, any size
01-01-1997
A6251
Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. In. Or less, without adhesive border, each dressing
01-01-1997
A6252
Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., without adhesive border, each dressing
01-01-1997
A6253
Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. In., without adhesive border, each dressing
01-01-1997
A6254
Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. In. Or less, with any size adhesive border, each dressing
01-01-1997
A6255
Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., with any size adhesive border, each dressing
01-01-1997
A6256
Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. In., with any size adhesive border, each dressing
01-01-1997
A6257
Transparent film, sterile, 16 sq. In. Or less, each dressing
01-01-1997
A6258
Transparent film, sterile, more than 16 sq. In. But less than or equal to 48 sq. In., each dressing
01-01-1997
A6259
Transparent film, sterile, more than 48 sq. In., each dressing
01-01-1997
A6260
Wound cleansers, any type, any size
01-01-1997
A6261
Wound filler, gel/paste, per fluid ounce, not otherwise specified
01-01-1997
A6262
Wound filler, dry form, per gram, not otherwise specified
01-01-1997
A6266
Gauze, impregnated, other than water, normal saline, or zinc paste, sterile, any width, per linear yard
01-01-1997
A6402
Gauze, nonimpregnated, sterile, pad size 16 sq. In. Or less, without adhesive border, each dressing
01-01-1997
A6403
Gauze, nonimpregnated, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., without adhesive border, each dressing
01-01-1997
A6404
Gauze, nonimpregnated, sterile, pad size more than 48 sq. In., without adhesive border, each dressing
01-01-1997
A6407
Packing strips, non-impregnated, sterile, up to 2 inches in width, per linear yard
01-01-2004
A6410
Eye pad, sterile, each
01-01-2003
A6411
Eye pad, nonsterile, each
01-01-2003
A6412
Eye patch, occlusive, each
01-01-2003
A6413
Adhesive bandage, first-aid type, any size, each
01-01-2008
A6441
Padding bandage, nonelastic, nonwoven/nonknitted, width greater than or equal to 3 in. And less than 5 in., per yd.
01-01-2004
A6442
Conforming bandage, nonelastic, knitted/woven, nonsterile, width less than 3 in., per yd.
01-01-2004
A6443
Conforming bandage, nonelastic, knitted/woven, nonsterile, width greater than or equal to 3 in. And less than 5 in., per yd.
01-01-2004
A6444
Conforming bandage, nonelastic, knitted/woven, nonsterile, width greater than or equal to 5 in., per yd.
01-01-2004
A6445
Conforming bandage, nonelastic, knitted/woven, sterile, width less than 3 in., per yd.
01-01-2004
A6446
Conforming bandage, nonelastic, knitted/woven, sterile, width greater than or equal to 3 in. And less than 5 in., per yd.
01-01-2004
A6447
Conforming bandage, nonelastic, knitted/woven, sterile, width greater than or equal to 5 in., per yd.
01-01-2004
A6448
Light compression bandage, elastic, knitted/woven, width less than 3 in., per yd.
01-01-2004
A6449
Light compression bandage, elastic, knitted/woven, width greater than or equal to 3 in. And less than 5 in., per yd.
01-01-2004
A6450
Light compression bandage, elastic, knitted/woven, width greater than or equal to 5 in., per yd.
01-01-2004
A6451
Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width greater than or equal to 3 in. And less than 5 in., per yd.
01-01-2004
A6452
High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50% maximum stretch, width greater than or equal to 3 in. And less than 5 in., per yd.
01-01-2004
A6453
Self-adherent bandage, elastic, nonknitted/nonwoven, width less than 3 in., per yd.
01-01-2004
A6454
Self-adherent bandage, elastic, nonknitted/nonwoven, width greater than or equal to 3 in. And less than 5 in., per yd.
01-01-2004
A6455
Self-adherent bandage, elastic, nonknitted/nonwoven, width greater than or equal to 5 in., per yd.
01-01-2004
A6456
Zinc paste impregnated bandage, nonelastic, knitted/woven, width greater than or equal to 3 in. And less than 5 in., per yd.
01-01-2004
A6457
Tubular dressing with or without elastic, any width, per linear yard
01-01-2006
A6460
Synthetic resorbable wound dressing, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing
01-01-2019
A6461
Synthetic resorbable wound dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing
01-01-2019
A6501
Compression burn garment, bodysuit (head to foot), custom fabricated
01-01-2003
A6502
Compression burn garment, chin strap, custom fabricated
01-01-2003
A6503
Compression burn garment, facial hood, custom fabricated
01-01-2003
A6504
Compression burn garment, glove to wrist, custom fabricated
01-01-2003
A6505
Compression burn garment, glove to elbow, custom fabricated
01-01-2003
A6506
Compression burn garment, glove to axilla, custom fabricated
01-01-2003
A6507
Compression burn garment, foot to knee length, custom fabricated
01-01-2003
A6508
Compression burn garment, foot to thigh length, custom fabricated
01-01-2003
A6509
Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated
01-01-2003
A6510
Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated
01-01-2003
A6511
Compression burn garment, lower trunk including leg openings (panty), custom fabricated
01-01-2003
A6512
Compression burn garment, not otherwise classified
01-01-2003
A6513
Compression burn mask, face and/or neck, plastic or equal, custom fabricated
01-01-2006
A6531
Gradient compression stocking, below knee, 30-40 mmhg, each
01-01-2006
A6532
Gradient compression stocking, below knee, 40-50 mmhg, each
01-01-2006
A6545
Gradient compression wrap, non-elastic, below knee, 30-50 mm hg, each
01-01-2009
A6550
Wound care set, for negative pressure wound therapy electrical pump, includes all accessories
01-01-2004
A7000
Canister, disposable, used with suction pump, each
01-01-2000
A7001
Canister, nondisposable, used with suction pump, each
01-01-2000
A7002
Tubing, used with suction pump, each
01-01-2000
A7003
Administration set, with small volume nonfiltered pneumatic nebulizer, disposable
01-01-2000

Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
A7004
Small volume nonfiltered pneumatic nebulizer, disposable
01-01-2000
A7005
Administration set, with small volume nonfiltered pneumatic nebulizer, nondisposable
01-01-2000
A7006
Administration set, with small volume filtered pneumatic nebulizer
01-01-2000
A7007
Large volume nebulizer, disposable, unfilled, used with aerosol compressor
01-01-2000
A7008
Large volume nebulizer, disposable, prefilled, used with aerosol compressor
01-01-2000
A7009
Reservoir bottle, nondisposable, used with large volume ultrasonic nebulizer
01-01-2000
A7010
Corrugated tubing, disposable, used with large volume nebulizer, 100 ft.
01-01-2000
A7011
Corrugated tubing, nondisposable, used with large volume nebulizer, 10 ft.
01-01-2000
12/31/2015
A7012
Water collection device, used with large volume nebulizer
01-01-2000
A7013
Filter, disposable, used with aerosol compressor or ultrasonic generator
01-01-2000
A7014
Filter, nondisposable, used with aerosol compressor or ultrasonic generator
01-01-2000
A7015
Aerosol mask, used with dme nebulizer
01-01-2000
A7016
Dome and mouthpiece, used with small volume ultrasonic nebulizer
01-01-2000
A7017
Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with oxygen
01-01-2000
A7018
Water, distilled, used with large volume nebulizer, 1000 ml
01-01-2001
A7025
High frequency chest wall oscillation system vest, replacement for use with patient owned equipment, each
01-01-2003
A7026
High frequency chest wall oscillation system hose, replacement for use with patient owned equipment, each
01-01-2003
A7027
Combination oral/nasal mask, used with continuous positive airway pressure device, each
01-01-2008
A7028
Oral cushion for combination oral/nasal mask, replacement only, each
01-01-2008
A7029
Nasal pillows for combination oral/nasal mask, replacement only, pair
01-01-2008
A7030
Full face mask used with positive airway pressure device, each
01-01-2003
A7031
Face mask interface, replacement for full face mask, each
01-01-2003
A7032
Cushion nasal mask interface, replacement only, each
01-01-2003
A7033
Pillow for nasal cannula type interface, replacement only, pair
01-01-2003
A7034
Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap
01-01-2003
A7035
Headgear used with positive airway pressure device
01-01-2003
A7036
Chinstrap used with positive airway pressure device
01-01-2003
A7037
Tubing used with positive airway pressure device
01-01-2003
A7038
Filter, disposable, used with positive airway pressure device
01-01-2003
A7039
Filter, nondisposable, used with positive airway pressure device
01-01-2003
A7040
One way chest drain valve
01-01-2005
A7041
Water seal drainage container and tubing for use with implanted chest tube
01-01-2005
A7042
Implanted pleural catheter, each
01-01-2003
12-31-2014
A7043
Vacuum drainage bottle and tubing for use with implanted catheter
01-01-2003
12-31-2014
A7044
Oral interface used with positive airway pressure device, each
01-01-2003
A7045
Exhalation port with or without swivel used with accessories for positive airway devices, replacement only
01-01-2005
A7046
Water chamber for humidifier, used with positive airway pressure device, replacement, each
01-01-2004
A7047
Oral interface used with respiratory suction pump, each
01-01-2014
A7048
Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each
01-01-2015
A7501
Tracheostoma valve, including diaphragm, each
01-01-2001
A7502
Replacement diaphragm/faceplate for tracheostoma valve, each
01-01-2001
A7503
Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture exchange system, each
01-01-2001
A7504
Filter for use in a tracheostoma heat and moisture exchange system, each
01-01-2001
A7505
Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each
01-01-2001
A7506
Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type each
01-01-2001
A7507
Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each
01-01-2001
A7508
Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each
01-01-2001
A7509
Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each
01-01-2001
A7520
Tracheostomy/laryngectomy tube, noncuffed, polyvinylchloride (pvc), silicone or equal, each
01-01-2004
A7521
Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (pvc), silicone or equal, each
01-01-2004
A7522
Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each
01-01-2004
A7523
Tracheostomy shower protector, each
01-01-2004
A7524
Tracheostoma stent/stud/button, each
01-01-2004
A7525
Tracheostomy mask, each
01-01-2004
A7526
Tracheostomy tube collar/holder, each
01-01-2004
A7527
Tracheostomy/laryngectomy tube plug/stop, each
01-01-2005
A8000
Helmet, protective, soft, prefabricated, includes all components and accessories
01-01-2007
A8001
Helmet, protective, hard, prefabricated, includes all components and accessories
01-01-2007
A8002
Helmet, protective, soft, custom fabricated, includes all components and accessories
01-01-2007
A8003
Helmet, protective, hard, custom fabricated, includes all components and accessories
01-01-2007
A8004
Hoft interface for helmet, replacement only
01-01-2007
A9150
Nonprescription drug
01-01-1986
A9152
Single vitamin/mineral/trace element, oral, per dose, not otherwise specified
01-01-2005
A9155
Artificial saliva, 30 ml
01-01-2008
A9180
Pediculosis (lice infestation) treatment, topical, for administration by patient/caretaker
01-01-2005
A9272
Wound suction, disposable, includes dressing, all accessories and components, any type, each
01-01-2012
A9274
External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories
01-01-2008
A9275
Home glucose disposable monitor, includes test strips
01-01-2006
A9276
Sensor; invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply
01-01-2008
A9277
Transmitter; external, for use with interstitial continuous glucose monitoring system
01-01-2008
A9278
Receiver (monitor); external, for use with interstitial continuous glucose monitoring system
01-01-2008
A9279
Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified
01-01-2007
A9280
Alert or alarm device, not otherwise classified
01-01-2004
A9281
Reaching/grabbing device, any type, any length, each
01-01-2006
A9283
Foot pressure off loading/supportive device, any type, each
01-01-2008
A9285
Inversion/eversion correction device
01-01-2017
A9286
Hygienic item or device, disposable or non-disposable, any type, each
01-01-2017
A9300
Exercise equipment
01-01-1993
A9900
Miscellaneous dme supply, accessory, and/or service component of another hcpcs code
01-01-2000
A9901
Dme delivery, set up, and/or dispensing service component of another hcpcs code
01-01-2000
A9999
Miscellaneous dme supply or accessory, not otherwise specified
01-01-2004
B4034
Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape
01-01-1986
B4035
Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape
01-01-1986
B4036
Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape
01-01-1986
B4081
Nasogastric tubing with stylet
01-01-1986
B4082
Nasogastric tubing without stylet
01-01-1986
B4083
Stomach tube - levine type
01-01-1986
B4086
Gastrostomy/jejunostomy tube, any material, any type, (standard or low profile), each
01-01-2002
12-31-2007
B4087
Gastrostomy/jejunostomy tube, standard, any material, any type, each
01-01-2008
B4088
Gastrostomy/jejunostomy tube, low-profile, any material, any type, each
01-01-2008
B4102
Enteral formula, for adults, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit
01-01-2005
B4103
Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit
01-01-2005
B4104
Additive for enteral formula (e.g., fiber)
01-01-2005
B4149
Enteral formula, manufactured blenderized natural foods with intact nutrients, 'includes proteins, fats, carbohydrates, vitamins and minerals, may include 'fiber, administered through an enteral feeding tube, 100 calories = 1 unit
01-01-2005
B4150
Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
01-01-1986
B4152
Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
01-01-1984
B4153
Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
01-01-1986
B4154
Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
01-01-1984
B4155
Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. glucose polymers), proteins/amino acids (e.g. glutamine, arginine), fat (e.g. medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit
01-01-1986
B4157
Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 uni
01-01-2005
B4158
Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit
01-01-2005
B4159
Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit
01-01-2005
B4160
Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feed
01-01-2005
B4161
Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
01-01-2005
B4162
Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
01-01-2005
B4164
Parenteral nutrition solution; carbohydrates (dextrose), 50% or less (500 ml = 1 unit) - home mix
01-01-1986
B4168
Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) - home mix
01-01-1984
B4172
Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml = 1 unit) - home mix
01-01-1984
B4176
Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1 unit) - home mix
01-01-1986
B4178
Parenteral nutrition solution; amino acid, greater than 8.5% (500 ml = 1 unit) - home mix
01-01-1988
B4180
Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) - home mix
01-01-1986
B4185
Parenteral nutrition solution, not otherwise specified, 10 grams lipids
01-01-2006
B4189
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein - premix
01-01-1988
B4193
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein - premix
01-01-1988
B4197
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - premix
01-01-1988
B4199
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein - premix
01-01-1988
B4216
Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes) - home mix, per day
01-01-1984
B4220
Parenteral nutrition supply kit; premix, per day
01-01-1984
B4222
Parenteral nutrition supply kit; home mix, per day
01-01-1986
B4224
Parenteral nutrition administration kit, per day
01-01-1986
B5000
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - amirosyn rf, nephramine, renamine - premix
01-01-1988
B5100
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic - freamine hbc, hepatamine - premix
01-01-1988
B5200
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress - branch chain amino acids - premix
01-01-1988
B9000
Enteral nutrition infusion pump - without alarm
01-01-1988
12-31-2016
B9002
Enteral nutrition infusion pump - with alarm
01-01-1988
B9004
Parenteral nutrition infusion pump, portable
01-01-1988
B9006
Parenteral nutrition infusion pump, stationary
01-01-1988
B9998
Noc for enteral supplies
01-01-1985
B9999
Noc for parenteral supplies
01-01-1985
C2624
Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components
01-01-2015
E0100
Cane, includes canes of all materials, adjustable or fixed, with tip
01-01-1986
E0105
Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips
01-01-1986
E0110
Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips
01-01-1986
E0111
Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip
01-01-1986
E0112
Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips
01-01-1986
E0113
Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip
01-01-1986
E0114
Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips
01-01-1986
E0116
Crutch, underarm, other than wood, adjustable or fixed, each with pad, tip, handgrip, with or without shock absorber, each
01-01-1986
E0117
Crutch, underarm, articulating, spring assisted, each
01-01-2003
E0118
Crutch substitute, lower leg platform, with or without wheels, each
01-01-2004
E0130
Walker, rigid (pickup), adjustable or fixed height
01-01-1986
E0135
Walker, folding (pickup), adjustable or fixed height
01-01-1986
E0140
Walker, with trunk support, adjustable or fixed height, any type
01-01-2004
E0141
Walker, rigid, wheeled, adjustable or fixed height
01-01-1986
E0143
Walker, folding, wheeled, adjustable or fixed height
01-01-1986
E0144
Walker, enclosed, four sided framed, rigid or folding, wheeled with posterior seat
01-01-2000
E0147
Walker, heavy duty, multiple braking system, variable wheel resistance
01-01-1986
E0148
Walker, heavy duty, without wheels, rigid or folding, any type, each
01-01-2001
E0149
Walker, heavy duty, wheeled, rigid or folding, any type
01-01-2001
E0153
Platform attachment, forearm crutch, each
01-01-1986
E0154
Platform attachment, walker, each
01-01-1986
E0155
Wheel attachment, rigid pick-up walker, per pair seat attachment, walker
01-01-1986
E0156
Seat attachment, walker
01-01-1986
E0157
Crutch attachment, walker, each
01-01-1986
E0158
Leg extensions for walker, per set of four (4)
01-01-1986
E0159
Brake attachment for wheeled walker, replacement, each
01-01-1997
E0160
Sitz type bath or equipment, portable, used with or without commode
01-01-1986
E0161
Sitz type bath or equipment, portable, used with or without commode, with faucet attachment(s)
01-01-1986
E0162
Sitz bath chair
01-01-1986
E0163
Commode chair, mobile or stationary, with fixed arms
01-01-1986
E0165
Commode chair, mobile or stationary, with detachable arms
01-01-1986
E0167
Pail or pan for use with commode chair, replacement only
01-01-1986
E0168
Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each
01-01-2001
E0170
Commode chair with integrated seat lift mechanism, electric, any type
01-01-2006
E0171
Commode chair with integrated seat lift mechanism, non-electric, any type
01-01-2006
E0172
Seat lift mechanism placed over or on top of toilet, any type
01-01-2006
E0175
Foot rest, for use with commode chair, each
01-01-1986
E0181
Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty
01-01-1986
E0182
Pump for alternating pressure pad, for replacement only
01-01-1986
E0184
Dry pressure mattress
01-01-1986
E0185
Gel or gel-like pressure pad for mattress, standard mattress length and width
01-01-1986
E0186
Air pressure mattress
01-01-1986
E0187
Water pressure mattress
01-01-1986
E0188
Synthetic sheepskin pad
01-01-1986
E0189
Lambswool sheepskin pad, any size
01-01-1986
E0190
Positioning cushion/pillow/wedge, any shape or size, includes all components and accessories
01-01-2004
E0191
Heel or elbow protector, each
01-01-1986
E0193
Powered air flotation bed (low air loss therapy)
01-01-1990
E0194
Air fluidized bed
01-01-1991
E0196
Gel pressure mattress
01-01-1991
E0197
Air pressure pad for mattress, standard mattress length and width
01-01-1991
E0198
Water pressure pad for mattress, standard mattress length and width
01-01-1991
E0199
Dry pressure pad for mattress, standard mattress length and width
01-01-1991
E0200
Heat lamp, without stand (table model), includes bulb, or infrared element
01-01-1986
E0202
Phototherapy (bilirubin) light with photometer
01-01-1985
E0203
Therapeutic lightbox, minimum 10,000 lux, table top model
01-01-2003
E0205
Heat lamp, with stand, includes bulb, or infrared element
01-01-1986
E0210
Electric heat pad, standard
01-01-1986
E0215
Electric heat pad, moist
01-01-1986
E0217
Water circulating heat pad with pump
01-01-1997
E0218
Fluid circulating cold pad with pump, any type
01-01-1997
E0220
Hot water bottle
01-01-1986
01-01-2011
E0221
Infrared heating pad system
01-01-2002
E0225
Hydrocollator unit, includes pads
01-01-1986
E0230
Ice cap or collar
01-01-1986
01-01-2011
E0231
Noncontact wound warming device (temperature control unit, ac adapter and power cord) for use with warming card and wound cover
01-01-2002
E0232
Warming card for use with the noncontact wound warming device and noncontact wound warming wound cover
01-01-2002
E0235
Paraffin bath unit, portable (see medical supply code a4265 for paraffin)
01-01-1986
E0236
Pump for water circulating pad
01-01-1986
E0238
Nonelectric heat pad, moist
01-01-1986
01-01-2011
E0239
Hydrocollator unit, portable
01-01-1986
E0241
Bathtub wall rail, each
01-01-1986
E0242
Bathtub rail, floor base
01-01-1986
E0243
Toilet rail, each
01-01-1986
E0244
Raised toilet seat
01-01-1986
E0245
Tub stool or bench
01-01-1986
E0246
Transfer tub rail attachment
01-01-1986
E0247
Transfer bench for tub or toilet with or without commode opening
01-01-2004
E0248
Transfer bench, heavy duty, for tub or toilet with or without commode opening
01-01-2004
E0249
Pad for water circulating heat unit, for replacement only
01-01-1986
E0250
Hospital bed, fixed height, with any type side rails, with mattress
01-01-1986
E0251
Hospital bed, fixed height, with any type side rails, without mattress
01-01-1986
E0255
Hospital bed, variable height, hi-lo, with any type side rails, with mattress
01-01-1986
E0256
Hospital bed, variable height, hi-lo, with any type side rails, without mattress
01-01-1991
E0260
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress
01-01-1986
E0261
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress
01-01-1991
E0265
Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress
01-01-1986
E0266
Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress
01-01-1986
E0270
Hospital bed, institutional type includes: oscillating, circulating and stryker frame, with mattress
01-01-1986
E0271
Mattress, inner spring
01-01-1986
E0272
Mattress, foam rubber
01-01-1986
E0273
Bed board
01-01-1986
E0274
Over-bed table
01-01-1986
E0275
Bed pan, standard, metal or plastic
01-01-1986
E0276
Bed pan, fracture, metal or plastic
01-01-1986
E0277
Powered pressure-reducing air mattress
01-01-1992
E0280
Bed cradle, any type
01-01-1986
E0290
Hospital bed, fixed height, without side rails, with mattress
01-01-1991
E0291
Hospital bed, fixed height, without side rails, without mattress
01-01-1991

Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
E0292
Hospital bed, variable height, hi-lo, without side rails, with mattress
01-01-1991
E0293
Hospital bed, variable height, hi-lo, without side rails, without mattress
01-01-1991
E0294
Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress
01-01-1991
E0295
Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress
01-01-1991
E0296
Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress
01-01-1991
E0297
Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress
01-01-1991
E0300
Pediatric crib, hospital grade, fully enclosed, with or without top enclosure
01-01-2004
E0301
Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress
01-01-2004
E0302
Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without mattress
01-01-2004
E0303
Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress
01-01-2004
E0304
Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress
01-01-2004
E0305
Bedside rails, half-length
01-01-1986
E0310
Bedside rails, full-length
01-01-1986
E0315
Bed accessory: board, table, or support device, any type
01-01-1986
E0316
Safety enclosure frame/canopy for use with hospital bed, any type
01-01-2002
E0325
Urinal; male, jug-type, any material
01-01-1986
E0326
Urinal; female, jug-type, any material
01-01-1986
E0328
Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress
01-01-2008
E0329
Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress
01-01-2008
E0350
Control unit for electronic bowel irrigation/evacuation system
01-01-1995
E0352
Disposable pack (water reservoir bag, speculum, valving mechanism and collection bag/box) for use with the electronic bowel irrigation/evacuation system
01-01-1995
E0370
Air pressure elevator for heel
01-01-1997
E0371
Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width
01-01-1998
E0372
Powered air overlay for mattress, standard mattress length and width
01-01-1998
E0373
Nonpowered advanced pressure reducing mattress
01-01-1998
E0424
Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
01-01-1993
E0425
Stationary compressed gas system, purchase; includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
01-01-1986
E0430
Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing
01-01-1986
E0431
Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing
01-01-1993
E0433
Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and contents gauge
01-01-2010
E0434
Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing
01-01-1993
E0435
Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing, and refill adapter
01-01-1986
E0439
Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
01-01-1993
E0440
Stationary liquid oxygen system, purchase; includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
01-01-1986
E0441
Stationary oxygen contents, gaseous, 1 month's supply = 1 unit
01-01-1993
E0442
Stationary oxygen contents, liquid, 1 month's supply = 1 unit
01-01-1993
E0443
Portable oxygen contents, gaseous, 1 month's supply = 1 unit
01-01-1993
E0444
Portable oxygen contents, liquid (for use only with portable liquid systems when no stationary gas or liquid system is used), one month's supply = 1 unit
01-01-1993
E0445
Oximeter device for measuring blood oxygen levels noninvasively
01-01-2003
E0446
Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories
01-01-2011
E0447
Portable oxygen contents, liquid, 1 month's supply = 1 unit, prescribed amount at rest or nighttime exceeds 4 liters per minute (lpm)
01-01-2019
E0450
Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)
01-01-1985
12/31/2015
E0455
Oxygen tent, excluding croup or pediatric tents
01-01-1986
E0457
Chest shell (cuirass)
01-01-1990
E0459
Chest wrap
01-01-1990
E0460
Negative pressure ventilator; portable or stationary
01-01-1990
12/31/2015
E0461
Volume control ventilator, without pressure support mode, may include pressure control mode, used with non-invasive interface (e.g. mask)
01-01-2003
12/31/2015
E0462
Rocking bed, with or without side rails
01-01-1990
E0463
Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)
01-01-2005
12/31/2015
E0464
Pressure support ventilator with volume control mode, may include pressure control mode, used with noninvasive interface (e.g., mask)
01-01-2005
12/31/2015
E0465
Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)
01-01-2016
E0466
Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)
01-01-2016
E0467
Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions
01-01-2019
E0470
Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
01-01-2004
E0471
Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
01-01-2004
E0472
Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)
01-01-2004
E0480
Percussor, electric or pneumatic, home model
01-01-1986
E0481
Intrapulmonary percussive ventilation system and related accessories
01-01-2002
E0482
Cough stimulating device, alternating positive and negative airway pressure
01-01-2002
E0483
High frequency chest wall oscillation system, includes all accessories and supplies, each
01-01-2003
E0484
Oscillatory positive expiratory pressure device, nonelectric, any type, each
01-01-2003
E0485
Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment
01-01-2006
E0486
Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment
01-01-2006
E0487
Spirometer, electronic, includes all accessories
01-01-2009
E0500
Ippb machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source
01-01-1986
E0550
Humidifier, durable for extensive supplemental humidification during ippb treatments or oxygen delivery
01-01-1986
E0555
Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter
01-01-1986
E0560
Humidifier, durable for supplemental humidification during ippb treatment or oxygen delivery
01-01-1986
E0561
Humidifier, nonheated, used with positive airway pressure device
01-01-2004
E0562
Humidifier, heated, used with positive airway pressure device
01-01-2004
E0565
Compressor, air power source for equipment which is not self-contained or cylinder driven
01-01-1982
E0570
Nebulizer, with compressor
01-01-1986
E0571
Aerosol compressor, battery powered, for use with small volume nebulizer
01-01-2001
12-31-2011
E0572
Aerosol compressor, adjustable pressure, light duty for intermittent use
01-01-2001
E0574
Ultrasonic/electronic aerosol generator with small volume nebulizer
01-01-2001
E0575
Nebulizer, ultrasonic, large volume
01-01-1986
E0580
Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter
01-01-1986
E0585
Nebulizer, with compressor and heater
01-01-1986
E0600
Respiratory suction pump, home model, portable or stationary, electric
01-01-1986
E0601
Continuous positive airway pressure (CPAP) device
01-01-1988
E0602
Breast pump, manual, any type
01-01-2000
E0603
Breast pump, electric (ac and/or dc), any type
01-01-2002
E0604
Breast pump, hospital grade, electric (ac and / or dc), any type
01-01-2002
E0605
Vaporizer, room type
01-01-1986
E0606
Postural drainage board
01-01-1986
E0607
Home blood glucose monitor
01-01-1986
E0610
Pacemaker monitor, self-contained, checks battery depletion, includes audible and visible check systems
01-01-1986
E0615
Pacemaker monitor, self-contained, checks battery depletion and other pacemaker components, includes digital/visible check systems
01-01-1986
E0616
Implantable cardiac event recorder with memory, activator and programmer
01-01-2000
E0617
External defibrillator with integrated electrocardiogram analysis
01-01-2001
E0618
Apnea monitor, without recording feature
01-01-2003
E0619
Apnea monitor, with recording feature
01-01-2003
E0620
Skin piercing device for collection of capillary blood, laser, each
01-01-2002
E0621
Sling or seat, patient lift, canvas or nylon
01-01-1986
E0625
Patient lift, bathroom or toilet, not otherwise classified
01-01-1986
E0627
Seat lift mechanism incorporated into a combination lift-chair mechanism
01-01-1992
E0628
Separate seat lift mechanism for use with patient owned furniture - electric
01-01-1992
12-31-2016
E0629
Separate seat lift mechanism for use with patient owned furniture - nonelectric
01-01-1992
E0630
Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s)
01-01-1986
E0635
Patient lift, electric, with seat or sling
01-01-1986
E0636
Multipositional patient support system, with integrated lift, patient accessible controls
01-01-2003
E0637
Combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels
01-01-2004
E0638
Standing frame/table system, one position (e.g. upright, supine or prone stander), any size including pediatric, with or without wheels
01-01-2004
E0639
Patient lift, moveable from room to room with disassembly and reassembly, includes all components/accessories
01-01-2005
E0640
Patient lift, fixed system, includes all components/accessories
01-01-2005
E0641
Standing frame/table system, multi-position (e.g. three-way stander), any size including pediatric, with or without wheels
01-01-2006
E0642
Standing frame/table system, mobile (dynamic stander), any size including pediatric
01-01-2006
E0650
Pneumatic compressor, nonsegmental home model
01-01-1986
E0651
Pneumatic compressor, segmental home model without calibrated gradient pressure
01-01-1988
E0652
Pneumatic compressor, segmental home model with calibrated gradient pressure
01-01-1988
E0655
Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm
01-01-1986
E0656
Segmental pneumatic appliance for use with pneumatic compressor, trunk
01-01-2009
E0657
Segmental pneumatic appliance for use with pneumatic compressor, chest functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified
01-01-2009
E0660
Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg
01-01-1986
E0665
Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm
01-01-1986
E0666
Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg
01-01-1986
E0667
Segmental pneumatic appliance for use with pneumatic compressor, full leg
01-01-1988
E0668
Segmental pneumatic appliance for use with pneumatic compressor, full arm
01-01-1988
E0669
Segmental pneumatic appliance for use with pneumatic compressor, half leg
01-01-1994
E0670
Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk
01-01-2013
E0671
Segmental gradient pressure pneumatic appliance, full leg
01-01-1995
E0672
Segmental gradient pressure pneumatic appliance, full arm
01-01-1995
E0673
Segmental gradient pressure pneumatic appliance, half leg
01-01-1995
E0675
Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system)
01-01-2004
E0676
Intermittent limb compression device (includes all accessories), not otherwise specified
01-01-2007
E0691
Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 square feet or less
01-01-2003
E0692
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, four foot panel
01-01-2003
E0693
Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, six foot panel
01-01-2003
E0694
Ultraviolet multidirectional light therapy system in six foot cabinet, includes bulbs/lamps, timer and eye protection
01-01-2003
E0700
Safety equipment, device or accessory, any type
01-01-1986
E0705
Transfer device, any type, each
01-01-2006
E0710
Restraint, any type (body, chest, wrist or ankle)
01-01-1986
E0720
Transcutaneous electrical nerve stimulation (tens) device, two lead, localized stimulation
01-01-1986
E0730
Transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation
01-01-1986
E0731
Form-fitting conductive garment for delivery of tens or nmes (with conductive fibers separated from the patient's skin by layers of fabric)
01-01-1989
E0740
Incontinence treatment system, pelvic floor stimulator, monitor, sensor and/or trainer
01-01-1986
E0744
Neuromuscular stimulator for scoliosis
01-01-1989
E0745
Neuromuscular stimulator, electronic shock unit
01-01-1986
E0746
Electromyography (emg), biofeedback device
01-01-1989
E0747
Osteogenesis stimulator, electrical, noninvasive, other than spinal applications
01-01-1986
E0748
Osteogenesis stimulator, electrical, noninvasive, spinal applications
01-01-1996
E0749
Osteogenesis stimulator, electrical, surgically implanted
01-01-1986
E0755
Electronic salivary reflex stimulator (intraoral/noninvasive)
01-01-1990
E0760
Osteogenesis stimulator, low intensity ultrasound, noninvasive
01-01-1997
E0761
Nonthermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device
01-01-2003
E0762
Transcutaneous electrical joint stimulation device system, includes all accessories
01-01-2006
E0764
Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program
01-01-2006
E0765
FDA approved nerve stimulator, with replaceable batteries, for treatment of nausea and vomiting
01-01-2001
E0766
Electrical stimulation device used for cancer treatment, includes all accessories, any type
01-01-2014
E0769
Electrical stimulation or electromagnetic wound treatment device, not otherwise classified
01-01-2005
E0770
Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified
01-01-2009
E0776
Iv pole
01-01-1985
E0779
Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater
01-01-2000
E0780
Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours
01-01-2000
E0781
Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient
01-01-1987
E0782
Infusion pump, implantable, nonprogrammable (includes all components, e.g., pump, catheter, connectors, etc.)
01-01-1986
E0783
Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.)
01-01-1995
E0784
External ambulatory infusion pump, insulin
01-01-1996
E0785
Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement
01-01-1999
E0786
Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter)
01-01-2001
E0787
External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing
01-01-2020
E0791
Parenteral infusion pump, stationary, single or multichannel
01-01-1989
E0830
Ambulatory traction device, all types, each
01-01-2001
E0840
Traction frame, attached to headboard, cervical traction
01-01-1984
E0849
Traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible
01-01-2005
E0850
Traction stand, freestanding, cervical traction
01-01-1982
E0855
Cervical traction equipment not requiring additional stand or frame
01-01-1998
E0856
Cervical traction device, with inflatable air bladder(s)
01-01-2008
E0860
Traction equipment, overdoor, cervical
01-01-1986
E0870
Traction frame, attached to footboard, extremity traction (e.g., buck's)
01-01-1986
E0880
Traction stand, freestanding, extremity traction (e.g., buck's)
01-01-1986
E0890
Traction frame, attached to footboard, pelvic traction
01-01-1986
E0900
Traction stand, freestanding, pelvic traction (e.g., buck's)
01-01-1986
E0910
Trapeze bars, also known as patient helper, attached to bed, with grab bar
01-01-1986
E0911
Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar
01-01-2006
E0912
Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, free standing, complete with grab bar
01-01-2006
E0920
Fracture frame, attached to bed, includes weights
01-01-1986
E0930
Fracture frame, freestanding, includes weights
01-01-1986
E0935
Continuous passive motion exercise device for use on knee only
01-01-1986
E0936
Continuous passive motion exercise device for use other than knee
01-01-2007
E0940
Trapeze bar, freestanding, complete with grab bar
01-01-1986
E0941
Gravity assisted traction device, any type
01-01-1986
E0942
Cervical head harness/halter
01-01-1986
E0944
Pelvic belt/harness/boot
01-01-1985
E0945
Extremity belt/harness
01-01-1985
E0946
Fracture frame, dual with cross bars, attached to bed (e.g., balken, four poster)
01-01-1986
E0947
Fracture frame, attachments for complex pelvic traction
01-01-1986
E0948
Fracture frame, attachments for complex cervical traction
01-01-1986
E0950
Wheelchair accessory, tray, each
01-01-1986
E0951
Heel loop/holder, any type, with or without ankle strap, each
01-01-1986
E0952
Toe loop/holder, any type, each
01-01-1986
E0953
Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each
01-01-2018
E0954
Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot
01-01-2018
E0955
Wheelchair accessory, headrest, cushioned, prefabricated, including fixed mounting hardware, each
01-01-2004
E0956
Wheelchair accessory, lateral trunk or hip support, prefabricated, including fixed mounting hardware, each
01-01-2004
E0957
Wheelchair accessory, medial thigh support, prefabricated, including fixed mounting hardware, each
01-01-2004
E0958
Manual wheelchair accessory, one-arm drive attachment, each
01-01-1986
E0959
Manual wheelchair accessory, adapter for amputee, each
01-01-1986
E0960
Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting hardware
01-01-2004
E0961
Manual wheelchair accessory, wheel lock brake extension (handle), each
01-01-1986
E0966
Manual wheelchair accessory, headrest extension, each
01-01-1986
E0967
Manual wheelchair accessory, hand rim with projections, any type, each
01-01-1986
E0968
Commode seat, wheelchair
01-01-1986
E0969
Narrowing device, wheelchair
01-01-1986
E0970
No. 2 footplates, except for elevating legrest
01-01-1986
E0971
Manual wheelchair accessory, anti-tipping device
01-01-1986
E0973
Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each
01-01-1986
E0974
Manual wheelchair accessory, anti-rollback device, each
01-01-1986
E0978
Wheelchair accessory, positioning belt/safety belt/pelvic strap, each
01-01-1986
E0980
Safety vest, wheelchair
01-01-1986
E0981
Wheelchair accessory, seat upholstery, replacement only, each
01-01-2004
E0982
Wheelchair accessory, back upholstery, replacement only, each
01-01-2004
E0983
Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control
01-01-2004
E0984
Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control
01-01-2004
E0985
Wheelchair accessory, seat lift mechanism
01-01-2004
E0986
Manual wheelchair accessory, push-rim activated power assist system
01-01-2004
E0988
Manual wheelchair accessory, lever-activated, wheel drive, pair
01-01-2012
E0990
Wheelchair accessory, elevating leg rest, complete assembly, each
01-01-1986
E0992
Manual wheelchair accessory, solid seat insert
01-01-1986
E0994
Armrest, each
01-01-1986
E0995
Wheelchair accessory, calf rest/pad, each
01-01-1986
E1002
Wheelchair accessory, power seating system, tilt only
01-01-2004

Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
E1003
Wheelchair accessory, power seating system, recline only, without shear reduction
01-01-2004
E1004
Wheelchair accessory, power seating system, recline only, with mechanical shear reduction
01-01-2004
E1005
Wheelchair accessory, power seating system, recline only, with power shear reduction
01-01-2004
E1006
Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction
01-01-2004
E1007
Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction
01-01-2004
E1008
Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction
01-01-2004
E1009
Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system, including pushrod and leg rest, each
01-01-2004
E1010
Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, each
01-01-2004
E1011
Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair)
01-01-2003
E1012
Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each
01-01-2016
E1014
Reclining back, addition to pediatric size wheelchair
01-01-2003
E1015
Shock absorber for manual wheelchair, each
01-01-2003
E1016
Shock absorber for power wheelchair, each
01-01-2003
E1017
Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each
01-01-2003
E1018
Heavy duty shock absorber for heavy duty or extra heavy duty power wheelchair, each
01-01-2003
E1020
Residual limb support system for wheelchair, any type
01-01-2003
E1028
Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory
01-01-2004
E1029
Wheelchair accessory, ventilator tray, fixed
01-01-2004
E1030
Wheelchair accessory, ventilator tray, gimbaled
01-01-2004
E1031
Rollabout chair, any and all types with casters five inches or greater
01-01-1990
E1035
Multi-positional patient transfer system, with integrated seat, operated by care giver, patient weight capacity up to and including 300 lbs
01-01-2001
E1036
Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs
01-01-2010
E1037
Transport chair, pediatric size
01-01-2003
E1038
Transport chair, adult size, patient weight capacity up to and including 300 pounds
01-01-2003
E1039
Transport chair, adult size, heavy duty, patient weight capacity greater than 300 pounds
01-01-2005
E1050
Fully reclining wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
01-01-1986
E1060
Fully reclining wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests
01-01-1986
E1070
Fully reclining wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
01-01-1986
E1083
Hemi-wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
01-01-1986
E1084
Hemi-wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests
01-01-1986
E1085
Hemi-wheelchair; fixed full-length arms, swing-away, detachable footrests
01-01-1986
E1086
Hemi-wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
01-01-1986
E1087
High-strength lightweight wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
01-01-1986
E1088
High-strength lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests
01-01-1986
E1089
High-strength lightweight wheelchair; fixed-length arms, swing-away, detachable footrests
01-01-1986
E1090
High-strength lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
01-01-1986
E1092
Wide, heavy-duty wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests
01-01-1986
E1093
Wide, heavy-duty wheelchair; detachable arms, desk or full-length arms, swing-away, detachable footrests
01-01-1986
E1100
Semi-reclining wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
01-01-1986
E1110
Semi-reclining wheelchair; detachable arms, desk or full-length, elevating legrest
01-01-1986
E1130
Standard wheelchair; fixed full-length arms, fixed or swing-away, detachable footrests
01-01-1986
E1140
Wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
01-01-1986
E1150
Wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests
01-01-1986
E1160
Wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
01-01-1986
E1161
Manual adult size wheelchair, includes tilt in space
01-01-2003
E1170
Amputee wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
01-01-1986
E1171
Amputee wheelchair; fixed full-length arms, without footrests or legrests
01-01-1986
E1172
Amputee wheelchair; detachable arms, desk or full-length, without footrests or legrests
01-01-1986
E1180
Amputee wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
01-01-1986
E1190
Amputee wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests
01-01-1986
E1195
Heavy duty wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests
01-01-1986
E1200
Amputee wheelchair; fixed full-length arms, swing-away, detachable footrests
01-01-1986
E1220
Wheelchair; specially sized or constructed (indicate brand name, model number, if any, and justification)
01-01-1986
E1221
Wheelchair with fixed arm, footrests
01-01-1986
E1222
Wheelchair with fixed arm, elevating legrests
01-01-1986
E1223
Wheelchair with detachable arms, footrests
01-01-1986
E1224
Wheelchair with detachable arms, elevating legrests
01-01-1986
E1225
Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each
01-01-1986
E1226
Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each
01-01-1986
E1227
Special height arms for wheelchair
01-01-1986
E1228
Special back height for wheelchair
01-01-1986
E1229
Wheelchair, pediatric size, not otherwise specified
01-01-2005
E1230
Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number
01-01-1986
E1231
Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system
01-01-2003
E1232
Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system
01-01-2003
E1233
Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system
01-01-2003
E1234
Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system
01-01-2003
E1235
Wheelchair, pediatric size, rigid, adjustable, with seating system
01-01-2003
E1236
Wheelchair, pediatric size, folding, adjustable, with seating system
01-01-2003
E1237
Wheelchair, pediatric size, rigid, adjustable, without seating system
01-01-2003
E1238
Wheelchair, pediatric size, folding, adjustable, without seating system
01-01-2003
E1239
Power wheelchair, pediatric size, not otherwise specified
01-01-2005
E1240
Lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrest
01-01-1986
E1250
Lightweight wheelchair; fixed full-length arms, swing-away, detachable footrests
01-01-1986
E1260
Lightweight wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
01-01-1986
E1270
Lightweight wheelchair; fixed full-length arms, swing-away, detachable elevating legrests
01-01-1986
E1280
Heavy-duty wheelchair; detachable arms, desk or full-length, elevating legrests
01-01-1986
E1285
Heavy-duty wheelchair; fixed full-length arms, swing-away, detachable footrests
01-01-1986
E1290
Heavy-duty wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests
01-01-1986
E1295
Heavy-duty wheelchair; fixed full-length arms, elevating legrests
01-01-1986
E1296
Special wheelchair seat height from floor
01-01-1986
E1297
Special wheelchair seat depth, by upholstery
01-01-1986
E1298
Special wheelchair seat depth and/or width, by construction
01-01-1986
E1300
Whirlpool, portable (overtub type)
01-01-1986
E1310
Whirlpool, nonportable (built-in type)
01-01-1986
E1340
Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes
01-01-1997
12-31-2009
E1352
Oxygen accessory, flow regulator capable of positive inspiratory pressure
01-01-2014
E1353
Regulator
01-01-1986
E1354
Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only, each
01-01-2009
E1355
Stand/rack
01-01-1986
E1356
Oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement only, each
01-01-2009
E1357
Oxygen accessory, battery charger for portable concentrator, any type, replacement only, each
01-01-2009
E1358
Oxygen accessory, dc power adapter for portable concentrator, any type, replacement only, each
01-01-2009
E1372
Immersion external heater for nebulizer
01-01-1986
E1390
Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate
01-01-2000
E1391
Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each
01-01-2004
E1392
Portable oxygen concentrator, rental
01-01-2006
E1399
Durable medical equipment, miscellaneous
01-01-1986
E1405
Oxygen and water vapor enriching system with heated delivery
01-01-1988
E1406
Oxygen and water vapor enriching system without heated delivery
01-01-1988
E1500
Centrifuge, for dialysis
01-01-2002
E1510
Kidney, dialysate delivery system kidney machine, pump recirculating, air removal system, flowrate meter, power off, heater and temp control with alarm, iv poles, pressure gauge, concentrate container
01-01-1986
E1520
Heparin infusion pump for hemodialysis
01-01-1986
E1530
Air bubble detector for hemodialysis, each, replacement
01-01-1986
E1540
Pressure alarm for hemodialysis, each, replacement
01-01-1986
E1550
Bath conductivity meter for hemodialysis, each
01-01-1986
E1560
Blood leak detector for hemodialysis, each, replacement
01-01-1986
E1570
Adjustable chair, for esrd patients
01-01-1986
E1575
Transducer protectors/fluid barriers, for hemodialysis, any size, per 10
01-01-1986
E1580
Unipuncture control system for hemodialysis
01-01-1986
E1590
Hemodialysis machine
01-01-1986
E1592
Automatic intermittent peritoneal dialysis system
01-01-1986
E1594
Cycler dialysis machine for peritoneal dialysis
01-01-1986
E1600
Delivery and/or installation charges for hemodialysis equipment
01-01-1986
E1610
Reverse osmosis water purification system, for hemodialysis
01-01-1986
E1615
Deionizer water purification system, for hemodialysis
01-01-1986
E1620
Blood pump for hemodialysis, replacement
01-01-1986
E1625
Water softening system, for hemodialysis
01-01-1986
E1630
Reciprocating peritoneal dialysis system
01-01-1986
E1632
Wearable artificial kidney, each
01-01-1986
E1634
Peritoneal dialysis clamps, each
01-01-2004
E1635
Compact (portable) travel hemodialyzer system
01-01-1986
E1636
Sorbent cartridges, for hemodialysis, per 10
01-01-1986
E1637
Hemostats, each
01-01-2002
E1639
Scale, each
01-01-2002
E1699
Dialysis equipment, not otherwise specified
01-01-1986
E1700
Jaw motion rehabilitation system
01-01-1993
E1701
Replacement cushions for jaw motion rehabilitation system, package of six
01-01-1993
E1702
Replacement measuring scales for jaw motion rehabilitation system, package of 200
01-01-1993
E1800
Dynamic adjustable elbow extension/flexion device, includes soft interface material
01-01-1996
E1801
Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
01-01-2002
E1802
Dynamic adjustable forearm pronation/supination device, includes soft interface material
01-01-2003
E1805
Dynamic adjustable wrist extension/flexion device, includes soft interface material
01-01-1996
E1806
Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
01-01-2002
E1810
Dynamic adjustable knee extension/flexion device, includes soft interface material
01-01-1996
E1811
Static progressive stretch knee device, extension and/or flexion, with range of motion adjustment, includes all components and accessories
01-01-2002
E1812
Dynamic knee, extension/flexion device with active resistance control
01-01-2006
E1815
Dynamic adjustable ankle extension/flexion, includes soft interface material
01-01-1996
E1816
Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
01-01-2002
E1818
Static progressive stretch forearm pronation / supination device, with or without range of motion adjustment, includes all components and accessories
01-01-2002
E1820
Replacement soft interface material, dynamic adjustable extension/flexion device
01-01-1996
E1821
Replacement soft interface material/cuffs for bi-directional static progressive stretch device
01-01-2002
E1825
Dynamic adjustable finger extension/flexion device, includes soft interface material
01-01-1996
E1830
Dynamic adjustable toe extension/flexion device, includes soft interface material
01-01-1996
E1831
Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
01-01-2011
E1840
Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material
01-01-2002
E1841
Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories
01-01-2005
E1902
Communication board, nonelectronic augmentative or alternative communication device
01-01-2002
E2000
Gastric suction pump, home model, portable or stationary, electric
01-01-2002
E2100
Blood glucose monitor with integrated voice synthesizer
01-01-2002
E2101
Blood glucose monitor with integrated lancing/blood sample
01-01-2002
E2120
Pulse generator system for tympanic treatment of inner ear endolymphatic fluid
01-01-2004
E2201
Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches
01-01-2004
E2202
Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches
01-01-2004
E2203
Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 inches
01-01-2004
E2204
Manual wheelchair accessory, nonstandard seat frame depth, 22-25 inches
01-01-2004
E2205
Manual wheelchair accessory, handrim without projections (includes ergonomic or contoured), any type, replacement only, each
01-01-2005
E2206
Manual wheelchair accessory, wheel lock assembly, complete, each
01-01-2005
E2207
Wheelchair accessory, crutch and cane holder, each
01-01-2006
E2208
Wheelchair accessory, cylinder tank carrier, each
01-01-2006
E2209
Arm trough, with or without hand support, each
01-01-2006
E2210
Wheelchair accessory, bearings, any type, replacement only, each
01-01-2006
E2211
Manual wheelchair accessory, pneumatic propulsion tire, any size, each
01-01-2006
E2212
Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each
01-01-2006
E2213
Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each
01-01-2006
E2214
Manual wheelchair accessory, pneumatic caster tire, any size, each
01-01-2006
E2215
Manual wheelchair accessory, tube for pneumatic caster tire, any size, each
01-01-2006
E2216
Manual wheelchair accessory, foam filled propulsion tire, any size, each
01-01-2006
E2217
Manual wheelchair accessory, foam filled caster tire, any size, each
01-01-2006
E2218
Manual wheelchair accessory, foam propulsion tire, any size, each
01-01-2006
E2219
Manual wheelchair accessory, foam caster tire, any size, each
01-01-2006
E2220
Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, each
01-01-2006
E2221
Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, each
01-01-2006
E2222
Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, each
01-01-2006
E2223
Manual wheelchair accessory, valve, any type, replacement only, each
01-01-2006
12-31-2009
E2224
Manual wheelchair accessory, propulsion wheel excludes tire, any size, each
01-01-2006
E2225
Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each
01-01-2006
E2226
Manual wheelchair accessory, caster fork, any size, replacement only, each
01-01-2006
E2227
Manual wheelchair accessory, gear reduction drive wheel, each
01-01-2008
E2228
Manual wheelchair accessory, wheel braking system and lock, complete, each
01-01-2008
E2230
Manual wheelchair accessory, manual standing system
01-01-2009
E2231
Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardware
01-01-2009
E2291
Back, planar, for pediatric size wheelchair including fixed attaching hardware
01-01-2005
E2292
Seat, planar, for pediatric size wheelchair including fixed attaching hardware
01-01-2005
E2293
Back, contoured, for pediatric size wheelchair including fixed attaching hardware
01-01-2005
E2294
Seat, contoured, for pediatric size wheelchair including fixed attaching hardware
01-01-2005
E2295
Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning features
01-01-2009
E2300
Wheelchair accessory, power seat elevation system, any type
01-01-2004
E2301
Wheelchair accessory, power standing system, any type
01-01-2004
E2310
Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware
01-01-2004
E2311
Power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware
01-01-2004
E2312
Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware
01-01-2008
E2313
Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each
01-01-2008
E2321
Power wheelchair accessory, hand control interface, remote joystick, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware
01-01-2004
E2322
Power wheelchair accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware
01-01-2004
E2323
Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated
01-01-2004
E2324
Power wheelchair accessory, chin cup for chin control interface
01-01-2004
E2325
Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware
01-01-2004
E2326
Power wheelchair accessory, breath tube kit for sip and puff interface
01-01-2004
E2327
Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware
01-01-2004
E2328
Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware
01-01-2004
E2329
Power wheelchair accessory, head control interface, contact switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware
01-01-2004
E2330
Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware
01-01-2004
E2331
Power wheelchair accessory, attendant control, proportional, including all related electronics and fixed mounting hardware
01-01-2004
E2340
Power wheelchair accessory, nonstandard seat frame width, 20-23 in.
01-01-2004
E2341
Power wheelchair accessory, nonstandard seat frame width, 24-27 in.
01-01-2004
E2342
Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 in.
01-01-2004
E2343
Power wheelchair accessory, nonstandard seat frame depth, 22-25 in.
01-01-2004
E2351
Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface
01-01-2004
E2358
Power wheelchair accessory, group 34 non-sealed lead acid battery, each
01-01-2012
E2359
Power wheelchair accessory, group 34 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat)
01-01-2012
E2360
Power wheelchair accessory, 22 nf nonsealed lead acid battery, each
01-01-2004
E2361
Power wheelchair accessory, 22 nf sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat)
01-01-2004
E2362
Power wheelchair accessory, group 24 nonsealed lead acid battery, each
01-01-2004
E2363
Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)
01-01-2004
E2364
Power wheelchair accessory, u-1 nonsealed lead acid battery, each
01-01-2004
E2365
Power wheelchair accessory, u-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)
01-01-2004




Version Effective Date: 05/18/2020
Version Issued Date: 05/18/2020
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.