DME-ORTHOTIC-PROSTHETIC FEE SCHEDULE Effective …

1 CodeCode StatusPADescriptionMin AgeMax AgeBegin DateEnd DateMax UnitsFeeB9002KR-Fee on FileYesENTERAL NUTRITION INFUSION PUMP, ANY TYPE099907/01/201712/31 on FileYesENTERAL NUTRITION INFUSION PUMP, ANY TYPE099907/01/201712/31 on FileYesENTERAL NUTRITION INFUSION PUMP, ANY TYPE099907/01/201712/31 on FileYesENTERAL NUTRITION INFUSION PUMP, ANY TYPE099907/01/201712/31 on FileYesPARENTERAL NUTRITION INFUSION PUMP, PORTABLE099907/01/201812/31 on FileYesPARENTERAL NUTRITION INFUSION PUMP, PORTABLE099907/01/201812/31/999912, on FileYesPARENTERAL NUTRITION INFUSION PUMP, PORTABLE099907/01/201812/31 on FileYesPARENTERAL NUTRITION INFUSION PUMP, PORTABLE099907/01/201812/31/999911, on FileYesPARENTERAL NUTRITION INFUSION PUMP, STATIONARY099907/01/201812/31 on FileYesPARENTERAL NUTRITION INFUSION PUMP, STATIONARY099907/01/201812/31/999912, on FileYesPARENTERAL NUTRITION INFUSION PUMP, STATIONARY099907/01/201812/31 on FileYesPARENTERAL NUTRITION INFUSION PUMP, STATIONARY099907/01/201812/31/999911, on FileYesCANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIP099907/01/201812/31 on FileYesCANE, QUAD OR THREE PRONG, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED WITH TIP099907/01/201812/31 on FileYesCRUTCHES, FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR OR FIXED PAIR COMPLETE WITH TIPS AND HANDGRIPS099907/01/201812/31 on FileYesCRUTCH, FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS ADJUSTABLE OR FIXED EACH WITH TIP AND HANDGRIP099907/01/201812/31 on FileYesCRUTCHES, UNDERARM, WOOD, ADJUSTABLE OR FIXED PAIR WITH PADS TIPS AND HANDGRIPS099907/01/201812/31 on FileYesCRUTCH, UNDERARM, WOOD, ADJUSTABLE OR FIXED, EACH, WITH PAD.

2 TIP AND HANDGRIP099907/01/201812/31 on FileYesCRUTCHES, UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED PAIR WITH PADS TIPS AND HANDGRIPS099907/01/201812/31 on FileYesCRUTCH, UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, WITH PAD, TIP, AND HANDGRIP099907/01/201812/31 on FileYesCRUTCH, UNDERARM, ARTICULATING, SPRING ASSISTED, EACH02007/01/201812/31 on FileYesWALKER, RIGID (PICKUP), ADJUSTABLE OR FIXED HEIGHT099907/01/201712/31 on FileYesWALKER, FOLDING (PICKUP), ADJUSTABLE OR FIXED HEIGHT099907/01/201712/31 on FileYesWALKER, RIGID, WHEELED, ADJUSTABLE OR FIXED HEIGHT099907/01/201712/31 on FileYesWALKER, FOLDING, WHEELED, ADJUSTABLE OR FIXED HEIGHT099907/01/201712/31 on FileYesWALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RESISTANCE099907/01/201812/31 FEE SCHEDULE Effective 07/01/2018 Print Date 1/2/19 CodeCode StatusPADescriptionMin AgeMax AgeBegin DateEnd DateMax UnitsFeeE0147NU-Fee on FileYesWALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RESISTANCE099907/01/201812/31 on FileYesWALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RESISTANCE099907/01/201812/31 on FileYesWALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RESISTANCE099907/01/201812/31 on FileYesWALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE.

3 EACH099907/01/201712/31 on FileYesWALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACH099907/01/201712/31 on FileYesWALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACH099907/01/201712/31 on FileYesWALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACH099907/01/201712/31 on FileYesWALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE099907/01/201712/31 on FileYesWALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE099907/01/201712/31 on FileYesWALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE099907/01/201712/31 on FileYesWALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE099907/01/201712/31 on FileYesPLATFORM ATTACHMENT, FOREARM CRUTCH, EACH32007/01/201812/31 on FileYesPLATFORM ATTACHMENT, WALKER EACH099907/01/201712/31 on FileYesWHEEL ATTACHMENT, RIGID PICK-UP WALKER, PER PAIR SEAT ATTACHMENT, WALKER099907/01/201712/31 on FileYesSEAT ATTACHMENT, WALKER099907/01/201712/31 on FileYesCRUTCH ATTACHMENT, WALKER, EACH099907/01/201712/31 on FileYesLEG EXTENSIONS FOR WALKER, PER SET OF FOUR (4)

4 099907/01/201712/31 on FileYesBRAKE ATTACHMENT FOR WHEELED WALKER, REPLACEMENT EACH099907/01/201712/31 on FileYesCOMMODE CHAIR, MOBILE OR STATIONARY, WITH FIXED ARMS099907/01/201712/31 on FileYesCOMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMS099907/01/201712/31 on FileYesCOMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMS099907/01/201712/31 on FileYesCOMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMS099907/01/201712/31 on FileYesCOMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMS099907/01/201712/31 on FileYesPAIL OR PAN FOR USE WITH COMMODE CHAIR, REPLACEMENT ONLY099907/01/201712/31 on FileYesCOMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH099907/01/201712/31 on FileYesCOMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH099907/01/201712/31 on FileYesCOMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH099907/01/201712/31 on FileYesCOMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH099907/01/201712/31 StatusPADescriptionMin AgeMax AgeBegin DateEnd DateMax UnitsFeeE0181KR-Fee on FileYesPOWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP,099907/01/201712/31 on FileYesPOWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP,099907/01/201712/31 on FileYesPOWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP,099907/01/201712/31 on FileYesPOWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP,099907/01/201712/31 on FileYesDRY PRESSURE MATTRESS099907/01/201712/31 on FileYesGEL OR GEL LIKE PRESSURE PAD FOR MATTRESS.

5 STANDARD MATTRESS LENGTH AND WIDTH099907/01/201712/31 on FileYesGEL OR GEL LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH099907/01/201712/31 on FileYesGEL OR GEL LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH099907/01/201712/31 on FileYesGEL OR GEL LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH099907/01/201712/31 on FileYesAIR PRESSURE MATTRESS099907/01/201812/31 on FileYesAIR PRESSURE MATTRESS099907/01/201812/31 on FileYesAIR PRESSURE MATTRESS099907/01/201812/31 on FileYesAIR PRESSURE MATTRESS099907/01/201812/31 on FileYesWATER PRESSURE MATTRESS099907/01/201812/31 on FileYesWATER PRESSURE MATTRESS099907/01/201812/31 on FileYesWATER PRESSURE MATTRESS099907/01/201812/31 on FileYesWATER PRESSURE MATTRESS099907/01/201712/31 on FileYesSYNTHETIC SHEEPSKIN PAD02007/01/201712/31 on FileYesLAMBSWOOL SHEEPSKIN PAD, ANY SIZE02007/01/201812/31 on FileYesHEEL OR ELBOW PROTECTOR, EACH099907/01/201812/31 on FileYesAIR FLUIDIZED BED02007/01/201812/31 on FileYesAIR FLUIDIZED BED02007/01/201812/31/999912.

6 On FileYesGEL PRESSURE MATTRESS099907/01/201812/31 on FileYesGEL PRESSURE MATTRESS099907/01/201812/31 on FileYesGEL PRESSURE MATTRESS099907/01/201812/31 on FileYesGEL PRESSURE MATTRESS099907/01/201812/31 on FileYesAIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH099907/01/201712/31 on FileYesAIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH099907/01/201712/31 on FileYesAIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH099907/01/201712/31 on FileYesAIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH099907/01/201612/31 on FileYesWATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH099907/01/201812/31 on FileYesWATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH099907/01/201812/31 StatusPADescriptionMin AgeMax AgeBegin DateEnd DateMax UnitsFeeE0198RR-Fee on FileYesWATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH099907/01/201812/31 on FileYesWATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH099907/01/201812/31 on FileYesDRY PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH099907/01/201812/31 on FileYesHEAT LAMP, WITHOUT STAND (TABLE MODEL), INCLUDES BULB, OR INFRARED ELEMENT02007/01/201812/31 on FileYesHEAT LAMP, WITHOUT STAND (TABLE MODEL), INCLUDES BULB, OR INFRARED ELEMENT02007/01/201512/31 on FileYesPHOTOTHERAPY (BILIRUBIN)

7 LIGHT WITH PHOTOMETER0107/01/201112/31 on FileYesHEAT LAMP, WITH STAND, INCLUDES BULB, OR INFRARED ELEMENT02007/01/201812/31 on FileYesHEAT LAMP, WITH STAND, INCLUDES BULB, OR INFRARED ELEMENT02007/01/201812/31 on FileYesELECTRIC HEAT PAD, STANDARD099907/01/201812/31 on FileYesELECTRIC HEAT PAD, MOIST099907/01/201812/31 on FileYesWATER CIRCULATING HEAT PAD WITH PUMP02007/01/201812/31 on FileYesWATER CIRCULATING HEAT PAD WITH PUMP02007/01/201812/31 on FileYesWATER CIRCULATING HEAT PAD WITH PUMP02007/01/201812/31 on FileYesWATER CIRCULATING HEAT PAD WITH PUMP02007/01/201812/31 on FileYesPARAFFIN BATH UNIT, PORTABLE (SEE MEDICAL SUPPLY CODE A4265 FOR PARAFFIN)099907/01/201812/31 on FileYesPARAFFIN BATH UNIT, PORTABLE (SEE MEDICAL SUPPLY CODE A4265 FOR PARAFFIN)099907/01/201812/31 on FileYesPARAFFIN BATH UNIT, PORTABLE (SEE MEDICAL SUPPLY CODE A4265 FOR PARAFFIN)099907/01/201812/31 on FileYesPARAFFIN BATH UNIT, PORTABLE (SEE MEDICAL SUPPLY CODE A4265 FOR PARAFFIN)

8 099907/01/201812/31 by PAYesBATH/SHOWER CHAIR, WITH OR WITHOUT WHEELS, ANY SIZE099901/01/200412/31 on FileYesRAISED TOILET SEAT099910/01/199812/31 on FileYesTUB STOOL OR BENCH099910/01/200312/31 on FileYesHOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS099907/01/201712/31 on FileYesHOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS099907/01/201712/31 on FileYesHOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS099907/01/201712/31 on FileYesHOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS099907/01/201712/31 on FileYesHOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT 099907/01/201712/31 on FileYesHOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT 099907/01/201712/31 on FileYesHOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT 099907/01/201712/31 on FileYesHOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT 099907/01/201712/31 StatusPADescriptionMin AgeMax AgeBegin DateEnd DateMax UnitsFeeE0255KR-Fee on FileYesHOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS099907/01/201712/31 on FileYesHOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS099907/01/201712/31 on FileYesHOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS099907/01/201712/31 on FileYesHOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS099907/01/201712/31 on FileYesHOSPITAL BED, VARIABLE HEIGHT, HI-LO WITH ANY TYPE SIDERAILS, W/O MATTR099907/01/201712/31 on FileYesHOSPITAL BED, VARIABLE HEIGHT, HI-LO WITH ANY TYPE SIDERAILS, W/O MATTR099907/01/201712/31 on FileYesHOSPITAL BED.

9 VARIABLE HEIGHT, HI-LO WITH ANY TYPE SIDERAILS, W/O MATTR099907/01/201712/31 on FileYesHOSPITAL BED, VARIABLE HEIGHT, HI-LO WITH ANY TYPE SIDERAILS, W/O MATTR099907/01/201712/31 on FileYesHOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS WITH MATTRESS099907/01/201712/31 on FileYesHOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS WITH MATTRESS099907/01/201712/31 on FileYesHOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS WITH MATTRESS099907/01/201712/31 on FileYesHOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS WITH MATTRESS099907/01/201712/31 on FileYesHOSP BED, SEMI ELEC HEAD AND FOOT ADJ, WITH ANY TYPE SIDE RAILS, W/O MAT099907/01/201712/31 on FileYesHOSP BED, SEMI ELEC HEAD AND FOOT ADJ, WITH ANY TYPE SIDE RAILS, W/O MAT099907/01/201712/31 on FileYesHOSP BED, SEMI ELEC HEAD AND FOOT ADJ, WITH ANY TYPE SIDE RAILS, W/O MAT099907/01/201712/31 on FileYesHOSP BED, SEMI ELEC HEAD AND FOOT ADJ, WITH ANY TYPE SIDE RAILS, W/O MAT099907/01/201712/31 on FileYesHOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH A099909/01/201812/31 on FileYesHOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH A099909/01/201812/31/999911, on FileYesHOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH A099909/01/201812/31 on FileYesHOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS)

10 , WITH A099909/01/201812/31 on FileYesHOSPITAL BED, TOTAL ELEC HEAD, FOOT, AND HGHT ADJ, WITH ANY TYPE SIDE099909/01/201812/31 on FileYesHOSPITAL BED, TOTAL ELEC HEAD, FOOT, AND HGHT ADJ, WITH ANY TYPE SIDE099909/01/201812/31 on FileYesHOSPITAL BED, TOTAL ELEC HEAD, FOOT, AND HGHT ADJ, WITH ANY TYPE SIDE099909/01/201812/31 StatusPADescriptionMin AgeMax AgeBegin DateEnd DateMax UnitsFeeE0266UE-Fee on FileYesHOSPITAL BED, TOTAL ELEC HEAD, FOOT, AND HGHT ADJ, WITH ANY TYPE SIDE099909/01/201812/31 on FileYesMATTRESS, INNERSPRING099907/01/201712/31 on FileYesMATTRESS, FOAM RUBBER099907/01/201712/31 on FileYesBED BOARD02010/01/199812/31 on FileYesOVERBED TABLE