dhmh - marylandxl 025 administration set for enteral feeding with 1400ml. (and above) bag or...
TRANSCRIPT
PT20-01
STATE OF MARYLAND
DHMH Office of Health ServicesMedical Care Programs
MARYLAND MEDICAL ASSISTANCE PROGRAMMEDICAL SUPPLY AND EQUIPMENT TRANSMITTAL NO. 51
May16,2001
Medical Supply and Equipment Providers
Joseph M. Millstone, Executive Director ~l)t.tOffice of Health Services V
FROM:
NOTE: Please ensure that appropriate staff members in your organization areinformed of the contents of this transmittal
Updated Approved List of Items
The Maryland Medical Assistance Program has updated the Disposable MedicalSupplies/Durable Medical Equipment Approved List of Items, effective March 1, 2001.
Please note that unused procedure codes have been deleted from the Approved List.This process was perfonned to prepare for the implementation of the Health InsurancePortability and Accountability Act of 1996 (HIPAA) conversion.
If you have further questions concerning this list, please call the Staff Specialist forDisposable Medical Supplies and Durable Medical Equipment at (410) 767-1739.
Reminder: Diabetic-monitoring supplies cannot be billed as point-or-sale pharmac):items. The): must be billed on the HCF A 1500 using ):our DMS/DME provider number.
Toll Free .877-4MD-DHMH.1TY for Disabled - Maryland Relay Service 1-800,.735-2258
Web Site: www.dhmh.state.md.us
20 I W. Preston Street. Baltimore, Maryland 2120 IPanis N. Glendening. Governor - Georges C. Benjamin, M.D., Secretary
MARYLAND MEDICAL ASSISTANCE PROGRAM
DISPOSABLE MEDICAL SUPPLIES
AND
DURABLE MEDICAL EQUIPMENT
APPROVED LIST OF ITEMS
EFFECTIVE MARCH 1, 2001
'1 ~ . .
rPREAUTHORIZA TION REQUIREMENTS
COMAR 10.09.12.06
A. Preauthorization is required for:
(1) Disposable medical supplies listed in Regulations .04A and B with a charge exceeding
$300;(2) All incontinency pants and disposable under pads;(3) DME priced on the list of items as individual consideration (I/C)(4) Any rental of durable medical equipment after the third month of rental;(5) Osteogenesis stimulators; and(6) All repairs to purchased dme exceeding $500.
B. Preauthorization is not required for:
(1) Any disposable medical supplies and durable medical equipment for home kidney
dialysis;(2) Prosthetic devices; and(3) DME on the approved list of items with both a procedure code and a purchase price
under $750.(4) Labor charges for repairs under three hours.
~
MARYLAND MEDICAL ASSISTANCE PROGRAM
DISPOSABLE MEDICAL SUPPLIESAND
DURABLE MEDICAL EQUIPMENT
APPROVED LIST OF ITEMSProcedure Codes and Maximum Allowable Prices
TABLE OF CONTENTS
~3
4 -20
4-5S-7
General Notes Pertaining to DMS/DME
Part I: DISPOSABLE MEDICAL SUPPLIES
Administration Supplies for Intravenous Medication
Administration Supplies for Enteral and Parenteral Nutrition
7
12
12
13
13
14 - 20
21
22222222
23
Diabetic Monitoring Supplies
Ostomy and Permanent Urinary Incontinence Supplies
Spinal Cord Dysfunction Care Supply Kits
Bum Gannents
Support Stockings. Individually Form - Fitted
Osteogenesis Simulators
Suction Supplies
Miscellaneous Medical Supplies (including Wound Care Supplies)
Part II: DURABLE MEDICAL EOUIPMENT (Purchase/Rental)
Apnea Monitors and Accessories
Beds, HospitalMattressSide Rails
Blood Glucose Monitoring Equipment
Braces and Supports
Canes,Crutches and Shower Chairs
2S
2S
2S.
Commodes
Enteral and Parenteral Nutrition Equipment
Intravenous Medication Equipment
Nebulizers and Accessories
1 .
.26
. '
r~27272727
Prosthetic DevicesEyeBreastLimbs
28
28
28
29
30-35
33-34
Suction Equipment and Accessories
TENS Equipment and Accessories
Traction Equipment
Walkers and Accessories
Wheelchairs, Power-operated Vehicles and Transporters
Accessories
34Modifications
36
363636363636363636363636363637
37
38-42
Pediatric Adaptive/Positioning Accessories
Miscellaneous Durable Medical EquipmentAugmentative Communication Devices and AccessoriesBed PansBlood Pressure EquipmentCollarsDrug Delivery SystemIncontinence Pants and PadsPatil'nt LiftPhototherapy Unit, Home usePressure Pads, AlternatingSplints, Wrist and PositioningTrapeze BarsTruss Support
VaporizerDurable Medical Equipment, not otherwise classified
Repairs to Durable Medical Equipment
Pediatric DME
43-44
44
Respiratory Equipment and Accessories
Used Equipment
)-2-
General Notes Pertaining to DMS/DME
For certain categories of Disposable Medical Supplies and Durable Wedical Equipmentwhich are unlisted and/or priced by individual consideration (I/C), the word "~if'i" isshown, indicating that additional information is needed to process preauthorizationrequests and/or claim forms.
This information usually consists of the following:1. Manufacturer's name;2. Manufacturer's product number;3. Number of individual items per packaging unit (for supplies 2..Tld accessories);4. Provider's usual and customary charge;If this information cannot be provided, please attach a product she~t identifying
each item, manufacturer, distributor, or supplier; or submit other appropriate informationwhich describes the item(s) and identifies a contact source. In all these instances, pleaseinclude addresses and telephone numbers as well.
Your cooperation in supplying this information initially wilt reduce the time toprocess your request or claim.
If you have questions or comments concerning this list please taU (410) 767-1739 or you may send an e-mail to [email protected].
Preauthorization Requirements
COMAR 10.09.12.06
A. Preauthorization is required for:
(1) Disposable medical supplies listed in Regulations .04A and B ,..'ith a chargeexceeding $300;
(2) All incontinency pants and disposable underpads;(3) Osteogenesis stimulators;(4) Durable medical equipment priced on the approved list ofiten.s as individual
consideration (I/C);(5) Disposable medical supplies and durable medical equipment n.:>t on the approved
list of items;(6) Any rental of durable medical equipment after 3 months of rer,tal; and(7) All repairs to purchased durable medical equipment exceedin~ $500.
B. Preauthorization is not required for:(1 ) Prosthetic devices; and(2) Durable medical equipment on the approved list with both a r-rocedure code and
a purchase price under $750.
-3-
t '"
MARYLAND MEDICAL ASSISTANCE PROGRAMDISPOSABLE MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT
APPROVED LIST OF ITEMSr
~I/C - Individual ConsiderationNC - Not CoveredUC - Usual and CustomaryAN - As Needed
Part 1: DISPOSABLE MEDICAL SUPPLIES
ADMINISTRATION SUPPLIES FOR INTRA VENOUS MEDICATION ANDPARENTAL NUTRITION
PricePerl!niL
MaximumUnits perService.
ProcedureCode
Pricing!1nLItem Descri~tion
$ 5.0010.70
eacheach
9090
4.55 each 90
33.00 each 30
10.002.45
eacheach
1090
10.504.28
eacheach
306
5.93 each 6
8.99 each 6
5.93 each 90
7.45 each 90
.20
.31
.16
eacheacheach
100100100
XI030Injection cap, needlesX I 000 Administration Set for intravenous
medication (with filter)X I 00 I Administration Set for intravenous
medication (without filter)X I 04 7 Administration set for ambulatory
infusion pumpX 1049 Central line trayX 1002 Filter for intravenous medication
administration (when sold
separately)XI043 IV extension setX I 051 Sharps disposable container, 1 quart
capacityXI052 Sharps disposable container, 5 quart
capac ityXI053 Sharps disposable container, 8 quart
capacityX I 044 Infusion Bag, disposable, for mechanical
driverXI045 Infusion Bag, multi-use for mechanical
driverXI054 Syringe only, 0.5ml or ImlXI055 Syringe with needle, 0.5ml or ImlXI056 Syringe only, 3ml
4-
Maximu::.'.Units pt~.Service
PricePer!.!niL
Pricing!.!.niL
Procedure
Code Item Descriotion
10010010010010010010010010010025
$ .23.26.39.2944.28.41.31.46.76
1.15I/C
eacheacheacheacheacheacheacheacheacheacheach
each 9011.90
each 908.85
903.15 each
8.00 each 2
30
XI057 Syringe with needle, 3ml
XI058Syringeonly,5mlXI059 Syringe with needle 5mlXI060Syringe only, 6mlXI061 Syringe with needle, 6mlXI062 Syringe only, IOmIX I 063 Syringe with needle, IOmIX I 064 Syringe only, 12mlX I 065 Syringe with needle, 12mlXI 066 Syringe, 20mlXI 067 Syringe, 3OmI- 35mlX I 079 Unlisted Administration Supplies
for intravenous medicationX 1003 Administration Set for parenteral, feeding (with filter)
X 1004 Administration Set for parenteral feeding
(without filter)X 1005 Filter for parenteral feeding
(when sold separately)X 1006 Dravon Clamp for use with parenteral
feedingX 1007 Injection Caps for use with parenteral
feeding
2.50 each
XI 019 Unlisted Administration supplies forparenteral nutrition (specify)
I/C
ADMINISTRATION SUPPLIES FOR ENTERAL NUTRITION ONLY
1.102.50.67.26.26.16.20.29.31
1.15
eacheacheacheacheacheacheacheacheacheach
10010010010010010010010010025
X I 0 II Adapters for enteral feedingX I 0 12 Syringe for enteral feeding - 50-60mlX I 0 14 Syringe for enteral feeding - 20mlX I 0 IS Syringe for enteral feeding - 10mlXIOl6Syringe for enteral feeding - 5mlX 1017 Syringe for enteral feeding - 3mlX I 069 Syringe for enteral feeding - 0.5 or I mlX 1070 Syringe for enteral feeding - 6mlXI 071 Syringe for enteral feeding - 12mlX 1072 Syringe for enteral feeding - 3Oml - 35ml
- ~-
~ ~ .v
MaximumUnits perService
PricePer!l!!i!
PricingUnit.
ProcedureCode Item Descriotion
9090159090
eacheacheach b':/SOeacheach
S 3.006.30
46.505.307.85
30each.20
30each11.45
3011.80 each
90each5.75
90each6.25
each 907.25
Xl 0 18 Tubing for enteral feeding pediatricXl 020 Tubing for enteral feeding adultB4081 Nasogastric tubingXI021 Administration Set for enteral feedingXl 022 Administration Set for enteral feeding
with 500/60OmI. bag or containerXl 023 Administration Set for enteral feeding
with l000ml. bag or containerXl 024 Administration Set for enteral feeding
with 1200ml. bag or containerXl 025 Administration Set for enteral feeding
with 1400ml. (and above) bag orcontainer
Xl 026 Container or Bag for enteral feeding-500/60Oml.
Xl 027 Container or Bag for enteral feeding1000/1200ml
Xl 028 Container or Bag for enteral feeding -1400ml and above
each 905.00Xl 046 Adapter, pediatric
9050
14.0033.00
eacheach
9090SO
eacheacheach
2.095.401.50
644.78 each
each 4132.00
each194.00
9010.50 each
6013.13 each
Xl 031 Administration Set, with filter - pediatric
Xl 032 Administration Set for ambulatoryinfusion pump
Xl 034 Extension Set, standardXI03SExtension Set, with port(s)XI 036 Extension Set or bolus feeding
replacement, "MIC-Key" typeXI 038 Gastrostomy Feeding Tube, Scc and
20cc balloon, "MIC-Key" type, allsizes
X I 037 Gastrostomy Feeding Kit, Skin Level,"MIC-Key" type, all sizes
X I 040 Gastrostomy Feeding Device System,"Button" type, sterile, complete
X I 042 Feeding Tube for Gastrostomy Device"Button" type, replacement, all sizes
X I 041 Decompression Tube for GastrostomyDevices "Button" type, replacement,all sizes
)-6-
MaximumUnits perService
PricePer!Inn
Pricin~Unit
ProcedureCode Item Descriotion
each$ 4.28 6
each 65.93
8.99 each 6
X 1796 Sharps Disposable Container, 1 quart
capac ityX 1797 Sharps Disposable Container, 5 quart
capac ityX 1798 Sharps Disposable Container, 8 quart
capacity
Xl 029 Unlisted administration supplies forenteral nutrition (specify)
I/C
(NOTE: Covered I. V . and Nutrition Infusion Pumps are listed under Durable 'Aedical
Equipment)
DIABETIC MONITORING SUPPLIES
URINE KETONE MONITORING SUPPLIES
X 1320 Reagent StripsX1321 Reagent Strips
8.2613.62
SO'slCO's
42
URINE GLUCOSE AND KETONE MONITORING SUPPLIES
X 1420 Reagent ShipsX 1421 Reagent Ships
50'~
IO}'s
54
9.7617.09
BLOOD GLUCOSE MONITORING SUPPLIES
X 151 0 Reagent or Test StripsX 1511 Reagent or Test StripsX1512 Reagent or Test Strips
23.8144.3976.40
25's50's100's
24
(NOTE: Home Blood Glucose Monitor is listed under Durable Medical Equipn:ent)
FINGER STICKING AIDS
X1610 DeviceXI611 Lancets
19.4110.51
each100's
12
7.
i';
X 1612 Lancets 13.55 200's cOSTOMY AND PERMANENT URINARY INCONTINENCE SJPPLIES
PricePer
!lnit
MaximumUnits perService
ProcedureCode
PricingJ.!giLItem Descri~tion
A4364 Adhesive for Ostomy or Catheter,Liquid, Cement, Powder orPaste, any composition
X4666 Adhesive Paste, with skin barrier, 2ozA5126 Adhesive, Disc or Foam PadA4455 Adhesive Remover or Solvent
$ 4.00 10per ou:~ce
6.727.182.00
104
10
per ou:-.cePkg of 10per ou.-;ce
12.501.646.7619.68
box of 50eacheachdozen
210030
8
X4600Ostomy Adhesive Remover, wipesX4601 External CatheterX4602 External Catheter, male, reusableA 4 34 7 Male External Catheter, with or without
adhesive with or without anti-refluxdevice
4.346.258.85
eacheacheach
363630 ~
)11.30 each 10
12.05 each 30
]8.44 each 30
1.921.914.68.65
1.20.90.83
eacheacheacheacheacheacheach
1006036
100100100100
1.821.465.811.002.191.46
eacheacheacheacheacheach
10010090
53020
X4603 Foley Catheter, 2-way, latexX4604 Foley Catheter, 2-way, silicone-coatedA4338 Indwelling Catheter, Foley type, 2-way
latex with coating (Teflon, silicone,
elastomer, etc.)A434Slndwelling Catheter, Foley type, 2-way,
all siliconeX460S Foley Catheter, 2 way, silicone with
elastomer coatingA4346 Indwelling Catheter, Foley type, 3-way,
for continuous irritationX4606lntermittent Catheter, male/femaleX4607 Catheter, red rubberX4608 Catheter, red rubber, Tieman typeX4609 Self-Catheter, femaleX4610 Self-Catheter, long, male/femaleX4611 Self-Catheter, pediatric/adolescentX4612 Urethral Catheter, all purpose, rubber,
disposableX4613 Urethral Catheter, plasticX4614 Utility Catheter, Robinson/Nelaton typeX461S Catheter Care TrayX4616 Catheter ClampX4617 Connective Tubing, external catheterX4618 Catheter Extension Tubing
~-8-
PricingUnit
Units perService
_ProcedureCode
Per!.1:ni!Item Descrigtion
7.3042.4537.15
eacheachbox of 5
1055
13.73 each IS
X4619Drain/fube Attachment DeviceX4620 Ileal Bladder ApplianceX4663 "Duoderm" Dressing (4 x 4s),
ostomy onlyX462 I Mounting Ring for ileostomy
appliance, white vinyl flexible
X4622 Incontinency Pants, disposable
(requires preauth)
.85 each 400
7.74 each 30
9.04 each 30
each 30
A4354 Insertion Tray with Drainage Bagwithout catheter
X4624 Insertion Tray with Drainage withcatheter
A4399 Ostomy Irrigation Supply, Cone/Catheter,including brush
.25
5402515
60.005.001.404.81
eacheacheacheach
each 304.84
9.502.2519.258.852.251.734.50
I/C
eacheacheachpkg of 10eacheacheach
2205
103055
30100
3.002.09
eacheach
100
A4400 Ostomy Irrigation SetA4397 Irrigation Supply, SleeveA4322 Irrigation Syringe, bulb or pistonA4320 Irrigation Tray for bladder irrigation
with bulb/piston syringeA43SSlrrigation Tubing Set, for continuous
bladder irrigation through a 3-wayindwelling Foley catheter
A4367 Ostomy BeltAS093 Ostomy Accessory, Convex InsertA4361 Ostomy Face PlateX4627 Ostomy Gasket
A4404Ostomy RingX4628 Ostomy Tape, I" rollX4629 Ostomy Tape 2" rollA44S4 Tape, all types, all sizes (Ostomy
other than above) (specify)ASOSI Pouch, Closed, with barrier (I piece)A50S2 Pouch, Closed, without barrier attached
(I piece) (disposable)AS054 Pouch, Closed (2 piece) 1.60Incontinence pants, reusable, pair X9650 10.40Incontinence pads, for reusable X I 793 11.70
pants, regular absorbency pack of 20Incontinence pads, extra absorbent X 1794 8.91
pack of 12Incontinence pads, extra absorbent X I 795
eacheach
NC NC
NC NC13.74
-9
pack of20 or 2S('
PricePer!!nj,t
MaximumUnits perService
ProcedureCode
Pricin~UnitItem Descriution
3.401.502.76
eacheacheach
100100100
4..62 each 100
2.50 each 100
5.001.88
10.008.503.5011.106.003.75
eachper ou:o;:ebox of 50eachounceeachper ou!.~eeach
100102
1543
1060
8.25 each 60
A5073 Pouch, urinary (2 piece)X4667 Pouch, mini (2 piece)A5062 Pouch, Drainable, without barrier
attached (1 piece) (reusable)X4665 Pouch, Drainable system, with barrier
(1 piece)A5063 Pouch, Drainable for use on barrier
with flange (2-piece system)A5071 Pouch, urinary with barrier (I piece)X4631 Protective Dressing, spray-onX4632 Protective Dressing, wipesX4633 Protective Powder, loz.X4634 Karaya Powder, loz.X4635 Karaya Gum Powder, 12 oz.A4363 Skin Barrier, Liquid (spray, brush, etc.)A4362 Skin Barrier, Solid, 4 x 4 or
equivalentA5121 Skin Barrier, Solid, 6 x 6 or
equivalentA5122 Skin Barrier, 8 x 8 or equivalentA5123 Skin Barrier with flange (solid
flexible or accordion), any size
15.007.00
eacheach
36100
2.75.98
1.955.77
eacheacheacheach
1001001015
7.78 each 15
.60 each 300
6.50 each 20
10.00 each 36
A5055 Stoma CapX4636 Stoma Mini Pouch, closedX4637 Tincture of Benzoin, sprayX4638 Extension/Connective Tubing - to
connect leg bag to external orFoley catheter, plastic, sterile
X4639 Extension/Connective Tubing - toconnect bag to McGuire urinalseries, latex, non-sterile
A4554 Underpads disposable, all sizes
(requires preauth)X4640 Urinary Diversion Pouch, with anti-
reflux valve and night drain adapterA4357 Bedside Drainage Bag, day or night,
with or without anti-reflux device,with or without tube (urinary)
A4358 Urinary Leg Bag, vinyl, with orwithout tube
S.2S each 36
10-
PricePer!:!n!!
MaximumUnits perService
Pricin[Unit
Procedure
Code Item DescriRtion
36152
$ 2.444.58
31.15I/C
eacheacheach
X4641 Leg Bag Extension TubeX4642 Leg Bag Sb'apSX4643 Urostomy Appliance System, all sizesA4335 Incontinence Supply, Miscellaneous
(specify)A4421 Ostomy Supply, Miscellaneous (specify) I/C
X5799 Unlisted catheters/accessories (specif)r) I/C
Reuseable incontinence pads and pants are listed under miscellaneo\;.. DME)(NOTE:
SPINAL CORD DYSFUNCTION CARE SUPPLY KIT,?
XI 100 Skin Care Kit I-A 4" x 4" sterile $ 17.708-ply gauze pads - 4 dozen
Sterile cotton tipped applicators - 8dozen packages of 2 each I" poroussurgical tape - 4 rolls
XIIOI Skin Care Kit I-B 4" x 4" sterile 8-ply-gauze pads - 2Y2 dozen Sterile elastic
2-ply gauze bandages -2Y2 dozen 4"rubber elastic bandages - I Steriletongue blades - 2Y2 dozen
X 1103 Urinary Incontinence Kit II-B I" elasticadhesive bandages - 3 rolls Liquid skincement I can (4 oz.) Unsterile catheterextension tubing with connector - 4
X 1104 Urinary Incontinence Kit II-C Alcoholwipes 3 boxes of 100 each pH testingpaper - I roll of 15 feet I" clear hypoallergenic tape - 3 rolls
X II 05 Bowel Incontinence Kit Ill-A Bisocodylsuppositories 10mg - I box of 50
Disposable exam gloves - I box of 100
Lubricating jelly (5 oz.)X II 06 Bowel Incontinence Kit III-B Disposable
exam gloves - I box of 100
1 kit e' ery2 week;
6
I kit e\ ~ry2 week:;
49.90 6
kit every 322.90month
316.65 1 kit e' erymonth
15.60 1 kit e\~ry3 monI.1S
1 kit every3 mOn1:;lS
9.90
-11-
lubricating jelly (5 oz.) rBURN GARMENTS
NOTE: Charges for bum garments shall include all fitting, dispensing, and follow-up care.
PricePer!.!nit
MaximumUnits perService
ProcedureCode
PricingUnitItem Descri~tion
77.36129.2766.2188.95
eacheacheacheach
4444
228.03228.00
eacheach
22
X1953 Glove to WristX1954 Glove to ElbowX1957 Ann Sleeve - wrist to axillaX 1958 Ann Sleeve & Gauntlet - metacarpals
to axillaX1971 Body Briefwith SleevesX1972 Sleeveless Body Suit (to distal
measurement) (above knee)X1978 Foot Glove to KneeX 1980 Knee LengthX 1981 Thigh Length
124.2349.9358.92
eacheacheach
222
~
SUPPORT STOCKINGS, INDIVIDUALLY FORM-FI1TED
NOTE: Charges for individually fonn-fitted support stockings shall inchlde all fitting,dispensing, and follow-up care.
$ 52.00120.41
eacheach
44
139.82 each 4
59.6073.11
209.01209.01209.71214.74
eacheacheacheacheacheach
44222?
X 190 I MittenXI908 Ann Sleeve & Gauntlet-
metacarpals to axillaX 191 0 Ann Sleeve, Gauntlet & Shoulder
FlapXI91SKnee LengthXl916Thigh LengthXI917Waist Height, Two Legs, closed pubisXI918Waist Height, Two Legs, open pubisXI 922 Maternity, Two LegsXI92S Waist Height, One Leg, plus stump
X 1928 Waist Height, Two StumpsX 1931 Chap Style, Two LegsX1932Chap Style, One LegX1938 Fitting Fee
214.74226.34184.6727.00
eacheacheachone tiff.~
222
-12-
per yeE.':X1939 Accessories/Modifications for leg or ann (specif)')I/C
OSTEOGENESIS STIMULATOR
NOTE: Charges for the osteogenesis stimulator shall include all t...Jllow-li? care, batteries,repairs and replacement parts (with pre-auth required)
686.66
686.66 each
686.66
E0747 Osteogenesis Stimulator-Initial
X 180 1 Osteogenesis Stimulator - First
Evaluation (after six weeks)X 1802 Osteogenesis Stimulator - Second
Evaluation (after three weeks)
SUCTION SUPPLIES
7.50 each 10X9150 Suction collection container, disposablestandard
X9149 Suction collection container, disposablelarge capacity
12.00 each 10
X9055 Suction catheter 2.00 each 100
2.
2.
4.
45.
eacheacheachroll
1010106
X9151 Suction connecting tubing 6 feetX9153 Suction connecting tubing 9 feetX9155 Suction connecting tubing 12 feetX9158 Suction connecting tubing 100 feet, roll
-13-
~
.50
.60
.45
.50
.. .
rMiscellaneous Medical Supplies
PricePer!In!!
Procedure~
Per~
MaximumUnitsItem DescriQtion
Alcohol Wipes/Prep Pads A4245 $ 2.48 box 0:.200 24
10.8816.73
4.27
pack cf 12packrf12pint
2424
Bandages-2ply, 131" x 3" widthnon-sterile X1711sterile X1712
Bentadine or Iodine Swabs/Wipes A424624
Bentadine or Iodine Swabs/Wipes A4247 6.00 box of 2S 24
Cotton-Tipped Wooden Applicators Xl748Sterile
7.13 box of 100 24
Disinfectant-"Control ill"8 ounces XI72516 ounces X 1726gallon X1727
10.00 each15.00 each31.00 each
242424
Dressing. Control Gel Fonnula-Sterile ('DuoDenn' type)
4" x 4" Xl7136" x 6" Xl714
Extra thin 4" x 4" Xl7t 5
7.6514.635.30
eacheacheach
606060
7.6524.50
97.43
eacheacheach
606015
Dressing. Flexible, 'Hydro-active'sterile ('DuoDenn' type)
4" x 4" XI716S" x S" XI717
Dressing, Surgical 3" x S", XI71S3 strips per envelope3" x 6", I strip per envelopeXI720 84.75 each
- 14-
Procedure~
Price!:!nit
MaximumUnits
Per~Item Descri}2tion
Dressing, transparent2" x 3" (approx. size)4" x 5" (approx. size)5" x 7"6" x 8"
X1722X1723X1724Xl721
$ .922.935.807.46
eacheacheacheach
100100100100
Foam Pads, Self-adhering7/16" x 7 7/8" x II 3/4"I" x 7 7/8" x II 3/4"
X1730X1731
40.5029.00
pack 0:'10pack c;' 5
33
Germicide - "Solution If'8 ounces16 ounces X 1736
X1735 7.6411.29 each
24each24
Gloves, Sterile and Non Sterileall sizes
A4927 40.00 box of ~ 00
Lemon Glycerin Swabs XI?3? 6.00 box OJ' 25 24
Lubricating Jelly 4.25-ounce X1738 2.15 each 12
Pads, Gauze-Sterile, 12 ply2" x2"3" x3"4" x 4"
X1732X1733X1734
16.3219.4932.16
pack (:I~ 100pack cf 100pack (Z 100
121212
Skin Creamsup to 2 ouncesup to 5 ouncesup to 9 ounces
X1762X1763X1764
7.9410.8813.49
eacheacheach
121212
Skin Paste2.5 ounce tube X1765
Sodium Chloride O.~/o Solution500 mI. bottle X18051000 mI. bottle X1806
10.79 each 12
6.707.87
eacheach
1212
Solution nonnal saline or 0.94>/0sodium chloride, 100 doses, 3 ml X97J2 25.00
-15-
5ml X9713 32.50 each 1 rrocedure~
PricinfUnit
MaximwnUnitsItem Descril2tion Price
Sponges-Drain and I. V .,Sterile, fenestrated2" x 2", 6 ply4" x 4",6 ply
X1758X1750
$15.6819.43
pack cf70packC':70
33
Sponges-Dressing, Sterile4" x 3"4" x4"
X1756X1757
5.936.89
pack ( i 50pack ( -;:' 50
33
Sponges-Dressing, Sterile, 2'5,4" x 4" 6 ply
X1151 3.43 pack CI 50 .1
Sponges-Gauze covered, non-sterile
3" x 3"4" X 4"
X1753X1754
6.1410.94
packc:lOOpacklflOO
33
Sponges-Gauze, Sterile, 2's2" x 2" 8-ply
3" x 3" 12-ply X17604" x 4" 12-ply4" x 4" 8 ply
X1759 5.546.89
6.419.74
pack cpack r:
pack,pack ('
1212123
X1761X1752
Sponges-Soft net facing, non-Xl 755sterile 4" x 4"
9.89 box o~ 100
Water (sterile and distilled)250-500 mI. bottle1000 mI. bottle1500 mI. bottle
X1745X1746X1747
6.427.49
10.27
eacheacheach
121212
Tape-Paper1/2" width x 10 yards X17831" width x 10 yards X17842" width x 10 yards X1785
.501.002.00
eacheacheach
121212
- 16- ./
fl00f80[50['100
Tap Pric~Procedure Per Pricing
MaximumItem Descri~tion ~ !:!!li! lLn!! Units
Tape-Plastic, clear, perforated
1/2" width x 10 yards X17802" width x 10 yards X17813" width x 10 yards X1789
1.112.214.42
eacheacheach
121212
Tape-Multi-Purpose, silk1" width x 10 yards2" width x 10 yards3" width x 10 yards
X1786X1787X1788
1.663.314.97
eacheacheach
121212
Tape-Elastic1" x 10 yards2" x 10 yards
Xl777Xl778
$ 1.753.49
eacheach
1212
4.58 pack (' f 20 24Tooth Cleaning Applicators, X1710disposable
Wrap-Elastic, non-adhesive, self-adherent, 5 yards
1 inch X17902 inches X17913 inch X1792
1.773.143.98
eacheacheach
121212
- 17-
~
~WOUND CARE SUPPLIES
Procedure~
Pricing~
Units PerServiceItem Description Price Per Unit
A6154A6196
Bx/lOBx/lO
24
A6197
Wound Pouch $ 107.64Alginate Dressing, cover 60.5916 sq. in. or lessAlginate Dressing, cover 96.0416-48sq.inAlginate Dressing, fillerComposite Dressing, 16 sq.in. or less w/out adhesiveborderComposite Dressing, 16- 48 sq. in. w/out adhesive
borderComposite Dressing, morethan 48 sq. in. w/out adhesiveborderComposite Dressing, 16 sq 34.10in. or less, with adhesiveborderComposite Dressing, 16 -48 133.33sq. in. with adhesive borderFoam Dressing, cover, 16 sq. 32.00in. or less, w/out adhesiveborderFoam Dressing, cover, 16- 48 45.53sq. in. w/out adhesive borderFoam Dressing, cover, more 57.63than 48 sq. in., w/out adhesiveborderFoam Dressing, cover, 16 sq. in 80.00or less, w/adhesive border
Bx/5 2
A6199A6200
32.0075.26
Bx/5Bx/IO
52
A6201 82.82 Bx/5 3
A6202 137.97 Bx/5 2
A6203 Bx/50 4
A6204 Bx/25 2
A6209 Bx/l0 s
A6210 8x/l0 5
A6211 Bx/lO 4
A6212 Bx/IO 3
18
U nits PerService
Pricing!L!!!
Procedure~ Price Per UnitItem Description
A62143$ 90.00 Bx/lJ
427.50 Bx/51JA6219
Bx/25 4A6220 55.94
335.99 Bx/5vA6222
288.82 Bx/53A6223
Bx/12 5A6224 27.71
527.71 8x/12A6229
Bx/5 10A6234 27.76
473.10 Ox/tOA6235
4
Foam Dressing, cover,more than 16 sq. in.w/adhesive borderGauze, non-impregnated16 sq. in. or less,w/adhesive borderGauze, non-impregnatedmore than 16 sq. in.,w/adhesive borderGauze, impregnated, otherthan water or nonnal saline,16 sq. in. or less,w/out adhesive borderGauze, impregnated, otherthan water or nonnal saline,17 to 48 sq. in., w/outadhesive borderGauze, impregnated, otherthan water or nonnal saline,more than 48 sq. in.Gauze, impregnated, wateror normal saline, 17 to 48 sq.in., w/out adhesive borderHydrocolloid Dressing, cover,16 sq. in or less, w/outadhesive borderHydrocolloid Dressing, cover,17 to 48 sq. in., w/out adhesiveborderHydrocolloid Dressing, cover,more than 48 sq. in.,w/out adhesive border
60.59 Bx/lOA6236
19
MaximumProcedurePer
~Sen'ice
UnitsPric_og
!l!1J!Item Description Price Per Unit
Bx/.::J 4$ 52.08A6237
A62383Bx!93.57
per~: fluidounc~ tubeBx/O
417.78A6240
360.05A6242
48X/., 056.82A6243
28x/:0121.02A6244
523.51 BX/A6245
536.45 Bx/A6246
546.90 BX/A6247
4per ~ fluidoun:e tubeBx/- ')0
7.50A6248
65.10A6257
Hydrocolloid Dressing,cover 16 sq. in. or less,w/adhesive borderHydrocolloid Dressing,cover, more than 16 sq.in., w/adhesive borderHydrocolloid Dressing,filler pasteHydrogel Dressing, cover,16 sq. in.or less, w/outadhesive borderHydrogel Dressing, cover,17 to 48 sq. in., w/outadhesive borderHydrogel Dressing, covermore than 48 sq. in., w/outadhesive borderHydrogel Dressing, cover,16 sq. in. or less,w/adhesive borderHydrogel Dressing, cover,17 to 48 sq. in,Hydrogel Dressing, cover,more than 48 sq. in.,w/adhesive borderHydrogel Dressing, filler,gelTransparent film, 16 sq. in.
4B",.5073.68A6258or lessTransparent fi~ 17 to 48 sqIn.Transparent film, more than48 sq. in.Tape
4BXi:O69.28A6259
2Bx!212.00A626S
)20
Part II. DURABLE MEDICAL EOUIPMENT
ProcedureCodePurchase
MaximumPurchasePrice
ProcedureCodeRental
MaximtmRentalCh~e
MaximumUnits perServiceItem Descri~tion
Aonea Monitors and Accessories
NC s NC X8361 s 7.<5/day
NC NC X8362 224.00imo.
NC NC X8354 12.00/c'ay 29
NC NC X8364 350.00/:TlO.
Standard Monitor, electric/29
battery (AC/DC): dailyrental infant
Standard Monitor, electric/
battery (ACIDC): monthlyrental
Monitor with memory dailyrental
Monitor with memory monthlyrental
Recorder, daily rental NC NC X8351 7.70/cay 29
Accessories:
X9352X9358X9359X9354
10.8072.8052.0017.50
NCNCNCNC
4
6
X93SSX93S6X93S7X9363
9.2512.5044.10
I/C
NCNCNCNC
23
X9364 ]7.50 NC 4
BeltBelt Kit I (with cable)Belt Kit II (without cable)Disposable Red Dot
Electrodes, 25/bag(or equivalent)
Lead Wires - Straight EndLead Wires - Clip End
Patient CablePatient Cables for portable
infant monitorCardio- Trace Electrodes,
30/package (or equivalent)
Unlisted Apnea Monitors!Accessories (specify)
X9369 J/C X8369 I/C
21
Ma>_:mumMaximum Procedure Mor. :hlyPurchase Code Reo;.?}Price ~ Charge
ProcedureCodePurchase
LifeEx~ctancvItem Descri~tion
Beds HosRital
EO252 577.00 X8101 4~.38 1 0 years
EO250 748.00 X8081 57.54 1 0 years
EO251 673.00 X8082 5",.77 1 0 years
EO255 ,257.00 X8083 9 ).69 10 years
EO260 1699.00 X8079 10.70 to years
EO265 $2,190.00 X8080 $ .68.46 10
Hospital Bed, fixed height. withmattress, without side rails
Hospital Bed. fixed height. withside rails, with mattress
Hospital Bed. fixed height. withside rails, without mattress
Hospital Bed, variable height.hi-Io, with side rails, withmattress
Hospital Bed. semi-electric (headand foot adjustments), withmattress, with side rails,
Hospital Bed, total electric (head,years
foot and height adjustments),with mattress, with side rails
Hospital Bed, total electric (head.foot and height adjustments),without mattress, with side rails
E0266 2,050.00 X8084 157.69 1 0 years
Accessories
EO271EO272X9230
194.00127.0027.00
X8085X8403
NC
1-:-.92
~.76
NC
2 years2 years2 year
Mattress, innerspringMattress, foam rubberMattress, eggcrate type
Bed Side Rails, half lengthBed Side Rails, full length
EO305EO310
158.00184.00
X8404X8405
.~.lS
:.1 S1 0 years10 years
Unlisted Hospital Beds!Accessories (specify)
X9119 I/C X8119 vc
Blood Glucose Monitoring Egui~ment
EO607EO609
125.00I/C
NCNC
NCNC
3 years3 years
Home Blood Glucose MonitorHome Blood Glucose Monitor
with special featuresBattery, Replacement X9301 NC NC AN3.25
22
~
ProcedureCodePurchase
Maximum Procedure MoJl:hlyPurchase Code RentalPrice ~ Charge
LifeExpectanc~Item DescriRtion
Braces & SUnl2Qrts
X9330X9370
110.00135.00
NCNC
NO:1\C
yearyear
X9331X9333
150.00250.00
NCNC
NCNC
I year3 years
X9332X9337X9334X9343X9344X9345X9346X9347X9371X9349X9350
225.00220.00295.00650.00895.00955.00625.00800.00995.00780.00875.00
NCNCNCNCNCNCNCNCNCNCNC
NC}.;C}liC~CNCt:C~';;J.;C}l\CNC~C
1 year1 year1 year1 year1 year1 year1 year1 year1 year1 year1 year
X9372 900.00 NC }oJC year
X2001X2002X2003X2004X9379
450.00675.00600.00
1450.00I/C
NCNCNCNCNC
}I.~C
NC}I.;C}I.:C}I.:C
Support, back, lumbo-sacralSupport, back, lumbo-sacral,
heat moldedSupport, dorsal lumbarSupport, chair back/Knight
spinal (including moldedtype)
Support, hyperextension, JewettSupport, neck brace, 2-posterSupport, Taylor-KnightWilmington brace, with moldMilwaukee brace, unlinedMilwaukee brace, linedBoston brace, unlinedNew Boston brace, linedBoston jacket with "cow horns"TLSO body jacket, linedTLSO body jacket, lined with
controls/padsTLSO split body jacket
"clamshell" t'bi-valve")Orthoses-C ustom
Ankle-foot, solid/rigid, eacharticulatedfloor reaction
Knee-Ankle-foot, eachUnlisted Braces/Supports
(specify)
Canes. Crutches and Shower Chairs
EOl00 18.00 NC NC I year
EOIO5 45.00 NC '!Io.C 1 year
Cane of all materials, adjustableor fixed, with tip
Cane, quad or three prong;includes canes of all materials,adjustable or fixed, with tips
Shower chairssmallmediumadolescent
adolescent/1arge
X9642X9643X9644X9645
413.00438.00463.00475.00
NCNCNCNC
}I.-:
}I.:C
~C
J\:C
2 years2 years2 years2 years
23
0Maximum Procedure Mor.i:hly MaximumPurchase Code Ren::11 LifePrice ~ Cha:'~e Ex~tancx
ProcedureCodePurchaseItem Descrip;tjon
s NC NC 6 monthsEOl13 20.00
NC ~C 6 monthsEOl12 39.00
6 monthsEOl16 29.00 NC Jl.C
Jl.C 6 monthsEOl14 58.00 NC
EOt 40.00 NC 1\: 6 months
6 monthsBOlIO 80.00 NC NC
~
Crutch, underann, woodadjustable or fIXed, withpads, tips, handgrips, each
Crutch, underann, wood,adjustable or fixed, with
pads, tips, handgrips, pairCrutch, underann, other than
wood, adjustable or fixed,with pad, tip and handgrip,each
Crutches, underann, other thanwood adjustable or fixed,with pads, tips and handgrips,
pairCrutch, foreann, of various
materials, adjustable or fIXed,with tip and handgrips(Canadian or Lofstrand), each
Crutch, foreann, of variousmaterials, adjustable or fIXed,with tips and handgrips(Canadian or Lofstrand), pair
Crutches, platform, pairCrutch, platform, single
~ 1.92 6 monthsNC 6 months
X9229X9201
155.0080.00
X8229NC
Unlisted crutches (specify) X9202 lIC I/CI/C X8202
Commodes
EOl63 NC 2 years85.00 NC
EO165 167.00 X8228 12.85 2 years
X9111 90.00 NC NC 2 years
X9112 70.00 X8112 !;;.07 2 years
X9113 164.00 XII13 11.62 2 years
EOl64 147.00 X8116 1: .31 2 years
Commode Chair, stationary,with fIXed arms
Commode Chair, stationary,with detachable arms
Commode Chair, adjustable,with fixed arms
Commode Chair, adjustable,with detachable arms
Commode Chair, adjustable,with attachment for pailor pan
Commode Chair, mobile, withfixed arms
Commode Chair, mobile, withdetachable arms
Commode Chair, drop arms
EO166 225.00 X8117 7.31 2 years
X9225 167.00 X8225 2.85 2 years
24
"~
MaximumMaximum Procedure MonrhlyPurchase Code RemalPrice ~ Chm"ge
Procedure
Code
~hase
LifeEx~tancvItem Descriotion
NC NCCommode Chair, drop arms, withsoft seat. and pail or pan
Commode Chair,large/extrawide/heavy duty
Pail or Pan for use withcommode chair
X9114 $ 200.00
NCX9115 187.00 NC
NC20.00 NCEO167 year
Enteral and Parenteral Nutrition Eauioment
57.69 10 years750.00 X800SB9002
X8110 80.76 10 yearsX9110 1,050.00
~ 34.77 1 0 yearsB9006 ,752.00 X8001
1')1.53 1 0 yearsB9004 3,190.00 X8015
~C8.00
AN10 years
X9631EO776
100.00105.00
NCX8002
Enteral Nutrition Infusion Pump,with alann
Enteral Nutrition Infusion Pump,
pediatricParenteral Nutrition Infusion
Pump, stationary (specify)Parenteral Nutrition Infusion
Pump, portableBattery Pack, ReplacementIV Pole
Intravenous Medication EauiDment
291.54 1 0 yearsEO781 3,790.00 X8021
NC AN
Ambulatory Infusion Pump withadministrative equipment.worn by patient (preauth
required)Battery Pack for Ambulatory
Infusion PumpX9118 100.00 NC
Nebulizers and Accessories
Aerosol compressor, complete X90 16system compressor unit,medication cup, connectorfitting, tubing, hand-held nebulizer,and mouth piece, face mask, ortracheostomy collar or T -tube
130.00 X8016 J.OO 2 years
25
. ". ,
Mv.imumMaximum Procedure Mon:hlyPurchase Code Ren!:llPrice ~ Charge
rProcedureCodePurchase
LifeEx~ctanc):Item DescriQtion
$ 165.00 X8017 S 12.69 2 yearsX9017Aerosol compressor, ultrasoniccomplete system with ultrasonicaerosol chamber with blower,medication cup, connectorfitting, corrugated tubing, andmouth piece, face mask, ortracheostomy collar or T -tube
Compressor System pneumaticstationary (pulmo-aide, type)
Same, portable with batteryadapter charge, power cord
2 yearsX9725 180.00 X8725 14.00
33.00 2 yearsX9726 420.00 X8726
NCNCNC
5 /montl-.2/month5/month
2.254.053.75
NCNCNC
NCNC
2/ year2/month
6.252.00
NCNC
Nebulizer Replacement kit X9707Nebulizer Mask Kit X9722Administrative Set used with KOl71
nebulizerAerosol Mask used with nebulizer KO180Filter, disposable used with KOl78
nebulizerFilter, non-disposable used with KOI 79
nebulizerNC NC l/month2.00 ~ ,
-..J
Unlisted nebulizers/accessories
(specify)X9729 I/C X8729 I/C I/C
26
MaximumPurchasePrice
ProcedureCodePurchase
LifeExRectancyItem Descriotion
Prosthetic Devices
NOTE: Charges for prosthetic devices shall include the cost of the de,';ce as well asnecessary stump covers or harnesses, power sources, and all fitting, dispensing,and follow-up care.Does not require preauthorization
Artificial Eye:
NCNC
$ UICU/C
NCNC
V2623V2629
Prosthetic, eye, plastic, customProsthetic eye, not otherwise
classified
~:cKC
~C
JI.~C
NC
J\'C
NCNCNCNCNCNC
X3100X3101X3200X3202X3204X3207
U/CU/CU/CUICU/CU/C
X3209 UIC NC
NC 1I:CX3210 UIC
NCNC
~Cro,:c
Breast Prosthesis (includingmastectomy fonn and 2
mastectomy bras):UnilateralBilateral
Lower Limb - Partial FootLower Limb - Below KneeLower Limb - Above KneeLower Limb - Endoskeletal -
Below KneeLower Limb - Endoskeletal -
Above KneeLower Limb - Endoskeletal - Hip
DisarticulationUpper Limb - Partial HandUpper Limb - Below Elbow
X3212X3214
U/CUIC
tjCX3222 u/C NC
L7S00 I/C NC
Upper Limb - Endoskeletal -Shoulder Disarticulation
Repair of Prosthetic Device,hourly rate (specify repairand rate)
Repair Prosthetic Device, RepairReplace Minor Parts (specify)
L7S10 uc NC
NC ~.eUnlisted Prosthetic Devices!Accessories (specify)
X3299 U/C
27
::;~::~
ProcedureCode~
MaximumMon::hlyRen...~lCha:-l!e
. ,
MaximumMaximll.11 Procedure MonthlyPurchas~ Code RentalPrice ~ Charge
('ProcedureCodePurchase
LifeEx~tancvItem DescriRtion
Suction EguiRment and Accessories
X9050X9152
234.00780.00
NCX8152
NC60.00 I 0 years
Suction Machine, StationarySuction Machine, AC/DC
( electric/battery)Suction Pump, home model,
portable
EO6O0 600.00 46.15 1 0 yearsX8153
X9157X9670
NCNC
6 ~'.J...
140.00NCNC
2/month1 year
Suction Device, Yankauer typeSuction Device for airway mucus
clearance (~utter" type)
Unlisted Suction Equipment!Accessories (specify)
X91S9 1/( X8159 I/C I/C
TENS (Transcutaneous Electrical Nerve Stimulator)
EO720 39.62515.00 X8310 year
0TENS, two lead, localized
stimulationTENS, four lead, larger areal
multiple nerve stimulationE0730 S93.C-J XI31 45.62 year
Accessories
X9312X9318X9313X9314
$ $NCNCNC
NC4.1:560.003.10
10.40
NCNCNCNC
ANANAN
X931SX9316
16.002.00
NCNC5.00
NCNCNC
ANANNC
BatteryBattery PackGel, tubeTape Patches, pack of 100
(or equivalent)Lead Wires, setElectrode, disposable, eachElectrode, reusable, each X9317
AN
Traction EauiDment
EO840 52.70 NC NC year
62.5040.0043.00
I/C
NCNCX9324X9129X9123
1 year1 year
I/C
Traction, Frame, attached toheadboard, simple cervicaltraction
Traction, complete, Buck X9325Traction Stand, BuckTraction Stand for hospital bedFracture Frame, Bed (specif}') X8123 I/C
28
MaximumMaximum Procedure MonthlyPurchase Code RentalPrice Rental Charge
ProcedureCodePurchase
Life
Ex~tanc~Item Descrintion
Walkers
64.00 X8223 4.62 2 years
79.00 X8227 6.00 2 years
Walker, rigid (pick up), adjustable EO130or fixed height
Walker, folding (pick up), EO135adjustable or fIXed height
EO141X9236X9218
X8226NCNC
7.92NCNC
2 years2 years2 years
X92J9 185.00 NC NC 2 years
X9690X9694
100.00225.00
NCNC
NCNC
2 years2 years
X9237X9238X9220
83.00140.00211.00
NC NC 2 years2 years2 yearsNC NC
X9222 275.00 NC KC 2yeai's
Walker, wheeled, without seatWalker, platfonn attachment forWalker, adjustable height, with
wheelsWalker, adjustable height and
width, with wheelsWalker, folding, pediatricWalker, large/extra wide/heavy
dutyWalker, pediatric, standardWalker, pediatric, with wheelsWalker, pediatric, posture control
with wheelsWalker, pediatric, adjustable
height and width, with wheelsWalkcane or herni-walker X9239 67.00 NC NC 2 years
Walker Accessories
X9695X9696X9697
NCNCNC
NCNC~C
6months6 month~6 months
Wheeled foot piece, pairWheeled foot pieces, swivel, pairPlatfonn attachment, pediatric
onlyLeg Extensions for walker EO]58 36.00 X8240 2.76 6 months
29
I_~
103.0084.00
132.00
33.1044.00
106.00
MaximumMaximum Procedure MonthlyPurchase Code RentalPrice ~ Cha:ge
nProcedureCodePurchase
LifeEx~ctanc'"Item DescriQtion
Wheelchairs
Standard Wheelchair, fIXed fulllength anns, fIXed or swingaway detachable footrests
Standard Wheelchair, detachableanns (desk or full length) swingaway detachable footrests
Standard Wheelchair, fixed fulllength anns, elevating legrests
Standard Wheelchair, detachableanns (desk)or full length,
elevating legrestsFully-Reclining Wheelchair,
detahable anns (desk or full-length) swing-away detachableelevating legrests
Fully-Reclining Wheelchair,detachable anns (desk or full
length), swing-awaydetachable footrests
El130 $ 703.29 X8204 $54.10 5 years
El140 942.48 X8244 54.08 5 years
EII60 800.87 X8242 61.60 5 years
El150 1041.25 X8203 80.10 5 years
E1060 1156.68 X8255 88.97 5 years
EI070 1101.94 X8254 84.76 5 years
01047.72 X8257 80.59 5 years
894.88 X8407 68.84 5 years
958.11 X8256 73.70 5 years
Lightweight Wheelchair, E 1240detachable anns (desk or fulllength), swing-away detachableelevating legrests
Lightweight Wheelchair, fIXed full EI250length anns, swing-awaydetachable footrests
Lightweight Wheelchair, EI260detachable anns (desk or fulllength), swing-away detachablefootrests
Lightweight Wheelchair, fixed full EI270length anns, swing-awaydetachable elevating legrests
15.03 X8408 85.;7 5 years
High Strength Lightweight E 1088Wheelchair, detachable arms(desk or full length), swingaway detachable elevating legrests
1235.22 X8060 95.02 5 years
-::)
J
30
.~~~
MaximumMaximum Procedure MonthlyPurchase Code RentalPrice ~ Charge
ProcedureCodePurchase
LifeEXRectanc.,.Item Descrintion
High Strength LightweightWheelchair, detachable anns(desk or full length), swingaway detachable footrest
EI090 79.29 X8062 90.71 5 years
Wide Heavy Duty Wheelchair,detachable arms (desk or full
length), elevating legrestsWide Heavy Duty Wheelchair,
fiXed full length arms, swingaway detachable footrest
E1280 962.71 X8075 74.05 2 years
E1285 840.14 X8076 64.63 2 years
Wide Heavy Duty Wheelchair,detachable anns (desk or fulllength), swing-away detachablefootrests
E1290 1021.02 X8077 78.54 5 years
E1295 910.35 X8078 70.03 5 years
X9247 852.00 X8247 65.54 2 years
X9249 1,143.00 X8249 $ 87.92 2 years
Wide Heavy Duty Wheelchair,fixed full length arms,
elevating legrestsWheelchair, child's, with ,
adjustable height, removablefull or desk length anns,swing-away detachableelevating legrests
Wheelchair, child's reclining,with adjustable height,removable full or desk lengthanns, swing-away detachableelevating legrests
Wheelchair, growing:Same as Standard Wheelchairs
EIO83 998.41 X8410 76.80 5 years
EIO84 1094.80 X8253 84.21 5 years
Hemi-Wheelchair, fixed fulllength arms, swing-awaydetachable elevatinglegrests
Hemi- Wheelchair, detachablearms (desk or full-length),swing-away detachable
elevating legrestsHemi-Wheelchair, fIXed full
length arms, swing-awaydetachable footrests
EI085 677. X8406 52.08 5 years
31
- .-
MaximumMaximum Procedure Mon::hlyPurchase Code Rental LifePrice Rental Charge Ex~tanc~
rProcedureCodePurchaseItem DescriRtion
Hem i- Wheelchair, detachableanns (desk or full length),swing-away detachablefootrests
EIO86 1059.10 X8252 81.~7 5 years
El170 800.87 X8414 61.60 5 years
E1171 681.87 X8068 52.45 5 years
£1 J 72 714.00 X8069 54.92 5 years
EI180 942.48 X8070 72.50 5 years
El190 $ ]078.]4 X807] $ 82.93 Syears~
)"'"'
Amputee Wheelchair, fixed fulllength arms, swing-awaydetachable elevating legrests
Amputee Wheelchair, fIXed fulllength arms, with out footrestsor legrests
Amputee Wheelchair, detachableanns (desk or full length),without footrests or legrests
Amputee Wheelchair, detachablearms (desk or full length),swing-away detachablefootrest
Amputee Wheelchair, detachablearms (desk or full length),swing-away detachableelevating leg rests
Amputee Wheelchair, fixed fulllength arms, swing-awaydetachable footrests
E1200 1059.10 X8415 81.47 5 years
3,243.84 X8267 249.53 5 years
3,449.85 X8267 265.37 5 years
7,073.01 X8266 544.07 5 years
Motorized Wheelchair, detachable El213arms (desk or full length),
swing-away detachablefootrests
Motorized Wheelchair, detachable El21 Iarms (desk or full length),swing-away elevating leg rests
Motorized Wheelchair, detachable X9266adjustable height arms, swing-away detachable footrests withheel loops
Motorized Wheelchair, detachable X9268adjustable height arms, swing-away detachable elevatingleg rests
7297.55 X8268 561.35 5 years
I/C X8299 I/C I/CWheelchair, specially sized or E 1220constructed (Indicate brandname, model number, and medical justification)
32
ProcedureCodePurchaseItem Descri~tion
E1350 YC NC NC AN
E1230 2,069.91 X8074 159.22 5 years
Wheelchair, Repairs (parts andlabor) or Non- or routineservice, requiring the skill ofa technician)
Power-Operated Vehicle, 3 or 4wheel, non-highway(Indicate brand name andmodel number)
Pediatric Transporter (stroller,buggy etc.) (Indicate brandname and model number)
X9289 420.00 NA NA 2 years
Wheelchair Accessories
E0959 102.30 NC NC AN
E0971E0973
52.0093.50
NCNC
NCNC
ANAN
E0958 I/C NC NC AN
ElOO5 I/C NC NC AN
EI068EI069EO978E0979X9264E0961X9240X9258X9259
ucUC
42.0030.0021.0031.00
195.0047.00
340.00
NCNCNCNCNCNCNCNCNC
NNNNNNNNN
ANANANANANANANANAN
X9221E0970
68.0058.00
NCNC
NCNC
ANAN
Amputee Adapter (device used tocompensate for transfer ofweight due to lost limbs tomaintain proper balance)
Anti-Tipping Device (pair)Adjustable Height Detachable
Anns, desk or full length
(pair)Attachment to convert any
wheelchair to one-arm drive
(specify)Replacement Batteries for
medically necessary electricwheelchair owned by patient
(specify)Battery, each (specify)
Deep Cycle Battery (specify)Belt, Safety, with airplane buckleBelt, Safety, with Velcro closureToggle BrakesBrake Extensions (pair)Cushion, GelCushion, FoamCushion, Jay/Roho type
(or equivalent)Footrests, extra large (pair)No.2 Foot plates, except for
elevating leg rests (pair)
33
ccccccccc
~. .
ProcedureCodePurchase
MaximumMaximum Procedure MonthlyPurchase Code Rental LifePrice ~ Charge Ex~tancyItem DescriRtion
"Grade-Aid" (device to prevent EO974rolling back on an incline)
Hand Rims with 8 vertical rubber- E0967
tipped projections, pairHook-on Head Rest ExtensionLoop, Heel, eachLoop, Toe, eachNarrowing DeviceSolid Back InsertSold Seat InsertPneumatic Tire, eachPneumatic Tire with wheel, each
$ 77.00 NC NC AN
420.00 NC NC AN
E0966EO951EO952E0969X9262E0992£0953£0999
158.0016.5019.8094.00
110.00108.0041.8083.60
NCNCNCNCNCNCNCNC
NCNCNCNCNCNCNCNC
ANANANANANANANAN
EI065 I/C NC NC ANPower Attachment (to convertany wheelchair to motorizedwheelchair) (specify)
Tire, Pneumatic, Caster, eachSemi-Pneumatic, Caster, eachTray
EIOOOE0954EO950
8.5027.30
168.00
6months6 months5 years
NCNCNC
NCNCNC
Legrest, elevating, eachUnlisted Wheelchair Accessories
(specify)
EO990E1399
140.80I/C
NCNC
NCNC
5 yearsI/C
Wheelchair Modifications
38.5042.00
448.69187.00312.00104.00
NCNCNCNCNCNC
NCNCNCNCNCNC
yearyearyearyearyearyear
J/C NC NC 1 year
Reinforced Seat Upholstery E0975Reinforced Back Upholstery E0976Full Reclining Back X9272Special Back Height X9274Special Seat Height from floor EI296Special Seat Depth, by E 1297
upholsterySpecial Seat Depth and/or Width, E 1298
by construction (specify)Special Seat Width, by upholstery X9275
for customized wheelchair104.00 NC NC 1 year
Unlisted Wheelchair Modifications E 1399
(specify)I/C NC NC I/C
34
MaximumPurchasePrice
ProcedureCodePurchase
LifeEx~ctanc:JItem DescriRtion
Pediatric Adagtive/Positioning Accessories(For transporters or wheelchairs only)
X9160X9161
$ 174.00284.00
NCNC
NCNC
1 year1 year
Abductor, stationaryAbductor, removable with
adjustable hardwareCushions, smallFoot Rest additionFoot Straps
NCNCNC
X9162X9167X9168
NCNCNC
1 year1 year1 year
70.00 NC NCHeadrest, fixed X9169Headrest, removable, withhardware X9170Insert, hinged, with leg extensions X9172
NCNC
NCNC
130.00195.00
I yearI year
X91X91X91X91X91X91X91X91X91X9J
134.00139.00144.0060.00
160.00185.0040.0046.0052.0060.00
I/C
NNNNNNNNNNN
NNNNNNNNNNN
ANANANANANANANANANANAN
Lateral Supports, smallLateral Supports, mediumLateral Supports, largePelvic StrapsTrayTray, with hardwareVest Support, smallVest Support, mediumVest Support, large
Wedge Support, largeSeating System
Unlisted Pediatric Adaptive!Positioning Accessories(specify)
E1399 uc NC NC
35
ProcedureCode~
MaximumMonthlyRentalCh8r2e
20.00135.0025.00
73747576818283848588
ccccccccccc
ccccccccccc
-t'
MaximumMaximum Procedure MonthlyPurchase Code Rental LifePrice ~ Charge ExRectancy
rProcedureCodePurchaseItem DescriRtion
Miscellaneous EguiRment
$ I/C $ NCNC
I/C10.00
NCNC
NCNC 2 years
Augmentative CommunicationEquipment X9559Augmentative Accessories
(provided after initial purchase) X9558Bed Pan, metal or plastic E0275Blood Pressure Equipment
economy kit X9527cuff with bladder X9528
Collar, rigid, cervical X9340Collar, rigid, Philadelphia X934 IDrug Delivery System, spacer, bag A4627
or reservoir with or withoutmask, for metered dose inhaler
Phototherapy Unit NC
25.0015.0018.0036.5036.75
NCNCNCNCNC
NCNCNCNCNC
] year] year
6 months6 months6 months
N/C EO202 50.00 (daily)
E0630 1000.00 X8124 55.23 5 years
EO621 80.25 NC NC year
EOl80 77.00 X8140 13.61 3 years
X9141X9339X9338X9342X9638X9684E0910
23.0013.0065.0065.00
169.00206.00129.00
NCNCNCNCNCNC
X8121
NCNCNCNCNCNC
9.93
3 years6 months6 months6 months2 years2 years2 years
Patient Lift. hydraulic, with seator sling
Sling or Seat, patient lift canvasor nylon
Pressure Pad, Alternating, with
pumpPad OnlySplint, cock-up wristSplint, positioning, handSplint, positioning, footTransfer Bench, padded
with commode seat, paddedTrapeze Bar (a/k/a Patient
Helper), attached to bed,with grab bar
Trapeze Bar, free standing,complete with grab bar
Vaporizer, room
E0940 279.00 X8400 21.46 5 years
E0605 15.00 NC NC 2 years
36
Max:mumMaximum Procedure MonthlyPurchase Code Rental LifePrice ~ Charge Ex~ctanc'"
Procedure
CodePurchaseItem DescriQtion
E1399 $Durable Medical Equipment, nototherwise classified (specify)
I/C X8999 s I/C I/C
Reoairs to Durable Medical EguiRment
Repair or non-routine services fordme requiring the skill of a tech-nician, labor component, per 1 hr.,up to 3 hours
E1340 60.00 NC NC
37
l'
PEDIATRIC MEDICAL EQUIPMENT AND SUPPLIES
Durable Medical Equipment and Accessories-Purchase
NOTE: See separate list for Equipment Rentals
ProcedureCodePurchase
MaximumPurchasePriceItem DescriRtion
Activity Chair, adaptiveHigh-back X9545 494.00
Bath chair - adjustable, adaptivesmallmediumlarge X9504extra large
X9534X9503
294.00319.00344.00357.00X9542
X9523X9524X9525
289.00325.50335.00
Bath Seat - tilting, adaptive
mediumadolescentadolescent, largeExtension Legs orHead Pad/Support, each X9526 103.00
BedsX91X91X91X91
2,888.0062.50
112.50344.00
cribmattressbumper padstop cover
youth bedmattress
X9130X9132
3,738.00269.00
)
38
13313413536
ProcedureCodePurchase
Maximt;" .1
Purchas?PriceItem DescriRtion
X9561X9562X9563
$
Bolster Chair-adaptive, includingadjustable/swing-away annrests
smallmediumAdolescent/large
complete including3 bolsters, 2 pro sandals X9564 619.00
Chair - Multi-Purpose, adaptive X9S0S 65.00
X9142X9144
332.00432.00
Commode Chair/Potty Chair, adaptivesmalladolescent
Commode Chair/RollingShower Chair. adaptive
with large rear wheelswith swivel rear casters
X9565X9566
999.00940.00
Corner Chair - adjustable, adaptive X9567 413.00
X9530 128.00Feeder Seat, adaptive
smallWedge to convert feederseat to floor sitter X9S33 97.00
X9508X9509X9568
98.00110.00150.00
Floor Sitter, adaptivesmallmediumwith adjustable angle
Footwear, Orthopedic/Con'ectiveOpen toe shoes, straight orreverse last, pair
small
largeX9572Dennis Brown Bar
X9570 51.95
X957 1 55.9558.9520.95X9S73
39
425.00432.00438.00
~
ProcedureCodePurchase
rItem DescriRtion
MaximumPurchasePrice
X9574X9575
$ 44.9510.00
Fillauer BarDepth Inlay Shoe (aka extra depth). pairOrthotic Inserts. custom-molded (flexible
semi-rigid. rigid), pair 150.00X9576
X9579 350.00
X9577X9578
10.0045.00
Custom molded shoes, pairLift on shoe, each,
each 1/4 incheach 1 inch
Gait Trainer-adjustable, adaptivesmall X9582 688.00
110.00105.00115.00125.00
X9587X9588X9513X9514
Head Support-Hensinger typelarge
mounted, extra smallsmallmedium
Heel or Elbow Protector, each EO191
)X9540 6590
19036,
Helmet-protectivesoft shellhard shell X9541
super smalVsuper largechin guard
X9625X9626
Mobile Stander-adaptive, with body support system,II X95
X95X95X95
994.001,119.001,744.002,063.00
Peak Flowmeter X9634
Pressure Pad - bed pad or mattress, reusablestandard
heavy dutyX9S01X9S02
20.0032.00
Prone Board! Adaptive Stander, adjustablesmallmediumadolescent
X9516X9635X9636
619.00669.00
1,081.00
40
.00
.00
.00
.00
smallmediumadolescentadolescent, large
i94i95i96i97
ProcedureCodePurchase
MaximumPurchasePriceItem DescriQtion
ScalesBaby-Portable home care 20 kg.
50 grams or 36 Ibs. x 1/4 Ibs.X9518 65.00
Balance beam, 16 kg. x 1 0 grams or36 Ibs. x 1/8 oz.
X9S19 270.00
Mechanical, 15 kg. x 5 grams or 31 Ibs.x 1/4 oz.
X9520 224.00
Beam, dual reading 40 Ibs. x Y2 oz. and17.5 kg. x .01 kg.
X9641 310.00
Diaper, bowl type (aka 'Pee Wee') X9S43 197.50
Shower Chair - adjustable, adaptive
adolescent
adolescent/1argeX9644X9645
463.00475.00
X9646X9647
344.007].90
Side- Lying Board - adjustableadolescent
trunk support block
Standing Frame - adjustable X9648 707.00
Stethoscope X9084 15.00
Supine Board-adjustablechildX9671adolescent
1,232.001,375.00X9672
Thennometer-standardrectal or oralear (instant)
X9673X9675
2.5080.00
4
I .+1'
ProcedureCodePurchase
MaximumPurchasePrice
rItem Descriotion
Toddler Chair, adaptive withadjustable back X9682 164.00
Urinometer X9522 8.00
X9546X9547
91.0098.00
Vestrrronk SuRRQrt(Whitworth type)
Extra support, naugahydesmalVrnediumlarge
Lightweight, nylon cotton weavesrnalVrnediumlarge
X9548X9549
84.0089.00
X9237X9690X9238
WalkersStandardfolding
with wheels
X9222X9694X9220
~adustable, with wheels and seatlarge/extra wide/heavy dutywalker, posture control with wheels
EO158X9695X9696X9697
Walker Accessoriesleg extensions (set of 4)wheeled foot piece, pairwheeled foot piece, swivel, pairplatfonn attachment, pediatric only
Wedge, abductor X9560 46.88
42
83.00100.00140.00
275.00225.00211.00
36.0033.0044.00
106.00
Respiratory Medical EQuipment and Accessories
. Note: These codes can also be used to bill for adults
MaximumMonthlyRentalCharge
Proced uteCodePurchase
MaximumPurchasePrice
ProcedureCode~
LifeEx~tanc~Item Descri~tion
Bi-Pap VentilatorSupport SystemWith MaskWith Headgear
$ NCNC
NCNC
X8718X8719
$ 461.00468.00
Bi-Pap VentilatorAccessories
X9718 51.35 NC NCMask, replace-
mentHeadgear, re-
placement X9719 35.35 NC NC
Cannula, Nasal A4615 1.45 NC NC
Cannula. tubing,7 feet X9702 1.60 NC NC
HumidificationHeaterSystem(Cascade type) X9720 780.00 $60.00X8720
Humidification Kit,(aka Trach Ventor Heat'Mois-ture exchange X9703 4.75 NC NC
HumidificationFilter, each X9704 2.30 NC NC
X9721 42.00 NC NCManometer
Oxygen Analyzer X9708 240.00 X8708 $ 18.50
43
~7:c~
ProcedureCode
Item DescriRtion Purchase
MaximumPurchasePrice
ProcedureCode~
MonthlyRentalCharge
rLifeEx~ctancy
Pulse OximeterWith Recorder NC NC X8709 500.00
16.00 dailyrate
Multi-use probe(aka Sensor,Transducer) NC NC X8728 13.00
NC NC X8094 520.00Respirator Support
System -Ventilator withaccessorypower source andHumidity system,appropriatecircuits (includingtubing, connec-tors, adaptors,thermal indicator)and secondary lowpressure alarm 0
Resusciator, manual NC NC X8711 13.50
USED MEDICAL EQUIPMENT
ProcedureCodePurchase
MaximumPurchasePriceItem Descri~tion
Beds. Hos~ital
Hospital Bed, total electric (head, foot and heightadjustments), with matb'ess, with side rails
Hospital Bed, total electric (head, foot and heightadjustments), without mattress, with side rails
X7114 ,642.50
X7115 1,537.50
44