Medical Supplies
October 1, 1999
COVERAGE INDEX MEDICAL SUPPLIES AND EQUIPMENT LIST The following pages outline specific coverage policy for supplies and services. This list contains the medical supplies and equipment covered by Medicaid, subject to the conditions stated and subject to changes adopted by federal or state law, changes in policy or procedures, or changes announced in Medicaid Information Bulletins. The Supplies and Equipment List includes the HCPCS code and descriptor, or the state Medicaid code and descriptor, criteria for approval, whether Prior Authorization is required, and any limits on quantity. All rental items are subject to capped rental unless otherwise specified. Items that require prior authorization are indicated with a “P” before the billing code. Bills that are submitted with rental items should contain the appropriate code followed by an "RR” modifier. If a code is not listed in the manual, a provider may contact ACS/Consultec in writing with a request to cover any code not included in the Medical Supply manual. This request must include a complete description of the item, including brand, product number, size, etc. Use procedure code modifiers when appropriate. A physician’s written order is required. Medicaid or ACS/Consultec may request additional documentation. Prior authorization is required.
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Medical Supplies
October 1, 1999
AIR FLUIDIZED AND LOW AIR LOSS BED UNITS - See also “HOSPITAL BEDS” Rental:
Covered.
Equipment: P E0193 Powered air flotation bed (low air loss therapy) Note: E0193 describes a semi-electric or total electric hospital bed with a fully integrated powered pressure reducing mattress, which is characterized by all of the following: 1) An air pump or blower, which provides either sequentilia inflation and deflation of the air cells or a low interface pressure throughout the mattress; 2) Inflated cell height of the air cells through which air is being circulated is five inches or greater; 3) Height of the air chambers, proximity of the air chambers to one another frequency of air cycling (for alternating pressure mattresses), and air pressure provide adequate patient lift, reduce pressure and prevent bottoming out; 4) A surface designed to reduce friction and shear; Can be placed directly on a hospital bed frame; and 5) Automatically re-adjusts inflation pressures with change in position of bed (e.g. head elevation, etc.) P E0194 Air fluidized bed Note: E0194 describes a device employing the circulation of filtered air through silicone coated ceramic beads creating the characteristics of fluid. Documentation: Prior to authorization of the bed the following conditions must be met and documented: 1. Recipient is bedridden or chair bound. 2. A comprehensive recipient assessment and evaluation by the attending physician has occurred documenting Stage III or IV decubitus ulcer(s) or postoperative healing of major skin grafts or myocutaneous flaps on the trunk and pelvis. The recipient should be placed on the bed unit immediately after the surgical procedure or severe insult to skin integrity. 3. A description of all alternative equipment and conservative treatment that has been attempted and why it was deemed inappropriate or ineffective. 4. A trained adult caregiver is available to assist the recipient with the activities of daily living and the management and support of the air fluidized bed system. 5. Evidence that in the absence of the bed, the recipient would need to be institutionalized. Prior Authorization: Required.
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October 1, 1999
Note: Not covered for a recipient in a nursing facility APNEA MONITOR Rental:
Apnea monitors are exempt from capped rental. Covered on a rental basis for recipients that meet one of the following criteria: 1. One or more apparent life threatening events requiring mouth-to-mouth resuscitation or vigorous stimulation or an episode that is characterized by some combination of apnea or color change, choking or gagging; 2. Symptomatic pre-term infants; 3. Sibling of a SIDS victim; 4. A medical condition such as central hyperventilation, bronchopulmonary dysplasia, infant with tracheostomy, history of recent vent dependency, infant born to a substance abusing mother, infant/child with severe respiratory complications resulting in periods of apnea.
Equipment: E0608 Apnea monitor Supplies/Accessories: The following items are included in the rental fee for the apnea monitor and CANNOT be billed separately: 1.
2.
All supplies, accessories and services necessary for proper functioning and effective use of the equipment. ** Reimbursement for remote alarms will be included in the monitor rental payment. ** Wyoming Medicaid does not cover monitors that do not use rechargeable batteries. Complete parent/caregiver training on use of the equipment and completion of necessary medical record paperwork.
Documentation: Prior to initiation of home apnea monitoring the following conditions must be met: 1.
A certification of medical necessity must be obtained from the attending physician, which describes the criteria for use of an apnea monitor and specifies the projected length of time the equipment will be needed.
2
Apnea monitor rental exceeding six months requires a physician’s narrative report of recipient progress attached to the claim form. A new progress report is required every two months, after the initial six months. The report must include: a.)
The number of apnea episodes during the previous two-month period of use;
b.)
Tests and results of tests performed during the previous two-month period
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Medical Supplies
October 1, 1999 of use;
c.)
Estimated additional length of time the monitor will be needed;
d.)
Any additional pertinent information the physician may wish to provide.
Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
BATH and TOILET AIDS Note:
For Toilet Aids refer to “Commode” section.
Purchase:
Covered for recipients with medical conditions, which cause a recipient to be unstable with ambulation and puts the recipient at risk for falls/injury. Covered items include but are not limited to bath/toilet rails, raised toilet seats, tub stools and benches, transfer tub benches and attachments, and bath support chairs. Bathtub patient lifts and rehabilitation shower chairs are covered for recipients with medical conditions who, without use of the equipment, would be unable to bathe or shower.
Equipment: E0160 E0161 E0162 E0241 E0242 E0243 E0244 E0245 E0246 E0625
Sitz type bath or equipment, portable, used with or without commode Sitz type bath or equipment, portable, used with or without commode, with faucet attachments Sitz bath chair Bath tub wall rail, each Bath tub rail, floor base Toilet rail, each Raised toilet seat Tub stool or bench Transfer tub rail attachment Patient lift, kartop, bathroom or toilet lift Note: E0625 may only be used for billing bathtub patient lifts.
Limitations: Bed baths and shower attachments (e.g. hand-held shower attachments, faucet adapters, etc.) are not covered. Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
BEDPANS and URINALS Purchase:
Covered for recipients who are confined to bed.
Equipment: E0275 E0276 E0325 E0326
Bed pan, standard, metal or plastic Bed pan, fracture, metal or plastic Urinal; male, jug-type, any material Urinal; female, jug-type, any material
Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
BEDS, HOSPITAL - See “HOSPITAL BEDS”
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Medical Supplies
October 1, 1999
BLOOD GLUCOSE MONITORING Purchase:
Covered for recipients that meet all of the following conditions: 1.
The recipient is a physician diagnosed diabetic; and
2.
The recipient’s physician documents that the recipient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases, the recipient may not be able to perform this function, but a responsible individual can be trained to use the equipment and monitor the recipient to assure that the intended effect is achieved. This is permissible if this information is properly documented by the recipient’s physician; and
3.
The device is designed for home rather than clinical use.
Blood glucose monitors with such features as voice synthesizers, automatic timers, and specially designed arrangements of supplies and materials to enable recipients with visual impairments to use the equipment without assistance are covered when the following conditions are met: 1.
The recipient and device meet the three conditions listed above for coverage of standard blood glucose monitors; and
2.
The recipient’s physician certifies that the recipient has a visual impairment severe enough to require use of this special monitoring system.
Equipment: E0607 E0609
Home blood glucose monitor Blood glucose monitor with special features (e.g. voice synthesizers, automatic timers, etc.)
Supplies/Accessories: Supplies necessary for effective use and proper functioning of a blood glucose monitor are covered for use with rental and recipient-owned monitors for recipients whose condition meets the criteria for coverage of the monitor. Alcohol or peroxide, per pint Alcohol wipes, per box (Note: 1 unit of service = 1 box of 50 wipes) Betadine or pHisohex solution, per unit Betadine or iodine swabs/wipes, per box (Note: 1 unit of service = 1 box of 50) A4253 Blood glucose test or reagent strips for home blood glucose monitor per 50strips A4254 Replacement battery, any type, for use with medically necessary home blood glucose monitor owned by patient, each A4244 A4245 A4246 A4247
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Medical Supplies A4255 A4256 A4258 A4259 Z4026 Z4027
October 1, 1999 Platforms for home blood glucose monitor, 50 per box Normal, low and high calibrator solution/chips Spring-powered device for lancet, each Lancets, per box of 100 Glucose monitor speech module to attach to blood glucose monitor Sure drop device to attach to blood glucose monitor
Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
BLOOD PRESSURE MONITORS: Purchase:
Covered for recipients with hypertension whose condition must be self-monitored at home. An electronic blood pressure monitor is covered only if the recipient is unable to use a standard cuff and stethoscope due to conditions such as poor eyesight or hearing, arthritis, or other physical disability.
Equipment: A4660 A4670 A4663
Sphygmomanometer/blood pressure apparatus with cuff and stethoscope Automatic blood pressure monitor Cuff
Limitations: Blood pressure monitors required for renal dialysis are payable ONLY to approved renal dialysis facilities. (See Dialysis Equipment and Supplies).
Documentation: Written order.
Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
BONE GROWTH STIMULATORS - See “OSTEOGENIC STIMULATORS”
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Medical Supplies
October 1, 1999
BREAST PROSTHESES (EXTERNAL) and SUPPLIES Purchase:
Covered for recipients who have had a mastectomy.
Equipment/Supplies: L8000 L8010 L8020 L8030
Breast prosthesis, mastectomy bra Breast prosthesis, mastectomy sleeve Breast prosthesis, mastectomy form Breast prosthesis, silicone or equal
Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
BREAST PUMPS Rental:
Electric breast pumps are covered on a rental basis only when “Documentation of Medical Necessity” is supplied by the prescribing physician.
Equipment: Z4733 Electric breast pump set Supplies/Accessories: The rental reimbursement for a breast pump includes all supplies and accessories necessary for proper functioning and effective use of the pump. Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
CANES AND CRUTCHES Purchase/ Rental:
Covered for recipients with a medical condition that causes instability or impairs ambulation.
Equipment: E0100 Cane, includes canes of all materials, adjustable or fixed with tips E0105 Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips E0110 Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips E0111 Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips E0112 Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips E0113 Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip E0114 Crutches underarm, other that wood, adjustable or fixed, pair, with pads, tips and handgrips E0116 Crutch, underarm, other than wood, adjustable or fixed, each, with pad, tip and handgrip E0153 Platform attachment, forearm, crutch, each Supplies/ Payment for purchase and rental includes all accessories necessary for Accessories: proper functioning and effective use of the item. Accessories such as tips, handgrips, etc., are payable for recipient owned equipment when the recipient’s condition meets the criteria for coverage of the item. The following supplies/accessories are covered as replacement for recipientowned canes and crutches only and CANNOT be billed in addition to the equipment at the time of purchase or with rental equipment: A4635 Underarm pad, crutch, replacement, each A4636 Replacement handgrip, cane, crutch, or walker, each A4637 Replacement tip, cane, crutch, or walker, each Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
COMMODES Purchase/ Rental:
Covered for recipients who are confined to bed or room or confined to home in which there are no bathroom facilities on that floor or bathroom facilities are inaccessible. Payment for purchase and rental of a commode includes all accessories necessary for proper functioning and effective use of the commode. Accessories such as a commode pail or pan are payable only as replacement for use with recipient-owned commodes whose condition meets the criteria for coverage.
Equipment: E0163 E0164 E0165 E0166 K0457
Commode chair, stationary, with fixed arms Commode chair, mobile, with fixed arms Commode chair, stationary, with detachable arms Commode chair, mobile, with detachable arms Extra wide/heavy duty commode chair
Supplies/Accessories: The following supplies/accessories are covered as replacement for recipient-owned commodes only and CANNOT be billed in addition to the equipment at the time of purchase or with rental equipment. E0167 Pail or pan for use with commode chair E0175 Foot rest for use with commode chair, each Limitations: A commode chair with detachable arms is covered only if documentation supports medical necessity in cases such as obesity, paraplegia, etc. Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
CONTINUOUS PASSIVE MOTION (CPM) DEVICES Rental:
Covered for recipients who have received a total knee replacement. To qualify for coverage, use of the device must commence within two days following surgery. Coverage is limited to that portion of the three week-period following shoulder or knee injury or surgery when the device is used in the recipient’s home. Payment for rental of CPM devices includes all accessories necessary for proper functioning and effective use of the device.
Equipment: P
E0935 Passive motion exercise device
Documentation: Written order. Prior Authorization: Required.
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Medical Supplies
October 1, 1999
CONTINUOUS POSITIVE AIRWAY PRESSURE SYSTEMS (CPAP) (BiPAP) Rental:
This item is exempt from capped rental. Covered for recipients with moderate or severe obstructive sleep apnea for whom surgery is a likely alternative. Intermittent assist devices (BiPAP S or BiPAP ST) are covered for recipients that after trial use with CPAP are unable tolerate use of straight CPAP. Humidifiers for use with airway pressure systems are covered for recipients that require supplemental humidification with these systems.
Equipment: P E0452 Intermittent assist with continuous positive airway pressure device (BiPAP S) P E0453 Therapeutic ventilator; suitable for 12 hours or less per day (BiPAP ST) P E0601 Continuous airway pressure (CPAP) device P K0193 CPAP device with humidifier P K0268 Humidifier, used with CPAP or BiPAP Supplies/Accessories: The following supplies/accessories are covered as replacement for recipient owned systems and CANNOT be billed in addition to the equipment at the time of purchase or with rental equipment. K0183 K0184 K0185 K0186 K0187 K0188 K0189
Nasal application device, used with CPAP device Nasal pillows/seals, replacement for nasal application device, pair Headgear, used with CPAP device Chin strap, used with CPAP device Tubing, used with CPAP device Filter, disposable, used with CPAP device Filter, non-disposable, used with CPAP device
Documentation: Written order. The following documentation must be included in the recipient’s file: 1. Diagnosis of obstructive sleep apnea - at least 30 episodes of apnea, each lasting a minimum of 10 seconds, during 6-7 hours of recorded sleep. 2. Any relevant copies of recipient’s sleep lab evaluation, including polysomnograms, pulmonary function tests, sleep latency testing and O2 saturations. 3. Physical symptoms: morning headache, fatigue level, increases in irritability, difficulty with memory or intellect. 4. Pertinent lab values (e.g. elevated PaCO2, etc.) 5. Other methods attempted and why those methods were deemed inappropriate or ineffective. 6. Follow-up at 1 - 3 months documenting improvement in recipient’s condition. Prior Authorization: Required for items indicated with a “P”.
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Medical Supplies
October 1, 1999
DIALYSIS EQUIPMENT and SUPPLIES Wyoming Medicaid reimburses for dialysis systems, related supplies and equipment only to approved renal dialysis facilities under the Medicare payment methodology. Payment CANNOT be made to suppliers, pharmacies or home health agencies for dialysis systems, related supplies and equipment.
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Medical Supplies
October 1, 1999
DRESSINGS Purchase:
Covered for recipients who require treatment of a wound or surgical incision. NOTE: Skin and wound cleansers are not covered. A4454 A4460 A6020 A6154 A6196 A6197 A6198 A6199 A6203 A6204 A6205 A6206 A6207 A6208 A6209 A6210 A6211 A6212 A6213 A6214 A6215 A6216 A6217
A6218
Tape, all types, all sizes Elastic Bandage, per roll (e.g., compression bandage) Collagen based wound dressing, wound cover, each dressing Wound pouch, each Alginate dressing, wound cover, pad size 16 sq. in. or less, each dressing Alginate dressing, wound cover, pad size more than 16 but less than or equal to 4 to 8 sq. in., each dressing Alginate dressing, wound cover, pad size more than 48 sq. in., each dressing Alginate dressing, wound filler, per 6 inches Composite dressing, pad size 16 sq. in. or less, with any size adhesive border, each dressing Composite dressing, pad size more than 16 but less than or equal to 48 sq. in., with any size adhesive border, each dressing Composite dressing, pad size more than 48 sq. in., with any size adhesive border, each dressing Contact layer, 16 sq. in. or less, each dressing Contact layer, more than 16 but less or equal to 48 sq. in., each dressing Contact layer, more than 48 sq. in., each dressing Foam dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing Foam dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., without adhesive border, each dressing Foam dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing Foam dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., with any size adhesive border, each dressing Foam dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing Foam dressing, wound filler, each gram Gauze, non-impregnated, non-sterile, pad size 16 sq. in. Or less, without adhesive border, each dressing Gauze, non-impregnated, non-sterile, pad size more than 16 but less than or equal to 48 sq. in., without adhesive border, each dressing Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in., without adhesive border, each dressing
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Medical Supplies A6219 A6220 A6221 A6222 A6223
A6224 A6228 A6229
A6230 A6234 A6235
A6236 A6237 A6238
A6239 A6240 A6241 A6242 A6243 A6244 A6245 A6246
October 1, 1999 Gauze, non-impregnated, pad size 16 sq. in. or less, with any size adhesive border, each dressing Gauze, non-impregnated, pad size more than 16 but less than or equal to 48 sq. in., with any size adhesive border, each dressing Gauze, non-impregnated, pad size more than 48 sq. in., with any size adhesive border, each dressing Gauze, impregnated, other than water or normal saline, pad size 16 sq. in. or less, without adhesive border, each dressing Gauze, impregnated, other than water or normal saline, pad size more tan 16 but less than or equal to 48 sq. in., without adhesive border, each dressing Gauze, impregnated, other than water or normal saline, pad size more the 48 sq. in., without adhesive border, each dressing Gauze, impregnated, water or normal saline, pad size 16 sq. in. Or less, without adhesive border, each dressing Gauze, impregnated, water or normal saline, pad size more than 16 but less than or equal to 48 sq. in., without adhesive border, each dressing Gauze, impregnated, water or normal saline, pad size more than 48 sq. in., without adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., without adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in. with any size adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing Hydrocolloid dressing, wound filler, per fluid ounce Hydrocolloid dressing, wound filler, dry form, per gram Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing Hydrogel dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., without adhesive border, each dressing Hydrogel dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing Hydrogel dressing, wound cover, pad size more than 16 sq. in., or less, with any size adhesive border, each dressing Hydrogel dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., with any size adhesive border, each
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Medical Supplies
A6247 A6248 A6251 A6252
A6253 A6254 A6255
A6256 A6257 A6258 A6259 A6261 A6262 A6263 A6264 A6265 A6266 A6402 A6403 A6404 A6405 A6406
October 1, 1999 dressing Hydrogel dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing Hydrogel dressing, wound filler, gel, per fluid ounce Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., without adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing Specially absorptive dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., with any size adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing Transparent film, 16 sq. in. or less, each dressing Transparent film, more than 16, but less than or equal to 48 sq. in., each dressing Transparent film, more than 48 sq. in., each dressing Wound filler, not elsewhere classified, gel/paste, per fluid ounce Wound filler, not elsewhere classified, dry form, per gram Gauze, elastic, non-sterile, all types, per linear yard Gauze, non-elastic, non-sterile, per linear yard Tape, all types, per 18 square inches Gauze, impregnated, other than water or normal saline, any width, per linear yard Gauze, non-impregnated, sterile, pad 16 sq. in. or less, without adhesive border, each dressing Gauze, non-impregnated, sterile, pad size more than 16 but less than or equal to 48 sq. in., without adhesive border, each dressing Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing Gauze, elastic, sterile, all types, per linear yard Gauze, non-elastic, sterile, per linear yard
Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
ELECTRICAL NERVE STIMULATORS - See “NEUROMUSCULAR ELECTRICAL STIMULATORS; TRANSCUTANEOUS ELECTRICAL NERVE STIMULATORS”
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Medical Supplies
October 1, 1999
ENTERAL NUTRITION - See “NUTRITION”
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Medical Supplies
October 1, 1999
EYE PROSTHESES Purchase:
Covered for recipients with absence or shrinkage of an eye due to birth defect, trauma, or surgical removal. V2623 V2624 V2625 V2626 V2627 V2628 V2629
Prosthetic eye, plastic, custom Polishing/resurfacing of ocular prosthesis Enlargement of ocular prosthesis Reduction of ocular prosthesis Scleral cover shell Fabrication and fitting of ocular conformer Prosthetic eye, other type
Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
FOOT ORTHOSES (Orthopedic shoes, shoe modification, transfers)- see “ORTHOTICS”
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Medical Supplies
October 1, 1999
HEAT/COLD APPLICATION DEVICES, See also “PARAFFIN BATH UNITS, PORTABLE” Purchase:
Covered for recipients with medical conditions for which the application of heat and cold is therapeutic.
Equipment: E0210 E0215 E0217 E0218 E0220 E0225 E0230 E0238 E0239 Supplies/ Accessories:
Electric heat pad, standard Electric heat pad, moist Water circulating heat pad with pump Water circulating cold pad with pump Hot water bottle Hydro collator unit, includes pads Ice cap or collar Non-electric heat pad, moist Hydro collator unit, portable
The following supplies/accessories are covered as replacement for recipient-owned equipment only and CANNOT be billed in addition to the equipment at the time of purchase or with rental equipment. E0249
Pad for water circulating heat unit
Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
HOSPITAL BEDS AND ACCESSORIES - See also “AIR FLUIDIZED and LOW AIR LOSS BED UNITS”, “PRESSURE REDUCING SURFACES” Purchase/ Rental:
All hospital beds may be rented or purchased with the exception of E0193 and E0194, which are rental only and can only be purchased through capped rental. Hospital beds and accessories are covered according to the following: A fixed height hospital bed is one with manual head and leg elevation adjustments, but no height adjustments. A fixed height hospital bed is covered for recipients whose condition meets at least one of the following criteria: 1. Requires positioning of the body in ways not feasible with an ordinary bed due to a medical condition, which is expected to last at least one month. (Elevation of the head/upper body less than 30 degrees does not usually require use of a hospital bed.) 2. Requires, for the alleviation of pain, positioning of the body in ways not feasible with an ordinary bed; 3. Requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease or problems with aspiration. An attempt must have been made at using pillows or wedges and there must be documentation as to why they did not work; or 4. Requires traction or other attachments that can only be attached to a hospital bed. A variable height hospital bed is one with manual height adjustment and with manual head and leg elevation adjustments. A variable height hospital bed is covered if the recipient’s condition meets the criteria for coverage of a fixed height hospital bed and the recipient also requires a bed height different from that provided by fixed height hospital bed in order to permit transfers to chair, wheelchair or standing position. Documentation must show the medical condition, which necessitates the manual variable-height feature. This feature is not reimbursable when it is used convenience of a caregiver. A semi-electric hospital bed is one with manual height adjustment and with electric head and leg elevation adjustments. This item requires prior authorization. A semi-electric hospital bed is covered if the recipient’s condition meets the criteria for coverage of a fixed height hospital bed and the recipient also requires frequent changes in body position and/or has an immediate need for a change in body position. Recipient must be able to operate bed controls. A total electric bed is one with electric height adjustment and with electric head and leg elevation adjustments. This item requires prior authorization. A total electric bed is covered if the recipient’s condition meets the criteria for coverage
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Medical Supplies
October 1, 1999
of a fixed height hospital bed and: 1. There is need for an immediate change in position to avert a life-threatening situation, and 2. The change cannot be accomplished by the use of the bed side rails, trapeze, or the assistance of a caregiver, and 3. The recipient is alert and capable of effecting this change by operating the electric controls in a safe manner. 4. The recipient’s medical condition requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair, or standing position. A bed cradle is covered for recipients with acute gouty arthritis, for treatment of burns or gangrene to prevent contact with the bed coverings, or for persons with recent leg or foot surgery or related conditions. The following items are not reimbursable as they are items, which are not primarily medical in nature: 1. overbed table 2. bed board Equipment: P E0193 Powered Air Flotation Bed (Low Air Loss Therapy). May be purchased through capped rental only. E0193 describes a semielectric or total electric hospital bed with a fully integrated powered pressure-reducing mattress. P E0194 Air Fluidized Bed - describes a device employing the circulation of filtered air through silicone coated ceramic beads creating the characteristics of fluid. May be purchased through capped rental only. E0250 Hospital bed, fixed height, with any type side rails, with mattress E0251 Hospital bed, fixed height, with any type side rails, without mattress E0255 Hospital bed, variable height, hi-lo, with any type side rails, with mattress E0256 Hospital bed, variable height, hi-lo, with any type side rails, without mattress P E0260 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress P E0261 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress P E0265 Hospital bed, total electric, (head, foot and height adjustments), with any type side rails, with mattress P E0266 Hospital bed, total electric (head, foot and height adjustments), with any type side rails, without mattress E0290 Hospital bed, fixed height, without side rails, with mattress E0291 Hospital bed, fixed height, without side rails, without mattress E0292 Hospital bed, variable height, hi-lo, without side rails, with mattress
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Medical Supplies
P P P P
October 1, 1999
E0293 Hospital bed, variable height, hi-lo, without side rails, without mattress E0294 Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress E0295 Hospital bed, semi-electric (head and foot adjustments), without side rails, without mattress E0296 Hospital bed, total electric (head, foot and height adjustments), without side rails, with mattress E0297 Hospital bed, total electric (head, foot and height adjustments), without side rails, without mattress
Supplies/Accessories: E0180 E0181 E0182 E0185 E0188 E0189 E0192 E0197 E0198 E0199 E0280 E0370 P P
Pressure pad, alternating with pump Pressure pad, alternating with pump, heavy duty Pump for alternating pressure pad Gel or gel-like pressure pad for mattress Synthetic sheepskin pad Lambs-wool sheepskin pad, any size Low pressure and positioning equalization pad Air pressure pad for mattress Water pressure pad for mattress Dry pressure pad for mattress Bed cradle, any type Air pressure pad elevator for heel
E0371 Non-powered advanced pressure reducing overlay for mattress, standard mattress length and width E0372 Powered air overlay for mattress, standard mattress length and width
The following items are covered for recipient-owned equipment only and CANNOT be billed with rental equipment or at the time of purchase:
P
E0271 E0272 E0373 E0186 E0184 E0187 E0196 E0277
Mattress, inner-spring Mattress, foam rubber Non-powered advanced pressure reducing mattress Air pressure mattress Dry pressure mattress Water pressure mattress Gel pressure mattress Powered pressure-reducing air mattress
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Medical Supplies
October 1, 1999
Documentation: Written order. Documentation for pressure reducing surfaces must include and indicate that the recipient: 1. Has tried other conservative methods of treatment and why those treatments were deemed inappropriate or ineffective; 2. Has one or more Stage III or IV decubitus ulcers, pressure sores, or related conditions, or is highly susceptible to decubitus ulcers, or has a condition of fragile skin integrity, or a history of skin ulcers, or insult to skin integrity, or 3. Has multiple Stage II decubitus ulcers on trunk or pelvis which have been unresponsive to a comprehensive treatment for at least 30 days using a lesser support surface; or 4. Has myocutaneous flap or skin graft for pressure ulcer on the trunk or pelvis within the past 60 days; or 5. Is bedridden or chairbound, or has limited mobility, but cannot independently make changes in body position significant enough to alleviate pressure; or 6. Is completely immobile and cannot make changes in body position without assistance. The recipient must have a care plan established by the physician other licensed healthcare practitioner directly involved in the recipient’s care that should include the following: 1. 2. 3. 4. 5. 6.
Education of the recipient and caregiver on the prevention and/or management of pressure ulcers; Regular assessment by a licensed healthcare practitioner; Appropriate turning and positioning; Appropriate wound care (for Stage II, III, or IV ulcer); Moisture/incontinence control, if needed; and Nutritional assessment and intervention consistent with the overall plan of care if there is impaired nutritional status.
Adherence to the care plan/treatment is not to be construed as elements for coverage criteria. Pressure reducing cushions are covered for recipients with or who are highly susceptible to pressure ulcers and whose physician will be supervising its use in connection with recipient’s course of treatment. Prior Authorization: Required for items indicated with “P”.
C-30
Medical Supplies
October 1, 1999
INCONTINENCE APPLIANCES and CARE SUPPLIES Purchase:
Covered for recipients who are unable to control bladder or bowel function.
Equipment: A4310 Insertion tray without drainage bag and without catheter (accessories only) A4311 Insertion tray without drainage bag with indwelling catheter, foley type, two-way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.) A4312 Insertion tray without drainage bag with indwelling catheter, foley type, two-way, all silicone A4313 Insertion tray without drainage bag with indwelling catheter, foley type, three-way, for continuous irrigation A4314 Insertion tray with drainage bag with indwelling catheter, foley type, twoway latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.) A4315 Insertion tray with drainage bag with indwelling catheter, foley type, twoway, all silicone A4316 Insertion tray with drainage bag with indwelling catheter, foley type, three-way for continuous irrigation A4320 Irrigation tray with bulb or piston syringe, any purpose A4322 Irrigation syringe, bulb or piston A4326 Male external catheter specialty type, e.g., inflatable, faceplate, etc., each A4327 Female external urinary collection device; metal cup, each A4328 Female external urinary collection device; pouch, each A4329 External catheter starter set, male/female, includes catheters/urinary collection device, bag/pouch and accessories (tubing, clamps, etc.), sevenday supply A4330 Perineal fecal collection pouch with adhesive, each A4335 Incontinence supply; miscellaneous (Note: Include a complete description of the item including brand, product number, size, etc.) A4338 Indwelling catheter; foley type; two-way latex with coating (teflon, silicone, elastomer, or hydrophilic, etc.), each A4340 Indwelling catheter; specialty type, e.g., coude, mushroom, wing, etc., each A4344 Indwelling catheter; foley type, two-way, all silicone, each A4346 Indwelling catheter; foley type, three-way for continuous irrigation, each A4347 Male external catheter with or without adhesive, with or without antireflux device; per dozen A4351 Intermittent urinary catheter; straight tip, each A4352 Intermittent urinary catheter; coude (curved) tip, each A4353 Intermittent urinary catheter; with insertion supplies A4354 Insertion tray with drainage bag but without catheter A4355 Irrigation tubing set for continuous bladder irrigation through a three-way indwelling foley catheter, each A4356 External urethral clamp or compression device (not to be used for catheter
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Medical Supplies
A4357 A4358 A4359 A4364 A4402
A4454 A4455 A4554 A5102 A5105 A5112 A5113 A5114 A5131 K0280 K0281
K0407 K0408 K0410 K0411 K0451 Z4717 Z4718
October 1, 1999 clamp), each Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each Urinary leg bag; vinyl, with or without tube, each Urinary suspensory without leg bag, each Adhesive for ostomy or catheter; liquid (spray, brush, etc.), cement, powder or paste; any composition (e.g., silicone, latex, etc.), per ounce Lubricant, per ounce (Note: For individual sterile packets, see K0281.) Note: A4402 and K0281 are included in catheter insertion trays and may be billed for clients who do not use catheter insertion trays. Tape, all types, all sizes Adhesive remover or solvent (for tape, cement or other adhesive) per ounce Disposable underpads, all sizes, (e.g., Chux’s) Bedside drainage bottle, rigid or expandable Urinary suspensory; with leg bag, with or without tube Urinary leg bag; latex Leg strap; latex, per set Leg strap; foam or fabric, per set Appliance cleaner, incontinence and ostomy appliances, per 16 ounce Extension drainage tubing, any type, any length, with connector/adapter, for use with urinary leg bag or urostomy pouch, each Lubricant, individual sterile packets, for insertion of urinary catheter, each Note: A4402 and K0281 are included in catheter insertion trays and may only be billed for clients who do not use catheter insertion trays. Urinary catheter anchoring device, adhesive skin attachment Urinary catheter anchoring device, leg strap Male external catheter, with adhesive coating, each Male external catheter, with adhesive strip, each Adhesive remover wipes, per box of 50 Attends washcloths; box of 100. Incontinence briefs, per package
Limitations: Incontinence diapers/briefs and liners are not covered for recipients under age three. Limited to 30-day supply. Documentation: Written order. Prior Authorization: Not required.
C-32
Medical Supplies
October 1, 1999
INFUSION PUMPS, EXTERNAL and Accessories Purchase/ Rental:
Covered for recipients with conditions requiring intermittent or continual infusion of medication or nutrition when this form of administration is safe, reasonable and necessary (e.g. chemotherapy, severe spasms, chronic intractable pain), and when an infusion pump is necessary to safely administer the medication. Also covered for recipients with conditions that require the subcutaneous infusion of insulin in the treatment of diabetes.
Equipment:
P P P P P P P P P
B9000 Enteral nutrition infusion pump without alarm B9002 Enteral nutrition infusion pump with alarm B9004 Parenteral nutrition infusion pumps, portable B9006 Parenteral nutrition infusion pumps, stationary E0776 IV pole E0781 Ambulatory infusion pump, single or multiple channels, with administrative equipment, worn by the patient E0782 Infusion pump, implantable, non-programmable (for purchase only) E0783 Infusion pump system, implantable, programmable (includes components, e.g., pump catheter, connectors, etc.) (for purchase only) E0784 External ambulatory infusion pump, insulin E0791 Parenteral infusion pump, stationary, single or multi channel K0284 External infusion pump, mechanical, reusable, for extended drug infusion K0417 External infusion pump, mechanical, reusable, for short-term drug infusion
Supplies/Accessories: Supplies necessary for effective use and proper functioning of an external infusion pump are covered for use with rental and recipient-owned pumps for recipients whose condition meets the criteria for coverage of the pump. Note: For billing of medications administered with external infusion pumps, see Pharmacy manual. A4220 Refill kit for implantable infusion pump A4221 Supplies for maintenance of drug infusion catheter, per week A4222 Supplies for external drug infusion pump, per cassette or bag A4230 Infusion set for external insulin pump, non-needle cannula type A4231 Infusion set for external insulin pump, needle type A4232 Syringe with needle for external insulin pump, sterile, 3 cc A4300 Implantable access catheter (venous, arterial, epidural, or peritoneal), external access A4301 Implantable access total system; catheter, port/reservoir (venous, arterial or epidural), percutaneous access A4305 Disposable drug delivery system, flow rate of 50 ml or greater per hour A4306 Disposable drug delivery system, flow rate of 50 ml or less per hour
C-33
Medical Supplies
October 1, 1999
Documentation: Written order. When pump is to be used for infusing of medication, the following criteria must be met (1,2, and 3 or 1, 4, and 5): 1. Parenteral administration of medication in the home is reasonable and necessary; 2. The drug is administered by a prolonged infusion of at least 4 hours because of proven improved clinical efficiency; 3. The therapeutic regimen is proven or generally accepted to have significant advantages over (a) intermittent bolus administration regimens, (b) infusions lasting less than eight hours, or (c) when pump is used for infusion of medications (ex. antibiotic or steroids) which require an intermittent syringe pump; 4. The drug is administered by intermittent infusion (each episode lasting less than eight hours), which does not require the patient to return to the physician’s office prior to the beginning of each infusion; 5. Systemic toxicity or adverse effects of the drug is unavoidable without infusing it at a strictly controlled rate as indicated by the Facts and Comparisons, American Medical Association’s Drug Evaluations, or the U.S. Pharmacopeia Drug Information. Documentation of the following pertinent information must be provided: 1. Medical history of recipient; 2. Parenteral nutrition solution or medication to be administered, quantity, frequency and duration; 3. Specific route of administration (e.g. Hep lock, PICC line, central line, etc.); 4. Person who will be administering the medication or nutrition; and 5. All other methods attempted and why they were deemed ineffective or inappropriate. In addition: 1. If pump is to be used for chemotherapy: - location of cancer; - specific medication to be given; and - the expected outcome. 2. If pump is to be used for anti-spasmodic drugs: - length and severity of spasms; - minimum six week trial documenting that recipient cannot be maintained on non-invasive methods of spasm control or that these methods have intolerable side effects; and - prior to pump placement, recipient must have responded favorably to a trial dose of the intrathecal, anti-spasmodic medication. 3. If pump is to be used for chronic, intractable pain: - specific location of pain;
C-34
Medical Supplies
October 1, 1999 - length and severity of pain; - recipient history must indicate that he/she would not (or did not) respond adequately to non-invasive methods of pain control (including attempts to eliminate physical and behavioral abnormalities which may cause an exaggerated reaction to pain); - a preliminary trial of intraspinal opioid drug administration must be undertaken with a temporary intrathecal/epidural catheter to substantiate adequately acceptable pain relief and degree of side effects (including effects on the activities of daily living) and recipient acceptance. 4. If pump is to be used for uncontrolled diabetes: - length of time the recipient has had condition; - frequency of blood sugar testing; and - the previous treatment regimen for the recipient
Prior Authorization: Required for items indicated with a “P”.
C-35
Medical Supplies
October 1, 1999
INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) MACHINES Rental:
Covered for recipients whose ability to breathe is severely impaired or whose condition or diagnosis indicates the necessity for IPPB therapy. Payment for rental of an IPPB machine includes all accessories necessary for proper functioning and effective use of the machine. Accessories are payable only as replacement for use with recipient-owned devices for recipients whose condition meets the criteria for coverage of the machine.
Equipment: E0500 IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source. Supplies/Accessories: The following supplies/accessories are covered as replacement for recipient-owned IPPB machines only and CANNOT be billed in addition to the equipment at the time of purchase or with rental equipment. A4618 Breathing circuits E0550 Humidifier, durable for extensive supplemental humidification during IPPB treatments or oxygen delivery E0560 Humidifier, durable for supplemental humidification during IPPB treatments or oxygen Documentation: Written order. Prior Authorization: Not required.
C-36
Medical Supplies
October 1, 1999
LIFTS, PATIENT Purchase/ Rental:
Covered for recipients who meet specific criteria.
Equipment: P E0630 Patient lift, hydraulic, with seat or sling Supplies/Accessories: The following supplies/accessories are covered as replacement for recipient-owned patient lift only and CANNOT be billed in addition to the equipment at the time of purchase or with rental equipment. E0621 Sling or seat, patient lift, canvas or nylon Documentation: Written order. 1. Documentation must verify the recipient/caregiver can use the lift and has had a successful trial, if first time; and 2. Without the use of a lift, the recipient would be confined to bed; or 3. Transfer between bed and a chair, wheelchair or commode requires the assistance of more than one person. Prior Authorization: Required for items indicated with a “P".
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Medical Supplies
October 1, 1999
LOW AIR LOSS BED UNITS – See “HOSPITAL BEDS”
C-38
Medical Supplies
October 1, 1999
LOWER and UPPER LIMB ORTHOTICS – See “ORTHOTICS”
C-39
Medical Supplies
October 1, 1999
LOWER and UPPER LIMB PROSTHESIS - See “PROSTHETICS”
C-40
Medical Supplies
October 1, 1999
LYMPHEDEMA PUMPS - See “PNEUMATIC COMPRESSORS”
C-41
Medical Supplies
October 1, 1999
MEDICAL/SURGICAL SUPPLIES - See also “DRESSINGS”, “INCONTINENCE APPLIANCES and CARE SUPPLIES”, and “TRACHEOSTOMY CARE SUPPLIES” Purchase:
Covered for recipients that require home treatment of a specific medical condition, protection or support of a wound, surgical incision or diseased or injured body part.
Limitations: Skin/wound cleansers and “ready to use” disinfectant cleaning solutions are not covered. Syringe with needle, sterile 1cc, each Syringe with needle, sterile 2cc, each Syringe with needle, sterile 3cc, each Syringe with needle, sterile 5cc or greater, each Non-coring needle or stylet with or without catheter Syringe, sterile, 20cc or greater, each Needles only, sterile, any size, each Alcohol or peroxide, per pint Alcohol wipes, per box, (Note: 1 unit of service = 1 box of 50) Betadine or pHisohex solution, per pint Betadine or iodine swabs/wipes, per box (Note: 1 unit of service = 1 box of 50) A4250 Urine test or reagant strips or tablets (100 tablets or strips) A4320 Irrigation tray with bulb or piston syringe, any purpose A4322 Irrigation syringe, bulb or piston, each A4402 Lubricant, per ounce A4454 Tape, all types, all sizes A4455 Adhesive remover or solvent (for tape, cement or adhesive), per ounce A4460 Elastic bandage, per roll (e.g., compression bandage) A4554 Disposable underpads, all sizes (e.g., Chux’s) A4627 Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler (Example: Aerochamber) A4772 Dextrostick or glucose test strips, per box (Note: 1 unit of service = 1 box of 50) E0191 Heel or elbow protector, each A4206 A4207 A4208 A4209 A4212 A4213 A4215 A4244 A4245 A4246 A4247
Documentation: Written order. Prior Authorization: Not required.
C-42
Medical Supplies
October 1, 1999
MEDICATION DISPENSER (Automatic) Purchase:
Covered after a trial/rental period of 3 months.
Rental:
Automatic medication dispensers are covered for recipients who are unable to effectively and safely self-medicate, due to a medical or mental condition, or are non-compliant due to lack of supervision.
Equipment: P Z4025 CompuMed medication dispenser Limitations: Not covered for residents of nursing facilities. Documentation: Written order and documentation of medical necessity must include: 1.)
2.)
A determination that the recipient may be non-compliant due to one or more of the following factors: Complex drug regimen Forgetful Sensory deficit Lack of understanding Lack of supervision Inability to self-medicate Documentation that non-compliance has resulted in the following conditions due to INAPPROPRIATE use of medication: Relapse into illness Under-utilization of medications Ineffective drug therapy Overdosage Hospitalization Varying drug levels leading to unpredictable therapeutic results
Documentation: Written order and Certificate of medical necessity. Prior Authorization: Required.
C-43
Medical Supplies
October 1, 1999
NEBULIZERS and COMPRESSORS Purchase/ Rental:
Covered to administer aerosol therapy when use of a metered dose inhaler is not adequate or appropriate, when the recipient’s ability to breathe is severely impaired, or when required for use in connection with durable medical equipment for purposes of moisturizing oxygen. A heated nebulizer is covered for a recipient with a tracheostomy that requires heated oxygen. A portable compressor with an internal battery feature requires specific documentation from the physician justifying the medical necessity of the portable feature. An ultrasonic nebulizer is covered only when other means of nebulization are documented by the physician to be ineffective.
Equipment: E0565 Compressor, air power source for equipment which is not self-contained or cylinder driven E0570 Nebulizer with compressor E0575 Nebulizer; ultrasonic E0580 Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter (purchase only) E0585 Nebulizer, with compressor and heater K0269 Aerosol compressor, adjustable pressure, light duty for intermittent use K0270 Ultrasonic generator with small volume ultrasonic chamber for medication delivery K0501 Aerosol compressor, battery powered, for use with small volume nebulizer
Supplies/Accessories: The following supplies/accessories are covered as replacement for use with recipient-owned equipment for a recipient whose condition meets the criteria for coverage of the compressor and CANNOT be billed at the time of purchase or with rental equipment. Note: Distilled water is not covered. For billing of medications for inhalation therapy, see the Pharmacy Services Manual. A4617 A4619 A4621 E1372 K0168 K0169
Mouthpiece Face tent Tracheostomy mask or collar Immersion external heater for nebulizer Administration set, small volume non-filtered pneumatic Small volume non-filtered pneumatic nebulizer, disposable
C-44
Medical Supplies
October 1, 1999
K0170 Administration set, small volume non-filtered pneumatic nebulizer, nondisposable K0171 Administration set, small volume filtered pneumatic nebulizer K0172 Large volume nebulizer, disposable, unfilled, used with aerosol compressor K0173 Large volume nebulizer, disposable, prefilled, used with aerosol compressor K0174 Reservoir bottle, non-disposable, used with large volume ultrasonic nebulizer K0175 Corrugated tubing, disposable, used with large volume nebulizer, 100 feet K0176 Corrugated tubing, non-disposable, used with large volume nebulizer, 10 feet K0177 Water collection device, used with large volume nebulizer K0178 Filter, disposable, used with aerosol compressor K0179 Filter, non-disposable, used with aerosol compressor or ultrasonic generator Documentation: Written order. Prior Authorization: Not required.
C-45
Medical Supplies
October 1, 1999
NEUROMUSCULAR ELECTRICAL STIMULATORS (NMES) Purchase/ Rental:
Covered for treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves, and other nonneurological reasons for disuse are causing atrophy. Some examples would be castings or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training begins). Note: Neuromuscular electric stimulators are not covered for treatment of Scoliosis.
Equipment: E0745
Neuromuscular stimulator, electronic shock unit
Supplies/Accessories: The following supplies/accessories are covered as replacement for recipient-owned equipment only and CANNOT be billed in addition to the equipment at the time of purchase or with rental equipment. A4556 A4557 E0753
Electrodes Lead wires Implantable neurostimulator electrodes, per group of four
Documentation: Written order. Prior Authorization: Not required.
C-46
Medical Supplies
October 1, 1999
NUTRITION THERAPY Nutrition therapy is providing essential nutrients, vitamins, and minerals to meet the recommended dietary allowances, to provide adequate calories to meet energy requirements, and to provide adequate proteins to maintain weight and strength. Nutrition therapy is provided in two ways, enteral or parenternal. Nutrition Therapy Provider Guidelines Provider must be enrolled as a retail pharmacy provider and as a medical supply (DME) provider to be eligible for reimbursement for any legend nutrition therapy (mainly parenteral). Provider must comply with current Wyoming State Board of Pharmacy rules and regulations. In addition to these enrollment requirements, a provider is required to verify recipient eligibility, maintain the required documentation and coordinate with other healthcare providers involved in the recipient’s care. Provider documentation: 1.) A current home assessment stating that the environment in which nutrition therapy is to be given is safe and sanitary. 2.) A documented systematic ongoing process which will increase recipient compliance and decrease negative outcomes. 3.) A recipient profile consisting of: * Name, age, sex, height, and weight of the recipient * Current drug therapy, including prescription and nonprescription drugs and home remedies * Recipient’s current diagnosis(es) in relation to therapy * Recipient specific drug-related problem list * Goals for nutrition therapy * Pertinent medical history * Pertinent physical findings * Pertinent laboratory findings This profile must be updated on a quarterly basis to include: * Documentation of recipient education * Additions to or deletions from nutrition therapy * Outcomes associated with nutrition therapy * Ongoing recipient assessments * Results of ongoing laboratory tests * Ongoing pertinent medical findings This information shall be made available upon request and maintained for six years after therapy is completed.
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Medical Supplies
October 1, 1999
Recipient/Family Requirements and Education Recipients or their family who administer the enteral or parenteral therapy must: 1.)
be trainable and able to maintain the appropriate procedures needed in the home setting.
2.)
provide a clean and safe environment in which to administer the therapy.
3.)
demonstrate the appropriate disposal of hazardous solutions, intravenous administration supplies, and substances.
4.)
must be able to properly dispose of controlled substances in the home.
5.)
must have documentation stating the recipient has the ability to perform independent administration.
Education by the provider must include instructions and demonstrations in aseptic technique and appropriate storage methods for solutions. Provider must document that the above requirements and education standards have been met before providing enteral/parenteral therapy. Covered supplies: The following medical supplies are covered when used in conjunction with home enteral/parenteral therapy and are considered necessary for administration of the therapy. All items listed must be billed through the medical supplies program using the HCFA-1500 form. IV Poles Parenteral/Enteral Pumps Cassettes Administration Kits Dressing Kits Preparation Supplies Pump Supplies Flush Supplies Nursing Facilities: Parenteral nutrition is separately reimbursable in addition to the nursing facility per diem if the recipient meets the requirements. Enteral nutrition is not a legend drug and is included in the nursing facility per diem rate.
C-48
Medical Supplies
October 1, 1999
ENTERAL NUTRITION THERAPY Enteral Nutrition Therapy is considered reasonable and necessary for a recipient with a functioning gastrointestinal tract who, due to pathology or nonfunction of the structures that normally permit food to reach the digestive tract, cannot maintain weight and strength and overall health status. Enteral therapy is not covered for recipients whose nutritional defeciencies are due to a lack of appetite or cognitive problem. Enteral therapy may be given by nasogastric, jejunostomy, or gastrostomy tube when ordered by a physician who: 1.
has seen the recipient within 30 days prior to ordering the therapy.
2.
has documented that the recipient cannot receive adequate nutrition by dietary adjustments and/or oral supplements.
Enteral therapy is covered for recipients who: 1. 2.
have a condition involving the GI tract somewhere between the mouth and the duodenum; and require tube feedings to sustain life.
B4034 B4035 B4036 B4081 B4082 B4083 B4084 B4085 B4150 B4151 B4152 B4153 B4154 B4155 B4156 Z4356
Enteral feeding supply kit; syringe per day Enteral feeding supply kit; pump fed, per day Enteral feeding supply kit; gravity fed, per day Nasogastric tubing with stylet Nasogastric tubing without stylet Stomach tube - Levine type Gastrostomy/jejunostomy tubing Gastronomy tube, silicone with sliding ring, each Enteral formulae; category I, semi-synthetic Enteral formulae; category I, natural Enteral formulae; category II Enteral formulae; category III Enteral formulae; category IV Enteral formulae; category V Enteral formulae; category VI Specialized gastrostomy tube
Equipment:
C-49
Medical Supplies
October 1, 1999
PARENTERAL NUTRITION THERAPY Parenteral nutrition is considered reasonable and necessary for a recipient with severe pathology of the alimentary tract, which does not allow absorption of sufficient nutrients to maintain weight, strength and general health status. Parenteral therapy is given intravenously when ordered by a physician who: 1. 2.
has seen the recipient within 30 days prior to ordering the therapy. has documented that the recipient cannot receive adequate nutrition by dietary adjustments and/or oral supplements, or tube enteral nutrition.
Parenteral therapy is covered for recipients who: 1. 2.
have a condition of the GI tract that prevents absorption of sufficient nutrients. require IV feedings to sustain life.
**Parenteral therapy will not be covered for convenience or when the recipient’s nutritional needs can be met with enteral therapy. Equipment and supplies: (See also “Infusion Pump” section) P P P P P P
B4164 - B4199 B4216 B4220 B4222 B4224 B5000, B5100, B5200
Parenteral nutrition solution Parenteral nutrition; additives Parenteral nutrition supply kit; premix Parenteral nutrition supply kit; home mix Parenteral nutrition administration kit Parenteral nutrition solution
Limitations: Nutrition therapy is not covered for recipients whose nutritional deficiencies are due to a lack of appetite or cognitive problem Documentation: Enteral Nutrition Therapy - Written order. Documentation of medical necessity must be kept on file by the provider and made available on request. Parenteral Nutrition Therapy - Written order is required in addition to a Wyoming Medicaid “Certificate of Medical Necessity: Parenteral Nutrition” form. (See Chapter 4). Prior Authorization: Required for items indicated with a “P”.
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Medical Supplies
October 1, 1999
OCULAR PROSTHESES - See “EYE PROSTHESES”
C-51
Medical Supplies
October 1, 1999
ORTHOPEDIC SHOES - See also “ORTHOTICS”
C-52
Medical Supplies
October 1, 1999
ORTHOTICS: For spinal orthotics see “WHEELCHAIRS, (Manual and Power)” Purchase:
Orthotic appliances are those items employed for correction or prevention of skeletal deformities (braces, splints, etc.). Braces include rigid and semi-rigid devices that are used for the purpose of supporting weak or deformed body members or for restriction or eliminating motion in a diseased or impaired part of the body. Back braces include, but are not limited to: corsets, special sacroliac, sacrolumbar, or dorso-lumbar. Orthotic services include the replacement or repair of braces; devices for the legs, arms, back and neck; and trusses.
Equipment: L0100-L4398 are covered codes. Exception: Miscellaneous codes L0999, L1499, L2999, L3649, and L3999 are not reimbursable. 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 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 A5502 For diabetics only, multiple density insert(s), per shoe A5503 For diabetics only, modification (including fitting) of off-the-shelf depthinlay shoe or custom-molded shoe with roller or rigid rocker bottom, per shoe A5504 For diabetics only, modification (including fitting) of off-the-shelf depthinlay shoe or custom-molded shoe with wedge(s), per shoe A5505 For diabetics only, modification (including fitting) of off-the-shelf depthinlay shoe or custom-molded shoe with metatarsal bar, per shoe A5506 For diabetics only, modification (including fitting) of off-the-shelf depthinlay shoe or custom-molded shoe with offset heel(s), per shoe A5507 For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe **Miscellaneous modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe for diabetics only, per shoe Note: Coverage of orthopedic shoes is limited to one pair at the time of purchase. Except when documentation indicates excessive wear or necessary increase in size due to growth, only one pair of orthopedic shoes is covered in a one year period. E1800 E1805 E1810 E1815 E1820 E1825 E1830
Dynamic adjustable elbow extension/flexion device Dynamic adjustable wrist extension/flexion device Dynamic adjustable knee extension/flexion device Dynamic adjustable ankle extension/flexion device Soft interface material, dynamic adjustable extension/flexion device Dynamic adjustable finger extension/flexion device Dynamic adjustable toe extension/flexion device
Prior Authorization: Not required.
C-53
Medical Supplies
October 1, 1999
OSTEOGENESIS STIMULATORS Purchase/ Rental:
Covered for recipient’s meeting specific criteria.
Equipment: P E0747 Osteogenic stimulator, electrical, noninvasive other than spinal applications P E0748 Osteogenic stimulator, electrical, noninvasive, spinal applications P E0749 Osteogenic stimulator, electrical, (surgically implanted) (for purchase only) P E0760 Osteogenesis stimulator, low intensity ultrasound, non-invasive Documentation: Written order. Any one of the following criteria must be documented for coverage: 1. Non-union of long bone fracture after six months or more has elapsed without healing of the fracture; or 2. Failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last surgery; or 3. Congenital pseudoarthrosis. Prior Authorization: Required.
C-54
Medical Supplies
October 1, 1999
OSTOMY SUPPLIES Purchase:
Covered for recipients with an ostomy.
Supplies/Accessories: A4357 Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube A4361 Ostomy faceplate, each A4362 Skin barrier; solid, 4X4 or equivalent, each A4363 Skin barrier; liquid (spray, brush, etc.) powder or paste; per ounce A4364 Adhesive for ostomy or catheter; liquid (spray, brush, etc.), cement, powder or paste; any combination (e.g., silicone, latex, etc.), per ounce A4365 Ostomy adhesive remover wipes, 50 per box A4367 Ostomy belt, each A4368 Ostomy filter, any type, each A4397 Irrigation supply; sleeve, each A4398 Ostomy irrigation supply; bag, each A4399 Ostomy irrigation supply; cone/catheter, including brush A4402 Lubricant, per ounce A4404 Ostomy ring, each A4454 Tape, all types, all sizes A4455 Adhesive remover or solvent (for tape, cement, or other adhesive), per ounce Z4717 attends wash cloths; box of 100. A5051 Pouch, closed; with barrier attached (1 piece) A5052 Pouch, closed; without barrier attached (1 piece) A5053 Pouch, closed; for use on faceplate A5054 Pouch, closed; for use on barrier with flange (2 piece) A5055 Stoma cap A5061 Pouch, drain able; with barrier attached (1 piece) A5062 Pouch, drain able; without barrier attached (1 piece) A5063 Pouch, drain able; for use on barrier with flange (2 piece system) A5064 Pouch, drain able, with faceplate attached; plastic or rubber A5065 Pouch, drain able, for use on faceplate; plastic or rubber A5071 Pouch, urinary; with barrier attached (1 piece) A5072 Pouch, urinary; without barrier attached (1 piece) A5073 Pouch, urinary; for use on barrier with flange (2 piece) A5074 Pouch, urinary, with faceplate attached; plastic or rubber A5075 Pouch, urinary, for use on faceplate; plastic or rubber A5081 Continent Device; plug for continent stoma A5082 Continent device; catheter for continent stoma A5093 Ostomy accessory; convex insert A5102 Bedside drainage bottle with or without tubing, rigid or expandable, each A5119 Skin barrier; wipes, box per 50 A5121 Skin barrier; solid, 6X6 or equivalent, each A5122 Skin barrier; solid, 8X8 or equivalent, each A5123 Skin barrier; with flange (solid, flexible or accordion), any size, each
C-55
Medical Supplies
October 1, 1999
A5126 Adhesive; disc or foam pad A5131 Appliance cleaner, incontinence and ostomy appliances, per 16 ounce A6250 Skin sealants, protectants, moisturizers, ointments, any type, any size (Note: 1 unit = 1 ounce) K0137 Skin barrier, liquid (spray, brush, etc.), per ounce K0138 Skin barrier, paste, per ounce K0139 Skin barrier, powder, per ounce K0277 Skin barrier, solid 4X4 or equivalent, standard wear with built-in convexity, each K0278 Skin barrier, with flange (solid, flexible or accordion), standard wear with built-in convexity, any size, each K0279 Skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, any size, each K0280 Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, each K0419 Pouch, drain able, with faceplate attached, plastic, each K0420 Pouch, drain able, with faceplate attached, rubber, each K0421 Pouch, drain able, for use on faceplate, plastic, each K0422 Pouch, drain able, for use on faceplate, rubber, each K0423 Pouch, urinary, with faceplate attached, plastic, each K0424 Pouch, urinary, with faceplate attached, rubber, each K0425 Pouch, urinary, for use on faceplate, plastic, each K0426 Pouch, urinary, for use on faceplate, heavy plastic, each K0427 Pouch, urinary, for use on faceplate, rubber, each K0428 Ostomy faceplate equivalent, silicone ring, each K0429 Skin barrier, solid 4X4 or equivalent, extended wear, without built-in convexity, each K0430 Skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, any size, each K0431 Pouch, closed, with standard wear barrier attached, with built-in convexity (1 piece), each K0432 Pouch, drain able, with extended wear barrier attached, without built-in convexity (1piece), each K0433 Pouch, drain able, with standard wear barrier attached, with built-in convexity (1piece), each K0434 Pouch, drain able, with extended wear barrier attached, with built-in convexity (1piece), each Limitations: Skin moisturizers, protectants and sealants are covered only if medically necessary for a recipient with an ostomy. Note: Skin cleansers are not covered. Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
OXIMETERS, EARS/PULSE Rental:
Covered for recipients who require a minimum of daily monitoring of arterial blood oxygen saturation levels for evaluating and regulation of home oxygen therapy. Coverage for other indications will be determined on a case-by-case basis.
Limitations: In-home, overnight, 12-hour, or similar oximetry trend studies and other single “one-time” oximetry testing are not covered. Pulse oximetry readings are covered in the monthly fee for concentrators. Equipment: P 5015
Oximeter
Supplies/Accessories: Supplies and accessories necessary for proper functioning and effective use of the device are included in the rental reimbursement. Documentation: Written order, must include: 1. 2. 3.
The recipient’s medical condition, which documents the need for in-home use of an oximeter; The estimated length of time recipient will require monitoring; and The frequency of monitoring required (e.g., continuous, daily, etc.).
A monthly report is required when the oximeter is necessary for evaluation and regulation of home oxygen therapy. O2 saturation readings by a pulse oximeter may be performed by a provider and reviewed and signed off by the physician. Prior Authorization: Required.
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Medical Supplies
October 1, 1999
OXYGEN and OXYGEN EQUIPMENT Purchase/ Rental:
Oxygen concentrators are exempt from capped rental. Covered on a rental basis for recipients with severe hypoxemia in the chronic stable state provided the following conditions are met: 1. The physician has determined that the recipient suffers from severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, or 2. The recipient’s blood gas levels or O2 Sat indicate the need for oxygen therapy. Note: For Medicaid purposes, “severe hypoxemia” is defined as a PO2 below 55mmHg or an 02 Saturation of less than 89%. Portable oxygen systems alone or to complement a stationary oxygen system may be covered if the recipient is mobile within the residence. Claims submitted for oxygen delivery systems and contents must be billed on a monthly basis. Rental reimbursement includes: 1. 2. 3.
Concentrator, regulator, demurrage, supplies and accessories; Equipment testing, cleaning, repair and routine maintenance; and Delivery, setup and patient instruction.
Limitations: Oxygen therapy is not reimbursable for: 1. 2. 3. 4.
Angina pectoris in the absence of hypoxemia; Dyspnea without cor pulmonale or evidence of hypoxemia; Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; and Terminal illness that does not affect the lungs.
Note: Respiratory therapy services are not covered. The durable medical equipment benefit provides coverage of oxygen and oxygen equipment, but does not include a professional component in the delivery of such services. Note: A “piped-in” oxygen system is not considered durable medical equipment for reimbursement purposes and is not reimbursable.
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Medical Supplies
October 1, 1999
Equipment: E0424 Stationary compressed gaseous oxygen system, rental; includes contents (per unit), regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing. E0431 Portable gaseous oxygen system, rental; includes regulator, flowmeter, humidifier, cannula or mask, and tubing E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adapter, contents gauge, cannula or mask, and tubing E0439 Stationary liquid oxygen system, rental; includes use of reservoir, contents (per unit), regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing E1400 Oxygen concentrator manufacturer specified maximum flow rate does not exceed two liters per minute, at 85-percent or greater concentration E1401 Oxygen concentrator, manufacturer specified maximum flow rate greater than two liters per minute, does not exceed three liters per minute, at 85percent or greater concentration E1402 Oxygen concentrator, manufacturer specified maximum flow rate greater than three liters per minute, does not exceed four liters per minute, at 85percent or greater concentration E1403 Oxygen concentrator, manufacturer specified maximum flow rate greater than four liters per minute, does not exceed five liters per minute, at 85percent or greater concentration E1404 Oxygen concentrator, manufacturer specified maximum flow rate greater than five liters per minute, at 85-percent or greater concentration Note: Contents may be billed in addition to the oxygen delivery system. Oxygen contents are billed on a monthly basis, not daily or weekly. E0441 Oxygen contents gaseous, per unit, (for use with recipient-owned gaseous stationary systems or when both a stationary and portable gaseous system are recipient-owned) E0442 Oxygen contents, liquid, per unit (for use with recipient-owned liquid stationary systems or when both a stationary and portable liquid system are recipient-owned) E0443 Portable oxygen contents, gaseous, per unit (for use only with portable gaseous systems when no stationary gas or liquid is used; 1 unit = 5 cubic feet) E0444 Portable oxygen contents, liquid, per unit (for use only with portable liquid systems when no stationary gas or liquid system is used; 1 unit = 1 pound) Supplies/Accessories: The following supplies/accessories are covered as replacements for recipient-owned oxygen equipment only and CANNOT be billed in addition to the equipment at the time of purchase or with rental equipment. The rental fee
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October 1, 1999
includes all of the items listed below: A4615 A4616 A4619 A4620 A4621 E0455 E0550 E0555 E0560 E1353 E1355 Z0011
Cannula, nasal Tubing (oxygen), per foot Face tent Variable concentration mask Tracheostomy mask or collar Oxygen tent, excluding croup or pediatric tents Humidifier durable for extensive supplemental humidification during IPPB treatment or oxygen delivery Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter (purchase only) Humidifier, durable for supplemental humidification during IPPB treatments or oxygen (purchase only) Regulator Stand/rack (purchase only for patient owned equipment) O2 conserving device
Documentation: A current physician’s written order must be on file. Use of the Medicare CMN form is required. Documentation must include the results of a blood gas study that has been ordered and evaluated by the attending physician, specifically, a measurement of the partial pressure of oxygen (PO2) in the arterial blood. A measurement of oxygen saturation by pulse oximetry may also be acceptable when ordered and evaluated by the attending physician and performed under his/her supervision or when performed by a qualified provider or supplier of laboratory services. A pulse oximetry reading of the recipient’s O2 saturation may be performed and documented by a provider and reviewed and signed off by the physician. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
PACEMAKER MONITORS, SELF CONTAINED Purchase:
Covered for recipients with cardiac pacemakers.
Equipment: E0610 Pacemaker monitor, self-contained, checks battery depletion, includes audible and visible check systems E0615 Pacemaker monitor, self-contained, checks battery depletion and other pacemaker components, includes digital/visible check systems Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
PARAFFIN BATH UNITS, PORTABLE Purchase/ Rental:
Covered for recipients with conditions that are expected to be relieved by long term use of this modality and who have undergone a successful trial period of paraffin therapy.
Equipment: E0235
Paraffin bath unit, portable
Supplies/Accessories: A4265
Paraffin covered for use with rental and recipient-owned paraffin bath units for recipients whose condition meets the criteria for coverage of the device.
Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
PEAK FLOW METERS Purchase: Covered for recipients with chronic asthma. Equipment: A4614 Peak expiratory flow rate meter, hand held Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
PERCUSSORS Purchase/ Rental:
Covered for mobilizing respiratory tract secretions in recipients with cystic fibrosis, chronic obstructive lung disease, chronic bronchitis, or emphysema, when the recipient or operator of powered percussor has received appropriate training by a physician or therapist and no one competent to administer manual therapy is available.
Equipment: P Z0007 THAIRapy generator, (purchase through capped rental only) P Z0008 THAIRapy vest, (purchase only) E0480 Percussor, electric or pneumatic, home model All supplies necessary for proper use and maintenance of equipment and complete caregiver/recipient training are included in the rental/purchase reimbursement. Documentation: Written order. Documentation must include the following: 1. Diagnosis of cystic fibrosis or similar condition that causes an over production of secretions. 2. Other methods of treatment attempted, the length of time of each and why they were deemed inappropriate and/or ineffective. 3. Recipient’s medical and social history. 4. Caregiver/recipient understanding of the use and cleaning of equipment. Prior Authorization: Required for items indicated with a “P”.
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Medical Supplies
October 1, 1999
PHOTOTHERAPY SERVICES Rental:
Covered on a rental basis for infants that meet the following criteria: 1. 2. 3. 4. 5.
Neonatal hyperbilirubinemia is the infant’s sole clinical problem; The infant is greater than or equal to 37 weeks gestational age and birth weight greater than 2,270 gm (5lbs); The infant is greater than 48 hours of age; Bilirubin level at initiation of phototherapy (greater than 48 hours of age) is 14 mgs per deciliter or above; and Direct bilirubin level is less than two mgs per deciliter.
The following conditions must be met prior to initiation of home phototherapy; 1.
2. 3. 4. 5.
History and physical assessment by the infant’s attending physician has occurred. If home phototherapy begins immediately upon discharge from the hospital, the newborn discharge exam will suffice; Required laboratory studies have been performed, including CBC, blood type on mother and infant, direct Coombs, direct and indirect bilirubin; The physician certifies that the parent/care giver is capable of administering home phototherapy; and Parent/caregiver has successfully completed training on use of the equipment; and Equipment must be delivered and set up within four hours of discharge from the hospital or notification of provider, whichever is more appropriate. Repair and/or replacement service must be available 24hours per day.
Equipment: E0202 Phototherapy (bilirubin) light with photometer
Payment:
Daily rental payment includes: 1. 2.
Phototherapy unit and all supplies, accessories, and services necessary for proper functioning and effective use of the therapy; Complete caregiver training on use of equipment and completion of necessary records.
Documentation: A physician’s written order and narrative report outlining the recipient’s progress and documentation of the above outlined criteria and conditions necessitating therapy must be attached to the claim form when billing for home phototherapy. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
PNEUMATIC COMPRESSORS and APPLIANCES Purchase/ Rental:
Covered for recipients with intractable edema of the extremities.
Equipment: (For Rental Only) E0650 Pneumatic compressor, non-segmental home model E0651 Pneumatic compressor, segmental home model without calibrated gradient pressure E0652 Pneumatic compressor, segmental home model with calibrated gradient pressure Supplies/accessories:
(For Purchase Only)
E0655 Non-segmental pneumatic appliance for use with pneumatic compressor, half arm E0660 Non-segmental pneumatic appliance for use with pneumatic compressor, full leg E0665 Non-segmental pneumatic appliance for use with pneumatic compressor, full arm E0666 Non-segmental pneumatic appliance for use with pneumatic compressor, half leg E0667 Segmental pneumatic appliance for use with pneumatic compressor, full leg E0668 Segmental pneumatic appliance for use with pneumatic compressor, full arm E0669 Segmental pneumatic appliance for use with pneumatic compressor, half leg E0671 Segmental gradient pressure pneumatic appliance, full leg E0672 Segmental gradient pressure pneumatic appliance, full arm Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
PRESSURE REDUCING SUPPORT SURFACES - see also “HOSPITAL BEDS AND ACCESSORIES”, “WHEELCHAIRS, (Manual and Power)” Purchase/ Rental:
Pressure reducing mattress pads/overlays are covered when the recipient meets one of the following criteria: 1. Completely immobile (i.e., the recipient cannot make changes in body position without assistance); 2. Limited mobility (i.e., the recipient can not independently make changes in body position significant enough to alleviate pressure); or 3. Any stage pressure ulcer on the trunk or pelvis. If the recipient meets criteria 2 or 3 above, the recipient must also meet at least one of the following criteria: a. b. c. d.
Impaired nutritional status; Fecal or urinary incontinence; Altered sensory perception; or Compromised circulatory status.
Pressure reducing mattress replacements are covered when the recipient meets the coverage criteria for a pressure reducing mattress pad/overlay and; 1. Anticipated length of need is at least one year; or 2. “Bottoming out” is anticipated on a comparable pad/overlay. “Bottoming out” is the finding that the recipient’s body will be in contact with a flat outstretched hand (palm up) that is placed underneath the support surface in various body positions. Equipment: E0180 Pressure pad, alternating with pump E0181 Pressure pad, alternation with pump, heavy duty E0184 Dry pressure mattress Note: E0184 describes a non-powered pressure-reducing mattress. It is characterized by all of the following: 1. Form height of five inches or greater; 2. Foam with a density and other qualities that provide adequate pressure reduction; 3. Durable, waterproof cover; and 4. Can be placed directly on a hospital bed frame. E0185 Gel or gel-like pressure pad for mattress Note: E0185 describes a non-powered pressure reducing mattress overlay designed to be placed on top of a standard hospital or home
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October 1, 1999
mattress. It is characterized by a gel layer with a height of two inches or greater. E0186 Air pressure mattress Note: E0186 describes a non-powered pressure-reducing mattress. It is characterized by all of the following: 1. Height of five inches or greater of the air layer; 2. Durable, waterproof cover; and 3. Can be placed directly on a hospital bed frame. E0187 Water pressure mattress Note: E0187 describes a non-powered pressure-reducing mattress. It is characterized by all of the following: 1. Height of five inches or greater of the water layer; 2. Durable, waterproof cover; and 3. Can be placed directly on a hospital bed frame. E0188 Synthetic sheepskin pad E0189 Lambswool sheepskin pad, any size E0196 Gel pressure mattress Note: E0196 describes a non-powered pressure-reducing mattress. It is characterized by all of the following: 1. Height of five inches or greater of the gel layer; 2. Durable, waterproof cover; and 3. Can be placed directly on a hospital bed frame. E0197 Air pressure pad for mattress Note: E0197 describes a non-powered pressure reducing mattress overlay designed to be placed on top of a standard hospital or home mattress. It is characterized by interconnected air cells having a cell height of three inches or greater that are inflated with an air pump. E0198 Water pressure pad for mattress Note: E0198 describes a non-powered pressure reducing mattress overlay designed to be placed on top of a standard hospital or home mattress. It is characterized by a filled height of three inched or greater. E0199 Dry pressure pad for mattress Note: E0199 describes a non-powered pressure reducing mattress overlay designed to be placed on top of a standard hospital or home mattress. It is characterized by all of the following: 1. Base thickness of two inches or greater and peak height of three inches or greater if it is a convoluted overlay (e.g., egg crate) or an overall height of at least three inches if it non-convoluted overlay;
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October 1, 1999
2. Foam with a density and other qualities that provide adequate pressure reduction; and 3. Durable, waterproof cover. E0370 Air pressure pad elevator for heel Supplies/accessories: The following supplies/accessories are covered as replacement for recipient-owned alternating pressure pads only and CANNOT be billed in addition to the equipment at the time of purchase or with rental equipment. A4640 Replacement pad for use with medically necessary alternating pressure pad owned by recipient E0182 Pump for alternating pressure pad Limitations: Powered mattress pads/overlays and mattress replacements, except alternating pressure pads, are not reimbursable. Documentation: Documentation for pressure reducing surfaces must include and indicate that the recipient: 1. Has tried other conservative methods of treatment, the length of time of each and why those treatments were deemed inappropriate or ineffective; 2. Has one or more Stage III or IV decubitus ulcers, pressure sores, or related conditions, or is highly susceptible to decubitus ulcers, or has a condition of fragile skin integrity, or a history of skin ulcers, or insult to skin or integrity; or 3. Has multiple Stage II decubitus ulcers on trunk or pelvis which have been unresponsive to a comprehensive treatment for at least 30 days using a lesser support surface; or 4. Has myocutaneous flap or skin graft for pressure ulcer on the trunk or pelvis within the past 60 days; or 5. Is bedridden or chairbound, or has limited mobility, but cannot independently make changes in body position significant enough to alleviate pressure; or 6. Is completely immobile and cannot make changes in body position without assistance. The recipient must have a care plan established by the physician or other licensed healthcare practitioner directly involved in the recipient’s care which should include the following: 1. Education of the recipient and caregiver on the prevention and/or management of pressure ulcers; 2. Regular assessment by a licensed healthcare practitioner; 3. Appropriate turning and positioning; 4. Appropriate wound care (for Stage II, III, or IV ulcer); 5. Moisture/incontinence control, if needed; and 6. Nutritional assessment and intervention consistent with the overall plan of care if there is impaired nutritional status.
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October 1, 1999
Adherence to the care plan/treatment is not to be construed as elements for coverage criteria. Pressure reducing cushions are covered for recipients with or highly susceptible to pressure ulcers and whose physician will be supervising its use in connection with recipient’s course of treatment. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
PROSTHETICS - See also “BREAST PROSTHESES”, “EYE PROSTHESES” Prosthetic devices replace all or part of the body function of a permanently inoperative or malfunctioning body organ. A terminal device (for example a hand or hook) is covered when the recipient requires an artificial arm. Diagnosis would include conditions that require prosthetic devices due to accident, injury, surgery, birth defects or disease process. Stump socks and harnesses, including replacements, are covered when documentation substantiates that the appliance was in use before the recipient became eligible for Medicaid. Devices in this section do not include surgically implanted prosthesis. The devices in this section are considered as “base” or “basic devices” and may be modified by listing devices from the additions section and adding them to the base procedure. Prosthetic services include repair or replacement of prosthetic devices, other than dental. Replacement of usable appliances or artificial limbs may be required because of a change in the recipient’s physical condition. Medicaid will reimburse for repairs and adjustment of appliances when necessary, even when the appliance had been in use before the recipient became eligible for Medicaid. Equipment: HCPCS codes L5000-L9999 are approved codes for Wyoming Medicaid. Exception: Miscellaneous codes L5999, L7499, L8499, and 8699 will not be reimbursed. Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
REPAIRS/MAINTENANCE/LABOR Wyoming Medicaid reimburses repairs when: 1. 2. 3. P
equipment is still medically necessary for the recipient; and the equipment is no longer under warranty; and it is not routine maintenance
E1340 Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes
Limitations: Limited to 16 units per calendar year This code does NOT cover routine maintenance, such as tire change, equipment inspection, battery change, etc. It does not cover repairs for rental equipment or equipment under warranty. This code is NOT to be used to assemble or deliver and set up equipment to a recipient. Documentation: Written order. Prior Authorization: Required.
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Medical Supplies
October 1, 1999
SITZ BATHS Purchase:
Covered for recipients with infection or injury of the perineal area and use of the item is part of the physician ordered planned regimen of treatment in the recipient’s home.
Equipment: E0160 Sitz type bath or equipment, used with or without commode E0161 Sitz type bath or equipment, portable, used with or without commode, with faucet attachments E0162 Sitz bath chair Documentation: Written order. Prior Authorization: Not required.
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October 1, 1999
SPINAL ORTHOTICS - see “WHEELCHAIRS, (Manual and Power)”
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October 1, 1999
STOCKINGS, SURGICAL - See “SUPPORTS”
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Medical Supplies
October 1, 1999
SUCTION PUMPS - See also “TRACHEOSTOMY CARE SUPPLIES” Purchase/ Rental:
Covered for recipients who have difficulty raising and clearing secretions secondary to cancer or surgery of the throat or mouth; dysfunction of the swallowing muscles; unconsciousness or obtunded state; or tracheostomy.
Equipment: E0600 Suction pump, home model, portable Supplies/Accessories: A4624 A4628 K0190 K0191 K0192
Tracheal suction catheter, any type, each Oropharyngeal suction catheter, each Canister, disposable, used with suction pump Canister, non-disposable, used with suction pump Tubing, used with suction pump
Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
SUPPORTS (including elastic supports, elastic/surgical stockings, slings, trusses, etc.). Purchase:
Covered for post surgical recipients, and recipients with intractable edema of the lower extremities or other circulatory disorders. Support pantyhose are not covered.
Equipment: A4465 Non-elastic binder for extremity A4490 Surgical stockings above knee length, each A4495 Surgical stockings thigh length, each A4500 Surgical stockings below knee length, each A4510 Surgical stockings full length, each A4565 Slings L8100 Gradient compression stocking, below knee, 18-30 mmhg, each L8110 Gradient compression stocking, below knee, 30-40 mmhg, each L8120 Gradient compression stocking, below knee, 40-50 mmhg, each L8130 Gradient compression stocking, thigh length, 18-30 mmhg, each L8140 Gradient compression stocking, thigh length, 30-40 mmhg, each L8150 Gradient compression stocking, thigh length, 40-50 mmhg, each L8160 Gradient compression stocking, full length/chap style, 18-30 mmhg, each L8170 Gradient compression stocking, full length/chap style, 30-40 mmhg, each L8180 Gradient compression stocking, full length/chap style, 40-50 mmhg, each L8190 Gradient compression stocking, waist length, 18-30 mmhg, each L8195 Gradient compression stocking, waist length, 30-40 mmhg, each L8200 Gradient compression stocking, waist length, 40-50 mmhg, each L8210 Gradient compression stocking, custom made L8220 Gradient compression stocking, lymphedema L8230 Gradient compression stocking, garter belt L8300 Truss, single with standard pad L8310 Truss, double with standard pads L8320 Truss, addition to standard pad, water pad L8330 Truss, addition to standard pad, scrotal pad Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
TRACHEOSTOMY CARE SUPPLIES Purchase:
Covered for recipients with an open surgical tracheostomy. A tracheostomy care or cleaning starter kit is covered following an open surgical tracheostomy for a two week post-operative period. An artificial larynx is covered for recipients that have had a laryngectomy or whose larynx is permanently inoperable.
Equipment: A4481 A4622 A4623 A4625
A4626 A4629
L8500 L8501
Tracheostoma filter, any type, any size, each Tracheostomy or laryngectomy tube Tracheostomy, inner cannula (replacement only) Tracheostomy care kit for new tracheostomy Note: A4625 includes: 1 plastic tray, 1 basin, 1 pair of sterile gloves, tube brush, 3 pipe cleaners, 1 pre-cut tracheostomy dressing, 1 roll of gauze, 4-4x4 sponges, 2 cotton tip applicators, 30 inches twill tape Tracheostomy cleaning brush, each Tracheostomy care kit for established tracheostomy Note: A4629 includes: 1 tube brush, 2 pipe cleaners, 2 cotton tip applicators, 30 inches twill tape, 2-4x4 sponges Artificial larynx, any type Tracheostomy speaking valve
Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
TRACTION EQUIPMENT Purchase:
Covered for recipients with orthopedic impairments requiring traction equipment that prevents ambulation during the period of use. Payment for purchase and rental of traction equipment includes all accessories necessary for proper functioning and effective use of the equipment. Accessories are payable only as replacement for use with recipient-owned traction equipment for recipients whose condition meets the criteria for the equipment.
Equipment: Traction frame, attached to headboard, cervical traction Traction frame, free standing, cervical traction Traction equipment, over-door, cervical Traction frame, attached to footboard, extremity traction (e.g., Buck’s) Traction stand, free standing, extremity traction (e.g., Buck’s) Traction frame, attached to footboard, pelvic traction Traction stand, free standing, pelvic traction (e.g., Buck’s) Fracture frame, attached to bed, includes weights Fracture frame, free standing, includes weights Gravity assisted traction device, any type Fracture frame, dual with cross bars, attached to bed (e.g., Blaken, 4 poster) E0947 Fracture frame, attachments for complex pelvic traction E0948 Fracture frame, attachments for complex cervical traction
E0840 E0850 E0860 E0870 E0880 E0890 E0900 E0920 E0930 E0941 E0946
Supplies/Accessories: The following supplies/accessories are covered replacements for recipient-owned traction equipment only and CANNOT be billed in addition to the equipment at the time of purchase or with rental equipment. E0942 E0943 E0944 E0945
Cervical head harness/halter Cervical pillow Pelvic belt/harness/boot Extremity belt/harness
Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
TRANSCUTANEOUS ELECTRICAL NERVE SIMULATORS (TENS) Purchase/ Rental:
Covered for recipients with chronic, intractable pain when the pain has been present for at least three months and the presumed etiology of the pain is accepted as responding to TENS therapy and for recipients with acute postoperative pain. For purchase, the physician must determine that the recipient is likely to derive significant therapeutic benefit from continuous usage of the unit over a long period of time.
Equipment: E0720 TENS, two lead, localized stimulation E0730 TENS, four lead, larger area/multiple nerve stimulation Supplies/accessories: The following supplies/accessories are covered as replacement for recipient owned equipment only and CANNOT billed at the time of purchase or with rental equipment: A4556 Electrodes A4557 Lead wires A4595 TENS supplies, two lead, per month Note: A4595 includes electrodes (any type), conductive paste or gel (if needed, depending on the type of electrode), tape or other adhesive (if needed, depending on the type of electrode), adhesive remover, skin preparation materials, batteries (9 volt or AA, single use or rechargeable), and a battery charger (if rechargeable batteries are used). One unit of service represents supplies needed for one month for a two lead TENS, assuming daily use. If the TENS unit is used less than daily, the frequency of billing for the TENS supply code must be reduced proportionally. Limitations: A TENS unit is not covered for acute pain (less than three months duration) other than post-operative pain. For acute, post-operative pain, coverage is for no more than one month following the day of surgery. Documentation: Written order. Claims for chronic, intractable pain must also include the following: 1. Documentation must reflect a trial period. A. Must last a minimum of one month, but not to exceed two months. B. The trial period may not begin sooner than the three months used to establish the existence of chronic pain. The trial period will be paid as a rental. C. The trial period must be monitored by the physician to determine
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October 1, 1999 effectiveness of the TENS unit in modulating the pain. D. They physician’s record must document a re-evaluation at the end of the trial period and must indicate how often the recipient used the TENS unit, the typical duration of use each time, and the results. 2. Location and duration of time recipient has had the pain. 3. Other appropriate treatment modalities that have been attempted and why they were deemed inappropriate or ineffective (this is to include any medication name and dosage, duration and results of treatment.
If a four lead TENS unit is ordered, the medical record must document why a two lead TENS is insufficient to meet the recipient’s needs.
Prior Authorization: Not required.
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October 1, 1999
TRANSFER EQUIPMENT - See also “LIFTS, PATIENT; Wheelchair Options/Accessories” Purchase:
Covered for recipients that require assistance with transfer.
Equipment: E0972 Transfer board or device Z0028 Beasy transfer system Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
TRAPEZE EQUIPMENT Purchase/ Rental:
Covered when required for recipients to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed.
Equipment: E0910 Trapeze bars, A/K/A patient helper, attached to bed with grab bar E0940 Trapeze bar, free standing, complete with grab bar Documentation: Written order. Prior Authorization: Not required.
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Medical Supplies
October 1, 1999
URINALS - See “BEDPANS and URINALS”
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Medical Supplies
October 1, 1999
VEHICLE, POWER-OPERATED (POV) Purchase/ Rental:
A power-operated vehicle (POV) is covered instead of a manual wheelchair when all of the following criteria are met: 1. The recipient has a diagnosed medical condition, which impairs their ability to walk; 2. The recipient requires a POV for the purpose of: a. Increasing their independence with mobility, resulting in significant difference in their ability to perform major life activities that the average person in the general population can perform with little or no difficulty. They include, but are not limited to: caring for oneself, mobility, learning, working, performing manual tasks, breathing, seeing, and communicating; or b. Providing assisted mobility for recipients who show no means of safe independent mobility. 3. The recipient has significant limitation of limb function such that the recipient is not able to propel a manual wheelchair. Compared to their use of a manual wheelchair, the recipient’s use of a POV must result in a significant improvement in independent mobility and ability to perform major life activities; and 4. The recipient has demonstrated, through a trial period with a similar POV: a. the ability to safely and independently operate the controls of a POV; b. the ability to transfer safely in and out of a POV; and c. adequate trunk stability to be able to safely ride in the POV.
Equipment: P
E1230
Power Operated Vehicle
Documentation: An evaluation of the recipient’s wheelchair needs by a licensed physical or occupational therapist is required. “Wheelchair and Options/Accessories Certificate of Medical Necessity” must be completed indicating: 1. Justification for the type of POV as well as any options or accessories; and 2. Evidence of a coordinated assessment. A coordinated assessment includes communication between the recipient, caregiver(s), physician, physical and/or occupational therapist, and equipment supplier. The assessment should address physical, functional, and cognitive issues; accessibility, appropriateness of use in home (able to maneuver around home), ability to transport POV, and cost effectiveness of equipment. Prior Authorization: Prior authorization of payment is required for rental or purchase of power-operated vehicles.
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VENTILATORS Rental:
Ventilators are exempt from capped rental. Covered for rental when necessary in the treatment of neuromuscular diseases, thoracic restrictive diseases, chronic respiratory failure consequent to chronic obstructive pulmonary disease and respiratory paralysis. Reimbursement for rental of ventilators includes all backup equipment and accessories necessary for proper functioning and effective use of the device. Accessories are payable only as replacement for use with recipientowned ventilators for recipients whose condition meets the criteria for the device.
Equipment: E0450 Volume ventilator; stationary or portable E0460 Negative pressure ventilator; portable or stationary
P P
Supplies/Accessories: The following supplies/accessories are covered as replacement for recipientowned ventilators only and CANNOT be billed with rental equipment. A4611 A4612 A4613 E0457 E0459 Z6523 Documentation:
Battery, heavy duty; replacement for recipient-owned ventilator Battery cables; replacement for recipient-owned ventilator Battery charger; replacement for recipient-owned ventilator Chest shell (cuirass) Chest wrap Ventilator maintenance, annual, for recipient-owned equipment
Written order.
Documentation must include: 1. Pertinent lab values (e.g. elevated PaCO2, etc.) 2. Number and frequency of hospitalizations secondary to respiratory exacerbation or failure. 3. Other methods of treatment and why those methods were deemed inappropriate or ineffective. 4. Recipient’s social history. 5. Number and frequency of intubations. 6. History of recipient having difficulty being weaned from ventilator. 7. Episodes and frequency of disabling dyspnea, if pertinent. 8. Any other pertinent information documenting the necessity of home ventilation. Prior Authorization: Required for items indicated by “P”.
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WALKERS Purchase:
Covered for recipients with conditions that impair ambulation and who have a need for greater stability and security than provided by a cane or crutches. A heavy duty, multiple braking system, variable wheel resistance walker is covered for recipients who are unable to use a standard walker due to obesity, severe neurologic disorders, or restricted use of one hand. Payment for purchase and rental of walkers includes all accessories necessary for proper functioning and effective use of the item. Accessories such as tips, handgrips, etc., are payable only as replacement for use with recipient-owned walkers for recipients whose condition meets the criteria for coverage of the item.
Equipment: E0130 Walker, rigid (pickup), adjustable or fixed height E0135 Walker, folding (pickup), adjustable or fixed height E0141 Rigid walker, wheeled, without seat E0142 Rigid walker, wheeled, with seat E0143 Folding walker, wheeled, without seat E0145 Walker, wheeled, with seat and crutch attachments E0146 Folding walker, wheeled, with seat E0147 Heavy duty, multiple braking system, variable wheeled resistance walker K0458 Heavy-duty walker, without wheels K0459 Heavy-duty wheeled walker Supplies/Accessories: The following supplies/accessories are covered as replacement for recipient-owned walkers only and CANNOT be billed in addition to the equipment at the time of purchase or with rental equipment. A4636 Replacement handgrip, cane, crutch, or walker, each A4637 Replacement tip, cane, crutch, or walker, each E0154 Platform attachment, walker, each (Note: E0154 describes an armrest that is attached to a walker.) E0155 Wheel attachment, rigid pick-up walker E0156 Seat attachment, walker E0157 Crutch attachment, walker, each E0158 Leg extension for a walker E0159 Brake attachment for wheeled walker Documentation:
Written order.
Prior Authorization: Not required.
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WHEELCHAIRS, (Manual and Power) Purchase/ Rental:
A manual wheelchair is covered for recipients who meet the following criteria: 1. The recipient has a diagnosed medical condition which impairs their ability to walk; and 2. The recipient requires a wheelchair for the purpose of: a. Increasing their independence with mobility, resulting in significant difference in their ability to perform major life activities; or b. Providing assisted mobility for recipients who show no means of safe independent mobility. A power wheelchair is covered instead of a manual wheelchair if the recipient meets the criteria for a manual wheelchair and: 1. The recipient has significant limitation of upper limb function such that the client is not able to propel a manual wheelchair. 2. The recipient has demonstrated, through a trial period with a similar powered wheelchair, the ability to safely and independently operate the controls of a power wheelchair. All wheelchairs must carry the manufacturer’s warranty as part of the purchase price. (See Chapter Nine for specific warranty requirements). Assembly, labor and delivery are included in the price of the wheelchair and cannot be billed for separately. Medicaid covers repairs to a wheelchair owned by a recipient with a physician’s order and a determination of cost-effectiveness. (See Chapter Nine for specific provider responsibilities and repair policy).
Replacement: Any replacement of a wheelchair purchased by Medicaid must have prior authorization. Wheelchairs and seating systems may only be replaced on a five year basis, unless there are extenuating circumstances such as: 1. 2. 3.
Recipient has grown more than expected. A change in the recipient’s physical condition. Extensive wear of the wheelchair.
If a wheelchair is lost or stolen, the medical provider requesting a new wheelchair must obtain a copy of the police report. The medical provider must either document on the prior authorization request that a copy has been obtained or send a copy with the request. Medicaid will not consider authorization until two months after the filing of the police report to ensure adequate time for possible recovery of the wheelchair. If the chair is necessary for the recipient to maintain employment, or independence, Medicaid will consider a short-term rental chair for a period not to exceed 120 days.
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Replacement due to malicious damage, culpable neglect or wrongful disposition will not be covered. When a wheelchair is no longer suitable because of growth, development or changes to the recipient’s condition, and must be replaced, the recipient, the provider and Medicaid may negotiate a good faith trade-in of the item no longer needed. Such a trade-in shall be used to reduce the reimbursement from Medicaid on the new item. Multiple or Duplicate Wheelchairs: Wyoming Medicaid only covers purchase, rental or repair of multiple or duplicate wheelchairs used for the same or similar purposes when substantial documentation of medical necessity is received. Medicaid does not cover back-up equipment for convenience. The provider may supply back-up equipment, but the provider may not bill Medicaid. Nursing Facilities: Wheelchairs, accessories and repairs of personal wheelchairs are always included in the per diem for a resident of a nursing facility. However, under limited circumstances, the customization of a wheelchair may be covered outside the per diem with written prior authorization for the resident’s permanent and fulltime use. Repairs to specialized parts or customization of a wheelchair may be covered in addition to the per diem with appropriate documentation of need. Option/Accessories: Wheelchair options/accessories are covered when medically necessary for use with a medically necessary, rental or recipient-owned wheelchair base, to allow the recipient to perform activities of daily living, or to function in the home. An option/accessory that is beneficial primarily in allowing the recipient to perform leisure or recreational activities, or for the convenience of the recipient or caregiver is not covered. A wheelchair seating system (spinal orthotics) is covered when required to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured body part. A seating system, back module for use with a wheelchair is covered when medically necessary for use with a medically necessary wheelchair base, for a recipient who has a diagnosed medical condition that impairs their ability to sit. A wheelchair seating system may be covered for the purpose of: 1. Supporting the recipient in a position that minimizes the development or progression of musculoskeletal impairment; 2. Relieving pressure; or 3. Providing support in a position that improves the recipient’s ability to perform functional activities. Note: An evaluation of the recipient’s wheelchair seating needs, documented
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by a licensed physical or occupational therapist, is required. Documentation must be provided using Form MS-79 “Wheelchair and Wheelchair Seating System Selection Report”, and signed by a physician involved in the recipient’s care. This evaluation will generally not be required when diagnosis or prescribed length of need indicates the wheelchair will be required on a short-term basis only. The “Wheelchair and Wheelchair Seating System Selection Report” is required for all requests for prior authorization of wheelchairs, wheelchair option/accessories, and seating systems, unless the wheelchair will be required on a short-term basis only. Documentation must: 1. 2.
Justify the type of wheelchair seating system; and Provide evidence of a coordinated assessment. A coordinated assessment includes communication between the recipient, caregiver(s), physician, physical and/or occupational therapist, and equipment supplier. The assessment should address physical, functional, and cognitive issues, as well as accessibility and cost effectiveness of equipment.
A reclining back wheelchair frame is one in which the angle between the seat and the back of the frame is adjustable between 90 and 180 degrees. It may include elevating leg rests. A reclining back may be manually operated (by a caregiver) or power operated (usually by the wheelchair user). A tilt-in-space wheelchair frame is one in which the angle between the seat and the back remain relatively fixed, but the seat and back pivot as a unit away from the fully upright position, such that the angle that both the seat and back make with the ground is able to be adjusted, usually more than 30 degrees. A tilt-inspace wheelchair frame may be manually operated (by a caregiver) or power operated (usually by the wheelchair user). Reclining back or tilt-in-space wheelchair frames are covered for recipients who: 1. Have a diagnosed medical condition, which impairs their ability to tolerate the fully upright sitting position for significant amounts of time (usually greater than two hours); 2. Need to remain in a wheelchair for purposes of mobility or other interaction with their environment; and 3. Require frequent, significant adjustment of their position in the wheelchair, either to change hip angle or their sitting position relative to the ground.
Power operation of the reclining or tilt-in-space mechanism, which may include power operated elevation leg rests, is covered for recipients that meet the criteria for a reclining or tilt-in-space mechanism and:
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1. Have the cognitive and motor ability to operate the required control switch(es); and 2. Are routinely in situations (e.g., home, community, school, work, etc.) where caregivers are not available within a reasonable time to manually recline or tilt them as needed. Combination power recline/tilt-in-space frames, if unavailable in manually operated forms, are covered for recipients that require both recline and tilt-inspace features (e.g., lack of necessary passive hip flexion for use of a standard tiltin-space or inability to tolerate a significantly greater hip extension angle during sitting). Equipment: Manual P K0001 Standard wheelchair P K0002 Standard hemi (low seat) wheelchair P K0003 Lightweight wheelchair High strength, lightweight wheelchair P K0004 P K0005 Ultralightweight wheelchair P K0006 Heavy duty wheelchair P K0007 Extra heavy duty wheelchair P K0008 Custom manual wheelchair/base Note: A custom manual wheelchair base is one that has been uniquely constructed or substantially modified for a specific recipient and is so different from another item used for the same purpose that the two items cannot be grouped together for pricing purposes. The assembly of a wheelchair from modular components does not meet the requirements of a custom wheelchair base for payment purposes. The use of customized options or accessories does not result in the wheelchair base being considered as custom. There must be customization of the frame for the wheelchair base to be considered customized. P K0009 Other manual wheelchair/base Power P K0010 P K0011 P P
P P
Standard-weight frame motorized/power wheelchair Standard-weight frame motorized/power wheelchair with programmable control K0012 Lightweight portable motorized/power wheelchair K0013 Custom motorized/power wheelchair base Note: A custom power wheelchair base is one which has been uniquely constructed or substantially modified for a specific recipient and I so different from another item used for the same purpose that the two items can not be grouped together for pricing purposes. K0014 Other motorized/power wheelchair base E1065 Power attachment (to convert any wheelchair to motorized wheelchair - e.g. Solo)
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Arm of Chair Detachable, non-adjustable height armrest, each P K0015 P K0016 Detachable, adjustable height armrest, complete assembly, each P K0017 Detachable, adjustable height armrest, base, each P *K0018 Detachable, adjustable height armrest, upper portion, each P K0019 Arm pad, each P *K0020 Fixed, adjustable height armrest, pair P E1227 Special height arms for wheelchair *covered if the recipient requires an arm height that is different than that available using non-adjustable arms and the recipient spends at least two hours per day in the wheelchair. Back of Chair P K0021 Anti-tipping device, each P K0022 Reinforced back upholstery - Covered if used with a power wheelchair base (K0010-K0012) and the recipient weighs more than 200 pounds. When used in conjunction with heavy duty (K0006) or extra heavyduty (K0007) wheelchair bases, the allowance for reinforced upholstery is included in the allowance for the wheelchair base. Reinforced back and seat upholstery are not medically necessary if used in conjunction with other manual wheelchair bases (K0001K0005). P K0023 Solid back insert, planar back single density foam, attached with straps P K0024 Solid back insert, planar back, single density foam, with adjustable hook-on hardware Hook-on headrest extension - Covered if the recipient has weak neck P K0025 muscles and needs a headrest for support, or meets the criteria for and has a reclining back on the wheelchair. P K0026 Back upholstery for ultra lightweight or high strength lightweight wheelchair Back upholstery for wheelchair type other than ultra lightweight or P K0027 high strength lightweight wheelchair P K0028 Fully reclining back - Covered if the recipient spends at least 2 hours per day in the wheelchair and has one or more of the following conditions/needs: (1) Quadriplegia (2) Fixed hip angle (3) Trunk or lower extremity casts/braces that require the reclining back feature for positioning (4) Excess extensor tone of the trunk muscles; and/or (5) The need to rest in a recumbent position two or more times during the day and transfer between wheelchair and bed is very difficult. P E1225 Semi-reclining back for customized wheelchair
C-92
Medical Supplies P E1228 Seat P K0029 P K0030 P K0031
P K0032 P K0033
P P P P P
October 1, 1999 Special back height for wheelchair
Reinforced seat upholstery Solid seat insert, planar seat, single density foam-covered when the patient spends at least 2 hours per day in the wheelchair. Safety belt/pelvic strap - covered if the recipient has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning. Seat upholstery for ultra lightweight or high strength lightweight wheelchair Seat upholstery for wheelchair type other than ultra lightweight or high strength lightweight wheelchair
Pressure Reducing Support Cushions **E0176 Air pressure pad or cushion, non-positioning **E0177 Water pressure pad or cushion, non-positioning **E0178 Gel pressure pad or cushion, non-positioning E0179 Dry pressure pad or cushion, non-positioning **E0192 Low pressure and positioning equalization pad ** Requires prior authorization for clients residing in nursing facilities and ICF/MR’s.
Footrest/Leg rest K0034 Heel loop, each K0035 Heel loop with ankle strap each Toe loop, each K0036 K0037 High mount flip-up footrest, each K0038 Leg strap, each K0039 Leg strap, H style, each K0040 Adjustable angle footplate, each Large size footplate, each K0041 K0042 Standard size footplate, each K0043 Footrest, lower extension tube, each K0044 Footrest, upper hanger bracket, each K0045 Footrest, complete assembly K0046 Elevating leg rest, lower extension tube, each K0048 Elevating leg rest, complete assembly K0049 Calf pad, each K0050 Ratchet assembly K0051 Cam release assembly, footrest or leg rest, each K0052 Swing away, detachable footrests, each - are included in the allowance for the wheelchair base. They should be billed separately only when they are replacements. P *K0053 Elevating footrests, articulating (telescoping), each P P P P P P P P P P P P P P P P P P
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*Covered if: (1) the recipient has a musculosketal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or (2) the recipient has significant edema of the lower extremities that requires having an elevating leg rest; or (3) the recipient meets the criteria for, and has a reclining back on the wheelchair.
P P P P P
Seat width, depth, height K0054 Seat width of 10", 11", 12", 15", 17", or 20" for a high strength, lightweight or ultra lightweight wheelchair K0055 Seat depth of 15", 17", or 18" for a high strength, Ultra lightweight wheelchair K0056 Seat height < 17" or > 21" for a high strength, lightweight or ultra lightweight wheelchair K0057 Seat width 19" or 20" for heavy duty or extra heavy duty wheelchair Seat depth 17" or 18" for motorized/power wheelchair K0058
K0054-K0058 are covered only if: (1) the item is at least two inches greater than or less than a standard option, and (2) the recipient’s dimensions justify the need.
Handrims Without Projections P K0059 Plastic coated handrim, each P K0060 Steel handrim, each P K0061 Aluminum handrim, each
Handrims with Projections P K0062 Handrim with 8-10 vertical or oblique projections, each P K0063 Handrim with 12-16 vertical or oblique projections, each
Rear Wheels K0064 Zero pressure tube (flat free inserts), any size, each K0065 Spoke protectors K0066 Solid tire, any size, each K0067 Pneumatic tire, any size, each K0068 Pneumatic tire tube, each K0069 Rear wheel assembly, complete, with solid tire, spokes or molded, each P K0070 Rear wheel assembly, complete, with pneumatic tire, spokes or P P P P P P
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October 1, 1999 molded, each Pneumatic tire with wheel
P
E0999
P P P P P P P P P P
Front Casters K0071 Front caster assembly, complete, with pneumatic tire, each K0072 Front caster assembly, complete, with semi-pneumatic tire, each K0073 Caster pin lock, each K0074 Pneumatic caster tire, any size, each K0075 Semi-pneumatic caster tire, any size, each K0076 Solid caster tire, any size, each K0077 Front caster assembly, complete, with solid tire, each K0078 Pneumatic caster tire tube, each E0997 Caster with fork E0998 Caster without fork
P
Wheel Lock K0079 Wheel lock extension, pair Anti-rollback device, pair - covered if the recipient propels K0080 himself/herself and needs the device because of ramps. K0081 Wheel lock assembly, complete, each
P P P P P P P P
Batteries/Chargers for Motorized/Power Wheelchairs K0082 22 NF deep cycle lead acid battery, each K0083 22 NF gel cell battery, each K0084 Group 24 deep cycle lead acid battery, each K0085 Group 24 gel cell battery, each K0086 U-1 lead acid battery, each U-1 gel cell battery, each K0087 K0088 Battery charger, lead acid or gel cell K0089 Battery charger, dual mode
P P
P P P P P P P P P P
Motorized/Power Wheelchair Parts K0090 Rear wheel tire for power wheelchair, any size, each K0091 Rear wheel tire tube other than zero pressure for power wheelchair, any size, each K0092 Rear wheel assembly for power wheelchair, complete, each K0093 Rear wheel zero pressure tire tube (flat free insert) for power wheelchair any size, each K0094 Wheel tire for power base, any size, each K0095 Wheel tire tube other than zero pressure for each base, any size, each K0096 Wheel assembly for power base, complete, each K0097 Wheel zero pressure tire tube (flat free insert) for power base, any size, each K0098 Drive belt for power wheelchair K0099 Front caster for power wheelchair
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Medical Supplies
P P P P P
P
P P
P P P P P P P P P P P P P P P P P P P P P
October 1, 1999
Spinal Orthotics L0300 - L1520 Exception: Miscellaneous codes L0999 and L1499 will not be reimbursed. K0112 Trunk support device, vest type, with inner frame, prefabricated K0113 Trunk support device, vest type, without inner frame, prefabricated K0114 Back support system for use with a wheelchair, with inner frame, pre-fabricated Seating system, back module, posterior-lateral control, with or K0115 without lateral supports, custom fabricated for attachment to wheelchair base K0116 Seating system, combined back and seat module, custom fabricated for attachment to wheelchair base Miscellaneous Accessories K0100 Amputee adapter, pair K0101 One-arm drive attachment - covered if the patients propel the chair by themselves with only one hand and the need is expected to last at least six months. K0102 Crutch and cane holder - not medically necessary Transfer board, < 25" K0103 K0104 Cylinder tank carrier K0105 IV hanger K0106 Arm trough, each - covered if patient has quadriplegia, hemiplegia or uncontrolled arm movements. Wheelchair tray K0107 K0109 Customization of wheelchair base frame (options or accessories) K0452 Wheelchair bearings, any type E0962 One-inch cushion, for wheelchair Two-inch cushion for wheelchair E0963 E0964 Three-inch cushion for wheelchair E0965 Four-inch cushion for wheelchair E0968 Commode seat, wheelchair E0969 Narrowing device, wheelchair E0977 Wedge cushion, wheelchair E0980 Safety vest, wheelchair E1001 Wheel, single Z0025 Roho or similar cushion seating apparatus Z0026 Youth tilt-in-space mechanism for wheelchair, any size Z0027 Adult tilt-in-space mechanism for wheelchair, any size Z0028 Beasy transfer system for moving from wheelchair to bed
Custom Wheelchair: Defined as a wheelchair that has been uniquely constructed or
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substantially modified for a specific recipient and is so different from another item used for the same purpose that the two items cannot be grouped together for pricing purposes. The assembly of a wheelchair from modular components does not meet the requirement of a custom wheelchair for payment purposes. The use of customized options or accessories does not result in the wheelchair being considered customized. There must be customization of the frame of the wheelchair for it to be considered customized. Additionally, for nursing facility recipients, the item must be needed for discharge. Documentation: The “Wheelchair and Options/Accessories Certificate of Medical Necessity” is required for all requests for prior authorization of wheelchairs, wheelchair options, accessories, and seating systems. Documentation must be provided by using the form, and be reviewed and signed by a physician involved in the recipient’s care. An evaluation of the recipient’s wheelchair needs by a physician or a licensed physical or occupational therapist is required. In addition, if a customized wheelchair is prescribed for nursing facility recipients, the physician must include a statement describing the rehabilitation potential and how the customized wheelchair will enhance the prognosis. A written discharge plan stating the planned date of discharge to home or to a nonnursing facility setting must accompany the request for the wheelchair. Prior Authorization: Prior authorization of payment is required for rental and purchase of wheelchairs and wheelchair options/accessories when included as an integral part of a wheelchair purchase or rental. Note: Requests for prior authorization must include the vendor specifications or order form, which lists the type of wheelchair base, along with all options/accessories.
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WOUND V.A.C. Rental:
Covered for recipients who present with a level III or IV stage decubitus ulcer that meet specific criteria.
Equipment: P
Z0037
Vacuum assisted closure machine per day, rental
Documentation: Written order, to include the following: 1. Written measurement of level III or IV stage decubitus ulcers; and 2. Area of decubitus, (must be in an area which is difficult to heal e.g.: sacral or ischial area); and 3. Description of conservative treatments and alternative measures or equipment attempted and why they were deemed inappropriate or ineffective; and 4. Written statement that patient is bedridden or bound to a chair; and 5. Who will maintain the equipment and provide ongoing communication as to the effectiveness of the V.A.C; and 6. Written documentation that recipient does not fall into any of the Precaution or Contraindication categories listed; and. 7. For continuation beyond one month of therapy, documentation must reflect the following: * After four weeks of therapy - a minimum of a twenty-percent decrease in size and volume of decubitus ulcer. * After eight weeks of therapy - a minimum of a sixty-percent decrease in size and volume of decubitus ulcer. * After twelve weeks of therapy - a minimum of a ninety-percent decrease in size and volume of decubitus ulcer. Limitations: 1. Treatment is authorized for no more than one month at a time. 2. If a recipient falls into any of the following categories, V.A.C. treatment is NOT appropriate. Precautions: a. Recipients receiving anticoagulant therapy. b. Recipients experiencing difficult hemostasis following debridment. Contraindications: Recipients with any of the following: a. Fistulas to organs or body cavities. b. Presence of necrotic tissue. c. Osteomyelitis. d. Cancer in the wound margins.
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3. Wound V.A.C. treatment is NOT reimbursable outside of the per diem for recipient’s residing in a nursing facility. If a recipient is in an acute care setting and must be placed in a nursing facility on a short term basis (three months or less) while the wound heals, the nursing facility will be reimbursed for that period of time, providing all other criteria has been met. Prior Authorization: Required.
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October 1, 1999
NOT OTHERWISE CLASSIFIED (NOC) CODES Items, which are not listed in the Coverage Index, will not be covered. A provider may contact ACS/Consultec in writing with a request to cover any code not included in the medical supply manual. This request must include a complete description of the item, including brand, product number, size, etc. Use procedure code modifiers when appropriate. Documentation: Written Order minimum requirement. Other documentation may be requested. Prior Authorization: Prior authorization of payment is required for rental and purchase of durable medical equipment not otherwise classified.
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INDEX CODE
PAGE
CODE
PAGE
CODE
PAGE
A4206 A4207 A4208 A4209 A4212 A4213 A4215 A4220 A4221 A4222 A4230 A4231 A4232 A4244 A4245 A4246 A4247 A4250 A4253 A4254 A4255 A4256 A4258 A4259 A4265 A4300 A4301 A4305 A4306 A4310 A4311 A4312 A4313 A4314 A4315 A4316 A4320 A4322 A4326 A4327
C-42 C-42 C-42 C-42 C-42 C-42 C-42 C-33 C-33 C-33 C-33 C-33 C-33 C-8, C-42 C-8, C-42 C-8, C-42 C-8, C-42 C-42 C-8 C-8 C-8 C-8 C-8 C-8 C-62 C-33 C-33 C-33 C-33 C-31 C-31 C-31 C-31 C-31 C-31 C-31 C-31, C-42 C-31, C-42 C-31 C-31
A4335 A4338 A4340 A4352 A4353 A4354 A4355 A4356 A4357 A4358 A4359 A4361 A4362 A4364 A4365 A4367 A4368 A4397 A4398 A4399 A4402 A4404 A4454 A4455 A4460 A4465 A4481 A4490 A4500 A4510 A4554 A4556 A4557 A4565 A4595 A4611 A4612 A4613 A4614 A4615
C-31 C-31 C-31 C-31 C-31 C-31 C-31 C-31 C-31 C-31 C-31 C-55 C-55 C-31, C-55 C-55 C-55 C-55 C-55 C-55 C-55 C-32, C-42, C-55 C-55 C-32, C-42, C-55 C-32, C-42, C-55 C-42 C-76 C-77 C-76 C-76 C-76 C-32, C-44 C-46, C-79 C-46, C-79 C-76 C-79 C-85 C-85 C-85 C-63 C-59
A4619 A4620 A4621 A4622 A4623 A4624 A4625 A4626 A4627 A4628 A4629 A4636 A4637 A4640 A4772 A5051 A5052 A5053 A5054 A5055 A5061 A5062 A5063 A5064 A5065 A5071 A5072 A5073 A5074 A5075 A5081 A5082 A5093 A5102 A5105 A5112 A5113 A5114 A5119 A5121
C-59, C-44 C-59 C-59, C-44 C-77 C-77 C-75 C-77 C-77 C-42 C-75 C-77 C-86 C-86 C-69 C-42 C-55 C-55 C-55 C-55 C-55 C-55 C-55 C-55 C-55 C-55 C-55 C-55 C-55 C-55 C-55 C-55 C-55 C-55 C-32, C-55 C-32 C-32 C-32 C-32 C-55 C-55
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CODE
PAGE
CODE
PAGE
CODE
PAGE
A4328 A4329 A4330 A5130 A5131 A5500 A5501 A5502 A5503 A5504 A5505 A5506 A5507 A6020 A6154 A6196 A6197 A6198 A6199 A6203 A6204 A6205 A6206 A6207 A6208 A6209 A6210 A6211 A6212 A6213 A6214 A6215 A6216 A6217 A6218 A6219 A6220 A6221 A6222 A6223 A6228 A6229
C-31 C-31 C-31 C-55 C-32 C-53 C-53 C-53 C-53 C-53 C-53 C-53 C-53 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-19 C-20 C-20 C-20 C-20 C-20 C-20
A4616 A4617 A4618 A6241 A6242 A6243 A6244 A6245 A6246 A6247 A6248 A6250 A6251 A6252 A6253 A6254 A6255 A6256 A6257 A6258 A6259 A6261 A6262 A6263 A6264 A6265 A6266 A6402 A6403 A6404 A6405 A6406
C-59 C-44 C-36 C-20 C-20 C-20 C-20 C-20 C-20 C-20 C-20 C-56 C-21 C-21 C-21 C-21 C-21 C-21 C-21 C-21 C-21 C-21 C-21 C-21 C-21 C-21 C-21 C-21 C-21 C-21 C-21 C-21
A5122 A5123 A5126 B4220 B4222 B4224 B5000 B5100 B5200 B9000 B9002 B9004 B9006
C-55 C-55 C-55 C-50 C-50 C-50 C-50 C-50 C-50 C-33 C-33 C-33 C-33
B4034 B4035 B4036 B4081 B4082 B4083 B4084 B4085 B4150
C-49 C-49 C-49 C-49 C-49 C-49 C-49 C-49 C-49
E0100 E0105 E0110 E0111 E0112 E0113 E0114 E0116 E0130 E0135 E0141 E0142 E0143 E0145 E0146 E0147 E0153 E0154 E0155 E0156 E0157 E0158 E0159 E0160 E0161 E0162 E0163 E0164
C-14 C-14 C-14 C-14 C-14 C-14 C-14 C-14 C-86 C-86 C-86 C-86 C-86 C-86 C-86 C-86 C-14 C-86 C-86 C-86 C-86 C-86 C-86 C-5, C-72 C-5, C-72 C-5, C-72 C-15 C-15
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CODE
PAGE
CODE
A6230 A6234 A6235 A6236 A6237 A6238 A6239 A6240
C-20 C-20 C-20 C-20 C-20 C-20 C-20 C-20
E0180 E0181 E0182 E0184 E0185 E0186 E0187 E0188 E0189 E0191 E0192 E0193 E0194 E0196 E0197 E0198 E0199 E0202 E0210 E0215 E0217 E0218 E0220 E0225 E0230 E0235 E0238 E0239 E0241 E0242 E0243 E0244 E0245
C-29, C-67 C-29, C-67 C-29, C-69 C-29, C-67 C-29, C-67 C-29, C-67 C-29, C-68 C-29, C-68 C-29, C-68 C-42 C-29, C-92 C-1, C-28 C-1, C-28 C-29, C-68 C-29, C-68 C-29, C-68 C-29, C-68 C-65 C-26 C-26 C-26 C-26 C-26 C-26 C-26 C-26, C-62 C-26 C-26 C-5 C-5 C-5 C-5 C-5
PAGE
CODE
PAGE
B4151 C-49 B4152 C-49 B4153 C-49 B4154 C-49 B4155 C-49 B4156 C-49 B4164-B4199 C-50 B4216 C-50
E0165 E0166 E0167 E0175 E0176 E0177 E0178 E0179
C-15 C-15 C-15 C-15 C-92 C-92 C-92 C-92
E0277 E0280 E0290 E0291 E0292 E0293 E0294 E0295 E0296 E0297 E0325 E0326 E0370 E0371 E0372 E0373 E0424 E0431 E0434 E0439 E0441 E0442 E0443 E0444 E0450 E0452 E0453 E0455 E0457 E0460 E0480 E0500 E0550
E0621 E0625 E0630 E0650 E0651 E0652 E0655 E0660 E0666 E0667 E0668 E0669 E0671 E0672 E0720 E0730 E0745 E0747 E0748 E0749 E0753 E0760 E0776 E0781 E0782 E0783 E0784 E0791 E0840 E0850 E0860 E0870 E0880
C-37 C-66 C-66 C-66 C-66 C-66 C-66 C-66 C-66 C-66 C-66 C-66 C-66 C-66 C-79 C-79 C-46 C-54 C-54 C-54 C-46 C-54 C-33 C-33 C-33 C-33 C-33 C-33 C-78 C-78 C-78 C-78 C-78
C-29 C-29 C-28 C-28 C-28 C-28 C-28 C-28 C-28 C-29 C-6 C-6 C-29, C-68 C-29 C-29 C-29 C-58 C-58 C-58 C-58 C-59 C-59 C-59 C-59 C-85 C-17, C-85 C-17, C-85 C-59 C-85 C-85 C-64 C-36 C-36, C-59
C-103
Medical Supplies
October 1, 1999
CODE
PAGE
CODE
PAGE
CODE
PAGE
E0246 E0249 E0250 E0251 E0255 E0256 E0260 E0261 E0265 E0266 E0271 E0272 E0275 E0276
C-5 C-26 C-28 C-28 C-28 C-28 C-28 C-28 C-28 C-28 C-29 C-29 C-6 C-6
E0555 E0560 E0565 E0570 E0575 E0580 E0585 E0600 E0601 E0607 E0608 E0609 E0610 E0615
C-59 C-36, C-59 C-44 C-44 C-44 C-44 C-44 C-75 C-17 C-8 C-2 C-8 C-61 C-61
E0890 E0900 E0910 E0920 E0930 E0935 E0940 E0941 E0942 E0943 E0944 E0945 E0946 E0947
C-78 C-78 C-82 C-78 C-78 C-16 C-82 C-78 C-78 C-78 C-78 C-78 C-78 C-78
E0948 E0962 E0963 E0964 E0965 E0968 E0969 E0972 E0977 E0980 E0997 E0998 E0999 E1001 E1065 E1225 E1227 E1228 E1230 E1340 E1353 E1355 E1372 E1400 E1401 E1402 E1403
C-78 C-95 C-95 C-95 C-95 C-95 C-95 C-81 C-95 C-95 C-93 C-93 C-93 C-95 C-90 C-91 C-90 C-91 C-84 C-71 C-59 C-60 C-44 C-59 C-59 C-59 C-59
K0012 K0013 K0014 K0015 K0016 K0017 K0018 K0019 K0020 K0021 K0022 K0023 K0024 K0025 K0026 K0027 K0028 K0029 K0030 K0031 K0032 K0033 K0034 K0035 K0036 K0037 K0038
C-90 C-90 C-90 C-90 C-90 C-90 C-90 C-90 C-90 C-91 C-91 C-91 C-91 C-91 C-91 C-91 C-91 C-91 C-91 C-91 C-91 C-91 C-92 C-92 C-92 C-92 C-92
K0060 K0061 K0062 K0063 K0064 K0065 K0066 K0067 K0068 K0069 K0070 K0071 K0072 K0073 K0074 K0075 K0076 K0077 K0078 K0079 K0080 K0081 K0082 K0083 K0084 K0085 K0086
C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-93 C-94 C-94 C-94 C-94 C-94 C-94
C-104
Medical Supplies
October 1, 1999
CODE
PAGE
CODE
PAGE
CODE
PAGE
E1404 E1800 E1805 E1810 E1815 E1820 E1825 E1830
C-59 C-53 C-53 C-53 C-53 C-53 C-53 C-53
K0001 K0002 K0003 K0004 K0005 K0006 K0007 K0008 K0009 K0010 K0011
C-90 C-90 C-90 C-90 C-90 C-90 C-90 C-90 C-90 C-90 C-90
K0039 K0040 K0041 K0042 K0043 K0044 K0045 K0046 K0048 K0049 K0050 K0051 K0052 K0053 K0054 K0055 K0056 K0057 K0058 K0059
C-92 C-92 C-92 C-92 C-92 C-92 C-92 C-92 C-92 C-92 C-92 C-92 C-92 C-92 C-92 C-92 C-93 C-93 C-93 C-93
K0087 K0088 K0089 K0090 K0091 K0092 K0093 K0094 K0095 K0096 K0097 K0098 K0099 K0100 K0101 K0102 K0103 K0104 K0105 K0106
C-94 C-94 C-94 C-94 C-94 C-94 C-94 C-94 C-94 C-94 C-94 C-94 C-94 C-94 C-95 C-95 C-95 C-95 C-95 C-95
K0107 K0108 K0112 K0113 K0114 K0115 K0116 K0137 K0138 K0139 K0168 K0169 K0170 K0171 K0172 K0173 K0174 K0175 K0176 K0177 K0178
C-95 C-95 C-94 C-94 C-94 C-94 C-94 C-56 C-56 C-56 C-44 C-44 C-44 C-44 C-45 C-45 C-45 C-45 C-45 C-45 C-45
K0417 K0419 K0420 K0421 K0422 K0423 K0424 K0425 K0426 K0427 K0428 K0429 K0430 K0431 K0432 K0433 K0434 K0451 K0452 K0457 K0458
C-33 C-56 C-56 C-56 C-56 C-56 C-56 C-56 C-56 C-56 C-56 C-56 C-56 C-56 C-56 C-56 C-56 C-32 C-95 C-15 C-86
L8310 L8320 L8330 L8500 L8501
C-76 C-76 C-76 C-77 C-77
V2623 V2625 V2626 V2627 V2628 V2629
C-24 C-24 C-24 C-24 C-24 C-24
X5015
C-57
Z0007 Z0008 Z0011 Z0025 Z0026 Z0027
C-64 C-64 C-60 C-95 C-95 C-95
C-105
Medical Supplies
October 1, 1999
CODE
PAGE
CODE
PAGE
CODE
PAGE
K0179 K0183 K0184 K0185 K0186 K0187 K0188 K0189 K0190 K0191 K0192 K0193 K0194 K0268 K0269 K0270 K0277 K0278 K0279 K0280 K0281 K0284 K0407 K0408 K0410 K0411
C-45 C-17 C-17 C-17 C-17 C-17 C-17 C-17 C-75 C-75 C-75 C-17 C-17 C-17 C-44 C-44 C-56 C-56 C-56 C-56, C-32 C-32 C-32 C-32 C-32 C-32 C-32
K0459 K0501
C-86 C-44
Z0028 Z0037 Z4025 Z4026 Z4027 Z4356 Z4717 Z4718 Z4733 Z6523
C-95, C-81 C-97 C-43 C-8 C-8 C-43 C-32, C-55 C-32 C-13 C-85
L0100-4399 C-53 L0300-1520 C-94 L5000-9999 C-70 L8000 C-12 L8010 C-12 L8020 C-12 L8030 C-12 L8100 C-76 L8110 C-76 L8120 C-76 L8130 C-76 L8140 C-76 L8150 C-76 L8160 C-76 L8170 C-76 L8180 C-76 L8190 C-76 L8195 C-76 L8200 C-76 L8210 C-76 L8220 C-76 L8230 C-76 L8300 C-76
C-106
