Other (Prior Authorization Matrix) for Not specified models including: DME, medical supplies, prior authorization, healthcare services, medical codes, A4233, E0100, K0813, S9329, 97542, 73600, 99070, Durable Medical Equipment, Healthcare Administered Drugs, Home Health Care Services, Medical Supplies, Procedures, PA Matrix
Beach, Jill
[PDF] NON-PAR Providers require authorization regardless of services ...
GRADIENT COMPRS STK FULL LEN/CHAP 18-30 MMHG EA. Durable Medical Equipment ... All Inpatient Services Require Prior Authorization. Page 2. A7033. PILLW ...
THIS MATRIX IS NOT TO BE UTILIZED TO MAKE BENEFIT COVERAGE DETERMINATIONS.
FOR ANY PA CHANGES DUE TO REGULATORY GUIDANCE RELATED TO COVID 19 PLEASE SEE PROVIDER NOTIFICATIONS AND MOST CURRENT INFORMATION ON THE PROVIDER PORTAL
We attempt to provide the most current and accurate information on this PA Matrix. Prior Authorization is not a guarantee of payment for services. Payment is dependent on member eligibility at the time of service, benefit coverage and limitations, provider agreements, and
submission of accurate claims. If there is still a question that Prior Authorization is needed, please refer to your Provider Manual or submit a PA Request Form.
This Matrix is for Out-Patient services only. All Inpatient Services Require Prior Authorization.
All NON-PAR Providers require authorization regardless of services provided or codes submitted, except for Emergency Services.
Code
Description
Service Category
MHI PA eviCore PA Required? Required?
NCH PA Required?
State Exceptions
MCC NY PA Required
MHI Code Notes
A4233
REPL BATT ALKALINE NOT J CELL HOM BG MON OWND PT
Durable Medical Equipment (DME)
Y
A4234
REPL BATT ALKALINE J CELL HOM BG MON OWN PT EA
Durable Medical Equipment (DME)
Y
A4235
REPL BATT LITHIUM MED NECES HOM BG MON OWN PT EA
Durable Medical Equipment (DME)
Y
A4495
SURGICAL STOCKING THIGH LENGTH EACH
Durable Medical Equipment (DME)
Y
A4500
SURGICAL STOCKING BELOW KNEE LENGTH EACH
Durable Medical Equipment (DME)
Y
A4510
SURGICAL STOCKING FULL-LENGTH EACH
Durable Medical Equipment (DME)
Y
A4565
SLINGS
Durable Medical Equipment (DME)
Y
A4614
PEAK EXPIRATORY FLOW RATE METER HAND HELD
Durable Medical Equipment (DME)
Y
A4618
BREATHING CIRCUITS
Durable Medical Equipment (DME)
Y
A4619
FACE TENT
Durable Medical Equipment (DME)
Y
A4620
VARIABLE CONCENTRATION MASK
Durable Medical Equipment (DME)
Y
A4624
TRACHEAL SUCTN CATH TYPE OTH THAN CLOS SYS EA
Durable Medical Equipment (DME)
Y
A4625
TRACHEOSTOMY CARE KIT FOR NEW TRACHEOSTOMY
Durable Medical Equipment (DME)
Y
A4629
TRACHEOSTOMY CARE KIT ESTABLISHED TRACHEOSTOMY
Durable Medical Equipment (DME)
Y
A4630
REPLCMT BATTRY MED NECES TRNSQ ELEC STIM OWND PT
Durable Medical Equipment (DME)
Y
A4635
UNDERARM PAD CRUTCH REPLACEMENT EACH
Durable Medical Equipment (DME)
Y
A4636
REPLACEMENT HANDGRIP CANE CRUTCH OR WALKER EACH
Durable Medical Equipment (DME)
Y
A4637
REPLACEMENT TIP CANE CRUTCH WALKER EACH
Durable Medical Equipment (DME)
Y
A4640
REPLCMT PAD W/MED NECES ALTRNAT PRSS PAD OWND PT
Durable Medical Equipment (DME)
Y
A4660
SPHYGMOMANOMETER/BP APPARATUS W/CUFF and STETHOSCOPE Durable Medical Equipment (DME)
Y
A4670
AUTOMATIC BLOOD PRESSURE MONITOR
Durable Medical Equipment (DME)
Y
A4931
ORAL THERMOMETER REUSABLE ANY TYPE EACH
Durable Medical Equipment (DME)
Y
A4932
RECTAL THERMOMETER REUSABLE ANY TYPE EACH
Durable Medical Equipment (DME)
Y
A6457
TUBULAR DRSG W/WO ELASTIC ANY WDTH PER LINEAR YD
Durable Medical Equipment (DME)
Y
A6501
COMPRS BURN GARMENT BODYSUIT CUSTOM FABRICATED
Durable Medical Equipment (DME)
Y
A6502
COMPRS BURN GARMENT CHIN STRAP CUSTOM FABRICATED
Durable Medical Equipment (DME)
Y
A6503
COMPRS BURN GARMENT FACIAL HOOD CUSTOM FAB
Durable Medical Equipment (DME)
Y
A6504
COMPRS BURN GARMENT GLOVE WRIST CUSTOM FAB
Durable Medical Equipment (DME)
Y
A6505
COMPRS BURN GARMENT GLOVE ELB CUSTOM FABRICATED
Durable Medical Equipment (DME)
Y
A6506
COMPRS BURN GARMENT GLOVE AXILLA CUSTOM FAB
Durable Medical Equipment (DME)
Y
A6507
COMPRS BURN GARMENT FT KNEE LENGTH CUSTOM FAB
Durable Medical Equipment (DME)
Y
A6508
COMPRS BURN GARMENT FT THIGH LENGTH CUSTOM FAB
Durable Medical Equipment (DME)
Y
A6509
COMPRS BRN GARMNT UP TRNK WAIST ARM OPENING CSTM
Durable Medical Equipment (DME)
Y
A6510
COMPRS BRN GARMNT TRNK ARMS TO LEG OPENING CSTM
Durable Medical Equipment (DME)
Y
A6511
COMPRS BRN GARMNT LW TRNK W/LEG OPENING CSTM FAB
Durable Medical Equipment (DME)
Y
A6512
COMPRESSION BURN GARMENT NOC
Durable Medical Equipment (DME)
Y
A6530
GRADIENT COMPRESSION STK BELW KNEE 18-30 MMHG EA
Durable Medical Equipment (DME)
Y
A6531
GRADIENT COMPRESSION STK BELW KNEE 30-40 MMHG EA
Durable Medical Equipment (DME)
Y
A6532
GRADIENT COMPRESSION STK BELW KNEE 40-50 MMHG EA
Durable Medical Equipment (DME)
Y
A6533
GRADIENT COMPRESSION STK THIGH LEN 18-30 MMHG EA
Durable Medical Equipment (DME)
Y
A6534
GRADIENT COMPRESSION STK THIGH LEN 30-40 MMHG EA
Durable Medical Equipment (DME)
Y
A6535
GRADIENT COMPRESSION STK THIGH LEN 40-50 MMHG EA
Durable Medical Equipment (DME)
Y
A6536
GRADIENT COMPRS STK FULL LEN/CHAP 18-30 MMHG EA
Durable Medical Equipment (DME)
Y
A6537
GRADIENT COMPRS STK FULL LEN/CHAP 30-40 MMHG EA
Durable Medical Equipment (DME)
Y
A6538
GRADIENT COMPRS STK FULL LEN/CHAP 40-50 MMHG EA
Durable Medical Equipment (DME)
Y
A6539
GRADIENT COMPRESSION STK WAIST LEN 18-30 MMHG EA
Durable Medical Equipment (DME)
Y
A6540
GRADIENT COMPRESSION STK WAIST LEN 30-40 MMHG EA
Durable Medical Equipment (DME)
Y
A6541
GRADIENT COMPRESSION STK WAIST LEN 40-50 MMHG EA
Durable Medical Equipment (DME)
Y
A6544
GRADIENT COMPRESSION STOCKING GARTER BELT
Durable Medical Equipment (DME)
Y
A6549
GRADIENT COMPRESSION STOCKING/SLEEVE NOS
Durable Medical Equipment (DME)
Y
A7000
CANISTER DISPOSABLE USED WITH SUCTION PUMP EACH
Durable Medical Equipment (DME)
Y
A7003
ADMN SET SM VOL NONFILTR PNEUMAT NEBULIZR DISPBL
Durable Medical Equipment (DME)
Y
A7004
SMALL VOLUME NONFILTR PNEUMATIC NEBULIZER DISPBL
Durable Medical Equipment (DME)
Y
A7005
ADMN SET W/SM VOL NONFILTR NEBULIZR NON-DISPBL
Durable Medical Equipment (DME)
Y
A7007
LG VOL NEBULIZR DISPBL UNFIL USED W/AROSL COMPRS
Durable Medical Equipment (DME)
Y
A7013
FILTER DISPOSABL W/AREOSOL COMPRESS/US GENERATOR
Durable Medical Equipment (DME)
Y
A7014
FILTER NON-DISPBL USED W/AROSL COMPRS/US GEN
Durable Medical Equipment (DME)
Y
A7015
AREO MASK USED W/ DME NEB
Durable Medical Equipment (DME)
Y
A7027
COMB ORAL/NASAL MASK USED W/CPAP DEVICE EACH
Durable Medical Equipment (DME)
Y
A7028
ORAL CUSHION COMB ORAL/NASAL MASK REPL ONLY EACH
Durable Medical Equipment (DME)
Y
A7029
NASAL PILLOWS COMB ORAL/NASL MASK REPL ONLY PAIR
Durable Medical Equipment (DME)
Y
A7030
FULL FACE MASK USED W/POS ARWAY PRESS DEVICE EA
Durable Medical Equipment (DME)
Y
A7031
FACE MASK INTERFACE REPLCMT FULL FACE MASK EA
Durable Medical Equipment (DME)
Y
A7032
CUSHN NASAL MASK INTERFACE REPLACEMENT ONLY EACH
Durable Medical Equipment (DME)
Y
A7033
PILLW NASL CANNULA TYPE INTERFCE REPL ONLY PAIR
Durable Medical Equipment (DME)
Y
A7034
NASL INTRFCE POS ARWAY PRSS DEVC W/WO HEAD STRAP
Durable Medical Equipment (DME)
Y
A7035
HEADGEAR USED W/POSITIVE AIRWAY PRESSURE DEVICE
Durable Medical Equipment (DME)
Y
A7036
CHINSTRAP USED W/POSITIVE AIRWAY PRESSURE DEVICE
Durable Medical Equipment (DME)
Y
A7037
TUBING USED WITH POSITIVE AIRWAY PRESSURE DEVICE
Durable Medical Equipment (DME)
Y
A7039
FILTER NON DISPBL USED W/POS ARWAY PRESS DEVICE
Durable Medical Equipment (DME)
Y
A7045
EXHALATION PORT W/WO SWIVEL REPLACEMENT ONLY
Durable Medical Equipment (DME)
Y
A7522
TRACHEOST/LARYNGECT TUBE STNLESS STEEL/EQUAL EA
Durable Medical Equipment (DME)
Y
A7524
TRACHEOSTOMA STENT/STUD/BUTTON EACH
Durable Medical Equipment (DME)
Y
A7525
TRACHEOSTOMY MASK EACH
Durable Medical Equipment (DME)
Y
A8000
HELMET PROTECTVE SOFT PREFAB COMPONENT ACCSSRIES
Durable Medical Equipment (DME)
Y
A8001
HELMET PROTECTVE HARD PREFAB COMPONENT ACCSSRIES
Durable Medical Equipment (DME)
Y
A8002
HELMET PROTECTIVE SOFT CUSTOM FAB COMP ACCSSRIES
Durable Medical Equipment (DME)
Y
A8003
HELMET PROTECTIVE HARD CUSTOM FAB COMP ACCSSRIES
Durable Medical Equipment (DME)
Y
A8004
SOFT INTERFACE FOR HELMET REPLACEMENT ONLY
Durable Medical Equipment (DME)
Y
A9275
HOME GLUCOSE DISPBL MONITOR INCLUDES TEST STRIPS
Durable Medical Equipment (DME)
Y
A9276
SENSOR;INVSV DISP INTRSTL CONT GLU MON SYS 1U Equal to 1D
Durable Medical Equipment (DME)
Y
A9277
TRANSMITTER; EXT INTERSTITIAL CONT GLU MON SYS
Durable Medical Equipment (DME)
Y
A9278
RECEIVER MON; EXT INTERSTITIAL CONT GLU MON SYS
Durable Medical Equipment (DME)
Y
A9282
WIG ANY TYPE EACH
Durable Medical Equipment (DME)
Y
E0100
CANE INCL CANES ALL MATERIAL ADJUSTBLE/FIX W/TIP
Durable Medical Equipment (DME)
N
E0147
WALKER HEAVY DUTY MX BRAKE SYS VARIBLE WHL RSIST
Durable Medical Equipment (DME)
Y
E0163
COMMODE CHAIR MOBILE OR STATIONARY W/FIXED ARMS
Durable Medical Equipment (DME)
Y
E0165
COMMODE CHAIR MOBILE/STATIONARY W/DETACHBLE ARMS
Durable Medical Equipment (DME)
Y
E0181
PWR PRESSURE REDUCING MATTRESS OVERLY/PAD PUMP
Durable Medical Equipment (DME)
Y
E0182
PUMP ALTERNATING PRESSURE PAD REPLACEMENT ONLY
Durable Medical Equipment (DME)
Y
E0186
AIR PRESSURE MATTRESS
Durable Medical Equipment (DME)
Y
E0187
WATER PRESSURE MATTRESS
Durable Medical Equipment (DME)
Y
E0190
POSITIONING CUSH/PILLOW/WEDGE INCL ALL COMPONENT
Durable Medical Equipment (DME)
Y
E0196
GEL PRESSURE MATTRESS
Durable Medical Equipment (DME)
Y
E0235
PARAFFIN BATH UNIT PORTABLE
Durable Medical Equipment (DME)
Y
E0240
BATH/SHOWER CHAIR W/WO WHEELS ANY SIZE
Durable Medical Equipment (DME)
Y
E0241
BATHTUB WALL RAIL EACH
Durable Medical Equipment (DME)
Y
E0243
TOILET RAIL EACH
Durable Medical Equipment (DME)
Y
E0244
RAISED TOILET SEAT
Durable Medical Equipment (DME)
Y
E0245
TUB STOOL OR BENCH
Durable Medical Equipment (DME)
Y
E0246
TRANSFER TUB RAIL ATTACHMENT
Durable Medical Equipment (DME)
Y
E0247
TRANSFER BENCH TUB/TOILET W/WO COMMODE OPENING
Durable Medical Equipment (DME)
Y
E0248
TRNSF BENCH HEVY DUTY TUB/TOILET W/WO COMMODE OP
Durable Medical Equipment (DME)
Y
E0251
HOSP BED FIX HT W/ANY TYPE SIDE RAIL W/O MATTRSS
Durable Medical Equipment (DME)
Y
E0256
HOS BED VARIBL HT ANY TYPE SIDE RAIL W/O MATTRSS
Durable Medical Equipment (DME)
Y
E0261
HOS BED SEMI-ELEC ANY TYPE SIDE RAIL W/O MATTRSS
Durable Medical Equipment (DME)
Y
E0265
HOSPITAL BED TOTAL ELECTRIC W/MATRESS W/RAILS
Durable Medical Equipment (DME)
Y
E0266
HOS BED TOT ELEC ANY TYPE SIDE RAIL W/O MATTRSS
Durable Medical Equipment (DME)
Y
E0274
OVER-BED TABLE
Durable Medical Equipment (DME)
Y
E0277
POWERED PRESSURE-REDUCING AIR MATTRESS
Durable Medical Equipment (DME)
Y
E0301
HOS BED HEVY DUTY XTRA WIDE W/WT CAPACTY GT 350 PDS
Durable Medical Equipment (DME)
Y
E0302
HOS BED XTRA HEVY DUTY WT CAP GT 600 PDS W/O MTTRSS
Durable Medical Equipment (DME)
Y
E0303
HOSPITAL BED HEAVY DUTY EXTRA WIDE W/ MATRESS
Durable Medical Equipment (DME)
Y
E0305
BEDSIDE RAILS HALF-LENGTH
Durable Medical Equipment (DME)
Y
E0316
SFTY ENCLOS FRME/CANOPY USE W/HOSP BED ANY TYPE
Durable Medical Equipment (DME)
Y
E0371
NONPWR ADV PRSS RDUC OVRLAY MATTRSS STD LEN AND WDTH
Durable Medical Equipment (DME)
Y
E0372
PWR AIR OVRLAY MATTRSS STD MATTRSS LENGTH AND WIDTH
Durable Medical Equipment (DME)
Y
E0373
NONPOWERED ADVANCD PRESSURE REDUCING MATTRESS
Durable Medical Equipment (DME)
Y
E0445
OXIMETER DEVICE MSR BLD O2 LEVLS NON-INVASV
Durable Medical Equipment (DME)
Y
E0470
RESP ASST DEVC BI-LEVL PRSS CAPABILITY W/O BACKU
Durable Medical Equipment (DME)
Y
E0471
RESP ASST DEVC BI-LEVL PRSS CAPABILITY W/BACK-UP
Durable Medical Equipment (DME)
Y
E0472
RESP ASST DEVC BI-LEVL PRSS CAPABILITY W/BACKUP
Durable Medical Equipment (DME)
Y
E0480
PERCUSSOR ELECTRIC OR PNEUMATIC HOME MODEL
Durable Medical Equipment (DME)
Y
E0482
COUGH STIM DEVICE ALTRNAT POS AND NEG ARWAY PRESS
Durable Medical Equipment (DME)
Y
E0483
HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM EA
Durable Medical Equipment (DME)
Y
E0550
HUMDIFIR DURBLE EXT SUPLMNTL DUR IPPB TX/O2 DEL
Durable Medical Equipment (DME)
Y
E0565
COMPRS AIR PWR EQP NOT SLF-CONTAIND/CYL DRIVN
Durable Medical Equipment (DME)
Y
E0570
NEBULIZER WITH COMPRESSOR
Durable Medical Equipment (DME)
Y
E0600
RESP SUCTION PUMP HOME MODEL PRTBLE/STATION ELEC
Durable Medical Equipment (DME)
Y
E0601
CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE
Durable Medical Equipment (DME)
Y
E0604
BREAST PUMP HEVY DUTY HOSP GRADE PISTON OP
Durable Medical Equipment (DME)
Y
E0607
HOME BLOOD GLUCOSE MONITOR
Durable Medical Equipment (DME)
Y
E0630
PATIENT LIFT HYDRAULIC/MECH INCL SEAT SLING/PAD
Durable Medical Equipment (DME)
Y
E0637
COMB SIT STAND FRAME/TABLE SYS SEATLIFT FEATURE
Durable Medical Equipment (DME)
Y
E0638
STANDING FRAME/TABLE SYS ONE POSITION ANY SZ
Durable Medical Equipment (DME)
Y
E0651
PNEUMATIC COMPRES SEGMENTAL HOME WO/CAL PRESS
Durable Medical Equipment (DME)
Y
E0667
SEGMENTAL PNEUMATIC APPLIANCE FULL LEG
Durable Medical Equipment (DME)
Y
E0781
AMB INFUS PUMP 1/MX CHANNL W/ADMN EQP WORN BY PT
Durable Medical Equipment (DME)
Y
E0784
EXTERNAL AMBULATORY INFUSION PUMP INSULIN
Durable Medical Equipment (DME)
Y
E0791
PARNTRAL INFUS PUMP STATIONRY SINGLE/MULTICHANEL
Durable Medical Equipment (DME)
Y
E0910
TRAPEZ BAR KNOWN AS PT HLPR ATTCH BED W/GRAB BAR
Durable Medical Equipment (DME)
Y
E0911
TRAPEZ BAR HEVY DUTY PT WT GT 250 LBS BED GRAB BAR
Durable Medical Equipment (DME)
Y
E0912
TRAPEZ BAR HEVY DUTY PT WT GT 250 LBS FREE STAND
Durable Medical Equipment (DME)
Y
E0940
TRAPEZE BAR FREESTANDING COMPLETE WITH GRAB BAR
Durable Medical Equipment (DME)
Y
E0946
FRACTURE FRAME DUAL W/CROSS BARS ATTACHED TO BED
Durable Medical Equipment (DME)
Y
E0958
MANUAL WHLCHAIR ACCESS 1-ARM DRIVE ATTACHMENT EA
Durable Medical Equipment (DME)
Y
E1012
WC ACCSS PWR SEAT SYS CNTR MNT PWR ELEV LEG EA
Durable Medical Equipment (DME)
Y
E1225
WHLCHAIR ACCESS MANUAL SEMIRECLINING BACK EACH
Durable Medical Equipment (DME)
Y
E1228
SPECIAL BACK HEIGHT FOR WHEELCHAIR
Durable Medical Equipment (DME)
Y
E2100
BLD GLU MONITOR W/INTEGRATED VOICE SYNTHESIZER
Durable Medical Equipment (DME)
Y
E2358
PWR WC ACCESS GRP 34 NONSEALED LEAD ACID BATT EA
Durable Medical Equipment (DME)
Y
E2402
NEG PRESS WOUND THERAPY ELEC PUMP STATION/PRTBLE
Durable Medical Equipment (DME)
Y
E2609
CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION SIZE
Durable Medical Equipment (DME)
Y
E2617
CSTM FAB WC BACK CUSHN ANY SZ ANY MOUNT HARDWARE
Durable Medical Equipment (DME)
Y
K0001
STANDARD WHEELCHAIR
Durable Medical Equipment (DME)
Y
K0002
STANDARD HEMI WHEELCHAIR
Durable Medical Equipment (DME)
Y
K0003
LIGHTWEIGHT WHEELCHAIR
Durable Medical Equipment (DME)
Y
K0004
HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR
Durable Medical Equipment (DME)
Y
K0006
HEAVY-DUTY WHEELCHAIR
Durable Medical Equipment (DME)
Y
K0007
EXTRA HEAVY-DUTY WHEELCHAIR
Durable Medical Equipment (DME)
Y
K0009
OTHER MANUAL WHEELCHAIR/BASE
Durable Medical Equipment (DME)
Y
K0606
AUTO EXT DEFIB W/INTGR ECG ANALY GARMENT TYPE
Durable Medical Equipment (DME)
Y
K0812
POWER OPERATED VEHICLE NOT OTHERWISE CLASSIFIED
Durable Medical Equipment (DME)
Y
K0813
PWR WC GRP 1 STD PORT SLING SEAT PT TO 300 LBS
Durable Medical Equipment (DME)
Y
K0814
PWR WC GRP 1 STD PORT CAPT CHAIR PT TO 300 LBS
Durable Medical Equipment (DME)
Y
K0815
PWR WC GRP 1 STD SLING SEAT PT UP TO and Equal to 300 L
Durable Medical Equipment (DME)
Y
K0816
PWR WC GRP 1 STD CAPTAINS CHAIR PT TO and Equal to 300 L
Durable Medical Equipment (DME)
Y
K0820
PWR WC GRP 2 STD PORT SLING SEAT PT TO and Equal to 300
Durable Medical Equipment (DME)
Y
K0821
PWR WC GRP 2 STD PORT CAPT CHAIR PT TO and Equal to 300
Durable Medical Equipment (DME)
Y
K0822
PWR WC GRP 2 STD SLING SEAT PT TO and Equal to 300 LBS
Durable Medical Equipment (DME)
Y
K0823
PWR WC GRP 2 STD CAPTAINS CHAIR PT TO and Equal to 300 L
Durable Medical Equipment (DME)
Y
K0824
PWR WC GRP 2 HEVY DUTY SLING SEAT PT 301-450 LBS
Durable Medical Equipment (DME)
Y
K0825
PWR WC GRP 2 HEVY DUTY CAPT CHAIR PT 301-450 LBS
Durable Medical Equipment (DME)
Y
K0826
PWR WC GRP 2 VRY HVY DTY SLNG SEAT PT 451-600 LB
Durable Medical Equipment (DME)
Y
K0827
PWR WC GRP 2 VRY HVY DTY CAPT CHR PT 451-600 LBS
Durable Medical Equipment (DME)
Y
K0828
PWR WC GRP 2 XTRA HVY DUTY SLING SEAT PT 601LB OR GT
Durable Medical Equipment (DME)
Y
K0829
PWR WC GRP 2 XTRA HVY DUTY CHAIR PT 601 LBS OR GT
Durable Medical Equipment (DME)
Y
K0835
PWR WC GRP 2 STD 1 PWR SLING SEAT PT TO 300 LBS
Durable Medical Equipment (DME)
Y
K0836
PWR WC GRP 2 STD 1 PWR CAPT CHAIR PT TO 300 LBS
Durable Medical Equipment (DME)
Y
K0837
PWR WC GRP 2 HVY 1 PWR SLING SEAT PT 301-450 LBS
Durable Medical Equipment (DME)
Y
K0838
PWR WC GRP 2 HVY 1 PWR CAPT CHAIR PT 301-450 LBS
Durable Medical Equipment (DME)
Y
K0839
PWR WC GRP 2 VRY HVY 1 PWR SLING PT 451-600 LBS
Durable Medical Equipment (DME)
Y
K0840
PWR WC GRP 2 XTRA HVY 1 PWR SLING PT 601 LBS OR GT
Durable Medical Equipment (DME)
Y
K0841
PWR WC GRP 2 MX PWR SLING SEAT PT TO and Equal to 300 LB
Durable Medical Equipment (DME)
Y
K0842
PWR WC GRP 2 STD MX PWR CAPT CHR PT TO and Equal to 300
Durable Medical Equipment (DME)
Y
K0843
PWR WC GRP 2 HVY MX PWR SLNG SEAT PT 301-450 LBS
Durable Medical Equipment (DME)
Y
K0848
PWR WC GRP 3 STD SLING SEAT PT TO and Equal to 300 LBS
Durable Medical Equipment (DME)
Y
K0849
PWR WC GRP 3 STD CAPTAIN CHAIR PT TO and Equal to 300
Durable Medical Equipment (DME)
Y
K0850
PWR WC GRP 3 HVY DUTY SLING SEAT PT 301-450 LBS
Durable Medical Equipment (DME)
Y
K0851
PWR WC GRP 3 HVY DUTY CAPT CHAIR PT 301-450 LBS
Durable Medical Equipment (DME)
Y
K0852
PWR WC GRP 3 V HVY DUTY SLING SEAT PT 451-600 LB
Durable Medical Equipment (DME)
Y
K0853
PWR WC GRP 3 HVY DUTY CAPT CHAIR PT 451-600 LBS
Durable Medical Equipment (DME)
Y
K0854
PWR WC GRP 3 XTRA HVY DTY SLNG SEAT PT 601 LBS OR GT
Durable Medical Equipment (DME)
Y
K0855
PWR WC GRP 3X HVY DTY CHR PT WT CAP 601 LB OR GT
Durable Medical Equipment (DME)
Y
K0856
PWR WC GRP 3 STD 1 PWR SLING SEAT PT TO and Equal to 300
Durable Medical Equipment (DME)
Y
K0857
PWR WC GRP 3 STD 1 PWR CAPT CHAIR PT TO and Equal to 300
Durable Medical Equipment (DME)
Y
K0858
PWR WC GRP 3 HD 1 PWR SLING SEAT PT 301-450 LBS
Durable Medical Equipment (DME)
Y
K0859
PWR WC GRP 3 HD 1 PWR CAPT CHAIR PT 301-450 LBS
Durable Medical Equipment (DME)
Y
K0860
PWR WC GRP 3 V HD 1 PWR SLING SEAT PT 451-600 LB
Durable Medical Equipment (DME)
Y
K0861
PWR WC GRP 3 STD MX PWR SLNG SEAT PT TO and Equal to 300
Durable Medical Equipment (DME)
Y
K0862
PWR WC GRP 3 HD MX PWR SLING SEAT PT 301-450 LBS
Durable Medical Equipment (DME)
Y
K0863
PWR WC GRP 3 V HD MX PWR SLNG SEAT PT 451-600 LB
Durable Medical Equipment (DME)
Y
K0864
PWR WC GRP 3 XTR HD MX PWR SLNG SEAT PT 601 LB OR GT
Durable Medical Equipment (DME)
Y
K0868
PWR WC GRP 4 STD SLING SEAT PT TO and Equal to 300 LBS
Durable Medical Equipment (DME)
Y
K0869
PWR WC GRP 4 STD CAPTAIN CHAIR PT TO and Equal to 300
Durable Medical Equipment (DME)
Y
K0870
PWR WC GRP 4 HVY DUTY SLING SEAT PT 301-450 LBS
Durable Medical Equipment (DME)
Y
K0871
PWR WC GRP 4 V HVY DUTY SLING SEAT PT 451-600 LB
Durable Medical Equipment (DME)
Y
K0877
PWR WC GRP 4 STD 1 PWR SLING SEAT PT TO and Equal to 300
Durable Medical Equipment (DME)
Y
K0878
PWR WC GRP 4 STD 1 PWR CAPT CHAIR PT TO and Equal to 300
Durable Medical Equipment (DME)
Y
K0879
PWR WC GRP 4 HD 1 PWR SLING SEAT PT 301-450 LBS
Durable Medical Equipment (DME)
Y
K0880
PWR WC GRP 4 V HD 1 PWR SLING SEAT PT 451-600 LB
Durable Medical Equipment (DME)
Y
K0884
PWR WC GRP 4 STD MX PWR SLNG SEAT PT TO and Equal to 300
Durable Medical Equipment (DME)
Y
K0885
PWR WC GRP 4 STD MX PWR CAPT CHR PT TO and Equal to 300
Durable Medical Equipment (DME)
Y
K0886
PWR WC GRP 4 HD MX PWR SLING SEAT PT 301-450 LBS
Durable Medical Equipment (DME)
Y
K0890
PWR WC GRP 5 PED 1 PWR SLING SEAT PT TO and Equal to 125
Durable Medical Equipment (DME)
Y
K0891
PWR WC GRP 5 PED MX PWR SLNG SEAT PT TO and Equal to 125
Durable Medical Equipment (DME)
Y
L4360
WALK BOOT PNEUMAT&/VAC PREFAB CUSTM
Durable Medical Equipment (DME)
Y
L5848
KNEE-SHIN SYSTEM HYDRAULIC STANCE DAMPENING
Durable Medical Equipment (DME)
Y
L8509
TRACH-ESOPHAGEAL VOICE PROSTHESIS INSERTED PR
Durable Medical Equipment (DME)
Y
V5030
HEARING AID MONAURAL BODY WORN AIR CONDUCTION
Durable Medical Equipment (DME)
Y
V5040
HEARING AID MONAURAL BODY WORN BONE CONDUCTION
Durable Medical Equipment (DME)
Y
V5050
HEARING AID MONAURAL IN THE EAR
Durable Medical Equipment (DME)
Y
V5060
HEARING AID MONAURAL BEHIND THE EAR
Durable Medical Equipment (DME)
Y
V5070
GLASSES AIR CONDUCTION
Durable Medical Equipment (DME)
Y
V5080
GLASSES BONE CONDUCTION
Durable Medical Equipment (DME)
Y
V5120
BINAURAL BODY
Durable Medical Equipment (DME)
Y
V5130
BINAURAL IN THE EAR
Durable Medical Equipment (DME)
Y
V5140
BINAURAL BEHIND THE EAR
Durable Medical Equipment (DME)
Y
V5150
BINAURAL GLASSES
Durable Medical Equipment (DME)
Y
V5171
HEARING AID CONTRALAT ROUT DEVICE MONAURAL ITE
Durable Medical Equipment (DME)
Y
V5181
HEARING AID CONTRALATERAL ROUT DVC MONAURAL BTE
Durable Medical Equipment (DME)
Y
V5190
HEARING AID CONTRALATERAL RTE MONAURAL GLASSES
Durable Medical Equipment (DME)
Y
V5211
HEARING AID CONTRALAT ROUT SYS BINAURAL ITE/ITE
Durable Medical Equipment (DME)
Y
V5213
HEARING AID CONTRALAT ROUT SYS BINAURAL ITE/BTE
Durable Medical Equipment (DME)
Y
V5221
HEARING AID CONTRALAT ROUT SYS BINAURAL BTE/BTE
Durable Medical Equipment (DME)
Y
V5230
HEARING AID CONTRALAT RTE SYS BINAURAL GLASSES
Durable Medical Equipment (DME)
Y
V5246
HEARING AID DIGTLLY PROG ANALOG MONAURAL ITE
Durable Medical Equipment (DME)
Y
V5247
HEARING AID DIGTLLY PROG ANALOG MONAURAL BTE
Durable Medical Equipment (DME)
Y
V5252
HEARING AID DIGITALLY PROGRAMMABLE BINAURAL ITE
Durable Medical Equipment (DME)
Y
V5253
HEARING AID DIGITALLY PROGRAMMABLE BINAURAL BTE
Durable Medical Equipment (DME)
Y
V5256
HEARING AID DIGITAL MONAURAL ITE
Durable Medical Equipment (DME)
Y
V5257
HEARING AID DIGITAL MONAURAL BTE
Durable Medical Equipment (DME)
Y
V5260
HEARING AID DIGITAL BINAURAL ITE
Durable Medical Equipment (DME)
Y
V5261
HEARING AID DIGITAL BINAURAL BTE
Durable Medical Equipment (DME)
Y
V5264
EAR MOLD/INSERT NOT DISPOSABLE ANY TYPE
Durable Medical Equipment (DME)
Y
V5266
BATTERY FOR USE IN HEARING DEVICE
Durable Medical Equipment (DME)
Y
94640
PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT
Healthcare Administered Drugs
Y
S9329
HOME INFUSION TX CHEMOTHERAPY INFUSION; PER DIEM
Healthcare Administered Drugs
Y
S9330
HIT CONT CHEMOTHAPY INFUS; CARE COORD PER DIEM
Healthcare Administered Drugs
Y
S9331
HIT INTERMIT CHEMOTHAPY INFUS; CARE COORD-DIEM
Healthcare Administered Drugs
Y
S9335
HOM TX HD; ADMIN PROF PHRM SRVC SPL AND EQP PER DIEM
Healthcare Administered Drugs
Y
S9336
HOME INFUS TX CONT ANTICOAGULANT INFUS TX DIEM
Healthcare Administered Drugs
Y
S9338
HIT IMMUOTHAPY; CARE COORDINATION PER DIEM
Healthcare Administered Drugs
Y
S9345
HOME INFUSION TX ANTI-HEMOPHILIC AGENT; PER DIEM
Healthcare Administered Drugs
Y
S9346
HOME INFUS TX ALPHA-1-PROTEINASE INHIBITOR; DIEM
Healthcare Administered Drugs
Y
S9347
HIT UNINTRPED LNG-TERM CNTRL RATE IV/SUBQ;-DIEM
Healthcare Administered Drugs
Y
S9348
HIT SYMPATHOMIMETIC/INOTROPIC AGENT PER DIEM
Healthcare Administered Drugs
Y
S9349
HOME INFUSION THERAPY TOCOLYTIC; PER DIEM
Healthcare Administered Drugs
Y
S9351
HOME INFUSION THERAPY CONT ANTI-EMETIC; PER DIEM
Healthcare Administered Drugs
Y
S9353
HOME INFUSION THERAPY CONT INSULIN; PER DIEM
Healthcare Administered Drugs
Y
S9355
HOME INFUSION THERAPY CHELATION; PER DIEM
Healthcare Administered Drugs
Y
S9357
HOME INFUSION TX ENZYME REPL IV TX; PER DIEM
Healthcare Administered Drugs
Y
S9359
HIT ANTI-TUMOR NECROS FACTOR IV TX; PER DIEM
Healthcare Administered Drugs
Y
S9361
HOME INFUSION THERAPY DIURETIC IV TX; PER DIEM
Healthcare Administered Drugs
Y
S9363
HIT ANTI-SPASMOTIC TX; CARE SPL AND EQP PER DIEM
Healthcare Administered Drugs
Y
S9364
HIT TOTAL PARENTERAL NUTRITION; CARE COORD DIEM
Healthcare Administered Drugs
Y
S9365
HOM INFUS TX TPN; 1 LITER-DAY DIEM
Healthcare Administered Drugs
Y
S9366
HIT TPN; GT 1 LITER BUT NOT GT 2 LITERS-DA-DIEM
Healthcare Administered Drugs
Y
S9367
HIT TPN; GT 2 LITERS BUT NOT GT 3 LITERS-DA -DIEM
Healthcare Administered Drugs
Y
S9368
HIT TOTAL PARENTERAL NUTRIT; GT 3 LITERS-DA -DIEM
Healthcare Administered Drugs
Y
S9370
HOME THERAPY INTERMITTENT ANTI-EMETIC INJ TX;
Healthcare Administered Drugs
Y
S9372
HOME THERAPY; INTERMITTENT ANTICOAGULANT INJ TX;
Healthcare Administered Drugs
Y
S9373
HOME INFUSION THERAPY HYDRATION TX; PER DIEM
Healthcare Administered Drugs
Y
S9374
HOME INFUSION THERAPY HYDRATION TX; 1 LITER DAY
Healthcare Administered Drugs
Y
S9375
HIT HYDRATION TX; GT 1 LITER NO GT 2 LITERS DAY
Healthcare Administered Drugs
Y
S9376
HIT HYDRATION TX; GT 2 LITERS NO GT 3 LITERS DAY
Healthcare Administered Drugs
Y
S9377
HOME INFUS THERAPY HYDRATION TX; GT 3 LITERS DAY
Healthcare Administered Drugs
Y
S9379
HOME INFUSION THERAPY INFUSION THERAPY NOC; DIEM
Healthcare Administered Drugs
Y
S9490
HIT CORTICOSTEROID INFUS; ADMN SRVC PROF PHRM SR
Healthcare Administered Drugs
Y
S9494
HIT ABX ANTIVIRAL/ANTIFUNGAL THERAPY; PER DIEM
Healthcare Administered Drugs
Y
S9497
HIT ABX ANTIVIRAL/ANTIFUNGAL TX; Q3 HRS DIEM
Healthcare Administered Drugs
Y
S9500
HIT ABX ANTIVIRAL/ANTIFUNGAL TX; Q24 HRS DIEM
Healthcare Administered Drugs
Y
S9501
HIT ABX ANTIVIRAL/ANTIFUNGAL TX; Q12 HRS DIEM
Healthcare Administered Drugs
Y
S9502
HIT ABX ANTIVIRAL/ANTIFUNGAL; Q8 HRS PER DIEM
Healthcare Administered Drugs
Y
S9503
HIT ANTIBIOTC ANTIVIRAL/ANTIFUNGAL; Q6 HRS; DIEM
Healthcare Administered Drugs
Y
S9504
HIT ABX ANTIVIRAL/ANTIFUNGAL; Q4 HRS; PER DIEM
Healthcare Administered Drugs
Y
S9537
HOME TX HEMATOPOIETIC HORMONE INJ TX;PER DIEM
Healthcare Administered Drugs
Y
S9538
HOME TRANSFUSION OF BLOOD PRODUCT; PER DIEM
Healthcare Administered Drugs
Y
S9542
HOME INJ TX NOC W/CARE COORDINATION PER DIEM
Healthcare Administered Drugs
Y
S9558
HIT GROWTH HORMONE W/CARE COORDINATION PER DIEM
Healthcare Administered Drugs
Y
S9559
HIT INTERFERON W/CARE COORDINATION PER DIEM
Healthcare Administered Drugs
Y
S9560
HOME INJECTABLE THERAPY; HORMONAL THERAPY DIEM
Healthcare Administered Drugs
Y
S9562
HOM INJ TX PALIVIZUMAB W/ADMN PHRM CARE-PER DIEM
Healthcare Administered Drugs
Y
S9590
HOM TX IRRIG TX; W/ADMN PHRM SRVC CARE-PER DIEM
Healthcare Administered Drugs
Y
99601
HOME NFS/SPECTY DRUG ADMN PR VST <2 HR
Home Health Care Services
Y
G0156 SRVC HH/HOSPICE AIDE IN HH/HOSPICE SET EA 15 MIN
Home Health Care Services
Y
G0299 DIRECT SNS RN HOME HEALTH/HOSPICE SET EA 15 MIN
Home Health Care Services
Y
G0490 FACE-TO-FACE HH NSG VST RHC/FQHC AREA SHTG HHA
Home Health Care Services
Y
S0250
COMP GERIATRIC ASSESS AND TX PLAN PRFRM ASSESS TEAM
Home Health Care Services
Y
S5035
HOME INFUS THERAPY ROUTINE SERVICE INFUS DEVICE
Home Health Care Services
Y
S5036
HOME INFUSION THERAPY REPAIR OF INFUSION DEVICE
Home Health Care Services
Y
S5108
HOME CARE TRAINING HOME CARE CLIENT PER 15 MIN
Home Health Care Services
Y
S5109
HOME CARE TRAINING HOME CARE CLIENT PER SESSION
Home Health Care Services
Y
S5110
HOME CARE TRAINING FAMILY; PER 15 MINUTES
Home Health Care Services
Y
S5111
HOME CARE TRAINING FAMILY; PER SESSION
Home Health Care Services
Y
S5115
HOME CARE TRAINING NON-FAMILY; PER 15 MINUTES
Home Health Care Services
Y
S5116
HOME CARE TRAINING NON-FAMILY; PER SESSION
Home Health Care Services
Y
S5160
EMERGENCY RESPONSE SYSTEM, INSTALL AND TEST
Home Health Care Services
Y
S5161
EMERGENCY RESPONSE SYSTEM, SERVICE PER MONTH
Home Health Care Services
Y
S5170
HOME DELIVERED MEALS INCLUDING PREPARATION
Home Health Care Services
Y
S9122
HOM HLTH AIDE/CERT NURSE ASST PROV CARE HOM;-HR
Home Health Care Services
Y
S9122
HOM HLTH AIDE/CERT NURSE ASST PROV CARE HOM;-HR
Home Health Care Services
Y
S9123
NURSING CARE THE HOME; REGISTERED NURSE PER HOUR
Home Health Care Services
Y
S9123
NURSING CARE THE HOME; REGISTERED NURSE PER HOUR
Home Health Care Services
Y
S9124
NURSING CARE IN THE HOME; BY LPN PER HOUR
Home Health Care Services
Y
S9124
NURSING CARE IN THE HOME; BY LPN PER HOUR
Home Health Care Services
Y
S9124
NURSING CARE IN THE HOME; BY LPN PER HOUR
Home Health Care Services
Y
S9125
RESPITE CARE IN THE HOME PER DIEM
Home Health Care Services
Y
S9127
SOCIAL WORK VISIT IN THE HOME PER DIEM
Home Health Care Services
Y
S9127
SOCIAL WORK VISIT IN THE HOME PER DIEM
Home Health Care Services
Y
S9128
SPEECH THERAPY IN THE HOME PER DIEM
Home Health Care Services
Y
S9128
SPEECH THERAPY IN THE HOME PER DIEM
Home Health Care Services
Y
S9129
OCCUPATIONAL THERAPY IN THE HOME PER DIEM
Home Health Care Services
Y
S9131
PHYSICAL THERAPY; IN THE HOME PER DIEM
Home Health Care Services
Y
S9348
HOME INFUSION THERAPY SYMPATHOMIM AGENT /DIEM
Home Health Care Services
Y
S9500
HOME INFUSION THERAPY, ANTIBIOTIC Q24H /DIEM
Home Health Care Services
Y
S9501
HOME INFUSION THERAPY, ANTIBIOTIC Q12H /DIEM
Home Health Care Services
Y
A5120
SKIN BARRIER WIPES OR SWABS EACH
Hyperbaric/Wound Therapy
Y
A5121
SKIN BARRIER; SOLID 6 X 6 OR EQUIVALENT EACH
Hyperbaric/Wound Therapy
Y
A5122
SKIN BARRIER; SOLID 8 X 8 OR EQUIVALENT EACH
Hyperbaric/Wound Therapy
Y
A5126
ADHESIVE OR NON-ADHESIVE; DISK OR FOAM PAD
Hyperbaric/Wound Therapy
Y
A6010
COLLAGEN BASED WOUND FILLER DRY FORM STERL PER G
Hyperbaric/Wound Therapy
Y
A6011
COLLEGEN BASED WOUND FILLR GEL/PASTE STERL PER G
Hyperbaric/Wound Therapy
Y
A6021
COLLAGEN DRESSING STERILE SIZE 16 SQ IN/LESS EA
Hyperbaric/Wound Therapy
Y
A6022
COLL DRSG STERL PAD SIZE GT 16 SQ IN BUT/ Equal to 48 SQ E
Hyperbaric/Wound Therapy
Y
A6023
COLLAGEN DRESSING STERILE SIZE GT 48 SQ IN EACH
Hyperbaric/Wound Therapy
Y
A6024
COLLAGEN DRESSING WOUND FILLER STERILE PER 6 IN
Hyperbaric/Wound Therapy
Y
A6196
ALGINAT/OTH FIBER GELL DRESS STERIL PAD 16 SQ OR LT
Hyperbaric/Wound Therapy
Y
A6197
ALGINATE/OTH FIBER GELL DRESS PAD GT 16 LT or equal to 48
Hyperbaric/Wound Therapy
Y
A6198
ALGINATE/OTH FIBER GELL DRESS WND PAD GT 48 SQ EA
Hyperbaric/Wound Therapy
Y
A6199
ALGINATE/OTH FIBER GEL DRESS WND FIL STERL 6 IN
Hyperbaric/Wound Therapy
Y
A6203
COMPOS DRESS STERL PAD 16 SQ OR LT W/ADHES BORDR EA
Hyperbaric/Wound Therapy
Y
A6204
COMPOS DRESS GT 16SQ BUT LT or equal to 48 SQ W/ADHES BO
Hyperbaric/Wound Therapy
Y
A6205
COMPOS DRESS STERL PAD GT 48 SQ W/ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6206
CONTACT LAYER STERL 16 SQ IN/LESS EA DRESSING
Hyperbaric/Wound Therapy
Y
A6207
CNTC LAYER GT 16 SQ BUT LT EQUAL 48 SQ EA DRESSING
Hyperbaric/Wound Therapy
Y
A6208
CONTACT LAYER STERL GT 48 SQ IN EACH DRESSING
Hyperbaric/Wound Therapy
Y
A6209
FOAM DRESS STERL PAD 16 SQ OR LT NO ADHES BORDR EA
Hyperbaric/Wound Therapy
Y
A6210
FOAM DRESS GT 16 BUT LT or equal to 48 SQ W/O ADHES BO
Hyperbaric/Wound Therapy
Y
A6211
FOAM DRESS STERL PAD GT 48 SQ NO ADHES BORDR EA
Hyperbaric/Wound Therapy
Y
A6212
FOAM DRESS STERL PAD SZ 16 SQ OR GT W/ADHES BORDR EA
Hyperbaric/Wound Therapy
Y
A6213
FOAM DRESS GT 16 SQ BUT LT or equal to 48 SQ W/ADHES BO
Hyperbaric/Wound Therapy
Y
A6214
FOAM DRESS STERL PAD SZ GT 48 SQ W/ADHES BORDR EA
Hyperbaric/Wound Therapy
Y
A6216
GAUZE NON-IMPREG NONSTERL 16 SQ OR LT W/O ADHES EA
Hyperbaric/Wound Therapy
Y
A6217
GAUZE NON-IMPREG NONSTERL GT 16 LT or equal to 48 SQ W/O
Hyperbaric/Wound Therapy
Y
A6218
GAUZE NON-IMPREG NONSTERL GT 48 SQ W/O ADHES EA
Hyperbaric/Wound Therapy
Y
A6219
GAUZE NON-IMPREG STERL 16 SQ/LESS W/ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6220
GAUZE NON-IMPREG GT 16 LT or equal to 48 SQ W/ADHES BOR
Hyperbaric/Wound Therapy
Y
A6221
GAUZE NON-IMPREG STERL GT 48 SQ W/ADHES BORDR EA
Hyperbaric/Wound Therapy
Y
A6222
GAUZE IMPREG NOT H2O NL SALINE/HYDROGEL 16 SQ OR LT
Hyperbaric/Wound Therapy
Y
A6223
GAUZE IMPREG NOT H2O SALINE/HYDRGEL GT 16 LT or equal to
Hyperbaric/Wound Therapy
Y
A6224
GAUZE IMPREG NOT H2O NL SALINE/HYDROGEL GT 48 SQ
Hyperbaric/Wound Therapy
Y
A6228
GAUZE IMPREG H2O/NL SALINE STERL GT 16 SQ NO ADHES
Hyperbaric/Wound Therapy
Y
A6229
GAUZE IMPREG H2O/NL SALINE STERL GT 16 BUT LT or equal to
Hyperbaric/Wound Therapy
Y
A6230
GAUZE IMPREG H2O/NL SALINE STERL GT 48 SQ NO ADHES
Hyperbaric/Wound Therapy
Y
A6231
GAUZE IMPREG HYDROGEL DIR WND CNTC STERL 16 SQ OR LT
Hyperbaric/Wound Therapy
Y
A6232
GAUZE IMPREG HYDROGEL DIR WND CNTC GT 16 LT or equal to
Hyperbaric/Wound Therapy
Y
A6233
GAUZE IMPREG HYDROGEL DIR WND CNTC STERL GT 48 SQ
Hyperbaric/Wound Therapy
Y
A6234
HYDROCOLLOID DRESS STERL 16 SQ OR LT NO ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6235
HYDROCOLLOID DRESS GT 16 BUT LT or equal to 48 SQ W/O AD
Hyperbaric/Wound Therapy
Y
A6236
HYDROCOLLOID DRESS STERL GT 48 SQ NO ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6237
HYDROCOLLOID DRESS STERL 16 SQ OR LT ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6238
HYDROCOLLOID DRESS GT 16 BUT LT or equal to 48 SQ W/AD
Hyperbaric/Wound Therapy
Y
A6239
HYDROCOLLOID DRESS STERL GT 48 SQ W/ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6240
HYDROCOLLOID DRESSING WND FIL PASTE STERL PER OZ
Hyperbaric/Wound Therapy
Y
A6241
HYDROCOLLOID DRESS WND FIL DRY FORM STERL PER G
Hyperbaric/Wound Therapy
Y
A6242
HYDROGEL DRESS STERL PAD 16 SQ OR LT NO ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6243
HYDROGEL DRESS GT 16 SQ BUT LT or equal to 48 SQ W/O AD
Hyperbaric/Wound Therapy
Y
A6244
HYDROGEL DRESS STERL PAD GT 48 SQ NO ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6245
HYDROGEL DRESS STERL PAD 16 SQ OR LT ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6246
HYDROGEL DRESS GT 16 SQ BUT LT or equal to 48 SQ W/ADH
Hyperbaric/Wound Therapy
Y
A6247
HYDROGEL DRESS STERL PAD GT 48 SQ ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6248
HYDROGEL DRESSING WOUND FILLER GEL PER FL OZ
Hyperbaric/Wound Therapy
Y
A6251
SPCLTY ABSORB DRESS STERL 16 SQ OR LT NO ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6252
SPCLTY ABSORB DRESS GT 16 LT or equal to 48 SQ W/O ADHES
Hyperbaric/Wound Therapy
Y
A6253
SPCLTY ABSORB DRESS STERL GT 48 SQ NO ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6254
SPCLTY ABSORB DRESS STERL 16 SQ OR LT ADHES BORDR EA
Hyperbaric/Wound Therapy
Y
A6255
SPCLTY ABSORB DRESS STERL GT 16 LT or equal to 48 SQ W/
Hyperbaric/Wound Therapy
Y
A6256
SPCLTY ABSORB DRESS STERL GT 48 SQ ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6257
TRANSPARENT FILM STERL 16 SQ IN OR LESS EA DRESS
Hyperbaric/Wound Therapy
Y
A6258
TRNSPRT FILM STERL GT 16 SQ BUT LT or equal to 48 SQ EA
Hyperbaric/Wound Therapy
Y
A6259
TRANSPARENT FILM STERL GT 48 SQ IN EA DRESSING
Hyperbaric/Wound Therapy
Y
A6261
WOUND FILLER GEL/PASTE PER FL OZ NOS
Hyperbaric/Wound Therapy
Y
A6262
WOUND FILLER DRY FORM PER G NOT OTHERWISE SPEC
Hyperbaric/Wound Therapy
Y
A6266
GAUZE IMPREG NOT H2O SALINE/ZINC PASTE LINR YD
Hyperbaric/Wound Therapy
Y
A6402
GAUZE NON-IMPREG STERL 16 SQ OR LT W/O ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6403
GAUZE NON-IMPREG STERL GT 16 LT or equal to 48 SQ W/O
Hyperbaric/Wound Therapy
Y
A6404
GAUZE NON-IMPREG STERL GT 48 SQ W/O ADHES BORDR
Hyperbaric/Wound Therapy
Y
A6407
PACK STRIPS NON-IMPREGNTD UP 2 IN WDTH-LINR YARD
Hyperbaric/Wound Therapy
Y
A6410
EYE PAD STERILE EACH
Hyperbaric/Wound Therapy
Y
A6411
EYE PAD NON-STERILE EACH
Hyperbaric/Wound Therapy
Y
A6412
EYE PATCH OCCLUSIVE EACH
Hyperbaric/Wound Therapy
Y
A6441
PADD BANDGE NON-ELAST NON-WOVEN/NON-KNITTED WDTH
Hyperbaric/Wound Therapy
Y
A6442
CONFORMING BANDGE NON-ELAST KNITTED/WOVEN NON-ST
Hyperbaric/Wound Therapy
Y
A6443
CONFORMING BANDGE NON-ELAST KNITTED/WOVEN NON-ST
Hyperbaric/Wound Therapy
Y
A6444
CONFORMING BANDGE NON-ELAST KNITTED/WOVEN NON-ST
Hyperbaric/Wound Therapy
Y
A6445
CONFORMING BANDGE NON-ELAST KNITTED/WOVEN STERL
Hyperbaric/Wound Therapy
Y
A6446
CONFORMING BANDGE NON-ELAST KNITTED/WOVEN STERL
Hyperbaric/Wound Therapy
Y
A6447
CONFORMING BANDGE NON-ELAST KNITTED/WOVEN STERL
Hyperbaric/Wound Therapy
Y
A6448
LT COMPRS BANDGE ELAST WDTH LT 3 IN PER YARD
Hyperbaric/Wound Therapy
Y
A6449
LT COMPRS BANDGE ELAST WDTH GT or equal to 3 and LT 5
Hyperbaric/Wound Therapy
Y
A6450
LT COMPRS BANDGE ELAST WDTH GT or equal to 5 IN PER YARD
Hyperbaric/Wound Therapy
Y
A6451
MOD COMPRS BANDGE LOAD RESIST WDTH GT or equal to 3 and
Hyperbaric/Wound Therapy
Y
A6452
HI COMPRS BANDGE LOAD RESIST WDTH GT or equal to 3 and
Hyperbaric/Wound Therapy
Y
A6453
SELF-ADHERENT BANDGE WDTH LT or equal to 3 IN PER YARD
Hyperbaric/Wound Therapy
Y
A6454
SELF-ADHERENT BANDGE WDTH GT or equal to 3 and LT 5
Hyperbaric/Wound Therapy
Y
A6455 A6456 73600 73601 73602 73603 73604 99070 A4216 A4217 A4221 A4222 A4223 A4230 A4231 A4244 A4245 A4246 A4250 A4252 A4253 A4256 A4258 A4259 A4265 A4267 A4268 A4310 A4311 A4314
A4315 A4320 A4322 A4326 A4331
A4332
A4333 A4334 A4338 A4344 A4346 A4351 A4352 A4353 A4354 A4356 A4357 A4358 A4361 A4362 A4363 A4364 A4366 A4367 A4368 A4369 A4371 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 A4402 A4404
SELF-ADHERENT BANDGE WDTH GT or equal to 5 IN PER YARD ZINC PASTE IMPREGNTD BANDGE WDTH GT or equal to 3 and RADIOLOGIC EXAMINATION ANKLE 2 VIEWS RADEX ANKLE COMPLETE MINIMUM 3 VIEWS RADIOLOGIC EXAMINATION FOOT 2 VIEWS RADEX FOOT COMPLETE MINIMUM 3 VIEWS RADEX TOE MINIMUM 2 VIEWS SUPPLIES and MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP STERIL WATER SALINE and OR DXT DILUENT/FLUSH 10 ML STERILE WATER/SALINE 500 ML SUPPLIES FOR MAINT NON-INS RX INFUS CATH PER WK INFUS SPL EXT RX INFUS PUMP CASSETTE/BAG INFUS SPL NOT USED W/EXT INFUS PUMP CASSETTE/BAG INFUS SET EXT INSULIN PUMP NONNDLE CANNULA TYPE INFUSION SET EXTERNAL INSULIN PUMP NEEDLE TYPE 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 BLD GLU TEST/REAGT STRIPS HOME BLD GLU MON-50 NORMAL LOW AND HIGH CALIBRATOR SOLUTION/CHIPS SPRING-POWERED DEVICE FOR LANCET EACH LANCETS PER BOX OF 100 PARAFFIN PER POUND CONTRACEPTIVE SUPPLY CONDOM MALE EACH CONTRACEPTIVE SUPPLY CONDOM FEMALE EACH INSERTION TRAY W/O DRAIN BAG and W/O CATHETER INSRTION TRAY W/O DRN BAG W/CATH 2-WAY LATEX INSRTION TRAY W/DRN BAG W/CATH 2-WAY LATX W/COAT
INSRTION TRAY W/DRN BAG W/CATH2-WAY ALL SILCON IRRIGATION TRAY W/BULB/PISTON SYRINGE ANY PRPOS IRRIGATION SYRINGE BULB OR PISTON EACH MALE EXT CATH W/INTEGRAL CLCT CHAMB ANY TYPE EA EXT DRN TUBING W/CNCTOR/ADAPTR FOR LEG BAG EA
LUBRICANT INDIVIDUAL STERILE PACKET EACH
URIN CATHETER ANCHR DEVICE ADHES SKIN ATTCH EA URINARY CATHETER ANCHORING DEVICE LEG STRAP EACH INDWELL CATH; FOLEY TYPE TWO-WAY LATEX W/COAT EA INDWELL CATH FOLEY TYPE TWO-WAY ALL SILCON EA INDWELL CATH; FOLY TYPE 3-WAY CONT IRRIGATION EA INTERMIT URIN CATH; STRAIGHT TIP W/WO COAT EA INTERMITTENT URINARY CATHETER; COUDE TIP EACH INTERMIT URINARY CATHETER W/INSERTION SUPPLIES INSERTION TRAY W/DRAIN BAG BUT WITHOUT CATHETER EXTERNAL URETHRAL CLAMP/COMPRESSION DEVICE EACH BEDSID DRN BAG DAY/NGT W/WO ANTI-REFLX DEVC EA URINARY LEG BAG; VINYL W/WO TUBE EACH OSTOMY FACEPLATE EACH SKIN BARRIER; SOLID 4 FOUR OR EQUIVALENT; EACH OSTOMY CLAMP ANY TYPE REPLACEMENT ONLY EACH ADHESIVE LIQUID OR EQUAL ANY TYPE PER OUNCE OSTOMY VENT ANY TYPE EACH OSTOMY BELT EACH OSTOMY FILTER ANY TYPE EACH OSTOMY SKIN BARRIER LIQUID PER OZ OSTOMY SKIN BARRIER POWDER PER OZ OST SKIN BARR SOL 4X4/EQUV STD WEAR CONVXITY EA OST SKN BARR W/FLNGE W/BUILT-IN CONVXITY SZ EA OSTOMY POUCH DRAINABLE W/FCEPLATE ATTCH PLSTC EA OSTOMY POUCH DRAINABLE W/FACEPLATE ATTCH RUBR EA OSTOMY POUCH DRAINABLE USE FACEPLATE PLASTIC EA OSTOMY POUCH DRAINABLE USE FACEPLATE RUBBER EACH OSTOMY POUCH URINARY W/FACEPLATE ATTCH PLSTC EA OSTOMY POUCH URINARY W/FACEPLATE ATTCH RUBBER EA OSTOMY POUCH URINARY USE FACEPLATE PLASTIC EACH OSTOMY POUCH URIN USE FACEPLATE HEAVY PLSTC EA OSTOMY POUCH URINARY USE FACEPLATE RUBBER EACH OSTOMY FACEPLATE EQUIVALENT SILICONE RING EACH OST SKN BARRIER SOLID 4X4 EXT W/O CONVXITY EA OSTOMY POUCH CLOSED W/BARR BUILT-IN CONVEXITY EA OST POUCH DRAINABLE W/EXT WEAR BARRIER ATTCH EA OST POUCH DRNABLE W/BARR W/BUILT-IN CONVXITY EA OST POUCH DRNABLE W/EXT BARRIER W/CONVXITY EA OSTOMY POUCH URINARY W/EXT WEAR BARRIER ATTCH EA OST POUCH URIN W/STD WEAR BARRIER W/CONVXITY EA OST POUCH URIN W/EXT WEAR BARRIER W/CONVXITY EA OSTOMY DEODORANT W/WO LUBRICANT POUCH PER FL OZ OSTOMY DEODORANT USE OSTOMY POUCH SOLID PER TAB PERISTOMAL HERNIA SUPPORT BELT IRRIGATION SUPPLY; SLEEVE EACH OSTOMY IRRIGATION SUPPLY; BAG EACH OSTOMY IRRIGATION SUPPLY; CONE/CATH W/WO BRUSH OSTOMY IRRIGATION SET LUBRICANT PER OUNCE LUBRICANT PER OUNCE OSTOMY RING EACH
Hyperbaric/Wound Therapy Hyperbaric/Wound Therapy Imaging & Special Tests Imaging & Special Tests Imaging & Special Tests Imaging & Special Tests Imaging & Special Tests Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies
Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies
Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies
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Y
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Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y PA Required for requests >20 units/3
Y*
months
Y
Y
Y
Y PA Required for requests >180 units/3
Y*
months
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
A4405
OSTOMY SKIN BARRIER NONPECTIN-BASED PASTE-OZ
Medical Supplies
Y
A4406
OSTOMY SKIN BARRIER PECTIN-BASED PASTE PER OUNCE
Medical Supplies
Y
A4407
OST SKN BARRIER W/BUILT-IN CONVXITY 4X4 IN OR LT EA
Medical Supplies
Y
A4408
OST SKN BARRIER W/BUILT-IN CONVXITY GT 4X4 IN EA
Medical Supplies
Y
A4409
OST SKN BARR EXT W/O BUILT-IN CONVXTY 4X4 IN OR LT EA
Medical Supplies
Y
A4410
OST SKN BARR EXT W/O BUILT-IN CONVXITY GT 4X4 IN EA
Medical Supplies
Y
A4411
OST SKN BARRIER SOLID 4X4/EQ W/BUILT-IN CONVXITY
Medical Supplies
Y
A4412
OST POUCH DRNABLE BARRIER W/FLNGE W/O FLTR EA
Medical Supplies
Y
A4414
OST SKN BARRIER W/O BUILT-IN CONVXITY 4X4 IN OR LT EA
Medical Supplies
Y
A4415
OST SKN BARRIER W/O BUILT-IN CONVXITY GT 4X4 IN EA
Medical Supplies
Y
A4416
OSTOMY POUCH CLOSED W/BARRIER ATTCH W/FILTER EA
Medical Supplies
Y
A4417
OST POUCH CLO W/BARRIER ATTCH W/BUILT-IN CONVXIT
Medical Supplies
Y
A4418
OSTOMY POUCH CLOS; W/O BARRIER ATTCH W/FILTER EA
Medical Supplies
Y
A4419
OST POUCH CLOS; BARRIER W/NON-LOCK FLNGE W/FLTR
Medical Supplies
Y
A4420
OSTOMY POUCH CLOS; USE BARRIER W/LOCK FLNGE EA
Medical Supplies
Y
A4422
OST ABSORBNT MATL POUCH THICKEN LQD STOMAL OP EA
Medical Supplies
Y
A4423
OST POUCH CLOS; BARRIER W/LOCK FLNGE W/FLTR EA
Medical Supplies
Y
A4424
OSTOMY POUCH DRAINABLE W/BARRIER ATTCH W/FLTR EA
Medical Supplies
Y
A4425
OST POUCH DRNABL; BARR NON-LOCK FLNGE W/FILTR EA
Medical Supplies
Y
A4426
OST POUCH DRAINABLE; USE BARRIER W/LOCK FLNGE EA
Medical Supplies
Y
A4427
OST POUCH DRNABLE; BARRIER LOCK FLNGE W/FLTR EA
Medical Supplies
Y
A4428
OST POUCH URIN EXT BARR W/FAUCET TAP W/VALVE
Medical Supplies
Y
A4429
OST POUCH URIN BLT-IN CONVXI W/FAUCET TAP VALVE
Medical Supplies
Y
A4430
OST POUCH URIN EXT BARR BLT-IN CNVX FAUCT VLV EA
Medical Supplies
Y
A4431
OST POUCH URIN; W/BARR W/FAUCET TAP W/VALVE EA
Medical Supplies
Y
A4432
OST POUCH URIN;BARR NON-LOCK FLNG FAUCT TAP VALV
Medical Supplies
Y
A4433
OST POUCH URIN; FOR BARR W/LOCKING FLANGE EA
Medical Supplies
Y
A4434
OST POUCH URIN; BARR LOCK FLNG FAUCET TAP VALVE
Medical Supplies
Y
A4435
OST POUCH DRAIN HI OP EXT WEAR BARR W/WO FLTR EA
Medical Supplies
Y
A4554
DISPOSABLE UNDERPADS ALL SIZES
Medical Supplies
Y
A4615
CANNULA NASAL
Medical Supplies
Y
A4616
TUBING PER FOOT
Medical Supplies
Y
A4623
TRACHEOSTOMY INNER CANNULA
Medical Supplies
Y
A4626
TRACHEOSTOMY CLEANING BRUSH EACH
Medical Supplies
Y
A4628
OROPHARYNGEAL SUCTION CATHETER EACH
Medical Supplies
Y
A4927
GLOVES NON-STERILE PER 100
Medical Supplies
Y
A4930
GLOVES STERILE PER PAIR
Medical Supplies
Y
A5051
OSTOMY POUCH CLOSED; WITH BARRIER ATTACHED EACH
Medical Supplies
Y
A5052
OSTOMY POUCH CLOSED; WITHOUT BARRIER ATTACHED EA
Medical Supplies
Y
A5053
OSTOMY POUCH CLOSED; FOR USE ON FACEPLATE EACH
Medical Supplies
Y
A5054
OSTOMY POUCH CLOSED; USE BARRIER W/FLANGE EACH
Medical Supplies
Y
A5055
STOMA CAP
Medical Supplies
Y
A5056
OST POUCH DRAINABLE EXT WEAR BARRIER W/FILTER EA
Medical Supplies
Y
A5057
OST POUCH DRAINABL EXT WEAR BARR CONVXTY FLTR EA
Medical Supplies
Y
A5061
OSTOMY POUCH DRAINABLE; W/BARRIER ATTACHED EACH
Medical Supplies
Y
A5062
OSTOMY POUCH DRAINABLE; WITHOUT BARRIER ATTCH EA
Medical Supplies
Y
A5063
OSTOMY POUCH DRAINABLE; USE BARRIER W/FLANGE EA
Medical Supplies
Y
A5071
OSTOMY POUCH URINARY; WITH BARRIER ATTACHED EACH
Medical Supplies
Y
A5072
OSTOMY POUCH URINARY; WITHOUT BARRIER ATTCH EA
Medical Supplies
Y
A5073
OSTOMY POUCH URINARY; USE BARRIER W/FLANGE EACH
Medical Supplies
Y
A5081
STOMA PLUG OR SEAL ANY TYPE
Medical Supplies
Y
A5082
CONTINENT DEVICE; CATHETER FOR CONTINENT STOMA
Medical Supplies
Y
A5083
CONTINENT DEVICE STOMA ABSORPTIVE COVER STOMA
Medical Supplies
Y
A5093
OSTOMY ACCESSORY; CONVEX INSERT
Medical Supplies
Y
A5105
URINARY SUSPENSORY WITH LEG BAG W/WO TUBE EACH
Medical Supplies
Y
A5112
URINARY DRAINAGE BAG LEG OR ABDOMEN LATEX EACH
Medical Supplies
Y
A5113
LEG STRAP; LATEX REPLACEMENT ONLY PER SET
Medical Supplies
Y
A5114
LEG STRAP; FOAM/FABRIC REPLACEMENT ONLY PER SET
Medical Supplies
Y
A5131
APPLINC CLNR INCONT AND OSTOMY APPLINCS PER 16 OZ
Medical Supplies
Y
A5200
PERCUT CATH/TUBE ANCHR DEVICE ADHES SKIN ATTCH
Medical Supplies
Y
A6550
NEG PRESSURE WOUND THERAPY DRESSING SET, EACH
Medical Supplies
Y
A7002
TUBING USED WITH SUCTION PUMP EACH
Medical Supplies
Y
A7038
FILTER DISPBL USED W/POS ARWAY PRESSURE DEVICE
Medical Supplies
Y
A7048
VACUUM DRAINAGE COLLECTION UNIT AND TUBING KIT EA
Medical Supplies
Y
A7520
TRACHEOST/LARYNGECT TUBE NON-CUFFED POLYVINYLCHL
Medical Supplies
Y
A7521
TRACHEOST/LARYNGECT TUBE CUFFD PVC SILICONE/ Equal to EA
Medical Supplies
Y
A7523
TRACHEOSTOMY SHOWER PROTECTOR EACH
Medical Supplies
Y
A9273
COLD/HOT FL BTL ICE CAP/C HEAT and / COLD WRAP ANY
Medical Supplies
Y
S5497
HOME INFUS TX CATH CARE/MAINT NOC; PER DIEM
Medical Supplies
Y
S5498
HOME INFUS TX CATH CARE/MAINT SIMPLE PER DIEM
Medical Supplies
Y
S5501
HOME INFUS TX CATH CARE/MAINT COMPLEX PER DIEM
Medical Supplies
Y
S5502
HOME INFUS TX CATH CARE IMPL ACCESS DEVC DIEM
Medical Supplies
Y
S5517
HIT ALL SPL NECES RESTOR CATH PATENCY/DECLOT
Medical Supplies
Y
S5518
HOME INFUSION THERAPY ALL SPL NECES CATH REPAIR
Medical Supplies
Y
S5520
HOME INFUSION TX ALL SPL NECES PICC LINE INSERT
Medical Supplies
Y
S5521
HOME INFUS TX ALL SPL NECES MIDLINE CATH INSERT
Medical Supplies
Y
S5522
HOME INFUS TX INSERT PICC NRS SRVC ONLY
Medical Supplies
Y
S5523
HOME INFUS TX INSERT MIDLINE CVC NRS SRVC ONLY
Medical Supplies
Y
S9339
HOME THERAPY; PERITONEAL DIALYSIS PER DIEM
Medical Supplies
Y
S9340
HOME THERAPY; ENTERAL NUTRITION; PER DIEM
Medical Supplies
Y
S9341
HOME TX; ENTERAL NUTRITION VIA GRAVITY; PER DIEM
Medical Supplies
Y
S9342
HOME TX; ENTERAL NUTRITION VIA PUMP; PER DIEM
Medical Supplies
Y
S9343
HOME TX; ENTERAL NUTRITION VIA BOLUS; PER DIEM
Medical Supplies
Y
S9810
HOME THERAPY; NOT OTHERWISE CLASSIFIED PER HOUR
Medical Supplies
Y
T4521
ADLT SIZED DISPBL INCONT PROD BRF/DIAPER SM EA
Medical Supplies
Y
T4522
ADLT SIZED DISPBL INCONT PROD BRF/DIAPER MED EA
Medical Supplies
Y
T4523
ADLT SIZED DISPBL INCONT PROD BRF/DIAPER LG EA
Medical Supplies
Y
T4524
ADLT SZD DISPBL INCONT PROD BRF/DIAPER X-LG EA
Medical Supplies
Y
T4529 T4530 T4533 T4535 T4537 T4539 T4540 T4543 97542 10060 10061 10120 10121 10140 10160 11420 11421 11422 11423 11720 11721 11730 11732 11740 11750 11755 12001 12002 12004 12005 12020 16000 17000 17003 17004 17110 17111 17250 20600 20612 28001 28008 28010 28011 28020 28022 28024 28090 28092 28100 28104 28280 28285 28292 28302 28304 28306 28308 28310 28312 28315 28450 28455 28470 28475 28490 28495 28510 28515 28630 28635 28660 28665 28805 28810 28820 28825 29240 29405 29425 29580 64450 64455 64632 64776 64778 64782 64783
PED SZD DISPBL INCONT PROD BRF/DIAPER SM/MED EA PED SZD DISPBL INCONT PROD BRF/DIAPER LG SZ EA YOUTH SIZED DISPBL INCONT PRODUCT BRF/DIAPER EA DISPBL LINER/SHIELD/GUARD/PAD/UNDGRMNT INCONT EA INCONT PROD PROTVE UNDPAD REUSABLE BED SIZE EA INCONTINENCE PRODUCT DIAPER/BRF REUSABLE SIZE EA INCONT PROD PROTVE UNDPAD REUSABLE CHAIR SIZE EA ADULT SIZE DISP INCONTINENCE PROD ABOVE XL EA WHEELCHAIR MGMT EA 15 MIN INCISION and DRAINAGE ABSCESS SIMPLE/SINGLE INCISION and DRAINAGE ABSCESS COMPLICATED/MULTIPLE INCISION AND REMOVAL FOREIGN BODY SUBQ TISS SIMPLE INCISION AND REMOVAL FOREIGN BODY SUBQ TISS COMPL I and D HEMATOMA SEROMA/FLUID COLLECTION PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.5 CM OR LT EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 2.1-3.0CM DEBRIDEMENT NAIL ANY METHOD 1-5 DEBRIDEMENT NAIL ANY METHOD 6 OR GT AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL EVACUATION SUBUNGUAL HEMATOMA EXCISION NAIL MATRIX PERMANENT REMOVAL BIOPSY NAIL UNIT SEPARATE PROCEDURE SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM OR LT SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE INITIAL TX 1ST DEGREE BURN LOCAL TX DESTRUCTION PREMALIGNANT LESION 1ST DESTRUCTION PREMALIGNANT LESION 2-14 EA DESTRUCTION PREMALIGNANT LESION 15 OR GT DESTRUCTION BENIGN LESIONS UP TO 14 DESTRUCTION BENIGN LESIONS 15 OR GT CHEMICAL CAUTERIZATION OF GRANULATION TISSUE ARTHROCENTESIS ASPIR and /INJ SMALL JT/BURSA W/O US ASPIRATION and /INJECTION GANGLION CYST ANY LOCATJ INCISION AND DRAINAGE BURSA FOOT FASCIOTOMY FOOT and /TOE TENOTOMY PERCUTANEOUS TOE SINGLE TENDON TENOTOMY PERCUTANEOUS TOE MULTIPLE TENDON ARTHRT W/EXPL DRG/RMVL LOOSE/FB NTRTRSL/TARS JT ARTHRT W/EXPL DRG/RMVL LOOSE/FB MTTARPHLNGL JT ARTHRT W/EXPL DRG/RMVL LOOSE/FB IPHAL JT EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT FOOT EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT TOE EA EXCISION/CURETTAGE CYST/TUMOR TALUS/CALCANEUS EXC/CURTG BONE CYST/B9 TUMORTARSAL/METATARSAL SYNDACTYLIZATION TOES CORRECTION HAMMERTOE CORRJ HALLUX VALGUS W/SESMDC W/RESCJ PROX PHAL OSTEOTOMY TALUS OSTEOTOMY TARSAL BONES OTH/THN CALCANEUS/TALUS OSTEOT W/WO LNGTH SHRT/CORRJ 1ST METAR OSTEOT W/WO LNGTH SHRT/CORRJ METAR XCP 1ST EA OSTEOT SHRT CORRJ PROX PHALANX 1ST TOE OSTEOT SHRT CORRJ OTH PHALANGES ANY TOE SESAMOIDECTOMY FIRST TOE SPX TX TARSAL BONE FX XCP TALUS and CALCN W/O MANJ TX TARSAL BONE FX XCP TALUS and CALCN W/MANJ CLOSED TX METATARSAL FRACTURE W/O MANIPULATION CLTX METAR FX W/MANJ CLTX FX GRT TOE PHLX/PHLG W/O MANJ CLTX FX GRT TOE PHLX/PHLG W/MANJ CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MANJ CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ CLTX METATARSOPHLNGL JT DISLC W/O ANES CLTX METATARSOPHLNGL JT DISLC REQ ANES CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES CLTX INTERPHALANGEAL JOINT DISLOCATION REQ ANES AMPUTATION FOOT TRANSMETARSAL AMPUTATION METATARSAL W/TOE SINGLE AMPUTATION TOE METATARSOPHALANGEAL JOINT AMPUTATION TOE INTERPHALANGEAL JOINT STRAPPING SHOULDER APPLICATION SHORT LEG CAST BELOW KNEE-TOE APPLICATION SHORT LEG CAST WALKING/AMBULATORY STRAPPING UNNA BOOT INJECTION AA and /STRD OTHER PERIPHERAL NERVE/BRANCH NJX AA and /STRD PLANTAR COMMON DIGITAL NERVES DSTRJ NEUROLYTIC PLANTAR COMMON DIGITAL NERVE EXC NEUROMA DIGITAL NERVE 1 OR BOTH SAME DIGIT EXCISION NEUROMA DIGITAL NRV EA ADDL DIGIT EXC NEUROMA HAND/FOOT XCP DIGITAL NERVE EXC NEUROMA HAND/FOOT EA NRV XCP SM DGT
Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Medical Supplies Occupational Therapy OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures OP Hosp/Amb Surgery Center (ASC) Procedures
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
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Podiatry Only
Y
Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
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Y
Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
97810 S9325 S9326 S9327 S9328 99509 S5120 S5121 S5125 S5126 S5130 S5130 S5131 S5135 S5136 S5140 S5141 S5150 S5151 97018 97022 97032 97033 97035 97110 97112 97113 97140 97162 97530 97750 97760 97763 A5500 A5501 A5503 A5504 A5505 A5506 A5507 A5512 A5513 A5514 92507 92526 A0100 A0110 A0120 A0130 A0160 A0170 A0420 A0422 A0424 A0425 A0426 A0428 A0999 S0209 S0215 T2003 T2004 T2005 T2038 T2039 T2049 28899 73605 73606 73607 73608 73609 73610 73611 73612 73613 73614 73615 92551 92551 92557 94660 94760 97028 97803 99202 99203 99204
ACUPUNCT W/O STIMUL 15 MIN HIT PAIN MANAGEMENT INFUSION; PER DIEM HIT CONT PAIN MGMT INFUS; CARE COORD PER DIEM HIT INTERMIT PAIN MGMT INFUS; CARE COORD DIEM HIT IMPLANTED PUMP PAIN MGMT INFUS; PER DIEM HOME VISIT ASSISTANCE DAILY LIV AND PRSONAL CARE CHORE SERVICES; PER 15 MINUTES CHORE SERVICES; PER DIEM ATTENDANT CARE SERVICES; PER 15 MINUTES ATTENDANT CARE SERVICES; PER DIEM HOMEMAKER SERVICE NOS; PER 15 MINUTES HOMEMAKER SERVICE NOS; PER 15 MINUTES HOMEMAKER SERVICE NOS; PER DIEM COMPANION CARE ADULT ; PER 15 MINUTES COMPANION CARE ADULT ; PER DIEM FOSTER CARE ADULT; PER DIEM FOSTER CARE ADULT; PER MONTH UNSKILLED RESPITE CARE NOT HOSPICE; PER 15 MIN UNSKILLED RESPITE CARE NOT HOSPICE; PER DIEM APPL MODALITY 1 OR GT AREAS PARAFFIN BATH APPLICATION MODALITY 1 OR GT AREAS WHIRLPOOL APPL MODALITY 1 OR GT AREAS ELEC STIMJ EA 15 MIN APPL MODALITY 1 OR GT AREAS IONTOPHORESIS EA 15 MIN APPL MODALITY 1 OR GT AREAS ULTRASOUND EA 15 MIN THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCAJ THER PX 1 OR GT AREAS EACH 15 MIN AQUA THER W/XERSS MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES PT EVAL MOD COMPLEX 30 MIN THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN PHYSICAL PERFORMANCE TEST MEAS W REPRT EA 15 MIN ORTHOTICS MGMT AND TRAING INITIAL ENCTR EA 15 MINS ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN DIAB ONLY FIT CSTM PREP AND SPL SHOE MX DNSITY INSRT DIAB ONLY FIT CSTM PREP AND SPL SHOE MOLD PTS FT DIAB ONLY MOD SHOE/CSTM MOLD ROLLER/ROCKR BOTTOM DIAB ONLY MOD SHOE/CSTM MOLD SHOE W/WEDGE SHOE DIAB ONLY MOD SHOE/CSTM MOLD SHOE W/MT BAR SHOE DIAB ONLY MOD SHOE/CSTM MOLD SHOE W/OFF SET HEEL DIAB ONLY NOS MOD SHOE/CSTM MOLD SHOE PER SHOE FOR DIAB ONLY MX DNSITY INSRT DIR FORMD PRFAB EA DIA ONLY MX DEN INSRT CSTM FRM MDL PT FT CF EA DIAB ONLY MX DEN INSRT DIRECT CARV CUSTOM FAB EA TX SPEECH LANG VOICE COMMJ and /AUDITORY PROC IND TX SWALLOWING DYSFUNCTION&/ORAL FUNCJ FEEDING NONEMERGENCY TRANSPORTATION; TAXI NONEMERG TRNSPRT and BUS INTRA-/INTERSTATE CARRIER NONEMERG TRNSPRT: MINI-BUS MTN AREA/OTH SYS NONEMERGENCY TRANSPORTATION: WHEELCHAIR VAN NONEMERG TRNSPRT: PER MILE-CASE/SOCIAL WORKER TRANSPORTATION ANCILLARY: PARKING FEES TOLLS OTH AMBULANCE WAITING TIME ONE-HALF HOUR INCREMENTS AMB OXYGEN AND O2 SUPPLIES LIFE SUSTAINING SITUATION EXTRA AMBULANCE ATTENDANT GROUND OR AIR ; GROUND MILEAGE PER STATUTE MILE AMB SERVICE ALS NONEMERGENCY TRANSPORT LEVEL 1 AMBULANCE SERVICE BLS NONEMERGENCY TRANSPORT UNLISTED AMBULANCE SERVICE WHEELCHAIR VAN MILEAGE PER MILE NON-EMERGENCY TRANSPORTATION; PER MILE NON-EMERGENCY TRANSPORTION, ENCOUNTER/TRIP NON-EMERG TRNSPRT; COMMERCIAL CARRIER MULTI-PASS NONEMERGENCY TRANSPORTATION; STRETCHER VAN COMMUNITY TRANSITION WAIVER; PER SERVICE VEHICLE MODIFICATIONS WAIVER; PER SERVICE NON-EMERG TRNSPRT; STRETCHER VAN MILEAGE; MILE UNLISTED PROCEDURE FOOT/TOES URINLS DIP STICK/TABLET REAGNT NON-AUTO MICRSCPY URNLS DIP STICK/TABLET RGNT NON-AUTO W/O MICRSCP URINALYSIS MICROSCOPIC ONLY BLOOD COUNT SMEAR MCRSCP W/MNL DIFRNTL WBC COUNT BLOOD COUNT SPUN MICROHEMATOCRIT BLOOD COUNT HEMOGLOBIN BLOOD COUNT COMPLETE AUTO AND AUTO DIFRNTL WBC BLOOD COUNT RED BLOOD CELL AUTOMATED BLOOD COUNT LEUKOCYTE WBC AUTOMATED SEDIMENTATION RATE RBC NON-AUTOMATED SEDIMENTATION RATE RBC AUTOMATED SCREENING TEST PURE TONE AIR ONLY SCREENING TEST PURE TONE AIR ONLY COMPRE AUDIOMETRY THRESHOLD EVAL SP RECOGNIJ CPAP VENTILATION CPAP INITIATION&MGMT NONINVASIVE EAR/PULSE OXIMETRY SINGLE DETER APPL MODALITY 1 OR GT AREAS ULTRAVIOLET MEDICAL NUTRITION RE-ASSMT&IVNTJ INDIV EA 15 MIN OFFICE/OUTPATIENT NEW SF MDM 15-29 MINUTES OFFICE/OUTPATIENT NEW LOW MDM 30-44 MINUTES OFFICE/OUTPATIENT NEW MODERATE MDM 45-59 MINUTES
Pain Management Procedures Pain Management Procedures Pain Management Procedures Pain Management Procedures Pain Management Procedures Personal Care Services Personal Care Services Personal Care Services Personal Care Services Personal Care Services Personal Care Services Personal Care Services Personal Care Services Personal Care Services Personal Care Services Personal Care Services Personal Care Services Personal Care Services Personal Care Services Physical Therapy Physical Therapy Physical Therapy Physical Therapy Physical Therapy Physical Therapy Physical Therapy Physical Therapy Physical Therapy Physical Therapy Physical Therapy Physical Therapy Physical Therapy Prosthetics & Orthotics Prosthetics & Orthotics Prosthetics & Orthotics Prosthetics & Orthotics Prosthetics & Orthotics Prosthetics & Orthotics Prosthetics & Orthotics Prosthetics & Orthotics Prosthetics & Orthotics Prosthetics & Orthotics Prosthetics & Orthotics Speech Therapy Speech Therapy Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Transportation Services Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
No PA for initial eval
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Podiatry Only
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Podiatry Only
Y
Podiatry Only
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Podiatry Only
99205 99211 99212 99213 99214 99215 99231 99232 99233 99238 99239 99304 99305 99306 99307 99308 99309 99310 99324 99325 99326 99327 99328 99334 99335 99336 99337 99341 99342 99343 99344 99345 99347 99348 99349 99350 A4913 B4154 E1399 G0108 H0043 H2014 K0108 K0898 S5102 S5105 S5165 S5175 S5180 S5181 S5185 S5190 S5199 S9470 S9529 T1001 T1013 T1014 T1016 T1019 T1020 T1028 T1030 T1031 T5999 V5010 V5014 V5020 V5160 V5200 V5240 V5241 V5267 V5299
OFFICE/OUTPATIENT NEW HIGH MDM 60-74 MINUTES OFFICE/OUTPATIENT ESTABLISHED MINIMAL PROBLEM(S) OFFICE/OUTPATIENT ESTABLISHED SF MDM 10-19 MIN OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20-29 MIN OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30-39 MIN OFFICE/OUTPATIENT ESTABLISHED HIGH MDM 40-54 MIN SBSQ HOSPITAL CARE/DAY 15 MINUTES SBSQ HOSPITAL CARE/DAY 25 MINUTES SBSQ HOSPITAL CARE/DAY 35 MINUTES HOSPITAL DISCHARGE DAY MANAGEMENT 30 MIN OR LT HOSPITAL DISCHARGE DAY MANAGEMENT GT 30 MIN INITIAL NURSING FACILITY CARE/DAY 25 MINUTES INITIAL NURSING FACILITY CARE/DAY 35 MINUTES INITIAL NURSING FACILITY CARE/DAY 45 MINUTES SBSQ NURSING FACILITY CARE/DAY E/M STABLE 10 MIN SBSQ NURSING FACIL CARE/DAY MINOR COMPLJ 15 MIN SBSQ NURSING FACIL CARE/DAY NEW PROBLEM 25 MIN SBSQ NURS FACIL CARE/DAY UNSTABL/NEW PROB 35 MIN DOMICIL/REST HOME NEW PT VISIT LOW SEVER 20 MIN DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN DOMICIL/REST HOME NEW PT HI-MOD SEVER 45 MINUTES DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES HOME VISIT NEW PATIENT LOW SEVERITY 20 MINUTES HOME VISIT NEW PATIENT MOD SEVERITY 30 MINUTES HOME VST NEW PATIENT MOD-HI SEVERITY 45 MINUTES HOME VISIT NEW PATIENT HI SEVERITY 60 MINUTES HOME VISIT NEW PT UNSTABL/SIGNIF NEW PROB 75 MIN HOME VISIT EST PT SELF LIMITED/MINOR 15 MINUTES HOME VISIT EST PT LOW-MOD SEVERITY 25 MINUTES HOME VISIT EST PT MOD-HI SEVERITY 40 MINUTES HOME VST EST PT UNSTABLE/SIGNIF NEW PROB 60 MINS ESRD SUPPLY MISCELLANEOUS, NOC ENTRAL F NUTRITION CMPL NO INHERITED DZ METAB DURABLE MEDICAL EQUIPMENT MISCELLANEOUS DIABETES OUTPT SELF-MGT SVCS, INDIV PER 30 MN SUPPORTED HOUSING PER DIEM SKILLS TRAINING AND DEVELOPMENT PER 15 MINUTES OTHER ACCESSORIES POWER WHEELCHAIR NOT OTHERWISE CLASSIFIED DAY CARE SERVICES ADULT; PER DIEM DAY CARE SRVC CENTER-BASED; SRVC NOT W/PROGM FEE HOME MODIFICATIONS; PER SERVICE LAUNDRY SERVICE EXTERNAL PROFESSIONAL; PER ORDER HOME HEALTH RESPIRATORY THERAPY INIT EVALUATION HOME HEALTH RESPIRATORY THERAPY NOS PER DIEM MED REMINDER SERVICE NON-FACE-TO-FACE; MONTH WELLNESS ASSESSMENT PERFORMED BY NONPHYSICIAN PERSONAL CARE ITEM NOS EACH NUTRITIONAL COUNSELING DIETITIAN VISIT HOME OR SKILLED NURSING FACILITY PATIENT NURSING ASSESSMENT/EVALUATION SIGN LANGUAGE/ORAL INTEPR SERVICES PER 15 MIN TELEHEALTH TRANSMISSION, PER MIN PROF SERVICE CASE MANAGEMENT EACH 15 MINS PERSONAL CARE SERVICES PER 15 MINUTES PERSONAL CARE SERVICES PER DIEM ASSESSMENT HOME PHYSICAL AND FAMILY ENVIRONMENT NURSING CARE THE HOME REGISTERED NURSE PER DIEM NURSING CARE IN THE HOME BY LPN PER DIEM SUPPLY NOT OTHERWISE SPECIFIED ASSESSMENT FOR HEARING AID REPAIR/MODIFICATION OF A HEARING AID CONFORMITY EVALUATION DISPENSING FEE BINAURAL DISPENSING FEE CONTRALATERAL MONAURAL DISPENSING FEE CONTRALATERAL RTE SYSTEM BINAURAL DISPENSING FEE MONAURAL HEARING AID ANY TYPE HEARING AID/ALD/SUPP/ACCESS NOT OTHERWISE SPEC HEARING SERVICE MISCELLANEOUS
Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous Unlisted/Miscellaneous
Y
Podiatry Only
Y
Podiatry Only
Y
Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
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Podiatry Only
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Adobe PDF Library 20.1.68
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