Change to DME benefit limits for miscellaneous durable and expendable supplies

Miscellaneous Durable and Expendable Supplies 

New HCPCS Code

Description

Billing unit

Limit

A4265

Paraffin

Per pound

1/2 months

A4402

Lubricant - All Brands

Per ounce

20 oz./month

A4453

Rectal catheter for use with manual pump-operated enema system, replacement only

Each

2/month

A4456

Adhesive remover, wipes, any type, each

Each

20/month

A4458

Enema bag w/tubing, reusable

Each

15/month

A4459

Manual pump-operated enema system, includes balloon, catheter and all accessories, reusable any type

Each

1/3 months

A4561

Pessary; rubber, any type

Each

1/3 months

A4562

Pessary, non-rubber, any type

Each

1/3 months

A4565

Sling-any Type

Each

2/12 months

A4566

Shoulder sling or vest design, abduction restrainer, with or without swathe control, prefabricated, includes fitting and adjustment.

Each

1/12 months

A4467

Belt, strap, sleeve, garment, or covering any type

Each

2/3months

A4600

Sleeve for intermittent limb compression device, replacement only, each

Each

1/6 months

A4601

Lithium-ion battery for non-prosthetic use, replacement

Each

1/6 months

A4602

Replacement battery for external infusion pump owned by patient, lithium,1.5 volt, each

Each

1/6 months

A4611

Battery, heavy duty; replacement for patient-owner ventilator

Each

1/6 months

A4612

Battery, cables; replacement for patient-owner ventilator

Each

1/6 months

A4613

Battery, charger; replacement for patient-owner ventilator

Each

1/6 months

A4638

Replacement battery, for patient–owned ear pulse generator, each

Each

1/6 months

A4660

Sphygmomanometer/Bp Apparatus W/Cuff and Stethoscope

Each

1/36 months

A4670

Automatic Blood Pressure Monitor

Each

1/36 months

A4927

Gloves, Non-Sterile, Sm., Med., Lg.

Per box of 100

2 boxes/month

A4930

Gloves, Sterile, Sm., Med., Lg.

Per pair

50 pairs/month

E0160

Sitz bath or equipment, portable, used with or without commode

Each

1/12 months

E0161

Sitz type bath or equipment, portable, used with or without commode, with faucet attachment's)

Each

1/12 months

E0162

Sitz bath chair

Each

1/12 months

E0163

Commode chair, mobile or stationary, with fixed arms

Each

1/36 months

E0165

Commode chair, mobile or stationary, with detachable arms

Each

1/36 months

E0167

Pail or pan for use with commode chair, replacement only

Each

1/36 months

E0168

Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each

Each

1/36 months

E0175

Footrest, for use with commode chair, each

Each

2/36 months

E0235

Paraffin bath unit, portable

Each

1/2 months

E0236

Pump for water circulating pad

Each

1/12 months

E0239

Hydrocollator unit, portable

Each

2 months/year

E0240

Bath/Shower chair, with or without wheels, any size

Each

1/36 months

E0244

Raised Toilet Seat

Each

1/36 months

E0245

Tub stool or bench

Each

1/36 months

E0246

Transfer tub rail attachment

Each

1/36 months

E0247

Transfer bench for tub or toilet with or without commode opening

Each

1/60 months

E0248

Transfer bench, heavy duty, for tub or toilet with or without commode opening

Each

1/60 months

E0249

Pad for water circulating heat unit

Each

1/month

E0602

Breast pump, manual, any type

Each

1 per year

E0603

Breast pump, electric (AC and/or DC), any type

Each

1/36 months

E0604

Breast pump, hospital grade, electric (AC and/or DC), any type

Day

6 months

E0610

Pacemaker monitor, self-contained, checks battery depletion, includes audible and visible check systems

Each

1/60 months

E0621

Sling or seat, patient lift, canvas or nylon

Each

1/24 months

E0630

Patient lift, hydraulic or mechanical, includes any seat, sling, strap (s) or pad(s)

Each

1/60 months

E0638

Standing frame /Table system, One Position (E.G. Upright, Supine or Prone Stander), any Size Including Pediatric, With or Without Wheels

Each

1/36 month

E0641

Standing Frame/Table System, Multi-Position (E.G. Three-Way Stander), Any Size Including Pediatric, With or Without Wheels

Each

1/60 months

E0642

Standing Frame/Table System, Mobile (Dynamic Stander), Any Size Including Pediatric

Each

1/60 months

E0650

Pneumatic compressor, nonsegmental home model

Each

1/36 months

E0651

Pneumatic compressor, segmental home model without calibrated gradient pressure

Each

1/36 months

E0652

Pneumatic compressor, segmental home model with calibrated gradient pressure

Each

1/36 months

E0655

Nonsegmental Pneumatic appliance for use with pneumatic compressor, half arm

Each

1/36 months

E0656

Segmental pneumatic appliance for use with pneumatic compressor, trunk

Each

1/36 months

E0657

Segmental pneumatic appliance for use with pneumatic compressor, chest

Each

1/36 months

E0660

Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg

Each

1/36 months

E0665

Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm

Each

1/36 months

E0666

Nonsegmental Pneumatic appliance for use with pneumatic compressor, half leg

Each

1/36 months

E0667

Segmental pneumatic appliance for use with pneumatic compressor, full leg

Each

1/36 months

E0668

Segmental pneumatic appliance for use with pneumatic compressor, full arm

Each

1/36 months

E0669

Segmental pneumatic appliance, half leg

Each

1/36 months

E0670

Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk

Each

1/36 months

E0671

Segmental gradient pressure pneumatic appliance, full leg

Each

1/36 months

E0672

Segmental gradient pressure pneumatic appliance, full arm

Each

1/36 months

E0673

Segmental gradient pressure pneumatic appliance, half leg

Each

1/36 months

E0676

Intermittent limb compression device (includes all accessories), not otherwise specified

Each

1/36 months

E0705

Transfer device, any type, each

Each

1/36 months

E0968

Commode seat, wheelchair

Each

1/60 months

E1820

Replacement soft interface material, dynamic adjustable extension/flexion

Each

3/year

E1821

Replacement soft interface material/cuffs for bi-directional static progressive stretch

Each

3/year

K0601

Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each

Each

1/6 months

K0602

Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each

Each

1/6 months

K0603

Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each

Each

1/6 months

K0604

Replacement battery for external infusion pump owned by patient, lithium 3.6 volt, each

Each

1/6 months

K0605

Replacement battery for external infusion pump owned by patient, lithium 4.5 volt, each

Each

1/6 months

K0607

Replacement battery for automated external defibrillator, garment type only, each

Each

1/6 months

K0739

Repair or non-routine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes

Per 15 mins

14/12 months

K0740

Repair or non-routine service for oxygen equipment requiring the skill of a technician, labor component, per 15 minutes

Per 15 mins

14/12 months

K1013

Enema tube, any type, replacement only, each

Each

2/ month

K1021

Exsufflation belt, includes all supplies and accessories

Each

1/12 months

T5001

Positioning seat for persons w/ special orthopedic needs, for use in vehicles (Previously 'Customized Seating System for Use in Vehicle; Special Pediatric/Young Adult')

Each

1/60 months

L7360

Six-volt battery, each

Each

1/6 months

L7362

Battery charger, six-volt, each

Each

1/6 months

L7364

Twelve-volt battery, each

Each

1/6 months

L7366

Battery charger, twelve-volt, each

Each

1/6 months

L7367

Lithium ion, battery replacement

Each

1/6 months