DHMH - MarylandXl 025 Administration Set for enteral feeding with 1400ml. (and above) bag or...

PT20-01

STATE OF MARYLAND

DHMH Office of Health ServicesMedical Care Programs

MARYLAND MEDICAL ASSISTANCE PROGRAMMEDICAL SUPPLY AND EQUIPMENT TRANSMITTAL NO. 51

May16,2001

Medical Supply and Equipment Providers

Joseph M. Millstone, Executive Director ~l)t.tOffice of Health Services V

FROM:

NOTE: Please ensure that appropriate staff members in your organization areinformed of the contents of this transmittal

Updated Approved List of Items

The Maryland Medical Assistance Program has updated the Disposable MedicalSupplies/Durable Medical Equipment Approved List of Items, effective March 1, 2001.

Please note that unused procedure codes have been deleted from the Approved List.This process was perfonned to prepare for the implementation of the Health InsurancePortability and Accountability Act of 1996 (HIPAA) conversion.

If you have further questions concerning this list, please call the Staff Specialist forDisposable Medical Supplies and Durable Medical Equipment at (410) 767-1739.

Reminder: Diabetic-monitoring supplies cannot be billed as point-or-sale pharmac):items. The): must be billed on the HCF A 1500 using ):our DMS/DME provider number.

Toll Free .877-4MD-DHMH.1TY for Disabled - Maryland Relay Service 1-800,.735-2258

Web Site: www.dhmh.state.md.us

20 I W. Preston Street. Baltimore, Maryland 2120 IPanis N. Glendening. Governor - Georges C. Benjamin, M.D., Secretary

MARYLAND MEDICAL ASSISTANCE PROGRAM

DISPOSABLE MEDICAL SUPPLIES

AND

DURABLE MEDICAL EQUIPMENT

APPROVED LIST OF ITEMS

EFFECTIVE MARCH 1, 2001

'1 ~ . .

rPREAUTHORIZA TION REQUIREMENTS

COMAR 10.09.12.06

A. Preauthorization is required for:

(1) Disposable medical supplies listed in Regulations .04A and B with a charge exceeding

$300;(2) All incontinency pants and disposable under pads;(3) DME priced on the list of items as individual consideration (I/C)(4) Any rental of durable medical equipment after the third month of rental;(5) Osteogenesis stimulators; and(6) All repairs to purchased dme exceeding $500.

B. Preauthorization is not required for:

(1) Any disposable medical supplies and durable medical equipment for home kidney

dialysis;(2) Prosthetic devices; and(3) DME on the approved list of items with both a procedure code and a purchase price

under $750.(4) Labor charges for repairs under three hours.

~

MARYLAND MEDICAL ASSISTANCE PROGRAM

DISPOSABLE MEDICAL SUPPLIESAND

DURABLE MEDICAL EQUIPMENT

APPROVED LIST OF ITEMSProcedure Codes and Maximum Allowable Prices

TABLE OF CONTENTS

~3

4 -20

4-5S-7

General Notes Pertaining to DMS/DME

Part I: DISPOSABLE MEDICAL SUPPLIES

Administration Supplies for Intravenous Medication

Administration Supplies for Enteral and Parenteral Nutrition

7

12

12

13

13

14 - 20

21

22222222

23

Diabetic Monitoring Supplies

Ostomy and Permanent Urinary Incontinence Supplies

Spinal Cord Dysfunction Care Supply Kits

Bum Gannents

Support Stockings. Individually Form - Fitted

Osteogenesis Simulators

Suction Supplies

Miscellaneous Medical Supplies (including Wound Care Supplies)

Part II: DURABLE MEDICAL EOUIPMENT (Purchase/Rental)

Apnea Monitors and Accessories

Beds, HospitalMattressSide Rails

Blood Glucose Monitoring Equipment

Braces and Supports

Canes,Crutches and Shower Chairs

2S

2S

2S.

Commodes

Enteral and Parenteral Nutrition Equipment

Intravenous Medication Equipment

Nebulizers and Accessories

1 .

.26

. '

r~27272727

Prosthetic DevicesEyeBreastLimbs

28

28

28

29

30-35

33-34

Suction Equipment and Accessories

TENS Equipment and Accessories

Traction Equipment

Walkers and Accessories

Wheelchairs, Power-operated Vehicles and Transporters

Accessories

34Modifications

36

363636363636363636363636363637

37

38-42

Pediatric Adaptive/Positioning Accessories

Miscellaneous Durable Medical EquipmentAugmentative Communication Devices and AccessoriesBed PansBlood Pressure EquipmentCollarsDrug Delivery SystemIncontinence Pants and PadsPatil'nt LiftPhototherapy Unit, Home usePressure Pads, AlternatingSplints, Wrist and PositioningTrapeze BarsTruss Support

VaporizerDurable Medical Equipment, not otherwise classified

Repairs to Durable Medical Equipment

Pediatric DME

43-44

44

Respiratory Equipment and Accessories

Used Equipment

)-2-

General Notes Pertaining to DMS/DME

For certain categories of Disposable Medical Supplies and Durable Wedical Equipmentwhich are unlisted and/or priced by individual consideration (I/C), the word "~if'i" isshown, indicating that additional information is needed to process preauthorizationrequests and/or claim forms.

This information usually consists of the following:1. Manufacturer's name;2. Manufacturer's product number;3. Number of individual items per packaging unit (for supplies 2..Tld accessories);4. Provider's usual and customary charge;If this information cannot be provided, please attach a product she~t identifying

each item, manufacturer, distributor, or supplier; or submit other appropriate informationwhich describes the item(s) and identifies a contact source. In all these instances, pleaseinclude addresses and telephone numbers as well.

Your cooperation in supplying this information initially wilt reduce the time toprocess your request or claim.

If you have questions or comments concerning this list please taU (410) 767-1739 or you may send an e-mail to [email protected].

Preauthorization Requirements

COMAR 10.09.12.06

A. Preauthorization is required for:

(1) Disposable medical supplies listed in Regulations .04A and B ,..'ith a chargeexceeding $300;

(2) All incontinency pants and disposable underpads;(3) Osteogenesis stimulators;(4) Durable medical equipment priced on the approved list ofiten.s as individual

consideration (I/C);(5) Disposable medical supplies and durable medical equipment n.:>t on the approved

list of items;(6) Any rental of durable medical equipment after 3 months of rer,tal; and(7) All repairs to purchased durable medical equipment exceedin~ $500.

B. Preauthorization is not required for:(1 ) Prosthetic devices; and(2) Durable medical equipment on the approved list with both a r-rocedure code and

a purchase price under $750.

-3-

t '"

MARYLAND MEDICAL ASSISTANCE PROGRAMDISPOSABLE MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT

APPROVED LIST OF ITEMSr

~I/C - Individual ConsiderationNC - Not CoveredUC - Usual and CustomaryAN - As Needed

Part 1: DISPOSABLE MEDICAL SUPPLIES

ADMINISTRATION SUPPLIES FOR INTRA VENOUS MEDICATION ANDPARENTAL NUTRITION

PricePerl!niL

MaximumUnits perService.

ProcedureCode

Pricing!1nLItem Descri~tion

$ 5.0010.70

eacheach

9090

4.55 each 90

33.00 each 30

10.002.45

eacheach

1090

10.504.28

eacheach

306

5.93 each 6

8.99 each 6

5.93 each 90

7.45 each 90

.20

.31

.16

eacheacheach

100100100

XI030Injection cap, needlesX I 000 Administration Set for intravenous

medication (with filter)X I 00 I Administration Set for intravenous

medication (without filter)X I 04 7 Administration set for ambulatory

infusion pumpX 1049 Central line trayX 1002 Filter for intravenous medication

administration (when sold

separately)XI043 IV extension setX I 051 Sharps disposable container, 1 quart

capacityXI052 Sharps disposable container, 5 quart

capac ityXI053 Sharps disposable container, 8 quart

capacityX I 044 Infusion Bag, disposable, for mechanical

driverXI045 Infusion Bag, multi-use for mechanical

driverXI054 Syringe only, 0.5ml or ImlXI055 Syringe with needle, 0.5ml or ImlXI056 Syringe only, 3ml

4-

Maximu::.'.Units pt~.Service

PricePer!.!niL

Pricing!.!.niL

Procedure

Code Item Descriotion

10010010010010010010010010010025

$ .23.26.39.2944.28.41.31.46.76

1.15I/C

eacheacheacheacheacheacheacheacheacheacheach

each 9011.90

each 908.85

903.15 each

8.00 each 2

30

XI057 Syringe with needle, 3ml

XI058Syringeonly,5mlXI059 Syringe with needle 5mlXI060Syringe only, 6mlXI061 Syringe with needle, 6mlXI062 Syringe only, IOmIX I 063 Syringe with needle, IOmIX I 064 Syringe only, 12mlX I 065 Syringe with needle, 12mlXI 066 Syringe, 20mlXI 067 Syringe, 3OmI- 35mlX I 079 Unlisted Administration Supplies

for intravenous medicationX 1003 Administration Set for parenteral, feeding (with filter)

X 1004 Administration Set for parenteral feeding

(without filter)X 1005 Filter for parenteral feeding

(when sold separately)X 1006 Dravon Clamp for use with parenteral

feedingX 1007 Injection Caps for use with parenteral

feeding

2.50 each

XI 019 Unlisted Administration supplies forparenteral nutrition (specify)

I/C

ADMINISTRATION SUPPLIES FOR ENTERAL NUTRITION ONLY

1.102.50.67.26.26.16.20.29.31

1.15

eacheacheacheacheacheacheacheacheacheach

10010010010010010010010010025

X I 0 II Adapters for enteral feedingX I 0 12 Syringe for enteral feeding - 50-60mlX I 0 14 Syringe for enteral feeding - 20mlX I 0 IS Syringe for enteral feeding - 10mlXIOl6Syringe for enteral feeding - 5mlX 1017 Syringe for enteral feeding - 3mlX I 069 Syringe for enteral feeding - 0.5 or I mlX 1070 Syringe for enteral feeding - 6mlXI 071 Syringe for enteral feeding - 12mlX 1072 Syringe for enteral feeding - 3Oml - 35ml

- ~-

~ ~ .v

MaximumUnits perService

PricePer!l!!i!

PricingUnit.

ProcedureCode Item Descriotion

9090159090

eacheacheach b':/SOeacheach

S 3.006.30

46.505.307.85

30each.20

30each11.45

3011.80 each

90each5.75

90each6.25

each 907.25

Xl 0 18 Tubing for enteral feeding pediatricXl 020 Tubing for enteral feeding adultB4081 Nasogastric tubingXI021 Administration Set for enteral feedingXl 022 Administration Set for enteral feeding

with 500/60OmI. bag or containerXl 023 Administration Set for enteral feeding

with l000ml. bag or containerXl 024 Administration Set for enteral feeding

with 1200ml. bag or containerXl 025 Administration Set for enteral feeding

with 1400ml. (and above) bag orcontainer

Xl 026 Container or Bag for enteral feeding-500/60Oml.

Xl 027 Container or Bag for enteral feeding1000/1200ml

Xl 028 Container or Bag for enteral feeding -1400ml and above

each 905.00Xl 046 Adapter, pediatric

9050

14.0033.00

eacheach

9090SO

eacheacheach

2.095.401.50

644.78 each

each 4132.00

each194.00

9010.50 each

6013.13 each

Xl 031 Administration Set, with filter - pediatric

Xl 032 Administration Set for ambulatoryinfusion pump

Xl 034 Extension Set, standardXI03SExtension Set, with port(s)XI 036 Extension Set or bolus feeding

replacement, "MIC-Key" typeXI 038 Gastrostomy Feeding Tube, Scc and

20cc balloon, "MIC-Key" type, allsizes

X I 037 Gastrostomy Feeding Kit, Skin Level,"MIC-Key" type, all sizes

X I 040 Gastrostomy Feeding Device System,"Button" type, sterile, complete

X I 042 Feeding Tube for Gastrostomy Device"Button" type, replacement, all sizes

X I 041 Decompression Tube for GastrostomyDevices "Button" type, replacement,all sizes

)-6-


PricePer!Inn

Pricin~Unit

ProcedureCode Item Descriotion

each$ 4.28 6

each 65.93

8.99 each 6

X 1796 Sharps Disposable Container, 1 quart

capac ityX 1797 Sharps Disposable Container, 5 quart

capac ityX 1798 Sharps Disposable Container, 8 quart

capacity

Xl 029 Unlisted administration supplies forenteral nutrition (specify)

I/C

(NOTE: Covered I. V . and Nutrition Infusion Pumps are listed under Durable 'Aedical

Equipment)

DIABETIC MONITORING SUPPLIES

URINE KETONE MONITORING SUPPLIES

X 1320 Reagent StripsX1321 Reagent Strips

8.2613.62

SO'slCO's

42

URINE GLUCOSE AND KETONE MONITORING SUPPLIES

X 1420 Reagent ShipsX 1421 Reagent Ships

50'~

IO}'s

54

9.7617.09

BLOOD GLUCOSE MONITORING SUPPLIES

X 151 0 Reagent or Test StripsX 1511 Reagent or Test StripsX1512 Reagent or Test Strips

23.8144.3976.40

25's50's100's

24

(NOTE: Home Blood Glucose Monitor is listed under Durable Medical Equipn:ent)

FINGER STICKING AIDS

X1610 DeviceXI611 Lancets

19.4110.51

each100's

12

7.

i';

X 1612 Lancets 13.55 200's cOSTOMY AND PERMANENT URINARY INCONTINENCE SJPPLIES

PricePer

!lnit


ProcedureCode

PricingJ.!giLItem Descri~tion

A4364 Adhesive for Ostomy or Catheter,Liquid, Cement, Powder orPaste, any composition

X4666 Adhesive Paste, with skin barrier, 2ozA5126 Adhesive, Disc or Foam PadA4455 Adhesive Remover or Solvent

$ 4.00 10per ou:~ce

6.727.182.00

104

10

per ou:-.cePkg of 10per ou.-;ce

12.501.646.7619.68

box of 50eacheachdozen

210030

8

X4600Ostomy Adhesive Remover, wipesX4601 External CatheterX4602 External Catheter, male, reusableA 4 34 7 Male External Catheter, with or without

adhesive with or without anti-refluxdevice

4.346.258.85

eacheacheach

363630 ~

)11.30 each 10

12.05 each 30

]8.44 each 30

1.921.914.68.65

1.20.90.83

eacheacheacheacheacheacheach

1006036

100100100100

1.821.465.811.002.191.46

eacheacheacheacheacheach

10010090

53020

X4603 Foley Catheter, 2-way, latexX4604 Foley Catheter, 2-way, silicone-coatedA4338 Indwelling Catheter, Foley type, 2-way

latex with coating (Teflon, silicone,

elastomer, etc.)A434Slndwelling Catheter, Foley type, 2-way,

all siliconeX460S Foley Catheter, 2 way, silicone with

elastomer coatingA4346 Indwelling Catheter, Foley type, 3-way,

for continuous irritationX4606lntermittent Catheter, male/femaleX4607 Catheter, red rubberX4608 Catheter, red rubber, Tieman typeX4609 Self-Catheter, femaleX4610 Self-Catheter, long, male/femaleX4611 Self-Catheter, pediatric/adolescentX4612 Urethral Catheter, all purpose, rubber,

disposableX4613 Urethral Catheter, plasticX4614 Utility Catheter, Robinson/Nelaton typeX461S Catheter Care TrayX4616 Catheter ClampX4617 Connective Tubing, external catheterX4618 Catheter Extension Tubing

~-8-

PricingUnit

Units perService

_ProcedureCode

Per!.1:ni!Item Descrigtion

7.3042.4537.15

eacheachbox of 5

1055

13.73 each IS

X4619Drain/fube Attachment DeviceX4620 Ileal Bladder ApplianceX4663 "Duoderm" Dressing (4 x 4s),

ostomy onlyX462 I Mounting Ring for ileostomy

appliance, white vinyl flexible

X4622 Incontinency Pants, disposable

(requires preauth)

.85 each 400

7.74 each 30

9.04 each 30

each 30

A4354 Insertion Tray with Drainage Bagwithout catheter

X4624 Insertion Tray with Drainage withcatheter

A4399 Ostomy Irrigation Supply, Cone/Catheter,including brush

.25

5402515

60.005.001.404.81

eacheacheacheach

each 304.84

9.502.2519.258.852.251.734.50

I/C

eacheacheachpkg of 10eacheacheach

2205

103055

30100

3.002.09

eacheach

100

A4400 Ostomy Irrigation SetA4397 Irrigation Supply, SleeveA4322 Irrigation Syringe, bulb or pistonA4320 Irrigation Tray for bladder irrigation

with bulb/piston syringeA43SSlrrigation Tubing Set, for continuous

bladder irrigation through a 3-wayindwelling Foley catheter

A4367 Ostomy BeltAS093 Ostomy Accessory, Convex InsertA4361 Ostomy Face PlateX4627 Ostomy Gasket

A4404Ostomy RingX4628 Ostomy Tape, I" rollX4629 Ostomy Tape 2" rollA44S4 Tape, all types, all sizes (Ostomy

other than above) (specify)ASOSI Pouch, Closed, with barrier (I piece)A50S2 Pouch, Closed, without barrier attached

(I piece) (disposable)AS054 Pouch, Closed (2 piece) 1.60Incontinence pants, reusable, pair X9650 10.40Incontinence pads, for reusable X I 793 11.70

pants, regular absorbency pack of 20Incontinence pads, extra absorbent X 1794 8.91

pack of 12Incontinence pads, extra absorbent X I 795

eacheach

NC NC

NC NC13.74

-9

pack of20 or 2S('

PricePer!!nj,t


ProcedureCode

Pricin~UnitItem Descriution

3.401.502.76

eacheacheach

100100100

4..62 each 100

2.50 each 100

5.001.88

10.008.503.5011.106.003.75

eachper ou:o;:ebox of 50eachounceeachper ou!.~eeach

100102

1543

1060

8.25 each 60

A5073 Pouch, urinary (2 piece)X4667 Pouch, mini (2 piece)A5062 Pouch, Drainable, without barrier

attached (1 piece) (reusable)X4665 Pouch, Drainable system, with barrier

(1 piece)A5063 Pouch, Drainable for use on barrier

with flange (2-piece system)A5071 Pouch, urinary with barrier (I piece)X4631 Protective Dressing, spray-onX4632 Protective Dressing, wipesX4633 Protective Powder, loz.X4634 Karaya Powder, loz.X4635 Karaya Gum Powder, 12 oz.A4363 Skin Barrier, Liquid (spray, brush, etc.)A4362 Skin Barrier, Solid, 4 x 4 or

equivalentA5121 Skin Barrier, Solid, 6 x 6 or

equivalentA5122 Skin Barrier, 8 x 8 or equivalentA5123 Skin Barrier with flange (solid

flexible or accordion), any size

15.007.00

eacheach

36100

2.75.98

1.955.77

eacheacheacheach

1001001015

7.78 each 15

.60 each 300

6.50 each 20

10.00 each 36

A5055 Stoma CapX4636 Stoma Mini Pouch, closedX4637 Tincture of Benzoin, sprayX4638 Extension/Connective Tubing - to

connect leg bag to external orFoley catheter, plastic, sterile

X4639 Extension/Connective Tubing - toconnect bag to McGuire urinalseries, latex, non-sterile

A4554 Underpads disposable, all sizes

(requires preauth)X4640 Urinary Diversion Pouch, with anti-

reflux valve and night drain adapterA4357 Bedside Drainage Bag, day or night,

with or without anti-reflux device,with or without tube (urinary)

A4358 Urinary Leg Bag, vinyl, with orwithout tube

S.2S each 36

10-

PricePer!:!n!!


Pricin[Unit

Procedure

Code Item DescriRtion

36152

$ 2.444.58

31.15I/C

eacheacheach

X4641 Leg Bag Extension TubeX4642 Leg Bag Sb'apSX4643 Urostomy Appliance System, all sizesA4335 Incontinence Supply, Miscellaneous

(specify)A4421 Ostomy Supply, Miscellaneous (specify) I/C

X5799 Unlisted catheters/accessories (specif)r) I/C

Reuseable incontinence pads and pants are listed under miscellaneo\;.. DME)(NOTE:

SPINAL CORD DYSFUNCTION CARE SUPPLY KIT,?

XI 100 Skin Care Kit I-A 4" x 4" sterile $ 17.708-ply gauze pads - 4 dozen

Sterile cotton tipped applicators - 8dozen packages of 2 each I" poroussurgical tape - 4 rolls

XIIOI Skin Care Kit I-B 4" x 4" sterile 8-ply-gauze pads - 2Y2 dozen Sterile elastic

2-ply gauze bandages -2Y2 dozen 4"rubber elastic bandages - I Steriletongue blades - 2Y2 dozen

X 1103 Urinary Incontinence Kit II-B I" elasticadhesive bandages - 3 rolls Liquid skincement I can (4 oz.) Unsterile catheterextension tubing with connector - 4

X 1104 Urinary Incontinence Kit II-C Alcoholwipes 3 boxes of 100 each pH testingpaper - I roll of 15 feet I" clear hypoallergenic tape - 3 rolls

X II 05 Bowel Incontinence Kit Ill-A Bisocodylsuppositories 10mg - I box of 50

Disposable exam gloves - I box of 100

Lubricating jelly (5 oz.)X II 06 Bowel Incontinence Kit III-B Disposable

exam gloves - I box of 100

1 kit e' ery2 week;

6

I kit e\ ~ry2 week:;

49.90 6

kit every 322.90month

316.65 1 kit e' erymonth

15.60 1 kit e\~ry3 monI.1S

1 kit every3 mOn1:;lS

9.90

-11-

lubricating jelly (5 oz.) rBURN GARMENTS

NOTE: Charges for bum garments shall include all fitting, dispensing, and follow-up care.

PricePer!.!nit


ProcedureCode

PricingUnitItem Descri~tion

77.36129.2766.2188.95

eacheacheacheach

4444

228.03228.00

eacheach

22

X1953 Glove to WristX1954 Glove to ElbowX1957 Ann Sleeve - wrist to axillaX 1958 Ann Sleeve & Gauntlet - metacarpals

to axillaX1971 Body Briefwith SleevesX1972 Sleeveless Body Suit (to distal

measurement) (above knee)X1978 Foot Glove to KneeX 1980 Knee LengthX 1981 Thigh Length

124.2349.9358.92

eacheacheach

222

~

SUPPORT STOCKINGS, INDIVIDUALLY FORM-FI1TED

NOTE: Charges for individually fonn-fitted support stockings shall inchlde all fitting,dispensing, and follow-up care.

$ 52.00120.41

eacheach

44

139.82 each 4

59.6073.11

209.01209.01209.71214.74

eacheacheacheacheacheach

44222?

X 190 I MittenXI908 Ann Sleeve & Gauntlet-

metacarpals to axillaX 191 0 Ann Sleeve, Gauntlet & Shoulder

FlapXI91SKnee LengthXl916Thigh LengthXI917Waist Height, Two Legs, closed pubisXI918Waist Height, Two Legs, open pubisXI 922 Maternity, Two LegsXI92S Waist Height, One Leg, plus stump

X 1928 Waist Height, Two StumpsX 1931 Chap Style, Two LegsX1932Chap Style, One LegX1938 Fitting Fee

214.74226.34184.6727.00

eacheacheachone tiff.~

222

-12-

per yeE.':X1939 Accessories/Modifications for leg or ann (specif)')I/C

OSTEOGENESIS STIMULATOR

NOTE: Charges for the osteogenesis stimulator shall include all t...Jllow-li? care, batteries,repairs and replacement parts (with pre-auth required)

686.66

686.66 each

686.66

E0747 Osteogenesis Stimulator-Initial

X 180 1 Osteogenesis Stimulator - First

Evaluation (after six weeks)X 1802 Osteogenesis Stimulator - Second

Evaluation (after three weeks)

SUCTION SUPPLIES

7.50 each 10X9150 Suction collection container, disposablestandard

X9149 Suction collection container, disposablelarge capacity

12.00 each 10

X9055 Suction catheter 2.00 each 100

2.

2.

4.

45.

eacheacheachroll

1010106

X9151 Suction connecting tubing 6 feetX9153 Suction connecting tubing 9 feetX9155 Suction connecting tubing 12 feetX9158 Suction connecting tubing 100 feet, roll

-13-

~

.50

.60

.45

.50

.. .

rMiscellaneous Medical Supplies

PricePer!In!!

Procedure~

Per~

MaximumUnitsItem DescriQtion

Alcohol Wipes/Prep Pads A4245 $ 2.48 box 0:.200 24

10.8816.73

4.27

pack cf 12packrf12pint

2424

Bandages-2ply, 131" x 3" widthnon-sterile X1711sterile X1712

Bentadine or Iodine Swabs/Wipes A424624

Bentadine or Iodine Swabs/Wipes A4247 6.00 box of 2S 24

Cotton-Tipped Wooden Applicators Xl748Sterile

7.13 box of 100 24

Disinfectant-"Control ill"8 ounces XI72516 ounces X 1726gallon X1727

10.00 each15.00 each31.00 each

242424

Dressing. Control Gel Fonnula-Sterile ('DuoDenn' type)

4" x 4" Xl7136" x 6" Xl714

Extra thin 4" x 4" Xl7t 5

7.6514.635.30

eacheacheach

606060

7.6524.50

97.43

eacheacheach

606015

Dressing. Flexible, 'Hydro-active'sterile ('DuoDenn' type)

4" x 4" XI716S" x S" XI717

Dressing, Surgical 3" x S", XI71S3 strips per envelope3" x 6", I strip per envelopeXI720 84.75 each

- 14-

Procedure~

Price!:!nit

MaximumUnits

Per~Item Descri}2tion

Dressing, transparent2" x 3" (approx. size)4" x 5" (approx. size)5" x 7"6" x 8"

X1722X1723X1724Xl721

$ .922.935.807.46

eacheacheacheach

100100100100

Foam Pads, Self-adhering7/16" x 7 7/8" x II 3/4"I" x 7 7/8" x II 3/4"

X1730X1731

40.5029.00

pack 0:'10pack c;' 5

33

Germicide - "Solution If'8 ounces16 ounces X 1736

X1735 7.6411.29 each

24each24

Gloves, Sterile and Non Sterileall sizes

A4927 40.00 box of ~ 00

Lemon Glycerin Swabs XI?3? 6.00 box OJ' 25 24

Lubricating Jelly 4.25-ounce X1738 2.15 each 12

Pads, Gauze-Sterile, 12 ply2" x2"3" x3"4" x 4"

X1732X1733X1734

16.3219.4932.16

pack (:I~ 100pack cf 100pack (Z 100

121212

Skin Creamsup to 2 ouncesup to 5 ouncesup to 9 ounces

X1762X1763X1764

7.9410.8813.49

eacheacheach

121212

Skin Paste2.5 ounce tube X1765

Sodium Chloride O.~/o Solution500 mI. bottle X18051000 mI. bottle X1806

10.79 each 12

6.707.87

eacheach

1212

Solution nonnal saline or 0.94>/0sodium chloride, 100 doses, 3 ml X97J2 25.00

-15-

5ml X9713 32.50 each 1 rrocedure~

PricinfUnit

MaximwnUnitsItem Descril2tion Price

Sponges-Drain and I. V .,Sterile, fenestrated2" x 2", 6 ply4" x 4",6 ply

X1758X1750

$15.6819.43

pack cf70packC':70

33

Sponges-Dressing, Sterile4" x 3"4" x4"

X1756X1757

5.936.89

pack ( i 50pack ( -;:' 50

33

Sponges-Dressing, Sterile, 2'5,4" x 4" 6 ply

X1151 3.43 pack CI 50 .1

Sponges-Gauze covered, non-sterile

3" x 3"4" X 4"

X1753X1754

6.1410.94

packc:lOOpacklflOO

33

Sponges-Gauze, Sterile, 2's2" x 2" 8-ply

3" x 3" 12-ply X17604" x 4" 12-ply4" x 4" 8 ply

X1759 5.546.89

6.419.74

pack cpack r:

pack,pack ('

1212123

X1761X1752

Sponges-Soft net facing, non-Xl 755sterile 4" x 4"

9.89 box o~ 100

Water (sterile and distilled)250-500 mI. bottle1000 mI. bottle1500 mI. bottle

X1745X1746X1747

6.427.49

10.27

eacheacheach

121212

Tape-Paper1/2" width x 10 yards X17831" width x 10 yards X17842" width x 10 yards X1785

.501.002.00

eacheacheach

121212

- 16- ./

fl00f80[50['100

Tap Pric~Procedure Per Pricing

MaximumItem Descri~tion ~ !:!!li! lLn!! Units

Tape-Plastic, clear, perforated

1/2" width x 10 yards X17802" width x 10 yards X17813" width x 10 yards X1789

1.112.214.42

eacheacheach

121212

Tape-Multi-Purpose, silk1" width x 10 yards2" width x 10 yards3" width x 10 yards

X1786X1787X1788

1.663.314.97

eacheacheach

121212

Tape-Elastic1" x 10 yards2" x 10 yards

Xl777Xl778

$ 1.753.49

eacheach

1212

4.58 pack (' f 20 24Tooth Cleaning Applicators, X1710disposable

Wrap-Elastic, non-adhesive, self-adherent, 5 yards

1 inch X17902 inches X17913 inch X1792

1.773.143.98

eacheacheach

121212

- 17-

~

~WOUND CARE SUPPLIES

Procedure~

Pricing~

Units PerServiceItem Description Price Per Unit

A6154A6196

Bx/lOBx/lO

24

A6197

Wound Pouch $ 107.64Alginate Dressing, cover 60.5916 sq. in. or lessAlginate Dressing, cover 96.0416-48sq.inAlginate Dressing, fillerComposite Dressing, 16 sq.in. or less w/out adhesiveborderComposite Dressing, 16- 48 sq. in. w/out adhesive

borderComposite Dressing, morethan 48 sq. in. w/out adhesiveborderComposite Dressing, 16 sq 34.10in. or less, with adhesiveborderComposite Dressing, 16 -48 133.33sq. in. with adhesive borderFoam Dressing, cover, 16 sq. 32.00in. or less, w/out adhesiveborderFoam Dressing, cover, 16- 48 45.53sq. in. w/out adhesive borderFoam Dressing, cover, more 57.63than 48 sq. in., w/out adhesiveborderFoam Dressing, cover, 16 sq. in 80.00or less, w/adhesive border

Bx/5 2

A6199A6200

32.0075.26

Bx/5Bx/IO

52

A6201 82.82 Bx/5 3

A6202 137.97 Bx/5 2

A6203 Bx/50 4

A6204 Bx/25 2

A6209 Bx/l0 s

A6210 8x/l0 5

A6211 Bx/lO 4

A6212 Bx/IO 3

18

U nits PerService

Pricing!L!!!

Procedure~ Price Per UnitItem Description

A62143$ 90.00 Bx/lJ

427.50 Bx/51JA6219

Bx/25 4A6220 55.94

335.99 Bx/5vA6222

288.82 Bx/53A6223

Bx/12 5A6224 27.71

527.71 8x/12A6229

Bx/5 10A6234 27.76

473.10 Ox/tOA6235

4

Foam Dressing, cover,more than 16 sq. in.w/adhesive borderGauze, non-impregnated16 sq. in. or less,w/adhesive borderGauze, non-impregnatedmore than 16 sq. in.,w/adhesive borderGauze, impregnated, otherthan water or nonnal saline,16 sq. in. or less,w/out adhesive borderGauze, impregnated, otherthan water or nonnal saline,17 to 48 sq. in., w/outadhesive borderGauze, impregnated, otherthan water or nonnal saline,more than 48 sq. in.Gauze, impregnated, wateror normal saline, 17 to 48 sq.in., w/out adhesive borderHydrocolloid Dressing, cover,16 sq. in or less, w/outadhesive borderHydrocolloid Dressing, cover,17 to 48 sq. in., w/out adhesiveborderHydrocolloid Dressing, cover,more than 48 sq. in.,w/out adhesive border

60.59 Bx/lOA6236

19

MaximumProcedurePer

~Sen'ice

UnitsPric_og

!l!1J!Item Description Price Per Unit

Bx/.::J 4$ 52.08A6237

A62383Bx!93.57

per~: fluidounc~ tubeBx/O

417.78A6240

360.05A6242

48X/., 056.82A6243

28x/:0121.02A6244

523.51 BX/A6245

536.45 Bx/A6246

546.90 BX/A6247

4per ~ fluidoun:e tubeBx/- ')0

7.50A6248

65.10A6257

Hydrocolloid Dressing,cover 16 sq. in. or less,w/adhesive borderHydrocolloid Dressing,cover, more than 16 sq.in., w/adhesive borderHydrocolloid Dressing,filler pasteHydrogel Dressing, cover,16 sq. in.or less, w/outadhesive borderHydrogel Dressing, cover,17 to 48 sq. in., w/outadhesive borderHydrogel Dressing, covermore than 48 sq. in., w/outadhesive borderHydrogel Dressing, cover,16 sq. in. or less,w/adhesive borderHydrogel Dressing, cover,17 to 48 sq. in,Hydrogel Dressing, cover,more than 48 sq. in.,w/adhesive borderHydrogel Dressing, filler,gelTransparent film, 16 sq. in.

4B",.5073.68A6258or lessTransparent fi~ 17 to 48 sqIn.Transparent film, more than48 sq. in.Tape

4BXi:O69.28A6259

2Bx!212.00A626S

)20

Part II. DURABLE MEDICAL EOUIPMENT

ProcedureCodePurchase

MaximumPurchasePrice

ProcedureCodeRental

MaximtmRentalCh~e

MaximumUnits perServiceItem Descri~tion

Aonea Monitors and Accessories

NC s NC X8361 s 7.<5/day

NC NC X8362 224.00imo.

NC NC X8354 12.00/c'ay 29

NC NC X8364 350.00/:TlO.

Standard Monitor, electric/29

battery (AC/DC): dailyrental infant

Standard Monitor, electric/

battery (ACIDC): monthlyrental

Monitor with memory dailyrental

Monitor with memory monthlyrental

Recorder, daily rental NC NC X8351 7.70/cay 29

Accessories:

X9352X9358X9359X9354

10.8072.8052.0017.50

NCNCNCNC

4

6

X93SSX93S6X93S7X9363

9.2512.5044.10

I/C

NCNCNCNC

23

X9364 ]7.50 NC 4

BeltBelt Kit I (with cable)Belt Kit II (without cable)Disposable Red Dot

Electrodes, 25/bag(or equivalent)

Lead Wires - Straight EndLead Wires - Clip End

Patient CablePatient Cables for portable

infant monitorCardio- Trace Electrodes,

30/package (or equivalent)

Unlisted Apnea Monitors!Accessories (specify)

X9369 J/C X8369 I/C

21

Ma>_:mumMaximum Procedure Mor. :hlyPurchase Code Reo;.?}Price ~ Charge


LifeEx~ctancvItem Descri~tion

Beds HosRital

EO252 577.00 X8101 4~.38 1 0 years

EO250 748.00 X8081 57.54 1 0 years

EO251 673.00 X8082 5",.77 1 0 years

EO255 ,257.00 X8083 9 ).69 10 years

EO260 1699.00 X8079 10.70 to years

EO265 $2,190.00 X8080 $ .68.46 10

Hospital Bed, fixed height. withmattress, without side rails

Hospital Bed. fixed height. withside rails, with mattress

Hospital Bed. fixed height. withside rails, without mattress

Hospital Bed, variable height.hi-Io, with side rails, withmattress

Hospital Bed. semi-electric (headand foot adjustments), withmattress, with side rails,

Hospital Bed, total electric (head,years

foot and height adjustments),with mattress, with side rails

Hospital Bed, total electric (head.foot and height adjustments),without mattress, with side rails

E0266 2,050.00 X8084 157.69 1 0 years

Accessories

EO271EO272X9230

194.00127.0027.00

X8085X8403

NC

1-:-.92

~.76

NC

2 years2 years2 year

Mattress, innerspringMattress, foam rubberMattress, eggcrate type

Bed Side Rails, half lengthBed Side Rails, full length

EO305EO310

158.00184.00

X8404X8405

.~.lS

:.1 S1 0 years10 years

Unlisted Hospital Beds!Accessories (specify)

X9119 I/C X8119 vc

Blood Glucose Monitoring Egui~ment

EO607EO609

125.00I/C

NCNC

NCNC

3 years3 years

Home Blood Glucose MonitorHome Blood Glucose Monitor

with special featuresBattery, Replacement X9301 NC NC AN3.25

22

~


Maximum Procedure MoJl:hlyPurchase Code RentalPrice ~ Charge

LifeExpectanc~Item DescriRtion

Braces & SUnl2Qrts

X9330X9370

110.00135.00

NCNC

NO:1\C

yearyear

X9331X9333

150.00250.00

NCNC

NCNC

I year3 years

X9332X9337X9334X9343X9344X9345X9346X9347X9371X9349X9350

225.00220.00295.00650.00895.00955.00625.00800.00995.00780.00875.00

NCNCNCNCNCNCNCNCNCNCNC

NC}.;C}liC~CNCt:C~';;J.;C}l\CNC~C

1 year1 year1 year1 year1 year1 year1 year1 year1 year1 year1 year

X9372 900.00 NC }oJC year

X2001X2002X2003X2004X9379

450.00675.00600.00

1450.00I/C

NCNCNCNCNC

}I.~C

NC}I.;C}I.:C}I.:C

Support, back, lumbo-sacralSupport, back, lumbo-sacral,

heat moldedSupport, dorsal lumbarSupport, chair back/Knight

spinal (including moldedtype)

Support, hyperextension, JewettSupport, neck brace, 2-posterSupport, Taylor-KnightWilmington brace, with moldMilwaukee brace, unlinedMilwaukee brace, linedBoston brace, unlinedNew Boston brace, linedBoston jacket with "cow horns"TLSO body jacket, linedTLSO body jacket, lined with

controls/padsTLSO split body jacket

"clamshell" t'bi-valve")Orthoses-C ustom

Ankle-foot, solid/rigid, eacharticulatedfloor reaction

Knee-Ankle-foot, eachUnlisted Braces/Supports

(specify)

Canes. Crutches and Shower Chairs

EOl00 18.00 NC NC I year

EOIO5 45.00 NC '!Io.C 1 year

Cane of all materials, adjustableor fixed, with tip

Cane, quad or three prong;includes canes of all materials,adjustable or fixed, with tips

Shower chairssmallmediumadolescent

adolescent/1arge

X9642X9643X9644X9645

413.00438.00463.00475.00

NCNCNCNC

}I.-:

}I.:C

~C

J\:C

2 years2 years2 years2 years

23

0Maximum Procedure Mor.i:hly MaximumPurchase Code Ren::11 LifePrice ~ Cha:'~e Ex~tancx

ProcedureCodePurchaseItem Descrip;tjon

s NC NC 6 monthsEOl13 20.00

NC ~C 6 monthsEOl12 39.00

6 monthsEOl16 29.00 NC Jl.C

Jl.C 6 monthsEOl14 58.00 NC

EOt 40.00 NC 1\: 6 months

6 monthsBOlIO 80.00 NC NC

~

Crutch, underann, woodadjustable or fIXed, withpads, tips, handgrips, each

Crutch, underann, wood,adjustable or fixed, with

pads, tips, handgrips, pairCrutch, underann, other than

wood, adjustable or fixed,with pad, tip and handgrip,each

Crutches, underann, other thanwood adjustable or fixed,with pads, tips and handgrips,

pairCrutch, foreann, of various

materials, adjustable or fIXed,with tip and handgrips(Canadian or Lofstrand), each

Crutch, foreann, of variousmaterials, adjustable or fIXed,with tips and handgrips(Canadian or Lofstrand), pair

Crutches, platform, pairCrutch, platform, single

~ 1.92 6 monthsNC 6 months

X9229X9201

155.0080.00

X8229NC

Unlisted crutches (specify) X9202 lIC I/CI/C X8202

Commodes

EOl63 NC 2 years85.00 NC

EO165 167.00 X8228 12.85 2 years

X9111 90.00 NC NC 2 years

X9112 70.00 X8112 !;;.07 2 years

X9113 164.00 XII13 11.62 2 years

EOl64 147.00 X8116 1: .31 2 years

Commode Chair, stationary,with fIXed arms

Commode Chair, stationary,with detachable arms

Commode Chair, adjustable,with fixed arms

Commode Chair, adjustable,with detachable arms

Commode Chair, adjustable,with attachment for pailor pan

Commode Chair, mobile, withfixed arms

Commode Chair, mobile, withdetachable arms

Commode Chair, drop arms

EO166 225.00 X8117 7.31 2 years

X9225 167.00 X8225 2.85 2 years

24

"~

MaximumMaximum Procedure MonrhlyPurchase Code RemalPrice ~ Chm"ge

Procedure

Code

~hase

LifeEx~tancvItem Descriotion

NC NCCommode Chair, drop arms, withsoft seat. and pail or pan

Commode Chair,large/extrawide/heavy duty

Pail or Pan for use withcommode chair

X9114 $ 200.00

NCX9115 187.00 NC

NC20.00 NCEO167 year

Enteral and Parenteral Nutrition Eauioment

57.69 10 years750.00 X800SB9002

X8110 80.76 10 yearsX9110 1,050.00

~ 34.77 1 0 yearsB9006 ,752.00 X8001

1')1.53 1 0 yearsB9004 3,190.00 X8015

~C8.00

AN10 years

X9631EO776

100.00105.00

NCX8002

Enteral Nutrition Infusion Pump,with alann

Enteral Nutrition Infusion Pump,

pediatricParenteral Nutrition Infusion

Pump, stationary (specify)Parenteral Nutrition Infusion

Pump, portableBattery Pack, ReplacementIV Pole

Intravenous Medication EauiDment

291.54 1 0 yearsEO781 3,790.00 X8021

NC AN

Ambulatory Infusion Pump withadministrative equipment.worn by patient (preauth

required)Battery Pack for Ambulatory

Infusion PumpX9118 100.00 NC

Nebulizers and Accessories

Aerosol compressor, complete X90 16system compressor unit,medication cup, connectorfitting, tubing, hand-held nebulizer,and mouth piece, face mask, ortracheostomy collar or T -tube

130.00 X8016 J.OO 2 years

25

. ". ,

Mv.imumMaximum Procedure Mon:hlyPurchase Code Ren!:llPrice ~ Charge

rProcedureCodePurchase

LifeEx~ctanc):Item DescriQtion

$ 165.00 X8017 S 12.69 2 yearsX9017Aerosol compressor, ultrasoniccomplete system with ultrasonicaerosol chamber with blower,medication cup, connectorfitting, corrugated tubing, andmouth piece, face mask, ortracheostomy collar or T -tube

Compressor System pneumaticstationary (pulmo-aide, type)

Same, portable with batteryadapter charge, power cord

2 yearsX9725 180.00 X8725 14.00

33.00 2 yearsX9726 420.00 X8726

NCNCNC

5 /montl-.2/month5/month

2.254.053.75

NCNCNC

NCNC

2/ year2/month

6.252.00

NCNC

Nebulizer Replacement kit X9707Nebulizer Mask Kit X9722Administrative Set used with KOl71

nebulizerAerosol Mask used with nebulizer KO180Filter, disposable used with KOl78

nebulizerFilter, non-disposable used with KOI 79

nebulizerNC NC l/month2.00 ~ ,

-..J

Unlisted nebulizers/accessories

(specify)X9729 I/C X8729 I/C I/C

26



LifeExRectancyItem Descriotion

Prosthetic Devices

NOTE: Charges for prosthetic devices shall include the cost of the de,';ce as well asnecessary stump covers or harnesses, power sources, and all fitting, dispensing,and follow-up care.Does not require preauthorization

Artificial Eye:

NCNC

$ UICU/C

NCNC

V2623V2629

Prosthetic, eye, plastic, customProsthetic eye, not otherwise

classified

~:cKC

~C

JI.~C

NC

J\'C

NCNCNCNCNCNC

X3100X3101X3200X3202X3204X3207

U/CU/CU/CUICU/CU/C

X3209 UIC NC

NC 1I:CX3210 UIC

NCNC

~Cro,:c

Breast Prosthesis (includingmastectomy fonn and 2

mastectomy bras):UnilateralBilateral

Lower Limb - Partial FootLower Limb - Below KneeLower Limb - Above KneeLower Limb - Endoskeletal -

Below KneeLower Limb - Endoskeletal -

Above KneeLower Limb - Endoskeletal - Hip

DisarticulationUpper Limb - Partial HandUpper Limb - Below Elbow

X3212X3214

U/CUIC

tjCX3222 u/C NC

L7S00 I/C NC

Upper Limb - Endoskeletal -Shoulder Disarticulation

Repair of Prosthetic Device,hourly rate (specify repairand rate)

Repair Prosthetic Device, RepairReplace Minor Parts (specify)

L7S10 uc NC

NC ~.eUnlisted Prosthetic Devices!Accessories (specify)

X3299 U/C

27

::;~::~

ProcedureCode~

MaximumMon::hlyRen...~lCha:-l!e

. ,

MaximumMaximll.11 Procedure MonthlyPurchas~ Code RentalPrice ~ Charge

('ProcedureCodePurchase

LifeEx~tancvItem DescriRtion

Suction EguiRment and Accessories

X9050X9152

234.00780.00

NCX8152

NC60.00 I 0 years

Suction Machine, StationarySuction Machine, AC/DC

( electric/battery)Suction Pump, home model,

portable

EO6O0 600.00 46.15 1 0 yearsX8153

X9157X9670

NCNC

6 ~'.J...

140.00NCNC

2/month1 year

Suction Device, Yankauer typeSuction Device for airway mucus

clearance (~utter" type)

Unlisted Suction Equipment!Accessories (specify)

X91S9 1/( X8159 I/C I/C

TENS (Transcutaneous Electrical Nerve Stimulator)

EO720 39.62515.00 X8310 year

0TENS, two lead, localized

stimulationTENS, four lead, larger areal

multiple nerve stimulationE0730 S93.C-J XI31 45.62 year

Accessories

X9312X9318X9313X9314

$ $NCNCNC

NC4.1:560.003.10

10.40

NCNCNCNC

ANANAN

X931SX9316

16.002.00

NCNC5.00

NCNCNC

ANANNC

BatteryBattery PackGel, tubeTape Patches, pack of 100

(or equivalent)Lead Wires, setElectrode, disposable, eachElectrode, reusable, each X9317

AN

Traction EauiDment

EO840 52.70 NC NC year

62.5040.0043.00

I/C

NCNCX9324X9129X9123

1 year1 year

I/C

Traction, Frame, attached toheadboard, simple cervicaltraction

Traction, complete, Buck X9325Traction Stand, BuckTraction Stand for hospital bedFracture Frame, Bed (specif}') X8123 I/C

28

MaximumMaximum Procedure MonthlyPurchase Code RentalPrice Rental Charge


Life

Ex~tanc~Item Descrintion

Walkers

64.00 X8223 4.62 2 years

79.00 X8227 6.00 2 years

Walker, rigid (pick up), adjustable EO130or fixed height

Walker, folding (pick up), EO135adjustable or fIXed height

EO141X9236X9218

X8226NCNC

7.92NCNC

2 years2 years2 years

X92J9 185.00 NC NC 2 years

X9690X9694

100.00225.00

NCNC

NCNC

2 years2 years

X9237X9238X9220

83.00140.00211.00

NC NC 2 years2 years2 yearsNC NC

X9222 275.00 NC KC 2yeai's

Walker, wheeled, without seatWalker, platfonn attachment forWalker, adjustable height, with

wheelsWalker, adjustable height and

width, with wheelsWalker, folding, pediatricWalker, large/extra wide/heavy

dutyWalker, pediatric, standardWalker, pediatric, with wheelsWalker, pediatric, posture control

with wheelsWalker, pediatric, adjustable

height and width, with wheelsWalkcane or herni-walker X9239 67.00 NC NC 2 years

Walker Accessories

X9695X9696X9697

NCNCNC

NCNC~C

6months6 month~6 months

Wheeled foot piece, pairWheeled foot pieces, swivel, pairPlatfonn attachment, pediatric

onlyLeg Extensions for walker EO]58 36.00 X8240 2.76 6 months

29

I_~

103.0084.00

132.00

33.1044.00

106.00

MaximumMaximum Procedure MonthlyPurchase Code RentalPrice ~ Cha:ge

nProcedureCodePurchase

LifeEx~ctanc'"Item DescriQtion

Wheelchairs

Standard Wheelchair, fIXed fulllength anns, fIXed or swingaway detachable footrests

Standard Wheelchair, detachableanns (desk or full length) swingaway detachable footrests

Standard Wheelchair, fixed fulllength anns, elevating legrests

Standard Wheelchair, detachableanns (desk)or full length,

elevating legrestsFully-Reclining Wheelchair,

detahable anns (desk or full-length) swing-away detachableelevating legrests

Fully-Reclining Wheelchair,detachable anns (desk or full

length), swing-awaydetachable footrests

El130 $ 703.29 X8204 $54.10 5 years

El140 942.48 X8244 54.08 5 years

EII60 800.87 X8242 61.60 5 years

El150 1041.25 X8203 80.10 5 years

E1060 1156.68 X8255 88.97 5 years

EI070 1101.94 X8254 84.76 5 years

01047.72 X8257 80.59 5 years

894.88 X8407 68.84 5 years

958.11 X8256 73.70 5 years

Lightweight Wheelchair, E 1240detachable anns (desk or fulllength), swing-away detachableelevating legrests

Lightweight Wheelchair, fIXed full EI250length anns, swing-awaydetachable footrests

Lightweight Wheelchair, EI260detachable anns (desk or fulllength), swing-away detachablefootrests

Lightweight Wheelchair, fixed full EI270length anns, swing-awaydetachable elevating legrests

15.03 X8408 85.;7 5 years

High Strength Lightweight E 1088Wheelchair, detachable arms(desk or full length), swingaway detachable elevating legrests

1235.22 X8060 95.02 5 years

-::)

J

30

.~~~

MaximumMaximum Procedure MonthlyPurchase Code RentalPrice ~ Charge


LifeEXRectanc.,.Item Descrintion

High Strength LightweightWheelchair, detachable anns(desk or full length), swingaway detachable footrest

EI090 79.29 X8062 90.71 5 years

Wide Heavy Duty Wheelchair,detachable arms (desk or full

length), elevating legrestsWide Heavy Duty Wheelchair,

fiXed full length arms, swingaway detachable footrest

E1280 962.71 X8075 74.05 2 years

E1285 840.14 X8076 64.63 2 years

Wide Heavy Duty Wheelchair,detachable anns (desk or fulllength), swing-away detachablefootrests

E1290 1021.02 X8077 78.54 5 years

E1295 910.35 X8078 70.03 5 years

X9247 852.00 X8247 65.54 2 years

X9249 1,143.00 X8249 $ 87.92 2 years

Wide Heavy Duty Wheelchair,fixed full length arms,

elevating legrestsWheelchair, child's, with ,

adjustable height, removablefull or desk length anns,swing-away detachableelevating legrests

Wheelchair, child's reclining,with adjustable height,removable full or desk lengthanns, swing-away detachableelevating legrests

Wheelchair, growing:Same as Standard Wheelchairs

EIO83 998.41 X8410 76.80 5 years

EIO84 1094.80 X8253 84.21 5 years

Hemi-Wheelchair, fixed fulllength arms, swing-awaydetachable elevatinglegrests

Hemi- Wheelchair, detachablearms (desk or full-length),swing-away detachable

elevating legrestsHemi-Wheelchair, fIXed full

length arms, swing-awaydetachable footrests

EI085 677. X8406 52.08 5 years

31

- .-

MaximumMaximum Procedure Mon::hlyPurchase Code Rental LifePrice Rental Charge Ex~tanc~

rProcedureCodePurchaseItem DescriRtion

Hem i- Wheelchair, detachableanns (desk or full length),swing-away detachablefootrests

EIO86 1059.10 X8252 81.~7 5 years

El170 800.87 X8414 61.60 5 years

E1171 681.87 X8068 52.45 5 years

£1 J 72 714.00 X8069 54.92 5 years

EI180 942.48 X8070 72.50 5 years

El190 $ ]078.]4 X807] $ 82.93 Syears~

)"'"'

Amputee Wheelchair, fixed fulllength arms, swing-awaydetachable elevating legrests

Amputee Wheelchair, fIXed fulllength arms, with out footrestsor legrests

Amputee Wheelchair, detachableanns (desk or full length),without footrests or legrests

Amputee Wheelchair, detachablearms (desk or full length),swing-away detachablefootrest

Amputee Wheelchair, detachablearms (desk or full length),swing-away detachableelevating leg rests

Amputee Wheelchair, fixed fulllength arms, swing-awaydetachable footrests

E1200 1059.10 X8415 81.47 5 years

3,243.84 X8267 249.53 5 years

3,449.85 X8267 265.37 5 years

7,073.01 X8266 544.07 5 years

Motorized Wheelchair, detachable El213arms (desk or full length),

swing-away detachablefootrests

Motorized Wheelchair, detachable El21 Iarms (desk or full length),swing-away elevating leg rests

Motorized Wheelchair, detachable X9266adjustable height arms, swing-away detachable footrests withheel loops

Motorized Wheelchair, detachable X9268adjustable height arms, swing-away detachable elevatingleg rests

7297.55 X8268 561.35 5 years

I/C X8299 I/C I/CWheelchair, specially sized or E 1220constructed (Indicate brandname, model number, and medical justification)

32

ProcedureCodePurchaseItem Descri~tion

E1350 YC NC NC AN

E1230 2,069.91 X8074 159.22 5 years

Wheelchair, Repairs (parts andlabor) or Non- or routineservice, requiring the skill ofa technician)

Power-Operated Vehicle, 3 or 4wheel, non-highway(Indicate brand name andmodel number)

Pediatric Transporter (stroller,buggy etc.) (Indicate brandname and model number)

X9289 420.00 NA NA 2 years

Wheelchair Accessories

E0959 102.30 NC NC AN

E0971E0973

52.0093.50

NCNC

NCNC

ANAN

E0958 I/C NC NC AN

ElOO5 I/C NC NC AN

EI068EI069EO978E0979X9264E0961X9240X9258X9259

ucUC

42.0030.0021.0031.00

195.0047.00

340.00

NCNCNCNCNCNCNCNCNC

NNNNNNNNN

ANANANANANANANANAN

X9221E0970

68.0058.00

NCNC

NCNC

ANAN

Amputee Adapter (device used tocompensate for transfer ofweight due to lost limbs tomaintain proper balance)

Anti-Tipping Device (pair)Adjustable Height Detachable

Anns, desk or full length

(pair)Attachment to convert any

wheelchair to one-arm drive

(specify)Replacement Batteries for

medically necessary electricwheelchair owned by patient

(specify)Battery, each (specify)

Deep Cycle Battery (specify)Belt, Safety, with airplane buckleBelt, Safety, with Velcro closureToggle BrakesBrake Extensions (pair)Cushion, GelCushion, FoamCushion, Jay/Roho type

(or equivalent)Footrests, extra large (pair)No.2 Foot plates, except for

elevating leg rests (pair)

33

ccccccccc

~. .


MaximumMaximum Procedure MonthlyPurchase Code Rental LifePrice ~ Charge Ex~tancyItem DescriRtion

"Grade-Aid" (device to prevent EO974rolling back on an incline)

Hand Rims with 8 vertical rubber- E0967

tipped projections, pairHook-on Head Rest ExtensionLoop, Heel, eachLoop, Toe, eachNarrowing DeviceSolid Back InsertSold Seat InsertPneumatic Tire, eachPneumatic Tire with wheel, each

$ 77.00 NC NC AN

420.00 NC NC AN

E0966EO951EO952E0969X9262E0992£0953£0999

158.0016.5019.8094.00

110.00108.0041.8083.60

NCNCNCNCNCNCNCNC

NCNCNCNCNCNCNCNC

ANANANANANANANAN

EI065 I/C NC NC ANPower Attachment (to convertany wheelchair to motorizedwheelchair) (specify)

Tire, Pneumatic, Caster, eachSemi-Pneumatic, Caster, eachTray

EIOOOE0954EO950

8.5027.30

168.00

6months6 months5 years

NCNCNC

NCNCNC

Legrest, elevating, eachUnlisted Wheelchair Accessories

(specify)

EO990E1399

140.80I/C

NCNC

NCNC

5 yearsI/C

Wheelchair Modifications

38.5042.00

448.69187.00312.00104.00

NCNCNCNCNCNC

NCNCNCNCNCNC

yearyearyearyearyearyear

J/C NC NC 1 year

Reinforced Seat Upholstery E0975Reinforced Back Upholstery E0976Full Reclining Back X9272Special Back Height X9274Special Seat Height from floor EI296Special Seat Depth, by E 1297

upholsterySpecial Seat Depth and/or Width, E 1298

by construction (specify)Special Seat Width, by upholstery X9275

for customized wheelchair104.00 NC NC 1 year

Unlisted Wheelchair Modifications E 1399

(specify)I/C NC NC I/C

34



LifeEx~ctanc:JItem DescriRtion

Pediatric Adagtive/Positioning Accessories(For transporters or wheelchairs only)

X9160X9161

$ 174.00284.00

NCNC

NCNC

1 year1 year

Abductor, stationaryAbductor, removable with

adjustable hardwareCushions, smallFoot Rest additionFoot Straps

NCNCNC

X9162X9167X9168

NCNCNC

1 year1 year1 year

70.00 NC NCHeadrest, fixed X9169Headrest, removable, withhardware X9170Insert, hinged, with leg extensions X9172

NCNC

NCNC

130.00195.00

I yearI year

X91X91X91X91X91X91X91X91X91X9J

134.00139.00144.0060.00

160.00185.0040.0046.0052.0060.00

I/C

NNNNNNNNNNN

NNNNNNNNNNN

ANANANANANANANANANANAN

Lateral Supports, smallLateral Supports, mediumLateral Supports, largePelvic StrapsTrayTray, with hardwareVest Support, smallVest Support, mediumVest Support, large

Wedge Support, largeSeating System

Unlisted Pediatric Adaptive!Positioning Accessories(specify)

E1399 uc NC NC

35

ProcedureCode~

MaximumMonthlyRentalCh8r2e

20.00135.0025.00

73747576818283848588

ccccccccccc

ccccccccccc

-t'

MaximumMaximum Procedure MonthlyPurchase Code Rental LifePrice ~ Charge ExRectancy

rProcedureCodePurchaseItem DescriRtion

Miscellaneous EguiRment

$ I/C $ NCNC

I/C10.00

NCNC

NCNC 2 years

Augmentative CommunicationEquipment X9559Augmentative Accessories

(provided after initial purchase) X9558Bed Pan, metal or plastic E0275Blood Pressure Equipment

economy kit X9527cuff with bladder X9528

Collar, rigid, cervical X9340Collar, rigid, Philadelphia X934 IDrug Delivery System, spacer, bag A4627

or reservoir with or withoutmask, for metered dose inhaler

Phototherapy Unit NC

25.0015.0018.0036.5036.75

NCNCNCNCNC

NCNCNCNCNC

] year] year

6 months6 months6 months

N/C EO202 50.00 (daily)

E0630 1000.00 X8124 55.23 5 years

EO621 80.25 NC NC year

EOl80 77.00 X8140 13.61 3 years

X9141X9339X9338X9342X9638X9684E0910

23.0013.0065.0065.00

169.00206.00129.00

NCNCNCNCNCNC

X8121

NCNCNCNCNCNC

9.93

3 years6 months6 months6 months2 years2 years2 years

Patient Lift. hydraulic, with seator sling

Sling or Seat, patient lift canvasor nylon

Pressure Pad, Alternating, with

pumpPad OnlySplint, cock-up wristSplint, positioning, handSplint, positioning, footTransfer Bench, padded

with commode seat, paddedTrapeze Bar (a/k/a Patient

Helper), attached to bed,with grab bar

Trapeze Bar, free standing,complete with grab bar

Vaporizer, room

E0940 279.00 X8400 21.46 5 years

E0605 15.00 NC NC 2 years

36

Max:mumMaximum Procedure MonthlyPurchase Code Rental LifePrice ~ Charge Ex~ctanc'"

Procedure

CodePurchaseItem DescriQtion

E1399 $Durable Medical Equipment, nototherwise classified (specify)

I/C X8999 s I/C I/C

Reoairs to Durable Medical EguiRment

Repair or non-routine services fordme requiring the skill of a tech-nician, labor component, per 1 hr.,up to 3 hours

E1340 60.00 NC NC

37

l'

PEDIATRIC MEDICAL EQUIPMENT AND SUPPLIES

Durable Medical Equipment and Accessories-Purchase

NOTE: See separate list for Equipment Rentals


MaximumPurchasePriceItem DescriRtion

Activity Chair, adaptiveHigh-back X9545 494.00

Bath chair - adjustable, adaptivesmallmediumlarge X9504extra large

X9534X9503

294.00319.00344.00357.00X9542

X9523X9524X9525

289.00325.50335.00

Bath Seat - tilting, adaptive

mediumadolescentadolescent, largeExtension Legs orHead Pad/Support, each X9526 103.00

BedsX91X91X91X91

2,888.0062.50

112.50344.00

cribmattressbumper padstop cover

youth bedmattress

X9130X9132

3,738.00269.00

)

38

13313413536


Maximt;" .1

Purchas?PriceItem DescriRtion

X9561X9562X9563

$

Bolster Chair-adaptive, includingadjustable/swing-away annrests

smallmediumAdolescent/large

complete including3 bolsters, 2 pro sandals X9564 619.00

Chair - Multi-Purpose, adaptive X9S0S 65.00

X9142X9144

332.00432.00

Commode Chair/Potty Chair, adaptivesmalladolescent

Commode Chair/RollingShower Chair. adaptive

with large rear wheelswith swivel rear casters

X9565X9566

999.00940.00

Corner Chair - adjustable, adaptive X9567 413.00

X9530 128.00Feeder Seat, adaptive

smallWedge to convert feederseat to floor sitter X9S33 97.00

X9508X9509X9568

98.00110.00150.00

Floor Sitter, adaptivesmallmediumwith adjustable angle

Footwear, Orthopedic/Con'ectiveOpen toe shoes, straight orreverse last, pair

small

largeX9572Dennis Brown Bar

X9570 51.95

X957 1 55.9558.9520.95X9S73

39

425.00432.00438.00

~


rItem DescriRtion


X9574X9575

$ 44.9510.00

Fillauer BarDepth Inlay Shoe (aka extra depth). pairOrthotic Inserts. custom-molded (flexible

semi-rigid. rigid), pair 150.00X9576

X9579 350.00

X9577X9578

10.0045.00

Custom molded shoes, pairLift on shoe, each,

each 1/4 incheach 1 inch

Gait Trainer-adjustable, adaptivesmall X9582 688.00

110.00105.00115.00125.00

X9587X9588X9513X9514

Head Support-Hensinger typelarge

mounted, extra smallsmallmedium

Heel or Elbow Protector, each EO191

)X9540 6590

19036,

Helmet-protectivesoft shellhard shell X9541

super smalVsuper largechin guard

X9625X9626

Mobile Stander-adaptive, with body support system,II X95

X95X95X95

994.001,119.001,744.002,063.00

Peak Flowmeter X9634

Pressure Pad - bed pad or mattress, reusablestandard

heavy dutyX9S01X9S02

20.0032.00

Prone Board! Adaptive Stander, adjustablesmallmediumadolescent

X9516X9635X9636

619.00669.00

1,081.00

40

.00

.00

.00

.00

smallmediumadolescentadolescent, large

i94i95i96i97


MaximumPurchasePriceItem DescriQtion

ScalesBaby-Portable home care 20 kg.

50 grams or 36 Ibs. x 1/4 Ibs.X9518 65.00

Balance beam, 16 kg. x 1 0 grams or36 Ibs. x 1/8 oz.

X9S19 270.00

Mechanical, 15 kg. x 5 grams or 31 Ibs.x 1/4 oz.

X9520 224.00

Beam, dual reading 40 Ibs. x Y2 oz. and17.5 kg. x .01 kg.

X9641 310.00

Diaper, bowl type (aka 'Pee Wee') X9S43 197.50

Shower Chair - adjustable, adaptive

adolescent

adolescent/1argeX9644X9645

463.00475.00

X9646X9647

344.007].90

Side- Lying Board - adjustableadolescent

trunk support block

Standing Frame - adjustable X9648 707.00

Stethoscope X9084 15.00

Supine Board-adjustablechildX9671adolescent

1,232.001,375.00X9672

Thennometer-standardrectal or oralear (instant)

X9673X9675

2.5080.00

4

I .+1'



rItem Descriotion

Toddler Chair, adaptive withadjustable back X9682 164.00

Urinometer X9522 8.00

X9546X9547

91.0098.00

Vestrrronk SuRRQrt(Whitworth type)

Extra support, naugahydesmalVrnediumlarge

Lightweight, nylon cotton weavesrnalVrnediumlarge

X9548X9549

84.0089.00

X9237X9690X9238

WalkersStandardfolding

with wheels

X9222X9694X9220

~adustable, with wheels and seatlarge/extra wide/heavy dutywalker, posture control with wheels

EO158X9695X9696X9697

Walker Accessoriesleg extensions (set of 4)wheeled foot piece, pairwheeled foot piece, swivel, pairplatfonn attachment, pediatric only

Wedge, abductor X9560 46.88

42

83.00100.00140.00

275.00225.00211.00

36.0033.0044.00

106.00

Respiratory Medical EQuipment and Accessories

. Note: These codes can also be used to bill for adults

MaximumMonthlyRentalCharge

Proced uteCodePurchase


ProcedureCode~

LifeEx~tanc~Item Descri~tion

Bi-Pap VentilatorSupport SystemWith MaskWith Headgear

$ NCNC

NCNC

X8718X8719

$ 461.00468.00

Bi-Pap VentilatorAccessories

X9718 51.35 NC NCMask, replace-

mentHeadgear, re-

placement X9719 35.35 NC NC

Cannula, Nasal A4615 1.45 NC NC

Cannula. tubing,7 feet X9702 1.60 NC NC

HumidificationHeaterSystem(Cascade type) X9720 780.00 $60.00X8720

Humidification Kit,(aka Trach Ventor Heat'Mois-ture exchange X9703 4.75 NC NC

HumidificationFilter, each X9704 2.30 NC NC

X9721 42.00 NC NCManometer

Oxygen Analyzer X9708 240.00 X8708 $ 18.50

43

~7:c~

ProcedureCode

Item DescriRtion Purchase


ProcedureCode~

MonthlyRentalCharge

rLifeEx~ctancy

Pulse OximeterWith Recorder NC NC X8709 500.00

16.00 dailyrate

Multi-use probe(aka Sensor,Transducer) NC NC X8728 13.00

NC NC X8094 520.00Respirator Support

System -Ventilator withaccessorypower source andHumidity system,appropriatecircuits (includingtubing, connec-tors, adaptors,thermal indicator)and secondary lowpressure alarm 0

Resusciator, manual NC NC X8711 13.50

USED MEDICAL EQUIPMENT


MaximumPurchasePriceItem Descri~tion

Beds. Hos~ital

Hospital Bed, total electric (head, foot and heightadjustments), with matb'ess, with side rails

Hospital Bed, total electric (head, foot and heightadjustments), without mattress, with side rails

X7114 ,642.50

X7115 1,537.50

44

DHMH - MarylandXl 025 Administration Set for enteral feeding with 1400ml. (and above) bag or...

Documents

Transcript of DHMH - MarylandXl 025 Administration Set for enteral feeding with 1400ml. (and above) bag or...