DMEPOS Administrative Rulebook - oregon.gov

1 Health Systems Division Integrated Health Programs Durable medical Equipment, Prosthetics, Orthotics and Supplies Administrative Rulebook Chapter 410, Division 122 Effective September 15, 2017 Table of Contents Table of Contents .. i 410-122-0010 Definitions (T) .. 1 410-122-0020 Orders (T) .. 4 410-122-0040 Prior Authorization .. 8 410-122-0080 Conditions of Coverage, Limitations, Restrictions and Exclusions (T) .. 9 410-122-0090 Face-to-Face Encounter Requirements (for fee-for-service clients) (T) .. 14 410-122-0180 Healthcare Common Procedure Coding System Level II Coding.

2 15 410-122-0182 Legend .. 17 410-122-0184 Repairs, Servicing, Replacement, Delivery, and Dispensing (T) .. 18 410-122-0186 Payment Methodology .. 25 Table 122-0186-1: Ostomy Codes ..28 Table 122-0186-2: Complex Rehabilitation ..29 410-122-0187 Durable medical Equipment (DME) Repurposing Pilot Program .. 30 410-122-0188 DMEPOS Rebate Agreements .. 31 410-122-0200 Pulse Oximeter for Home Use .. 32 410-122-0202 Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea .. 36 Table 122-0202 Positive Airway Pressure (PAP) Devices.

3 43 410-122-0203 Oxygen and Oxygen Equipment .. 45 Table 122-0203-1 Oxygen and Oxygen Equipment ..58 Table 122-0203-2 Oxygen Contents ..61 410-122-0204 Nebulizers .. 62 Table 122-0204-1 ..66 Table 122-0204-2 Nebulizer Code ..67 September 15, 2017 Rulebook 410-122-0205 Respiratory Assist Devices .. 69 Table 122-0205-1 Respiratory Assist Devices Coverage criteria for E0470 and E0471 devices First three months ..71 Restrictive Thoracic Disorders , progressive neuromuscular diseases or severe thoracic cage abnormalities.

4 71 Severe Chronic Obstructive Pulmonary Disease (COPD) ..71 Central Sleep Apnea (CSA) , apnea not due to airway obstruction: ..72 Continued coverage beyond the first three months of therapy ..72 Table 122-0205-2 Respiratory Supplies ..74 410-122-0206 Intermittent Positive Pressure Breathing .. 76 410-122-0207 Respiratory Supplies .. 77 Table 122-0207 Respiratory Supplies ..78 410-122-0208 Suction Pumps .. 79 Table 122-0208 Suction Pumps ..81 410-122-0209 Tracheostomy Care Supplies .. 82 Table 122-0209 Tracheostomy Care Supplies.

5 83 410-122-0210 Ventilators .. 85 Table 122-0210 Ventilators ..88 410-122-0211 Cough Stimulating Device .. 89 410-122-0220 Pacemaker Monitor .. 91 410-122-0240 Apnea Monitor for Infants .. 92 Table 122-0240 APNEA Monitor ..95 410-122-0250 Breast Pumps .. 96 410-122-0260 Home Uterine Monitoring .. 99 410-122-0280 Heating/Cooling Accessories .. 100 Table 122-0280 Heating/Cooling Accessories .. 101 410-122-0300 Light Therapy .. 102 Table 122-0300 Light Therapy .. 103 410-122-0320 Manual Wheelchair Base (T).

6 104 Table 122-0320 Manual Wheelchair Base .. 114 410-122-0325 Power Wheelchair Base (T) .. 115 Table 122-0325 .. 126 410-122-0330 Power-Operated Vehicle (T) .. 130 410-122-0340 Wheelchair Options/Accessories (T) .. 137 Durable medical Equipment, Prosthetics, Orthotics and Supplies Table 122-0340-1 .. 150 Table 122-0340 2 Wheelchair Options/Accessories .. 152 Arm of Chair .. 152 Foot rest/Leg rest .. 153 Non-standard Seat Frame Dimensions .. 153 Rear Wheels for Manual Wheelchairs .. 154 Front Casters for Manual Wheelchairs.

7 155 Batteries/Chargers .. 155 Power Seating Systems .. 156 Power Wheelchair Drive Control Systems .. 157 Other Power Wheelchair Accessories .. 158 Seat Cushions .. 160 Back Cushions .. 161 Miscellaneous & Positioning Accessories .. 162 410-122-0360 Canes and Crutches .. 166 Table 122-0360 Canes and Crutches .. 167 Canes .. 167 Crutches .. 167 410-122-0365 Standing and Positioning Aids .. 168 Table 122-0365 Standing and Positioning 172 E1399 - DME, miscellaneous .. 172 410-122-0375 Walkers .. 174 Table 122-0375-1.

8 177 Table 122-0375-2 Walkers .. 178 410-122-0380 Hospital Beds .. 180 Table 122-0380 Hospital Beds .. 183 Fixed Height .. 183 Variable Height .. 183 183 Heavy-Duty and Extra Heavy-Duty .. 183 410-122-0400 Pressure Reducing Support Surfaces .. 185 Table 122-0400-1 Pressure Reducing Support Surfaces-Group 1 .. 195 Table 122-0400-2 Pressure Reducing Support Surfaces- Group 2 .. 196 410-122-0420 Hospital Bed Accessories .. 197 September 15, 2017 Rulebook Table 122-0420 Hospital Bed Accessories Procedure codes.

9 198 Frames, Traction Devices, etc.. 198 Mattresses .. 198 Rails .. 199 Trapeze Bars .. 199 410-122-0475 Therapeutic Shoes for Diabetics .. 200 Table 122-0475 Therapeutic Shoes for Diabetics .. 202 410-122-0480 Pneumatic Compression Devices (Used for Lymphedema) .. 204 Table 122-0480 Pneumatic Compression Devices (Used for Lymphedema) .. 206 410-122-0500 Transcutaneous Electrical Nerve Stimulator (TENS) .. 208 Table 122-0500 Transcutaneous Electrical Nerve Stimulator (TENS) .. 211 410-122-0510 Osteogenesis Stimulator.

10 212 Table 122-0510 Electronic Stimulators .. 215 410-122-0515 Neuromuscular Electrical Stimulator (NMES) .. 216 410-122-0520 Glucose Monitors and Diabetic Supplies .. 219 Table 122-0520 Diabetic Supplies .. 225 410-122-0525 External Insulin Infusion Pump .. 227 Table 122-0525 External Insulin Infusion Pump .. 230 Equipment .. 230 410-122-0540 Ostomy Supplies .. 231 Table 122-0540-1, Maximum Quantity of Supplies Monthly 233 Table 122-0540-2, Maximum Quantity of Supplies 6-Month Basis .. 234 Table 122-0540-3, Faceplate Systems.