Durable And Home Medical Equipment Codes

2y ago
48 Views
2 Downloads
1.28 MB
96 Pages
Last View : 8d ago
Last Download : 5m ago
Upload by : Matteo Vollmer
Transcription

INDIANA HEALTH COVERAGE PROGRAMSPROVIDER CODE TABLESDurable and Home Medical Equipmentand Supplies CodesNote: Due to possible changes in Indiana Health Coverage Programs (IHCP) policy or nationalcoding updates, inclusion of a code on the code tables does not necessarily indicate currentcoverage. See IHCP Banner Pages and Bulletins and the IHCP Fee Schedules for updates tocoding, coverage and benefit information.For information about using these code tables, see the Durable and Home Medical Equipmentand Supplies provider reference module.Table 1 – Covered Procedure Codes for Durable Medical Equipment (DME) Providers(Specialty 250)Table 2 – Covered Procedure Codes for Home Medical Equipment (HME) Providers(Specialty 251)Table 3 – Procedure Codes for DME/HME Subject to a 15-Month Capped Rental PeriodTable 4 – Procedure Codes for DME/HME Subject to a 10-Month Capped Rental PeriodTable 5 – Procedure Codes for DME/HME Subject to a 6-Month Capped Rental PeriodTable 6 – Procedure Codes for Equipment and Supplies Classified by the IHCP as RequiringFrequent and Substantial ServicingTable 7 – Procedure Codes for Diabetic Test Strips That Allow a 90-Day Supply on MedicareCrossover ClaimsTable 8 – Procedure Codes for Respiratory Assist Devices (CPAP and BiPAP) and AccessoriesTable 9 – Incontinence, Ostomy and Urological Supplies Available Only Through ContractedVendors (for Fee-for-Service Members)Note: A table of procedure codes linked to revenue code 274 – Orthotic/Prosthetic Devices canbe found on Revenue Codes with Special Procedure Code Linkages, accessible from theCode Sets page at in.gov/medicaid/providers.For code tables related to implantable DME, including implantable DME that is separatelyreimbursable in an outpatient setting, see Surgical Services Codes, accessible from theCode Sets page at in.gov/medicaid/providers.For a list of DME and medical supply codes included in the long-term care (LTC) facilityper diem rate, see the LTC DME Per Diem Table, accessible from the Long Term Care DMEPer Diem Table page at in.gov/medicaid/providers.Some codes in the following tables may require a modifier to indicate that the item is a rental(RR) or new (NU). See the IHCP Professional Fee Schedule to determine whether an NU orRR modifier is allowed or required for a given code.Published: February 15, 20221

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 CodeDescription94760Noninvasive ear or pulse oximetry for oxygen saturation; single determination94762Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnightmonitoring94772 TCCircadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hours continuousrecording, infant; TC – Technical componentA4206Syringe with needle, sterile 1cc, eachA4207Syringe with needle, sterile 2cc, eachA4208Syringe with needle, sterile 3cc, eachA4209Syringe with needle, sterile 5cc or greater, eachA4210Needle-free injection device, eachA4211Supplies for self injectionA4212Non-coring needle or stylet with or without catheterA4213Syringe, sterile, 20cc or greater, eachA4215Needles, sterile, any size, eachA4220Refill kit for implantable infusion pumpA4221Supplies for maintenance of drug infusion catheter, per week (list drug separately)A4222Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately)A4223Infusion supplies not used with external infusion pump, per cassette or bag (list drugsseparately)A4224Supplies for maintenance of insulin infusion catheter, per weekA4225Supplies for external insulin infusion pump, syringe type cartridge, sterile, eachA4226Supplies for maintenance of insulin infusion pump with dosage rate adjustment usingtherapeutic continuous glucose sensing, per weekA4230Infusion set for external insulin pump, non needle cannula typeA4231Infusion set for external insulin pump, needle typeA4232Syringe with needle for external insulin pump, sterile, 3ccA4233Replacement battery, alkaline (other than J cell), for use with medically necessary homeblood glucose monitor owned by patient, eachA4234Replacement battery, alkaline, J cell, for use with medically necessary home blood glucosemonitor owned by patient, eachA4235Replacement battery, lithium, for use with medically necessary home blood glucose monitorowned by patient, eachA4236Replacement battery, silver oxide, for use with medically necessary home blood glucosemonitor owned by patient, eachA4244Alcohol or peroxide, per pintA4245Alcohol wipes, per boxA4246Betadine or phisohex solution, per pintA4247Betadine or iodine swabs/wipes, per boxA4250Urine test or reagent strips or tablets (100 tablets or strips)Published: February 15, 20222

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 CodeDescriptionA4253Blood glucose test or reagent strips for home blood glucose monitor, per 50 stripsA4253 U1Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips for nonpreferred manufacturerA4255Platforms for home blood glucose monitor, 50 per boxA4256Normal, low and high calibrator solution/chipsA4257Replacement lens shield cartridge for use with laser skin piercing device, eachA4258Spring-powered device for lancet, eachA4259Lancets, per box of 100A4265Paraffin, per poundA4280Adhesive skin support attachment for use with external breast prosthesis, eachA4281Tubing for breast pump, replacementA4282Adapter for breast pump, replacementA4283Cap for breast pump bottle, replacementA4284Breast shield and splash protector for use with breast pump, replacementA4285Polycarbonate bottle for use with breast pump, replacementA4286Locking ring for breast pump, replacementA4305Disposable drug delivery system, flow rate 50 ml or greater per hourA4306Disposable drug delivery system, flow rate of less than 50 ml per hourA4310Insertion tray without drainage bag and without catheter (accessories only)A4311Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex withcoating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)A4312Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all siliconeA4313Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, forcontinuous irrigationA4314Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex withcoating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.)A4315Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all siliconeA4316Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, forcontinuous irrigationA4320Irrigation tray with bulb or piston syringe, any purposeA4321Therapeutic agent for urinary catheter irrigationA4322Irrigation syringe, bulb or piston, eachA4326Male external catheter specialty type with integral collections chambers, eachA4327Female external urinary collection device; meatal cup, eachA4328Female external urinary collection device; pouch, eachA4331Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinaryleg bag or urostomy pouch, eachA4332Lubricant, individual sterile packet, eachA4333Urinary catheter anchoring device, adhesive skin attachment, eachPublished: February 15, 20223

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 CodeDescriptionA4334Urinary catheter anchoring device, leg strap, eachA4335Incontinence supply; miscellaneousA4338Indwelling catheter; Foley type, two-way latex with coating (Teflon, silicone, siliconeelastomer, or hydrophilic, etc), eachA4340Indwelling catheter; special type, (eg; coude, mushroom, wing, etc.), eachA4344Indwelling catheter, Foley type, two-way, all silicone, eachA4346Indwelling catheter; Foley type, three way for continuous irrigation, eachA4349Male external catheter, with or without adhesive, disposable, eachA4351Intermittent urinary catheter; straight tip with or without coating (Teflon, silicone, siliconeelastomer, or hydrophilic, etc.), eachA4352Intermittent urinary catheter; coude (curved) tip with or without coating (Teflon, silicone,silicone elastomer, or hydrophilic, etc.), eachA4353Intermittent urinary catheter, with insertion suppliesA4354Insertion tray with drainage bag but without catheterA4355Irrigation tubing set for continuous bladder irrigation through a three-way indwelling Foleycatheter, eachA4356External urethral clamp or compression device (not to be used for catheter clamp), eachA4357Bedside drainage bag, day or night, with or without anti reflux device, with or without tube,eachA4358Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, eachA4360Disposable external urethral clamp or compression device, with pad and/or pouch, eachA4361Ostomy faceplate, eachA4362Skin barrier; solid, four by four or equivalent; eachA4363Ostomy clamp, any type, replacement only, eachA4364Adhesive, liquid, or equal, any type, per ozA4366Ostomy vent, any type, eachA4367Ostomy belt, eachA4368Ostomy filter, any type, eachA4369Ostomy skin barrier, liquid (spray, brush, etc.), per ozA4371Ostomy skin barrier, powder, per ozA4372Ostomy skin barrier, solid 4x4 or equivalent standard wear, with built-in convexity, eachA4373Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, anysize, eachA4375Ostomy pouch, drainable, with faceplate attached, plastic, eachA4376Ostomy pouch, drainable, with faceplate attached, rubber, eachA4377Ostomy pouch, drainable, for use on faceplate, plastic, eachA4378Ostomy pouch, drainable, for use on faceplate, rubber, eachA4379Ostomy pouch, urinary, with faceplate attached, plastic, eachA4380Ostomy pouch, urinary, with faceplate attached, rubber, eachPublished: February 15, 20224

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

Related Documents:

Durable And Home Medical Equipment And SuppliesDurable And Home Medical Equipment And SuppliesDurable And Home Medical Equipment And Supplies Durable and Home Medical Equipment and Supplies . Library Reference Number: PROMOD00024 3 Published: Oct. 27, 2022 Policies and procedures as of June 1, 2022 Version: 5.0

1-1 Medical Supplies and Durable Medical Equipment (DME) Services The Utah Medicaid Provider Manual, Section 2, Medical Supplies and Durable Medical Equipment is designed to be used in conjunction with the Section I: General Information as well as other sections and attachments.

Federal Bureau of Prisons Durable Medical Equipment Clinical Guidance June 2018 1 PURPOSE OF THIS CLINICAL GUIDANCE Pain management may include use of Durable Medical Equipment (DME) to aid in reducing pain, enhancing balance/kinesthetic sense and improving functionality. DME includes wheelchairs, walking

Name / Provider # Specialty / Phone # ADVANCED CARDIO SERVICES Durable Medical Equipment (866) 416-8989 ADVANCED RESPIRATORY INC Durable Medical Equipment (800) 426-4224 AMEDA DIRECT Durable Medical Equipment (337) 326-5

Medical Commodities: A collective term to include pharmaceuticals, consumable medical supplies, and durable medical equipment. Medical Equipment (Durable): This term refers to commodities designed for humans or animals that may generally be reused after proper cleaning and disinfection. Medical equipment includes but is not limited to

Indications for Coverage Durable Medical Equipment (DME) is a Covered Health Care Service when the member has a DME benefit, the equipment is ordered by a physician to treat an injury or sickness (illness) and the equipment is not

Introduction Indiana Administrative Code 405 IAC 5-19-2defines durable medical equipment (DME) as equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, and generally is not useful to a member in the absence of illness or injury. Indiana Code IC 25-26-21-2 defines

Durable Medical Equipment includes equipment such as wheelchairs, hospital beds, traction equipment, canes, crutches, walkers, ventilators, oxygen, prosthetic and orthotic devices and other medically needed items. If you have questions about policies and procedures, please contact the SCDHHS Provider Service