016.06.09 Ark. Code R. 046

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.09-046 - Prosthetics Provider Manual Update Transmittal #135

Section IIProsthetics

242.110 Respiratory and Diabetic Equipment, All Ages 1-1-10

When billed either electronically or on paper, procedure codes found in this section must be billed with certain modifiers. Modifiers in the section are indicated by the headings M1 and M2. When only the NU modifier is shown in the M1 column, the procedure code may be billed for beneficiaries of all ages. When NU and EP are listed together in the M1 column, the NU modifier must be used when billing for beneficiaries age 21 and over, and the EP modifier must be used when billing for beneficiaries under age 21. When a modifier is listed in the M2 heading, that modifier must be used in conjunction with either NU or EP.

Prior authorization requirements are shown under the heading PA. .If prior authorization is needed, the information is indicated with a "Y" in the column; if not, an "N" is shown.

* Prior authorization is not required when other insurance pays at least 50% of the

Medicaid maximum allowable reimbursement amount.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.

Respiratory and Diabetic Equipment, All Ages (section 242.110)

Procedure Code	M1	M2	Description	PA	Payment Method
A4230	NU	Infusion set for external insulin pump, nonneedle cannula type	Y*	Purchase
A4231	NU	Infusion set for external insulin pump, needle type	Y*	Purchase
A4232	NU	Syringe with needle for external insulin pump, sterile, 3 cc	Y*	Purchase
A4627	NU	UB	***(Spacer bag or reservoir without mask, for use with metered dose inhaler) Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler	N	Purchase
A4627	NU	***(Spacer bag or reservoir with mask, for use with metered dose inhaler) Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler	N	Purchase
A6021	NU	Collagen dressing, pad size 16 sq. in. or less, each	Y*	Purchase
A6022	NU	Collagen dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each	Y*	Purchase
A6023	NU	Collagen dressing, pad size more than 48 sq. in., each	Y*	Purchase
A6024	NU	Collagen dressing wound filler, per 6 in.	Y*	Purchase
A7034	NU	RR	*(CPAP Device Nasal Continuous Positive Airway Pressure (CPAP) Device; includes necessary accessory items) NOTE: Complete medical data pertinent to the request must be submitted with the prior authorization request. NOTE: Bill A7034 as the global daily rental service.** Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap	Y*	Rental Only
A7045	NU	Exhalation port with or without swivel used with accessories for positive airway devices, replacement only	N	Purchase
A7046	NU	Water chamber for humidifier, used with positive airway pressure device, replacement, each	N	Purchase
A9999	NU	*(Unlisted Durable Medical Equipment. The manufacturer's invoice must be attached to the claim form.)** Misc. DME supply or accessory, not otherwise specified	Y	Manually Priced
E0424	NU	Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing	Y*	Rental Only
E0430	NU	Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula or mask, and tubing	Y*	Rental Only
E0434	NU	Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adapter, contents gauge, cannula or mask, and tubing	Y*	Rental Only
E0435	NU	Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapter	Y*	Rental Only
E0439	NU	Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing	Y*	Rental Only
E0441	NU	Oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned), one month's supply = I unit	Y	Purchase
E0442	NU	Oxygen contents, liquid (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned), one month's supply = 1 unit	Y	Purchase
E0443	NU	Portable oxygen contents, gaseous (for use only with portable gaseous systems when no stationary gas or liquid system is used), one month's supply=1 unit	Y*	Purchase
E0444	NU	Portable oxygen contents, liquid (for use only with portable liquid systems when no stationary gas or liquid system is used), one month's supply=1 unit	Y*	Purchase
E0470	NU EP	RR RR	*(BIPAP Device, Nasal Bi-level Positive Airway support system; includes necessary accessory items. NOTE: Complete medical data pertinent to the request must be submitted with the prior authorization request.)** Respiratory assist device, bi-level pressure capacity, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)	Y4 Y4	Rental Only
E0471	NU EP	RR RR	Respiratory assist device, bi-level pressure capacity, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)	Y* Y4	Rental Only
E0472	NU EP	RR RR	Respiratory assist device, bi-level pressure capacity, with backup rate feature, used with invasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)	Y* Y4	Rental Only
E0482	NU EP	Cough stimulating device, alternating positive and negative airway pressure	Y*	Capped Rental
E0483	NU	RR	***(Bronchial Drainage System) High-frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each	Y*	Capped Rental
E0483	NU	UB	*(Pulmonary Vest. The manufacturer invoice must be attached to the claim form.)** High-frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each	Y*	Purchase
E0560	NU UE	Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery	N	Purchase
E0561	NU EP	Humidifier, non-heated, used w/positive airway pressure device	Y*	Purchase
E0562	NU	Humidifier, heated, used w/positive airway	Y*	Purchase
EP	pressure device	Y*
E0570	NU UE	Nebulizer, with compressor	Y*	Purchase
E0575	NU UE	Nebulizer, ultrasonic, large volume	Y*	Capped Rental
E0600	NU UE	Respiratory suction pump, home model, portable or stationary, electric	N	Rental Only
E0779	NU	RR	***(Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home) Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater	Y*	Rental Only
E0784	NU	External ambulatory infusion pump, insulin	Y*	Purchase
E1340	NU	*(DME Repair: Parts Only Repairs will not be approved for more than the allowed purchase price of new equipment. The manufacturer's invoice must be attached to the repair claim for all parts.)** Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes	N	N/A
E1340	NU	U4	/*(Maintenance for Capped Rental items) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes	N	N/A
E1340	NU	U1	***(Labor Only; a maximum of twenty (20) units per date of service is allowable. 20 units = 5 hours of labor) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes	N	N/A
E1340	EP	U1	***(Labor Only; a maximum of twenty (20) units per date of service is allowable. 20 units = 5 hours of labor) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes	N	N/A
E1390	NU	Oxygen concentrator, single delivery port, capable of delivering 85 % or greater oxygen concentration at the prescribed flow rate	Y*	Rental Only
E1391	NU	02 concentrator, dual delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate, each	Y4	Rental Only

242.111 Initial Rental of a DME Item for Individuals of All Ages 1-1-10

Procedure codes found in this section may be billed either electronically or on paper.

Some procedure codes have been assigned a modifier that affects the billing process. Required modifiers are indicated in the M1 column in the list below. When a modifier is shown in the M1 column, it must be listed along with the procedure code when requesting payment by Arkansas Medicaid.

Procedure codes shown in the list below are either covered for all ages (AA), only for individuals under age 21 (U21) or only for individuals age 21 and over (21+). A column in the list below defines the differences.

* Prior authorization is not required when other insurance pays at least 50% of the

Medicaid maximum allowable reimbursement amount.

Initial Rental of a DME Item for Individuals of All Ages (section 242.111)

Procedure Code	M1	Description	All U21 21 +
A7034*	*(CPAP Device Nasal Continuous Positive Airway Pressure (CPAP) Device; includes necessary accessory items. NOTE: For 21+, complete medical data pertinent to the request must be submitted with the prior authorization request.** Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap	AA
E0181	Pressure pad, alternating with pump, heavy duty	U21
E0200	Heat lamp, without stand (table model), includes bulb, or infrared element	U21
E0205	Heat lamp, with stand includes bulb, or infrared element	U21
E0217	Water circulating heat pad with pump	U21
E0225	Hydrocollatorunit, includes pad	U21
E0236	Pump for water circulating pad	U21
E0239	Hydrocollatorunit, portable	U21
E0250*	Hospital bed, fixed height, with any type side rails, with mattress	U21
E0250*	U1	Hospital bed, fixed height, with any type side rails, with mattress	U21
E0250*	UE	Hospital bed, fixed height, with any type side rails, with mattress	21 +
E0255*	Hospital bed, variable height; hi-lo, with any type side rails, with mattress	U21
E0255	KH	Hospital bed, variable height; hi-lo, with any type side rails, with mattress	21 +
E0260*	Hospital bed, semi-electric (head and foot adjustment), with any type side rails with mattress	U21
E0260*	KH	Hospital bed, semi-electric (head and foot adjustment), with any type side rails with mattress	21 +
E0271	Mattress, inner spring	U21
E0272	Mattress, foam rubber	U21
E0303	Hospital bed, heavy duty, extra wide, with weight capacity [GREATER THAN] 350 but [LESS THAN] or = 600, any type side rails, w/mattress	AA
E0424	Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator flowmeter, humidifier, nebulizer cannula or mask, and tubing	AA
E0430*	Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula, or mask, and tubing	AA
E0434	Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing	AA
E0435*	Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapter	AA
E0439	Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing	AA
E0445*	Oximeter for measuring blood oxygen levels non-invasively. *** (Pulse oximeter, including 4 disposable probes)	AA
E0480	Percussor, electric or pneumatic, home model	U21
E0565*	Compressor, air power source for equipment which is not self-contained or cylinder driven	U21
E0575*	Nebulizer, ultrasonic, large volume	AA
E0585	Nebulizer, with compressor and heater	U21
E0600	Respiratory suction pump, home model, portable or stationary, electric	AA
E0606	Vaporizer, room type	U21
E0630*	Patient lift, hydraulic, with seat or sling	U21
E0630	KH	Patient lift, hydraulic, with seat or sling	21 +
E0650*	Pneumatic compressor, nonsegmental home model	U21
E0667*	Segmental pneumatic appliance for use with pneumatic compressor, full leg	U21
E0668*	Segmental pneumatic appliance for use with pneumatic compressor, full arm	U21
E0691	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or less	U21
E0692	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel	U21
E0693	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel	U21
E0694	Ultraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protection	U21
E0720*	TENS, two lead, localized stimulation	U21
E0730*	Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation	AA
E0730*	KH	Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation	21 +
E0745*	Neuromuscular stimulator, electronic shock unit	U21
E0779*	***(Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home) Ambulatory infusion device pump, mechanical, reusable, for infusion 8 hours or greater	AA
E0910	Trapeze bars, also known as Patient Helper, attached to bed, with grab bar	AA
E0910	KH	Trapeze bars, also known as Patient Helper, attached to bed, with grab bar	21 +
E0911	Trapeze bar, heavy-duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar	AA
E0920	Fracture frame, attached to bed, includes weights	U21
E0930	Fracture frame, freestanding, includes weights	U21
E0935*	Passive motion exercise device	U21
E0940	Trapeze bar, freestanding, complete with grab bar	U21
E0941	Gravity assisted traction device, any type	U21
E1130*	Standard wheelchair, fixed full-length arms, fixed or swing-away, detachable footrests	U21
E1130*	KH	Standard wheelchair, fixed full-length arms, fixed or swing-away, detachable footrests	21 +
E1224*	Wheelchair with detachable arms, elevating legrests	AA
E1224*	U1	***(Footrests wheelchair with detachable arms, elevating leg rests) Wheelchair with detachable arms, elevating legrests	21 +
E1390	Oxygen concentrator, single delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate	AA
E1391	Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each	AA

Providers will be reimbursed for a minimum of 30 days of rental when the equipment is used less than 30 days. Initial rental codes must be billed when equipment is used less than 30 days during the first month of rental.

Arkansas Medicaid will only reimburse for one initial minimum 30 days of rental per state fiscal year period per beneficiary per procedure code. The provider will not be reimbursed for the same procedure code utilizing another modifier for the same time period.

242.160 Durable Medical Equipment, All Ages 1-1-10

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU. Modifier UE is required when billing for used equipment.

Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a "Y" in the column; if not, an "N" is shown.

* The purchase of wheelchairs for individuals age 21 and older is limited to one per five-year period.

*** This procedure code may not be billed for used equipment.

* Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.

Durable Medical Equipment, All Ages (section 242.160)

Procedure Code	M1	M2	M3	PA	Description	Payment Method
A4635	NU EP UE	N	Underarm pad, crutch, replacement, each	Purchase
A4636	NU EP UE	N	Replacement, handgrip, cane, crutch, or walker, each	Purchase
A4637	DQ.UJ ZUJD	N	Replacement, tip, cane, crutch, walker, each	Purchase
E0100	DQ.UJ ZUJD	N	Cane, includes canes of all materials, adjustable or fixed, with tip	Purchase
E0105	3 0_ LU ZUJD	N	Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips	Purchase
E0110	NU EP UE	N	Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips	Purchase
E0111	3 CL LU ZUJD	N	Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip	Purchase
E0111	NU	U1	N	Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip	Purchase
E0112	3 CL LU Z LU 3	N	Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips	Purchase
E0113	3 CL LLI Z LU 3	N	Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip	Purchase
E0114	3 CL LU Z LU 3	N	Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips	Purchase
E0116	3 CL LU Z LU 3	N	Crutch, underarm, other than wood, adjustable or fixed, each, with pad, tip and handgrip	Purchase
E0130	3 CL LU Z LU 3	N	Walker, rigid (pickup), adjustable or fixed height	Purchase
E0135	NU EP UE	N	Walker, folding (pickup), adjustable or fixed height	Purchase
E0140	NU EP	N	Walker, w/trunk support, adjustable or fixed height, any type	Purchase
E0141	3 CL LU Z LU 3	N	Walker, rigid, wheeled, adjustable or fixed height	Purchase
E0143	3 CL LU Z LU 3	N	Walker, folding, wheeled, adjustable or fixed height	Purchase
E0147	3 CL LU Z LU 3	N	Walker, heavy duty, multiple braking system, variable wheel resistance	Purchase
E0153	3 CL LU Z LU 3	N	Platform attachment, forearm crutch, each	Purchase
E0154	NU EP UE	N	Platform attachment, walker, each	Purchase
E0155	3 CL LU ZUJD	N	Wheel attachment, rigid pick-up walker, per pair seat attachment, walker	Purchase
E0156	NU EP	N	Seat attachment, walker	Purchase
E0157	3 CL LU Z LLI 3	N	Crutch attachment, walker, each	Purchase
E0158	3 CL LLI Z LU 3	N	Leg extensions for walker, per set of four (4)	Purchase
E0159	NU EP	N	Brake attachment for wheeled walker, replacement, each	Purchase
E0160	3 CL LLI Z LU 3	N	Sitz type bath or equipment, portable, used with or without commode	Purchase
E0161	3 CL LLI Z LU 3	N	Sitz type bath or equipment, portable, used with or without commode, with faucet attachment(s)	Purchase
E0163	3 CL LLI Z LLI 3	N	Commode chair, stationary, with fixed arms	Purchase
E0167	NU EP UE	N	Pail or pan for use with commode chair	Purchase
E0175	3 CL LLI Z LLI 3	N	Foot rest, for use with commode chair, each	Purchase
E0181	3 CL LLI Z LLI 3	N	Pressure pad, alternating with pump, heavy duty	Capped Rental
E0182	3 CL LLI Z LLI 3	N	Pump for alternating pressure pad	Purchase
E0184	3 CL LLI Z LLI 3	N	Dry pressure mattress	Purchase
E0185	NU EP UE	N	Gel or gel-like pressure pad for mattress, standard mattress length and width	Purchase
E0186	NU EP	Y	Air pressure mattress	Purchase
E0187	NU EP	Y	Water pressure mattress	Purchase
E0189	NU EP UE	N	Lambswool sheepskin pad, any size	Purchase
E0190	NU UE	N	Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	N	*** (Tumble Form Therapy Roll 4") Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U1	N	*** (Tumble Form Therapy Roll 6") Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U2	N	*** (Tumble Form Therapy Wedge 4") Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U3	N	*** (Tumble Form Therapy Roll 8") Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U4	N	*** (Tumble Form Therapy Wedge 6") Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U5	N	*** (Floor Sitter Wedge 4") Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U6	N	*** (Tumble Form Therapy Roll 12") Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U7	N	*** (Deluxe Wedge with strap 4") Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U8	N	*** (Deluxe Wedge with strap 6") Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	U9	N	A (Tumble Form Therapy Wedge 10") Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	KA	U1	N	A (Tumble Form Therapy Roll 14") Positioning cushion/pillow/wedge, any shape or size	Purchase
E0190	EP	KA	U2	N	(Tumble Form Therapy Roll 16") Positioning cushion/pillow/wedge, any shape or size A	Purchase
E0190	EP	KA	U3	N	A (Tumble Form Therapy Wedge 8") Positioning cushion/pillow/wedge, any shape or size	Purchase
E0191	NU EP UE	N	Heel or elbow protector, each	Purchase
E0194³	NU EP	Y	A(Clinitron Bed) Airfluidized bed	Capped Rental
E0196	NU EP	N	Gel pressure mattress	Purchase
E0197	NU EP UE	N	Air pressure pad for mattress, standard mattress length and width	Purchase
E0198	NU EP	Y	Water pressure pad for mattress, standard mattress length and width	Purchase
E0200	NU EP UE	N	Heat lamp, without stand (table model), includes bulb, or infrared element	Capped Rental
E0202	NU EP UE	N	Phototherapy (bilirubin) light with photometer	Rental Only
E0202	U	U1	N	Phototherapy (bilirubin) light with photometer	Capped Rental
E0205	NU EP UE	N	Heat lamp, with stand includes bulb, or infrared element	Capped Rental
E0217	NU EP UE	N	Water circulating heat pad with pump	Capped Rental
E0225	NU EP UE	N	Hydrocollatorunit, includes pad	Capped Rental
E0235	NU EP UE	N	Paraffin bath unit, portable (see medical supply code A4265 for paraffin)	Purchase
E0236	NU EP UE	N	Pump for water circulating pad	Capped Rental
E0238	3 CL LU ZUJD	N	Nonelectric heat pad, moist	Purchase
E0239	3 CL LU Z LLI 3	N	Hydrocollatorunit, portable	Capped Rental
E0240	NU EP	N	Bath/shower chair w/wo wheels, any size	Purchase
E0240	NU EP	U1 U1	N	Bath/shower chair w/wo wheels, any size	Purchase
E0240	NU EP	U2 U2	N	Bath/shower chair w/wo wheels, any size	Purchase
E0240	NU EP	U3 U3	N	Bath/shower chair w/wo wheels, any size	Purchase
E0244	NU EP	N	Raised toilet seat	Purchase
E0245***	NU EP	U1 U1	N	***(Bath Frame Support, Large) Tub stool or bench	Purchase
E0247	NU EP	N	Transfer bench, tub/toilet, w/wo commode opening	Purchase
E0247	NU EP	U1 U1	N	Transfer bench, tub/toilet, w/wo commode opening	Purchase
E0248	NU EP	N	Transfer bench, heavy duty, tub/toilet w/wo commode opening	Purchase
E0248	NU EP	U1 U1	N	Transfer bench, heavy duty, tub/toilet w/wo commode opening	Purchase
E0249	3 CL LLI Z LU 3	N	Pad for water circulating heat unit	Purchase
E0250	NU EP	Y*	***(Hospital bed, with side rails, fixed height, with mattress, purchase) Hospital bed, fixed height, with any type side rails, with mattress	Purchase
E0250	NU EP	RR RR	Y*	Hospital bed, fixed height, with any type side rails, with mattress	Capped Rental
E0255	NU EP	Y*	Hospital bed, variable height; hi-lo, with any type side rails, with mattress	Purchase
E0255	NU EP	RR RR	Y*	Hospital bed, variable height; hi-lo, with any type side rails, with mattress	Capped Rental
E0255	NU	U1	Y*	***(Hospital bed, with side rails, variable height; hi-lo, with mattress, purchase) Hospital bed, variable height; hi-lo, with any type side rails, with mattress	Purchase
E0255	UE	Y*	Hospital bed, variable height; hi-lo, with any type side rails, with mattress	Capped Rental
E0260	3 CL LU ZUJD	Y*	***(Hospital bed, with side rails, semi-electric, head and foot adjustments, with mattress, purchase) Hospital bed, semi-electric, head and foot adjustment, with any type side rails with mattress	Purchase
E0260	NU EP	RR RR	Y*	Hospital bed, semi-electric, head and foot adjustment, with any type side rails with mattress	Capped Rental
E0271	3 CL LU Z LLI 3	N	Mattress, inner spring	Capped Rental
E0272	3 CL LLI Z LU 3	N	Mattress, foam rubber	Capped Rental
E0273	3 CL LLI Z LU 3	N	Bed board	Purchase
E0275	3 CL LLI Z LU 3	N	Bed pan, standard, metal or plastic	Purchase
E0276	NU EP UE	N	Bed pan, fracture, metal or plastic	Purchase
E0277³	NU EP	Y	***(Low Air Loss Mattress) Powered pressure-reducing air mattress	Capped Rental
E0280	NU EP UE	N	Bed cradle, any type	Purchase
E0300	EP	Y	Pediatric crib, hospital grade, fully enclosed	Purchase
E0300	EP	RR	Y	Pediatric crib, hospital grade, fully enclosed	Rental Only
E0302	NU EP	Y	Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress	Capped Rental
E0303	NU EP UE	Y Y Y	Hospital bed, heavy duty, extra wide, with weight capacity [GREATER THAN] 350 but [LESS THAN] or = 600, any type side rails, w/mattress	Rental Only (Rent to Purchase)
E0304	NU EP	J	Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress	Capped Rental
E0325	3 0_ LU ZUJD	N	Urinal; male, jug-type, any material	Purchase
E0325	NU EP UE	U1 U1 U1	N	Urinal; male, jug-type, any material	Purchase
E0326	NU EP UE	N	Urinal; female, jug-type, any material	Purchase
E0445***	NU EP	Y*	***(Pulse oximeter, including 4 disposable probes) Oximeter for measuring blood oxygen levels non-invasively	Rental Only
E0480	NU EP UE	N	Percussor, electric or pneumatic, home model	Capped Rental
E0565	NU EP UE	Y*	Compressor, air power source for equipment which is not self-contained or cylinder driven	Capped Rental
E0570	NU UE	Y	Nebulizer, with compressor	Purchase
E0585	NU EP UE	N	Nebulizer, with compressor and heater	Capped Rental
E0605	NU EP UE	N	Vaporizer, room type	Purchase
E0606	NU EP UE	N	Postural drainage board	Capped Rental
E0607***	NU EP	N	Home blood glucose monitor	Purchase
E0621	NU	N	Sling or seat, patient lift, canvas or nylon	Purchase
E0630	NU EP UE	Y*	Patient lift, hydraulic, with seat or sling	Capped Rental
E0650	NU EP UE	Y*	Pneumatic compressor, nonsegmental home model	Capped Rental
E0667	NU EP	Y*	Segmental pneumatic appliance for use with pneumatic compressor, full leg	Capped Rental
E0668	NU EP	Y*	Segmental pneumatic appliance for use with pneumatic compressor, full arm	Capped Rental
E0691	NU EP	N	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or less	Rental Only
E0692	NU EP	N	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panel	Rental Only
E0693	NU EP	N	Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panel	Rental Only
E0694	NU EP	N	Ultraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protection	Rental Only
E0720	NU EP UE	Y*	TENS, two lead, localized stimulation	Capped Rental
E0730	NU EP UE	Y*	Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation	Capped Rental
E0740	NU EP UE	N	Incontinence treatment system, pelvic floor stimulator, monitor, sensor and/or trainer	Purchase
E0745	NU EP UE	Y*	Neuromuscular stimulator, electronic shock unit	Capped Rental
E0747	NU EP UE	Y*	Osteogenesis stimulator, electrical noninvasive, other than spinal applications	Rental Only
E0748	NU EP	Y	Osteogenesis stimulator, electrical noninvasive, spinal applications	Rental Only
E0760	NU EP	Y	Osteogenesis stimulator, low intensity ultrasound, noninvasive	Rental Only
E0779	NU	RR	Y*	***(Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home) Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater	Rental Only
E0840	NU EP UE	N	Traction frame, attached to headboard, cervical traction	Purchase
E0850	3 CL LU ZUJD	N	Traction stand, freestanding, cervical traction	Purchase
E0860	3 CL LU Z LLI 3	N	Traction equipment, overdoor, cervical	Purchase
E0870	3 CL LLI Z LU 3	N	Traction frame, attached to footboard, extremity traction (e.g., Buck's)	Purchase
E0880	3 CL LLI Z LU 3	N	Traction stand, freestanding, extremity traction (e.g., Buck's)	Purchase
E0890	NU EP UE	N	Traction frame, attached to footboard, pelvic traction	Purchase
E0900	NU EP UE	N	Traction stand, freestanding, pelvic traction (e.g., Buck's)	Purchase
E0910	NU EP UE	N	Trapeze bars, also known as Patient Helper, attached to bed, with grab bar	Capped Rental
E0910	NU	RR	N	Trapeze bars, also known as Patient Helper, attached to bed, with grab bar	Capped Rental
E0920	NU EP UE	N	Fracture frame, attached to bed, includes weights	Capped Rental
E0930	NU EP UE	N	Fracture frame, freestanding, includes weights	Capped Rental
E0935	NU EP UE	Y*	Continuous passive motion exercise device for use on knee only	Capped Rental
E0940	NU EP UE	N	Trapeze bar, freestanding, complete with grab bar	Capped Rental
E0941	NU EP UE	N	Gravity assisted traction device, any type	Capped Rental
E0942	NU EP UE	N	Cervical head harness/halter	Purchase
E0944	NU EP UE	N	Pelvic belt/harness/boot	Purchase
E0945	NU EP UE	N	Extremity belt/harness	Purchase
E0946	NU EP UE	N	Fracture frame, dual with cross bars, attached to bed (e.g., Balken, Four Poster)	Purchase
E0947	NU EP UE	N	Fracture frame, attachments for complex pelvic traction	Purchase
E0948	NU EP UE	N	Fracture frame, attachments for complex cervical traction	Purchase
E0950	NU EP UE	N	Wheelchair accessory, tray, each	Purchase
E1130*	NU EP UE	Y*	Standard wheelchair, fixed full-length arms, fixed or swing-away, detachable footrests	Capped Rental
E1130*	NU	U1	Y*	Standard wheelchair, fixed full-length arms, fixed or swing-away, detachable footrests	Rental Only
E1140*	NU EP	Y*	Wheelchair, detachable arms, desk or full-length, swing-away, detachable footrests	Capped Rental
E1150*	NU EP	Y*	Wheelchair; detachable arms, desk or full-length, swing-away, detachable, elevating legrests	Capped Rental
E1160*	NU EP	Y*	Wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests	Capped Rental
E1224*	NU EP UE	Y*	Wheelchair with detachable arms, elevating leg rests	Capped Rental
E1224*	NU	U1	Y*	***(Footrests wheelchair with detachable arms, elevating leg rests) Wheelchair with detachable arms, elevating leg rests	Rental Only
E1340	NU	N	*(DME Repairs/Parts Only Repairs will not be approved for more than the allowed purchase price of new equipment. The manufacturer's invoice must be attached to the repair claim for all parts.)** Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes	Manually Priced
E1340***	NU EP	U1 U1	N	***(Labor Only; a maximum of twenty [20] units [20 units = 5 hours of labor] per date of service is allowable.) Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes	Manually Priced
E1399	NU	N	Durable medical equipment, miscellaneous	Manually Priced
K0105	NU EP	N	IV hanger, each	Purchase
K0606	NU EP	Y	Automatic external defibrillator, with integrated electrocardiogram analysis, garment type (covered only for beneficiaries ages 18 and over)	Capped Rental
S8096***	NU EP	N	***(Peak flow meter used by asthmatic patients) Portable peak flow meter	Purchase
Z2211 (Bill on Paper)	NU EP	Y	Power Kit/Batteries	Purchase

Procedure codes E0250*, E0255* and E0260* must be billed when hospital beds are purchased for Medicaid beneficiaries of all ages. Providers must only provide these purchase-only services to beneficiaries who are expected to require the bed for a long period of time. Each procedure code for hospital beds listed above may only be billed once every 10 years.

Procedure codes E0250*, E0255* and E0260* must also be used to bill for equipment that does not meet the purchase-only criteria. They are reimbursed on a capped rental basis. The capped rental items must be used until the equipment is no longer repairable or until it is no longer appropriate for the beneficiary as verified by the physician.

242.161 RESERVED 1-1-10

016.06.09 Ark. Code R. 046

12/18/2009