Notification



Notification Issue Date:



Policy Attachment



Attachment to Policy # 05.00.44k


Attachment:A

Policy #:05.00.44k

Description:HCPCS Codes For Repair and Replacment DME

Title:Repair and Replacement of Durable Medical Equipment (DME)


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



The following list includes only those codes with narratives that are specific to repair or replacement:

REPAIR

K0739 Repair or nonroutine service for durable medical equipment other than oxygen requiring the skill of a technician, labor component, per 15 minutes

K0740 Repair or nonroutine service for oxygen equipment requiring the skill of a technician, labor component, per 15 minutes

REPLACEMENT

A4233 Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by patient, each

A4234 Replacement battery, alkaline, J cell, for use with medically necessary home blood glucose monitor owned by patient, each

A4235 Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each

A4236 Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each

A4257 Replacement lens shield cartridge for use with laser skin piercing device, each

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 Locking ring for breast pump, replacement

A4600 Sleeve for intermittent limb compression device, replacement only, each

A4601 Lithium ion battery, rechargeable, for non-prosthetic use, replacement

A4602 Replacement battery for external infusion pump owned by patient, lithium, 1.5 volt, each

A4606 Oxygen probe for use with oximeter device, replacement

A4611 Battery, heavy duty; replacement for patient-owned ventilator

A4612 Battery cables; replacement for patient-owned ventilator

A4613 Battery charger; replacement for patient-owned ventilator

A4630 Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient

A4633 Replacement bulb/lamp for ultraviolet light therapy system, each

A4634 Replacement bulb for therapeutic light box, tabletop model

A4635 Underarm pad, crutch, replacement, each

A4636 Replacement, handgrip, cane, crutch, or walker, each

A4637 Replacement, tip, cane, crutch, walker, each

A4638 Replacement battery for patient-owned ear pulse generator, each

A4639 Replacement pad for infrared heating pad system, each

A4640 Replacement pad for use with medically necessary alternating pressure pad owned by patient

A4890 Contracts, repair and maintenance, for hemodialysis equipment

A5113 Leg strap; latex, replacement only, per set

A5114 Leg strap; foam or fabric, replacement only, per set

A7025 High frequency chest wall oscillation system vest, replacement for use with patient owned equipment, each

A7026 High frequency chest wall oscillation system hose, replacement for use with patient owned equipment, each

A7031 Face mask interface, replacement for full face mask, each

A7032 Cushion for use on nasal mask interface, replacement only, each

A7033 Pillow for use on nasal cannula type interface, replacement only, pair

A7045 Exhalation port with or without swivel used with accessories for positive airway devices, replacement only

A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, each

A7502 Replacement diaphragm/faceplate for tracheostoma valve, each

A8004 Soft interface for helmet, replacement only

E0159 Brake attachment for wheeled walker, replacement, each

E0167 Pail or pan for use with commode chair, replacement only

E0182 Pump for alternating pressure pad, for replacement only

E0249 Pad for water circulating heat unit, for replacement only

E1354 Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only, each

E1356 Oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement only, each

E1357 Oxygen accessory, battery charger for portable concentrator, any type, replacement only, each

E1358 Oxygen accessory, DC power adapter for portable concentrator, any type, replacement only, each

E0785 Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement

E0786 Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter)

E0967 Manual wheelchair accessory, hand rim with projections, any type, replacement only, each

E0981 Wheelchair accessory, seat upholstery, replacement only, each

E0982 Wheelchair accessory, back upholstery, replacement only, each

E0995 Wheelchair accessory, calf rest/pad, replacement only, each

E1530 Air bubble detector for hemodialysis, each, replacement

E1540 Pressure alarm for hemodialysis, each, replacement

E1560 Blood leak detector for hemodialysis, each, replacement

E1620 Blood pump for hemodialysis, replacement

E1701 Replacement cushions for jaw motion rehabilitation system, package of six

E1702 Replacement measuring scales for jaw motion rehabilitation system, package of 200

E1820 Replacement soft interface material, dynamic adjustable extension/flexion device

E1821 Replacement soft interface material/cuffs for bidirectional static progressive stretch device

E2205 Manual wheelchair accessory, handrim without projections, (includes ergonomic or contoured) any type, replacement only, each

E2206 Manual wheelchair accessory, wheel lock assembly, complete, replacement only, each

E2210 Wheelchair accessory, bearings, any type, replacement only, each

E2220 Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only, each

E2221 Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

E2222 Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

E2224 Manual wheelchair accessory, propulsion wheel excludes tire, any size, replacement only, each

E2368 Power wheelchair component, drive wheel motor, replacement only

E2369 Power wheelchair component, drive wheel gear box, replacement only

E2370 Power wheelchair component, integrated drive wheel motor and gear box combination, replacement only

E2374 Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only

E2375 Power wheelchair accessory, non-expandable controller, including all related electronics and mounting hardware, replacement only

E2376 Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only

E2378 Power wheelchair component, actuator, replacement only

E2381 Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each

E2382 Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each

E2383 Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each

E2384 Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each

E2385 Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each

E2386 Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each

E2387 Power wheelchair accessory, foam filled caster tire, any size, replacement only, each

E2388 Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each

E2389 Power wheelchair accessory, foam caster tire, any size, replacement only, each

E2390 Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each

E2391 Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

E2392 Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

E2394 Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each

E2395 Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each

E2396 Power wheelchair accessory, caster fork, any size, replacement only, each

E2619 Replacement cover for wheelchair seat cushion or back cushion, each

K0017 Detachable, adjustable height armrest, base, replacement only, each

K0018 Detachable, adjustable height armrest, upper portion, replacement only, each

K0019 Arm pad, replacement only, each

K0042 Standard size footplate, replacement only, each

K0043 Footrest, lower extension tube, replacement only, each

K0044 Footrest, upper hanger bracket, replacement only, each

K0045 Footrest, complete assembly, replacement only, each

K0046 Elevating legrest, lower extension tube, replacement only, each

K0047 Elevating legrest, upper hanger bracket, replacement only, each

K0050 Ratchet assembly, replacement only

K0051 Cam release assembly, footrest or legrest, replacement only, each

K0052 Swingaway, detachable footrests, replacement only, each

K0069 Rear wheel assembly, complete, with solid tire, spokes or molded, replacement only, each

K0071 Front caster assembly, complete, with pneumatic tire, replacement only, each

K0072 Front caster assembly, complete, with semi-pneumatic tire, replacement only, each

K0077 Front caster assembly, complete, with solid tire, replacement only, each

K0098 Drive belt for power wheelchair, replacement only

K0462 Temporary replacement for patient-owned equipment being repaired, any type

K0601 Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each

K0602 Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each

K0603 Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each

K0604 Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each

K0605 Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each

K0607 Replacement battery for automated external defibrillator, garment type only, each

K0608 Replacement garment for use with automated external defibrillator, each

K0609 Replacement electrodes for use with automated external defibrillator, garment type only, each

Version Effective Date: 10/01/2018
Version Issued Date: 10/02/2018
Version Reissued Date: N/A



2017 AmeriHealth.