Durable And Home Medical Equipment Codes

Indiana Health Coverage ProgramsDurable and Home Medical Equipment and Supplies CodesTable 1 – Covered Procedure Codes for Durable Medical Equipment (DME) Providers(Specialty 250)Reviewed/Updated: January 1, 2022Procedure CodeDescriptionA4381Ostomy pouch, urinary, for use on faceplate, plastic, eachA4382Ostomy pouch, urinary, for use on faceplate, heavy plastic, eachA4383Ostomy pouch, urinary, for use on faceplate, rubber, eachA4384Ostomy faceplate equivalent, silicone ring, eachA4385Ostomy skin barrier, solid 4x4 or equivalent, extended wear, without built-in convexity, eachA4387Ostomy pouch closed, with barrier attached, with built-in convexity (1 piece), eachA4388Ostomy pouch, drainable, with extended wear barrier attached, (one piece) eachA4389Ostomy pouch, drainable, with barrier attached, with built-in convexity (one piece), eachA4390Ostomy pouch, drainable, with extended wear barrier attached with built-in convexity(1 piece), eachA4391Ostomy pouch, urinary, with extended wear barrier attached, (1 piece), eachA4392Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (1 piece),eachA4393Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity(1 piece), eachA4394Ostomy deodorant for use in ostomy pouch, liquid, per fluid ozA4395Ostomy deodorant for use in ostomy pouch, solid, per tabletA4396Ostomy belt with peristomal hernia supportA4398Ostomy irrigation supply; bag, eachA4399Ostomy irrigation supply; cone/catheter, including brushA4400Ostomy irrigation setA4402Lubricant, per oz.A4404Ostomy ring, eachA4405Ostomy skin barrier, non-pectin based, paste, per oz.A4406Ostomy skin barrier, pectin-based, paste, per oz.A4407Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-inconvexity, 4 x 4 inches or smaller, eachA4408Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-inconvexity, larger than 4 x 4 inches, eachA4409Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without builtin convexity, 4 x 4 inches or smaller, eachA4410Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without builtin convexity, larger than 4 x 4 inches, eachA4411Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, with built-in convexity, eachA4412Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system),without filter, eachA4413Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), withfilter, eachA4414Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity,4 x 4 inches or smaller, eachPublished: February 15, 20225

Indiana Health Coverage ProgramsDurable and Home Medical Equipment and Supplies CodesTable 1 – Covered Procedure Codes for Durable Medical Equipment (DME) Providers(Specialty 250)Reviewed/Updated: January 1, 2022Procedure CodeDescriptionA4415Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity,larger than 4 x 4 inches, eachA4416Ostomy pouch, closed, with barrier attached, with filter (one piece), eachA4417Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (one piece),eachA4418Ostomy pouch, closed; without barrier attached, with filter (one piece), eachA4419Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), eachA4420Ostomy pouch, closed; for use on barrier with locking flange (two piece), eachA4421Ostomy supply; miscellaneousA4422Ostomy absorbent material (sheet/pad/crystal packet) for use in ostomy pouch to thickenliquid stomal output, eachA4423Ostomy pouch, closed; for use on barrier with locking flange, with filter (two piece), eachA4424Ostomy pouch, drainable, with barrier attached, with filter (one piece), eachA4425Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (two piecesystem), eachA4426Ostomy pouch, drainable; for use on barrier with locking flange ( piece system), eachA4427Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece system),eachA4428Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve(one piece), eachA4429Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tapwith valve (one piece), eachA4430Ostomy pouch, urinary, with extended wear barrier attached, with built- in convexity, withfaucet -type tap with valve (one piece), eachA4431Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (one piece),eachA4432Ostomy pouch, urinary; for use on barrier with non-locking flange, with faucet-type tap withvalve (two piece), eachA4433Ostomy pouch, urinary; for use on barrier with locking flange (two piece), eachA4434Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap withvalve (two piece), eachA4435Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), withor without filter, eachA4436Irrigation supply; sleeve, reusable, per monthA4437Irrigation supply; sleeve, disposable, per monthA4450Tape, non-waterproof, per 18 square inchesA4452Tape, waterproof, per 18 square inchesA4453Rectal catheter for use with the manual pump-operated enema system, replacement onlyA4455Adhesive remover or solvent (for tape, cement or other adhesive), per ounceA4456Adhesive remover, wipes, any type, eachPublished: February 15, 20226

Indiana Health Coverage ProgramsDurable and Home Medical Equipment and Supplies CodesTable 1 – Covered Procedure Codes for Durable Medical Equipment (DME) Providers(Specialty 250)Reviewed/Updated: January 1, 2022Procedure CodeDescriptionA4458Enema bag with tubing, reusableA4459Manual pump-operated enema system, includes balloon, catheter and all accessories,reusable, any typeA4461Surgical dressing holder, non-reusable, eachA4463Surgical dressing holder, reusable, eachA4467Belt, strap, sleeve, garment, or covering, any typeA4481Tracheostoma filter, any type, any size, eachA4483Moisture exchanger, disposable, for use with invasive mechanical ventilationA4490Surgical stockings above knee length, eachA4495Surgical stockings thigh length, eachA4500Surgical stockings below knee length, eachA4510Surgical stockings full length, eachA4555Electrode/transducer for use with electrical stimulation device used for cancer treatment,replacement onlyA4556Electrodes, (e.g., apnea monitor), per pairA4557Lead wires, (e.g., apnea monitor), per pairA4558Conductive paste or gelA4561Pessary, rubber, any typeA4562Pessary, non rubber, any typeA4565SlingsA4566Shoulder sling or vest design, abduction restrainer, with or without swathe control,prefabricated, includes fitting and adjustmentA4570SplintA4595Electrical stimulator supplies 2 lead, per month (e.g., TENS, NMES)A4601Lithium ion battery for non-prosthetic use, replacementA4602Replacement battery for external infusion pump owned by patient, lithium, 1.5 volt, eachA4604Lithium ion battery for non-prosthetic use, replacementA4605Tracheal suction catheter, closed system, eachA4606Oxygen probe for use with oximeter device, replacementA4608Transtracheal oxygen catheter, eachA4611Battery, heavy duty; replacement for patient owned ventilatorA4612Battery cables; replacement for patient-owned ventilatorA4613Battery charger; replacement for patient-owned ventilatorA4614Peak expiratory flow rate meter, hand heldA4615Cannula, nasalA4616Tubing, (oxygen), per footA4617MouthpieceA4618Breathing circuitsPublished: February 15, 20227

Indiana Health Coverage ProgramsDurable and Home Medical Equipment and Supplies CodesTable 1 – Covered Procedure Codes for Durable Medical Equipment (DME) Providers(Specialty 250)Reviewed/Updated: January 1, 2022Procedure CodeDescriptionA4619Face tentA4620Variable concentration maskA4623Tracheostomy, inner cannulaA4624Tracheal suction catheter, any type other than closed system, eachA4625Tracheostomy care kit for new tracheostomyA4626Tracheostomy cleaning brush, eachA4627Spacer, bag or reservoir, with or without mask, for use with metered dose inhalerA4628Oropharyngeal suction catheter, eachA4629Tracheostomy care kit for established tracheostomyA4630Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned bypatientA4633Replacement bulb/lamp for ultraviolet light therapy system, eachA4634Replacement bulb for therapeutic light box, tabletop modelA4635Underarm pad, crutch, replacement, eachA4636Replacement, handgrip, cane, crutch, or walker, eachA4637Replacement, tip, cane, crutch, walker, eachA4638Replacement battery for patient-owned ear pulse generator, eachA4639Replacement pad for infrared heating pad system, eachA4640Replacement pad for use with medically necessary alternating pressure pad owned by patientA4649Surgical supply; miscellaneousA4653Peritoneal dialysis catheter anchoring device, belt, eachA4660Sphygmomanometer/blood pressure apparatus with cuff and stethoscopeA4663Blood pressure cuff onlyA4670Automatic blood pressure monitorA4870Plumbing and/or electrical work for home hemodialysis equipmentA4913Miscellaneous dialysis supplies, not otherwise specifiedA4918Venous pressure clamp, for hemodialysis, eachA4927Gloves, non-sterile, per 100A4930Gloves, sterile, per pairA5051Ostomy pouch, closed; with barrier attached (one piece), eachA5052Ostomy pouch, closed; without barrier attached (one piece), eachA5053Ostomy pouch, closed; for use on faceplate, eachA5054Ostomy pouch, closed; for use on barrier with flange (two piece), eachA5055Stoma capA5056Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), eachA5057Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, withfilter, (1 piece), eachA5061Ostomy pouch, drainable; with barrier attached (one piece), eachPublished: February 15, 20228

Indiana Health Coverage ProgramsDurable and Home Medical Equipment and Supplies CodesTable 1 – Covered Procedure Codes for Durable Medical Equipment (DME) Providers(Specialty 250)Reviewed/Updated: January 1, 2022Procedure CodeDescriptionA5062Ostomy pouch, drainable; without barrier attached (one piece), eachA5063Ostomy pouch, drainable; for use on barrier with flange (two piece system), eachA5071Ostomy pouch, urinary; with barrier attached (one piece), eachA5072Ostomy pouch, urinary; without barrier attached (one piece), eachA5073Ostomy pouch, urinary; for use on barrier with flange (two piece), eachA5081Continent device; plug for continent stomaA5082Continent device; catheter for continent stomaA5083Continent device, stoma absorptive cover for continent stomaA5093Ostomy accessory; convex insertA5102Bedside drainage bottle, with or without tubing, rigid or expandable, eachA5105Urinary suspensory; with leg bag, with or without tubeA5112Urinary leg bag; latexA5113Leg strap; latex, replacement only, per setA5114Leg strap; foam or fabric, replacement only, per setA5120Skin barrier, wipes or swabs, eachA5121Skin barrier; solid, 6 x 6 or equivalent, eachA5122Skin barrier; solid, 8 x 8 or equivalent, eachA5126Adhesive or non-adhesive; disc or foam padA5131Appliance cleaner, incontinence and ostomy appliances, per 16 ozA5200Percutaneous catheter/tube anchoring device, adhesive skin attachmentA5500For diabetics only, fitting (including follow-up) custom preparation and supply of off-theshelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoeA5501For diabetics only, fitting (including follow-up) custom preparation and supply of shoemolded from cast(s) of patient’s foot (custom molded shoe), per shoeA5503For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe orcustom-molded shoe with roller or rigid rocker bottom, per shoeA5504For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe orcustom-molded shoe with wedge(s), per shoeA5505For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe orcustom molded shoe with metatarsal bar, per shoeA5506For diabetics only, modification (including fitting) of off-the shelf depth-inlay shoe orcustom-molded shoe with off-set heel(s), per shoeA5507For diabetics only, not otherwise specified modification (including fitting) of off-the-shelfdepth- inlay shoe or custom-molded shoe, per shoeA5508For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe,per shoeA5510For diabetics only, direct formed, compression molded to patient’s foot without external heatsource, multiple-density insert(s) prefabricated, per shoePublished: February 15, 20229

Indiana Health Coverage ProgramsDurable and Home Medical Equipment and Supplies CodesTable 1 – Covered Procedure Codes for Durable Medical Equipment (DME) Providers(Specialty 250)Reviewed/Updated: January 1, 2022Procedure CodeDescriptionA5512For diabetics only, multiple density insert, direct formed, molded to foot after external heatsource of 230 degrees Fahrenheit or higher, total contact with patient’s foot, including arch,base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material ofshore a 40 durometer (or higher), prefabricated, eachA5513For diabetics only, multiple density insert, custom molded from model of patient’s foot, totalcontact with patient’s foot, including arch, base layer minimum of 3/16 inch material ofShore A 35 durometer (or higher), includes arch filler and other shaping material, customfabricated, eachA5514For diabetics only, multiple density insert, made by direct carving with cam technology froma rectified cad model created from a digitized scan of the patient, total contact with patient'sfoot, including arch, base layer minimum of 3/16 inch material of Shore A 35 durometer (orhigher), includes arch filler and other shaping material, custom fabricated, eachA6000Non-contact wound warming wound cover for use with the non-contact wound warmingdevice and warming cardA6010Collagen based wound filler, dry form, per gram of collagenA6011Collagen based wound filler, gel/paste, per gram of collagenA6021Collagen dressing, pad size 16 sq. in. or less, eachA6022Collagen dressing, pad size more than 16 sq. in. But less than or equal to 48 sq. in., eachA6023Collagen dressing, pad size more than 48 sq. in., eachA6024Collagen dressing wound filler, per 6 inchesA6025Gel sheet for dermal or epidermal application (e.g. silicone, hydrogel, other), eachA6154Wound pouch, eachA6196Alginate or other fiber gelling dressing, wound cover, pad size 16 sq. in. or less, each dressingA6197Alginate or other fiber gelling dressing, wound cover, pad size more than 16 sq. in. But lessthan or equal to 48 sq. in., each dressingA6198Alginate or other fiber gelling dressing, wound cover, pad size more than 48 sq. in., eachdressingA6199Alginate or other fiber gelling dressing, wound filler, per 6 inchesA6203Composite dressing, pad size 16 sq. in. Or less, with any size adhesive border, each dressingA6204Composite dressing, pad size more than 16 sq. in. But less than or equal to 48 sq. in., withany size adhesive border, each dressingA6205Composite dressing, pad size more than 48 sq. in., with any size adhesive border, eachdressingA6206Contact layer, 16 sq. in. or less, each dressingA6207Contact layer, more than 16 sq. in. But less than or equal to 48 sq. in., each dressingA6208Contact layer, more than 48 sq. in., each dressingA6209Foam dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, eachdressingA6210Foam dressing, wound cover, pad size more than 16 sq. in. But less than or equal to 48 sq.in., without adhesive border, each dressingA6211Foam dressing, wound cover, pad size more than 48 sq. in., without adhesive border, eachdressingPublished: February 15, 202210

Indiana Health Coverage ProgramsDurable and Home Medical Equipment and Supplies CodesTable 1 – Covered Procedure Codes for Durable Medical Equipment (DME) Providers(Specialty 250)Reviewed/Updated: January 1, 2022Procedure CodeDescriptionA6212Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, eachdressingA6213Foam dressing, wound cover, pad size more than 16 sq. in. But less than or equal to 48 sq.in., with any size adhesive border, each dressingA6214Foam dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border,each dressingA6215Foam dressing, wound filler, per gramA6216Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border,each dressingA6217Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in. But less than or equal to48 sq. in., without adhesive border, each dressingA6218Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in., without adhesive border,each dressingA6219Gauze, non-impregnated, pad size 16 sq. in. or less, with any size adhesive border, eachdressingA6220Gauze, non-impregnated, pad

A4281 Tubing for breast pump, replacement A4282 Adapter for breast pump, replacement A4283 Cap for breast pump bottle, replacement A4284 Breast shield and splash protector for use with breast pump, replacement A4285 Polycarbonate bottle for use with breast pump, replacement A4286 L