Page 1 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE A4216 A4217 A4221 A4230 A4231 A4233 A4234 A4235 A4244 A4245 A4246 A4250 A4252 A4253 A4256 A4258 A4259 A4265 A4267 A4268 A4310 A4311 A4314 A4320 A4322 A4326 A4331 A4333 A4334 A4335 A4338 A4344 A4346 A4349 A4351 A4352 A4353 A4354 A4356 A4357 A4358 A4361 A4362 A4363 A4364 A4366 A4367 A4368 A4369 A4371
DESCRIPTION STERILE WATER, SALINE AND/OR DEXTROSE, D STERILE WATER/SALINE,500 ML SUPPLIES FOR MAINTENANCE OF DRUG INFUSIO INFUSION SET FOR EXTERNAL INSULIN PUMP, INFUSION SET FOR EXTERNAL INSULIN PUMP, REPLACEMENT BATTERY, ALKALINE (OTHER THA REPLACEMENT BATTERY, ALKALINE, J CELL, F REPLACEMENT BATTERY, LITHIUM, FOR USE WI ALCOHOL OR PEROXIDE, PER PINT ALCOHOL WIPES, PER BOX BETADINE OR PHISOHEX SOLUTION, PER PINT URINE TEST OR REAGENT STRIPS OR TABLETS BLOOD KETONE TEST OR REAGENT STRIP, EACH BLOOD GLUCOSE TEST OR REAGENT STRIPS FOR NORMAL, LOW AND HIGH CALIBRATOR SOLUTION SPRING-POWERED DEVICE FOR LANCET, EACH LANCETS, PER BOX OF 100 PARAFFIN, PER POUND CONTRACEPTIVE SUPPLY, CONDOM, MALE, EACH CONTRACEPTIVE SUPPLY, CONDOM, FEMALE, EA INSERTION TRAY WITHOUT DRAINAGE BAG AND INSERTION TRAY WITHOUT DRAINAGE BAG WITH INSERTION TRAY WITH DRAINAGE BAG WITH IN IRRIGATION TRAY WITH BULB OR PISTON SYRI IRRIGATION SYRINGE, BULB OR PISTON, EACH MALE EXTERNAL CATHETER WITH INTEGRAL COL EXTENSION DRAINAGE TUBING, ANY TYPE, ANY URINARY CATHETER ANCHORING DEVICE, ADHES URINARY CATHETER ANCHORING DEVICE, LEG S INCONTINENCE SUPPLY MISC INDWELLING CATHETER; FOLEY TYPE, TWO-WAY INDWELLING CATHETER, FOLEY TYPE, TWO-WAY INDWELLING CATHETER; FOLEY TYPE, THREE W MALE EXTERNAL CATHETER, WITH OR WITHOUT INTERMITTENT URINARY CATHETER; STRAIGHT INTERMITTENT URINARY CATHETER; COUDE (CU INTERMITTENT URINARY CATHETER, WITH INSE INSERTION TRAY WITH DRAINAGE BAG BUT WIT EXTERNAL URETHRAL CLAMP OR COMPRESSION D BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH URINARY DRAINAGE BAG, LEG OR ABDOMEN, VI OSTOMY FACE PLATE, EACH SKIN BARRIER; SOLID, 4 X 4 OR EQUIVALENT OSTOMY CLAMP, ANY TYPE, REPLACEMENT ONLY ADHESIVE, LIQUID OR EQUAL, ANY TYPE, PE OSTOMY VENT, ANY TYPE, EACH OSTOMY BELT, EACH OSTOMY FILTER,ANY TYPE, EACH OSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUS OSTOMY SKIN BARRIER,POWDER,PER OZ
FEE 0.43 1.58 1.00 15.05 6.27 0.71 3.25 2.34 1.12 1.39 2.96 18.85 4.45 24.37 8.62 12.95 5.40 3.33 0.39 3.50 2.13 5.94 11.73 1.67 1.01 4.82 1.80 2.31 1.36 1.34 6.13 10.92 1.51 0.81 2.58 3.11 7.57 37.98 10.19 4.13 11.99 3.63 1.81 2.19 0.86 7.18 0.27 2.04 2.49
RENTAL FEE
BR
MAX UNITS 120 10 200 30 24 2 1 1 5 5 3 2 100 4 1 1 2 1 108 108 10 10 10 30 50 2 5 5 12 30 10 10 10 60 250 250 60 30 1 10 30 15 25 5 20 10 5 40 22 21
PA
6 6 6 6 6 6
6 6
1
1
1
6 6 6 6 6 6 6 6 6
Page 2 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE A4372 A4373 A4375 A4376 A4377 A4378 A4379 A4380 A4381 A4382 A4383 A4384 A4385 A4387 A4388 A4389 A4390 A4391 A4392 A4393 A4394 A4395 A4396 A4397 A4398 A4399 A4400 A4402 A4404 A4405 A4406 A4407 A4408 A4409 A4410 A4411 A4412 A4413 A4414 A4415 A4416 A4417 A4418 A4419 A4420 A4421 A4422 A4423 A4424 A4425
DESCRIPTION OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVA OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTA OSTOMY POUCH, DRAINABLE, WITH FACEPLATE OSTOMY POUCH, DRAINABLE, FOR USE ON FACE OSTOMY POUCH, DRAINABLE, FOR USE ON FACE OSTOMY POUCH, URINARY, WITH FACEPLATE AT OSTOMY POUCH, URINARY, WITH FACEPLATE AT OSTOMY POUCH, URINARY, FOR USE ON FACEPL OSTOMY POUCH, URINARY, FOR USE ON FACEPL OSTOMY POUCH, URINARY, FOR USE ON FACEPL OSTOMY FACEPLATE EQUIVALENT, SILICONE RING, EA OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVA OSTOMY POUCH, CLOSED, WITH BARRIER ATTAC OSTOMY POUCH, DRAINABLE, WITH EXTENDED W OSTOMY POUCH, DRAINABLE, WITH BARRIER AT OSTOMY POUCH, DRAINABLE, WITH EXTENDED W OSTOMY POUCH, URINARY, WITH EXTENDED WEA OSTOMY POUCH, URINARY, WITH STANDARD WEA OSTOMY POUCH, URINARY, WITH EXTENDED WEA OSTOMY DEODORANT, WITH OR WITHOUT LUBRIC OSTOMY DEODORANT FOR USE IN OSTOMY POUCH OSTOMY BELT W/PERISTOMAL HERNIA SUPPORT IRRIGATION SUPPLY SLEEVE EACH OSTOMY IRRIGATION SUPPLY; BAG, EACH OSTOMY IRRIGATION SUPPLY; CONE/CATHETER, OSTOMY IRRIGATION SET EACH LUBRICANT, PER OUNCE OSTOMY RING, EACH OSTOMY SKIN BARRIER, NON-PECTIN BASED, P OSTOMY SKIN BARRIER, PECTIN-BASED, PASTE OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, OSTOMY SKIN BARRIER, WTIH FLANGE (SOLID, OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVA OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FO OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FO OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, OSTOMY POUCH, CLOSED, WITH BARRIER ATTAC OSTOMY POUCH, CLOSED, WITH BARRIER ATTAC OSTOMY POUCH, CLOSED; WITHOUT BARRIER AT OSTOMY POUCH, CLOSED; FOR USE ON BARRIER OSTOMY POUCH, CLOSED; FOR USE ON BARRIER OSTOMY SUPPLY; MISCELLANEOUS OSTOMY ABSORBENT MATERIAL (SHEET/PAD/CRYST OSTOMY POUCH, CLOSED; FOR USE ON BARRIER OSTOMY POUCH, DRAINABLE, WITH BARRIER AT OSTOMY POUCH, DRAINABLE; FOR USE ON BARR
FEE 4.19 6.58 18.04 47.40 4.50 30.11 15.77 39.16 3.53 3.53 29.57 10.10 5.35 3.23 3.77 6.46 8.41 6.40 8.58 9.48 2.71 0.05 40.40 2.73 1.00 12.86 30.09 0.43 1.62 2.36 4.66 8.69 8.64 4.80 4.80 5.10 2.84 5.77 4.54 4.54 2.61 3.82 1.90 1.77 1.55 0.13 1.90 3.15 3.52
RENTAL FEE
BR
MAX UNITS 15 15 2 2 15 2 15 2 10 15 2 10 15 15 15 15 15 15 15 15 8 60 2 125 125 1 30 20 15 18 18 10 10 10 10 10 15 15 20 20 60 60 60 60 60 30 60 60 20 20
PA 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 1 6 6 6 6
Page 3 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE A4426 A4427 A4428 A4429 A4430 A4431 A4432 A4433 A4434 A4435 A4450 A4452 A4455 A4456 A4458 A4463 A4481 A4495 A4500 A4510 A4554 A4556 A4557 A4565 A4570 A4575 A4602 A4605 A4614 A4615 A4616 A4618 A4619 A4620 A4623 A4624 A4625 A4626 A4628 A4629 A4630 A4632 A4635 A4636 A4637 A4640 A4649 A4660 A4670 A4670
DESCRIPTION OSTOMY POUCH, DRAINABLE; FOR USE ON BARR OSTOMY POUCH, DRAINABLE; FOR USE ON BARR OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BA OSTOMY POUCH, URINARY, WITH BARRIER ATTACHE OSTOMY POUCH, URINARY, WITH EXTENDED WEAR B OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED OSTOMY POUCH, URINARY; FOR USE ON BARRIER WIT OSTOMY POUCH, URINARY; FOR USE ON BARRIER WIT OSTOMY POUCH, URINARY; FOR USE ON BARRIER WIT OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, TAPE, NON-WATERPROOF, PER 18 SQUARE INCH TAPE, WATERPROOF, PER 18 SQUARE INCHES ADHESIVE REMOVER OR SOLVENT (FOR TAPE, C ADHESIVE REMOVER, WIPES, ANY TYPE, EACH ENEMA BAG WITH TUBING, REUSABLE SURGICAL DRESSING HOLDER, REUSABLE, EACH TRACHEOSTOMA FILTER, ANY TYPE, ANY SIZE, SURGICAL STOCKINGS THIGH LENGTH, EACH SURGICAL STOCKINGS BELOW KNEE LENGTH, EA SURGICAL STOCKINGS FULL LENGTH, EACH DISPOSABLE UNDERPADS, ALL SIZES ELECTRODES, (E.G., APNEA MONITOR), PER P LEAD WIRES, (E.G., APNEA MONITOR), PER P SLINGS SPLINT TOPICAL HYPERBARIC OXYGEN CHAMBER, DISPO REPLACEMENT BATTERY FOR EXTERNAL INFUSIO TRACHEAL SUCTION CATHETER, CLOSED SYSTEM PEAK EXPIRATORY FLOW RATE METER, HAND HE CANNULA NASAL TUBING,(OXYGEN),PER FOOT BREATHING CIRCUITS FACE TENT VARIABLE CONCENTRATION MASK TRACHEOSTOMY, INNER CANNULA TRACHEAL SUCTION CATHETER, ANY TYPE OTHE TRACHEOSTOMY CARE KIT FOR NEW TRACHEOSTO TRACHEOSTOMY CLEANING BRUSH EA OROPHARYNGEAL SUCTION CATHETER, EACH TRACHEOSTOMY CARE KIT FOR ESTABLISHED TR REPLACEMENT BATTERIES, MEDICALLY NECESSA REPLACEMENT BATTERY FOR EXTERNAL INFUSIO UNDERARM PAD,CRUTCH,REPLACEMENT EACH REPLACEMENT, HANDGRIP, CANE, CRUTCH, OR REPLACEMENT, TIP, CANE, CRUTCH, WALKER, REPLACEMENT PAD FOR USE WITH MEDICALLY SURGICAL SUPPLY MISC SPHYGMOMANOMETER/BLOOD PRESSURE APPARATU AUTOMATIC BLOOD PRESSURE MONITOR - SEMI AUTO AUTOMATIC BLOOD PRESSURE MONITOR- FULLY AUTO
FEE 1.76 2.75 6.84 8.66 8.95 6.53 3.77 3.51 3.95 6.26 0.06 0.11 1.28 0.24 16.26 11.15 2.73 14.97 12.41 36.39 0.28 6.13 18.86 6.47 1.97 1.75 10.63 19.24 0.75 0.07 2.95 1.27 0.62 5.61 1.40 4.25 1.51 2.02 3.08 2.46 2.83 3.53 1.64 38.83 20.59 31.00 65.00
RENTAL FEE
BR
MAX UNITS 20 20 15 15 15 15 15 15 15 15 300 100 40 50 1 3 30 4 4 2 300 2 2 1 5 16 30 15 1 4 30 4 4 4 5 250 90 2 5 90 1 2 2 2 4 1 30 1 1 1
PA 6 6 6 6 6 6 6 6 6 6
6 6 6 6 6 6 6
6 6
6 1
6 1 6 1 1
Page 4 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE A4927 A4930 A4931 A4932 A5051 A5052 A5053 A5054 A5055 A5056 A5057 A5061 A5062 A5063 A5071 A5072 A5073 A5081 A5082 A5083 A5093 A5105 A5112 A5113 A5114 A5120 A5121 A5122 A5126 A5131 A5200 A5500 A5501 A5503 A5504 A5505 A5506 A5507 A5512 A5513 A6010 A6011 A6021 A6022 A6023 A6024 A6196 A6197 A6198 A6199
DESCRIPTION GLOVES, NON-STERILE, PER 100 GLOVES,STERILE PER PAIR ORAL THERMOMETER, REUSABLE, ANY TYPE, EA RECTAL THERMOMETER, REUSABLE, ANY TYPE, OSTOMY POUCH, CLOSED; WITH BARRIER ATTAC OSTOMY POUCH, CLOSED; WITHOUT BARRIER AT OSTOMY POUCH, CLOSED; FOR USE ON FACEPLA OSTOMY POUCH, CLOSED; FOR USE ON BARRIER STOMA CAP EACH OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR OSTOMY POUCH, DRAINABLE; WITH BARRIER AT OSTOMY POUCH, DRAINABLE; WITHOUT BARRIER OSTOMY POUCH, DRAINABLE; FOR USE ON BARR OSTOMY POUCH, URINARY; WITH BARRIER ATTA OSTOMY POUCH, URINARY; WITHOUT BARRIER A OSTOMY POUCH, URINARY; FOR USE ON BARRIE CONTINENT DEVICE; PLUG FOR CONTINENT STO CONTINENT DEVICE; CATHETER FOR CONTINENT CONTINENT DEVICE, STOMA ABSORPTIVE COVER OSTOMY ACCESSORY CONVEX INSERT URINARY SUSPENSORY WITH LEG BAG, WITH OR URINARY DRAINAGE BAG, LEG OR ABDOMEN, LA LEG STRAP; LATEX, REPLACEMENT ONLY, PER LEG STRAP; FOAM OR FABRIC, REPLACEMENT SKIN BARRIER, WIPES OR SWABS, EACH SKIN BARRIER; SOLID, 6 X 6 OR EQUIVALENT SKIN BARRIER; SOLID, 8 X 8 OR EQUIVALENT ADHESIVE OR NON-ADHESIVE; DISK OR FOAM APPLIANCE CLEANER, INCONTINENCE AND OSTO PERCUTANEOUS CATHETER/TUBE ANCHORING DEV FOR DIABETICS ONLY, FITTING FOR DIABETICS ONLY, FITTING, CUSTOM PREPARATIO FOR DIABETICS ONLY, MODIFICATION (OF OFF-THE-S FOR DIABETICS ONLY, MODIFICATION ) OF OFF-THE-S FOR DIABETICS ONLY, MODIFICATION OF OFF-THE-SH DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WIT FOR DIABETICS ONLY, NOT OTHERWISE SPECIFIED M FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, D FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CU COLLAGEN BASED WOUND FILLER, DRY FORM, S COLLAGEN BASED WOUND FILLER, GEL/PASTE, COLLAGEN DRESSING, STERILE, SIZE 16 SQUARE COLLAGEN DRESSING, STERILE, SIZE MORE THA COLLAGEN DRESSING, STERILE, SIZE MORE THA COLLAGEN DRESSING WOUND FILLER, STERILE, ALGINATE OR OTHER FIBER GELLING DRESSING ALGINATE OR OTHER FIBER GELLING DRESSING ALGINATE OR OTHER FIBER GELLING DRESSING ALGINATE OR OTHER FIBER GELLING DRESSING
FEE 4.55 0.40 1.97 1.34 2.17 1.56 1.73 1.68 1.49 5.01 10.32 3.37 2.33 2.27 4.41 3.70 3.20 3.37 10.60 0.22 1.87 42.76 29.64 1.86 3.92 0.20 6.65 11.95 1.16 8.06 2.70 66.69 200.05 32.60 32.60 32.60 32.60 32.60 27.21 40.61 4.51 2.39 19.88 22.05 76.88 4.39 5.50 6.43 14.52 2.76
RENTAL FEE
BR
MAX UNITS 1 30 1 1 60 60 60 60 5 20 20 150 150 50 50 50 50 31 1 120 5 5 5 2 2 100 25 25 30 1 30 1 1 1 1 1 1 1 1 1 30 30 5 5 5 3 30 30 15 60
PA 6 6
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
Page 5 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE A6203 A6204 A6205 A6206 A6207 A6208 A6209 A6210 A6211 A6212 A6213 A6214 A6216 A6217 A6218 A6219 A6220 A6221 A6222 A6223 A6224 A6228 A6229 A6230 A6231 A6232 A6233 A6234 A6235 A6236 A6237 A6238 A6239 A6240 A6241 A6242 A6243 A6244 A6245 A6246 A6247 A6248 A6251 A6252 A6253 A6254 A6255 A6256 A6257 A6258
DESCRIPTION COMPOSITE DRESSING, STERILE, PAD SIZE 16 COMPOSITE DRESSING, STERILE, PAD SIZE MO COMPOSITE DRESSING, STERILE, PAD SIZE MO CONTACT LAYER, STERILE, 16 SQ. IN. OR LE CONTACT LAYER, STERILE, MORE THAN 16 SQ. CONTACT LAYER, STERILE, MORE THAN 48 SQ. FOAM DRESSING, WOUND COVER, STERILE, PAD FOAM DRESSING, WOUND COVER, STERILE, PAD FOAM DRESSING, WOUND COVER, STERILE, PAD FOAM DRESSING, WOUND COVER, STERILE, PAD FOAM DRESSING, WOUND COVER, STERILE, PAD FOAM DRESSING, WOUND COVER, STERILE, PAD GAUZE NON-IMP NON-STER UP TO 1 A6216; MORE THAN 16 UP TO 48SQ A6216; MORE THAN 48 SQ IN GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ GAUZE, IMPREGNATED WITH OTHER THAN WATER GAUZE, IMPREGNATED WITH OTHER THAN WATER GAUZE, IMPREGNATED WITH OTHER THAN WATER GAUZE, IMPREGNATED, WATER OR NORMAL SALI GAUZE, IMPREGNATED, WATER OR NORMAL SALI GAUZE, IMPREGNATED, WATER OR NORMAL SALI GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT HYDROCOLLOID DRESSING, WOUND COVER, STER HYDROCOLLOID DRESSING, WOUND COVER, STER HYDROCOLLOID DRESSING, WOUND COVER, STER HYDROCOLLOID DRESSING, WOUND COVER, STER HYDROCOLLOID DRESSING, WOUND COVER, STER HYDROCOLLOID DRESSING, WOUND COVER, STER HYDROCOLLOID DRESSING, WOUND FILLER, PAS HYDROCOLLOID DRESSING, WOUND FILLER, DRY HYDROGEL DRESSING, WOUND COVER, STERILE, HYDROGEL DRESSING, WOUND COVER, STERILE, HYDROGEL DRESSING, WOUND COVER, STERILE, HYDROGEL DRESSING, WOUND COVER, STERILE, HYDROGEL DRESSING, WOUND COVER, STERILE, HYDROGEL DRESSING, WOUND COVER, STERILE, HYDROGEL DRESSING, WOUND FILLER, GEL, PE SPECIALTY ABSORPTIVE DRESSING, WOUND COV SPECIALTY ABSORPTIVE DRESSING, WOUND COV SPECIALTY ABSORPTIVE DRESSING, WOUND COV SPECIALTY ABSORPTIVE DRESSING, WOUND COV SPECIALTY ABSORPTIVE DRESSING, WOUND COV SPECIALTY ABSORPTIVE DRESSING, WOUND COV TRANSPARENT FILM, STERILE, 16 SQ. IN. OR TRANSPARENT FILM, STERILE, MORE THAN 16
FEE 2.11 4.09 5.65 1.53 2.68 6.50 1.66 3.57 8.09 3.99 9.06 10.79 0.04 0.08 0.19 0.22 1.08 2.42 1.44 1.71 1.79 1.62 1.69 1.82 1.32 4.01 5.57 5.69 11.26 13.88 5.11 8.20 10.54 8.12 1.59 3.06 6.49 14.05 3.56 7.39 18.77 4.16 2.09 2.54 3.61 1.07 1.71 3.85 0.35 1.16
RENTAL FEE
BR
MAX UNITS PA 30 30 15 30 30 15 30 30 30 30 30 15 120 120 60 120 30 15 30 60 15 30 30 30 30 30 30 30 30 30 30 30 30 20 25 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30
Page 6 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE A6259 A6261 A6262 A6266 A6402 A6403 A6404 A6407 A6410 A6411 A6412 A6441 A6442 A6443 A6444 A6445 A6446 A6447 A6448 A6449 A6450 A6451 A6452 A6453 A6454 A6455 A6456 A6457 A6501 A6502 A6503 A6504 A6505 A6506 A6507 A6508 A6509 A6510 A6511 A6512 A6530 A6531 A6532 A6533 A6534 A6535 A6536 A6537
DESCRIPTION TRANSPARENT FILM, STERILE, MORE THAN 48 WOUND FILLER, GEL/PASTE, PER FLUID OUNCE WOUND FILLER, DRY FORM, PER GRAM, NOT OT GAUZE, IMPREGNATED, OTHER THAN WATER, NO GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ GAUZE, NON-IMPREGNATED, STERILE, PAD SIZ PACKING STRIPS, NON-IMPREGNATED, STERILE EYE PAD, STERILE, EACH EYE PAD,NON-STERILE, EACH EYE PATCH, OCCLUSIVE, EACH PADDING BANDAGE, NON-ELASTIC, NON-WOVEN/ CONFORMING BANDAGE, NON-ELASTIC, KNITTED CONFORMING BANDAGE, NON-ELASTIC, KNITTED CONFORMING BANDAGE, NON-ELASTIC, KNITTED CONFORMING BANDAGE, NON-ELASTIC, KNITTED CONFORMING BANDAGE, NON-ELASTIC, KNITTED CONFORMING BANDAGE, NON-ELASTIC, KNITTED LIGHT COMPRESSION BANDAGE, ELASTIC, KNIT LIGHT COMPRESSION BANDAGE, ELASTIC, KNIT LIGHT COMPRESSION BANDAGE, ELASTIC, KNIT MODERATE COMPRESSION BANDAGE, ELASTIC, K HIGH COMPRESSION BANDAGE, ELASTIC, KNITT SELF-ADHERENT BANDAGE, ELASTIC, NON-KNIT SELF-ADHERENT BANDAGE, ELASTIC, NON-KNIT SELF-ADHERENT BANDAGE, ELASTIC, NON-KNIT ZINC PASTE IMPREGNATED BANDAGE, NON-ELAS TUBULAR DRESSING WITH OR WITHOUT ELASTIC COMPRESSION BURN GARMENT, BODYSUIT (HEAD COMPRESSION BURN GARMENT, CHIN STRAP, CU COMPRESSION BURN GARMENT, FACIAL HOOD, C COMPRESSION BURN GARMENT, GLOVE TO WRIST COMPRESSION BURN GARMENT, GLOVE TO ELBOW COMPRESSION BURN GARMENT, GLOVE TO AXILL COMPRESSION BURN GARMENT, FOOT TO KNEE L COMPRESSION BURN GARMENT, FOOT TO THIGH COMPRESSION BURN GARMENT, UPPER TRUNK TO COMPRESSION BURN GARMENT, TRUNK, INCLUDI COMPRESSION BURN GARMENT, LOWER TRUNK IN COMPRESSION BURN GARMET NOC GRADIENT COMPRESSION STOCKING, BELOW KNE GRADIENT COMPRESSION STOCKING, BELOW KNE GRADIENT COMPRESSION STOCKING, BELOW KNE GRADIENT COMPRESSION STOCKING, THIGH LEN GRADIENT COMPRESSION STOCKING, THIGH LEN GRADIENT COMPRESSION STOCKING, THIGH LEN GRADIENT COMPRESSION STOCKING, FULL LENG GRADIENT COMPRESSION STOCKING, FULL LENG
FEE 2.46
2.02 0.13 0.26 0.35 1.91 0.23 0.16 0.27 0.70 0.04 0.06 0.08 0.06 0.10 0.18 0.06 0.09 0.16 0.17 1.22 0.40 0.57 0.68 0.80 1.20
18.06 18.88 26.96 22.31 26.61 31.71 31.47 33.24
RENTAL FEE
BR
MAX UNITS 30 30 30 30 180 120 30 30 50 50 30 30 120 120 120 120 120 120 90 90 90 90 15 30 30 30 24 25 1 1 1 2 2 2 2 2 1 1 1 2 2 2 2 2 2 2 2 2
PA 1 1
1 1 1 1 1 1 1 1 1 1 1 1 1 6 6 6 6 6 6 6 6
Page 7 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE A6538 A6539 A6540 A6541 A6544 A6549 A7000 A7002 A7003 A7004 A7005 A7007 A7013 A7014 A7015 A7025 A7026 A7027 A7028 A7029 A7030 A7031 A7032 A7033 A7034 A7035 A7036 A7037 A7038 A7039 A7044 A7045 A7520 A7521 A7522 A7523 A7524 A7525 A8000 A8001 A8002 A8003 A8004 A9273 A9275 A9282 A9900 A9999 B4034
DESCRIPTION GRADIENT COMPRESSION STOCKING, FULL LENG GRADIENT COMPRESSION STOCKING, WAIST LEN GRADIENT COMPRESSION STOCKING, WAIST LEN GRADIENT COMPRESSION STOCKING, WAIST LEN GRADIENT COMPRESSION STOCKING, GARTER BE GRADIENT COMPRESSION STOCKING/SLEEVE, NO CANISTER, DISPOSABLE, USED WITH SUCTION TUBING, USED WITH SUCTION PUMP, EACH ADMINISTRATION SET, WITH SMALL VOLUME NO SMALL VOLUME NONFILTERED PNEUMATIC NEBUL ADMINISTRATION SET, WITH SMALL VOLUME NO LARGE VOLUME NEBULIZER, DISPOSABLE, UNFI FILTER, DISPOSABLE, USED WITH AEROSOL CO FILTER, NONDISPOSABLE, USED WITH AEROSOL AEROSOL MASK, USED WITH DME NEBULIZER HIGH FREQUENCY CHEST WALL OSCILLATION SY HIGH FREQUENCY CHEST WALL OSCILLATION SY COMBINATION ORAL/NASAL MASK, USED WITH C ORAL CUSHION FOR COMBINATION ORAL/NASAL NASAL PILLOWS FOR COMBINATION ORAL/NASAL FULL FACE MASK USED WITH POSITIVE AIRWAY FACE MASK INTERFACE, REPLACEMENT FOR FUL CUSHION FOR USE ON NASAL MASK INTERFACE, PILLOW FOR USE ON NASAL CANNULA TYPE INT NASAL INTERFACE (MASK OR CANNULA TYPE) U HEADGEAR USED WITH POSITIVE AIRWAY PRESS CHINSTRAP USED WITH POSITIVE AIRWAY PRES TUBING USED WITH POSITIVE AIRWAY PRESSUR FILTER, DISPOSABLE, USED WITH POSITIVE A FILTER, NON DISPOSABLE, USED WITH POSITI ORAL INTERFACE USED WITH POSITIVE AIRWAY EXHALATION PORT WITH OR WITHOUT SWIVEL U TRACHEOSTOMY/LARYNGECTOMY TUBE, NON-CUFF TRACHEOSTOMY/LARYNGECTOMY TUBE, CUFFED, TRACHEOSTOMY/LARYNGECTOMY TUBE, STAINLES TRACH SHOWER PROTECTOR,EACH TRACHEOSTOMA STENT/STUD/BUTTON, EACH TRACHEOSTOMY MASK,EACH HELMET, PROTECTIVE, SOFT, PREFABRICATED, HELMET, PROTECTIVE, HARD, PREFABRICATED, HELMET, PROTECTIVE, SOFT, CUSTOM FABRICA HELMET, PROTECTIVE, HARD, CUSTOM FABRICA SOFT INTERFACE FOR HELMET, REPLACEMENT O HOT WATER BOTTLE, ICE CAP OR COLLAR, HEA HOME GLUCOSE DISPOSABLE MONITOR, INCLUDE WIG, ANY TYPE, EACH MISCELLANEOUS DME SUPPLY, ACCESSORY, AND MISCELLANEOUS DME SUPPLY OR ACCESSORY, N ENTERAL FEEDING SUPPLY KIT; SYRINGE FED,
FEE 43.22 62.72 101.23 104.94 15.00 4.35 0.92 2.23 1.29 16.19 2.89 0.11 0.80 1.06 275.00 28.75 179.35 49.54 20.24 143.21 63.08 36.64 25.68 48.86 29.55 14.10 21.16 1.71 2.40 109.31 17.60 49.80 49.35 47.37 8.10 59.63 1.68 116.10 151.65 426.00 426.00 5.40 28.75 110.84
3.12
RENTAL FEE
BR
MAX UNITS 2 2 2 2 2 2 5 30 2 5 1 5 5 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 4 1 1 1 1 1 1 2 1 1 5 30
PA 6 6 6 6 6 1
6
6 6 6 6 6 6 6 6 6 6 6 6 6
6 6
6 6 6 6 1 6 1 1 1 6
Page 8 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE B4035 B4036 B4081 B4082 B4083 B4087 B4088 B4100 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B9002 B9004 B9006 B9998 E0100 E0105 E0110 E0111 E0112 E0113 E0114 E0116 E0130 E0135 E0140 E0141 E0143 E0144 E0147 E0148 E0149 E0153 E0154 E0155 E0156 E0157 E0159 E0160 E0163 E0165
DESCRIPTION ENTERAL FEEDING SUPPLY KIT; PUMP FED, PE ENTERAL FEEDING SUPPLY KIT; GRAVITY FED, NASOGASTRIC TUBING WITH STYLET NASOGASTRIC TUBING WITHOUT STYLET STOMACH TUBE-LEVINE TYPE GASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD, GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFIL FOOD THICKENER, ADMINISTERED ORALLY, PER ENTERAL FORMULA, MANUFACTURED BLENDERIZE ENTERAL FORMULA, NUTRITIONALLY COMPLETE ENTERAL FORMULA, NUTRITIONALLY COMPLETE, ENTERAL FORMULA, NUTRITIONALLY COMPLETE, ENTERAL FORMULA, NUTRITIONALLY COMPLETE, ENTERAL FORMULA, NUTRITIONALLY INCOMPLET ENTERAL FORMULA, NUTRITIONALLY COMPLETE, ENTERAL FORMULA, FOR PEDIATRICS, NUTRITI ENTERAL FORMULA, FOR PEDIATRICS, NUTRITI ENTERAL FORMULA, FOR PEDIATRICS, NUTRITI ENTERAL FORMULA, FOR PEDIATRICS, HYDROLY ENTERAL FORMULA, FOR PEDIATRICS, SPECIAL ENTERAL NUTRITION INFUSION PUMP - WITH A PARENTERAL NUTRITION INFUSION PUMP, PORT PARENTERAL NUTRITION INFUSION PUMP, STAT NOC FOR ENTERAL SUPPLIES CANE, INCLUDES CANES OF ALL MATERIALS, A CANE, QUAD OR THREE PRONG, INCLUDES CANE CRUTCHES, FOREARM, INCLUDES CRUTCHES OF CRUTCH FOREARM, INCLUDES CRUTCHES OF VAR CRUTCHES UNDERARM, WOOD, ADJUSTABLE OR F CRUTCH UNDERARM, WOOD, ADJUSTABLE OR FIX CRUTCHES UNDERARM, OTHER THAN WOOD, ADJU CRUTCH, UNDERARM, OTHER THAN WOOD, ADJUS WALKER, RIGID (PICKUP), ADJUSTABLE OR FI WALKER, FOLDING (PICKUP), ADJUSTABLE OR WALKER, WITH TRUNK SUPPORT, ADJUSTABLE O WALKER, RIGID, WHEELED, ADJUSTABLE OR FI WALKER, FOLDING, WHEELED, ADJUSTABLE OR WALKER, ENCLOSED, FOUR SIDED FRAMED, RIG WALKER, HEAVY DUTY, MULTIPLE BRAKING SYS WALKER, HEAVY DUTY, WITHOUT WHEELS, RIGI WALKER, HEAVY DUTY, WHEELED, RIGID OR FO PLATFORM ATTACHMENT, FOREARM CRUTCH, EAC PLATFORM ATTACHMENT,WALKER,EACH WHEEL ATTACHMENT, RIGID PICK-UP WALKER, SEAT ATTACHMENT, WALKER CRUTCH ATTACHMENT, WALKER, EACH BRAKE ATTACHMENT FOR WHEELED WALKER, REP SITZ TYPE BATH OR EQUIPMENT, PORTABLE, U COMMODE CHAIR, MOBILE OR STATIONARY, WIT COMMODE CHAIR, MOBILE OR STATIONARY, WIT
FEE 5.66 4.30 16.17 10.06 1.07 22.89 134.58 0.53 0.99 0.49 0.38 1.85 0.85 1.21 4.58 0.73 0.84 0.60 1.35 4.58 715.56 2748.36 2039.92
RENTAL FEE
BR SC BR SC BR SC
BR SC BR SC 60.00 60.00 60.00
12.00 18.75 58.93 29.46 23.93 11.96 23.38 11.69 37.33 47.63 100.00 104.24 92.21 287.91 306.70 114.87 201.80 61.29 57.15 24.25 23.90 20.09 14.92 4.31 103.63 174.18
BR
MAX UNITS 30 30 1 2 2 1 1 180 600 600 600 600 600 300 600 600 600 600 600 600 1 1 1 90 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 2 2 1 1 1
PA 6 6 6 6 6 6 6 6 4 4 4 4 4 4 4 4 4 4 4 4 6 6 6 1 6 6
6 6 1 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
Page 9 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE E0167 E0168 E0175 E0181 E0182 E0184 E0185 E0186 E0187 E0188 E0190 E0191 E0193 E0196 E0197 E0198 E0199 E0202 E0210 E0215 E0235 E0240 E0241 E0243 E0244 E0245 E0246 E0247 E0248 E0251 E0256 E0261 E0266 E0271 E0272 E0274 E0275 E0276 E0277 E0301 E0302 E0305 E0310 E0316 E0325 E0326 E0328 E0371 E0372 E0424
DESCRIPTION PAIL OR PAN FOR USE WITH COMMODE CHAIR, COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY D FOOT REST, FOR USE WITH COMMODE CHAIR, E POWERED PRESSURE REDUCING MATTRESS OVERL PUMP FOR ALTERNATING PRESSURE PAD, FOR R DRY PRESSURE MATTRESS GEL OR GEL-LIKE PRESSURE PAD FOR MATTRES AIR PRESSURE MATTRESS WATER PRESSURE MATTRESS SYNTHETIC SHEEPSKIN PAD POSITIONING CUSHION/PILLOW/WEDGE, ANY SH HEEL OR ELBOW PROTECTOR EACH POWERED AIR FLOTATION BED (LOW AIR LOSS GEL PRESSURE MATTRESS AIR PRESSURE PAD FOR MATTRESS, STANDARD WATER PRESSURE PAD FOR MATTRESS, STANDAR DRY PRESSURE PAD FOR MATTRESS, STANDARD PHOTOTHERAPY (BILIRUBIN) LIGHT WITH PHOT ELECTRIC HEAT PAD, STANDARD ELECTRIC HEAT PAD MOIST PARAFFIN BATH UNIT, PORTABLE (SEE MEDICA BATH/SHOWER CHAIR, WITH OR WITHOUT WHEEL BATHTUB WALL RAIL EACH TOILET RAIL EACH RAISED TOILET SEAT TUB STOOL OR BENCH TRANSFER TUB RAIL ATTACHMENT TRANSFER BENCH FOR TUB OR TOILET WITH OR TRANSFER BENCH, HEAVY DUTY, FOR TUB OR T HOSPITAL BED, FIXED HEIGHT, WITH ANY TYP HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WI HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FO HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT MATTRESS, INNERSPRING MATTRESS, FOAM RUBBER TABLE, OVERBED BED PAN STANDARD METAL OR PLASTIC BED PAN FRACTURE METAL OR PLASTIC POWERED PRESSURE-REDUCING AIR MATTRESS HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WI HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WI BED SIDE RAILS, HALF LENGTH BED SIDE RAILS, FULL LENGTH SAFETY ENCLOSURE FRAME/CANOPY FOR USE WI URINAL MALE JUG-TYPE ANY MATERIAL URINAL FEMALE JUG-TYPE ANY MATERIAL HOSPITAL BED, PEDIATRIC, MANUAL, 360 DEG NONPOWERED ADVANCED PRESSURE REDUCING OV POWERED AIR OVERLAY FOR MATTRESS, STANDA STATIONARY COMPRESSED GASEOUS OXYGEN SYS
FEE 6.08 153.52 59.05 121.46 88.65 153.13 165.74 91.55 61.20 19.50 22.04 2.81 4543.50 74.00 64.63 40.23 19.48 10.00 14.40 20.93 59.94 38.34 27.07 35.87 20.99 28.79 48.10 89.83 170.34 288.81 450.06 713.97 863.68 157.21 155.52 101.85 3.78 4.25 3961.75 2206.15 4865.84 95.24 115.35 2.99 7.20 4457.81 3801.20 1412.00 100.00
RENTAL FEE
15.31 9.16 6.12
454.35 7.40
10.00
28.89 45.01 71.40 86.37 15.72 15.55
396.18 220.62 486.58
445.78 380.12 141.20 100.00
BR
MAX UNITS 1 1 1 1 1 1 1 1 1 1 1 5 1 1 1 1 1 10 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
PA 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 1 6
6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 1 6 6 6 6 6 6
Page 10 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE E0431 E0434 E0439 E0445 E0465 E0466 E0470 E0471 E0472 E0480 E0481 E0482 E0483 E0500 E0550 E0561 E0562 E0565 E0570 E0575 E0580 E0600 E0601 E0602 E0603 E0604 E0605 E0607 E0619 E0621 E0628 E0629 E0630 E0637 E0638 E0641 E0642 E0650 E0655 E0660 E0665 E0666 E0700 E0705 E0710 E0730 E0747 E0748 E0760 E0776
DESCRIPTION FEE PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; 30.42 PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; I 45.00 STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; 72.50 OXIMETER DEVICE FOR MEASURING BLOOD OXYG 165.00 HOME VENTILATOR, ANY TYPE, USED WITH INVASIVE INTERFACE 731.00 HOME VENTILATOR, ANY TYPE, USED WITH NON- INVASIVE INTE 731.00 RESPIRATORY ASSIST DEVICE, BI-LEVEL PRES 2088.50 RESPIRATORY ASSIST DEVICE, BI-LEVEL PRES 190.00 RESPIRATORY ASSIST DEVICE, BI-LEVEL PRES 190.00 PERCUSSOR, ELECTRIC OR PNEUMATIC, HOME M 355.56 INTRAPULMONARY PERCUSSIVE VENTILATION SY 190.00 COUGH STIMULATING DEVICE, ALTERNATING PO 190.00 HIGH FREQUENCY CHEST WALL OSCILLATION AI 195.00 IPPB MACHINE, ALL TYPES, WITH BUILT-IN 1524.17 HUMIDIFIER, DURABLE FOR EXTENSIVE SUPPLE 136.64 HUMIDIFIER, NON-HEATED, USED WITH POSITI 96.74 HUMIDIFIER, HEATED, USED WITH POSITIVE A 186.33 COMPRESSOR, AIR POWER SOURCE FOR EQUIPME 377.69 NEBULIZER, WITH COMPRESSOR 117.89 NEBULIZER; ULTRASONIC 433.91 NEBULIZER, DURABLE, GLASS OR AUTOCLAVABL 105.38 RESPIRATORY SUCTION PUMP, HOME MODEL, PO 290.66 CONTINUOUS AIRWAY PRESSURE (CPAP) DEVICE 496.20 BREAST PUMP, MANUAL, ANY TYPE 31.71 BREAST PUMP ELECTRIC (AC/DC), ANY TYPE 173.47 BREAST PUMP, HOSPITAL GRADE, ELECTRIC (A 38.61 VAPORIZER,ROOM TYPE 16.73 HOME BLOOD GLUCOSE MONITOR 0.00 APNEA MONITOR W/RECORDING FEATURE 190.00 SLING OR SEAT,PATIENT LIFT, CANVAS OR NYLON 76.59 SEPARATE SEAT LIFT MECHANISM FOR USE WIT 189.00 SEPARATE SEAT LIFT MECHANISM FOR USE WIT 133.50 PATIENT LIFT, HYDRAULIC OR MECHANICAL, I 1035.36 COMBINATION SIT TO STAND SYSTEM, ANY SIZ 3229.11 STANDING FRAME SYSTEM, ONE POSITION (E.G 1273.22 STANDING FRAME SYSTEM, MULTI-POSITION (E 1663.88 STANDING FRAME SYSTEM, MOBILE (DYNAMIC S PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME 531.06 NON-SEGMENTAL PNEUMATIC APPLIANCE FOR US 56.04 NON-SEGMENTAL PNEUMATIC APPLIANCE FOR US 166.98 NON-SEGMENTAL PNEUMATIC APPLIANCE FOR US 135.15 NON-SEGMENTAL PNEUMATIC APPLIANCE FOR US 89.56 SAFETY EQUIPMENT, DEVICE OR ACCESSORY, A 15.15 TRANSFER DEVICE, ANY TYPE, EACH 37.22 RESTRAINTS, ANY TYPE (BODY, CHEST, WRIST 13.65 TRANSCUTANEOUS ELECTRICAL NERVE STIMULAT 76.25 OSTEOGENESIS STIMULATOR, ELECTRICAL, NON 3,300.00 OSTEOGENESIS STIMULATOR, ELECTRICAL, NON 3,300.00 OSTEOGENESIS STIMULATOR, LOW INTENSITY U 2,700.00 IV POLE 127.64
RENTAL FEE 30.42 45.00 72.50 165.00 731.00 731.00 190.00 190.00 190.00 35.55 190.00 190.00 195.00
BR
13.66 9.67 18.63 37.77
49.62
38.61
190.00
322.91 127.32 166.39 BR BR BR BR BR
BR BR BR 12.76
MAX UNITS 1 1 6 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 1 1 4 1 1 1 1 1
PA 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
6 6 6 6 6 6 6 6 1 6 6 1
6
6 6 6 6 6
Page 11 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE E0781 E0784 E0791 E0849 E0855 E0860 E0890 E0900 E0910 E0911 E0912 E0940 E0944 E0946 E0950 E0951 E0952 E0955 E0956 E0957 E0958 E0959 E0960 E0961 E0966 E0967 E0971 E0973 E0974 E0978 E0986 E0990 E0992 E0995 E1002 E1003 E1004 E1005 E1006 E1007 E1008 E1009 E1010 E1011 E1012 E1014 E1020 E1028 E1161 E1225
DESCRIPTION AMBULATORY INFUSION PUMP, SINGLE OR MULT EXTERNAL AMBULATORY INFUSION PUMP, INSUL PARENTERAL INFUSION PUMP, STATIONARY, SI TRACTION EQUIPMENT, CERVICAL, FREE-STAND CERVICAL TRACTION EQUIPMENT NOT REQUIRIN TRACTION EQUIPMENT, OVERDOOR, CERVICAL TRACTION FRAME, ATTACHED TO FOOTBOARD, P TRACTION STAND, FREE STANDING, PELVIC TR TRAPEZE BARS, A/K/A PATIENT HELPER, ATTA TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEI TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEI TRAPEZE BAR, FREE STANDING, COMPLETE WIT PELVIC BELT/HARNESS/BOOT FRACTURE, FRAME, DUAL WITH CROSS BARS, A WHEELCHAIR ACCESSORY, TRAY, EACH HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITH TOE LOOP/HOLDER, ANY TYPE, EACH WHEELCHAIR ACCESSORY, HEADREST, CUSHIONE WHEELCHAIR ACCESSORY, LATERAL TRUNK OR H WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPO MANUAL WHEELCHAIR ACCESSORY, ONE-ARM DRI MANUAL WHEELCHAIR ACCESSORY, ADAPTER FOR WHEELCHAIR ACCESSORY, SHOULDER HARNESS/S MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK MANUAL WHEELCHAIR ACCESSORY, HEADREST EX MANUAL WHEELCHAIR ACCESSORY, HAND RIM WI MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPIN WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, MANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBA WHEELCHAIR ACCESSORY, POSITIONING BELT/S MANUAL WHEELCHAIR ACCESSORY, PUSH ACTIVA WHEELCHAIR ACCESSORY, ELEVATING LEG REST MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT WHEELCHAIR ACCESSORY, CALF REST/PAD, EAC WHEELCHAIR ACCESSORY, POWER SEATING SYST WHEELCHAIR ACCESSORY, POWER SEATING SYST WHEELCHAIR ACCESSORY, POWER SEATING SYST WHEELCHAIR ACCESSORY, POWER SEATNG SYSTE WHEELCHAIR ACCESSORY, POWER SEATING SYST WHEELCHAIR ACCESSORY, POWER SEATING SYST WHEELCHAIR ACCESSORY, POWER SEATING SYST WHEELCHAIR ACCESSORY, ADDITION TO POWER WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SY MODIFICATION TO PEDIATRIC SIZE WHEELCHAI WHEELCHAIR ACCESSORY,ADDITION TO POWER SEATING SYST RECLINING BACK, ADDITION TO PEDIATRIC SI RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCH WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, MANUAL ADULT SIZE WHEELCHAIR, INCLUDES T WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLIN
FEE 2647.67 4399.30 2039.92 371.70 502.63 21.36 80.83 78.54 173.33 432.00 742.07 254.98 40.90 514.42 148.97 17.16 17.02 182.79 89.12 124.71
RENTAL FEE 60.00 60.00 37.17 50.26
17.33 43.20 74.21 25.50 51.44
45.06 81.20 16.13 60.45 65.66 37.92 92.39 44.55 29.39 106.16 70.88 23.21
10.62
365.14 220.07
36.51
2287.24
BR
MAX UNITS 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 4 1 1 1 1 2 1 2 2 2 2 1 1 2 1 2 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1
PA 6 6 6 6 6
6 6 6 6 6 6 6 6 6 6 6 6 1 6 6 6 6 6 6 6 6 6 1 6 6 6 1 1 1 1 1 1 1 1 1 1 1 6 6 1 6 1
Page 12 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE E1226 E1228 E1229 E1233 E1234 E1298 E1390 E1392 E1399 E1399 E1399 E1399 E1399 E2100 E2201 E2202 E2203 E2204 E2205 E2206 E2207 E2209 E2210 E2211 E2212 E2213 E2214 E2215 E2218 E2219 E2220 E2221 E2222 E2224 E2225 E2226 E2231 E2291 E2292 E2300 E2310 E2311 E2312 E2313 E2323 E2324 E2325 E2326 E2327 E2328
DESCRIPTION WHEELCHAIR ACCESSORY, MANUAL FULLY RECLI SPECIAL BACK HEIGHT FOR WHEELCHAIR WHEELCHAIR, PEDIATRIC SIZE, NOT OTHERWIS WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPAC WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPAC SPECIAL WHEELCHAIR SEAT DEPTH AND/OR WID OXYGEN CONCENTRATOR, SINGLE DELIVERY POR PORTABLE OXYGEN CONCENTRATOR, RENTAL DURABLE MEDICAL EQUIPMENT,MISC Positioning bath chair, small/medium Positioning bath chair, large Positioning bath chair tub stand addition Positioning bath chair shower stand addition BLOOD GLUCOSE MONITOR WITH INTEGRATED VO MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD MANUAL WHEELCHAIR ACCESSORY, HANDRIM WIT MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK WHEELCHAIR ACCESSORY, CRUTCH AND CANE HO ARM TROUGH, WITH OR WITHOUT HAND SUPPORT WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC P MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PN MANUAL WHEELCHAIR ACCESSORY, INSERT FOR MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC C MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PN MANUAL WHEELCHAIR ACCESSORY, FOAM PROPUL MANUAL WHEELCHAIR ACCESSORY, FOAM CASTER MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBB MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBB MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBB MANUAL WHEELCHAIR ACCESSORY, PROPULSION MANUAL WHEELCHAIR ACCESSORY, CASTER WHEE MANUAL WHEELCHAIR ACCESSORY, CASTER FORK MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT BACK, PLANAR, FOR PEDIATRIC SIZE WHEELCH SEAT, PLANAR, FOR PEDIATRIC SIZE WHEELCH WHEELCHAIR ACCESORRY, POWER SEAT ELEVATION SYSTE POWER WHEELCHAIR ACCESSORY, ELECTRONIC C POWER WHEELCHAIR ACCESSORY, ELECTRONIC C POWER WHEELCHAIR ACCESSORY, HAND OR CHIN POWER WHEELCHAIR ACCESSORY, HARNESS FOR POWER WHEELCHAIR ACCESSORY, SPECIALTY JO POWER WHEELCHAIR ACCESSORY, CHIN CUP FOR POWER WHEELCHAIR ACCESSORY, SIP AND PUFF POWER WHEELCHAIR ACCESSORY, BREATH TUBE POWER WHEELCHAIR ACCESSORY, HEAD CONTROL POWER WHEELCHAIR ACCESSORY, HEAD CONTROL
FEE 491.09
RENTAL FEE 49.11
2451.60 2362.05 150.00 195.00 295.91 320.56 84.44 205.76 59.06 326.4 414.4 418.4 711.2 29.40 39.31 43.50 96.88 5.92 15.00 5.51 31.89 11.21 5.60 38.00 25.43 14.63 10.08 21.06 85.89 17.40 22.70 153.68 352.58 352.58
1939.18 307.93 62.53 39.62 1217.66 313.85 2361.84 4480.08
150.00 195.00
BR
MAX UNITS 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 2 12 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1
PA 6 1 1 6 6 1 6 6 1 1 1 1 1 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 1 1 1 1 1 6 6 1 1 1 1
Page 13 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE E2329 E2330 E2340 E2341 E2342 E2343 E2358 E2359 E2360 E2361 E2362 E2363 E2364 E2365 E2366 E2367 E2368 E2369 E2370 E2371 E2373 E2374 E2375 E2376 E2377 E2378 E2381 E2382 E2383 E2384 E2385 E2386 E2387 E2388 E2389 E2390 E2391 E2392 E2394 E2395 E2396 E2402 E2500 E2502 E2504 E2506 E2508 E2510 E2511 E2512
DESCRIPTION POWER WHEELCHAIR ACCESSORY, HEAD CONTROL POWER WHEELCHAIR ACCESSORY, HEAD CONTROL POWER WHEELCHAIR ACCESSORY, NONSTANDARD POWER WHEELCHAIR ACCESSORY, NONSTANDARD POWER WHEELCHAIR ACCESSORY, NONSTANDARD POWER WHEELCHAIR ACCESSORY, NONSTANDARD POWER WHEELCHAIR ACCESSORY, GROUP 34 NON POWER WHEELCHAIR ACCESSORY, GROUP 34 SEAL POWER WHEELCHAIR ACCESSORY, 22 NF NON-SE POWER WHEELCHAIR ACCESSORY, 22NF SEALED POWER WHEELCHAIR ACCESSORY, GROUP 24 NON POWER WHEELCHAIR ACCESSORY, GROUP 24 SEA POWER WHEELCHAIR ACCESSORY, U-1 NON-SEAL POWER WHEELCHAIR ACCESSORY, U-1 SEALED L POWER WHEELCHAIR ACCESSORY, BATTERY CHAR POWER WHEELCHAIR ACCESSORY, BATTERY CHAR POWER WHEELCHAIR COMPONENT, DRIVE WHEEL POWER WHEELCHAIR COMPONENT, DRIVE WHEEL POWER WHEELCHAIR COMPONENT, INTEGRATED DR POWER WHEELCHAIR ACCESSORY, GROUP 27 SEA POWER WHEELCHAIR ACCESSORY, HAND OR CHIN POWER WHEELCHAIR ACCESSORY, HAND OR CHIN POWER WHEELCHAIR ACCESSORY, NON-EXPANDAB POWER WHEELCHAIR ACCESSORY, EXPANDABLE C POWER WHEELCHAIR ACCESSORY, EXPANDABLE C POWER WHEELCHAIR COMPONENT, ACTUATOR, POWER WHEELCHAIR ACCESSORY, PNEUMATIC DR POWER WHEELCHAIR ACCESSORY, TUBE FOR PNE POWER WHEELCHAIR ACCESSORY, INSERT FOR P POWER WHEELCHAIR ACCESSORY, PNEUMATIC CA POWER WHEELCHAIR ACCESSORY, TUBE FOR PNE POWER WHEELCHAIR ACCESSORY, FOAM FILLED POWER WHEELCHAIR ACCESSORY, FOAM FILLED POWER WHEELCHAIR ACCESSORY, FOAM DRIVE W POWER WHEELCHAIR ACCESSORY, FOAM CASTER POWER WHEELCHAIR ACCESSORY, SOLID (RUBBE POWER WHEELCHAIR ACCESSORY, SOLID (RUBBE POWER WHEELCHAIR ACCESSORY, SOLID (RUBBE POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL POWER WHEELCHAIR ACCESSORY, CASTER WHEEL POWER WHEELCHAIR ACCESSORY, CASTER FORK, NEGATIVE PRESSURE WOUND THERAPY ELECTRIC SPEECH GENERATING DEVICE, DIGITIZED SPEE SPEECH GENERATING DEVICE, DIGITIZED SPEE SPEECH GENERATING DEVICE, DIGITIZED SPEE SPEECH GENERATING DEVICE, DIGITIZED SPEE SPEECH GENERATING DEVICE, SYNTHESIZED SP SPEECH GENERATING DEVICE, SYNTHESIZED SP SPEECH GENERATING SOFTWARE PROGRAM, FO ACCESSORY FOR SPEECH GENERATING DEVICE,
FEE 1596.75 3093.89 375.90
RENTAL FEE
1.00 179.83 117.84 126.09 96.48 168.16 117.84 101.41 233.50 378.89 467.03 406.79 725.84 136.28 709.01 482.81 774.41 1213.54 439.13
BR
68.87 18.78 137.31 73.15 44.76 136.07 61.02 45.55 24.74 38.68 18.53 48.71 69.39 49.32 51.97 384.87 1176.89 1552.47 2276.40 3520.05 5345.62
BR
38.49 117.69 155.25 227.64 352.00 534.56
MAX UNITS 1 1 1 1 1 1 2 2 2 2 2 2 2 2 1 1 2 2 2 2 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 4 4 2 4 2 30 1 1 1 1 1 1 1 1
PA 1 1 6 1 1 1
6 6 6 6 6 6 1 1 1 1 1 1 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 1 1 1
Page 14 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE E2599 E2601 E2602 E2603 E2604 E2605 E2606 E2607 E2608 E2609 E2611 E2612 E2613 E2614 E2615 E2616 E2617 E2619 E2620 E2621 E2622 E2623 E2624 E2625 E2626 E2627 E2628 E2629 E2630 E2631 E2632 E2633 E8000 E8001 E8002 K0001 K0002 K0003 K0004 K0005 K0006 K0007 K0009 K0015 K0017 K0018 K0019 K0037 K0038 K0039
DESCRIPTION FEE ACCESSORY FOR SPEECH GENERATING DEVICE, GENERAL USE WHEELCHAIR SEAT CUSHION, WID 55.29 GENERAL USE WHEELCHAIR SEAT CUSHION, WID 107.95 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, 137.05 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, 170.34 POSITIONING WHEELCHAIR SEAT CUSHION, WID 243.36 POSITIONING WHEELCHAIR SEAT CUSHION, WID 379.66 SKIN PROTECTION AND POSITIONING WHEELCHA 244.22 SKIN PROTECTION AND POSITIONING WHEELCHA 314.70 CUSTOM FABRICATED WHEELCHAIR SEAT CUSHIO GENERAL USE WHEELCHAIR BACK CUSHION, WID 282.40 GENERAL USE WHEELCHAIR BACK CUSHION, WID 382.02 POSITIONING WHEELCHAIR BACK CUSHION, POS 355.34 POSITIONING WHEELCHAIR BACK CUSHION, POS 491.77 POSITIONING WHEELCHAIR BACK CUSHION, POS 408.94 POSITIONING WHEELCHAIR BACK CUSHION, POS 550.21 CUSTOM FABRICATED WHEELCHAIR BACK CUSHIO REPLACEMENT COVER FOR WHEELCHAIR SEAT CU 46.39 POSITIONING WHEELCHAIR BACK CUSHION, PLA 495.17 POSITIONING WHEELCHAIR BACK CUSHION, PLA 519.64 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, 299.68 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, 381.33 SKIN PROTECTION AND POSITIONING WHEELCHA 302.14 SKIN PROTECTION AND POSITIONING WHEELCHA 382.49 SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPP 592.43 SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPP 803.55 SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPP 712.17 SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPP 991.11 SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPP 450.00 SEO, ADDITION TO MOBILE ARM SUPPORT, ELE 252.10 SEO, ADDITION TO MOBILE ARM SUPPORT, OFF 160.31 SEO, ADDITION TO MOBILE ARM SUPPORT, SUP 135.97 GAIT TRAINER, PEDIATRIC SIZE, POSTERIOR GAIT TRAINER, PEDIATRIC SIZE, UPRIGHT SU GAIT TRAINER, PEDIATRIC SIZE, ANTERIOR S STANDARD WHEELCHAIR 280.39 STANDARD HEMI/LOW SEAT WHEELCH 465.32 LIGHTWEIGHT WHEELCHAIR 559.50 HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR 810.86 WHEELCHAIR,ULTRALIGHTWEIGHT 1779.08 HEAVY DUTY WHEELCHAIR 737.03 EXTRA HEAVY DUTY WHEEL CHAIR 1074.78 OTHER MANUAL WHEELCHAIR DETACHABLE, NON-ADJUSTABLE HEIGHT ARMRES 53.55 DETACHABLE, ADJUSTABLE HEIGHT ARMREST,BASE,REPLACEM 46.20 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER PORTION 25.81 ARM PAD EACH 14.79 HIGH MOUNT FLIP-UP FOOTREST, EACH 37.01 LEG STRAP,EACH 21.94 LEG STRAP H-STYLE, EACH 48.71
RENTAL FEE
100.00 100.00 100.00 28.04 46.53 55.95 81.09 73.70
BR
MAX UNITS 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 1
PA 1 6 6 6 6 6 6 6 6 1 6 6 6 6 6 6 1 6 6 1 6 6 6 6 6 6 6 6 6 6 6 6 1 1 1 6 6 6 6 6 6 6 1 6 6 6 6 6 6 6
Page 15 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE K0040 K0041 K0042 K0043 K0044 K0045 K0046 K0047 K0052 K0053 K0056 K0065 K0071 K0072 K0073 K0077 K0098 K0105 K0108 K0601 K0602 K0603 K0604 K0605 K0606 K0730 K0739 K0800 K0801 K0802 K0806 K0807 K0808 K0812 K0813 K0814 K0815 K0816 K0820 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0835 K0836
DESCRIPTION ANGLE ADJUSTABLE FOOTPLATE, EACH LARGE SIZED FOOTPLATE, EACH STANDARD FOOTPLATE, EACH FOOTREST, LOWER EXTENSION TUBE, EACH FOOTREST, UPPER HANGER BRACKET, EACH FOOTREST, COMPLETE ASSEMBLY ELEVATING LEGREST, LOWER EXTENSION TUBE, ELEVATING LEGREST, UPPER HANGER BRACKET, SWINGAWAY, DETACHABLE FOOTRESTS, EACH ELEVATING FOOTRESTS, ARTICULATING (TELES SEAT HEIGHT LESS THAN 17" OR EQUAL TO SPOKE PROTECTORS,EACH FRONT CASTER ASSEMBLY, COMPLETE, WITH PN FRONT CASTER ASSEMBLY, COMPLETE, WITH SE CASTER PIN LOCK,EACH FRONT CASTER ASSEMBLY, COMPLETE, WITH SO DRIVE BELT FOR POWER WHEELCHAIR IV HANGER, EACH WHEELCHAIR COMPONENT OR ACCESSORY, NOT O REPLACEMENT BATTERY FOR EXTERNAL INFUSIO REPLACEMENT BATTERY FOR EXTERNAL INFUSIO REPLACEMENT BATTERY FOR EXTERNAL INFUSIO REPLACEMENT BATTERY FOR EXTERNAL INFUSIO REPLACEMENT BATTERY FOR EXTERNAL INFUSIO AUTOMATIC EXTERNAL DEFIBRILLATOR, WITH I CONTROLLED DOSE INHALATION DRUG DELIVERY REPAIR OR NON-ROUTINE SERVICE FOR DURABL POWER OPERATED VEHICLE, GROUP 1 STANDARD POWER OPERATED VEHICLE, GROUP 1 HEAVY DU POWER OPERATED VEHICLE, GROUP 1 VERY HEA POWER OPERATED VEHICLE, GROUP 2 STANDARD POWER OPERATED VEHICLE, GROUP 2 HEAVY DU POWER OPERATED VEHICLE, GROUP 2 VERY HEA POWER OPERATED VEHICLE, NOT OTHERWISE CL POWER WHEELCHAIR, GROUP 1 STANDARD, PORT POWER WHEELCHAIR, GROUP 1 STANDARD, PORT POWER WHEELCHAIR, GROUP 1 STANDARD, SLIN POWER WHEELCHAIR, GROUP 1 STANDARD, CAPT POWER WHEELCHAIR, GROUP 2 STANDARD, PORT POWER WHEELCHAIR, GROUP 2 STANDARD, PORT POWER WHEELCHAIR, GROUP 2 STANDARD, SLIN POWER WHEELCHAIR, GROUP 2 STANDARD, CAPT POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SL POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CA POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUT POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUT POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DU POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DU POWER WHEELCHAIR, GROUP 2 STANDARD, SING POWER WHEELCHAIR, GROUP 2 STANDARD, SING
FEE 67.51 47.84 32.94 17.65 15.04 51.19 17.65 69.14 83.58 92.23 95.10 36.00 50.11 42.30 16.60 35.93 24.61 104.30
RENTAL FEE
1.10 6.67 0.57 6.38 14.60 1569.32 1569.32 100.00 100.00 18.00 1168.79 1884.33 2132.46 1413.92 2145.46 3319.48 2412.40 3087.80 3516.30 3367.40 2576.60 3307.70 3997.50 4023.70 4842.70 4433.20 6269.30 5330.90 6908.20 6343.70 4057.40 4207.50
BR
MAX UNITS 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 1 1 90 30 25 6 6 1 1 8 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
PA 6 6 6 6 6 6 6 6 6 6 1 6 6 6 6 6 6 6 1 6 6 6 6 6 1 6 6 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Page 16 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE K0837 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0864 K0868 K0869 K0870 K0871 K0877 K0878 K0879 K0880 K0884 K0885 K0886 K0890 K0891 K0898 L0112 L0113 L0120 L0130 L0140 L0150 L0160 L0170 L0172 L0174 L0180 L0190
DESCRIPTION POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SI POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SI POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUT POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DU POWER WHEELCHAIR, GROUP 2 STANDARD, MULT POWER WHEELCHAIR, GROUP 2 STANDARD, MULT POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, MU POWER WHEELCHAIR, GROUP 3 STANDARD, SLIN POWER WHEELCHAIR, GROUP 3 STANDARD, CAPT POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SL POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, CA POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUT POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUT POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DU POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DU POWER WHEELCHAIR, GROUP 3 STANDARD, SING POWER WHEELCHAIR, GROUP 3 STANDARD, SING POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SI POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SI POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUT POWER WHEELCHAIR, GROUP 3 STANDARD, MULT POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, MU POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUT POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DU POWER WHEELCHAIR, GROUP 4 STANDARD, SLIN POWER WHEELCHAIR, GROUP 4 STANDARD, CAPT POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SL POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUT POWER WHEELCHAIR, GROUP 4 STANDARD, SING POWER WHEELCHAIR, GROUP 4 STANDARD, SING POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SI POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUT POWER WHEELCHAIR, GROUP 4 STANDARD, MULT POWER WHEELCHAIR, GROUP 4 STANDARD, MULT POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, MU POWER WHEELCHAIR, GROUP 5 PEDIATRIC, SIN POWER WHEELCHAIR, GROUP 5 PEDIATRIC, MUL POWER WHEELCHAIR, NOT OTHERWISE CLASSIFI CRANIAL CERVICAL ORTHOSIS, CONGENITAL TO CRANIAL CERVICAL ORTHOSIS, TORTICOLLIS T CERVICAL, FLEXIBLE, NON-ADJUSTABLE (FOAM CERVICAL, FLEXIBLE, THERMOPLASTIC COLLAR CERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTI CERVICAL, SEMI-RIGID, ADJUSTABLE MOLDED CERVICAL, SEMI-RIGID, WIRE FRAME OCCIPIT CERVICAL, COLLAR, MOLDED TO PATIENT MODE CERVICAL, COLLAR, SEMI-RIGID THERMOPLAST CERVICAL, COLLAR, SEMI-RIGID, THERMOPLAS CERVICAL, MULTIPLE POST COLLAR, OCCIPITA CERVICAL, MULTIPLE POST COLLAR, OCCIPITA
FEE 4842.70 4332.30 6269.30 9498.30 4318.60 4318.60 5199.60 5284.40 5080.70 6129.80 5893.70 7082.60 7275.60 9638.60 9105.10 5672.30 5786.00 7037.60 6711.70 10054.10 5681.40 7037.60 10054.10 11964.50
1265.35 257.81 6.80 183.99 50.00 74.00 79.50 357.00 75.00 130.00 233.00 311.75
RENTAL FEE
BR
MAX UNITS 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
PA 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 6 6 6 6 6 6 6 6 6 6 6
Page 17 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L0200 L0220 L0450 L0452 L0454 L0455 L0456 L0457 L0458 L0460 L0462 L0464 L0466 L0467 L0468 L0469 L0470 L0472 L0480 L0482 L0484 L0486 L0488 L0490 L0491 L0492 L0621 L0622 L0623 L0624 L0625 L0626 L0627 L0628 L0629 L0630 L0631 L0632 L0633 L0634 L0635 L0636 L0637 L0638 L0639 L0640 L0641 L0642 L0643 L0648
DESCRIPTION CERVICAL, MULTIPLE POST COLLAR, OCCIPITA THORACIC, RIB BELT, CUSTOM FABRICATED TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, TLSO FLEXIBLE, PROVIDES TRUNK SUPPORT, E TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, E TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, THORACIC TLSO, TRIPLANAR CONTROL, MODULAR SEGMENT TLSO, TRIPLANAR CONTROL, MODULAR SEGMENT TLSO, TRIPLANAR CONTROL, MODULAR SEGMENT TLSO, TRIPLANAR CONTROL, MODULAR SEGMENT TLSO, SAGITTAL CONTROL, RIGID POSTERIOR TLSO, SAGITTAL CONTROL, RIGID POSTERIOR TLSO, SAGITTAL-CORONAL CONTROL, RIGID PO TLSO, SAGITTAL-CORONAL CONTROL, RIGID PO TLSO, TRIPLANAR CONTROL, RIGID POSTERIOR TLSO, TRIPLANAR CONTROL, HYPEREXTENSION, TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID TLSO, SAGITTAL-CORONAL CONTROL, ONE PIEC TLSO, SAGITTAL-CORONAL CONTROL, MODULAR TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES SACROILIAC ORTHOSIS, PROVIDES PELVIC-SAC SACROILIAC ORTHOSIS, PROVIDES PELVIC-SAC LUMBAR ORTHOSIS, FLEXIBLE, PROVIDES LUMB LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVID LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVID LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL LUMBAR SACRAL ORTHOSIS, SAGITTAL-CORONAL LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL
FEE 322.50 98.00 144.00 330.85 270.00 239.42 778.11 686.57 400.18 400.18 400.18 400.18 280.02 247.07 343.54 303.13 402.39 295.00 900.00 1442.24 1432.83 1523.40 886.23 249.76 543.13 356.79 72.82 183.65 212.50 212.50 43.27 61.25 322.98 65.92 175.00 127.26 806.64 1150.00 225.31 759.92 765.98 1036.35 844.13 1036.35 844.13 822.21 53.80 283.76 111.80 708.65
RENTAL FEE
BR
MAX UNITS 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
PA 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
Page 18 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L0649 L0650 L0651 L0700 L0710 L0810 L0820 L0830 L0861 L0970 L0972 L0974 L0976 L0978 L0980 L0982 L0984 L0999 L1000 L1001 L1005 L1010 L1020 L1025 L1030 L1040 L1050 L1060 L1070 L1080 L1085 L1090 L1100 L1110 L1120 L1200 L1210 L1220 L1230 L1240 L1250 L1260 L1270 L1280 L1290 L1300 L1310 L1499 L1600 L1610
DESCRIPTION LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CERVICAL-THORACIC-LUMBAR-SACRAL-ORTHOSES CTLSO, ANTERIOR-POSTERIOR-LATERAL-CONTRO HALO PROCEDURE, CERVICAL HALO INCORPORA HALO PROCEDURE, CERVICAL HALO INCORPORA HALO PROCEDURE, CERVICAL HALO INCORPORA ADDITION TO HALO PROCEDURE, REPLACEMENT TLSO, CORSET FRONT LSO, CORSET FRONT TLSO, FULL CORSET LSO, FULL CORSET AXILLARY CRUTCH EXTENSION PERITONEAL STRAPS, PAIR STOCKING SUPPORTER GRIPS, SET OF FOUR (4 PROTECTIVE BODY SOCK EACH ADDITION TO SPINAL ORTHOSIS, NOT OTHERWI CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS CERVICAL THORACIC LUMBAR SACRAL ORTHOSIS TENSION BASED SCOLIOSIS ORTHOSIS AND ACC ADDITION TO CERVICAL-THORACIC-LUMBAR-SAC ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, ADDITION TO CTLSO, SCOLIOSIS ORTHOSIS, C THORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO), ADDITION TO TLSO, (LOW PROFILE), LATERAL ADDITION TO TLSO, (LOW PROFILE), ANTERIO ADDITION TO TLSO, (LOW PROFILE), MILWAUK ADDITION TO TLSO, (LOW PROFILE), LUMBAR ADDITION TO TLSO, (LOW PROFILE), ANTERIO ADDITION TO TLSO, (LOW PROFILE), ANTERIO ADDITION TO TLSO, (LOW PROFILE), ABDOMIN ADDITION TO TLSO, (LOW PROFILE), RIB GUS ADDITION TO TLSO, (LOW PROFILE), LATERAL OTHER SCOLIOSIS PROCEDURE, BODY JACKET M OTHER SCOLIOSIS PROCEDURE, POST-OPERATI SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J
FEE 197.95 741.59 741.59 1237.50 1480.00 2000.00 1320.00 2225.00 89.42 44.00 40.00 78.00 78.00 68.00 10.00 10.00 21.00 1375.00 2514.93 30.00 23.00 140.77 40.00 30.00 30.00 45.00 30.00 10.00 85.00 71.51 50.00 181.56 4.60 1000.00 235.00 240.00 362.00 45.00 35.00 35.00 40.00 55.00 40.00 1450.00 1405.00 56.00 27.00
RENTAL FEE
BR
MAX UNITS 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 3 1 1 1 1 1 2 1 2 2 2 1 1 5 1 1
PA 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 1 6 1 1 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 1 6 6
Page 19 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L1620 L1630 L1640 L1650 L1652 L1660 L1680 L1685 L1686 L1690 L1700 L1710 L1720 L1730 L1755 L1810 L1812 L1820 L1830 L1831 L1832 L1833 L1834 L1836 L1840 L1843 L1844 L1845 L1846 L1847 L1848 L1850 L1860 L1900 L1902 L1904 L1906 L1907 L1910 L1920 L1930 L1932 L1940 L1945 L1950 L1951 L1960 L1970 L1971 L1980
DESCRIPTION HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J HIP ORTHOSIS, BILATERAL THIGH CUFFS WITH HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J HIP ORTHOSIS, ABDUCTION CONTROL OF HIP J COMBINATION, BILATERAL, LUMBO-SACRAL, HI LEGG PERTHES ORTHOSIS, (TORONTO TYPE), C LEGG PERTHES ORTHOSIS, (NEWINGTON TYPE), LEGG PERTHES ORTHOSIS, TRILATERAL, (TACH LEGG PERTHES ORTHOSIS, (SCOTTISH RITE TY LEGG PERTHES ORTHOSIS, (PATTEN BOTTOM TY KNEE ORTHOSIS, ELASTIC WITH JOINTS, PREF KNEE ORTHOSIS, ELASTIC WITH JOINTS, PREF KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PAD KNEE ORTHOSIS, IMMOBILIZER, CANVAS LONGI KNEE ORTHOSIS, LOCKING KNEE JOINT(S), PO KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (U KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (U KNEE ORTHOSIS, WITHOUT KNEE JOINT, RIGID KNEE ORTHOSIS, RIGID, WITHOUT JOINT(S), KNEE ORTHOSIS, DEROTATION, MEDIAL-LATERA KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUS KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUS KNEE ORTHOSIS, SWEDISH TYPE, PREFABRICAT KNEE ORTHOSIS, MODIFICATION OF SUPRACOND ANKLE FOOT ORTHOSIS, SPRING WIRE, DORSIF AFO, ANKLE GAUNTLET, PREFABRICATED, INCL AFO, MOLDED ANKLE GAUNTLET, CUSTOM-FABRI ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANK AFO, SUPRAMALLEOLAR WITH STRAPS, WITH OR ANKLE FOOT ORTHOSIS, POSTERIOR, SINGLE B ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MA AFO, RIGID ANTERIOR TIBIAL SECTION, TOTA ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MA ANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTE ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANK ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MA ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE
FEE 75.00 80.00 456.01 95.00 95.00 70.00 533.50 850.00 750.00 1434.95 900.00 990.00 785.00 750.00 900.00 80.51 71.04 110.00 65.00 208.13 607.55 536.08 595.41 104.84 597.50 634.53 1107.70 693.00 828.15 449.98 397.04 185.00 617.00 185.00 45.00 290.00 75.00 397.93 145.00 228.00 194.00 410.00 410.00 410.00 690.00 593.92 550.00 750.00 331.47 250.00
RENTAL FEE
BR
MAX UNITS 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 2 2 1 1 2 2 1 1
PA 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
Page 20 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L1990 L2000 L2005 L2010 L2020 L2030 L2034 L2035 L2036 L2037 L2038 L2040 L2050 L2060 L2070 L2080 L2090 L2106 L2108 L2112 L2114 L2116 L2126 L2128 L2132 L2134 L2136 L2180 L2182 L2184 L2186 L2188 L2190 L2192 L2210 L2220 L2230 L2232 L2250 L2260 L2265 L2270 L2275 L2280 L2300 L2310 L2320 L2330 L2335 L2340
DESCRIPTION ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT KNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CO HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CO HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CO HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CO HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CO HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CO ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHO KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHO KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTUR KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTUR KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTUR ADDITION TO LOWER EXTREMITY FRACTURE ORT ADDITION TO LOWER EXTREMITY FRACTURE ORT ADDITION TO LOWER EXTREMITY FRACTURE ORT ADDITION TO LOWER EXTREMITY FRACTURE ORT ADDITION TO LOWER EXTREMITY FRACTURE ORT ADDITION TO LOWER EXTREMITY FRACTURE ORT ADDITION TO LOWER EXTREMITY FRACTURE ORT ADDITION TO LOWER EXTREMITY, DORSIFLEXIO ADDITION TO LOWER EXTREMITY, DORSIFLEXIO ADDITION TO LOWER EXTREMITY, SPLIT FLAT ADDITION TO LOWER EXTREMITY ORTHOSIS, RO ADDITION TO LOWER EXTREMITY, FOOT PLATE ADDITION TO LOWER EXTREMITY, REINFORCED ADDITION TO LOWER EXTREMITY, LONG TONGUE ADDITION TO LOWER EXTREMITY, VARUS/VALG ADDITION TO LOWER EXTREMITY, VARUS/VALGU ADDITION TO LOWER EXTREMITY, MOLDED INN ADDITION TO LOWER EXTREMITY, ABDUCTION ADDITION TO LOWER EXTREMITY, ABDUCTION ADDITION TO LOWER EXTREMITY, NON-MOLDED ADDITION TO LOWER EXTREMITY, LACER MOLDE ADDITION TO LOWER EXTREMITY, ANTERIOR S ADDITION TO LOWER EXTREMITY, PRE-TIBIAL
FEE 295.00 650.00 2828.47 750.00 775.00 705.00 1754.51 130.74 1554.50 1554.50 1100.00 75.00 295.00 310.00 65.00 210.00 225.00 427.50 625.00 350.00 375.00 427.50 850.00 1200.00 750.00 675.00 975.00 50.00 35.00 35.00 120.00 338.08 67.00 290.00 43.85 55.50 57.76 30.00 182.50 226.06 85.00 32.00 106.61 270.00 303.63 60.00 208.28 442.81 75.00 255.00
RENTAL FEE
BR
MAX UNITS 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1
PA 6 6 6 6 6 6 1 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
Page 21 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L2350 L2360 L2370 L2375 L2380 L2385 L2387 L2390 L2395 L2397 L2405 L2415 L2425 L2430 L2492 L2500 L2510 L2520 L2525 L2526 L2530 L2540 L2550 L2570 L2580 L2600 L2610 L2620 L2622 L2624 L2627 L2628 L2630 L2640 L2650 L2660 L2670 L2680 L2750 L2755 L2760 L2768 L2780 L2785 L2795 L2800 L2810 L2820 L2830 L2840
DESCRIPTION ADDITION TO LOWER EXTREMITY, PROSTHETIC ADDITION TO LOWER EXTREMITY, EXTENDED S ADD LOW EXT, PATTEN BOTTOM ADDITION TO LOWER EXTREMITY, TORSION CO ADDITION TO LOWER EXTREMITY, TORSION CO ADDITION TO LOWER EXTREMITY, STRAIGHT K ADDITION TO LOWER EXTREMITY, POLYCENTRIC ADDITION TO LOWER EXTREMITY, OFFSET KNE ADDITION TO LOWER EXTREMITY, OFFSET KNE ADDITION TO LOWER EXTREMITY ORTHOSIS, SU ADDITION TO KNEE JOINT, DROP LOCK, EACH ADDITION TO KNEE LOCK WITH INTEGRATED RE ADDITION TO KNEE JOINT, DISC OR DIAL LOC ADDITION TO KNEE JOINT, RATCHET LOCK FOR ADDITION TO KNEE JOINT, LIFT LOOP FOR DR ADDITION TO LOWER EXTREMITY, THIGH/WEIGH ADDITION TO LOWER EXTREMITY, THIGH/WEIGH ADDITION TO LOWER EXTREMITY, THIGH/WEIG ADDITION TO LOWER EXTREMITY, THIGH/WEIGH ADDITION TO LOWER EXTREMITY, THIGH/WEIGH ADDITION TO LOWER EXTREMITY, THIGH-WEIG ADDITION TO LOWER EXTREMITY, THIGH/WEIG ADDITION TO LOWER EXTREMITY, THIGH/WEIG ADDITION TO LOWER EXTREMITY, PELVIC CONT ADDITION TO LOWER EXTREMITY, PELVIC CONT ADDITION TO LOWER EXTREMITY, PELVIC CONT ADDITION TO LOWER EXTREMITY, PELVIC CONT ADDITION TO LOWER EXTREMITY, PELVIC CONT ADDITION TO LOWER EXTREMITY, PELVIC CONT ADDITION TO LOWER EXTREMITY, PELVIC CONT ADDITION TO LOWER EXTREMITY, PELVIC CONT ADDITION TO LOWER EXTREMITY, PELVIC CONT ADDITION TO LOWER EXTREMITY, PELVIC CONT ADDITION TO LOWER EXTREMITY, PELVIC CONT ADDITION TO LOWER EXTREMITY, PELVIC AND ADDITION TO LOWER EXTREMITY, THORACIC CO ADDITION TO LOWER EXTREMITY, THORACIC CO ADDITION TO LOWER EXTREMITY, THORACIC CO ADDITION TO LOWER EXTREMITY ORTHOSIS, PL ADDITION TO LOWER EXTREMITY ORTHOSIS, HI ADDITION TO LOWER EXTREMITY ORTHOSIS, EX ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER ADDITION TO LOWER EXTREMITY ORTHOSIS, NO ADDITION TO LOWER EXTREMITY ORTHOSIS, DR ADDITION TO LOWER EXTREMITY ORTHOSIS, KN ADDITION TO LOWER EXTREMITY ORTHOSIS, KN ADDITION TO LOWER EXTREMITY ORTHOSIS, KN ADDITION TO LOWER EXTREMITY ORTHOSIS, SO ADDITION TO LOWER EXTREMITY ORTHOSIS, SO ADDITION TO LOWER EXTREMITY ORTHOSIS, TI
FEE 975.00 50.00 130.00 45.00 26.00 32.00 133.44 26.00 26.00 24.00 35.00 45.00 122.50 122.50 45.00 168.00 715.09 450.00 1186.65 579.32 250.00 264.00 295.20 155.00 350.00 85.00 239.70 301.53 140.00 250.00 1110.00 1110.00 255.07 378.98 27.50 118.00 133.00 126.00 83.22 60.00 63.21 92.14 60.00 24.50 53.50 75.00 30.00 84.37 97.84 30.00
RENTAL FEE
BR
MAX UNITS 1 1 1 1 2 2 1 2 2 1 2 2 2 2 2 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 6 1 6 2 1 1 2 1 1 2
PA 6 6 6 6 6 6 1 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
Page 22 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L2850 L2861 L2999 L3000 L3001 L3002 L3003 L3010 L3020 L3030 L3040 L3050 L3060 L3070 L3080 L3090 L3100 L3140 L3150 L3160 L3170 L3201 L3202 L3203 L3204 L3206 L3207 L3208 L3209 L3211 L3212 L3213 L3214 L3215 L3216 L3217 L3219 L3221 L3222 L3224 L3225 L3230 L3250 L3252 L3253 L3254 L3255 L3257 L3260 L3265
DESCRIPTION ADDITION TO LOWER EXTREMITY ORTHOSIS, FE ADDITION TO LOWER EXTREMITY JOINT, KNEE LOWER EXTREMITY ORTHOSES, NOT OTHERWISE FOOT, INSERT, REMOVABLE, MOLDED TO PATIE FOOT, INSERT, REMOVABLE, MOLDED TO PATIE FOOT, INSERT, REMOVABLE, MOLDED TO PATIE FOOT, INSERT, REMOVABLE, MOLDED TO PATIE FOOT, INSERT, REMOVABLE, MOLDED TO PATIE FOOT, INSERT, REMOVABLE, MOLDED TO PATIE FOOT, INSERT, REMOVABLE, FORMED TO PATIE FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACH FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACH FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACH HALLUS-VALGUS NIGHT DYNAMIC SPLINT FOOT, ABDUCTION ROTATION BAR, INCLUDING FOOT, ABDUCTION ROTATATION BAR, WITHOUT FOOT, ADJUSTABLE SHOE-STYLED POSITIONING FOOT, PLASTIC, SILICONE OR EQUAL, HEEL S ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR O ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR O ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR O ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR SURGICAL BOOT EACH INFANT SURGICAL BOOT EACH CHILD SURGICAL BOOT EACH JUNIOR BENESCH BOOT PAIR INFANT BENESCH BOOT PAIR CHILD BENESCH BOOT PAIR JUNIOR ORTHOPEDIC FOOTWEAR, LADIES SHOE, OXFORD ORTHOPEDIC FOOTWEAR, LADIES SHOE, DEPTH ORTHOPEDIC FOOTWEAR, LADIES SHOE, HIGHTO ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, ORTHOPEDIC FOOTWEAR, MENS SHOE, DEPTH IN ORTHOPEDIC FOOTWEAR, MENS SHOE, HIGHTOP, ORTHOPEDIC FOOTWEAR, WOMAN'S SHOE, OXFOR ORTHOPEDIC FOOTWEAR, MAN'S SHOE, OXFORD, ORTHOPEDIC FOOTWEAR, CUSTOM SHOE, DEPTH ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED SHOE, FOOT, SHOE MOLDED TO PATIENT MODEL, PLAS FOOT, MOLDED SHOE PLASTAZOTE (OR SIMILAR NON-STANDARD SIZE OR WIDTH NON-STANDARD SIZE OR LENGTH ORTHOPEDIC FOOTWEAR, ADDITIONAL CHARGE F SURGICAL BOOT/SHOE, EACH PLASTAZOTE SANDAL EACH
FEE 40.00
262.44 114.05 114.05 114.05 114.05 114.05 67.38 41.54 41.54 52.10 28.04 28.04 35.94 38.17 62.89 57.50 130.00 35.95 30.00 35.00 35.00 35.00 35.00 35.00 20.00 25.00 25.00 22.00 22.00 22.00 75.55 44.63 79.77 88.88 52.50 93.84 54.78 61.52 337.50 363.40 18.00 50.00 2.06 3.30 12.00 22.50 25.00
RENTAL FEE
MAX UNITS 2 1 BR SC 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 BR
PA 6 1 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
Page 23 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L3300 L3310 L3320 L3330 L3332 L3334 L3340 L3350 L3360 L3370 L3380 L3390 L3400 L3410 L3420 L3430 L3440 L3450 L3455 L3460 L3465 L3470 L3480 L3485 L3540 L3570 L3580 L3600 L3610 L3620 L3630 L3640 L3649 L3650 L3660 L3670 L3671 L3674 L3675 L3677 L3702 L3710 L3720 L3730 L3740 L3760 L3762 L3763 L3764 L3765
DESCRIPTION LIFT, ELEVATION, HEEL, TAPERED TO METATA LIFT, ELEVATION, HEEL AND SOLE, NEOPRENE LIFT, ELEVATION, HEEL AND SOLE, CORK, PE LIFT, ELEVATION, METAL EXTENSION (SKATE) LIFT, ELEVATION, INSIDE SHOE, TAPERED, U LIFT, ELEVATION, HEEL, PER INCH HEEL WEDGE, SACH HEEL WEDGE SOLE WEDGE, OUTSIDE SOLE SOLE WEDGE, BETWEEN SOLE CLUBFOOT WEDGE OUTFLARE WEDGE METATARSAL BAR WEDGE, ROCKER METATARSAL BAR WEDGE, BTWN SOL FULL SOLE AND HEEL WEDGE, BETWEEN SOLE HEEL COUNTER PLASTIC REINFORCED HEEL, COUNTER, LEATHER REINFORCED HEEL, SACH CUSHION TYPE HEEL, NEW LEATHER, STANDARD HEEL, NEW RUBBER, STANDARD HEEL, THOMAS WITH WEDGE HEEL, THOMAS EXTENDED TO BALL HEEL, PAD & DEPRESSION FOR SPUR HEEL, PAD, REMOVABLE FOR SPUR ORTHOPEDIC SHOE ADDITION, SOLE, FULL ORTHOPEDIC SHOE ADDITION, SPECIAL EXTENS ORTHOPEDIC SHOE ADDITION, CONVERT INSTEP TRANSFER OF AN ORTHOSIS FROM ONE SHOE T TRANSFER OF AN ORTHOSIS FROM ONE SHOE T TRANSFER OF AN ORTHOSIS FROM ONE SHOE T TRANSFER OF AN ORTHOSIS FROM ONE SHOE T TRANSFER OF AN ORTHOSIS FROM ONE SHOE T ORTHOPEDIC SHOE, MODIFICATION, ADDITION SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIG SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIG SHOULDER ORTHOSIS, ACROMIO/CLAVICULAR (C SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN SHOULDER ORTHOSIS, ABDUCTION POSITIONING SHOULDER ORTHOSIS, VEST TYPE ABDUCTION R SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN ELBOW ORTHOSIS, WITHOUT JOINTS, MAY INCL ELBOW ORTHOSIS, ELASTIC WITH METAL JOINT ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FORE ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FORE ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FORE ELBOW ORTHOSIS, WITH ADJUSTABLE POSITION ELBOW ORTHOSIS, RIGID, WITHOUT JOINTS, I ELBOW WRIST HAND ORTHOSIS, RIGID, WITHOU ELBOW WRIST HAND ORTHOSIS, INCLUDES ONE ELBOW WRIST HAND FINGER ORTHOSIS, RIGID,
FEE 46.02 71.87 71.87 399.73 52.10 29.00 47.06 16.18 25.15 35.02 35.02 35.02 28.75 65.57 38.62 4.50 4.50 4.50 4.50 4.50 4.50 4.50 22.00 35.00 20.00 12.00 13.00 53.90 70.95 53.90 70.95 30.54 24.00 40.00 40.00 251.34 690.23 896.92 141.14 221.18 77.00 721.79 902.00 1091.24 251.34 69.20 590.25 742.84 982.19
RENTAL FEE
BR
MAX UNITS 4 4 2 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 1 1 1
PA 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 1 1 6 1 1 6 6 6 6 6 6 1 1 1
Page 24 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L3766 L3806 L3807 L3808 L3809 L3891 L3900 L3901 L3904 L3905 L3906 L3908 L3912 L3913 L3915 L3916 L3917 L3918 L3919 L3921 L3923 L3924 L3925 L3927 L3929 L3930 L3931 L3933 L3935 L3960 L3961 L3962 L3967 L3971 L3973 L3975 L3976 L3977 L3978 L3980 L3982 L3984 L3995 L3999 L4000 L4002 L4010 L4020 L4030 L4040
DESCRIPTION ELBOW WRIST HAND FINGER ORTHOSIS, INCLUD WRIST HAND FINGER ORTHOSIS, INCLUDES ONE WRIST HAND FINGER ORTHOSIS, WITHOUT JOIN WRIST HAND FINGER ORTHOSIS, RIGID WITHOU WRIST HAND FINGER ORTHOSIS, WITHOUT JOIN ADDITION TO UPPER EXTREMITY JOINT, WRIST WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEX WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEX WRIST HAND FINGER ORTHOSIS, EXTERNAL POW WRIST HAND ORTHOSIS, INCLUDES ONE OR MOR WRIST HAND ORTHOSIS, WITHOUT JOINTS, MAY WRIST HAND ORTHOSIS, WRIST EXTENSION CON HAND FINGER ORTHOSIS, FLEXION GLOVE WITH HAND FINGER ORTHOSIS, WITHOUT JOINTS, MA WRIST HAND ORTHOSIS, INCLUDES ONE OR MOR WRIST HAND ORTHOSIS, INCLUDES ONE OR MOR HAND ORTHOSIS, METACARPAL FRACTURE ORTHO HAND ORTHOSIS, METACARPAL FRACTURE ORTHO HAND ORTHOSIS, WITHOUT JOINTS, MAY INCLU HAND FINGER ORTHOSIS, INCLUDES ONE OR MO HAND FINGER ORTHOSIS, WITHOUT JOINTS, MA HAND FINGER ORTHOSIS, WITHOUT JOINTS, MA FINGER ORTHOSIS, PROXIMAL INTERPHALANGEA FINGER ORTHOSIS, PROXIMAL INTERPHALANGEA HAND FINGER ORTHOSIS, INCLUDES ONE OR MO HAND FINGER ORTHOSIS, INCLUDES ONE OR MO WRIST HAND FINGER ORTHOSIS, INCLUDES ONE FINGER ORTHOSIS, WITHOUT JOINTS, MAY INC FINGER ORTHOSIS, NONTORSION JOINT, MAY I SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDU SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOU SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDU SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDU SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOU SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDU SHOULDER ELBOW WRIST HAND FINGER ORTHOSI SHOULDER ELBOW WRIST HAND FINGER ORTHOSI SHOULDER ELBOW WRIST HAND FINGER ORTHOSI SHOULDER ELBOW WRIST HAND FINGER ORTHOSI UPPER EXTREMITY FRACTURE ORTHOSIS, HUMER UPPER EXTREMITY FRACTURE ORTHOSIS, RADIU UPPER EXTREMITY FRACTURE ORTHOSIS, WRIST ADDITION TO UPPER EXTREMITY ORTHOSIS, SO UPPER LIMB ORTHOSIS, NOT OTHERWISE SPECI REPLACE GIRDLE FOR SPINAL ORTHOSIS (CTLS REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDE REPLACE TRILATERAL SOCKET BRIM REPLACE QUADRILATERAL SOCKET BRIM, MOLDE REPLACE QUADRILATERAL SOCKET BRIM, CUSTO REPLACE MOLDED THIGH LACER, FOR CUSTOM F
FEE 1090.98 347.95 178.04 310.80 157.10 585.00 1471.49 759.66 232.50 47.50 45.00 207.47 407.17 333.36 75.23 66.38 207.47 246.06 63.80 56.30 31.83 28.10 57.33 50.59 72.55 163.44 169.22 372.50 1286.96 499.12 1519.48 1442.33 1519.48 1286.96 1286.96 1442.33 1519.48 292.56 411.96 260.00 30.00 650.00 20.00 500.00 615.00 455.00 408.23
RENTAL FEE
MAX UNITS 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 BR SC 1 1 4 1 1 1 1 BR
PA 1 1 6 1 6 1 6 1 1 6 6 6 6 6 6 6 6 6 1 1 6 6 6 6 6 6 6 6 6 6 1 6 1 1 1 1 1 1 1 6 6 6 6 6 6 6 6 6 6 6
Page 25 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L4045 L4050 L4055 L4060 L4070 L4080 L4090 L4100 L4110 L4130 L4205 L4210 L4396 L4397 L4398 L5000 L5010 L5020 L5050 L5100 L5105 L5150 L5160 L5200 L5210 L5220 L5230 L5250 L5270 L5280 L5301 L5312 L5321 L5331 L5341 L5400 L5410 L5420 L5430 L5450 L5460 L5500 L5505 L5510 L5520 L5530 L5535 L5540 L5560
DESCRIPTION REPLACE NON-MOLDED THIGH LACER, FOR CUST REPLACE MOLDED CALF LACER, FOR CUSTOM FA REPLACE NON-MOLDED CALF LACER, FOR CUSTO REPLACE HIGH ROLL CUFF REPLACE PROXIMAL AND DISTAL UPRIGHT FOR REPLACE METAL BANDS KAFO, PROXIMAL THIGH REPLACE METAL BANDS KAFO-AFO, CALF OR DI REPLACE LEATHER CUFF KAFO, PROXIMAL THIG REPLACE LEATHER CUFF KAFO-AFO, CALF OR D REPLACE PRETIBIAL SHELL REPAIR OF ORTHOTIC DEVICE, LABOR COMPONE REPAIR OF ORTHOTIC DEVICE, REPAIR OR REP STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDE STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDE DROP FOOT SPLINT, RECUMENT POSITIONING DEVICE PARTIAL FOOT, SHOE INSERT WITH LONGITUDI PARTIAL FOOT, MOLDED SOCKET, ANKLE HEIGH PARTIAL FOOT, MOLDED SOCKET, TIBIAL TUBE ANKLE, SYMES, MOLDED SOCKET, SACH FOOT BELOW KNEE, MOLDED SOCKET, SHIN, SACH FO BELOW KNEE, PLASTIC SOCKET, JOINTS AND T KNEE DISARTICULATION (OR THROUGH KNEE), KNEE DISARTICULATION (OR THROUGH KNEE), ABOVE KNEE, MOLDED SOCKET, SINGLE AXIS C ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JO ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JO ABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL D HIP DISARTICULATION, CANADIAN TYPE; MOLD HIP DISARTICULATION, TILT TABLE TYPE; MO HEMIPELVECTOMY, CANADIAN TYPE; MOLDED SO BELOW KNEE, MOLDED SOCKET, SHIN, SACH FO KNEE DISARTICULATION (OR THROUGH KNEE), ABOVE KNEE, MOLDED SOCKET, OPEN END, SAC HIP DISARTICULATION, CANADIAN TYPE, MOLD HEMIPELVECTOMY, CANADIAN TYPE, MOLDED SO IMMEDIATE POST SURGICAL OR EARLY FITTING IMMEDIATE POST SURGICAL OR EARLY FITTING IMMEDIATE POST SURGICAL OR EARLY FITTING IMMEDIATE POST SURGICAL OR EARLY FITTING IMMEDIATE POST SURGICAL OR EARLY FITTING IMMEDIATE POST SURGICAL OR EARLY FITTING INITIAL, BELOW KNEE 'PTB' TYPE SOCKET, N INITIAL, ABOVE KNEE - KNEE DISARTICULATI PREPARATORY, BELOW KNEE 'PTB' TYPE SOC PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKE PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKE PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKE PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKE PREPARATORY, ABOVE KNEE- KNEE DISARTICUL
FEE 185.00 590.00 185.00 115.00 101.00 52.50 52.50 75.00 60.00 188.00 18.00 35.00 151.70 115.83 69.85 300.00 871.07 1019.50 1500.00 1635.00 2850.00 2000.00 2235.00 2000.00 2630.00 2236.62 2150.00 3135.00 3000.00 3500.00 1300.00 1825.00 2010.00 2531.00 2816.10 705.00 305.00 900.00 305.00 408.38 491.35 633.50 878.50 1180.00 1250.00 1767.00 1235.00 1630.93 1584.00
RENTAL FEE
BR
MAX UNITS 1 1 1 1 1 1 1 1 1 1 8 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
PA 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
Page 26 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L5570 L5580 L5585 L5590 L5595 L5600 L5610 L5611 L5613 L5614 L5618 L5620 L5622 L5624 L5626 L5628 L5629 L5630 L5631 L5632 L5634 L5636 L5637 L5638 L5639 L5640 L5642 L5643 L5644 L5645 L5646 L5647 L5648 L5649 L5650 L5651 L5652 L5653 L5654 L5655 L5656 L5658 L5661 L5665 L5666 L5668 L5670 L5671 L5672 L5673
DESCRIPTION PREPARATORY, ABOVE KNEE - KNEE DISARTICU PREPARATORY, ABOVE KNEE - KNEE DISARTICU PREPARATORY, ABOVE KNEE - KNEE DISARTICU PREPARATORY, ABOVE KNEE - KNEE DISARTICU PREPARATORY, HIP DISARTICULATION-HEMIPEL PREPARATORY, HIP DISARTICULATION-HEMIPEL ADD TO LOWER EXT,ABOVE KNEE HY ADDITION TO LOWER EXTREMITY, ENDOSKELETA ADDITION TO LOWER EXTREMITY, ENDOSKELETA ADDITION TO LOWER EXTREMITY, EXOSKELETAL ADDITION TO LOWER EXTREMITY, TEST SOCKET ADDITION TO LOWER EXTREMITY, TEST SOCKET ADDITION TO LOWER EXTREMITY, TEST SOCKET ADDITION TO LOWER EXTREMITY, TEST SOCKET ADDITION TO LOWER EXTREMITY, TEST SOCKET ADDITION TO LOWER EXTREMITY, TEST SOCKET ADDITION TO LOWER EXTREMITY, BELOW KNEE, ADDITION TO LOWER EXTREMITY, SYMES TYPE, ADDITION TO LOWER EXTREMITY, ABOVE KNEE ADDITION TO LOWER EXTREMITY, SYMES TYPE, ADDITION TO LOWER EXTREMITY, SYMES TYPE, ADDITION TO LOWER EXTREMITY, SYMES TYPE ADDITION TO LOWER EXTREMITY, BELOW KNEE, ADDITION TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY, BELOW KNEE, ADDITION TO LOWER EXTREMITY, KNEE DISAR ADDITION TO LOWER EXTREMITY, ABOVE KNEE ADDITION TO LOWER EXTREMITY, HIP DISART ADDITION TO LOWER EXTREMITY, ABOVE KNEE ADDITION TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY, BELOW KNEE, ADDITION TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY, ABOVE KNEE, ADDITION TO LOWER EXTREMITY, ISCHIAL CO ADDITIONS TO LOWER EXTREMITY, TOTAL CONT ADDITION TO LOWER EXTREMITY, ABOVE KNEE ADDITION TO LOWER EXTREMITY, SUCTION SU ADDITION TO LOWER EXTREMITY, KNEE DISAR ADDITION TO LOWER EXTREMITY, SOCKET INS ADDITION TO LOWER EXTREMITY, SOCKET INS ADDITION TO LOWER EXTREMITY, SOCKET INS ADDITION TO LOWER EXTREMITY, SOCKET INS ADDITION TO LOWER EXTREMITY, SOCKET INS ADDITION TO LOWER EXTREMITY, SOCKET INS ADDITION TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY, BELOW KNEE/
FEE 1700.00 1948.00 1518.00 2150.00 3300.00 3895.00 1650.00 1050.00 1525.00 1492.71 222.00 222.00 264.00 264.00 280.00 375.00 300.00 250.00 450.00 160.00 350.00 306.13 332.12 465.00 600.00 675.00 590.00 725.00 475.00 425.00 494.50 585.00 528.12 1000.00 555.00 725.00 96.00 300.00 210.00 210.00 250.00 250.00 450.00 350.00 35.00 65.00 180.00 448.21 100.00 413.48
RENTAL FEE
BR
MAX UNITS 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2
PA 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6
Page 27 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L5676 L5677 L5678 L5679 L5680 L5681 L5682 L5683 L5684 L5685 L5686 L5688 L5690 L5692 L5694 L5695 L5696 L5697 L5698 L5699 L5700 L5701 L5702 L5703 L5704 L5705 L5706 L5707 L5710 L5711 L5712 L5714 L5716 L5722 L5724 L5726 L5728 L5780 L5781 L5785 L5790 L5795 L5810 L5811 L5812 L5814 L5816 L5818 L5822 L5824
DESCRIPTION ADDITIONS TO LOWER EXTREMITY, BELOW KNEE ADDITIONS TO LOWER EXTREMITY, BELOW KNEE ADDITIONS TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY, BELOW KNEE/ ADDITION TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY, BELOW KNEE/ ADDITION TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY, BELOW KNEE/ ADDITION TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY PROSTHESIS, ADDITION TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY, BELOW KNEE ADDITION TO LOWER EXTREMITY, ABOVE KNEE ADDITION TO LOWER EXTREMITY, ABOVE KNEE ADDITION TO LOWER EXTREMITY, ABOVE KNEE, ADDITION TO LOWER EXTREMITY, ABOVE KNEE ADDITION TO LOWER EXTREMITY, ABOVE KNEE ADDITION TO LOWER EXTREMITY, ABOVE KNEE ALL LOWER EXTREMITY PROSTHESES, SHOULDER REPLACEMENT, SOCKET, BELOW KNEE, MOLDED REPLACEMENT, SOCKET, ABOVE KNEE/KNEE DIS REPLACEMENT, SOCKET, HIP DISARTICULATION ANKLE, SYMES, MOLDED TO PATIENT MODEL, S CUSTOM SHAPED PROTECTIVE COVER, BELOW KN CUSTOM SHAPED PROTECTIVE COVER, ABOVE KN CUSTOM SHAPED PROTECTIVE COVER, KNEE DIS CUSTOM SHAPED PROTECTIVE COVER, HIP DISA ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, ADDITIONS EXOSKELETAL KNEE-SHIN SYSTEM, ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, ADDITON TO LOWER LIMB, PROSTHESIS VACUUM ADDITION, EXOSKELETAL SYSTEM, BELOW KNEE ADDITION, EXOSKELETAL SYSTEM, ABOVE KNEE ADDITION, EXOSKELETAL SYSTEM, HIP DISART ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM,
FEE 275.00 125.00 25.00 398.59 285.00 729.24 510.00 729.24 25.00 95.53 54.00 50.00 60.00 75.00 85.00 99.00 135.00 55.00 80.00 125.00 1572.31 2000.00 2700.00 1998.19 475.00 650.00 675.00 923.00 240.00 330.00 293.00 200.00 280.00 531.00 1170.00 1297.50 1405.00 598.00 3689.88 254.00 375.00 575.00 250.00 325.00 275.00 2761.26 644.10 779.49 1902.62 1710.93
RENTAL FEE
BR
MAX UNITS 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
PA 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 1 6 6 6 6 6 6 6 6 6 6 6
Page 28 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L5826 L5828 L5830 L5840 L5845 L5850 L5855 L5856 L5857 L5858 L5910 L5920 L5925 L5930 L5940 L5950 L5960 L5962 L5964 L5966 L5968 L5970 L5971 L5972 L5973 L5974 L5975 L5976 L5978 L5979 L5980 L5981 L5982 L5984 L5985 L5986 L5987 L5988 L5990 L5999 L6000 L6010 L6020 L6026 L6050 L6055 L6100 L6110 L6120 L6130
DESCRIPTION ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, ADDITION, ENDOSKELETAL KNEE/SHIN SYSTEM, ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM ADDITION, ENDOSKELETAL SYSTEM, ABOVE KN ADDITION, ENDOSKELETAL SYSTEM, HIP DISAR ADDITION TO LOWER EXTREMITY PROSTHESIS, ADDITION TO LOWER EXTREMITY PROSTHESIS, ADDITION TO LOWER EXTREMITY PROSTHESIS, ADDITION, ENDOSKELETAL SYSTEM, BELOW KN ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNE ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNE ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTI ADDITION, ENDOSKELETAL SYSTEM, BELOW KN ADDITION, ENDOSKELETAL SYSTEM, ABOVE KN ADDITION, ENDOSKELETAL SYSTEM, HIP DISA ADDITION, ENDOSKELETAL SYSTEM, BELOW KNE ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNE ADDITION, ENDOSKELETAL SYSTEM, HIP DISAR ADDITION TO LOWER LIMB PROSTHESIS, MULTI ALL LOWER EXTREMITY PROSTHESES, FOOT, EX ALL LOWER EXTREMITY PROSTHESIS, SOLID AN ALL LOWER EXTREMITY PROSTHESES, FLEXIBLE ENDOSKELETAL ANKLE FOOT SYSTEM, MICROPRO ALL LOWER EXTREMITY PROSTHESES, FLEXIBLE ALL LOWER EXTREMITY PROSTHESIS, COMBINAT ALL LOWER EXTREMITY PROSTHESES, ENERGY S ALL LOWER EXTREMITY PROSTHESES, FOOT, MU ALL LOWER EXTREMITY PROSTHESIS, MULTI-AX ALL LOWER EXTREMITY PROSTHESES, FLEX FOO ALL LOWER EXTREMITY PROSTHESES, FLEX-WAL ALL EXOSKELETAL LOWER EXTREMITY PROSTHES ALL ENDOSKELETAL LOWER EXTREMITY PROSTHE ALL ENDOSKELETAL LOWER EXTREMITY PROSTHE ALL LOWER EXTREMITY PROSTHESES, MULTI-AX ALL LOWER EXTREMITY PROSTHESIS, SHANK FO ADDITION TO LOWER LIMB PROSTHESIS, VERTI ADDITION TO LOWER EXTREMITY PROSTHESIS, LOWER EXTREMITY PROSTHESIS, NOT OTHERWIS PARTIAL HAND, ROBIN-AIDS, THUMB REMAININ PARTIAL HAND, ROBIN-AIDS, LITTLE AND/OR PARTIAL HAND, ROBIN-AIDS, NO FINGER REMA TRANSCARPAL/METACARPAL OR PARTIAL HAND D WRIST DISARTICULATION, MOLDED SOCKET, FL WRIST DISARTICULATION, MOLDED SOCKET WIT BELOW ELBOW, MOLDED SOCKET, FLEXIBLE ELB BELOW ELBOW, MOLDED SOCKET, (MUENSTER OR BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SO BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SO
FEE 2809.50 3020.00 1625.00 3195.78 1332.63 60.00 100.00
250.00 250.00 100.00 2552.81 475.00 650.00 950.00 450.00 600.00 700.00 3214.56 145.00 174.46 175.00 110.00 410.09 475.00 150.00 2056.06 3500.00 1850.00 275.00 456.86 214.16 275.00 5348.57 1755.00 1285.48 1025.00 1000.00 1050.00 5760.19 1480.00 1847.00 1890.00 2080.00 2290.00 2415.00
RENTAL FEE
BR
MAX UNITS 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 5 1 1 1 2 1 1 1 1 1 1
PA 6 6 6 6 6 6 6 1 1 1 6 6 6 6 6 6 6 6 6 6 6 6 1 6 1 6 6 6 6 6 1 1 6 6 6 6 1 6 6 1 6 6 6 1 6 6 6 6 6 6
Page 29 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L6200 L6205 L6250 L6300 L6310 L6320 L6350 L6360 L6370 L6380 L6382 L6384 L6386 L6388 L6400 L6450 L6500 L6550 L6570 L6580 L6582 L6584 L6586 L6588 L6590 L6600 L6605 L6610 L6611 L6615 L6616 L6620 L6621 L6623 L6624 L6625 L6628 L6629 L6630 L6632 L6635 L6637 L6638 L6640 L6641 L6642 L6645 L6646 L6650 L6655
DESCRIPTION ELBOW DISARTICULATION, MOLDED SOCKET, OU ELBOW DISARTICULATION, MOLDED SOCKET WIT ABOVE ELBOW, MOLDED DOUBLE WALL SOCKET, SHOULDER DISARTICULATION, MOLDED SOCKET, SHOULDER DISARTICULATION, PASSIVE RESTOR SHOULDER DISARTICULATION, PASSIVE RESTOR INTERSCAPULAR THORACIC, MOLDED SOCKET, S INTERSCAPULAR THORACIC, PASSIVE RESTORAT INTERSCAPULAR THORACIC, PASSIVE RESTORAT IMMEDIATE POST SURGICAL OR EARLY FITTING IMMEDIATE POST SURGICAL OR EARLY FITTING IMMEDIATE POST SURGICAL OR EARLY FITTING IMMEDIATE POST SURGICAL OR EARLY FITTING IMMEDIATE POST SURGICAL OR EARLY FITTING BELOW ELBOW, MOLDED SOCKET, ENDOSKELETAL ELBOW DISARTICULATION, MOLDED SOCKET, EN ABOVE ELBOW, MOLDED SOCKET, ENDOSKELETAL SHOULDER DISARTICULATION, MOLDED SOCKET, INTERSCAPULAR THORACIC, MOLDED SOCKET, E PREPARATORY, WRIST DISARTICULATION OR BE PREPARATORY, WRIST DISARTICULATION OR BE PREPARATORY, ELBOW DISARTICULATION OR AB PREPARATORY, ELBOW DISARTICULATION OR AB PREPARATORY, SHOULDER DISARTICULATION OR PREPARATORY, SHOULDER DISARTICULATION OR UPPER EXTREMITY ADDITIONS, POLYCENTRIC H UPPER EXTREMITY ADDITIONS, SINGLE PIVOT UPPER EXTREMITY ADDITIONS, FLEXIBLE META ADDITION TO UPPER EXTREMITY PROSTHESIS, UPPER EXTREMITY ADDITION, DISCONNECT LO UPPER EXTREMITY ADDITION, ADDITIONAL DIS UPPER EXTREMITY ADDITION, FLEXION/EXTENS UPPER EXTREMITY PROSTHESIS ADDITION, FLE UPPER EXTREMITY ADDITION, SPRING ASSIST UPPER EXTREMITY ADDITION, FLEXION/EXTENS UPPER EXTREMITY ADDITION, ROTATION WRIS UPPER EXTREMITY ADDITION, QUICK DISCONN UPPER EXTREMITY ADDITION, QUICK DISCONN UPPER EXTREMITY ADDITION, STAINLESS STE UPPER EXTREMITY ADDITION, LATEX SUSPENS UPPER EXTREMITY ADDITION, LIFT ASSIST F UPPER EXTREMITY ADDITION, NUDGE CONTROL UPPER EXTREMITY ADDITION TO PROSTHESIS, UPPER EXTREMITY ADDITIONS, SHOULDER ABDU UPPER EXTREMITY ADDITION, EXCURSION AMP UPPER EXTREMITY ADDITION, EXCURSION AMP UPPER EXTREMITY ADDITION, SHOULDER FLEX UPPER EXTREMITY ADDITION, SHOULDER JOINT UPPER EXTREMITY ADDITION, SHOULDER UNIV UPPER EXTREMITY ADDITION, STANDARD CONT
FEE 1532.50 2300.00 2150.00 3000.00 1950.00 850.00 4025.00 2870.12 1875.00 705.00 900.00 1200.00 305.00 396.14 1850.00 2200.00 2000.00 2390.00 3529.98 1070.00 918.00 1350.00 1200.00 1800.00 1650.00 194.00 175.00 90.00 347.22 105.50 37.00 205.00 1928.92 274.00 3176.01 250.00 75.00 125.00 194.20 42.00 115.00 177.50 1771.93 300.00 65.00 261.25 290.80 2234.80 300.00 49.00
RENTAL FEE
BR
MAX UNITS 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 2 1 1
PA 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 1 6 6 6 1 6 1 6 6 6 6 6 6 6 1 6 6 6 6 1 6 6
Page 30 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L6660 L6665 L6670 L6672 L6675 L6676 L6677 L6680 L6682 L6684 L6686 L6687 L6688 L6689 L6690 L6691 L6692 L6693 L6694 L6695 L6696 L6697 L6698 L6703 L6706 L6707 L6708 L6709 L6711 L6712 L6713 L6714 L6721 L6722 L6805 L6810 L6881 L6882 L6883 L6884 L6885 L6890 L6895 L6900 L6905 L6910 L6915 L6920 L6925 L6930
DESCRIPTION UPPER EXTREMITY ADDITION, HEAVY DUTY CO UPPER EXTREMITY ADDITION, TEFLON, OR EQ UPPER EXTREMITY ADDITION, HOOK TO HAND, UPPER EXTREMITY ADDITION, HARNESS, CHES UPPER EXTREMITY ADDITION, HARNESS, (E.G. UPPER EXTREMITY ADDITION, HARNESS, (E.G. UPPER EXTREMITY ADDITION, HARNESS, TRIPL UPPER EXTREMITY ADDITION, TEST SOCKET, UPPER EXTREMITY ADDITION, TEST SOCKET, UPPER EXTREMITY ADDITION, TEST SOCKET, UP EXT ADD, SUCTION SOCKET UPPER EXTREMITY ADDITION, FRAME TYPE SOC UPPER EXTREMITY ADDITION, FRAME TYPE SOC UPPER EXTREMITY ADDITION, FRAME TYPE SO UPPER EXTREMITY ADDITION, FRAME TYPE SO UPPER EXTREMITY ADDITION, REMOVABLE INS UPPER EXTREMITY ADDITION, SILICONE GEL I UPPER EXTREMITY ADDITION, LOCKING ELBOW, ADDITION TO UPPER EXTREMITY PROSTHESIS, ADDITION TO UPPER EXTREMITY PROSTHESIS, ADDITION TO UPPER EXTREMITY PROSTHESIS, ADDITION TO UPPER EXTREMITY PROSTHESIS, ADDITION TO UPPER EXTREMITY PROSTHESIS, TERMINAL DEVICE, PASSIVE HAND/MITT, ANY TERMINAL DEVICE, HOOK, MECHANICAL, VOLUN TERMINAL DEVICE, HOOK, MECHANICAL, VOLUN TERMINAL DEVICE, HAND, MECHANICAL, VOLUN TERMINAL DEVICE, HAND, MECHANICAL, VOLUN TERMINAL DEVICE, HOOK, MECHANICAL, VOLUN TERMINAL DEVICE, HOOK, MECHANICAL, VOLUN TERMINAL DEVICE, HAND, MECHANICAL, VOLUN TERMINAL DEVICE, HAND, MECHANICAL, VOLUN TERMINAL DEVICE, HOOK OR HAND, HEAVY DUT TERMINAL DEVICE, HOOK OR HAND, HEAVY DUT ADDITION TO TERMINAL DEVICE, MODIFIER WR ADDITION TO TERMINAL DEVICE, PRECISION P AUTOMATIC GRASP FEATURE, ADDITION TO UPP MICROPROCESSOR CONTROL FEATURE, ADDITION REPLACEMENT SOCKET, BELOW ELBOW/WRIST DI REPLACEMENT SOCKET, ABOVE ELBOW/ELBOW DI REPLACEMENT SOCKET, SHOULDER DISARTICULA ADDITION TO UPPER EXTREMITY PROSTHESIS, ADDITION TO UPPER EXTREMITY PROSTHESIS, HAND RESTORATION (CASTS, SHADING AND MEA HAND RESTORATION (CASTS, SHADING AND MEA HAND RESTORATION (CASTS, SHADING AND MEA HAND RESTORATION (SHADING, AND MEASUREME WRIST DISARTICULATION, EXTERNAL POWER, S WRIST DISARTICULATION, EXTERNAL POWER, S BELOW ELBOW, EXTERNAL POWER, SELF-SUSPEN
FEE 64.00 35.00 25.00 133.00 90.00 130.00 250.16 210.00 210.00 330.00 585.00 425.00 491.19 725.00 725.00 210.00 450.00 2511.38 450.00 450.00
177.50 372.35 250.00 892.92 612.87 678.50
295.00 115.00 2896.79 2197.34 1817.59 1998.82 2736.19 185.25 278.00 1050.00 1050.00 1050.00 278.00
RENTAL FEE
BR
MAX UNITS 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1
PA 6 6 6 6 6 6 1 6 6 6 6 6 6 6 6 6 6 1 6 6 1 1 6 1 6 6 6 6 1 1 1 1 1 1 6 6 1 1 1 1 1 6 6 6 6 6 6 1 1 1
Page 31 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L6935 L6940 L6945 L6950 L6955 L6960 L6965 L6970 L6975 L7007 L7008 L7009 L7040 L7045 L7170 L7180 L7181 L7185 L7186 L7190 L7191 L7259 L7360 L7362 L7364 L7366 L7367 L7368 L7499 L7510 L7520 L7900 L8000 L8001 L8002 L8010 L8020 L8030 L8031 L8035 L8300 L8310 L8320 L8330 L8400 L8410 L8415 L8417 L8420 L8430
DESCRIPTION BELOW ELBOW, EXTERNAL POWER, SELF-SUSPEN ELBOW DISARTICULATION, EXTERNAL POWER, M ELBOW DISARTICULATION, EXTERNAL POWER, M ABOVE ELBOW, EXTERNAL POWER, MOLDED INNE ABOVE ELBOW, EXTERNAL POWER, MOLDED INNE SHOULDER DISARTICULATION, EXTERNAL POWER SHOULDER DISARTICULATION, EXTERNAL POWER INTERSCAPULAR-THORACIC, EXTERNAL POWER, INTERSCAPULAR-THORACIC, EXTERNAL POWER, ELECTRIC HAND, SWITCH OR MYOELECTRIC CON ELECTRIC HAND, SWITCH OR MYOELECTRIC, CO ELECTRIC HOOK, SWITCH OR MYOELECTRIC CON PREHENSILE ACTUATOR, SWITCH CONTROLLED ELECTRIC HOOK, SWITCH OR MYOELECTRIC ONT ELECTRONIC ELBOW, HOSMER OR EQUAL, SWITC ELECTRONIC ELBOW, MICROPROCESSOR SEQUENT ELECTRONIC ELBOW, MICROPROCESSOR SIMULTA ELECTRONIC ELBOW, ADOLESCENT, VARIETY VI ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE ELECTRONIC ELBOW, ADOLESCENT, VARIETY VI ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE ELECTRONIC WIRST ROTATOR, ANY TYPE SIX VOLT BATTERY, EACH BATTERY CHARGER, SIX VOLT, EACH TWELVE VOLT BATTERY, EACH BATTERY CHARGER, TWELVE VOLT, EACH LITHIUM ION BATTERY, RECHARGEABLE REPLACEMENT LITHIUM 10N BATTERY CHARGER UPPER EXTREMITY PROSTHESIS, NOT OTHERWIS REPAIR OF PROSTHETIC DEVICE, REPAIR OR R REPAIR PROSTHETIC DEVICE, LABOR COMPONEN MALE VACUUM ERECTION SYSTEM BREAST PROSTHESIS, MASTECTOMY BRA BREAST PROSTHESIS, MASTECTOMY BRA, WITH BREAST PROSTHESIS, MASTECTOMY BRA, WITH BREAST PROSTHESIS, MASTECTOMY SLEEVE BREAST PROSTHESIS, MASTECTOMY FORM BREAST PROSTHESIS, SILICONE OR EQUAL, WI BREAST PROSTHESIS, SILICONE OR EQUAL, WI CUSTOM BREAST PROSTHESIS, POST MASTECTOM TRUSS, SINGLE WITH STANDARD PAD TRUSS, DOUBLE WITH STANDARD PADS TRUSS, ADDITION TO STANDARD PAD, WATER P TRUSS, ADDITION TO STANDARD PAD, SCROTAL PROSTHETIC SHEATH, BELOW KNEE, EACH PROSTHETIC SHEATH, ABOVE KNEE, EACH PROSTHETIC SHEATH, UPPER LIMB, EACH PROSTHETIC SHEATH/SOCK, INCLUDING A GEL PROSTHETIC SOCK, MULTIPLE PLY, BELOW KNE PROSTHETIC SOCK, MULTIPLE PLY, ABOVE KNE
FEE
3367.16 5279.07 3195.10
6810.00
222.50 211.00 383.48 516.56 275.86 357.61 35.00 18.00 183.75 31.22 93.74 123.74 49.22 180.63 180.63 180.63 180.63 59.18 90.00 25.00 30.00 18.91 18.00 19.00 31.80 15.84 16.67
RENTAL FEE
BR
MAX UNITS 2 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 8 1 5 5 5 2 2 2 2 2 1 1 1 1 6 6 6 2 12 12
PA 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 6 6 6 6 6 6 1 6 6 1
6
6 6 6 6 6 6 6 6 6 6 6
Page 32 of 66
NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE L8435 L8440 L8460 L8465 L8470 L8480 L8485 L8499 L8500 L8501 L8505 L8507 L8510 L8511 L8512 L8513 L8514 L8515 L8621 L9900 S1040 S8100 S8101 S8185 S8189 S8265 S8270 S8421 S8424 S8427 S8428 S8460 S8999 T4521 T4522 T4523 T4524 T4529 T4530 T4533 T4535 T4537 T4539 T4540 T4543 T5001 T5999 T5999 T5999 T5999
DESCRIPTION FEE PROSTHETIC SOCK, MULTIPLE PLY, UPPER LI 16.00 PROSTHETIC SHRINKER, BELOW KNEE, EACH 25.00 PROSTHETIC SHRINKER, ABOVE KNEE, EACH 33.33 PROSTHETIC SHRINKER, UPPER LIMB, EACH 25.00 PROSTHETIC SOCK, SINGLE PLY, FITTING, BE 6.01 PROSTHETIC SOCK, SINGLE PLY, FITTING, AB 8.29 PROSTHETIC SOCK, SINGLE PLY, FITTING, UP 8.06 UNLISTED PROCEDURE FOR MISCELLANEOUS PRO ARTIFICAL LARYNX ANY TYPE 684.80 TRACHEOSTOMY SPEAKING VALVE 66.87 ARTIFICIAL LARYNX REPLACEMENT BATTERY / 46.50 TRACHEO-ESOPHAGEAL VOICE PROSTHESIS, PAT 37.06 VOICE AMPLIFIER 198.94 INSERT FOR INDWELLING TRACHEOESOPHAGEAL 37.80 GELATIN CAPSULES OR EQUIVALENT, FOR USE 1.67 CLEANING DEVICE USED WITH TRACHEOESOPHAG 3.13 TRACHEOESOPHAGEAL PUNCTURE DILATOR, REPL 48.60 GELATIN CAPSULE, APPLICATION DEVICE FOR 49.69 ZINC AIR BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE A 0.55 ORTHOTIC AND PROSTHETIC SUPPLY, ACCESSOR 5.00 CRANIAL REMOLDING ORTHOSIS, PEDIATRIC, R 1105.89 HOLDING CHAMBER OR SPACER FOR USE WITH A 16.50 HOLDING CHAMBER OR SPACER FOR USE WITH A 27.75 FLUTTER DEVICE 54.00 TRACHEOSTOMY SUPPLY, NOT OTHERWISE CLASS HABERMAN FEEDER FOR CLEFT LIP/PALATE 19.13 ENURESIS ALARM, USING AUDITORY BUZZER AN 54.71 GRADIENT PRESSURE AID (SLEEVE AND GLOVE 67.50 GRADIENT PRESSURE AID (SLEEVE), READY MA 33.82 GRADIENT PRESSURE AID (GLOVE), READY MAD 23.86 GRADIENT PRESSURE AID (GAUNTLET), READY 22.69 CAMISOLE,POST-MASTECTOMY 37.49 RESUSCITATION BAG (FOR USE BY PATIENT ON 189.43 ADULT SIZED DISPOSABLE INCONTINENCE PROD 0.47 ADULT SIZED DISPOSABLE INCONTINENCE PROD 0.51 ADULT SIZED DISPOSABLE INCONTINENCE PROD 0.68 ADULT SIZED DISPOSABLE INCONTINENCE PROD 0.72 PEDIATRIC SIZED DISPOSABLE INCONTINENCE 0.30 PEDIATRIC SIZED DISPOSABLE INCONTINENCE 0.36 YOUTH SIZED DISPOSABLE INCONTINENCE PROD 0.39 DISPOSABLE LINER/SHIELD/GUARD/PAD/UNDERG 0.28 INCONTINENCE PRODUCT, PROTECTIVE UNDERPA 13.44 INCONTINENCE PRODUCT, DIAPER/BRIEF, REUS 6.65 INCONTINENCE PRODUCT, PROTECTIVE UNDERPA 7.19 DISPOSABLE INCONTINENCE PRODUCT, BRIEF/D 1.38 POSITIONING SEAT FOR PERSONS WITH SPECIA 609.75 SUPPLY,NOT OTHERWISE SPECIFIED Plastic strips 2.81 Basal thermometer 10.41 Sterile 6” wood applicator w/cotton tips 2.97
RENTAL FEE
BR
BR
MAX UNITS 12 6 6 6 6 6 5 5 1 1 1 1 1 1 9 6 1 1 60 1 1 2 2 1 1 2 1 2 2 2 2 5 1 250 250 250 250 250 250 250 250 3 5 3 250 1 5
PA 6 6 6 6 6 6 6 1 6 6 6 6 6
6 6 6 6 6 6 6 1 6 6 6 6 6 6
6 6 6 6 6 6 6 6 6 6 6 1 6 1
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NYS Medicaid DME Services Fee Schedule Effective1-Jul-16
CODE DESCRIPTION T5999 Incentive spirometer T5999 Nasal aspirator V5266 BATTERY FOR USE IN HEARING DEVICE
FEE 5.88 2.40 0.55
RENTAL FEE
BR
MAX UNITS PA
24
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