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PUF___2011_Web_File
HCPC Seq Num RIC
A1 00100 7
A2 00100 7
A3 00100 7
A4 00100 7
A5 00100 7
A6 00100 7
A7 00100 7
A8 00100 7
A9 00100 7
AA 00100 7
AD 00100 7
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AF 00100 7
AG 00100 7
AH 00100 7
AI 00100 7
AJ 00100 7
AK 00100 7
AM 00100 7
AP 00100 7
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AQ 00200 8
AR 00100 7
AS 00100 7
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AT 00100 7
AT 00200 8
AU 00100 7
AV 00100 7
AW 00100 7
AX 00100 7
AY 00100 7
AY 00200 8
AZ 00100 7
AZ 00200 8
BA 00100 7
BL 00100 7
BO 00100 7
BP 00100 7
BP 00200 8
BR 00100 7
BR 00200 8
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BU 00200 8
CA 00100 7
CA 00200 8
CB 00100 7
CB 00200 8
CB 00300 8
Page 1
PUF___2011_Web_File
CC 00100 7
CC 00200 8
CD 00100 7
CD 00200 8
CE 00100 7
CE 00200 8
CE 00300 8
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CF 00200 8
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FA 00100 7
FB 00100 7
FB 00200 8
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PUF___2011_Web_File
FB 00300 8
FC 00100 7
FP 00100 7
G1 00100 7
G2 00100 7
G3 00100 7
G4 00100 7
G5 00100 7
G6 00100 7
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GC 00200 8
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GE 00100 7
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GF 00100 7
GF 00200 8
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GK 00100 7
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GR 00200 8
GR 00300 8
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GS 00200 8
GT 00100 7
GU 00100 7
GV 00100 7
GV 00200 8
GW 00100 7
GX 00100 7
Page 3
PUF___2011_Web_File
GY 00100 7
GY 00200 8
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HA 00100 7
HB 00100 7
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HD 00100 7
HE 00100 7
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HO 00100 7
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HS 00100 7
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HY 00100 7
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JC 00100 7
JD 00100 7
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K0 00100 7
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K0 00300 8
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K1 00300 8
K2 00100 7
K2 00200 8
K2 00300 8
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PUF___2011_Web_File
K2 00400 8
K3 00100 7
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NB 00100 7
NR 00100 7
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PUF___2011_Web_File
NR 00200 8
NU 00100 7
P1 00100 7
P2 00100 7
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QA 00100 7
QC 00100 7
QD 00100 7
QE 00100 7
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QP 00100 7
QP 00200 8
Page 6
PUF___2011_Web_File
QP 00300 8
QR 00100 7
QS 00100 7
QT 00100 7
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QW 00100 7
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SY 00100 7
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T1 00100 7
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T5 00100 7
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PUF___2011_Web_File
T6 00100 7
T7 00100 7
T8 00100 7
T9 00100 7
TA 00100 7
TC 00100 7
TC 00200 8
TC 00300 8
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TD 00100 7
TE 00100 7
TF 00100 7
TG 00100 7
TH 00100 7
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TK 00100 7
TL 00100 7
TM 00100 7
TN 00100 7
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TR 00100 7
TR 00200 8
TS 00100 7
TT 00100 7
TU 00100 7
TV 00100 7
TW 00100 7
U1 00100 7
U2 00100 7
U3 00100 7
U4 00100 7
U5 00100 7
U6 00100 7
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UA 00100 7
UB 00100 7
UC 00100 7
UD 00100 7
UE 00100 7
UF 00100 7
UG 00100 7
UH 00100 7
UJ 00100 7
UK 00100 7
UK 00200 8
UN 00100 7
Page 8
PUF___2011_Web_File
UP 00100 7
UQ 00100 7
UR 00100 7
US 00100 7
V5 00100 7
V6 00100 7
V7 00100 7
V8 00100 7
V9 00100 7
VP 00100 7
A0021 00100 3
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PUF___2011_Web_File
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PUF___2011_Web_File
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PUF___2011_Web_File
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PUF___2011_Web_File
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PUF___2011_Web_File
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PUF___2011_Web_File
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PUF___2011_Web_File
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PUF___2011_Web_File
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T4532 00200 4
T4533 00100 3
T4534 00100 3
T4535 00100 3
T4536 00100 3
T4537 00100 3
T4538 00100 3
T4539 00100 3
T4540 00100 3
T4541 00100 3
T4542 00100 3
T4543 00100 3
T5001 00100 3
T5999 00100 3
V2020 00100 3
V2025 00100 3
V2100 00100 3
V2101 00100 3
V2102 00100 3
V2103 00100 3
V2103 00200 4
V2104 00100 3
V2104 00200 4
V2105 00100 3
V2105 00200 4
V2106 00100 3
V2106 00200 4
V2107 00100 3
V2107 00200 4
V2108 00100 3
V2108 00200 4
V2109 00100 3
V2109 00200 4
V2110 00100 3
V2110 00200 4
V2111 00100 3
V2111 00200 4
V2112 00100 3
V2112 00200 4
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V2113 00100 3
V2113 00200 4
V2114 00100 3
V2115 00100 3
V2118 00100 3
V2121 00100 3
V2199 00100 3
V2200 00100 3
V2201 00100 3
V2202 00100 3
V2203 00100 3
V2203 00200 4
V2204 00100 3
V2204 00200 4
V2205 00100 3
V2205 00200 4
V2206 00100 3
V2206 00200 4
V2207 00100 3
V2207 00200 4
V2208 00100 3
V2208 00200 4
V2209 00100 3
V2209 00200 4
V2210 00100 3
V2210 00200 4
V2211 00100 3
V2211 00200 4
V2212 00100 3
V2212 00200 4
V2213 00100 3
V2213 00200 4
V2214 00100 3
V2215 00100 3
V2218 00100 3
V2219 00100 3
V2220 00100 3
V2221 00100 3
V2299 00100 3
V2300 00100 3
V2301 00100 3
V2302 00100 3
V2303 00100 3
V2303 00200 4
V2304 00100 3
V2304 00200 4
V2305 00100 3
V2305 00200 4
V2306 00100 3
V2306 00200 4
V2307 00100 3
V2307 00200 4
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V2308 00100 3
V2308 00200 4
V2309 00100 3
V2309 00200 4
V2310 00100 3
V2310 00200 4
V2311 00100 3
V2311 00200 4
V2312 00100 3
V2312 00200 4
V2313 00100 3
V2313 00200 4
V2314 00100 3
V2315 00100 3
V2318 00100 3
V2319 00100 3
V2320 00100 3
V2321 00100 3
V2399 00100 3
V2410 00100 3
V2430 00100 3
V2499 00100 3
V2500 00100 3
V2501 00100 3
V2502 00100 3
V2503 00100 3
V2510 00100 3
V2511 00100 3
V2512 00100 3
V2513 00100 3
V2520 00100 3
V2521 00100 3
V2522 00100 3
V2523 00100 3
V2530 00100 3
V2530 00200 4
V2531 00100 3
V2531 00200 4
V2599 00100 3
V2600 00100 3
V2610 00100 3
V2615 00100 3
V2615 00200 4
V2623 00100 3
V2624 00100 3
V2625 00100 3
V2626 00100 3
V2627 00100 3
V2628 00100 3
V2629 00100 3
V2630 00100 3
V2631 00100 3
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V2632 00100 3
V2700 00100 3
V2702 00100 3
V2710 00100 3
V2715 00100 3
V2718 00100 3
V2730 00100 3
V2744 00100 3
V2745 00100 3
V2745 00200 4
V2750 00100 3
V2755 00100 3
V2756 00100 3
V2760 00100 3
V2761 00100 3
V2762 00100 3
V2770 00100 3
V2780 00100 3
V2781 00100 3
V2782 00100 3
V2782 00200 4
V2783 00100 3
V2783 00200 4
V2784 00100 3
V2785 00100 3
V2786 00100 3
V2787 00100 3
V2788 00100 3
V2790 00100 3
V2797 00100 3
V2799 00100 3
V5008 00100 3
V5010 00100 3
V5011 00100 3
V5014 00100 3
V5020 00100 3
V5030 00100 3
V5040 00100 3
V5050 00100 3
V5060 00100 3
V5070 00100 3
V5080 00100 3
V5090 00100 3
V5095 00100 3
V5100 00100 3
V5110 00100 3
V5120 00100 3
V5130 00100 3
V5140 00100 3
V5150 00100 3
V5160 00100 3
V5170 00100 3
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V5180 00100 3
V5190 00100 3
V5200 00100 3
V5210 00100 3
V5220 00100 3
V5230 00100 3
V5240 00100 3
V5241 00100 3
V5242 00100 3
V5243 00100 3
V5244 00100 3
V5245 00100 3
V5246 00100 3
V5247 00100 3
V5248 00100 3
V5249 00100 3
V5250 00100 3
V5251 00100 3
V5252 00100 3
V5253 00100 3
V5254 00100 3
V5255 00100 3
V5256 00100 3
V5257 00100 3
V5258 00100 3
V5259 00100 3
V5260 00100 3
V5261 00100 3
V5262 00100 3
V5263 00100 3
V5264 00100 3
V5265 00100 3
V5266 00100 3
V5267 00100 3
V5268 00100 3
V5269 00100 3
V5270 00100 3
V5271 00100 3
V5272 00100 3
V5273 00100 3
V5274 00100 3
V5275 00100 3
V5298 00100 3
V5299 00100 3
V5336 00100 3
V5336 00200 4
V5362 00100 3
V5363 00100 3
V5364 00100 3
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Long Description
DRESSING FOR ONE WOUND
DRESSING FOR TWO WOUNDS
DRESSING FOR THREE WOUNDS
DRESSING FOR FOUR WOUNDS
DRESSING FOR FIVE WOUNDS
DRESSING FOR SIX WOUNDS
DRESSING FOR SEVEN WOUNDS
DRESSING FOR EIGHT WOUNDS
DRESSING FOR NINE OR MORE WOUNDS
ANESTHESIA SERVICES PERFORMED PERSONALLY BY ANESTHESIOLOGIST
MEDICAL SUPERVISION BY A PHYSICIAN: MORE THAN FOUR CONCURRENT ANESTHESIA
PROCEDURES
REGISTERED DIETICIAN
SPECIALTY PHYSICIAN
PRIMARY PHYSICIAN
CLINICAL PSYCHOLOGIST
PRINCIPAL PHYSICIAN OF RECORD
CLINICAL SOCIAL WORKER
NON PARTICIPATING PHYSICIAN
PHYSICIAN, TEAM MEMBER SERVICE
DETERMINATION OF REFRACTIVE STATE WAS NOT PERFORMED IN THE COURSE OF DIAGNOSTIC
OPHTHALMOLOGICAL EXAMINATION
PHYSICIAN PROVIDING A SERVICE IN AN UNLISTED HEALTH PROFESSIONAL SHORTAGE AREA
(HPSA)
PHYSICIAN PROVIDER SERVICES IN A PHYSICIAN SCARCITY AREA
PHYSICIAN ASSISTANT, NURSE PRACTITIONER, OR CLINICAL NURSE SPECIALIST SERVICES
FOR ASSISTANT AT SURGERY
ACUTE TREATMENT (THIS MODIFIER SHOULD BE USED WHEN REPORTING SERVICE 98940,
98941, 98942)
ITEM FURNISHED IN CONJUNCTION WITH A UROLOGICAL, OSTOMY, OR TRACHEOSTOMY SUPPLY
ITEM FURNISHED IN CONJUNCTION WITH A PROSTHETIC DEVICE, PROSTHETIC OR ORTHOTIC
ITEM FURNISHED IN CONJUNCTION WITH A SURGICAL DRESSING
ITEM FURNISHED IN CONJUNCTION WITH DIALYSIS SERVICES
ITEM OR SERVICE FURNISHED TO AN ESRD PATIENT THAT IS NOT FOR THE TREATMENT OF
ESRD
PHYSICIAN PROVIDING A SERVICE IN A DENTAL HEALTH PROFESSIONAL SHORTAGE AREA FOR
THE PURPOSE OF AN ELECTRONIC HEALTH RECORD INCENTIVE PAYMENT
ITEM FURNISHED IN CONJUNCTION WITH PARENTERAL ENTERAL NUTRITION (PEN) SERVICES
SPECIAL ACQUISITION OF BLOOD AND BLOOD PRODUCTS
ORALLY ADMINISTERED NUTRITION, NOT BY FEEDING TUBE
THE BENEFICIARY HAS BEEN INFORMED OF THE PURCHASE AND RENTAL OPTIONS AND HAS
ELECTED TO PURCHASE THE ITEM
THE BENEFICIARY HAS BEEN INFORMED OF THE PURCHASE AND RENTAL OPTIONS AND HAS
ELECTED TO RENT THE ITEM
THE BENEFICIARY HAS BEEN INFORMED OF THE PURCHASE AND RENTAL OPTIONS AND AFTER
30 DAYS HAS NOT INFORMED THE SUPPLIER OF HIS/HER DECISION
PROCEDURE PAYABLE ONLY IN THE INPATIENT SETTING WHEN PERFORMED EMERGENTLY ON AN
OUTPATIENT WHO EXPIRES PRIOR TO ADMISSION
SERVICE ORDERED BY A RENAL DIALYSIS FACILITY (RDF) PHYSICIAN AS PART OF THE
ESRD BENEFICIARY'S DIALYSIS BENEFIT, IS NOT PART OF THE COMPOSITE RATE, AND IS
SEPARATELY REIMBURSABLE
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PROCEDURE CODE CHANGE (USE 'CC' WHEN THE PROCEDURE CODE SUBMITTED WAS CHANGED
EITHER FOR ADMINISTRATIVE REASONS OR BECAUSE AN INCORRECT CODE WAS FILED)
AMCC TEST HAS BEEN ORDERED BY AN ESRD FACILITY OR MCP PHYSICIAN THAT IS PART OF
THE COMPOSITE RATE AND IS NOT SEPARATELY BILLABLE
AMCC TEST HAS BEEN ORDERED BY AN ESRD FACILITY OR MCP PHYSICIAN THAT IS A
COMPOSITE RATE TEST BUT IS BEYOND THE NORMAL FREQUENCY COVERED UNDER THE RATE
AND IS SEPARATELY REIMBURSABLE BASED ON MEDICAL NECESSITY
AMCC TEST HAS BEEN ORDERED BY AN ESRD FACILITY OR MCP PHYSICIAN THAT IS NOT
PART OF THE COMPOSITE RATE AND IS SEPARATELY BILLABLE
POLICY CRITERIA APPLIED
CATASTROPHE/DISASTER RELATED
ITEM OR SERVICE RELATED, IN WHOLE OR IN PART, TO AN ILLNESS, INJURY, OR
CONDITION THAT WAS CAUSED BY OR EXACERBATED BY THE EFFECTS, DIRECT OR INDIRECT,
OF THE 2010 OIL SPILL IN THE GULF OF MEXICO, INCLUDING BUT NOT LIMITED TO
SUBSEQUENT CLEAN-UP ACTIVITIE
ORAL HEALTH ASSESSMENT BY A LICENSED HEALTH PROFESSIONAL OTHER THAN A DENTIST
UPPER LEFT, EYELID
LOWER LEFT, EYELID
UPPER RIGHT, EYELID
LOWER RIGHT, EYELID
ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA DUE TO
ANTI-CANCER CHEMOTHERAPY
ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA DUE TO
ANTI-CANCER RADIOTHERAPY
ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA NOT DUE TO
ANTI-CANCER RADIOTHERAPY OR ANTI-CANCER CHEMOTHERAPY
HEMATOCRIT LEVEL HAS EXCEEDED 39% (OR HEMOGLOBIN LEVEL HAS EXCEEDED 13.0 G/DL)
FOR 3 OR MORE CONSECUTIVE BILLING CYCLES IMMEDIATELY PRIOR TO AND INCLUDING THE
CURRENT CYCLE
HEMATOCRIT LEVEL HAS NOT EXCEEDED 39% (OR HEMOGLOBIN LEVEL HAS NOT EXCEEDED
13.0 G/DL) FOR 3 OR MORE CONSECUTIVE BILLING CYCLES IMMEDIATELY PRIOR TO AND
INCLUDING THE CURRENT CYCLE
SUBSEQUENT CLAIMS FOR A DEFINED COURSE OF THERAPY, E.G., EPO, SODIUM
HYALURONATE, INFLIXIMAB
EMERGENCY RESERVE SUPPLY (FOR ESRD BENEFIT ONLY)
SERVICE PROVIDED AS PART OF MEDICAID EARLY PERIODIC SCREENING DIAGNOSIS AND
TREATMENT (EPSDT) PROGRAM
EMERGENCY SERVICES
NO PHYSICIAN OR OTHER LICENSED HEALTH CARE PROVIDER ORDER FOR THIS ITEM OR
SERVICE
LEFT HAND, SECOND DIGIT
LEFT HAND, THIRD DIGIT
LEFT HAND, FOURTH DIGIT
LEFT HAND, FIFTH DIGIT
RIGHT HAND, THUMB
RIGHT HAND, SECOND DIGIT
RIGHT HAND, THIRD DIGIT
RIGHT HAND, FOURTH DIGIT
RIGHT HAND, FIFTH DIGIT
LEFT HAND, THUMB
ITEM PROVIDED WITHOUT COST TO PROVIDER, SUPPLIER OR PRACTITIONER, OR FULL
CREDIT RECEIVED FOR REPLACED DEVICE (EXAMPLES, BUT NOT LIMITED TO, COVERED
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UNDER WARRANTY, REPLACED DUE TO DEFECT, FREE SAMPLES)
PARTIAL CREDIT RECEIVED FOR REPLACED DEVICE
SERVICE PROVIDED AS PART OF FAMILY PLANNING PROGRAM
MOST RECENT URR READING OF LESS THAN 60
MOST RECENT URR READING OF 60 TO 64.9
MOST RECENT URR READING OF 65 TO 69.9
MOST RECENT URR READING OF 70 TO 74.9
MOST RECENT URR READING OF 75 OR GREATER
ESRD PATIENT FOR WHOM LESS THAN SIX DIALYSIS SESSIONS HAVE BEEN PROVIDED IN A
MONTH
PREGNANCY RESULTED FROM RAPE OR INCEST OR PREGNANCY CERTIFIED BY PHYSICIAN AS
LIFE THREATENING
MONITORED ANESTHESIA CARE (MAC) FOR DEEP COMPLEX, COMPLICATED, OR MARKEDLY
INVASIVE SURGICAL PROCEDURE
MONITORED ANESTHESIA CARE FOR PATIENT WHO HAS HISTORY OF SEVERE
CARDIO-PULMONARY CONDITION
WAIVER OF LIABILITY STATEMENT ISSUED AS REQUIRED BY PAYER POLICY, INDIVIDUAL
CASE
CLAIM BEING RE-SUBMITTED FOR PAYMENT BECAUSE IT IS NO LONGER COVERED UNDER A
GLOBAL PAYMENT DEMONSTRATION
THIS SERVICE HAS BEEN PERFORMED IN PART BY A RESIDENT UNDER THE DIRECTION OF A
TEACHING PHYSICIAN
UNITS OF SERVICE EXCEEDS MEDICALLY UNLIKELY EDIT VALUE AND REPRESENTS
REASONABLE AND NECESSARY SERVICES
THIS SERVICE HAS BEEN PERFORMED BY A RESIDENT WITHOUT THE PRESENCE OF A
TEACHING PHYSICIAN UNDER THE PRIMARY CARE EXCEPTION
NON-PHYSICIAN (E.G. NURSE PRACTITIONER (NP), CERTIFIED REGISTERED NURSE
ANESTHETIST (CRNA), CERTIFIED REGISTERED NURSE (CRN), CLINICAL NURSE SPECIALIST
(CNS), PHYSICIAN ASSISTANT (PA)) SERVICES IN A CRITICAL ACCESS HOSPITAL
PERFORMANCE AND PAYMENT OF A SCREENING MAMMOGRAM AND DIAGNOSTIC MAMMOGRAM ON
THE SAME PATIENT, SAME DAY
DIAGNOSTIC MAMMOGRAM CONVERTED FROM SCREENING MAMMOGRAM ON SAME DAY
"OPT OUT" PHYSICIAN OR PRACTITIONER EMERGENCY OR URGENT SERVICE
REASONABLE AND NECESSARY ITEM/SERVICE ASSOCIATED WITH A GA OR GZ MODIFIER
MEDICALLY UNNECESSARY UPGRADE PROVIDED INSTEAD OF NON-UPGRADED ITEM, NO CHARGE,
NO ADVANCE BENEFICIARY NOTICE (ABN)
MULTIPLE PATIENTS ON ONE AMBULANCE TRIP
SERVICES DELIVERED UNDER AN OUTPATIENT SPEECH LANGUAGE PATHOLOGY PLAN OF CARE
SERVICES DELIVERED UNDER AN OUTPATIENT OCCUPATIONAL THERAPY PLAN OF CARE
SERVICES DELIVERED UNDER AN OUTPATIENT PHYSICAL THERAPY PLAN OF CARE
VIA ASYNCHRONOUS TELECOMMUNICATIONS SYSTEM
THIS SERVICE WAS PERFORMED IN WHOLE OR IN PART BY A RESIDENT IN A DEPARTMENT OF
VETERANS AFFAIRS MEDICAL CENTER OR CLINIC, SUPERVISED IN ACCORDANCE WITH VA
POLICY
DOSAGE OF EPO OR DARBEPOIETIN ALFA HAS BEEN REDUCED AND MAINTAINED IN RESPONSE
TO HEMATOCRIT OR HEMOGLOBIN LEVEL
VIA INTERACTIVE AUDIO AND VIDEO TELECOMMUNICATION SYSTEMS
WAIVER OF LIABILITY STATEMENT ISSUED AS REQUIRED BY PAYER POLICY, ROUTINE NOTICE
ATTENDING PHYSICIAN NOT EMPLOYED OR PAID UNDER ARRANGEMENT BY THE PATIENT'S
HOSPICE PROVIDER
SERVICE NOT RELATED TO THE HOSPICE PATIENT'S TERMINAL CONDITION
NOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICY
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ITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANY
MEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CONTRACT BENEFIT
ITEM OR SERVICE EXPECTED TO BE DENIED AS NOT REASONABLE AND NECESSARY
COURT-ORDERED
CHILD/ADOLESCENT PROGRAM
ADULT PROGRAM, NON GERIATRIC
ADULT PROGRAM, GERIATRIC
PREGNANT/PARENTING WOMEN'S PROGRAM
MENTAL HEALTH PROGRAM
SUBSTANCE ABUSE PROGRAM
OPIOID ADDICTION TREATMENT PROGRAM
INTEGRATED MENTAL HEALTH/SUBSTANCE ABUSE PROGRAM
INTEGRATED MENTAL HEALTH AND MENTAL RETARDATION/DEVELOPMENTAL DISABILITIES
PROGRAM
EMPLOYEE ASSISTANCE PROGRAM
SPECIALIZED MENTAL HEALTH PROGRAMS FOR HIGH-RISK POPULATIONS
INTERN
LESS THAN BACHELOR DEGREE LEVEL
BACHELORS DEGREE LEVEL
MASTERS DEGREE LEVEL
DOCTORAL LEVEL
GROUP SETTING
FAMILY/COUPLE WITH CLIENT PRESENT
FAMILY/COUPLE WITHOUT CLIENT PRESENT
MULTI-DISCIPLINARY TEAM
FUNDED BY CHILD WELFARE AGENCY
FUNDED STATE ADDICTIONS AGENCY
FUNDED BY STATE MENTAL HEALTH AGENCY
FUNDED BY COUNTY/LOCAL AGENCY
FUNDED BY JUVENILE JUSTICE AGENCY
FUNDED BY CRIMINAL JUSTICE AGENCY
COMPETITIVE ACQUISITION PROGRAM NO-PAY SUBMISSION FOR A PRESCRIPTION NUMBER
COMPETITIVE ACQUISITION PROGRAM, RESTOCKING OF EMERGENCY DRUGS AFTER EMERGENCY
ADMINISTRATION
COMPETITIVE ACQUISITION PROGRAM (CAP), DRUG NOT AVAILABLE THROUGH CAP AS
WRITTEN, REIMBURSED UNDER AVERAGE SALES PRICE METHODOLOGY
DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM THAT IS FURNISHED BY
A HOSPITAL UPON DISCHARGE
ADMINISTERED INTRAVENOUSLY
ADMINISTERED SUBCUTANEOUSLY
SKIN SUBSTITUTE USED AS A GRAFT
SKIN SUBSTITUTE NOT USED AS A GRAFT
DRUG AMOUNT DISCARDED/NOT ADMINISTERED TO ANY PATIENT
LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 0 - DOES NOT HAVE THE ABILITY OR
POTENTIAL TO AMBULATE OR TRANSFER SAFELY WITH OR WITHOUT ASSISTANCE AND A
PROSTHESIS DOES NOT ENHANCE THEIR QUALITY OF LIFE OR MOBILITY.
LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 1 - HAS THE ABILITY OR POTENTIAL TO
USE A PROSTHESIS FOR TRANSFERS OR AMBULATION ON LEVEL SURFACES AT FIXED
CADENCE. TYPICAL OF THE LIMITED AND UNLIMITED HOUSEHOLD AMBULATOR.
LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 2 - HAS THE ABILITY OR POTENTIAL
FOR AMBULATION WITH THE ABILITY TO TRAVERSE LOW LEVEL ENVIRONMENTAL BARRIERS
SUCH AS CURBS, STAIRS OR UNEVEN SURFACES. TYPICAL OF THE LIMITED COMMUNITY
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AMBULATOR.
LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 3 - HAS THE ABILITY OR POTENTIAL
FOR AMBULATION WITH VARIABLE CADENCE. TYPICAL OF THE COMMUNITY AMBULATOR WHO
HAS THE ABILITY TO TRANSVERSE MOST ENVIRONMENTAL BARRIERS AND MAY HAVE
VOCATIONAL, THERAPEUTIC, OR EXERCISE ACTIVITY THAT DEMANDS PROSTHETIC
UTILIZATION BEYOND SIMPLE LOCOMOTION.
LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 4 - HAS THE ABILITY OR POTENTIAL
FOR PROSTHETIC AMBULATION THAT EXCEEDS THE BASIC AMBULATION SKILLS, EXHIBITING
HIGH IMPACT, STRESS, OR ENERGY LEVELS, TYPICAL OF THE PROSTHETIC DEMANDS OF THE
CHILD, ACTIVE ADULT, OR ATHLETE.
ADD ON OPTION/ACCESSORY FOR WHEELCHAIR
BENEFICIARY REQUESTED UPGRADE FOR ABN, MORE THAN 4 MODIFIERS IDENTIFIED ON CLAIM
REPLACEMENT OF SPECIAL POWER WHEELCHAIR INTERFACE
DRUG OR BIOLOGICAL INFUSED THROUGH DME
BID UNDER ROUND ONE OF THE DMEPOS COMPETITIVE BIDDING PROGRAM FOR USE WITH
NON-COMPETITIVE BID BASE EQUIPMENT
ITEM DESIGNATED BY FDA AS CLASS III DEVICE
DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 1
DMEPOS ITEM, INITIAL CLAIM, PURCHASE OR FIRST MONTH RENTAL
DMEPOS ITEM, SECOND OR THIRD MONTH RENTAL
DMEPOS ITEM, PARENTERAL ENTERAL NUTRITION (PEN) PUMP OR CAPPED RENTAL, MONTHS
FOUR TO FIFTEEN
DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 2
DMEPOS ITEM DELIVERED VIA MAIL
REPLACEMENT OF FACIAL PROSTHESIS INCLUDING NEW IMPRESSION/MOULAGE
REPLACEMENT OF FACIAL PROSTHESIS USING PREVIOUS MASTER MODEL
SINGLE DRUG UNIT DOSE FORMULATION
FIRST DRUG OF A MULTIPLE DRUG UNIT DOSE FORMULATION
SECOND OR SUBSEQUENT DRUG OF A MULTIPLE DRUG UNIT DOSE FORMULATION
RENTAL ITEM, BILLING FOR PARTIAL MONTH
GLUCOSE MONITOR SUPPLY FOR DIABETIC BENEFICIARY NOT TREATED WITH INSULIN
BENEFICIARY RESIDES IN A COMPETITIVE BIDDING AREA AND TRAVELS OUTSIDE THAT
COMPETITIVE BIDDING AREA AND RECEIVES A COMPETITIVE BID ITEM
DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 3
DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM THAT IS FURNISHED AS
PART OF A PROFESSIONAL SERVICE
DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 4
REQUIREMENTS SPECIFIED IN THE MEDICAL POLICY HAVE BEEN MET
DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 5
NEW COVERAGE NOT IMPLEMENTED BY MANAGED CARE
LEFT CIRCUMFLEX CORONARY ARTERY
LEFT ANTERIOR DESCENDING CORONARY ARTERY
LEASE/RENTAL (USE THE 'LL' MODIFIER WHEN DME EQUIPMENT RENTAL IS TO BE APPLIED
AGAINST THE PURCHASE PRICE)
LABORATORY ROUND TRIP
FDA-MONITORED INTRAOCULAR LENS IMPLANT
LEFT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE LEFT SIDE OF THE BODY)
MEDICARE SECONDARY PAYER (MSP)
SIX MONTH MAINTENANCE AND SERVICING FEE FOR REASONABLE AND NECESSARY PARTS AND
LABOR WHICH ARE NOT COVERED UNDER ANY MANUFACTURER OR SUPPLIER WARRANTY
NEBULIZER SYSTEM, ANY TYPE, FDA-CLEARED FOR USE WITH SPECIFIC DRUG
NEW WHEN RENTED (USE THE 'NR' MODIFIER WHEN DME WHICH WAS NEW AT THE TIME OF
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RENTAL IS SUBSEQUENTLY PURCHASED)
NEW EQUIPMENT
A NORMAL HEALTHY PATIENT
A PATIENT WITH MILD SYSTEMIC DISEASE
A PATIENT WITH SEVERE SYSTEMIC DISEASE
A PATIENT WITH SEVERE SYSTEMIC DISEASE THAT IS A CONSTANT THREAT TO LIFE
A MORIBUND PATIENT WHO IS NOT EXPECTED TO SURVIVE WITHOUT THE OPERATION
A DECLARED BRAIN-DEAD PATIENT WHOSE ORGANS ARE BEING REMOVED FOR DONOR PURPOSES
SURGICAL OR OTHER INVASIVE PROCEDURE ON WRONG BODY PART
SURGICAL OR OTHER INVASIVE PROCEDURE ON WRONG PATIENT
WRONG SURGERY OR OTHER INVASIVE PROCEDURE ON PATIENT
POSITRON EMISSION TOMOGRAPHY (PET) OR PET/COMPUTED TOMOGRAPHY (CT) TO INFORM
THE INITIAL TREATMENT STRATEGY OF TUMORS THAT ARE BIOPSY PROVEN OR STRONGLY
SUSPECTED OF BEING CANCEROUS BASED ON OTHER DIAGNOSTIC TESTING
PROGRESSIVE ADDITION LENSES
POSITRON EMISSION TOMOGRAPHY (PET) OR PET/COMPUTED TOMOGRAPHY (CT) TO INFORM
THE SUBSEQUENT TREATMENT STRATEGY OF CANCEROUS TUMORS WHEN THE BENEFICIARY'S
TREATING PHYSICIAN DETERMINES THAT THE PET STUDY IS NEEDED TO INFORM SUBSEQUENT
ANTI-TUMOR STRATEGY
COLORECTAL CANCER SCREENING TEST; CONVERTED TO DIAGNOSTIC TEST OR OTHER
PROCEDURE
INVESTIGATIONAL CLINICAL SERVICE PROVIDED IN A CLINICAL RESEARCH STUDY THAT IS
IN AN APPROVED CLINICAL RESEARCH STUDY
ROUTINE CLINICAL SERVICE PROVIDED IN A CLINICAL RESEARCH STUDY THAT IS IN AN
APPROVED CLINICAL RESEARCH STUDY
HCFA/ORD DEMONSTRATION PROJECT PROCEDURE/SERVICE
LIVE KIDNEY DONOR SURGERY AND RELATED SERVICES
SERVICE FOR ORDERING/REFERRING PHYSICIAN QUALIFIES AS A SERVICE EXEMPTION
SERVICE FURNISHED BY A SUBSTITUTE PHYSICIAN UNDER A RECIPROCAL BILLING
ARRANGEMENT
SERVICE FURNISHED BY A LOCUM TENENS PHYSICIAN
ONE CLASS A FINDING
TWO CLASS B FINDINGS
ONE CLASS B AND TWO CLASS C FINDINGS
FDA INVESTIGATIONAL DEVICE EXEMPTION
SINGLE CHANNEL MONITORING
RECORDING AND STORAGE IN SOLID STATE MEMORY BY A DIGITAL RECORDER
PRESCRIBED AMOUNT OF OXYGEN IS LESS THAN 1 LITER PER MINUTE (LPM)
PRESCRIBED AMOUNT OF OXYGEN EXCEEDS 4 LITERS PER MINUTE (LPM) AND PORTABLE
OXYGEN IS PRESCRIBED
PRESCRIBED AMOUNT OF OXYGEN IS GREATER THAN 4 LITERS PER MINUTE(LPM)
OXYGEN CONSERVING DEVICE IS BEING USED WITH AN OXYGEN DELIVERY SYSTEM
SERVICES/ITEMS PROVIDED TO A PRISONER OR PATIENT IN STATE OR LOCAL CUSTODY,
HOWEVER THE STATE OR LOCAL GOVERNMENT, AS APPLICABLE, MEETS THE REQUIREMENTS IN
42 CFR 411.4 (B)
MEDICAL DIRECTION OF TWO, THREE, OR FOUR CONCURRENT ANESTHESIA PROCEDURES
INVOLVING QUALIFIED INDIVIDUALS
PATIENT PRONOUNCED DEAD AFTER AMBULANCE CALLED
AMBULANCE SERVICE PROVIDED UNDER ARRANGEMENT BY A PROVIDER OF SERVICES
AMBULANCE SERVICE FURNISHED DIRECTLY BY A PROVIDER OF SERVICES
DOCUMENTATION IS ON FILE SHOWING THAT THE LABORATORY TEST(S) WAS ORDERED
INDIVIDUALLY OR ORDERED AS A CPT-RECOGNIZED PANEL OTHER THAN AUTOMATED PROFILE
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CODES 80002-80019, G0058, G0059, AND G0060.
ITEM OR SERVICE PROVIDED IN A MEDICARE SPECIFIED STUDY
MONITORED ANESTHESIA CARE SERVICE
RECORDING AND STORAGE ON TAPE BY AN ANALOG TAPE RECORDER
ITEM OR SERVICE PROVIDED AS ROUTINE CARE IN A MEDICARE QUALIFYING CLINICAL TRIAL
CLIA WAIVED TEST
CRNA SERVICE: WITH MEDICAL DIRECTION BY A PHYSICIAN
MEDICAL DIRECTION OF ONE CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA) BY AN
ANESTHESIOLOGIST
CRNA SERVICE: WITHOUT MEDICAL DIRECTION BY A PHYSICIAN
REPLACEMENT OF A DME, ORTHOTIC OR PROSTHETIC ITEM
REPLACEMENT OF A PART OF A DME, ORTHOTIC OR PROSTHETIC ITEM FURNISHED AS PART
OF A REPAIR
RIGHT CORONARY ARTERY
DRUG PROVIDED TO BENEFICIARY, BUT NOT ADMINISTERED "INCIDENT-TO"
FURNISHED IN FULL COMPLIANCE WITH FDA-MANDATED RISK EVALUATION AND MITIGATION
STRATEGY (REMS)
REPLACEMENT AND REPAIR -RP MAY BE USED TO INDICATE REPLACEMENT OF DME, ORTHOTIC
AND PROSTHETIC DEVICES WHICH HAVE BEEN IN USE FOR SOMETIME. THE CLAIM SHOWS
THE CODE FOR THE PART, FOLLOWED BY THE 'RP' MODIFIER AND THE CHARGE FOR THE
PART.
RENTAL (USE THE 'RR' MODIFIER WHEN DME IS TO BE RENTED)
RIGHT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE RIGHT SIDE OF THE BODY)
NURSE PRACTITIONER RENDERING SERVICE IN COLLABORATION WITH A PHYSICIAN
NURSE MIDWIFE
MEDICALLY NECESSARY SERVICE OR SUPPLY
SERVICES PROVIDED BY REGISTERED NURSE WITH SPECIALIZED, HIGHLY TECHNICAL HOME
INFUSION TRAINING
STATE AND/OR FEDERALLY-FUNDED PROGRAMS/SERVICES
SECOND OPINION ORDERED BY A PROFESSIONAL REVIEW ORGANIZATION (PRO) PER SECTION
9401, P.L. 99-272 (100% REIMBURSEMENT - NO MEDICARE DEDUCTIBLE OR COINSURANCE)
AMBULATORY SURGICAL CENTER (ASC) FACILITY SERVICE
SECOND CONCURRENTLY ADMINISTERED INFUSION THERAPY
THIRD OR MORE CONCURRENTLY ADMINISTERED INFUSION THERAPY
MEMBER OF HIGH RISK POPULATION (USE ONLY WITH CODES FOR IMMUNIZATION)
STATE SUPPLIED VACCINE
SECOND SURGICAL OPINION
THIRD SURGICAL OPINION
ITEM ORDERED BY HOME HEALTH
HOME INFUSION SERVICES PROVIDED IN THE INFUSION SUITE OF THE IV THERAPY PROVIDER
RELATED TO TRAUMA OR INJURY
PROCEDURE PERFORMED IN PHYSICIAN'S OFFICE (TO DENOTE USE OF FACILITY AND
EQUIPMENT)
PHARMACEUTICALS DELIVERED TO PATIENT'S HOME BUT NOT UTILIZED
SERVICES PROVIDED BY A CERTIFIED DIABETIC EDUCATOR
PERSONS WHO ARE IN CLOSE CONTACT WITH MEMBER OF HIGH-RISK POPULATION (USE ONLY
WITH CODES FOR IMMUNIZATION)
LEFT FOOT, SECOND DIGIT
LEFT FOOT, THIRD DIGIT
LEFT FOOT, FOURTH DIGIT
LEFT FOOT, FIFTH DIGIT
RIGHT FOOT, GREAT TOE
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RIGHT FOOT, SECOND DIGIT
RIGHT FOOT, THIRD DIGIT
RIGHT FOOT, FOURTH DIGIT
RIGHT FOOT, FIFTH DIGIT
LEFT FOOT, GREAT TOE
TECHNICAL COMPONENT. UNDER CERTAIN CIRCUMSTANCES, A CHARGE MAY BE MADE FOR THE
TECHNICAL COMPONENT ALONE. UNDER THOSE CIRCUMSTANCES THE TECHNICAL COMPONENT
CHARGE IS IDENTIFIED BY ADDING MODIFIER 'TC' TO THE USUAL PROCEDURE NUMBER.
TECHNICAL COMPONENT CHARGES ARE INSTITUTIONAL CHARGES AND NOT BILLED SEPARATELY
BY PHYSICIANS. HOWEVER, PORTABLE X-RAY SUPPLIERS ONLY BILL FOR TECHNICAL
COMPONENT AND SHOULD UTILIZE MODIFIER TC. THE CHARGE DATA FROM PORTABLE X-RAY
SUPPLIERS WILL THEN BE USED TO BUILD CUSTOMARY AND PREVAILING PROFILES.
RN
LPN/LVN
INTERMEDIATE LEVEL OF CARE
COMPLEX/HIGH TECH LEVEL OF CARE
OBSTETRICAL TREATMENT/SERVICES, PRENATAL OR POSTPARTUM
PROGRAM GROUP, CHILD AND/OR ADOLESCENT
EXTRA PATIENT OR PASSENGER, NON-AMBULANCE
EARLY INTERVENTION/INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP)
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
RURAL/OUTSIDE PROVIDERS' CUSTOMARY SERVICE AREA
MEDICAL TRANSPORT, UNLOADED VEHICLE
BASIC LIFE SUPPORT TRANSPORT BY A VOLUNTEER AMBULANCE PROVIDER
SCHOOL-BASED INDIVIDUALIZED EDUCATION PROGRAM (IEP) SERVICES PROVIDED OUTSIDE
THE PUBLIC SCHOOL DISTRICT RESPONSIBLE FOR THE STUDENT
FOLLOW-UP SERVICE
INDIVIDUALIZED SERVICE PROVIDED TO MORE THAN ONE PATIENT IN SAME SETTING
SPECIAL PAYMENT RATE, OVERTIME
SPECIAL PAYMENT RATES, HOLIDAYS/WEEKENDS
BACK-UP EQUIPMENT
MEDICAID LEVEL OF CARE 1, AS DEFINED BY EACH STATE
MEDICAID LEVEL OF CARE 2, AS DEFINED BY EACH STATE
MEDICAID LEVEL OF CARE 3, AS DEFINED BY EACH STATE
MEDICAID LEVEL OF CARE 4, AS DEFINED BY EACH STATE
MEDICAID LEVEL OF CARE 5, AS DEFINED BY EACH STATE
MEDICAID LEVEL OF CARE 6, AS DEFINED BY EACH STATE
MEDICAID LEVEL OF CARE 7, AS DEFINED BY EACH STATE
MEDICAID LEVEL OF CARE 8, AS DEFINED BY EACH STATE
MEDICAID LEVEL OF CARE 9, AS DEFINED BY EACH STATE
MEDICAID LEVEL OF CARE 10, AS DEFINED BY EACH STATE
MEDICAID LEVEL OF CARE 11, AS DEFINED BY EACH STATE
MEDICAID LEVEL OF CARE 12, AS DEFINED BY EACH STATE
MEDICAID LEVEL OF CARE 13, AS DEFINED BY EACH STATE
USED DURABLE MEDICAL EQUIPMENT
SERVICES PROVIDED IN THE MORNING
SERVICES PROVIDED IN THE AFTERNOON
SERVICES PROVIDED IN THE EVENING
SERVICES PROVIDED AT NIGHT
SERVICES PROVIDED ON BEHALF OF THE CLIENT TO SOMEONE OTHER THAN THE CLIENT
(COLLATERAL RELATIONSHIP)
TWO PATIENTS SERVED
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THREE PATIENTS SERVED
FOUR PATIENTS SERVED
FIVE PATIENTS SERVED
SIX OR MORE PATIENTS SERVED
VASCULAR CATHETER (ALONE OR WITH ANY OTHER VASCULAR ACCESS)
ARTERIOVENOUS GRAFT (OR OTHER VASCULAR ACCESS NOT INCLUDING A VASCULAR CATHETER)
ARTERIOVENOUS FISTULA ONLY (IN USE WITH TWO NEEDLES)
INFECTION PRESENT
NO INFECTION PRESENT
APHAKIC PATIENT
AMBULANCE SERVICE, OUTSIDE STATE PER MILE, TRANSPORT (MEDICAID ONLY)
NON-EMERGENCY TRANSPORTATION, PER MILE - VEHICLE PROVIDED BY VOLUNTEER
(INDIVIDUAL OR ORGANIZATION), WITH NO VESTED INTEREST
NON-EMERGENCY TRANSPORTATION, PER MILE - VEHICLE PROVIDED BY INDIVIDUAL (FAMILY
MEMBER, SELF, NEIGHBOR) WITH VESTED INTEREST
NON-EMERGENCY TRANSPORTATION; TAXI
NON-EMERGENCY TRANSPORTATION AND BUS, INTRA OR INTER STATE CARRIER
NON-EMERGENCY TRANSPORTATION: MINI-BUS, MOUNTAIN AREA TRANSPORTS, OR OTHER
TRANSPORTATION SYSTEMS
NON-EMERGENCY TRANSPORTATION: WHEEL-CHAIR VAN
NON-EMERGENCY TRANSPORTATION AND AIR TRAVEL (PRIVATE OR COMMERCIAL) INTRA OR
INTER STATE
NON-EMERGENCY TRANSPORTATION: PER MILE - CASE WORKER OR SOCIAL WORKER
TRANSPORTATION ANCILLARY: PARKING FEES, TOLLS, OTHER
NON-EMERGENCY TRANSPORTATION: ANCILLARY: LODGING-RECIPIENT
NON-EMERGENCY TRANSPORTATION: ANCILLARY: MEALS-RECIPIENT
NON-EMERGENCY TRANSPORTATION: ANCILLARY: LODGING ESCORT
NON-EMERGENCY TRANSPORTATION: ANCILLARY: MEALS-ESCORT
AMBULANCE SERVICE, NEONATAL TRANSPORT, BASE RATE, EMERGENCY TRANSPORT, ONE WAY
BLS MILEAGE (PER MILE)
BLS ROUTINE DISPOSABLE SUPPLIES
BLS SPECIALIZED SERVICE DISPOSABLE SUPPLIES; DEFIBRILLATION (USED BY ALS
AMBULANCES AND BLS AMBULANCES IN JURISDICTIONS WHERE DEFIBRILLATION IS
PERMITTED IN BLS AMBULANCES)
ALS MILEAGE (PER MILE)
ALS SPECIALIZED SERVICE DISPOSABLE SUPPLIES; DEFIBRILLATION (TO BE USED ONLY IN
JURISDICTIONS WHERE DEFIBRILLATION CANNOT BE PERFORMED IN BLS AMBULANCES)
ALS SPECIALIZED SERVICE DISPOSABLE SUPPLIES; IV DRUG THERAPY
ALS SPECIALIZED SERVICE DISPOSABLE SUPPLIES; ESOPHAGEAL INTUBATION
ALS ROUTINE DISPOSABLE SUPPLIES
AMBULANCE WAITING TIME (ALS OR BLS), ONE HALF (1/2) HOUR INCREMENTS
AMBULANCE (ALS OR BLS) OXYGEN AND OXYGEN SUPPLIES, LIFE SUSTAINING SITUATION
EXTRA AMBULANCE ATTENDANT, GROUND (ALS OR BLS) OR AIR (FIXED OR ROTARY WINGED);
(REQUIRES MEDICAL REVIEW)
GROUND MILEAGE, PER STATUTE MILE
AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NON-EMERGENCY TRANSPORT, LEVEL 1 (ALS
1)
AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1
(ALS1-EMERGENCY)
AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY TRANSPORT, (BLS)
AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY)
AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (FIXED WING)
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AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (ROTARY WING)
PARAMEDIC INTERCEPT (PI), RURAL AREA, TRANSPORT FURNISHED BY A VOLUNTEER
AMBULANCE COMPANY WHICH IS PROHIBITED BY STATE LAW FROM BILLING THIRD PARTY
PAYERS
ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)
SPECIALTY CARE TRANSPORT (SCT)
FIXED WING AIR MILEAGE, PER STATUTE MILE
ROTARY WING AIR MILEAGE, PER STATUTE MILE
NONCOVERED AMBULANCE MILEAGE, PER MILE (E.G., FOR MILES TRAVELED BEYOND CLOSEST
APPROPRIATE FACILITY)
AMBULANCE RESPONSE AND TREATMENT, NO TRANSPORT
UNLISTED AMBULANCE SERVICE
SYRINGE WITH NEEDLE, STERILE, 1 CC OR LESS, EACH
SYRINGE WITH NEEDLE, STERILE 2CC, EACH
SYRINGE WITH NEEDLE, STERILE 3CC, EACH
SYRINGE WITH NEEDLE, STERILE 5CC OR GREATER, EACH
NEEDLE-FREE INJECTION DEVICE, EACH
SUPPLIES FOR SELF-ADMINISTERED INJECTIONS
NON-CORING NEEDLE OR STYLET WITH OR WITHOUT CATHETER
SYRINGE, STERILE, 20 CC OR GREATER, EACH
NEEDLE, STERILE, ANY SIZE, EACH
STERILE WATER, SALINE AND/OR DEXTROSE, DILUENT/FLUSH, 10 ML
STERILE WATER/SALINE, 500 ML
STERILE SALINE OR WATER, METERED DOSE DISPENSER, 10 ML
REFILL KIT FOR IMPLANTABLE INFUSION PUMP
SUPPLIES FOR MAINTENANCE OF DRUG INFUSION CATHETER, PER WEEK (LIST DRUG
SEPARATELY)
INFUSION SUPPLIES FOR EXTERNAL DRUG INFUSION PUMP, PER CASSETTE OR BAG (LIST
DRUGS SEPARATELY)
INFUSION SUPPLIES NOT USED WITH EXTERNAL INFUSION PUMP, PER CASSETTE OR BAG
(LIST DRUGS SEPARATELY)
INFUSION SET FOR EXTERNAL INSULIN PUMP, NON NEEDLE CANNULA TYPE
INFUSION SET FOR EXTERNAL INSULIN PUMP, NEEDLE TYPE
SYRINGE WITH NEEDLE FOR EXTERNAL INSULIN PUMP, STERILE, 3CC
REPLACEMENT BATTERY, ALKALINE (OTHER THAN J CELL), FOR USE WITH MEDICALLY
NECESSARY HOME BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH
REPLACEMENT BATTERY, ALKALINE, J CELL, FOR USE WITH MEDICALLY NECESSARY HOME
BLOOD GLUCOSE MONITOR OWNED BY PATIENT, EACH
REPLACEMENT BATTERY, LITHIUM, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD
GLUCOSE MONITOR OWNED BY PATIENT, EACH
REPLACEMENT BATTERY, SILVER OXIDE, FOR USE WITH MEDICALLY NECESSARY HOME BLOOD
GLUCOSE MONITOR OWNED BY PATIENT, EACH
ALCOHOL OR PEROXIDE, PER PINT
ALCOHOL WIPES, PER BOX
BETADINE OR PHISOHEX SOLUTION, PER PINT
BETADINE OR IODINE SWABS/WIPES, PER BOX
CHLORHEXIDINE CONTAINING ANTISEPTIC, 1 ML
URINE TEST OR REAGENT STRIPS OR TABLETS (100 TABLETS OR STRIPS)
BLOOD KETONE TEST OR REAGENT STRIP, EACH
BLOOD GLUCOSE TEST OR REAGENT STRIPS FOR HOME BLOOD GLUCOSE MONITOR, PER 50
STRIPS
PLATFORMS FOR HOME BLOOD GLUCOSE MONITOR, 50 PER BOX
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NORMAL, LOW AND HIGH CALIBRATOR SOLUTION / CHIPS
REPLACEMENT LENS SHIELD CARTRIDGE FOR USE WITH LASER SKIN PIERCING DEVICE, EACH
SPRING-POWERED DEVICE FOR LANCET, EACH
LANCETS, PER BOX OF 100
CERVICAL CAP FOR CONTRACEPTIVE USE
TEMPORARY, ABSORBABLE LACRIMAL DUCT IMPLANT, EACH
PERMANENT, LONG TERM, NON-DISSOLVABLE LACRIMAL DUCT IMPLANT, EACH
PERMANENT IMPLANTABLE CONTRACEPTIVE INTRATUBAL OCCLUSION DEVICE(S) AND DELIVERY
SYSTEM
PARAFFIN, PER POUND
DIAPHRAGM FOR CONTRACEPTIVE USE
CONTRACEPTIVE SUPPLY, CONDOM, MALE, EACH
CONTRACEPTIVE SUPPLY, CONDOM, FEMALE, EACH
CONTRACEPTIVE SUPPLY, SPERMICIDE (E.G., FOAM, GEL), EACH
DISPOSABLE ENDOSCOPE SHEATH, EACH
ADHESIVE SKIN SUPPORT ATTACHMENT FOR USE WITH EXTERNAL BREAST PROSTHESIS, EACH
TUBING FOR BREAST PUMP, REPLACEMENT
ADAPTER FOR BREAST PUMP, REPLACEMENT
CAP FOR BREAST PUMP BOTTLE, REPLACEMENT
BREAST SHIELD AND SPLASH PROTECTOR FOR USE WITH BREAST PUMP, REPLACEMENT
POLYCARBONATE BOTTLE FOR USE WITH BREAST PUMP, REPLACEMENT
LOCKING RING FOR BREAST PUMP, REPLACEMENT
SACRAL NERVE STIMULATION TEST LEAD, EACH
IMPLANTABLE ACCESS CATHETER, (E,G., VENOUS, ARTERIAL, EPIDURAL SUBARACHNOID, OR
PERITONEAL, ETC.) EXTERNAL ACCESS
IMPLANTABLE ACCESS TOTAL CATHETER, PORT/RESERVOIR (E.G., VENOUS, ARTERIAL,
EPIDURAL, SUBARACHNOID, PERITONEAL, ETC.)
DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF 50 ML OR GREATER PER HOUR
DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR
INSERTION TRAY WITHOUT DRAINAGE BAG AND WITHOUT CATHETER (ACCESSORIES ONLY)
INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE,
TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR
HYDROPHILIC, ETC.)
INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE,
TWO-WAY, ALL SILICONE
INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE,
THREE-WAY, FOR CONTINUOUS IRRIGATION
INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY
LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.)
INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY,
ALL SILICONE
INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE,
THREE-WAY, FOR CONTINUOUS IRRIGATION
IRRIGATION TRAY WITH BULB OR PISTON SYRINGE, ANY PURPOSE
THERAPEUTIC AGENT FOR URINARY CATHETER IRRIGATION
IRRIGATION SYRINGE, BULB OR PISTON, EACH
MALE EXTERNAL CATHETER WITH INTEGRAL COLLECTION CHAMBER, ANY TYPE, EACH
FEMALE EXTERNAL URINARY COLLECTION DEVICE; MEATAL CUP, EACH
FEMALE EXTERNAL URINARY COLLECTION DEVICE; POUCH, EACH
PERIANAL FECAL COLLECTION POUCH WITH ADHESIVE, EACH
EXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH CONNECTOR/ADAPTOR, FOR
USE WITH URINARY LEG BAG OR UROSTOMY POUCH, EACH
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LUBRICANT, INDIVIDUAL STERILE PACKET, EACH
URINARY CATHETER ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT, EACH
URINARY CATHETER ANCHORING DEVICE, LEG STRAP, EACH
INCONTINENCE SUPPLY; MISCELLANEOUS
INCONTINENCE SUPPLY, URETHRAL INSERT, ANY TYPE, EACH
INDWELLING CATHETER; FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE,
SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH
INDWELLING CATHETER; SPECIALTY TYPE, EG; COUDE, MUSHROOM, WING, ETC.), EACH
INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE, EACH
INDWELLING CATHETER; FOLEY TYPE, THREE WAY FOR CONTINUOUS IRRIGATION, EACH
MALE EXTERNAL CATHETER, WITH OR WITHOUT ADHESIVE, DISPOSABLE, EACH
INTERMITTENT URINARY CATHETER; STRAIGHT TIP, WITH OR WITHOUT COATING (TEFLON,
SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH
INTERMITTENT URINARY CATHETER; COUDE (CURVED) TIP, WITH OR WITHOUT COATING
(TEFLON, SILICONE, SILICONE ELASTOMERIC, OR HYDROPHILIC, ETC.), EACH
INTERMITTENT URINARY CATHETER, WITH INSERTION SUPPLIES
INSERTION TRAY WITH DRAINAGE BAG BUT WITHOUT CATHETER
IRRIGATION TUBING SET FOR CONTINUOUS BLADDER IRRIGATION THROUGH A THREE-WAY
INDWELLING FOLEY CATHETER, EACH
EXTERNAL URETHRAL CLAMP OR COMPRESSION DEVICE (NOT TO BE USED FOR CATHETER
CLAMP), EACH
BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH OR WITHOUT ANTI-REFLUX DEVICE, WITH OR
WITHOUT TUBE, EACH
URINARY DRAINAGE BAG, LEG OR ABDOMEN, VINYL, WITH OR WITHOUT TUBE, WITH STRAPS,
EACH
DISPOSABLE EXTERNAL URETHRAL CLAMP OR COMPRESSION DEVICE, WITH PAD AND/OR
POUCH, EACH
OSTOMY FACEPLATE, EACH
SKIN BARRIER; SOLID, 4 X 4 OR EQUIVALENT; EACH
OSTOMY CLAMP, ANY TYPE, REPLACEMENT ONLY, EACH
ADHESIVE, LIQUID OR EQUAL, ANY TYPE, PER OZ
ADHESIVE REMOVER WIPES, ANY TYPE, PER 50
OSTOMY VENT, ANY TYPE, EACH
OSTOMY BELT, EACH
OSTOMY FILTER, ANY TYPE, EACH
OSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUSH, ETC), PER OZ
OSTOMY SKIN BARRIER, POWDER, PER OZ
OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, STANDARD WEAR, WITH BUILT-IN
CONVEXITY, EACH
OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDIAN), WITH BUILT-IN
CONVEXITY, ANY SIZE, EACH
OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, PLASTIC, EACH
OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, RUBBER, EACH
OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, PLASTIC, EACH
OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, RUBBER, EACH
OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, PLASTIC, EACH
OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, RUBBER, EACH
OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, PLASTIC, EACH
OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, HEAVY PLASTIC, EACH
OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, RUBBER, EACH
OSTOMY FACEPLATE EQUIVALENT, SILICONE RING, EACH
OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, EXTENDED WEAR, WITHOUT BUILT-IN
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CONVEXITY, EACH
OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE),
EACH
OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, (1 PIECE), EACH
OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1
PIECE), EACH
OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN
CONVEXITY (1 PIECE), EACH
OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED (1 PIECE), EACH
OSTOMY POUCH, URINARY, WITH STANDARD WEAR BARRIER ATTACHED, WITH BUILT-IN
CONVEXITY (1 PIECE), EACH
OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN
CONVEXITY (1 PIECE), EACH
OSTOMY DEODORANT, WITH OR WITHOUT LUBRICANT, FOR USE IN OSTOMY POUCH, PER
FLUID OUNCE
OSTOMY DEODORANT FOR USE IN OSTOMY POUCH, SOLID, PER TABLET
OSTOMY BELT WITH PERISTOMAL HERNIA SUPPORT
IRRIGATION SUPPLY; SLEEVE, EACH
OSTOMY IRRIGATION SUPPLY; BAG, EACH
OSTOMY IRRIGATION SUPPLY; CONE/CATHETER, WITH OR WITHOUT BRUSH
OSTOMY IRRIGATION SET
LUBRICANT, PER OUNCE
OSTOMY RING, EACH
OSTOMY SKIN BARRIER, NON-PECTIN BASED, PASTE, PER OUNCE
OSTOMY SKIN BARRIER, PECTIN-BASED, PASTE, PER OUNCE
OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE, OR ACCORDION), EXTENDED
WEAR, WITH BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH
OSTOMY SKIN BARRIER, WTIH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR,
WITH BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH
OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR,
WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH
OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR,
WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH
OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, EXTENDED WEAR, WITH BUILT-IN
CONVEXITY, EACH
OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECE
SYSTEM), WITHOUT FILTER, EACH
OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECE
SYSTEM), WITH FILTER, EACH
OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT
BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH
OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT
BUILT-IN CONVEXITY, LARGER THAN 4X4 INCHES, EACH
OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH
OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH
FILTER (1 PIECE), EACH
OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH
OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH FILTER
(2 PIECE), EACH
OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACH
OSTOMY SUPPLY; MISCELLANEOUS
OSTOMY ABSORBENT MATERIAL (SHEET/PAD/CRYSTAL PACKET) FOR USE IN OSTOMY POUCH TO
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THICKEN LIQUID STOMAL OUTPUT, EACH
OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2
PIECE), EACH
OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH
OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH
FILTER (2 PIECE SYSTEM), EACH
OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE
SYSTEM), EACH
OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2
PIECE SYSTEM), EACH
OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH FAUCET-TYPE
TAP WITH VALVE (1 PIECE), EACH
OSTOMY POUCH, URINARY, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH
FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH
OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN
CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH
OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE
(1 PIECE), EACH
OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITH
FAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH
OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACH
OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FAUCET-TYPE
TAP WITH VALVE (2 PIECE), EACH
TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES
TAPE, WATERPROOF, PER 18 SQUARE INCHES
ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE
ADHESIVE REMOVER, WIPES, ANY TYPE, EACH
ENEMA BAG WITH TUBING, REUSABLE
SURGICAL DRESSING HOLDER, NON-REUSABLE, EACH
SURGICAL DRESSING HOLDER, REUSABLE, EACH
NON-ELASTIC BINDER FOR EXTREMITY
GARMENT, BELT, SLEEVE OR OTHER COVERING, ELASTIC OR SIMILAR STRETCHABLE
MATERIAL, ANY TYPE, EACH
GRAVLEE JET WASHER
VABRA ASPIRATOR
TRACHEOSTOMA FILTER, ANY TYPE, ANY SIZE, EACH
MOISTURE EXCHANGER, DISPOSABLE, FOR USE WITH INVASIVE MECHANICAL VENTILATION
SURGICAL STOCKINGS ABOVE KNEE LENGTH, EACH
SURGICAL STOCKINGS THIGH LENGTH, EACH
SURGICAL STOCKINGS BELOW KNEE LENGTH, EACH
SURGICAL STOCKINGS FULL LENGTH, EACH
INCONTINENCE GARMENT, ANY TYPE, (E.G. BRIEF, DIAPER), EACH
SURGICAL TRAYS
DISPOSABLE UNDERPADS, ALL SIZES
ELECTRODES, (E.G., APNEA MONITOR), PER PAIR
LEAD WIRES, (E.G., APNEA MONITOR), PER PAIR
CONDUCTIVE GEL OR PASTE, FOR USE WITH ELECTRICAL DEVICE (E.G., TENS, NMES), PER
OZ
COUPLING GEL OR PASTE, FOR USE WITH ULTRASOUND DEVICE, PER OZ
PESSARY, RUBBER, ANY TYPE
PESSARY, NON RUBBER, ANY TYPE
SLINGS
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SHOULDER SLING OR VEST DESIGN, ABDUCTION RESTRAINER, WITH OR WITHOUT SWATHE
CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
SPLINT
TOPICAL HYPERBARIC OXYGEN CHAMBER, DISPOSABLE
CAST SUPPLIES (E.G. PLASTER)
SPECIAL CASTING MATERIAL (E.G. FIBERGLASS)
ELECTRICAL STIMULATOR SUPPLIES, 2 LEAD, PER MONTH, (E.G. TENS, NMES)
SLEEVE FOR INTERMITTENT LIMB COMPRESSION DEVICE, REPLACEMENT ONLY, EACH
LITHIUM ION BATTERY FOR NON-PROSTHETIC USE, REPLACEMENT
TUBING WITH INTEGRATED HEATING ELEMENT FOR USE WITH POSITIVE AIRWAY PRESSURE
DEVICE
TRACHEAL SUCTION CATHETER, CLOSED SYSTEM, EACH
OXYGEN PROBE FOR USE WITH OXIMETER DEVICE, REPLACEMENT
TRANSTRACHEAL OXYGEN CATHETER, EACH
BATTERY, HEAVY DUTY; REPLACEMENT FOR PATIENT OWNED VENTILATOR
BATTERY CABLES; REPLACEMENT FOR PATIENT-OWNED VENTILATOR
BATTERY CHARGER; REPLACEMENT FOR PATIENT-OWNED VENTILATOR
PEAK EXPIRATORY FLOW RATE METER, HAND HELD
CANNULA, NASAL
TUBING (OXYGEN), PER FOOT
MOUTH PIECE
BREATHING CIRCUITS
FACE TENT
VARIABLE CONCENTRATION MASK
TRACHEOSTOMY, INNER CANNULA
TRACHEAL SUCTION CATHETER, ANY TYPE OTHER THAN CLOSED SYSTEM, EACH
TRACHEOSTOMY CARE KIT FOR NEW TRACHEOSTOMY
TRACHEOSTOMY CLEANING BRUSH, EACH
SPACER, BAG OR RESERVOIR, WITH OR WITHOUT MASK, FOR USE WITH METERED DOSE
INHALER
OROPHARYNGEAL SUCTION CATHETER, EACH
TRACHEOSTOMY CARE KIT FOR ESTABLISHED TRACHEOSTOMY
REPLACEMENT BATTERIES, MEDICALLY NECESSARY, TRANSCUTANEOUS ELECTRICAL
STIMULATOR, OWNED BY PATIENT
REPLACEMENT BULB/LAMP FOR ULTRAVIOLET LIGHT THERAPY SYSTEM, EACH
REPLACEMENT BULB FOR THERAPEUTIC LIGHT BOX, TABLETOP MODEL
UNDERARM PAD, CRUTCH, REPLACEMENT, EACH
REPLACEMENT, HANDGRIP, CANE, CRUTCH, OR WALKER, EACH
REPLACEMENT, TIP, CANE, CRUTCH, WALKER, EACH.
REPLACEMENT BATTERY FOR PATIENT-OWNED EAR PULSE GENERATOR, EACH
REPLACEMENT PAD FOR INFRARED HEATING PAD SYSTEM, EACH
REPLACEMENT PAD FOR USE WITH MEDICALLY NECESSARY ALTERNATING PRESSURE PAD
OWNED BY PATIENT
RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED
INDIUM IN-111 SATUMOMAB PENDETIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 6
MILLICURIES
TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH
SURGICAL SUPPLY; MISCELLANEOUS
IMPLANTABLE RADIATION DOSIMETER, EACH
CALIBRATED MICROCAPILLARY TUBE, EACH
MICROCAPILLARY TUBE SEALANT
PERITONEAL DIALYSIS CATHETER ANCHORING DEVICE, BELT, EACH
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SYRINGE, WITH OR WITHOUT NEEDLE, EACH
SPHYGMOMANOMETER/BLOOD PRESSURE APPARATUS WITH CUFF AND STETHOSCOPE
BLOOD PRESSURE CUFF ONLY
AUTOMATIC BLOOD PRESSURE MONITOR
DISPOSABLE CYCLER SET USED WITH CYCLER DIALYSIS MACHINE, EACH
DRAINAGE EXTENSION LINE, STERILE, FOR DIALYSIS, EACH
EXTENSION LINE WITH EASY LOCK CONNECTORS, USED WITH DIALYSIS
CHEMICALS/ANTISEPTICS SOLUTION USED TO CLEAN/STERILIZE DIALYSIS EQUIPMENT, PER
8 OZ
ACTIVATED CARBON FILTER FOR HEMODIALYSIS, EACH
DIALYZER (ARTIFICIAL KIDNEYS), ALL TYPES, ALL SIZES, FOR HEMODIALYSIS, EACH
BICARBONATE CONCENTRATE, SOLUTION, FOR HEMODIALYSIS, PER GALLON
BICARBONATE CONCENTRATE, POWDER, FOR HEMODIALYSIS, PER PACKET
ACETATE CONCENTRATE SOLUTION, FOR HEMODIALYSIS, PER GALLON
ACID CONCENTRATE, SOLUTION, FOR HEMODIALYSIS, PER GALLON
TREATED WATER (DEIONIZED, DISTILLED, OR REVERSE OSMOSIS) FOR PERITONEAL
DIALYSIS, PER GALLON
"Y SET" TUBING FOR PERITONEAL DIALYSIS
DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN
249CC, BUT LESS THAN OR EQUAL TO 999CC, FOR PERITONEAL DIALYSIS
DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN
999CC BUT LESS THAN OR EQUAL TO 1999CC, FOR PERITONEAL DIALYSIS
DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN
1999CC BUT LESS THAN OR EQUAL TO 2999CC, FOR PERITONEAL DIALYSIS
DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN
2999CC BUT LESS THAN OR EQUAL TO 3999CC, FOR PERITONEAL DIALYSIS
DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN
3999CC BUT LESS THAN OR EQUAL TO 4999CC, FOR PERITONEAL DIALYSIS
DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN
4999CC BUT LESS THAN OR EQUAL TO 5999CC, FOR PERITONEAL DIALYSIS
DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID VOLUME GREATER THAN
5999CC, FOR PERITONEAL DIALYSIS
DIALYSATE SOLUTION, NON-DEXTROSE CONTAINING, 500 ML
FISTULA CANNULATION SET FOR HEMODIALYSIS, EACH
TOPICAL ANESTHETIC, FOR DIALYSIS, PER GRAM
INJECTABLE ANESTHETIC, FOR DIALYSIS, PER 10 ML
SHUNT ACCESSORY, FOR HEMODIALYSIS, ANY TYPE, EACH
BLOOD TUBING, ARTERIAL OR VENOUS, FOR HEMODIALYSIS, EACH
BLOOD TUBING, ARTERIAL AND VENOUS COMBINED, FOR HEMODIALYSIS, EACH
DIALYSATE SOLUTION TEST KIT, FOR PERITONEAL DIALYSIS, ANY TYPE, EACH
DIALYSATE CONCENTRATE, POWDER, ADDITIVE FOR PERITONEAL DIALYSIS, PER PACKET
DIALYSATE CONCENTRATE, SOLUTION, ADDITIVE FOR PERITONEAL DIALYSIS, PER 10 ML
BLOOD COLLECTION TUBE, VACUUM, FOR DIALYSIS, PER 50
SERUM CLOTTING TIME TUBE, FOR DIALYSIS, PER 50
BLOOD GLUCOSE TEST STRIPS, FOR DIALYSIS, PER 50
OCCULT BLOOD TEST STRIPS, FOR DIALYSIS, PER 50
AMMONIA TEST STRIPS, FOR DIALYSIS, PER 50
PROTAMINE SULFATE, FOR HEMODIALYSIS, PER 50 MG
DISPOSABLE CATHETER TIPS FOR PERITONEAL DIALYSIS, PER 10
PLUMBING AND/OR ELECTRICAL WORK FOR HOME HEMODIALYSIS EQUIPMENT
CONTRACTS, REPAIR AND MAINTENANCE, FOR HEMODIALYSIS EQUIPMENT
DRAIN BAG/BOTTLE, FOR DIALYSIS, EACH
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MISCELLANEOUS DIALYSIS SUPPLIES, NOT OTHERWISE SPECIFIED
VENOUS PRESSURE CLAMP, FOR HEMODIALYSIS, EACH
GLOVES, NON-STERILE, PER 100
SURGICAL MASK, PER 20
TOURNIQUET FOR DIALYSIS, EACH
GLOVES, STERILE, PER PAIR
ORAL THERMOMETER, REUSABLE, ANY TYPE, EACH
RECTAL THERMOMETER, REUSABLE, ANY TYPE, EACH
OSTOMY POUCH, CLOSED; WITH BARRIER ATTACHED (1 PIECE), EACH
OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED (1 PIECE), EACH
OSTOMY POUCH, CLOSED; FOR USE ON FACEPLATE, EACH
OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH FLANGE (2 PIECE), EACH
STOMA CAP
OSTOMY POUCH, DRAINABLE; WITH BARRIER ATTACHED, (1 PIECE), EACH
OSTOMY POUCH, DRAINABLE; WITHOUT BARRIER ATTACHED (1 PIECE), EACH
OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH FLANGE (2 PIECE SYSTEM), EACH
OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED (1 PIECE), EACH
OSTOMY POUCH, URINARY; WITHOUT BARRIER ATTACHED (1 PIECE), EACH
OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH FLANGE (2 PIECE), EACH
CONTINENT DEVICE; PLUG FOR CONTINENT STOMA
CONTINENT DEVICE; CATHETER FOR CONTINENT STOMA
CONTINENT DEVICE, STOMA ABSORPTIVE COVER FOR CONTINENT STOMA
OSTOMY ACCESSORY; CONVEX INSERT
BEDSIDE DRAINAGE BOTTLE WITH OR WITHOUT TUBING, RIGID OR EXPANDABLE, EACH
URINARY SUSPENSORY WITH LEG BAG, WITH OR WITHOUT TUBE, EACH
URINARY DRAINAGE BAG, LEG OR ABDOMEN, LATEX, WITH OR WITHOUT TUBE, WITH STRAPS,
EACH
LEG STRAP; LATEX, REPLACEMENT ONLY, PER SET
LEG STRAP; FOAM OR FABRIC, REPLACEMENT ONLY, PER SET
SKIN BARRIER, WIPES OR SWABS, EACH
SKIN BARRIER; SOLID, 6 X 6 OR EQUIVALENT, EACH
SKIN BARRIER; SOLID, 8 X 8 OR EQUIVALENT, EACH
ADHESIVE OR NON-ADHESIVE; DISK OR FOAM PAD
APPLIANCE CLEANER, INCONTINENCE AND OSTOMY APPLIANCES, PER 16 OZ.
PERCUTANEOUS CATHETER/TUBE ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT
FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION AND
SUPPLY OF OFF-THE-SHELF DEPTH-INLAY SHOE MANUFACTURED TO ACCOMMODATE MULTI-
DENSITY INSERT(S), PER SHOE
FOR DIABETICS ONLY, FITTING (INCLUDING FOLLOW-UP), CUSTOM PREPARATION AND
SUPPLY OF SHOE MOLDED FROM CAST(S) OF PATIENT'S FOOT (CUSTOM MOLDED SHOE), PER
SHOE
FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF
DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH ROLLER OR RIGID ROCKER BOTTOM, PER
SHOE
FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF
DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH WEDGE(S), PER SHOE
FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF
DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH METATARSAL BAR, PER SHOE
FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF
DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH OFF-SET HEEL(S), PER SHOE
FOR DIABETICS ONLY, NOT OTHERWISE SPECIFIED MODIFICATION (INCLUDING FITTING) OF
OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE, PER SHOE
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FOR DIABETICS ONLY, DELUXE FEATURE OF OFF-THE-SHELF DEPTH-INLAY SHOE OR
CUSTOM-MOLDED SHOE, PER SHOE
FOR DIABETICS ONLY, DIRECT FORMED, COMPRESSION MOLDED TO PATIENT'S FOOT WITHOUT
EXTERNAL HEAT SOURCE, MULTIPLE-DENSITY INSERT(S) PREFABRICATED, PER SHOE
FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, DIRECT FORMED, MOLDED TO FOOT
AFTER EXTERNAL HEAT SOURCE OF 230 DEGREES FAHRENHEIT OR HIGHER, TOTAL CONTACT
WITH PATIENT'S FOOT, INCLUDING ARCH, BASE LAYER MINIMUM OF 1/4 INCH MATERIAL OF
SHORE A 35 DUROMETER OR 3/16 INCH MATERIAL OF SHORE A 40 DUROMETER (OR HIGHER),
PREFABRICATED, EACH
FOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CUSTOM MOLDED FROM MODEL OF
PATIENT'S FOOT, TOTAL CONTACT WITH PATIENT'S FOOT, INCLUDING ARCH, BASE LAYER
MINIMUM OF 3/16 INCH MATERIAL OF SHORE A 35 DUROMETER OR HIGHER), INCLUDES ARCH
FILLER AND OTHER SHAPING MATERIAL, CUSTOM FABRICATED, EACH
NON-CONTACT WOUND WARMING WOUND COVER FOR USE WITH THE NON-CONTACT WOUND
WARMING DEVICE AND WARMING CARD
COLLAGEN BASED WOUND FILLER, DRY FORM, STERILE, PER GRAM OF COLLAGEN
COLLAGEN BASED WOUND FILLER, GEL/PASTE, PER GRAM OF COLLAGEN
COLLAGEN DRESSING, STERILE, PAD SIZE 16 SQ. IN. OR LESS, EACH
COLLAGEN DRESSING, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR
EQUAL TO 48 SQ. IN., EACH
COLLAGEN DRESSING, STERILE, PAD SIZE MORE THAN 48 SQ. IN., EACH
COLLAGEN DRESSING WOUND FILLER, STERILE, PER 6 INCHES
GEL SHEET FOR DERMAL OR EPIDERMAL APPLICATION, (E.G., SILICONE, HYDROGEL,
OTHER), EACH
WOUND POUCH, EACH
ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ.
IN. OR LESS, EACH DRESSING
ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE MORE
THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING
ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE MORE
THAN 48 SQ. IN., EACH DRESSING
ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND FILLER, STERILE, PER 6 INCHES
COMPOSITE DRESSING, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH
DRESSING
COMPOSITE DRESSING, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48
SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING
COMPOSITE DRESSING, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER,
EACH DRESSING
COMPOSITE DRESSING, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE
ADHESIVE BORDER, EACH DRESSING
COMPOSITE DRESSING, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR
EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING
COMPOSITE DRESSING, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE
ADHESIVE BORDER, EACH DRESSING
CONTACT LAYER, STERILE, 16 SQ. IN. OR LESS, EACH DRESSING
CONTACT LAYER, STERILE, MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ.
IN., EACH DRESSING
CONTACT LAYER, STERILE, MORE THAN 48 SQ. IN., EACH DRESSING
FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT
ADHESIVE BORDER, EACH DRESSING
FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS
THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING
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FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT
ADHESIVE BORDER, EACH DRESSING
FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE
ADHESIVE BORDER, EACH DRESSING
FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS
THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING
FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY
SIZE ADHESIVE BORDER, EACH DRESSING
FOAM DRESSING, WOUND FILLER, STERILE, PER GRAM
GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT
ADHESIVE BORDER, EACH DRESSING
GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS
THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING
GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT
ADHESIVE BORDER, EACH DRESSING
GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE
ADHESIVE BORDER, EACH DRESSING
GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR
EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING
GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE
ADHESIVE BORDER, EACH DRESSING
GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, STERILE,
PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING
GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, STERILE,
PAD SIZE MORE THAN 16 SQ. IN., BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT
ADHESIVE BORDER, EACH DRESSING
GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, STERILE,
PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING
GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, STERILE, PAD SIZE 16 SQ. IN. OR
LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING
GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, STERILE, PAD SIZE MORE THAN 16 SQ.
IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING
GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, STERILE, PAD SIZE MORE THAN 48 SQ.
IN., WITHOUT ADHESIVE BORDER, EACH DRESSING
GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND CONTACT, STERILE, PAD SIZE 16
SQ. IN. OR LESS, EACH DRESSING
GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND CONTACT, STERILE, PAD SIZE
GREATER THAN 16 SQ. IN., BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING
GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND CONTACT, STERILE, PAD SIZE MORE
THAN 48 SQ. IN., EACH DRESSING
HYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS,
WITHOUT ADHESIVE BORDER, EACH DRESSING
HYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT
LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING
HYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN.,
WITHOUT ADHESIVE BORDER, EACH DRESSING
HYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH
ANY SIZE ADHESIVE BORDER, EACH DRESSING
HYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT
LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING
HYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN.,
WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING
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HYDROCOLLOID DRESSING, WOUND FILLER, PASTE, STERILE, PER OUNCE
HYDROCOLLOID DRESSING, WOUND FILLER, DRY FORM, STERILE, PER GRAM
HYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT
ADHESIVE BORDER, EACH DRESSING
HYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS
THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING
HYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT
ADHESIVE BORDER, EACH DRESSING
HYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY
SIZE ADHESIVE BORDER, EACH DRESSING
HYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS
THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING
HYDROGEL DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITH
ANY SIZE ADHESIVE BORDER, EACH DRESSING
HYDROGEL DRESSING, WOUND FILLER, GEL, PER FLUID OUNCE
SKIN SEALANTS, PROTECTANTS, MOISTURIZERS, OINTMENTS, ANY TYPE, ANY SIZE
SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR
LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING
SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ.
IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING
SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ.
IN., WITHOUT ADHESIVE BORDER, EACH DRESSING
SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE 16 SQ. IN. OR
LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING
SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ.
IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH
DRESSING
SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ.
IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING
TRANSPARENT FILM, STERILE, 16 SQ. IN. OR LESS, EACH DRESSING
TRANSPARENT FILM, STERILE, MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48
SQ. IN., EACH DRESSING
TRANSPARENT FILM, STERILE, MORE THAN 48 SQ. IN., EACH DRESSING
WOUND CLEANSERS, ANY TYPE, ANY SIZE
WOUND FILLER, GEL/PASTE, PER FLUID OUNCE, NOT OTHERWISE SPECIFIED
WOUND FILLER, DRY FORM, PER GRAM, NOT OTHERWISE SPECIFIED
GAUZE, IMPREGNATED, OTHER THAN WATER, NORMAL SALINE, OR ZINC PASTE, STERILE,
ANY WIDTH, PER LINEAR YARD
GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE
BORDER, EACH DRESSING
GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 16 SQ. IN. LESS THAN OR
EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING
GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT
ADHESIVE BORDER, EACH DRESSING
PACKING STRIPS, NON-IMPREGNATED, STERILE, UP TO 2 INCHES IN WIDTH, PER LINEAR
YARD
EYE PAD, STERILE, EACH
EYE PAD, NON-STERILE, EACH
EYE PATCH, OCCLUSIVE, EACH
ADHESIVE BANDAGE, FIRST-AID TYPE, ANY SIZE, EACH
PADDING BANDAGE, NON-ELASTIC, NON-WOVEN/NON-KNITTED, WIDTH GREATER THAN OR
EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD
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CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON-STERILE, WIDTH LESS THAN
THREE INCHES, PER YARD
CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON-STERILE, WIDTH GREATER THAN
OR EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD
CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON-STERILE, WIDTH GREATER THAN
OR EQUAL TO 5 INCHES, PER YARD
CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH LESS THAN THREE
INCHES, PER YARD
CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH GREATER THAN OR
EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD
CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, STERILE, WIDTH GREATER THAN OR
EQUAL TO FIVE INCHES, PER YARD
LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH LESS THAN THREE
INCHES, PER YARD
LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL
TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD
LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL
TO FIVE INCHES, PER YARD
MODERATE COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, LOAD RESISTANCE OF 1.25
TO 1.34 FOOT POUNDS AT 50% MAXIMUM STRETCH, WIDTH GREATER THAN OR EQUAL TO
THREE INCHES AND LESS THAN FIVE INCHES, PER YARD
HIGH COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, LOAD RESISTANCE GREATER THAN
OR EQUAL TO 1.35 FOOT POUNDS AT 50% MAXIMUM STRETCH, WIDTH GREATER THAN OR
EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD
SELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/NON-WOVEN, WIDTH LESS THAN THREE
INCHES, PER YARD
SELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/NON-WOVEN, WIDTH GREATER THAN OR
EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD
SELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/NON-WOVEN, WIDTH GREATER THAN OR
EQUAL TO FIVE INCHES, PER YARD
ZINC PASTE IMPREGNATED BANDAGE, NON-ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN
OR EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD
TUBULAR DRESSING WITH OR WITHOUT ELASTIC, ANY WIDTH, PER LINEAR YARD
COMPRESSION BURN GARMENT, BODYSUIT (HEAD TO FOOT), CUSTOM FABRICATED
COMPRESSION BURN GARMENT, CHIN STRAP, CUSTOM FABRICATED
COMPRESSION BURN GARMENT, FACIAL HOOD, CUSTOM FABRICATED
COMPRESSION BURN GARMENT, GLOVE TO WRIST, CUSTOM FABRICATED
COMPRESSION BURN GARMENT, GLOVE TO ELBOW, CUSTOM FABRICATED
COMPRESSION BURN GARMENT, GLOVE TO AXILLA, CUSTOM FABRICATED
COMPRESSION BURN GARMENT, FOOT TO KNEE LENGTH, CUSTOM FABRICATED
COMPRESSION BURN GARMENT, FOOT TO THIGH LENGTH, CUSTOM FABRICATED
COMPRESSION BURN GARMENT, UPPER TRUNK TO WAIST INCLUDING ARM OPENINGS (VEST),
CUSTOM FABRICATED
COMPRESSION BURN GARMENT, TRUNK, INCLUDING ARMS DOWN TO LEG OPENINGS (LEOTARD),
CUSTOM FABRICATED
COMPRESSION BURN GARMENT, LOWER TRUNK INCLUDING LEG OPENINGS (PANTY), CUSTOM
FABRICATED
COMPRESSION BURN GARMENT, NOT OTHERWISE CLASSIFIED
COMPRESSION BURN MASK, FACE AND/OR NECK, PLASTIC OR EQUAL, CUSTOM FABRICATED
GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, EACH
GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACH
GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40-50 MMHG, EACH
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GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, EACH
GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, EACH
GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40-50 MMHG, EACH
GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18-30 MMHG, EACH
GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 30-40 MMHG, EACH
GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 40-50 MMHG, EACH
GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 18-30 MMHG, EACH
GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 30-40 MMHG, EACH
GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 40-50 MMHG, EACH
GRADIENT COMPRESSION STOCKING, CUSTOM MADE
GRADIENT COMPRESSION STOCKING, LYMPHEDEMA
GRADIENT COMPRESSION STOCKING, GARTER BELT
GRADIENT COMPRESSION WRAP, NON-ELASTIC, BELOW KNEE, 30-50 MM HG, EACH
GRADIENT COMPRESSION STOCKING/SLEEVE, NOT OTHERWISE SPECIFIED
WOUND CARE SET, FOR NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, INCLUDES
ALL SUPPLIES AND ACCESSORIES
CANISTER, DISPOSABLE, USED WITH SUCTION PUMP, EACH
CANISTER, NON-DISPOSABLE, USED WITH SUCTION PUMP, EACH
TUBING, USED WITH SUCTION PUMP, EACH
ADMINISTRATION SET, WITH SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER,
DISPOSABLE
SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER, DISPOSABLE
ADMINISTRATION SET, WITH SMALL VOLUME NONFILTERED PNEUMATIC NEBULIZER,
NON-DISPOSABLE
ADMINISTRATION SET, WITH SMALL VOLUME FILTERED PNEUMATIC NEBULIZER
LARGE VOLUME NEBULIZER, DISPOSABLE, UNFILLED, USED WITH AEROSOL COMPRESSOR
LARGE VOLUME NEBULIZER, DISPOSABLE, PREFILLED, USED WITH AEROSOL COMPRESSOR
RESERVOIR BOTTLE, NON-DISPOSABLE, USED WITH LARGE VOLUME ULTRASONIC NEBULIZER
CORRUGATED TUBING, DISPOSABLE, USED WITH LARGE VOLUME NEBULIZER, 100 FEET
CORRUGATED TUBING, NON-DISPOSABLE, USED WITH LARGE VOLUME NEBULIZER, 10 FEET
WATER COLLECTION DEVICE, USED WITH LARGE VOLUME NEBULIZER
FILTER, DISPOSABLE, USED WITH AEROSOL COMPRESSOR OR ULTRASONIC GENERATOR
FILTER, NONDISPOSABLE, USED WITH AEROSOL COMPRESSOR OR ULTRASONIC GENERATOR
AEROSOL MASK, USED WITH DME NEBULIZER
DOME AND MOUTHPIECE, USED WITH SMALL VOLUME ULTRASONIC NEBULIZER
NEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, NOT USED WITH
OXYGEN
WATER, DISTILLED, USED WITH LARGE VOLUME NEBULIZER, 1000 ML
INTERFACE FOR COUGH STIMULATING DEVICE, INCLUDES ALL COMPONENTS, REPLACEMENT
ONLY
HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM VEST, REPLACEMENT FOR USE WITH
PATIENT OWNED EQUIPMENT, EACH
HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM HOSE, REPLACEMENT FOR USE WITH
PATIENT OWNED EQUIPMENT, EACH
COMBINATION ORAL/NASAL MASK, USED WITH CONTINUOUS POSITIVE AIRWAY PRESSURE
DEVICE, EACH
ORAL CUSHION FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, EACH
NASAL PILLOWS FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, PAIR
FULL FACE MASK USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACH
FACE MASK INTERFACE, REPLACEMENT FOR FULL FACE MASK, EACH
CUSHION FOR USE ON NASAL MASK INTERFACE, REPLACEMENT ONLY, EACH
PILLOW FOR USE ON NASAL CANNULA TYPE INTERFACE, REPLACEMENT ONLY, PAIR
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NASAL INTERFACE (MASK OR CANNULA TYPE) USED WITH POSITIVE AIRWAY PRESSURE
DEVICE, WITH OR WITHOUT HEAD STRAP
HEADGEAR USED WITH POSITIVE AIRWAY PRESSURE DEVICE
CHINSTRAP USED WITH POSITIVE AIRWAY PRESSURE DEVICE
TUBING USED WITH POSITIVE AIRWAY PRESSURE DEVICE
FILTER, DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICE
FILTER, NON DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICE
ONE WAY CHEST DRAIN VALVE
WATER SEAL DRAINAGE CONTAINER AND TUBING FOR USE WITH IMPLANTED CHEST TUBE
IMPLANTED PLEURAL CATHETER, EACH
VACUUM DRAINAGE BOTTLE AND TUBING FOR USE WITH IMPLANTED CATHETER
ORAL INTERFACE USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACH
EXHALATION PORT WITH OR WITHOUT SWIVEL USED WITH ACCESSORIES FOR POSITIVE
AIRWAY DEVICES, REPLACEMENT ONLY
WATER CHAMBER FOR HUMIDIFIER, USED WITH POSITIVE AIRWAY PRESSURE DEVICE,
REPLACEMENT, EACH
TRACHEOSTOMA VALVE, INCLUDING DIAPHRAGM, EACH
REPLACEMENT DIAPHRAGM/FACEPLATE FOR TRACHEOSTOMA VALVE, EACH
FILTER HOLDER OR FILTER CAP, REUSABLE, FOR USE IN A TRACHEOSTOMA HEAT AND
MOISTURE EXCHANGE SYSTEM, EACH
FILTER FOR USE IN A TRACHEOSTOMA HEAT AND MOISTURE EXCHANGE SYSTEM, EACH
HOUSING, REUSABLE WITHOUT ADHESIVE, FOR USE IN A HEAT AND MOISTURE EXCHANGE
SYSTEM AND/OR WITH A TRACHEOSTOMA VALVE, EACH
ADHESIVE DISC FOR USE IN A HEAT AND MOISTURE EXCHANGE SYSTEM AND/OR WITH
TRACHEOSTOMA VALVE, ANY TYPE EACH
FILTER HOLDER AND INTEGRATED FILTER WITHOUT ADHESIVE, FOR USE IN A TRACHEOSTOMA
HEAT AND MOISTURE EXCHANGE SYSTEM, EACH
HOUSING AND INTEGRATED ADHESIVE, FOR USE IN A TRACHEOSTOMA HEAT AND MOISTURE
EXCHANGE SYSTEM AND/OR WITH A TRACHEOSTOMA VALVE, EACH
FILTER HOLDER AND INTEGRATED FILTER HOUSING, AND ADHESIVE, FOR USE AS A
TRACHEOSTOMA HEAT AND MOISTURE EXCHANGE SYSTEM, EACH
TRACHEOSTOMY/LARYNGECTOMY TUBE, NON-CUFFED, POLYVINYLCHLORIDE (PVC), SILICONE
OR EQUAL, EACH
TRACHEOSTOMY/LARYNGECTOMY TUBE, CUFFED, POLYVINYLCHLORIDE (PVC), SILICONE OR
EQUAL, EACH
TRACHEOSTOMY/LARYNGECTOMY TUBE, STAINLESS STEEL OR EQUAL (STERILIZABLE AND
REUSABLE), EACH
TRACHEOSTOMY SHOWER PROTECTOR, EACH
TRACHEOSTOMA STENT/STUD/BUTTON, EACH
TRACHEOSTOMY MASK, EACH
TRACHEOSTOMY TUBE COLLAR/HOLDER, EACH
TRACHEOSTOMY/LARYNGECTOMY TUBE PLUG/STOP, EACH
HELMET, PROTECTIVE, SOFT, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES
HELMET, PROTECTIVE, HARD, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES
HELMET, PROTECTIVE, SOFT, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS AND
ACCESSORIES
HELMET, PROTECTIVE, HARD, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS AND
ACCESSORIES
SOFT INTERFACE FOR HELMET, REPLACEMENT ONLY
NON-PRESCRIPTION DRUGS
SINGLE VITAMIN/MINERAL/TRACE ELEMENT, ORAL, PER DOSE, NOT OTHERWISE SPECIFIED
MULTIPLE VITAMINS, WITH OR WITHOUT MINERALS AND TRACE ELEMENTS, ORAL, PER DOSE,
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NOT OTHERWISE SPECIFIED
ARTIFICIAL SALIVA, 30 ML
PEDICULOSIS (LICE INFESTATION) TREATMENT, TOPICAL, FOR ADMINISTRATION BY
PATIENT/CARETAKER
NON-COVERED ITEM OR SERVICE
HOT WATER BOTTLE, ICE CAP OR COLLAR, HEAT AND/OR COLD WRAP, ANY TYPE
EXTERNAL AMBULATORY INSULIN DELIVERY SYSTEM, DISPOSABLE, EACH, INCLUDES ALL
SUPPLIES AND ACCESSORIES
HOME GLUCOSE DISPOSABLE MONITOR, INCLUDES TEST STRIPS
SENSOR; INVASIVE (E.G. SUBCUTANEOUS), DISPOSABLE, FOR USE WITH INTERSTITIAL
CONTINUOUS GLUCOSE MONITORING SYSTEM, ONE UNIT = 1 DAY SUPPLY
TRANSMITTER; EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING
SYSTEM
RECEIVER (MONITOR); EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE
MONITORING SYSTEM
MONITORING FEATURE/DEVICE, STAND-ALONE OR INTEGRATED, ANY TYPE, INCLUDES ALL
ACCESSORIES, COMPONENTS AND ELECTRONICS, NOT OTHERWISE CLASSIFIED
ALERT OR ALARM DEVICE, NOT OTHERWISE CLASSIFIED
REACHING/GRABBING DEVICE, ANY TYPE, ANY LENGTH, EACH
WIG, ANY TYPE, EACH
FOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANY TYPE, EACH
SPIROMETER, NON-ELECTRONIC, INCLUDES ALL ACCESSORIES
EXERCISE EQUIPMENT
TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE
TECHNETIUM TC-99M TEBOROXIME, DIAGNOSTIC, PER STUDY DOSE
TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE
TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES
TECHNETIUM TC-99M APCITIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES
THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE
INDIUM IN-111 CAPROMAB PENDETIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 10
MILLICURIES
IODINE I-131 IOBENGUANE SULFATE, DIAGNOSTIC, PER 0.5 MILLICURIE
IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER MILLICURIE
TECHNETIUM TC-99M DISOFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES
TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE
IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999
MICROCURIES
IODINE I-131 SODIUM IODIDE CAPSULE(S), THERAPEUTIC, PER MILLICURIE
TECHNETIUM TC-99M EXAMETAZIME, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES
IODINE I-131 IODINATED SERUM ALBUMIN, DIAGNOSTIC, PER 5 MICROCURIES
NITROGEN N-13 AMMONIA, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 MILLICURIES
IODINE I-125, SODIUM IODIDE SOLUTION, THERAPEUTIC, PER MILLICURIE
IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE
IODINE I-131 SODIUM IODIDE SOLUTION, DIAGNOSTIC, PER MILLICURIE
IODINE I-131 SODIUM IODIDE SOLUTION, THERAPEUTIC, PER MILLICURIE
IODINE I-131 SODIUM IODIDE, DIAGNOSTIC, PER MICROCURIE (UP TO 100 MICROCURIES)
IODINE I-125 SERUM ALBUMIN, DIAGNOSTIC, PER 5 MICROCURIES
INJECTION, METHYLENE BLUE, 1 ML
TECHNETIUM TC-99M DEPREOTIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 35 MILLICURIES
TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES
TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25
MILLICURIES
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TECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES
TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10
MILLICURIES
TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20
MILLICURIES
INDIUM IN-111 IBRITUMOMAB TIUXETAN, DIAGNOSTIC, PER STUDY DOSE, UP TO 5
MILLICURIES
YTTRIUM Y-90 IBRITUMOMAB TIUXETAN, THERAPEUTIC, PER TREATMENT DOSE, UP TO 40
MILLICURIES
IODINE I-131 TOSITUMOMAB, DIAGNOSTIC, PER STUDY DOSE
IODINE I-131 TOSITUMOMAB, THERAPEUTIC, PER TREATMENT DOSE
COBALT CO-57/58, CYANOCOBALAMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 1 MICROCURIE
INDIUM IN-111 OXYQUINOLINE, DIAGNOSTIC, PER 0.5 MILLICURIE
INDIUM IN-111 PENTETATE, DIAGNOSTIC, PER 0.5 MILLICURIE
TECHNETIUM TC-99M SODIUM GLUCEPTATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25
MILLICURIE
TECHNETIUM TC-99M SUCCIMER, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES
FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES
CHROMIUM CR-51 SODIUM CHROMATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 250
MICROCURIES
IODINE I-125 SODIUM IOTHALAMATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 10
MICROCURIES
RUBIDIUM RB-82, DIAGNOSTIC, PER STUDY DOSE, UP TO 60 MILLICURIES
GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE
TECHNETIUM TC-99M BICISATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES
XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES
COBALT CO-57 CYANOCOBALAMIN, ORAL, DIAGNOSTIC, PER STUDY DOSE, UP TO 1
MICROCURIE
TECHNETIUM TC-99M LABELED RED BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE, UP TO 30
MILLICURIES
TECHNETIUM TC-99M OXIDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES
TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES
SODIUM PHOSPHATE P-32, THERAPEUTIC, PER MILLICURIE
CHROMIC PHOSPHATE P-32 SUSPENSION, THERAPEUTIC, PER MILLICURIE
INDIUM IN-111 PENTETREOTIDE, DIAGNOSTIC, PER MILLICURIE
TECHNETIUM TC-99M FANOLESOMAB, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES
TECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, AEROSOL, PER STUDY DOSE, UP TO 75
MILLICURIES
TECHNETIUM TC-99M ARCITUMOMAB, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES
TECHNETIUM TC-99M EXAMETAZIME LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC,
PER STUDY DOSE
INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE
INDIUM IN-111 LABELED AUTOLOGOUS PLATELETS, DIAGNOSTIC, PER STUDY DOSE
INDIUM IN-111 PENTETREOTIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 6 MILLICURIES
INJECTION, GADOTERIDOL, (PROHANCE MULTIPACK), PER ML
INJECTION, GADOBENATE DIMEGLUMINE (MULTIHANCE), PER ML
INJECTION, GADOBENATE DIMEGLUMINE (MULTIHANCE MULTIPACK), PER ML
INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE
SPECIFIED (NOS), PER ML
SODIUM FLUORIDE F-18, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES
INJECTION, GADOXETATE DISODIUM, 1 ML
IODINE I-123 IOBENGUANE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES
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INJECTION, GADOFOSVESET TRISODIUM, 1 ML
STRONTIUM SR-89 CHLORIDE, THERAPEUTIC, PER MILLICURIE
SAMARIUM SM-153 LEXIDRONAM, THERAPEUTIC, PER TREATMENT DOSE, UP TO 150
MILLICURIES
SAMARIUM SM-153 LEXIDRONAMM, THERAPEUTIC, PER 50 MILLICURIES
NON-RADIOACTIVE CONTRAST IMAGING MATERIAL, NOT OTHERWISE CLASSIFIED, PER STUDY
RADIOPHARMACEUTICAL, THERAPEUTIC, NOT OTHERWISE CLASSIFIED
SUPPLY OF INJECTABLE CONTRAST MATERIAL FOR USE IN ECHOCARDIOGRAPHY, PER STUDY
MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS
CODE
DME DELIVERY, SET UP, AND/OR DISPENSING SERVICE COMPONENT OF ANOTHER HCPCS CODE
MISCELLANEOUS DME SUPPLY OR ACCESSORY, NOT OTHERWISE SPECIFIED
ENTERAL FEEDING SUPPLY KIT; SYRINGE FED, PER DAY, INCLUDES BUT NOT LIMITED TO
FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE
ENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAY, INCLUDES BUT NOT LIMITED TO
FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE
ENTERAL FEEDING SUPPLY KIT; GRAVITY FED, PER DAY, INCLUDES BUT NOT LIMITED TO
FEEDING/FLUSHING SYRINGE, ADMINISTRATION SET TUBING, DRESSINGS, TAPE
NASOGASTRIC TUBING WITH STYLET
NASOGASTRIC TUBING WITHOUT STYLET
STOMACH TUBE - LEVINE TYPE
GASTROSTOMY / JEJUNOSTOMY TUBE, ANY MATERIAL, ANY TYPE, (STANDARD OR LOW
PROFILE), EACH
GASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD, ANY MATERIAL, ANY TYPE, EACH
GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFILE, ANY MATERIAL, ANY TYPE, EACH
FOOD THICKENER, ADMINISTERED ORALLY, PER OUNCE
ENTERAL FORMULA, FOR ADULTS, USED TO REPLACE FLUIDS AND ELECTROLYTES (E.G.
CLEAR LIQUIDS), 500 ML = 1 UNIT
ENTERAL FORMULA, FOR PEDIATRICS, USED TO REPLACE FLUIDS AND ELECTROLYTES (E.G.
CLEAR LIQUIDS), 500 ML = 1 UNIT
ADDITIVE FOR ENTERAL FORMULA (E.G. FIBER)
ENTERAL FORMULA, MANUFACTURED BLENDERIZED NATURAL FOODS WITH INTACT NUTRIENTS,
INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE
FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT
ENTERAL FORMULA, NUTRITIONALLY COMPLETE WITH INTACT NUTRIENTS, INCLUDES
PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER,
ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT
ENTERAL FORMULA, NUTRITIONALLY COMPLETE, CALORICALLY DENSE (EQUAL TO OR GREATER
THAN 1.5 KCAL/ML) WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS,
CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH
AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT
ENTERAL FORMULA, NUTRITIONALLY COMPLETE, HYDROLYZED PROTEINS (AMINO ACIDS AND
PEPTIDE CHAIN), INCLUDES FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY
INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1
UNIT
ENTERAL FORMULA, NUTRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS, EXCLUDES
INHERITED DISEASE OF METABOLISM, INCLUDES ALTERED COMPOSITION OF PROTEINS,
FATS, CARBOHYDRATES, VITAMINS AND/OR MINERALS, MAY INCLUDE FIBER, ADMINISTERED
THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT
ENTERAL FORMULA, NUTRITIONALLY INCOMPLETE/MODULAR NUTRIENTS, INCLUDES SPECIFIC
NUTRIENTS, CARBOHYDRATES (E.G. GLUCOSE POLYMERS), PROTEINS/AMINO ACIDS (E.G.
GLUTAMINE, ARGININE), FAT (E.G. MEDIUM CHAIN TRIGLYCERIDES) OR COMBINATION,
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ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT
ENTERAL FORMULA, NUTRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS FOR
INHERITED DISEASE OF METABOLISM, INCLUDES PROTEINS, FATS, CARBOHYDRATES,
VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL
FEEDING TUBE, 100 CALORIES = 1 UNIT
ENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE WITH INTACT NUTRIENTS,
INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE
FIBER AND/OR IRON, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES =
1 UNIT
ENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE SOY BASED WITH INTACT
NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY
INCLUDE FIBER AND/OR IRON, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100
CALORIES = 1 UNIT
ENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE CALORICALLY DENSE
(EQUAL TO OR GREATER THAN 0.7 KCAL/ML) WITH INTACT NUTRIENTS, INCLUDES
PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER,
ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT
ENTERAL FORMULA, FOR PEDIATRICS, HYDROLYZED/AMINO ACIDS AND PEPTIDE CHAIN
PROTEINS, INCLUDES FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE
FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT
ENTERAL FORMULA, FOR PEDIATRICS, SPECIAL METABOLIC NEEDS FOR INHERITED DISEASE
OF METABOLISM, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS,
MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES =
1 UNIT
PARENTERAL NUTRITION SOLUTION: CARBOHYDRATES (DEXTROSE), 50% OR LESS (500 ML =
1 UNIT) - HOMEMIX
PARENTERAL NUTRITION SOLUTION; AMINO ACID, 3.5%, (500 ML = 1 UNIT) - HOMEMIX
PARENTERAL NUTRITION SOLUTION; AMINO ACID, 5.5% THROUGH 7%, (500 ML = 1 UNIT) -
HOMEMIX
PARENTERAL NUTRITION SOLUTION; AMINO ACID, 7% THROUGH 8.5%, (500 ML = 1 UNIT) -
HOMEMIX
PARENTERAL NUTRITION SOLUTION: AMINO ACID, GREATER THAN 8.5% (500 ML = 1 UNIT)
- HOMEMIX
PARENTERAL NUTRITION SOLUTION; CARBOHYDRATES (DEXTROSE), GREATER THAN 50% (500
ML=1 UNIT) - HOMEMIX
PARENTERAL NUTRITION SOLUTION, PER 10 GRAMS LIPIDS
PARENTERAL NUTRITION SOLUTION; COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH
ELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANY
STRENGTH, 10 TO 51 GRAMS OF PROTEIN - PREMIX
PARENTERAL NUTRITION SOLUTION; COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH
ELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANY
STRENGTH, 52 TO 73 GRAMS OF PROTEIN - PREMIX
PARENTERAL NUTRITION SOLUTION; COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH
ELECTROLYTES, TRACE ELEMENTS AND VITAMINS, INCLUDING PREPARATION, ANY STRENGTH,
74 TO 100 GRAMS OF PROTEIN - PREMIX
PARENTERAL NUTRITION SOLUTION; COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH
ELECTROLYTES, TRACE ELEMENTS AND VITAMINS, INCLUDING PREPARATION, ANY STRENGTH,
OVER 100 GRAMS OF PROTEIN - PREMIX
PARENTERAL NUTRITION; ADDITIVES (VITAMINS, TRACE ELEMENTS, HEPARIN,
ELECTROLYTES) HOMEMIX PER DAY
PARENTERAL NUTRITION SUPPLY KIT; PREMIX, PER DAY
PARENTERAL NUTRITION SUPPLY KIT; HOME MIX, PER DAY
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PARENTERAL NUTRITION ADMINISTRATION KIT, PER DAY
PARENTERAL NUTRITION SOLUTION: COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH
ELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANY
STRENGTH, RENAL - AMIROSYN RF, NEPHRAMINE, RENAMINE - PREMIX
PARENTERAL NUTRITION SOLUTION: COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH
ELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANY
STRENGTH, HEPATIC - FREAMINE HBC, HEPATAMINE - PREMIX
PARENTERAL NUTRITION SOLUTION: COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH
ELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANY
STRENGTH, STRESS - BRANCH CHAIN AMINO ACIDS - PREMIX
ENTERAL NUTRITION INFUSION PUMP - WITHOUT ALARM
ENTERAL NUTRITION INFUSION PUMP - WITH ALARM
PARENTERAL NUTRITION INFUSION PUMP, PORTABLE
PARENTERAL NUTRITION INFUSION PUMP, STATIONARY
NOC FOR ENTERAL SUPPLIES
NOC FOR PARENTERAL SUPPLIES
HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL
ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE)
CATHETER, TRANSLUMINAL ATHERECTOMY, DIRECTIONAL
BRACHYTHERAPY NEEDLE
BRACHYTHERAPY SOURCE, NON-STRANDED, GOLD-198, PER SOURCE
BRACHYTHERAPY SOURCE, NON-STRANDED, HIGH DOSE RATE IRIDIUM-192, PER SOURCE
BRACHYTHERAPY SOURCE, IODINE 125, PER SOURCE
BRACHYTHERAPY SOURCE, NON-STRANDED, NON-HIGH DOSE RATE IRIDIUM-192, PER SOURCE
BRACHYTHERAPY SOURCE, PALLADIUM 103, PER SOURCE
CARDIOVERTER-DEFIBRILLATOR, DUAL CHAMBER (IMPLANTABLE)
CARDIOVERTER-DEFIBRILLATOR, SINGLE CHAMBER (IMPLANTABLE)
CATHETER, TRANSLUMINAL ATHERECTOMY, ROTATIONAL
CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE,
INFUSION/PERFUSION CAPABILITY)
CATHETER, BALLOON DILATATION, NON-VASCULAR
CATHETER, BALLOON TISSUE DISSECTOR, NON-VASCULAR (INSERTABLE)
CATHETER, BRACHYTHERAPY SEED ADMINISTRATION
CATHETER, DRAINAGE
CATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC, OTHER THAN 3D MAPPING (19 OR FEWER
ELECTRODES)
CATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC, OTHER THAN 3D MAPPING (20 OR MORE
ELECTRODES)
CATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC/ABLATION, 3D OR VECTOR MAPPING
CATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC/ABLATION, OTHER THAN 3D OR VECTOR
MAPPING, OTHER THAN COOL-TIP
ENDOSCOPE, RETROGRADE IMAGING/ILLUMINATION COLONOSCOPE DEVICE (IMPLANTABLE)
CATHETER, HEMODIALYSIS/PERITONEAL, LONG-TERM
CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN
HEMODIALYSIS)
CATHETER, HEMODIALYSIS/PERITONEAL, SHORT-TERM
CATHETER, INTRAVASCULAR ULTRASOUND
CATHETER, INTRADISCAL
CATHETER, INTRASPINAL
CATHETER, PACING, TRANSESOPHAGEAL
CATHETER, THROMBECTOMY/EMBOLECTOMY
CATHETER, URETERAL
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CATHETER, INTRACARDIAC ECHOCARDIOGRAPHY
CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)
CONNECTIVE TISSUE, HUMAN (INCLUDES FASCIA LATA)
CONNECTIVE TISSUE, NON-HUMAN (INCLUDES SYNTHETIC)
EVENT RECORDER, CARDIAC (IMPLANTABLE)
ADHESION BARRIER
INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER
THAN PEEL-AWAY
GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE
GRAFT, VASCULAR
GUIDE WIRE
IMAGING COIL, MAGNETIC RESONANCE (INSERTABLE)
REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT
INFUSION PUMP, PROGRAMMABLE (IMPLANTABLE)
RETRIEVAL DEVICE, INSERTABLE (USED TO RETRIEVE FRACTURED MEDICAL DEVICES)
JOINT DEVICE (IMPLANTABLE)
LEAD, CARDIOVERTER-DEFIBRILLATOR, ENDOCARDIAL SINGLE COIL (IMPLANTABLE)
LEAD, NEUROSTIMULATOR (IMPLANTABLE)
LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS
LENS, INTRAOCULAR (NEW TECHNOLOGY)
MESH (IMPLANTABLE)
MORCELLATOR
OCULAR IMPLANT, AQUEOUS DRAINAGE ASSIST DEVICE
OCULAR DEVICE, INTRAOPERATIVE, DETACHED RETINA
PACEMAKER, DUAL CHAMBER, RATE-RESPONSIVE (IMPLANTABLE)
PACEMAKER, SINGLE CHAMBER, RATE-RESPONSIVE (IMPLANTABLE)
PATIENT PROGRAMMER, NEUROSTIMULATOR
PORT, INDWELLING (IMPLANTABLE)
PROSTHESIS, BREAST (IMPLANTABLE)
PROSTHESIS, PENILE, INFLATABLE
RETINAL TAMPONADE DEVICE, SILICONE OIL
PROSTHESIS, URINARY SPHINCTER (IMPLANTABLE)
RECEIVER AND/OR TRANSMITTER, NEUROSTIMULATOR (IMPLANTABLE)
SEPTAL DEFECT IMPLANT SYSTEM, INTRACARDIAC
INTEGRATED KERATOPROSTHESIS
SURGICAL TISSUE LOCALIZATION AND EXCISION DEVICE (IMPLANTABLE)
GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), WITH RECHARGEABLE BATTERY AND
CHARGING SYSTEM
INTERSPINOUS PROCESS DISTRACTION DEVICE (IMPLANTABLE)
STENT, COATED/COVERED, WITH DELIVERY SYSTEM
STENT, COATED/COVERED, WITHOUT DELIVERY SYSTEM
STENT, NON-COATED/NON-COVERED, WITH DELIVERY SYSTEM
STENT, NON-COATED/NON-COVERED, WITHOUT DELIVERY SYSTEM
MATERIAL FOR VOCAL CORD MEDIALIZATION, SYNTHETIC (IMPLANTABLE)
TISSUE MARKER (IMPLANTABLE)
VENA CAVA FILTER
DIALYSIS ACCESS SYSTEM (IMPLANTABLE)
CARDIOVERTER-DEFIBRILLATOR, OTHER THAN SINGLE OR DUAL CHAMBER (IMPLANTABLE)
ADAPTOR/EXTENSION, PACING LEAD OR NEUROSTIMULATOR LEAD (IMPLANTABLE)
EMBOLIZATION PROTECTIVE SYSTEM
CATHETER, TRANSLUMINAL ANGIOPLASTY, LASER
CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)
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CATHETER, ABLATION, NON-CARDIAC, ENDOVASCULAR (IMPLANTABLE)
INFUSION PUMP, NON-PROGRAMMABLE, PERMANENT (IMPLANTABLE)
INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, FIXED-CURVE,
PEEL-AWAY
INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, FIXED-CURVE,
OTHER THAN PEEL-AWAY
INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC
ELECTROPHYSIOLOGICAL, NON-LASER
LEAD, CARDIOVERTER-DEFIBRILLATOR, ENDOCARDIAL DUAL COIL (IMPLANTABLE)
LEAD, CARDIOVERTER-DEFIBRILLATOR, OTHER THAN ENDOCARDIAL SINGLE OR DUAL COIL
(IMPLANTABLE)
LEAD, NEUROSTIMULATOR TEST KIT (IMPLANTABLE)
LEAD, PACEMAKER, OTHER THAN TRANSVENOUS VDD SINGLE PASS
LEAD, PACEMAKER/CARDIOVERTER-DEFIBRILLATOR COMBINATION (IMPLANTABLE)
LEAD, LEFT VENTRICULAR CORONARY VENOUS SYSTEM
PROBE, PERCUTANEOUS LUMBAR DISCECTOMY
SEALANT, PULMONARY, LIQUID
BRACHYTHERAPY SOURCE, NON-STRANDED, YTTRIUM-90, PER SOURCE
STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM
PROBE, CRYOABLATION
PACEMAKER, DUAL CHAMBER, NON RATE-RESPONSIVE (IMPLANTABLE)
PACEMAKER, SINGLE CHAMBER, NON RATE-RESPONSIVE (IMPLANTABLE)
PACEMAKER, OTHER THAN SINGLE OR DUAL CHAMBER (IMPLANTABLE)
PROSTHESIS, PENILE, NON-INFLATABLE
STENT, NON-CORONARY, TEMPORARY, WITH DELIVERY SYSTEM
INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)
CATHETER, SUPRAPUBIC/CYSTOSCOPIC
CATHETER, OCCLUSION
INTRODUCER/SHEATH, OTHER THAN GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, LASER
CATHETER, ELECTROPHYSIOLOGY, DIAGNOSTIC/ABLATION, OTHER THAN 3D OR VECTOR
MAPPING, COOL-TIP
REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT
BRACHYTHERAPY SOURCE, CESIUM-131, PER SOURCE
BRACHYTHERAPY SOURCE, NON-STRANDED, HIGH ACTIVITY, IODINE-125, GREATER THAN
1.01 MCI (NIST), PER SOURCE
BRACHYTHERAPY SOURCE, NON-STRANDED, HIGH ACTIVITY, PALADIUM-103, GREATER THAN
2.2 MCI (NIST), PER SOURCE
BRACHYTHERAPY LINEAR SOURCE, NON-STRANDED, PALADIUM-103, PER 1 MM
BRACHYTHERAPY SOURCE, NON-STRANDED, YTTERBIUM-169, PER SOURCE
BRACHYTHERAPY SOURCE, STRANDED, IODINE-125, PER SOURCE
BRACHYTHERAPY SOURCE, NON-STRANDED, IODINE-125, PER SOURCE
BRACHYTHERAPY SOURCE, STRANDED, PALLADIUM-103, PER SOURCE
BRACHYTHERAPY SOURCE, NON-STRANDED, PALLADIUM-103, PER SOURCE
BRACHYTHERAPY SOURCE, STRANDED, CESIUM-131, PER SOURCE
BRACHYTHERAPY SOURCE, NON-STRANDED, CESIUM-131, PER SOURCE
BRACHYTHERAPY SOURCE, STRANDED, NOT OTHERWISE SPECIFIED, PER SOURCE
BRACHYTHERAPY SOURCE, NON-STRANDED, NOT OTHERWISE SPECIFIED, PER SOURCE
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, ABDOMEN
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, ABDOMEN
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,
ABDOMEN
MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; UNILATERAL
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MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST, BREAST; UNILATERAL
MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, BREAST;
UNILATERAL
MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; BILATERAL
MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST, BREAST; BILATERAL
MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, BREAST;
BILATERAL
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, CHEST (EXCLUDING MYOCARDIUM)
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, CHEST (EXCLUDING MYOCARDIUM)
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,
CHEST (EXCLUDING MYOCARDIUM)
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, LOWER EXTREMITY
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, LOWER EXTREMITY
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,
LOWER EXTREMITY
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, PELVIS
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, PELVIS
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,
PELVIS
TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY
WITH CONTRAST, FOR CONGENITAL CARDIAC ANOMALIES; COMPLETE
TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY
WITH CONTRAST, FOR CONGENITAL CARDIAC ANOMALIES; FOLLOW-UP OR LIMITED STUDY
TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY
WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE
RECORDING, WHEN PERFORMED, COMPLETE, WITHOUT SPECTRAL OR COLOR DOPPLER
ECHOCARDIOGRAPHY
TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY
WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE
RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY
TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST
FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR
WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION,
INTERPRETATION AND REPORT
TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST
FOLLOWED BY WITH CONTRAST, FOR CONGENITAL CARDIAC ANOMALIES; INCLUDING PROBE
PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT
TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST
FOLLOWED BY WITH CONTRAST, FOR MONITORING PURPOSES, INCLUDING PROBE PLACEMENT,
REAL TIME 2-DIMENSIONAL IMAGE ACQUISITION AND INTERPRETATION LEADING TO ONGOING
(CONTINUOUS) ASSESSMENT OF (DYNAMICALLY CHANGING) CARDIAC PUMPING FUNCTION AND
TO THERAPEUTIC MEASURES ON AN IMMEDIATE TIME BASIS
TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY
WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE
RECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USING
TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH
INTERPRETATION AND REPORT
TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY
WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE
RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY,
AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY
TRANSTHORACIC ECHOCARDIOGRAPHY, WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY
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WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE
RECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USING
TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH
INTERPRETATION AND REPORT; INCLUDING PERFORMANCE OF CONTINUOUS
ELECTROCARDIOGRAPHIC MONITORING, WITH PHYSICIAN SUPERVISION
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,
SPINAL CANAL AND CONTENTS
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, SPINAL CANAL AND CONTENTS
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,
SPINAL CANAL AND CONTENTS
MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, UPPER EXTREMITY
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, UPPER EXTREMITY
MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST,
UPPER EXTREMITY
INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION
(MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP
PALIVIZUMAB-RSV-IGM, PER 50 MG
INJECTION, PANTOPRAZOLE SODIUM, PER VIAL
INJECTION, ARGATROBAN, PER 5 MG
INJECTION, IDURSULFASE, 1 MG
INJECTION, RANIBIZUMAB, 0.5 MG
INJECTION, ALGLUCOSIDASE ALFA, 10 MG
INJECTION, PANITUMUMAB, 10 MG
INJECTION, ECULIZUMAB, 10 MG
INJECTION, LANREOTIDE ACETATE, 1 MG
INJECTION, LEVETIRACETAM, 10 MG
INJECTION, TEMSIROLIMUS, 1 MG
INJECTION, IXABEPILONE, 1 MG
INJECTION, DORIPENEM, 10 MG
INJECTION, FOSAPREPITANT, 1 MG
INJECTION, BENDAMUSTINE HCL, 1 MG
INJECTION, REGADENOSON, 0.4 MG
INJECTION, ROMIPLOSTIM, 10 MCG
INJECTION, GADOXETATE DISODIUM, PER ML
IOBENGUANE, I-123, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES
INJECTION, CLEVIDIPINE BUTYRATE, 1 MG
INJECTION, CERTOLIZUMAB PEGOL, 1 MG
HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2ML
INJECTION, C1 ESTERASE INHIBITOR (HUMAN), 10 UNITS
INJECTION, PLERIXAFOR, 1 MG
INJECTION, TEMOZOLOMIDE, 1 MG
INJECTION, LACOSAMIDE, 1 MG
INJECTION, PALIPERIDONE PALMITATE, 1 MG
INJECTION, DEXAMETHASONE INTRAVITREAL IMPLANT, 0.1 MG
INJECTION, BEVACIZUMAB, 0.25 MG
INJECTION, TELAVANCIN, 10 MG
INJECTION, PRALATREXATE, 1 MG
INJECTION, OFATUMUMAB, 10 MG
INJECTION, USTEKINUMAB, 1 MG
FLUDARABINE PHOSPHATE, ORAL, 1 MG
INJECTION, ECALLANTIDE, 1 MG
INJECTION, TOCILIZUMAB, 1 MG
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INJECTION, ROMIDEPSIN, 1 MG
INJECTION, COLLAGENASE CLOSTRIDIUM HISTOLYTICUM, 0.1 MG
INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE, PER 100 IU VWF: RCO
CAPSAICIN, PATCH, 10CM2
INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), BERINERT, 10 UNITS
INJECTION, IMMUNE GLOBULIN (GAMMAPLEX), INTRAVENOUS, NON-LYOPHILIZED (E.G.
LIQUID), 500 MG
INJECTION, VELAGLUCERASE ALFA, 100 UNITS
INJECTION, DENOSUMAB, 1 MG
SIPULEUCEL-T, MINIMUM OF 50 MILLION AUTOLOGOUS CD54+ CELLS ACTIVATED WITH
PAP-GM-CSF, INCLUDING LEUKAPHERESIS AND ALL OTHER PREPARATORY PROCEDURES, PER
INFUSION
CROTALIDAE POLYVALENT IMMUNE FAB (OVINE), 1 VIAL
INJECTION, HEXAMINOLEVULINATE HYDROCHLORIDE, 100 MG, PER STUDY DOSE
INJECTION, CABAZITAXEL, 1 MG
INJECTION, ALGLUCOSIDASE ALFA (LUMIZYME), 1 MG
INJECTION, INCOBOTULINUMTOXIN A, 1 UNIT
INJECTION, IBUPROFEN, 100 MG
MICROPOROUS COLLAGEN TUBE OF NON-HUMAN ORIGIN, PER CENTIMETER LENGTH
ACELLULAR DERMAL TISSUE MATRIX OF NON-HUMAN ORIGIN, PER SQUARE CENTIMETER (DO
NOT REPORT C9351 IN CONJUNCTION WITH J7345)
MICROPOROUS COLLAGEN IMPLANTABLE TUBE (NEURAGEN NERVE GUIDE), PER CENTIMETER
LENGTH
MICROPOROUS COLLAGEN IMPLANTABLE SLIT TUBE (NEURAWRAP NERVE PROTECTOR), PER
CENTIMETER LENGTH
ACELLULAR PERICARDIAL TISSUE MATRIX OF NON-HUMAN ORIGIN (VERITAS), PER SQUARE
CENTIMETER
COLLAGEN NERVE CUFF (NEUROMATRIX), PER 0.5 CENTIMETER LENGTH
TENDON, POROUS MATRIX OF CROSS-LINKED COLLAGEN AND GLYCOSAMINOGLYCAN MATRIX
(TENOGLIDE TENDON PROTECTOR SHEET), PER SQUARE CENTIMETER
DERMAL SUBSTITUTE, GRANULATED CROSS-LINKED COLLAGEN AND GLYCOSAMINOGLYCAN
MATRIX (FLOWABLE WOUND MATRIX), 1 CC
DERMAL SUBSTITUTE, NATIVE, NON-DENATURED COLLAGEN, FETAL BOVINE ORIGIN
(SURGIMEND COLLAGEN MATRIX), PER 0.5 SQUARE CENTIMETERS
POROUS PURIFIED COLLAGEN MATRIX BONE VOID FILLER (INTEGRA MOZAIK
OSTEOCONDUCTIVE SCAFFOLD PUTTY, INTEGRA OS OSTEOCONDUCTIVE SCAFFOLD PUTTY), PER
0.5 CC
DERMAL SUBSTITUTE, NATIVE, NON-DENATURED COLLAGEN, NEONATAL BOVINE ORIGIN
(SURGIMEND COLLAGEN MATRIX), PER 0.5 SQUARE CENTIMETERS
COLLAGEN MATRIX NERVE WRAP (NEUROMEND COLLAGEN NERVE WRAP), PER 0.5 CENTIMETER
LENGTH
POROUS PURIFIED COLLAGEN MATRIX BONE VOID FILLER (INTEGRA MOZAIK
OSTEOCONDUCTIVE SCAFFOLD STRIP), PER 0.5 CC
SKIN SUBSTITUTE, INTEGRA MESHED BILAYER WOUND MATRIX, PER SQUARE CENTIMETER
PORCINE IMPLANT, PERMACOL, PER SQUARE CENTIMETER
SKIN SUBSTITUTE, ENDOFORM DERMAL TEMPLATE, PER SQUARE CENTIMETER
UNCLASSIFIED DRUGS OR BIOLOGICALS
CREATIONS OF THERMAL ANAL LESIONS BY RADIOFREQUENCY ENERGY
DYNAMIC INFRARED BLOOD PERFUSION IMAGING (DIRI)
ENDOSCOPIC FULL-THICKNESS PLICATION IN THE GASTRIC CARDIA USING ENDOSCOPIC
PLICATION SYSTEM (EPS); INCLUDES ENDOSCOPY
PLACEMENT OF ENDORECTAL INTRACAVITARY APPLICATOR FOR HIGH INTENSITY
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BRACHYTHERAPY
PLACEMENT AND REMOVAL (IF PERFORMED) OF APPLICATOR INTO BREAST FOR RADIATION
THERAPY
INSERTION OF IMPLANTS INTO THE SOFT PALATE; MINIMUM OF THREE IMPLANTS
PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY/SURGERY GUIDANCE (EG,
FIDUCIAL MARKERS, DOSIMETER), FOR OTHER THAN THE FOLLOWING SITES (ANY
APPROACH): ABDOMEN, PELVIS, PROSTATE, RETROPERITONEUM, THORAX, SINGLE OR
MULTIPLE
DERMAL INJECTION PROCEDURE(S) FOR FACIAL LIPODYSTROPHY SYNDROME (LDS) AND
PROVISION OF RADIESSE OR SCULPTRA DERMAL FILLER, INCLUDING ALL ITEMS AND
SUPPLIES
SMOKING AND TOBACCO CESSATION COUNSELING VISIT FOR THE ASYMPTOMATIC PATIENT;
INTERMEDIATE, GREATER THAN 3 MINUTES, UP TO 10 MINUTES
SMOKING AND TOBACCO CESSATION COUNSELING VISIT FOR THE ASYMPTOMATIC PATIENT;
INTENSIVE, GREATER THAN 10 MINUTES
RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY
IMPLANTED PROSTHETIC DEVICE, PAYABLE ONLY FOR INPATIENTS WHO DO NOT HAVE
INPATIENT COVERAGE
CANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIP
CANE, QUAD OR THREE PRONG, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR
FIXED, WITH TIPS
CRUTCHES, FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED,
PAIR, COMPLETE WITH TIPS AND HANDGRIPS
CRUTCH FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED,
EACH, WITH TIP AND HANDGRIPS
CRUTCHES UNDERARM, WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPS AND
HANDGRIPS
CRUTCH UNDERARM, WOOD, ADJUSTABLE OR FIXED, EACH, WITH PAD, TIP AND HANDGRIP
CRUTCHES UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPS
AND HANDGRIPS
CRUTCH, UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, WITH PAD, TIP,
HANDGRIP, WITH OR WITHOUT SHOCK ABSORBER, EACH
CRUTCH, UNDERARM, ARTICULATING, SPRING ASSISTED, EACH
CRUTCH SUBSTITUTE, LOWER LEG PLATFORM, WITH OR WITHOUT WHEELS, EACH
WALKER, RIGID (PICKUP), ADJUSTABLE OR FIXED HEIGHT
WALKER, FOLDING (PICKUP), ADJUSTABLE OR FIXED HEIGHT
WALKER, WITH TRUNK SUPPORT, ADJUSTABLE OR FIXED HEIGHT, ANY TYPE
WALKER, RIGID, WHEELED, ADJUSTABLE OR FIXED HEIGHT
WALKER, FOLDING, WHEELED, ADJUSTABLE OR FIXED HEIGHT
WALKER, ENCLOSED, FOUR SIDED FRAMED, RIGID OR FOLDING, WHEELED WITH POSTERIOR
SEAT
WALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RESISTANCE
WALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACH
WALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE
PLATFORM ATTACHMENT, FOREARM CRUTCH, EACH
PLATFORM ATTACHMENT, WALKER, EACH
WHEEL ATTACHMENT, RIGID PICK-UP WALKER, PER PAIR
SEAT ATTACHMENT, WALKER
CRUTCH ATTACHMENT, WALKER, EACH
LEG EXTENSIONS FOR WALKER, PER SET OF FOUR (4)
BRAKE ATTACHMENT FOR WHEELED WALKER, REPLACEMENT, EACH
SITZ TYPE BATH OR EQUIPMENT, PORTABLE, USED WITH OR WITHOUT COMMODE
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SITZ TYPE BATH OR EQUIPMENT, PORTABLE, USED WITH OR WITHOUT COMMODE, WITH
FAUCET ATTACHMENT/S
SITZ BATH CHAIR
COMMODE CHAIR, MOBILE OR STATIONARY, WITH FIXED ARMS
COMMODE CHAIR, MOBILE OR STATIONARY, WITH DETACHABLE ARMS
PAIL OR PAN FOR USE WITH COMMODE CHAIR, REPLACEMENT ONLY
COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH OR
WITHOUT ARMS, ANY TYPE, EACH
COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE
COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, NON-ELECTRIC, ANY TYPE
SEAT LIFT MECHANISM PLACED OVER OR ON TOP OF TOILET, ANY TYPE
FOOT REST, FOR USE WITH COMMODE CHAIR, EACH
POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP,
INCLUDES HEAVY DUTY
PUMP FOR ALTERNATING PRESSURE PAD, FOR REPLACEMENT ONLY
DRY PRESSURE MATTRESS
GEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
AIR PRESSURE MATTRESS
WATER PRESSURE MATTRESS
SYNTHETIC SHEEPSKIN PAD
LAMBSWOOL SHEEPSKIN PAD, ANY SIZE
POSITIONING CUSHION/PILLOW/WEDGE, ANY SHAPE OR SIZE, INCLUDES ALL COMPONENTS
AND ACCESSORIES
HEEL OR ELBOW PROTECTOR, EACH
POWERED AIR FLOTATION BED (LOW AIR LOSS THERAPY)
AIR FLUIDIZED BED
GEL PRESSURE MATTRESS
AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
WATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
DRY PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
HEAT LAMP, WITHOUT STAND (TABLE MODEL), INCLUDES BULB, OR INFRARED ELEMENT
PHOTOTHERAPY (BILIRUBIN) LIGHT WITH PHOTOMETER
THERAPEUTIC LIGHTBOX, MINIMUM 10,000 LUX, TABLE TOP MODEL
HEAT LAMP, WITH STAND, INCLUDES BULB, OR INFRARED ELEMENT
ELECTRIC HEAT PAD, STANDARD
ELECTRIC HEAT PAD, MOIST
WATER CIRCULATING HEAT PAD WITH PUMP
WATER CIRCULATING COLD PAD WITH PUMP
HOT WATER BOTTLE
INFRARED HEATING PAD SYSTEM
HYDROCOLLATOR UNIT, INCLUDES PADS
ICE CAP OR COLLAR
NON-CONTACT WOUND WARMING DEVICE (TEMPERATURE CONTROL UNIT, AC ADAPTER AND
POWER CORD) FOR USE WITH WARMING CARD AND WOUND COVER
WARMING CARD FOR USE WITH THE NON CONTACT WOUND WARMING DEVICE AND NON CONTACT
WOUND WARMING WOUND COVER
PARAFFIN BATH UNIT, PORTABLE (SEE MEDICAL SUPPLY CODE A4265 FOR PARAFFIN)
PUMP FOR WATER CIRCULATING PAD
NON-ELECTRIC HEAT PAD, MOIST
HYDROCOLLATOR UNIT, PORTABLE
BATH/SHOWER CHAIR, WITH OR WITHOUT WHEELS, ANY SIZE
BATH TUB WALL RAIL, EACH
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BATH TUB RAIL, FLOOR BASE
TOILET RAIL, EACH
RAISED TOILET SEAT
TUB STOOL OR BENCH
TRANSFER TUB RAIL ATTACHMENT
TRANSFER BENCH FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING
TRANSFER BENCH, HEAVY DUTY, FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING
PAD FOR WATER CIRCULATING HEAT UNIT, FOR REPLACEMENT ONLY
HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS
HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS
HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS
HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS
HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE
RAILS, WITH MATTRESS
HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE
RAILS, WITHOUT MATTRESS
HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE
SIDE RAILS, WITH MATTRESS
HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE
SIDE RAILS, WITHOUT MATTRESS
HOSPITAL BED, INSTITUTIONAL TYPE INCLUDES: OSCILLATING, CIRCULATING AND STRYKER
FRAME, WITH MATTRESS
MATTRESS, INNERSPRING
MATTRESS, FOAM RUBBER
BED BOARD
OVER-BED TABLE
BED PAN, STANDARD, METAL OR PLASTIC
BED PAN, FRACTURE, METAL OR PLASTIC
POWERED PRESSURE-REDUCING AIR MATTRESS
BED CRADLE, ANY TYPE
HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITH MATTRESS
HOSPITAL BED, FIXED HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESS
HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITH MATTRESS
HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITHOUT MATTRESS
HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS,
WITH MATTRESS
HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS,
WITHOUT MATTRESS
HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS). WITHOUT SIDE
RAILS, WITH MATTRESS
HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT SIDE
RAILS, WITHOUT MATTRESS
PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED
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, WITHOUT
MATTRESS
HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN
600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS
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
HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN
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600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS
BED SIDE RAILS, HALF LENGTH
BED SIDE RAILS, FULL LENGTH
BED ACCESSORY: BOARD, TABLE, OR SUPPORT DEVICE, ANY TYPE
SAFETY ENCLOSURE FRAME/CANOPY FOR USE WITH HOSPITAL BED, ANY TYPE
URINAL; MALE, JUG-TYPE, ANY MATERIAL
URINAL; FEMALE, JUG-TYPE, ANY MATERIAL
HOSPITAL BED, PEDIATRIC, MANUAL, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD,
FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING, INCLUDES MATTRESS
HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES,
TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING,
INCLUDES MATTRESS
CONTROL UNIT FOR ELECTRONIC BOWEL IRRIGATION/EVACUATION SYSTEM
DISPOSABLE PACK (WATER RESERVOIR BAG, SPECULUM, VALVING MECHANISM AND
COLLECTION BAG/BOX) FOR USE WITH THE ELECTRONIC BOWEL IRRIGATION/EVACUATION
SYSTEM
AIR PRESSURE ELEVATOR FOR HEEL
NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STANDARD MATTRESS
LENGTH AND WIDTH
POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS
STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER,
CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND
TUBING
STATIONARY COMPRESSED GAS SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER,
HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING
PORTABLE GASEOUS OXYGEN SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER,
HUMIDIFIER, CANNULA OR MASK, AND TUBING
PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, REGULATOR,
FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING
PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; HOME LIQUEFIER USED TO FILL PORTABLE
LIQUID OXYGEN CONTAINERS, INCLUDES PORTABLE CONTAINERS, REGULATOR, FLOWMETER,
HUMIDIFIER, CANNULA OR MASK AND TUBING, WITH OR WITHOUT SUPPLY RESERVOIR AND
CONTENTS GAUGE
PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, SUPPLY
RESERVOIR, HUMIDIFIER, FLOWMETER, REFILL ADAPTOR, CONTENTS GAUGE, CANNULA OR
MASK, AND TUBING
PORTABLE LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES PORTABLE CONTAINER, SUPPLY
RESERVOIR, FLOWMETER, HUMIDIFIER, CONTENTS GAUGE, CANNULA OR MASK, TUBING AND
REFILL ADAPTOR
STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS,
REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, & TUBING
STATIONARY LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES USE OF RESERVOIR, CONTENTS
INDICATOR, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND
TUBING
STATIONARY OXYGEN CONTENTS, GASEOUS, 1 MONTH'S SUPPLY = 1 UNIT
STATIONARY OXYGEN CONTENTS, LIQUID, 1 MONTH'S SUPPLY = 1 UNIT
PORTABLE OXYGEN CONTENTS, GASEOUS, 1 MONTH'S SUPPLY = 1 UNIT
PORTABLE OXYGEN CONTENTS, LIQUID, 1 MONTH'S SUPPLY = 1 UNIT
OXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON-INVASIVELY
TOPICAL OXYGEN DELIVERY SYSTEM, NOT OTHERWISE SPECIFIED, INCLUDES ALL SUPPLIES
AND ACCESSORIES
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VOLUME CONTROL VENTILATOR, WITHOUT PRESSURE SUPPORT MODE, MAY INCLUDE PRESSURE
CONTROL MODE, USED WITH INVASIVE INTERFACE (E.G., TRACHEOSTOMY TUBE)
OXYGEN TENT, EXCLUDING CROUP OR PEDIATRIC TENTS
CHEST SHELL (CUIRASS)
CHEST WRAP
NEGATIVE PRESSURE VENTILATOR; PORTABLE OR STATIONARY
VOLUME CONTROL VENTILATOR, WITHOUT PRESSURE SUPPORT MODE, MAY INCLUDE PRESSURE
CONTROL MODE, USED WITH NON-INVASIVE INTERFACE (E.G. MASK)
ROCKING BED WITH OR WITHOUT SIDE RAILS
PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE
CONTROL MODE, USED WITH INVASIVE INTERFACE (E.G. TRACHEOSTOMY TUBE)
PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE
CONTROL MODE, USED WITH NON-INVASIVE INTERFACE (E.G. MASK)
RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE
FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK
(INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE)
RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACK-UP RATE
FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK
(INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE)
RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACKUP RATE
FEATURE, USED WITH INVASIVE INTERFACE, E.G., TRACHEOSTOMY TUBE (INTERMITTENT
ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE)
PERCUSSOR, ELECTRIC OR PNEUMATIC, HOME MODEL
INTRAPULMONARY PERCUSSIVE VENTILATION SYSTEM AND RELATED ACCESSORIES
COUGH STIMULATING DEVICE, ALTERNATING POSITIVE AND NEGATIVE AIRWAY PRESSURE
HIGH FREQUENCY CHEST WALL OSCILLATION AIR-PULSE GENERATOR SYSTEM, (INCLUDES
HOSES AND VEST), EACH
OSCILLATORY POSITIVE EXPIRATORY PRESSURE DEVICE, NON-ELECTRIC, ANY TYPE, EACH
ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR
NON-ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR
NON-ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
SPIROMETER, ELECTRONIC, INCLUDES ALL ACCESSORIES
IPPB MACHINE, ALL TYPES, WITH BUILT-IN NEBULIZATION; MANUAL OR AUTOMATIC
VALVES; INTERNAL OR EXTERNAL POWER SOURCE
HUMIDIFIER, DURABLE FOR EXTENSIVE SUPPLEMENTAL HUMIDIFICATION DURING IPPB
TREATMENTS OR OXYGEN DELIVERY
HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC BOTTLE TYPE, FOR USE WITH
REGULATOR OR FLOWMETER
HUMIDIFIER, DURABLE FOR SUPPLEMENTAL HUMIDIFICATION DURING IPPB TREATMENT OR
OXYGEN DELIVERY
HUMIDIFIER, NON-HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE
HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE
COMPRESSOR, AIR POWER SOURCE FOR EQUIPMENT WHICH IS NOT SELF- CONTAINED OR
CYLINDER DRIVEN
NEBULIZER, WITH COMPRESSOR
AEROSOL COMPRESSOR, BATTERY POWERED, FOR USE WITH SMALL VOLUME NEBULIZER
AEROSOL COMPRESSOR, ADJUSTABLE PRESSURE, LIGHT DUTY FOR INTERMITTENT USE
ULTRASONIC/ELECTRONIC AEROSOL GENERATOR WITH SMALL VOLUME NEBULIZER
NEBULIZER, ULTRASONIC, LARGE VOLUME
NEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITH
REGULATOR OR FLOWMETER
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NEBULIZER, WITH COMPRESSOR AND HEATER
RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC
CONTINUOUS AIRWAY PRESSURE (CPAP) DEVICE
BREAST PUMP, MANUAL, ANY TYPE
BREAST PUMP, ELECTRIC (AC AND/OR DC), ANY TYPE
BREAST PUMP, HOSPITAL GRADE, ELECTRIC (AC AND / OR DC), ANY TYPE
VAPORIZER, ROOM TYPE
POSTURAL DRAINAGE BOARD
HOME BLOOD GLUCOSE MONITOR
PACEMAKER MONITOR, SELF-CONTAINED, (CHECKS BATTERY DEPLETION, INCLUDES AUDIBLE
AND VISIBLE CHECK SYSTEMS)
PACEMAKER MONITOR, SELF CONTAINED, CHECKS BATTERY DEPLETION AND OTHER PACEMAKER
COMPONENTS, INCLUDES DIGITAL/VISIBLE CHECK SYSTEMS
IMPLANTABLE CARDIAC EVENT RECORDER WITH MEMORY, ACTIVATOR AND PROGRAMMER
EXTERNAL DEFIBRILLATOR WITH INTEGRATED ELECTROCARDIOGRAM ANALYSIS
APNEA MONITOR, WITHOUT RECORDING FEATURE
APNEA MONITOR, WITH RECORDING FEATURE
SKIN PIERCING DEVICE FOR COLLECTION OF CAPILLARY BLOOD, LASER, EACH
SLING OR SEAT, PATIENT LIFT, CANVAS OR NYLON
PATIENT LIFT, BATHROOM OR TOILET, NOT OTHERWISE CLASSIFIED
SEAT LIFT MECHANISM INCORPORATED INTO A COMBINATION LIFT-CHAIR MECHANISM
SEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED FURNITURE-ELECTRIC
SEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED FURNITURE-NON-ELECTRIC
PATIENT LIFT, HYDRAULIC OR MECHANICAL, INCLUDES ANY SEAT, SLING, STRAP(S) OR
PAD(S)
PATIENT LIFT, ELECTRIC WITH SEAT OR SLING
MULTIPOSITIONAL PATIENT SUPPORT SYSTEM, WITH INTEGRATED LIFT, PATIENT
ACCESSIBLE CONTROLS
COMBINATION SIT TO STAND SYSTEM, ANY SIZE INCLUDING PEDIATRIC, WITH SEATLIFT
FEATURE, WITH OR WITHOUT WHEELS
STANDING FRAME SYSTEM, ONE POSITION (E.G. UPRIGHT, SUPINE OR PRONE STANDER),
ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS
PATIENT LIFT, MOVEABLE FROM ROOM TO ROOM WITH DISASSEMBLY AND REASSEMBLY,
INCLUDES ALL COMPONENTS/ACCESSORIES
PATIENT LIFT, FIXED SYSTEM, INCLUDES ALL COMPONENTS/ACCESSORIES
STANDING FRAME SYSTEM, MULTI-POSITION (E.G. THREE-WAY STANDER), ANY SIZE
INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS
STANDING FRAME SYSTEM, MOBILE (DYNAMIC STANDER), ANY SIZE INCLUDING PEDIATRIC
PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME MODEL
PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITHOUT CALIBRATED GRADIENT PRESSURE
PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE
NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF ARM
SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, TRUNK
SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, CHEST
NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEG
NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM
NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG
SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL LEG
SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, FULL ARM
SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, HALF LEG
SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL LEG
SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, FULL ARM
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SEGMENTAL GRADIENT PRESSURE PNEUMATIC APPLIANCE, HALF LEG
PNEUMATIC COMPRESSION DEVICE, HIGH PRESSURE, RAPID INFLATION/DEFLATION CYCLE,
FOR ARTERIAL INSUFFICIENCY (UNILATERAL OR BILATERAL SYSTEM)
INTERMITTENT LIMB COMPRESSION DEVICE (INCLUDES ALL ACCESSORIES), NOT OTHERWISE
SPECIFIED
ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE
PROTECTION; TREATMENT AREA 2 SQUARE FEET OR LESS
ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE
PROTECTION, 4 FOOT PANEL
ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE
PROTECTION, 6 FOOT PANEL
ULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT CABINET, INCLUDES
BULBS/LAMPS, TIMER AND EYE PROTECTION
SAFETY EQUIPMENT, DEVICE OR ACCESSORY, ANY TYPE
TRANSFER DEVICE, ANY TYPE, EACH
RESTRAINTS, ANY TYPE (BODY, CHEST, WRIST OR ANKLE)
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED
STIMULATION
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS,
FOR MULTIPLE NERVE STIMULATION
FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES (WITH CONDUCTIVE
FIBERS SEPARATED FROM THE PATIENT'S SKIN BY LAYERS OF FABRIC)
INCONTINENCE TREATMENT SYSTEM, PELVIC FLOOR STIMULATOR, MONITOR, SENSOR AND/OR
TRAINER
NEUROMUSCULAR STIMULATOR FOR SCOLIOSIS
NEUROMUSCULAR STIMULATOR, ELECTRONIC SHOCK UNIT
ELECTROMYOGRAPHY (EMG), BIOFEEDBACK DEVICE
OSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, OTHER THAN SPINAL
APPLICATIONS
OSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, SPINAL APPLICATIONS
OSTEOGENESIS STIMULATOR, ELECTRICAL, SURGICALLY IMPLANTED
ELECTRONIC SALIVARY REFLEX STIMULATOR (INTRA-ORAL/NON-INVASIVE)
OSTEOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON-INVASIVE
NON-THERMAL PULSED HIGH FREQUENCY RADIOWAVES, HIGH PEAK POWER ELECTROMAGNETIC
ENERGY TREATMENT DEVICE
TRANSCUTANEOUS ELECTRICAL JOINT STIMULATION DEVICE SYSTEM, INCLUDES ALL
ACCESSORIES
FUNCTIONAL NEUROMUSCULAR STIMULATION, TRANSCUTANEOUS STIMULATION OF SEQUENTIAL
MUSCLE GROUPS OF AMBULATION WITH COMPUTER CONTROL, USED FOR WALKING BY SPINAL
CORD INJURED, ENTIRE SYSTEM, AFTER COMPLETION OF TRAINING PROGRAM
FDA APPROVED NERVE STIMULATOR, WITH REPLACEABLE BATTERIES, FOR TREATMENT OF
NAUSEA AND VOMITING
ELECTRICAL STIMULATION OR ELECTROMAGNETIC WOUND TREATMENT DEVICE, NOT OTHERWISE
CLASSIFIED
FUNCTIONAL ELECTRICAL STIMULATOR, TRANSCUTANEOUS STIMULATION OF NERVE AND/OR
MUSCLE GROUPS, ANY TYPE, COMPLETE SYSTEM, NOT OTHERWISE SPECIFIED
IV POLE
AMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR INFUSION 8 HOURS OR GREATER
AMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR INFUSION LESS THAN 8 HOURS
AMBULATORY INFUSION PUMP, SINGLE OR MULTIPLE CHANNELS, ELECTRIC OR BATTERY
OPERATED, WITH ADMINISTRATIVE EQUIPMENT, WORN BY PATIENT
INFUSION PUMP, IMPLANTABLE, NON-PROGRAMMABLE (INCLUDES ALL COMPONENTS, E.G.,
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PUMP, CATHETER, CONNECTORS, ETC.)
INFUSION PUMP SYSTEM, IMPLANTABLE, PROGRAMMABLE (INCLUDES ALL COMPONENTS, E.G.,
PUMP, CATHETER, CONNECTORS, ETC.)
EXTERNAL AMBULATORY INFUSION PUMP, INSULIN
IMPLANTABLE INTRASPINAL (EPIDURAL/INTRATHECAL) CATHETER USED WITH IMPLANTABLE
INFUSION PUMP, REPLACEMENT
IMPLANTABLE PROGRAMMABLE INFUSION PUMP, REPLACEMENT (EXCLUDES IMPLANTABLE
INTRASPINAL CATHETER)
PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR MULTI-CHANNEL
AMBULATORY TRACTION DEVICE, ALL TYPES, EACH
TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION
TRACTION EQUIPMENT, CERVICAL, FREE-STANDING STAND/FRAME, PNEUMATIC, APPLYING
TRACTION FORCE TO OTHER THAN MANDIBLE
TRACTION STAND, FREE STANDING, CERVICAL TRACTION
CERVICAL TRACTION EQUIPMENT NOT REQUIRING ADDITIONAL STAND OR FRAME
CERVICAL TRACTION DEVICE, CERVICAL COLLAR WITH INFLATABLE AIR BLADDER
TRACTION EQUIPMENT, OVERDOOR, CERVICAL
TRACTION FRAME, ATTACHED TO FOOTBOARD, EXTREMITY TRACTION, (E.G. BUCK'S)
TRACTION STAND, FREE STANDING, EXTREMITY TRACTION, (E.G., BUCK'S)
TRACTION FRAME, ATTACHED TO FOOTBOARD, PELVIC TRACTION
TRACTION STAND, FREE STANDING, PELVIC TRACTION, (E.G., BUCK'S)
TRAPEZE BARS, A/K/A PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR
TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS,
ATTACHED TO BED, WITH GRAB BAR
TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS,
FREE STANDING, COMPLETE WITH GRAB BAR
FRACTURE FRAME, ATTACHED TO BED, INCLUDES WEIGHTS
FRACTURE FRAME, FREE STANDING, INCLUDES WEIGHTS
CONTINUOUS PASSIVE MOTION EXERCISE DEVICE FOR USE ON KNEE ONLY
CONTINUOUS PASSIVE MOTION EXERCISE DEVICE FOR USE OTHER THAN KNEE
TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR
GRAVITY ASSISTED TRACTION DEVICE, ANY TYPE
CERVICAL HEAD HARNESS/HALTER
PELVIC BELT/HARNESS/BOOT
EXTREMITY BELT/HARNESS
FRACTURE, FRAME, DUAL WITH CROSS BARS, ATTACHED TO BED, (E.G. BALKEN, 4 POSTER)
FRACTURE FRAME, ATTACHMENTS FOR COMPLEX PELVIC TRACTION
FRACTURE FRAME, ATTACHMENTS FOR COMPLEX CERVICAL TRACTION
WHEELCHAIR ACCESSORY, TRAY, EACH
HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH
TOE LOOP/HOLDER, ANY TYPE, EACH
WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING
HARDWARE, EACH
WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED
MOUNTING HARDWARE, EACH
WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING
HARDWARE, EACH
MANUAL WHEELCHAIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACH
MANUAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH
WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY
TYPE MOUNTING HARDWARE
MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH
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MANUAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACH
MANUAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, EACH
COMMODE SEAT, WHEELCHAIR
NARROWING DEVICE, WHEELCHAIR
NO.2 FOOTPLATES, EXCEPT FOR ELEVATING LEG REST
MANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH
WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY,
EACH
MANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH
WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH
SAFETY VEST, WHEELCHAIR
WHEELCHAIR ACCESSORY, SEAT UPHOLSTERY, REPLACEMENT ONLY, EACH
WHEELCHAIR ACCESSORY, BACK UPHOLSTERY, REPLACEMENT ONLY, EACH
MANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MANUAL WHEELCHAIR TO
MOTORIZED WHEELCHAIR, JOYSTICK CONTROL
MANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MANUAL WHEELCHAIR TO
MOTORIZED WHEELCHAIR, TILLER CONTROL
WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM
MANUAL WHEELCHAIR ACCESSORY, PUSH ACTIVATED POWER ASSIST, EACH
WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH
MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT
ARM REST, EACH
WHEELCHAIR ACCESSORY, CALF REST/PAD, EACH
WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY
WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR
REDUCTION
WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR
REDUCTION
WHEELCHAIR ACCESSORY, POWER SEATNG SYSTEM, RECLINE ONLY, WITH POWER SHEAR
REDUCTION
WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE,
WITHOUT SHEAR REDUCTION
WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH
MECHANICAL SHEAR REDUCTION
WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH
POWER SHEAR REDUCTION
WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEG
ELEVATION SYSTEM, INCLUDING PUSHROD AND LEG REST, EACH
WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATION
SYSTEM, INCLUDING LEG REST, PAIR
MODIFICATION TO PEDIATRIC SIZE WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO BE
DISPENSED WITH INITIAL CHAIR)
RECLINING BACK, ADDITION TO PEDIATRIC SIZE WHEELCHAIR
SHOCK ABSORBER FOR MANUAL WHEELCHAIR, EACH
SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH
HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MANUAL WHEELCHAIR,
EACH
HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR,
EACH
RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR
WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING
HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY
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WHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXED
WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED
ROLLABOUT CHAIR, ANY AND ALL TYPES WITH CASTORS 5" OR GREATER
MULTI-POSITIONAL PATIENT TRANSFER SYSTEM, WITH INTEGRATED SEAT, OPERATED BY
CARE GIVER, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 LBS
MULTI-POSITIONAL PATIENT TRANSFER SYSTEM, EXTRA-WIDE, WITH INTEGRATED SEAT,
OPERATED BY CAREGIVER, PATIENT WEIGHT CAPACITY GREATER THAN 300 LBS
TRANSPORT CHAIR, PEDIATRIC SIZE
TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300
POUNDS
TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN
300 POUNDS
FULLY-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE
ELEVATING LEG RESTS
FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY
DETACHABLE ELEVATING LEGRESTS
FULLY-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY
DETACHABLE FOOTREST
HEMI-WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEG
REST
HEMI-WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING AWAY
DETACHABLE ELEVATING LEG RESTS
HEMI-WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOT RESTS
HEMI-WHEELCHAIR DETACHABLE ARMS DESK OR FULL LENGTH, SWING AWAY DETACHABLE
FOOTRESTS
HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY
DETACHABLE ELEVATING LEG RESTS
HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH,
SWING AWAY DETACHABLE ELEVATING LEG RESTS
HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, FIXED LENGTH ARMS, SWING AWAY DETACHABLE
FOOTREST
HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH,
SWING AWAY DETACHABLE FOOT RESTS
WIDE HEAVY DUTY WHEEL CHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH), SWING AWAY
DETACHABLE ELEVATING LEG RESTS
WIDE HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS DESK OR FULL LENGTH ARMS, SWING
AWAY DETACHABLE FOOTRESTS
SEMI-RECLINING WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE
ELEVATING LEG RESTS
SEMI-RECLINING WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEG
REST
STANDARD WHEELCHAIR, FIXED FULL LENGTH ARMS, FIXED OR SWING AWAY DETACHABLE
FOOTRESTS
WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH, SWING AWAY DETACHABLE
FOOTRESTS
WHEELCHAIR, DETACHABLE ARMS, DESK OR FULL LENGTH SWING AWAY DETACHABLE
ELEVATING LEGRESTS
WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING LEGRESTS
MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE
AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING
LEGRESTS
AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, WITHOUT FOOTRESTS OR LEGREST
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AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) WITHOUT FOOTRESTS OR
LEGREST
AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE
FOOTRESTS
AMPUTEE WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY DETACHABLE
ELEVATING LEGRESTS
HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING
LEGRESTS
AMPUTEE WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTREST
WHEELCHAIR; SPECIALLY SIZED OR CONSTRUCTED, (INDICATE BRAND NAME, MODEL NUMBER,
IF ANY) AND JUSTIFICATION
WHEELCHAIR WITH FIXED ARM, FOOTRESTS
WHEELCHAIR WITH FIXED ARM, ELEVATING LEGRESTS
WHEELCHAIR WITH DETACHABLE ARMS, FOOTRESTS
WHEELCHAIR WITH DETACHABLE ARMS, ELEVATING LEGRESTS
WHEELCHAIR ACCESSORY, MANUAL SEMI-RECLINING BACK, (RECLINE GREATER THAN 15
DEGREES, BUT LESS THAN 80 DEGREES), EACH
WHEELCHAIR ACCESSORY, MANUAL FULLY RECLINING BACK, (RECLINE GREATER THAN 80
DEGREES), EACH
SPECIAL HEIGHT ARMS FOR WHEELCHAIR
SPECIAL BACK HEIGHT FOR WHEELCHAIR
WHEELCHAIR, PEDIATRIC SIZE, NOT OTHERWISE SPECIFIED
POWER OPERATED VEHICLE (THREE OR FOUR WHEEL NONHIGHWAY) SPECIFY BRAND NAME AND
MODEL NUMBER
WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITH SEATING
SYSTEM
WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITH SEATING
SYSTEM
WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, RIGID, ADJUSTABLE, WITHOUT SEATING
SYSTEM
WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACE, FOLDING, ADJUSTABLE, WITHOUT SEATING
SYSTEM
WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM
WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM
WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM
WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM
POWER WHEELCHAIR, PEDIATRIC SIZE, NOT OTHERWISE SPECIFIED
LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS, (DESK OR FULL LENGTH) SWING AWAY
DETACHABLE, ELEVATING LEGREST
LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTREST
LIGHTWEIGHT WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY
DETACHABLE FOOTREST
LIGHTWEIGHT WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE ELEVATING
LEGRESTS
HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) ELEVATING LEGRESTS
HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, SWING AWAY DETACHABLE FOOTREST
HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR FULL LENGTH) SWING AWAY
DETACHABLE FOOTREST
HEAVY DUTY WHEELCHAIR, FIXED FULL LENGTH ARMS, ELEVATING LEGREST
SPECIAL WHEELCHAIR SEAT HEIGHT FROM FLOOR
SPECIAL WHEELCHAIR SEAT DEPTH, BY UPHOLSTERY
SPECIAL WHEELCHAIR SEAT DEPTH AND/OR WIDTH, BY CONSTRUCTION
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WHIRLPOOL, PORTABLE (OVERTUB TYPE)
WHIRLPOOL, NON-PORTABLE (BUILT-IN TYPE)
REPAIR OR NONROUTINE SERVICE FOR DURABLE MEDICAL EQUIPMENT REQUIRING THE SKILL
OF A TECHNICIAN, LABOR COMPONENT, PER 15 MINUTES
REGULATOR
OXYGEN ACCESSORY, WHEELED CART FOR PORTABLE CYLINDER OR PORTABLE CONCENTRATOR,
ANY TYPE, REPLACEMENT ONLY, EACH
STAND/RACK
OXYGEN ACCESSORY, BATTERY PACK/CARTRIDGE FOR PORTABLE CONCENTRATOR, ANY TYPE,
REPLACEMENT ONLY, EACH
OXYGEN ACCESSORY, BATTERY CHARGER FOR PORTABLE CONCENTRATOR, ANY TYPE,
REPLACEMENT ONLY, EACH
OXYGEN ACCESSORY, DC POWER ADAPTER FOR PORTABLE CONCENTRATOR, ANY TYPE,
REPLACEMENT ONLY, EACH
IMMERSION EXTERNAL HEATER FOR NEBULIZER
OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR
GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE
OXYGEN CONCENTRATOR, DUAL DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR
GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE, EACH
PORTABLE OXYGEN CONCENTRATOR, RENTAL
DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS
OXYGEN AND WATER VAPOR ENRICHING SYSTEM WITH HEATED DELIVERY
OXYGEN AND WATER VAPOR ENRICHING SYSTEM WITHOUT HEATED DELIVERY
CENTRIFUGE, FOR DIALYSIS
KIDNEY, DIALYSATE DELIVERY SYST. KIDNEY MACHINE, PUMP RECIRCULAT- ING, AIR
REMOVAL SYST, FLOWRATE METER, POWER OFF, HEATER AND TEMPERATURE CONTROL WITH
ALARM, I.V.POLES, PRESSURE GAUGE, CONCENTRATE CONTAINER
HEPARIN INFUSION PUMP FOR HEMODIALYSIS
AIR BUBBLE DETECTOR FOR HEMODIALYSIS, EACH, REPLACEMENT
PRESSURE ALARM FOR HEMODIALYSIS, EACH, REPLACEMENT
BATH CONDUCTIVITY METER FOR HEMODIALYSIS, EACH
BLOOD LEAK DETECTOR FOR HEMODIALYSIS, EACH, REPLACEMENT
ADJUSTABLE CHAIR, FOR ESRD PATIENTS
TRANSDUCER PROTECTORS/FLUID BARRIERS, FOR HEMODIALYSIS, ANY SIZE, PER 10
UNIPUNCTURE CONTROL SYSTEM FOR HEMODIALYSIS
HEMODIALYSIS MACHINE
AUTOMATIC INTERMITTENT PERITIONEAL DIALYSIS SYSTEM
CYCLER DIALYSIS MACHINE FOR PERITONEAL DIALYSIS
DELIVERY AND/OR INSTALLATION CHARGES FOR HEMODIALYSIS EQUIPMENT
REVERSE OSMOSIS WATER PURIFICATION SYSTEM, FOR HEMODIALYSIS
DEIONIZER WATER PURIFICATION SYSTEM, FOR HEMODIALYSIS
BLOOD PUMP FOR HEMODIALYSIS, REPLACEMENT
WATER SOFTENING SYSTEM, FOR HEMODIALYSIS
RECIPROCATING PERITONEAL DIALYSIS SYSTEM
WEARABLE ARTIFICIAL KIDNEY, EACH
PERITONEAL DIALYSIS CLAMPS, EACH
COMPACT (PORTABLE) TRAVEL HEMODIALYZER SYSTEM
SORBENT CARTRIDGES, FOR HEMODIALYSIS, PER 10
HEMOSTATS, EACH
SCALE, EACH
DIALYSIS EQUIPMENT, NOT OTHERWISE SPECIFIED
JAW MOTION REHABILITATION SYSTEM
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REPLACEMENT CUSHIONS FOR JAW MOTION REHABILITATION SYSTEM, PKG. OF 6
REPLACEMENT MEASURING SCALES FOR JAW MOTION REHABILITATION SYSTEM, PKG. OF 200
DYNAMIC ADJUSTABLE ELBOW EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE
MATERIAL
STATIC PROGRESSIVE STRETCH ELBOW DEVICE, EXTENSION AND/OR FLEXION, WITH OR
WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES
DYNAMIC ADJUSTABLE FOREARM PRONATION/SUPINATION DEVICE, INCLUDES SOFT INTERFACE
MATERIAL
DYNAMIC ADJUSTABLE WRIST EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE
MATERIAL
STATIC PROGRESSIVE STRETCH WRIST DEVICE, FLEXION AND/OR EXTENSION, WITH OR
WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES
DYNAMIC ADJUSTABLE KNEE EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE
MATERIAL
STATIC PROGRESSIVE STRETCH KNEE DEVICE, EXTENSION AND/OR FLEXION, WITH OR
WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES
DYNAMIC KNEE, EXTENSION/FLEXION DEVICE WITH ACTIVE RESISTANCE CONTROL
DYNAMIC ADJUSTABLE ANKLE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE
MATERIAL
STATIC PROGRESSIVE STRETCH ANKLE DEVICE, FLEXION AND/OR EXTENSION, WITH OR
WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES
STATIC PROGRESSIVE STRETCH FOREARM PRONATION / SUPINATION DEVICE, WITH OR
WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES
REPLACEMENT SOFT INTERFACE MATERIAL, DYNAMIC ADJUSTABLE EXTENSION/FLEXION DEVICE
REPLACEMENT SOFT INTERFACE MATERIAL/CUFFS FOR BI-DIRECTIONAL STATIC PROGRESSIVE
STRETCH DEVICE
DYNAMIC ADJUSTABLE FINGER EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE
MATERIAL
DYNAMIC ADJUSTABLE TOE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE
MATERIAL
STATIC PROGRESSIVE STRETCH TOE DEVICE, EXTENSION AND/OR FLEXION, WITH OR
WITHOUT RANGE OF MOTION ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES
DYNAMIC ADJUSTABLE SHOULDER FLEXION / ABDUCTION / ROTATION DEVICE, INCLUDES
SOFT INTERFACE MATERIAL
STATIC PROGRESSIVE STRETCH SHOULDER DEVICE, WITH OR WITHOUT RANGE OF MOTION
ADJUSTMENT, INCLUDES ALL COMPONENTS AND ACCESSORIES
COMMUNICATION BOARD, NON-ELECTRONIC AUGMENTATIVE OR ALTERNATIVE COMMUNICATION
DEVICE
GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC
BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER
BLOOD GLUCOSE MONITOR WITH INTEGRATED LANCING/BLOOD SAMPLE
PULSE GENERATOR SYSTEM FOR TYMPANIC TREATMENT OF INNER EAR ENDOLYMPHATIC FLUID
MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR
EQUAL TO 20 INCHES AND LESS THAN 24 INCHES
MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES
MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN 22
INCHES
MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES
MANUAL WHEELCHAIR ACCESSORY, HANDRIM WITHOUT PROJECTIONS (INCLUDES ERGONOMIC OR
CONTOURED), ANY TYPE, REPLACEMENT ONLY, EACH
MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, EACH
WHEELCHAIR ACCESSORY, CRUTCH AND CANE HOLDER, EACH
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WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH
ACCESSORY, ARM TROUGH, WITH OR WITHOUT HAND SUPPORT, EACH
WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE, REPLACEMENT ONLY, EACH
MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC PROPULSION TIRE (REMOVABLE),
ANY TYPE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED PROPULSION TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, FOAM PROPULSION TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) PROPULSION TIRE, ANY SIZE,
EACH
MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE),
ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATED
WHEEL, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, VALVE, ANY TYPE, REPLACEMENT ONLY, EACH
MANUAL WHEELCHAIR ACCESSORY, PROPULSION WHEEL EXCLUDES TIRE, ANY SIZE, EACH
MANUAL WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT
ONLY, EACH
MANUAL WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH
MANUAL WHEELCHAIR ACCESSORY, GEAR REDUCTION DRIVE WHEEL, EACH
MANUAL WHEELCHAIR ACCESSORY, WHEEL BRAKING SYSTEM AND LOCK, COMPLETE, EACH
MANUAL WHEELCHAIR ACCESSORY, MANUAL STANDING SYSTEM
MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT),
INCLUDES ANY TYPE MOUNTING HARDWARE
BACK, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE
SEAT, PLANAR, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING HARDWARE
BACK, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING
HARDWARE
SEAT, CONTOURED, FOR PEDIATRIC SIZE WHEELCHAIR INCLUDING FIXED ATTACHING
HARDWARE
MANUAL WHEELCHAIR ACCESSORY, FOR PEDIATRIC SIZE WHEELCHAIR, DYNAMIC SEATING
FRAME, ALLOWS COORDINATED MOVEMENT OF MULTIPLE POSITIONING FEATURES
POWER WHEELCHAIR ACCESSORY, POWER SEAT ELEVATION SYSTEM
POWER WHEELCHAIR ACCESSORY, POWER STANDING SYSTEM
POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER
AND ONE POWER SEATING SYSTEM MOTOR, INCLUDING ALL RELATED ELECTRONICS,
INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING
HARDWARE
POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER
AND TWO OR MORE POWER SEATING SYSTEM MOTORS, INCLUDING ALL RELATED ELECTRONICS,
INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING
HARDWARE
POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, MINI-PROPORTIONAL
REMOTE JOYSTICK, PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, HARNESS FOR UPGRADE TO EXPANDABLE CONTROLLER,
INCLUDING ALL FASTENERS, CONNECTORS AND MOUNTING HARDWARE, EACH
POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, REMOTE JOYSTICK,
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NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND
FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, MULTIPLE MECHANICAL
SWITCHES, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP
SWITCH, AND FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, SPECIALTY JOYSTICK HANDLE FOR HAND CONTROL
INTERFACE, PREFABRICATED
POWER WHEELCHAIR ACCESSORY, CHIN CUP FOR CHIN CONTROL INTERFACE
POWER WHEELCHAIR ACCESSORY, SIP AND PUFF INTERFACE, NONPROPORTIONAL, INCLUDING
ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND MANUAL SWINGAWAY MOUNTING
HARDWARE
POWER WHEELCHAIR ACCESSORY, BREATH TUBE KIT FOR SIP AND PUFF INTERFACE
POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, MECHANICAL, PROPORTIONAL,
INCLUDING ALL RELATED ELECTRONICS, MECHANICAL DIRECTION CHANGE SWITCH, AND
FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, HEAD CONTROL OR EXTREMITY CONTROL INTERFACE,
ELECTRONIC, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING
HARDWARE
POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, CONTACT SWITCH MECHANISM,
NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH,
MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, PROXIMITY SWITCH MECHANISM,
NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH,
MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, ATTENDANT CONTROL, PROPORTIONAL, INCLUDING ALL
RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 20-23 INCHES
POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES
POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 OR 21 INCHES
POWER WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22-25 INCHES
POWER WHEELCHAIR ACCESSORY, ELECTRONIC INTERFACE TO OPERATE SPEECH GENERATING
DEVICE USING POWER WHEELCHAIR CONTROL INTERFACE
POWER WHEELCHAIR ACCESSORY, 22 NF NON-SEALED LEAD ACID BATTERY, EACH
POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E.G. GEL
CELL, ABSORBED GLASSMAT)
POWER WHEELCHAIR ACCESSORY, GROUP 24 NON-SEALED LEAD ACID BATTERY, EACH
POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E.G. GEL
CELL, ABSORBED GLASSMAT)
POWER WHEELCHAIR ACCESSORY, U-1 NON-SEALED LEAD ACID BATTERY, EACH
POWER WHEELCHAIR ACCESSORY, U-1 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL,
ABSORBED GLASSMAT)
POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY ONE
BATTERY TYPE, SEALED OR NON-SEALED, EACH
POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER
BATTERY TYPE, SEALED OR NON-SEALED, EACH
POWER WHEELCHAIR COMPONENT, MOTOR, REPLACEMENT ONLY
POWER WHEELCHAIR COMPONENT, GEAR BOX, REPLACEMENT ONLY
POWER WHEELCHAIR COMPONENT, MOTOR AND GEAR BOX COMBINATION, REPLACEMENT ONLY
POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E.G. GEL CELL,
ABSORBED GLASSMAT), EACH
POWER WHEELCHAIR ACCESSORY, GROUP 27 NON-SEALED LEAD ACID BATTERY, EACH
POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, COMPACT REMOTE
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JOYSTICK, PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWARE
POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, STANDARD REMOTE
JOYSTICK (NOT INCLUDING CONTROLLER), PROPORTIONAL, INCLUDING ALL RELATED
ELECTRONICS AND FIXED MOUNTING HARDWARE, REPLACEMENT ONLY
POWER WHEELCHAIR ACCESSORY, NON-EXPANDABLE CONTROLLER, INCLUDING ALL RELATED
ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY
POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED
ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY
POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED
ELECTRONICS AND MOUNTING HARDWARE, UPGRADE PROVIDED AT INITIAL ISSUE
POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT
ONLY, EACH
POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE,
REPLACEMENT ONLY, EACH
POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE (REMOVABLE),
ANY TYPE, ANY SIZE, REPLACEMENT ONLY, EACH
POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY,
EACH
POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE,
REPLACEMENT ONLY, EACH
POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT
ONLY, EACH
POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT
ONLY, EACH
POWER WHEELCHAIR ACCESSORY, FOAM DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY,
EACH
POWER WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH
POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) DRIVE WHEEL TIRE, ANY SIZE,
REPLACEMENT ONLY, EACH
POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), ANY
SIZE, REPLACEMENT ONLY, EACH
POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATED
WHEEL, ANY SIZE, REPLACEMENT ONLY, EACH
POWER WHEELCHAIR ACCESSORY, VALVE FOR PNEUMATIC TIRE TUBE, ANY TYPE,
REPLACEMENT ONLY, EACH
POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT
ONLY, EACH
POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT
ONLY, EACH
POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH
POWER WHEELCHAIR ACCESSORY, LITHIUM-BASED BATTERY, EACH
POWER WHEELCHAIR ACCESSORY, NOT OTHERWISE CLASSIFIED INTERFACE, INCLUDING ALL
RELATED ELECTRONICS AND ANY TYPE MOUNTING HARDWARE
NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE
SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, LESS
THAN OR EQUAL TO 8 MINUTES RECORDING TIME
SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES,
GREATER THAN 8 MINUTES BUT LESS THAN OR EQUAL TO 20 MINUTES RECORDING TIME
SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES,
GREATER THAN 20 MINUTES BUT LESS THAN OR EQUAL TO 40 MINUTES RECORDING TIME
SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES,
GREATER THAN 40 MINUTES RECORDING TIME
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SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, REQUIRING MESSAGE FORMULATION BY
SPELLING AND ACCESS BY PHYSICAL CONTACT WITH THE DEVICE
SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, PERMITTING MULTIPLE METHODS OF
MESSAGE FORMULATION AND MULTIPLE METHODS OF DEVICE ACCESS
SPEECH GENERATING SOFTWARE PROGRAM, FOR PERSONAL COMPUTER OR PERSONAL DIGITAL
ASSISTANT
ACCESSORY FOR SPEECH GENERATING DEVICE, MOUNTING SYSTEM
ACCESSORY FOR SPEECH GENERATING DEVICE, NOT OTHERWISE CLASSIFIED
GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH
POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH
SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22
INCHES, ANY DEPTH
SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR
GREATER, ANY DEPTH
CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZE
WHEELCHAIR SEAT CUSHION, POWERED
GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT,
INCLUDING ANY TYPE MOUNTING HARDWARE
GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT,
INCLUDING ANY TYPE MOUNTING HARDWARE
POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY
HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, ANY
HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22
INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR
GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
CUSTOM FABRICATED WHEELCHAIR BACK CUSHION, ANY SIZE, INCLUDING ANY TYPE
MOUNTING HARDWARE
WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT), FOR USE
WITH MANUAL WHEELCHAIR OR LIGHTWEIGHT POWER WHEELCHAIR, INCLUDES ANY TYPE
MOUNTING HARDWARE
REPLACEMENT COVER FOR WHEELCHAIR SEAT CUSHION OR BACK CUSHION, EACH
POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH
LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH
22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES,
ANY DEPTH
SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR
GREATER, ANY DEPTH
SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS
THAN 22 INCHES, ANY DEPTH
SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22
INCHES OR GREATER, ANY DEPTH
GAIT TRAINER, PEDIATRIC SIZE, POSTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND
COMPONENTS
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GAIT TRAINER, PEDIATRIC SIZE, UPRIGHT SUPPORT, INCLUDES ALL ACCESSORIES AND
COMPONENTS
GAIT TRAINER, PEDIATRIC SIZE, ANTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND
COMPONENTS
ADMINISTRATION OF INFLUENZA VIRUS VACCINE
ADMINISTRATION OF PNEUMOCOCCAL VACCINE
ADMINISTRATION OF HEPATITIS B VACCINE
SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF SPERM EXCLUDING HUHNER
CERVICAL OR VAGINAL CANCER SCREENING; PELVIC AND CLINICAL BREAST EXAMINATION
PROSTATE CANCER SCREENING; DIGITAL RECTAL EXAMINATION
PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA)
COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK
COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY,
BARIUM ENEMA
DIABETES OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES, INDIVIDUAL, PER 30
MINUTES
DIABETES OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES, GROUP SESSION (2 OR
MORE), PER 30 MINUTES
GLAUCOMA SCREENING FOR HIGH RISK PATIENTS FURNISHED BY AN OPTOMETRIST OR
OPHTHALMOLOGIST
GLAUCOMA SCREENING FOR HIGH RISK PATIENT FURNISHED UNDER THE DIRECT SUPERVISION
OF AN OPTOMETRIST OR OPHTHALOMOLOGIST
COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0105, SCREENING COLONOSCOPY,
BARIUM ENEMA.
COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR
HIGH RISK
COLORECTAL CANCER SCREENING; BARIUM ENEMA
SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED
IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, SCREENING BY
CYTOTECHNOLOGIST UNDER PHYSICIAN SUPERVISION
SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED
IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, REQUIRING
INTERPRETATION BY PHYSICIAN
TRIMMING OF DYSTROPHIC NAILS, ANY NUMBER
DIRECT (FACE-TO-FACE WITH PATIENT) SKILLED NURSING SERVICES OF A REGISTERED
NURSE PROVIDED IN A COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY, EACH 10
MINUTES BEYOND THE FIRST 5 MINUTES
OCCUPATIONAL THERAPY SERVICES REQUIRING THE SKILLS OF A QUALIFIED OCCUPATIONAL
THERAPIST, FURNISHED AS A COMPONENT OF A PARTIAL HOSPITALIZATION TREATMENT
PROGRAM, PER SESSION (45 MINUTES OR MORE)
SINGLE ENERGY X-RAY ABSORPTIOMETRY (SEXA) BONE DENSITY STUDY, ONE OR MORE
SITES; APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL)
SCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, PERFORMED BY AUTOMATED
SYSTEM, WITH MANUAL RESCREENING, REQUIRING INTERPRETATION BY PHYSICIAN
SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED
IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, WITH MANUAL SCREENING
AND RESCREENING BY CYTOTECHNOLOGIST UNDER PHYSICIAN SUPERVISION
SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED
IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, WITH SCREENING BY
AUTOMATED SYSTEM, UNDER PHYSICIAN SUPERVISION
SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED
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IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, WITH SCREENING BY
AUTOMATED SYSTEM AND MANUAL RESCREENING UNDER PHYSICIAN SUPERVISION
SCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, PERFORMED BY AUTOMATED
SYSTEM UNDER PHYSICIAN SUPERVISION
SCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, PERFORMED BY AUTOMATED
SYSTEM WITH MANUAL RESCREENING
SERVICES PERFORMED BY A QUALIFIED PHYSICAL THERAPIST IN THE HOME HEALTH OR
HOSPICE SETTING, EACH 15 MINUTES
SERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL THERAPIST IN THE HOME HEALTH OR
HOSPICE SETTING, EACH 15 MINUTES
SERVICES PERFORMED BY A QUALIFIED SPEECH-LANGUAGE PATHOLOGIST IN THE HOME
HEALTH OR HOSPICE SETTING, EACH 15 MINUTES
DIRECT SKILLED NURSING SERVICES OF A LICENSED NURSE (LPN OR RN) IN THE HOME
HEALTH OR HOSPICE SETTING, EACH 15 MINUTES
SERVICES OF CLINICAL SOCIAL WORKER IN HOME HEALTH OR HOSPICE SETTINGS, EACH 15
MINUTES
SERVICES OF HOME HEALTH/HOSPICE AIDE IN HOME HEALTH OR HOSPICE SETTINGS, EACH
15 MINUTES
SERVICES PERFORMED BY A QUALIFIED PHYSICAL THERAPIST ASSISTANT IN THE HOME
HEALTH OR HOSPICE SETTING, EACH 15 MINUTES
SERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL THERAPIST ASSISTANT IN THE HOME
HEALTH OR HOSPICE SETTING, EACH 15 MINUTES
SERVICES PERFORMED BY A QUALIFIED PHYSICAL THERAPIST, IN THE HOME HEALTH
SETTING, IN THE ESTABLISHMENT OR DELIVERY OF A SAFE AND EFFECTIVE THERAPY
MAINTENANCE PROGRAM, EACH 15 MINUTES
SERVICES PERFORMED BY A QUALIFIED OCCUPATIONAL THERAPIST, IN THE HOME HEALTH
SETTING, IN THE ESTABLISHMENT OR DELIVERY OF A SAFE AND EFFECTIVE THERAPY
MAINTENANCE PROGRAM, EACH 15 MINUTES
SERVICES PERFORMED BY A QUALIFIED SPEECH-LANGUAGE PATHOLOGIST, IN THE HOME
HEALTH SETTING, IN THE ESTABLISHMENT OR DELIVERY OF A SAFE AND EFFECTIVE
THERAPY MAINTENANCE PROGRAM, EACH 15 MINUTES
SKILLED SERVICES BY A REGISTERED NURSE (RN) IN THE DELIVERY OF MANAGEMENT &
EVALUATION OF THE PLAN OF CARE; EACH 15 MINUTES (THE PATIENT'S UNDERLYING
CONDITION OR COMPLICATION REQUIRES AN RN TO ENSURE THAT ESSENTIAL NON-SKILLED
CARE ACHIEVE ITS PURPOSE IN THE HOME HEALTH OR HOSPICE SETTING)
SKILLED SERVICES OF A LICENSED NURSE (LPN OR RN) IN THE DELIVERY OF OBSERVATION
& ASSESSMENT OF THE PATIENT'S CONDITION, EACH 15 MINUTES (WHEN THE LIKELIHOOD
OF CHANGE IN THE PATIENT'S CONDITION REQUIRES SKILLED NURSING PERSONNEL TO
IDENTIFY AND EVALUATE THE PATIENT'S NEED FOR POSSIBLE MODIFICATION OF TREATMENT
IN THE HOME HEALTH OR HOSPICE SETTING)
SKILLED SERVICES OF A LICENSED NURSE, IN THE TRAINING AND/OR EDUCATION OF A
PATIENT OR FAMILY MEMBER, IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES
EXTERNAL COUNTERPULSATION, PER TREATMENT SESSION
WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY
LINEAR ACCELERATOR BASED STEREOTACTIC RADIOSURGERY, COMPLETE COURSE OF THERAPY
IN ONE SESSION
SCHEDULED INTERDISCIPLINARY TEAM CONFERENCE (MINIMUM OF THREE EXCLUSIVE OF
PATIENT CARE NURSING STAFF) WITH PATIENT PRESENT
ACTIVITY THERAPY, SUCH AS MUSIC, DANCE, ART OR PLAY THERAPIES NOT FOR
RECREATION, RELATED TO THE CARE AND TREATMENT OF PATIENT'S DISABLING MENTAL
HEALTH PROBLEMS, PER SESSION (45 MINUTES OR MORE)
TRAINING AND EDUCATIONAL SERVICES RELATED TO THE CARE AND TREATMENT OF
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PATIENT'S DISABLING MENTAL HEALTH PROBLEMS PER SESSION (45 MINUTES OR MORE)
PHYSICIAN RE-CERTIFICATION FOR MEDICARE-COVERED HOME HEALTH SERVICES UNDER A
HOME HEALTH PLAN OF CARE (PATIENT NOT PRESENT), INCLUDING CONTACTS WITH HOME
HEALTH AGENCY AND REVIEW OF REPORTS OF PATIENT STATUS REQUIRED BY PHYSICIANS TO
AFFIRM THE INITIAL IMPLEMENTATION OF THE PLAN OF CARE THAT MEETS PATIENT'S
NEEDS, PER RE-CERTIFICATION PERIOD
PHYSICIAN CERTIFICATION FOR MEDICARE-COVERED HOME HEALTH SERVICES UNDER A HOME
HEALTH PLAN OF CARE (PATIENT NOT PRESENT), INCLUDING CONTACTS WITH HOME HEALTH
AGENCY AND REVIEW OF REPORTS OF PATIENT STATUS REQUIRED BY PHYSICIANS TO AFFIRM
THE INITIAL IMPLEMENTATION OF THE PLAN OF CARE THAT MEETS PATIENT'S NEEDS, PER
CERTIFICATION PERIOD
PHYSICIAN SUPERVISION OF A PATIENT RECEIVING MEDICARE-COVERED SERVICES PROVIDED
BY A PARTICIPATING HOME HEALTH AGENCY (PATIENT NOT PRESENT) REQUIRING COMPLEX
AND MULTIDISCIPLINARY CARE MODALITIES INVOLVING REGULAR PHYSICIAN DEVELOPMENT
AND/OR REVISION OF CARE PLANS, REVIEW OF SUBSEQUENT REPORTS OF PATIENT STATUS,
REVIEW OF LABORATORY AND OTHER STUDIES, COMMUNICATION (INCLUDING TELEPHONE
CALLS) WITH OTHER HEALTH CARE PROFESSIONALS INVOLVED IN THE PATIENT'S CARE,
INTEGRATION OF NEW INFORMATION INTO THE MEDICAL TREATMENT PLAN AND/OR
ADJUSTMENT OF MEDICAL THERAPY, WITHIN A CALENDAR MONTH, 30 MINUTES OR MORE
PHYSICIAN SUPERVISION OF A PATIENT UNDER A MEDICARE-APPROVED HOSPICE (PATIENT
NOT PRESENT) REQUIRING COMPLEX AND MULTIDISCIPLINARY CARE MODALITIES INVOLVING
REGULAR PHYSICIAN DEVELOPMENT AND/OR REVISION OF CARE PLANS, REVIEW OF
SUBSEQUENT REPORTS OF PATIENT STATUS, REVIEW OF LABORATORY AND OTHER STUDIES,
COMMUNICATION (INCLUDING TELEPHONE CALLS) WITH OTHER HEALTH CARE PROFESSIONALS
INVOLVED IN THE PATIENT'S CARE, INTEGRATION OF NEW INFORMATION INTO THE MEDICAL
TREATMENT PLAN AND/OR ADJUSTMENT OF MEDICAL THERAPY, WITHIN A CALENDAR MONTH,
30 MINUTES OR MORE
DESTRUCTION OF LOCALIZED LESION OF CHOROID (FOR EXAMPLE, CHOROIDAL
NEOVASCULARIZATION); PHOTOCOAGULATION, FEEDER VESSEL TECHNIQUE (ONE OR MORE
SESSIONS)
SCREENING MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, BILATERAL, ALL VIEWS
DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, BILATERAL, ALL VIEWS
DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, UNILATERAL, ALL VIEWS
PET IMAGING WHOLE BODY; MELANOMA FOR NON-COVERED INDICATIONS
PET IMAGING, ANY SITE, NOT OTHERWISE SPECIFIED
THERAPEUTIC PROCEDURES TO INCREASE STRENGTH OR ENDURANCE OF RESPIRATORY
MUSCLES, FACE TO FACE, ONE ON ONE, EACH 15 MINUTES (INCLUDES MONITORING)
THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION, OTHER THAN DESCRIBED BY
G0237, ONE ON ONE, FACE TO FACE, PER 15 MINUTES (INCLUDES MONITORING)
THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION OR INCREASE STRENGTH OR
ENDURANCE OF RESPIRATORY MUSCLES, TWO OR MORE INDIVIDUALS (INCLUDES MONITORING)
INITIAL PHYSICIAN EVALUATION AND MANAGEMENT OF A DIABETIC PATIENT WITH DIABETIC
SENSORY NEUROPATHY RESULTING IN A LOSS OF PROTECTIVE SENSATION (LOPS) WHICH
MUST INCLUDE: (1) THE DIAGNOSIS OF LOPS, (2) A PATIENT HISTORY, (3) A PHYSICAL
EXAMINATION THAT CONSISTS OF AT LEAST THE FOLLOWING ELEMENTS: (A) VISUAL
INSPECTION OF THE FOREFOOT, HINDFOOT AND TOE WEB SPACES, (B)EVALUATION OF A
PROTECTIVE SENSATION, (C) EVALUATION OF FOOT STRUCTURE AND BIOMECHANICS, (D)
EVALUATION OF VASCULAR STATUS AND SKIN INTEGRITY, AND (E) EVALUATION AND
RECOMMENDATION OF FOOTWEAR AND (4) PATIENT EDUCATION
FOLLOW-UP PHYSICIAN EVALUATION AND MANAGEMENT OF A DIABETIC PATIENT WITH
DIABETIC SENSORY NEUROPATHY RESULTING IN A LOSS OF PROTECTIVE SENSATION (LOPS)
TO INCLUDE AT LEAST THE FOLLOWING: (1) A PATIENT HISTORY, (2) A PHYSICAL
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EXAMINATION THAT INCLUDES: (A) VISUAL INSPECTION OF THE FOREFOOT, HINDFOOT AND
TOE WEB SPACES, (B) EVALUATION OF PROTECTIVE SENSATION, (C) EVALUATION OF FOOT
STRUCTURE AND BIOMECHANICS, (D) EVALUATION OF VASCULAR STATUS AND SKIN
INTEGRITY, AND (E) EVALUATION AND RECOMMENDATION OF FOOTWEAR, AND (3) PATIENT
EDUCATION
ROUTINE FOOT CARE BY A PHYSICIAN OF A DIABETIC PATIENT WITH DIABETIC SENSORY
NEUROPATHY RESULTING IN A LOSS OF PROTECTIVE SENSATION (LOPS) TO INCLUDE, THE
LOCAL CARE OF SUPERFICIAL WOUNDS (I.E. SUPERFICIAL TO MUSCLE AND FASCIA) AND AT
LEAST THE FOLLOWING IF PRESENT: (1) LOCAL CARE OF SUPERFICIAL WOUNDS, (2)
DEBRIDEMENT OF CORNS AND CALLUSES, AND (3) TRIMMING AND DEBRIDEMENT OF NAILS
DEMONSTRATION, PRIOR TO INITIATION OF HOME INR MONITORING, FOR PATIENT WITH
EITHER MECHANICAL HEART VALVE(S), CHRONIC ATRIAL FIBRILLATION, OR VENOUS
THROMBOEMBOLISM WHO MEETS MEDICARE COVERAGE CRITERIA, UNDER THE DIRECTION OF A
PHYSICIAN; INCLUDES: FACE-TO-FACE DEMONSTRATION OF USE AND CARE OF THE INR
MONITOR, OBTAINING AT LEAST ONE BLOOD SAMPLE, PROVISION OF INSTRUCTIONS FOR
REPORTING HOME INR TEST RESULTS, AND DOCUMENTATION OF PATIENT'S ABILITY TO
PERFORM TESTING AND REPORT RESULTS
PROVISION OF TEST MATERIALS AND EQUIPMENT FOR HOME INR MONITORING OF PATIENT
WITH EITHER MECHANICAL HEART VALVE(S), CHRONIC ATRIAL FIBRILLATION, OR VENOUS
THROMBOEMBOLISM WHO MEETS MEDICARE COVERAGE CRITERIA; INCLUDES: PROVISION OF
MATERIALS FOR USE IN THE HOME AND REPORTING OF TEST RESULTS TO PHYSICIAN;
TESTING NOT OCCURRING MORE FREQUENTLY THAN ONCE A WEEK; TESTING MATERIALS,
BILLING UNITS OF SERVICE INCLUDE 4 TESTS
PHYSICIAN REVIEW, INTERPRETATION, AND PATIENT MANAGEMENT OF HOME INR TESTING
FOR PATIENT WITH EITHER MECHANICAL HEART VALVE(S), CHRONIC ATRIAL FIBRILLATION,
OR VENOUS THROMBOEMBOLISM WHO MEETS MEDICARE COVERAGE CRITERIA; TESTING NOT
OCCURRING MORE FREQUENTLY THAN ONCE A WEEK; BILLING UNITS OF SERVICE INCLUDE 4
TESTS
LINEAR ACCELERATOR BASED STEREOTACTIC RADIOSURGERY, DELIVERY INCLUDING
COLLIMATOR CHANGES AND CUSTOM PLUGGING, FRACTIONATED TREATMENT, ALL LESIONS,
PER SESSION, MAXIMUM FIVE SESSIONS PER COURSE OF TREATMENT
PET IMAGING, FULL AND PARTIAL-RING PET SCANNERS ONLY, FOR INITIAL DIAGNOSIS OF
BREAST CANCER AND/OR SURGICAL PLANNING FOR BREAST CANCER (E.G. INITIAL STAGING
OF AXILLARY LYMPH NODES)
CURRENT PERCEPTION THRESHOLD/SENSORY NERVE CONDUCTION TEST, (SNCT) PER LIMB,
ANY NERVE
UNSCHEDULED OR EMERGENCY DIALYSIS TREATMENT FOR AN ESRD PATIENT IN A HOSPITAL
OUTPATIENT DEPARTMENT THAT IS NOT CERTIFIED AS AN ESRD FACILITY
INJECTION PROCEDURE FOR SACROILIAC JOINT; ARTHROGRAPY
INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID
AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY
CRYOPRESERVATION, FREEZING AND STORAGE OF CELLS FOR THERAPEUTIC USE, EACH CELL
LINE
THAWING AND EXPANSION OF FROZEN CELLS FOR THERAPEUTIC USE, EACH ALIQUOT
BONE MARROW OR PERIPHERAL STEM CELL HARVEST, MODIFICATION OR TREATMENT TO
ELIMINATE CELL TYPE(S) (E.G. T-CELLS, METASTATIC CARCINOMA)
REMOVAL OF IMPACTED CERUMEN (ONE OR BOTH EARS) BY PHYSICIAN ON SAME DATE OF
SERVICE AS AUDIOLOGIC FUNCTION TESTING
PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE,
POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G. ANGIOSEAL PLUG, VASCULAR PLUG)
MEDICAL NUTRITION THERAPY; REASSESSMENT AND SUBSEQUENT INTERVENTION(S)
FOLLOWING SECOND REFERRAL IN SAME YEAR FOR CHANGE IN DIAGNOSIS, MEDICAL
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CONDITION OR TREATMENT REGIMEN (INCLUDING ADDITIONAL HOURS NEEDED FOR RENAL
DISEASE), INDIVIDUAL, FACE TO FACE WITH THE PATIENT, EACH 15 MINUTES
MEDICAL NUTRITION THERAPY, REASSESSMENT AND SUBSEQUENT INTERVENTION(S)
FOLLOWING SECOND REFERRAL IN SAME YEAR FOR CHANGE IN DIAGNOSIS, MEDICAL
CONDITION, OR TREATMENT REGIMEN (INCLUDING ADDITIONAL HOURS NEEDED FOR RENAL
DISEASE), GROUP (2 OR MORE INDIVIDUALS), EACH 30 MINUTES
RENAL ANGIOGRAPHY, NON-SELECTIVE, ONE OR BOTH KIDNEYS, PERFORMED AT THE SAME
TIME AS CARDIAC CATHETERIZATION AND/OR CORONARY ANGIOGRAPHY, INCLUDES
POSITIONING OR PLACEMENT OF ANY CATHETER IN THE ABDOMINAL AORTA AT OR NEAR THE
ORIGINS (OSTIA) OF THE RENAL ARTERIES, INJECTION OF DYE, FLUSH AORTOGRAM,
PRODUCTION OF PERMANENT IMAGES, AND RADIOLOGIC SUPERVISION AND INTERPRETATION
(LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE)
ILIAC AND/OR FEMORAL ARTERY ANGIOGRAPHY, NON-SELECTIVE, BILATERAL OR
IPSILATERAL TO CATHETER INSERTION, PERFORMED AT THE SAME TIME AS CARDIAC
CATHETERIZATION AND/OR CORONARY ANGIOGRAPHY, INCLUDES POSITIONING OR PLACEMENT
OF THE CATHETER IN THE DISTAL AORTA OR IPSILATERAL FEMORAL OR ILIAC ARTERY,
INJECTION OF DYE, PRODUCTION OF PERMANENT IMAGES, AND RADIOLOGIC SUPERVISION
AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE)
ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR CHRONIC STAGE
III AND STAGE IV PRESSURE ULCERS, ARTERIAL ULCERS, DIABETIC ULCERS, AND VENOUS
STATSIS ULCERS NOT DEMONSTRATING MEASURABLE SIGNS OF HEALING AFTER 30 DAYS OF
CONVENTIONAL CARE, AS PART OF A THERAPY PLAN OF CARE
ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR WOUND CARE
OTHER THAN DESCRIBED IN G0281
ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S)
OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE
RECONSTRUCTION, COMPUTED TOMOGRAPHIC ANGIOGRAPHY OF AORTA FOR SURGICAL PLANNING
FOR VASCULAR SURGERY
ARTHROSCOPY, KNEE, SURGICAL, FOR REMOVAL OF LOOSE BODY, FOREIGN BODY,
DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHRONDROPLASTY) AT THE TIME OF
OTHER SURGICAL KNEE ARTHROSCOPY IN A DIFFERENT COMPARTMENT OF THE SAME KNEE
TRANSCATHETER PLACEMENT OF A DRUG ELUTING INTRACORONARY STENT(S), PERCUTANEOUS,
WITH OR WITHOUT OTHER THERAPEUTIC INTERVENTION, ANY METHOD; SINGLE VESSEL
TRANSCATHETER PLACEMENT OF A DRUG ELUTING INTRACORONARY STENT(S), PERCUTANEOUS,
WITH OR WITHOUT OTHER THERAPEUTIC INTERVENTION, ANY METHOD; EACH ADDITIONAL
VESSEL
NONCOVERED SURGICAL PROCEDURE(S) USING CONSCIOUS SEDATION, REGIONAL, GENERAL OR
SPINAL ANESTHESIA IN A MEDICARE QUALIFYING CLINICAL TRIAL, PER DAY
NONCOVERED PROCEDURE(S) USING EITHER NO ANESTHESIA OR LOCAL ANESTHESIA ONLY, IN
A MEDICARE QUALIFYING CLINICAL TRIAL, PER DAY
ELECTROMAGNETIC THERAPY, TO ONE OR MORE AREAS, FOR WOUND CARE OTHER THAN
DESCRIBED IN G0329 OR FOR OTHER USES
INSERTION OF SINGLE CHAMBER PACING CARDIOVERTER DEFIBRILLATOR PULSE GENERATOR
INSERTION OF DUAL CHAMBER PACING CARDIOVERTER DEFIBRILLATOR PULSE GENERATOR
INSERTION OR REPOSITIONING OF ELECTRODE LEAD FOR SINGLE CHAMBER PACING
CARDIOVERTER DEFIBRILLATOR AND INSERTION OF PULSE GENERATOR
INSERTION OR REPOSITIONING OF ELECTRODE LEAD(S) FOR DUAL CHAMBER PACING
CARDIOVERTER DEFIBRILLATOR AND INSERTION OF PULSE GENERATOR
PRE-OPERATIVE PULMONARY SURGERY SERVICES FOR PREPARATION FOR LVRS, COMPLETE
COURSE OF SERVICES, TO INCLUDE A MINIMUM OF 16 DAYS OF SERVICES
PRE-OPERATIVE PULMONARY SURGERY SERVICES FOR PREPARATION FOR LVRS, 10 TO 15
DAYS OF SERVICES
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PRE-OPERATIVE PULMONARY SURGERY SERVICES FOR PREPARATION FOR LVRS, 1 TO 9 DAYS
OF SERVICES
POST-DISCHARGE PULMONARY SURGERY SERVICES AFTER LVRS, MINIMUM OF 6 DAYS OF
SERVICES
COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, WITHOUT PLATELET COUNT) AND
AUTOMATED WBC DIFFERENTIAL COUNT
COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC; WITHOUT PLATELET COUNT)
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,
FOR PATIENTS UNDER 2 YEARS OF AGE TO INCLUDE MONITORING FOR THE ADEQUACY OF
NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF PARENTS;
WITH 4 OR MORE FACE-TO-FACE PHYSICIAN VISITS PER MONTH
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT
FOR PATIENTS UNDER 2 YEARS OF AGE TO INCLUDE MONITORING FOR THE ADEQUACY OF
NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF PARENTS;
WITH 2 OR 3 FACE-TO-FACE PHYSICIAN VISITS PER MONTH
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,
FOR PATIENTS UNDER 2 YEARS OF AGE TO INCLUDE MONITORING FOR THE ADEQUACY OF
NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF PARENTS;
WITH 1 FACE-TO-FACE PHYSICIAN VISIT PER MONTH
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,
FOR PATIENTS BETWEEN 2 AND 11 YEARS OF AGE TO INCLUDE MONITORING FOR THE
ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF
PARENTS; WITH 4 OR MORE FACE-TO-FACE PHYSICIAN VISITS PER MONTH
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,
FOR PATIENTS BETWEEN 2 AND 11 YEARS OF AGE TO INCLUDE MONITORING FOR THE
ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF
PARENTS; WITH 2 OR 3 FACE-TO-FACE PHYSICIAN VISITS PER MONTH
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,
FOR PATIENTS BETWEEN 2 AND 11 YEARS OF AGE TO INCLUDE MONITORING FOR THE
ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF
PARENTS; WITH 1 FACE-TO-FACE PHYSICIAN VISIT PER MONTH
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES, DURING THE COURSE OF
TREATMENT, FOR PATIENTS BETWEEN 12 AND 19 YEARS OF AGE TO INCLUDE MONITORING
FOR THE ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND
COUNSELING OF PARENTS; WITH 4 OR MORE FACE-TO-FACE PHYSICIAN VISITS PER MONTH
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,
FOR PATIENTS BETWEEN 12 AND 19 YEARS OF AGE TO INCLUDE MONITORING FOR THE
ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF
PARENTS; WITH 2 OR 3 FACE-TO-FACE PHYSICIAN VISITS PER MONTH
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,
FOR PATIENTS BETWEEN 12 AND 19 YEARS OF AGE TO INCLUDE MONITORING FOR THE
ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF
PARENTS; WITH 1 FACE-TO-FACE PHYSICIAN VISIT PER MONTH
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,
FOR PATIENTS 20 YEARS OF AGE AND OVER; WITH 4 OR MORE FACE-TO-FACE PHYSICIAN
VISITS PER MONTH
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,
FOR PATIENTS 20 YEARS OF AGE AND OVER; WITH 2 OR 3 FACE-TO-FACE PHYSICIAN
VISITS PER MONTH
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT,
FOR PATIENTS 20 YEARS OF AGE AND OVER; WITH 1 FACE-TO-FACE PHYSICIAN VISIT PER
MONTH
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END STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR HOME DIALYSIS PATIENTS PER
FULL MONTH; FOR PATIENTS UNDER TWO YEARS OF AGE TO INCLUDE MONITORING FOR
ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF
PARENTS
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR HOME DIALYSIS PATIENTS PER
FULL MONTH; FOR PATIENTS TWO TO ELEVEN YEARS OF AGE TO INCLUDE MONITORING FOR
ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF
PARENTS
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR HOME DIALYSIS PATIENTS PER
FULL MONTH; FOR PATIENTS TWELVE TO NINETEEN YEARS OF AGE TO INCLUDE MONITORING
FOR ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING
OF PARENTS
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR HOME DIALYSIS PATIENTS PER
FULL MONTH; FOR PATIENTS TWENTY YEARS OF AGE AND OLDER
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES LESS THAN FULL MONTH, PER DAY;
FOR PATIENTS UNDER TWO YEARS OF AGE
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES LESS THAN FULL MONTH, PER DAY;
FOR PATIENTS BETWEEN TWO AND ELEVEN YEARS OF AGE
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES LESS THAN FULL MONTH, PER DAY;
FOR PATIENTS BETWEEN TWELVE AND NINETEEN YEARS OF AGE
END STAGE RENAL DISEASE (ESRD) RELATED SERVICES LESS THAN FULL MONTH, PER DAY;
FOR PATIENTS TWENTY YEARS OF AGE AND OVER
COLORECTAL CANCER SCREENING; FECAL OCCULT BLOOD TEST, IMMUNOASSAY, 1-3
SIMULTANEOUS
ELECTROMAGNETIC THERAPY, TO ONE OR MORE AREAS FOR CHRONIC STAGE III AND STAGE
IV PRESSURE ULCERS, ARTERIAL ULCERS, DIABETIC ULCERS AND VENOUS STASIS ULCERS
NOT DEMONSTRATING MEASURABLE SIGNS OF HEALING AFTER 30 DAYS OF CONVENTIONAL
CARE AS PART OF A THERAPY PLAN OF CARE
SERVICES FOR INTRAVENOUS INFUSION OF IMMUNOGLOBULIN PRIOR TO ADMINISTRATION
(THIS SERVICE IS TO BE BILLED IN CONJUNCTION WITH ADMINISTRATION OF
IMMUNOGLOBULIN)
PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); INITIAL 30-DAY SUPPLY AS A
BENEFICIARY
HOSPICE EVALUATION AND COUNSELING SERVICES, PRE-ELECTION
IMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY,
COMPLETE COURSE OF THERAPY IN ONE SESSION OR FIRST SESSION OF FRACTIONATED
TREATMENT
IMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY,
DELIVERY INCLUDING COLLIMATOR CHANGES AND CUSTOM PLUGGING, FRACTIONATED
TREATMENT, ALL LESIONS, PER SESSION, SECOND THROUGH FIFTH SESSIONS, MAXIMUM
FIVE SESSIONS PER COURSE OF TREATMENT
PERCUTANEOUS ISLET CELL TRANSPLANT, INCLUDES PORTAL VEIN CATHETERIZATION AND
INFUSION
LAPAROSCOPY FOR ISLET CELL TRANSPLANT, INCLUDES PORTAL VEIN CATHETERIZATION AND
INFUSION
LAPAROTOMY FOR ISLET CELL TRANSPLANT, INCLUDES PORTAL VEIN CATHETERIZATION AND
INFUSION
INITIAL PREVENTIVE PHYSICAL EXAMINATION; FACE-TO-FACE VISIT, SERVICES LIMITED
TO A NEW BENEFICIARY DURING THE FIRST 12 MONTHS OF MEDICARE ENROLLMENT
BONE MARROW ASPIRATION PERFORMED WITH BONE MARROW BIOPSY THROUGH THE SAME
INCISION ON THE SAME DATE OF SERVICE
VESSEL MAPPING OF VESSELS FOR HEMODIALYSIS ACCESS (SERVICES FOR PREOPERATIVE
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VESSEL MAPPING PRIOR TO CREATION OF HEMODIALYSIS ACCESS USING AN AUTOGENOUS
HEMODIALYSIS CONDUIT, INCLUDING ARTERIAL INFLOW AND VENOUS OUTFLOW)
ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; PERFORMED AS A COMPONENT OF THE
INITIAL PREVENTIVE EXAMINATION WITH INTERPRETATION AND REPORT
TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A COMPONENT OF
THE INITIAL PREVENTIVE EXAMINATION
INTERPRETATION AND REPORT ONLY, PERFORMED AS A COMPONENT OF THE INITIAL
PREVENTIVE EXAMINATION
PHYSICIAN SERVICE REQUIRED TO ESTABLISH AND DOCUMENT THE NEED FOR A POWER
MOBILITY DEVICE
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT; INTERMEDIATE, GREATER THAN
3 MINUTES UP TO 10 MINUTES
SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT; INTENSIVE, GREATER THAN 10
MINUTES
ADMINISTRATION OF VACCINE FOR PART D DRUG
HOSPITAL OBSERVATION SERVICE, PER HOUR
DIRECT ADMISSION OF PATIENT FOR HOSPITAL OBSERVATION CARE
LEVEL 1 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY
DEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1)
IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAW
AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC
(BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDES
CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A
PREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY
PRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR 489.24 IS
BEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED
DURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITS
OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON AN
URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)
LEVEL 2 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY
DEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1)
IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAW
AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC
(BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDES
CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A
PREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY
PRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR 489.24 IS
BEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED
DURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITS
OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON AN
URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)
LEVEL 3 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY
DEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1)
IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAW
AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC
(BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDES
CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A
PREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY
PRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR 489.24 IS
BEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED
DURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITS
OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON AN
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URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)
LEVEL 4 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY
DEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1)
IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAW
AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC
(BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDES
CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A
PREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY
PRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR 489.24 IS
BEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED
DURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITS
OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON AN
URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)
LEVEL 5 HOSPITAL EMERGENCY DEPARTMENT VISIT PROVIDED IN A TYPE B EMERGENCY
DEPARTMENT; (THE ED MUST MEET AT LEAST ONE OF THE FOLLOWING REQUIREMENTS: (1)
IT IS LICENSED BY THE STATE IN WHICH IT IS LOCATED UNDER APPLICABLE STATE LAW
AS AN EMERGENCY ROOM OR EMERGENCY DEPARTMENT; (2) IT IS HELD OUT TO THE PUBLIC
(BY NAME, POSTED SIGNS, ADVERTISING, OR OTHER MEANS) AS A PLACE THAT PROVIDES
CARE FOR EMERGENCY MEDICAL CONDITIONS ON AN URGENT BASIS WITHOUT REQUIRING A
PREVIOUSLY SCHEDULED APPOINTMENT; OR (3) DURING THE CALENDAR YEAR IMMEDIATELY
PRECEDING THE CALENDAR YEAR IN WHICH A DETERMINATION UNDER 42 CFR 489.24 IS
BEING MADE, BASED ON A REPRESENTATIVE SAMPLE OF PATIENT VISITS THAT OCCURRED
DURING THAT CALENDAR YEAR, IT PROVIDES AT LEAST ONE-THIRD OF ALL OF ITS
OUTPATIENT VISITS FOR THE TREATMENT OF EMERGENCY MEDICAL CONDITIONS ON AN
URGENT BASIS WITHOUT REQUIRING A PREVIOUSLY SCHEDULED APPOINTMENT)
ULTRASOUND B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; FOR ABDOMINAL
AORTIC ANEURYSM (AAA) SCREENING
TRAUMA RESPONSE TEAM ASSOCIATED WITH HOSPITAL CRITICAL CARE SERVICE
TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; FOR MAINTENANCE OF HEMODIALYSIS
ACCESS, ARTERIOVENOUS FISTULA OR GRAFT; ARTERIAL
TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; FOR MAINTENANCE OF HEMODIALYSIS
ACCESS, ARTERIOVENOUS FISTULA OR GRAFT; VENOUS
BLOOD OCCULT TEST (E.G., GUAIAC), FECES, FOR SINGLE DETERMINATION FOR
COLORECTAL NEOPLASM (I.E., PATIENT WAS PROVIDED THREE CARDS OR SINGLE TRIPLE
CARD FOR CONSECUTIVE COLLECTION)
ALCOHOL AND/OR SUBSTANCE (OTHER THAN TOBACCO) ABUSE STRUCTURED ASSESSMENT
(E.G., AUDIT, DAST), AND BRIEF INTERVENTION 15 TO 30 MINUTES
ALCOHOL AND/OR SUBSTANCE (OTHER THAN TOBACCO) ABUSE STRUCTURED ASSESSMENT
(E.G., AUDIT, DAST), AND INTERVENTION, GREATER THAN 30 MINUTES
HOME SLEEP STUDY TEST (HST) WITH TYPE II PORTABLE MONITOR, UNATTENDED; MINIMUM
OF 7 CHANNELS: EEG, EOG, EMG, ECG/HEART RATE, AIRFLOW, RESPIRATORY EFFORT AND
OXYGEN SATURATION
HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4
CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN
SATURATION
HOME SLEEP TEST (HST) WITH TYPE IV PORTABLE MONITOR, UNATTENDED; MINIMUM OF 3
CHANNELS
INITIAL PREVENTIVE PHYSICAL EXAMINATION; FACE-TO-FACE VISIT, SERVICES LIMITED
TO NEW BENEFICIARY DURING THE FIRST 12 MONTHS OF MEDICARE ENROLLMENT
ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; PERFORMED AS A SCREENING FOR THE
INITIAL PREVENTIVE PHYSICAL EXAMINATION WITH INTERPRETATION AND REPORT
ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; TRACING ONLY, WITHOUT
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INTERPRETATION AND REPORT, PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE
PHYSICAL EXAMINATION
ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; INTERPRETATION AND REPORT ONLY,
PERFORMED AS A SCREENING FOR THE INITIAL PREVENTIVE PHYSICAL EXAMINATION
FOLLOW-UP INPATIENT TELEHEALTH CONSULTATION, LIMITED, PHYSICIANS TYPICALLY
SPEND 15 MINUTES COMMUNICATING WITH THE PATIENT VIA TELEHEALTH
FOLLOW-UP INPATIENT TELEHEALTH CONSULTATION, INTERMEDIATE, PHYSICIANS TYPICALLY
SPEND 25 MINUTES COMMUNICATING WITH THE PATIENT VIA TELEHEALTH
FOLLOW-UP INPATIENT TELEHEALTH CONSULTATION, COMPLEX, PHYSICIANS TYPICALLY
SPEND 35 MINUTES OR MORE COMMUNICATING WITH THE PATIENT VIA TELEHEALTH
SOCIAL WORK AND PSYCHOLOGICAL SERVICES, DIRECTLY RELATING TO AND/OR FURTHERING
THE PATIENT'S REHABILITATION GOALS, EACH 15 MINUTES, FACE-TO-FACE; INDIVIDUAL
(SERVICES PROVIDED BY A CORF-QUALIFIED SOCIAL WORKER OR PSYCHOLOGIST IN A CORF)
GROUP PSYCHOTHERAPY OTHER THAN OF A MULTIPLE-FAMILY GROUP, IN A PARTIAL
HOSPITALIZATION SETTING, APPROXIMATELY 45 TO 50 MINUTES
INTERACTIVE GROUP PSYCHOTHERAPY, IN A PARTIAL HOSPITALIZATION SETTING,
APPROXIMATELY 45 TO 50 MINUTES
OPEN TREATMENT OF ILIAC SPINE(S), TUBEROSITY AVULSION, OR ILIAC WING
FRACTURE(S), UNILATERAL OR BILATERAL FOR PELVIC BONE FRACTURE PATTERNS WHICH DO
NOT DISRUPT THE PELVIC RING INCLUDES INTERNAL FIXATION, WHEN PERFORMED
PERCUTANEOUS SKELETAL FIXATION OF POSTERIOR PELVIC BONE FRACTURE AND/OR
DISLOCATION, FOR FRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR
BILATERAL, (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM)
OPEN TREATMENT OF ANTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION FOR FRACTURE
PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL, INCLUDES
INTERNAL FIXATION WHEN PERFORMED (INCLUDES PUBIC SYMPHYSIS AND/OR
SUPERIOR/INFERIOR RAMI)
OPEN TREATMENT OF POSTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION, FOR
FRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL,
INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ILIUM, SACROILIAC JOINT
AND/OR SACRUM)
SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION FOR PROSTATE NEEDLE
SATURATION BIOPSY SAMPLING, 1-20 SPECIMENS
SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION FOR PROSTATE NEEDLE
SATURATION BIOPSY SAMPLING, 21-40 SPECIMENS
SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION FOR PROSTATE NEEDLE
SATURATION BIOPSY SAMPLING, 41-60 SPECIMENS
SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION FOR PROSTATE NEEDLE
SATURATION BIOPSY SAMPLING, GREATER THAN 60 SPECIMENS
FACE-TO-FACE EDUCATIONAL SERVICES RELATED TO THE CARE OF CHRONIC KIDNEY
DISEASE; INDIVIDUAL, PER SESSION, PER ONE HOUR
FACE-TO-FACE EDUCATIONAL SERVICES RELATED TO THE CARE OF CHRONIC KIDNEY
DISEASE; GROUP, PER SESSION, PER ONE HOUR
INTENSIVE CARDIAC REHABILITATION; WITH OR WITHOUT CONTINUOUS ECG MONITORING
WITH EXERCISE, PER SESSION
INTENSIVE CARDIAC REHABILITATION; WITH OR WITHOUT CONTINUOUS ECG MONITORING;
WITHOUT EXERCISE, PER SESSION
PULMONARY REHABILITATION, INCLUDING EXERCISE (INCLUDES MONITORING), ONE HOUR,
PER SESSION, UP TO TWO SESSIONS PER DAY
INITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 30 MINUTES COMMUNICATING
WITH THE PATIENT VIA TELEHEALTH
INITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 50 MINUTES COMMUNICATING
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WITH THE PATIENT VIA TELEHEALTH
INITIAL INPATIENT TELEHEALTH CONSULTATION, TYPICALLY 70 MINUTES OR MORE
COMMUNICATING WITH THE PATIENT VIA TELEHEALTH
COLLAGEN MENISCUS IMPLANT PROCEDURE FOR FILLING MENISCAL DEFECTS (E.G., CMI,
COLLAGEN SCAFFOLD, MENAFLEX)
DERMAL FILLER INJECTION(S) FOR THE TREATMENT OF FACIAL LIPODYSTROPHY SYNDROME
(LDS) (E.G., AS A RESULT OF HIGHLY ACTIVE ANTIRETROVIRAL THERAPY)
DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES OTHER THAN CHROMATOGRAPHIC
METHOD, EACH PROCEDURE
DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES BY HIGH COMPLEXITY TEST METHOD
(E.G., IMMUNOASSAY, ENZYME ASSAY), PER PATIENT ENCOUNTER
INFECTIOUS AGENT ANTIBODY DETECTION BY ENZYME IMMUNOASSAY (EIA) TECHNIQUE,
HIV-1 AND/OR HIV-2, SCREENING
INFECTIOUS AGENT ANTIBODY DETECTION BY ENZYME-LINKED IMMUNOSORBENT ASSAY
(ELISA) TECHNIQUE, HIV-1 AND/OR HIV-2, SCREENING
DRUG SCREEN, OTHER THAN CHROMATOGRAPHIC; ANY NUMBER OF DRUG CLASSES, BY CLIA
WAIVED TEST OR MODERATE COMPLEXITY TEST, PER PATIENT ENCOUNTER
INFECTIOUS AGENT ANTIBODY DETECTION BY RAPID ANTIBODY TEST, HIV-1 AND/OR HIV-2,
SCREENING
SMOKING AND TOBACCO CESSATION COUNSELING VISIT FOR THE ASYMPTOMATIC PATIENT;
INTERMEDIATE, GREATER THAN 3 MINUTES, UP TO 10 MINUTES
SMOKING AND TOBACCO CESSATION COUNSELING VISIT FOR THE ASYMPTOMATIC PATIENT;
INTENSIVE, GREATER THAN 10 MINUTES
ANNUAL WELLNESS VISIT; INCLUDES A PERSONALIZED PREVENTION PLAN OF SERVICE
(PPS), INITIAL VISIT
ANNUAL WELLNESS VISIT, INCLUDES A PERSONALIZED PREVENTION PLAN OF SERVICE
(PPS), SUBSEQUENT VISIT
APPLICATION OF TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE OR DERMAL SUBSTITUTE;
FOR USE ON LOWER LIMB, INCLUDES THE SITE PREPARATION AND DEBRIDEMENT IF
PERFORMED; FIRST 25 SQ CM OR LESS
APPLICATION OF TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE OR DERMAL SUBSTITUTE;
FOR USE ON LOWER LIMB, INCLUDES THE SITE PREPARATION AND DEBRIDEMENT IF
PERFORMED; EACH ADDITIONAL 25 SQ CM
ADMINISTRATION AND SUPPLY OF TOSITUMOMAB, 450 MG
ACUTE MYOCARDIAL INFARCTION: PATIENT DOCUMENTED TO HAVE RECEIVED ASPIRIN AT
ARRIVAL
ACUTE MYOCARDIAL INFARCTION: PATIENT NOT DOCUMENTED TO HAVE RECEIVED ASPIRIN AT
ARRIVAL
CLINICIAN DOCUMENTED THAT ACUTE MYOCARDIAL INFARCTION PATIENT WAS NOT AN
ELIGIBLE CANDIDATE TO RECEIVE ASPIRIN AT ARRIVAL MEASURE
ACUTE MYOCARDIAL INFARCTION: PATIENT DOCUMENTED TO HAVE RECEIVED BETA-BLOCKER
AT ARRIVAL
ACUTE MYOCARDIAL INFARCTION: PATIENT NOT DOCUMENTED TO HAVE RECEIVED
BETA-BLOCKER AT ARRIVAL
CLINICIAN DOCUMENTED THAT ACUTE MYOCARDIAL INFARCTION PATIENT WAS NOT AN
ELIGIBLE CANDIDATE FOR BETA-BLOCKER AT ARRIVAL MEASURE
PNEUMONIA: PATIENT DOCUMENTED TO HAVE RECEIVED ANTIBIOTIC WITHIN 4 HOURS OF
PRESENTATION
PNEUMONIA: PATIENT NOT DOCUMENTED TO HAVE RECEIVED ANTIBIOTIC WITHIN 4 HOURS OF
PRESENTATION
CLINICIAN DOCUMENTED THAT PNEUMONIA PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
ANTIBIOTIC WITHIN 4 HOURS OF PRESENTATION MEASURE
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DIABETIC PATIENT WITH MOST RECENT HEMOGLOBIN A1C LEVEL (WITHIN THE LAST 6
MONTHS) DOCUMENTED AS GREATER THAN 9%
DIABETIC PATIENT WITH MOST RECENT HEMOGLOBIN A1C LEVEL (WITHIN THE LAST 6
MONTHS) DOCUMENTED AS LESS THAN OR EQUAL TO 9%
CLINICIAN DOCUMENTED THAT DIABETIC PATIENT WAS NOT ELIGIBLE CANDIDATE FOR
HEMOGLOBIN A1C MEASURE
CLINICIAN HAS NOT PROVIDED CARE FOR THE DIABETIC PATIENT FOR THE REQUIRED TIME
FOR HEMOGLOBIN A1C MEASURE (6 MONTHS)
DIABETIC PATIENT WITH MOST RECENT LOW-DENSITY LIPOPROTEIN (WITHIN THE LAST 12
MONTHS) DOCUMENTED AS GREATER THAN OR EQUAL TO 100 MG/DL
DIABETIC PATIENT WITH MOST RECENT LOW-DENSITY LIPOPROTEIN (WITHIN THE LAST 12
MONTHS) DOCUMENTED AS LESS THAN 100 MG/DL
CLINICIAN DOCUMENTED THAT DIABETIC PATIENT WAS NOT ELIGIBLE CANDIDATE FOR
LOW-DENSITY LIPOPROTEIN MEASURE
CLINICIAN HAS NOT PROVIDED CARE FOR THE DIABETIC PATIENT FOR THE REQUIRED TIME
FOR LOW-DENSITY LIPOPROTEIN MEASURE (12 MONTHS)
DIABETIC PATIENT WITH MOST RECENT BLOOD PRESSURE (WITHIN THE LAST 6 MONTHS)
DOCUMENTED AS EQUAL TO OR GREATER THAN 140 SYSTOLIC OR EQUAL TO OR GREATER THAN
80 MMHG DIASTOLIC
DIABETIC PATIENT WITH MOST RECENT BLOOD PRESSURE (WITHIN THE LAST 6 MONTHS)
DOCUMENTED AS LESS THAN 140 SYSTOLIC AND LESS THAN 80 DIASTOLIC
CLINICIAN DOCUMENTED THAT THE DIABETIC PATIENT WAS NOT ELIGIBLE CANDIDATE FOR
BLOOD PRESSURE MEASURE
CLINICIAN HAS NOT PROVIDED CARE FOR THE DIABETIC PATIENT FOR THE REQUIRED TIME
FOR BLOOD PRESSURE MEASURE (WITHIN THE LAST 6 MONTHS)
HEART FAILURE PATIENT WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION (LVSD)
DOCUMENTED TO BE ON EITHER ANGIOTENSIN-CONVERTING ENZYME INHIBITOR OR
ANGIOTENSIN-RECEPTOR BLOCKER (ACE-I OR ARB) THERAPY
HEART FAILURE PATIENT WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION (LVSD) NOT
DOCUMENTED TO BE ON EITHER ANGIOTENSIN-CONVERTING ENZYME INHIBITOR OR
ANGIOTENSIN-RECEPTOR BLOCKER (ACE-I OR ARB) THERAPY
CLINICIAN DOCUMENTED THAT HEART FAILURE PATIENT WAS NOT AN ELIGIBLE CANDIDATE
FOR EITHER ANGIOTENSIN-CONVERTING ENZYME INHIBITOR OR ANGIOTENSIN-RECEPTOR
BLOCKER (ACE-I OR ARB) THERAPY MEASURE
HEART FAILURE PATIENT WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION (LVSD)
DOCUMENTED TO BE ON BETA-BLOCKER THERAPY
HEART FAILURE PATIENT WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION (LVSD) NOT
DOCUMENTED TO BE ON BETA-BLOCKER THERAPY
CLINICIAN DOCUMENTED THAT HEART FAILURE PATIENT WAS NOT ELIGIBLE CANDIDATE FOR
BETA-BLOCKER THERAPY MEASURE
PRIOR MYOCARDIAL INFARCTION - CORONARY ARTERY DISEASE PATIENT DOCUMENTED TO BE
ON BETA-BLOCKER THERAPY
PRIOR MYOCARDIAL INFARCTION - CORONARY ARTERY DISEASE PATIENT NOT DOCUMENTED TO
BE ON BETA-BLOCKER THERAPY
CLINICIAN DOCUMENTED THAT PRIOR MYOCARDIAL INFARCTION - CORONARY ARTERY DISEASE
PATIENT WAS NOT ELIGIBLE CANDIDATE FOR BETA-BLOCKER THERAPY MEASURE
CORONARY ARTERY DISEASE PATIENT DOCUMENTED TO BE ON ANTIPLATELET THERAPY
CORONARY ARTERY DISEASE PATIENT NOT DOCUMENTED TO BE ON ANTIPLATELET THERAPY
CLINICIAN DOCUMENTED THAT CORONARY ARTERY DISEASE PATIENT WAS NOT ELIGIBLE
CANDIDATE FOR ANTIPLATELET THERAPY MEASURE
CORONARY ARTERY DISEASE - PATIENT WITH LOW-DENSITY LIPOPROTEIN DOCUMENTED TO BE
GREATER THAN 100MG/DL
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CORONARY ARTERY DISEASE - PATIENT WITH LOW-DENSITY LIPOPROTEIN DOCUMENTED TO BE
LESS THAN OR EQUAL TO 100MG/DL
CLINICIAN DOCUMENTED THAT CORONARY ARTERY DISEASE PATIENT WAS NOT ELIGIBLE
CANDIDATE FOR LOW-DENSITY LIPOPROTEIN MEASURE
PATIENT (FEMALE) DOCUMENTED TO HAVE BEEN ASSESSED FOR OSTEOPOROSIS
PATIENT (FEMALE) NOT DOCUMENTED TO HAVE BEEN ASSESSED FOR OSTEOPOROSIS
CLINICIAN DOCUMENTED THAT (FEMALE) PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
OSTEOPOROSIS ASSESSMENT MEASURE
PATIENT NOT DOCUMENTED FOR THE ASSESSMENT FOR FALLS WITHIN LAST 12 MONTHS
PATIENT DOCUMENTED FOR THE ASSESSMENT FOR FALLS WITHIN LAST 12 MONTHS
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR THE FALLS
ASSESSMENT MEASURE WITHIN THE LAST 12 MONTHS
PATIENT DOCUMENTED TO HAVE RECEIVED HEARING ASSESSMENT
PATIENT NOT DOCUMENTED TO HAVE RECEIVED HEARING ASSESSMENT
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR HEARING
ASSESSMENT MEASURE
PATIENT DOCUMENTED FOR THE ASSESSMENT OF URINARY INCONTINENCE
PATIENT NOT DOCUMENTED FOR THE ASSESSMENT OF URINARY INCONTINENCE
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR URINARY
INCONTINENCE ASSESSMENT MEASURE
END STAGE RENAL DISEASE PATIENT WITH DOCUMENTED DIALYSIS DOSE OF URR GREATER
THAN OR EQUAL TO 65% (OR KT/V GREATER THAN OR EQUAL TO 1.2)
END STAGE RENAL DISEASE PATIENT WITH DOCUMENTED DIALYSIS DOSE OF URR LESS THAN
65% (OR KT/V LESS THAN 1.2)
CLINICIAN DOCUMENTED THAT END STAGE RENAL DISEASE PATIENT WAS NOT AN ELIGIBLE
CANDIDATE FOR URR OR KT/V MEASURE
END STAGE RENAL DISEASE PATIENT WITH DOCUMENTED HEMATOCRIT GREATER THAN OR
EQUAL TO 33 (OR HEMOGLOBIN GREATER THAN OR EQUAL TO 11)
END STAGE RENAL DISEASE PATIENT WITH DOCUMENTED HEMATOCRIT LESS THAN 33 (OR
HEMOGLOBIN LESS THAN 11)
CLINICIAN DOCUMENTED THAT END STAGE RENAL DISEASE PATIENT WAS NOT AN ELIGIBLE
CANDIDATE FOR HEMATOCRIT (HEMOGLOBIN) MEASURE
END STAGE RENAL DISEASE PATIENT REQUIRING HEMODIALYSIS VASCULAR ACCESS
DOCUMENTED TO HAVE RECEIVED AUTOGENOUS AV FISTULA
END STAGE RENAL DISEASE PATIENT REQUIRING HEMODIALYSIS DOCUMENTED TO HAVE
RECEIVED VASCULAR ACCESS OTHER THAN AUTOGENOUS AV FISTULA
END-STAGE RENAL DISEASE PATIENT REQUIRING HEMODIALYSIS VASCULAR ACCESS WAS NOT
AN ELIGIBLE CANDIDATE FOR AUTOGENOUS AV FISTULA
NEWLY DIAGNOSED CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) PATIENT DOCUMENTED
TO HAVE RECEIVED SMOKING CESSATION INTERVENTION, WITHIN 3 MONTHS OF DIAGNOSIS
NEWLY DIAGNOSED CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) PATIENT NOT
DOCUMENTED TO HAVE RECEIVED SMOKING CESSATION INTERVENTION, WITHIN 3 MONTHS OF
DIAGNOSIS
OSTEOPOROSIS PATIENT DOCUMENTED TO HAVE BEEN PRESCRIBED CALCIUM AND VITAMIN D
SUPPLEMENTS
CLINICIAN DOCUMENTED THAT OSTEOPOROSIS PATIENT WAS NOT AN ELIGIBLE CANDIDATE
FOR CALCIUM AND VITAMIN D SUPPLEMENT MEASURE
NEWLY DIAGNOSED OSTEOPOROSIS PATIENTS DOCUMENTED TO HAVE BEEN TREATED WITH
ANTIRESORPTIVE THERAPY AND/OR PTH WITHIN 3 MONTHS OF DIAGNOSIS
CLINICIAN DOCUMENTED THAT NEWLY DIAGNOSED OSTEOPOROSIS PATIENT WAS NOT AN
ELIGIBLE CANDIDATE FOR ANTIRESORPTIVE THERAPY AND/OR PTH TREATMENT MEASURE
WITHIN 3 MONTHS OF DIAGNOSIS
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WITHIN 6 MONTHS OF SUFFERING A NONTRAUMATIC FRACTURE, FEMALE PATIENT 65 YEARS
OF AGE OR OLDER DOCUMENTED TO HAVE UNDERGONE BONE MINERAL DENSITY TESTING OR TO
HAVE BEEN PRESCRIBED A DRUG TO TREAT OR PREVENT OSTEOPOROSIS
CLINICIAN DOCUMENTED THAT FEMALE PATIENT 65 YEARS OF AGE OR OLDER WHO SUFFERED
A NONTRAUMATIC FRACTURE WITHIN THE LAST 6 MONTHS WAS NOT AN ELIGIBLE CANDIDATE
FOR MEASURE TO TEST BONE MINERAL DENSITY OR DRUG TO TREAT OR PREVENT
OSTEOPOROSIS
PATIENT DOCUMENTED TO HAVE RECEIVED INFLUENZA VACCINATION DURING INFLUENZA
SEASON
PATIENT NOT DOCUMENTED TO HAVE RECEIVED INFLUENZA VACCINATION DURING INFLUENZA
SEASON
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR INFLUENZA
VACCINATION MEASURE
PATIENT (FEMALE) DOCUMENTED TO HAVE RECEIVED A MAMMOGRAM DURING THE MEASUREMENT
YEAR OR PRIOR YEAR TO THE MEASUREMENT YEAR
PATIENT (FEMALE) NOT DOCUMENTED TO HAVE RECEIVED A MAMMOGRAM DURING THE
MEASUREMENT YEAR OR PRIOR YEAR TO THE MEASUREMENT YEAR
CLINICIAN DOCUMENTED THAT FEMALE PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
MAMMOGRAPHY MEASURE
CLINICIAN DID NOT PROVIDE CARE TO PATIENT FOR THE REQUIRED TIME OF MAMMOGRAPHY
MEASURE (I.E., MEASUREMENT YEAR OR PRIOR YEAR)
PATIENT DOCUMENTED TO HAVE RECEIVED PNEUMOCOCCAL VACCINATION
PATIENT NOT DOCUMENTED TO HAVE RECEIVED PNEUMOCOCCAL VACCINATION
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
PNEUMOCOCCAL VACCINATION MEASURE
PATIENT DOCUMENTED AS BEING TREATED WITH ANTIDEPRESSANT MEDICATION DURING THE
ENTIRE 12 WEEK ACUTE TREATMENT PHASE
PATIENT NOT DOCUMENTED AS BEING TREATED WITH ANTIDEPRESSANT MEDICATION DURING
THE ENTIRE 12 WEEKS ACUTE TREATMENT PHASE
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
ANTIDEPRESSANT MEDICATION DURING THE ENTIRE 12 WEEK ACUTE TREATMENT PHASE
MEASURE
PATIENT DOCUMENTED AS BEING TREATED WITH ANTIDEPRESSANT MEDICATION FOR AT LEAST
6 MONTHS CONTINUOUS TREATMENT PHASE
PATIENT NOT DOCUMENTED AS BEING TREATED WITH ANTIDEPRESSANT MEDICATION FOR AT
LEAST 6 MONTHS CONTINUOUS TREATMENT PHASE
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
ANTIDEPRESSANT MEDICATION FOR CONTINUOUS TREATMENT PHASE
PATIENT DOCUMENTED TO HAVE RECEIVED ANTIBIOTIC PROPHYLAXIS ONE HOUR PRIOR TO
INCISION TIME (TWO HOURS FOR VANCOMYCIN)
PATIENT NOT DOCUMENTED TO HAVE RECEIVED ANTIBIOTIC PROPHYLAXIS ONE HOUR PRIOR
TO INCISION TIME (TWO HOURS FOR VANCOMYCIN)
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ANTIBIOTIC
PROPHYLAXIS ONE HOUR PRIOR TO INCISION TIME (TWO HOURS FOR VANCOMYCIN) MEASURE
PATIENT WITH DOCUMENTED RECEIPT OF THROMBOEMBOLISM PROPHYLAXIS
PATIENT WITHOUT DOCUMENTED RECEIPT OF THROMBOEMBOLISM PROPHYLAXIS
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
THROMBOEMBOLISM PROPHYLAXIS MEASURE
PATIENT DOCUMENTED TO HAVE RECEIVED CORONARY ARTERY BYPASS GRAFT WITH USE OF
INTERNAL MAMMARY ARTERY
PATIENT DOCUMENTED TO HAVE RECEIVED CORONARY ARTERY BYPASS GRAFT WITHOUT USE OF
INTERNAL MAMMARY ARTERY
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CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR CORONARY
ARTERY BYPASS GRAFT WITH USE OF INTERNAL MAMMARY ARTERY MEASURE
PATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT DOCUMENTED TO HAVE RECEIVED
PRE-OPERATIVE BETA-BLOCKADE
PATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT NOT DOCUMENTED TO HAVE
RECEIVED PRE-OPERATIVE BETA-BLOCKADE
CLINICIAN DOCUMENTED THAT PATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT
WAS NOT AN ELIGIBLE CANDIDATE FOR PRE-OPERATIVE BETA-BLOCKADE MEASURE
PATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT DOCUMENTED TO HAVE PROLONGED
INTUBATION
PATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT NOT DOCUMENTED TO HAVE
PROLONGED INTUBATION
PATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT DOCUMENTED TO HAVE REQUIRED
SURGICAL RE-EXPLORATION
PATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT DID NOT REQUIRE SURGICAL
RE-EXPLORATION
PATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT DOCUMENTED TO HAVE BEEN
DISCHARGED ON ASPIRIN OR CLOPIDOGREL
PATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT NOT DOCUMENTED TO HAVE BEEN
DISCHARGED ON ASPIRIN OR CLOPIDOGREL
CLINICIAN DOCUMENTED THAT PATIENT WITH ISOLATED CORONARY ARTERY BYPASS GRAFT
WAS NOT AN ELIGIBLE CANDIDATE FOR ANTIPLATELET THERAPY AT DISCHARGE MEASURE
CLINICIAN HAS NOT PROVIDED CARE FOR THE CARDIAC PATIENT FOR THE REQUIRED TIME
FOR LOW-DENSITY LIPOPROTEIN MEASURE (6 MONTHS)
PATIENT WITH HEART FAILURE AND ATRIAL FIBRILLATION DOCUMENTED TO BE ON WARFARIN
THERAPY
CLINICIAN DOCUMENTED THAT PATIENT WITH HEART FAILURE AND ATRIAL FIBRILLATION
WAS NOT AN ELIGIBLE CANDIDATE FOR WARFARIN THERAPY MEASURE
PATIENTS DIAGNOSED WITH SYMPTOMATIC OSTEOARTHRITIS WITH DOCUMENTED ANNUAL
ASSESSMENT OF FUNCTION AND PAIN
CLINICIAN DOCUMENTED THAT SYMPTOMATIC OSTEOARTHRITIS PATIENT WAS NOT AN
ELIGIBLE CANDIDATE FOR ANNUAL ASSESSMENT OF FUNCTION AND PAIN MEASURE
CLINICIAN DOCUMENTED TO HAVE GIVEN ORDER FOR PROPHYLACTIC ANTIBIOTIC TO BE
GIVEN WITHIN ONE HOUR (IF VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (OR
START OF PROCEDURE WHEN NO INCISION IS REQUIRED)
CLINICIAN DOCUMENTED TO HAVE GIVEN THE PROPHYLACTIC ANTIBIOTIC WITHIN ONE HOUR
(IF VANCOMYCIN, TWO HOURS) PRIOR TO THE SURGICAL INCISION (OR START OF
PROCEDURE WHEN NO INCISION IS REQUIRED)
CLINICIAN DID NOT DOCUMENT THAT AN ORDER FOR PROPHYLACTIC ANTIBIOTIC TO BE
GIVEN WITHIN ONE HOUR (IF VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (OR
START OF PROCEDURE WHEN NO INCISION IS REQUIRED) WAS GIVEN
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
PROPHYLACTIC ANTIBIOTIC
CLINICIAN DOCUMENTED TO HAVE GIVEN THE PROPHYLACTIC ANTIBIOTIC WITHIN ONE HOUR
(IF VANCOMYCIN, TWO HOURS) PRIOR TO THE SURGICAL INCISION (OR START OF
PROCEDURE WHEN NO INCISION IS REQUIRED)
CLINICIAN DID NOT DOCUMENT A PROPHYLACTIC ANTIBIOTIC WAS ADMINISTERED WITHIN
ONE HOUR (IF VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (OR START OF
PROCEDURE WHEN NO INCISION IS REQUIRED)
PATIENT DOCUMENTED TO HAVE ORDER FOR PROPHYLACTIC ANTIBIOTIC TO BE GIVEN WITHIN
ONE HOUR (IF VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (OR START OF
PROCEDURE WHEN NO INCISION IS REQUIRED)
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PATIENT DOCUMENTED TO HAVE ORDER FOR CEFAZOLIN OR CEFUROXIME FOR ANTIMICROBIAL
PROPHYLAXIS
CLINICIAN DOCUMENTED TO HAVE GIVEN CEFAZOLIN OR CEFUROXIME FOR ANTIMICROBIAL
PROPHYLAXIS
ORDER FOR CEFAZOLIN OR CEFUROXIME FOR ANTIMICROBIAL PROPHYLAXIS NOT DOCUMENTED
PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR CEFAZOLIN OR CEFUROXIME FOR
ANTIMICROBIAL PROPHYLAXIS
CLINICIAN DOCUMENTED AN ORDER WAS GIVEN TO DISCONTINUE PROPHYLACTIC ANTIBIOTICS
WITHIN 24 HOURS OF SURGICAL END TIME
CLINICIAN DOCUMENTED THAT PROPHYLACTIC ANTIBIOTICS WERE DISCONTINUED WITHIN 24
HOURS OF SURGICAL END TIME
CLINICIAN DID NOT DOCUMENT AN ORDER WAS GIVEN TO DISCONTINUE PROPHYLACTIC
ANTIBIOTICS WITHIN 24 HOURS OF SURGICAL END TIME
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
PROPHYLACTIC ANTIBIOTIC DISCONTINUATION WITHIN 24 HOURS OF SURGICAL END TIME
CLINICIAN DOCUMENTED THAT PROPHYLACTIC ANTIBIOTIC WAS GIVEN
CLINICIAN DOCUMENTED AN ORDER WAS GIVEN TO DISCONTINUE PROPHYLACTIC ANTIBIOTICS
WITHIN 48 HOURS OF SURGICAL END TIME
CLINICIAN DOCUMENTED THAT PROPHYLACTIC ANTIBIOTICS WERE DISCONTINUED WITHIN 48
HOURS OF SURGICAL END TIME
CLINICIAN DID NOT DOCUMENT AN ORDER WAS GIVEN TO DISCONTINUE PROPHYLACTIC
ANTIBIOTICS WITHIN 48 HOURS OF SURGICAL END TIME
CLINICIAN DOCUMENTED PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR DISCONTINUATION
OF PROPHYLACTIC ANTIBIOTIC DISCONTINUATION WITHIN 48 HOURS OF SURGICAL END TIME
CLINICIAN DOCUMENTED THAT PROPHYLACTIC ANTIBIOTIC WAS GIVEN
CLINICIAN DOCUMENTED AN ORDER WAS GIVEN FOR APPROPRIATE VENOUS THROMBOEMBOLISM
(VTE) PROPHYLAXIS TO BE GIVEN WITHIN 24 HRS PRIOR TO INCISION TIME OR 24 HOURS
AFTER SURGERY END TIME
CLINICIAN DOCUMENTED TO HAVE GIVEN VTE PROPHYLAXIS WITHIN 24 HRS PRIOR TO
INCISION TIME OR 24 HOURS AFTER SURGERY END TIME
CLINICIAN DID NOT DOCUMENT AN ORDER WAS GIVEN FOR APPROPRIATE VENOUS
THROMBOEMBOLISM (VTE) PROPHYLAXIS TO BE GIVEN WITHIN 24 HRS PRIOR TO INCISION
TIME OR 24 HOURS AFTER SURGERY END TIME
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR VENOUS
THROMBOEMBOLISM (VTE) PROPHYLAXIS TO BE GIVEN WITHIN 24 HOURS PRIOR TO INCISION
TIME OR 24 HOURS AFTER SURGERY END TIME
PATIENT DOCUMENTED TO HAVE RECEIVED DVT PROPHYLAXIS BY END OF HOSPITAL DAY TWO
PATIENT NOT DOCUMENTED TO HAVE RECEIVED DVT PROPHYLAXIS BY END OF HOSPITAL DAY 2
PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR DVT PROPHYLAXIS BY END OF HOSPITAL
DAY 2, INCLUDING PHYSICIAN DOCUMENTATION THAT PATIENT IS AMBULATORY
PATIENT DOCUMENTED TO HAVE RECEIVED DVT PROPHYLAXIS BY END OF HOSPITAL DAY 2
PATIENT NOT DOCUMENTED TO HAVE RECEIVED DVT PROPHYLAXIS BY END OF HOSPITAL DAY 2
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR DVT
PROPHYLAXIS BY THE END OF HOSPITAL DAY 2, INCLUDING PHYSICIAN DOCUMENTATION
THAT PATIENT IS AMBULATORY
PATIENT DOCUMENTED TO HAVE BEEN PRESCRIBED ANTIPLATELET THERAPY AT DISCHARGE
PATIENT NOT DOCUMENTED TO HAVE RECEIVED PRESCRIPTION FOR ANTIPLATELET THERAPY
AT DISCHARGE
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
ANTIPLATELET THERAPY AT DISCHARGE, INCLUDING IDENTIFICATION FROM MEDICAL RECORD
THAT PATIENT IS ON ANTICOAGULATION THERAPY
PATIENT DOCUMENTED TO HAVE BEEN PRESCRIBED AN ANTICOAGULANT AT DISCHARGE
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PATIENT NOT DOCUMENTED TO HAVE RECEIVED PRESCRIPTION FOR ANTICOAGULANT THERAPY
AT DISCHARGE
PATIENT NOT DOCUMENTED TO HAVE PERMANENT, PERSISTENT, OR PAROXYSMAL ATRIAL
FIBRILLATION
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
ANTICOAGULANT THERAPY AT DISCHARGE
PATIENT DOCUMENTED TO HAVE BEEN ADMINISTERED OR CONSIDERED FOR T-PA
PATIENT NOT ELIGIBLE FOR T-PA ADMINISTRATION, ISCHEMIC STROKE SYMPTOM ONSET OF
MORE THAN 3 HOURS
PATIENT NOT DOCUMENTED TO HAVE RECEIVED T-PA OR NOT DOCUMENTED TO HAVE BEEN
CONSIDERED A CANDIDATE FOR T-PA ADMINISTRATION
PATIENT DOCUMENTED TO HAVE RECEIVED DYSPHAGIA SCREENING PRIOR TO TAKING ANY
FOODS, FLUIDS OR MEDICATION BY MOUTH
PATIENT NOT DOCUMENTED TO HAVE RECEIVED DYSPHAGIA SCREENING
PATIENT NOT RECEIVING OR INELIGIBLE TO RECEIVE FOOD, FLUIDS OR MEDICATION BY
MOUTH, OR DOCUMENTATION OF NPO (NOTHING BY MOUTH) ORDER
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR DYSPHAGIA
SCREENING PRIOR TO TAKING ANY FOODS, FLUIDS OR MEDICATION BY MOUTH
PATIENT DOCUMENTED TO HAVE RECEIVED ORDER FOR REHABILITATION SERVICES OR
DOCUMENTATION OF CONSIDERATION FOR REHABILITATION SERVICES
PATIENT NOT DOCUMENTED TO HAVE RECEIVED ORDER FOR OR CONSIDERATION FOR
REHABILITATION SERVICES
INTERNAL CAROTID STENOSIS PATIENT BELOW 30%, REFERENCE TO MEASUREMENTS OF
DISTAL INTERNAL CAROTID DIAMETER AS THE DENOMINATOR FOR STENOSIS MEASUREMENT
NOT NECESSARY
INTERNAL CAROTID STENOSIS PATIENT IN THE 30-99% RANGE, AND NO DOCUMENTATION OF
REFERENCE TO MEASUREMENTS OF DISTAL INTERNAL CAROTID DIAMETER AS THE
DENOMINATOR FOR STENOSIS MEASUREMENT
CLINICIAN DOCUMENTED THAT PATIENT WHOSE FINAL REPORT OF THE CAROTID IMAGING
STUDY PERFORMED (NECK MRA, NECK CTA, NECK DUPLEX ULTRASOUND, CAROTID
ANGIOGRAM), WITH CHARACTERIZATION OF AN INTERNAL CAROTID STENOSIS IN THE 30-99%
RANGE, WAS NOT AN ELIGIBLE CANDIDATE FOR REFERENCE TO MEASUREMENTS OF DISTAL
INTERNAL CAROTID DIAMETER AS THE DENOMINATOR FOR STENOSIS MEASUREMENT
PATIENT DOCUMENTED TO HAVE RECEIVED CT OR MRI WITH PRESENCE OR ABSENCE OF
HEMORRHAGE, MASS LESION AND ACUTE INFARCTION DOCUMENTED IN THE FINAL REPORT
PATIENT NOT DOCUMENTED TO HAVE RECEIVED CT OR MRI AND THE PRESENCE OR ABSENCE
OF HEMORRHAGE, MASS LESION AND ACUTE INFARCTION NOT DOCUMENTED IN THE FINAL
REPORT
CLINICIAN DOCUMENTED PRESENCE OR ABSENCE ALARM SYMPTOMS
PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR MEDICAL HISTORY REVIEW WITH
ASSESSMENT OF NEW OR CHANGING MOLES
PATIENT WITH ALARM SYMPTOM(S) DOCUMENTED TO HAVE HAD UPPER ENDOSCOPY PERFORMED
OR REFERRAL FOR UPPER ENDOSCOPY
PATIENT WITH AT LEAST ONE ALARM SYMPTOM NOT DOCUMENTED TO HAVE HAD UPPER
ENDOSCOPY OR REFERRAL FOR UPPER ENDOSCOPY
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR UPPER
ENDOSCOPY
PATIENT WITH SUSPICION OF BARRETT'S ESOPHAGUS IN ENDOSCOPY REPORT AND
DOCUMENTED TO HAVE RECEIVED AN ESOPHAGEAL BIOPSY
PATIENT NOT DOCUMENTED TO HAVE RECEIVED AN ESOPHAGEAL BIOPSY WHEN SUSPICION OF
BARRETT'S ESOPHAGUS IS INDICATED IN THE ENDOSCOPY REPORT
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ESOPHAGEAL
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BIOPSY
PATIENT DOCUMENTED TO HAVE RECEIVED AN ORDER FOR A BARIUM SWALLOW TEST
PATIENT WITH NO DOCUMENTATION ORDER FOR BARIUM SWALLOW TEST
CLINICIAN DOCUMENTATION THAT PATIENT WAS AN ELIGIBLE CANDIDATE FOR BARIUM
SWALLOW TEST
CLINICIAN DOCUMENTED RECONCILIATION OF DISCHARGE MEDICATIONS WITH CURRENT
MEDICATION LIST IN MEDICAL RECORD
CLINICIAN HAS NOT DOCUMENTED RECONCILIATION OF DISCHARGE MEDICATIONS WITH
CURRENT MEDICATION LIST IN MEDICAL RECORD
PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR DISCHARGE MEDICATIONS REVIEW
PATIENT DOCUMENTED TO HAVE SURROGATE DECISION MAKER OR ADVANCE CARE PLAN IN
MEDICAL RECORD
PATIENT NOT DOCUMENTED TO HAVE SURROGATE DECISION MAKER OR ADVANCE CARE PLAN IN
MEDICAL RECORD
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR SURROGATE
DECISION MAKER OR ADVANCE CARE PLAN
PATIENT DOCUMENTED TO HAVE BEEN ASSESSED FOR PRESENCE OR ABSENCE OF URINARY
INCONTINENCE
PATIENT NOT DOCUMENTED TO HAVE BEEN ASSESSED FOR PRESENCE OR ABSENCE OF URINARY
INCONTINENCE
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR AN
ASSESSMENT OF THE PRESENCE OR ABSENCE OF URINARY INCONTINENCE
PATIENT DOCUMENTED TO HAVE RECEIVED CHARACTERIZATION OF URINARY INCONTINENCE
PATIENT NOT DOCUMENTED TO HAVE RECEIVED CHARACTERIZATION OF URINARY INCONTINENCE
PATIENT DOCUMENTED TO HAVE RECEIVED A PLAN OF CARE FOR URINARY INCONTINENCE
PATIENT NOT DOCUMENTED TO HAVE RECEIVED PLAN OF CARE FOR URINARY INCONTINENCE
CLINICIAN HAS NOT PROVIDED CARE FOR THE PATIENT FOR THE REQUIRED TIME TO
DEVELOP PLAN OF CARE FOR URINARY INCONTINENCE
PATIENT DOCUMENTED TO HAVE RECEIVED SCREENING FOR FALL RISK (2 OR MORE FALLS IN
THE PAST YEAR OR ANY FALL WITH INJURY IN THE PAST YEAR)
PATIENT WITH NO DOCUMENTATION OF SCREENING FOR FALL RISKS (2 OR MORE FALLS IN
THE PAST YEAR OR ANY FALL WITH INJURY IN THE PAST YEAR)
CLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR FALL
RISK SCREENING
CLINICIAN HAS NOT PROVIDED CARE FOR THE PATIENT FOR THE REQUIRED TIME TO SCREEN
FOR FALL RISK
CLINICIAN HAS NOT DOCUMENTED PRESENCE OR ABSENCE OF ALARM SYMPTOMS
PATIENT DOCUMENTED TO HAVE MEDICAL HISTORY TAKEN WHICH INCLUDED ASSESSMENT OF
NEW OR CHANGING MOLES
PATIENT NOT DOCUMENTED TO HAVE RECEIVED MEDICAL HISTORY WITH ASSESSMENT OF NEW
OR CHANGING MOLES
PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR MEDICAL HISTORY REVIEW WITH
ASSESSMENT OF NEW OR CHANGING MOLES
PATIENT DOCUMENTED TO HAVE RECEIVED COMPLETE PHYSICAL SKIN EXAM
PATIENT NOT DOCUMENTED TO HAVE RECEIVED A COMPLETE PHYSICAL SKIN EXAM
PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR COMPLETE PHYSICAL SKIN EXAM DURING
THE REPORTING YEAR
PATIENT DOCUMENTED TO HAVE RECEIVED COUNSELING TO PERFORM A SELF-EXAMINATION
PATIENT NOT DOCUMENTED TO HAVE RECEIVED COUNSELING TO PERFORM A SELF-EXAMINATION
PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR COUNSELING TO PERFORM SELF-EXAMINATION
PATIENT DOCUMENTED TO HAVE RECEIVED A PRESCRIPTION FOR PHARMACOLOGIC THERAPY
FOR OSTEOPOROSIS
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PATIENT NOT DOCUMENTED TO HAVE RECEIVED PHARMACOLOGIC THERAPY
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
PHARMACOLOGIC THERAPY
CLINICIAN HAS NOT PROVIDED CARE FOR THE PATIENT FOR THE REQUIRED TIME FOR THE
PHARMACOLOGIC THERAPY MEASURE
PATIENT DOCUMENTED TO HAVE RECEIVED CALCIUM AND VITAMIN D OR COUNSELING ON BOTH
CALCIUM AND VITAMIN D USE, AND EXERCISE
PATIENT WITH NO DOCUMENTATION OF CALCIUM AND VITAMIN D USE OR COUNSELING
REGARDING BOTH CALCIUM AND VITAMIN D USE, OR EXERCISE
CLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR CALCIUM
AND VITAMIN D, AND EXERCISE DURING THE REPORTING YEAR
CLINICIAN HAS NOT PROVIDED CARE FOR THE PATIENT FOR THE REQUIRED TIME FOR THE
CALCIUM, VITAMIN D, AND EXERCISE MEASURE
COPD PATIENT WITH SPIROMETRY RESULTS DOCUMENTED
COPD PATIENT WITHOUT SPIROMETRY RESULTS DOCUMENTED
COPD PATIENT WAS NOT ELIGIBLE FOR SPIROMETRY RESULTS
COPD PATIENT DOCUMENTED TO HAVE RECEIVED INHALED BRONCHODILATOR THERAPY
COPD PATIENT NOT DOCUMENTED TO HAVE INHALED BRONCHODILATOR THERAPY PRESCRIBED
COPD PATIENT WAS NOT ELIGIBLE FOR INHALED BRONCHODILATOR THERAPY
PATIENT DOCUMENTED TO HAVE RECEIVED OPTIC NERVE HEAD EVALUATION
PATIENT NOT DOCUMENTED TO HAVE RECEIVED OPTIC NERVE HEAD EVALUATION
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR OPTIC NERVE
HEAD EVALUATION DURING THE REPORTING YEAR
CLINICIAN HAS NOT PROVIDED CARE FOR THE PRIMARY OPEN-ANGLE GLAUCOMA PATIENT FOR
THE REQUIRED TIME FOR OPTIC NERVE HEAD EVALUATION MEASURE
PATIENT DOCUMENTED TO HAVE A SPECIFIC TARGET INTRAOCULAR PRESSURE RANGE GOAL
PATIENT NOT DOCUMENTED TO HAVE A SPECIFIC TARGET INTRAOCULAR PRESSURE RANGE GOAL
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR A SPECIFIC
TARGET INTRAOCULAR PRESSURE RANGE GOAL
CLINICIAN HAS NOT PROVIDED CARE FOR THE PRIMARY OPEN-ANGLE GLAUCOMA PATIENT FOR
THE REQUIRED TIME FOR TREATMENT RANGE GOAL DOCUMENTATION MEASUREMENT
PRIMARY OPEN-ANGLE GLAUCOMA PATIENT WITH INTRAOCULAR PRESSURE ABOVE THE TARGET
RANGE GOAL DOCUMENTED TO HAVE RECEIVED PLAN OF CARE
PRIMARY OPEN-ANGLE GLAUCOMA PATIENT WITH INTRAOCULAR PRESSURE AT OR BELOW GOAL,
NO PLAN OF CARE NECESSARY
PRIMARY OPEN-ANGLE GLAUCOMA PATIENT WITH INTRAOCULAR PRESSURE ABOVE THE TARGET
RANGE GOAL, AND NOT DOCUMENTED TO HAVE RECEIVED PLAN OF CARE DURING THE
REPORTING YEAR
PATIENT DOCUMENTED TO HAVE BEEN PRESCRIBED/RECOMMENDED ANTIOXIDANT VITAMIN OR
MINERAL SUPPLEMENT
PATIENT NOT DOCUMENTED TO HAVE BEEN PRESCRIBED/RECOMMENDED AT LEAST ONE
ANTIOXIDANT VITAMIN OR MINERAL SUPPLEMENT DURING THE REPORTING YEAR
CLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
ANTIOXIDANT VITAMIN OR MINERAL SUPPLEMENT DURING THE REPORTING YEAR
CLINICIAN HAS NOT PROVIDED CARE FOR THE AGE-RELATED MACULAR DEGENERATION
PATIENT FOR THE REQUIRED TIME FOR ANTIOXIDANT SUPPLEMENT
PRESCRIPTION/RECOMMENDED MEASURE
PATIENT DOCUMENTED TO HAVE RECEIVED MACULAR EXAM, INCLUDING DOCUMENTATION OF
THE PRESENCE OR ABSENCE OF MACULAR THICKENING OR HEMORRHAGE AND THE LEVEL OF
MACULAR DEGENERATION SEVERITY
PATIENT NOT DOCUMENTED TO HAVE RECEIVED MACULAR EXAM WITH DOCUMENTATION OF
PRESENCE OR ABSENCE OF MACULAR THICKENING OR HEMORRHAGE AND NO DOCUMENTATION OF
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LEVEL OF MACULAR DEGENERATION SEVERITY
CLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR MACULAR
EXAMINATION DURING THE REPORTING YEAR
CLINICIAN HAS NOT PROVIDED CARE FOR THE AGE-RELATED MACULAR DEGENERATION
PATIENT FOR THE REQUIRED TIME FOR MACULAR EXAMINATION MEASUREMENT
PATIENT DOCUMENTED TO HAVE VISUAL FUNCTIONAL STATUS ASSESSED
PATIENT DOCUMENTED NOT TO HAVE VISUAL FUNCTIONAL STATUS ASSESSED
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ASSESSMENT
OF VISUAL FUNCTIONAL STATUS
CLINICIAN HAS NOT PROVIDED CARE FOR THE CATARACT PATIENT FOR THE REQUIRED TIME
FOR ASSESSMENT OF VISUAL FUNCTIONAL STATUS MEASUREMENT
PATIENT DOCUMENTED TO HAVE HAD PRE-SURGICAL AXIAL LENGTH, CORNEAL POWER
MEASUREMENT AND METHOD OF INTRAOCULAR LENS POWER CALCULATION
PATIENT NOT DOCUMENTED TO HAVE HAD PRE-SURGICAL AXIAL LENGTH, CORNEAL POWER
MEASUREMENT AND METHOD OF INTRAOCULAR LENS POWER CALCULATION
CLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
PRE-SURGICAL AXIAL LENGTH, CORNEAL POWER MEASUREMENT AND METHOD OF INTRAOCULAR
LENS POWER CALCULATION
CLINICIAN HAS NOT PROVIDED CARE FOR THE CATARACT PATIENT FOR THE REQUIRED TIME
FOR PRE-SURGICAL MEASUREMENT AND INTRAOCULAR LENS POWER CALCULATION MEASURE
PATIENT DOCUMENTED TO HAVE RECEIVED FUNDUS EVALUATION WITHIN SIX MONTHS PRIOR
TO CATARACT SURGERY
PATIENT NOT DOCUMENTED TO HAVE RECEIVED FUNDUS EVALUATION WITHIN SIX MONTHS
PRIOR TO CATARACT SURGERY
PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR PRE-SURGICAL FUNDUS EVALUATION
CLINICIAN HAS NOT PROVIDED CARE FOR THE CATARACT PATIENT FOR THE REQUIRED TIME
FOR FUNDUS EVALUATION MEASUREMENT
PATIENT DOCUMENTED TO HAVE RECEIVED DILATED MACULAR OR FUNDUS EXAM WITH LEVEL
OF SEVERITY OF RETINOPATHY AND THE PRESENCE OR ABSENCE OF MACULAR EDEMA
DOCUMENTED
PATIENT NOT DOCUMENTED TO HAVE RECEIVED DILATED MACULAR OR FUNDUS EXAM WITH
LEVEL OF SEVERITY OF RETINOPATHY AND THE PRESENCE OR ABSENCE OF MACULAR EDEMA
NOT DOCUMENTED
CLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR DILATED
MACULAR OR FUNDUS EXAM DURING THE REPORTING YEAR
CLINICIAN HAS NOT PROVIDED CARE FOR THE DIABETIC RETINOPATHY PATIENT FOR THE
REQUIRED TIME FOR MACULAR EDEMA AND RETINOPATHY MEASUREMENT
PATIENT DOCUMENTED TO HAVE HAD FINDINGS OF MACULAR OR FUNDUS EXAM COMMUNICATED
TO THE PHYSICIAN MANAGING THE DIABETES CARE
DOCUMENTATION OF FINDINGS OF MACULAR OR FUNDUS EXAM NOT COMMUNICATED TO THE
PHYSICIAN MANAGING THE PATIENT'S ONGOING DIABETES CARE
CLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR THE
FINDINGS OF THEIR MACULAR OR FUNDUS EXAM BEING COMMUNICATED TO THE PHYSICIAN
MANAGING THEIR DIABETES CARE DURING THE REPORTING YEAR
CLINICIAN HAS NOT PROVIDED CARE FOR THE DIABETIC RETINOPATHY PATIENT FOR THE
REQUIRED TIME FOR PHYSICIAN COMMUNICATION MEASUREMENT
CLINICIAN DOCUMENTED THAT COMMUNICATION WAS SENT TO THE PHYSICIAN MANAGING
ONGOING CARE OF PATIENT THAT A FRACTURE OCCURRED AND THAT THE PATIENT WAS OR
SHOULD BE TESTED OR TREATED FOR OSTEOPOROSIS
CLINICIAN HAS NOT DOCUMENTED THAT COMMUNICATION WAS SENT TO THE PHYSICIAN
MANAGING ONGOING CARE OF PATIENT THAT A FRACTURE OCCURRED AND THAT THE PATIENT
WAS OR SHOULD BE TESTED OR TREATED FOR OSTEOPOROSIS
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PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR COMMUNICATION WITH THE PHYSICIAN
MANAGING THE PATIENT'S ONGOING CARE THAT A FRACTURE OCCURRED AND THAT THE
PATIENT WAS OR SHOULD BE TESTED OR TREATED FOR OSTEOPOROSIS
PATIENT DOCUMENTED TO HAVE HAD CENTRAL DEXA PERFORMED AND RESULTS DOCUMENTED OR
CENTRAL DEXA ORDERED OR PHARMACOLOGIC THERAPY PRESCRIBED
PATIENT NOT DOCUMENTED TO HAVE HAD CENTRAL DEXA MEASUREMENT OR PHARMACOLOGIC
THERAPY
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR CENTRAL
DEXA MEASUREMENT OR PRESCRIBING PHARMACOLOGIC
CLINICIAN HAS NOT PROVIDED CARE FOR THE PATIENT FOR THE REQUIRED TIME FOR
CENTRAL DEXA MEASUREMENT OR PHARMACOLOGICAL THERAPY MEASURE
PATIENT DOCUMENTED TO HAVE HAD CENTRAL DEXA ORDERED OR PERFORMED AND RESULTS
DOCUMENTED OR PHARMACOLOGICAL THERAPY PRESCRIBED
PATIENT NOT DOCUMENTED TO HAVE HAD CENTRAL DEXA MEASUREMENT ORDERED OR
PERFORMED OR PHARMACOLOGIC THERAPY
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR CENTRAL
DEXA MEASUREMENT OR PHARMACOLOGIC THERAPY
CLINICIAN HAS NOT PROVIDED CARE FOR THE PATIENT FOR THE REQUIRED TIME FOR
CENTRAL DEXA MEASUREMENT OR PHARMACOLOGICAL THERAPY MEASURE
INTERNAL CAROTID STENOSIS PATIENT IN THE 30-99% RANGE DOCUMENTED TO HAVE
REFERENCE TO MEASUREMENTS OF DISTAL INTERNAL CAROTID DIAMETER AS THE
DENOMINATOR FOR STENOSIS MEASUREMENT
PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR DOCUMENTATION OF PRESENCE OR ABSENCE
OF ALARM SYMPTOMS
PATIENT DOCUMENTED TO HAVE HAD 12-LEAD ECG PERFORMED
PATIENT NOT DOCUMENTED TO HAVE HAD ECG
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ECG
PATIENT DOCUMENTED TO HAVE RECEIVED OR TAKEN ASPIRIN 24 HOURS BEFORE EMERGENCY
DEPARTMENT ARRIVAL OR DURING EMERGENCY DEPARTMENT STAY
PATIENT NOT DOCUMENTED TO HAVE RECEIVED OR TAKEN ASPIRIN 24 HOURS BEFORE
EMERGENCY DEPARTMENT ARRIVAL OR DURING EMERGENCY DEPARTMENT STAY
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE TO RECEIVE
ASPIRIN
PATIENT DOCUMENTED TO HAVE HAD ECG PERFORMED
PATIENT NOT DOCUMENTED TO HAVE HAD ECG
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ECG
PATIENT DOCUMENTED TO HAVE HAD VITAL SIGNS RECORDED AND REVIEWED
PATIENT NOT DOCUMENTED TO HAVE VITAL SIGNS RECORDED AND REVIEWED
PATIENT DOCUMENTED TO HAVE OXYGEN SATURATION ASSESSED
PATIENT NOT DOCUMENTED TO HAVE OXYGEN SATURATION ASSESSED
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR OXYGEN
SATURATION ASSESSMENT
PATIENT DOCUMENTED TO HAVE MENTAL STATUS ASSESSED
PATIENT NOT DOCUMENTED TO HAVE MENTAL STATUS ASSESSED
PATIENT DOCUMENTED TO HAVE APPROPRIATE EMPIRIC ANTIBIOTIC PRESCRIBED
PATIENT NOT DOCUMENTED TO HAVE APPROPRIATE EMPIRIC ANTIBIOTIC PRESCRIBED
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR APPROPRIATE
EMPIRIC ANTIBIOTIC
ASTHMA PATIENTS WITH NUMERIC FREQUENCY OF SYMPTOMS OR PATIENT COMPLETION OF AN
ASTHMA ASSESSMENT TOOL/SURVEY/QUESTIONNAIRE NOT DOCUMENTED
CHEMOTHERAPY DOCUMENTED AS NOT RECEIVED OR PRESCRIBED FOR STAGE III COLON
CANCER PATIENTS
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CHEMOTHERAPY DOCUMENTED AS RECEIVED OR PRESCRIBED FOR STAGE III COLON CANCER
PATIENTS
CHEMOTHERAPY PLAN DOCUMENTED PRIOR TO CHEMOTHERAPY ADMINISTRATION
CHEMOTHERAPY PLAN NOT DOCUMENTED PRIOR TO CHEMOTHERAPY ADMINISTRATION
CHRONIC LYMPHOCYTIC LEUKEMIA (CLL) PATIENT WITH NO DOCUMENTATION OF BASELINE
FLOW CYTOMETRY PERFORMED
CLINICIAN DOCUMENTATION THAT BREAST CANCER PATIENT WAS NOT ELIGIBLE FOR
TAMOXIFEN OR AROMATASE INHIBITOR THERAPY MEASURE
CLINICIAN DOCUMENTATION THAT COLON CANCER PATIENT IS NOT ELIGIBLE FOR
CHEMOTHERAPY MEASURE
CLINICIAN DOCUMENTATION THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
RADIATION THERAPY MEASURE
DOCUMENTATION OF RADIATION THERAPY RECOMMENDED WITHIN 12 MONTHS OF FIRST OFFICE
VISIT
FOR PATIENTS WITH ER OR PR POSITIVE, STAGE IC-III BREAST CANCER, CLINICIAN DID
NOT DOCUMENT THAT THE PATIENT RECEIVED OR WAS PRESCRIBED TAMOXIFEN OR AROMATASE
INHIBITOR
FOR PATIENTS WITH ER OR PR POSITIVE, STAGE IC-III BREAST CANCER, CLINICIAN
DOCUMENTED OR PRESCRIBED THAT THE PATIENT IS RECEIVING TAMOXIFEN OR AROMATASE
INHIBITOR
MULTIPLE MYELOMA PATIENTS WITH NO DOCUMENTATION OF PRESCRIBED OR RECEIVED
INTRAVENOUS BISPHOSPHONATE THERAPY
NO DOCUMENTATION OF RADIATION THERAPY RECOMMENDED WITHIN 12 MONTHS OF FIRST
OFFICE VISIT
BASELINE CYTOGENETIC TESTING NOT PERFORMED IN PATIENTS WITH MYELODYSPLASTIC
SYNDROME (MDS) OR ACUTE LEUKEMIAS
DIABETIC PATIENTS WITH NO DOCUMENTATION OF HEMOGLOBIN A1C LEVEL (WITHIN THE
LAST 12 MONTHS)
DIABETIC PATIENTS WITH NO DOCUMENTATION OF LOW-DENSITY LIPOPROTEIN (WITHIN THE
LAST 12 MONTHS)
END-STAGE RENAL DISEASE PATIENT WITH A HEMATOCRIT OR HEMOGLOBIN NOT DOCUMENTED
END-STAGE RENAL DISEASE PATIENT WITH URR OR KT/V VALUE NOT DOCUMENTED, BUT
OTHERWISE ELIGIBLE FOR MEASURE
MYELODYSPLASTIC SYNDROME (MDS) PATIENTS WITH NO DOCUMENTATION OF IRON STORES
PRIOR TO RECEIVING ERYTHROPOIETIN THERAPY
DIABETIC PATIENTS WITH NO DOCUMENTATION OF BLOOD PRESSURE MEASUREMENT (WITHIN
THE LAST 12 MONTHS)
PATIENTS WITH PERSISTENT ASTHMA, NO DOCUMENTATION OF PREFERRED LONG TERM
CONTROL MEDICATION OR ACCEPTABLE ALTERNATIVE TREATMENT PRESCRIBED
LEFT VENTRICULAR EJECTION FRACTION (LVEF) >= 40% OR DOCUMENTATION AS NORMAL OR
MILDLY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTION
LEFT VENTRICULAR EJECTION FRACTION (LVEF) NOT PERFORMED OR DOCUMENTED
DILATED MACULAR OR FUNDUS EXAM PERFORMED, INCLUDING DOCUMENTATION OF THE
PRESENCE OR ABSENCE OF MACULAR EDEMA AND LEVEL OF SEVERITY OF RETINOPATHY
DILATED MACULAR OR FUNDUS EXAM NOT PERFORMED
PATIENT WITH CENTRAL DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) RESULTS DOCUMENTED
OR ORDERED OR PHARMACOLOGIC THERAPY (OTHER THAN MINERALS/VITAMINS) FOR
OSTEOPOROSIS PRESCRIBED)
PATIENT WITH CENTRAL DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) RESULTS NOT
DOCUMENTED OR NOT ORDERED OR PHARMACOLOGIC THERAPY (OTHER THAN
MINERALS/VITAMINS) FOR OSTEOPOROSIS NOT PRESCRIBED
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR SCREENING
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OR THERAPY FOR OSTEOPOROSIS FOR WOMEN MEASURE
TOBACCO (SMOKE) USE CESSATION INTERVENTION, COUNSELING
TOBACCO (SMOKE) USE CESSATION INTERVENTION NOT COUNSELED
LOWER EXTREMITY NEUROLOGICAL EXAM PERFORMED AND DOCUMENTED
LOWER EXTREMITY NEUROLOGICAL EXAM NOT PERFORMED
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR LOWER
EXTREMITY NEUROLOGICAL EXAM MEASURE
ABI MEASURED AND DOCUMENTED
ABI MEASUREMENT WAS NOT OBTAINED
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ABI
MEASUREMENT MEASURE
FOOTWEAR EVALUATION PERFORMED AND DOCUMENTED
FOOTWEAR EVALUATION WAS NOT PERFORMED
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR FOOTWEAR
EVALUATION MEASURE
CALCULATED BMI ABOVE THE UPPER PARAMETER AND A FOLLOW-UP PLAN WAS DOCUMENTED IN
THE MEDICAL RECORD
CALCULATED BMI BELOW THE LOWER PARAMETER AND A FOLLOW-UP PLAN WAS DOCUMENTED IN
THE MEDICAL RECORD
CALCULATED BMI OUTSIDE NORMAL PARAMETERS, NO FOLLOW-UP PLAN WAS DOCUMENTED IN
THE MEDICAL RECORD
CALCULATED BMI WITHIN NORMAL PARAMETERS AND DOCUMENTED
BMI NOT CALCULATED
PATIENT NOT ELIGIBLE FOR BMI CALCULATION
DOCUMENTED THAT PATIENT WAS SCREENED AND EITHER INFLUENZA VACCINATION STATUS IS
CURRENT OR PATIENT WAS COUNSELED
INFLUENZA VACCINE STATUS WAS NOT SCREENED
INFLUENZA VACCINE STATUS SCREENED, PATIENT NOT CURRENT AND COUNSELING WAS NOT
PROVIDED
DOCUMENTED THAT PATIENT WAS NOT APPROPRIATE FOR SCREENING AND/OR COUNSELING
ABOUT THE INFLUENZA VACCINE (E.G., ALLERGY TO EGGS)
LIST OF CURRENT MEDICATIONS (INCLUDES PRESCRIPTION, OVER-THE-COUNTER, HERBALS,
VITAMIN/MINERAL/DIETARY [NUTRITIONAL] SUPPLEMENTS) DOCUMENTED BY THE PROVIDER,
INCLUDING DRUG NAME, DOSAGE, FREQUENCY AND ROUTE
CURRENT MEDICATIONS (INCLUDES PRESCRIPTION, OVER-THE-COUNTER, HERBALS,
VITAMIN/MINERAL/DIETARY [NUTRITIONAL] SUPPLEMENTS) WITH DRUG NAME, DOSAGE,
FREQUENCY AND ROUTE NOT DOCUMENTED BY THE PROVIDER, REASON NOT SPECIFIED
INCOMPLETE OR NO PROVIDER DOCUMENTATION THAT PATIENT'S CURRENT MEDICATIONS WITH
DOSAGES (INCLUDES PRESCRIPTION, OVER-THE-COUNTER, HERBALS,
VITAMIN/MINERAL/DIETARY [NUTRITIONAL] SUPPLEMENTS) WERE ASSESSED
PROVIDER DOCUMENTATION THAT PATIENT IS NOT ELIGIBLE FOR MEDICATION ASSESSMENT
POSITIVE SCREEN FOR CLINICAL DEPRESSION USING A STANDARDIZED TOOL AND A
FOLLOW-UP PLAN DOCUMENTED
NO DOCUMENTATION OF CLINICAL DEPRESSION SCREENING USING A STANDARDIZED TOOL
SCREENING FOR CLINICAL DEPRESSION USING A STANDARDIZED TOOL NOT DOCUMENTED,
PATIENT NOT ELIGIBLE/APPROPRIATE
DOCUMENTATION OF COGNITIVE IMPAIRMENT SCREENING USING A STANDARDIZED TOOL
NO DOCUMENTATION OF COGNITIVE IMPAIRMENT SCREENING USING A STANDARDIZED TOOL
PATIENT NOT ELIGIBLE/NOT APPROPRIATE FOR COGNITIVE IMPAIRMENT SCREENING
DOCUMENTATION OF CLINICIAN AND PATIENT INVOLVEMENT WITH THE DEVELOPMENT OF A
PLAN OF CARE INCLUDING SIGNATURE BY THE PRACTITIONER/THERAPIST AND EITHER A
CO-SIGNATURE BY THE PATIENT OR DOCUMENTED VERBAL AGREEMENT OBTAINED FROM THE
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PATIENT OR, WHEN NECESSARY, AN AUTHORIZED REPRESENTATIVE
NO DOCUMENTATION OF CLINICIAN AND PATIENT INVOLVEMENT WITH THE DEVELOPMENT OF A
PLAN OF CARE INCLUDING SIGNATURE BY THE PRACTITIONER/THERAPIST AND EITHER A
CO-SIGNATURE BY THE PATIENT OR DOCUMENTED VERBAL AGREEMENT OBTAINED FROM THE
PATIENT OR, WHEN NECESSARY, AN AUTHORIZED REPRESENTATIVE
DOCUMENTATION THAT PATIENT IS NOT ELIGIBLE FOR CO-DEVELOPING A PLAN OF CARE
INCLUDING SIGNATURE BY THE PRACTITIONER/THERAPIST AND EITHER A CO-SIGNATURE BY
THE PATIENT OR DOCUMENTED VERBAL AGREEMENT OBTAINED FROM THE PATIENT OR, WHEN
NECESSARY, AN AUTHORIZED REPRESENTATIVE
DOCUMENTATION OF PAIN ASSESSMENT (INCLUDING LOCATION, INTENSITY AND
DESCRIPTION) PRIOR TO INITIATION OF THERAPY OR DOCUMENTATION OF THE ABSENCE OF
PAIN AS A RESULT OF ASSESSMENT THROUGH DISCUSSION WITH THE PATIENT INCLUDING
THE USE OF A STANDARDIZED TOOL AND A FOLLOW-UP PLAN IS DOCUMENTED
NO DOCUMENTATION OF PAIN ASSESSMENT (INCLUDING LOCATION, INTENSITY AND
DESCRIPTION) PRIOR TO INITIATION OF THERAPY
DOCUMENTATION THAT PATIENT IS NOT ELIGIBLE FOR PAIN ASSESSMENT
ALL PRESCRIPTIONS CREATED DURING THE ENCOUNTER WERE GENERATED USING A QUALIFIED
E-PRESCRIBING SYSTEM
NO PRESCRIPTIONS WERE GENERATED DURING THE ENCOUNTER, PROVIDER DOES HAVE ACCESS
TO A QUALIFIED E-PRESCRIBING SYSTEM
PROVIDER DOES HAVE ACCESS TO A QUALIFIED E-PRESCRIBING SYSTEM AND SOME OR ALL
OF THE PRESCRIPTIONS GENERATED DURING THE ENCOUNTER WERE PRINTED OR PHONED IN
AS REQUIRED BY STATE OR FEDERAL LAW OR REGULATIONS, PATIENT REQUEST OR PHARMACY
SYSTEM BEING UNABLE TO RECEIVE ELECTRONIC TRANSMISSION; OR BECAUSE THEY WERE
FOR NARCOTICS OR OTHER CONTROLLED SUBSTANCES
PATIENT ENCOUNTER WAS DOCUMENTED USING AN EHR SYSTEM THAT HAS BEEN CERTIFIED BY
AN AUTHORIZED TESTING AND CERTIFICATION BODY (ATCB)
PATIENT ENCOUNTER WAS DOCUMENTED USING A PQRI QUALIFIED EHR OR OTHER ACCEPTABLE
SYSTEMS
PATIENT ENCOUNTER WAS NOT DOCUMENTED USING AN EMR DUE TO SYSTEM REASONS SUCH
AS, THE SYSTEM BEING INOPERABLE AT THE TIME OF THE VISIT; USE OF THIS CODE
IMPLIES THAT AN EMR IS IN PLACE AND GENERALLY AVAILABLE
BETA-BLOCKER THERAPY PRESCRIBED FOR PATIENTS WITH LEFT VENTRICULAR EJECTION
FRACTION (LVEF) <40% OR DOCUMENTATION AS MODERATELY OR SEVERELY DEPRESSED LEFT
VENTRICULAR SYSTOLIC FUNCTION
CLINICIAN DOCUMENTED PATIENT WITH LEFT VENTRICULAR EJECTION FRACTION (LVEF)
<40% OR DOCUMENTATION AS MODERATELY OR SEVERELY DEPRESSED LEFT VENTRICULAR
SYSTOLIC FUNCTION WAS NOT ELIGIBLE CANDIDATE FOR BETA-BLOCKER THERAPY
BETA-BLOCKER THERAPY NOT PRESCRIBED FOR PATIENTS WITH LEFT VENTRICULAR EJECTION
FRACTION (LVEF) <40% OR DOCUMENTATION AS MODERATELY OR SEVERELY DEPRESSED LEFT
VENTRICULAR SYSTOLIC FUNCTION
TOBACCO USE CESSATION INTERVENTION, COUNSELING
TOBACCO USE CESSATION INTERVENTION NOT COUNSELED, REASON NOT SPECIFIED
CURRENT TOBACCO SMOKER
CURRENT SMOKELESS TOBACCO USER
CURRENT TOBACCO NON-USER
CLINICIAN DOCUMENTED THAT PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR GENOTYPE
TESTING; PATIENT NOT RECEIVING ANTIVIRAL TREATMENT FOR HEPATITIS C
CLINICIAN DOCUMENTED THAT PATIENT IS RECEIVING ANTIVIRAL TREATMENT FOR
HEPATITIS C
CLINICIAN DOCUMENTED THAT PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR QUANTITATIVE
RNA TESTING AT WEEK 12; PATIENT NOT RECEIVING ANTIVIRAL TREATMENT FOR HEPATITIS
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C
PATIENT RECEIVING ANTIVIRAL TREATMENT FOR HEPATITIS C
CLINICIAN DOCUMENTED THAT PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR COUNSELING
REGARDING CONTRACEPTION PRIOR TO ANTIVIRAL TREATMENT; PATIENT NOT RECEIVING
ANTIVIRAL TREATMENT FOR HEPATITIS C
PATIENT RECEIVING ANTIVIRAL TREATMENT FOR HEPATITIS C DOCUMENTED
CLINICIAN DOCUMENTED THAT PROSTATE CANCER PATIENT IS NOT AN ELIGIBLE CANDIDATE
FOR ADJUVANT HORMONAL THERAPY; LOW OR INTERMEDIATE RISK OF RECURRENCE OR RISK
OF RECURRENCE NOT DETERMINED
HIGH RISK OF RECURRENCE OF PROSTATE CANCER
CLINICIAN DOCUMENTED THAT PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR SUICIDE RISK
ASSESSMENT; MAJOR DEPRESSIVE DISORDER, IN REMISSION
DOCUMENTATION OF NEW DIAGNOSIS OF INITIAL OR RECURRENT EPISODE OF MAJOR
DEPRESSIVE DISORDER
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER
(ARB) THERAPY PRESCRIBED FOR PATIENTS WITH A LEFT VENTRICULAR EJECTION FRACTION
(LVEF) <40% OR DOCUMENTATION OF MODERATELY OR SEVERELY DEPRESSED LEFT
VENTRICULAR SYSTOLIC FUNCTION
CLINICIAN DOCUMENTED THAT PATIENT WITH A LEFT VENTRICULAR EJECTION FRACTION
(LVEF) <40% OR DOCUMENTATION OF MODERATELY OR SEVERELY DEPRESSED LEFT
VENTRICULAR SYSTOLIC FUNCTION WAS NOT AN ELIGIBLE CANDIDATE FOR ANGIOTENSIN
CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY
PATIENT WITH LEFT VENTRICULAR EJECTION FRACTION (LVEF) >=40% OR DOCUMENTATION
AS NORMAL OR MILDLY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTION
LEFT VENTRICULAR EJECTION FRACTION (LVEF) WAS NOT PERFORMED OR DOCUMENTED
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER
(ARB) THERAPY NOT PRESCRIBED FOR PATIENTS WITH A LEFT VENTRICULAR EJECTION
FRACTION (LVEF) <40% OR DOCUMENTATION OF MODERATELY OR SEVERELY DEPRESSED LEFT
VENTRICULAR SYSTOLIC FUNCTION, REASON NOT SPECIFIED
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER
(ARB) THERAPY PRESCRIBED
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER
(ARB) THERAPY NOT PRESCRIBED FOR REASONS DOCUMENTED BY THE CLINICIAN
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER
(ARB) THERAPY NOT PRESCRIBED, REASON NOT SPECIFIED
MOST RECENT BLOOD PRESSURE HAS A SYSTOLIC MEASUREMENT OF <130 MM/HG AND A
DIASTOLIC MEASUREMENT OF <80 MM/HG
MOST RECENT BLOOD PRESSURE HAS A SYSTOLIC MEASUREMENT OF >=130 MM/HG AND/OR A
DIASTOLIC MEASUREMENT OF >=80 MM/HG
BLOOD PRESSURE MEASUREMENT NOT PERFORMED OR DOCUMENTED, REASON NOT SPECIFIED
CLINICIAN PRESCRIBED ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR
ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ANGIOTENSIN
CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY
CLINICIAN DID NOT PRESCRIBE ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR
ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY, REASON NOT SPECIFIED
INFLUENZA IMMUNIZATION WAS ORDERED OR ADMINISTERED
INFLUENZA IMMUNIZATION WAS NOT ORDERED OR ADMINISTERED FOR REASONS DOCUMENTED
BY CLINICIAN
INFLUENZA IMMUNIZATION WAS NOT ORDERED OR ADMINISTERED, REASON NOT SPECIFIED
I INTEND TO REPORT THE DIABETES MELLITUS MEASURES GROUP
I INTEND TO REPORT THE PREVENTIVE CARE MEASURES GROUP
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I INTEND TO REPORT THE CHRONIC KIDNEY DISEASE (CKD) MEASURES GROUP
CLINICIAN INTENDS TO REPORT THE END STAGE RENAL DISEASE (ESRD) MEASURE GROUP
I INTEND TO REPORT THE CORONARY ARTERY DISEASE (CAD) MEASURES GROUP
I INTEND TO REPORT THE RHEUMATOID ARTHRITIS MEASURES GROUP
I INTEND TO REPORT THE HIV/AIDS MEASURES GROUP
I INTEND TO REPORT THE PERIOPERATIVE CARE MEASURES GROUP
I INTEND TO REPORT THE BACK PAIN MEASURES GROUP
ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE DIABETES MELLITUS
MEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENT
ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE CKD MEASURES GROUP HAVE
BEEN PERFORMED FOR THIS PATIENT
ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE PREVENTIVE CARE MEASURES
GROUP HAVE BEEN PERFORMED FOR THIS PATIENT
ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE CORONARY ARTERY BYPASS
GRAFT (CABG) MEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENT
ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE CORONARY ARTERY DISEASE
(CAD) MEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENT
ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE RHEUMATOID ARTHRITIS
MEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENT
ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE HIV/AIDS MEASURES GROUP
HAVE BEEN PERFORMED FOR THIS PATIENT
ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE PERIOPERATIVE CARE
MEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENT
ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE BACK PAIN MEASURES GROUP
HAVE BEEN PERFORMED FOR THIS PATIENT
DOCUMENTATION THAT PROPHYLACTIC ANTIBIOTIC WAS GIVEN WITHIN ONE HOUR (IF
FLUOROQUINOLONE OR VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (OR START
OF PROCEDURE WHEN NO INCISION IS REQUIRED)
DOCUMENTATION OF ORDER FOR PROPHYLACTIC ANTIBIOTICS TO BE GIVEN WITHIN ONE HOUR
(IF FLUOROQUINOLONE OR VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (OR
START OF PROCEDURE WHEN NO INCISION IS REQUIRED)
DOCUMENTATION THAT PROPHYLACTIC ANTIBIOTIC WAS NOT GIVEN WITHIN ONE HOUR (IF
FLUOROQUINOLONE OR VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (OR START
OF PROCEDURE WHEN NO INCISION IS REQUIRED), REASON NOT SPECIFIED
PATIENT RECEIVING ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN
RECEPTOR BLOCKER (ARB) THERAPY
PROVIDER DOCUMENTATION THAT PATIENT IS NOT ELIGIBLE FOR PATIENT VERIFICATION OF
CURRENT MEDICATIONS
DOCUMENTATION OF PAIN ASSESSMENT (INCLUDING LOCATION, INTENSITY AND
DESCRIPTION) PRIOR TO INITIATION OF THERAPY OR DOCUMENTATION OF THE ABSENCE OF
PAIN AS A RESULT OF ASSESSMENT THROUGH DISCUSSION WITH THE PATIENT INCLUDING
THE USE OF A STANDARDIZED TOOL; NO DOCUMENTATION OF A FOLLOW-UP PLAN, PATIENT
NOT ELIGIBLE
DOCUMENTATION OF PAIN ASSESSMENT (INCLUDING LOCATION, INTENSITY AND
DESCRIPTION) PRIOR TO INITIATION OF THERAPY OR DOCUMENTATION OF THE ABSENCE OF
PAIN AS A RESULT OF ASSESSMENT THROUGH DISCUSSION WITH THE PATIENT INCLUDING
THE USE OF A STANDARDIZED TOOL; NO DOCUMENTATION OF A FOLLOW-UP PLAN, REASON
NOT SPECIFIED
NEGATIVE SCREEN FOR CLINICAL DEPRESSION USING A STANDARDIZED TOOL, PATIENT NOT
ELIGIBLE/APPROPRIATE FOR FOLLOW-UP PLAN DOCUMENTED
SCREEN FOR CLINICAL DEPRESSION USING A STANDARDIZED TOOL DOCUMENTED, FOLLOW UP
PLAN NOT DOCUMENTED, REASON NOT SPECIFIED
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PAIN SEVERITY QUANTIFIED; PAIN PRESENT
ABI MEASURED AND DOCUMENTED
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ABI
MEASUREMENT MEASURE
ABI MEASUREMENT WAS NOT OBTAINED
PATIENT SCREENED FOR FUTURE FALLS RISK; DOCUMENTATION OF TWO OR MORE FALLS IN
THE PAST YEAR OR ANY FALL WITH INJURY IN THE PAST YEAR
PATIENT SCREENED FOR FUTURE FALL RISK; DOCUMENTATION OF NO FALLS IN THE PAST
YEAR OR ONLY ONE FALL WITHOUT INJURY IN THE PAST YEAR
CLINICAL STAGE PRIOR TO SURGERY FOR LUNG CANCER AND ESOPHAGEAL CANCER RESECTION
WAS RECORDED
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT ELIGIBLE FOR CLINICAL STAGE PRIOR TO
SURGERY FOR LUNG CANCER AND ESOPHAGEAL CANCER RESECTION MEASURE
CLINICIAN STAGE PRIOR TO SURGERY FOR LUNG CANCER AND ESOPHAGEAL CANCER
RESECTION WAS NOT RECORDED, REASON NOT SPECIFIED
ANTIPLATELET THERAPY RECEIVED (ASA [81-325 MG/DAY] AND/OR CLOPIDOGREL [75
MG/DAY]) WITHIN 48 HOURS OF THE INITIATION OF SURGERY AND AT DISCHARGE
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR
ANTIPLATELET THERAPY
ANTIPLATELET THERAPY NOT RECEIVED 48 HOURS PRIOR TO CEA AND AT DISCHARGE,
REASON NOT SPECIFIED
PATCH CLOSURE USED FOR PATIENT UNDERGOING CONVENTIONAL CEA
CLINICIAN DOCUMENTED THAT PATIENT DID NOT RECEIVE CONVENTIONAL CEA
PATCH CLOSURE NOT USED FOR PATIENT UNDERGOING CONVENTIONAL CEA, REASON NOT
SPECIFIED
DOCUMENTATION OF ORDER FOR CEFAZOLIN OR CEFUROXIME FOR ANTIMICROBIAL PROPHYLAXIS
CLINICIAN DOCUMENTED THAT PATIENT WAS INELIGIBLE FOR PROPHYLACTIC ANTIBIOTIC
SELECTION MEASURE
ORDER FOR CEFAZOLIN OR CEFUROXIME FOR ANTIMICROBIAL PROPHYLAXIS NOT DOCUMENTED,
REASON NOT SPECIFIED
AUTOGENOUS AV FISTULA RECEIVED
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR AUTOGENOUS
AV FISTULA
CLINICIAN DOCUMENTED THAT PATIENT RECEVIED VASCULAR ACCESS OTHER THAN
AUTOGENOUS AV FISTULA, REASON NOT SPECIFIED
PARTICIPATION BY A PHYSICIAN OR OTHER CLINICIAN IN SYSTEMATIC CLINICAL DATABASE
REGISTRY THAT INCLUDES CONSENSUS-ENDORSED QUALITY MEASURES
DOCUMENTATION OF AN ELDER MALTREATMENT SCREEN AND FOLLOW-UP PLAN
NO DOCUMENTATION OF AN ELDER MALTREATMENT SCREEN, PATIENT NOT ELIGIBLE
NO DOCUMENTATION OF AN ELDER MALTREATMENT SCREEN, REASON NOT SPECIFIED
ELDER MALTREATMENT SCREEN DOCUMENTED, FOLLOW-UP PLAN NOT DOCUMENTED, PATIENT
NOT ELIGIBLE
ELDER MALTREATMENT SCREEN DOCUMENTED, FOLLOW-UP PLAN NOT DOCUMENTED, REASON NOT
SPECIFIED
DOCUMENTATION OF A CURRENT FUNCTIONAL OUTCOME ASSESSMENT USING A STANDARDIZED
TOOL AND CARE PLAN BASED ON IDENTIFIED DEFICIENCIES
DOCUMENTATION THAT THE PATIENT IS NOT ELIGIBLE FOR A FUNCTIONAL OUTCOME
ASSESSMENT USING A STANDARDIZED TOOL
NO DOCUMENTATION OF A CURRENT FUNCTIONAL OUTCOME ASSESSMENT USING A
STANDARDIZED TOOL, REASON NOT SPECIFIED
DOCUMENTATION OF A CURRENT FUNCTIONAL OUTCOME ASSESSMENT USING A STANDARDIZED
TOOL; NO DOCUMENTATION OF A CARE PLAN, PATIENT NOT ELIGIBLE
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DOCUMENTATION OF A CURRENT FUNCTIONAL OUTCOME ASSESSMENT USING A STANDARDIZED
TOOL; NO DOCUMENTATION OF A CARE PLAN, REASON NOT SPECIFIED
I INTEND TO REPORT THE CORONARY ARTERY BYPASS GRAFT (CABG) MEASURES GROUP
I INTEND TO REPORT THE HEPATITIS C MEASURES GROUP
I INTEND TO REPORT THE COMMUNITY-ACQUIRED PNEUMONIA (CAP) MEASURES GROUP
I INTEND TO REPORT THE ISCHEMIC VASCULAR DISEASE (IVD) MEASURES GROUP
I INTEND TO REPORT THE HEART FAILURE (HF) MEASURES GROUP
ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE HEPATITIS C MEASURES
GROUP HAVE BEEN PERFORMED FOR THIS PATIENT
ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE COMMUNITY-ACQUIRED
PNEUMONIA (CAP) MEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENT
ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE HEART FAILURE (HF)
MEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENT
ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE ISCHEMIC VASCULAR
DISEASE (IVD) MEASURES GROUP HAVE BEEN PERFORMED FOR THIS PATIENT
AT LEAST ONE PRESCRIPTION CREATED DURING THE ENCOUNTER WAS GENERATED AND
TRANSMITTED ELECTRONICALLY USING A QUALIFIED ERX SYSTEM
REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING IN DISORDERS OF
THE EAR) FOR AN OTOLOGIC EVALUATION
PATIENT IS NOT ELIGIBLE FOR THE REFERRAL FOR OTOLOGIC EVALUATION MEASURE
NOT REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING IN DISORDERS
OF THE EAR) FOR AN OTOLOGIC EVALUATION, REASON NOT SPECIFIED
PATIENT REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING IN
DISORDERS OF THE EAR) FOR AN OTOLOGIC EVALUATION
PATIENT HAS A HISTORY OF ACTIVE DRAINAGE FROM THE EAR WITHIN THE PREVIOUS 90
DAYS
PATIENT IS NOT ELIGIBLE FOR THE REFERRAL FOR OTOLOGIC EVALUATION FOR PATIENTS
WITH A HISTORY OF ACTIVE DRAINAGE MEASURE
PATIENT DOES NOT HAVE A HISTORY OF ACTIVE DRAINAGE FROM THE EAR WITHIN THE
PREVIOUS 90 DAYS
PATIENT NOT REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING IN
DISORDERS OF THE EAR) FOR AN OTOLOGIC EVALUATION, REASON NOT SPECIFIED
PATIENT WAS REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING IN
DISORDERS OF THE EAR) FOR AN OTOLOGIC EVALUATION, REASON NOT SPECIFIED)
VERIFICATION AND DOCUMENTATION OF SUDDEN OR RAPIDLY PROGRESSIVE HEARING LOSS
PATIENT IS NOT ELIGIBLE FOR THE "REFERRAL FOR OTOLOGIC EVALUATION FOR SUDDEN OR
RAPIDLY PROGRESSIVE HEARING LOSS" MEASURE
PATIENT DOES NOT HAVE VERIFICATION AND DOCUMENTATION OF SUDDEN OR RAPIDLY
PROGRESSIVE HEARING LOSS
PATIENT WAS NOT REFERRED TO A PHYSICIAN (PREFERABLY A PHYSICIAN WITH TRAINING
IN DISORDERS OF THE EAR) FOR AN OTOLOGIC EVALUATION, REASON NOT SPECIFIED)
PROLONGED INTUBATION (>24 HRS) REQUIRED
PROLONGED INTUBATION (>24 HRS) NOT REQUIRED
DEVELOPMENT OF DEEP STERNAL WOUND INFECTION WITHIN 30 DAYS POSTOPERATIVELY
NO DEEP STERNAL WOUND INFECTION
STROKE/CBA FOLLOWING ISOLATED CABG SURGERY
NO STROKE/CVA FOLLOWING ISOLATED CABG SURGERY
DEVELOPED POSTOPERATIVE RENAL INSUFFICIENCY OR REQUIRED DIALYSIS
NO POSTOPERATIVE RENAL INSUFFICIENCY/DIALYSIS NOT REQUIRED
REOPERATION REQUIRED DUE TO BLEEDING/TAMPONADE, GRAFT OCCLUSION OR OTHER
CARDIAC REASON
REOPERATION NOT REQUIRED DUE TO BLEEDING/TAMPONADE, GRAFT OCCLUSION OR OTHER
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CARDIAC REASON
ANTIPLATELET MEDICATION AT DISCHARGE
ANTIPLATELET MEDICATION CONTRAINDICATED/NOT INDICATED
NO ANTIPLATELET MEDICATION AT DISCHARGE
BETA-BLOCKER AT DISCHARGE
BETA-BLOCKER CONTRAINDICATED/NOT INDICATED
NO BETA-BLOCKER AT DISCHARGE
ANTI-LIPID TREATMENT AT DISCHARGE
ANTI-LIPID TREATMENT CONTRAINDICATED/NOT INDICATED
NO ANTI-LIPID TREATMENT AT DISCHARGE
MOST RECENT SYSTOLIC BLOOD PRESSURE < 140 MMHG
MOST RECENT SYSTOLIC BLOOD PRESSURE >= 140 MMHG
MOST RECENT DIASTOLIC BLOOD PRESSURE < 90 MMHG
MOST RECENT DIASTOLIC BLOOD PRESSURE >= 90 MMHG
NO DOCUMENTATION OF BLOOD PRESSURE MEASUREMENT
LIPID PROFILE RESULTS DOCUMENTED AND REVIEWED (MUST INCLUDE TOTAL CHOLESTEROL,
HDL-C, TRIGLYCERIDES AND CALCULATED LDL-C)
LIPID PROFILE NOT PERFORMED, REASON NOT OTHERWISE SPECIFIED
MOST RECENT LDL-C < 100 MG/DL
LDL-C WAS NOT PERFORMED
MOST RECENT LDL-C >= 100 MG/DL
ASPIRIN OR ANOTHER ANTITHROMBOTIC THERAPY USED
ASPIRIN OR ANOTHER ANTITHROMBOTIC THERAPY NOT USED, REASON NOT OTHERWISE
SPECIFIED
IV T-PA INITIATED WITHIN THREE HOURS (<= 180 MINUTES) OF TIME LAST KNOWN WELL
IV T-PA NOT INITIATED WITHIN THREE HOURS (<= 180 MINUTES) OF TIME LAST KNOWN
WELL FOR REASONS DOCUMENTED BY CLINICIAN
IV T-PA NOT INITIATED WITHIN THREE HOURS (<= 180 MINUTES) OF TIME LAST KNOWN
WELL, REASON NOT SPECIFIED
SCORE ON THE SPOKEN LANGUAGE COMPREHENSION FUNCTIONAL COMMUNICATION MEASURE AT
DISCHARGE WAS HIGHER THAN AT ADMISSION
SCORE ON THE SPOKEN LANGUAGE COMPREHENSION FUNCTIONAL COMMUNICATION MEASURE AT
DISCHARGE WAS NOT HIGHER THAN AT ADMISSION, REASON NOT SPECIFIED
PATIENT WAS NOT SCORED ON THE SPOKEN LANGUAGE COMPREHENSION FUNCTIONAL
COMMUNICATION MEASURE EITHER AT ADMISSION OR AT DISCHARGE
SCORE ON THE ATTENTION FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS HIGHER
THAN AT ADMISSION
SCORE ON THE ATTENTION FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS NOT
HIGHER THAN AT ADMISSION, REASON NOT SPECIFIED
PATIENT WAS NOT SCORED ON THE ATTENTION FUNCTIONAL COMMUNICATION MEASURE EITHER
AT ADMISSION OR AT DISCHARGE
SCORE ON THE MEMORY FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS HIGHER
THAN AT ADMISSION
SCORE ON THE MEMORY FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS NOT
HIGHER THAN AT ADMISSION, REASON NOT SPECIFIED
PATIENT WAS NOT SCORED ON THE MEMORY FUNCTIONAL COMMUNICATION MEASURE AT EITHER
ADMISSION OR AT DISCHARGE
SCORE ON THE MOTOR SPEECH FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS
HIGHER THAN AT ADMISSION
SCORE ON THE MOTOR SPEECH FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS NOT
HIGHER THAN AT ADMISSION, REASON NOT SPECIFIED
PATIENT WAS NOT SCORED ON THE MOTOR SPEECH FUNCTIONAL COMMUNICATION MEASURE
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EITHER AT ADMISSION OR AT DISCHARGE
SCORE ON THE READING FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS HIGHER
THAN AT ADMISSION
SCORE ON THE READING FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS NOT
HIGHER THAN AT ADMISSION, REASON NOT SPECIFIED
PATIENT WAS NOT SCORED ON THE READING FUNCTIONAL COMMUNICATION MEASURE EITHER
AT ADMISSION OR AT DISCHARGE
SCORE ON THE SPOKEN LANGUAGE EXPRESSION FUNCTIONAL COMMUNICATION MEASURE AT
DISCHARGE WAS HIGHER THAN AT ADMISSION
SCORE ON THE SPOKEN LANGUAGE EXPRESSION FUNCTIONAL COMMUNICATION MEASURE AT
DISCHARGE WAS NOT HIGHER THAN AT ADMISSION, REASON NOT SPECIFIED
PATIENT WAS NOT SCORED ON THE SPOKEN LANGUAGE EXPRESSION FUNCTIONAL
COMMUNICATION MEASURE EITHER AT ADMISSION OR AT DISCHARGE
SCORE ON THE WRITING FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS HIGHER
THAN AT ADMISSION
SCORE ON THE WRITING FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS NOT
HIGHER THAN AT ADMISSION, REASON NOT SPECIFIED
PATIENT WAS NOT SCORED ON THE WRITING FUNCTIONAL COMMUNICATION MEASURE EITHER
AT ADMISSION OR AT DISCHARGE
SCORE ON THE SWALLOWING FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS
HIGHER THAN AT ADMISSION
SCORE ON THE SWALLOWING FUNCTIONAL COMMUNICATION MEASURE AT DISCHARGE WAS NOT
HIGHER THAN AT ADMISSION, REASON NOT SPECIFIED
PATIENT WAS NOT SCORED ON THE SWALLOWING FUNCTIONAL COMMUNICATION MEASURE AT
ADMISSION OR AT DISCHARGE
SURGICAL PROCEDURE PERFORMED WITHIN 30 DAYS FOLLOWING CATARACT SURGERY FOR
MAJOR COMPLICATIONS (E.G. RETAINED NUCLEAR FRAGMENTS, ENDOPHTHALMITIS,
DISLOCATED OR WRONG POWER IOL, RETINAL DETACHMENT, OR WOUND DEHISCENCE)
SURGICAL PROCEDURE NOT PERFORMED WITHIN 30 DAYS FOLLOWING CATARACT SURGERY FOR
MAJOR COMPLICATIONS (E.G. RETAINED NUCLEAR FRAGMENTS, ENDOPHTHALMITIS,
DISLOCATED OR WRONG POWER IOL, RETINAL DETACHMENT, OR WOUND DEHISCENCE)
DOCUMENTATION OF ORDER FOR PROPHYLACTIC PARENTERAL ANTIBIOTIC TO BE GIVEN
WITHIN ONE HOUR (IF FLUOROQUINOLONE OR VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL
INCISION (OR START OF PROCEDURE WHEN NO INCISION IS REQUIRED)
DOCUMENTATION THAT ADMINISTRATION OF PROPHYLACTIC PARENTERAL ANTIBIOTICS WAS
INITIATED WITHIN ONE HOUR (IF FLUOROQUINOLONE OR VANCOMYCIN, TWO HOURS) PRIOR
TO SURGICAL INCISION (OR START OF PROCEDURE WHEN NO INCISION IS REQUIRED), AS
ORDERED
CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ORDERING
PROPHYLACTIC PARENTERAL ANTIBIOTICS TO BE GIVEN WITHIN ONE HOUR (IF
FLUOROQUINOLONE OR VANCOMYCIN, TWO HOURS) PRIOR TO SURGICAL INCISION (OR START
OF PROCEDURE WHEN NO INCISION IS REQUIRED)
PROPHYLACTIC PARENTERAL ANTIBIOTICS WERE NOT ORDERED TO BE GIVEN OR GIVEN
WITHIN ONE HOUR (IF FLUOROQUINOLONE OR VANCOMYCIN, TWO HOURS) PRIOR TO THE
SURGICAL INCISION (OR START OF PROCEDURE WHEN NO INCISION IS REQUIRED), REASON
NOT OTHERWISE SPECIFIED)
PHARMACOLOGIC THERAPY (OTHER THAN MINIERALS/VITAMINS) FOR OSTEOPOROSIS
PRESCRIBED
CLINICIAN DOCUMENTED PATIENT NOT AN ELIGIBLE CANDIDATE TO RECEIVE PHARMACOLOGIC
THERAPY FOR OSTEOPOROSIS
PHARMACOLOGIC THERAPY FOR OSTEOPOROSIS WAS NOT PRESCRIBED, REASON NOT OTHERWISE
SPECIFIED
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INFLUENZA IMMUNIZATION ADMINISTERED OR PREVIOUSLY RECEIVED
CLINICIAN DOCUMENTED THAT PATIENT IS NOT ELIGIBLE TO RECEIVE THE INFLUENZA
IMMUNIZATION
INFLUENZA IMMUNIZATION NOT ADMINISTERED OR PREVIOUSLY RECEIVED, REASON NOT
OTHERWISE SPECIFIED
INFLUENZA IMMUNIZATION WAS ADMINISTERED OR PREVIOUSLY RECEIVED
CLINICIAN HAS DOCUMENTED THAT PATIENT IS NOT ELIGIBLE TO RECEIVE THE INFLUENZA
IMMUNIZATION
INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED OR PREVIOUSLY RECEIVED, REASON NOT
OTHERWISE SPECIFIED
THE ELIGIBLE PROFESSIONAL PRACTICES IN A RURAL AREA WITHOUT SUFFICIENT HIGH
SPEED INTERNET ACCESS AND REQUESTS A HARDSHIP EXEMPTION FROM THE APPLICATION OF
THE PAYMENT ADJUSTMENT UNDER SECTION 1848(A)(5)(A) OF THE SOCIAL SECURITY ACT
THE ELIGIBLE PROFESSIONAL PRACTICES IN AN AREA WITHOUT SUFFICIENT AVAILABLE
PHARMACIES FOR ELECTRONIC PRESCRIBING AND REQUESTS A HARDSHIP EXEMPTION FOR THE
APPLICATION OF THE PAYMENT ADJUSTMENT UNDER SECTION 1848(A)(5)(A) OF THE SOCIAL
SECURITY ACT
ELIGIBLE PROFESSIONAL DOES NOT HAVE PRESCRIBING PRIVILEGES
I INTEND TO REPORT THE ASTHMA MEASURES GROUP
ALL QUALITY ACTIONS FOR THE APPLICABLE MEASURES IN THE ASTHMA MEASURES GROUP
HAVE BEEN PERFORMED FOR THIS PATIENT
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE KNEE SUCCESSFULLY
CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THAN ZERO (>0)
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE KNEE SUCCESSFULLY
CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0)
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE KNEE NOT
MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON
ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT
ELIGIBLE/NOT APPROPRIATE
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE KNEE NOT
MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON
ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIED
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE HIP SUCCESSFULLY
CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THAN ZERO (>0)
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE HIP SUCCESSFULLY
CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0)
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE HIP NOT MEASURED
BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION
AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT ELIGIBLE/NOT
APPROPRIATE
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE HIP NOT MEASURED
BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON ADMISSION
AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIED
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE LOWER LEG, FOOT
OR ANKLE SUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER
THAN ZERO(>0)
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE LOWER LEG, FOOT
OR ANKLE SUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0)
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE LOWER LEG, FOOT
OR ANKLE NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL
INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT
ELIGIBLE/NOT APPROPRIATE
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RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE LOWER LEG, FOOT
OR ANKLE NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL
INTAKE ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT
SPECIFIED
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE LUMBAR SPINE
SUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THAN
ZERO (>0)
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE LUMBAR SPINE
SUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0)
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE LUMBAR SPINE NOT
MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON
ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT
ELIGIBLE/NOT APPROPRIATE
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE LUMBAR SPINE NOT
MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON
ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIED
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE SHOULDER
SUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THAN
ZERO (>0)
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE SHOULDER
SUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0)
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE SHOULDER NOT
MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON
ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT
ELIGIBLE/NOT APPROPRIATE
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE SHOULDER NOT
MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON
ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIED
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE ELBOW, WRIST OR
HAND SUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER
THAN ZERO (>0)
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE ELBOW, WRIST OR
HAND SUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0)
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE ELBOW, WRIST OR
HAND NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE
ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT
ELIGIBLE/NOT APPROPRIATE
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE ELBOW, WRIST OR
HAND NOT MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE
ON ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIED
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE NECK, CRANIUM,
MANDIBLE, THORACIC SPINE, RIBS, OR OTHER GENERAL ORTHOPEDIC IMPAIRMENT
SUCCESSFULLY CALCULATED AND THE SCORE WAS EQUAL TO ZERO (0) OR GREATER THAN
ZERO (>0)
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORE FOR THE NECK, CRANIUM,
MANDIBLE, THORACIC SPINE, RIBS, OR OTHER GENERAL ORTHOPEDIC IMPAIRMENT
SUCCESSFULLY CALCULATED AND THE SCORE WAS LESS THAN ZERO (<0)
RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE NECK, CRANIUM,
MANDIBLE, THORACIC SPINE, RIBS, OR OTHER GENERAL ORTHOPEDIC IMPAIRMENT NOT
MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON
ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, PATIENT NOT
ELIGIBLE/NOT APPROPRIATE
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RISK-ADJUSTED FUNCTIONAL STATUS CHANGE RESIDUAL SCORES FOR THE NECK, CRANIUM,
MANDIBLE, THORACIC SPINE, RIBS, OR OTHER GENERAL ORTHOPEDIC IMPAIRMENT NOT
MEASURED BECAUSE THE PATIENT DID NOT COMPLETE FOTO'S FUNCTIONAL INTAKE ON
ADMISSION AND/OR FOLLOW UP STATUS SURVEY NEAR DISCHARGE, REASON NOT SPECIFIED
MOST RECENT SYSTOLIC BLOOD PRESSURE >= 140 MM HG
MOST RECENT DIASTOLIC BLOOD PRESSURE >= 90 MM HG
MOST RECENT SYSTOLIC BLOOD PRESSURE < 130 MM HG
MOST RECENT SYSTOLIC BLOOD PRESSURE 130 TO 139 MM HG
MOST RECENT DIASTOLIC BLOOD PRESSURE < 80 MM HG
MOST RECENT DIASTOLIC BLOOD PRESSURE 80 - 89 MM HG
PATIENT HOSPITALIZED WITH PRINCIPAL DIAGNOSIS OF HEART FAILURE DURING THE
MEASUREMENT PERIOD
LEFT VENTRICULAR FUNCTION TESTING PERFORMED DURING THE MEASUREMENT PERIOD
CLINICIAN DOCUMENTED THAT PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR LEFT
VENTRICULAR FUNCTION TESTING DURING THE MEASUREMENT PERIOD
PATIENT NOT HOSPITALIZED WITH PRINCIPAL DIAGNOSIS OF HEART FAILURE DURING THE
MEASUREMENT PERIOD
LEFT VENTRICULAR FUNCTION TESTING NOT PERFORMED DURING THE MEASUREMENT PERIOD,
REASON NOT SPECIFIED
CURRENTLY A TOBACCO SMOKER OR CURRENT EXPOSURE TO SECONDHAND SMOKE
CURRENTLY A TOBACCO NON-USER AND NO EXPOSURE TO SECONDHAND SMOKE
CURRENTLY A SMOKELESS TOBACCO USER (EG, CHEW, SNUFF) AND NO EXPOSURE TO
SECONDHAND SMOKE
TOBACCO USE NOT ASSESSED, REASON NOT OTHERWISE SPECIFIED
CURRENT TOBACCO SMOKER OR CURRENT EXPOSURE TO SECONDHAND SMOKE
CURRENT TOBACCO NON-USER AND NO EXPOSURE TO SECONDHAND SMOKE
CURRENT SMOKELESS TOBACCO USER (EG, CHEW, SNUFF) AND NO EXPOSURE TO SECONDHAND
SMOKE
TOBACCO USE NOT ASSESSED, REASON NOT SPECIFIED
COORDINATED CARE FEE, INITIAL RATE
COORDINATED CARE FEE, MAINTENANCE RATE
COORDINATED CARE FEE, RISK ADJUSTED HIGH, INITIAL
COORDINATED CARE FEE, RISK ADJUSTED LOW, INITIAL
COORDINATED CARE FEE, RISK ADJUSTED MAINTENANCE
COORDINATED CARE FEE, HOME MONITORING
COORDINATED CARE FEE, SCHEDULED TEAM CONFERENCE
COORDINATED CARE FEE, PHYSICIAN COORDINATED CARE OVERSIGHT SERVICES
COORDINATED CARE FEE, RISK ADJUSTED MAINTENANCE, LEVEL 3
COORDINATED CARE FEE, RISK ADJUSTED MAINTENANCE, LEVEL 4
COORDINATED CARE FEE, RISK ADJUSTED MAINTENANCE, LEVEL 5
OTHER SPECIFIED CASE MANAGEMENT SERVICE NOT ELSEWHERE CLASSIFIED
ESRD DEMO BASIC BUNDLE LEVEL I
ESRD DEMO EXPANDED BUNDLE INCLUDING VENOUS ACCESS AND RELATED SERVICES
SMOKING CESSATION COUNSELING, INDIVIDUAL, IN THE ABSENCE OF OR IN ADDITION TO
ANY OTHER EVALUATION AND MANAGEMENT SERVICE, PER SESSION (6-10 MINUTES) [DEMO
PROJECT CODE ONLY]
AMANTADINE HYDROCHLORIDE, ORAL, PER 100 MG (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
ZANAMIVIR, INHALATION POWDER, ADMINISTERED THROUGH INHALER, PER 10 MG (FOR USE
IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
OSELTAMIVIR PHOSPHATE, ORAL, PER 75 MG (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
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RIMANTADINE HYDROCHLORIDE, ORAL, PER 100 MG (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
AMANTADINE HYDROCHLORIDE, ORAL BRAND, PER 100 MG (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ZANAMIVIR, INHALATION POWDER, ADMINISTERED THROUGH INHALER, BRAND, PER 10 MG
(FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
OSELTAMIVIR PHOSPHATE, ORAL, BRAND, PER 75 MG (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
RIMANTADINE HYDROCHLORIDE, ORAL, BRAND, PER 100 MG (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
REHABILITATION SERVICES FOR LOW VISION BY QUALIFIED OCCUPATIONAL THERAPIST,
DIRECT ONE-ON-ONE CONTACT, EACH 15 MINUTES
REHABILITATION SERVICES FOR LOW VISION BY CERTIFIED ORIENTATION AND MOBILITY
SPECIALISTS, DIRECT ONE-ON-ONE CONTACT, EACH 15 MINUTES
REHABILITATION SERVICES FOR LOW VISION BY CERTIFIED LOW VISION REHABILITATION
THERAPIST, DIRECT ONE-ON-ONE CONTACT, EACH 15 MINUTES
REHABILITATION SERVICES FOR LOW VISION BY CERTIFIED LOW VISION REHABILITATION
TEACHER, DIRECT ONE-ON-ONE CONTACT, EACH 15 MINUTES
ONCOLOGY; PRIMARY FOCUS OF VISIT; WORK-UP, EVALUATION, OR STAGING AT THE TIME
OF CANCER DIAGNOSIS OR RECURRENCE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION
PROJECT)
ONCOLOGY; PRIMARY FOCUS OF VISIT; TREATMENT DECISION-MAKING AFTER DISEASE IS
STAGED OR RESTAGED, DISCUSSION OF TREATMENT OPTIONS, SUPERVISING/COORDINATING
ACTIVE CANCER DIRECTED THERAPY OR MANAGING CONSEQUENCES OF CANCER DIRECTED
THERAPY (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; PRIMARY FOCUS OF VISIT; SURVEILLANCE FOR DISEASE RECURRENCE FOR
PATIENT WHO HAS COMPLETED DEFINITIVE CANCER-DIRECTED THERAPY AND CURRENTLY
LACKS EVIDENCE OF RECURRENT DISEASE; CANCER DIRECTED THERAPY MIGHT BE
CONSIDERED IN THE FUTURE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; PRIMARY FOCUS OF VISIT; EXPECTANT MANAGEMENT OF PATIENT WITH EVIDENCE
OF CANCER FOR WHOM NO CANCER DIRECTED THERAPY IS BEING ADMINISTERED OR ARRANGED
AT PRESENT; CANCER DIRECTED THERAPY MIGHT BE CONSIDERED IN THE FUTURE (FOR USE
IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; PRIMARY FOCUS OF VISIT; SUPERVISING, COORDINATING OR MANAGING CARE OF
PATIENT WITH TERMINAL CANCER OR FOR WHOM OTHER MEDICAL ILLNESS PREVENTS FURTHER
CANCER TREATMENT; INCLUDES SYMPTOM MANAGEMENT, END-OF-LIFE CARE PLANNING,
MANAGEMENT OF PALLIATIVE THERAPIES (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
ONCOLOGY; PRIMARY FOCUS OF VISIT; OTHER, UNSPECIFIED SERVICE NOT OTHERWISE
LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT ADHERES TO GUIDELINES (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM GUIDELINES AS A RESULT
OF PATIENT ENROLLMENT IN AN INSTITUTIONAL REVIEW BOARD APPROVED CLINICAL TRIAL
(FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM GUIDELINES BECAUSE THE
TREATING PHYSICIAN DISAGREES WITH GUIDELINE RECOMMENDATIONS (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM GUIDELINES BECAUSE THE
PATIENT, AFTER BEING OFFERED TREATMENT CONSISTENT WITH GUIDELINES, HAS OPTED
FOR ALTERNATIVE TREATMENT OR MANAGEMENT, INCLUDING NO TREATMENT (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
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ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM GUIDELINES FOR REASON(S)
ASSOCIATED WITH PATIENT COMORBID ILLNESS OR PERFORMANCE STATUS NOT FACTORED
INTO GUIDELINES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; PRACTICE GUIDELINES; PATIENT'S CONDITION NOT ADDRESSED BY AVAILABLE
GUIDELINES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; PRACTICE GUIDELINES; MANAGEMENT DIFFERS FROM GUIDELINES FOR OTHER
REASON(S) NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG CANCER; EXTENT OF
DISEASE INITIALLY ESTABLISHED AS STAGE I (PRIOR TO NEO-ADJUVANT THERAPY, IF
ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR
USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG CANCER; EXTENT OF
DISEASE INITIALLY ESTABLISHED AS STAGE II (PRIOR TO NEO-ADJUVANT THERAPY, IF
ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR
USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG CANCER; EXTENT OF
DISEASE INITIALLY ESTABLISHED AS STAGE III A (PRIOR TO NEO-ADJUVANT THERAPY, IF
ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR
USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG CANCER; STAGE III B-
IV AT DIAGNOSIS, METASTATIC, LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; LIMITED TO NON-SMALL CELL LUNG CANCER; EXTENT OF
DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; LIMITED TO SMALL CELL AND COMBINED SMALL
CELL/NON-SMALL CELL; EXTENT OF DISEASE INITIALLY ESTABLISHED AS LIMITED WITH NO
EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; SMALL CELL LUNG CANCER, LIMITED TO SMALL CELL AND
COMBINED SMALL CELL/NON-SMALL CELL; EXTENSIVE STAGE AT DIAGNOSIS, METASTATIC,
LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION
PROJECT)
ONCOLOGY; DISEASE STATUS; SMALL CELL LUNG CANCER, LIMITED TO SMALL CELL AND
COMBINED SMALL CELL/NON-SMALL; EXTENT OF DISEASE UNKNOWN, STAGING IN PROGRESS,
OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER (DOES NOT INCLUDE
DUCTAL CARCINOMA IN SITU); ADENOCARCINOMA AS PREDOMINANT CELL TYPE; STAGE I OR
STAGE IIA-IIB; OR T3, N1, M0; AND ER AND/OR PR POSITIVE; WITH NO EVIDENCE OF
DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER (DOES NOT INCLUDE
DUCTAL CARCINOMA IN SITU); ADENOCARCINOMA AS PREDOMINANT CELL TYPE; STAGE I, OR
STAGE IIA-IIB; OR T3, N1, M0; AND ER AND PR NEGATIVE; WITH NO EVIDENCE OF
DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER (DOES NOT INCLUDE
DUCTAL CARCINOMA IN SITU); ADENOCARCINOMA AS PREDOMINANT CELL TYPE; STAGE
IIIA-IIIB; AND NOT T3, N1, M0; AND ER AND/OR PR POSITIVE; WITH NO EVIDENCE OF
DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER (DOES NOT INCLUDE
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DUCTAL CARCINOMA IN SITU); ADENOCARCINOMA AS PREDOMINANT CELL TYPE; STAGE
IIIA-IIIB; AND NOT T3, N1, M0; AND ER AND PR NEGATIVE; WITH NO EVIDENCE OF
DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER (DOES NOT INCLUDE
DUCTAL CARCINOMA IN SITU); ADENOCARCINOMA AS PREDOMINANT CELL TYPE; M1 AT
DIAGNOSIS, METASTATIC, LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA AS
PREDOMINANT CELL TYPE; T1-T2C AND GLEASON 2-7 AND PSA < OR EQUAL TO 20 AT
DIAGNOSIS WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES
(FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA AS
PREDOMINANT CELL TYPE; T2 OR T3A GLEASON 8-10 OR PSA > 20 AT DIAGNOSIS WITH NO
EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA AS
PREDOMINANT CELL TYPE; T3B-T4, ANY N; ANY T, N1 AT DIAGNOSIS WITH NO EVIDENCE
OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA; AFTER
INITIAL TREATMENT WITH RISING PSA OR FAILURE OF PSA DECLINE (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA; EXTENT OF
DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO INVASIVE CANCER,
ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY
ESTABLISHED AS T1-3, N0, M0 WITH NO EVIDENCE OF DISEASE PROGRESSION,
RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO INVASIVE CANCER,
ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY
ESTABLISHED AS T4, N0, M0 WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE,
OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO INVASIVE CANCER,
ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY
ESTABLISHED AS T1-4, N1-2, M0 WITH NO EVIDENCE OF DISEASE PROGRESSION,
RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO INVASIVE CANCER,
ADENOCARCINOMA AS PREDOMINANT CELL TYPE; M1 AT DIAGNOSIS, METASTATIC, LOCALLY
RECURRENT, OR PROGRESSIVE WITH CURRENT CLINICAL, RADIOLOGIC, OR BIOCHEMICAL
EVIDENCE OF DISEASE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO INVASIVE CANCER,
ADENOCARCINOMA AS PREDOMINANT CELL TYPE; M1 AT DIAGNOSIS, METASTATIC, LOCALLY
RECURRENT, OR PROGRESSIVE WITHOUT CURRENT CLINICAL, RADIOLOGIC, OR BIOCHEMICAL
EVIDENCE OF DISEASE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; COLON CANCER, LIMITED TO INVASIVE CANCER,
ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE UNKNOWN, STAGING IN
PROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER,
ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY
ESTABLISHED AS T1-2, N0, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NO
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EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER,
ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY
ESTABLISHED AS T3, N0, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NO
EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER,
ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY
ESTABLISHED AS T1-3, N1-2, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NO
EVIDENCE OF DISEASE PROGRESSION, RECURRENCE OR METASTASES (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER,
ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY
ESTABLISHED AS T4, ANY N, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NO
EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER,
ADENOCARCINOMA AS PREDOMINANT CELL TYPE; M1 AT DIAGNOSIS, METASTATIC, LOCALLY
RECURRENT, OR PROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; RECTAL CANCER, LIMITED TO INVASIVE CANCER,
ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE UNKNOWN, STAGING IN
PROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO ADENOCARCINOMA OR
SQUAMOUS CELL CARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY
ESTABLISHED AS T1-T3, N0-N1 OR NX (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH
NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO ADENOCARCINOMA OR
SQUAMOUS CELL CARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE INITIALLY
ESTABLISHED AS T4, ANY N, M0 (PRIOR TO NEO-ADJUVANT THERAPY, IF ANY) WITH NO
EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO ADENOCARCINOMA OR
SQUAMOUS CELL CARCINOMA AS PREDOMINANT CELL TYPE; M1 AT DIAGNOSIS, METASTATIC,
LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION
PROJECT)
ONCOLOGY; DISEASE STATUS; ESOPHAGEAL CANCER, LIMITED TO ADENOCARCINOMA OR
SQUAMOUS CELL CARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF DISEASE UNKNOWN,
STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA AS
PREDOMINANT CELL TYPE; POST R0 RESECTION (WITH OR WITHOUT NEOADJUVANT THERAPY)
WITH NO EVIDENCE OF DISEASE RECURRENCE, PROGRESSION, OR METASTASES (FOR USE IN
A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA AS
PREDOMINANT CELL TYPE; POST R1 OR R2 RESECTION (WITH OR WITHOUT NEOADJUVANT
THERAPY) WITH NO EVIDENCE OF DISEASE PROGRESSION, OR METASTASES (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA AS
PREDOMINANT CELL TYPE; CLINICAL OR PATHOLOGIC M0, UNRESECTABLE WITH NO EVIDENCE
OF DISEASE PROGRESSION, OR METASTASES (FOR USE IN A MEDICARE-APPROVED
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DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA AS
PREDOMINANT CELL TYPE; CLINICAL OR PATHOLOGIC M1 AT DIAGNOSIS, METASTATIC,
LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION
PROJECT)
ONCOLOGY; DISEASE STATUS; GASTRIC CANCER, LIMITED TO ADENOCARCINOMA AS
PREDOMINANT CELL TYPE; EXTENT OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT
LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO ADENOCARCINOMA AS
PREDOMINANT CELL TYPE; POST R0 RESECTION WITHOUT EVIDENCE OF DISEASE
PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO ADENOCARCINOMA; POST R1
OR R2 RESECTION WITH NO EVIDENCE OF DISEASE PROGRESSION, OR METASTASES (FOR USE
IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO ADENOCARCINOMA;
UNRESECTABLE AT DIAGNOSIS, M1 AT DIAGNOSIS, METASTATIC, LOCALLY RECURRENT, OR
PROGRESSIVE (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; PANCREATIC CANCER, LIMITED TO ADENOCARCINOMA; EXTENT
OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO CANCERS OF ORAL
CAVITY, PHARYNX AND LARYNX WITH SQUAMOUS CELL AS PREDOMINANT CELL TYPE; EXTENT
OF DISEASE INITIALLY ESTABLISHED AS T1-T2 AND N0, M0 (PRIOR TO NEO-ADJUVANT
THERAPY, IF ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR
METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO CANCERS OF ORAL
CAVITY, PHARYNX AND LARYNX WITH SQUAMOUS CELL AS PREDOMINANT CELL TYPE; EXTENT
OF DISEASE INITIALLY ESTABLISHED AS T3-4 AND/OR N1-3, M0 (PRIOR TO NEO-ADJUVANT
THERAPY, IF ANY) WITH NO EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR
METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO CANCERS OF ORAL
CAVITY, PHARYNX AND LARYNX WITH SQUAMOUS CELL AS PREDOMINANT CELL TYPE; M1 AT
DIAGNOSIS, METASTATIC, LOCALLY RECURRENT, OR PROGRESSIVE (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; HEAD AND NECK CANCER, LIMITED TO CANCERS OF ORAL
CAVITY, PHARYNX AND LARYNX WITH SQUAMOUS CELL AS PREDOMINANT CELL TYPE; EXTENT
OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER;
PATHOLOGIC STAGE IA-B (GRADE 1) WITHOUT EVIDENCE OF DISEASE PROGRESSION,
RECURRENCE, OR METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER;
PATHOLOGIC STAGE IA-B (GRADE 2-3); OR STAGE IC (ALL GRADES); OR STAGE II;
WITHOUT EVIDENCE OF DISEASE PROGRESSION, RECURRENCE, OR METASTASES (FOR USE IN
A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER;
PATHOLOGIC STAGE III-IV; WITHOUT EVIDENCE OF PROGRESSION, RECURRENCE, OR
METASTASES (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER;
EVIDENCE OF DISEASE PROGRESSION, OR RECURRENCE, AND/OR PLATINUM RESISTANCE (FOR
USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
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ONCOLOGY; DISEASE STATUS; OVARIAN CANCER, LIMITED TO EPITHELIAL CANCER; EXTENT
OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIA
CHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; CHRONIC PHASE NOT IN HEMATOLOGIC,
CYTOGENETIC, OR MOLECULAR REMISSION (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIA
CHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; ACCELERATED PHASE NOT IN
HEMATOLOGIC CYTOGENETIC, OR MOLECULAR REMISSION (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIA
CHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; BLAST PHASE NOT IN HEMATOLOGIC,
CYTOGENETIC, OR MOLECULAR REMISSION (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIA
CHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; IN HEMATOLOGIC, CYTOGENETIC, OR
MOLECULAR REMISSION (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; LIMITED TO MULTIPLE MYELOMA, SYSTEMIC DISEASE;
SMOLDERING, STAGE I (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; LIMITED TO MULTIPLE MYELOMA, SYSTEMIC DISEASE; STAGE
II OR HIGHER (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; LIMITED TO MULTIPLE MYELOMA, SYSTEMIC DISEASE; EXTENT
OF DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; INVASIVE FEMALE BREAST CANCER (DOES NOT INCLUDE
DUCTAL CARCINOMA IN SITU); ADENOCARCINOMA AS PREDOMINANT CELL TYPE; EXTENT OF
DISEASE UNKNOWN, STAGING IN PROGRESS, OR NOT LISTED (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA;
HORMONE-REFRACTORY/ANDROGEN-INDEPENDENT (E.G., RISING PSA ON ANTI-ANDROGEN
THERAPY OR POST-ORCHIECTOMY); CLINICAL METASTASES (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; PROSTATE CANCER, LIMITED TO ADENOCARCINOMA;
HORMONE-RESPONSIVE; CLINICAL METASTASES OR M1 AT DIAGNOSIS (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION;
STAGE I, II AT DIAGNOSIS, NOT RELAPSED, NOT REFRACTORY (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION;
STAGE III, IV, NOT RELAPSED, NOT REFRACTORY (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, TRANSFORMED FROM ORIGINAL
CELLULAR DIAGNOSIS TO A SECOND CELLULAR CLASSIFICATION (FOR USE IN A
MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION;
RELAPSED/REFRACTORY (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; NON-HODGKIN'S LYMPHOMA, ANY CELLULAR CLASSIFICATION;
DIAGNOSTIC EVALUATION, STAGE NOT DETERMINED, EVALUATION OF POSSIBLE RELAPSE OR
NON-RESPONSE TO THERAPY, OR NOT LISTED (FOR USE IN A MEDICARE-APPROVED
DEMONSTRATION PROJECT)
ONCOLOGY; DISEASE STATUS; CHRONIC MYELOGENOUS LEUKEMIA, LIMITED TO PHILADELPHIA
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CHROMOSOME POSITIVE AND/OR BCR-ABL POSITIVE; EXTENT OF DISEASE UNKNOWN, STAGING
IN PROGRESS, NOT LISTED (FOR USE IN A MEDICARE-APPROVED DEMONSTRATION PROJECT)
FRONTIER EXTENDED STAY CLINIC DEMONSTRATION; FOR A PATIENT STAY IN A CLINIC
APPROVED FOR THE CMS DEMONSTRATION PROJECT; THE FOLLOWING MEASURES SHOULD BE
PRESENT: THE STAY MUST BE EQUAL TO OR GREATER THAN 4 HOURS; WEATHER OR OTHER
CONDITIONS MUST PREVENT TRANSFER OR THE CASE FALLS INTO A CATEGORY OF
MONITORING AND OBSERVATION CASES THAT ARE PERMITTED BY THE RULES OF THE
DEMONSTRATION; THERE IS A MAXIMUM FRONTIER EXTENDED STAY CLINIC (FESC) VISIT OF
48 HOURS, EXCEPT IN THE CASE WHEN WEATHER OR OTHER CONDITIONS PREVENT TRANSFER;
PAYMENT IS MADE ON EACH PERIOD UP TO 4 HOURS, AFTER THE FIRST 4 HOURS
INFLUENZA A (H1N1) IMMUNIZATION ADMINISTRATION (INCLUDES THE PHYSICIAN
COUNSELING THE PATIENT/FAMILY)
INFLUENZA A (H1N1) VACCINE, ANY ROUTE OF ADMINISTRATION
WARFARIN RESPONSIVENESS TESTING BY GENETIC TECHNIQUE USING ANY METHOD, ANY
NUMBER OF SPECIMEN(S)
OUTPATIENT INTRAVENOUS INSULIN TREATMENT (OIVIT) EITHER PULSATILE OR
CONTINUOUS, BY ANY MEANS, GUIDED BY THE RESULTS OF MEASUREMENTS FOR:
RESPIRATORY QUOTIENT; AND/OR, URINE UREA NITROGEN (UUN); AND/OR, ARTERIAL,
VENOUS OR CAPILLARY GLUCOSE; AND/OR POTASSIUM CONCENTRATION
ALCOHOL AND/OR DRUG ASSESSMENT
BEHAVIORAL HEALTH SCREENING TO DETERMINE ELIGIBILITY FOR ADMISSION TO TREATMENT
PROGRAM
ALCOHOL AND/OR DRUG SCREENING; LABORATORY ANALYSIS OF SPECIMENS FOR PRESENCE OF
ALCOHOL AND/OR DRUGS
BEHAVIORAL HEALTH COUNSELING AND THERAPY, PER 15 MINUTES
ALCOHOL AND/OR DRUG SERVICES; GROUP COUNSELING BY A CLINICIAN
ALCOHOL AND/OR DRUG SERVICES; CASE MANAGEMENT
ALCOHOL AND/OR DRUG SERVICES; CRISIS INTERVENTION (OUTPATIENT)
ALCOHOL AND/OR DRUG SERVICES; SUB-ACUTE DETOXIFICATION (HOSPITAL INPATIENT)
ALCOHOL AND/OR DRUG SERVICES; ACUTE DETOXIFICATION (HOSPITAL INPATIENT)
ALCOHOL AND/OR DRUG SERVICES; SUB-ACUTE DETOXIFICATION (RESIDENTIAL ADDICTION
PROGRAM INPATIENT)
ALCOHOL AND/OR DRUG SERVICES; ACUTE DETOXIFICATION (RESIDENTIAL ADDICTION
PROGRAM INPATIENT)
ALCOHOL AND/OR DRUG SERVICES; SUB-ACUTE DETOXIFICATION (RESIDENTIAL ADDICTION
PROGRAM OUTPATIENT)
ALCOHOL AND/OR DRUG SERVICES; ACUTE DETOXIFICATION (RESIDENTIAL ADDICTION
PROGRAM OUTPATIENT)
ALCOHOL AND/OR DRUG SERVICES; AMBULATORY DETOXIFICATION
ALCOHOL AND/OR DRUG SERVICES; INTENSIVE OUTPATIENT (TREATMENT PROGRAM THAT
OPERATES AT LEAST 3 HOURS/DAY AND AT LEAST 3 DAYS/WEEK AND IS BASED ON AN
INDIVIDUALIZED TREATMENT PLAN), INCLUDING ASSESSMENT, COUNSELING; CRISIS
INTERVENTION, AND ACTIVITY THERAPIES OR EDUCATION
ALCOHOL AND/OR DRUG SERVICES; MEDICAL/SOMATIC (MEDICAL INTERVENTION IN
AMBULATORY SETTING)
BEHAVIORAL HEALTH; RESIDENTIAL (HOSPITAL RESIDENTIAL TREATMENT PROGRAM),
WITHOUT ROOM AND BOARD, PER DIEM
BEHAVIORAL HEALTH; SHORT-TERM RESIDENTIAL (NON-HOSPITAL RESIDENTIAL TREATMENT
PROGRAM), WITHOUT ROOM AND BOARD, PER DIEM
BEHAVIORAL HEALTH; LONG-TERM RESIDENTIAL (NON-MEDICAL, NON-ACUTE CARE IN A
RESIDENTIAL TREATMENT PROGRAM WHERE STAY IS TYPICALLY LONGER THAN 30 DAYS),
WITHOUT ROOM AND BOARD, PER DIEM
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ALCOHOL AND/OR DRUG SERVICES; METHADONE ADMINISTRATION AND/OR SERVICE
(PROVISION OF THE DRUG BY A LICENSED PROGRAM)
ALCOHOL AND/OR DRUG TRAINING SERVICE (FOR STAFF AND PERSONNEL NOT EMPLOYED BY
PROVIDERS)
ALCOHOL AND/OR DRUG INTERVENTION SERVICE (PLANNED FACILITATION)
BEHAVIORAL HEALTH OUTREACH SERVICE (PLANNED APPROACH TO REACH A TARGETED
POPULATION)
BEHAVIORAL HEALTH PREVENTION INFORMATION DISSEMINATION SERVICE (ONE-WAY DIRECT
OR NON-DIRECT CONTACT WITH SERVICE AUDIENCES TO AFFECT KNOWLEDGE AND ATTITUDE)
BEHAVIORAL HEALTH PREVENTION EDUCATION SERVICE (DELIVERY OF SERVICES WITH
TARGET POPULATION TO AFFECT KNOWLEDGE, ATTITUDE AND/OR BEHAVIOR)
ALCOHOL AND/OR DRUG PREVENTION PROCESS SERVICE, COMMUNITY-BASED (DELIVERY OF
SERVICES TO DEVELOP SKILLS OF IMPACTORS)
ALCOHOL AND/OR DRUG PREVENTION ENVIRONMENTAL SERVICE (BROAD RANGE OF EXTERNAL
ACTIVITIES GEARED TOWARD MODIFYING SYSTEMS IN ORDER TO MAINSTREAM PREVENTION
THROUGH POLICY AND LAW)
ALCOHOL AND/OR DRUG PREVENTION PROBLEM IDENTIFICATION AND REFERRAL SERVICE
(E.G. STUDENT ASSISTANCE AND EMPLOYEE ASSISTANCE PROGRAMS), DOES NOT INCLUDE
ASSESSMENT
ALCOHOL AND/OR DRUG PREVENTION ALTERNATIVES SERVICE (SERVICES FOR POPULATIONS
THAT EXCLUDE ALCOHOL AND OTHER DRUG USE E.G. ALCOHOL FREE SOCIAL EVENTS)
BEHAVIORAL HEALTH HOTLINE SERVICE
MENTAL HEALTH ASSESSMENT, BY NON-PHYSICIAN
MENTAL HEALTH SERVICE PLAN DEVELOPMENT BY NON-PHYSICIAN
ORAL MEDICATION ADMINISTRATION, DIRECT OBSERVATION
MEDICATION TRAINING AND SUPPORT, PER 15 MINUTES
MENTAL HEALTH PARTIAL HOSPITALIZATION, TREATMENT, LESS THAN 24 HOURS
COMMUNITY PSYCHIATRIC SUPPORTIVE TREATMENT, FACE-TO-FACE, PER 15 MINUTES
COMMUNITY PSYCHIATRIC SUPPORTIVE TREATMENT PROGRAM, PER DIEM
SELF-HELP/PEER SERVICES, PER 15 MINUTES
ASSERTIVE COMMUNITY TREATMENT, FACE-TO-FACE, PER 15 MINUTES
ASSERTIVE COMMUNITY TREATMENT PROGRAM, PER DIEM
FOSTER CARE, CHILD, NON-THERAPEUTIC, PER DIEM
FOSTER CARE, CHILD, NON-THERAPEUTIC, PER MONTH
SUPPORTED HOUSING, PER DIEM
SUPPORTED HOUSING, PER MONTH
RESPITE CARE SERVICES, NOT IN THE HOME, PER DIEM
MENTAL HEALTH SERVICES, NOT OTHERWISE SPECIFIED
ALCOHOL AND/OR OTHER DRUG ABUSE SERVICES, NOT OTHERWISE SPECIFIED
ALCOHOL AND/OR OTHER DRUG TESTING: COLLECTION AND HANDLING ONLY, SPECIMENS
OTHER THAN BLOOD
ALCOHOL AND/OR DRUG SCREENING
ALCOHOL AND/OR DRUG SERVICES, BRIEF INTERVENTION, PER 15 MINUTES
PRENATAL CARE, AT-RISK ASSESSMENT
PRENATAL CARE, AT-RISK ENHANCED SERVICE; ANTEPARTUM MANAGEMENT
PRENATAL CARE, AT RISK ENHANCED SERVICE; CARE COORDINATION
PRENATAL CARE, AT-RISK ENHANCED SERVICE; EDUCATION
PRENATAL CARE, AT-RISK ENHANCED SERVICE; FOLLOW-UP HOME VISIT
PRENATAL CARE, AT-RISK ENHANCED SERVICE PACKAGE (INCLUDES H1001-H1004)
NON-MEDICAL FAMILY PLANNING EDUCATION, PER SESSION
FAMILY ASSESSMENT BY LICENSED BEHAVIORAL HEALTH PROFESSIONAL FOR STATE DEFINED
PURPOSES
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COMPREHENSIVE MULTIDISCIPLINARY EVALUATION
REHABILITATION PROGRAM, PER 1/2 DAY
COMPREHENSIVE MEDICATION SERVICES, PER 15 MINUTES
CRISIS INTERVENTION SERVICE, PER 15 MINUTES
BEHAVIORAL HEALTH DAY TREATMENT, PER HOUR
PSYCHIATRIC HEALTH FACILITY SERVICE, PER DIEM
SKILLS TRAINING AND DEVELOPMENT, PER 15 MINUTES
COMPREHENSIVE COMMUNITY SUPPORT SERVICES, PER 15 MINUTES
COMPREHENSIVE COMMUNITY SUPPORT SERVICES, PER DIEM
PSYCHOSOCIAL REHABILITATION SERVICES, PER 15 MINUTES
PSYCHOSOCIAL REHABILITATION SERVICES, PER DIEM
THERAPEUTIC BEHAVIORAL SERVICES, PER 15 MINUTES
THERAPEUTIC BEHAVIORAL SERVICES, PER DIEM
COMMUNITY-BASED WRAP-AROUND SERVICES, PER 15 MINUTES
COMMUNITY-BASED WRAP-AROUND SERVICES, PER DIEM
SUPPORTED EMPLOYMENT, PER 15 MINUTES
SUPPORTED EMPLOYMENT, PER DIEM
ONGOING SUPPORT TO MAINTAIN EMPLOYMENT, PER 15 MINUTES
ONGOING SUPPORT TO MAINTAIN EMPLOYMENT, PER DIEM
PSYCHOEDUCATIONAL SERVICE, PER 15 MINUTES
SEXUAL OFFENDER TREATMENT SERVICE, PER 15 MINUTES
SEXUAL OFFENDER TREATMENT SERVICE, PER DIEM
MENTAL HEALTH CLUBHOUSE SERVICES, PER 15 MINUTES
MENTAL HEALTH CLUBHOUSE SERVICES, PER DIEM
ACTIVITY THERAPY, PER 15 MINUTES
MULTISYSTEMIC THERAPY FOR JUVENILES, PER 15 MINUTES
ALCOHOL AND/OR DRUG ABUSE HALFWAY HOUSE SERVICES, PER DIEM
ALCOHOL AND/OR OTHER DRUG TREATMENT PROGRAM, PER HOUR
ALCOHOL AND/OR OTHER DRUG TREATMENT PROGRAM, PER DIEM
DEVELOPMENTAL DELAY PREVENTION ACTIVITIES, DEPENDENT CHILD OF CLIENT, PER 15
MINUTES
INJECTION, TETRACYCLINE, UP TO 250 MG
INJECTION, ABARELIX, 10 MG
INJECTION, ABATACEPT, 10 MG
INJECTION ABCIXIMAB, 10 MG
INJECTION, ACETYLCYSTEINE, 100 MG
INJECTION, ACYCLOVIR, 5 MG
INJECTION, ADALIMUMAB, 20 MG
INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE USED TO REPORT ANY
ADENOSINE PHOSPHATE COMPOUNDS, INSTEAD USE A9270)
INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG (NOT TO BE USED TO REPORT ANY
ADENOSINE PHOSPHATE COMPOUNDS; INSTEAD USE A9270)
INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE
INJECTION, ADRENALIN, EPINEPHRINE, 0.1 MG
INJECTION, AGALSIDASE BETA, 1 MG
INJECTION, BIPERIDEN LACTATE, PER 5 MG
INJECTION, ALATROFLOXACIN MESYLATE, 100 MG
INJECTION, ALGLUCERASE, PER 10 UNITS
INJECTION, AMIFOSTINE, 500 MG
INJECTION, METHYLDOPATE HCL, UP TO 250 MG
INJECTION, ALEFACEPT, 0.5 MG
INJECTION, ALGLUCOSIDASE ALFA, 10 MG
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INJECTION, ALPHA 1 - PROTEINASE INHIBITOR - HUMAN, 10 MG
INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDICARE WHEN DRUG
ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG
IS SELF ADMINISTERED)
ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDICARE WHEN DRUG
ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG
IS SELF ADMINISTERED)
INJECTION, AMIKACIN SULFATE, 100 MG
INJECTION, AMINOPHYLLIN, UP TO 250 MG
INJECTION, AMIODARONE HYDROCHLORIDE, 30 MG
INJECTION, AMPHOTERICIN B, 50 MG
INJECTION, AMPHOTERICIN B LIPID COMPLEX, 10 MG
INJECTION, AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX, 10 MG
INJECTION, AMPHOTERICIN B LIPOSOME, 10 MG
INJECTION, AMPICILLIN SODIUM, 500 MG
INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM
INJECTION, AMOBARBITAL, UP TO 125 MG
INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG
INJECTION, ANIDULAFUNGIN, 1 MG
INJECTION, ANISTREPLASE, PER 30 UNITS
INJECTION, HYDRALAZINE HCL, UP TO 20 MG
INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG
INJECTION, APROTONIN, 10,000 KIU
INJECTION, METARAMINOL BITARTRATE, PER 10 MG
INJECTION, CHLOROQUINE HYDROCHLORIDE, UP TO 250 MG
INJECTION, ARBUTAMINE HCL, 1 MG
INJECTION, ARIPIPRAZOLE, INTRAMUSCULAR, 0.25 MG
INJECTION, AZITHROMYCIN, 500 MG
INJECTION, ATROPINE SULFATE, UP TO 0.3 MG
INJECTION, ATROPINE SULFATE, 0.01 MG
INJECTION, DIMERCAPROL, PER 100 MG
INJECTION, BACLOFEN, 10 MG
INJECTION, BACLOFEN, 50 MCG FOR INTRATHECAL TRIAL
INJECTION, BASILIXIMAB, 20 MG
INJECTION, DICYCLOMINE HCL, UP TO 20 MG
INJECTION, BENZTROPINE MESYLATE, PER 1 MG
INJECTION, BETHANECHOL CHLORIDE, MYOTONACHOL OR URECHOLINE, UP TO 5 MG
INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, UP TO 600,000
UNITS
INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, UP TO 1,200,000
UNITS
INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, UP TO 2,400,000
UNITS
INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, 100,000 UNITS
INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, 2500 UNITS
INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS
INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS
INJECTION, PENICILLIN G BENZATHINE, UP TO 1,200,000 UNITS
INJECTION, PENICILLIN G BENZATHINE, UP TO 2,400,000 UNITS
INJECTION, BIVALIRUDIN, 1 MG
INJECTION, ONABOTULINUMTOXINA, 1 UNIT
INJECTION, ABOBOTULINUMTOXINA, 5 UNITS
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INJECTION, RIMABOTULINUMTOXINB, 100 UNITS
INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG
INJECTION, BUSULFAN, 1 MG
INJECTION, BUTORPHANOL TARTRATE, 1 MG
INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), BERINERT, 10 UNITS
INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), CINRYZE, 10 UNITS
INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG
INJECTION, CALCIUM GLUCONATE, PER 10 ML
INJECTION, CALCIUM GLYCEROPHOSPHATE AND CALCIUM LACTATE, PER 10 ML
INJECTION, CALCITONIN SALMON, UP TO 400 UNITS
INJECTION, CALCITRIOL, 0.1 MCG
INJECTION, CASPOFUNGIN ACETATE, 5 MG
INJECTION, CANAKINUMAB, 1 MG
INJECTION, LEUCOVORIN CALCIUM, PER 50 MG
INJECTION, LEVOLEUCOVORIN CALCIUM, 0.5 MG
INJECTION, MEPIVACAINE HYDROCHLORIDE, PER 10 ML
INJECTION, CEFAZOLIN SODIUM, 500 MG
INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG
INJECTION, CEFOXITIN SODIUM, 1 GM
INJECTION, CEFTRIAXONE SODIUM, PER 250 MG
INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG
INJECTION, CEFOTAXIME SODIUM, PER GM
INJECTION, BETAMETHASONE ACETATE 3MG AND BETAMETHASONE SODIUM PHOSPHATE 3MG
INJECTION, BETAMETHASONE SODIUM PHOSPHATE, PER 4 MG
INJECTION, CAFFEINE CITRATE, 5MG
INJECTION, CEPHAPIRIN SODIUM, UP TO 1 GM
INJECTION, CEFTAZIDIME, PER 500 MG
INJECTION, CEFTIZOXIME SODIUM, PER 500 MG
INJECTION, CERTOLIZUMAB PEGOL, 1 MG
INJECTION, CHLORAMPHENICOL SODIUM SUCCINATE, UP TO 1 GM
INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS
INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG
INJECTION, CIDOFOVIR, 375 MG
INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG
INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, 200 MG
INJECTION, CODEINE PHOSPHATE, PER 30 MG
INJECTION, COLCHICINE, PER 1MG
INJECTION, COLISTIMETHATE SODIUM, UP TO 150 MG
INJECTION, COLLAGENASE, CLOSTRIDIUM HISTOLYTICUM, 0.01 MG
INJECTION, PROCHLORPERAZINE, UP TO 10 MG
INJECTION, CORTICORELIN OVINE TRIFLUTATE, 1 MICROGRAM
INJECTION, CORTICOTROPIN, UP TO 40 UNITS
INJECTION, COSYNTROPIN, NOT OTHERWISE SPECIFIED, 0.25 MG
INJECTION, COSYNTROPIN (CORTROSYN), 0.25 MG
INJECTION, COSYNTROPIN, PER 0.25 MG
INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS (HUMAN), PER VIAL
INJECTION, DAPTOMYCIN, 1 MG
INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)
INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (FOR ESRD ON DIALYSIS)
INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS
INJECTION, EPOETIN ALFA, 1000 UNITS (FOR ESRD ON DIALYSIS)
INJECTION, DECITABINE, 1 MG
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INJECTION, DEFEROXAMINE MESYLATE, 500 MG
INJECTION, TESTOSTERONE ENANTHATE AND ESTRADIOL VALERATE, UP TO 1 CC
INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG
INJECTION, ESTRADIOL VALERATE, UP TO 40 MG
INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG
INJECTION, METHYLPREDNISOLONE ACETATE, 20 MG
INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG
INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG
INJECTION, MEDROXYPROGESTERONE ACETATE, 50 MG
INJECTION, MEDROXYPROGESTERONE ACETATE FOR CONTRACEPTIVE USE, 150 MG
INJECTION, MEDROXYPROGESTERONE ACETATE / ESTRADIOL CYPIONATE, 5MG / 25MG
INJECTION, TESTOSTERONE CYPIONATE AND ESTRADIOL CYPIONATE, UP TO 1 ML
INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG
INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG
INJECTION, DEXAMETHASONE ACETATE, 1 MG
INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG
INJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MG
INJECTION, ACETAZOLAMIDE SODIUM, UP TO 500 MG
INJECTION, DIGOXIN, UP TO 0.5 MG
INJECTION, DIGOXIN IMMUNE FAB (OVINE), PER VIAL
INJECTION, PHENYTOIN SODIUM, PER 50 MG
INJECTION, HYDROMORPHONE, UP TO 4 MG
INJECTION, DYPHYLLINE, UP TO 500 MG
INJECTION, DEXRAZOXANE HYDROCHLORIDE, PER 250 MG
INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG
INJECTION, CHLOROTHIAZIDE SODIUM, PER 500 MG
INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML
INJECTION, METHADONE HCL, UP TO 10 MG
INJECTION, DIMENHYDRINATE, UP TO 50 MG
INJECTION, DIPYRIDAMOLE, PER 10 MG
INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG
INJECTION, DOLASETRON MESYLATE, 10 MG
INJECTION, DOPAMINE HCL, 40 MG
INJECTION, DORIPENEM, 10 MG
INJECTION, DOXERCALCIFEROL, 1 MCG
INJECTION, ECALLANTIDE, 1 MG
INJECTION, ECULIZUMAB, 10 MG
INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG
INJECTION, ENFUVIRTIDE, 1 MG
INJECTION, EPOPROSTENOL, 0.5 MG
INJECTION, EPTIFIBATIDE, 5 MG
INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG
INJECTION, ERTAPENEM SODIUM, 500 MG
INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG
INJECTION, ESTRADIOL VALERATE, UP TO 10 MG
INJECTION, ESTRADIOL VALERATE, UP TO 20 MG
INJECTION, ESTROGEN CONJUGATED, PER 25 MG
INJECTION, ETHANOLAMINE OLEATE, 100 MG
INJECTION, ESTRONE, PER 1 MG
INJECTION, ETIDRONATE DISODIUM, PER 300 MG
INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG
ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG
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INJECTION, FILGRASTIM (G-CSF), 300 MCG
INJECTION, FILGRASTIM (G-CSF), 480 MCG
INJECTION FLUCONAZOLE, 200 MG
INJECTION, FOMEPIZOLE, 15 MG
INJECTION, FOMIVIRSEN SODIUM, INTRAOCULAR, 1.65 MG
INJECTION, FOSAPREPITANT, 1 MG
INJECTION, FOSCARNET SODIUM, PER 1000 MG
INJECTION, GALLIUM NITRATE, 1 MG
INJECTION, GALSULFASE, 1 MG
INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G.
LIQUID), 500 MG
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC
INJECTION, IMMUNE GLOBULIN (HIZENTRA), 100 MG
INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CC
INJECTION, IMMUNE GLOBULIN, (GAMUNEX), INTRAVENOUS, NON-LYOPHILIZED (E.G.
LIQUID), 500 MG
INJECTION, IMMUNE GLOBULIN (VIVAGLOBIN), 100 MG
INJECTION, RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN, INTRAVENOUS, 50 MG
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), NOT
OTHERWISE SPECIFIED, 500 MG
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), 500 MG
INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G.
LIQUID), 500 MG
INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), INTRAVENOUS, NON-LYOPHILIZED,
(E.G. LIQUID), 500 MG
INJECTION, GANCICLOVIR SODIUM, 500 MG
INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML
INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS,
NON-LYOPHILIZED (E.G. LIQUID), 500 MG
INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAVENOUS, 0.5 ML
INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG
INJECTION, GATIFLOXACIN, 10MG
INJECTION, GLATIRAMER ACETATE, 20 MG
INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), NOT
OTHERWISE SPECIFIED, 500 MG
INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG
INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG
INJECTION, GONADORELIN HYDROCHLORIDE, PER 100 MCG
INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG
INJECTION, HALOPERIDOL, UP TO 5 MG
INJECTION, HALOPERIDOL DECANOATE, PER 50 MG
INJECTION, HEMIN, 1 MG
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INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS
INJECTION, HEPARIN SODIUM, PER 1000 UNITS
INJECTION, DALTEPARIN SODIUM, PER 2500 IU
INJECTION, ENOXAPARIN SODIUM, 10 MG
INJECTION, FONDAPARINUX SODIUM, 0.5 MG
INJECTION, TINZAPARIN SODIUM, 1000 IU
INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITS
INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS
INJECTION, HUMAN FIBRINOGEN CONCENTRATE, 100 MG
INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG
INJECTION, HYDROCORTISONE SODIUM PHOSPHATE, UP TO 50 MG
INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 MG
INJECTION, DIAZOXIDE, UP TO 300 MG
INJECTION, IBANDRONATE SODIUM, 1 MG
INJECTION, IBUTILIDE FUMARATE, 1 MG
INJECTION, IDURSULFASE, 1 MG
INJECTION INFLIXIMAB, 10 MG
INJECTION, IRON DEXTRAN, 50 MG
INJECTION, IRON DEXTRAN 165, 50 MG
INJECTION, IRON DEXTRAN 267, 50 MG
INJECTION, IRON SUCROSE, 1 MG
INJECTION, IMIGLUCERASE, PER UNIT
INJECTION, IMIGLUCERASE, 10 UNITS
INJECTION, DROPERIDOL, UP TO 5 MG
INJECTION, PROPRANOLOL HCL, UP TO 1 MG
INJECTION, DROPERIDOL AND FENTANYL CITRATE, UP TO 2 ML AMPULE
INJECTION, INSULIN, PER 5 UNITS
INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS
INJECTION, INTERFERON BETA-1A, 33 MCG
INJECTION, INTERFERON BETA-1A, 30 MCG
INJECTION INTERFERON BETA-1B, 0.25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG
ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN
DRUG IS SELF ADMINISTERED)
INJECTION, ITRACONAZOLE, 50 MG
INJECTION, KANAMYCIN SULFATE, UP TO 500 MG
INJECTION, KANAMYCIN SULFATE, UP TO 75 MG
INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG
INJECTION, CEPHALOTHIN SODIUM, UP TO 1 GRAM
INJECTION, LANREOTIDE, 1 MG
INJECTION, LARONIDASE, 0.1 MG
INJECTION, FUROSEMIDE, UP TO 20 MG
INJECTION, LEPIRUDIN, 50 MG
INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG
INJECTION, LEVETIRACETAM, 10 MG
INJECTION, LEVOCARNITINE, PER 1 GM
INJECTION, LEVOFLOXACIN, 250 MG
INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG
INJECTION, HYOSCYAMINE SULFATE, UP TO 0.25 MG
INJECTION, CHLORDIAZEPOXIDE HCL, UP TO 100 MG
INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG
INJECTION, LINCOMYCIN HCL, UP TO 300 MG
INJECTION, LINEZOLID, 200MG
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INJECTION, LORAZEPAM, 2 MG
INJECTION, MANNITOL, 25% IN 50 ML
INJECTION, MECASERMIN, 1 MG
INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG
INJECTION, MEPERIDINE AND PROMETHAZINE HCL, UP TO 50 MG
INJECTION, MEROPENEM, 100 MG
INJECTION, METHYLERGONOVINE MALEATE, UP TO 0.2 MG
INJECTION, MICAFUNGIN SODIUM, 1 MG
INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG
INJECTION, MILRINONE LACTATE, 5 MG
INJECTION, MORPHINE SULFATE, UP TO 10 MG
INJECTION, MORPHINE SULFATE, 100MG
INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER 10 MG
INJECTION, ZICONOTIDE, 1 MICROGRAM
INJECTION, MOXIFLOXACIN, 100 MG
INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG
INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG
INJECTION, NALTREXONE, DEPOT FORM, 1 MG
INJECTION, NANDROLONE DECANOATE, UP TO 50 MG
INJECTION, NANDROLONE DECANOATE, UP TO 100 MG
INJECTION, NANDROLONE DECANOATE, UP TO 200 MG
INJECTION, NATALIZUMAB, 1 MG
INJECTION, NESIRITIDE, 0.1 MG
INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG
INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS
INJECTION, 25 MCG
INJECTION, OPRELVEKIN, 5 MG
INJECTION, OMALIZUMAB, 5 MG
INJECTION, OLANZAPINE, LONG-ACTING, 1 MG
INJECTION, ORPHENADRINE CITRATE, UP TO 60 MG
INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML
INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 ML
INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG
INJECTION, OXYMORPHONE HCL, UP TO 1 MG
INJECTION, PALIFERMIN, 50 MICROGRAMS
INJECTION, PALIPERIDONE PALMITATE EXTENDED RELEASE, 1 MG
INJECTION, PAMIDRONATE DISODIUM, PER 30 MG
INJECTION, PAPAVERINE HCL, UP TO 60 MG
INJECTION, OXYTETRACYCLINE HCL, UP TO 50 MG
INJECTION, PALONOSETRON HCL, 25 MCG
INJECTION, PARICALCITOL, 1 MCG
INJECTION, PEGAPTANIB SODIUM, 0.3 MG
INJECTION, PEGADEMASE BOVINE, 25 IU
INJECTION, PEGFILGRASTIM, 6 MG
INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNITS
INJECTION, PENTASTARCH, 10% SOLUTION, 100 ML
INJECTION, PENTOBARBITAL SODIUM, PER 50 MG
INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS
INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 GRAM/0.125 GRAMS (1.125
GRAMS)
PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,
NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 300 MG
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INJECTION, PROMETHAZINE HCL, UP TO 50 MG
INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG
INJECTION, PLERIXAFOR, 1 MG
INJECTION, OXYTOCIN, UP TO 10 UNITS
INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG
INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML
INJECTION, TOLAZOLINE HCL, UP TO 25 MG
INJECTION, PROGESTERONE, PER 50 MG
INJECTION, FLUPHENAZINE DECANOATE, UP TO 25 MG
INJECTION, PROCAINAMIDE HCL, UP TO 1 GM
INJECTION, OXACILLIN SODIUM, UP TO 250 MG
INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG
INJECTION, PROTAMINE SULFATE, PER 10 MG
INJECTION, PROTEIN C CONCENTRATE, INTRAVENOUS, HUMAN, 10 IU
INJECTION, PROTIRELIN, PER 250 MCG
INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 GM
INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG
INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG
INJECTION, QUINUPRISTIN/DALFOPRISTIN, 500 MG (150/350)
INJECTION, RANIBIZUMAB, 0.1 MG
INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG
INJECTION, RASBURICASE, 0.5 MG
INJECTION, REGADENOSON, 0.1 MG
INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MICROGRAMS (250 I.U.)
INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)
INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC), INTRAMUSCULAR OR
INTRAVENOUS, 100 IU
INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, SOLVENT DETERGENT, 100 IU
INJECTION, RILONACEPT, 1 MG
INJECTION, RISPERIDONE, LONG ACTING, 0.5 MG
INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG
INJECTION, ROMIPLOSTIM, 10 MICROGRAMS
INJECTION, METHOCARBAMOL, UP TO 10 ML
INJECTION, SINCALIDE, 5 MICROGRAMS
INJECTION, THEOPHYLLINE, PER 40 MG
INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG
INJECTION, SECRETIN, SYNTHETIC, HUMAN, 1 MICROGRAM
INJECTION, AUROTHIOGLUCOSE, UP TO 50 MG
INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG
INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG
INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG
INJECTION, SOMATREM, 1 MG
INJECTION, SOMATROPIN, 1 MG
INJECTION, PROMAZINE HCL, UP TO 25 MG
INJECTION, RETEPLASE, 18.1 MG
INJECTION, STREPTOKINASE, PER 250,000 IU
INJECTION, ALTEPLASE RECOMBINANT, 1 MG
INJECTION, STREPTOMYCIN, UP TO 1 GM
INJECTION, FENTANYL CITRATE, 0.1 MG
INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG
ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG
IS SELF ADMINISTERED)
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INJECTION, PENTAZOCINE, 30 MG
INJECTION, TELEVANCIN, 10 MG
INJECTION, TENECTEPLASE, 50MG
INJECTION, TENECTEPLASE, 1 MG
INJECTION, TERBUTALINE SULFATE, UP TO 1 MG
INJECTION, TERIPARATIDE, 10 MCG
INJECTION, TESTOSTERONE ENANTHATE, UP TO 100 MG
INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG
INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG
INJECTION, TESTOSTERONE PROPIONATE, UP TO 100 MG
INJECTION, CHLORPROMAZINE HCL, UP TO 50 MG
INJECTION, THYROTROPIN ALPHA, 0.9 MG, PROVIDED IN 1.1 MG VIAL
INJECTION, TIGECYCLINE, 1 MG
INJECTION, TIROFIBAN HCL, 0.25MG
INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG
INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG
INJECTION, TOCILIZUMAB, 1 MG
INJECTION, TORSEMIDE, 10 MG/ML
INJECTION, THIETHYLPERAZINE MALEATE, UP TO 10 MG
INJECTION, TREPROSTINIL, 1 MG
INJECTION, TRIAMCINOLONE ACETONIDE, PRESERVATIVE FREE, 1 MG
INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG
INJECTION, TRIAMCINOLONE DIACETATE, PER 5MG
INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5MG
INJECTION, TRIMETREXATE GLUCURONATE, PER 25 MG
INJECTION, PERPHENAZINE, UP TO 5 MG
INJECTION, TRIPTORELIN PAMOATE, 3.75 MG
INJECTION, SPECTINOMYCIN DIHYDROCHLORIDE, UP TO 2 GM
INJECTION, UREA, UP TO 40 GM
INJECTION, UROFOLLITROPIN, 75 IU
INJECTION, USTEKINUMAB, 1 MG
INJECTION, DIAZEPAM, UP TO 5 MG
INJECTION, UROKINASE, 5000 IU VIAL
INJECTION, IV, UROKINASE, 250,000 I.U. VIAL
INJECTION, VANCOMYCIN HCL, 500 MG
INJECTION, VELAGLUCERASE ALFA, 100 UNITS
INJECTION, VERTEPORFIN, 0.1 MG
INJECTION, TRIFLUPROMAZINE HCL, UP TO 20 MG
INJECTION, HYDROXYZINE HCL, UP TO 25 MG
INJECTION, THIAMINE HCL, 100 MG
INJECTION, PYRIDOXINE HCL, 100 MG
INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG
INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG
INJECTION, VORICONAZOLE, 10 MG
INJECTION, HYALURONIDASE, UP TO 150 UNITS
INJECTION, HYALURONIDASE, OVINE, PRESERVATIVE FREE, PER 1 USP UNIT (UP TO 999
USP UNITS)
INJECTION, HYALURONIDASE, OVINE, PRESERVATIVE FREE, PER 1000 USP UNITS
INJECTION, HYALURONIDASE, RECOMBINANT, 1 USP UNIT
INJECTION, MAGNESIUM SULFATE, PER 500 MG
INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ
INJECTION, ZIDOVUDINE, 10 MG
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INJECTION, ZIPRASIDONE MESYLATE, 10 MG
INJECTION, ZOLEDRONIC ACID (ZOMETA), 1 MG
INJECTION, ZOLEDRONIC ACID (RECLAST), 1 MG
UNCLASSIFIED DRUGS
EDETATE DISODIUM, PER 150 MG
NASAL VACCINE INHALATION
DRUG ADMINISTERED THROUGH A METERED DOSE INHALER
LAETRILE, AMYGDALIN, VITAMIN B17
UNCLASSIFIED BIOLOGICS
INFUSION, NORMAL SALINE SOLUTION , 1000 CC
INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML=1 UNIT)
5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT)
INFUSION, NORMAL SALINE SOLUTION , 250 CC
5% DEXTROSE/WATER (500 ML = 1 UNIT)
INFUSION, D5W, 1000 CC
INFUSION, DEXTRAN 40, 500 ML
INFUSION, DEXTRAN 75, 500 ML
RINGERS LACTATE INFUSION, UP TO 1000 CC
HYPERTONIC SALINE SOLUTION, 50 OR 100 MEQ, 20 CC VIAL
INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMAN), WILATE, PER 100 IU VWF:RCO
INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) (XYNTHA), PER I.U.
INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR COMPLEX (HUMAN),
PER FACTOR VIII I.U.
INJECTION, VON WILLEBRAND FACTOR COMPLEX (HUMATE-P), PER IU VWF:RCO
FACTOR VIIA (ANTIHEMOPHILIC FACTOR, RECOMBINANT), PER 1 MICROGRAM
FACTOR VIII (ANTIHEMOPHILIC FACTOR, HUMAN) PER I.U.
FACTOR VIII (ANTIHEMOPHILIC FACTOR (PORCINE)), PER I.U.
FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U., NOT OTHERWISE
SPECIFIED
FACTOR IX (ANTIHEMOPHILIC FACTOR, PURIFIED, NON-RECOMBINANT) PER I.U.
FACTOR IX, COMPLEX, PER I.U.
FACTOR IX (ANTIHEMOPHILIC FACTOR, RECOMBINANT) PER I.U.
INJECTION, ANTITHROMBIN RECOMBINANT, 50 I.U.
ANTITHROMBIN III (HUMAN), PER I.U.
ANTI-INHIBITOR, PER I.U.
HEMOPHILIA CLOTTING FACTOR, NOT OTHERWISE CLASSIFIED
INTRAUTERINE COPPER CONTRACEPTIVE
LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG
CONTRACEPTIVE SUPPLY, HORMONE CONTAINING VAGINAL RING, EACH
CONTRACEPTIVE SUPPLY, HORMONE CONTAINING PATCH, EACH
LEVONORGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANTS AND SUPPLIES
ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES
AMINOLEVULINIC ACID HCL FOR TOPICAL ADMINISTRATION, 20%, SINGLE UNIT DOSAGE
FORM (354 MG)
METHYL AMINOLEVULINATE (MAL) FOR TOPICAL ADMINISTRATION, 16.8%, 1 GRAM
GANCICLOVIR, 4.5 MG, LONG-ACTING IMPLANT
FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT
INJECTION, DEXAMETHASONE, INTRAVITREAL IMPLANT, 0.1 MG
HYALURONAN (SODIUM HYALURONATE) OR DERIVATIVE, INTRA-ARTICULAR INJECTION, PER
INJECTION
HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTICULAR INJECTION,
PER DOSE
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HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE
HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJECTION, PER DOSE
HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE
HYALURONAN OR DERIVATIVE, SYNVISC OR SYNVISC-ONE, FOR INTRA-ARTICULAR
INJECTION, 1 MG
AUTOLOGOUS CULTURED CHONDROCYTES, IMPLANT
CAPSAICIN 8% PATCH, PER 10 SQUARE CENTIMETERS
DERMAL AND EPIDERMAL, (SUBSTITUTE) TISSUE OF HUMAN ORIGIN, WITH OR WITHOUT
BIOENGINEERED OR PROCESSED ELEMENTS, WITH METABOLICALLY ACTIVE ELEMENTS, PER
SQUARE CENTIMETER
DERMAL (SUBSTITUTE) TISSUE OF NON-HUMAN ORIGIN, WITH OR WITHOUT OTHER
BIOENGINEERED OR PROCESSED ELEMENTS, WITH METABOLICALLY ACTIVE ELEMENTS, PER
SQUARE CENTIMETER
DERMAL (SUBSTITUTE) TISSUE OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENGINEERED
OR PROCESSED ELEMENTS, WITH METABOLICALLY ACTIVE ELEMENTS, PER SQUARE CENTIMETER
DERMAL AND EPIDERMAL, (SUBSTITUTE) TISSUE OF NON-HUMAN ORIGIN, WITH OR WITHOUT
OTHER BIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE
ELEMENTS, PER SQUARE CENTIMETER
DERMAL (SUBSTITUTE) TISSUE OF HUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENGINEERED
OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS, PER SQUARE
CENTIMETER
DERMAL (SUBSTITUTE) TISSUE OF NON-HUMAN ORIGIN, WITH OR WITHOUT OTHER
BIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS, PER
SQUARE CENTIMETER
DERMAL (SUBSTITUTE) TISSUE OF HUMAN ORIGIN, INJECTABLE, WITH OR WITHOUT OTHER
BIOENGINEERED OR PROCESSED ELEMENTS, BUT WITHOUT METABOLICALLY ACTIVE ELEMENTS,
1 CC
DERMAL (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHOUT OTHER
BIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS
(INTEGRA MATRIX), PER SQUARE CENTIMETER
DERMAL (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHOUT OTHER
BIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS
(TISSUEMEND), PER SQUARE CENTIMETER
DERMAL (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHOUT OTHER
BIOENGINEERED OR PROCESSED ELEMENTS, WITHOUT METABOLICALLY ACTIVE ELEMENTS
(PRIMATRIX), PER SQUARE CENTIMETER
AZATHIOPRINE, ORAL, 50 MG
AZATHIOPRINE, PARENTERAL, 100 MG
CYCLOSPORINE, ORAL, 100 MG
LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE, PARENTERAL, 250 MG
MUROMONAB-CD3, PARENTERAL, 5 MG
PREDNISONE, ORAL, PER 5MG
TACROLIMUS, ORAL, PER 1 MG
METHYLPREDNISOLONE ORAL, PER 4 MG
PREDNISOLONE ORAL, PER 5 MG
LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT, PARENTERAL, 25MG
DACLIZUMAB, PARENTERAL, 25 MG
CYCLOSPORINE, ORAL, 25 MG
CYCLOSPORIN, PARENTERAL, 250 MG
MYCOPHENOLATE MOFETIL, ORAL, 250 MG
MYCOPHENOLIC ACID, ORAL, 180 MG
SIROLIMUS, ORAL, 1 MG
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TACROLIMUS, PARENTERAL, 5 MG
IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED
ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION,
FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME,
CONCENTRATED FORM, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)
ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION,
FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT
DOSE, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)
ACETYLCYSTEINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
DME, UNIT DOSE FORM, PER GRAM
ARFORMOTEROL, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE FORM, 15 MICROGRAMS
FORMOTEROL FUMARATE, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT,
NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 20 MICROGRAMS
LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
DME, CONCENTRATED FORM, 0.5 MG
ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,
NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM
ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,
UNIT DOSE, 1 MG
ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,
CONCENTRATED FORM, 1 MG
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, CONCENTRATED FORM, 1 MG
LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, CONCENTRATED FORM, 0.5 MG
ALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG
LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG
LEVALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
DME, UNIT DOSE, 0.5 MG
ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED
FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME
BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
DME, UNIT DOSE FORM, PER MILLIGRAM
BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
DME, UNIT DOSE FORM, PER MILLIGRAM
BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG
BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,
UNIT DOSE FORM, UP TO 0.5 MG
BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM
BITOLTEROL MESYLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,
NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS
CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
DME, UNIT DOSE FORM, PER 10 MILLIGRAMS
BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM
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BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,
CONCENTRATED FORM, PER 0.25 MILLIGRAM
ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,
CONCENTRATED FORM, PER MILLIGRAM
ATROPINE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,
UNIT DOSE FORM, PER MILLIGRAM
DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
DME, CONCENTRATED FORM, PER MILLIGRAM
DEXAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
DME, UNIT DOSE FORM, PER MILLIGRAM
DORNASE ALFA, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
FORMOTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,
UNIT DOSE FORM, 12 MICROGRAMS
FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,
UNIT DOSE, PER MILLIGRAM
GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
DME, CONCENTRATED FORM, PER MILLIGRAM
GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
DME, UNIT DOSE FORM, PER MILLIGRAM
IPRATROPIUM BROMIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,
NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
IPRATROPIUM BROMIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
DME, CONCENTRATED FORM, PER MILLIGRAM
ISOETHARINE HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,
NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM
ISOETHARINE HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,
NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
ISOETHARINE HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
DME, UNIT DOSE FORM, PER MILLIGRAM
ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM
ISOPROTERENOL HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,
NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM
ISOPROTERENOL HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,
NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, CONCENTRATED
FORM, PER 10 MILLIGRAMS
METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,
NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 10 MILLIGRAMS
METAPROTERENOL SULFATE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT,
NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS
METAPROTERENOL SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS
METHACHOLINE CHLORIDE ADMINISTERED AS INHALATION SOLUTION THROUGH A NEBULIZER,
PER 1 MG
PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
THROUGH DME, UNIT DOSE FORM, PER 300 MG
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TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM
TERBUTALINE SULFATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED
THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM
TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,
UNIT DOSE FORM, ADMINISTERED THROUGH DME, PER 300 MILLIGRAMS
TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
DME, CONCENTRATED FORM, PER MILLIGRAM
TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
DME, UNIT DOSE FORM, PER MILLIGRAM
TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME,
UNIT DOSE FORM, PER 300 MILLIGRAMS
TREPROSTINIL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE FORM, 1.74 MG
NOC DRUGS, INHALATION SOLUTION ADMINISTERED THROUGH DME
NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME
ANTIEMETIC DRUG, RECTAL/SUPPOSITORY, NOT OTHERWISE SPECIFIED
PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS
APREPITANT, ORAL, 5 MG
BUSULFAN; ORAL, 2 MG
CABERGOLINE, ORAL, 0.25 MG
CAPECITABINE, ORAL, 150 MG
CAPECITABINE, ORAL, 500 MG
CYCLOPHOSPHAMIDE; ORAL, 25 MG
DEXAMETHASONE, ORAL, 0.25 MG
ETOPOSIDE; ORAL, 50 MG
FLUDARABINE PHOSPHATE, ORAL, 10 MG
GEFITINIB, ORAL, 250 MG
ANTIEMETIC DRUG, ORAL, NOT OTHERWISE SPECIFIED
MELPHALAN; ORAL, 2 MG
METHOTREXATE; ORAL, 2.5 MG
NABILONE, ORAL, 1 MG
TEMOZOLOMIDE, ORAL, 5 MG
TOPOTECAN, ORAL, 0.25 MG
PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS
INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG
INJECTION, DOXORUBICIN HYDROCHLORIDE, ALL LIPID FORMULATIONS, 10 MG
INJECTION, ALEMTUZUMAB, 10 MG
INJECTION, ALDESLEUKIN, PER SINGLE USE VIAL
INJECTION, ARSENIC TRIOXIDE, 1 MG
INJECTION, ASPARAGINASE, 10,000 UNITS
INJECTION, AZACITIDINE, 1 MG
INJECTION, CLOFARABINE, 1 MG
BCG (INTRAVESICAL) PER INSTILLATION
INJECTION, BENDAMUSTINE HCL, 1 MG
INJECTION, BEVACIZUMAB, 10 MG
INJECTION, BLEOMYCIN SULFATE, 15 UNITS
INJECTION, BORTEZOMIB, 0.1 MG
INJECTION, CARBOPLATIN, 50 MG
INJECTION, CARMUSTINE, 100 MG
INJECTION, CETUXIMAB, 10 MG
INJECTION, CISPLATIN, POWDER OR S0LUTION, 10 MG
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CISPLATIN, 50 MG
INJECTION, CLADRIBINE, PER 1 MG
CYCLOPHOSPHAMIDE, 100 MG
CYCLOPHOSPHAMIDE, 200 MG
CYCLOPHOSPHAMIDE, 500 MG
CYCLOPHOSPHAMIDE, 1.0 GRAM
CYCLOPHOSPHAMIDE, 2.0 GRAM
CYCLOPHOSPHAMIDE, LYOPHILIZED, 100 MG
CYCLOPHOSPHAMIDE, LYOPHILIZED, 200 MG
CYCLOPHOSPHAMIDE, LYOPHILIZED, 500 MG
CYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 GRAM
CYCLOPHOSPHAMIDE, LYOPHILIZED, 2.0 GRAM
INJECTION, CYTARABINE LIPOSOME, 10 MG
INJECTION, CYTARABINE, 100 MG
INJECTION, CYTARABINE, 500 MG
INJECTION, DACTINOMYCIN, 0.5 MG
DACARBAZINE, 100 MG
DACARBAZINE, 200 MG
INJECTION, DAUNORUBICIN, 10 MG
INJECTION, DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION, 10 MG
INJECTION, DEGARELIX, 1 MG
INJECTION, DENILEUKIN DIFTITOX, 300 MICROGRAMS
INJECTION, DIETHYLSTILBESTROL DIPHOSPHATE, 250 MG
INJECTION, DOCETAXEL, 20 MG
INJECTION, DOCETAXEL, 1 MG
INJECTION, ELLIOTTS' B SOLUTION, 1 ML
INJECTION, EPIRUBICIN HCL, 2 MG
INJECTION, ETOPOSIDE, 10 MG
ETOPOSIDE, 100 MG
INJECTION, FLUDARABINE PHOSPHATE, 50 MG
INJECTION, FLUOROURACIL, 500 MG
INJECTION, FLOXURIDINE, 500 MG
INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG
GOSERELIN ACETATE IMPLANT, PER 3.6 MG
INJECTION, IRINOTECAN, 20 MG
INJECTION, IXABEPILONE, 1 MG
INJECTION, IFOSFAMIDE, 1 GRAM
INJECTION, MESNA, 200 MG
INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG
INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MICROGRAM
INJECTION, INTERFERON, ALFA-2A, RECOMBINANT, 3 MILLION UNITS
INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS
INJECTION, INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU
INJECTION, INTERFERON, GAMMA 1-B, 3 MILLION UNITS
LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG
LEUPROLIDE ACETATE, PER 1 MG
LEUPROLIDE ACETATE IMPLANT, 65 MG
HISTRELIN IMPLANT (VANTAS), 50 MG
HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG
INJECTION, MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARD), 10 MG
INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG
METHOTREXATE SODIUM, 5 MG
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METHOTREXATE SODIUM, 50 MG
INJECTION, NELARABINE, 50 MG
INJECTION, OXALIPLATIN, 0.5 MG
INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG
INJECTION, PACLITAXEL, 30 MG
INJECTION, PEGASPARGASE, PER SINGLE DOSE VIAL
INJECTION, PENTOSTATIN, 10 MG
INJECTION, PLICAMYCIN, 2.5 MG
MITOMYCIN, 5 MG
MITOMYCIN, 20 MG
MITOMYCIN, 40 MG
INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG
INJECTION, GEMTUZUMAB OZOGAMICIN, 5 MG
INJECTION, OFATUMUMAB, 10 MG
INJECTION, PANITUMUMAB, 10 MG
INJECTION, PEMETREXED, 10 MG
INJECTION, PRALATREXATE, 1 MG
INJECTION, RITUXIMAB, 100 MG
INJECTION, ROMIDEPSIN, 1 MG
INJECTION, STREPTOZOCIN, 1 GRAM
INJECTION, TEMOZOLOMIDE, 1 MG
INJECTION, TEMSIROLIMUS, 1 MG
INJECTION, THIOTEPA, 15 MG
INJECTION, TOPOTECAN, 4 MG
INJECTION, TOPOTECAN, 0.1 MG
INJECTION, TRASTUZUMAB, 10 MG
INJECTION, VALRUBICIN, INTRAVESICAL, 200 MG
INJECTION, VINBLASTINE SULFATE, 1 MG
VINCRISTINE SULFATE, 1 MG
VINCRISTINE SULFATE, 2 MG
VINCRISTINE SULFATE, 5 MG
INJECTION, VINORELBINE TARTRATE, 10 MG
INJECTION, FULVESTRANT, 25 MG
INJECTION, PORFIMER SODIUM, 75 MG
NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS
STANDARD WHEELCHAIR
STANDARD HEMI (LOW SEAT) WHEELCHAIR
LIGHTWEIGHT WHEELCHAIR
HIGH STRENGTH, LIGHTWEIGHT WHEELCHAIR
ULTRALIGHTWEIGHT WHEELCHAIR
HEAVY DUTY WHEELCHAIR
EXTRA HEAVY DUTY WHEELCHAIR
OTHER MANUAL WHEELCHAIR/BASE
STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR
STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR WITH PROGRAMMABLE CONTROL
PARAMETERS FOR SPEED ADJUSTMENT, TREMOR DAMPENING, ACCELERATION CONTROL AND
BRAKING
LIGHTWEIGHT PORTABLE MOTORIZED/POWER WHEELCHAIR
OTHER MOTORIZED/POWER WHEELCHAIR BASE
DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH
DETACHABLE, ADJUSTABLE HEIGHT ARMREST, BASE, EACH
DETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER PORTION, EACH
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ARM PAD, EACH
FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR
HIGH MOUNT FLIP-UP FOOTREST, EACH
LEG STRAP, EACH
LEG STRAP, H STYLE, EACH
ADJUSTABLE ANGLE FOOTPLATE, EACH
LARGE SIZE FOOTPLATE, EACH
STANDARD SIZE FOOTPLATE, EACH
FOOTREST, LOWER EXTENSION TUBE, EACH
FOOTREST, UPPER HANGER BRACKET, EACH
FOOTREST, COMPLETE ASSEMBLY
ELEVATING LEGREST, LOWER EXTENSION TUBE, EACH
ELEVATING LEGREST, UPPER HANGER BRACKET, EACH
RATCHET ASSEMBLY
CAM RELEASE ASSEMBLY, FOOTREST OR LEGREST, EACH
SWINGAWAY, DETACHABLE FOOTRESTS, EACH
ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH
SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH
STRENGTH, LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR
SPOKE PROTECTORS, EACH
REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR MOLDED, EACH
REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDED, EACH
FRONT CASTER ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, EACH
FRONT CASTER ASSEMBLY, COMPLETE, WITH SEMI-PNEUMATIC TIRE, EACH
CASTER PIN LOCK,EACH
FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACH
DRIVE BELT FOR POWER WHEELCHAIR
IV HANGER, EACH
WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED
ELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE)
INFUSION PUMP USED FOR UNINTERRUPTED PARENTERAL ADMINISTRATION OF MEDICATION,
(E.G., EPOPROSTENOL OR TREPROSTINOL)
TEMPORARY REPLACEMENT FOR PATIENT OWNED EQUIPMENT BEING REPAIRED, ANY TYPE
SUPPLIES FOR EXTERNAL DRUG INFUSION PUMP, SYRINGE TYPE CARTRIDGE, STERILE, EACH
COMBINATION ORAL/NASAL MASK, USED WITH CONTINUOUS POSITIVE AIRWAY PRESSURE
DEVICE, EACH
ORAL CUSHION FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, EACH
NASAL PILLOWS FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, PAIR
REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, SILVER OXIDE,
1.5 VOLT, EACH
REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, SILVER OXIDE,
3 VOLT, EACH
REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, ALKALINE, 1.5
VOLT, EACH
REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, LITHIUM, 3.6
VOLT, EACH
REPLACEMENT BATTERY FOR EXTERNAL INFUSION PUMP OWNED BY PATIENT, LITHIUM, 4.5
VOLT, EACH
AUTOMATIC EXTERNAL DEFIBRILLATOR, WITH INTEGRATED ELECTROCARDIOGRAM ANALYSIS,
GARMENT TYPE
REPLACEMENT BATTERY FOR AUTOMATED EXTERNAL DEFIBRILLATOR, GARMENT TYPE ONLY,
EACH
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REPLACEMENT GARMENT FOR USE WITH AUTOMATED EXTERNAL DEFIBRILLATOR, EACH
REPLACEMENT ELECTRODES FOR USE WITH AUTOMATED EXTERNAL DEFIBRILLATOR, GARMENT
TYPE ONLY, EACH
WHEELCHAIR ACCESSORY, WHEELCHAIR SEAT OR BACK CUSHION, DOES NOT MEET SPECIFIC
CODE CRITERIA OR NO WRITTEN CODING VERIFICATION FROM DME PDAC
ADDITION TO LOWER EXTREMITY ORTHOSIS, REMOVABLE SOFT INTERFACE, ALL COMPONENTS,
REPLACEMENT ONLY, EACH
CONTROLLED DOSE INHALATION DRUG DELIVERY SYSTEM
POWER WHEELCHAIR ACCESSORY, 12 TO 24 AMP HOUR SEALED LEAD ACID BATTERY, EACH
(E.G., GEL CELL, ABSORBED GLASSMAT)
SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES,
ANY DEPTH
SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR
GREATER, ANY DEPTH
SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS
THAN 22 INCHES, ANY DEPTH
SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22
INCHES OR GREATER, ANY DEPTH
PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; HOME COMPRESSOR USED TO FILL PORTABLE
OXYGEN CYLINDERS; INCLUDES PORTABLE CONTAINERS, REGULATOR, FLOWMETER,
HUMIDIFIER, CANNULA OR MASK, AND TUBING
REPAIR OR NONROUTINE SERVICE FOR DURABLE MEDICAL EQUIPMENT OTHER THAN OXYGEN
EQUIPMENT REQUIRING THE SKILL OF A TECHNICIAN, LABOR COMPONENT, PER 15 MINUTES
REPAIR OR NONROUTINE SERVICE FOR OXYGEN EQUIPMENT REQUIRING THE SKILL OF A
TECHNICIAN, LABOR COMPONENT, PER 15 MINUTES
POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND
INCLUDING 300 POUNDS
POWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450
POUNDS
POWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO
600 POUNDS
POWER OPERATED VEHICLE, GROUP 2 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND
INCLUDING 300 POUNDS
POWER OPERATED VEHICLE, GROUP 2 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450
POUNDS
POWER OPERATED VEHICLE, GROUP 2 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO
600 POUNDS
POWER OPERATED VEHICLE, NOT OTHERWISE CLASSIFIED
POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK,
PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT
CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 1 STANDARD, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT
CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 1 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP
TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, SLING/SOLID SEAT/BACK, PATIENT
WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT
CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT
CAPACITY UP TO AND INCLUDING 300 POUNDS
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POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP
TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT
CAPACITY 301 TO 450 POUNDS
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY
301 TO 450 POUNDS
POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT
WEIGHT CAPACITY 451 TO 600 POUNDS
POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT
CAPACITY 451 TO 600 POUNDS
POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT
WEIGHT CAPACITY 601 POUNDS OR MORE
POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT 601
POUNDS OR MORE
POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, SLING/SOLID SEAT/BACK,
PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, CAPTAINS CHAIR, PATIENT
WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK,
PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR,
PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR,
PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS
POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SINGLE POWER OPTION SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS
POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE
POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR,
PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS
POWER WHEELCHAIR, GROUP 3 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT
CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 3 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP
TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT
CAPACITY 301 TO 450 POUNDS
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY
301 TO 450 POUNDS
POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT
WEIGHT CAPACITY 451 TO 600 POUNDS
POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT
CAPACITY 451 TO 600 POUNDS
POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT
WEIGHT CAPACITY 601 POUNDS OR MORE
POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT
CAPACITY 601 POUNDS OR MORE
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POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK,
PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR,
PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT 301 TO 450 POUNDS
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR,
PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS
POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS
POWER WHEELCHAIR, GROUP 3 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS
POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS
POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE
POWER WHEELCHAIR, GROUP 4 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT
CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 4 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP
TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT
CAPACITY 301 TO 450 POUNDS
POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT
WEIGHT CAPACITY 451 TO 600 POUNDS
POWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK,
PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR,
PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS
POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT 451 TO 600 POUNDS
POWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR,
PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS
POWER WHEELCHAIR, GROUP 5 PEDIATRIC, SINGLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 125 POUNDS
POWER WHEELCHAIR, GROUP 5 PEDIATRIC, MULTIPLE POWER OPTION, SLING/SOLID
SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 125 POUNDS
POWER WHEELCHAIR, NOT OTHERWISE CLASSIFIED
POWER MOBILITY DEVICE, NOT CODED BY DME PDAC OR DOES NOT MEET CRITERIA
CRANIAL CERVICAL ORTHOSIS, CONGENITAL TORTICOLLIS TYPE, WITH OR WITHOUT SOFT
INTERFACE MATERIAL, ADJUSTABLE RANGE OF MOTION JOINT, CUSTOM FABRICATED
CRANIAL CERVICAL ORTHOSIS, TORTICOLLIS TYPE, WITH OR WITHOUT JOINT, WITH OR
WITHOUT SOFT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
CERVICAL, FLEXIBLE, NON-ADJUSTABLE (FOAM COLLAR)
CERVICAL, FLEXIBLE, THERMOPLASTIC COLLAR, MOLDED TO PATIENT
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CERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTIC COLLAR)
CERVICAL, SEMI-RIGID, ADJUSTABLE MOLDED CHIN CUP (PLASTIC COLLAR WITH
MANDIBULAR/OCCIPITAL PIECE)
CERVICAL, SEMI-RIGID, WIRE FRAME OCCIPITAL/MANDIBULAR SUPPORT
CERVICAL, COLLAR, MOLDED TO PATIENT MODEL
CERVICAL, COLLAR, SEMI-RIGID THERMOPLASTIC FOAM, TWO PIECE
CERVICAL, COLLAR, SEMI-RIGID, THERMOPLASTIC FOAM, TWO PIECE WITH THORACIC
EXTENSION
CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABLE
CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABLE
CERVICAL BARS (SOMI, GUILFORD, TAYLOR TYPES)
CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABLE
CERVICAL BARS, AND THORACIC EXTENSION
THORACIC, RIB BELT
THORACIC, RIB BELT, CUSTOM FABRICATED
SPINAL ORTHOSIS, ANTERIOR-POSTERIOR-LATERAL CONTROL, WITH INTERFACE MATERIAL,
CUSTOM FITTED (DEWALL POSTURE PROTECTOR ONLY)
TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC REGION, PRODUCES
INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS WITH RIGID
STAYS OR PANEL(S), INCLUDES SHOULDER STRAPS AND CLOSURES, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC REGION, PRODUCES
INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS WITH RIGID
STAYS OR PANEL(S), INCLUDES SHOULDER STRAPS AND CLOSURES, CUSTOM FABRICATED
TLSO FLEXIBLE, PROVIDES TRUNK SUPPORT, EXTENDS FROM SACROCOCCYGEAL JUNCTION TO
ABOVE T-9 VERTEBRA, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL PLANE,
PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS WITH
RIGID STAYS OR PANEL(S), INCLUDES SHOULDER STRAPS AND CLOSURES, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, THORACIC REGION, RIGID POSTERIOR PANEL
AND SOFT ANTERIOR APRON, EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND
TERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, RESTRICTS GROSS TRUNK MOTION IN
THE SAGITTAL PLANE, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE
INTERVERTEBRAL DISKS, INCLUDES STRAPS AND CLOSURES, PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTIC
SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUST
INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TO
THE XIPHOID, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL, CORONAL,
AND TRANVERSE PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPING PLASTIC AND
STABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID PLASTIC
SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUST
INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TO
THE STERNAL NOTCH, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL,
CORONAL, AND TRANSVERSE PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPING
PLASTIC AND STABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGID PLASTIC
SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUST
INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TO
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THE STERNAL NOTCH, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL,
CORONAL, AND TRANSVERSE PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPING
PLASTIC AND STABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, FOUR RIGID PLASTIC
SHELLS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION AND TERMINATES JUST
INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS PUBIS TO THE
STERNAL NOTCH, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL, CORONAL,
AND TRANSVERSE PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPING PLASTIC AND
STABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
TLSO, SAGITTAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR APRON
WITH STRAPS, CLOSURES AND PADDING, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL
PLANE, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISKS,
INCLUDES FITTING AND SHAPING THE FRAME, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
TLSO, SAGITTAL-CORONAL CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT
ANTERIOR APRON WITH STRAPS, CLOSURES AND PADDING, EXTENDS FROM SACROCOCCYGEAL
JUNCTION OVER SCAPULAE, LATERAL STRENGTH PROVIDED BY PELVIC, THORACIC, AND
LATERAL FRAME PIECES, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL, AND CORONAL
PLANES, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISKS,
INCLUDES FITTING AND SHAPING THE FRAME, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
TLSO, TRIPLANAR CONTROL, RIGID POSTERIOR FRAME AND FLEXIBLE SOFT ANTERIOR APRON
WITH STRAPS, CLOSURES AND PADDING EXTENDS FROM SACROCOCCYGEAL JUNCTION TO
SCAPULA, LATERAL STRENGTH PROVIDED BY PELVIC, THORACIC, AND LATERAL FRAME
PIECES, ROTATIONAL STRENGTH PROVIDED BY SUBCLAVICULAR EXTENSIONS, RESTRICTS
GROSS TRUNK MOTION IN SAGITTAL, CORONAL, AND TRANSVERSE PLANES, PROVIDES
INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS, INCLUDES
FITTING AND SHAPING THE FRAME, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
TLSO, TRIPLANAR CONTROL, HYPEREXTENSION, RIGID ANTERIOR AND LATERAL FRAME
EXTENDS FROM SYMPHYSIS PUBIS TO STERNAL NOTCH WITH TWO ANTERIOR COMPONENTS (ONE
PUBIC AND ONE STERNAL), POSTERIOR AND LATERAL PADS WITH STRAPS AND CLOSURES,
LIMITS SPINAL FLEXION, RESTRICTS GROSS TRUNK MOTION IN SAGITTAL, CORONAL, AND
TRANSVERSE PLANES, INCLUDES FITTING AND SHAPING THE FRAME, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITHOUT INTERFACE LINER,
WITH MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL
JUNCTION AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM
SYMPHYSIS PUBIS TO STERNAL NOTCH, ANTERIOR OR POSTERIOR OPENING, RESTRICTS
GROSS TRUNK MOTION IN SAGITTAL, CORONAL, AND TRANSVERSE PLANES, INCLUDES A
CARVED PLASTER OR CAD-CAM MODEL, CUSTOM FABRICATED
TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER,
MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION
AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS
PUBIS TO STERNAL NOTCH, ANTERIOR OR POSTERIOR OPENING, RESTRICTS GROSS TRUNK
MOTION IN SAGITTAL, CORONAL, AND TRANSVERSE PLANES, INCLUDES A CARVED PLASTER
OR CAD-CAM MODEL, CUSTOM FABRICATED
TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITHOUT INTERFACE LINER,
WITH MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL
JUNCTION AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM
SYMPHYSIS PUBIS TO STERNAL NOTCH, LATERAL STRENGTH IS ENHANCED BY OVERLAPPING
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PLASTIC, RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL, CORONAL, AND TRANSVERSE
PLANES, INCLUDES A CARVED PLASTER OR CAD-CAM MODEL, CUSTOM FABRICATED
TLSO, TRIPLANAR CONTROL, TWO PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER,
MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION
AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS
PUBIS TO STERNAL NOTCH, LATERAL STRENGTH IS ENHANCED BY OVERLAPPING PLASTIC,
RESTRICTS GROSS TRUNK MOTION IN THE SAGITTAL, CORONAL, AND TRANSVERSE PLANES,
INCLUDES A CARVED PLASTER OR CAD-CAM MODEL, CUSTOM FABRICATED
TLSO, TRIPLANAR CONTROL, ONE PIECE RIGID PLASTIC SHELL WITH INTERFACE LINER,
MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION
AND TERMINATES JUST INFERIOR TO SCAPULAR SPINE, ANTERIOR EXTENDS FROM SYMPHYSIS
PUBIS TO STERNAL NOTCH, ANTERIOR OR POSTERIOR OPENING, RESTRICTS GROSS TRUNK
MOTION IN SAGITTAL, CORONAL, AND TRANSVERSE PLANES, PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
TLSO, SAGITTAL-CORONAL CONTROL, ONE PIECE RIGID PLASTIC SHELL, WITH OVERLAPPING
REINFORCED ANTERIOR, WITH MULTIPLE STRAPS AND CLOSURES, POSTERIOR EXTENDS FROM
SACROCOCCYGEAL JUNCTION AND TERMINATES AT OR BEFORE THE T-9 VERTEBRA, ANTERIOR
EXTENDS FROM SYMPHYSIS PUBIS TO XIPHOID, ANTERIOR OPENING, RESTRICTS GROSS
TRUNK MOTION IN SAGITTAL AND CORONAL PLANES, PREFABRICATED, INCLUDES FITTING
AND ADJUSTMENT
TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, TWO RIGID
PLASTIC SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND
TERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE
SYMPHYSIS PUBIS TO THE XIPHOID, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THE
SAGITTAL AND CORONAL PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPING
PLASTIC AND STABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
TLSO, SAGITTAL-CORONAL CONTROL, MODULAR SEGMENTED SPINAL SYSTEM, THREE RIGID
PLASTIC SHELLS, POSTERIOR EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND
TERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE
SYMPHYSIS PUBIS TO THE XIPHOID, SOFT LINER, RESTRICTS GROSS TRUNK MOTION IN THE
SAGITTAL AND CORONAL PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPING
PLASTIC AND STABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTION
ABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS
ABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTION
ABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS
ABDOMEN DESIGN, CUSTOM FABRICATED
SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGID
PANELS OVER THE SACRUM AND ABDOMEN, REDUCES MOTION ABOUT THE SACROILIAC JOINT,
INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
SACROILIAC ORTHOSIS, PROVIDES PELVIC-SACRAL SUPPORT, WITH RIGID OR SEMI-RIGID
PANELS PLACED OVER THE SACRUM AND ABDOMEN, REDUCES MOTION ABOUT THE SACROILIAC
JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, CUSTOM
FABRICATED
LUMBAR ORTHOSIS, FLEXIBLE, PROVIDES LUMBAR SUPPORT, POSTERIOR EXTENDS FROM L-1
TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE
INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN
DESIGN, SHOULDER STRAPS, STAYS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
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LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S), POSTERIOR
EXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO
REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE
PADDING, STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
LUMBAR ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR PANELS,
POSTERIOR EXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES INTRACAVITARY
PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES,
MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOR
EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY
PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES,
MAY INCLUDE STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES LUMBO-SACRAL SUPPORT, POSTERIOR
EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY
PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES,
MAY INCLUDE STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, CUSTOM FABRICATED
LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID POSTERIOR PANEL(S),
POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, PRODUCES
INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS, INCLUDES
STRAPS, CLOSURES, MAY INCLUDE PADDING, STAYS, SHOULDER STRAPS, PENDULOUS
ABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR
PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA,
PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS,
INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS
ABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
LUMBAR-SACRAL ORTHOSIS, SAGITTAL CONTROL, WITH RIGID ANTERIOR AND POSTERIOR
PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA,
PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISCS,
INCLUDES STRAPS, CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS
ABDOMEN DESIGN, CUSTOM FABRICATED
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIOR
FRAME/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA,
LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARY
PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY
INCLUDE PADDING, STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID POSTERIOR
FRAME/PANEL(S), POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA,
LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANEL(S), PRODUCES
INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS,
CLOSURES, MAY INCLUDE PADDING, STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN
DESIGN, CUSTOM FABRICATED
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FLEXION, RIGID
POSTERIOR FRAME/PANEL(S), LATERAL ARTICULATING DESIGN TO FLEX THE LUMBAR SPINE,
POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL
STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANEL(S), PRODUCES INTRACAVITARY
PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY
INCLUDE PADDING, ANTERIOR PANEL, PENDULOUS ABDOMEN DESIGN, PREFABRICATED,
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INCLUDES FITTING AND ADJUSTMENT
LUMBAR SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, LUMBAR FLEXION, RIGID
POSTERIOR FRAME/PANELS, LATERAL ARTICULATING DESIGN TO FLEX THE LUMBAR SPINE,
POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, LATERAL
STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES INTRACAVITARY
PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS, CLOSURES, MAY
INCLUDE PADDING, ANTERIOR PANEL, PENDULOUS ABDOMEN DESIGN, CUSTOM FABRICATED
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND
POSTERIOR FRAME/PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9
VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES
INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS,
CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND
POSTERIOR FRAME/PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9
VERTEBRA, LATERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME/PANELS, PRODUCES
INTRACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISCS, INCLUDES STRAPS,
CLOSURES, MAY INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN,
CUSTOM FABRICATED
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S),
POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, ANTERIOR
EXTENDS FROM SYMPHYSIS PUBIS TO XYPHOID, PRODUCES INTRACAVITARY PRESSURE TO
REDUCE LOAD ON THE INTERVERTEBRAL DISCS, OVERALL STRENGTH IS PROVIDED BY
OVERLAPPING RIGID MATERIAL AND STABILIZING CLOSURES, INCLUDES STRAPS, CLOSURES,
MAY INCLUDE SOFT INTERFACE, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, RIGID SHELL(S)/PANEL(S),
POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, ANTERIOR
EXTENDS FROM SYMPHYSIS PUBIS TO XYPHOID, PRODUCES INTRACAVITARY PRESSURE TO
REDUCE LOAD ON THE INTERVERTEBRAL DISCS, OVERALL STRENGTH IS PROVIDED BY
OVERLAPPING RIGID MATERIAL AND STABILIZING CLOSURES, INCLUDES STRAPS, CLOSURES,
MAY INCLUDE SOFT INTERFACE, PENDULOUS ABDOMEN DESIGN, CUSTOM FABRICATED
CERVICAL-THORACIC-LUMBAR-SACRAL-ORTHOSES (CTLSO), ANTERIOR-POSTERIOR-LATERAL
CONTROL, MOLDED TO PATIENT MODEL, (MINERVA TYPE)
CTLSO, ANTERIOR-POSTERIOR-LATERAL-CONTROL, MOLDED TO PATIENT MODEL, WITH
INTERFACE MATERIAL, (MINERVA TYPE)
HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO JACKET VEST
HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO PLASTER BODY JACKET
HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO MILWAUKEE TYPE ORTHOSIS
ADDITION TO HALO PROCEDURE, MAGNETIC RESONANCE IMAGE COMPATIBLE SYSTEMS, RINGS
AND PINS, ANY MATERIAL
ADDITION TO HALO PROCEDURE, REPLACEMENT LINER/INTERFACE MATERIAL
TORSO SUPPORT, POST SURGICAL SUPPORT, PADS FOR POST SURGICAL SUPPORT
TLSO, CORSET FRONT
LSO, CORSET FRONT
TLSO, FULL CORSET
LSO, FULL CORSET
AXILLARY CRUTCH EXTENSION
PERONEAL STRAPS, PAIR
STOCKING SUPPORTER GRIPS, SET OF FOUR (4)
PROTECTIVE BODY SOCK, EACH
ADDITION TO SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED
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CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) (MILWAUKEE), INCLUSIVE OF
FURNISHING INITIAL ORTHOSIS, INCLUDING MODEL
CERVICAL THORACIC LUMBAR SACRAL ORTHOSIS, IMMOBILIZER, INFANT SIZE,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
TENSION BASED SCOLIOSIS ORTHOSIS AND ACCESSORY PADS, INCLUDES FITTING AND
ADJUSTMENT
ADDITION TO CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) OR SCOLIOSIS
ORTHOSIS, AXILLA SLING
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD, FLOATING
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR BOLSTER PAD
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR OR LUMBAR RIB PAD
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, STERNAL PAD
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, THORACIC PAD
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, TRAPEZIUS SLING
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGER
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGER, BILATERAL WITH VERTICAL
EXTENSIONS
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR SLING
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RING FLANGE, PLASTIC OR LEATHER
ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RING FLANGE, PLASTIC OR LEATHER,
MOLDED TO PATIENT MODEL
ADDITION TO CTLSO, SCOLIOSIS ORTHOSIS, COVER FOR UPRIGHT, EACH
THORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO), INCLUSIVE OF FURNISHING INITIAL
ORTHOSIS ONLY
ADDITION TO TLSO, (LOW PROFILE), LATERAL THORACIC EXTENSION
ADDITION TO TLSO, (LOW PROFILE), ANTERIOR THORACIC EXTENSION
ADDITION TO TLSO, (LOW PROFILE), MILWAUKEE TYPE SUPERSTRUCTURE
ADDITION TO TLSO, (LOW PROFILE), LUMBAR DEROTATION PAD
ADDITION TO TLSO, (LOW PROFILE), ANTERIOR ASIS PAD
ADDITION TO TLSO, (LOW PROFILE), ANTERIOR THORACIC DEROTATION PAD
ADDITION TO TLSO, (LOW PROFILE), ABDOMINAL PAD
ADDITION TO TLSO, (LOW PROFILE), RIB GUSSET (ELASTIC), EACH
ADDITION TO TLSO, (LOW PROFILE), LATERAL TROCHANTERIC PAD
OTHER SCOLIOSIS PROCEDURE, BODY JACKET MOLDED TO PATIENT MODEL
OTHER SCOLIOSIS PROCEDURE, POST-OPERATIVE BODY JACKET
SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED
THORACIC-HIP-KNEE-ANKLE ORTHOSIS (THKAO), MOBILITY FRAME (NEWINGTON, PARAPODIUM
TYPES)
THKAO, STANDING FRAME, WITH OR WITHOUT TRAY AND ACCESSORIES
THKAO, SWIVEL WALKER
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, FREJKA TYPE WITH
COVER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (FREJKA COVER ONLY),
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (PAVLIK HARNESS),
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, SEMI-FLEXIBLE (VON ROSEN TYPE),
CUSTOM-FABRICATED
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, PELVIC BAND OR SPREADER
BAR, THIGH CUFFS, CUSTOM-FABRICATED
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, ADJUSTABLE, (ILFLED
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TYPE), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
HIP ORTHOSIS, BILATERAL THIGH CUFFS WITH ADJUSTABLE ABDUCTOR SPREADER BAR,
ADULT SIZE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT, ANY TYPE
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, PLASTIC, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, DYNAMIC, PELVIC CONTROL,
ADJUSTABLE HIP MOTION CONTROL, THIGH CUFFS (RANCHO HIP ACTION TYPE), CUSTOM
FABRICATED
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTION TYPE,
CUSTOM FABRICATED
HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTION TYPE,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
COMBINATION, BILATERAL, LUMBO-SACRAL, HIP, FEMUR ORTHOSIS PROVIDING ADDUCTION
AND INTERNAL ROTATION CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
LEGG PERTHES ORTHOSIS, (TORONTO TYPE), CUSTOM-FABRICATED
LEGG PERTHES ORTHOSIS, (NEWINGTON TYPE), CUSTOM FABRICATED
LEGG PERTHES ORTHOSIS, TRILATERAL, (TACHDIJAN TYPE), CUSTOM-FABRICATED
LEGG PERTHES ORTHOSIS, (SCOTTISH RITE TYPE), CUSTOM-FABRICATED
LEGG PERTHES ORTHOSIS, (PATTEN BOTTOM TYPE), CUSTOM-FABRICATED
KNEE ORTHOSIS, ELASTIC WITH STAYS, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
KNEE ORTHOSIS, ELASTIC WITH JOINTS, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
KNEE ORTHOSIS, ELASTIC OR OTHER ELASTIC TYPE MATERIAL WITH CONDYLAR PAD(S),
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR
CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
KNEE ORTHOSIS, ELASTIC KNEE CAP, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
KNEE ORTHOSIS, IMMOBILIZER, CANVAS LONGITUDINAL, PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
KNEE ORTHOSIS, LOCKING KNEE JOINT(S), POSITIONAL ORTHOSIS, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC), POSITIONAL
ORTHOSIS, RIGID SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
KNEE ORTHOSIS, WITHOUT KNEE JOINT, RIGID, CUSTOM-FABRICATED
KNEE ORTHOSIS, RIGID, WITHOUT JOINT(S), INCLUDES SOFT INTERFACE MATERIAL,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
KNEE ORTHOSIS, DEROTATION, MEDIAL-LATERAL, ANTERIOR CRUCIATE LIGAMENT, CUSTOM
FABRICATED
KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND
EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION
CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND
EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION
CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATED
KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND
EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION
CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND
EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION
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CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATED
KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUSTABLE JOINT, WITH INFLATABLE AIR
SUPPORT CHAMBER(S), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
KNEE ORTHOSIS, SWEDISH TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
KNEE ORTHOSIS, MOLDED PLASTIC, THIGH AND CALF SECTIONS, WITH DOUBLE UPRIGHT
KNEE JOINTS, CUSTOM-FABRICATED
KNEE ORTHOSIS, MOLDED PLASTIC, POLYCENTRIC KNEE JOINTS, PNEUMATIC KNEE PADS
(CTI), CUSTOM-FABRICATED
KNEE ORTHOSIS, MODIFICATION OF SUPRACONDYLAR PROSTHETIC SOCKET,
CUSTOM-FABRICATED (SK)
KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF LACERS WITH KNEE JOINTS,
CUSTOM-FABRICATED
KNEE ORTHOSIS, DOUBLE UPRIGHT, NON-MOLDED THIGH AND CALF CUFFS/LACERS WITH KNEE
JOINTS, CUSTOM-FABRICATED
ANKLE FOOT ORTHOSIS, SPRING WIRE, DORSIFLEXION ASSIST CALF BAND,
CUSTOM-FABRICATED
ANKLE ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G.
NEOPRENE, LYCRA)
ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
ANKLE FOOT ORTHOSIS, MOLDED ANKLE GAUNTLET, CUSTOM-FABRICATED
ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
AFO, SUPRAMALLEOLAR WITH STRAPS, WITH OR WITHOUT INTERFACE/PADS, CUSTOM
FABRICATED
ANKLE FOOT ORTHOSIS, POSTERIOR, SINGLE BAR, CLASP ATTACHMENT TO SHOE COUNTER,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH STATIC OR ADJUSTABLE STOP (PHELPS OR
PERLSTEIN TYPE), CUSTOM-FABRICATED
ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING
AND ADJUSTMENT
AFO, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, CUSTOM-FABRICATED
ANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTERIOR TIBIAL SECTION (FLOOR REACTION),
CUSTOM-FABRICATED
ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE),
PLASTIC, CUSTOM-FABRICATED
ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE),
PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM-FABRICATED
ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOM-FABRICATED
ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP,
CALF BAND/CUFF (SINGLE BAR 'BK' ORTHOSIS), CUSTOM-FABRICATED
ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP,
CALF BAND/CUFF (DOUBLE BAR 'BK' ORTHOSIS), CUSTOM-FABRICATED
KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE KNEE, FREE ANKLE, SOLID STIRRUP,
THIGH AND CALF BANDS/CUFFS (SINGLE BAR 'AK' ORTHOSIS), CUSTOM-FABRICATED
KNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, SINGLE OR DOUBLE UPRIGHT, STANCE
CONTROL, AUTOMATIC LOCK AND SWING PHASE RELEASE, MECHANICAL ACTIVATION,
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INCLUDES ANKLE JOINT, ANY TYPE, CUSTOM FABRICATED
KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND
CALF BANDS/CUFFS (SINGLE BAR 'AK' ORTHOSIS), WITHOUT KNEE JOINT,
CUSTOM-FABRICATED
KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND
CALF BANDS/CUFFS (DOUBLE BAR 'AK' ORTHOSIS), CUSTOM-FABRICATED
KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND
CALF BANDS/CUFFS, (DOUBLE BAR 'AK' ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM
FABRICATED
KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE
MOTION KNEE, MEDIAL LATERAL ROTATION CONTROL, WITH OR WITHOUT FREE MOTION
ANKLE, CUSTOM FABRICATED
KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, STATIC (PEDIATRIC SIZE), WITHOUT FREE
MOTION ANKLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, DOUBLE UPRIGHT, WITH OR WITHOUT FREE
MOTION KNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED
KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE
MOTION KNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED
KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, WITH OR WITHOUT FREE MOTION KNEE,
MULTI-AXIS ANKLE, CUSTOM FABRICATED
HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL ROTATION STRAPS,
PELVIC BAND/BELT, CUSTOM FABRICATED
HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL TORSION CABLES, HIP
JOINT, PELVIC BAND/BELT, CUSTOM-FABRICATED
HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL TORSION CABLES, BALL
BEARING HIP JOINT, PELVIC BAND/ BELT, CUSTOM-FABRICATED
HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL ROTATION STRAPS,
PELVIC BAND/BELT, CUSTOM FABRICATED
HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL TORSION CABLE, HIP
JOINT, PELVIC BAND/BELT, CUSTOM-FABRICATED
HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL TORSION CABLE, BALL
BEARING HIP JOINT, PELVIC BAND/ BELT, CUSTOM-FABRICATED
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS,
THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS,
CUSTOM-FABRICATED
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SOFT,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SEMI-RIGID,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, RIGID,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS,
THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED
KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS,
CUSTOM-FABRICATED
KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SOFT, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SEMI-RIGID,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, RIGID, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
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ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, PLASTIC SHOE INSERT WITH ANKLE
JOINTS
ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, DROP LOCK KNEE JOINT
ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, LIMITED MOTION KNEE JOINT
ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, ADJUSTABLE MOTION KNEE JOINT,
LERMAN TYPE
ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, QUADRILATERAL BRIM
ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, WAIST BELT
ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, HIP JOINT, PELVIC BAND, THIGH
FLANGE, AND PELVIC BELT
ADDITION TO LOWER EXTREMITY, LIMITED ANKLE MOTION, EACH JOINT
ADDITION TO LOWER EXTREMITY, DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST), EACH
JOINT
ADDITION TO LOWER EXTREMITY, DORSIFLEXION AND PLANTAR FLEXION ASSIST/RESIST,
EACH JOINT
ADDITION TO LOWER EXTREMITY, SPLIT FLAT CALIPER STIRRUPS AND PLATE ATTACHMENT
ADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOM FOR TOTAL CONTACT ANKLE
FOOT ORTHOSIS, FOR CUSTOM FABRICATED ORTHOSIS ONLY
ADDITION TO LOWER EXTREMITY, ROUND CALIPER AND PLATE ATTACHMENT
ADDITION TO LOWER EXTREMITY, FOOT PLATE, MOLDED TO PATIENT MODEL, STIRRUP
ATTACHMENT
ADDITION TO LOWER EXTREMITY, REINFORCED SOLID STIRRUP (SCOTT-CRAIG TYPE)
ADDITION TO LOWER EXTREMITY, LONG TONGUE STIRRUP
ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION ('T') STRAP, PADDED/LINED
OR MALLEOLUS PAD
ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC MODIFICATION,
PADDED/LINED
ADDITION TO LOWER EXTREMITY, MOLDED INNER BOOT
ADDITION TO LOWER EXTREMITY, ABDUCTION BAR (BILATERAL HIP INVOLVEMENT),
JOINTED, ADJUSTABLE
ADDITION TO LOWER EXTREMITY, ABDUCTION BAR-STRAIGHT
ADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED ORTHOSIS
ONLY
ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM
FABRICATED ORTHOSIS ONLY
ADDITION TO LOWER EXTREMITY, ANTERIOR SWING BAND
ADDITION TO LOWER EXTREMITY, PRE-TIBIAL SHELL, MOLDED TO PATIENT MODEL
ADDITION TO LOWER EXTREMITY, PROSTHETIC TYPE, (BK) SOCKET, MOLDED TO PATIENT
MODEL, (USED FOR 'PTB' 'AFO' ORTHOSES)
ADDITION TO LOWER EXTREMITY, EXTENDED STEEL SHANK
ADDITION TO LOWER EXTREMITY, PATTEN BOTTOM
ADDITION TO LOWER EXTREMITY, TORSION CONTROL, ANKLE JOINT AND HALF SOLID
STIRRUP
ADDITION TO LOWER EXTREMITY, TORSION CONTROL, STRAIGHT KNEE JOINT, EACH JOINT
ADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT, HEAVY DUTY, EACH JOINT
ADDITION TO LOWER EXTREMITY, POLYCENTRIC KNEE JOINT, FOR CUSTOM FABRICATED KNEE
ANKLE FOOT ORTHOSIS, EACH JOINT
ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH JOINT
ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINT
ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE
ADDITION TO KNEE JOINT, DROP LOCK, EACH
ADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM ( BAIL, CABLE, OR
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EQUAL), ANY MATERIAL, EACH JOINT
ADDITION TO KNEE JOINT, DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION, EACH
JOINT
ADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE AND PROGRESSIVE KNEE EXTENSION,
EACH JOINT
ADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RING
ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, GLUTEAL/ ISCHIAL WEIGHT
BEARING, RING
ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, MOLDED
TO PATIENT MODEL
ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM,
CUSTOM FITTED
ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW
M-L BRIM MOLDED TO PATIENT MODEL
ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW
M-L BRIM, CUSTOM FITTED
ADDITION TO LOWER EXTREMITY, THIGH-WEIGHT BEARING, LACER, NON-MOLDED
ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, LACER, MOLDED TO PATIENT
MODEL
ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, HIGH ROLL CUFF
ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS TYPE TWO
POSITION JOINT, EACH
ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, PELVIC SLING
ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS TYPE, OR THRUST
BEARING, FREE, EACH
ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS OR THRUST
BEARING, LOCK, EACH
ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, HEAVY DUTY, EACH
ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, ADJUSTABLE FLEXION, EACH
ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, ADJUSTABLE FLEXION,
EXTENSION, ABDUCTION CONTROL, EACH
ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, PLASTIC, MOLDED TO PATIENT MODEL,
RECIPROCATING HIP JOINT AND CABLES
ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, METAL FRAME, RECIPROCATING HIP
JOINT AND CABLES
ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, BAND AND BELT, UNILATERAL
ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, BAND AND BELT, BILATERAL
ADDITION TO LOWER EXTREMITY, PELVIC AND THORACIC CONTROL, GLUTEAL PAD, EACH
ADDITION TO LOWER EXTREMITY, THORACIC CONTROL, THORACIC BAND
ADDITION TO LOWER EXTREMITY, THORACIC CONTROL, PARASPINAL UPRIGHTS
ADDITION TO LOWER EXTREMITY, THORACIC CONTROL, LATERAL SUPPORT UPRIGHTS
ADDITION TO LOWER EXTREMITY ORTHOSIS, PLATING CHROME OR NICKEL, PER BAR
ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL
HYBRID LAMINATION/PREPREG COMPOSITE, PER SEGMENT, FOR CUSTOM FABRICATED
ORTHOSIS ONLY
ADDITION TO LOWER EXTREMITY ORTHOSIS, EXTENSION, PER EXTENSION, PER BAR (FOR
LINEAL ADJUSTMENT FOR GROWTH)
ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER BAR
ADDITION TO LOWER EXTREMITY ORTHOSIS, ANY MATERIAL - PER BAR OR JOINT
ADDITION TO LOWER EXTREMITY ORTHOSIS, NON-CORROSIVE FINISH, PER BAR
ADDITION TO LOWER EXTREMITY ORTHOSIS, DROP LOCK RETAINER, EACH
ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, FULL KNEECAP
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ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, KNEE CAP, MEDIAL OR LATERAL
PULL, FOR USE WITH CUSTOM FABRICATED ORTHOSIS ONLY
ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, CONDYLAR PAD
ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, BELOW
KNEE SECTION
ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, ABOVE
KNEE SECTION
ADDITION TO LOWER EXTREMITY ORTHOSIS, TIBIAL LENGTH SOCK, FRACTURE OR EQUAL,
EACH
ADDITION TO LOWER EXTREMITY ORTHOSIS, FEMORAL LENGTH SOCK, FRACTURE OR EQUAL,
EACH
ADDITION TO LOWER EXTREMITY JOINT, KNEE OR ANKLE, CONCENTRIC ADJUSTABLE TORSION
STYLE MECHANISM, EACH
ADDITION TO LOWER EXTREMITY JOINT, KNEE OR ANKLE, CONCENTRIC ADJUSTABLE TORSION
STYLE MECHANISM FOR CUSTOM FABRICATED ORTHOTICS ONLY, EACH
LOWER EXTREMITY ORTHOSES, NOT OTHERWISE SPECIFIED
FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, 'UCB' TYPE, BERKELEY SHELL,
EACH
FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SPENCO, EACH
FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, PLASTAZOTE OR EQUAL, EACH
FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SILICONE GEL, EACH
FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL ARCH SUPPORT,
EACH
FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL/ METATARSAL
SUPPORT, EACH
FOOT, INSERT, REMOVABLE, FORMED TO PATIENT FOOT, EACH
FOOT, INSERT/PLATE, REMOVABLE, ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH
STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, EACH
FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL, EACH
FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, METATARSAL, EACH
FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL/ METATARSAL, EACH
FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL, EACH
FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, METATARSAL, EACH
FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL/METATARSAL,
EACH
HALLUS-VALGUS NIGHT DYNAMIC SPLINT
FOOT, ABDUCTION ROTATION BAR, INCLUDING SHOES
FOOT, ABDUCTION ROTATATION BAR, WITHOUT SHOES
FOOT, ADJUSTABLE SHOE-STYLED POSITIONING DEVICE
FOOT, PLASTIC, SILICONE OR EQUAL, HEEL STABILIZER, EACH
ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, INFANT
ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, CHILD
ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, JUNIOR
ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, INFANT
ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, CHILD
ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, JUNIOR
SURGICAL BOOT, EACH, INFANT
SURGICAL BOOT, EACH, CHILD
SURGICAL BOOT, EACH, JUNIOR
BENESCH BOOT, PAIR, INFANT
BENESCH BOOT, PAIR, CHILD
BENESCH BOOT, PAIR, JUNIOR
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ORTHOPEDIC FOOTWEAR, LADIES SHOE, OXFORD, EACH
ORTHOPEDIC FOOTWEAR, LADIES SHOE, DEPTH INLAY, EACH
ORTHOPEDIC FOOTWEAR, LADIES SHOE, HIGHTOP, DEPTH INLAY, EACH
ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, EACH
ORTHOPEDIC FOOTWEAR, MENS SHOE, DEPTH INLAY, EACH
ORTHOPEDIC FOOTWEAR, MENS SHOE, HIGHTOP, DEPTH INLAY, EACH
ORTHOPEDIC FOOTWEAR, WOMAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE
(ORTHOSIS)
ORTHOPEDIC FOOTWEAR, MAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE
(ORTHOSIS)
ORTHOPEDIC FOOTWEAR, CUSTOM SHOE, DEPTH INLAY, EACH
ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED SHOE, REMOVABLE INNER MOLD, PROSTHETIC SHOE,
EACH
FOOT, SHOE MOLDED TO PATIENT MODEL, SILICONE SHOE, EACH
FOOT, SHOE MOLDED TO PATIENT MODEL, PLASTAZOTE (OR SIMILAR), CUSTOM FABRICATED,
EACH
FOOT, MOLDED SHOE PLASTAZOTE (OR SIMILAR) CUSTOM FITTED, EACH
NON-STANDARD SIZE OR WIDTH
NON-STANDARD SIZE OR LENGTH
ORTHOPEDIC FOOTWEAR, ADDITIONAL CHARGE FOR SPLIT SIZE
SURGICAL BOOT/SHOE, EACH
PLASTAZOTE SANDAL, EACH
LIFT, ELEVATION, HEEL, TAPERED TO METATARSALS, PER INCH
LIFT, ELEVATION, HEEL AND SOLE, NEOPRENE, PER INCH
LIFT, ELEVATION, HEEL AND SOLE, CORK, PER INCH
LIFT, ELEVATION, METAL EXTENSION (SKATE)
LIFT, ELEVATION, INSIDE SHOE, TAPERED, UP TO ONE-HALF INCH
LIFT, ELEVATION, HEEL, PER INCH
HEEL WEDGE, SACH
HEEL WEDGE
SOLE WEDGE, OUTSIDE SOLE
SOLE WEDGE, BETWEEN SOLE
CLUBFOOT WEDGE
OUTFLARE WEDGE
METATARSAL BAR WEDGE, ROCKER
METATARSAL BAR WEDGE, BETWEEN SOLE
FULL SOLE AND HEEL WEDGE, BETWEEN SOLE
HEEL, COUNTER, PLASTIC REINFORCED
HEEL, COUNTER, LEATHER REINFORCED
HEEL, SACH CUSHION TYPE
HEEL, NEW LEATHER, STANDARD
HEEL, NEW RUBBER, STANDARD
HEEL, THOMAS WITH WEDGE
HEEL, THOMAS EXTENDED TO BALL
HEEL, PAD AND DEPRESSION FOR SPUR
HEEL, PAD, REMOVABLE FOR SPUR
ORTHOPEDIC SHOE ADDITION, INSOLE, LEATHER
ORTHOPEDIC SHOE ADDITION, INSOLE, RUBBER
ORTHOPEDIC SHOE ADDITION, INSOLE, FELT COVERED WITH LEATHER
ORTHOPEDIC SHOE ADDITION, SOLE, HALF
ORTHOPEDIC SHOE ADDITION, SOLE, FULL
ORTHOPEDIC SHOE ADDITION, TOE TAP STANDARD
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ORTHOPEDIC SHOE ADDITION, TOE TAP, HORSESHOE
ORTHOPEDIC SHOE ADDITION, SPECIAL EXTENSION TO INSTEP (LEATHER WITH EYELETS)
ORTHOPEDIC SHOE ADDITION, CONVERT INSTEP TO VELCRO CLOSURE
ORTHOPEDIC SHOE ADDITION, CONVERT FIRM SHOE COUNTER TO SOFT COUNTER
ORTHOPEDIC SHOE ADDITION, MARCH BAR
TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, EXISTING
TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, NEW
TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, EXISTING
TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, NEW
TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, DENNIS BROWNE SPLINT
(RIVETON), BOTH SHOES
ORTHOPEDIC SHOE, MODIFICATION, ADDITION OR TRANSFER, NOT OTHERWISE SPECIFIED
SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
SHOULDER ORTHOSIS, SINGLE SHOULDER, ELASTIC, PREFABRICATED, INCLUDES FITTING
AND ADJUSTMENT (E.G. NEOPRENE, LYCRA)
SHOULDER ORTHOSIS, DOUBLE SHOULDER, ELASTIC, PREFABRICATED, INCLUDES FITTING
AND ADJUSTMENT (E.G. NEOPRENE, LYCRA)
SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, CANVAS AND
WEBBING, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ORTHOSIS, ACROMIO/CLAVICULAR (CANVAS AND WEBBING TYPE), PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT
INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT
AND SUPPORT BAR, WITHOUT JOINTS, MAY INLCUDE SOFT INTERFACE, STRAPS, CUSTOM
FABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT
AND SUPPORT BAR, INCLUDES NONTORSION JOINT/TURNBUCKLE, MAY INCLUDE SOFT
INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT
AND SUPPORT BAR, WITH OR WITHOUT NONTORSION JOINT/TURNBUCKLE, MAY INCLUDE SOFT
INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ORTHOSIS, VEST TYPE ABDUCTION RESTRAINER, CANVAS WEBBING TYPE OR
EQUAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT
INTERFACE, STRAPS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
ELBOW ORTHOSIS, ELASTIC WITH STAYS, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
ELBOW ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G.
NEOPRENE, LYCRA)
ELBOW ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM
FABRICATED, INCLUDES FITTING AND ADJUSTMENT
ELBOW ORTHOSIS, ELASTIC WITH METAL JOINTS, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, FREE MOTION,
CUSTOM-FABRICATED
ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, EXTENSION/ FLEXION
ASSIST, CUSTOM-FABRICATED
ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, ADJUSTABLE POSITION LOCK
WITH ACTIVE CONTROL, CUSTOM-FABRICATED
ELBOW ORTHOSIS, WITH ADJUSTABLE POSITION LOCKING JOINT(S), PREFABRICATED,
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INCLUDES FITTING AND ADJUSTMENTS, ANY TYPE
ELBOW ORTHOSIS, RIGID, WITHOUT JOINTS, INCLUDES SOFT INTERFACE MATERIAL,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
ELBOW WRIST HAND ORTHOSIS, RIGID, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE,
STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
ELBOW WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC
BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED,
INCLUDES FITTING AND ADJUSTMENT
ELBOW WRIST HAND FINGER ORTHOSIS, RIGID, WITHOUT JOINTS, MAY INCLUDE SOFT
INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
ELBOW WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS,
ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM
FABRICATED, INCLUDES FITTING AND ADJUSTMENT
WRIST HAND FINGER ORTHOSIS, SHORT OPPONENS, NO ATTACHMENTS, CUSTOM-FABRICATED
WRIST HAND FINGER ORTHOSIS, LONG OPPONENS, NO ATTACHMENT, CUSTOM-FABRICATED
WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S),
TURNBUCKLES, ELASTIC BANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL,
STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
WRIST HAND FINGER ORTHOSIS, WITHOUT JOINT(S), PREFABRICATED, INCLUDES FITTING
AND ADJUSTMENTS, ANY TYPE
WRIST HAND FINGER ORTHOSIS, RIGID WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE
MATERIAL; STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
WHFO, ADDITION TO SHORT AND LONG OPPONENS, THUMB ABDUCTION ('C') BAR
WHFO, ADDITION TO SHORT AND LONG OPPONENS, SECOND M.P. ABDUCTION ASSIST
WHFO, ADDITION TO SHORT AND LONG OPPONENS, I.P. EXTENSION ASSIST, WITH M.P.
EXTENSION STOP
WHFO, ADDITION TO SHORT AND LONG OPPONENS, M.P. EXTENSION STOP
WHFO, ADDITION TO SHORT AND LONG OPPONENS, M.P. EXTENSION ASSIST
WHFO, ADDITION TO SHORT AND LONG OPPONENS, M.P. SPRING EXTENSION ASSIST
WHFO, ADDITION TO SHORT AND LONG OPPONENS, SPRING SWIVEL THUMB
WHFO, ADDITION TO SHORT AND LONG OPPONENS, THUMB I.P. EXTENSION ASSIST, WITH
M.P. STOP
WHO, ADDITION TO SHORT AND LONG OPPONENS, ACTION WRIST, WITH DORSIFLEXION ASSIST
WHFO, ADDITION TO SHORT AND LONG OPPONENS, ADJUSTABLE M.P. FLEXION CONTROL
WHFO, ADDITION TO SHORT AND LONG OPPONENS, ADJUSTABLE M.P. FLEXION CONTROL AND
I.P.
ADDITION TO UPPER EXTREMITY JOINT, WRIST OR ELBOW, CONCENTRIC ADJUSTABLE
TORSION STYLE MECHANISM, EACH
ADDITION TO UPPER EXTREMITY JOINT, WRIST OR ELBOW, CONCENTRIC ADJUSTABLE
TORSION STYLE MECHANISM FOR CUSTOM FABRICATED ORTHOTICS ONLY, EACH
WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/
FLEXION, FINGER FLEXION/EXTENSION, WRIST OR FINGER DRIVEN, CUSTOM-FABRICATED
WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/
FLEXION, FINGER FLEXION/EXTENSION, CABLE DRIVEN, CUSTOM-FABRICATED
WRIST HAND FINGER ORTHOSIS, EXTERNAL POWERED, ELECTRIC, CUSTOM-FABRICATED
WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS,
TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES
FITTING AND ADJUSTMENT
WRIST HAND ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM
FABRICATED, INCLUDES FITTING AND ADJUSTMENT
WRIST HAND FINGER ORTHOSIS, WRIST GAUNTLET WITH THUMB SPICA, CUSTOM-FABRICATED
WRIST HAND ORTHOSIS, WRIST EXTENSION CONTROL COCK-UP, NON MOLDED,
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PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
WRIST ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G.
NEOPRENE, LYCRA)
WRIST HAND FINGER ORTHOSIS, SWANSON DESIGN, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
WRIST HAND FINGER ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT (E.G. NEOPRENE, LYCRA)
HAND FINGER ORTHOSIS, FLEXION GLOVE WITH ELASTIC FINGER CONTROL, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
HAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS,
CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), ELASTIC BANDS,
TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
WRIST HAND FINGER ORTHOSIS, WRIST EXTENSION COCK-UP WITH OUTRIGGER,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
HAND ORTHOSIS, METACARPAL FRACTURE ORTHOSIS, PREFABRICATED, INCLUDES FITTING
AND ADJUSTMENT
HAND FINGER ORTHOSIS, KNUCKLE BENDER, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
HAND ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM
FABRICATED, INCLUDES FITTING AND ADJUSTMENT
HAND FINGER ORTHOSIS, KNUCKLE BENDER WITH OUTRIGGER, PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS,
TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES
FITTING AND ADJUSTMENT
HAND FINGER ORTHOSIS, KNUCKLE BENDER, TWO SEGMENT TO FLEX JOINTS,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
HAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
WRIST HAND FINGER ORTHOSIS, OPPENHEIMER, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
FINGER ORTHOSIS, PROXIMAL INTERPHALANGEAL (PIP)/DISTAL INTERPHALANGEAL (DIP),
NON TORSION JOINT/SPRING, EXTENSION/FLEXION, MAY INCLUDE SOFT INTERFACE
MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
WRIST HAND FINGER ORTHOSIS, THOMAS SUSPENSION, PREFABRICATED, INCLUDES FITTING
AND ADJUSTMENT
FINGER ORTHOSIS, PROXIMAL INTERPHALANGEAL (PIP)/DISTAL INTERPHALANGEAL (DIP),
WITHOUT JOINT/SPRING, EXTENSION/FLEXION (E.G. STATIC OR RING TYPE), MAY INCLUDE
SOFT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
HAND FINGER ORTHOSIS, FINGER EXTENSION, WITH CLOCK SPRING, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES,
ELASTIC BANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL, STRAPS,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
WRIST HAND FINGER ORTHOSIS, FINGER EXTENSION, WITH WRIST SUPPORT,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S),
TURNBUCKLES, ELASTIC BANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL,
STRAPS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
FINGER ORTHOSIS, SAFETY PIN, SPRING WIRE, PREFABRICATED, INCLUDES FITTING AND
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ADJUSTMENT
FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, CUSTOM FABRICATED,
INCLUDES FITTING AND ADJUSTMENT
FINGER ORTHOSIS, SAFETY PIN, MODIFIED, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
FINGER ORTHOSIS, NONTORSION JOINT, MAY INCLUDE SOFT INTERFACE, CUSTOM
FABRICATED, INCLUDES FITTING AND ADJUSTMENT
WRIST HAND FINGER ORTHOSIS, PALMER, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
WRIST HAND FINGER ORTHOSIS, DORSAL WRIST, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
WRIST HAND FINGER ORTHOSIS, DORSAL WRIST, WITH OUTRIGGER ATTACHMENT,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
HAND FINGER ORTHOSIS, REVERSE KNUCKLE BENDER, PREFABRICATED, INCLUDES FITTING
AND ADJUSTMENT
HAND FINGER ORTHOSIS, REVERSE KNUCKLE BENDER, WITH OUTRIGGER, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
HAND FINGER ORTHOSIS, COMPOSITE ELASTIC, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
FINGER ORTHOSIS, FINGER KNUCKLE BENDER, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
WRIST HAND FINGER ORTHOSIS, COMBINATION OPPENHEIMER, WITH KNUCKLE BENDER AND
TWO ATTACHMENTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
WRIST HAND FINGER ORTHOSIS, COMBINATION OPPENHEIMER, WITH REVERSE KNUCKLE AND
TWO ATTACHMENTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
HAND FINGER ORTHOSIS, SPREADING HAND, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
ADDITION OF JOINT TO UPPER EXTREMITY ORTHOSIS, ANY MATERIAL; PER JOINT
SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, AIRPLANE DESIGN,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY
INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND
ADJUSTMENT
SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, ERBS PALSEY DESIGN,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED,
ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED,
ADJUSTABLE RANCHO TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED,
RECLINING, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN),
THORACIC COMPONENT AND SUPPORT BAR, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE,
STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED,
FRICTION ARM SUPPORT (FRICTION DAMPENING TO PROXIMAL AND DISTAL JOINTS),
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT, MONOSUSPENSION ARM AND HAND
SUPPORT, OVERHEAD ELBOW FOREARM HAND SLING SUPPORT, YOKE TYPE SUSPENSION
SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
SEO, ADDITION TO MOBILE ARM SUPPORT, ELEVATING PROXIMAL ARM
SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR MORE
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NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE,
STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
SEO, ADDITION TO MOBILE ARM SUPPORT, OFFSET OR LATERAL ROCKER ARM WITH ELASTIC
BALANCE CONTROL
SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN),
THORACIC COMPONENT AND SUPPORT BAR, INCLUDES ONE OR MORE NONTORSION JOINTS,
ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM
FABRICATED, INCLUDES FITTING AND ADJUSTMENT
SEO, ADDITION TO MOBILE ARM SUPPORT, SUPINATOR
SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS,
MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND
ADJUSTMENT
SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE
DESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITHOUT JOINTS, MAY INCLUDE SOFT
INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR
MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE,
STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE
DESIGN), THORACIC COMPONENT AND SUPPORT BAR, INCLUDES ONE OR MORE NONTORSION
JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM
FABRICATED, INCLUDES FITTING AND ADJUSTMENT
UPPER EXTREMITY FRACTURE ORTHOSIS, HUMERAL, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
UPPER EXTREMITY FRACTURE ORTHOSIS, RADIUS/ULNAR, PREFABRICATED, INCLUDES
FITTING AND ADJUSTMENT
UPPER EXTREMITY FRACTURE ORTHOSIS, WRIST, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
UPPER EXTREMITY FRACTURE ORTHOSIS, FOREARM, HAND WITH WRIST HINGE,
CUSTOM-FABRICATED
UPPER EXTREMITY FRACTURE ORTHOSIS, COMBINATION OF HUMERAL, RADIUS/ULNAR, WRIST,
(EXAMPLE--COLLES' FRACTURE), CUSTOM FABRICATED
ADDITION TO UPPER EXTREMITY ORTHOSIS, SOCK, FRACTURE OR EQUAL, EACH
UPPER LIMB ORTHOSIS, NOT OTHERWISE SPECIFIED
REPLACE GIRDLE FOR SPINAL ORTHOSIS (CTLSO OR SO)
REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH, ANY TYPE
REPLACE TRILATERAL SOCKET BRIM
REPLACE QUADRILATERAL SOCKET BRIM, MOLDED TO PATIENT MODEL
REPLACE QUADRILATERAL SOCKET BRIM, CUSTOM FITTED
REPLACE MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY
REPLACE NON-MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY
REPLACE MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY
REPLACE NON-MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY
REPLACE HIGH ROLL CUFF
REPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFO
REPLACE METAL BANDS KAFO, PROXIMAL THIGH
REPLACE METAL BANDS KAFO-AFO, CALF OR DISTAL THIGH
REPLACE LEATHER CUFF KAFO, PROXIMAL THIGH
REPLACE LEATHER CUFF KAFO-AFO, CALF OR DISTAL THIGH
REPLACE PRETIBIAL SHELL
REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTES
REPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINOR PARTS
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ANKLE CONTROL ORTHOSIS, STIRRUP STYLE, RIGID, INCLUDES ANY TYPE INTERFACE
(E.G., PNEUMATIC, GEL), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT
INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
PNEUMATIC FULL LEG SPLINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
PNEUMATIC KNEE SPLINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE
MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
REPLACEMENT, SOFT INTERFACE MATERIAL, STATIC AFO
REPLACE SOFT INTERFACE MATERIAL, FOOT DROP SPLINT
STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL,
ADJUSTABLE FOR FIT, FOR POSITIONING, MAY BE USED FOR MINIMAL AMBULATION,
PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
FOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE, PREFABRICATED, INCLUDES FITTING
AND ADJUSTMENT
ANKLE FOOT ORTHOSIS, WALKING BOOT TYPE, VARUS/VALGUS CORRECTION, ROCKER BOTTOM,
ANTERIOR TIBIAL SHELL, SOFT INTERFACE, CUSTOM ARCH SUPPORT, PLASTIC OR OTHER
MATERIAL, INCLUDES STRAPS AND CLOSURES, CUSTOM FABRICATED
PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARCH, TOE FILLER
PARTIAL FOOT, MOLDED SOCKET, ANKLE HEIGHT, WITH TOE FILLER
PARTIAL FOOT, MOLDED SOCKET, TIBIAL TUBERCLE HEIGHT, WITH TOE FILLER
ANKLE, SYMES, MOLDED SOCKET, SACH FOOT
ANKLE, SYMES, METAL FRAME, MOLDED LEATHER SOCKET, ARTICULATED ANKLE/FOOT
BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT
BELOW KNEE, PLASTIC SOCKET, JOINTS AND THIGH LACER, SACH FOOT
KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, EXTERNAL KNEE JOINTS,
SHIN, SACH FOOT
KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, BENT KNEE CONFIGURATION,
EXTERNAL KNEE JOINTS, SHIN, SACH FOOT
ABOVE KNEE, MOLDED SOCKET, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT
ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT ('STUBBIES'), WITH FOOT BLOCKS, NO
ANKLE JOINTS, EACH
ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT ('STUBBIES'), WITH ARTICULATED
ANKLE/FOOT, DYNAMICALLY ALIGNED, EACH
ABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL DEFICIENCY, CONSTANT FRICTION KNEE,
SHIN, SACH FOOT
HIP DISARTICULATION, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE AXIS
CONSTANT FRICTION KNEE, SHIN, SACH FOOT
HIP DISARTICULATION, TILT TABLE TYPE; MOLDED SOCKET, LOCKING HIP JOINT, SINGLE
AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT
HEMIPELVECTOMY, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE AXIS CONSTANT
FRICTION KNEE, SHIN, SACH FOOT
BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT, ENDOSKELETAL SYSTEM
KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, EXTERNAL KNEE JOINTS,
SHIN, SACH FOOT, ENDOSKELETAL SYSTEM
ABOVE KNEE, MOLDED SOCKET, OPEN END, SACH FOOT, ENDOSKELETAL SYSTEM, SINGLE
AXIS KNEE
HIP DISARTICULATION, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP
JOINT, SINGLE AXIS KNEE, SACH FOOT
HEMIPELVECTOMY, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT,
SINGLE AXIS KNEE, SACH FOOT
IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID
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DRESSING, INCLUDING FITTING, ALIGNMENT, SUSPENSION, AND ONE CAST CHANGE, BELOW
KNEE
IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID
DRESSING, INCLUDING FITTING, ALIGNMENT AND SUSPENSION, BELOW KNEE, EACH
ADDITIONAL CAST CHANGE AND REALIGNMENT
IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID
DRESSING, INCLUDING FITTING, ALIGNMENT AND SUSPENSION AND ONE CAST CHANGE 'AK'
OR KNEE DISARTICULATION
IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID
DRESSING, INCL. FITTING, ALIGNMENT AND SUPENSION, 'AK' OR KNEE DISARTICULATION,
EACH ADDITIONAL CAST CHANGE AND REALIGNMENT
IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF NON-WEIGHT BEARING
RIGID DRESSING, BELOW KNEE
IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF NON-WEIGHT BEARING
RIGID DRESSING, ABOVE KNEE
INITIAL, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER,
SACH FOOT, PLASTER SOCKET, DIRECT FORMED
INITIAL, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE
SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, DIRECT FORMED
PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO
COVER, SACH FOOT, PLASTER SOCKET, MOLDED TO MODEL
PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO
COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, DIRECT FORMED
PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO
COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO MODEL
PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, NO COVER, SACH
FOOT, PREFABRICATED, ADJUSTABLE OPEN END SOCKET
PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO
COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL
PREPARATORY, ABOVE KNEE- KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET,
NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, MOLDED TO
MODEL
PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET,
NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL,
DIRECT FORMED
PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION ISCHIAL LEVEL SOCKET,
NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL,
MOLDED TO MODEL
PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET,
NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PREFABRICATED ADJUSTABLE OPEN
END SOCKET
PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION ISCHIAL LEVEL SOCKET,
NON-ALIGNABLE SYSTEM, PYLON NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO
MODEL
PREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT,
THERMOPLASTIC OR EQUAL, MOLDED TO PATIENT MODEL
PREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT,
LAMINATED SOCKET, MOLDED TO PATIENT MODEL
ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE, HYDRACADENCE
SYSTEM
ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE - KNEE
DISARTICULATION, 4 BAR LINKAGE, WITH FRICTION SWING PHASE CONTROL
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ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE-KNEE
DISARTICULATION, 4 BAR LINKAGE, WITH HYDRAULIC SWING PHASE CONTROL
ADDITION TO LOWER EXTREMITY, EXOSKELETAL SYSTEM, ABOVE KNEE-KNEE
DISARTICULATION, 4 BAR LINKAGE, WITH PNEUMATIC SWING PHASE CONTROL
ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE, UNIVERSAL
MULTIPLEX SYSTEM, FRICTION SWING PHASE CONTROL
ADDITION TO LOWER EXTREMITY, QUICK CHANGE SELF-ALIGNING UNIT, ABOVE KNEE OR
BELOW KNEE, EACH
ADDITION TO LOWER EXTREMITY, TEST SOCKET, SYMES
ADDITION TO LOWER EXTREMITY, TEST SOCKET, BELOW KNEE
ADDITION TO LOWER EXTREMITY, TEST SOCKET, KNEE DISARTICULATION
ADDITION TO LOWER EXTREMITY, TEST SOCKET, ABOVE KNEE
ADDITION TO LOWER EXTREMITY, TEST SOCKET, HIP DISARTICULATION
ADDITION TO LOWER EXTREMITY, TEST SOCKET, HEMIPELVECTOMY
ADDITION TO LOWER EXTREMITY, BELOW KNEE, ACRYLIC SOCKET
ADDITION TO LOWER EXTREMITY, SYMES TYPE, EXPANDABLE WALL SOCKET
ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, ACRYLIC SOCKET
ADDITION TO LOWER EXTREMITY, SYMES TYPE, 'PTB' BRIM DESIGN SOCKET
ADDITION TO LOWER EXTREMITY, SYMES TYPE, POSTERIOR OPENING (CANADIAN) SOCKET
ADDITION TO LOWER EXTREMITY, SYMES TYPE, MEDIAL OPENING SOCKET
ADDITION TO LOWER EXTREMITY, BELOW KNEE, TOTAL CONTACT
ADDITION TO LOWER EXTREMITY, BELOW KNEE, LEATHER SOCKET
ADDITION TO LOWER EXTREMITY, BELOW KNEE, WOOD SOCKET
ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, LEATHER SOCKET
ADDITION TO LOWER EXTREMITY, ABOVE KNEE, LEATHER SOCKET
ADDITION TO LOWER EXTREMITY, HIP DISARTICULATION, FLEXIBLE INNER SOCKET,
EXTERNAL FRAME
ADDITION TO LOWER EXTREMITY, ABOVE KNEE, WOOD SOCKET
ADDITION TO LOWER EXTREMITY, BELOW KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAME
ADDITION TO LOWER EXTREMITY, BELOW KNEE, AIR, FLUID, GEL OR EQUAL, CUSHION
SOCKET
ADDITION TO LOWER EXTREMITY, BELOW KNEE SUCTION SOCKET
ADDITION TO LOWER EXTREMITY, ABOVE KNEE, AIR, FLUID, GEL OR EQUAL, CUSHION
SOCKET
ADDITION TO LOWER EXTREMITY, ISCHIAL CONTAINMENT/NARROW M-L SOCKET
ADDITIONS TO LOWER EXTREMITY, TOTAL CONTACT, ABOVE KNEE OR KNEE DISARTICULATION
SOCKET
ADDITION TO LOWER EXTREMITY, ABOVE KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAME
ADDITION TO LOWER EXTREMITY, SUCTION SUSPENSION, ABOVE KNEE OR KNEE
DISARTICULATION SOCKET
ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, EXPANDABLE WALL SOCKET
ADDITION TO LOWER EXTREMITY, SOCKET INSERT, SYMES, (KEMBLO, PELITE, ALIPLAST,
PLASTAZOTE OR EQUAL)
ADDITION TO LOWER EXTREMITY, SOCKET INSERT, BELOW KNEE (KEMBLO, PELITE,
ALIPLAST, PLASTAZOTE OR EQUAL)
ADDITION TO LOWER EXTREMITY, SOCKET INSERT, KNEE DISARTICULATION (KEMBLO,
PELITE, ALIPLAST, PLASTAZOTE OR EQUAL)
ADDITION TO LOWER EXTREMITY, SOCKET INSERT, ABOVE KNEE (KEMBLO, PELITE,
ALIPLAST, PLASTAZOTE OR EQUAL)
ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROMETER SYMES
ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROMETER, BELOW KNEE
ADDITION TO LOWER EXTREMITY, BELOW KNEE, CUFF SUSPENSION
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ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED DISTAL CUSHION
ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED SUPRACONDYLAR SUSPENSION
('PTS' OR SIMILAR)
ADDITION TO LOWER EXTREMITY, BELOW KNEE / ABOVE KNEE SUSPENSION LOCKING
MECHANISM (SHUTTLE, LANYARD OR EQUAL), EXCLUDES SOCKET INSERT
ADDITION TO LOWER EXTREMITY, BELOW KNEE, REMOVABLE MEDIAL BRIM SUSPENSION
ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM
EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR
EQUAL, FOR USE WITH LOCKING MECHANISM
ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, SINGLE AXIS, PAIR
ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, POLYCENTRIC, PAIR
ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, JOINT COVERS, PAIR
ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM
EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR
EQUAL, NOT FOR USE WITH LOCKING MECHANISM
ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, NONMOLDED
ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET
INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC
OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER
THAN INITIAL, USE CODE L5673 OR L5679)
ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, GLUTEAL/ISCHIAL, MOLDED
ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET
INSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL,
ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY
(FOR OTHER THAN INITIAL, USE CODE L5673 OR L5679)
ADDITION TO LOWER EXTREMITY, BELOW KNEE, FORK STRAP
ADDITION TO LOWER EXTREMITY PROSTHESIS, BELOW KNEE, SUSPENSION/SEALING SLEEVE,
WITH OR WITHOUT VALVE, ANY MATERIAL, EACH
ADDITION TO LOWER EXTREMITY, BELOW KNEE, BACK CHECK (EXTENSION CONTROL)
ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, WEBBING
ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, PADDED AND LINED
ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, LIGHT
ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, PADDED AND LINED
ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL, SLEEVE SUSPENSION,
NEOPRENE OR EQUAL, EACH
ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, PELVIC JOINT
ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, PELVIC BAND
ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, SILESIAN
BANDAGE
ALL LOWER EXTREMITY PROSTHESES, SHOULDER HARNESS
REPLACEMENT, SOCKET, BELOW KNEE, MOLDED TO PATIENT MODEL
REPLACEMENT, SOCKET, ABOVE KNEE/KNEE DISARTICULATION, INCLUDING ATTACHMENT
PLATE, MOLDED TO PATIENT MODEL
REPLACEMENT, SOCKET, HIP DISARTICULATION, INCLUDING HIP JOINT, MOLDED TO
PATIENT MODEL
ANKLE, SYMES, MOLDED TO PATIENT MODEL, SOCKET WITHOUT SOLID ANKLE CUSHION HEEL
(SACH) FOOT, REPLACEMENT ONLY
CUSTOM SHAPED PROTECTIVE COVER, BELOW KNEE
CUSTOM SHAPED PROTECTIVE COVER, ABOVE KNEE
CUSTOM SHAPED PROTECTIVE COVER, KNEE DISARTICULATION
CUSTOM SHAPED PROTECTIVE COVER, HIP DISARTICULATION
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK
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ADDITIONS EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHT
MATERIAL
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND STANCE
PHASE CONTROL (SAFETY KNEE)
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, VARIABLE FRICTION SWING
PHASE CONTROL
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE PHASE
LOCK
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING AND
STANCE PHASE CONTROL
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTION
STANCE PHASE CONTROL
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROL
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, EXTERNAL JOINTS FLUID
SWING PHASE CONTROL
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE
PHASE CONTROL
ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/HYDRA PNEUMATIC
SWING PHASE CONTROL
ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENT
AND MOISTURE EVACUATION SYSTEM
ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENT
AND MOISTURE EVACUATION SYSTEM, HEAVY DUTY
ADDITION, EXOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT MATERIAL (TITANIUM,
CARBON FIBER OR EQUAL)
ADDITION, EXOSKELETAL SYSTEM, ABOVE KNEE, ULTRA-LIGHT MATERIAL (TITANIUM,
CARBON FIBER OR EQUAL)
ADDITION, EXOSKELETAL SYSTEM, HIP DISARTICULATION, ULTRA-LIGHT MATERIAL
(TITANIUM, CARBON FIBER OR EQUAL)
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHT
MATERIAL
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND STANCE
PHASE CONTROL (SAFETY KNEE)
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, HYDRAULIC SWING PHASE
CONTROL, MECHANICAL STANCE PHASE LOCK
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE PHASE
LOCK
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING, AND
STANCE PHASE CONTROL
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTION
STANCE PHASE CONTROL
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROL
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, HYDRAULIC SWING PHASE
CONTROL, WITH MINIATURE HIGH ACTIVITY FRAME
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE
PHASE CONTROL
ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/ SWING PHASE
CONTROL
ADDITION, ENDOSKELETAL KNEE/SHIN SYSTEM, 4-BAR LINKAGE OR MULTIAXIAL, PNEUMATIC
SWING PHASE CONTROL
ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, STANCE FLEXION FEATURE, ADJUSTABLE
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ADDITION TO ENDOSKELETAL KNEE-SHIN SYSTEM, FLUID STANCE EXTENSION, DAMPENING
FEATURE, WITH OR WITHOUT ADJUSTABILITY
ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISARTICULATION, KNEE
EXTENSION ASSIST
ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, MECHANICAL HIP EXTENSION
ASSIST
ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM,
MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE, INCLUDES ELECTRONIC
SENSOR(S), ANY TYPE
ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM,
MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY, INCLUDES ELECTRONIC
SENSOR(S), ANY TYPE
ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE SHIN SYSTEM,
MICROPROCESSOR CONTROL FEATURE, STANCE PHASE ONLY, INCLUDES ELECTRONIC
SENSOR(S), ANY TYPE
ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ALIGNABLE SYSTEM
ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISARTICULATION, ALIGNABLE
SYSTEM
ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, KNEE DISARTICULATION OR HIP
DISARTICULATION, MANUAL LOCK
ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTIVITY KNEE CONTROL FRAME
ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT MATERIAL (TITANIUM,
CARBON FIBER OR EQUAL)
ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, ULTRA-LIGHT MATERIAL (TITANIUM,
CARBON FIBER OR EQUAL)
ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, ULTRA-LIGHT MATERIAL
(TITANIUM, CARBON FIBER OR EQUAL)
ADDITION, ENDOSKELETAL SYSTEM, POLYCENTRIC HIP JOINT, PNEUMATIC OR HYDRAULIC
CONTROL, ROTATION CONTROL, WITH OR WITHOUT FLEXION AND/OR EXTENSION CONTROL
ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, FLEXIBLE PROTECTIVE OUTER SURFACE
COVERING SYSTEM
ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, FLEXIBLE PROTECTIVE OUTER SURFACE
COVERING SYSTEM
ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, FLEXIBLE PROTECTIVE OUTER
SURFACE COVERING SYSTEM
ADDITION TO LOWER LIMB PROSTHESIS, MULTIAXIAL ANKLE WITH SWING PHASE ACTIVE
DORSIFLEXION FEATURE
ALL LOWER EXTREMITY PROSTHESES, FOOT, EXTERNAL KEEL, SACH FOOT
ALL LOWER EXTREMITY PROSTHESIS, SOLID ANKLE CUSHION HEEL (SACH) FOOT,
REPLACEMENT ONLY
ALL LOWER EXTREMITY PROSTHESES, FLEXIBLE KEEL FOOT (SAFE, STEN, BOCK DYNAMIC OR
EQUAL)
ENDOSKELETAL ANKLE FOOT SYSTEM, MICROPROCESSOR CONTROLLED FEATURE, DORSIFLEXION
AND/OR PLANTAR FLEXION CONTROL, INCLUDES POWER SOURCE
ALL LOWER EXTREMITY PROSTHESES, FOOT, SINGLE AXIS ANKLE/FOOT
ALL LOWER EXTREMITY PROSTHESIS, COMBINATION SINGLE AXIS ANKLE AND FLEXIBLE KEEL
FOOT
ALL LOWER EXTREMITY PROSTHESES, ENERGY STORING FOOT (SEATTLE CARBON COPY II OR
EQUAL)
ALL LOWER EXTREMITY PROSTHESES, FOOT, MULTIAXIAL ANKLE/FOOT
ALL LOWER EXTREMITY PROSTHESIS, MULTI-AXIAL ANKLE, DYNAMIC RESPONSE FOOT, ONE
PIECE SYSTEM
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ALL LOWER EXTREMITY PROSTHESES, FLEX FOOT SYSTEM
ALL LOWER EXTREMITY PROSTHESES, FLEX-WALK SYSTEM OR EQUAL
ALL EXOSKELETAL LOWER EXTREMITY PROSTHESES, AXIAL ROTATION UNIT
ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESIS, AXIAL ROTATION UNIT, WITH OR
WITHOUT ADJUSTABILITY
ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESES, DYNAMIC PROSTHETIC PYLON
ALL LOWER EXTREMITY PROSTHESES, MULTI-AXIAL ROTATION UNIT ('MCP' OR EQUAL)
ALL LOWER EXTREMITY PROSTHESIS, SHANK FOOT SYSTEM WITH VERTICAL LOADING PYLON
ADDITION TO LOWER LIMB PROSTHESIS, VERTICAL SHOCK REDUCING PYLON FEATURE
ADDITION TO LOWER EXTREMITY PROSTHESIS, USER ADJUSTABLE HEEL HEIGHT
ADDITION TO LOWER EXTREMITY PROSTHESIS, HEAVY DUTY FEATURE, FOOT ONLY, (FOR
PATIENT WEIGHT GREATER THAN 300 LBS)
ADDITION TO LOWER EXTREMITY PROSTHESIS, HEAVY DUTY FEATURE, KNEE ONLY, (FOR
PATIENT WEIGHT GREATER THAN 300 LBS)
ADDITION TO LOWER EXTREMITY PROSTHESIS, HEAVY DUTY FEATURE, OTHER THAN FOOT OR
KNEE, (FOR PATIENT WEIGHT GREATER THAN 300 LBS)
LOWER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED
PARTIAL HAND, ROBIN-AIDS, THUMB REMAINING (OR EQUAL)
PARTIAL HAND, ROBIN-AIDS, LITTLE AND/OR RING FINGER REMAINING (OR EQUAL)
PARTIAL HAND, ROBIN-AIDS, NO FINGER REMAINING (OR EQUAL)
TRANSCARPAL/METACARPAL OR PARTIAL HAND DISARTICULATION PROSTHESIS, EXTERNAL
POWER, SELF-SUSPENDED, INNER SOCKET WITH REMOVABLE FOREARM SECTION, ELECTRODES
AND CABLES, TWO BATTERIES, CHARGER, MYOELECTRIC CONTROL OF TERMINAL DEVICE
WRIST DISARTICULATION, MOLDED SOCKET, FLEXIBLE ELBOW HINGES, TRICEPS PAD
WRIST DISARTICULATION, MOLDED SOCKET WITH EXPANDABLE INTERFACE, FLEXIBLE ELBOW
HINGES, TRICEPS PAD
BELOW ELBOW, MOLDED SOCKET, FLEXIBLE ELBOW HINGE, TRICEPS PAD
BELOW ELBOW, MOLDED SOCKET, (MUENSTER OR NORTHWESTERN SUSPENSION TYPES)
BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SOCKET, STEP-UP HINGES, HALF CUFF
BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SOCKET, STUMP ACTIVATED LOCKING HINGE,
HALF CUFF
ELBOW DISARTICULATION, MOLDED SOCKET, OUTSIDE LOCKING HINGE, FOREARM
ELBOW DISARTICULATION, MOLDED SOCKET WITH EXPANDABLE INTERFACE, OUTSIDE LOCKING
HINGES, FOREARM
ABOVE ELBOW, MOLDED DOUBLE WALL SOCKET, INTERNAL LOCKING ELBOW, FOREARM
SHOULDER DISARTICULATION, MOLDED SOCKET, SHOULDER BULKHEAD, HUMERAL SECTION,
INTERNAL LOCKING ELBOW, FOREARM
SHOULDER DISARTICULATION, PASSIVE RESTORATION (COMPLETE PROSTHESIS)
SHOULDER DISARTICULATION, PASSIVE RESTORATION (SHOULDER CAP ONLY)
INTERSCAPULAR THORACIC, MOLDED SOCKET, SHOULDER BULKHEAD, HUMERAL SECTION,
INTERNAL LOCKING ELBOW, FOREARM
INTERSCAPULAR THORACIC, PASSIVE RESTORATION (COMPLETE PROSTHESIS)
INTERSCAPULAR THORACIC, PASSIVE RESTORATION (SHOULDER CAP ONLY)
IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID
DRESSING, INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE
CAST CHANGE, WRIST DISARTICULATION OR BELOW ELBOW
IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING
INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE,
ELBOW DISARTICULATION OR ABOVE ELBOW
IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING
INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE,
SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC
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IMMEDIATE POST SURGICAL OR EARLY FITTING, EACH ADDITIONAL CAST CHANGE AND
REALIGNMENT
IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF RIGID DRESSING ONLY
BELOW ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC
TISSUE SHAPING
ELBOW DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT
PROSTHETIC TISSUE SHAPING
ABOVE ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC
TISSUE SHAPING
SHOULDER DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT
PROSTHETIC TISSUE SHAPING
INTERSCAPULAR THORACIC, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT
PROSTHETIC TISSUE SHAPING
PREPARATORY, WRIST DISARTICULATION OR BELOW ELBOW, SINGLE WALL PLASTIC SOCKET,
FRICTION WRIST, FLEXIBLE ELBOW HINGES, FIGURE OF EIGHT HARNESS, HUMERAL CUFF,
BOWDEN CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODEL
PREPARATORY, WRIST DISARTICULATION OR BELOW ELBOW, SINGLE WALL SOCKET, FRICTION
WRIST, FLEXIBLE ELBOW HINGES, FIGURE OF EIGHT HARNESS, HUMERAL CUFF, BOWDEN
CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMED
PREPARATORY, ELBOW DISARTICULATION OR ABOVE ELBOW, SINGLE WALL PLASTIC SOCKET,
FRICTION WRIST, LOCKING ELBOW, FIGURE OF EIGHT HARNESS, FAIR LEAD CABLE
CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODEL
PREPARATORY, ELBOW DISARTICULATION OR ABOVE ELBOW, SINGLE WALL SOCKET, FRICTION
WRIST, LOCKING ELBOW, FIGURE OF EIGHT HARNESS, FAIR LEAD CABLE CONTROL, USMC OR
EQUAL PYLON, NO COVER, DIRECT FORMED
PREPARATORY, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC, SINGLE WALL
PLASTIC SOCKET, SHOULDER JOINT, LOCKING ELBOW, FRICTION WRIST, CHEST STRAP,
FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODEL
PREPARATORY, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC, SINGLE WALL
SOCKET, SHOULDER JOINT, LOCKING ELBOW, FRICTION WRIST, CHEST STRAP, FAIR LEAD
CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMED
UPPER EXTREMITY ADDITIONS, POLYCENTRIC HINGE, PAIR
UPPER EXTREMITY ADDITIONS, SINGLE PIVOT HINGE, PAIR
UPPER EXTREMITY ADDITIONS, FLEXIBLE METAL HINGE, PAIR
ADDITION TO UPPER EXTREMITY PROSTHESIS, EXTERNAL POWERED, ADDITIONAL SWITCH,
ANY TYPE
UPPER EXTREMITY ADDITION, DISCONNECT LOCKING WRIST UNIT
UPPER EXTREMITY ADDITION, ADDITIONAL DISCONNECT INSERT FOR LOCKING WRIST UNIT,
EACH
UPPER EXTREMITY ADDITION, FLEXION/EXTENSION WRIST UNIT, WITH OR WITHOUT
FRICTION
UPPER EXTREMITY PROSTHESIS ADDITION, FLEXION/EXTENSION WRIST WITH OR WITHOUT
FRICTION, FOR USE WITH EXTERNAL POWERED TERMINAL DEVICE
UPPER EXTREMITY ADDITION, SPRING ASSISTED ROTATIONAL WRIST UNIT WITH LATCH
RELEASE
UPPER EXTREMITY ADDITION, FLEXION/EXTENSION AND ROTATION WRIST UNIT
UPPER EXTREMITY ADDITION, ROTATION WRIST UNIT WITH CABLE LOCK
UPPER EXTREMITY ADDITION, QUICK DISCONNECT HOOK ADAPTER, OTTO BOCK OR EQUAL
UPPER EXTREMITY ADDITION, QUICK DISCONNECT LAMINATION COLLAR WITH COUPLING
PIECE, OTTO BOCK OR EQUAL
UPPER EXTREMITY ADDITION, STAINLESS STEEL, ANY WRIST
UPPER EXTREMITY ADDITION, LATEX SUSPENSION SLEEVE, EACH
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UPPER EXTREMITY ADDITION, LIFT ASSIST FOR ELBOW
UPPER EXTREMITY ADDITION, NUDGE CONTROL ELBOW LOCK
UPPER EXTREMITY ADDITION TO PROSTHESIS, ELECTRIC LOCKING FEATURE, ONLY FOR USE
WITH MANUALLY POWERED ELBOW
UPPER EXTREMITY ADDITION, HEAVY DUTY FEATURE, ANY ELBOW
UPPER EXTREMITY ADDITIONS, SHOULDER ABDUCTION JOINT, PAIR
UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, PULLEY TYPE
UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, LEVER TYPE
UPPER EXTREMITY ADDITION, SHOULDER FLEXION-ABDUCTION JOINT, EACH
UPPER EXTREMITY ADDITION, SHOULDER JOINT, MULTIPOSITIONAL LOCKING, FLEXION,
ADJUSTABLE ABDUCTION FRICTION CONTROL, FOR USE WITH BODY POWERED OR EXTERNAL
POWERED SYSTEM
UPPER EXTREMITY ADDITION, SHOULDER LOCK MECHANISM, BODY POWERED ACTUATOR
UPPER EXTREMITY ADDITION, SHOULDER LOCK MECHANISM, EXTERNAL POWERED ACTUATOR
UPPER EXTREMITY ADDITION, SHOULDER UNIVERSAL JOINT, EACH
UPPER EXTREMITY ADDITION, STANDARD CONTROL CABLE, EXTRA
UPPER EXTREMITY ADDITION, HEAVY DUTY CONTROL CABLE
UPPER EXTREMITY ADDITION, TEFLON, OR EQUAL, CABLE LINING
UPPER EXTREMITY ADDITION, HOOK TO HAND, CABLE ADAPTER
UPPER EXTREMITY ADDITION, HARNESS, CHEST OR SHOULDER, SADDLE TYPE
UPPER EXTREMITY ADDITION, HARNESS, (E.G. FIGURE OF EIGHT TYPE), SINGLE CABLE
DESIGN
UPPER EXTREMITY ADDITION, HARNESS, (E.G. FIGURE OF EIGHT TYPE), DUAL CABLE
DESIGN
UPPER EXTREMITY ADDITION, HARNESS, TRIPLE CONTROL, SIMULTANEOUS OPERATION OF
TERMINAL DEVICE AND ELBOW
UPPER EXTREMITY ADDITION, TEST SOCKET, WRIST DISARTICULATION OR BELOW ELBOW
UPPER EXTREMITY ADDITION, TEST SOCKET, ELBOW DISARTICULATION OR ABOVE ELBOW
UPPER EXTREMITY ADDITION, TEST SOCKET, SHOULDER DISARTICULATION OR
INTERSCAPULAR THORACIC
UPPER EXTREMITY ADDITION, SUCTION SOCKET
UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, BELOW ELBOW OR WRIST
DISARTICULATION
UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, ABOVE ELBOW OR ELBOW
DISARTICULATION
UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, SHOULDER DISARTICULATION
UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, INTERSCAPULAR-THORACIC
UPPER EXTREMITY ADDITION, REMOVABLE INSERT, EACH
UPPER EXTREMITY ADDITION, SILICONE GEL INSERT OR EQUAL, EACH
UPPER EXTREMITY ADDITION, LOCKING ELBOW, FOREARM COUNTERBALANCE
ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM
FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL,
ELASTOMERIC OR EQUAL, FOR USE WITH LOCKING MECHANISM
ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM
FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL,
ELASTOMERIC OR EQUAL, NOT FOR USE WITH LOCKING MECHANISM
ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM
FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE
GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL
ONLY (FOR OTHER THAN INITIAL, USE CODE L6694 OR L6695)
ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM
FABRICATED SOCKET INSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATIC
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AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING
MECHANISM, INITIAL ONLY (FOR OTHER THAN INITIAL, USE CODE L6694 OR L6695)
ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, LOCK
MECHANISM, EXCLUDES SOCKET INSERT
TERMINAL DEVICE, PASSIVE HAND/MITT, ANY MATERIAL, ANY SIZE
TERMINAL DEVICE, SPORT/RECREATIONAL/WORK ATTACHMENT, ANY MATERIAL, ANY SIZE
TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE,
LINED OR UNLINED
TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE,
LINED OR UNLINED
TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE
TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE
TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE,
LINED OR UNLINED, PEDIATRIC
TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE,
LINED OR UNLINED, PEDIATRIC
TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE,
PEDIATRIC
TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE,
PEDIATRIC
TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY OPENING, ANY
MATERIAL, ANY SIZE, LINED OR UNLINED
TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY CLOSING, ANY
MATERIAL, ANY SIZE, LINED OR UNLINED
ADDITION TO TERMINAL DEVICE, MODIFIER WRIST UNIT
ADDITION TO TERMINAL DEVICE, PRECISION PINCH DEVICE
AUTOMATIC GRASP FEATURE, ADDITION TO UPPER LIMB ELECTRIC PROSTHETIC TERMINAL
DEVICE
MICROPROCESSOR CONTROL FEATURE, ADDITION TO UPPER LIMB PROSTHETIC TERMINAL
DEVICE
REPLACEMENT SOCKET, BELOW ELBOW/WRIST DISARTICULATION, MOLDED TO PATIENT MODEL,
FOR USE WITH OR WITHOUT EXTERNAL POWER
REPLACEMENT SOCKET, ABOVE ELBOW/ELBOW DISARTICULATION, MOLDED TO PATIENT MODEL,
FOR USE WITH OR WITHOUT EXTERNAL POWER
REPLACEMENT SOCKET, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, MOLDED TO
PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER
ADDITION TO UPPER EXTREMITY PROSTHESIS, GLOVE FOR TERMINAL DEVICE, ANY
MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
ADDITION TO UPPER EXTREMITY PROSTHESIS, GLOVE FOR TERMINAL DEVICE, ANY
MATERIAL, CUSTOM FABRICATED
HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITH
GLOVE, THUMB OR ONE FINGER REMAINING
HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITH
GLOVE, MULTIPLE FINGERS REMAINING
HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITH
GLOVE, NO FINGERS REMAINING
HAND RESTORATION (SHADING, AND MEASUREMENTS INCLUDED), REPLACEMENT GLOVE FOR
ABOVE
WRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE
FOREARM SHELL, OTTO BOCK OR EQUAL, SWITCH, CABLES, TWO BATTERIES AND ONE
CHARGER, SWITCH CONTROL OF TERMINAL DEVICE
WRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE
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FOREARM SHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE
CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE
BELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM
SHELL, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH
CONTROL OF TERMINAL DEVICE
BELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM
SHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER,
MYOELECTRONIC CONTROL OF TERMINAL DEVICE
ELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL
SHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO
BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE
ELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL
SHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES,
TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE
ABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL,
INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO
BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE
ABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL,
INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO
BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE
SHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE
SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM,
OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH
CONTROL OF TERMINAL DEVICE
SHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE
SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM,
OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER,
MYOELECTRONIC CONTROL OF TERMINAL DEVICE
INTERSCAPULAR-THORACIC, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER
SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK
OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF
TERMINAL DEVICE
INTERSCAPULAR-THORACIC, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER
SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK
OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC
CONTROL OF TERMINAL DEVICE
ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, ADULT
ELECTRIC HAND, SWITCH OR MYOELECTRIC, CONTROLLED, PEDIATRIC
ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, ADULT
PREHENSILE ACTUATOR, SWITCH CONTROLLED
ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, PEDIATRIC
ELECTRONIC ELBOW, HOSMER OR EQUAL, SWITCH CONTROLLED
ELECTRONIC ELBOW, MICROPROCESSOR SEQUENTIAL CONTROL OF ELBOW AND TERMINAL DEVICE
ELECTRONIC ELBOW, MICROPROCESSOR SIMULTANEOUS CONTROL OF ELBOW AND TERMINAL
DEVICE
ELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLED
ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLED
ELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY
CONTROLLED
ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY CONTROLLED
ELECTRONIC WRIST ROTATOR, OTTO BOCK OR EQUAL
ELECTRONIC WRIST ROTATOR, FOR UTAH ARM
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SERVO CONTROL, STEEPER OR EQUAL
ANALOGUE CONTROL, UNB OR EQUAL
PROPORTIONAL CONTROL, 6-12 VOLT, LIBERTY, UTAH OR EQUAL
SIX VOLT BATTERY, EACH
BATTERY CHARGER, SIX VOLT, EACH
TWELVE VOLT BATTERY, EACH
BATTERY CHARGER, TWELVE VOLT, EACH
LITHIUM ION BATTERY, REPLACEMENT
LITHIUM ION BATTERY CHARGER
ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION,
ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL)
ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ULTRALIGHT
MATERIAL (TITANIUM, CARBON FIBER OR EQUAL)
ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER DISARTICULATION/INTERSCAPULAR
THORACIC, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL)
ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION,
ACRYLIC MATERIAL
ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ACRYLIC
MATERIAL
ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER DISARTICULATION/INTERSCAPULAR
THORACIC, ACRYLIC MATERIAL
UPPER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED
REPAIR OF PROSTHETIC DEVICE, HOURLY RATE (EXCLUDES V5335 REPAIR OF ORAL OR
LARYNGEAL PROSTHESIS OR ARTIFICIAL LARYNX)
REPAIR OF PROSTHETIC DEVICE, REPAIR OR REPLACE MINOR PARTS
REPAIR PROSTHETIC DEVICE, LABOR COMPONENT, PER 15 MINUTES
PROSTHETIC DONNING SLEEVE, ANY MATERIAL, EACH
TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE,
LINED OR UNLINED, PEDIATRIC
TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE,
LINED OR UNLINED, PEDIATRIC
TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE,
PEDIATRIC
TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE,
PEDIATRIC
TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY OPENING, ANY
MATERIAL, ANY SIZE, LINED OR UNLINED
TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY CLOSING, ANY
MATERIAL, ANY SIZE, LINED OR UNLINED
MALE VACUUM ERECTION SYSTEM
BREAST PROSTHESIS, MASTECTOMY BRA
BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM,
UNILATERAL
BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM,
BILATERAL
BREAST PROSTHESIS, MASTECTOMY SLEEVE
EXTERNAL BREAST PROSTHESIS GARMENT, WITH MASTECTOMY FORM, POST MASTECTOMY
BREAST PROSTHESIS, MASTECTOMY FORM
BREAST PROSTHESIS, SILICONE OR EQUAL, WITHOUT INTEGRAL ADHESIVE
BREAST PROSTHESIS, SILICONE OR EQUAL, WITH INTEGRAL ADHESIVE
NIPPLE PROSTHESIS, REUSABLE, ANY TYPE, EACH
CUSTOM BREAST PROSTHESIS, POST MASTECTOMY, MOLDED TO PATIENT MODEL
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BREAST PROSTHESIS, NOT OTHERWISE SPECIFIED
NASAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
MIDFACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
ORBITAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
UPPER FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
HEMI-FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
AURICULAR PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
PARTIAL FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
NASAL SEPTAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN
UNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORT, PROVIDED BY A NON-PHYSICIAN
REPAIR OR MODIFICATION OF MAXILLOFACIAL PROSTHESIS, LABOR COMPONENT, 15 MINUTE
INCREMENTS, PROVIDED BY A NON-PHYSICIAN
TRUSS, SINGLE WITH STANDARD PAD
TRUSS, DOUBLE WITH STANDARD PADS
TRUSS, ADDITION TO STANDARD PAD, WATER PAD
TRUSS, ADDITION TO STANDARD PAD, SCROTAL PAD
PROSTHETIC SHEATH, BELOW KNEE, EACH
PROSTHETIC SHEATH, ABOVE KNEE, EACH
PROSTHETIC SHEATH, UPPER LIMB, EACH
PROSTHETIC SHEATH/SOCK, INCLUDING A GEL CUSHION LAYER, BELOW KNEE OR ABOVE
KNEE, EACH
PROSTHETIC SOCK, MULTIPLE PLY, BELOW KNEE, EACH
PROSTHETIC SOCK, MULTIPLE PLY, ABOVE KNEE, EACH
PROSTHETIC SOCK, MULTIPLE PLY, UPPER LIMB, EACH
PROSTHETIC SHRINKER, BELOW KNEE, EACH
PROSTHETIC SHRINKER, ABOVE KNEE, EACH
PROSTHETIC SHRINKER, UPPER LIMB, EACH
PROSTHETIC SOCK, SINGLE PLY, FITTING, BELOW KNEE, EACH
PROSTHETIC SOCK, SINGLE PLY, FITTING, ABOVE KNEE, EACH
PROSTHETIC SOCK, SINGLE PLY, FITTING, UPPER LIMB, EACH
UNLISTED PROCEDURE FOR MISCELLANEOUS PROSTHETIC SERVICES
ARTIFICIAL LARYNX, ANY TYPE
TRACHEOSTOMY SPEAKING VALVE
ARTIFICIAL LARYNX REPLACEMENT BATTERY / ACCESSORY, ANY TYPE
TRACHEO-ESOPHAGEAL VOICE PROSTHESIS, PATIENT INSERTED, ANY TYPE, EACH
TRACHEO-ESOPHAGEAL VOICE PROSTHESIS, INSERTED BY A LICENSED HEALTH CARE
PROVIDER, ANY TYPE
VOICE AMPLIFIER
INSERT FOR INDWELLING TRACHEOESOPHAGEAL PROSTHESIS, WITH OR WITHOUT VALVE,
REPLACEMENT ONLY, EACH
GELATIN CAPSULES OR EQUIVALENT, FOR USE WITH TRACHEOESOPHAGEAL VOICE
PROSTHESIS, REPLACEMENT ONLY, PER 10
CLEANING DEVICE USED WITH TRACHEOESOPHAGEAL VOICE PROSTHESIS, PIPET, BRUSH, OR
EQUAL, REPLACEMENT ONLY, EACH
TRACHEOESOPHAGEAL PUNCTURE DILATOR, REPLACEMENT ONLY, EACH
GELATIN CAPSULE, APPLICATION DEVICE FOR USE WITH TRACHEOESOPHAGEAL VOICE
PROSTHESIS, EACH
IMPLANTABLE BREAST PROSTHESIS, SILICONE OR EQUAL
INJECTABLE BULKING AGENT, COLLAGEN IMPLANT, URINARY TRACT, 2.5 ML SYRINGE,
INCLUDES SHIPPING AND NECESSARY SUPPLIES
INJECTABLE BULKING AGENT, DEXTRANOMER/HYALURONIC ACID COPOLYMER IMPLANT,
URINARY TRACT, 1 ML, INCLUDES SHIPPING AND NECESSARY SUPPLIES
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INJECTABLE BULKING AGENT, SYNTHETIC IMPLANT, URINARY TRACT, 1 ML SYRINGE,
INCLUDES SHIPPING AND NECESSARY SUPPLIES
ARTIFICIAL CORNEA
OCULAR IMPLANT
AQUEOUS SHUNT
OSSICULA IMPLANT
COCHLEAR DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL COMPONENTS
HEADSET/HEADPIECE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT
MICROPHONE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT
TRANSMITTING COIL FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT
TRANSMITTER CABLE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT
COCHLEAR IMPLANT, EXTERNAL SPEECH PROCESSOR AND CONTROLLER, INTEGRATED SYSTEM,
REPLACEMENT
ZINC AIR BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT, EACH
ALKALINE BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE, ANY SIZE, REPLACEMENT,
EACH
LITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOR,
OTHER THAN EAR LEVEL, REPLACEMENT, EACH
LITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOR, EAR
LEVEL, REPLACEMENT, EACH
COCHLEAR IMPLANT, EXTERNAL SPEECH PROCESSOR, COMPONENT, REPLACEMENT
COCHLEAR IMPLANT, EXTERNAL CONTROLLER COMPONENT, REPLACEMENT
TRANSMITTING COIL AND CABLE, INTEGRATED, FOR USE WITH COCHLEAR IMPLANT DEVICE,
REPLACEMENT
METACARPOPHALANGEAL JOINT IMPLANT
METACARPAL PHALANGEAL JOINT REPLACEMENT, TWO OR MORE PIECES, METAL (E.G.,
STAINLESS STEEL OR COBALT CHROME), CERAMIC-LIKE MATERIAL (E.G., PYROCARBON),
FOR SURGICAL IMPLANTATION (ALL SIZES, INCLUDES ENTIRE SYSTEM)
METATARSAL JOINT IMPLANT
HALLUX IMPLANT
INTERPHALANGEAL JOINT SPACER, SILICONE OR EQUAL, EACH
INTERPHALANGEAL FINGER JOINT REPLACEMENT, 2 OR MORE PIECES, METAL (E.G.,
STAINLESS STEEL OR COBALT CHROME), CERAMIC-LIKE MATERIAL (E.G., PYROCARBON) FOR
SURGICAL IMPLANTATION, ANY SIZE
VASCULAR GRAFT MATERIAL, SYNTHETIC, IMPLANT
IMPLANTABLE NEUROSTIMULATOR ELECTRODE, EACH
PATIENT PROGRAMMER (EXTERNAL) FOR USE WITH IMPLANTABLE PROGRAMMABLE
NEUROSTIMULATOR PULSE GENERATOR, REPLACEMENT ONLY
IMPLANTABLE NEUROSTIMULATOR RADIOFREQUENCY RECEIVER
RADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH IMPLANTABLE NEUROSTIMULATOR
RADIOFREQUENCY RECEIVER
RADIOFREQUENCY TRANSMITTER (EXTERNAL) FOR USE WITH IMPLANTABLE SACRAL ROOT
NEUROSTIMULATOR RECEIVER FOR BOWEL AND BLADDER MANAGEMENT, REPLACEMENT
IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, SINGLE ARRAY, RECHARGEABLE,
INCLUDES EXTENSION
IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, SINGLE ARRAY, NON-RECHARGEABLE,
INCLUDES EXTENSION
IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, RECHARGEABLE, INCLUDES
EXTENSION
IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, NON-RECHARGEABLE,
INCLUDES EXTENSION
EXTERNAL RECHARGING SYSTEM FOR BATTERY (INTERNAL) FOR USE WITH IMPLANTABLE
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NEUROSTIMULATOR, REPLACEMENT ONLY
AUDITORY OSSEOINTEGRATED DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL COMPONENTS
AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, REPLACEMENT
AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, USED WITHOUT
OSSEOINTEGRATION, BODY WORN, INCLUDES HEADBAND OR OTHER MEANS OF EXTERNAL
ATTACHMENT
AUDITORY OSSEOINTEGRATED DEVICE ABUTMENT, ANY LENGTH, REPLACEMENT ONLY
EXTERNAL RECHARGING SYSTEM FOR BATTERY (EXTERNAL) FOR USE WITH IMPLANTABLE
NEUROSTIMULATOR, REPLACEMENT ONLY
PROSTHETIC IMPLANT, NOT OTHERWISE SPECIFIED
ORTHOTIC AND PROSTHETIC SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER
HCPCS "L" CODE
BRIEF OFFICE VISIT FOR THE SOLE PURPOSE OF MONITORING OR CHANGING DRUG
PRESCRIPTIONS USED IN THE TREATMENT OF MENTAL PSYCHONEUROTIC AND PERSONALITY
DISORDERS
CELLULAR THERAPY
PROLOTHERAPY
INTRAGASTRIC HYPOTHERMIA USING GASTRIC FREEZING
IV CHELATION THERAPY (CHEMICAL ENDARTERECTOMY)
FABRIC WRAPPING OF ABDOMINAL ANEURYSM
CEPHALIN FLOCULATION, BLOOD
CONGO RED, BLOOD
HAIR ANALYSIS (EXCLUDING ARSENIC)
THYMOL TURBIDITY, BLOOD
MUCOPROTEIN, BLOOD (SEROMUCOID) (MEDICAL NECESSITY PROCEDURE)
SCREENING PAPANICOLAOU SMEAR, CERVICAL OR VAGINAL, UP TO THREE SMEARS, BY
TECHNICIAN UNDER PHYSICIAN SUPERVISION
SCREENING PAPANICOLAOU SMEAR, CERVICAL OR VAGINAL, UP TO THREE SMEARS,
REQUIRING INTERPRETATION BY PHYSICIAN
CULTURE, BACTERIAL, URINE; QUANTITATIVE, SENSITIVITY STUDY
BLOOD (WHOLE), FOR TRANSFUSION, PER UNIT
BLOOD, SPLIT UNIT
CRYOPRECIPITATE, EACH UNIT
RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT
FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH
UNIT
PLATELETS, EACH UNIT
PLATELET RICH PLASMA, EACH UNIT
RED BLOOD CELLS, EACH UNIT
RED BLOOD CELLS, WASHED, EACH UNIT
PLASMA, POOLED MULTIPLE DONOR, SOLVENT/DETERGENT TREATED, FROZEN, EACH UNIT
PLATELETS, LEUKOCYTES REDUCED, EACH UNIT
PLATELETS, IRRADIATED, EACH UNIT
PLATELETS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT
PLATELETS, PHERESIS, EACH UNIT
PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT
PLATELETS, PHERESIS, IRRADIATED, EACH UNIT
PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT
RED BLOOD CELLS, IRRADIATED, EACH UNIT
RED BLOOD CELLS, DEGLYCEROLIZED, EACH UNIT
RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT
INFUSION, ALBUMIN (HUMAN), 5%, 50 ML
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INFUSION, PLASMA PROTEIN FRACTION (HUMAN), 5%, 50 ML
PLASMA, CRYOPRECIPITATE REDUCED, EACH UNIT
INFUSION, ALBUMIN (HUMAN), 5%, 250 ML
INFUSION, ALBUMIN (HUMAN), 25%, 20 ML
INFUSION, ALBUMIN (HUMAN), 25%, 50 ML
INFUSION, PLASMA PROTEIN FRACTION (HUMAN), 5%, 250ML
GRANULOCYTES, PHERESIS, EACH UNIT
WHOLE BLOOD OR RED BLOOD CELLS, LEUKOCYTES REDUCED, CMV-NEGATIVE, EACH UNIT
PLATELETS, HLA-MATCHED LEUKOCYTES REDUCED, APHERESIS/PHERESIS, EACH UNIT
PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT
WHOLE BLOOD OR RED BLOOD CELLS, LEUKOCYTES REDUCED, FROZEN, DEGLYCEROL, WASHED,
EACH UNIT
PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT
WHOLE BLOOD, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT
RED BLOOD CELLS, FROZEN/DEGLYCEROLIZED/WASHED, LEUKOCYTES REDUCED, IRRADIATED,
EACH UNIT
RED BLOOD CELLS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT
FRESH FROZEN PLASMA BETWEEN 8-24 HOURS OF COLLECTION, EACH UNIT
FRESH FROZEN PLASMA, DONOR RETESTED, EACH UNIT
TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY
SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT;
PRORATED MILES ACTUALLY TRAVELLED.
TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY
SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT;
PRORATED TRIP CHARGE.
CATHETERIZATION FOR COLLECTION OF SPECIMEN, SINGLE PATIENT, ALL PLACES OF
SERVICE
CATHETERIZATION FOR COLLECTION OF SPECIMEN (S) (MULTIPLE PATIENTS)
CARDIOKYMOGRAPHY
INFUSION THERAPY, USING OTHER THAN CHEMOTHERAPEUTIC DRUGS, PER VISIT
CHEMOTHERAPY ADMINISTRATION BY OTHER THAN INFUSION TECHNIQUE ONLY (EG
SUBCUTANEOUS, INTRAMUSCULAR, PUSH), PER VISIT
CHEMOTHERAPY ADMINISTRATION BY INFUSION TECHNIQUE ONLY, PER VISIT
CHEMOTHERAPY ADMINISTRATION BY BOTH INFUSION TECHNIQUE AND OTHER TECHIQUE(S)
(EG SUBCUTANEOUS, INTRAMUSCULAR, PUSH), PER VISIT
SCREENING PAPANICOLAOU SMEAR; OBTAINING, PREPARING AND CONVEYANCE OF CERVICAL
OR VAGINAL SMEAR TO LABORATORY
SET-UP PORTABLE X-RAY EQUIPMENT
WET MOUNTS, INCLUDING PREPARATIONS OF VAGINAL, CERVICAL OR SKIN SPECIMENS
ALL POTASSIUM HYDROXIDE (KOH) PREPARATIONS
PINWORM EXAMINATIONS
FERN TEST
POST-COITAL DIRECT, QUALITATIVE EXAMINATIONS OF VAGINAL OR CERVICAL MUCOUS
INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD
USE)
INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (FOR ESRD
ON DIALYSIS)
AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM
DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION
ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC
AT TIME OF CHEMOTHERAPY TREATMENT NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC,
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FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME
OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC,
FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME
OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
GRANISETRON HYDROCHLORIDE, 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC,
FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME
OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24 HOUR DOSAGE REGIMEN
DRONABINOL, 2.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A
COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF
CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A
COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF
CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION
ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC
AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
PROMETHAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESCRIPTION
ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC
AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
CHLORPROMAZINE HYDROCHLORIDE, 10 MG, ORAL, FDA APPROVED PRESCRIPTION
ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC
AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
CHLORPROMAZINE HYDROCHLORIDE, 25 MG, ORAL, FDA APPROVED PRESCRIPTION
ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC
AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
TRIMETHOBENZAMIDE HYDROCHLORIDE, 250 MG, ORAL, FDA APPROVED PRESCRIPTION
ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC
AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
THIETHYLPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC,
FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME
OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
PERPHENAZINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A
COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF
CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
PERPHENAZINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A
COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF
CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
HYDROXYZINE PAMOATE, 25 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR
USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF
CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
HYDROXYZINE PAMOATE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR
USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF
CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
ONDANSETRON HYDROCHLORIDE 8 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC,
FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME
OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
DOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR
USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF
CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 24 HOUR DOSAGE REGIMEN
UNSPECIFIED ORAL DOSAGE FORM, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS
A COMPLETE THERAPEUTIC SUBSTITUTE FOR A IV ANTI-EMETIC AT THE TIME OF
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CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN
POWER ADAPTER FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST
DEVICE, VEHICLE TYPE
POWER MODULE FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST
DEVICE, REPLACEMENT ONLY
DRIVER FOR USE WITH PNEUMATIC VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY
MICROPROCESSOR CONTROL UNIT FOR USE WITH ELECTRIC VENTRICULAR ASSIST DEVICE,
REPLACEMENT ONLY
MICROPROCESSOR CONTROL UNIT FOR USE WITH ELECTRIC/PNEUMATIC COMBINATION
VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY
MONITOR/DISPLAY MODULE FOR USE WITH ELECTRIC VENTRICULAR ASSIST DEVICE,
REPLACEMENT ONLY
MONITOR/DISPLAY MODULE FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR
ASSIST DEVICE, REPLACEMENT ONLY
MONITOR CONTROL CABLE FOR USE WITH ELECTRIC VENTRICULAR ASSIST DEVICE,
REPLACEMENT ONLY
MONITOR CONTROL CABLE FOR USE WITH ELECTRIC/PNEUMATIC VENTRICULAR ASSIST
DEVICE, REPLACEMENT ONLY
LEADS (PNEUMATIC/ELECTRICAL) FOR USE WITH ANY TYPE ELECTRIC/PNEUMATIC
VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY
POWER PACK BASE FOR USE WITH ELECTRIC VENTRICULAR ASSIST DEVICE, REPLACEMENT
ONLY
POWER PACK BASE FOR USE WITH ELECTRIC/PNEUMATIC VENTRICULAR ASSIST DEVICE,
REPLACEMENT ONLY
EMERGENCY POWER SOURCE FOR USE WITH ELECTRIC VENTRICULAR ASSIST DEVICE,
REPLACEMENT ONLY
EMERGENCY POWER SOURCE FOR USE WITH ELECTRIC/PNEUMATIC VENTRICULAR ASSIST
DEVICE, REPLACEMENT ONLY
EMERGENCY POWER SUPPLY CABLE FOR USE WITH ELECTRIC VENTRICULAR ASSIST DEVICE,
REPLACEMENT ONLY
EMERGENCY POWER SUPPLY CABLE FOR USE WITH ELECTRIC/PNEUMATIC VENTRICULAR ASSIST
DEVICE, REPLACEMENT ONLY
EMERGENCY HAND PUMP FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR
ASSIST DEVICE, REPLACEMENT ONLY
BATTERY/POWER PACK CHARGER FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC
VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY
BATTERY, OTHER THAN LITHIUM-ION, FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC
VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY
BATTERY CLIPS FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST
DEVICE, REPLACEMENT ONLY
HOLSTER FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST DEVICE,
REPLACEMENT ONLY
BELT/VEST/BAG FOR USE TO CARRY EXTERNAL PERIPHERAL COMPONENTS OF ANY TYPE
VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY
FILTERS FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST DEVICE,
REPLACEMENT ONLY
SHOWER COVER FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR ASSIST
DEVICE, REPLACEMENT ONLY
MOBILITY CART FOR PNEUMATIC VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY
BATTERY FOR PNEUMATIC VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY, EACH
POWER ADAPTER FOR PNEUMATIC VENTRICULAR ASSIST DEVICE, REPLACEMENT ONLY,
VEHICLE TYPE
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MISCELLANEOUS SUPPLY OR ACCESSORY FOR USE WITH VENTRICULAR ASSIST DEVICE
BATTERY, LITHIUM-ION, FOR USE WITH ELECTRIC OR ELECTRIC/PNEUMATIC VENTRICULAR
ASSIST DEVICE, REPLACEMENT ONLY
PHARMACY SUPPLY FEE FOR INITIAL IMMUNOSUPPRESSIVE DRUG(S), FIRST MONTH
FOLLOWING TRANSPLANT
PHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL ANTI-EMETIC OR IMMUNOSUPPRESSIVE
DRUG(S); FOR THE FIRST PRESCRIPTION IN A 30-DAY PERIOD
PHARMACY SUPPLY FEE FOR ORAL ANTI-CANCER, ORAL ANTI-EMETIC OR IMMUNOSUPPRESSIVE
DRUG(S); FOR A SUBSEQUENT PRESCRIPTION IN A 30-DAY PERIOD
PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); PER 30 DAYS
PHARMACY DISPENSING FEE FOR INHALATION DRUG(S); PER 90 DAYS
INJECTION, SERMORELIN ACETATE, 1 MICROGRAM
NEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 3 (REDUCED SPHERICAL ABERRATION)
NEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 4 AS DEFINED IN FEDERAL REGISTER NOTICE
NEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 5 AS DEFINED IN FEDERAL REGISTER NOTICE
IRRIGATION SOLUTION FOR TREATMENT OF BLADDER CALCULI, FOR EXAMPLE RENACIDIN,
PER 500 ML
INJECTION, FOSPHENYTOIN, 50 MG PHENYTOIN EQUIVALENT
INJECTION, TENIPOSIDE, 50 MG
INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) (XYNTHA), PER I.U.
INJECTION, BEVACIZUMAB, 0.25 MG
FLUDARABINE PHOSPHATE, ORAL, 1 MG
INJECTION, RADIESSE, 0.1 ML
INJECTION, SCULPTRA, 0.1 ML
INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS
OF AGE AND OLDER, FOR INTRAMUSCULAR USE (AFLURIA)
INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS
OF AGE AND OLDER, FOR INTRAMUSCULAR USE (FLULAVAL)
INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS
OF AGE AND OLDER, FOR INTRAMUSCULAR USE (FLUVIRIN)
INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS
OF AGE AND OLDER, FOR INTRAMUSCULAR USE (FLUZONE)
INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS
OF AGE AND OLDER, FOR INTRAMUSCULAR USE (NOT OTHERWISE SPECIFIED)
RADIOELEMENTS FOR BRACHYTHERAPY, ANY TYPE, EACH
TELEHEALTH ORIGINATING SITE FACILITY FEE
INJECTION, INTERFERON BETA-1A, 11 MCG FOR INTRAMUSCULAR USE
INJECTION, INTERFERON BETA-1A, 11 MCG FOR SUBCUTANEOUS USE
COLLAGEN SKIN TEST
CASTING SUPPLIES, BODY CAST ADULT, WITH OR WITHOUT HEAD, PLASTER
CAST SUPPLIES, BODY CAST ADULT, WITH OR WITHOUT HEAD, FIBERGLASS
CAST SUPPLIES, SHOULDER CAST, ADULT (11 YEARS +), PLASTER
CAST SUPPLIES, SHOULDER CAST, ADULT (11 YEARS +), FIBERGLASS
CAST SUPPLIES, LONG ARM CAST, ADULT (11 YEARS +), PLASTER
CAST SUPPLIES, LONG ARM CAST, ADULT (11 YEARS +), FIBERGLASS
CAST SUPPLIES, LONG ARM CAST, PEDIATRIC (0-10 YEARS), PLASTER
CAST SUPPLIES, LONG ARM CAST, PEDIATRIC (0-10 YEARS), FIBERGLASS
CAST SUPPLIES, SHORT ARM CAST, ADULT (11 YEARS +), PLASTER
CAST SUPPLIES, SHORT ARM CAST, ADULT (11 YEARS +), FIBERGLASS
CAST SUPPLIES, SHORT ARM CAST, PEDIATRIC (0-10 YEARS), PLASTER
CAST SUPPLIES, SHORT ARM CAST, PEDIATRIC (0-10 YEARS), FIBERGLASS
CAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM AND HAND), ADULT (11 YEARS
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+), PLASTER
CAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM AND HAND), ADULT (11 YEARS
+), FIBERGLASS
CAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM AND HAND), PEDIATRIC (0-10
YEARS), PLASTER
CAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM AND HAND), PEDIATRIC (0-10
YEARS), FIBERGLASS
CAST SUPPLIES, LONG ARM SPLINT, ADULT (11 YEARS +), PLASTER
CAST SUPPLIES, LONG ARM SPLINT, ADULT (11 YEARS +), FIBERGLASS
CAST SUPPLIES, LONG ARM SPLINT, PEDIATRIC (0-10 YEARS), PLASTER
CAST SUPPLIES, LONG ARM SPLINT, PEDIATRIC (0-10 YEARS), FIBERGLASS
CAST SUPPLIES, SHORT ARM SPLINT, ADULT (11 YEARS +), PLASTER
CAST SUPPLIES, SHORT ARM SPLINT, ADULT (11 YEARS +), FIBERGLASS
CAST SUPPLIES, SHORT ARM SPLINT, PEDIATRIC (0-10 YEARS), PLASTER
CAST SUPPLIES, SHORT ARM SPLINT, PEDIATRIC (0-10 YEARS), FIBERGLASS
CAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), ADULT (11 YEARS +), PLASTER
CAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), ADULT (11 YEARS +), FIBERGLASS
CAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), PEDIATRIC (0-10 YEARS), PLASTER
CAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), PEDIATRIC (0-10 YEARS), FIBERGLASS
CAST SUPPLIES, LONG LEG CAST, ADULT (11 YEARS +), PLASTER
CAST SUPPLIES, LONG LEG CAST, ADULT (11 YEARS +), FIBERGLASS
CAST SUPPLIES, LONG LEG CAST, PEDIATRIC (0-10 YEARS), PLASTER
CAST SUPPLIES, LONG LEG CAST, PEDIATRIC (0-10 YEARS), FIBERGLASS
CAST SUPPLIES, LONG LEG CYLINDER CAST, ADULT (11 YEARS +), PLASTER
CAST SUPPLIES, LONG LEG CYLINDER CAST, ADULT (11 YEARS +), FIBERGLASS
CAST SUPPLIES, LONG LEG CYLINDER CAST, PEDIATRIC (0-10 YEARS), PLASTER
CAST SUPPLIES, LONG LEG CYLINDER CAST, PEDIATRIC (0-10 YEARS), FIBERGLASS
CAST SUPPLIES, SHORT LEG CAST, ADULT (11 YEARS +), PLASTER
CAST SUPPLIES, SHORT LEG CAST, ADULT (11 YEARS +), FIBERGLASS
CAST SUPPLIES, SHORT LEG CAST, PEDIATRIC (0-10 YEARS), PLASTER
CAST SUPPLIES, SHORT LEG CAST, PEDIATRIC (0-10 YEARS), FIBERGLASS
CAST SUPPLIES, LONG LEG SPLINT, ADULT (11 YEARS +), PLASTER
CAST SUPPLIES, LONG LEG SPLINT, ADULT (11 YEARS +), FIBERGLASS
CAST SUPPLIES, LONG LEG SPLINT, PEDIATRIC (0-10 YEARS), PLASTER
CAST SUPPLIES, LONG LEG SPLINT, PEDIATRIC (0-10 YEARS), FIBERGLASS
CAST SUPPLIES, SHORT LEG SPLINT, ADULT (11 YEARS +), PLASTER
CAST SUPPLIES, SHORT LEG SPLINT, ADULT (11 YEARS +), FIBERGLASS
CAST SUPPLIES, SHORT LEG SPLINT, PEDIATRIC (0-10 YEARS), PLASTER
CAST SUPPLIES, SHORT LEG SPLINT, PEDIATRIC (0-10 YEARS), FIBERGLASS
FINGER SPLINT, STATIC
CAST SUPPLIES, FOR UNLISTED TYPES AND MATERIALS OF CASTS
SPLINT SUPPLIES, MISCELLANEOUS (INCLUDES THERMOPLASTICS, STRAPPING, FASTENERS,
PADDING AND OTHER SUPPLIES)
ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 20 MICROGRAMS
INJECTION, NATALIZUMAB, 1 MG
ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED,
ADMINISTERED THROUGH DME, UNIT DOSE FORM, 20 MICROGRAMS
INJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS)
DRUG OR BIOLOGICAL, NOT OTHERWISE CLASSIFIED, PART B DRUG COMPETITIVE
ACQUISITION PROGRAM (CAP)
HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTICULAR INJECTION,
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PER DOSE
HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE
HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJECTION, PER DOSE
HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE
INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G.
LIQUID), 500 MG
INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), INTRAVENOUS, NON-LYOPHILIZED,
(E.G. LIQUID), 500 MG
INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC), INTRAMUSCULAR OR
INTRAVENOUS, 100 IU
INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML
INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA), INTRAVENOUS, NON-LYOPHILIZED, (E.G.
LIQUID), 500 MG
INJECTION, IMMUNE GLOBULIN, (GAMUNEX), INTRAVENOUS, NON-LYOPHILIZED (E.G.
LIQUID), 500 MG
ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION,
FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME,
CONCENTRATED FORM, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)
ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION,
FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT
DOSE, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)
INJECTION, ZOLEDRONIC ACID (RECLAST), 1 MG
INJECTION, VON WILLEBRAND FACTOR COMPLEX, HUMAN, RISTOCETIN COFACTOR (NOT
OTHERWISE SPECIFIED), PER I.U. VWF: RCO
INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G.
LIQUID), 500 MG
INJECTION, IRON DEXTRAN, 50 MG
FORMOTEROL FUMARATE, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT,
NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 20 MICROGRAMS
SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED
APLIGRAF, PER SQUARE CENTIMETER
OASIS WOUND MATRIX, PER SQUARE CENTIMETER
OASIS BURN MATRIX, PER SQUARE CENTIMETER
INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD), PER SQUARE CENTIMETER
INTEGRA DERMAL REGENERATION TEMPLATE (DRT), PER SQUARE CENTIMETER
DERMAGRAFT, PER SQUARE CENTIMETER
GRAFTJACKET, PER SQUARE CENTIMETER
INTEGRA MATRIX, PER SQUARE CENTIMETER
SKIN SUBSTITUTE, TISSUEMEND, PER SQUARE CENTIMETER
PRIMATRIX, PER SQUARE CENTIMETER
GAMMAGRAFT, PER SQUARE CENTIMETER
CYMETRA, INJECTABLE, 1CC
GRAFTJACKET XPRESS, INJECTABLE, 1CC
INTEGRA FLOWABLE WOUND MATRIX, INJECTABLE, 1CC
ALLOSKIN, PER SQUARE CENTIMETER
ALLODERM, PER SQUARE CENTIMETER
HYALOMATRIX, PER SQUARE CENTIMETER
MATRISTEM MICROMATRIX, 1 MG
MATRISTEM WOUND MATRIX, PER SQUARE CENTIMETER
MATRISTEM BURN MATRIX, PER SQUARE CENTIMETER
THERASKIN, PER SQUARE CENTIMETER
HOSPICE CARE PROVIDED IN PATIENT'S HOME/RESIDENCE
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HOSPICE CARE PROVIDED IN ASSISTED LIVING FACILITY
HOSPICE CARE PROVIDED IN NURSING LONG TERM CARE FACILITY (LTC) OR NON-SKILLED
NURSING FACILITY (NF)
HOSPICE CARE PROVIDED IN SKILLED NURSING FACILITY (SNF)
HOSPICE CARE PROVIDED IN INPATIENT HOSPITAL
HOSPICE CARE PROVIDED IN INPATIENT HOSPICE FACILITY
HOSPICE CARE PROVIDED IN LONG TERM CARE FACILITY
HOSPICE CARE PROVIDED IN INPATIENT PSYCHIATRIC FACILITY
HOSPICE CARE PROVIDED IN PLACE NOT OTHERWISE SPECIFIED (NOS)
HOSPICE HOME CARE PROVIDED IN A HOSPICE FACILITY
LOW OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML
LOW OSMOLAR CONTRAST MATERIAL, 150-199 MG/ML IODINE CONCENTRATION, PER ML
LOW OSMOLAR CONTRAST MATERIAL, 200-249 MG/ML IODINE CONCENTRATION, PER ML
LOW OSMOLAR CONTRAST MATERIAL, 250-299 MG/ML IODINE CONCENTRATION, PER ML
LOW OSMOLAR CONTRAST MATERIAL, 300-349 MG/ML IODINE CONCENTRATION, PER ML
LOW OSMOLAR CONTRAST MATERIAL, 350-399 MG/ML IODINE CONCENTRATION, PER ML
LOW OSMOLAR CONTRAST MATERIAL, 400 OR GREATER MG/ML IODINE CONCENTRATION, PER ML
INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, PER ML
INJECTION, IRON-BASED MAGNETIC RESONANCE CONTRAST AGENT, PER ML
ORAL MAGNETIC RESONANCE CONTRAST AGENT, PER 100 ML
INJECTION, PERFLEXANE LIPID MICROSPHERES, PER ML
INJECTION, OCTAFLUOROPROPANE MICROSPHERES, PER ML
INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML
HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML
HIGH OSMOLAR CONTRAST MATERIAL, 150-199 MG/ML IODINE CONCENTRATION, PER ML
HIGH OSMOLAR CONTRAST MATERIAL, 200-249 MG/ML IODINE CONCENTRATION, PER ML
HIGH OSMOLAR CONTRAST MATERIAL, 250-299 MG/ML IODINE CONCENTRATION, PER ML
HIGH OSMOLAR CONTRAST MATERIAL, 300-349 MG/ML IODINE CONCENTRATION, PER ML
HIGH OSMOLAR CONTRAST MATERIAL, 350-399 MG/ML IODINE CONCENTRATION, PER ML
HIGH OSMOLAR CONTRAST MATERIAL, 400 OR GREATER MG/ML IODINE CONCENTRATION, PER
ML
LOW OSMOLAR CONTRAST MATERIAL, 100-199 MG/ML IODINE CONCENTRATION, PER ML
LOW OSMOLAR CONTRAST MATERIAL, 200-299 MG/ML IODINE CONCENTRATION, PER ML
LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML
INJECTION, NON-RADIOACTIVE, NON-CONTRAST, VISUALIZATION ADJUNCT (E.G.,
METHYLENE BLUE, ISOSULFAN BLUE), 1 MG
TRANSPORTATION OF PORTABLE X-RAY EQUIPMENT AND PERSONNEL TO HOME OR NURSING
HOME, PER TRIP TO FACILITY OR LOCATION, ONE PATIENT SEEN
TRANSPORTATION OF PORTABLE X-RAY EQUIPMENT AND PERSONNEL TO HOME OR NURSING
HOME, PER TRIP TO FACILITY OR LOCATION, MORE THAN ONE PATIENT SEEN
TRANSPORTATION OF PORTABLE EKG TO FACILITY OR LOCATION, PER PATIENT
BUTORPHANOL TARTRATE, NASAL SPRAY, 25 MG
TACRINE HYDROCHLORIDE, 10 MG
INJECTION, AMINOCAPROIC ACID, 5 GRAMS
INJECTION, BUPIVICAINE HYDROCHLORIDE, 30 ML
INJECTION, CEFOPERAZONE SODIUM, 1 GRAM
INJECTION, CIMETIDINE HYDROCHLORIDE, 300 MG
INJECTION, FAMOTIDINE, 20 MG
INJECTION, METRONIDAZOLE, 500 MG
INJECTION, NAFCILLIN SODIUM, 2 GRAMS
INJECTION, OFLOXACIN, 400 MG
INJECTION, SULFAMETHOXAZOLE AND TRIMETHOPRIM, 10 ML
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INJECTION, TICARCILLIN DISODIUM AND CLAVULANATE POTASSIUM, 3.1 GRAMS
INJECTION, AZTREONAM, 500 MG
INJECTION, CEFOTETAN DISODIUM, 500 MG
INJECTION, CLINDAMYCIN PHOSPHATE, 300 MG
INJECTION, FOSPHENYTOIN SODIUM, 750 MG
INJECTION, PENTAMIDINE ISETHIONATE, 300 MG
INJECTION, PIPERACILLIN SODIUM, 500 MG
IMATINIB, 100 MG
SILDENAFIL CITRATE, 25 MG
GRANISETRON HYDROCHLORIDE, 1MG (FOR CIRCUMSTANCES FALLING UNDER THE MEDICARE
STATUTE, USE Q0166)
INJECTION, HYDROMORPHONE HYDROCHLORIDE, 250 MG (LOADING DOSE FOR INFUSION PUMP)
INJECTION, MORPHINE SULFATE, 500 MG (LOADING DOSE FOR INFUSION PUMP)
ZIDOVUDINE, ORAL, 100 MG
BUPROPION HCL SUSTAINED RELEASE TABLET, 150 MG, PER BOTTLE OF 60 TABLETS
MERCAPTOPURINE, ORAL, 50 MG
METHADONE, ORAL, 5 MG
TRETINOIN, TOPICAL, 5 GRAMS
INJECTION, MENOTROPINS, 75 IU
INJECTION, FOLLITROPIN ALFA, 75 IU
INJECTION, FOLLITROPIN BETA, 75 IU
INJECTION, GANIRELIX ACETATE, 250 MCG
CLOZAPINE, 25 MG
DIDANOSINE (DDI), 25 MG
FINASTERIDE, 5 MG
MINOXIDIL, 10 MG
SAQUINAVIR, 200 MG
ZALCITABINE (DDC), 0.375 MG
COLISTIMETHATE SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DME,
CONCENTRATED FORM, PER MG
AZTREONAM, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER
GRAM
INJECTION, PEGYLATED INTERFERON ALFA-2A, 180 MCG PER ML
INJECTION, PEGYLATED INTERFERON ALFA-2B, 10 MCG PER 0.5 ML
INJECTION, ALGLUCOSIDASE ALFA, 20 MG
INJECTION, PEGYLATED INTERFERON ALFA-2B, 10 MCG
STERILE DILUTANT FOR EPOPROSTENOL, 50ML
EXEMESTANE, 25 MG
BECAPLERMIN GEL 0.01%, 0.5 GM
DEXTROAMPHETAMINE SULFATE, 5 MG
CALCITROL, 0.25 MG
INJECTION, EFALIZUMAB, 125 MG
INJECTION, PANTOPRAZOLE SODIUM, 40 MG
INJECTION, OLANZAPINE, 2.5 MG
INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG
CALCITROL, 0.25 MICROGRAM
ANASTROZOLE, ORAL, 1MG
INJECTION, BUMETANIDE, 0.5MG
CHLORAMBUCIL, ORAL, 2MG
DOLASETRON MESYLATE, ORAL 50MG (FOR CIRCUMSTANCES FALLING UNDER THE MEDICARE
STATUTE, USE Q0180)
FLUTAMIDE, ORAL, 125MG
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HYDROXYUREA, ORAL, 500MG
LEVAMISOLE HYDROCHLORIDE, ORAL, 50MG
LOMUSTINE, ORAL, 10MG
MEGESTROL ACETATE, ORAL, 20MG
ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES
ONDANSETRON HYDROCHLORIDE, ORAL, 4MG (FOR CIRCUMSTANCES FALLING UNDER THE
MEDICARE STATUTE, USE Q0179)
PROCARBAZINE HYDROCHLORIDE, ORAL, 50MG
PROCHLORPERAZINE MALEATE, ORAL, 5MG (FOR CIRCUMSTANCES FALLING UNDER THE
MEDICARE STATUTE, USE Q0164 - Q0165)
TAMOXIFEN CITRATE, ORAL, 10MG
TESTOSTERONE PELLET, 75MG
MIFEPRISTONE, ORAL, 200 MG
MISOPROSTOL, ORAL, 200 MCG
DIALYSIS/STRESS VITAMIN SUPPLEMENT, ORAL, 100 CAPSULES
PNEUMOCOCCAL CONJUGATE VACCINE, POLYVALENT, INTRAMUSCULAR, FOR CHILDREN FROM
FIVE YEARS TO NINE YEARS OF AGE WHO HAVE NOT PREVIOUSLY RECEIVED THE VACCINE
INJECTABLE POLY-L-LACTIC ACID, RESTORATIVE IMPLANT, 1 ML, FACE (DEEP DERMIS,
SUBCUTANEOUS LAYERS)
PRENATAL VITAMINS, 30-DAY SUPPLY
MEDICALLY INDUCED ABORTION BY ORAL INGESTION OF MEDICATION INCLUDING ALL
ASSOCIATED SERVICES AND SUPPLIES (E.G., PATIENT COUNSELING, OFFICE VISITS,
CONFIRMATION OF PREGNANCY BY HCG, ULTRASOUND TO CONFIRM DURATION OF PREGNANCY,
ULTRASOUND TO CONFIRM COMPLETION OF ABORTION) EXCEPT DRUGS
PARTIAL HOSPITALIZATION SERVICES, LESS THAN 24 HOURS, PER DIEM
PARAMEDIC INTERCEPT, NON-HOSPITAL-BASED ALS SERVICE (NON-VOLUNTARY),
NON-TRANSPORT
PARAMEDIC INTERCEPT, HOSPITAL-BASED ALS SERVICE (NON-VOLUNTARY), NON-TRANSPORT
WHEELCHAIR VAN, MILEAGE, PER MILE
NON-EMERGENCY TRANSPORTATION; MILEAGE, PER MILE
MEDICAL CONFERENCE BY A PHYSICIAN WITH INTERDISCIPLINARY TEAM OF HEALTH
PROFESSIONALS OR REPRESENTATIVES OF COMMUNITY AGENCIES TO COORDINATE ACTIVITIES
OF PATIENT CARE (PATIENT IS PRESENT); APPROXIMATELY 30 MINUTES
MEDICAL CONFERENCE BY A PHYSICIAN WITH INTERDISCIPLINARY TEAM OF HEALTH
PROFESSIONALS OR REPRESENTATIVES OF COMMUNITY AGENCIES TO COORDINATE ACTIVITIES
OF PATIENT CARE (PATIENT IS PRESENT); APPROXIMATELY 60 MINUTES
COMPREHENSIVE GERIATRIC ASSESSMENT AND TREATMENT PLANNING PERFORMED BY
ASSESSMENT TEAM
HOSPICE REFERRAL VISIT (ADVISING PATIENT AND FAMILY OF CARE OPTIONS) PERFORMED
BY NURSE, SOCIAL WORKER, OR OTHER DESIGNATED STAFF
COUNSELING AND DISCUSSION REGARDING ADVANCE DIRECTIVES OR END OF LIFE CARE
PLANNING AND DECISIONS, WITH PATIENT AND/OR SURROGATE (LIST SEPARATELY IN
ADDITION TO CODE FOR APPROPRIATE EVALUATION AND MANAGEMENT SERVICE)
HISTORY AND PHYSICAL (OUTPATIENT OR OFFICE) RELATED TO SURGICAL PROCEDURE (LIST
SEPARATELY IN ADDITION TO CODE FOR APPROPRIATE EVALUATION AND MANAGEMENT
SERVICE)
GENETIC COUNSELING, UNDER PHYSICIAN SUPERVISION, EACH 15 MINUTES
PHYSICIAN MANAGEMENT OF PATIENT HOME CARE, STANDARD MONTHLY CASE RATE (PER 30
DAYS)
PHYSICIAN MANAGEMENT OF PATIENT HOME CARE, HOSPICE MONTHLY CASE RATE (PER 30
DAYS)
PHYSICIAN MANAGEMENT OF PATIENT HOME CARE, EPISODIC CARE MONTHLY CASE RATE (PER
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30 DAYS)
PHYSICIAN VISIT AT MEMBER'S HOME, OUTSIDE OF A CAPITATION ARRANGEMENT
NURSE PRACTITIONER VISIT AT MEMBER'S HOME, OUTSIDE OF A CAPITATION ARRANGEMENT
MEDICAL HOME PROGRAM, COMPREHENSIVE CARE COORDINATION AND PLANNING, INITIAL PLAN
MEDICAL HOME PROGRAM, COMPREHENSIVE CARE COORDINATION AND PLANNING, MAINTENANCE
OF PLAN
COMPLETED EARLY PERIODIC SCREENING DIAGNOSIS AND TREATMENT (EPSDT) SERVICE
(LIST IN ADDITION TO CODE FOR APPROPRIATE EVALUATION AND MANAGEMENT SERVICE)
HOSPITALIST SERVICES (LIST SEPARATELY IN ADDITION TO CODE FOR APPROPRIATE
EVALUATION AND MANAGEMENT SERVICE)
DISEASE MANAGEMENT PROGRAM; INITIAL ASSESSMENT AND INITIATION OF THE PROGRAM
DISEASE MANAGEMENT PROGRAM, FOLLOW-UP/REASSESSMENT
DISEASE MANAGEMENT PROGRAM; PER DIEM
TELEPHONE CALLS BY A REGISTERED NURSE TO A DISEASE MANAGEMENT PROGRAM MEMBER
FOR MONITORING PURPOSES; PER MONTH
LIFESTYLE MODIFICATION PROGRAM FOR MANAGEMENT OF CORONARY ARTERY DISEASE,
INCLUDING ALL SUPPORTIVE SERVICES; FIRST QUARTER / STAGE
LIFESTYLE MODIFICATION PROGRAM FOR MANAGEMENT OF CORONARY ARTERY DISEASE,
INCLUDING ALL SUPPORTIVE SERVICES; SECOND OR THIRD QUARTER / STAGE
LIFESTYLE MODIFICATION PROGRAM FOR MANAGEMENT OF CORONARY ARTERY DISEASE,
INCLUDING ALL SUPPORTIVE SERVICES; FOURTH QUARTER / STAGE
ELECTROCARDIOGRAPHIC MONITORING UTILIZING A HOME COMPUTERIZED TELEMETRY STATION
WITH AUTOMATIC ACTIVATION AND REAL-TIME NOTIFICATION OF MONITORING STATION,
24-HOUR ATTENDED MONITORING, INCLUDING RECORDING, MONITORING, RECEIPT OF
TRANSMISSIONS, ANALYSIS, AND PHYSICIAN REVIEW AND INTERPRETATION; PER 24-HOUR
PERIOD
ELECTROCARDIOGRAPHIC MONITORING UTILIZING A HOME COMPUTERIZED TELEMETRY STATION
WITH AUTOMATIC ACTIVATION AND REAL-TIME NOTIFICATION OF MONITORING STATION,
24-HOUR ATTENDED MONITORING, INCLUDING RECORDING, MONITORING, RECEIPT OF
TRANSMISSIONS, AND ANALYSIS; PER 24-HOUR PERIOD
ELECTROCARDIOGRAPHIC MONITORING UTILIZING A HOME COMPUTERIZED TELEMETRY STATION
WITH AUTOMATIC ACTIVATION AND REAL-TIME NOTIFICATION OF MONITORING STATION,
24-HOUR ATTENDED MONITORING, INCLUDING PHYSICIAN REVIEW AND INTERPRETATION;
24-HOUR PERIOD
ROUTINE FOOT CARE; REMOVAL AND/OR TRIMMING OF CORNS, CALLUSES AND/OR NAILS AND
PREVENTIVE MAINTENANCE IN SPECIFIC MEDICAL CONDITIONS (E.G. DIABETES), PER VISIT
IMPRESSION CASTING OF A FOOT PERFORMED BY A PRACTITIONER OTHER THAN THE
MANUFACTURER OF THE ORTHOTIC
GLOBAL FEE FOR EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY TREATMENT OF KIDNEY
STONE(S)
DISPOSABLE CONTACT LENS, PER LENS
SINGLE VISION PRESCRIPTION LENS (SAFETY, ATHLETIC, OR SUNGLASS), PER LENS
BIFOCAL VISION PRESCRIPTION LENS (SAFETY, ATHLETIC, OR SUNGLASS), PER LENS
TRIFOCAL VISION PRESCRIPTION LENS (SAFETY, ATHLETIC, OR SUNGLASS), PER LENS
NON-PRESCRIPTION LENS (SAFETY, ATHLETIC, OR SUNGLASS), PER LENS
DAILY WEAR SPECIALTY CONTACT LENS, PER LENS
COLOR CONTACT LENS, PER LENS
SCLERAL LENS, LIQUID BANDAGE DEVICE, PER LENS
SAFETY EYEGLASS FRAMES
SUNGLASSES FRAMES
POLYCARBONATE LENS (LIST THIS CODE IN ADDITION TO THE BASIC CODE FOR THE LENS)
NONSTANDARD LENS (LIST THIS CODE IN ADDITION TO THE BASIC CODE FOR THE LENS)
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INTEGRAL LENS SERVICE, MISCELLANEOUS SERVICES REPORTED SEPARATELY
COMPREHENSIVE CONTACT LENS EVALUATION
DISPENSING NEW SPECTACLE LENSES FOR PATIENT SUPPLIED FRAME
SCREENING PROCTOSCOPY
DIGITAL RECTAL EXAMINATION, MALE, ANNUAL
ANNUAL GYNECOLOGICAL EXAMINATION, NEW PATIENT
ANNUAL GYNECOLOGICAL EXAMINATION, ESTABLISHED PATIENT
ANNUAL GYNECOLOGICAL EXAMINATION; CLINICAL BREAST EXAMINATION WITHOUT PELVIC
EVALUATION
AUDIOMETRY FOR HEARING AID EVALUATION TO DETERMINE THE LEVEL AND DEGREE OF
HEARING LOSS
ROUTINE OPHTHALMOLOGICAL EXAMINATION INCLUDING REFRACTION; NEW PATIENT
ROUTINE OPHTHALMOLOGICAL EXAMINATION INCLUDING REFRACTION; ESTABLISHED PATIENT
PHYSICAL EXAM FOR COLLEGE, NEW OR ESTABLISHED PATIENT (LIST SEPARATELY IN
ADDITION TO APPROPRIATE EVALUATION AND MANAGEMENT CODE)
RETINAL TELESCREENING BY DIGITAL IMAGING OF MULTIPLE DIFFERENT FUNDUS AREAS TO
SCREEN FOR VISION-THREATENING CONDITIONS, INCLUDING IMAGING, INTERPRETATION AND
REPORT
REMOVAL OF SUTURES; BY A PHYSICIAN OTHER THAN THE PHYSICIAN WHO ORIGINALLY
CLOSED THE WOUND
LASER IN SITU KERATOMILEUSIS (LASIK)
PHOTOREFRACTIVE KERATECTOMY (PRK)
PHOTOTHERAPEUTIC KERATECTOMY (PTK)
COMPUTERIZED CORNEAL TOPOGRAPHY, UNILATERAL
DELUXE ITEM, PATIENT AWARE (LIST IN ADDITION TO CODE FOR BASIC ITEM)
CUSTOMIZED ITEM (LIST IN ADDITION TO CODE FOR BASIC ITEM)
IV TUBING EXTENSION SET
NON-PVC (POLYVINYL CHLORIDE) INTRAVENOUS ADMINISTRATION SET, FOR USE WITH DRUGS
THAT ARE NOT STABLE IN PVC E.G. PACLITAXEL
INHALED NITRIC OXIDE FOR THE TREATMENT OF HYPOXIC RESPIRATORY FAILURE IN THE
NEONATE; PER DIEM
CONTINUOUS NONINVASIVE GLUCOSE MONITORING DEVICE, PURCHASE (FOR PHYSICIAN
INTERPRETATION OF DATA, USE CPT CODE)
CONTINUOUS NONINVASIVE GLUCOSE MONITORING DEVICE, RENTAL, INCLUDING SENSOR,
SENSOR REPLACEMENT, AND DOWNLOAD TO MONITOR (FOR PHYSICIAN INTERPRETATION OF
DATA, USE CPT CODE)
CRANIAL REMOLDING ORTHOSIS, PEDIATRIC, RIGID, WITH SOFT INTERFACE MATERIAL,
CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT(S)
TRANSPLANTATION OF SMALL INTESTINE AND LIVER ALLOGRAFTS
TRANSPLANTATION OF MULTIVISCERAL ORGANS
HARVESTING OF DONOR MULTIVISCERAL ORGANS, WITH PREPARATION AND MAINTENANCE OF
ALLOGRAFTS; FROM CADAVER DONOR
LOBAR LUNG TRANSPLANTATION
DONOR LOBECTOMY (LUNG) FOR TRANSPLANTATION, LIVING DONOR
SIMULTANEOUS PANCREAS KIDNEY TRANSPLANTATION
BREAST RECONSTRUCTION WITH GLUTEAL ARTERY PERFORATOR (GAP) FLAP, INCLUDING
HARVESTING OF THE FLAP, MICROVASCULAR TRANSFER, CLOSURE OF DONOR SITE AND
SHAPING THE FLAP INTO A BREAST, UNILATERAL
BREAST RECONSTRUCTION OF A SINGLE BREAST WITH "STACKED" DEEP INFERIOR
EPIGASTRIC PERFORATOR (DIEP) FLAP(S) AND/OR GLUTEAL ARTERY PERFORATOR (GAP)
FLAP(S), INCLUDING HARVESTING OF THE FLAP(S), MICROVASCULAR TRANSFER, CLOSURE
OF DONOR SITE(S) AND SHAPING THE FLAP INTO A BREAST, UNILATERAL
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BREAST RECONSTRUCTION WITH DEEP INFERIOR EPIGASTRIC PERFORATOR (DIEP) FLAP OR
SUPERFICIAL INFERIOR EPIGASTRIC ARTERY (SIEA) FLAP, INCLUDING HARVESTING OF THE
FLAP, MICROVASCULAR TRANSFER, CLOSURE OF DONOR SITE AND SHAPING THE FLAP INTO A
BREAST, UNILATERA
CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH ENDOSCOPIC LASER
TREATMENT OF URETERAL CALCULI (INCLUDES URETERAL CATHETERIZATION)
LAPAROSCOPY, SURGICAL; REPAIR INCISIONAL OR VENTRAL HERNIA
LAPAROSCOPY, SURGICAL; REPAIR UMBILICAL HERNIA
LAPAROSCOPY, SURGICAL; IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR INCISIONAL
OR VENTRAL HERNIA REPAIR (LIST SEPARATELY IN ADDITION TO CODE FOR INCISIONAL OR
VENTRAL HERNIA REPAIR)
LAPAROSCOPIC SUPRACERVICAL HYSTERECTOMY (SUBTOTAL HYSTERECTOMY), WITH OR
WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S)
LAPAROSCOPIC ESOPHAGOMYOTOMY (HELLER TYPE)
LASER-ASSISTED UVULOPALATOPLASTY (LAUP)
ADJUSTMENT OF GASTRIC BAND DIAMETER VIA SUBCUTANEOUS PORT BY INJECTION OR
ASPIRATION OF SALINE
TRANSCATHETER OCCLUSION OR EMBOLIZATION FOR TUMOR DESTRUCTION, PERCUTANEOUS,
ANY METHOD, USING YTTRIUM-90 MICROSPHERES
ISLET CELL TISSUE TRANSPLANT FROM PANCREAS; ALLOGENEIC
ADRENAL TISSUE TRANSPLANT TO BRAIN
ADOPTIVE IMMUNOTHERAPY I.E. DEVELOPMENT OF SPECIFIC ANTI-TUMOR REACTIVITY (E.G.
TUMOR-INFILTRATING LYMPHOCYTE THERAPY) PER COURSE OF TREATMENT
ARTHROSCOPY, KNEE, SURGICAL FOR HARVESTING OF CARTILAGE (CHONDROCYTE CELLS)
ARTHROSCOPY, SHOULDER, SURGICAL; TENODESIS OF BICEPS
OSTEOTOMY, PERIACETABULAR, WITH INTERNAL FIXATION
ARTHROEREISIS, SUBTALAR
METAL-ON-METAL TOTAL HIP RESURFACING, INCLUDING ACETABULAR AND FEMORAL
COMPONENTS
LOW DENSITY LIPOPROTEIN (LDL) APHERESIS USING HEPARIN-INDUCED EXTRACORPOREAL
LDL PRECIPITATION
NEUROLYSIS, BY INJECTION, OF METATARSAL NEUROMA/INTERDIGITAL NEURITIS, ANY
INTERSPACE OF THE FOOT
CORD BLOOD HARVESTING FOR TRANSPLANTATION, ALLOGENEIC
CORD BLOOD-DERIVED STEM-CELL TRANSPLANTATION, ALLOGENEIC
BONE MARROW OR BLOOD-DERIVED STEM CELLS (PERIPHERAL OR UMBILICAL), ALLOGENEIC
OR AUTOLOGOUS, HARVESTING, TRANSPLANTATION, AND RELATED COMPLICATIONS;
INCLUDING: PHERESIS AND CELL PREPARATION/STORAGE; MARROW ABLATIVE THERAPY;
DRUGS, SUPPLIES, HOSPITALIZATION WITH OUTPATIENT FOLLOW-UP; MEDICAL/SURGICAL,
DIAGNOSTIC, EMERGENCY, AND REHABILITATIVE SERVICES; AND THE NUMBER OF DAYS OF
PRE-AND POST-TRANSPLANT CARE IN THE GLOBAL DEFINITION
SOLID ORGAN(S), COMPLETE OR SEGMENTAL, SINGLE ORGAN OR COMBINATION OF ORGANS;
DECEASED OR LIVING DONOR (S), PROCUREMENT, TRANSPLANTATION, AND RELATED
COMPLICATIONS; INCLUDING: DRUGS; SUPPLIES; HOSPITALIZATION WITH OUTPATIENT
FOLLOW-UP; MEDICAL/SURGICAL, DIAGNOSTIC, EMERGENCY, AND REHABILITATIVE
SERVICES, AND THE NUMBER OF DAYS OF PRE- AND POST-TRANSPLANT CARE IN THE GLOBAL
DEFINITION
ECHOSCLEROTHERAPY
MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING
MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION;
USING ARTERIAL GRAFT(S), SINGLE CORONARY ARTERIAL GRAFT
MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING
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MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION;
USING ARTERIAL GRAFT(S), TWO CORONARY ARTERIAL GRAFTS
MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING
MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION;
USING VENOUS GRAFT ONLY, SINGLE CORONARY VENOUS GRAFT
MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING
MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION;
USING SINGLE ARTERIAL AND VENOUS GRAFT(S), SINGLE VENOUS GRAFT
MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING
MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION;
USING TWO ARTERIAL GRAFTS AND SINGLE VENOUS GRAFT
IMPLANTATION OF GASTRIC ELECTRICAL STIMULATION DEVICE
MYRINGOTOMY, LASER-ASSISTED
IMPLANTATION OF MAGNETIC COMPONENT OF SEMI-IMPLANTABLE HEARING DEVICE ON
OSSICLES IN MIDDLE EAR
IMPLANTATION OF AUDITORY BRAIN STEM IMPLANT
UTERINE ARTERY EMBOLIZATION FOR UTERINE FIBROIDS
INDUCED ABORTION, 17 TO 24 WEEKS
INDUCED ABORTION, 25 TO 28 WEEKS
INDUCED ABORTION, 29 TO 31 WEEKS
INDUCED ABORTION, 32 WEEKS OR GREATER
INSERTION OF VAGINAL CYLINDER FOR APPLICATION OF RADIATION SOURCE OR CLINICAL
BRACHYTHERAPY (REPORT SEPARATELY IN ADDITION TO RADIATION SOURCE DELIVERY)
ARTHROSCOPY, SHOULDER, SURGICAL; WITH THERMALLY-INDUCED CAPSULORRHAPHY
HIP CORE DECOMPRESSION
CHEMODENERVATION OF ABDUCTOR MUSCLE(S) OF VOCAL CORD
CHEMODENERVATION OF ADDUCTOR MUSCLE(S) OF VOCAL CORD
NASAL ENDOSCOPY FOR POST-OPERATIVE DEBRIDEMENT FOLLOWING FUNCTIONAL ENDOSCOPIC
SINUS SURGERY, NASAL AND/OR SINUS CAVITY(S), UNILATERAL OR BILATERAL
NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ENLARGEMENT OF SINUS OSTIUM OPENING USING
INFLATABLE DEVICE (I.E., BALLOON SINUPLASTY)
DECOMPRESSION PROCEDURE, PERCUTANEOUS, OF NUCLEUS PULPOSUS OF INTERVERTEBRAL
DISC, USING RADIOFREQUENCY ENERGY, SINGLE OR MULTIPLE LEVELS, LUMBAR
DISKECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S),
INCLUDING OSTEOPHYTECTOMY; LUMBAR, SINGLE INTERSPACE
DISKECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S),
INCLUDING OSTEOPHYTECTOMY; LUMBAR, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY
IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL
INJECTION; CERVICAL
EACH ADDITIONAL CERVICAL VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE
FOR PRIMARY PROCEDURE)
REPAIR, CONGENITAL DIAPHRAGMATIC HERNIA IN THE FETUS USING TEMPORARY TRACHEAL
OCCLUSION, PROCEDURE PERFORMED IN UTERO
REPAIR, URINARY TRACT OBSTRUCTION IN THE FETUS, PROCEDURE PERFORMED IN UTERO
REPAIR, CONGENITAL CYSTIC ADENOMATOID MALFORMATION IN THE FETUS, PROCEDURE
PERFORMED IN UTERO
REPAIR, EXTRALOBAR PULMONARY SEQUESTRATION IN THE FETUS, PROCEDURE PERFORMED IN
UTERO
REPAIR, MYELOMENINGOCELE IN THE FETUS, PROCEDURE PERFORMED IN UTERO
REPAIR OF SACROCOCCYGEAL TERATOMA IN THE FETUS, PROCEDURE PERFORMED IN UTERO
REPAIR, CONGENITAL MALFORMATION OF FETUS, PROCEDURE PERFORMED IN UTERO, NOT
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OTHERWISE CLASSIFIED
FETOSCOPIC LASER THERAPY FOR TREATMENT OF TWIN-TO-TWIN TRANSFUSION SYNDROME
SURGICAL TECHNIQUES REQUIRING USE OF ROBOTIC SURGICAL SYSTEM (LIST SEPARATELY
IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
DIABETIC INDICATOR; RETINAL EYE EXAM, DILATED, BILATERAL
PERFORMANCE MEASUREMENT, EVALUATION OF PATIENT SELF ASSESSMENT, DEPRESSION
STAT LABORATORY REQUEST (SITUATIONS OTHER THAN S3601)
EMERGENCY STAT LABORATORY CHARGE FOR PATIENT WHO IS HOMEBOUND OR RESIDING IN A
NURSING FACILITY
BLOOD CHEMISTRY FOR FREE BETA HUMAN CHORIONIC GONADOTROPIN (HCG)
NEWBORN METABOLIC SCREENING PANEL, INCLUDES TEST KIT, POSTAGE AND THE
LABORATORY TESTS SPECIFIED BY THE STATE FOR INCLUSION IN THIS PANEL (E.G.
GALACTOSE; HEMOGLOBIN, ELECTROPHORESIS; HYDROXYPROGESTERONE, 17-D; PHENYLANINE
(PKU); AND THYROXINE, TOTAL)
MATERNAL SERUM TRIPLE MARKER SCREEN INCLUDING ALPHA-FETOPROTEIN (AFP), ESTRIOL,
AND HUMAN CHORIONIC GONADOTROPIN (HCG)
MATERNAL SERUM QUADRUPLE MARKER SCREEN INCLUDING ALPHA-FETOPROTEIN (AFP),
ESTRIOL, HUMAN CHORIONIC GONADOTROPIN (HCG) AND INHIBIN A
PLACENTAL ALPHA MICROGLOBULIN-1 RAPID IMMUNOASSAY FOR DETECTION OF RUPTURE OF
FETAL MEMBRANES
EOSINOPHIL COUNT, BLOOD, DIRECT
HIV-1 ANTIBODY TESTING OF ORAL MUCOSAL TRANSUDATE
SALIVA TEST, HORMONE LEVEL; DURING MENOPAUSE
SALIVA TEST, HORMONE LEVEL; TO ASSESS PRETERM LABOR RISK
ANTISPERM ANTIBODIES TEST (IMMUNOBEAD)
GASTROINTESTINAL FAT ABSORPTION STUDY
CIRCULATING TUMOR CELL TEST
KRAS MUTATION ANALYSIS TESTING
GENETIC TESTING FOR AMYOTROPHIC LATERAL SCLEROSIS (ALS)
COMPLETE GENE SEQUENCE ANALYSIS; BRCA1 GENE
COMPLETE GENE SEQUENCE ANALYSIS; BRCA2 GENE
COMPLETE BRCA1 AND BRCA2 GENE SEQUENCE ANALYSIS FOR SUSCEPTIBILITY TO BREAST
AND OVARIAN CANCER
SINGLE MUTATION ANALYSIS (IN INDIVIDUAL WITH A KNOWN BRCA1 OR BRCA2 MUTATION IN
THE FAMILY) FOR SUSCEPTIBILITY TO BREAST AND OVARIAN CANCER
THREE-MUTATION BRCA1 AND BRCA2 ANALYSIS FOR SUSCEPTIBILITY TO BREAST AND
OVARIAN CANCER IN ASHKENAZI INDIVIDUALS
COMPLETE GENE SEQUENCE ANALYSIS; MLH1 GENE
COMPLETE GENE SEQUENCE ANALYSIS; MSH2 GENE
COMPLETE MLH1 AND MSH2 GENE SEQUENCE ANALYSIS FOR HEREDITARY NONPOLYPOSIS
COLORECTAL CANCER (HNPCC) GENETIC TESTING
SINGLE-MUTATION ANALYSIS (IN INDIVIDUAL WITH A KNOWN MLH1 AND MSH2 MUTATION IN
THE FAMILY) FOR HEREDITARY NONPOLYPOSIS COLORECTAL CANCER (HNPCC) GENETIC
TESTING
COMPLETE APC GENE SEQUENCE ANALYSIS FOR SUSCEPTIBILITY TO FAMILIAL ADENOMATOUS
POLYPOSIS (FAP) AND ATTENUATED FAP
SINGLE-MUTATION ANALYSIS (IN INDIVIDUAL WITH A KNOWN APC MUTATION IN THE
FAMILY) FOR SUSCEPTIBILITY TO FAMILIAL ADENOMATOUS POLYPOSIS (FAP) AND
ATTENUATED FAP
COMPLETE GENE SEQUENCE ANALYSIS FOR CYSTIC FIBROSIS GENETIC TESTING
COMPLETE GENE SEQUENCE ANALYSIS FOR HEMOCHROMATOSIS GENETIC TESTING
DNA ANALYSIS FOR GERMLINE MUTATIONS OF THE RET PROTO-ONCOGENE FOR
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SUSCEPTIBILITY TO MULTIPLE ENDOCRINE NEOPLASIA TYPE 2
GENETIC TESTING FOR RETINOBLASTOMA
GENETIC TESTING FOR VON HIPPEL-LINDAU DISEASE
DNA ANALYSIS OF THE F5 GENE FOR SUSCEPTIBILITY TO FACTOR V LEIDEN THROMBOPHILIA
DNA ANALYSIS OF THE CONNEXIN 26 GENE (GJB2) FOR SUSCEPTIBILITY TO CONGENITAL,
PROFOUND DEAFNESS
GENETIC TESTING FOR ALPHA-THALASSEMIA
GENETIC TESTING FOR HEMOGLOBIN E BETA-THALASSEMIA
GENETIC TESTING FOR TAY-SACHS DISEASE
GENETIC TESTING FOR GAUCHER DISEASE
GENETIC TESTING FOR NIEMANN-PICK DISEASE
GENETIC TESTING FOR SICKLE CELL ANEMIA
GENETIC TESTING FOR CANAVAN DISEASE
DNA ANALYSIS FOR APOE EPSILON 4 ALLELE FOR SUSCEPTIBILITY TO ALZHEIMER'S DISEASE
GENETIC TESTING FOR MYOTONIC MUSCULAR DYSTROPHY
GENE EXPRESSION PROFILING PANEL FOR USE IN THE MANAGEMENT OF BREAST CANCER
TREATMENT
GENETIC TESTING FOR DETECTION OF MUTATIONS IN THE PRESENILIN - 1 GENE
GENETIC TESTING, COMPREHENSIVE CARDIAC ION CHANNEL ANALYSIS, FOR VARIANTS IN 5
MAJOR CARDIAC ION CHANNEL GENES FOR INDIVIDUALS WITH HIGH INDEX OF SUSPICION
FOR FAMILIAL LONG QT SYNDROME (LQTS) OR RELATED SYNDROMES
GENETIC TESTING, SODIUM CHANNEL, VOLTAGE-GATED, TYPE V, ALPHA SUBUNIT (SCN5A)
AND VARIANTS FOR SUSPECTED BRUGADA SYNDROME
GENETIC TESTING, FAMILY-SPECIFIC ION CHANNEL ANALYSIS, FOR BLOOD-RELATIVES OF
INDIVIDUALS (INDEX CASE) WHO HAVE PREVIOUSLY TESTED POSITIVE FOR A GENETIC
VARIANT OF A CARDIAC ION CHANNEL SYNDROME USING EITHER ONE OF THE ABOVE TEST
CONFIGURATIONS OR CONFIRMED RESULTS FROM ANOTHER LABORATORY
COMPREHENSIVE GENE SEQUENCE ANALYSIS FOR HYPERTROPHIC CARDIOMYOPATHY
GENETIC ANALYSIS FOR A SPECIFIC GENE MUTATION FOR HYPERTROPHIC CARDIOMYOPATHY
(HCM) IN AN INDIVIDUAL WITH A KNOWN HCM MUTATION IN THE FAMILY
COMPARATIVE GENOMIC HYBRIZATION (CGH) MICROARRAY TESTING FOR DEVELOPMENTAL
DELAY, AUTISM SPECTRUM DISORDER AND/OR MENTAL RETARDATION
DNA ANALYSIS, FECAL, FOR COLORECTAL CANCER SCREENING
SURFACE ELECTROMYOGRAPHY (EMG)
BALLISTOCARDIOGRAM
MASTERS TWO STEP
NON-INVASIVE ELECTRODIAGNOSTIC TESTING WITH AUTOMATIC COMPUTERIZED HAND-HELD
DEVICE TO STIMULATE AND MEASURE NEUROMUSCULAR SIGNALS IN DIAGNOSING AND
EVALUATING SYSTEMIC AND ENTRAPMENT NEUROPATHIES
INTERIM LABOR FACILITY GLOBAL (LABOR OCCURRING BUT NOT RESULTING IN DELIVERY)
IN VITRO FERTILIZATION; INCLUDING BUT NOT LIMITED TO IDENTIFICATION AND
INCUBATION OF MATURE OOCYTES, FERTILIZATION WITH SPERM, INCUBATION OF
EMBRYO(S), AND SUBSEQUENT VISUALIZATION FOR DETERMINATION OF DEVELOPMENT
COMPLETE CYCLE, GAMETE INTRAFALLOPIAN TRANSFER (GIFT), CASE RATE
COMPLETE CYCLE, ZYGOTE INTRAFALLOPIAN TRANSFER (ZIFT), CASE RATE
COMPLETE IN VITRO FERTILIZATION CYCLE, NOT OTHERWISE SPECIFIED, CASE RATE
FROZEN IN VITRO FERTILIZATION CYCLE, CASE RATE
INCOMPLETE CYCLE, TREATMENT CANCELLED PRIOR TO STIMULATION, CASE RATE
FROZEN EMBRYO TRANSFER PROCEDURE CANCELLED BEFORE TRANSFER, CASE RATE
IN VITRO FERTILIZATION PROCEDURE CANCELLED BEFORE ASPIRATION, CASE RATE
IN VITRO FERTILIZATION PROCEDURE CANCELLED AFTER ASPIRATION, CASE RATE
ASSISTED OOCYTE FERTILIZATION, CASE RATE
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DONOR EGG CYCLE, INCOMPLETE, CASE RATE
DONOR SERVICES FOR IN VITRO FERTILIZATION (SPERM OR EMBRYO), CASE RATE
PROCUREMENT OF DONOR SPERM FROM SPERM BANK
STORAGE OF PREVIOUSLY FROZEN EMBRYOS
MICROSURGICAL EPIDIDYMAL SPERM ASPIRATION (MESA)
SPERM PROCUREMENT AND CRYOPRESERVATION SERVICES; INITIAL VISIT
SPERM PROCUREMENT AND CRYOPRESERVATION SERVICES; SUBSEQUENT VISIT
STIMULATED INTRAUTERINE INSEMINATION (IUI), CASE RATE
CRYOPRESERVED EMBRYO TRANSFER, CASE RATE
MONITORING AND STORAGE OF CRYOPRESERVED EMBRYOS, PER 30 DAYS
MANAGEMENT OF OVULATION INDUCTION (INTERPRETATION OF DIAGNOSTIC TESTS AND
STUDIES, NON-FACE-TO-FACE MEDICAL MANAGEMENT OF THE PATIENT), PER CYCLE
INSERTION OF LEVONORGESTREL-RELEASING INTRAUTERINE SYSTEM
CONTRACEPTIVE INTRAUTERINE DEVICE (E.G. PROGESTACERT IUD), INCLUDING IMPLANTS
AND SUPPLIES
NICOTINE PATCHES, LEGEND
NICOTINE PATCHES, NON-LEGEND
CONTRACEPTIVE PILLS FOR BIRTH CONTROL
SMOKING CESSATION GUM
PRESCRIPTION DRUG, GENERIC
PRESCRIPTION DRUG, BRAND NAME
5% DEXTROSE AND 0.45% NORMAL SALINE, 1000 ML
5% DEXTROSE IN LACTATED RINGER'S, 1000 ML
5% DEXTROSE WITH POTASSIUM CHLORIDE, 1000 ML
5% DEXTROSE/0.45% NORMAL SALINE WITH POTASSIUM CHLORIDE AND MAGNESIUM SULFATE,
1000 ML
5% DEXTROSE/0.45% NORMAL SALINE WITH POTASSIUM CHLORIDE AND MAGNESIUM SULFATE,
1500 ML
HOME INFUSION THERAPY, ROUTINE SERVICE OF INFUSION DEVICE (E.G. PUMP
MAINTENANCE)
HOME INFUSION THERAPY, REPAIR OF INFUSION DEVICE (E.G. PUMP REPAIR)
DAY CARE SERVICES, ADULT; PER 15 MINUTES
DAY CARE SERVICES, ADULT; PER HALF DAY
DAY CARE SERVICES, ADULT; PER DIEM
DAY CARE SERVICES, CENTER-BASED; SERVICES NOT INCLUDED IN PROGRAM FEE, PER DIEM
HOME CARE TRAINING TO HOME CARE CLIENT, PER 15 MINUTES
HOME CARE TRAINING TO HOME CARE CLIENT, PER SESSION
HOME CARE TRAINING, FAMILY; PER 15 MINUTES
HOME CARE TRAINING, FAMILY; PER SESSION
HOME CARE TRAINING, NON-FAMILY; PER 15 MINUTES
HOME CARE TRAINING, NON-FAMILY; PER SESSION
CHORE SERVICES; PER 15 MINUTES
CHORE SERVICES; PER DIEM
ATTENDANT CARE SERVICES; PER 15 MINUTES
ATTENDANT CARE SERVICES; PER DIEM
HOMEMAKER SERVICE, NOS; PER 15 MINUTES
HOMEMAKER SERVICE, NOS; PER DIEM
COMPANION CARE, ADULT (E.G. IADL/ADL); PER 15 MINUTES
COMPANION CARE, ADULT (E.G. IADL/ADL); PER DIEM
FOSTER CARE, ADULT; PER DIEM
FOSTER CARE, ADULT; PER MONTH
FOSTER CARE, THERAPEUTIC, CHILD; PER DIEM
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FOSTER CARE, THERAPEUTIC, CHILD; PER MONTH
UNSKILLED RESPITE CARE, NOT HOSPICE; PER 15 MINUTES
UNSKILLED RESPITE CARE, NOT HOSPICE; PER DIEM
EMERGENCY RESPONSE SYSTEM; INSTALLATION AND TESTING
EMERGENCY RESPONSE SYSTEM; SERVICE FEE, PER MONTH (EXCLUDES INSTALLATION AND
TESTING)
EMERGENCY RESPONSE SYSTEM; PURCHASE ONLY
HOME MODIFICATIONS; PER SERVICE
HOME DELIVERED MEALS, INCLUDING PREPARATION; PER MEAL
LAUNDRY SERVICE, EXTERNAL, PROFESSIONAL; PER ORDER
HOME HEALTH RESPIRATORY THERAPY, INITIAL EVALUATION
HOME HEALTH RESPIRATORY THERAPY, NOS, PER DIEM
MEDICATION REMINDER SERVICE, NON-FACE-TO-FACE; PER MONTH
WELLNESS ASSESSMENT, PERFORMED BY NON-PHYSICIAN
PERSONAL CARE ITEM, NOS, EACH
HOME INFUSION THERAPY, CATHETER CARE / MAINTENANCE, NOT OTHERWISE CLASSIFIED;
INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, CATHETER CARE / MAINTENANCE, SIMPLE (SINGLE LUMEN),
INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION AND ALL NECESSARY SUPPLIES AND EQUIPMENT, (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, CATHETER CARE / MAINTENANCE, COMPLEX (MORE THAN ONE
LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, CATHETER CARE / MAINTENANCE, IMPLANTED ACCESS DEVICE,
INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION AND ALL NECESSARY SUPPLIES AND EQUIPMENT, (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM (USE THIS CODE FOR INTERIM MAINTENANCE OF
VASCULAR ACCESS NOT CURRENTLY IN USE)
HOME INFUSION THERAPY, ALL SUPPLIES NECESSARY FOR RESTORATION OF CATHETER
PATENCY OR DECLOTTING
HOME INFUSION THERAPY, ALL SUPPLIES NECESSARY FOR CATHETER REPAIR
HOME INFUSION THERAPY, ALL SUPPLIES (INCLUDING CATHETER) NECESSARY FOR A
PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC) LINE INSERTION
HOME INFUSION THERAPY, ALL SUPPLIES (INCLUDING CATHETER) NECESSARY FOR A
MIDLINE CATHETER INSERTION
HOME INFUSION THERAPY, INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS
CATHETER (PICC), NURSING SERVICES ONLY (NO SUPPLIES OR CATHETER INCLUDED)
HOME INFUSION THERAPY, INSERTION OF MIDLINE VENOUS CATHETER, NURSING SERVICES
ONLY (NO SUPPLIES OR CATHETER INCLUDED)
INSULIN, RAPID ONSET, 5 UNITS
INSULIN, MOST RAPID ONSET (LISPRO OR ASPART); 5 UNITS
INSULIN, INTERMEDIATE ACTING (NPH OR LENTE); 5 UNITS
INSULIN, LONG ACTING; 5 UNITS
INSULIN DELIVERY DEVICE, REUSABLE PEN; 1.5 ML SIZE
INSULIN DELIVERY DEVICE, REUSABLE PEN; 3 ML SIZE
INSULIN CARTRIDGE FOR USE IN INSULIN DELIVERY DEVICE OTHER THAN PUMP; 150 UNITS
INSULIN CARTRIDGE FOR USE IN INSULIN DELIVERY DEVICE OTHER THAN PUMP; 300 UNITS
INSULIN DELIVERY DEVICE, DISPOSABLE PEN (INCLUDING INSULIN); 1.5 ML SIZE
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INSULIN DELIVERY DEVICE, DISPOSABLE PEN (INCLUDING INSULIN); 3 ML SIZE
SCLERAL APPLICATION OF TANTALUM RING(S) FOR LOCALIZATION OF LESIONS FOR PROTON
BEAM THERAPY
MAGNETIC SOURCE IMAGING
MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP)
TOPOGRAPHIC BRAIN MAPPING
MAGNETIC RESONANCE IMAGING (MRI), LOW-FIELD
INTRAOPERATIVE RADIATION THERAPY (SINGLE ADMINISTRATION)
ULTRASOUND GUIDANCE FOR MULTIFETAL PREGNANCY REDUCTION(S), TECHNICAL COMPONENT
(ONLY TO BE USED WHEN THE PHYSICIAN DOING THE REDUCTION PROCEDURE DOES NOT
PERFORM THE ULTRASOUND, GUIDANCE IS INCLUDED IN THE CPT CODE FOR MULTIFETAL
PREGNANCY REDUCTION - 59866)
SCINTIMAMMOGRAPHY (RADIOIMMUNOSCINTIGRAPHY OF THE BREAST), UNILATERAL,
INCLUDING SUPPLY OF RADIOPHARMACEUTICAL
FLUORINE-18 FLUORODEOXYGLUCOSE (F-18 FDG) IMAGING USING DUAL-HEAD COINCIDENCE
DETECTION SYSTEM (NON-DEDICATED PET SCAN)
ELECTRON BEAM COMPUTED TOMOGRAPHY (ALSO KNOWN AS ULTRAFAST CT, CINE CT)
PORTABLE PEAK FLOW METER
ASTHMA KIT (INCLUDING BUT NOT LIMITED TO PORTABLE PEAK EXPIRATORY FLOW METER,
INSTRUCTIONAL VIDEO, BROCHURE, AND/OR SPACER)
HOLDING CHAMBER OR SPACER FOR USE WITH AN INHALER OR NEBULIZER; WITHOUT MASK
HOLDING CHAMBER OR SPACER FOR USE WITH AN INHALER OR NEBULIZER; WITH MASK
PEAK EXPIRATORY FLOW RATE (PHYSICIAN SERVICES)
OXYGEN CONTENTS, GASEOUS, 1 UNIT EQUALS 1 CUBIC FOOT
OXYGEN CONTENTS, LIQUID, 1 UNIT EQUALS 1 POUND
FLUTTER DEVICE
SWIVEL ADAPTOR
TRACHEOSTOMY SUPPLY, NOT OTHERWISE CLASSIFIED
ELECTRONIC SPIROMETER (OR MICROSPIROMETER)
MUCUS TRAP
MANDIBULAR ORTHOPEDIC REPOSITIONING DEVICE, EACH
HABERMAN FEEDER FOR CLEFT LIP/PALATE
ENURESIS ALARM, USING AUDITORY BUZZER AND/OR VIBRATION DEVICE
INFECTION CONTROL SUPPLIES, NOT OTHERWISE SPECIFIED
SUPPLIES FOR HOME DELIVERY OF INFANT
GRADIENT PRESSURE AID (SLEEVE AND GLOVE COMBINATION), CUSTOM MADE
GRADIENT PRESSURE AID (SLEEVE AND GLOVE COMBINATION), READY MADE
GRADIENT PRESSURE AID (SLEEVE), CUSTOM MADE, MEDIUM WEIGHT
GRADIENT PRESSURE AID (SLEEVE), CUSTOM MADE, HEAVY WEIGHT
GRADIENT PRESSURE AID (SLEEVE), READY MADE
GRADIENT PRESSURE AID (GLOVE), CUSTOM MADE, MEDIUM WEIGHT
GRADIENT PRESSURE AID (GLOVE), CUSTOM MADE, HEAVY WEIGHT
GRADIENT PRESSURE AID (GLOVE), READY MADE
GRADIENT PRESSURE AID (GAUNTLET), READY MADE
GRADIENT PRESSURE EXTERIOR WRAP
PADDING FOR COMPRESSION BANDAGE, ROLL
COMPRESSION BANDAGE, ROLL
SPLINT, PREFABRICATED, DIGIT (SPECIFY DIGIT BY USE OF MODIFIER)
SPLINT, PREFABRICATED, WRIST OR ANKLE
SPLINT, PREFABRICATED, ELBOW
CAMISOLE, POST-MASTECTOMY
INSULIN SYRINGES (100 SYRINGES, ANY SIZE)
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EQUESTRIAN/HIPPOTHERAPY, PER SESSION
APPLICATION OF A MODALITY (REQUIRING CONSTANT PROVIDER ATTENDANCE) TO ONE OR
MORE AREAS; LOW-LEVEL LASER; EACH 15 MINUTES
COMPLEX LYMPHEDEMA THERAPY, EACH 15 MINUTES
PHYSICAL OR MANIPULATIVE THERAPY PERFORMED FOR MAINTENANCE RATHER THAN
RESTORATION
RESUSCITATION BAG (FOR USE BY PATIENT ON ARTIFICIAL RESPIRATION DURING POWER
FAILURE OR OTHER CATASTROPHIC EVENT)
HOME UTERINE MONITOR WITH OR WITHOUT ASSOCIATED NURSING SERVICES
ULTRAFILTRATION MONITOR
AUTOMATED EEG MONITORING
PARANASAL SINUS ULTRASOUND
OMNICARDIOGRAM/CARDIOINTEGRAM
EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY FOR GALL STONES (IF PERFORMED WITH ERCP,
USE 43265)
PROCUREN OR OTHER GROWTH FACTOR PREPARATION TO PROMOTE WOUND HEALING
COMA STIMULATION PER DIEM
HOME ADMINISTRATION OF AEROSOLIZED DRUG THERAPY (E.G., PENTAMIDINE);
ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, ALL
NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY),
PER DIEM
SMOKING CESSATION TREATMENT
GLOBAL FEE URGENT CARE CENTERS
SERVICES PROVIDED IN AN URGENT CARE CENTER (LIST IN ADDITION TO CODE FOR
SERVICE)
VERTEBRAL AXIAL DECOMPRESSION, PER SESSION
CANOLITH REPOSITIONING, PER VISIT
HOME VISIT FOR WOUND CARE
HOME VISIT, PHOTOTHERAPY SERVICES (E.G. BILI-LITE), INCLUDING EQUIPMENT RENTAL,
NURSING SERVICES, BLOOD DRAW, SUPPLIES, AND OTHER SERVICES, PER DIEM
CONGESTIVE HEART FAILURE TELEMONITORING, EQUIPMENT RENTAL, INCLUDING TELESCALE,
COMPUTER SYSTEM AND SOFTWARE, TELEPHONE CONNECTIONS, AND MAINTENANCE, PER MONTH
BACK SCHOOL, PER VISIT
HOME HEALTH AIDE OR CERTIFIED NURSE ASSISTANT, PROVIDING CARE IN THE HOME; PER
HOUR
NURSING CARE, IN THE HOME; BY REGISTERED NURSE, PER HOUR (USE FOR GENERAL
NURSING CARE ONLY, NOT TO BE USED WHEN CPT CODES 99500-99602 CAN BE USED)
NURSING CARE, IN THE HOME; BY LICENSED PRACTICAL NURSE, PER HOUR
RESPITE CARE, IN THE HOME, PER DIEM
HOSPICE CARE, IN THE HOME, PER DIEM
SOCIAL WORK VISIT, IN THE HOME, PER DIEM
SPEECH THERAPY, IN THE HOME, PER DIEM
OCCUPATIONAL THERAPY, IN THE HOME, PER DIEM
PHYSICAL THERAPY; IN THE HOME, PER DIEM
DIABETIC MANAGEMENT PROGRAM, FOLLOW-UP VISIT TO NON-MD PROVIDER
DIABETIC MANAGEMENT PROGRAM, FOLLOW-UP VISIT TO MD PROVIDER
INSULIN PUMP INITIATION, INSTRUCTION IN INITIAL USE OF PUMP (PUMP NOT INCLUDED)
EVALUATION BY OCULARIST
SPEECH THERAPY, RE-EVALUATION
HOME MANAGEMENT OF PRETERM LABOR, INCLUDING ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
OR EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE
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THIS CODE WITH ANY HOME INFUSION PER DIEM CODE)
HOME MANAGEMENT OF PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM), INCLUDING
ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND
ALL NECESSARY SUPPLIES OR EQUIPMENT (DRUGS AND NURSING VISITS CODED
SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH ANY HOME INFUSION PER DIEM
CODE)
HOME MANAGEMENT OF GESTATIONAL HYPERTENSION, INCLUDES ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION AND ALL NECESSARY SUPPLIES
AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY); PER DIEM (DO NOT USE
THIS CODE WITH ANY HOME INFUSION PER DIEM CODE)
HOME MANAGEMENT OF POSTPARTUM HYPERTENSION, INCLUDES ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE
THIS CODE WITH ANY HOME INFUSION PER DIEM CODE)
HOME MANAGEMENT OF PREECLAMPSIA, INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL
PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT
(DRUGS AND NURSING SERVICES CODED SEPARATELY); PER DIEM (DO NOT USE THIS CODE
WITH ANY HOME INFUSION PER DIEM CODE)
HOME MANAGEMENT OF GESTATIONAL DIABETES, INCLUDES ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY); PER DIEM (DO NOT USE
THIS CODE WITH ANY HOME INFUSION PER DIEM CODE)
HOME INFUSION THERAPY, PAIN MANAGEMENT INFUSION; ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
AND EQUIPMENT, (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT
USE THIS CODE WITH S9326, S9327 OR S9328)
HOME INFUSION THERAPY, CONTINUOUS (TWENTY-FOUR HOURS OR MORE) PAIN MANAGEMENT
INFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS
CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, INTERMITTENT (LESS THAN TWENTY-FOUR HOURS) PAIN
MANAGEMENT INFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES,
CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, IMPLANTED PUMP PAIN MANAGEMENT INFUSION; ADMINISTRATIVE
SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY
SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, CHEMOTHERAPY INFUSION; ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE
THIS CODE WITH S9330 OR S9331)
HOME INFUSION THERAPY, CONTINUOUS (TWENTY-FOUR HOURS OR MORE) CHEMOTHERAPY
INFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, INTERMITTENT (LESS THAN TWENTY-FOUR HOURS) CHEMOTHERAPY
INFUSION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME THERAPY, HEMODIALYSIS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY
SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS
AND NURSING SERVICES CODED SEPARATELY), PER DIEM
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HOME INFUSION THERAPY, CONTINUOUS ANTICOAGULANT INFUSION THERAPY (E.G.
HEPARIN), ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS
CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, IMMUNOTHERAPY, ADMINISTRATIVE SERVICES, PROFESSIONAL
PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT
(DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME THERAPY; PERITONEAL DIALYSIS, ADMINISTRATIVE SERVICES, PROFESSIONAL
PHARMACY SERVICES, CARE COORDINATION AND ALL NECESSARY SUPPLIES AND EQUIPMENT
(DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME THERAPY; ENTERAL NUTRITION; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY
SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (ENTERAL
FORMULA AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME THERAPY; ENTERAL NUTRITION VIA GRAVITY; ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
AND EQUIPMENT (ENTERAL FORMULA AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME THERAPY; ENTERAL NUTRITION VIA PUMP; ADMINISTRATIVE SERVICES, PROFESSIONAL
PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT
(ENTERAL FORMULA AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME THERAPY; ENTERAL NUTRITION VIA BOLUS; ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
AND EQUIPMENT (ENTERAL FORMULA AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, ANTI-HEMOPHILIC AGENT INFUSION THERAPY (E.G. FACTOR
VIII); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, ALPHA-1-PROTEINASE INHIBITOR (E.G., PROLASTIN);
ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND
ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED
SEPARATELY), PER DIEM
HOME INFUSION THERAPY, UNINTERRUPTED, LONG-TERM, CONTROLLED RATE INTRAVENOUS OR
SUBCUTANEOUS INFUSION THERAPY (E.G. EPOPROSTENOL); ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, SYMPATHOMIMETIC/INOTROPIC AGENT INFUSION THERAPY (E.G.,
DOBUTAMINE); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS
CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, TOCOLYTIC INFUSION THERAPY; ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, CONTINUOUS OR INTERMITTENT ANTI-EMETIC INFUSION THERAPY;
ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND
ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND VISITS CODED SEPARATELY), PER
DIEM
HOME INFUSION THERAPY, CONTINUOUS INSULIN INFUSION THERAPY; ADMINISTRATIVE
SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY
SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, CHELATION THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONAL
PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT
(DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, ENZYME REPLACEMENT INTRAVENOUS THERAPY; (E.G.
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IMIGLUCERASE); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, ANTI-TUMOR NECROSIS FACTOR INTRAVENOUS THERAPY; (E.G.
INFLIXIMAB); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, DIURETIC INTRAVENOUS THERAPY; ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, ANTI-SPASMOTIC THERAPY; ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); ADMINISTRATIVE
SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY
SUPPLIES AND EQUIPMENT INCLUDING STANDARD TPN FORMULA (LIPIDS, SPECIALTY AMINO
ACID FORMULAS, DRUGS OTHER THAN IN STANDARD FORMULA AND NURSING VISITS CODED
SEPARATELY), PER DIEM (DO NOT USE WITH HOME INFUSION CODES S9365-S9368 USING
DAILY VOLUME SCALES)
HOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); ONE LITER PER DAY,
ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND
ALL NECESSARY SUPPLIES AND EQUIPMENT INCLUDING STANDARD TPN FORMULA (LIPIDS,
SPECIALTY AMINO ACID FORMULAS, DRUGS OTHER THAN IN STANDARD FORMULA AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); MORE THAN ONE LITER
BUT NO MORE THAN TWO LITERS PER DAY, ADMINISTRATIVE SERVICES, PROFESSIONAL
PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT
INCLUDING STANDARD TPN FORMULA (LIPIDS, SPECIALTY AMINO ACID FORMULAS, DRUGS
OTHER THAN IN STANDARD FORMULA AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); MORE THAN TWO LITERS
BUT NO MORE THAN THREE LITERS PER DAY, ADMINISTRATIVE SERVICES, PROFESSIONAL
PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT
INCLUDING STANDARD TPN FORMULA (LIPIDS, SPECIALTY AMINO ACID FORMULAS, DRUGS
OTHER THAN IN STANDARD FORMULA AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, TOTAL PARENTERAL NUTRITION (TPN); MORE THAN THREE LITERS
PER DAY, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT INCLUDING STANDARD TPN
FORMULA (LIPIDS, SPECIALTY AMINO ACID FORMULAS, DRUGS OTHER THAN IN STANDARD
FORMULA AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME THERAPY, INTERMITTENT ANTI-EMETIC INJECTION THERAPY; ADMINISTRATIVE
SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY
SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME THERAPY; INTERMITTENT ANTICOAGULANT INJECTION THERAPY (E.G. HEPARIN);
ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND
ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED
SEPARATELY), PER DIEM (DO NOT USE THIS CODE FOR FLUSHING OF INFUSION DEVICES
WITH HEPARIN TO MAINTAIN PATENCY)
HOME INFUSION THERAPY, HYDRATION THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONAL
PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT
(DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE WITH
HYDRATION THERAPY CODES S9374-S9377 USING DAILY VOLUME SCALES)
HOME INFUSION THERAPY, HYDRATION THERAPY; ONE LITER PER DAY, ADMINISTRATIVE
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SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY
SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, HYDRATION THERAPY; MORE THAN ONE LITER BUT NO MORE THAN
TWO LITERS PER DAY, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES,
CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, HYDRATION THERAPY; MORE THAN TWO LITERS BUT NO MORE THAN
THREE LITERS PER DAY, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES,
CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, HYDRATION THERAPY; MORE THAN THREE LITERS PER DAY,
ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND
ALL NECESSARY SUPPLIES (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, INFUSION THERAPY, NOT OTHERWISE CLASSIFIED;
ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND
ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED
SEPARATELY), PER DIEM
DELIVERY OR SERVICE TO HIGH RISK AREAS REQUIRING ESCORT OR EXTRA PROTECTION,
PER VISIT
ANTICOAGULATION CLINIC, INCLUSIVE OF ALL SERVICES EXCEPT LABORATORY TESTS, PER
SESSION
PHARMACY COMPOUNDING AND DISPENSING SERVICES
MEDICAL FOOD NUTRITIONALLY COMPLETE, ADMINISTERED ORALLY, PROVIDING 100% OF
NUTRITIONAL INTAKE
MODIFIED SOLID FOOD SUPPLEMENTS FOR INBORN ERRORS OF METABOLISM
MEDICAL FOODS FOR INBORN ERRORS OF METABOLISM
CHILDBIRTH PREPARATION/LAMAZE CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION
CHILDBIRTH REFRESHER CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION
CESAREAN BIRTH CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION
VBAC (VAGINAL BIRTH AFTER CESAREAN) CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION
ASTHMA EDUCATION, NON-PHYSICIAN PROVIDER, PER SESSION
BIRTHING CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION
LACTATION CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION
PARENTING CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION
PATIENT EDUCATION, NOT OTHERWISE CLASSIFIED, NON-PHYSICIAN PROVIDER,
INDIVIDUAL, PER SESSION
PATIENT EDUCATION, NOT OTHERWISE CLASSIFIED, NON-PHYSICIAN PROVIDER, GROUP, PER
SESSION
INFANT SAFETY (INCLUDING CPR) CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION
WEIGHT MANAGEMENT CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION
EXERCISE CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION
NUTRITION CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION
SMOKING CESSATION CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION
STRESS MANAGEMENT CLASSES, NON-PHYSICIAN PROVIDER, PER SESSION
DIABETIC MANAGEMENT PROGRAM, GROUP SESSION
DIABETIC MANAGEMENT PROGRAM, NURSE VISIT
DIABETIC MANAGEMENT PROGRAM, DIETITIAN VISIT
NUTRITIONAL COUNSELING, DIETITIAN VISIT
CARDIAC REHABILITATION PROGRAM, NON-PHYSICIAN PROVIDER, PER DIEM
PULMONARY REHABILITATION PROGRAM, NON-PHYSICIAN PROVIDER, PER DIEM
ENTEROSTOMAL THERAPY BY A REGISTERED NURSE CERTIFIED IN ENTEROSTOMAL THERAPY,
PER DIEM
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AMBULATORY SETTING SUBSTANCE ABUSE TREATMENT OR DETOXIFICATION SERVICES, PER
DIEM
VESTIBULAR REHABILITATION PROGRAM, NON-PHYSICIAN PROVIDER, PER DIEM
INTENSIVE OUTPATIENT PSYCHIATRIC SERVICES, PER DIEM
FAMILY STABILIZATION SERVICES, PER 15 MINUTES
CRISIS INTERVENTION MENTAL HEALTH SERVICES, PER HOUR
CRISIS INTERVENTION MENTAL HEALTH SERVICES, PER DIEM
HOME INFUSION THERAPY, CORTICOSTEROID INFUSION; ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY;
ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND
ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED
SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH HOME INFUSION CODES FOR HOURLY
DOSING SCHEDULES S9497-S9504)
HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY; ONCE EVERY
3 HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY; ONCE EVERY
24 HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY; ONCE EVERY
12 HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL THERAPY; ONCE EVERY
8 HOURS, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL; ONCE EVERY 6
HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR ANTIFUNGAL; ONCE EVERY 4
HOURS; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
ROUTINE VENIPUNCTURE FOR COLLECTION OF SPECIMEN(S), SINGLE HOME BOUND, NURSING
HOME, OR SKILLED NURSING FACILITY PATIENT
HOME THERAPY; HEMATOPOIETIC HORMONE INJECTION THERAPY (E.G.ERYTHROPOIETIN,
G-CSF, GM-CSF); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME TRANSFUSION OF BLOOD PRODUCT(S); ADMINISTRATIVE SERVICES, PROFESSIONAL
PHARMACY SERVICES, CARE COORDINATION AND ALL NECESSARY SUPPLIES AND EQUIPMENT
(BLOOD PRODUCTS, DRUGS, AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INJECTABLE THERAPY, NOT OTHERWISE CLASSIFIED, INCLUDING ADMINISTRATIVE
SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY
SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INJECTABLE THERAPY; GROWTH HORMONE, INCLUDING ADMINISTRATIVE SERVICES,
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PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INJECTABLE THERAPY, INTERFERON, INCLUDING ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME INJECTABLE THERAPY; HORMONAL THERAPY (E.G.; LEUPROLIDE, GOSERELIN),
INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE
COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING
VISITS CODED SEPARATELY), PER DIEM
HOME INJECTABLE THERAPY, PALIVIZUMAB, INCLUDING ADMINISTRATIVE SERVICES,
PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES
AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME THERAPY, IRRIGATION THERAPY (E.G. STERILE IRRIGATION OF AN ORGAN OR
ANATOMICAL CAVITY); INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY
SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS
AND NURSING VISITS CODED SEPARATELY), PER DIEM
HOME THERAPY; PROFESSIONAL PHARMACY SERVICES FOR PROVISION OF INFUSION,
SPECIALTY DRUG ADMINISTRATION, AND/OR DISEASE STATE MANAGEMENT, NOT OTHERWISE
CLASSIFIED, PER HOUR (DO NOT USE THIS CODE WITH ANY PER DIEM CODE)
SERVICES BY AUTHORIZED CHRISTIAN SCIENCE PRACTITIONER FOR THE PROCESS OF
HEALING, PER DIEM; NOT TO BE USED FOR REST OR STUDY; EXCLUDES IN-PATIENT
SERVICES
HEALTH CLUB MEMBERSHIP, ANNUAL
TRANSPLANT RELATED LODGING, MEALS AND TRANSPORTATION, PER DIEM
LODGING, PER DIEM, NOT OTHERWISE CLASSIFIED
MEALS, PER DIEM, NOT OTHERWISE SPECIFIED
MEDICAL RECORDS COPYING FEE, ADMINISTRATIVE
MEDICAL RECORDS COPYING FEE, PER PAGE
NOT MEDICALLY NECESSARY SERVICE (PATIENT IS AWARE THAT SERVICE NOT MEDICALLY
NECESSARY)
SERVICES PROVIDED AS PART OF A PHASE I CLINICAL TRIAL
SERVICES PROVIDED OUTSIDE OF THE UNITED STATES OF AMERICA (LIST IN ADDITION TO
CODE(S) FOR SERVICES(S))
SERVICES PROVIDED AS PART OF A PHASE II CLINICAL TRIAL
SERVICES PROVIDED AS PART OF A PHASE III CLINICAL TRIAL
TRANSPORTATION COSTS TO AND FROM TRIAL LOCATION AND LOCAL TRANSPORTATION COSTS
(E.G., FARES FOR TAXICAB OR BUS) FOR CLINICAL TRIAL PARTICIPANT AND ONE
CAREGIVER/COMPANION
LODGING COSTS (E.G., HOTEL CHARGES) FOR CLINICAL TRIAL PARTICIPANT AND ONE
CAREGIVER/COMPANION
MEALS FOR CLINICAL TRIAL PARTICIPANT AND ONE CAREGIVER/COMPANION
SALES TAX
PRIVATE DUTY / INDEPENDENT NURSING SERVICE(S) - LICENSED, UP TO 15 MINUTES
NURSING ASSESSMENT / EVALUATION
RN SERVICES, UP TO 15 MINUTES
LPN/LVN SERVICES, UP TO 15 MINUTES
SERVICES OF A QUALIFIED NURSING AIDE, UP TO 15 MINUTES
RESPITE CARE SERVICES, UP TO 15 MINUTES
ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES, FAMILY/COUPLE COUNSELING
ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES, TREATMENT PLAN DEVELOPMENT AND/OR
MODIFICATION
CHILD SITTING SERVICES FOR CHILDREN OF THE INDIVIDUAL RECEIVING ALCOHOL AND/OR
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SUBSTANCE ABUSE SERVICES
MEALS FOR INDIVIDUALS RECEIVING ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES (WHEN
MEALS NOT INCLUDED IN THE PROGRAM)
ALCOHOL AND/OR SUBSTANCE ABUSE SERVICES, SKILLS DEVELOPMENT
SIGN LANGUAGE OR ORAL INTERPRETIVE SERVICES, PER 15 MINUTES
TELEHEALTH TRANSMISSION, PER MINUTE, PROFESSIONAL SERVICES BILL SEPARATELY
CLINIC VISIT/ENCOUNTER, ALL-INCLUSIVE
CASE MANAGEMENT, EACH 15 MINUTES
TARGETED CASE MANAGEMENT, EACH 15 MINUTES
SCHOOL-BASED INDIVIDUALIZED EDUCATION PROGRAM (IEP) SERVICES, BUNDLED
PERSONAL CARE SERVICES, PER 15 MINUTES, NOT FOR AN INPATIENT OR RESIDENT OF A
HOSPITAL, NURSING FACILITY, ICF/MR OR IMD, PART OF THE INDIVIDUALIZED PLAN OF
TREATMENT (CODE MAY NOT BE USED TO IDENTIFY SERVICES PROVIDED BY HOME HEALTH
AIDE OR CERTIFIED NURSE ASSISTANT)
PERSONAL CARE SERVICES, PER DIEM, NOT FOR AN INPATIENT OR RESIDENT OF A
HOSPITAL, NURSING FACILITY, ICF/MR OR IMD, PART OF THE INDIVIDUALIZED PLAN OF
TREATMENT (CODE MAY NOT BE USED TO IDENTIFY SERVICES PROVIDED BY HOME HEALTH
AIDE OR CERTIFIED NURSE ASSISTANT)
HOME HEALTH AIDE OR CERTIFIED NURSE ASSISTANT, PER VISIT
CONTRACTED HOME HEALTH AGENCY SERVICES, ALL SERVICES PROVIDED UNDER CONTRACT,
PER DAY
SCREENING TO DETERMINE THE APPROPRIATENESS OF CONSIDERATION OF AN INDIVIDUAL
FOR PARTICIPATION IN A SPECIFIED PROGRAM, PROJECT OR TREATMENT PROTOCOL, PER
ENCOUNTER
EVALUATION AND TREATMENT BY AN INTEGRATED, SPECIALTY TEAM CONTRACTED TO PROVIDE
COORDINATED CARE TO MULTIPLE OR SEVERELY HANDICAPPED CHILDREN, PER ENCOUNTER
INTENSIVE, EXTENDED MULTIDISCIPLINARY SERVICES PROVIDED IN A CLINIC SETTING TO
CHILDREN WITH COMPLEX MEDICAL, PHYSICAL, MENTAL AND PSYCHOSOCIAL IMPAIRMENTS,
PER DIEM
INTENSIVE, EXTENDED MULTIDISCIPLINARY SERVICES PROVIDED IN A CLINIC SETTING TO
CHILDREN WITH COMPLEX MEDICAL, PHYSICAL, MEDICAL AND PSYCHOSOCIAL IMPAIRMENTS,
PER HOUR
FAMILY TRAINING AND COUNSELING FOR CHILD DEVELOPMENT, PER 15 MINUTES
ASSESSMENT OF HOME, PHYSICAL AND FAMILY ENVIRONMENT, TO DETERMINE SUITABILITY
TO MEET PATIENT'S MEDICAL NEEDS
COMPREHENSIVE ENVIRONMENTAL LEAD INVESTIGATION, NOT INCLUDING LABORATORY
ANALYSIS, PER DWELLING
NURSING CARE, IN THE HOME, BY REGISTERED NURSE, PER DIEM
NURSING CARE, IN THE HOME, BY LICENSED PRACTICAL NURSE, PER DIEM
ADMINISTRATION OF ORAL, INTRAMUSCULAR AND/OR SUBCUTANEOUS MEDICATION BY HEALTH
CARE AGENCY/PROFESSIONAL, PER VISIT
ADMINISTRATION OF MEDICATION, OTHER THAN ORAL AND/OR INJECTABLE, BY A HEALTH
CARE AGENCY/PROFESSIONAL, PER VISIT
ELECTRONIC MEDICATION COMPLIANCE MANAGEMENT DEVICE, INCLUDES ALL COMPONENTS AND
ACCESSORIES, NOT OTHERWISE CLASSIFIED
MISCELLANEOUS THERAPEUTIC ITEMS AND SUPPLIES, RETAIL PURCHASES, NOT OTHERWISE
CLASSIFIED; IDENTIFY PRODUCT IN "REMARKS"
NON-EMERGENCY TRANSPORTATION; PATIENT ATTENDANT/ESCORT
NON-EMERGENCY TRANSPORTATION; PER DIEM
NON-EMERGENCY TRANSPORTATION; ENCOUNTER/TRIP
NON-EMERGENCY TRANSPORT; COMMERCIAL CARRIER, MULTI-PASS
NON-EMERGENCY TRANSPORTATION; STRETCHER VAN
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TRANSPORTATION WAITING TIME, AIR AMBULANCE AND NON-EMERGENCY VEHICLE, ONE-HALF
(1/2) HOUR INCREMENTS
PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) LEVEL I IDENTIFICATION
SCREENING, PER SCREEN
PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) LEVEL II EVALUATION, PER
EVALUATION
HABILITATION, EDUCATIONAL; WAIVER, PER DIEM
HABILITATION, EDUCATIONAL, WAIVER; PER HOUR
HABILITATION, PREVOCATIONAL, WAIVER; PER DIEM
HABILITATION, PREVOCATIONAL, WAIVER; PER HOUR
HABILITATION, RESIDENTIAL, WAIVER; PER DIEM
HABILITATION, RESIDENTIAL, WAIVER; 15 MINUTES
HABILITATION, SUPPORTED EMPLOYMENT, WAIVER; PER DIEM
HABILITATION, SUPPORTED EMPLOYMENT, WAIVER; PER 15 MINUTES
DAY HABILITATION, WAIVER; PER DIEM
DAY HABILITATION, WAIVER; PER 15 MINUTES
CASE MANAGEMENT, PER MONTH
TARGETED CASE MANAGEMENT; PER MONTH
SERVICE ASSESSMENT/PLAN OF CARE DEVELOPMENT, WAIVER
WAIVER SERVICES; NOT OTHERWISE SPECIFIED (NOS)
SPECIALIZED CHILDCARE, WAIVER; PER DIEM
SPECIALIZED CHILDCARE, WAIVER; PER 15 MINUTES
SPECIALIZED SUPPLY, NOT OTHERWISE SPECIFIED, WAIVER
SPECIALIZED MEDICAL EQUIPMENT, NOT OTHERWISE SPECIFIED, WAIVER
ASSISTED LIVING, WAIVER; PER MONTH
ASSISTED LIVING; WAIVER, PER DIEM
RESIDENTIAL CARE, NOT OTHERWISE SPECIFIED (NOS), WAIVER; PER MONTH
RESIDENTIAL CARE, NOT OTHERWISE SPECIFIED (NOS), WAIVER; PER DIEM
CRISIS INTERVENTION, WAIVER; PER DIEM
UTILITY SERVICES TO SUPPORT MEDICAL EQUIPMENT AND ASSISTIVE TECHNOLOGY/DEVICES,
WAIVER
THERAPEUTIC CAMPING, OVERNIGHT, WAIVER; EACH SESSION
THERAPEUTIC CAMPING, DAY, WAIVER; EACH SESSION
COMMUNITY TRANSITION, WAIVER; PER SERVICE
VEHICLE MODIFICATIONS, WAIVER; PER SERVICE
FINANCIAL MANAGEMENT, SELF-DIRECTED, WAIVER; PER 15 MINUTES
SUPPORTS BROKERAGE, SELF-DIRECTED, WAIVER; PER 15 MINUTES
HOSPICE ROUTINE HOME CARE; PER DIEM
HOSPICE CONTINUOUS HOME CARE; PER HOUR
HOSPICE INPATIENT RESPITE CARE; PER DIEM
HOSPICE GENERAL INPATIENT CARE; PER DIEM
HOSPICE LONG TERM CARE, ROOM AND BOARD ONLY; PER DIEM
BEHAVIORAL HEALTH; LONG-TERM CARE RESIDENTIAL (NON-ACUTE CARE IN A RESIDENTIAL
TREATMENT PROGRAM WHERE STAY IS TYPICALLY LONGER THAN 30 DAYS), WITH ROOM AND
BOARD, PER DIEM
NON-EMERGENCY TRANSPORTATION; STRETCHER VAN, MILEAGE; PER MILE
HUMAN BREAST MILK PROCESSING, STORAGE AND DISTRIBUTION ONLY
ADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, SMALL, EACH
ADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, MEDIUM, EACH
ADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, LARGE, EACH
ADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, EXTRA LARGE, EACH
ADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON,
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SMALL SIZE, EACH
ADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON,
MEDIUM SIZE, EACH
ADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON,
LARGE SIZE, EACH
ADULT SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON,
EXTRA LARGE SIZE, EACH
PEDIATRIC SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, SMALL/MEDIUM
SIZE, EACH
PEDIATRIC SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, LARGE SIZE, EACH
PEDIATRIC SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON,
SMALL/MEDIUM SIZE, EACH
PEDIATRIC SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON,
LARGE SIZE, EACH
YOUTH SIZED DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, EACH
YOUTH SIZED DISPOSABLE INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON, EACH
DISPOSABLE LINER/SHIELD/GUARD/PAD/UNDERGARMENT, FOR INCONTINENCE, EACH
INCONTINENCE PRODUCT, PROTECTIVE UNDERWEAR/PULL-ON, REUSABLE, ANY SIZE, EACH
INCONTINENCE PRODUCT, PROTECTIVE UNDERPAD, REUSABLE, BED SIZE, EACH
DIAPER SERVICE, REUSABLE DIAPER, EACH DIAPER
INCONTINENCE PRODUCT, DIAPER/BRIEF, REUSABLE, ANY SIZE, EACH
INCONTINENCE PRODUCT, PROTECTIVE UNDERPAD, REUSABLE, CHAIR SIZE, EACH
INCONTINENCE PRODUCT, DISPOSABLE UNDERPAD, LARGE, EACH
INCONTINENCE PRODUCT, DISPOSABLE UNDERPAD, SMALL SIZE, EACH
DISPOSABLE INCONTINENCE PRODUCT, BRIEF/DIAPER, BARIATRIC, EACH
POSITIONING SEAT FOR PERSONS WITH SPECIAL ORTHOPEDIC NEEDS
SUPPLY, NOT OTHERWISE SPECIFIED
FRAMES, PURCHASES
DELUXE FRAME
SPHERE, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00, PER LENS
SPHERE, SINGLE VISION, PLUS OR MINUS 4.12 TO PLUS OR MINUS 7.00D, PER LENS
SPHERE, SINGLE VISION, PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00D, PER LENS
SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12 TO
2.00D CYLINDER, PER LENS
SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.12 TO
4.00D CYLINDER, PER LENS
SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25 TO
6.00D CYLINDER, PER LENS
SPHEROCYLINDER, SINGLE VISION, PLANO TO PLUS OR MINUS 4.00D SPHERE, OVER 6.00D
CYLINDER, PER LENS
SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00 SPHERE,
.12 TO 2.00D CYLINDER, PER LENS
SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25D TO PLUS OR MINUS 7.00D
SPHERE, 2.12 TO 4.00D CYLINDER, PER LENS
SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D
SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS
SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 4.25 TO 7.00D SPHERE, OVER 6.00D
CYLINDER, PER LENS
SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D
SPHERE, .25 TO 2.25D CYLINDER, PER LENS
SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D
SPHERE, 2.25D TO 4.00D CYLINDER, PER LENS
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SPHEROCYLINDER, SINGLE VISION, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D
SPHERE, 4.25 TO 6.00D CYLINDER, PER LENS
SPHEROCYLINDER, SINGLE VISION, SPHERE OVER PLUS OR MINUS 12.00D, PER LENS
LENTICULAR, (MYODISC), PER LENS, SINGLE VISION
ANISEIKONIC LENS, SINGLE VISION
LENTICULAR LENS, PER LENS, SINGLE
NOT OTHERWISE CLASSIFIED, SINGLE VISION LENS
SPHERE, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D, PER LENS
SPHERE, BIFOCAL, PLUS OR MINUS 4.12 TO PLUS OR MINUS 7.00D, PER LENS
SPHERE, BIFOCAL, PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00D, PER LENS
SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12 TO 2.00D
CYLINDER, PER LENS
SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.12 TO 4.00D
CYLINDER, PER LENS
SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25 TO 6.00D
CYLINDER, PER LENS
SPHEROCYLINDER, BIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, OVER 6.00D
CYLINDER, PER LENS
SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE,.12
TO 2.00D CYLINDER, PER LENS
SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, 2.12
TO 4.00D CYLINDER, PER LENS
SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, 4.25
TO 6.00D CYLINDER, PER LENS
SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, OVER
6.00D CYLINDER,PER LENS
SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE, .25
TO 2.25D CYLINDER, PER LENS
SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE,
2.25 TO 4.00D CYLINDER, PER LENS
SPHEROCYLINDER, BIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE,
4.25 TO 6.00D CYLINDER, PER LENS
SPHEROCYLINDER, BIFOCAL, SPHERE OVER PLUS OR MINUS 12.00D, PER LENS
LENTICULAR (MYODISC), PER LENS, BIFOCAL
ANISEIKONIC, PER LENS, BIFOCAL
BIFOCAL SEG WIDTH OVER 28MM
BIFOCAL ADD OVER 3.25D
LENTICULAR LENS, PER LENS, BIFOCAL
SPECIALTY BIFOCAL (BY REPORT)
SPHERE, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D, PER LENS
SPHERE, TRIFOCAL, PLUS OR MINUS 4.12 TO PLUS OR MINUS 7.00D, PER LENS
SPHERE, TRIFOCAL, PLUS OR MINUS 7.12 TO PLUS OR MINUS 20.00, PER LENS
SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, .12-2.00D
CYLINDER, PER LENS
SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 2.25-4.00D
CYLINDER, PER LENS
SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, 4.25 TO 6.00
CYLINDER, PER LENS
SPHEROCYLINDER, TRIFOCAL, PLANO TO PLUS OR MINUS 4.00D SPHERE, OVER 6.00D
CYLINDER, PER LENS
SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE, .12
TO 2.00D CYLINDER, PER LENS
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SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE,
2.12 TO 4.00D CYLINDER, PER LENS
SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE,
4.25 TO 6.00D CYLINDER, PER LENS
SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 4.25 TO PLUS OR MINUS 7.00D SPHERE,
OVER 6.00D CYLINDER, PER LENS
SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE,
.25 TO 2.25D CYLINDER, PER LENS
SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE,
2.25 TO 4.00D CYLINDER, PER LENS
SPHEROCYLINDER, TRIFOCAL, PLUS OR MINUS 7.25 TO PLUS OR MINUS 12.00D SPHERE,
4.25 TO 6.00D CYLINDER, PER LENS
SPHEROCYLINDER, TRIFOCAL, SPHERE OVER PLUS OR MINUS 12 .00D, PER LENS
LENTICULAR, (MYODISC), PER LENS, TRIFOCAL
ANISEIKONIC LENS, TRIFOCAL
TRIFOCAL SEG WIDTH OVER 28 MM
TRIFOCAL ADD OVER 3.25D
LENTICULAR LENS, PER LENS, TRIFOCAL
SPECIALTY TRIFOCAL (BY REPORT)
VARIABLE ASPHERICITY LENS, SINGLE VISION, FULL FIELD, GLASS OR PLASTIC, PER LENS
VARIABLE ASPHERICITY LENS, BIFOCAL, FULL FIELD, GLASS OR PLASTIC, PER LENS
VARIABLE SPHERICITY LENS, OTHER TYPE
CONTACT LENS, PMMA, SPHERICAL, PER LENS
CONTACT LENS, PMMA, TORIC OR PRISM BALLAST, PER LENS
CONTACT LENS PMMA, BIFOCAL, PER LENS
CONTACT LENS, PMMA, COLOR VISION DEFICIENCY, PER LENS
CONTACT LENS, GAS PERMEABLE, SPHERICAL, PER LENS
CONTACT LENS, GAS PERMEABLE, TORIC, PRISM BALLAST, PER LENS
CONTACT LENS, GAS PERMEABLE, BIFOCAL, PER LENS
CONTACT LENS, GAS PERMEABLE, EXTENDED WEAR, PER LENS
CONTACT LENS, HYDROPHILIC, SPHERICAL, PER LENS
CONTACT LENS, HYDROPHILIC, TORIC, OR PRISM BALLAST, PER LENS
CONTACT LENS, HYDROPHILLIC, BIFOCAL, PER LENS
CONTACT LENS, HYDROPHILIC, EXTENDED WEAR, PER LENS
CONTACT LENS, SCLERAL, GAS IMPERMEABLE, PER LENS (FOR CONTACT LENS
MODIFICATION, SEE 92325)
CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS (FOR CONTACT LENS MODIFICATION,
SEE 92325)
CONTACT LENS, OTHER TYPE
HAND HELD LOW VISION AIDS AND OTHER NONSPECTACLE MOUNTED AIDS
SINGLE LENS SPECTACLE MOUNTED LOW VISION AIDS
TELESCOPIC AND OTHER COMPOUND LENS SYSTEM, INCLUDING DISTANCE VISION
TELESCOPIC, NEAR VISION TELESCOPES AND COMPOUND MICROSCOPIC LENS SYSTEM
PROSTHETIC EYE, PLASTIC, CUSTOM
POLISHING/RESURFACING OF OCULAR PROSTHESIS
ENLARGEMENT OF OCULAR PROSTHESIS
REDUCTION OF OCULAR PROSTHESIS
SCLERAL COVER SHELL
FABRICATION AND FITTING OF OCULAR CONFORMER
PROSTHETIC EYE, OTHER TYPE
ANTERIOR CHAMBER INTRAOCULAR LENS
IRIS SUPPORTED INTRAOCULAR LENS
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POSTERIOR CHAMBER INTRAOCULAR LENS
BALANCE LENS, PER LENS
DELUXE LENS FEATURE
SLAB OFF PRISM, GLASS OR PLASTIC, PER LENS
PRISM, PER LENS
PRESS-ON LENS, FRESNELL PRISM, PER LENS
SPECIAL BASE CURVE, GLASS OR PLASTIC, PER LENS
TINT, PHOTOCHROMATIC, PER LENS
ADDITION TO LENS; TINT, ANY COLOR, SOLID, GRADIENT OR EQUAL, EXCLUDES
PHOTOCHROMATIC, ANY LENS MATERIAL, PER LENS
ANTI-REFLECTIVE COATING, PER LENS
U-V LENS, PER LENS
EYE GLASS CASE
SCRATCH RESISTANT COATING, PER LENS
MIRROR COATING, ANY TYPE, SOLID, GRADIENT OR EQUAL, ANY LENS MATERIAL, PER LENS
POLARIZATION, ANY LENS MATERIAL, PER LENS
OCCLUDER LENS, PER LENS
OVERSIZE LENS, PER LENS
PROGRESSIVE LENS, PER LENS
LENS, INDEX 1.54 TO 1.65 PLASTIC OR 1.60 TO 1.79 GLASS, EXCLUDES POLYCARBONATE,
PER LENS
LENS, INDEX GREATER THAN OR EQUAL TO 1.66 PLASTIC OR GREATER THAN OR EQUAL TO
1.80 GLASS, EXCLUDES POLYCARBONATE, PER LENS
LENS, POLYCARBONATE OR EQUAL, ANY INDEX, PER LENS
PROCESSING, PRESERVING AND TRANSPORTING CORNEAL TISSUE
SPECIALTY OCCUPATIONAL MULTIFOCAL LENS, PER LENS
ASTIGMATISM CORRECTING FUNCTION OF INTRAOCULAR LENS
PRESBYOPIA CORRECTING FUNCTION OF INTRAOCULAR LENS
AMNIOTIC MEMBRANE FOR SURGICAL RECONSTRUCTION, PER PROCEDURE
VISION SUPPLY, ACCESSORY AND/OR SERVICE COMPONENT OF ANOTHER HCPCS VISION CODE
VISION SERVICE, MISCELLANEOUS
HEARING SCREENING
ASSESSMENT FOR HEARING AID
FITTING/ORIENTATION/CHECKING OF HEARING AID
REPAIR/MODIFICATION OF A HEARING AID
CONFORMITY EVALUATION
HEARING AID, MONAURAL, BODY WORN, AIR CONDUCTION
HEARING AID, MONAURAL, BODY WORN, BONE CONDUCTION
HEARING AID, MONAURAL, IN THE EAR
HEARING AID, MONAURAL, BEHIND THE EAR
GLASSES, AIR CONDUCTION
GLASSES, BONE CONDUCTION
DISPENSING FEE, UNSPECIFIED HEARING AID
SEMI-IMPLANTABLE MIDDLE EAR HEARING PROSTHESIS
HEARING AID, BILATERAL, BODY WORN
DISPENSING FEE, BILATERAL
BINAURAL, BODY
BINAURAL, IN THE EAR
BINAURAL, BEHIND THE EAR
BINAURAL, GLASSES
DISPENSING FEE, BINAURAL
HEARING AID, CROS, IN THE EAR
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HEARING AID, CROS, BEHIND THE EAR
HEARING AID, CROS, GLASSES
DISPENSING FEE, CROS
HEARING AID, BICROS, IN THE EAR
HEARING AID, BICROS, BEHIND THE EAR
HEARING AID, BICROS, GLASSES
DISPENSING FEE, BICROS
DISPENSING FEE, MONAURAL HEARING AID, ANY TYPE
HEARING AID, ANALOG, MONAURAL, CIC (COMPLETELY IN THE EAR CANAL)
HEARING AID, ANALOG, MONAURAL, ITC (IN THE CANAL)
HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, CIC
HEARING AID, DIGITALLY PROGRAMMABLE, ANALOG, MONAURAL, ITC
HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, ITE (IN THE EAR)
HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, BTE (BEHIND THE EAR)
HEARING AID, ANALOG, BINAURAL, CIC
HEARING AID, ANALOG, BINAURAL, ITC
HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, BINAURAL, CIC
HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, BINAURAL, ITC
HEARING AID, DIGITALLY PROGRAMMABLE, BINAURAL, ITE
HEARING AID, DIGITALLY PROGRAMMABLE, BINAURAL, BTE
HEARING AID, DIGITAL, MONAURAL, CIC
HEARING AID, DIGITAL, MONAURAL, ITC
HEARING AID, DIGITAL, MONAURAL, ITE
HEARING AID, DIGITAL, MONAURAL, BTE
HEARING AID, DIGITAL, BINAURAL, CIC
HEARING AID, DIGITAL, BINAURAL, ITC
HEARING AID, DIGITAL, BINAURAL, ITE
HEARING AID, DIGITAL, BINAURAL, BTE
HEARING AID, DISPOSABLE, ANY TYPE, MONAURAL
HEARING AID, DISPOSABLE, ANY TYPE, BINAURAL
EAR MOLD/INSERT, NOT DISPOSABLE, ANY TYPE
EAR MOLD/INSERT, DISPOSABLE, ANY TYPE
BATTERY FOR USE IN HEARING DEVICE
HEARING AID SUPPLIES / ACCESSORIES
ASSISTIVE LISTENING DEVICE, TELEPHONE AMPLIFIER, ANY TYPE
ASSISTIVE LISTENING DEVICE, ALERTING, ANY TYPE
ASSISTIVE LISTENING DEVICE, TELEVISION AMPLIFIER, ANY TYPE
ASSISTIVE LISTENING DEVICE, TELEVISION CAPTION DECODER
ASSISTIVE LISTENING DEVICE, TDD
ASSISTIVE LISTENING DEVICE, FOR USE WITH COCHLEAR IMPLANT
ASSISTIVE LISTENING DEVICE, NOT OTHERWISE SPECIFIED
EAR IMPRESSION, EACH
HEARING AID, NOT OTHERWISE CLASSIFIED
HEARING SERVICE, MISCELLANEOUS
REPAIR/MODIFICATION OF AUGMENTATIVE COMMUNICATIVE SYSTEM OR DEVICE (EXCLUDES
ADAPTIVE HEARING AID)
SPEECH SCREENING
LANGUAGE SCREENING
DYSPHAGIA SCREENING
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Short Description PI1 PI2 PI3 PI4 MPI CIM1
Dressing for one wound
Dressing for two wounds
Dressing for three wounds
Dressing for four wounds
Dressing for five wounds
Dressing for six wounds
Dressing for seven wounds
Dressing for eight wounds
Dressing for 9 or more wound
Anesthesia perf by anesgst
MD supervision, >4 anes proc
Registered dietician
Specialty physician
Primary physician
Clinical psychologist
Principal physician of rec
Clinical social worker
Non participating physician
Physician, team member svc
No dtmn of refractive state
Physician service HPSA area
Physician scarcity area
Assistant at surgery service
Acute treatment
Uro, ostomy or trach item
Item w prosthetic/orthotic
Item w a surgical dressing
Item w dialysis services
Item/service not for ESRD tx
Physician serv in dent HPSA
Item w pen services
Spec acquisition blood prods
Nutrition oral admin no tube
Bene electd to purchase item
Bene elected to rent item
Bene undecided on purch/rent
Procedure payable inpatient
ESRD bene part a snf-sep pay
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Procedure code change
AMCC test for ESRD or MCP MD
Med neces AMCC tst sep reimb
AMCC tst not composite rate
Policy criteria applied
Catastrophe/disaster related
Gulf Oil 2010 Spill Related
Oral health assess, not dent
Upper left eyelid
Lower left eyelid
Upper right eyelid
Lower right eyelid
ESA, anemia, chemo-induced
ESA, anemia, radio-induced
ESA, anemia, non-chemo/radio
HCT>39% or Hgb>13g>=3 cycle
HCT>39% or Hgb>13g<3 cycle
Subsequent claim
Emer reserve supply (ESRD)
Medicaid EPSDT program svc
Emergency Services
No md order for item/service
Left hand, second digit
Left hand, third digit
Left hand, fourth digit
Left hand, fifth digit
Right hand, thumb
Right hand, second digit
Right hand, third digit
Right hand, fourth digit
Right hand, fifth digit
Left hand, thumb
Item provided without cost
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Part credit, replaced device
Svc part of family plan pgm
URR reading of less than 60
URR reading of 60 to 64.9
URR reading of 65 to 69.9
URR reading of 70 to 74.9
URR reading of 75 or greater
ESRD patient <6 dialysis/mth
Payment limits do not apply 35-99
Monitored anesthesia care
MAC for at risk patient
Liability waiver ind case
Claim resubmitted
Resident/teaching phys serv
Unit of service > MUE value
Resident prim care exception
Nonphysician serv c a hosp
Payment screen mam + diagmam
Diag mammo to screening mamo
Opt out provider of er srvc
Actual item/service ordered
Upgraded item, no charge
Multiple transports
OP speech language service
OP occupational therapy serv
OP PT services
Telehealth store and forward
Service by va resident
Epo/darbepoietin reduced 25%
InteractiveTelecommunication
Liability waiver rout notice
Attending phys not hospice
Service unrelated to term co
Voluntary liability notice
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Statutorily excluded
Not reasonable and necessary
Court-ordered
Child/adolescent program
Adult program non-geriatric
Adult program geriatric
Pregnant/parenting program
Mental health program
Substance abuse program
Opioid addiction tx program
Mental hlth/substance abs pr
M hlth/m retrdtn/dev dis pro
Employee assistance program
Spec hgh rsk mntl hlth pop p
intern
Less than bachelor degree lv
Bachelors degree level
Masters degree level
Doctoral level
Group setting
Family/couple w client prsnt
Family/couple w/o client prs
Multi-disciplinary team
Child welfare agency funded
Funded state addiction agncy
State mntl hlth agncy funded
County/local agency funded
Funded by juvenile justice
Criminal justice agncy fund
CAP no-pay for prescript num
CAP restock of emerg drugs
CAP drug unavail thru cap
DMEPOS comp bid furn by hosp
Administered intravenously
Administered subcutaneously
Skin substitute graft
Skin sub not used as a graft
Discarded drug not administe
Lwr ext prost functnl lvl 0
Lwr ext prost functnl lvl 1
Lwr ext prost functnl lvl 2
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Lwr ext prost functnl lvl 3
Lwr ext prost functnl lvl 4
Wheelchair add-on option/acc
>4 modifiers on claim
Repl special pwr wc intrface
Drug/biological DME infused
Bid under round 1 DMEPOS CB
FDA class III device
DMEPOS comp bid prgm no 1
DMEPOS ini clm, pur/1 mo rnt
DMEPOS 2nd or 3rd mo rental
DMEPOS PEN pmp or 4-15mo rnt
DMEPOS comp bid prgm no 2
DMEPOS mailorder comp bid
Rplc facial prosth new imp
Rplc facial prosth old mod
Single drug unit dose form
First drug of multi drug u d
2nd/subsqnt drg multi drg ud
Rental item partial month
Glucose monitor supply
Item from noncontract supply
DMEPOS comp bid prgm no 3
DMEPOS item, profession serv
DMEPOS comp bid prgm no 4
Documentation on file
DMEPOS comp bid prgm no 5
New cov not implement by m+c
Lft circum coronary artery
Left ant des coronary artery
Lease/rental (appld to pur)
Laboratory round trip
FDA-monitored IOL implant 65-7
Left side
Medicare secondary payer
6-mo maint/svc fee parts/lbr
Drug specific nebulizer
New when rented
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New equipment
Normal healthy patient
Patient w/mild syst disease
Patient w/severe sys disease
Pt w/sev sys dis threat life
Pt not expect surv w/o oper
Brain-dead pt organs removed
Surgery, wrong body part
Surgery, wrong patient
Wrong surgery on patient
PET tumor init tx strat
Progressive addition lenses
PET tumor subsq tx strategy
Clrctal screen to diagn
Invest clinical research
Routine clinical research
HCFA/ORD demo procedure/svc
Live donor surgery/services
Svc exempt - ordrg/rfrng MD
Subst MD svc, recip bill arr
Locum tenens MD service
One Class A finding
Two Class B findings
1 Class B & 2 Class C fndngs
FDA investigational device
Single channel monitoring
Rcrdg/strg in sld st memory
Prescribed oxygen < 1 LPM
Prscrbd oxygen >4 LPM & port
Prescribed oxygen > 4 LPM
Oxygen cnsrvg dvc w del sys
Patient in state/locl custod
Med dir 2-4 cncrnt anes proc
Patient died after amb call
Ambulance arr by provider
Ambulance furn by provider
Individually ordered lab tst
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Item/serv in medicare study
Monitored anesthesia care 15018I
Rcrdg/strg tape analog recdr
Item or service provided 30-1
CLIA waived test
CRNA svc w/ MD med direction
Medically directed CRNA
CRNA svc w/o med dir by MD
Replacement of DME item
Replacement part, DME item
Right coronary artery
Drug admin not incident-to
Furnish full compliance REMS
Replacement & repair(DMEPOS)
Rental (DME)
Right side
Nurse practitioner w physici
Nurse midwife
Medically necessary serv/sup
Serv by home infusion RN
State/fed funded program/ser
2nd opinion ordered by PRO
ASC facility service
2nd concurrent infusion ther
3rd concurrent infusion ther
High risk population
State supplied vaccine
Second opinion
Third opinion
Item ordered by home health
HIT in infusion suite
Related to trauma or injury
Performed in phys office
Drugs delivered not used
Serv by cert diab educator
Contact w/high-risk pop
Left foot, second digit
Left foot, third digit
Left foot, fourth digit
Left foot, fifth digit
Right foot, great toe
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Right foot, second digit
Right foot, third digit
Right foot, fourth digit
Right foot, fifth digit
Left foot, great toe
Technical component
RN
LPN/LVN
Intermediate level of care
Complex/High Tech level care
OB TX/Srvcs prenatl/postpart
Child/adolescent program gp
Extra patient or passenger
Early intervention IFSP
Individualized ed prgrm(IEP)
Rural/out of service area
Med transprt unloaded vehicl
BLS by volunteer amb providr
School-based IEP out of dist
Follow-up service
Additional patient
Overtime payment rate
Holiday/weekend payment rate
Back-up equipment
M/caid care lev 1 state def
M/caid care lev 2 state def
M/caid care lev 3 state def
M/caid care lev 4 state def
M/caid care lev 5 state def
M/caid care lev 6 state def
M/caid care lev 7 state def
M/caid care lev 8 state def
M/caid care lev 9 state def
M/caid care lev 10 state def
M/caid care lev 11 state def
M/caid care lev 12 state def
M/caid care lev 13 state def
Used durable med equipment
Services provided, morning
Services provided, afternoon
Services provided, evening
Services provided, night
Svc on behalf client-collat
Two patients served
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Three patients served
Four patients served
Five patients served
Six or more patients served
Vascular catheter
Arteriovenous graft
Arteriovenous fistula
Infection present
No infection present
Aphakic patient
Outside state ambulance serv 00 9
Noninterest escort in non er 00 9
Interest escort in non er 00 9
Nonemergency transport taxi 00 9
Nonemergency transport bus 00 9
Noner transport mini-bus 00 9
Noner transport wheelch van 00 9
Nonemergency transport air 00 9
Noner transport case worker 00 9
Transport parking fees/tolls 00 9
Noner transport lodgng recip 00 9
Noner transport meals recip 00 9
Noner transport lodgng escrt 00 9
Noner transport meals escort 00 9
Neonatal emergency transport 00 9
Basic life support mileage 00 9
Basic support routine suppls 52 A
Bls defibrillation supplies 52 A
Advanced life support mileag 00 9
Als defibrillation supplies 52 A
Als IV drug therapy supplies 52 A
Als esophageal intub suppls 52 A
Als routine disposble suppls 52 A
Ambulance waiting 1/2 hr 52 A
Ambulance 02 life sustaining 52 A
Extra ambulance attendant 52 A
Ground mileage 52 A
Als 1 52 A
ALS1-emergency 52 A
bls 52 A
BLS-emergency 52 A
Fixed wing air transport 52 A
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Rotary wing air transport 52 A
PI volunteer ambulance co 52 A
als 2 52 A
Specialty care transport 52 A
Fixed wing air mileage 52 A
Rotary wing air mileage 52 A
Noncovered ambulance mileage 00 9
Ambulance response/treatment 00 9
Unlisted ambulance service 57 A
1 CC sterile syringe&needle 00 9
2 CC sterile syringe&needle 00 9
3 CC sterile syringe&needle 00 9
5+ CC sterile syringe&needle 00 9
Nonneedle injection device 00 9 60-9
Supp for self-adm injections 00 9
Non coring needle or stylet 57 A
20+ CC syringe only 00 9
Sterile needle 00 9
Sterile water/saline, 10 ml 37 A
Sterile water/saline, 500 ml 37 A
Sterile saline or water 51 A
Infusion pump refill kit 57 A 60-14
Maint drug infus cath per wk 34 A
Infusion supplies with pump 34 A
Infusion supplies w/o pump 00 9
Infus insulin pump non needl 34 A 60-14
Infusion insulin pump needle 34 A 60-14
Syringe w/needle insulin 3cc 00 9 60-14
Alkalin batt for glucose mon 36 A
J-cell batt for glucose mon 36 A
Lithium batt for glucose mon 36 A
Silvr oxide batt glucose mon 36 A
Alcohol or peroxide per pint 00 9
Alcohol wipes per box 00 9
Betadine/phisohex solution 00 9
Betadine/iodine swabs/wipes 00 9
Chlorhexidine antisept 52 A
Urine reagent strips/tablets 00 9
Blood ketone test or strip 00 9
Blood glucose/reagent strips 32 A 60-11
Glucose monitor platforms 34 A 60-11
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Calibrator solution/chips 34 A 60-11
Replace Lensshield Cartridge 34 A
Lancet device each 34 A 60-11
Lancets per box 34 A 60-11
Cervical cap contraceptive 00 9
Temporary tear duct plug 00 9
Permanent tear duct plug 11 A
Intratubal occlusion device 00 9
Paraffin 34 A 60-9
Diaphragm 00 9
Male condom 00 9
Female condom 00 9
Spermicide 00 9
Disposable endoscope sheath 00 9
Brst prsths adhsv attchmnt 38 A
Replacement breastpump tube 00 9
Replacement breastpump adpt 00 9
Replacement breastpump cap 00 9
Replcmnt breast pump shield 00 9
Replcmnt breast pump bottle 00 9
Replcmnt breastpump lok ring 00 9
Sacral nerve stim test lead 00 9
Cath impl vasc access portal 11 A
Implantable access syst perc 00 9
Drug delivery system >=50 ML 00 9
Drug delivery system <=50 ml 00 9
Insert tray w/o bag/cath 37 A
Catheter w/o bag 2-way latex 37 A
Cath w/o bag 2-way silicone 37 A
Catheter w/bag 3-way 37 A
Cath w/drainage 2-way latex 37 A
Cath w/drainage 2-way silcne 37 A
Cath w/drainage 3-way 37 A
Irrigation tray 37 A
Cath therapeutic irrig agent 37 A
Irrigation syringe 37 A
Male external catheter 37 A
Fem urinary collect dev cup 37 A
Fem urinary collect pouch 37 A
Stool collection pouch 37 A
Extension drainage tubing 37 A
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Lube sterile packet 37 A
Urinary cath anchor device 37 A
Urinary cath leg strap 37 A
Incontinence supply 46 A
Urethral insert 37 A
Indwelling catheter latex 37 A
Indwelling catheter special 37 A
Cath indw foley 2 way silicn 37 A
Cath indw foley 3 way 37 A
Disposable male external cat 37 A
Straight tip urine catheter 37 A
Coude tip urinary catheter 37 A
Intermittent urinary cath 37 A
Cath insertion tray w/bag 37 A
Bladder irrigation tubing 37 A
Ext ureth clmp or compr dvc 37 A
Bedside drainage bag 37 A
Urinary leg or abdomen bag 37 A
Disposable ext urethral dev 37 A
Ostomy face plate 37 A
Solid skin barrier 37 A
Ostomy clamp, replacement 37 A
Adhesive, liquid or equal 37 A
Adhesive remover wipes 37 A
Ostomy vent 37 A
Ostomy belt 37 A
Ostomy filter 37 A
Skin barrier liquid per oz 37 A
Skin barrier powder per oz 37 A
Skin barrier solid 4x4 equiv 37 A
Skin barrier with flange 37 A
Drainable plastic pch w fcpl 37 A
Drainable rubber pch w fcplt 37 A
Drainable plstic pch w/o fp 37 A
Drainable rubber pch w/o fp 37 A
Urinary plastic pouch w fcpl 37 A
Urinary rubber pouch w fcplt 37 A
Urinary plastic pouch w/o fp 37 A
Urinary hvy plstc pch w/o fp 37 A
Urinary rubber pouch w/o fp 37 A
Ostomy faceplt/silicone ring 37 A
Ost skn barrier sld ext wear 37 A
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Ost clsd pouch w att st barr 37 A
Drainable pch w ex wear barr 37 A
Drainable pch w st wear barr 37 A
Drainable pch ex wear convex 37 A
Urinary pouch w ex wear barr 37 A
Urinary pouch w st wear barr 37 A
Urine pch w ex wear bar conv 37 A
Ostomy pouch liq deodorant 37 A
Ostomy pouch solid deodorant 37 A
Peristomal hernia supprt blt 37 A
Irrigation supply sleeve 37 A
Ostomy irrigation bag 37 A
Ostomy irrig cone/cath w brs 37 A
Ostomy irrigation set 37 A
Lubricant per ounce 37 A
Ostomy ring each 37 A
Nonpectin based ostomy paste 37 A
Pectin based ostomy paste 37 A
Ext wear ost skn barr <=4sq" 37 A
Ext wear ost skn barr >4sq" 37 A
Ost skn barr convex <=4 sq i 37 A
Ost skn barr extnd >4 sq 37 A
Ost skn barr extnd =4sq 37 A
Ost pouch drain high output 37 A
2 pc drainable ost pouch 37 A
Ost sknbar w/o conv<=4 sq in 37 A
Ost skn barr w/o conv >4 sqi 37 A
Ost pch clsd w barrier/filtr 37 A
Ost pch w bar/bltinconv/fltr 37 A
Ost pch clsd w/o bar w filtr 37 A
Ost pch for bar w flange/flt 37 A
Ost pch clsd for bar w lk fl 37 A
Ostomy supply misc 00 9
Ost pouch absorbent material 37 A
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Ost pch for bar w lk fl/fltr 37 A
Ost pch drain w bar & filter 37 A
Ost pch drain for barrier fl 37 A
Ost pch drain 2 piece system 37 A
Ost pch drain/barr lk flng/f 37 A
Urine ost pouch w faucet/tap 37 A
Urine ost pouch w bltinconv 37 A
Ost urine pch w b/bltin conv 37 A
Ost pch urine w barrier/tapv 37 A
Os pch urine w bar/fange/tap 37 A
Urine ost pch bar w lock fln 37 A
Ost pch urine w lock flng/ft 37 A
Non-waterproof tape 37 A
Waterproof tape 37 A
Adhesive remover per ounce 37 A
Adhesive remover, wipes 37 A
Reusable enema bag 00 9
Surgicl dress hold non-reuse 35 A
Surgical dress holder reuse 35 A
Non-elastic extremity binder 00 9
Elastic garment/covering 00 9
Gravlee jet washer 00 9 50-4
Vabra aspirator 00 9 50-10
Tracheostoma filter 37 A
Moisture exchanger 37 A
Above knee surgical stocking 00 9 60-9
Thigh length surg stocking 00 9 60-9
Below knee surgical stocking 00 9 60-9
Full length surg stocking 00 9 60-9
Incontinence garment anytype 00 9 60-9
Surgical trays 11 A
Disposable underpads 00 9 60-9
Electrodes, pair 34 A
Lead wires, pair 34 A
Conductive gel or paste 34 A
Coupling gel or paste 34 A
Pessary rubber, any type 38 A
Pessary, non rubber,any type 38 A
Slings 52 A
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Should sling/vest/abrestrain 00 9
Splint 52 A
Hyperbaric o2 chamber disps 00 9 35-10
Cast supplies (plaster) 00 9
Special casting material 00 9
TENS suppl 2 lead per month 34 A 45-25
Sleeve, inter limb comp dev 32 A
Lith ion batt, non-pros use 32 A
Tubing with heating element 32 A
Trach suction cath close sys 32 A
Oxygen probe used w oximeter 00 9
Transtracheal oxygen cath 00 9
Heavy duty battery 32 A
Battery cables 32 A
Battery charger 32 A
Hand-held PEFR meter 46 A
Cannula nasal 00 9 60-4
Tubing (oxygen) per foot 00 9 60-4
Mouth piece 00 9 60-4
Breathing circuits 32 A 60-4
Face tent 33 A 60-4
Variable concentration mask 00 9 60-4
Tracheostomy inner cannula 37 A 65-16
Tracheal suction tube 32 A
Trach care kit for new trach 37 A
Tracheostomy cleaning brush 37 A
Spacer bag/reservoir 00 9
Oropharyngeal suction cath 32 A
Tracheostomy care kit 37 A
Repl bat t.e.n.s. own by pt 32 A 65-8
Uvl replacement bulb 32 A
Replacement bulb th lightbox 00 9
Underarm crutch pad 32 A 60-9
Handgrip for cane etc 32 A 60-9
Repl tip cane/crutch/walker 32 A 60-9
Repl batt pulse gen sys 32 A
Infrared ht sys replcmnt pad 32 A
Alternating pressure pad 32 A 60-9
Radiopharm dx agent noc 51 A
In111 satumomab 51 A
Implantable tissue marker 57 A
Surgical supplies 46 A
Implant radiation dosimeter 57 A
Calibrated microcap tube 52 A
Microcapillary tube sealant 52 A
PD catheter anchor belt 52 A
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Syringe w/wo needle 52 A
Sphyg/bp app w cuff and stet 52 A
Dialysis blood pressure cuff 52 A
Automatic bp monitor, dial 00 9 50-42
Disposable cycler set 52 A
Drainage ext line, dialysis 52 A
Ext line w easy lock connect 52 A
Chem/antisept solution, 8oz 52 A
Activated carbon filter, ea 52 A 55-1
Dialyzer, each 52 A
Bicarbonate conc sol per gal 52 A
Bicarbonate conc pow per pac 52 A
Acetate conc sol per gallon 52 A
Acid conc sol per gallon 52 A
Treated water per gallon 52 A 55-1
"Y set" tubing 52 A
Dialysat sol fld vol > 249cc 52 A
Dialysat sol fld vol > 999cc 52 A
Dialys sol fld vol > 1999cc 52 A
Dialys sol fld vol > 2999cc 52 A
Dialys sol fld vol > 3999cc 52 A
Dialys sol fld vol > 4999cc 52 A
Dialys sol fld vol > 5999cc 52 A
Dialysate solution, non-dex 52 A
Fistula cannulation set, ea 52 A
Topical anesthetic, per gram 52 A
Inj anesthetic per 10 ml 52 A
Shunt accessory 52 A
Art or venous blood tubing 52 A
Comb art/venous blood tubing 52 A
Dialysate sol test kit, each 52 A
Dialysate conc pow per pack 52 A
Dialysate conc sol add 10 ml 52 A
Blood collection tube/vacuum 52 A
Serum clotting time tube 52 A
Blood glucose test strips 52 A
Occult blood test strips 52 A
Ammonia test strips 52 A
Protamine sulfate per 50 mg 52 A
Disposable catheter tips 52 A
Plumb/elec wk hm hemo equip 52 A
Repair/maint cont hemo equip 52 A
Drain bag/bottle 52 A
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Misc dialysis supplies noc 52 A
Venous pressure clamp 52 A
Non-sterile gloves 52 A
Surgical mask 52 A
Tourniquet for dialysis, ea 52 A
Sterile, gloves per pair 52 A
Reusable oral thermometer 52 A
Reusable rectal thermometer 00 9
Pouch clsd w barr attached 37 A
Clsd ostomy pouch w/o barr 37 A
Clsd ostomy pouch faceplate 37 A
Clsd ostomy pouch w/flange 37 A
Stoma cap 37 A
Pouch drainable w barrier at 37 A
Drnble ostomy pouch w/o barr 37 A
Drain ostomy pouch w/flange 37 A
Urinary pouch w/barrier 37 A
Urinary pouch w/o barrier 37 A
Urinary pouch on barr w/flng 37 A
Continent stoma plug 37 A
Continent stoma catheter 37 A
Stoma absorptive cover 37 A
Ostomy accessory convex inse 37 A
Bedside drain btl w/wo tube 37 A
Urinary suspensory 37 A
Urinary leg bag 37 A
Latex leg strap 37 A
Foam/fabric leg strap 37 A
Skin barrier, wipe or swab 37 A
Solid skin barrier 6x6 37 A
Solid skin barrier 8x8 37 A
Disk/foam pad +or- adhesive 37 A
Appliance cleaner 37 A
Percutaneous catheter anchor 37 A
Diab shoe for density insert 38 A
Diabetic custom molded shoe 38 A
Diabetic shoe w/roller/rockr 38 A
Diabetic shoe with wedge 38 A
Diab shoe w/metatarsal bar 38 A
Diabetic shoe w/off set heel 38 A
Modification diabetic shoe 38 A
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Diabetic deluxe shoe 38 A
Compression form shoe insert 38 A
Multi den insert direct form 38 A
Multi den insert custom mold 38 A
Wound warming wound cover 00 9
Collagen based wound filler 35 A
Collagen gel/paste wound fil 35 A
Collagen dressing <=16 sq in 35 A
Collagen drsg>16<=48 sq in 35 A
Collagen dressing >48 sq in 35 A
Collagen dsg wound filler 35 A
Silicone gel sheet, each 00 9
Wound pouch each 35 A
Alginate dressing <=16 sq in 35 A
Alginate drsg >16 <=48 sq in 35 A
alginate dressing > 48 sq in 46 A
Alginate drsg wound filler 35 A
Compos drsg <=16 no border 00 9
Compos drsg >16<=48 no bdr 00 9
Compos drsg >48 no border 00 9
Composite drsg <= 16 sq in 35 A
Composite drsg >16<=48 sq in 35 A
Composite drsg > 48 sq in 46 A
Contact layer <= 16 sq in 46 A
Contact layer >16<= 48 sq in 35 A
Contact layer > 48 sq in 46 A
Foam drsg <=16 sq in w/o bdr 35 A
Foam drg >16<=48 sq in w/o b 35 A
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Foam drg > 48 sq in w/o brdr 35 A
Foam drg <=16 sq in w/border 35 A
Foam drg >16<=48 sq in w/bdr 46 A
Foam drg > 48 sq in w/border 35 A
Foam dressing wound filler 46 A
Non-sterile gauze<=16 sq in 35 A
Non-sterile gauze>16<=48 sq 35 A
Non-sterile gauze > 48 sq in 46 A
Gauze <= 16 sq in w/border 35 A
Gauze >16 <=48 sq in w/bordr 35 A
Gauze > 48 sq in w/border 46 A
Gauze <=16 in no w/sal w/o b 35 A
Gauze >16<=48 no w/sal w/o b 35 A
Gauze > 48 in no w/sal w/o b 35 A
Gauze <= 16 sq in water/sal 46 A
Gauze >16<=48 sq in watr/sal 35 A
Gauze > 48 sq in water/salne 46 A
Hydrogel dsg<=16 sq in 35 A
Hydrogel dsg>16<=48 sq in 35 A
Hydrogel dressing >48 sq in 35 A
Hydrocolld drg <=16 w/o bdr 35 A
Hydrocolld drg >16<=48 w/o b 35 A
Hydrocolld drg > 48 in w/o b 35 A
Hydrocolld drg <=16 in w/bdr 35 A
Hydrocolld drg >16<=48 w/bdr 35 A
Hydrocolld drg > 48 in w/bdr 46 A
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Hydrocolld drg filler paste 35 A
Hydrocolloid drg filler dry 35 A
Hydrogel drg <=16 in w/o bdr 35 A
Hydrogel drg >16<=48 w/o bdr 35 A
Hydrogel drg >48 in w/o bdr 35 A
Hydrogel drg <= 16 in w/bdr 35 A
Hydrogel drg >16<=48 in w/b 35 A
Hydrogel drg > 48 sq in w/b 35 A
Hydrogel drsg gel filler 35 A
Skin seal protect moisturizr 00 9
Absorpt drg <=16 sq in w/o b 35 A
Absorpt drg >16 <=48 w/o bdr 35 A
Absorpt drg > 48 sq in w/o b 35 A
Absorpt drg <=16 sq in w/bdr 35 A
Absorpt drg >16<=48 in w/bdr 35 A
Absorpt drg > 48 sq in w/bdr 46 A
Transparent film <= 16 sq in 35 A
Transparent film >16<=48 in 35 A
Transparent film > 48 sq in 35 A
Wound cleanser any type/size 00 9
Wound filler gel/paste /oz 46 A
Wound filler dry form / gram 46 A
Impreg gauze no h20/sal/yard 35 A
Sterile gauze <= 16 sq in 35 A
Sterile gauze>16 <= 48 sq in 35 A
Sterile gauze > 48 sq in 35 A
Packing strips, non-impreg 35 A
Sterile eye pad 35 A
Non-sterile eye pad 35 A
Occlusive eye patch 00 9
Adhesive bandage, first-aid 00 9
Pad band w>=3" <5"/yd 35 A
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Conform band n/s w<3"/yd 35 A
Conform band n/s w>=3"<5"/yd 35 A
Conform band n/s w>=5"/yd 35 A
Conform band s w <3"/yd 35 A
Conform band s w>=3" <5"/yd 35 A
Conform band s w >=5"/yd 35 A
Lt compres band <3"/yd 35 A
Lt compres band >=3" <5"/yd 35 A
Lt compres band >=5"/yd 35 A
Mod compres band w>=3"<5"/yd 35 A
High compres band w>=3"<5"yd 35 A
Self-adher band w <3"/yd 35 A
Self-adher band w>=3" <5"/yd 35 A
Self-adher band >=5"/yd 35 A
Zinc paste band w >=3"<5"/yd 35 A
Tubular dressing 35 A
Compres burngarment bodysuit 35 A
Compres burngarment chinstrp 35 A
Compres burngarment facehood 35 A
Cmprsburngarment glove-wrist 35 A
Cmprsburngarment glove-elbow 35 A
Cmprsburngrmnt glove-axilla 35 A
Cmprs burngarment foot-knee 35 A
Cmprs burngarment foot-thigh 35 A
Compres burn garment jacket 35 A
Compres burn garment leotard 35 A
Compres burn garment panty 35 A
Compres burn garment, noc 35 A
Compress burn mask face/neck 00 9
Compression stocking BK18-30 00 9 60-9
Compression stocking BK30-40 35 A
Compression stocking BK40-50 35 A
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Gc stocking thighlngth 18-30 00 9 60-9
Gc stocking thighlngth 30-40 00 9 60-9
Gc stocking thighlngth 40-50 00 9 60-9
Gc stocking full lngth 18-30 00 9 60-9
Gc stocking full lngth 30-40 00 9 60-9
Gc stocking full lngth 40-50 00 9 60-9
Gc stocking waistlngth 18-30 00 9 60-9
Gc stocking waistlngth 30-40 00 9 60-9
Gc stocking waistlngth 40-50 00 9 60-9
Gc stocking custom made 00 9 60-9
Gc stocking lymphedema 00 9 60-9
Gc stocking garter belt 00 9 60-9
Grad comp non-elastic BK 35 A
G compression stocking 00 9 60-9
Neg pres wound ther drsg set 34 A
Disposable canister for pump 32 A
Nondisposable pump canister 32 A
Tubing used w suction pump 32 A
Nebulizer administration set 32 A
Disposable nebulizer sml vol 32 A
Nondisposable nebulizer set 32 A
Filtered nebulizer admin set 32 A
Lg vol nebulizer disposable 32 A
Disposable nebulizer prefill 32 A
Nebulizer reservoir bottle 32 A
Disposable corrugated tubing 32 A
Nondispos corrugated tubing 46 A
Nebulizer water collec devic 32 A
Disposable compressor filter 32 A
Compressor nondispos filter 32 A
Aerosol mask used w nebulize 32 A
Nebulizer dome & mouthpiece 32 A
Nebulizer not used w oxygen 32 A 60-9
Water distilled w/nebulizer 32 A
Interface, cough stim device 32 A
Replace chest compress vest 32 A
Replace chst cmprss sys hose 32 A
Combination oral/nasal mask 32 A
Repl oral cushion combo mask 32 A
Repl nasal pillow comb mask 32 A
CPAP full face mask 32 A
Replacement facemask interfa 32 A
Replacement nasal cushion 32 A
Replacement nasal pillows 32 A
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Nasal application device 32 A
Pos airway press headgear 32 A
Pos airway press chinstrap 32 A
Pos airway pressure tubing 32 A
Pos airway pressure filter 32 A
Filter, non disposable w pap 32 A
One way chest drain valve 38 A
Water seal drain container 38 A
Implanted pleural catheter 38 A
Vacuum drainagebottle/tubing 38 A
PAP oral interface 32 A
Repl exhalation port for PAP 32 A 60-17
Repl water chamber, PAP dev 32 A 60-17
Tracheostoma valve w diaphra 37 A
Replacement diaphragm/fplate 37 A
HMES filter holder or cap 37 A
Tracheostoma HMES filter 37 A
HMES or trach valve housing 37 A
HMES/trachvalve adhesivedisk 37 A
Integrated filter & holder 37 A
Housing & Integrated Adhesiv 37 A
Heat & moisture exchange sys 37 A
Trach/laryn tube non-cuffed 37 A
Trach/laryn tube cuffed 37 A
Trach/laryn tube stainless 37 A
Tracheostomy shower protect 37 A
Tracheostoma stent/stud/bttn 37 A
Tracheostomy mask 37 A
Tracheostomy tube collar 37 A
Trach/laryn tube plug/stop 37 A
Soft protect helmet prefab 32 A
Hard protect helmet prefab 32 A
Soft protect helmet custom 45 A
Hard protect helmet custom 45 A
Repl soft interface, helmet 32 A
Misc/exper non-prescript dru 57 A
Single vitamin nos 00 9
Multi-vitamin nos 00 9
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Artificial saliva 57 A
Lice treatment, topical 00 9
Non-covered item or service 00 9
Hot/cold h2obot/cap/col/wrap 00 9
Ext amb insulin delivery sys 00 9
Disp home glucose monitor 00 9
Disposable sensor, CGM sys 00 9
External transmitter, CGM 00 9
External receiver, CGM sys 00 9
Monitoring feature/deviceNOC 00 9
Alert device, noc 00 9
Reaching/grabbing device 00 9
Wig any type 00 9
Foot press off load supp dev 00 9
Non-electronic spirometer 00 9
Exercise equipment 00 9 60-9
Tc99m sestamibi 57 A
Technetium TC-99m teboroxime 57 A
Tc99m tetrofosmin 57 A
Tc99m medronate 57 A
Tc99m apcitide 57 A
TL201 thallium 57 A
In111 capromab 57 A
I131 iodobenguate, dx 51 A
Iodine I-123 sod iodide mil 57 A
Tc99m disofenin 51 A
Tc99m pertechnetate 57 A
Iodine I-123 sod iodide mic 57 A
I131 iodide cap, rx 57 A
Tc99m exametazime 57 A
I131 serum albumin, dx 57 A
Nitrogen N-13 ammonia 53 A
Iodine I-125 sodium iodide 57 A
Iodine I-131 iodide cap, dx 57 A
I131 iodide sol, dx 57 A
I131 iodide sol, rx 57 A
I131 max 100uCi 57 A
I125 serum albumin, dx 57 A
Injection, methylene blue 51 A
Tc99m depreotide 57 A
Tc99m mebrofenin 57 A
Tc99m pyrophosphate 57 A
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Tc99m pentetate 57 A
Tc99m MAA 57 A
Tc99m sulfur colloid 57 A
In111 ibritumomab, dx 51 A
Y90 ibritumomab, rx 51 A
I131 tositumomab, dx 57 A
I131 tositumomab, rx 57 A
Co57/58 53 A
In111 oxyquinoline 53 A
In111 pentetate 53 A
Tc99m gluceptate 53 A
Tc99m succimer 53 A
F18 fdg 53 A
Cr51 chromate 53 A
I125 iothalamate, dx 53 A
Rb82 rubidium 99 9
Ga67 gallium 57 A
Tc99m bicisate 57 A
Xe133 xenon 10mci 57 A
Co57 cyano 57 A
Tc99m labeled rbc 57 A
Tc99m oxidronate 57 A
Tc99m mertiatide 57 A
P32 Na phosphate 57 A
P32 chromic phosphate 57 A
In111 pentetreotide 57 A
Tc99m fanolesomab 57 A
Technetium TC-99m aerosol 57 A
Technetium tc99m arcitumomab 53 A
Technetium TC-99m auto WBC 57 A
Indium In-111 auto WBC 57 A
Indium IN-111 auto platelet 57 A
Indium In-111 pentetreotide 57 A
Inj prohance multipack 51 A
Inj multihance 51 A
Inj multihance multipack 51 A
Gad-base MR contrast NOS,1ml 51 A
Sodium fluoride F-18 57 A
Gadoxetate disodium inj 51 A
Iodine I-123 iobenguane 51 A
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Gadofosveset trisodium inj 51 A
Sr89 strontium 57 A
Sm 153 lexidronam 57 A
Sm 153 lexidronm 57 A
Non-rad contrast materialNOC 51 A
Radiopharm rx agent noc 57 A
Echocardiography Contrast 57 A
Supply/accessory/service 46 A
Delivery/set up/dispensing 46 A
DME supply or accessory, nos 46 A
Enter feed supkit syr by day 39 A 65-10
Enteral feed supp pump per d 39 A 65-10
Enteral feed sup kit grav by 39 A 65-10
Enteral ng tubing w/ stylet 39 A 65-10
Enteral ng tubing w/o stylet 39 A 65-10
Enteral stomach tube levine 39 A 65-10
Gastrostomy/jejunostomy tube 39 A
Gastro/jejuno tube, std 39 A
Gastro/jejuno tube, low-pro 39 A
Food thickener oral 00 9 60-9
EF adult fluids and electro 39 A 65-10
EF ped fluid and electrolyte 46 A 65-10
Additive for enteral formula 00 9 65-10
EF blenderized foods 39 A 65-10
EF complet w/intact nutrient 39 A 65-10
EF calorie dense>/=1.5Kcal 39 A 65-10
EF hydrolyzed/amino acids 39 A 65-10
EF spec metabolic noninherit 39 A 65-10
EF incomplete/modular 39 A 65-10
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EF special metabolic inherit 39 A 65-10
EF ped complete intact nut 46 A 65-10
EF ped complete soy based 46 A 65-10
EF ped caloric dense>/=0.7kc 46 A 65-10
EF ped hydrolyzed/amino acid 46 A 65-10
EF ped specmetabolic inherit 46 A 65-10
Parenteral 50% dextrose solu 39 A 65-10
Parenteral sol amino acid 3. 39 A 65-10
Parenteral sol amino acid 5. 39 A 65-10
Parenteral sol amino acid 7- 39 A 65-10
Parenteral sol amino acid > 39 A 65-10
Parenteral sol carb > 50% 39 A 65-10
Parenteral sol 10 gm lipids 39 A
Parenteral sol amino acid & 39 A 65-10
Parenteral sol 52-73 gm prot 39 A 65-10
Parenteral sol 74-100 gm pro 39 A 65-10
Parenteral sol > 100gm prote 39 A 65-10
Parenteral nutrition additiv 39 A 65-10
Parenteral supply kit premix 39 A 65-10
Parenteral supply kit homemi 39 A 65-10
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Parenteral administration ki 39 A 65-10
Parenteral sol renal-amirosy 39 A 65-10
Parenteral sol hepatic-fream 39 A 65-10
Parenteral sol stres-brnch c 39 A 65-10
Enter infusion pump w/o alrm 39 A 65-10
Enteral infusion pump w/ ala 39 A 65-10
Parenteral infus pump portab 39 A 65-10
Parenteral infus pump statio 39 A 65-10
Enteral supp not otherwise c 57 A 65-10
Parenteral supp not othrws c 57 A 65-10
HYPERBARIC Oxygen 53 A
Anchor/screw bn/bn,tis/bn 53 A
Cath, trans atherectomy, dir 53 A
Brachytherapy needle 53 A
Brachytx, non-str, Gold-198 53 A
Brachytx, non-str,HDR Ir-192 53 A
Brachytx source, Iodine 125 53 A
Brachytx, NS, Non-HDRIr-192 53 A
Brachytx sour, Palladium 103 53 A
AICD, dual chamber 53 A
AICD, single chamber 53 A
Cath, trans atherec,rotation 53 A
Cath, translumin non-laser 53 A
Cath, bal dil, non-vascular 53 A
Cath, bal tis dis, non-vas 53 A
Cath, brachytx seed adm 53 A
Cath, drainage 53 A
Cath, EP, 19 or few elect 53 A
Cath, EP, 20 or more elec 53 A
Cath, EP, diag/abl, 3D/vect 53 A
Cath, EP, othr than cool-tip 53 A
Endo, colon, retro imaging 53 A
Cath, hemodialysis,long-term 53 A
Cath, inf, per/cent/midline 53 A
Cath,hemodialysis,short-term 53 A
Cath, intravas ultrasound 53 A
Catheter, intradiscal 53 A
Catheter, intraspinal 53 A
Cath, pacing, transesoph 53 A
Cath, thrombectomy/embolect 53 A
Catheter, ureteral 53 A
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Cath, intra echocardiography 53 A
Closure dev, vasc 53 A
Conn tiss, human(inc fascia) 53 A
Conn tiss, non-human 53 A
Event recorder, cardiac 53 A
Adhesion barrier 53 A
Intro/sheath,strble,non-peel 53 A
Generator, neuro non-recharg 53 A
Graft, vascular 53 A
Guide wire 53 A
Imaging coil, MR, insertable 53 A
Rep dev, urinary, w/sling 53 A
Infusion pump, programmable 53 A
Ret dev, insertable 53 A
Joint device (implantable) 53 A
Lead, AICD, endo single coil 53 A
Lead, neurostimulator 53 A
Lead, pmkr, transvenous VDD 53 A
Lens, intraocular (new tech) 53 A
Mesh (implantable) 53 A
Morcellator 53 A
Ocular imp, aqueous drain de 53 A
Ocular dev, intraop, det ret 53 A
Pmkr, dual, rate-resp 53 A
Pmkr, single, rate-resp 53 A
Patient progr, neurostim 53 A
Port, indwelling, imp 53 A
Prosthesis, breast, imp 53 A
Prosthesis, penile, inflatab 53 A
Retinal tamp, silicone oil 53 A
Pros, urinary sph, imp 53 A
Receiver/transmitter, neuro 53 A
Septal defect imp sys 53 A
Integrated keratoprosthesis 53 A
Tissue localization-excision 53 A
Generator neuro rechg bat sy 53 A
Interspinous implant 53 A
Stent, coated/cov w/del sys 53 A
Stent, coated/cov w/o del sy 53 A
Stent, non-coa/non-cov w/del 53 A
Stent, non-coat/cov w/o del 53 A
Matrl for vocal cord 53 A
Tissue marker, implantable 53 A
Vena cava filter 53 A
Dialysis access system 53 A
AICD, other than sing/dual 53 A
Adapt/ext, pacing/neuro lead 53 A
Embolization Protect syst 53 A
Cath, translumin angio laser 53 A
Catheter, guiding 53 A
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Endovas non-cardiac abl cath 53 A
Infusion pump,non-prog, perm 53 A
Intro/sheath,fixed,peel-away 53 A
Intro/sheath, fixed,non-peel 53 A
Intro/sheath, non-laser 53 A
Lead, AICD, endo dual coil 53 A
Lead, AICD, non sing/dual 53 A
Lead, neurostim test kit 53 A
Lead, pmkr, other than trans 53 A
Lead, pmkr/AICD combination 53 A
Lead, coronary venous 53 A
Probe, perc lumb disc 53 A
Sealant, pulmonary, liquid 53 A
Brachytx, non-str,Yttrium-90 53 A
Stent, non-cor, tem w/o del 53 A
Probe, cryoablation 53 A
Pmkr, dual, non rate-resp 53 A
Pmkr, single, non rate-resp 53 A
Pmkr, other than sing/dual 53 A
Prosthesis, penile, non-inf 53 A
Stent, non-cor, tem w/del sy 53 A
Infusion pump, non-prog,temp 53 A
Cath, suprapubic/cystoscopic 53 A
Catheter, occlusion 53 A
Intro/sheath, laser 53 A
Cath, EP, cool-tip 53 A
Rep dev, urinary, w/o sling 53 A
Brachytx source, Cesium-131 53 A
Brachytx, non-str, HA, I-125 53 A
Brachytx, non-str, HA, P-103 53 A
Brachy linear, non-str,P-103 53 A
Brachy,non-str,Ytterbium-169 53 A
Brachytx, stranded, I-125 53 A
Brachytx, non-stranded,I-125 53 A
Brachytx, stranded, P-103 53 A
Brachytx, non-stranded,P-103 53 A
Brachytx, stranded, C-131 53 A
Brachytx, non-stranded,C-131 53 A
Brachytx, stranded, NOS 53 A
Brachytx, non-stranded, NOS 53 A
MRA w/cont, abd 53 A
MRA w/o cont, abd 53 A
MRA w/o fol w/cont, abd 53 A
MRI w/cont, breast, uni 53 A
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MRI w/o cont, breast, uni 53 A
MRI w/o fol w/cont, brst, un 53 A
MRI w/cont, breast, bi 53 A
MRI w/o cont, breast, bi 53 A
MRI w/o fol w/cont, breast, 53 A
MRA w/cont, chest 53 A
MRA w/o cont, chest 53 A
MRA w/o fol w/cont, chest 53 A
MRA w/cont, lwr ext 53 A
MRA w/o cont, lwr ext 53 A
MRA w/o fol w/cont, lwr ext 53 A
MRA w/cont, pelvis 53 A
MRA w/o cont, pelvis 53 A
MRA w/o fol w/cont, pelvis 53 A
TTE w or w/o fol w/cont, com 53 A
TTE w or w/o fol w/cont, f/u 53 A
2D TTE w or w/o fol w/con,co 53 A
2D TTE w or w/o fol w/con,fu 53 A
2D TEE w or w/o fol w/con,in 53 A
TEE w or w/o fol w/cont,cong 53 A
TEE w or w/o fol w/cont, mon 53 A
TTE w or w/o fol w/con,stres 53 A
TTE w or wo fol wcon,Doppler 53 A
TTE w or w/o contr, cont ECG 53 A
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MRA, w/dye, spinal canal 53 A
MRA, w/o dye, spinal canal 53 A
MRA, w/o&w/dye, spinal canal 53 A
MRA, w/dye, upper extremity 53 A
MRA, w/o dye, upper extr 53 A
MRA, w/o&w/dye, upper extr 53 A
Prolonged IV inf, req pump 99 9
Palivizumab, per 50 mg 53 A
Inj pantoprazole sodium, via 53 A
Injection, argatroban 53 A
Injection, idursulfase 53 A
Injection, ranibizumab 53 A
Inj, alglucosidase alfa 53 A
Injection, panitumumab 53 A
Injection, eculizumab 53 A
Inj, lanreotide acetate 53 A
Inj, levetiracetam 53 A
Inj, temsirolimus 53 A
Injection, ixabepilone 53 A
Injection, doripenem 53 A
Injection, fosaprepitant 53 A
Injection, bendamustine hcl 53 A
Injection, regadenoson 53 A
Injection, romiplostim 53 A
Inj, gadoxetate disodium 53 A
Inj, iobenguane, I-123, dx 53 A
Inj, clevidipine butyrate 53 A
Inj, certolizumab pegol 53 A
Artiss fibrin sealant 53 A
Inj, C1 esterase inhibitor 53 A
Injection, plerixafor 53 A
Injection, temozolomide 53 A
Injection, lacosamide 53 A
Paliperidone palmitate inj 53 A
Dexamethasone intravitreal 53 A
Bevacizumab injection 53 A
Telavancin injection 53 A
Pralatrexate injection 53 A
Ofatumumab injection 53 A
Ustekinumab injection 53 A
Fludarabine phosphate, oral 53 A
Ecallantide injection 53 A
Tocilizumab injection 53 A
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Romidepsin injection 53 A
Collagenase clostridum histo 53 A
Injection, Wilate 53 A
Capsaicin patch 53 A
C-1 esterase, berinert 53 A
Gammaplex IVIG 53 A
Velaglucerase alfa 53 A
Inj, denosumab 53 A
Sipuleucel-T, per infusion 53 A
Crotalidae Poly Immune Fab 53 A
Hexaminolevulinate HCl 53 A
Cabazitaxel injection 53 A
Lumizyme, 1 mg 53 A
Incobotulinumtoxin A 53 A
Injection, ibuprofen 53 A
Porous collagen tube per cm 53 A
Acellular derm tissue percm2 53 A
Neuragen nerve guide, per cm 53 A
Neurawrap nerve protector,cm 53 A
Veritas collagen matrix, cm2 53 A
Neuromatrix nerve cuff, cm 53 A
TenoGlide tendon prot, cm2 53 A
Flowable wound matrix, 1 cc 53 A
SurgiMend, fetal 53 A
Implnt,bon void filler-putty 53 A
SurgiMend, neonatal 53 A
NeuroMend nerve wrap 53 A
Implnt,bon void filler-strip 53 A
Integra Meshed Bil Wound Mat 53 A
Porcine implant, Permacol 53 A
Endoform Dermal Template 53 A
Unclassified drugs or biolog 53 A
Radiofrequency energy to anu 53 A
Dyn IR Perf Img 53 A
EPS gast cardia plic 53 A
Place endorectal app 53 A
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Rxt breast appl place/remov 53 A
Insert palate implants 53 A
Place device/marker, non pro 53 A
Dermal filler inj px/suppl 53 A
Tobacco-use counsel 3-10 min 53 A
Tobacco-use counsel >10min 53 A
Inpnt stay radiolabeled item 00 9
Inpt implant pros dev,no cov 53 A
Cane adjust/fixed with tip 32 A 60-3
Cane adjust/fixed quad/3 pro 32 A 60-15
Crutch forearm pair 32 A 60-9
Crutch forearm each 32 A 60-9
Crutch underarm pair wood 32 A 60-9
Crutch underarm each wood 32 A 60-9
Crutch underarm pair no wood 32 A 60-9
Crutch underarm each no wood 32 A 60-9
Underarm springassist crutch 32 A
Crutch substitute 32 A
Walker rigid adjust/fixed ht 32 A 60-9
Walker folding adjust/fixed 32 A 60-9
Walker w trunk support 32 A 60-9
Rigid wheeled walker adj/fix 32 A 60-9
Walker folding wheeled w/o s 32 A 60-9
Enclosed walker w rear seat 32 A 60-9
Walker variable wheel resist 32 A 60-15
Heavyduty walker no wheels 32 A
Heavy duty wheeled walker 32 A
Forearm crutch platform atta 32 A
Walker platform attachment 32 A
Walker wheel attachment,pair 32 A
Walker seat attachment 32 A
Walker crutch attachment 32 A
Walker leg extenders set of4 32 A
Brake for wheeled walker 32 A
Sitz type bath or equipment 32 A 60-9
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Sitz bath/equipment w/faucet 32 A 60-9
Sitz bath chair 32 A 60-9
Commode chair with fixed arm 32 A 60-9
Commode chair with detacharm 36 A 60-9
Commode chair pail or pan 32 A 60-9
Heavyduty/wide commode chair 32 A
Commode chair electric 36 A
Commode chair non-electric 36 A
Seat lift mechanism toilet 00 9
Commode chair foot rest 32 A
Press pad alternating w/ pum 36 A 60-9
Replace pump, alt press pad 36 A 60-9
Dry pressure mattress 32 A 60-9
Gel pressure mattress pad 32 A 60-9
Air pressure mattress 36 A 60-9
Water pressure mattress 36 A 60-9
Synthetic sheepskin pad 32 A 60-9
Lambswool sheepskin pad 32 A 60-9
Positioning cushion 00 9
Protector heel or elbow 32 A
Powered air flotation bed 36 A
Air fluidized bed 36 A 60-19
Gel pressure mattress 36 A 60-9
Air pressure pad for mattres 32 A 60-9
Water pressure pad for mattr 32 A 60-9
Dry pressure pad for mattres 32 A 60-9
Heat lamp without stand 32 A 60-9
Phototherapy light w/ photom 36 A
Therapeutic lightbox tabletp 00 9 60-9
Heat lamp with stand 32 A 60-9
Electric heat pad standard 32 A 60-9
Electric heat pad moist 32 A 60-9
Water circ heat pad w pump 32 A 60-9
Water circ cold pad w pump 36 A 60-9
Hot water bottle 32 A
Infrared heating pad system 00 9
Hydrocollator unit 32 A 60-9
Ice cap or collar 32 A
Wound warming device 00 9
Warming card for NWT 00 9
Paraffin bath unit portable 36 A 60-9
Pump for water circulating p 36 A 60-9
Heat pad non-electric moist 32 A 60-9
Hydrocollator unit portable 32 A 60-9
Bath/shower chair 00 9 60-9
Bath tub wall rail 00 9 60-9
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Bath tub rail floor 00 9 60-9
Toilet rail 00 9 60-9
Toilet seat raised 00 9 60-9
Tub stool or bench 00 9 60-9
Transfer tub rail attachment 00 9
Trans bench w/wo comm open 00 9 60-9
HDtrans bench w/wo comm open 00 9 60-9
Pad water circulating heat u 32 A 60-9
Hosp bed fixed ht w/ mattres 36 A 60-18
Hosp bed fixd ht w/o mattres 36 A 60-18
Hospital bed var ht w/ mattr 36 A 60-18
Hospital bed var ht w/o matt 36 A 60-18
Hosp bed semi-electr w/ matt 36 A 60-18
Hosp bed semi-electr w/o mat 36 A 60-18
Hosp bed total electr w/ mat 36 A 60-18
Hosp bed total elec w/o matt 36 A 60-18
Hospital bed institutional t 00 9 60-9
Mattress innerspring 32 A 60-18
Mattress foam rubber 32 A 60-18
Bed board 00 9 60-9
Over-bed table 00 9 60-9
Bed pan standard 32 A 60-9
Bed pan fracture 32 A 60-9
Powered pres-redu air mattrs 36 A 60-9
Bed cradle 32 A
Hosp bed fx ht w/o rails w/m 36 A 60-18
Hosp bed fx ht w/o rail w/o 36 A 60-18
Hosp bed var ht w/o rail w/o 36 A 60-18
Hosp bed var ht w/o rail w/ 36 A 60-18
Hosp bed semi-elect w/ mattr 36 A 60-18
Hosp bed semi-elect w/o matt 36 A 60-18
Hosp bed total elect w/ matt 36 A 60-18
Hosp bed total elect w/o mat 36 A 60-18
Enclosed ped crib hosp grade 32 A
HD hosp bed, 350-600 lbs 36 A 60-18
Ex hd hosp bed > 600 lbs 36 A 60-18
Hosp bed hvy dty xtra wide 36 A 60-18
Hosp bed xtra hvy dty x wide 36 A 60-18
Page 388
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Rails bed side half length 36 A 60-18
Rails bed side full length 32 A 60-18
Bed accessory brd/tbl/supprt 00 9 60-9
Bed safety enclosure 36 A
Urinal male jug-type 32 A 60-9
Urinal female jug-type 32 A 60-9
Ped hospital bed, manual 36 A
Ped hospital bed semi/elect 36 A
Control unit bowel system 57 A
Disposable pack w/bowel syst 57 A
Air elevator for heel 00 9
Nonpower mattress overlay 36 A
Powered air mattress overlay 36 A
Nonpowered pressure mattress 36 A
Stationary compressed gas 02 33 A 60-4
Gas system stationary compre 00 9 60-4
Oxygen system gas portable 00 9 60-4
Portable gaseous 02 33 A 60-4
Portable liquid oxygen sys 33 A
Portable liquid 02 33 A 60-4
Oxygen system liquid portabl 00 9 60-4
Stationary liquid 02 33 A 60-4
Oxygen system liquid station 00 9 60-4
Stationary O2 contents, gas 33 A 60-4
Stationary O2 contents, liq 33 A 60-4
Portable 02 contents, gas 33 A 60-4
Portable 02 contents, liquid 33 A 60-4
Oximeter non-invasive 00 9
Topical Ox Deliver sys, nos 00 9
Page 389
PUF___2011_Web_File
Vol control vent invasiv int 31 A 60-9
Oxygen tent excl croup/ped t 33 A 60-4
Chest shell 32 A
Chest wrap 36 A
Neg press vent portabl/statn 31 A 60-9
Vol control vent noninv int 31 A 60-9
Rocking bed w/ or w/o side r 36 A
Press supp vent invasive int 31 A
Press supp vent noninv int 31 A
RAD w/o backup non-inv intfc 36 A 60-9
RAD w/backup non inv intrfc 36 A 60-9
RAD w backup invasive intrfc 36 A 60-9
Percussor elect/pneum home m 36 A 60-9
Intrpulmnry percuss vent sys 00 9 60-21
Cough stimulating device 36 A
Chest compression gen system 36 A
Non-elec oscillatory pep dvc 32 A
Oral device/appliance prefab 32 A
Oral device/appliance cusfab 32 A
Electronic spirometer 00 9
Ippb all types 31 A 60-9
Humidif extens supple w ippb 33 A 60-9
Humidifier for use w/ regula 33 A 60-9
Humidifier supplemental w/ i 33 A 60-9
Humidifier nonheated w PAP 32 A
Humidifier heated used w PAP 32 A
Compressor air power source 36 A
Nebulizer with compression 36 A 60-9
Aerosol compressor for svneb 36 A 60-9
Aerosol compressor adjust pr 36 A
Ultrasonic generator w svneb 36 A
Nebulizer ultrasonic 31 A 60-9
Nebulizer for use w/ regulat 32 A 60-9
Page 390
PUF___2011_Web_File
Nebulizer w/ compressor & he 36 A 60-9
Suction pump portab hom modl 36 A 60-9
Cont airway pressure device 36 A 60-17
Manual breast pump 32 A
Electric breast pump 00 9
Hosp grade elec breast pump 00 9
Vaporizer room type 32 A 60-9
Drainage board postural 36 A 60-9
Blood glucose monitor home 32 A 60-11
Pacemaker monitr audible/vis 32 A 60-7
Pacemaker monitr digital/vis 32 A 60-7
Cardiac event recorder 00 9
Automatic ext defibrillator 36 A
Apnea monitor 00 9
Apnea monitor w recorder 00 9
Cap bld skin piercing laser 32 A
Patient lift sling or seat 32 A 60-9
Patient lift bathroom or toi 00 9 60-9
Seat lift incorp lift-chair 32 A 60-8
Seat lift for pt furn-electr 32 A 60-8
Seat lift for pt furn-non-el 32 A
Patient lift hydraulic 36 A 60-9
Patient lift electric 36 A 60-9
PT support & positioning sys 36 A
Combination sit to stand sys 32 A 60-9
Standing frame sys 00 9 60-9
Moveable patient lift system 00 9
Fixed patient lift system 00 9
Multi-position stnd fram sys 00 9 60-9
Dynamic standing frame 00 9 60-9
Pneuma compresor non-segment 32 A 60-16
Pneum compressor segmental 32 A 60-16
Pneum compres w/cal pressure 32 A 60-16
Pneumatic appliance half arm 32 A 60-16
Segmental pneumatic trunk 32 A
Segmental pneumatic chest 32 A
Pneumatic appliance full leg 32 A 60-16
Pneumatic appliance full arm 32 A 60-16
Pneumatic appliance half leg 32 A 60-16
Seg pneumatic appl full leg 32 A 60-16
Seg pneumatic appl full arm 32 A 60-16
Seg pneumatic appli half leg 32 A 60-16
Pressure pneum appl full leg 32 A 60-16
Pressure pneum appl full arm 32 A 60-16
Page 391
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Pressure pneum appl half leg 32 A 60-16
Pneumatic compression device 36 A
Inter limb compress dev NOS 00 9
Uvl pnl 2 sq ft or less 32 A
Uvl sys panel 4 ft 32 A
Uvl sys panel 6 ft 32 A
Uvl md cabinet sys 6 ft 32 A
Safety equipment 00 9
Transfer device 32 A
Restraints any type 57 A
Tens two lead 32 A 35-20
Tens four lead 32 A 35-20
Conductive garment for tens/ 34 A 45-25
Incontinence treatment systm 32 A 60.24
Neuromuscular stim for scoli 36 A
Neuromuscular stim for shock 36 A 35-77
Electromyograph biofeedback 52 A 35-27
Elec osteogen stim not spine 32 A 35-48
Elec osteogen stim spinal 32 A 35-48
Elec osteogen stim implanted 36 A 35-48
Electronic salivary reflex s 52 A
Osteogen ultrasound stimltor 32 A
Nontherm electromgntc device 00 9 35-102
Trans elec jt stim dev sys 36 A
Functional neuromuscularstim 32 A 35-77
Nerve stimulator for tx n&v 32 A
Electric wound treatment dev 00 9 35-102
Functional electric stim NOS 46 A
Iv pole 32 A
Amb infusion pump mechanical 36 A
Mech amb infusion pump <8hrs 32 A
External ambulatory infus pu 36 A 60-14
Non-programble infusion pump 32 A 60-14
Page 392
PUF___2011_Web_File
Programmable infusion pump 32 A 60-14
Ext amb infusn pump insulin 36 A 60-14
Replacement impl pump cathet 32 A
Implantable pump replacement 32 A 60-14
Parenteral infusion pump sta 36 A 65-10
Ambulatory traction device 00 9 60-9
Tract frame attach headboard 32 A 60-9
Cervical pneum trac equip 32 A
Traction stand free standing 32 A 60-9
Cervical traction equipment 32 A
Cervic collar w air bladder 32 A
Tract equip cervical tract 32 A 60-9
Tract frame attach footboard 32 A 60-9
Trac stand free stand extrem 32 A 60-9
Traction frame attach pelvic 32 A 60-9
Trac stand free stand pelvic 32 A 60-9
Trapeze bar attached to bed 36 A 60-9
HD trapeze bar attach to bed 36 A 60-9
HD trapeze bar free standing 36 A 60-9
Fracture frame attached to b 36 A 60-9
Fracture frame free standing 36 A 60-9
Cont pas motion exercise dev 31 A 60-9
CPM device, other than knee 00 9
Trapeze bar free standing 36 A 60-9
Gravity assisted traction de 36 A 60-9
Cervical head harness/halter 32 A
Pelvic belt/harness/boot 32 A
Belt/harness extremity 32 A
Fracture frame dual w cross 36 A 60-9
Fracture frame attachmnts pe 32 A 60-9
Fracture frame attachmnts ce 32 A 60-9
Tray 00 9 60-9
Loop heel 00 9
Toe loop/holder, each 00 9 60-9
Cushioned headrest 32 A
W/c lateral trunk/hip suppor 32 A
W/c medial thigh support 32 A
Whlchr att- conv 1 arm drive 00 9 60-9
Amputee adapter 00 9 60-9
W/c shoulder harness/straps 32 A
Wheelchair brake extension 00 9 60-9
Page 393
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Wheelchair head rest extensi 00 9 60-9
Manual wc hand rim w project 32 A 60-9
Wheelchair commode seat 36 A 60-9
Wheelchair narrowing device 32 A 60-9
Wheelchair no. 2 footplates 00 9 60-9
Wheelchair anti-tipping devi 00 9 60-9
W/Ch access det adj armrest 00 9 60-9
W/Ch access anti-rollback 00 9 60-9
W/C acc,saf belt pelv strap 32 A
Wheelchair safety vest 32 A
Seat upholstery, replacement 32 A
Back upholstery, replacement 32 A
Add pwr joystick 36 A
Add pwr tiller 32 A
W/c seat lift mechanism 32 A
Man w/c push-rim pow assist 32 A
Wheelchair elevating leg res 00 9 60-9
Wheelchair solid seat insert 32 A
Wheelchair arm rest 32 A 60-9
Wheelchair calf rest 00 9 60-9
Pwr seat tilt 32 A
Pwr seat recline 32 A
Pwr seat recline mech 32 A
Pwr seat recline pwr 32 A
Pwr seat combo w/o shear 32 A
Pwr seat combo w/shear 32 A
Pwr seat combo pwr shear 32 A
Add mech leg elevation 32 A
Add pwr leg elevation 32 A
Ped wc modify width adjustm 32 A 60-9
Reclining back add ped w/c 32 A 60-9
Shock absorber for man w/c 32 A
Shock absorber for power w/c 32 A
HD shck absrbr for hd man wc 32 A
HD shck absrber for hd powwc 32 A
Residual limb support system 32 A
W/c manual swingaway 32 A
Page 394
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W/c vent tray fixed 32 A
W/c vent tray gimbaled 32 A
Rollabout chair with casters 36 A 60-9
Patient transfer system <300 36 A
Patient transfer system >300 36 A
Transport chair, ped size 36 A 60-9
Transport chair pt wt<=300lb 36 A 60-9
Transport chair pt wt >300lb 36 A
Whelchr fxd full length arms 36 A 60-9
Wheelchair detachable arms 36 A 60-9
Wheelchair detachable foot r 36 A 60-9
Hemi-wheelchair fixed arms 36 A 60-9
Hemi-wheelchair detachable a 36 A 60-9
Hemi-wheelchair fixed arms 00 9 60-9
Hemi-wheelchair detachable a 00 9 60-9
Wheelchair lightwt fixed arm 36 A 60-9
Wheelchair lightweight det a 36 A 60-9
Wheelchair lightwt fixed arm 00 9 60-9
Wheelchair lightweight det a 00 9 60-9
Wheelchair wide w/ leg rests 36 A 60-9
Wheelchair wide w/ foot rest 36 A 60-9
Whchr s-recl fxd arm leg res 36 A 60-9
Wheelchair semi-recl detach 36 A 60-9
Whlchr stand fxd arm ft rest 00 9 60-9
Wheelchair standard detach a 00 9 60-9
Wheelchair standard w/ leg r 36 A 60-9
Wheelchair fixed arms 36 A 60-9
Manual adult wc w tiltinspac 32 A
Whlchr ampu fxd arm leg rest 36 A 60-9
Wheelchair amputee w/o leg r 36 A 60-9
Page 395
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Wheelchair amputee detach ar 36 A 60-9
Wheelchair amputee w/ foot r 36 A 60-9
Wheelchair amputee w/ leg re 36 A 60-9
Wheelchair amputee heavy dut 36 A 60-9
Wheelchair amputee fixed arm 36 A 60-9
Whlchr special size/constrc 45 A 60-6
Wheelchair spec size w foot 36 A 60-6
Wheelchair spec size w/ leg 36 A 60-6
Wheelchair spec size w foot 36 A 60-6
Wheelchair spec size w/ leg 36 A 60-6
Manual semi-reclining back 36 A 60-6
Manual fully reclining back 00 9 60-9
Wheelchair spec sz spec ht a 32 A 60-6
Wheelchair spec sz spec ht b 36 A 60-6
Pediatric wheelchair NOS 32 A
Power operated vehicle 32 A 60-5
Rigid ped w/c tilt-in-space 32 A 60-9
Folding ped wc tilt-in-space 32 A 60-9
Rig ped wc tltnspc w/o seat 32 A 60-9
Fld ped wc tltnspc w/o seat 32 A 60-9
Rigid ped wc adjustable 32 A 60-9
Folding ped wc adjustable 32 A 60-9
Rgd ped wc adjstabl w/o seat 32 A 60-9
Fld ped wc adjstabl w/o seat 32 A 60-9
Ped power wheelchair NOS 36 A
Whchr litwt det arm leg rest 36 A 60-9
Wheelchair lightwt fixed arm 00 9 60-9
Wheelchair lightwt foot rest 00 9 60-9
Wheelchair lightweight leg r 36 A 60-9
Whchr h-duty det arm leg res 36 A 60-9
Wheelchair heavy duty fixed 00 9 60-9
Wheelchair hvy duty detach a 00 9 60-9
Wheelchair heavy duty fixed 36 A 60-9
Wheelchair special seat heig 32 A 60-6
Wheelchair special seat dept 32 A 60-6
Wheelchair spec seat depth/w 32 A 60-6
Page 396
PUF___2011_Web_File
Whirlpool portable 00 9 60-9
Whirlpool non-portable 32 A 60-9
Repair for DME, per 15 min 00 9
Oxygen supplies regulator 00 9 60-4
Wheeled cart, port cyl/conc 00 9
Oxygen supplies stand/rack 00 9 60-4
Batt pack/cart, port conc 00 9
Battery charger, port conc 00 9
DC power adapter, port conc 00 9
Oxy suppl heater for nebuliz 32 A 60-4
Oxygen concentrator 33 A 60-4
Oxygen concentrator, dual 33 A 60-4
Portable oxygen concentrator 33 A 60-4
Durable medical equipment mi 46 A
O2/water vapor enrich w/heat 33 A 60-4
O2/water vapor enrich w/o he 33 A 60-4
Centrifuge 52 A
Kidney dialysate delivry sys 52 A
Heparin infusion pump 52 A
Replacement air bubble detec 52 A
Replacement pressure alarm 52 A
Bath conductivity meter 52 A
Replace blood leak detector 52 A
Adjustable chair for esrd pt 52 A
Transducer protect/fld bar 52 A
Unipuncture control system 52 A
Hemodialysis machine 52 A
Auto interm peritoneal dialy 52 A
Cycler dialysis machine 52 A
Deli/install chrg hemo equip 52 A
Reverse osmosis h2o puri sys 52 A 55-1A
Deionizer H2O puri system 52 A 55-1A
Replacement blood pump 52 A
Water softening system 52 A 55-1B
Reciprocating peritoneal dia 52 A
Wearable artificial kidney 52 A
Peritoneal dialysis clamp 52 A
Compact travel hemodialyzer 52 A
Sorbent cartridges per 10 52 A
Hemostats for dialysis, each 52 A
Dialysis scale 52 A
Dialysis equipment noc 52 A
Jaw motion rehab system 32 A
Page 397
PUF___2011_Web_File
Repl cushions for jaw motion 34 A
Repl measr scales jaw motion 34 A
Adjust elbow ext/flex device 36 A
SPS elbow device 36 A
Adjst forearm pro/sup device 36 A
Adjust wrist ext/flex device 36 A
SPS wrist device 36 A
Adjust knee ext/flex device 36 A
SPS knee device 36 A
Knee ext/flex w act res ctrl 36 A
Adjust ankle ext/flex device 36 A
SPS ankle device 36 A
SPS forearm device 36 A
Soft interface material 32 A
Replacement interface SPSD 32 A
Adjust finger ext/flex devc 36 A
Adjust toe ext/flex device 36 A
Static str toe dev ext/flex 36 A
Adj shoulder ext/flex device 36 A
Static str shldr dev rom adj 36 A
AAC non-electronic board 00 9
Gastric suction pump hme mdl 36 A
Bld glucose monitor w voice 32 A 60-11
Bld glucose monitor w lance 32 A 60-11
Pulse gen sys tx endolymp fl 36 A
Man w/ch acc seat w>=20"<24" 32 A
Seat width 24-27 in 32 A
Frame depth less than 22 in 32 A
Frame depth 22 to 25 in 32 A
Manual wc accessory, handrim 32 A
Complete wheel lock assembly 32 A
Crutch and cane holder 32 A
Page 398
PUF___2011_Web_File
Cylinder tank carrier 32 A
Arm trough each 32 A
Wheelchair bearings 32 A
Pneumatic propulsion tire 32 A
Pneumatic prop tire tube 32 A
Pneumatic prop tire insert 32 A
Pneumatic caster tire each 32 A
Pneumatic caster tire tube 32 A
Foam filled propulsion tire 32 A
Foam filled caster tire each 32 A
Foam propulsion tire each 32 A
Foam caster tire any size ea 32 A
Solid propulsion tire each 32 A
Solid caster tire each 32 A
Solid caster integrated whl 32 A
Valve replacement only each 32 A
Propulsion whl excludes tire 32 A
Caster wheel excludes tire 32 A
Caster fork replacement only 32 A
Gear reduction drive wheel 32 A
Mwc acc, wheelchair brake 32 A
Manual standing system 00 9
Solid seat support base 32 A
Planar back for ped size wc 32 A
Planar seat for ped size wc 32 A
Contour back for ped size wc 32 A
Contour seat for ped size wc 32 A
Ped dynamic seating frame 32 A
Pwr seat elevation sys 32 A
Pwr standing 00 9
Electro connect btw control 32 A
Electro connect btw 2 sys 32 A
Mini-prop remote joystick 32 A
PWC harness, expand control 32 A
Hand interface joystick 32 A
Page 399
PUF___2011_Web_File
Mult mech switches 32 A
Special joystick handle 32 A
Chin cup interface 32 A
Sip and puff interface 32 A
Breath tube kit 32 A
Head control interface mech 32 A
Head/extremity control inter 32 A
Head control nonproportional 32 A
Head control proximity switc 32 A
Attendant control 32 A
W/c wdth 20-23 in seat frame 32 A
W/c wdth 24-27 in seat frame 32 A
W/c dpth 20-21 in seat frame 32 A
W/c dpth 22-25 in seat frame 32 A
Electronic SGD interface 32 A
22nf nonsealed leadacid 32 A
22nf sealed leadacid battery 32 A
Gr24 nonsealed leadacid 32 A
Gr24 sealed leadacid battery 32 A
U1nonsealed leadacid battery 32 A
U1 sealed leadacid battery 32 A
Battery charger, single mode 32 A
Battery charger, dual mode 32 A
Power wc motor replacement 32 A
Pwr wc gear box replacement 32 A
Pwr wc motor/gear box combo 32 A
Gr27 sealed leadacid battery 32 A
Gr27 non-sealed leadacid 32 A
Hand/chin ctrl spec joystick 32 A
Page 400
PUF___2011_Web_File
Hand/chin ctrl std joystick 32 A
Non-expandable controller 32 A
Expandable controller, repl 32 A
Expandable controller, initl 32 A
Pneum drive wheel tire 32 A
Tube, pneum wheel drive tire 32 A
Insert, pneum wheel drive 32 A
Pneumatic caster tire 32 A
Tube, pneumatic caster tire 32 A
Foam filled drive wheel tire 32 A
Foam filled caster tire 32 A
Foam drive wheel tire 32 A
Foam caster tire 32 A
Solid drive wheel tire 32 A
Solid caster tire 32 A
Solid caster tire, integrate 32 A
Valve, pneumatic tire tube 32 A
Drive wheel excludes tire 32 A
Caster wheel excludes tire 32 A
Caster fork 32 A
Pwc acc, lith-based battery 32 A
Noc interface 32 A
Neg press wound therapy pump 36 A
SGD digitized pre-rec <=8min 32 A 60-23
SGD prerec msg >8min <=20min 32 A 60-23
SGD prerec msg>20min <=40min 32 A 60-23
SGD prerec msg > 40 min 32 A 60-23
Page 401
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SGD spelling phys contact 32 A 60-23
SGD w multi methods msg/accs 32 A 60-23
SGD sftwre prgrm for PC/PDA 32 A 60-23
SGD accessory, mounting sys 32 A 60-23
SGD accessory noc 32 A 60-23
Gen w/c cushion wdth < 22 in 32 A
Gen w/c cushion wdth >=22 in 32 A
Skin protect wc cus wd <22in 32 A
Skin protect wc cus wd>=22in 32 A
Position wc cush wdth <22 in 32 A
Position wc cush wdth>=22 in 32 A
Skin pro/pos wc cus wd <22in 32 A
Skin pro/pos wc cus wd>=22in 32 A
Custom fabricate w/c cushion 32 A
Powered w/c cushion 32 A
Gen use back cush wdth <22in 32 A
Gen use back cush wdth>=22in 32 A
Position back cush wd <22in 32 A
Position back cush wd>=22in 32 A
Pos back post/lat wdth <22in 32 A
Pos back post/lat wdth>=22in 32 A
Custom fab w/c back cushion 32 A
Wc acc solid seat supp base 32 A
Replace cover w/c seat cush 32 A
WC planar back cush wd <22in 32 A
WC planar back cush wd>=22in 32 A
Adj skin pro w/c cus wd<22in 32 A
Adj skin pro wc cus wd>=22in 32 A
Adj skin pro/pos cus<22in 32 A
Adj skin pro/pos wc cus>=22 32 A
Posterior gait trainer 00 9
Page 402
PUF___2011_Web_File
Upright gait trainer 00 9
Anterior gait trainer 00 9
Admin influenza virus vac 54 A
Admin pneumococcal vaccine 54 A
Admin hepatitis b vaccine 54 A
Semen analysis 21 A
CA screen;pelvic/breast exam 11 A
Prostate ca screening; dre 11 A 50-55
PSA screening 21 A 50-55
CA screen;flexi sigmoidscope 11 A
Colorectal scrn; hi risk ind 11 A
Colon CA screen;barium enema 11 A
Diab manage trn per indiv 11 A
Diab manage trn ind/group 11 A
Glaucoma scrn hgh risk direc 11 A
Glaucoma scrn hgh risk direc 11 A
Colon ca scrn; barium enema 11 A
Colon ca scrn not hi rsk ind 11 A
Colon ca scrn; barium enema 00 9
Screen cerv/vag thin layer 21 A 50-20
Screen c/v thin layer by MD 11 21 C 50-20
Trim nail(s) 11 A
CORF skilled nursing service 99 9
Partial hosp prog service 00 9
Single energy x-ray study 11 A 50-44
Scr c/v cyto,autosys and md 11 A
Scr c/v cyto,thinlayer,rescr 21 A
Scr c/v cyto,thinlayer,rescr 21 A
Scr c/v cyto,thinlayer,rescr 21 A
Page 403
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Scr c/v cyto, automated sys 21 A
Scr c/v cyto, autosys, rescr 21 A
HHCP-serv of pt,ea 15 min 00 9
HHCP-serv of ot,ea 15 min 00 9
HHCP-svs of s/l path,ea 15mn 00 9
HHCP-svs of rn,ea 15 min 00 9
HHCP-svs of csw,ea 15 min 00 9
HHCP-svs of aide,ea 15 min 00 9
HHC PT assistant ea 15 00 9
HHC OT assistant ea 15 00 9
HHC PT maint ea 15 min 00 9
HHC Occup Therapy ea 15 00 9
HHC SLP ea 15 min 00 9
HHC RN E&M plan svs, 15 min 00 9
HHC LPN/RN obs/asses ea 15 00 9
HHC lis nurse train ea 15 00 9
Extrnl counterpulse, per tx 11 A 35-74
Wound closure by adhesive 00 9
Linear acc stereo radsur com 00 9
OPPS Service,sched team conf 00 9
OPPS/PHP;activity therapy 00 9
OPPS/PHP; train & educ serv 00 9
Page 404
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MD recertification HHA PT 11 A
MD certification HHA patient 11 A
Home health care supervision 11 A
Hospice care supervision 11 A
Dstry eye lesn,fdr vssl tech 00 9
Screeningmammographydigital 11 A
Diagnosticmammographydigital 11 A
Diagnosticmammographydigital 11 A
PET img wholbod melano nonco 00 9 50-36
PET not otherwise specified 00 9 50-36
Therapeutic procd strg endur 11 A
Oth resp proc, indiv 11 A
Oth resp proc, group 11 A
Initial foot exam pt lops 11 A 50.81
Followup eval of foot pt lop 11 A 50.81
Page 405
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Routine footcare pt w lops 11 A 50.81
Demonstrate use home inr mon 11 A 50.55
Provide INR test mater/equip 11 A 50.55
MD INR test revie inter mgmt 11 A 50.55
Linear acc based stero radio 00 9
PET imaging initial dx 00 9 50-36
Current percep threshold tst 00 9 50-57
Unsched dialysis ESRD pt hos 00 9
Inject for sacroiliac joint 00 9
Inj for sacroiliac jt anesth 00 9
Cryopresevation Freeze+stora 13 A
Thawing + expansion froz cel 11 A
Bone marrow or psc harvest 11 A
Removal of impacted wax md 11 A
Occlusive device in vein art 00 9
MNT subs tx for change dx 11 A
Page 406
PUF___2011_Web_File
Group MNT 2 or more 30 mins 11 A
Renal angio, cardiac cath 11 A
Iliac art angio,cardiac cath 11 A
Elec stim unattend for press 11 A
Elect stim wound care not pd 00 9
Elec stim other than wound 11 A
Recon, CTA for surg plan 11 A
Arthro, loose body + chondro 11 A
Drug-eluting stents, single 00 9
Drug-eluting stents,each add 00 9
Non-cov surg proc,clin trial 00 9
Non-cov proc, clinical trial 00 9
Electromagnetic therapy onc 00 9 35-98
Insert single chamber/cd 00 9
Insert dual chamber/cd 00 9
Inser/repos single icd+leads 00 9
Insert reposit lead dual+gen 00 9
Pre-op service LVRS complete 00 9
Pre-op service LVRS 10-15dos 00 9
Page 407
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Pre-op service LVRS 1-9 dos 00 9
Post op service LVRS min 6 00 9
CBC/diffwbc w/o platelet 00 9
CBC without platelet 00 9
ESRD related svc 4+mo < 2yrs 11 A
ESRD related svc 2-3mo <2yrs 11 A
ESRD related svc 1 vst <2yrs 11 A
ESRD related svs 4+mo 2-11yr 11 A
ESRD relate svs 2-3 mo 2-11y 11 A
ESRD related svs 1 mon 2-11y 11 A
ESRD related svs 4+ mo 12-19 11 A
ESRD related svs 2-3mo/12-19 11 A
ESRD related svs 1vis/12-19y 11 A
ESRD related svs 4+mo 20+yrs 11 A
ESRD related svs 2-3 mo 20+y 11 A
ESRD related svs 1visit 20+y 11 A
Page 408
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ESD related svs home undr 2 11 A
ESRDrelatedsvs home mo 2-11y 11 A
ESRD related svs hom mo12-19 11 A
ESRD related svs home mo 20+ 11 A
ESRD related serv/dy, 2y 11 A
ESRD relate serv/dy 2-11yr 11 A
ESRD relate serv/dy 12-19y 11 A
ESRD relate serv/dy 20+yrs 11 A
Fecal blood scrn immunoassay 21 A
Electromagntic tx for ulcers 00 9
Preadmin IV immunoglobulin 13 A
Dispense fee initial 30 day 46 A
Hospice evaluation preelecti 11 A
Robot lin-radsurg com, first 00 9
Robt lin-radsurg fractx 2-5 00 9
Percutaneous islet celltrans 13 A 260.3
Laparoscopy islet cell trans 13 A 35-82
Laparotomy islet cell transp 13 A 35-82
Initial preventive exam 11 A
Bone marrow aspirate &biopsy 11 A
Vessel mapping hemo access 11 A
Page 409
PUF___2011_Web_File
EKG for initial prevent exam 11 A
EKG tracing for initial prev 11 A
EKG interpret & report preve 11 A
MD service required for PMD 13 A
Smoke/tobacco counselng 3-10 13 A
Smoke/tobacco counseling >10 13 A
Administra Part D vaccine 11 A
Hospital observation per hr 00 9
Direct refer hospital observ 00 9
Lev 1 hosp type B ED visit 00 9
Lev 2 hosp type B ED visit 00 9
Lev 3 hosp type B ED visit 00 9
Page 410
PUF___2011_Web_File
Lev 4 hosp type B ED visit 00 9
Lev 5 hosp type B ED visit 00 9
Ultrasound exam AAA screen 13 A
Trauma Respons w/hosp criti 00 9
AV fistula or graft arterial 13 A
AV fistula or graft venous 13 A
Blood occult test,colorectal 21 A
Alcohol/subs interv 15-30mn 11 A
Alcohol/subs interv >30 min 11 A
Home sleep test/type 2 Porta 13 A
Home sleep test/type 3 Porta 13 A
Home sleep test/type 4 Porta 13 A
Initial preventive exam 11 A
EKG for initial prevent exam 11 A
EKG tracing for initial prev 11 A
Page 411
PUF___2011_Web_File
EKG interpret & report preve 11 A
Telhealth inpt consult 15min 13 A
Telheath inpt consult 25min 11 A
Telhealth inpt consult 35min 11 A
CORF related serv 15 mins ea 13 A
Grp psych partial hosp 45-50 13 A
Inter active grp psych parti 13 A
Open tx iliac spine uni/bil 13 A
Pelvic ring fracture uni/bil 13 A
Pelvic ring fx treat int fix 13 A
Open tx post pelvic fxcture 13 A
Sat biopsy prostate 1-20 spc 13 A
Sat biopsy prostate 21-40 13 A
Sat biopsy prostate 41-60 13 A
Sat biopsy prostate: >60 13 A
Ed svc CKD ind per session 11 A
Ed svc CKD grp per session 11 A
Intens cardiac rehab w/exerc 11 A
Intens cardiac rehab no exer 11 A
Pulmonary rehab w exer 11 A
Inpt telehealth consult 30m 13 A
Inpt telehealth consult 50m 13 A
Page 412
PUF___2011_Web_File
Inpt telehealth con 70/>m 13 A
Collagen Meniscus Implant 00 9
Dermal filler injection(s) 13 A
Drug screen multi class 13 A
Drug screen multip class 13 A
EIA HIV-1/HIV-2 screen 21 A
ELISA HIV-1/HIV-2 screen 21 A
Drug screen multi drug class 21 A
Oral HIV-1/HIV-2 screen 21 A
Tobacco-use counsel 3-10 min 13 A
Tobacco-use counsel>10min 13 A
PPPS, initial visit 13 A
PPPS, subseq visit 13 A
Skin/dermal subs init 25or< 13 A
Skin/dermal subs each additi 13 A
Admin + supply, tositumomab 13 A
AMI pt recd aspirin at arriv 00 9
AMI pt did not receiv aspiri 00 9
AMI pt ineligible for aspiri 00 9
AMI pt recd Bblock at arr 00 9
AMI pt did not rec bblock 00 9
AMI pt inelig Bbloc at arriv 00 9
Pneum pt recv antibiotic 4 h 00 9
Pneum pt w/o antibiotic 4 hr 00 9
Pneum pt not elig antibiotic 00 9
Page 413
PUF___2011_Web_File
Diabetic pt w/ HBA1c>9% 00 9
Diabetic pt w/ HBA1c<or=9% 00 9
DM pt inelig for HBA1c measu 00 9
Care not provided for HbA1c 00 9
Diabetic pt w/LDL>= 100mg/dl 00 9
Diab pt w/LDL< 100mg/dl 00 9
Diab pt inelig for LDL meas 00 9
Care not provided for LDL 00 9
DM pt w BP>=140/80 00 9
Diabetic pt wBP<140/80 00 9
Diabetic pt inelig for BP me 00 9
Diabet pt w no care re BP me 00 9
HF p w/LVSD on ACE-I/ARB 00 9
HF pt w/LVSD not on ACE-I/AR 00 9
HF pt not elig for ACE-I/ARB 00 9
HF pt w/LVSD on Bblocker 00 9
HF pt w/LVSD not on Bblocker 00 9
HF pt not elig for Bblocker 00 9
PMI-CAD pt on Bblocker 00 9
PMI-CAD pt not on Bblocker 00 9
PMI-CAD pt inelig Bblocker 00 9
AMI-CAD pt doc on antiplatel 00 9
AMI-CAD pt not docu on antip 00 9
AMI-CAD inelig antiplate mea 00 9
CAD pt w/LDL>100mg/dl 00 9
Page 414
PUF___2011_Web_File
CAD pt w/LDL<or=100mg/dl 00 9
CAD pt not eligible for LDL 00 9
Osteoporosis assess 00 9
Osteopor pt not assess 00 9
Pt inelig for osteopor meas 00 9
Falls assess not docum 12 mo 00 9
Falls assess w/ 12 mon 00 9
Not elig for falls assessmen 00 9
Hearing assess receive 00 9
Pt w/o hearing assess 00 9
Pt inelig for hearing assess 00 9
Urinary incont pt assess 00 9
Pt not assess for urinary in 00 9
Pt not elig for urinary inco 00 9
ESRD pt w/ dialy of URR>=65% 00 9
ESRD pt w/ dialy of URR<65% 00 9
ESRD pt not elig for URR/KtV 00 9
ESRD pt w/Hct>or=33 00 9
ESRD pt w/Hct<33 00 9
ESRD pt inelig for HCT/Hgb 00 9
ESRD pt w/ auto AV fistula 00 9
ESRD pt w other fistula 00 9
ESRD PT inelig auto AV FISTU 00 9
COPD pt rec smoking cessat 00 9
COPD pt w/o smoke cessat int 00 9
Osteopo pt given Ca+VitD sup 00 9
Osteop pt inelig for Ca+VitD 00 9
New dx osteo pt w/antiresorp 00 9
Osteo pt inelig for antireso 00 9
Page 415
PUF___2011_Web_File
Bone dens meas test perf 00 9
Bone dens meas test inelig 00 9
Pt receiv influenza vacc 00 9
Pt w/o influenza vacc 00 9
Pt inelig for influenza vacc 00 9
Pt receiv mammogram 00 9
Pt not doc mammogram 00 9
Pt ineligible mammography 00 9
Care not provided for mamogr 00 9
Pt receiv pneumo vacc 00 9
Pt did not rec pneumo vacc 00 9
Pt was inelig for pneumo vac 00 9
Pt treat w/antidepress12wks 00 9
Pt not treat w/antidepres12w 00 9
Pt inelig for antidepres med 00 9
Pt treat w/antidepres for 6m 00 9
Pt not treat w/antidepres 6m 00 9
Pt inelig for antidepres med 00 9
Pt w/AB 1 hr prior to incisi 00 9
Pt not doc for AB 1 hr prior 00 9
Pt ineligi for AB therapy 00 9
Pt recd thromboemb prophylax 00 9
Pt did not rec thromboembo 00 9
Pt ineligi for thrombolism 00 9
Pt recd CABG w/ IMA 00 9
Pt w/CABG w/o IMA 00 9
Page 416
PUF___2011_Web_File
Pt inelig for CABG w/IMA 00 9
Iso CABG pt rec preop bblock 00 9
Iso CABG pt w/o preop Bblock 00 9
Iso CABG pt inelig for preo 00 9
Iso CABG pt w/prolng intub 00 9
Iso CABG pt w/o prolng intub 00 9
Iso CABG req surg rexpo 00 9
Iso CABG w/o surg explo 00 9
CEA/ext bypass pt on aspirin 00 9
Pt w/carot endarct/ext bypas 00 9
CEA/ext bypass pt not on asp 00 9
CAD pt care not prov LDL 00 9
HF/atrial fib pt on warfarin 00 9
HF/atrial fib pt inelig warf 00 9
Osteoarth pt w/ assess pain 00 9
Osteoarth pt inelig assess 00 9
Antibiotic given prior surg 00 9
Antib given prior surg incis 00 9
Antibio not doc prior surg 00 9
Pt not elig for antibiotic 00 9
Antibiotic given prior surg 00 9
Antibio not docum prior surg 00 9
Antib order prior to surg 00 9
Page 417
PUF___2011_Web_File
Cefazolin documented ordered 00 9
Cefazolin given prophylaxis 00 9
Cefazolin not docum prophy 00 9
Pt not eligi for cefazolin 00 9
Order given to d/c antibio 00 9
Antib was D/C 24hrs surg tim 00 9
MD not doc order to d/c anti 00 9
Pt not eligi for proph antib 00 9
MD doc prophylactic AB given 00 9
Clini doc order to D/C antib 00 9
Clini doc AB was D/C 48 h 00 9
Clinician did not doc 00 9
Clini doc pt ineligib anti 00 9
Clini doc proph AB giv 00 9
Clini order given for VTE 00 9
Clini given VTE prop 00 9
Clini not doc order VTE 00 9
Clini doc pt inelig VTE 00 9
Pt received DVT prophylaxis 00 9
Pt not received DVT proph 00 9
Pt inelig DVT prophylaxis 00 9
Received DVT proph day 2 00 9
Pt not rec DVT proph day 2 00 9
Pt inelig for DVT proph 00 9
Pt prescribe platelet at D/C 00 9
Pt not doc for presc antipla 00 9
Pt inelig for antiplat proph 00 9
Pt prescrib anticoag at D/C 00 9
Page 418
PUF___2011_Web_File
Pt no prescr anticoa at D/C 00 9
Pt not doc to have perm/AF 00 9
Clin pt inelig anticoag D/C 00 9
Pt doc to have admin t-PA 00 9
Pt inelig t-PA isch strok>3h 00 9
Pt not doc for admin t-PA 00 9
Pt received dysphagia screen 00 9
Pt not doc dysphagia screen 00 9
Pt received NPO 00 9
Pt inelig dysphagia screen 00 9
Pt doc rec rehab serv 00 9
Pt not doc to rec rehab serv 00 9
Inter carotid stenosis <30% 00 9
Inter carotid stenosis30-99% 00 9
Pt inelig candidate ito meas 00 9
Pt doc to have CT/MRI w/les 00 9
Pt not doc MRI/CT w/o lesion 00 9
Clini doc prese/abs alarm 00 9
Pt inelig hx w new/chg mole 00 9
Pt w/alarm symp upper endo 00 9
Pt w/one alarm symp not doc 00 9
Pt inelig for upper endo 00 9
Pt w/Barretts esoph endo re 00 9
Pt not doc w/Barretts, endo 00 9
Pt inelig for esophag biop 00 9
Page 419
PUF___2011_Web_File
Pt rec order for barium 00 9
Pt w/no doc order for barium 00 9
Clini doc pt inelig bar swal 00 9
Clini doc rev D/C meds w/med 00 9
Pt not doc rev meds D/C 00 9
Pt inelig for d/c meds rev 00 9
Pt doc to hav decision maker 00 9
Pt not doc to have dec maker 00 9
Clin doc pt inelig dec maker 00 9
Pt doc assess uriny incon 00 9
Pt not doc assess urinary in 00 9
Pt inelig assess urinary inc 00 9
Pt doc rec charc urin incon 00 9
Pt not doc charc urin incon 00 9
Pt doc rec plan urinary inco 00 9
Pt not doc rec care urin inc 00 9
Clin not prov care urin inco 00 9
Pt receiv screen for fall 00 9
Pt no doc screen fall 00 9
Clin doc pt inelig fall risk 00 9
Clin not prov care scre fall 00 9
Clini not doc pres/abs alarm 00 9
Pt hx w/ new moles 00 9
Pt not doc mole change 00 9
Pt inelig for assess mole 00 9
Pt doc rec PE skin 00 9
Pt not doc rec PE 00 9
Pt inelig PE skin 00 9
Pt rec counsel for self-exam 00 9
Pt not doc to rec couns 00 9
Pt inelig for counsel 00 9
Pt doc to rec pres osteo 00 9
Page 420
PUF___2011_Web_File
Pt did not rec pres osteo 00 9
Pt inelig to rec pres osteo 00 9
Clin not prov care for pharm 00 9
Pt doc rec Ca/Vit D 00 9
Pt not doc rec Ca/Vit D 00 9
Clin doc pt inelig Ca/Vit D 00 9
Clin no pro care pt Ca/Vit D 00 9
COPD pt w/spir results 00 9
COPD pt w/o spir results 00 9
COPD pt inelig spir results 00 9
COPD pt doc bronch ther 00 9
COPD pt not doc bronch ther 00 9
COPD pt inelig bronch therap 00 9
Pt doc optic nerve eval 00 9
Pt not doc optic nerv eval 00 9
Pt inelig for optic nerv eva 00 9
Clin not prov care POAG 00 9
Pt doc w/ target IOP 00 9
Pt not doc w/ IOP 00 9
Clin doc pt inelig IOP 00 9
Clin not prov care POAG 00 9
POAG w/ IOP rec care plan 00 9
POAG w/ IOP no care plan 00 9
POAG w/ IOP not doc plan 00 9
Pt doc rec antioxidant 00 9
Pt not doc rec antiox 00 9
Pt inelig for antioxidant 00 9
Clin no prov care for antiox 00 9
Pt doc rec macular exam 00 9
Pt not doc to rec mac exam 00 9
Page 421
PUF___2011_Web_File
Clin doc pt inelig mac exam 00 9
Clin no pro care for mac deg 00 9
Pt doc to have visual func 00 9
Pt doc not have visual func 00 9
Pt inelig for vis func stat 00 9
Clin not prov care catarac 00 9
Pt doc to pre axial leng 00 9
Pt not doc pre axial leng 00 9
Pt inelig for pre surg axial 00 9
Clin not prov care for IOL 00 9
Pt rec fund exam prior surg 00 9
Pt not doc rec fundus exam 00 9
Pt inelig for pre surg fundu 00 9
Clin not prov care fund eval 00 9
Pt doc rec dilated macular 00 9
Pt not doc rec dilated mac 00 9
Pt inelig dilate fundus 00 9
Clin prov no care diabetic r 00 9
Pt doc to have macular exam 00 9
Doc of macular not giv MD 00 9
Clin doc pt inelig macular 00 9
Clin did not pro care diabet 00 9
Clin doc pt was test osteo 00 9
Clin not doc pt test osteo 00 9
Page 422
PUF___2011_Web_File
Pt inelig for test osteo 00 9
Pt doc have DEXA 00 9
Pt not doc for DEXA 00 9
Clin doc pt inelig DEXA 00 9
Clin not prov care DEXA 00 9
Pt doc have DEXA perform 00 9
Pt not doc have DEXA 00 9
Clin doc pt inelig DEXA 00 9
Clin not prov care DEXA 00 9
Int carotid stenosis meas 00 9
Pt inelig for doc of alarm 00 9
Pt doc 12 lead ECG 00 9
Pt not doc ECG 00 9
Pt inelig for ECG 00 9
Pt doc rec aspirin 24hrs ER 00 9
Pt not rec aspirin prior ER 00 9
Clin doc pt inelig aspirin 00 9
Pt doc to have ECG 00 9
Pt not doc to have ECG 00 9
Clin doc pt inelig ECG 00 9
Pt doc vital signs recorded 00 9
Pt not doc vital signs recor 00 9
Pt doc to have 02 SAT assess 00 9
Pt not doc 02 SAT assess 00 9
Clin doc pt inelig 02 SAT 00 9
Pt doc mental status assess 00 9
Pt not doc mental status 00 9
Pt doc to have empiric AB 00 9
Pt not doc have empiric AB 00 9
Clin doc pt inelig empiri AB 00 9
Asthma pt w survey not docum 00 9
Chemother not rec stg3 colon 00 9
Page 423
PUF___2011_Web_File
Chemother rec stg3 colon ca 00 9
Chemo plan documen prior che 00 9
Chemo plan not doc prior che 00 9
CLL pt w/o doc flow cytometr 00 9
Brst ca pt inelig tamoxifen 00 9
MD doc colon ca pt inelig ch 00 9
MD doc pt inelig radiation 00 9
Doc radiat tx recom 12mo ov 00 9
Pt w stgIC-3Brst ca not rec 00 9
Pt w stgIC-3Brst ca rec tam 00 9
MM pt w/o doc IV bisphophon 00 9
No doc radiation rec 12mo ov 00 9
Base cytogen test MDS notper 00 9
Diabet pt no do Hgb A1c 12m 00 9
Diabet pt nodoc LDLiprotei 00 9
ESRD pt w Hct/Hgb not docume 00 9
ESRD pt w URR/Ktv notdoc eli 00 9
MDS pt no doc FE st prio EPO 00 9
Diabetic w/o document BP 12m 00 9
Pt w asthma no doc med or tx 00 9
LVEF>=40% doc normal or mild 00 9
LVEF not performed 00 9
Dil macula/fundus exam/w doc 00 9
Dil macular/fundus not perfo 00 9
Pt w/DXA document or order 00 9
Pt w/DXA no document or orde 00 9
Pt inelig osteo screen measu 00 9
Page 424
PUF___2011_Web_File
Smoke preven interven counse 00 9
Smoke preven nocounsel 00 9
Low extemity neur exam docum 00 9
Low extemity neur not perfor 00 9
Pt inelig lower extrem neuro 00 9
ABI documented 00 9
ABI not documented 00 9
Pt inelig for ABI measure 00 9
Eval on foot documented 00 9
Eval on foot not performed 00 9
Pt inelig footwear evaluatio 00 9
Calc BMI abv up param f/u 00 9
Calc BMI blw low param f/u 00 9
Calc BMI out nrm param nof/u 00 9
Calc BMI norm parameters 00 9
BMI not calculated 00 9
Pt inelig BMI calculation 00 9
Pt screen flu vac & counsel 00 9
Flu vaccine not screen 00 9
Flu vaccine screen not curre 00 9
Pt not approp screen & counc 00 9
Doc cur meds by prov 00 9
Cur meds not document 00 9
Incomplete doc pt on meds 00 9
Pt inelig med check 00 9
Pos clin depres scrn f/u doc 00 9
Clin depression screen not d 00 9
Pt inelig; scrn clin dep 00 9
Cognitive impairment screen 00 9
Cognitive screen not documen 00 9
Pt inelig for cognitive impa 00 9
Care plan develop & document 00 9
Page 425
PUF___2011_Web_File
Pt inelig for devlp care pln 00 9
Care plan develp & not docum 00 9
Pain assess f/u pln document 00 9
No document of pain assess 00 9
Pt inelig pain assessment 00 9
Prescription by E-Prescrib s 00 9
Prescrip not gen at encounte 00 9
Some prescrib print or call 00 9
Pt vis doc use EHR cer ATCB 00 9
Pt vis doc w/PQRI qual EHR 00 9
Pt not doc w/EMR due to syst 00 9
Beta-bloc rx pt w/abn lvef 00 9
Pt w/abn lvef inelig b-bloc 00 9
Pt w/abn lvef b-bloc no rx 00 9
Tob use cess int counsel 00 9
Tob use cess int no counsel 00 9
Current tobacco smoker 00 9
Current smkless tobacco user 00 9
Cur tobacco non-user 00 9
Pt inelig geno no antvir tx 00 9
Doc pt rec antivir treat 00 9
Pt inelig RNA no antvir tx 00 9
Page 426
PUF___2011_Web_File
Pt rec antivir treat hep c 00 9
Pt inelig couns no antvir tx 00 9
Pt rec antiviral treat doc 00 9
Pt inelig; lo to no dter rsk 00 9
High risk recurrence pro ca 00 9
Pt inelig suic; MDD remis 00 9
New dx init/rec episode MDD 00 9
ACE/ARB rx pt w/abn lvef 00 9
Pt w/abn lvef inelig ACE/ARB 00 9
Pt w/ normal lvef 00 9
LVEF not performed/doc 00 9
ACE/ARB no rx pt w/abn lvef 00 9
ACE/ARB thxpy rx'd 00 9
ACE/ARB not rx'd; doc reas 00 9
ACE/ARB thxpy not rx'd 00 9
BP sys <130 and dias <80 00 9
BP sys>=130 and/or dias >=80 00 9
BP not performed/doc 00 9
MD rxÆd ACE/ARB thxpy 00 9
Pt inelig ACE/ARB thxpy 00 9
MD not rxÆd ACE/ARB thxpy 00 9
Flu immunize order/admin 00 9
Flu imm no ord/admin doc rea 00 9
Flu immunize no order/admin 00 9
Report, Diabetes measures 00 9
Report, Prev Care Measures 00 9
Page 427
PUF___2011_Web_File
Report CKD Measures 00 9
Report ESRD Measures 00 9
CAD measures grp 00 9
RA measures grp 00 9
HIV/AIDS measures grp 00 9
Periop Care measures grp 00 9
Back pain measures grp 00 9
DM meas qual act perform 00 9
CKD meas qual act perform 00 9
Prev Care MG qual act perfrm 00 9
CABG meas qual act perform 00 9
CAD meas qual act perform 00 9
RA meas qual act perform 00 9
HIV meas qual act perform 00 9
Perio meas qual act perform 00 9
Back Pain MG qual act perfrm 00 9
Doc proph antibx w/in 1 hr 00 9
Doc ord pro antbx w/in 1 hr 00 9
No doc proph antibx w/in 1hr 00 9
Pt rec ACE/ARB 00 9
Pt inelig pt verif meds 00 9
Pt inelig; pain asses no f/u 00 9
Pain assess no f/u pln doc 00 9
Pt inelig neg scrn depres 00 9
Clin depres scrn no f/u doc 00 9
Page 428
PUF___2011_Web_File
Pain sev quant present 00 9
ABI meas & doc 00 9
PT inelig; ABI measure 00 9
No ABI measurement 00 9
Scrn fal rsk >2 fal or w/inj 00 9
Scrn fall rsk; <2 falls 00 9
Clin stg b/f lun/eso ca surg 00 9
Pt in; clin ca stg b/f surg 00 9
Clin stg b/f surg not doc 00 9
Antplt recd 48 hrs & disch 00 9
Pt inelig; antiplt therapy 00 9
Antplt not recd reas no spec 00 9
Patch closure conv CEA 00 9
No patch closure CEA 00 9
No patch closure conv CEA 00 9
Doc ord antimic prophy 00 9
Pt inelig; proph antibiot 00 9
No doc ord antimic prophy 00 9
Auto AV fistula recd 00 9
Pt inelig; auto AV fistula 00 9
No auto AV fistula; no reas 00 9
Partic in clin data base reg 00 9
Doc elder mal scrn f/u plan 00 9
Pt inelig no eld mal scrn 00 9
No doc elder mal scrn 00 9
Pt inelig eldmal scrn no f/u 00 9
Eld mal scrn no f/u pln 00 9
Cur funct assess & care pln 00 9
Pt inelig funct assess 00 9
No doc cur funct assess 00 9
Pt inelig func asses no pln 00 9
Page 429
PUF___2011_Web_File
Cur funct asses; no care pln 00 9
CABG measures grp 00 9
HepC measures grp 00 9
CAP measures grp 00 9
IVD measures grp 00 9
HF measures grp 00 9
HepC MG qual act perform 00 9
CAP MG qual act perform 00 9
HF MG qual act perform 00 9
IVD MG qual act perform 00 9
1 Rx via qualified eRx sys 00 9
Ref to doc otolog eval 00 9
Pt inelig ref otolog eval 00 9
No ref to doc otolog eval 00 9
Pt ref doc oto eval 00 9
Pt hx act drain prev 90 days 00 9
Pt inelig for ref oto eval 00 9
Pt no hx act drain 90 d 00 9
Pt no ref oto reas no spec 00 9
Pt ref oto eval 00 9
Ver doc hear loss 00 9
Pt inelig ref oto eval 00 9
Pt no doc hear loss 00 9
Pt no ref otolo no spec 00 9
Prol intubation req 00 9
No prol intub req 00 9
Ster wd ifx 30 d postop 00 9
No ster wd ifx 00 9
Stk/CVA CABG 00 9
No strk/CVA CABG 00 9
Postop ren insuf 00 9
No postop ren insuf 00 9
Reop req bld grft oth 00 9
No reop req bld grft oth 00 9
Page 430
PUF___2011_Web_File
Antplt med disch 00 9
Antplt med contraind 00 9
no antplt med disch 00 9
Bblock disch 00 9
Bblock contraind 00 9
No bblock disch 00 9
Antilipid treat disch 00 9
Antlip disch contra 00 9
No antlipid treat disch 00 9
Sys BP <140 00 9
Sys BP >= 140 00 9
Dia BP < 90 00 9
Dia BP >= 90 00 9
No BP measure 00 9
Lipid pn results 00 9
No lipid prof perf 00 9
Ldl < 100 00 9
No LDL perf 00 9
Ldl >= 100 00 9
Asp therp used 00 9
No asp therp used 00 9
tPA initi w/in 3 hrs 00 9
No elig tPA init w/in 3 hrs 00 9
No tPA init w/in 3 hrs 00 9
Spok lang comp score 00 9
No high score spok lang 00 9
No spok lang comp score 00 9
Attention score 00 9
No high score attention 00 9
No attention score 00 9
Memory score 00 9
No high score memory 00 9
No memory score 00 9
Moto speech score 00 9
No high score moto speech 00 9
No moto speech score 00 9
Page 431
PUF___2011_Web_File
Reading score 00 9
No high score reading 00 9
No reading score 00 9
Spok lang exp score 00 9
No high score spok lang exp 00 9
No spok lang exp score 00 9
Writing score 00 9
No high score writing 00 9
No writing score 00 9
Swallowing score 00 9
No high score swallowing 00 9
No swallowing score 00 9
Surg proc w/in 30 days 00 9
No surg proc w/in 30 days 00 9
Doc antibio order b/4 surg 00 9
Doc antibio given b/4 surg 00 9
Pt no elg 4 order antbi give 00 9
Doc no antibi order b/4 surg 00 9
Pharm ther osteo rx 00 9
Pt no elg phar ther osteo 00 9
No pharm ther osteo rx 00 9
Page 432
PUF___2011_Web_File
Flu immun admin/prev rec 00 9
Pt no elg receiv flu immun 00 9
Flu immun no admin/prev rec 00 9
Flu immun admin or prev rec 00 9
Pt no elg rec flu immun 00 9
Flu immun not admin/pre rec 00 9
Hrdshp rural w/o internet 00 9
Hrdshp w/o suff pharm w/eRx 00 9
EP no prescribe priv 00 9
Asthma measures grp 00 9
Asthma MG qual act perform 00 9
Fun stat score knee >= 0 00 9
Fun stat score knee < 0 00 9
Fun stat score knee pt noelg 00 9
Fun stat score knee not done 00 9
Fun stat score hip >= 0 00 9
Fun stat score hip < 0 00 9
Fun stat score hip pt no elg 00 9
Fun stat score hip not done 00 9
Fun stat score LE >= 0 00 9
Fun stat score LE < 0 00 9
Fun stat score LE pt no elg 00 9
Page 433
PUF___2011_Web_File
Fun stat score LE not done 00 9
Fun stat score LS >= 0 00 9
Fun stat score LS < 0 00 9
Fun stat score LS pt no elg 00 9
Fun stat score LS not done 00 9
Fun stat score shdl >=0 00 9
Fun stat score shdl < 0 00 9
Fun stat score shdl pt no el 00 9
Fun stat score shdl not done 00 9
Fun stat score UE >=0 00 9
Fun stat score UE < 0 00 9
Fun stat score UE pt no elg 00 9
Fun stat score UE not done 00 9
Fun stat score neck/TS >=0 00 9
Fun stat score neck/TS < 0 00 9
Fun stat scor nek/TS pt no e 00 9
Page 434
PUF___2011_Web_File
Fun stat scor nek/TS not don 00 9
BP Syst >= 140 mmHg 00 9
BP Diast >= 90 mmHg 00 9
BP Syst < 130 mmHg 00 9
BP Syst >=130 - 139 mmHg 00 9
BP Diast < 80 mmHg 00 9
BP Diast 80-89 mmHg 00 9
Pt hosp w/HF 00 9
LVG test perf 00 9
Pt not elig for LVF test 00 9
Pt not hosp w/HF 00 9
LVF test not perf 00 9
Toba smkr curr or 2 hand exp 00 9
No tob smkr cur no 2 hnd exp 00 9
Smkls tob cur; no 2 hnd exp 00 9
Toba use not assess 00 9
Curr toba smkr or 2 hand exp 00 9
No cur tob smkr no 2 hnd exp 00 9
Curr smkls tob; no 2 hnd exp 00 9
Tobacco no assess 00 9
MCCD, initial rate 00 9
MCCD,maintenance rate 00 9
MCCD, risk adj hi, initial 00 9
MCCD, risk adj lo, initial 00 9
MCCD, risk adj, maintenance 00 9
MCCD, Home monitoring 00 9
MCCD, sch team conf 00 9
Mccd,phys coor-care ovrsght 00 9
MCCD, risk adj, level 3 00 9
MCCD, risk adj, level 4 00 9
MCCD, risk adj, level 5 00 9
Other Specified Case Mgmt 00 9
ESRD demo bundle level I 00 9
ESRD demo bundle-level II 00 9
Demo-smoking cessation coun 00 9
Amantadine HCL 100mg oral 13 A
Zanamivir,inhalation pwd 10m 13 A
Oseltamivir phosphate 75mg 13 A
Page 435
PUF___2011_Web_File
Rimantadine HCL 100mg oral 13 A
Amantadine HCL oral brand 13 A
Zanamivir, inh pwdr, brand 00 9
Oseltamivir phosp, brand 00 9
Rimantadine HCL, brand 00 9
Low vision rehab occupationa 00 9
Low vision rehab orient/mobi 00 9
Low vision lowvision therapi 00 9
Low vision rehabilate teache 00 9
Oncology work-up evaluation 00 9
Oncology tx decision-mgmt 00 9
Onc surveillance for disease 00 9
Onc expectant management pt 00 9
Onc supervision palliative 00 9
Onc visit unspecified NOS 00 9
Onc prac mgmt adheres guide 00 9
Onc pract mgmt differs trial 00 9
Onc prac mgmt disagree w/gui 00 9
Onc prac mgmt pt opt alterna 00 9
Page 436
PUF___2011_Web_File
Onc prac mgmt dif pt comorb 00 9
Onc prac cond noadd by guide 00 9
Onc prac guide differs nos 00 9
Onc dx nsclc stgI no progres 00 9
Onc dx nsclc stg2 no progres 00 9
Onc dx nsclc stg3A no progre 00 9
Onc dx nsclc stg3B-4 metasta 00 9
Onc dx nsclc dx unknown nos 00 9
Onc dx sclc/nsclc limited 00 9
Onc dx sclc/nsclc ext at dx 00 9
Onc dx sclc/nsclc ext unknwn 00 9
Onc dx brst stg1-2B HR,nopro 00 9
Onc dx brst stg1-2 noprogres 00 9
Onc dx brst stg3-HR, no pro 00 9
Onc dx brst stg3-noprogress 00 9
Page 437
PUF___2011_Web_File
Onc dx brst metastic/ recur 00 9
Onc dx prostate T1no progres 00 9
Onc dx prostate T2no progres 00 9
Onc dx prostate T3b-T4noprog 00 9
Onc dx prostate w/rise PSA 00 9
Onc dx prostate unknwn nos 00 9
Onc dx colon t1-3,n1-2,no pr 00 9
Onc dx colon T4, N0 w/o prog 00 9
Onc dx colon T1-4 no dx prog 00 9
Onc dx colon metas evid dx 00 9
Onc dx colon metas noevid dx 00 9
Onc dx colon extent unknown 00 9
Onc dx rectal T1-2 no progr 00 9
Page 438
PUF___2011_Web_File
Onc dx rectal T3 N0 no prog 00 9
Onc dx rectal T1-3,N1-2noprg 00 9
Onc dx rectal T4,N,M0 no prg 00 9
Onc dx rectal M1 w/mets prog 00 9
Onc dx rectal extent unknwn 00 9
Onc dx esophag T1-T3 noprog 00 9
Onc dx esophageal T4 no prog 00 9
Onc dx esophageal mets recur 00 9
Onc dx esophageal unknown 00 9
Onc dx gastric no recurrence 00 9
Onc dx gastric p R1-R2noprog 00 9
Onc dx gastric unresectable 00 9
Page 439
PUF___2011_Web_File
Onc dx gastric recurrent 00 9
Onc dx gastric unknown NOS 00 9
Onc dx pancreatc p R0 res no 00 9
Onc dx pancreatc p R1/R2 no 00 9
Onc dx pancreatic unresectab 00 9
Onc dx pancreatic unknwn NOS 00 9
Onc dx head/neck T1-T2no prg 00 9
Onc dx head/neck T3-4 noprog 00 9
Onc dx head/neck M1 mets rec 00 9
Onc dx head/neck ext unknown 00 9
Onc dx ovarian stg1A-B no pr 00 9
Onc dx ovarian stg1A-B or 2 00 9
Onc dx ovarian stg3/4 noprog 00 9
Onc dx ovarian recurrence 00 9
Page 440
PUF___2011_Web_File
Onc dx ovarian unknown NOS 00 9
Onc dx CML chronic phase 00 9
Onc dx CML acceler phase 00 9
Onc dx CML blast phase 00 9
Onc dx CML remission 00 9
Onc dx multi myeloma stage I 00 9
Onc dx mult myeloma stg2 hig 00 9
Onc dx multi myeloma unknown 00 9
Onc dx brst unknown NOS 00 9
Onc dx prostate mets no cast 00 9
Onc dx prostate clinical met 00 9
Onc NHLstg 1-2 no relap no 00 9
Onc dx NHL stg 3-4 not relap 00 9
Onc dx NHL trans to lg Bcell 00 9
Onc dx NHL relapse/refractor 00 9
Onc dx NHL stg unknown 00 9
Onc dx CML dx status unknown 00 9
Page 441
PUF___2011_Web_File
Frontier extended stay demo 00 9
Influenza A H1N1,admin w cou 13 A
Influenza A H1N1, vaccine 13 A
Warfarin respon genetic test 13 A
Outpt IV insulin tx any mea 00 9
Alcohol and/or drug assess 00 9
Alcohol and/or drug screenin 00 9
Alcohol and/or drug screenin 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Alcohol and/or drug services 00 9
Page 442
PUF___2011_Web_File
Alcohol and/or drug services 00 9
Alcohol and/or drug training 00 9
Alcohol and/or drug interven 00 9
Alcohol and/or drug outreach 00 9
Alcohol and/or drug preventi 00 9
Alcohol and/or drug preventi 00 9
Alcohol and/or drug preventi 00 9
Alcohol and/or drug preventi 00 9
Alcohol and/or drug preventi 00 9
Alcohol and/or drug preventi 00 9
Alcohol and/or drug hotline 00 9
MH health assess by non-md 00 9
MH svc plan dev by non-md 00 9
Oral med adm direct observe 00 9
Med trng & support per 15min 00 9
MH partial hosp tx under 24h 00 9
Comm psy face-face per 15min 00 9
Comm psy sup tx pgm per diem 00 9
Self-help/peer svc per 15min 00 9
Asser com tx face-face/15min 00 9
Assert comm tx pgm per diem 00 9
Fos c chld non-ther per diem 00 9
Fos c chld non-ther per mon 00 9
Supported housing, per diem 00 9
Supported housing, per month 00 9
Respite not-in-home per diem 00 9
Mental health service, nos 00 9
Alcohol/drug abuse svc nos 00 9
Spec coll non-blood:a/d test 00 9
Alcohol/drug screening 00 9
Alcohol/drug service 15 min 00 9
Prenatal care atrisk assessm 00 9
Antepartum management 00 9
Carecoordination prenatal 00 9
Prenatal at risk education 00 9
Follow up home visit/prental 00 9
Prenatalcare enhanced srv pk 00 9
Nonmed family planning ed 00 9
Family assessment 00 9
Page 443
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Comp multidisipln evaluation 00 9
Rehabilitation program 1/2 d 00 9
Comprehensive med svc 15 min 00 9
Crisis interven svc, 15 min 00 9
Behav hlth day treat, per hr 00 9
Psych hlth fac svc, per diem 00 9
Skills train and dev, 15 min 00 9
Comp comm supp svc, 15 min 00 9
Comp comm supp svc, per diem 00 9
Psysoc rehab svc, per 15 min 00 9
Psysoc rehab svc, per diem 00 9
Ther behav svc, per 15 min 00 9
Ther behav svc, per diem 00 9
Com wrap-around sv, 15 min 00 9
Com wrap-around sv, per diem 00 9
Supported employ, per 15 min 00 9
Supported employ, per diem 00 9
Supp maint employ, 15 min 00 9
Supp maint employ, per diem 00 9
Psychoed svc, per 15 min 00 9
Sex offend tx svc, 15 min 00 9
Sex offend tx svc, per diem 00 9
MH clubhouse svc, per 15 min 00 9
MH clubhouse svc, per diem 00 9
Activity therapy, per 15 min 00 9
Multisys ther/juvenile 15min 00 9
A/D halfway house, per diem 00 9
A/D tx program, per hour 00 9
A/D tx program, per diem 00 9
Dev delay prev dp ch, 15 min 00 9
Tetracyclin injection 51 A
Abarelix injection 51 A
Abatacept injection 51 A
Abciximab injection 51 A
Acetylcysteine injection 51 A
Acyclovir injection 51 A
Adalimumab injection 51 A
Injection adenosine 6 MG 51 A
Adenosine injection 51 A
Adrenalin epinephrin inject 51 A
Adrenalin epinephrine inject 51 A
Agalsidase beta injection 51 A
Inj biperiden lactate/5 mg 51 A
Alatrofloxacin mesylate 51 A
Alglucerase injection 51 A
Amifostine 51 A
Methyldopate hcl injection 51 A
Alefacept 51 A
Alglucosidase alfa injection 51 A
Page 444
PUF___2011_Web_File
Alpha 1 proteinase inhibitor 51 A
Alprostadil for injection 51 A
Alprostadil urethral suppos 51 A
Amikacin sulfate injection 51 A
Aminophyllin 250 MG inj 51 A
Amiodarone HCl 51 A
Amphotericin B 51 A
Amphotericin b lipid complex 51 A
Ampho b cholesteryl sulfate 51 A
Amphotericin b liposome inj 51 A
Ampicillin 500 MG inj 51 A
Ampicillin sodium per 1.5 gm 51 A
Amobarbital 125 MG inj 51 A
Succinycholine chloride inj 51 A
Anidulafungin injection 51 A
Injection anistreplase 30 u 51 A
Hydralazine hcl injection 51 A
Apomorphine hydrochloride 51 A
Aprotonin, 10,000 kiu 51 A
Inj metaraminol bitartrate 51 A
Chloroquine injection 51 A
Arbutamine hcl injection 51 A
Aripiprazole injection 51 A
Azithromycin 51 A
Atropine sulfate injection 51 A
Atropine sulfate injection 51 A
Dimecaprol injection 51 A
Baclofen 10 MG injection 51 A
Baclofen intrathecal trial 51 A
Basiliximab 51 A
Dicyclomine injection 51 A
Inj benztropine mesylate 51 A
Bethanechol chloride inject 51 A
Penicillin g benzathine inj 51 A
Penicillin g benzathine inj 51 A
Penicillin g benzathine inj 51 A
PenG benzathine/procaine inj 51 A
PenG benzathine/procaine inj 51 A
Penicillin g benzathine inj 51 A
Penicillin g benzathine inj 51 A
Penicillin g benzathine inj 51 A
Penicillin g benzathine inj 51 A
Bivalirudin 51 A
Injection,onabotulinumtoxinA 51 A
AbobotulinumtoxinA 51 A
Page 445
PUF___2011_Web_File
Inj, rimabotulinumtoxinB 51 A
Buprenorphine hydrochloride 51 A
Busulfan injection 51 A
Butorphanol tartrate 1 mg 51 A
C-1 esterase, berinert 51 A
C-1 esterase, cinryze 51 A
Edetate calcium disodium inj 51 A
Calcium gluconate injection 51 A
Calcium glycer & lact/10 ML 51 A
Calcitonin salmon injection 51 A
Inj calcitriol per 0.1 mcg 51 A
Caspofungin acetate 51 A
Canakinumab injection 51 A
Leucovorin calcium injection 51 A
Levoleucovorin injection 51 A
Inj mepivacaine HCL/10 ml 51 A
Cefazolin sodium injection 51 A
Cefepime HCl for injection 51 A
Cefoxitin sodium injection 51 A
Ceftriaxone sodium injection 51 A
Sterile cefuroxime injection 51 A
Cefotaxime sodium injection 51 A
Betamethasone acet&sod phosp 51 A
Betamethasone sod phosp/4 MG 51 A
Caffeine citrate injection 51 A
Cephapirin sodium injection 51 A
Inj ceftazidime per 500 mg 51 A
Ceftizoxime sodium / 500 MG 51 A
Certolizumab pegol inj 51 A
Chloramphenicol sodium injec 51 A
Chorionic gonadotropin/1000u 51 A
Clonidine hydrochloride 51 A
Cidofovir injection 51 A
Cilastatin sodium injection 51 A
Ciprofloxacin iv 51 A
Inj codeine phosphate /30 MG 51 A
Colchicine injection 51 A
Colistimethate sodium inj 51 A
Collagenase, clost hist inj 51 A
Prochlorperazine injection 51 A
Corticorelin ovine triflutal 51 A
Corticotropin injection 51 A
Cosyntropin injection NOS 51 A
Cosyntropin cortrosyn inj 51 A
Inj cosyntropin per 0.25 MG 51 A
Cytomegalovirus imm IV /vial 51 A
Daptomycin injection 51 A
Darbepoetin alfa, non-esrd 51 A
Darbepoetin alfa, esrd use 57 A
Epoetin alfa, non-esrd 51 A
Epoetin alfa 1000 units ESRD 57 A
Decitabine injection 51 A
Page 446
PUF___2011_Web_File
Deferoxamine mesylate inj 51 A
Testosterone enanthate inj 51 A
Brompheniramine maleate inj 51 A
Estradiol valerate injection 51 A
Depo-estradiol cypionate inj 51 A
Methylprednisolone 20 MG inj 51 A
Methylprednisolone 40 MG inj 51 A
Methylprednisolone 80 MG inj 51 A
Medroxyprogesterone inj 51 A
Medrxyprogester acetate inj 00 9
MA/EC contraceptiveinjection 51 A
Testosterone cypionate 1 ML 51 A
Testosterone cypionat 100 MG 51 A
Testosterone cypionat 200 MG 51 A
Inj dexamethasone acetate 51 A
Dexamethasone sodium phos 51 A
Inj dihydroergotamine mesylt 51 A
Acetazolamid sodium injectio 51 A
Digoxin injection 51 A
Digoxin immune fab (ovine) 51 A
Phenytoin sodium injection 51 A
Hydromorphone injection 51 A
Dyphylline injection 51 A
Dexrazoxane HCl injection 51 A
Diphenhydramine hcl injectio 51 A
Chlorothiazide sodium inj 51 A
Dimethyl sulfoxide 50% 50 ML 51 A 45-23
Methadone injection 51 A
Dimenhydrinate injection 51 A
Dipyridamole injection 51 A
Inj dobutamine HCL/250 mg 51 A
Dolasetron mesylate 51 A
Dopamine injection 51 A
Doripenem injection 51 A
Injection, doxercalciferol 51 A
Ecallantide injection 51 A
Eculizumab injection 51 A
Amitriptyline injection 51 A
Enfuvirtide injection 51 A
Epoprostenol injection 51 A
Eptifibatide injection 51 A
Ergonovine maleate injection 51 A
Ertapenem injection 51 A
Erythro lactobionate /500 MG 51 A
Estradiol valerate 10 MG inj 51 A
Estradiol valerate 20 MG inj 51 A
Inj estrogen conjugate 25 MG 51 A
Ethanolamine oleate 100 mg 51 A
Injection estrone per 1 MG 51 A
Etidronate disodium inj 51 A
Etanercept injection 51 A
Page 447
PUF___2011_Web_File
Filgrastim 300 mcg injection 51 A
Filgrastim 480 mcg injection 51 A
Fluconazole 51 A
Fomepizole, 15 mg 51 A
Intraocular Fomivirsen na 51 A
Fosaprepitant injection 51 A
Foscarnet sodium injection 51 A
Gallium nitrate injection 51 A
Galsulfase injection 51 A
Inj IVIG privigen 500 mg 51 A
Gamma globulin 1 CC inj 51 A
Gamma globulin 2 CC inj 51 A
Gamma globulin 3 CC inj 51 A
Gamma globulin 4 CC inj 51 A
Gamma globulin 5 CC inj 51 A
Gamma globulin 6 CC inj 51 A
Gamma globulin 7 CC inj 51 A
Gamma globulin 8 CC inj 51 A
Gamma globulin 9 CC inj 51 A
Gamma globulin 10 CC inj 51 A
Hizentra injection 51 A
Gamma globulin > 10 CC inj 51 A
Gamunex injection 51 A
Vivaglobin, inj 51 A
RSV-ivig 51 A
Immune globulin, powder 51 A
Immune globulin, liquid 00 9
Octagam injection 51 A
Gammagard liquid injection 51 A
Ganciclovir sodium injection 51 A
Hepagam b im injection 51 A
Flebogamma injection 51 A
Hepagam b intravenous, inj 51 A
Garamycin gentamicin inj 51 A
Gatifloxacin injection 51 A
Injection glatiramer acetate 51 A
Ivig non-lyophilized, NOS 51 A
Gold sodium thiomaleate inj 51 A
Glucagon hydrochloride/1 MG 51 A
Gonadorelin hydroch/ 100 mcg 51 A
Granisetron hcl injection 51 A
Haloperidol injection 51 A
Haloperidol decanoate inj 51 A
Hemin, 1 mg 51 A
Page 448
PUF___2011_Web_File
Inj heparin sodium per 10 u 51 A
Inj heparin sodium per 1000u 51 A
Dalteparin sodium 51 A
Inj enoxaparin sodium 51 A
Fondaparinux sodium 51 A
Tinzaparin sodium injection 51 A
Tetanus immune globulin inj 51 A
Histrelin acetate 51 A
Human fibrinogen conc inj 51 A
Hydrocortisone acetate inj 51 A
Hydrocortisone sodium ph inj 51 A
Hydrocortisone sodium succ i 51 A
Diazoxide injection 51 A
Ibandronate sodium injection 51 A
Ibutilide fumarate injection 51 A
Idursulfase injection 51 A
Infliximab injection 51 A
Inj iron dextran 51 A
Iron dextran 165 injection 00 9
Iron dextran 267 injection 00 9
Iron sucrose injection 51 A
Injection imiglucerase /unit 51 A
Imuglucerase injection 51 A
Droperidol injection 51 A
Propranolol injection 51 A
Droperidol/fentanyl inj 51 A
Insulin injection 51 A 60-14
Insulin for insulin pump use 51 A
Interferon beta-1a 00 9
Interferon Beta-1A inj 00 9
Interferon beta-1b / .25 MG 51 A
Itraconazole injection 51 A
Kanamycin sulfate 500 MG inj 51 A
Kanamycin sulfate 75 MG inj 51 A
Ketorolac tromethamine inj 51 A
Cephalothin sodium injection 51 A
Lanreotide injection 51 A
Laronidase injection 51 A
Furosemide injection 51 A
Lepirudin 51 A
Leuprolide acetate /3.75 MG 51 A
Levetiracetam injection 51 A
Inj levocarnitine per 1 gm 51 A
Levofloxacin injection 51 A
Levorphanol tartrate inj 51 A
Hyoscyamine sulfate inj 51 A
Chlordiazepoxide injection 51 A
Lidocaine injection 51 A
Lincomycin injection 51 A
Linezolid injection 51 A
Page 449
PUF___2011_Web_File
Lorazepam injection 51 A
Mannitol injection 51 A
Mecasermin injection 51 A
Meperidine hydrochl /100 MG 51 A
Meperidine/promethazine inj 51 A
Meropenem 51 A
Methylergonovin maleate inj 51 A
Micafungin sodium injection 51 A
Inj midazolam hydrochloride 51 A
Inj milrinone lactate / 5 MG 51 A
Morphine sulfate injection 51 A
Morphine so4 injection 100mg 51 A 60-14a
Morphine sulfate injection 51 A 60-14b
Ziconotide injection 51 A
Inj, moxifloxacin 100 mg 51 A
Inj nalbuphine hydrochloride 51 A
Inj naloxone hydrochloride 51 A
Naltrexone, depot form 51 A
Nandrolone decanoate 50 MG 51 A
Nandrolone decanoate 100 MG 51 A
Nandrolone decanoate 200 MG 51 A
Natalizumab injection 51 A
Nesiritide injection 51 A
Octreotide injection, depot 51 A
Octreotide inj, non-depot 51 A
Oprelvekin injection 51 A
Omalizumab injection 51 A
Olanzapine long-acting inj 51 A
Orphenadrine injection 51 A
Phenylephrine hcl injection 51 A
Chloroprocaine hcl injection 51 A
Ondansetron hcl injection 51 A
Oxymorphone hcl injection 51 A
Palifermin injection 51 A
Paliperidone palmitate inj 51 A
Pamidronate disodium /30 MG 51 A
Papaverin hcl injection 51 A
Oxytetracycline injection 51 A
Palonosetron hcl 51 A
Paricalcitol 51 A
Pegaptanib sodium injection 51 A
Pegademase bovine, 25 iu 51 A
Injection, pegfilgrastim 6mg 53 A
Penicillin g procaine inj 51 A
Pentastarch 10% solution 51 A
Pentobarbital sodium inj 51 A
Penicillin g potassium inj 51 A
Piperacillin/tazobactam 51 A
Pentamidine non-comp unit 51 A
Page 450
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Promethazine hcl injection 51 A
Phenobarbital sodium inj 51 A
Plerixafor injection 51 A
Oxytocin injection 51 A
Inj desmopressin acetate 51 A
Prednisolone acetate inj 51 A
Totazoline hcl injection 51 A
Inj progesterone per 50 MG 51 A
Fluphenazine decanoate 25 MG 51 A
Procainamide hcl injection 51 A
Oxacillin sodium injeciton 51 A
Neostigmine methylslfte inj 51 A
Inj protamine sulfate/10 MG 51 A
Protein c concentrate 51 A
Inj protirelin per 250 mcg 51 A
Pralidoxime chloride inj 51 A
Phentolaine mesylate inj 51 A
Metoclopramide hcl injection 51 A
Quinupristin/dalfopristin 51 A
Ranibizumab injection 51 A
Ranitidine hydrochloride inj 51 A
Rasburicase 51 A
Regadenoson injection 51 A
Rho d immune globulin 50 mcg 51 A
Rho d immune globulin inj 51 A
Rhophylac injection 51 A
Rho(D) immune globulin h, sd 51 A
Rilonacept injection 51 A
Risperidone, long acting 51 A
Ropivacaine HCl injection 51 A
Romiplostim injection 51 A
Methocarbamol injection 51 A
Sincalide injection 51 A
Inj theophylline per 40 MG 51 A
Sargramostim injection 51 A
Inj secretin synthetic human 51 A
Aurothioglucose injeciton 51 A
Na ferric gluconate complex 51 A
Methylprednisolone injection 51 A
Methylprednisolone injection 51 A
Somatrem injection 51 A
Somatropin injection 51 A
Promazine hcl injection 51 A
Reteplase injection 51 A
Inj streptokinase /250000 IU 51 A
Alteplase recombinant 51 A
Streptomycin injection 51 A
Fentanyl citrate injeciton 51 A
Sumatriptan succinate / 6 MG 51 A
Page 451
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Pentazocine injection 51 A
Televancin injection 51 A
Tenecteplase injection 51 A
Tenecteplase injection 51 A
Terbutaline sulfate inj 51 A
Teriparatide injection 51 A
Testosterone enanthate inj 51 A
Testosterone enanthate inj 51 A
Testosterone suspension inj 51 A
Testosteron propionate inj 51 A
Chlorpromazine hcl injection 51 A
Thyrotropin injection 51 A
Tigecycline injection 51 A
Tirofiban HCl 51 A
Trimethobenzamide hcl inj 51 A
Tobramycin sulfate injection 51 A
Tocilizumab injection 51 A
Injection torsemide 10 mg/ml 51 A
Thiethylperazine maleate inj 51 A
Treprostinil injection 51 A
Triamcinolone A inj PRS-free 51 A
Triamcinolone acet inj NOS 51 A
Triamcinolone diacetate inj 51 A
Triamcinolone hexacetonl inj 51 A
Inj trimetrexate glucoronate 51 A
Perphenazine injeciton 51 A
Triptorelin pamoate 51 A
Spectinomycn di-hcl inj 51 A
Urea injection 51 A
Urofollitropin, 75 iu 51 A
Ustekinumab injection 51 A
Diazepam injection 51 A
Urokinase 5000 IU injection 51 A
Urokinase 250,000 IU inj 51 A
Vancomycin hcl injection 51 A 60-14
Velaglucerase alfa 51 A
Verteporfin injection 51 A
Triflupromazine hcl inj 51 A
Hydroxyzine hcl injection 51 A
Thiamine hcl 100 mg 51 A
Pyridoxine hcl 100 mg 51 A
Vitamin b12 injection 51 A 45-4
Vitamin k phytonadione inj 51 A
Injection, voriconazole 51 A
Hyaluronidase injection 51 A
Ovine, up to 999 USP units 51 A
Ovine, 1000 USP units 51 A
Hyaluronidase recombinant 51 A
Inj magnesium sulfate 51 A
Inj potassium chloride 51 A
Zidovudine 51 A
Page 452
PUF___2011_Web_File
Ziprasidone mesylate 51 A
Zoledronic acid 51 A
Reclast injection 51 A
Drugs unclassified injection 51 A
Edetate disodium per 150 mg 00 9 35-64
Nasal vaccine inhalation 51 A
Metered dose inhaler drug 00 9
Laetrile amygdalin vit B17 00 9 45-10
Unclassified biologics 51 A
Normal saline solution infus 51 A
Normal saline solution infus 51 A
5% dextrose/normal saline 51 A
Normal saline solution infus 51 A
5% dextrose/water 51 A
D5w infusion 51 A
Dextran 40 infusion 51 A
Dextran 75 infusion 51 A
Ringers lactate infusion 51 A
Hypertonic saline solution 51 A
Wilate injection 51 A
Xyntha inj 51 A
Antihemophilic viii/vwf comp 51 A
Humate-P, inj 51 A
Factor viia 51 A
Factor viii 51 A
Factor VIII (porcine) 51 A
Factor viii recombinant NOS 51 A
Factor IX non-recombinant 51 A
Factor ix complex 51 A
Factor IX recombinant 51 A
Antithrombin recombinant 51 A
Antithrombin iii injection 51 A
Anti-inhibitor 51 A 45-24
Hemophilia clot factor noc 51 A 45-24
Intraut copper contraceptive 00 9
Levonorgestrel iu contracept 00 9
Contraceptive vaginal ring 00 9
Contraceptive hormone patch 00 9
Levonorgestrel implant sys 00 9
Etonogestrel implant system 00 9
Aminolevulinic acid hcl top 51 A
Methyl aminolevulinate, top 51 A
Ganciclovir long act implant 51 A
Fluocinolone acetonide implt 51 A
Dexamethasone intra implant 51 A
Sodium Hyaluronate Injection 00 9
Hyalgan/supartz inj per dose 51 A
Page 453
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Synvisc inj per dose 51 A
Euflexxa inj per dose 51 A
Orthovisc inj per dose 51 A
Synvisc or Synvisc-One 51 A
Cultured chondrocytes implnt 57 A
Capsaicin 8% patch 51 A
Metabolic active D/E tissue 51 A
Non-human, metabolic tissue 51 A
Metabolically active tissue 46 A
Nonmetabolic act d/e tissue 51 A
Nonmetabolic active tissue 51 A
Non-human, non-metab tissue 51 A
Injectable human tissue 51 A
Integra matrix tissue 51 A
Tissuemend tissue 51 A
Primatrix tissue 51 A
Azathioprine oral 50mg 51 A
Azathioprine parenteral 51 A
Cyclosporine oral 100 mg 57 A
Lymphocyte immune globulin 51 A 45-22
Monoclonal antibodies 51 A
Prednisone oral 51 A
Tacrolimus oral per 1 MG 51 A
Methylprednisolone oral 51 A
Prednisolone oral per 5 mg 51 A
Antithymocyte globuln rabbit 51 A
Daclizumab, parenteral 51 A
Cyclosporine oral 25 mg 51 A
Cyclosporin parenteral 250mg 51 A
Mycophenolate mofetil oral 51 A
Mycophenolic acid 51 A
Sirolimus, oral 51 A
Page 454
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Tacrolimus injection 51 A
Immunosuppressive drug noc 51 A
Albuterol inh non-comp con 00 9
Albuterol inh non-comp u d 00 9
Acetylcysteine comp unit 51 A
Arformoterol non-comp unit 51 A
Formoterol fumarate, inh 51 A
Levalbuterol comp con 51 A
Acetylcysteine non-comp unit 51 A
Albuterol comp unit 51 A
Albuterol comp con 51 A
Albuterol non-comp con 00 9
Levalbuterol non-comp con 00 9
Albuterol non-comp unit 00 9
Levalbuterol non-comp unit 00 9
Levalbuterol comp unit 51 A
Albuterol ipratrop non-comp 51 A
Beclomethasone comp unit 51 A
Betamethasone comp unit 51 A
Budesonide non-comp unit 51 A
Budesonide comp unit 51 A
Bitolterol mesylate comp con 51 A
Bitolterol mesylate comp unt 51 A
Cromolyn sodium noncomp unit 51 A
Cromolyn sodium comp unit 51 A
Budesonide non-comp con 51 A
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Budesonide comp con 51 A
Atropine comp con 51 A
Atropine comp unit 51 A
Dexamethasone comp con 51 A
Dexamethasone comp unit 51 A
Dornase alfa non-comp unit 51 A
Formoterol comp unit 00 9
Flunisolide comp unit 51 A
Glycopyrrolate comp con 51 A
Glycopyrrolate comp unit 51 A
Ipratropium bromide non-comp 51 A
Ipratropium bromide comp 51 A
Isoetharine comp con 51 A
Isoetharine non-comp con 51 A
Isoetharine non-comp unit 51 A
Isoetharine comp unit 51 A
Isoproterenol comp con 51 A
Isoproterenol non-comp con 51 A
Isoproterenol non-comp unit 51 A
Isoproterenol comp unit 51 A
Metaproterenol comp con 51 A
Metaproterenol non-comp con 51 A
Metaproterenol non-comp unit 51 A
Metaproterenol comp unit 51 A
Methacholine chloride, neb 51 A
Pentamidine comp unit dose 51 A
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Terbutaline sulf comp con 51 A
Terbutaline sulf comp unit 51 A
Tobramycin non-comp unit 51 A
Triamcinolone comp con 51 A
Triamcinolone comp unit 51 A
Tobramycin comp unit 51 A
Treprostinil, non-comp unit 51 A
Inhalation solution for DME 51 A
Non-inhalation drug for DME 51 A
Antiemetic rectal/supp NOS 51 A
Oral prescrip drug non chemo 00 9
Oral aprepitant 51 A
Oral busulfan 51 A
Cabergoline, oral 0.25mg 00 9
Capecitabine, oral, 150 mg 51 A
Capecitabine, oral, 500 mg 51 A
Cyclophosphamide oral 25 MG 51 A
Oral dexamethasone 51 A
Etoposide oral 50 MG 51 A
Oral fludarabine phosphate 51 A
Gefitinib oral 00 9
Antiemetic drug oral NOS 51 A
Melphalan oral 2 MG 51 A
Methotrexate oral 2.5 MG 51 A
Nabilone oral 51 A
Temozolomide 51 A
Topotecan oral 51 A
Oral prescription drug chemo 51 A
Doxorubicin hcl injection 51 A
Doxorubicin hcl liposome inj 51 A
Alemtuzumab injection 51 A
Aldesleukin injection 51 A
Arsenic trioxide injection 51 A
Asparaginase injection 51 A
Azacitidine injection 51 A
Clofarabine injection 51 A
Bcg live intravesical vac 51 A
Bendamustine injection 51 A
Bevacizumab injection 51 A
Bleomycin sulfate injection 51 A
Bortezomib injection 51 A
Carboplatin injection 51 A
Carmustine injection 51 A
Cetuximab injection 51 A
Cisplatin 10 MG injection 51 A
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Cisplatin 50 MG injection 51 A
Inj cladribine per 1 MG 51 A
Cyclophosphamide 100 MG inj 51 A
Cyclophosphamide 200 MG inj 51 A
Cyclophosphamide 500 MG inj 51 A
Cyclophosphamide 1.0 grm inj 51 A
Cyclophosphamide 2.0 grm inj 51 A
Cyclophosphamide lyophilized 51 A
Cyclophosphamide lyophilized 51 A
Cyclophosphamide lyophilized 51 A
Cyclophosphamide lyophilized 51 A
Cyclophosphamide lyophilized 51 A
Cytarabine liposome inj 51 A
Cytarabine hcl 100 MG inj 51 A
Cytarabine hcl 500 MG inj 51 A
Dactinomycin injection 51 A
Dacarbazine 100 mg inj 51 A
Dacarbazine 200 MG inj 51 A
Daunorubicin injection 51 A
Daunorubicin citrate inj 51 A
Degarelix injection 51 A
Denileukin diftitox inj 51 A
Diethylstilbestrol injection 51 A
Docetaxel injection 51 A
Docetaxel injection 51 A
Elliotts b solution per ml 51 A
Inj, epirubicin hcl, 2 mg 51 A
Etoposide injection 51 A
Etoposide 100 MG inj 51 A
Fludarabine phosphate inj 51 A
Fluorouracil injection 51 A
Floxuridine injection 51 A
Gemcitabine hcl injection 51 A
Goserelin acetate implant 51 A
Irinotecan injection 51 A
Ixabepilone injection 51 A
Ifosfomide injection 51 A
Mesna injection 51 A
Idarubicin hcl injection 51 A
Interferon alfacon-1 inj 51 A
Interferon alfa-2a inj 51 A
Interferon alfa-2b inj 51 A
Interferon alfa-n3 inj 51 A
Interferon gamma 1-b inj 51 A
Leuprolide acetate suspnsion 51 A
Leuprolide acetate injeciton 51 A
Leuprolide acetate implant 51 A
Vantas implant 51 A
Supprelin LA implant 51 A
Mechlorethamine hcl inj 51 A
Inj melphalan hydrochl 50 MG 51 A
Methotrexate sodium inj 51 A
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Methotrexate sodium inj 51 A
Nelarabine injection 51 A
Oxaliplatin 51 A
Paclitaxel protein bound 51 A
Paclitaxel injection 51 A
Pegaspargase injection 51 A
Pentostatin injection 51 A
Plicamycin (mithramycin) inj 51 A
Mitomycin 5 MG inj 51 A
Mitomycin 20 MG inj 51 A
Mitomycin 40 MG inj 51 A
Mitoxantrone hydrochl / 5 MG 51 A
Gemtuzumab ozogamicin inj 51 A
Ofatumumab injection 51 A
Panitumumab injection 51 A
Pemetrexed injection 51 A
Pralatrexate injection 51 A
Rituximab injection 51 A
Romidepsin injection 51 A
Streptozocin injection 51 A
Temozolomide injection 51 A
Temsirolimus injection 51 A
Thiotepa injection 51 A
Topotecan injection 51 A
Topotecan injection 51 A
Trastuzumab injection 51 A
Valrubicin injection 51 A
Vinblastine sulfate inj 51 A
Vincristine sulfate 1 MG inj 51 A
Vincristine sulfate 2 MG inj 51 A
Vincristine sulfate 5 MG inj 51 A
Vinorelbine tartrate inj 51 A
Injection, Fulvestrant 51 A
Porfimer sodium injection 51 A
Chemotherapy drug 51 A 45-16
Standard wheelchair 36 A
Stnd hemi (low seat) whlchr 36 A
Lightweight wheelchair 36 A
High strength ltwt whlchr 36 A
Ultralightweight wheelchair 32 A
Heavy duty wheelchair 36 A
Extra heavy duty wheelchair 36 A
Other manual wheelchair/base 46 A
Stnd wt frame power whlchr 36 A
Stnd wt pwr whlchr w control 36 A
Ltwt portbl power whlchr 36 A
Other power whlchr base 36 A
Detach non-adjus hght armrst 32 A
Detach adjust armrest base 32 A
Detach adjust armrst upper 32 A
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Arm pad each 32 A
Fixed adjust armrest pair 32 A
High mount flip-up footrest 32 A
Leg strap each 32 A
Leg strap h style each 32 A
Adjustable angle footplate 32 A
Large size footplate each 32 A
Standard size footplate each 32 A
Ftrst lower extension tube 32 A
Ftrst upper hanger bracket 32 A
Footrest complete assembly 32 A
Elevat legrst low extension 32 A
Elevat legrst up hangr brack 32 A
Ratchet assembly 32 A
Cam relese assem ftrst/lgrst 32 A
Swingaway detach footrest 32 A
Elevate footrest articulate 32 A
Seat ht <17 or >=21 ltwt wc 32 A
Spoke protectors 32 A
Rear whl complete solid tire 32 A
Rear whl compl pneum tire 32 A
Front castr compl pneum tire 32 A
Frnt cstr cmpl sem-pneum tir 32 A
Caster pin lock each 32 A
Front caster assem complete 32 A
Drive belt power wheelchair 32 A
Iv hanger 32 A
W/c component-accessory NOS 46 A
Elevating whlchair leg rests 36 A 60-9
Pump uninterrupted infusion 31 A 60-14
Temporary replacement eqpmnt 32 A
Supply/ext inf pump syr type 34 A 60-14
Combination oral/nasal mask 32 A
Repl oral cushion combo mask 32 A
Repl nasal pillow comb mask 32 A
Repl batt silver oxide 1.5 v 32 A
Repl batt silver oxide 3 v 32 A
Repl batt alkaline 1.5 v 32 A
Repl batt lithium 3.6 v 32 A
Repl batt lithium 4.5 v 32 A
AED garment w elec analysis 36 A
Repl batt for AED 32 A
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Repl garment for AED 32 A
Repl electrode for AED 34 A
Seat/back cus no dmepdac ver 32 A
Removable soft interface LE 38 A
Ctrl dose inh drug deliv sys 32 A
12-24hr sealed lead acid 32 A
Adj skin pro w/c cus wd<22in 32 A
Adj skin pro wc cus wd>=22in 32 A
Adj skin pro/pos wc cus<22in 32 A
Adj skin pro/pos wc cus>=22" 32 A
Portable gas oxygen system 33 A
Repair/svc DME non-oxygen eq 46 A
Repair/svc oxygen equipment 00 9
POV group 1 std up to 300lbs 32 A
POV group 1 hd 301-450 lbs 32 A
POV group 1 vhd 451-600 lbs 32 A
POV group 2 std up to 300lbs 32 A
POV group 2 hd 301-450 lbs 32 A
POV group 2 vhd 451-600 lbs 32 A
Power operated vehicle NOC 32 A
PWC gp 1 std port seat/back 36 A
PWC gp 1 std port cap chair 36 A
PWC gp 1 std seat/back 36 A
PWC gp 1 std cap chair 36 A
PWC gp 2 std port seat/back 36 A
PWC gp 2 std port cap chair 36 A
PWC gp 2 std seat/back 36 A
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PWC gp 2 std cap chair 36 A
PWC gp 2 hd seat/back 36 A
PWC gp 2 hd cap chair 36 A
PWC gp 2 vhd seat/back 36 A
PWC gp vhd cap chair 36 A
PWC gp 2 xtra hd seat/back 36 A
PWC gp 2 xtra hd cap chair 36 A
PWC gp2 std seat elevate s/b 36 A
PWC gp2 std seat elevate cap 36 A
PWC gp2 std sing pow opt s/b 36 A
PWC gp2 std sing pow opt cap 36 A
PWC gp 2 hd sing pow opt s/b 36 A
PWC gp 2 hd sing pow opt cap 36 A
PWC gp2 vhd sing pow opt s/b 36 A
PWC gp2 xhd sing pow opt s/b 36 A
PWC gp2 std mult pow opt s/b 36 A
PWC gp2 std mult pow opt cap 36 A
PWC gp2 hd mult pow opt s/b 36 A
PWC gp 3 std seat/back 36 A
PWC gp 3 std cap chair 36 A
PWC gp 3 hd seat/back 36 A
PWC gp 3 hd cap chair 36 A
PWC gp 3 vhd seat/back 36 A
PWC gp 3 vhd cap chair 36 A
PWC gp 3 xhd seat/back 36 A
PWC gp 3 xhd cap chair 36 A
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PWC gp3 std sing pow opt s/b 36 A
PWC gp3 std sing pow opt cap 36 A
PWC gp3 hd sing pow opt s/b 36 A
PWC gp3 hd sing pow opt cap 36 A
PWC gp3 vhd sing pow opt s/b 36 A
PWC gp3 std mult pow opt s/b 36 A
PWC gp3 hd mult pow opt s/b 36 A
PWC gp3 vhd mult pow opt s/b 36 A
PWC gp3 xhd mult pow opt s/b 36 A
PWC gp 4 std seat/back 36 A
PWC gp 4 std cap chair 36 A
PWC gp 4 hd seat/back 36 A
PWC gp 4 vhd seat/back 36 A
PWC gp4 std sing pow opt s/b 36 A
PWC gp4 std sing pow opt cap 36 A
PWC gp4 hd sing pow opt s/b 36 A
PWC gp4 vhd sing pow opt s/b 36 A
PWC gp4 std mult pow opt s/b 36 A
PWC gp4 std mult pow opt cap 36 A
PWC gp4 hd mult pow s/b 36 A
PWC gp5 ped sing pow opt s/b 36 A
PWC gp5 ped mult pow opt s/b 36 A
Power wheelchair NOC 36 A
Pow mobil dev no dmepdac 36 A
Cranial cervical orthosis 38 A
Cranial cervical torticollis 38 A
Cerv flexible non-adjustable 38 A
Flex thermoplastic collar mo 38 A
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Cervical semi-rigid adjustab 38 A
Cerv semi-rig adj molded chn 38 A
Cerv semi-rig wire occ/mand 38 A
Cervical collar molded to pt 38 A
Cerv col thermplas foam 2 pi 38 A
Cerv col foam 2 piece w thor 38 A
Cer post col occ/man sup adj 38 A
Cerv collar supp adj cerv ba 38 A
Cerv col supp adj bar & thor 38 A
Thoracic rib belt 38 A
Thor rib belt custom fabrica 38 A
Dewall posture protector 38 A
TLSO flex prefab thoracic 38 A
tlso flex custom fab thoraci 38 A
TLSO flex prefab sacrococ-T9 38 A
TLSO flex prefab 38 A
TLSO 2Mod symphis-xipho pre 38 A
TLSO2Mod symphysis-stern pre 38 A
TLSO 3Mod sacro-scap pre 38 A
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TLSO 4Mod sacro-scap pre 38 A
TLSO rigid frame pre soft ap 38 A
TLSO rigid frame prefab pelv 38 A
TLSO rigid frame pre subclav 38 A
TLSO rigid frame hyperex pre 38 A
TLSO rigid plastic custom fa 38 A
TLSO rigid lined custom fab 38 A
TLSO rigid plastic cust fab 38 A
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PUF___2011_Web_File
TLSO rigidlined cust fab two 38 A
TLSO rigid lined pre one pie 38 A
TLSO rigid plastic pre one 38 A
TLSO 2 piece rigid shell 38 A
TLSO 3 piece rigid shell 38 A
SIO flex pelvisacral prefab 38 A
SIO flex pelvisacral custom 38 A
SIO panel prefab 38 A
SIO panel custom 38 A
LO flexibl L1-below L5 pre 38 A
Page 466
PUF___2011_Web_File
LO sag stays/panels pre-fab 38 A
LO sagitt rigid panel prefab 38 A
LO flex w/o rigid stays pre 38 A
LSO flex w/rigid stays cust 38 A
LSO post rigid panel pre 38 A
LSO sag-coro rigid frame pre 38 A
LSO sag rigid frame cust 38 A
LSO flexion control prefab 38 A
LSO flexion control custom 38 A
LSO sagit rigid panel prefab 38 A
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PUF___2011_Web_File
LSO sagittal rigid panel cus 38 A
LSO sag-coronal panel prefab 38 A
LSO sag-coronal panel custom 38 A
LSO s/c shell/panel prefab 38 A
LSO s/c shell/panel custom 38 A
Ctlso a-p-l control molded 38 A
Ctlso a-p-l control w/ inter 38 A
Halo cervical into jckt vest 38 A
Halo cervical into body jack 38 A
Halo cerv into milwaukee typ 38 A
MRI compatible system 38 A
Halo repl liner/interface 38 A
Post surgical support pads 38 A
Tlso corset front 38 A
Lso corset front 38 A
Tlso full corset 38 A
Lso full corset 38 A
Axillary crutch extension 38 A
Peroneal straps pair 38 A
Stocking supp grips set of f 38 A
Protective body sock each 38 A
Add to spinal orthosis NOS 46 A
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PUF___2011_Web_File
Ctlso milwauke initial model 38 A
CTLSO infant immobilizer 38 A
Tension based scoliosis orth 38 A
Ctlso axilla sling 38 A
Kyphosis pad 38 A
Kyphosis pad floating 38 A
Lumbar bolster pad 38 A
Lumbar or lumbar rib pad 38 A
Sternal pad 38 A
Thoracic pad 38 A
Trapezius sling 38 A
Outrigger 38 A
Outrigger bil w/ vert extens 38 A
Lumbar sling 38 A
Ring flange plastic/leather 38 A
Ring flange plas/leather mol 38 A
Covers for upright each 38 A
Furnsh initial orthosis only 38 A
Lateral thoracic extension 38 A
Anterior thoracic extension 38 A
Milwaukee type superstructur 38 A
Lumbar derotation pad 38 A
Anterior asis pad 38 A
Anterior thoracic derotation 38 A
Abdominal pad 38 A
Rib gusset (elastic) each 38 A
Lateral trochanteric pad 38 A
Body jacket mold to patient 38 A
Post-operative body jacket 38 A
Spinal orthosis NOS 46 A
Thkao mobility frame 38 A
Thkao standing frame 38 A
Thkao swivel walker 38 A
Abduct hip flex frejka w cvr 38 A
Abduct hip flex frejka covr 38 A
Abduct hip flex pavlik harne 38 A
Abduct control hip semi-flex 38 A
Pelv band/spread bar thigh c 38 A
HO abduction hip adjustable 38 A
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HO bi thighcuffs w sprdr bar 38 A
HO abduction static plastic 38 A
Pelvic & hip control thigh c 38 A
Post-op hip abduct custom fa 38 A
HO post-op hip abduction 38 A
Combination bilateral HO 38 A
Leg perthes orth toronto typ 38 A
Legg perthes orth newington 38 A
Legg perthes orthosis trilat 38 A
Legg perthes orth scottish r 38 A
Legg perthes patten bottom t 38 A
Knee orthoses elas w stays 38 A
Ko elastic with joints 38 A
Elastic with condylar pads 38 A
Ko elas w/ condyle pads & jo 38 A
Ko elastic knee cap 38 A
Ko immobilizer canvas longit 38 A
Knee orth pos locking joint 38 A
KO adj jnt pos rigid support 38 A
Ko w/0 joint rigid molded to 38 A
Rigid KO wo joints 38 A
Ko derot ant cruciate custom 38 A
KO single upright custom fit 38 A
Ko w/adj jt rot cntrl molded 38 A
Ko w/ adj flex/ext rotat cus 38 A
Ko w adj flex/ext rotat mold 38 A
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KO adjustable w air chambers 38 A
Ko swedish type 38 A
Ko plas doub upright jnt mol 38 A
Ko polycentric pneumatic pad 38 A
Ko supracondylar socket mold 38 A
Ko doub upright lacers molde 38 A
Ko doub upright cuffs/lacers 38 A
Afo sprng wir drsflx calf bd 38 A
Prefab ankle orthosis 38 A
Afo ankle gauntlet 38 A
Afo molded ankle gauntlet 38 A
Afo multiligamentus ankle su 38 A
AFO supramalleolar custom 38 A
Afo sing bar clasp attach sh 38 A
Afo sing upright w/ adjust s 38 A
Afo plastic 38 A
Afo rig ant tib prefab TCF/= 38 A
Afo molded to patient plasti 38 A
Afo molded plas rig ant tib 38 A
Afo spiral molded to pt plas 38 A
AFO spiral prefabricated 38 A
Afo pos solid ank plastic mo 38 A
Afo plastic molded w/ankle j 38 A
AFO w/ankle joint, prefab 38 A
Afo sing solid stirrup calf 38 A
Afo doub solid stirrup calf 38 A
Kafo sing fre stirr thi/calf 38 A
KAFO sng/dbl mechanical act 38 A
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Kafo sng solid stirrup w/o j 38 A
Kafo dbl solid stirrup band/ 38 A
Kafo dbl solid stirrup w/o j 38 A
KAFO pla sin up w/wo k/a cus 38 A
KAFO plastic pediatric size 38 A
Kafo plas doub free knee mol 38 A
Kafo plas sing free knee mol 38 A
Kafo w/o joint multi-axis an 38 A
Hkafo torsion bil rot straps 38 A
Hkafo torsion cable hip pelv 38 A
Hkafo torsion ball bearing j 38 A
Hkafo torsion unilat rot str 38 A
Hkafo unilat torsion cable 38 A
Hkafo unilat torsion ball br 38 A
Afo tib fx cast plaster mold 38 A
Afo tib fx cast molded to pt 38 A
Afo tibial fracture soft 38 A
Afo tib fx semi-rigid 38 A
Afo tibial fracture rigid 38 A
Kafo fem fx cast thermoplas 38 A
Kafo fem fx cast molded to p 38 A
Kafo femoral fx cast soft 38 A
Kafo fem fx cast semi-rigid 38 A
Kafo femoral fx cast rigid 38 A
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Plas shoe insert w ank joint 38 A
Drop lock knee 38 A
Limited motion knee joint 38 A
Adj motion knee jnt lerman t 38 A
Quadrilateral brim 38 A
Waist belt 38 A
Pelvic band & belt thigh fla 38 A
Limited ankle motion ea jnt 38 A
Dorsiflexion assist each joi 38 A
Dorsi & plantar flex ass/res 38 A
Split flat caliper stirr & p 38 A
Rocker bottom, contact AFO 38 A
Round caliper and plate atta 38 A
Foot plate molded stirrup at 38 A
Reinforced solid stirrup 38 A
Long tongue stirrup 38 A
Varus/valgus strap padded/li 38 A
Plastic mod low ext pad/line 38 A
Molded inner boot 38 A
Abduction bar jointed adjust 38 A
Abduction bar-straight 38 A
Non-molded lacer 38 A
Lacer molded to patient mode 38 A
Anterior swing band 38 A
Pre-tibial shell molded to p 38 A
Prosthetic type socket molde 38 A
Extended steel shank 38 A
Patten bottom 38 A
Torsion ank & half solid sti 38 A
Torsion straight knee joint 38 A
Straight knee joint heavy du 38 A
Add LE poly knee custom KAFO 38 A
Offset knee joint each 38 A
Offset knee joint heavy duty 38 A
Suspension sleeve lower ext 38 A
Knee joint drop lock ea jnt 38 A
Knee joint cam lock each joi 38 A
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PUF___2011_Web_File
Knee disc/dial lock/adj flex 38 A
Knee jnt ratchet lock ea jnt 38 A
Knee lift loop drop lock rin 38 A
Thi/glut/ischia wgt bearing 38 A
Th/wght bear quad-lat brim m 38 A
Th/wght bear quad-lat brim c 38 A
Th/wght bear nar m-l brim mo 38 A
Th/wght bear nar m-l brim cu 38 A
Thigh/wght bear lacer non-mo 38 A
Thigh/wght bear lacer molded 38 A
Thigh/wght bear high roll cu 38 A
Hip clevis type 2 posit jnt 38 A
Pelvic control pelvic sling 38 A
Hip clevis/thrust bearing fr 38 A
Hip clevis/thrust bearing lo 38 A
Pelvic control hip heavy dut 38 A
Hip joint adjustable flexion 38 A
Hip adj flex ext abduct cont 38 A
Plastic mold recipro hip & c 38 A
Metal frame recipro hip & ca 38 A
Pelvic control band & belt u 38 A
Pelvic control band & belt b 38 A
Pelv & thor control gluteal 38 A
Thoracic control thoracic ba 38 A
Thorac cont paraspinal uprig 38 A
Thorac cont lat support upri 38 A
Plating chrome/nickel pr bar 38 A
Carbon graphite lamination 38 A
Extension per extension per 38 A
Ortho sidebar disconnect 38 A
Low ext orthosis per bar/jnt 38 A
Non-corrosive finish 38 A
Drop lock retainer each 38 A
Knee control full kneecap 38 A
Page 474
PUF___2011_Web_File
Knee cap medial or lateral p 38 A
Knee control condylar pad 38 A
Soft interface below knee se 38 A
Soft interface above knee se 38 A
Tibial length sock fx or equ 38 A
Femoral lgth sock fx or equa 38 A
Torsion mechanism knee/ankle 00 9
Torsion mechanism knee/ankle 00 9
Lower extremity orthosis NOS 46 A
Ft insert ucb berkeley shell 00 9
Foot insert remov molded spe 00 9
Foot insert plastazote or eq 00 9
Foot insert silicone gel eac 00 9
Foot longitudinal arch suppo 00 9
Foot longitud/metatarsal sup 00 9
Foot arch support remov prem 00 9
Foot lamin/prepreg composite 00 9
Ft arch suprt premold longit 00 9
Foot arch supp premold metat 00 9
Foot arch supp longitud/meta 00 9
Arch suprt att to sho longit 00 9
Arch supp att to shoe metata 00 9
Arch supp att to shoe long/m 00 9
Hallus-valgus nght dynamic s 00 9
Abduction rotation bar shoe 00 9
Abduct rotation bar w/o shoe 00 9
Shoe styled positioning dev 00 9
Foot plastic heel stabilizer 00 9
Oxford w supinat/pronat inf 00 9
Oxford w/ supinat/pronator c 00 9
Oxford w/ supinator/pronator 00 9
Hightop w/ supp/pronator inf 00 9
Hightop w/ supp/pronator chi 00 9
Hightop w/ supp/pronator jun 00 9
Surgical boot each infant 00 9
Surgical boot each child 00 9
Surgical boot each junior 00 9
Benesch boot pair infant 00 9
Benesch boot pair child 00 9
Benesch boot pair junior 00 9
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PUF___2011_Web_File
Orthopedic ftwear ladies oxf 00 9
Orthoped ladies shoes dpth i 00 9
Ladies shoes hightop depth i 00 9
Orthopedic mens shoes oxford 00 9
Orthopedic mens shoes dpth i 00 9
Mens shoes hightop depth inl 00 9
Woman's shoe oxford brace 38 A
Man's shoe oxford brace 38 A
Custom shoes depth inlay 00 9
Custom mold shoe remov prost 00 9
Shoe molded to pt silicone s 00 9
Shoe molded plastazote cust 00 9
Shoe molded plastazote cust 00 9
Orth foot non-stndard size/w 00 9
Orth foot non-standard size/ 00 9
Orth foot add charge split s 00 9
Ambulatory surgical boot eac 00 9
Plastazote sandal each 00 9
Sho lift taper to metatarsal 00 9
Shoe lift elev heel/sole neo 00 9
Shoe lift elev heel/sole cor 00 9
Lifts elevation metal extens 00 9
Shoe lifts tapered to one-ha 00 9
Shoe lifts elevation heel /i 00 9
Shoe wedge sach 00 9
Shoe heel wedge 00 9
Shoe sole wedge outside sole 00 9
Shoe sole wedge between sole 00 9
Shoe clubfoot wedge 00 9
Shoe outflare wedge 00 9
Shoe metatarsal bar wedge ro 00 9
Shoe metatarsal bar between 00 9
Full sole/heel wedge btween 00 9
Sho heel count plast reinfor 00 9
Heel leather reinforced 00 9
Shoe heel sach cushion type 00 9
Shoe heel new leather standa 00 9
Shoe heel new rubber standar 00 9
Shoe heel thomas with wedge 00 9
Shoe heel thomas extend to b 00 9
Shoe heel pad & depress for 00 9
Shoe heel pad removable for 00 9
Ortho shoe add leather insol 00 9
Orthopedic shoe add rub insl 00 9
O shoe add felt w leath insl 00 9
Ortho shoe add half sole 00 9
Ortho shoe add full sole 00 9
O shoe add standard toe tap 00 9
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PUF___2011_Web_File
O shoe add horseshoe toe tap 00 9
O shoe add instep extension 00 9
O shoe add instep velcro clo 00 9
O shoe convert to sof counte 00 9
Ortho shoe add march bar 00 9
Trans shoe calip plate exist 00 9
Trans shoe caliper plate new 00 9
Trans shoe solid stirrup exi 00 9
Trans shoe solid stirrup new 00 9
Shoe dennis browne splint bo 00 9
Orthopedic shoe modifica NOS 00 9
Shlder fig 8 abduct restrain 38 A
Prefab shoulder orthosis 38 A
Prefab dbl shoulder orthosis 38 A
Abduct restrainer canvas&web 38 A
Acromio/clavicular canvas&we 38 A
SO cap design w/o jnts CF 38 A
SO airplane w/o jnts CF 38 A
SO airplane w/joint CF 38 A
SO airplane w/wo joint CF 38 A
Canvas vest SO 38 A
SO hard plastic stabilizer 00 9
Elbow orthoses elas w stays 38 A
Prefab elbow orthosis 38 A
EO w/o joints CF 38 A
Elbow elastic with metal joi 38 A
Forearm/arm cuffs free motio 38 A
Forearm/arm cuffs ext/flex a 38 A
Cuffs adj lock w/ active con 38 A
EO withjoint, Prefabricated 38 A
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PUF___2011_Web_File
Rigid EO wo joints 38 A
EWHO rigid w/o jnts CF 38 A
EWHO w/joint(s) CF 38 A
EWHFO rigid w/o jnts CF 38 A
EWHFO w/joint(s) CF 38 A
Whfo short opponen no attach 38 A
Whfo long opponens no attach 38 A
WHFO w/joint(s) custom fab 38 A
WHFO,no joint, prefabricated 38 A
WHFO, rigid w/o joints 38 A
Whfo thumb abduction bar 38 A
Whfo second m.p. abduction a 38 A
Whfo ip ext asst w/ mp ext s 38 A
Whfo m.p. extension stop 38 A
Whfo m.p. extension assist 38 A
Whfo m.p. spring extension a 38 A
Whfo spring swivel thumb 38 A
Whfo thumb ip ext ass w/ mp 38 A
Action wrist w/ dorsiflex as 38 A
Whfo adj m.p. flexion contro 38 A
Whfo adj m.p. flex ctrl & i. 38 A
Torsion mechanism wrist/elbo 00 9
Torsion mechanism wrist/elbo 00 9
Hinge extension/flex wrist/f 38 A
Hinge ext/flex wrist finger 38 A
Whfo electric custom fitted 38 A
WHO w/nontorsion jnt(s) CF 38 A
WHO w/o joints CF 38 A
Whfo wrst gauntlt thmb spica 38 A
Wrist cock-up non-molded 38 A
Page 478
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Prefab wrist orthosis 38 A
Whfo swanson design 38 A
Prefab hand finger orthosis 38 A
Flex glove w/elastic finger 38 A
HFO w/o joints CF 38 A
WHO w nontor jnt(s) prefab 38 A
Whfo wrist extens w/ outrigg 38 A
Prefab metacarpl fx orthosis 38 A
HFO knuckle bender 38 A
HO w/o joints CF 38 A
Knuckle bender with outrigge 38 A
HFO w/joint(s) CF 38 A
Knuckle bend 2 seg to flex j 38 A
HFO w/o joints PF 38 A
Oppenheimer 38 A
FO pip/dip with joint/spring 38 A
Thomas suspension 38 A
FO pip/dip w/o joint/spring 38 A
Finger extension w/ clock sp 38 A
HFO nontorsion joint, prefab 38 A
Finger extension with wrist 38 A
WHFO nontorsion joint prefab 38 A
Safety pin spring wire 38 A
Page 479
PUF___2011_Web_File
FO w/o joints CF 38 A
Safety pin modified 38 A
FO nontorsion joint CF 38 A
Palmer 38 A
Dorsal wrist 38 A
Dorsal wrist w/ outrigger at 38 A
Reverse knuckle bender 38 A
Reverse knuckle bend w/ outr 38 A
HFO composite elastic 38 A
Finger knuckle bender 38 A
Oppenheimer w/ knuckle bend 38 A
Oppenheimer w/ rev knuckle 2 38 A
Spreading hand 38 A
Add joint upper ext orthosis 38 A
Sewho airplan desig abdu pos 38 A
SEWHO cap design w/o jnts CF 38 A
Sewho erbs palsey design abd 38 A
Seo mobile arm sup att to wc 32 A
Arm supp att to wc rancho ty 32 A
Mobile arm supports reclinin 32 A
SEWHO airplane w/o jnts CF 38 A
Friction dampening arm supp 32 A
Monosuspension arm/hand supp 32 A
Elevat proximal arm support 32 A
SEWHO cap design w/jnt(s) CF 38 A
Page 480
PUF___2011_Web_File
Offset/lat rocker arm w/ ela 32 A
SEWHO airplane w/jnt(s) CF 38 A
Mobile arm support supinator 32 A
SEWHFO cap design w/o jnt CF 38 A
SEWHFO airplane w/o jnts CF 38 A
SEWHFO cap desgn w/jnt(s) CF 38 A
SEWHFO airplane w/jnt(s) CF 38 A
Upp ext fx orthosis humeral 38 A
Upper ext fx orthosis rad/ul 38 A
Upper ext fx orthosis wrist 38 A
Forearm hand fx orth w/ wr h 38 A
Humeral rad/ulna wrist fx or 38 A
Sock fracture or equal each 38 A
Upper limb orthosis NOS 46 A
Repl girdle milwaukee orth 38 A
Replace strap, any orthosis 38 A
Replace trilateral socket br 38 A
Replace quadlat socket brim 38 A
Replace socket brim cust fit 38 A
Replace molded thigh lacer 38 A
Replace non-molded thigh lac 38 A
Replace molded calf lacer 38 A
Replace non-molded calf lace 38 A
Replace high roll cuff 38 A
Replace prox & dist upright 38 A
Repl met band kafo-afo prox 38 A
Repl met band kafo-afo calf/ 38 A
Repl leath cuff kafo prox th 38 A
Repl leath cuff kafo-afo cal 38 A
Replace pretibial shell 38 A
Ortho dvc repair per 15 min 46 A
Orth dev repair/repl minor p 46 A
Page 481
PUF___2011_Web_File
Ankle control orthosi prefab 38 A
Pneumati walking boot prefab 38 A
Pneumatic full leg splint 38 A
Pneumatic knee splint 38 A
Non-pneum walk boot prefab 38 A
Replace AFO soft interface 38 A
Replace foot drop spint 38 A
Static AFO 38 A
Foot drop splint recumbent 38 A
Afo, walk boot type, cus fab 38 A
Sho insert w arch toe filler 38 A
Mold socket ank hgt w/ toe f 38 A
Tibial tubercle hgt w/ toe f 38 A
Ank symes mold sckt sach ft 38 A
Symes met fr leath socket ar 38 A
Molded socket shin sach foot 38 A
Plast socket jts/thgh lacer 38 A
Mold sckt ext knee shin sach 38 A
Mold socket bent knee shin s 38 A
Kne sing axis fric shin sach 38 A
No knee/ankle joints w/ ft b 38 A
No knee joint with artic ali 38 A
Fem focal defic constant fri 38 A
Hip canad sing axi cons fric 38 A
Tilt table locking hip sing 38 A
Hemipelvect canad sing axis 38 A
BK mold socket SACH ft endo 38 A
Knee disart, SACH ft, endo 38 A
AK open end SACH 38 A
Hip disart canadian SACH ft 38 A
Hemipelvectomy canadian SACH 38 A
Postop dress & 1 cast chg bk 38 A
Page 482
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Postop dsg bk ea add cast ch 38 A
Postop dsg & 1 cast chg ak/d 38 A
Postop dsg ak ea add cast ch 38 A
Postop app non-wgt bear dsg 38 A
Postop app non-wgt bear dsg 38 A
Init bk ptb plaster direct 38 A
Init ak ischal plstr direct 38 A
Prep BK ptb plaster molded 38 A
Perp BK ptb thermopls direct 38 A
Prep BK ptb thermopls molded 38 A
Prep BK ptb open end socket 38 A
Prep BK ptb laminated socket 38 A
Prep AK ischial plast molded 38 A
Prep AK ischial direct form 38 A
Prep AK ischial thermo mold 38 A
Prep AK ischial open end 38 A
Prep AK ischial laminated 38 A
Hip disartic sach thermopls 38 A
Hip disart sach laminat mold 38 A
Above knee hydracadence 38 A
Ak 4 bar link w/fric swing 38 A
Page 483
PUF___2011_Web_File
Ak 4 bar ling w/hydraul swig 38 A
4-bar link above knee w/swng 38 A
Ak univ multiplex sys frict 38 A
AK/BK self-aligning unit ea 38 A
Test socket symes 38 A
Test socket below knee 38 A
Test socket knee disarticula 38 A
Test socket above knee 38 A
Test socket hip disarticulat 38 A
Test socket hemipelvectomy 38 A
Below knee acrylic socket 38 A
Syme typ expandabl wall sckt 38 A
Ak/knee disartic acrylic soc 38 A
Symes type ptb brim design s 38 A
Symes type poster opening so 38 A
Symes type medial opening so 38 A
Below knee total contact 38 A
Below knee leather socket 38 A
Below knee wood socket 38 A
Knee disarticulat leather so 38 A
Above knee leather socket 38 A
Hip flex inner socket ext fr 38 A
Above knee wood socket 38 A
Bk flex inner socket ext fra 38 A
Below knee cushion socket 38 A
Below knee suction socket 38 A
Above knee cushion socket 38 A
Isch containmt/narrow m-l so 38 A
Tot contact ak/knee disart s 38 A
Ak flex inner socket ext fra 38 A
Suction susp ak/knee disart 38 A
Knee disart expand wall sock 38 A
Socket insert symes 38 A
Socket insert below knee 38 A
Socket insert knee articulat 38 A
Socket insert above knee 38 A
Multi-durometer symes 38 A
Multi-durometer below knee 38 A
Below knee cuff suspension 38 A
Page 484
PUF___2011_Web_File
Socket insert w/o lock lower 38 A
Bk molded supracondylar susp 38 A
BK/AK locking mechanism 38 A
Bk removable medial brim sus 38 A
Socket insert w lock mech 38 A
Bk knee joints single axis p 38 A
Bk knee joints polycentric p 38 A
Bk joint covers pair 38 A
Socket insert w/o lock mech 38 A
Bk thigh lacer non-molded 38 A
Intl custm cong/latyp insert 38 A
Bk thigh lacer glut/ischia m 38 A
Initial custom socket insert 38 A
Bk fork strap 38 A
Below knee sus/seal sleeve 38 A
Bk back check 38 A
Bk waist belt webbing 38 A
Bk waist belt padded and lin 38 A
Ak pelvic control belt light 38 A
Ak pelvic control belt pad/l 38 A
Ak sleeve susp neoprene/equa 38 A
Ak/knee disartic pelvic join 38 A
Ak/knee disartic pelvic band 38 A
Ak/knee disartic silesian ba 38 A
Shoulder harness 38 A
Replace socket below knee 38 A
Replace socket above knee 38 A
Replace socket hip 38 A
Symes ankle w/o (SACH) foot 38 A
Custom shape cover BK 38 A
Custom shape cover AK 38 A
Custom shape cvr knee disart 38 A
Custom shape cvr hip disart 38 A
Kne-shin exo sng axi mnl loc 38 A
Page 485
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Knee-shin exo mnl lock ultra 38 A
Knee-shin exo frict swg & st 38 A
Knee-shin exo variable frict 38 A
Knee-shin exo mech stance ph 38 A
Knee-shin exo frct swg & sta 38 A
Knee-shin pneum swg frct exo 38 A
Knee-shin exo fluid swing ph 38 A
Knee-shin ext jnts fld swg e 38 A
Knee-shin fluid swg & stance 38 A
Knee-shin pneum/hydra pneum 38 A
Lower limb pros vacuum pump 38 A
HD low limb pros vacuum pump 38 A
Exoskeletal bk ultralt mater 38 A
Exoskeletal ak ultra-light m 38 A
Exoskel hip ultra-light mate 38 A
Endoskel knee-shin mnl lock 38 A
Endo knee-shin mnl lck ultra 38 A
Endo knee-shin frct swg & st 38 A
Endo knee-shin hydral swg ph 38 A
Endo knee-shin polyc mch sta 38 A
Endo knee-shin frct swg & st 38 A
Endo knee-shin pneum swg frc 38 A
Endo knee-shin fluid swing p 38 A
Miniature knee joint 38 A
Endo knee-shin fluid swg/sta 38 A
Endo knee-shin pneum/swg pha 38 A
Multi-axial knee/shin system 38 A
Knee-shin sys stance flexion 38 A
Page 486
PUF___2011_Web_File
Knee-shin sys hydraul stance 38 A
Endo ak/hip knee extens assi 38 A
Mech hip extension assist 38 A
Elec knee-shin swing/stance 38 A
Elec knee-shin swing only 38 A
Stance phase only 38 A
Endo below knee alignable sy 38 A
Endo ak/hip alignable system 38 A
Above knee manual lock 38 A
High activity knee frame 38 A
Endo bk ultra-light material 38 A
Endo ak ultra-light material 38 A
Endo hip ultra-light materia 38 A
Endo poly hip, pneu/hyd/rot 38 A
Below knee flex cover system 38 A
Above knee flex cover system 38 A
Hip flexible cover system 38 A
Multiaxial ankle w dorsiflex 38 A
Foot external keel sach foot 38 A
SACH foot, replacement 38 A
Flexible keel foot 38 A
Ank-foot sys dors-plant flex 38 A
Foot single axis ankle/foot 38 A
Combo ankle/foot prosthesis 38 A
Energy storing foot 38 A
Ft prosth multiaxial ankl/ft 38 A
Multi-axial ankle/ft prosth 38 A
Page 487
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Flex foot system 38 A
Flex-walk sys low ext prosth 38 A
Exoskeletal axial rotation u 38 A
Endoskeletal axial rotation 38 A
Lwr ext dynamic prosth pylon 38 A
Multi-axial rotation unit 38 A
Shank ft w vert load pylon 38 A
Vertical shock reducing pylo 38 A
User adjustable heel height 38 A
Heavy duty feature, foot 38 A
Heavy duty feature, knee 38 A
Lower ext pros heavyduty fea 38 A
Lowr extremity prosthes NOS 46 A
Par hand robin-aids thum rem 38 A
Hand robin-aids little/ring 38 A
Part hand robin-aids no fing 38 A
Part hand disart myoelectric 38 A
Wrst MLd sck flx hng tri pad 38 A
Wrst mold sock w/exp interfa 38 A
Elb mold sock flex hinge pad 38 A
Elbow mold sock suspension t 38 A
Elbow mold doub splt soc ste 38 A
Elbow stump activated lock h 38 A
Elbow mold outsid lock hinge 38 A
Elbow molded w/ expand inter 38 A
Elbow inter loc elbow forarm 38 A
Shlder disart int lock elbow 38 A
Shoulder passive restor comp 38 A
Shoulder passive restor cap 38 A
Thoracic intern lock elbow 38 A
Thoracic passive restor comp 38 A
Thoracic passive restor cap 38 A
Postop dsg cast chg wrst/elb 38 A
Postop dsg cast chg elb dis/ 38 A
Postop dsg cast chg shlder/t 38 A
Page 488
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Postop ea cast chg & realign 38 A
Postop applicat rigid dsg on 38 A
Below elbow prosth tiss shap 38 A
Elb disart prosth tiss shap 38 A
Above elbow prosth tiss shap 38 A
Shldr disar prosth tiss shap 38 A
Scap thorac prosth tiss shap 38 A
Wrist/elbow bowden cable mol 38 A
Wrist/elbow bowden cbl dir f 38 A
Elbow fair lead cable molded 38 A
Elbow fair lead cable dir fo 38 A
Shdr fair lead cable molded 38 A
Shdr fair lead cable direct 38 A
Polycentric hinge pair 38 A
Single pivot hinge pair 38 A
Flexible metal hinge pair 38 A
Additional switch, ext power 38 A
Disconnect locking wrist uni 38 A
Disconnect insert locking wr 38 A
Flexion/extension wrist unit 38 A
Flex/ext wrist w/wo friction 38 A
Spring-ass rot wrst w/ latch 38 A
Flex/ext/rotation wrist unit 38 A
Rotation wrst w/ cable lock 38 A
Quick disconn hook adapter o 38 A
Lamination collar w/ couplin 38 A
Stainless steel any wrist 38 A
Latex suspension sleeve each 38 A
Page 489
PUF___2011_Web_File
Lift assist for elbow 38 A
Nudge control elbow lock 38 A
Elec lock on manual pw elbow 38 A
Heavy duty elbow feature 38 A
Shoulder abduction joint pai 38 A
Excursion amplifier pulley t 38 A
Excursion amplifier lever ty 38 A
Shoulder flexion-abduction j 38 A
Multipo locking shoulder jnt 38 A
Shoulder lock actuator 38 A
Ext pwrd shlder lock/unlock 38 A
Shoulder universal joint 38 A
Standard control cable extra 38 A
Heavy duty control cable 38 A
Teflon or equal cable lining 38 A
Hook to hand cable adapter 38 A
Harness chest/shlder saddle 38 A
Harness figure of 8 sing con 38 A
Harness figure of 8 dual con 38 A
UE triple control harness 38 A
Test sock wrist disart/bel e 38 A
Test sock elbw disart/above 38 A
Test socket shldr disart/tho 38 A
Suction socket 38 A
Frame typ socket bel elbow/w 38 A
Frame typ sock above elb/dis 38 A
Frame typ socket shoulder di 38 A
Frame typ sock interscap-tho 38 A
Removable insert each 38 A
Silicone gel insert or equal 38 A
Lockingelbow forearm cntrbal 38 A
Elbow socket ins use w/lock 38 A
Elbow socket ins use w/o lck 38 A
Cus elbo skt in for con/atyp 38 A
Cus elbo skt in not con/atyp 38 A