DME Medical Review Criteria Attachment A2

Transcription

1 DME Medical Review Criteria Attachment A2 STRIDEsm (HMO) MEDICARE ADVANTAGE The equipment listed in the following table meets the CMS definition of durable medical equipment (DME) and may be covered if other requirements are met. HCPCS E2511 E2512 E2599 NARRATIVE DESCRIPTION Speech generating software program, for personal computer or personal digital assistant Accessory for speech generating device, mounting system Accessory for speech generating device, not otherwise classified 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 E2607 E2608 E2609 E2610 E2611 E2612 Positioning wheelchair seat cushion, width 22 inches or greater, any depth Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any depth Custom fabricated wheelchair seat cushion, any size Wheelchair seat cushion, powered General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware General use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardware DME- Attachment A2 Page 1 of 9

2 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 E2617 E2620 Positioning wheelchair back cushion, posterior-lateral, width 22 inches or greater, any height, including any type mounting hardware Custom fabricated wheelchair back cushion, any size, including any type mounting hardware Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 inches, any height, including any type mounting hardware E2621 E2622 E2623 E2624 E2625 E2630 E2631 E2632 E2633 K0001 K0002 K0003 K0004 Positioning wheelchair back cushion, planar back with lateral supports, width 22 inches or greater, any height, including any type mounting hardware Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth Skin protection and positioning wheelchair seat cushion, adjustable, width 22 inches or greater, any depth Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support Wheelchair accessory, addition to mobile arm support, elevating proximal arm Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control Wheelchair accessory, addition to mobile arm support, supinator Standard wheelchair Standard hemi (low seat) wheelchair Lightweight wheelchair High strength, lightweight wheelchair DME- Attachment A2 Page 2 of 9

3 K0005 K0006 K0007 K0008 K0009 K0010 K0011 K0012 K0013 K0014 K0015 K0017 K0018 K0019 K0020 K0037 K0038 K0039 K0040 K0041 K0042 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0052 K0053 K0056 K0065 K0069 Ultralightweight wheelchair Heavy-duty wheelchair Extra heavy-duty wheelchair Custom Manual Wheelchair Base Other manual wheelchair/base Standard-weight frame motorized/power wheelchair Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking Lightweight portable motorized/power wheelchair Custom Motorized/Power Wheelchair Base Other motorized/power wheelchair base Detachable, nonadjustable height armrest, each Detachable, adjustable height armrest, base, each Detachable, adjustable height armrest, upper portion, each Arm pad, each Fixed, adjustable height armrest, pair High mount flip-up footrest, each Leg strap, each Leg strap, H style, each Adjustable angle footplate, each Large size foot plate, each Standard size footplate, each Footrest, lower extension tube, each Footrest, upper hanger bracket, each Footrest, complete assembly Elevating legrest, lower extension tube, each Elevating legrest, upper hanger bracket, each Ratchet assembly Cam release assembly, footrest or legrest, each Swingaway, detachable footrests, each Elevating footrests, articulating (telescoping), each Seat height less than 17 inches or equal to or greater than 21 inches for a high strength, lightweight, or ultralightweight wheelchair Spoke protectors, each Rear wheel assembly, complete, with solid tire, spokes or molded, each K0070 Rear wheel assembly, complete with pneumatic tire, spokes or molded, each DME- Attachment A2 Page 3 of 9

4 K0071 K0072 K0073 K0077 K0098 K0105 K0108 K0195 K0455 K0462 K0552 K0601 K0602 K0603 K0604 K0605 K0606 K0607 K0608 K0609 K0669 K0672 K0730 K0733 Front caster assembly, complete, with pneumatic tire, each Front caster assembly, complete, with semipneumatic tire, each Caster pin lock, each Front caster assembly, complete, with solid tire, each Drive belt for power wheelchair IV hanger, each Other accessories Elevating legrest, pair (for use with capped rental wheelchair base) Infusion pump used for uninterrupted parenteral administration of medication (eg, epoprostenol or treprostinol) Temporary replacement for patient-owned equipment being repaired, any type Supplies for external drug infusion pump, syringe type cartridge, sterile, each Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each Automatic external defibrillator, with integrated electrocardiogram analysis, garment type Replacement battery for automated external defibrillator, garment type only, each Replacement garment for use with automated external defibrillator, each Replacement electrodes for use with automated external defibrillator, garment type only, each Wheelchair accessory, wheelchair seat or back cushion, does not meet specific code criteria or no written coding verification from DME PDAC Addition to lower extremity orthotic, removable soft interface, all components, replacement only, each Controlled dose inhalation drug delivery system Power wheelchair accessory, 12 to 24 AMP hour sealed lead acid battery, each (eg, gel cell, absorbed glassmat) DME- Attachment A2 Page 4 of 9

5 K0738 K0739 K0740 K0743 K0744 K0745 K0746 K0800 K0801 K0802 K0806 K0807 K0808 K0812 K0813 K0814 K0815 K0816 K0820 Portable gaseous oxygen system, rental: home compressor used to fill portable oxygen cylinders, includes containers, regulator, flowmeter, regulator, flometer, humidifier, cannula or mask and tubing Repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes Repair or nonroutine service for oxygen equipment requiring the skill of a technician, labor component, per 15 minutes Suction pump, home model, portable, for use on wounds Absorptive wound dressing for use with suction pump, home model, portable, pad size 16 square inches or less 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 square inches Absorptive wound dressing for use with suction pump, home model, portable, pad size greater than 48 square inches Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds Power operated vehicle, group 1 heavy duty, patient weight capacity, 301 to 450 pounds Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to 600 pounds Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds Power operated vehicle, group 2 heavy duty, Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to 600 pounds Power operated vehicle, not otherwise classified Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight Power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds Power wheelchair, group 1 standard, captains chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight DME- Attachment A2 Page 5 of 9

6 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0830 K0831 K0835 K0836 K0837 K0838 K0839 K0840 Power wheelchair, group 2 standard, portable, captains chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 451 to 600 pounds Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 600 pounds or more Power wheelchair, group 2 extra heavy duty, captains chair, patient weight capacity 601 pounds or more Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight Power wheelchair, group 2 standard, seat elevator, captain's chair, patient weight Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient, patient weight Power wheelchair, group 2 standard, single power option, captains chair, patient weight Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, Power wheelchair, group 2 heavy duty, single power option, captains chair, patient capacity 301 to 450 pounds Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds Power wheelchair, group 2 extra heavy duty, single power option sling/solid seat/back, patient capacity 601 pounds or more DME- Attachment A2 Page 6 of 9

7 K0841 K0842 K0843 K0848 K0849 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight Power wheelchair, group 2 standard, multiple power option, captains chair, patient weight Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to 450 pounds Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds Power wheelchair, group 3 very heavy duty, captains chair, patient weighty capacity, 451 to 600 pounds Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601 pounds or more Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight Power wheelchair, group 3 standard, single power option, captains chair, weight Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight DME- Attachment A2 Page 7 of 9

8 K0862 K0863 K0864 K0868 K0869 K0870 K0871 K0877 K0878 K0879 K0880 K0884 K0885 K0886 K0890 Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including up to and including 300 pounds Power wheelchair, group 4 standard, captains chair, patient weight capacity up to and including 300 pounds Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight Power wheelchair, group 4 standard, single power option, captains chair, patient weight Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient 451 to 600 pounds Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient Power wheelchair, group 4 standard, multiple power option, captains chair, weight Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds DME- Attachment A2 Page 8 of 9

9 K0891 K0898 K0899 K0900 S1030 S1031 S1040 S8097 S8100 S8101 S8185 S9007 Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds Power wheelchair, not otherwise classified Power mobility device not coded by DME PDAC or does not meet the criteria Customized Durable Medical Equipment, Other Than Wheelchair Continuous noninvasive glucose monitoring device, purchase (for physician interpretation of data, use CPT code) Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement and download to monitor (for physician interpretation of data, use CPT code) Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) Asthma kit (including but not limited to portable peak expiratory flow meter, instructional video, brochure, and/or spacer) Holding chamber or spacer for use with an inhaler or nebulizer; without mask Holding chamber or spacer for use with an inhaler or nebulizer; with mask Flutter device Ultrafiltration monitor DME- Attachment A2 Page 9 of 9