Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 05.00.21t


Attachment:A2

Policy #:05.00.21t

Description:Equipment that Meets the Definition of Durable Medical Equipment (DME)

Title:Durable Medical Equipment (DME) and Consumable Medical Supplies


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.



EQUIPMENT THAT MEETS THE DEFINITION OF DURABLE MEDICAL EQUIPMENT (DME)

The equipment listed in the following tables meets the Company's definition of durable medical equipment (DME). Reimbursement consideration by the Company is contingent upon the following:
  • The individual has the benefit for the item.
  • The item is neither considered experimental/investigational nor considered not medically necessary by the Company.
  • The item is considered medically necessary for the treatment of, or as an aid in the treatment of, a medical or surgical condition.
  • The item is ordered by an eligible professional provider.
  • The item is provided by a DME provider or, in limited circumstances, by another eligible provider type as allowed by the Company.
TABLE I
DURABLE MEDICAL EQUIPMENT
(CONTINUED FROM ATTACHMENT A1)
HCPCS
CODE
NARRATIVE DESCRIPTION
A9272
Wound suction, disposable, includes dressing, all accessories and components, any type, each
E2511
Speech generating software program, for personal computer or personal digital assistant
E2512
Accessory for speech generating device, mounting system
E2599
Accessory for speech generating device, not otherwise classified
E2601
General use wheelchair seat cushion, width less than 22 inches, any depth
E2602
General use wheelchair seat cushion, width 22 inches or greater, any depth
E2603
Skin protection wheelchair seat cushion, width less than 22 inches, any depth
E2604
Skin protection wheelchair seat cushion, width 22 inches or greater, any depth
E2605
Positioning wheelchair seat cushion, width less than 22 inches, any depth
E2606
Positioning wheelchair seat cushion, width 22 inches or greater, any depth
E2607
Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth
E2608
Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any depth
E2609
Custom fabricated wheelchair seat cushion, any size
E2610
Wheelchair seat cushion, powered
E2611
General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware
E2612
General use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardware
E2613
Positioning wheelchair back cushion, posterior, width less than 22 inches, any height, including any type mounting hardware
E2614
Positioning wheelchair back cushion, posterior, width 22 inches or greater, any height, including any type mounting hardware
E2615
Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any height, including any type mounting hardware
E2616
Positioning wheelchair back cushion, posterior-lateral, width 22 inches or greater, any height, including any type mounting hardware
E2617
Custom fabricated wheelchair back cushion, any size, including any type mounting hardware
E2620
Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 inches, any height, including any type mounting hardware
E2621
Positioning wheelchair back cushion, planar back with lateral supports, width 22 inches or greater, any height, including any type mounting hardware
E2622
Skin protection wheelchair seat cushion, adjustable, width less than 22 inches,
any depth
E2623
Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater,
any depth
E2624
Skin protection and positioning wheelchair seat cushion, adjustable, width less
than 22 inches, any depth
E2625
Skin protection and positioning wheelchair seat cushion, adjustable, width 22
inches or greater, any depth
E2630
Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support
E2631
Wheelchair accessory, addition to mobile arm support, elevating proximal arm
E2632
Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control
E2633
Wheelchair accessory, addition to mobile arm support, supinator
K0001
Standard wheelchair
K0002
Standard hemi (low seat) wheelchair
K0003
Lightweight wheelchair
K0004
High strength, lightweight wheelchair
K0005
Ultralightweight wheelchair
K0006
Heavy-duty wheelchair
K0007
Extra heavy-duty wheelchair
K0008
Custom Manual Wheelchair Base
K0009
Other manual wheelchair/base
K0010
Standard-weight frame motorized/power wheelchair
K0011
Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking
K0012
Lightweight portable motorized/power wheelchair
K0013
Custom Motorized/Power Wheelchair Base
K0014
Other motorized/power wheelchair base
K0015
Detachable, nonadjustable height armrest, each
K0020
Fixed, adjustable height armrest, pair
K0038
Leg strap, each
K0039
Leg strap, H style, each
K0040
Adjustable angle footplate, each
K0041
Large size foot plate, each
K0053
Elevating footrests, articulating (telescoping), each
K0056
Seat height less than 17 inches or equal to or greater than 21 in inches for a high strength, lightweight, or ultralightweight wheelchair
K0065
Spoke protectors, each
K0073
Caster pin lock, each
K0105
IV hanger, each
K0108
Wheelchair component or accessory, not otherwise specified
K0195
Elevating legrests, pair (for use with capped rental wheelchair base)
K0455
Infusion pump used for uninterrupted parenteral administration of medication (eg, epoprostenol or treprostinol)
K0552
Supplies for external non-insulin drug infusion pump, syringe type cartridge, sterile, each
K0606
Automatic external defibrillator, with integrated electrocardiogram analysis, garment type
K0669
Wheelchair accessory, wheelchair seat or back cushion, does not meet specific code criteria or no written coding verification from DME PDAC
K0730
Controlled dose inhalation drug delivery system
K0733
Power wheelchair accessory, 12 to 24 AMP hour sealed lead acid battery, each (eg, gel cell, absorbed glassmat)
K0738
Portable gaseous oxygen system, rental: home compressor used to fill portable oxygen cylinders, includes containers, regulator, flowmeter, regulator, flowmeter, humidifier, cannula or mask and tubing
K0743
Suction pump, home model, portable, for use on wounds
K0744
Absorptive wound dressing for use with suction pump, home model, portable, pad size 16 sq in or less
K0745
Absorptive wound dressing for use with suction pump, home model, portable, pad size more than 16 square inches but less than or equal to 48 sq in
K0746
Absorptive wound dressing for use with suction pump, home model, portable, pad size greater than 48 sq in
K0800
Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds
K0801
Power operated vehicle, group 1 heavy duty, patient weight capacity, 301 to 450 pounds
K0802
Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to 600 pounds
K0806
Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds
K0807
Power operated vehicle, group 2 heavy duty, patient weight capacity 301 to 450 pounds
K0808
Power operated vehicle, group 2 very heavy-duty, patient weight capacity 451 to 600 pounds
K0812
Power operated vehicle, not otherwise classified
K0813
Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds
K0814
Power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds
K0815
Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds
K0816
Power wheelchair, group 1 standard, captains chair, patient weight capacity up to and including 300 pounds
K0820
Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0821
Power wheelchair, group 2 standard, portable, captains chair, patient weight capacity up to and including 300 pounds
K0822
Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0823
Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds
K0824
Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0825
Power wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds
K0826
Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0827
Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds
K0828
Power wheelchair, group 2 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more
K0829
Power wheelchair, group 2 extra heavy-duty, captain's chair, patient weight 601 pounds or more
K0835
Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0836
Power wheelchair, group 2 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds
K0837
Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0838
Power wheelchair, group 2 heavy duty, single power option, captains chair, patient capacity 301 to 450 pounds
K0839
Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0840
Power wheelchair, group 2 extra heavy duty, single power option sling/solid seat/back, patient capacity 601 pounds or more
K0841
Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0842
Power wheelchair, group 2 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds
K0843
Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0848
Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0849
Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and including 300 pounds
K0850
Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0851
Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to 450 pounds
K0852
Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0853
Power wheelchair, group 3 very heavy duty, captains chair, patient weighty capacity, 451 to 600 pounds
K0854
Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more
K0855
Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601 pounds or more
K0856
Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0857
Power wheelchair, group 3 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds
K0858
Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0859
Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds
K0860
Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0861
Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0862
Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0863
Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0864
Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more
K0868
Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including up to and including 300 pounds
K0869
Power wheelchair, group 4 standard, captains chair, patient weight capacity up to and including 300 pounds
K0870
Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0871
Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0877
Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0878
Power wheelchair, group 4 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds
K0879
Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0880
Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient 451 to 600 pounds
K0884
Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient capacity up to and including 300 pounds
K0885
Power wheelchair, group 4 standard, multiple power option, captains chair, weight capacity up to and including 300 pounds
K0886
Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0890
Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds
K0891
Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds
K0898
Power wheelchair, not otherwise classified
K0899
Power mobility device not coded by DME PDAC or does not meet the criteria
K0900
Customized Durable Medical Equipment, Other Than Wheelchair
S1030
Continuous noninvasive glucose monitoring device, purchase (for physician interpretation of data, use CPT code)
S1031
Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement and download to monitor (for physician interpretation of data, use CPT code)
S8097
Asthma kit (including but not limited to portable peak expiratory flow meter, instructional video, brochure, and/or spacer)
S8100
Holding chamber or spacer for use with an inhaler or nebulizer; without mask
S8101
Holding chamber or spacer for use with an inhaler or nebulizer; with mask
S8185
Flutter device
S8186
Swivel adaptor
S8189
Tracheostomy supply, not otherwise classified
S8210
Mucus trap
S8265
Haberman feeder for cleft lip/palate
S8420
Gradient pressure aid (sleeve and glove combination), custom made
S8421
Gradient pressure aid (sleeve and glove combination), ready made
S8422
Gradient pressure aid (sleeve), custom made, medium weight
S8423
Gradient pressure aid (sleeve), custom made, heavy weight
S8424
Gradient pressure aid (sleeve), ready made
S8425
Gradient pressure aid (glove), custom made, medium weight
S8426
Gradient pressure aid (glove), custom made, heavy weight
S8427
Gradient pressure aid (glove), ready made
S8428
Gradient pressure aid (gauntlet), ready made
S8429
Gradient pressure exterior wrap
S8430
Padding for compression bandage, roll
S8431
Compression bandage, roll
S8999
Resuscitation bag (for use by patient on artificial respiration during power failure or other catastrophic event)
S9007
Ultrafiltration monitor
T1505
Electronic medication compliance management device, includes all components
and accessories, not otherwise classified


Version Effective Date: 01/01/2019
Version Issued Date: 01/10/2019
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.