| Attachment A: Repair and Replacement of Durable
Medical Equipment (DME) and Prosthetic Devices |
REPAIR AND REPLACEMENT OF DURABLE
MEDICAL EQUIPMENT (DME) |
| A4233 | Replacement battery, alkaline
(other than J cell), for use with medically necessary home blood glucose
monitor owned by patient, each |
|
A4234 | Replacement battery, alkaline, J
cell, for use with medically necessary home blood glucose monitor owned by
patient, each |
|
A4235 | Replacement battery, lithium,
for use with medically necessary home blood glucose monitor owned by patient,
each |
|
A4236 | Replacement battery, silver
oxide, for use with medically necessary home blood glucose monitor owned by
patient, each |
|
A4257 | Replacement lens shield
cartridge for use with laser skin piercing device, each |
|
A4281 | Tubing for breast pump,
replacement |
|
A4282 | Adapter for breast pump,
replacement |
|
A4283 | Cap for breast pump bottle,
replacement |
|
A4284 | Breast shield and splash
protector for use with breast pump, replacement |
|
A4285 | Polycarbonate bottle for use
with breast pump, replacement |
|
A4286 | Locking ring for breast pump,
replacement |
A4341
| Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each
|
A4342
| Accessories for patient inserted indwelling intraurethral drainage device with valve, replacement only, each
|
A4453
| Rectal catheter for use with the manual pump-operated enema system, replacement only
|
A4457
| Enema tube, with or without adapter, any type, replacement only, each
|
|
A4600 | Sleeve for intermittent limb
compression device, replacement only, each |
|
A4601 | Lithium ion battery,
rechargeable, for non-prosthetic use, replacement |
|
A4602 | Replacement battery for external
infusion pump owned by patient, lithium, 1.5 volt, each |
|
A4606 | Oxygen probe for use with
oximeter device, replacement |
|
A4611 | Battery, heavy duty; replacement
for patient-owned ventilator |
|
A4612 | Battery cables; replacement for
patient-owned ventilator |
|
A4613 | Battery charger; replacement for
patient-owned ventilator |
|
A4630 | Replacement batteries, medically
necessary, transcutaneous electrical stimulator, owned by patient |
|
A4633 | Replacement bulb/lamp for
ultraviolet light therapy system, each |
|
A4634 | Replacement bulb for therapeutic
light box, tabletop model |
|
A4635 | Underarm pad, crutch,
replacement, each |
|
A4636 | Replacement, handgrip, cane,
crutch, or walker, each |
|
A4637 | Replacement, tip, cane, crutch,
walker, each |
|
A4640 | Replacement pad for use with
medically necessary alternating pressure pad owned by patient |
|
A5113 | Leg strap; latex, replacement
only, per set |
|
A5114 | Leg strap; foam or fabric,
replacement only, per set |
|
A7020 | Interface for cough stimulating
device, includes all components, replacement only |
|
A7025 | High frequency chest wall
oscillation system vest, replacement for use with patient owned equipment,
each |
|
A7026 | High frequency chest wall
oscillation system hose, replacement for use with patient owned equipment,
each |
|
A8004 | Soft interface for helmet,
replacement only |
|
E0159 | Brake attachment for wheeled
walker, replacement, each |
|
E0167 | Pail or pan for use with commode
chair, replacement only |
|
E0182 | Pump for alternating pressure
pad, for replacement only |
|
E1354 | Oxygen accessory, wheeled cart
for portable cylinder or portable concentrator, any type, replacement only,
each |
|
E1356 | Oxygen accessory, battery
pack/cartridge for portable concentrator, any type, replacement only, each |
|
E1357 | Oxygen accessory, battery
charger for portable concentrator, any type, replacement only, each |
|
E1358 | Oxygen accessory, DC power
adapter for portable concentrator, any type, replacement only, each |
|
E0785 | Implantable intraspinal
(epidural/intrathecal) catheter used with implantable infusion pump,
replacement |
|
E0786 | Implantable programmable
infusion pump, replacement (excludes implantable intraspinal catheter) |
|
E0967 | Manual wheelchair accessory,
hand rim with projections, any type, replacement only, each |
|
E0981 | Wheelchair accessory, seat
upholstery, replacement only, each |
|
E0982 | Wheelchair accessory, back
upholstery, replacement only, each |
|
E0995 | Wheelchair accessory, calf
rest/pad, replacement only, each |
|
E1530 | Air bubble detector for
hemodialysis, each, replacement |
|
E1540 | Pressure alarm for hemodialysis,
each, replacement |
|
E1560 | Blood leak detector for
hemodialysis, each, replacement |
|
E1620 | Blood pump for hemodialysis,
replacement |
|
E1701 | Replacement cushions for jaw
motion rehabilitation system, package of six |
|
E1702 | Replacement measuring scales for
jaw motion rehabilitation system, package of 200 |
|
E1820 | Replacement soft interface
material, dynamic adjustable extension/flexion device |
|
E1821 | Replacement soft interface
material/cuffs for bidirectional static progressive stretch device |
|
E2205 | Manual wheelchair accessory,
handrim without projections, (includes ergonomic or contoured) any type,
replacement only, each |
|
E2206 | Manual wheelchair accessory,
wheel lock assembly, complete, replacement only, each |
|
E2210 | Wheelchair accessory, bearings,
any type, replacement only, each |
|
E2220 | Manual wheelchair accessory,
solid (rubber/plastic) propulsion tire, any size, replacement only, each |
|
E2221 | Manual wheelchair accessory,
solid (rubber/plastic) caster tire (removable), any size, replacement only,
each |
|
E2222 | Manual wheelchair accessory,
solid (rubber/plastic) caster tire with integrated wheel, any size,
replacement only, each |
|
E2224 | Manual wheelchair accessory,
propulsion wheel excludes tire, any size, replacement only, each |
|
E2225 | Manual wheelchair accessory,
caster wheel excludes tire, any size, replacement only, each |
|
E2226 | Manual wheelchair accessory,
caster fork, any size, replacement only, each |
|
E2368 | Power wheelchair component,
drive wheel motor, replacement only |
|
E2369 | Power wheelchair component,
drive wheel gear box, replacement only |
|
E2370 | Power wheelchair component,
integrated drive wheel motor and gear box combination, replacement only |
|
E2374 | Power wheelchair accessory, hand
or chin control interface, standard remote joystick (not including
controller), proportional, including all related electronics and fixed
mounting hardware, replacement only |
|
E2375 | Power wheelchair accessory,
non-expandable controller, including all related electronics and mounting
hardware, replacement only |
|
E2376 | Power wheelchair accessory,
expandable controller, including all related electronics and mounting
hardware, replacement only |
|
E2378 | Power wheelchair component,
actuator, replacement only |
|
E2381 | Power wheelchair accessory,
pneumatic drive wheel tire, any size, replacement only, each |
|
E2382 | Power wheelchair accessory, tube
for pneumatic drive wheel tire, any size, replacement only, each |
|
E2383 | Power wheelchair accessory,
insert for pneumatic drive wheel tire (removable), any type, any size,
replacement only, each |
|
E2384 | Power wheelchair accessory,
pneumatic caster tire, any size, replacement only, each |
|
E2385 | Power wheelchair accessory, tube
for pneumatic caster tire, any size, replacement only, each |
|
E2386 | Power wheelchair accessory, foam
filled drive wheel tire, any size, replacement only, each |
|
E2387 | Power wheelchair accessory, foam
filled caster tire, any size, replacement only, each |
|
E2388 | Power wheelchair accessory, foam
drive wheel tire, any size, replacement only, each |
|
E2389 | Power wheelchair accessory, foam
caster tire, any size, replacement only, each |
|
E2390 | Power wheelchair accessory,
solid (rubber/plastic) drive wheel tire, any size, replacement only, each |
|
E2391 | Power wheelchair accessory,
solid (rubber/plastic) caster tire (removable), any size, replacement only,
each |
|
E2392 | Power wheelchair accessory,
solid (rubber/plastic) caster tire with integrated wheel, any size,
replacement only, each |
|
E2394 | Power wheelchair accessory,
drive wheel excludes tire, any size, replacement only, each |
|
E2395 | Power wheelchair accessory,
caster wheel excludes tire, any size, replacement only, each |
|
E2396 | Power wheelchair accessory,
caster fork, any size, replacement only, each |
|
E2619 | Replacement cover for wheelchair
seat cushion or back cushion, each |
|
K0015 | Detachable, non-adjustable
height armrest, replacement only, each |
|
K0017 | Detachable, adjustable height
armrest, base, replacement only, each |
|
K0018 | Detachable, adjustable height
armrest, upper portion, replacement only, each |
|
K0019 | Arm pad, replacement only, each |
|
K0042 | Standard size footplate,
replacement only, each |
|
K0043 | Footrest, lower extension tube,
replacement only, each |
|
K0044 | Footrest, upper hanger bracket,
replacement only, each |
|
K0045 | Footrest, complete assembly,
replacement only, each |
|
K0046 | Elevating legrest, lower
extension tube, replacement only, each |
|
K0047 | Elevating legrest, upper hanger
bracket, replacement only, each |
|
K0050 | Ratchet assembly, replacement
only |
|
K0051 | Cam release assembly, footrest
or legrest, replacement only, each |
|
K0052 | Swingaway, detachable footrests,
replacement only, each |
|
K0069 | Rear wheel assembly, complete,
with solid tire, spokes or molded, replacement only, each |
|
K0070 | Rear wheel assembly, complete,
with pneumatic tire, spokes or molded, replacement only, each |
|
K0071 | Front caster assembly, complete,
with pneumatic tire, replacement only, each |
|
K0072 | Front caster assembly, complete,
with semi-pneumatic tire, replacement only, each |
|
K0077 | Front caster assembly, complete,
with solid tire, replacement only, each |
|
K0098 | Drive belt for power wheelchair,
replacement only |
|
K0462 | Temporary replacement for
patient-owned equipment being repaired, any type |
|
K0601 | Replacement battery for external
infusion pump owned by patient, silver oxide, 1.5 volt, each |
|
K0602 | Replacement battery for external
infusion pump owned by patient, silver oxide, 3 volt, each |
|
K0603 | Replacement battery for external
infusion pump owned by patient, alkaline, 1.5 volt, each |
|
K0604 | Replacement battery for external
infusion pump owned by patient, lithium, 3.6 volt, each |
|
K0605 | Replacement battery for external
infusion pump owned by patient, lithium, 4.5 volt, each |
|
K0607 | Replacement battery for
automated external defibrillator, garment type only, each |
|
K0608 | Replacement garment for use with
automated external defibrillator, each |
|
K0609 | Replacement electrodes for use
with automated external defibrillator, garment type only, each |
|
|
THE FOLLOWING CODES ARE USED TO REPRESENT THE
LABOR COMPONENT FOR REPAIR OF DME DEVICES: |
K0739 | Repair or nonroutine service for
durable medical equipment other than oxygen requiring the skill of a
technician, labor component, per 15 minutes |
K0740 | Repair or nonroutine service for
oxygen equipment requiring the skill of a technician, labor component, per 15
minutes |
|
|
REPAIR AND REPLACEMENT OF PROSTHETIC DEVICES |
|
A4363 | Ostomy clamp, any type,
replacement only, each |
|
A5113 | Leg strap; latex, replacement
only, per set |
|
A5114 | Leg strap; foam or fabric,
replacement only, per set |
|
L5700 | Replacement, socket, below knee,
molded to patient model |
|
L5701 | Replacement, socket, above
knee/knee disarticulation, including attachment plate, molded to patient
model |
|
L5702 | Replacement, socket, hip
disarticulation, including hip joint, molded to patient model |
|
L5703 | Ankle, Symes, molded to patient
model, socket without solid ankle cushion heel (SACH) foot, replacement only |
|
L5704 | Custom shaped protective cover,
below knee (BK) |
|
L5705 | Custom shaped protective cover,
above knee (AK) |
|
L5706 | Custom shaped protective cover,
knee disarticulation |
|
L5707 | Custom shaped protective cover,
hip disarticulation |
|
L5971 | All lower extremity prosthesis,
solid ankle cushion heel (SACH) foot, replacement only |
|
L6883 | Replacement socket, below
elbow/wrist disarticulation, molded to patient model, for use with or without
external power |
|
L6884 | Replacement docket, above
elbow/elbow disarticulation, molded to patient model, for with or without
external power. |
|
L6885 | Replacement socket, shoulder
disarticulation/interscapular thoracic, molded to patient model, for use with
or without external power |
|
L6915 | Hand restoration (shading and
measurements included), replacement glove for above |
|
L7367 | Lithium ion battery,
rechargeable, replacement |
|
L7368 | Lithium ion battery charger,
replacement only |
|
L7902 | Tension ring, for vacuum
erection device, any type, replacement only, each |
|
L8048 | Unspecified maxillofacial
prosthesis, by report, provided by a nonphysician |
|
L8505 | Artificial larynx replacement
battery/accessory, any type |
|
L8511 | Insert for indwelling
tracheoesophageal prosthesis, with or without valve, replacement only, each |
|
L8512 | Gelatin capsules or equivalent,
for use with tracheoesophageal voice prosthesis, replacement only, per 10 |
|
L8513 | Cleaning device used with
tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement only,
each |
|
L8514 | Tracheoesophageal puncture
dilator, replacement only, each |
|
L8615 | Headset/headpiece for use with
cochlear implant device, replacement |
|
L8616 | Microphone for use with cochlear
implant device, replacement |
|
L8617 | Transmitting coil for use with
cochlear implant device, replacement |
|
L8618 | Transmitter cable for use with
cochlear implant device or auditory osseointegrated device, replacement |
|
L8619 | Cochlear implant, external
speech processor and controller, integrated system, replacement |
|
L8621 | Zinc air battery for use with
cochlear implant device, replacement, each |
|
L8622 | Alkaline battery for use with
cochlear implant device, any size, replacement, each |
|
L8623 | Lithium ion battery for use with
cochlear implant device speech processor, other than ear level, replacement,
each |
|
L8624 | Lithium ion battery for use with
cochlear implant or auditory osseointegrated device speech processor, ear
level, replacement, each |
|
L8625 | External recharging system for
battery for use with cochlear implant or auditory osseointegrated device,
replacement only, each |
|
L8627 | Cochlear implant, external
speech processor, component, replacement |
|
L8628 | Cochlear implant, external
controller component, replacement |
|
L8629 | Transmitting coil and cable,
integrated, for use with cochlear implant device, replacement |
|
L8681 | Patient programmer (external)
for use with implantable programmable neurostimulator pulse generator,
replacement only |
|
L8684 | Radiofrequency transmitter
(external) for use with implantable sacral root neurostimulator receiver for
bowel and bladder management, replacement |
|
L8689 | External recharging system for
battery (internal) for use with implantable neurostimulator, replacement only |
|
L8691 | Auditory osseointegrated device,
external sound processor, excludes transducer/actuator, replacement only,
each |
|
L8693 | Auditory osseointegrated device
abutment, any length, replacement only |
|
L8694 | Auditory osseointegrated device,
transducer/actuator, replacement only, each |
|
L8695 | External recharging system for
battery (external) for use with implantable neurostimulator, replacement only |
|
L8696 | Antenna (external) for use with
implantable diaphragmatic/phrenic nerve stimulation device, replacement, each |
L8721
| Receptor sole for use with l8720, replacement, each
|
THE FOLLOWING CODES ARE USED TO REPRESENT THE
LABOR COMPONENT FOR REPAIR OF PROSTHETIC DEVICES: |
| L7510 | Repair of prosthetic device,
repair or replace minor parts |
| L7520 | Repair prosthetic device, labor
component, per 15 minutes |
| L8049 | Repair or modification of
maxillofacial prosthesis, labor component, 15 minute increments, provided by
a nonphysician
|
