 | TABLE I
DURABLE MEDICAL EQUIPMENT
(CONTINUED FROM ATTACHMENT A1) |
HCPCS
CODE | NARRATIVE DESCRIPTION |
E2601 | General use wheelchair seat cushion, width less than 22 inches, any depth |
E2602 | General use wheelchair seat cushion, width 22 inches or greater, any depth |
E2603 | Skin protection wheelchair seat cushion, width less than 22 inches, any depth |
E2604 | Skin protection wheelchair seat cushion, width 22 inches or greater, any depth |
E2605 | Positioning wheelchair seat cushion, width less than 22 inches, any depth |
E2606 | Positioning wheelchair seat cushion, width 22 inches or greater, any depth |
E2607 | Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth |
E2608 | Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any depth |
E2609 | Custom fabricated wheelchair seat cushion, any size |
E2610 | Wheelchair seat cushion, powered |
E2611 | General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware |
E2612 | General use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardware |
E2613 | Positioning wheelchair back cushion, posterior, width less than 22 inches, any height, including any type mounting hardware |
E2614 | Positioning wheelchair back cushion, posterior, width 22 inches or greater, any height, including any type mounting hardware |
E2615 | Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any height, including any type mounting hardware |
E2616 | Positioning wheelchair back cushion, posterior-lateral, width 22 inches or greater, any height, including any type mounting hardware |
E2617 | Custom fabricated wheelchair back cushion, any size, including any type mounting hardware |
E2620 | Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 inches, any height, including any type mounting hardware |
E2621 | Positioning wheelchair back cushion, planar back with lateral supports, width 22 inches or greater, any height, including any type mounting hardware |
E2622 | Skin protection wheelchair seat cushion, adjustable, width less than 22 inches,
any depth |
E2623 | Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater,
any depth |
E2624 | Skin protection and positioning wheelchair seat cushion, adjustable, width less
than 22 inches, any depth |
E2625 | Skin protection and positioning wheelchair seat cushion, adjustable, width 22
inches or greater, any depth |
E2630 | Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support |
E2631 | Wheelchair accessory, addition to mobile arm support, elevating proximal arm |
E2632 | Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control |
E2633 | Wheelchair accessory, addition to mobile arm support, supinator |
E3200
| Gait modulation system, rhythmic auditory stimulation, including restricted therapy software, all components and accessories, prescription only
|
K0001 | Standard wheelchair |
K0002 | Standard hemi (low seat) wheelchair |
K0003 | Lightweight wheelchair |
K0004 | High strength, lightweight wheelchair |
K0005 | Ultralightweight wheelchair |
K0006 | Heavy-duty wheelchair |
K0007 | Extra heavy-duty wheelchair |
K0008 | Custom Manual Wheelchair Base |
K0009 | Other manual wheelchair/base |
K0010 | Standard-weight frame motorized/power wheelchair |
K0011 | Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking |
K0012 | Lightweight portable motorized/power wheelchair |
K0013 | Custom Motorized/Power Wheelchair Base |
K0014 | Other motorized/power wheelchair base |
K0015 | Detachable, nonadjustable height armrest, each |
K0020 | Fixed, adjustable height armrest, pair |
K0038 | Leg strap, each |
K0039 | Leg strap, H style, each |
K0040 | Adjustable angle footplate, each |
K0041 | Large size foot plate, each |
K0053 | Elevating footrests, articulating (telescoping), each |
K0056 | Seat height less than 17 inches or equal to or greater than 21 in inches for a high strength, lightweight, or ultralightweight wheelchair |
K0065 | Spoke protectors, each |
K0073 | Caster pin lock, each |
K0105 | IV hanger, each |
K0108 | Wheelchair component or accessory, not otherwise specified |
K0195 | Elevating legrests, pair (for use with capped rental wheelchair base) |
K0455 | Infusion pump used for uninterrupted parenteral administration of medication (eg, epoprostenol or treprostinol) |
K0552 | Supplies for external non-insulin drug infusion pump, syringe type cartridge, sterile, each |
K0606 | Automatic external defibrillator, with integrated electrocardiogram analysis, garment type |
K0669 | Wheelchair accessory, wheelchair seat or back cushion, does not meet specific code criteria or no written coding verification from DME PDAC |
K0730 | Controlled dose inhalation drug delivery system |
K0733 | Power wheelchair accessory, 12 to 24 AMP hour sealed lead acid battery, each (eg, gel cell, absorbed glassmat) |
K0738 | Portable gaseous oxygen system, rental: home compressor used to fill portable oxygen cylinders, includes containers, regulator, flowmeter, regulator, flowmeter, humidifier, cannula or mask and tubing |
K0743 | Suction pump, home model, portable, for use on wounds |
K0744 | Absorptive wound dressing for use with suction pump, home model, portable, pad size 16 sq in or less |
K0745 | Absorptive wound dressing for use with suction pump, home model, portable, pad size more than 16 square inches but less than or equal to 48 sq in |
K0746 | Absorptive wound dressing for use with suction pump, home model, portable, pad size greater than 48 sq in |
K0800 | Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds |
K0801 | Power operated vehicle, group 1 heavy duty, patient weight capacity, 301 to 450 pounds |
K0802 | Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to 600 pounds |
K0806 | Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds |
K0807 | Power operated vehicle, group 2 heavy duty, patient weight capacity 301 to 450 pounds |
K0808 | Power operated vehicle, group 2 very heavy-duty, patient weight capacity 451 to 600 pounds |
K0812 | Power operated vehicle, not otherwise classified |
K0813 | Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds |
K0814 | Power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds |
K0815 | Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds |
K0816 | Power wheelchair, group 1 standard, captains chair, patient weight capacity up to and including 300 pounds |
K0820 | Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0821 | Power wheelchair, group 2 standard, portable, captains chair, patient weight capacity up to and including 300 pounds |
K0822 | Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0823 | Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds |
K0824 | Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0825 | Power wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds |
K0826 | Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
K0827 | Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds |
K0828 | Power wheelchair, group 2 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more |
K0829 | Power wheelchair, group 2 extra heavy-duty, captain's chair, patient weight 601 pounds or more |
K0835 | Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0836 | Power wheelchair, group 2 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds |
K0837 | Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0838 | Power wheelchair, group 2 heavy duty, single power option, captains chair, patient capacity 301 to 450 pounds |
K0839 | Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
K0840 | Power wheelchair, group 2 extra heavy duty, single power option sling/solid seat/back, patient capacity 601 pounds or more |
K0841 | Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0842 | Power wheelchair, group 2 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds |
K0843 | Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0848 | Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0849 | Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and including 300 pounds |
K0850 | Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0851 | Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to 450 pounds |
K0852 | Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
K0853 | Power wheelchair, group 3 very heavy duty, captains chair, patient weighty capacity, 451 to 600 pounds |
K0854 | Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more |
K0855 | Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601 pounds or more |
K0856 | Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0857 | Power wheelchair, group 3 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds |
K0858 | Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0859 | Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds |
K0860 | Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
K0861 | Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0862 | Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
K0863 | Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
K0864 | Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more |
K0868 | Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including up to and including 300 pounds |
K0869 | Power wheelchair, group 4 standard, captains chair, patient weight capacity up to and including 300 pounds |
K0870 | Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0871 | Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
K0877 | Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
K0878 | Power wheelchair, group 4 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds |
K0879 | Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0880 | Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient 451 to 600 pounds |
K0884 | Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient capacity up to and including 300 pounds |
K0885 | Power wheelchair, group 4 standard, multiple power option, captains chair, weight capacity up to and including 300 pounds |
K0886 | Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
K0890 | Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds |
K0891 | Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds |
K0898 | Power wheelchair, not otherwise classified |
K0899 | Power mobility device not coded by DME PDAC or does not meet the criteria |
K0900 | Customized Durable Medical Equipment, Other Than Wheelchair |
K1004 | Low frequency ultrasonic diathermy treatment device for home use, includes all components and accessories |
K1027
| Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment
|
K1037
| Docking station for use with oral device/appliance used to reduce upper airway collapsibility
|
S1030
| Continuous noninvasive glucose monitoring device, purchase (for physician interpretation of data, use CPT code)
|
S1031 | Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement and download to monitor (for physician interpretation of data, use CPT code) |
S8097 | Asthma kit (including but not limited to portable peak expiratory flow meter, instructional video, brochure, and/or spacer) |
S8185 | Flutter device |
S8186 | Swivel adaptor |
S8189 | Tracheostomy supply, not otherwise classified |
S8210 | Mucus trap |
S8265 | Haberman feeder for cleft lip/palate |
S8420 | Gradient pressure aid (sleeve and glove combination), custom made |
S8421 | Gradient pressure aid (sleeve and glove combination), ready made |
S8422 | Gradient pressure aid (sleeve), custom made, medium weight |
S8423 | Gradient pressure aid (sleeve), custom made, heavy weight |
S8424 | Gradient pressure aid (sleeve), ready made |
S8425 | Gradient pressure aid (glove), custom made, medium weight |
S8426 | Gradient pressure aid (glove), custom made, heavy weight |
S8427 | Gradient pressure aid (glove), ready made |
S8428 | Gradient pressure aid (gauntlet), ready made |
S8429 | Gradient pressure exterior wrap |
S8430 | Padding for compression bandage, roll |
S8431 | Compression bandage, roll |
S8999 | Resuscitation bag (for use by patient on artificial respiration during power failure or other catastrophic event) |
S9007 | Ultrafiltration monitor |
T1505 | Electronic medication compliance management device, includes all components
and accessories, not otherwise classified |
