Allwin Medicare Manual

Updated Winter 2004 Table Of Contents I - IMPORTANT PHONE NUMBERS, ADDRESSES AND WEBSITES .........................................................................5 GLOSSARY OF TERMS/DEFINITIONS........................................................................................................................................5 II - MEDICARE DOCUMENTATION REQUIREMENTS ...............................................................................................8 III - MEDICARE ELIGIBILITY AND THE ID CARD......................................................................................................9 ELIGIBILITY ............................................................................................................................................................................9 MEDICARE HEALTH INSURANCE CLAIM (HIC) NUMBER .......................................................................................................9 IV - CLAIMS FILING ..........................................................................................................................................................10 FIELD DEFINITIONS ..............................................................................................................................................................10 ALLWIN TRANSMITS .............................................................................................................................................................11 UNDERSTANDING ALLWIN DATA ON-LINE REJECTIONS .......................................................................................................14 VERSION 5.1 NCPDP FIELD LOCATIONS .............................................................................................................................15 V - NEBULIZERS & INHALATION SOLUTIONS..........................................................................................................16 COVERAGE AND PAYMENT RULES ........................................................................................................................................16 DOCUMENTATION REQUIREMENTS .......................................................................................................................................16 CLAIMS TRANSMISSION ........................................................................................................................................................17 HCPCS CODES.....................................................................................................................................................................18 VI - DIABETIC SUPPLIES..................................................................................................................................................21 COVERAGE AND PAYMENT RULES ........................................................................................................................................21 CODING GUIDELINES ............................................................................................................................................................22 DOCUMENTATION REQUIREMENTS .......................................................................................................................................22 CLAIMS TRANSMISSION ........................................................................................................................................................23 HCPCS CODES.....................................................................................................................................................................24 VII - OSTOMY SUPPLIES ..................................................................................................................................................25 COVERAGE AND PAYMENT RULES ........................................................................................................................................25 CODING GUIDELINES ............................................................................................................................................................25 DOCUMENTATION REQUIREMENTS .......................................................................................................................................25 CLAIMS TRANSMISSION ........................................................................................................................................................26 VIII - IMMUNOSUPPRESSIVE DRUGS...........................................................................................................................30 COVERAGE AND PAYMENT RULES ........................................................................................................................................30 CODING GUIDELINES ............................................................................................................................................................30 DOCUMENTATION REQUIREMENTS .......................................................................................................................................31 CLAIM TRANSMISSION..........................................................................................................................................................31 HCPCS CODES.....................................................................................................................................................................31 IX - ENTERAL NUTRITION ..............................................................................................................................................33 COVERAGE AND PAYMENT RULES ........................................................................................................................................33 CODING GUIDELINES ............................................................................................................................................................33 DOCUMENTATION REQUIREMENTS .......................................................................................................................................33 CLAIM TRANSMISSION..........................................................................................................................................................34 HCPCS CODES.....................................................................................................................................................................35 X - ORAL ANTI-CANCER DRUGS ...................................................................................................................................37 COVERAGE AND PAYMENT RULES ........................................................................................................................................37 CODING GUIDELINES ............................................................................................................................................................37 DOCUMENTATION REQUIREMENTS .......................................................................................................................................38 CLAIMS TRANSMISSION ........................................................................................................................................................38 Page 2 Updated Winter 2004 XI - ORAL ANTI-EMETIC DRUGS...................................................................................................................................39 COVERAGE AND PAYMENT RULES ........................................................................................................................................39 CODING GUIDELINES ............................................................................................................................................................39 DOCUMENTATION REQUIREMENTS .......................................................................................................................................40 CLAIM TRANSMISSION..........................................................................................................................................................40 HCPCS CODES.....................................................................................................................................................................40 XIII - UROLOGICAL SUPPLIES.......................................................................................................................................42 COVERAGE AND PAYMENT RULES ........................................................................................................................................42 CODING GUIDELINES ............................................................................................................................................................42 DOCUMENTATION REQUIREMENTS .......................................................................................................................................43 CLAIM TRANSMISSION..........................................................................................................................................................44 HCPCS CODES.....................................................................................................................................................................44 XIV - SURGICAL DRESSINGS ..........................................................................................................................................46 COVERAGE AND PAYMENT RULES ........................................................................................................................................46 CODING GUIDELINES ............................................................................................................................................................47 DOCUMENTATION REQUIREMENTS .......................................................................................................................................49 CLAIM TRANSMISSION..........................................................................................................................................................50 HCPCS CODES.....................................................................................................................................................................50 XV - WALKERS, CANES AND CRUTCHES....................................................................................................................56 COVERAGE AND PAYMENT RULES ........................................................................................................................................56 CODING GUIDELINES ............................................................................................................................................................56 HCPCS CODES.....................................................................................................................................................................58 XVI - SEAT LIFT MECHANISMS .....................................................................................................................................59 COVERAGE AND PAYMENT RULES ........................................................................................................................................59 CODING GUIDELINES ............................................................................................................................................................59 DOCUMENTATION REQUIREMENTS .......................................................................................................................................59 CLAIM TRANSMISSION..........................................................................................................................................................59 HCPCS CODES.....................................................................................................................................................................60 XVII - HOSPITAL BEDS .....................................................................................................................................................61 COVERAGE AND PAYMENT RULES ........................................................................................................................................61 ACCESSORIES .......................................................................................................................................................................61 CODING GUIDELINES ............................................................................................................................................................62 DOCUMENTATION REQUIREMENTS .......................................................................................................................................63 CLAIM TRANSMISSION..........................................................................................................................................................63 HCPCS CODES.....................................................................................................................................................................63 XVIII - MANUAL WHEELCHAIRS ..................................................................................................................................66 COVERAGE AND PAYMENT RULES ........................................................................................................................................66 CODING GUIDELINES ............................................................................................................................................................67 DOCUMENTATION REQUIREMENTS .......................................................................................................................................68 CLAIM TRANSMISSION..........................................................................................................................................................68 HCPCS CODES.....................................................................................................................................................................68 XIX - MOTORIZED WHEELCHAIRS..............................................................................................................................70 COVERAGE AND PAYMENT RULES ........................................................................................................................................70 CODING GUIDELINES ............................................................................................................................................................70 DOCUMENTATION REQUIREMENTS .......................................................................................................................................71 CLAIMS TRANSMISSION ........................................................................................................................................................71 HCPCS CODES.....................................................................................................................................................................71 XX - WHEELCHAIR ACCESSORIES...............................................................................................................................73 Page 3 ....................119 CERTIFICATES OF MEDICAL NECESSITY ..............................................................115 XXIV .....................................................................................................................................................................................................................................................................................124 Page 4 ....................................................................................................79 CLAIM TRANSMISSION....................................................................................................................APPENDIX I............................................................................................................................................................................................................Updated Winter 2004 COVERAGE AND PAYMENT RULES ................................................................APPENDIX III – CMN COMPLETION .....................................79 XXI ...........................................................................................................................74 DOCUMENTATION REQUIREMENTS ..........................................................................................................................................................................................................................................................79 HCPCS CODES......................93 COMPLEMENTARY CROSSOVER INSURANCE COMPANIES ..............................................................................................................................................................................................................................90 XXII ...............................................OXYGEN .....88 DOCUMENTATION REQUIREMENTS .........................93 SUPPLEMENTAL INSURANCE BILLING..........85 COVERAGE AND PAYMENT RULES ..................................................................................................................................85 CODING GUIDELINES ....................................................................................................................................................119 XXV ......................................................................................................................88 CLAIM TRANSMISSION................................................................................98 XXIII ............................95 OCNA NUMBER LIST .......................................73 CODING GUIDELINES ....................90 HCPCS CODES.......................................................................................................................................................................................................APPENDIX IV – MEDICARE AS SECONDARY PAYER QUESTIONNAIRE (SHORT FORM) .................................................................................................................................................................APPENDIX II – NON-COVERED HCPCS ......................................... Pennsylvania. REGION Region A Connecticut. Illinois. New Mexico. and Supplies Jurisdiction of DMEPOS Regional Carriers Claims jurisdiction is determined by the state in which the beneficiary permanently resides. Prosthetics. Medicare DMERC Operations Louisiana. SC 29202-3141 the Virgin Islands Region D Connecticut General Life Insurance Co.Updated Winter 2004 I . Massachusetts. the Marianna Islands. Maine. California. Montana. Florida.O. Rhode Island and Vermont Region B District of Columbia. Georgia. Missouri. Oregon. Maryland. North Carolina. Orthotics. Box 7078 Indianapolis. New Hampshire. Kentucky. New York. Arkansas. Ohio. Arizona. P. Guam/American Samoa. PA 18773-6800 AdminaStar Federal Inc. The following table is a listing of the four DMERC regions and their contact information. Michigan. Mississippi. South Dakota. Puerto Rico. (CIGNA Medicare) Alaska.O. Washington and Wyoming VRU: (877) 320-0390 Live Customer Service:(866) 243-7272 Beneficiary Line: (800)899-7095 Page 5 . Box 100141 Oklahoma. Indiana. IN 46207-7078 PHONE NUMBER (866) 419-9458 Beneficiary Line: (800)842-2052 (877) 299-7900 Beneficiary Line: (800)270-2313 VRU: (866) 238-9650 Live Customer Service:(866) 270-4909 Beneficiary Line: (800)583-2236 Region C Palmetto GBA Alabama. Nashville.Important Phone Numbers. The image below the table is a map representation of the four DMERC regions. Colorado. North Dakota. South Carolina. Addresses and Websites Glossary of Terms/Definitions DMEPOS Durable Medical Equipment.O. Utah . Kansas. Tennessee. New Jersey. TN 37202 Nebraska. Iowa. P. Box 690 Idaho. Virginia. Box 6800 Wilkes-Barre. Minnesota. Hawaii. Nevada. West Virginia and Wisconsin DMERC HealthNow NY P. P. Texas and Columbia.O. Delaware. com Region D – www.net UPIN Number Website upin.pgba. Ste.com Diagnosis Code Website www.allwin. call NSC at 866-238-9652 and ask for Provider Enrollment. orthotics. Prosthetics.com Medicare Initial Enrollment & Reenrollment To Enroll or Reenroll as a Medicare Provider / Supplier.com Region B – www.cignamedicare.com SADMERC The SADMERC HCPCS Unit offers guidance to manufacturers and suppliers on the proper use of the Healthcare Common Procedure Coding System (HCPCS). 1400 Asheville. verifies application information.upinregistry.allwin.com Region C – www.umd.com www. To request an extension or make inquiries. Phone – (866)238-9652 Website – www. NC 28801 Phone: 800-879-6153 Fax: 828-250-9553 www.net 31-1573823 Tax ID # Complete Section 8C by checking the Yes/No Boxes as it applies to you. and administers file activity. The NSC provides DMEPOS supplier applications. Check Section 9 as “Does Not Apply” and skip to section 10 You are allowed 30 days to reenroll or your Medicare provider number will be deactivated.nycpic. Phone – (877) 735-1326 Website – www. prosthetics. the means by which durable medical equipment.Updated Winter 2004 National Supplier Clearinghouse The National Supplier Clearinghouse (NSC) is the national entity contracted by the Centers for Medicare & Medicaid Services (CMS) that issues Medicare Durable Medical Equipment.pgba.com Medicare Websites Region A – www.pgba.ecare. and supplies (DMEPOS) services are identified for Medicare billing.. Page 6 .adminastar. Question 4 will always be answered “NO”. you must complete the Federal Health Care Provider/Supplier Enrollment Application--CMS 855B. See below for information on Medicare Enrollment & Reenrollment Guidelines. Complete Section 8-Billing Agency with the following information: Legal Business Name Doing Business Name NOW Technology Allwin Data One West Pack Sq. Orthotics and Supplies (DMEPOS) supplier authorization numbers. 13. 54. 12. 12. 55. 55. P & O supplies. 56 04.12. 13. 33. 14. 56 04. 13. 14. 33. 31. 55. 33. 56 04. 13. urinary incontinence and ostomy supplies Surgical dressings Drugs (oral anticancer. 33. POS Code 04. 54. 13. 56 04.Updated Winter 2004 DMERC Place of Service (POS) Definition All claims filed through Allwin Data to the DMERC must include a two digit place of service code in the Patient Location/Place of Service field in your pharmacy software system. 32. Claims filed without POS information (or with an invalid POS code) will default to POS code of 12 (Home). parenteral and enteral nutrition-related items and supplies (these include IV poles used to administer PEN (E0776XA). 13. 14. 14. 13. 33. 55. 33. 32. 54 04. 54. 32. 32. 33. 55. 14. 14. 54. 54. 54. 13. 55. 12. 55. 31. 31. 55. 56 Page 7 . 12. 31. 14. 14. 55. 12. 56 04. 12. 56 04. 33. 33. 13. 13. POS Code 04 12 13 14 31 32 33 54 55 56 65 Definition Homeless Shelter Home Assisted Living Facility Group Home Skilled Nursing Facility Nursing Facility Custodial Care Facility Intermediate Care Facility/Mentally Retarded Residential Substance Abuse Treatment Facility Psychiatric Residential Treatment Center End Stage Renal Disease Treatment Facility The following POS codes are valid for the following categories of durable medical equipment. 54. Only the following POS codes should be submitted to the DMERCs. 12. 54. immunosuppressive) Drugs administered through DME such as nebulizers and external infusion pump 04. 12. 56 Category Inexpensive or other routinely purchased DME Items requiring frequent and substantial servicing Customized items • Prosthetic and orthotics • DME Capped Rental Items Oxygen and oxygen equipment General prosthetic and orthotic devices. 56 04. 54. 33. 12. 14. Medicare Documentation Requirements First The pharmacy must have a dispensing order from the treating physician. concentration (if applicable). it must include appropriate information on the quantity used. and duration of infusion (if applicable). dosage. This order may be faxed. brand name and serial number. • The physician's signature and date. frequency of change or use. • The expected start date of the order. Note: The date of service on the claim must be the date of delivery. and must contain the following: • A description of the item • The beneficiary's name • The name of the physician • The date of the order Second The pharmacy must have a detailed written order that should be retained in the patient's file. • If the order is a drug. or authorized representative. A new Assignment of Benefits agreement is required with each new written order. ***All three of these items previously listed should be on file before the pharmacy bills the claim to Allwin Data*** Fourth A delivery slip which has been signed and dated by the beneficiary. Page 8 . Third The pharmacy must have the beneficiary sign an Assignment of Benefits for each Detailed Written Order that the pharmacy is going to accept assignment for. An acceptable delivery slip must include the patient's name.Updated Winter 2004 II . however. This Assignment of Benefits agreement must be kept in the patient's file. • Patient's diagnosis (policy applicable). frequency of administration. is required in order to verify the DMEPOS item(s) received. the quantity and detailed description of the item(s) being delivered. and length of need. • A description of the item (the description can be either a narrative or a brand name/model number) and the length of need. not with refills of an existing Detailed Written Order. written or verbal. • If the order is for accessories or supplies that will be provided on a periodic basis. and it is a good idea to attach the dispensing order to the detailed written order. The detailed written order must include the following: • Patient's name. it must specify the name of the drug. The Medicare number is probably the most important piece of information you can have about your Medicare patient. nor does the number always end with the letter A or B. Orthotics. NOTE: The Medicare identification number may be different than the beneficiary’s social security number. We recommend a copy of the Medicare card be obtained and incorporated in the patient’s file for accuracy of claim submissions. 65 years of age. In order for an individual to be eligible for medical insurance (Medicare Part B). therefore. and Supplies) filled at the pharmacy level.Updated Winter 2004 III . The Medicare beneficiary’s name and number should be entered on the claim exactly as it appears on the Medicare card to prevent unnecessary rejections from Medicare. Page 9 . The format of the Social Security Administration (SSA) issued Medicare number is 000-00-0000 followed by a letter. dies. Medicare Part A basically covers hospitalization expenses.S. Under age 65 and permanently disabled and entitled to SSA benefits. or 3. citizen and/or: 1. The effective date of Medicare Part B coverage depends on the month in which enrollment takes place. Medicare Part B is a voluntary program for which the insured must pay a monthly premium. Under age 65 with permanent kidney failure. Medicare Health Insurance Claim (HIC) Number The HIC number is the Social Security number that indicates that the beneficiary is eligible for Medicare benefits. This HIC number is shown on his or her Medicare card. An individual’s Medicare Part B coverage ends when the individual requests disenrollment. or when hospital insurance entitlement ends for those less than 65 years of age. he or she must be a U. and Part B covers treatment at a doctor’s office and any DMEPOS (Durable Medical Equipment Prosthetics. two letters.Medicare Eligibility and the ID Card Eligibility The Social Security Administration (SSA) determines Medicare eligibility. 2. or a letter-number combination. A Railroad Retiree Benefit issued number may be a nine digit or six digit number with one or more alphas in front. individuals who do not want coverage may refuse Medicare Part B enrollment. does not pay premiums. Your claims cannot be paid if the Medicare number is missing or incorrect. The NCPDP location of this field and many others can be found in the chart at the end of this section. and Anti-Emetic Drugs) USMCA Pharmacy ID Number When transmitting claims to Allwin Data use your NABP Number. Claims will process according to how your pharmacy was set up upon initially enrolling with Allwin Data USMCAASG Claims will process as assigned regardless of how your pharmacy is set up in the Allwin system. Allwin Data will always accept an NDC# in the following format: Using HCPCS A5061. USMCANON Claims will process as unassigned regardless of how your pharmacy is set up in the Allwin system. 3). Note: Pharmacies must always accept assignment on any claim for a drug or biological billed to Medicare. there will be occasions when it is necessary for the pharmacy to transmit a HCPCS code to Allwin Data. therefore. Allwin Data will convert your NABP# based on the particular plan being billed. and 2 “0”s behind 5061.Claims Filing Field Definitions BIN Numbers The standard BIN Number for Medicare transactions to Allwin Data is 004766. However. and will be useful when talking to your software vendor. Immunosuppressive Drugs. add 5 “0”s in front of 5061. Allwin will accept this format as a valid NDC#. Page 10 . NDC Numbers and Procedure/HCPCS Codes For most products Medicare does not accept NDC #’s to identify an item on a claim. Establishing this link may sometimes require a call to Allwin Data. Note: If you have the HCPCS code. provided there is a link established in our system between the NDC# and HCPCS code. the pharmacy should be familiar with the location and use of their HCPCS code field. 20% or “ 0” coinsurance depending upon the existence of supplemental insurance. Medicare will reimburse the beneficiary. The pharmacy’s software vendor should be helpful in locating and using this field. leaving an NDC# of 00000506100. Allwin Data will accept your NDC# on a claim transaction and convert it to a payable HCPCS code before transmitting the claim to Medicare.Updated Winter 2004 IV . you can call the National Supplier Clearinghouse (see pg. but no NDC#. Note: Pharmacies registered with Medicare as a Participating Provider must always accept assignment (USMCAASG or USMCA). Medicare only recognizes HCPCS (Procedure) codes as a valid product identifier. USNONCOVER Used when billing non-covered Medicare item that Medicaid or another insurance requires a Medicare rejection before assuming coverage. Those pharmacies using Envoy as a switch should use the BIN Number indicated in the chart below: Processor Control # USMCA USMCAASG USMCANON USNONCOVER Envoy BIN # 005200 005730 005917 002522 Processor Control Number Allwin Data offers 4 unique Processor Control Numbers to insure each claim processes as the pharmacy intended. drop the A. If you are unsure of how your pharmacy is set up with Medicare. 100% patient pay amount to the beneficiary. Anti-Cancer Drugs. Below the 4 Processor Control Numbers are listed along with the way each processes a claim. (Inhalation Solutions. the actual code may be found by using the diagnosis code search on www. Billing for surgical dressings being used on more than one wound Medicare’s monthly limits on surgical dressings are based per wound. The example used is a Nebulizer. Allwin Data automatically attaches the proper modifiers to most all HCPCS codes. These modifiers generally represent additional information without having to actually include all the documentation necessary for claim payment. A6402A2. Renting an item that is available for purchase. to indicate the intention to rent. If billing for both the left and right. Compounding inhalation solutions It is necessary to use the KP and KQ modifiers to indicate that the drug being billed is part of a compound. For example. indicating 1 wound.allwin. This number is one alpha character followed by 5 numeric characters. a pharmacy will have to call an Allwin Data Page 11 . A2 – A9. These modifiers dictate the amount at which Medicare will reimburse for each drug and must be used in such a way that the lowest price is returned to the beneficiary. Month Months 2&3 Months 4-10 Months 11-13 Months 11-15 Months 11-15 You Transmit E0570KI E0570KJ E0570BP E0570BR E0570BU Allwin Transmits E0570RRKI E0570RRKJ E0570RRKJBP E0570RRKJBR E0570RRKJBU Meaning Patient Purchase Patient Rent Patient Undecided • • • • Diagnosis Codes All Medicare claims transmitted to Allwin Data require a diagnosis code. there are a few instances when it will be necessary for the pharmacy to include the modifier and HCPCS code with the claim.Updated Winter 2004 Modifiers Medicare requires modifiers on most HCPCS codes. Because most Pharmacy Billing Systems are set up to transmit only the DEA #. Therefore the Allwin system defaults to modifier A1. the pharmacy should use the chart below to determine what HCPCS/modifier combination to use. However. Allwin currently has the majority of these DEA #s and UPINs linked in our system. and the claim is for any other month in the rental period other than the first. However. This code should be indicated on the order from the doctor. Allwin Data has developed a conversion file in which we will accept the DEA# and convert it to the correct UPIN before transmitting the claim to Medicare. the pharmacy would then transmit the HCPCS code with an XT modifier and a quantity of two. hospital beds. it will be necessary for the pharmacy to transmit the HCPCS code and the RR modifier. Should the pharmacy be billing for surgical dressings being used on more than one wound. The primary examples are listed below and covered in greater detail in the Medical Policies Section where necessary. and can be obtained from the website listed in Section I or by calling the doctor’s office. the pharmacy would transmit the HCPCS code for a Breast Prostheses and the LT modifier to indicate the left breast. Billing a capped rental item through Allwin Data that is not the first month of the rental period When a pharmacy is transmitting a claim for a capped rental item to Allwin Data for the first time. to indicate a standard cane rental you would transmit E0100RR. For example. or at the very least a narrative description of the diagnosis should be written on the order. the pharmacy will need to transmit the HCPCS code plus the proper modifier. as shown here – L8020LT.net. In the instance a pharmacy wishes to transmit a claim for a rental. occasionally. If all the pharmacy has is a narrative diagnosis. This policy does not apply to Capped Rental Items such as wheelchairs. when billing for a Left Breast Prostheses. such as a walker or cane Allwin will automatically attach modifiers to DME indicating purchase. • Billing for any item that can be used for a left or right body member For example. These will have to be repeated each month during the rental period. or by calling the prescribing physician. and nebulizers. Doctor ID Numbers The doctor identification number required on a claim by Medicare is the UPIN (Unique Physician Identifier Number). An LGHP is a health insurance or benefit plan that is offered through an employer who has 100 or more employees or is part of a multi-employer trust or association. where you will also find all of the OCNA codes listed. Medicare is the secondary payer for ESRD beneficiaries for the first 30 months of their Medicare eligibility. It is the pharmacy’s responsibility to determine the existence of supplemental coverage. An EGHP is a health insurance or benefit plan that is offered through an employer of 20 or more employees. The amount the other insurance paid should automatically appear in the Other Insurance Amount Field. the following steps need to be taken in order for the claim to transmit: 1. 2. the EGHP may be offered by an employer of any size. if you feel that the price being returned does not adequately reflect the quantities Page 12 . Medicare as Secondary Billing Procedure Should a situation arise in which a pharmacy needs to bill Medicare as secondary. Type the word “SECONDARY” in the Group Field of your Medicare claim. enter the number “3” in the Other Coverage Code Field. Enteral Nutrition. Once Allwin Data has loaded the beneficiary’s primary insurance info into the system. it will be necessary for the pharmacy to call an Allwin Data Representative and provide them with some information concerning the beneficiary’s primary insurance before the claim will process. This difference is explained in greater detail at the beginning of Appendix I. which has at least one employer of 100 or more employees. 116 to help in determining primary insurance) Working Aged Patients 65 years or older who have Employer Group Health Plan coverage through their own employment or employment of a spouse. If the primary insurance paid $0. the pharmacy would indicate this coverage by entering the OCNA # of that particular insurance company in the Group Field of the Medicare claim (see Supplemental Insurance Billing list on pg. Enter the number “2” in the Other Coverage Code Field. and Inhalation Solutions. This is especially the case with a newly enrolled pharmacy in an area not previously served by Allwin Data. Billing Medicare as Secondary There are generally only three instances in which a pharmacy would bill Medicare as secondary:(use form on pg. Medicare Supplemental Insurance Many Medicare beneficiaries have supplemental insurance that will cover the Medicare co-pays and deductible. There are two distinct types of supplemental coverage that are important to differentiate between.Updated Winter 2004 representative and have a DEA# linked to a UPIN in order for a claim to process. Medicare is always primary. 3. In the instance where there is no supplemental coverage the Group Field would simply be left blank. 93 of this manual). Disabled Patients under age 65 entitled to Medicare on the basis of permanent disability that have health insurance coverage under a Large Group Health Plan (LGHP) either through a family member or from their own current employment. End Stage Renal Disease (ESRD) For patients under age 65 (including dependent children) who are entitled to Medicare solely on the basis of ESRD and who have health insurance coverage under the Employer Group Health Plan (EGHP) as a result of the patient or any family member's current or former employment. This is especially true in the cases of Diabetic Supplies. Once the beneficiary’s supplemental coverage has been established. Allwin Data has in place quantity conversions for Medicare claims so the pharmacy can continue billing quantities as they always have. In most cases. upon application. Once these fields are populated Allwin Data will be able to correctly transmit the claim.00. Eligibility is determined by the first month that Medicare could have. made payments on behalf of the beneficiary. NOTE: These instances basically state that unless a beneficiary is still working or their spouse is still working. Quantities Dispensed and Medicare Billing Units The quantities a pharmacy bills and the billing units Medicare requires to pay a claim are sometimes very different. However. 100% coinsurance 20% coinsurance $0. and hospital beds. To find out if a supplemental plan covers the $110 deductible you may call that insurance company for confirmation of your patient’s benefits. the pharmacy can call the DMERC and use the automated response system. but are not limited to. Most often if a quantity is misrepresented the allowable price Allwin Data returns will be too low. The safest way to avoid a claim being filed with an erroneous quantity is to always pay close attention to allowable price Allwin Data returns for the claim. Pharmacy will receive 80% from Medicare and the other 20% from the patient’s supplemental insurance indicated in the Group Field. In 2005. Medicare will pay for a Capped Rental Item for up to 15 months. after which it becomes the property of the beneficiary. There are only 3 different coinsurance percentages Allwin Data will reply with on a transmitted claim and is important to understand what they mean. in the 10th month of the rental period the pharmacy should have the beneficiary sign a Rental/Purchase Option Form. To check on the status of a particular claim. Should the beneficiary chose to continue renting Medicare will make payments through the 15th month. Medicare will make payments through the 13th month. The quantity conversions Allwin Data currently use for different items are discussed in greater detail in the Medical Policies Section. Calling Medicare is the only option if a change needs to be made to a claim after it has been batched. Receiving Medicare Payment Upon enrolling with Allwin Data for Medicare billing. These items include. Many supplemental insurance companies pick up the 20% Medicare coinsurance and the $110 Medicare deductible.Updated Winter 2004 dispensed a custom conversion may be required for the product being billed. Allwin Data does offer a deductible tracking service in which we will return a full patient pay amount on each claim until $110 is spent through the Allwin Data system. and reimburse a servicing fee every 6 months after the 15th month. all subsequent checks should arrive on more routine (7-10 days) basis. In this instance (purchase option) it will be necessary for the pharmacy to transmit the HCPCS code along with a BP modifier in the 11th month’s billing. Medicare Deductible and Coinsurance Medicare pays only 80% of their allowable cost on everything they cover. The phone number for your region can be found on page 3. Should the beneficiary choose the purchase option. Billing Capped Rental Items Many popular items covered by Medicare are available as rental items only. as these coinsurance amounts dictate who will receive reimbursement and from where the reimbursement is coming. Pharmacy collects the 20% amount returned by Allwin Data from the patient. Patient pays nothing. the pharmacy’s first check from Medicare should arrive within 6 weeks. For more information on this option please contact an Allwin Data Representative. Reversing Claims Allwin Data batches all claims every Friday at midnight for transmission to Medicare. wheelchairs. Page 13 . however. nebulizers. Reimbursement will be sent directly to the beneficiary’s residence. Medicare has a $110 deductible each beneficiary must meet at the beginning of each calendar year before any coverage will take effect. Medicare will reimburse the pharmacy the other 80%. after that initial check. When the pharmacy is billing for these items it will be necessary to submit a claim to Allwin Data each month during the rental period. All State Medicaid plans pick up the entire 20% co-pay and the $110 deductible. Due to privacy issues Allwin Data can never know for sure if a beneficiary has meet their $110 deductible. Once Friday midnight has passed there is no way to reverse a claim filed during the previous week until remittance advice on the claim has been received.00 coinsurance Pharmacy collects full amount from the patient. Invalid NDC Number There are a couple different reasons you may be receiving this rejection. If you have validated the ICD-9 code and you are still receiving a rejection it may be that the product you are billing is not covered for that particular diagnosis. An excellent resource for the UPIN is the website upin. etc.01. Make sure not to include any leading or following zeros unless indicated in the ICD-9 coding. should be included on the order and the physician should approve any changes. Invalid Metric Quantity This rejection is encountered when billing for quantities in excess of the Medicare guidelines.e. For all other products a “02” may be used to override our frequency edits if there is a prescription on file supporting the medical necessity of the frequency/quantity. The UPIN format is one letter and five digits. Refilled Too Soon This rejection is commonly encountered when billing more frequently than the Medicare utilization guidelines. Invalid Diagnosis Code Medicare requires that each diagnosis code be brought out to its greatest specificity. Refer to the section of this manual on Medicare as a Secondary Payer.02. However. To increase the likelihood of payment from Medicare you may call Allwin Data to request that a narrative be attached to the claim describing the medical necessity. To increase the likelihood of payment from Medicare you may call Allwin Data to request that a narrative be attached to the claim describing the medical necessity. 493. For instance. 9 of this manual. or at least a diagnosis description. To expedite this call have the DEA# and UPIN handy. Invalid Group Number This is another rejection you may encounter when billing Medicare as a secondary payer. You can check the validity of the diagnosis code you are submitting using the Allwin Data website. A prescription stating the frequency of testing is sufficient. please have the NDC# and HCPCS code handy. For all other products a “02” may be used to override our quantity edits if there is a prescription on file supporting the medical necessity of the frequency/quantity. This code would need to be brought out to its greatest specificity to reflect the type of asthma the patient has (i. to determine if Medicare is in fact secondary. To remedy this rejection you may either transmit the UPIN or call Allwin Data to link the DEA# to the UPIN. When billing for glucose test strips or lancets you may use a “07” in your Rx Denial Override field if you have documentation to support the medical necessity for testing in excess of these guidelines.ecare.00. For example. A prescription stating the frequency of testing is sufficient. This section will also instruct you to call Allwin Data with the beneficiary’s primary payer information. this does not mean that all codes must have five digits. An excellent resource for the HCPCS codes is SADMERC at 877-735-1326. the general diagnosis code for asthma is 493. 9. Any rejected portion should be sent to the DMERC review department for payment. If it is a covered item then the NDC# will most likely need to be cross referenced with the HCPCS code by calling Allwin Data. When billing for glucose test strips or lancets you may use a “07” in your Rx Denial Override field if you have documentation to support the medical necessity for testing in excess of these guidelines. Page 14 . 496 is a valid code reflecting COPD. Keep in mind that the ICD-9 code. Patient First Name Invalid You will encounter this rejection when billing Medicare as a secondary payer. First of all verify that the product being billed is a Medicare covered item by referring to the non-covered items list beginning on page 115. To expedite this process. 493. Any rejected portion should be sent to the DMERC review department for payment. pg.Updated Winter 2004 Understanding Allwin Data On-line Rejections Invalid Prescriber ID Allwin Data offers the service of cross-referencing a physician’s DEA# with the Medicare required UPIN.).com or a call to the physician’s office. 493. First refer to the section on Medicare as a Secondary Payer on pg. Invalid Cardholder ID Number The format of the Social Security Administration (SSA) issued Medicare number is 000-00-0000 followed by a letter. If you are still receiving this rejection after waiting 24 hours there may have been missing or invalid information. or a letter-number combination.Updated Winter 2004 Supporting Documentation Required Some products require a Certificate of Medical Necessity (CMN) to be reimbursed by Medicare. use the following chart to locate important fields used in Medicare claims transmission: Field Product/Service ID Prescriber ID Group ID Eligibility Clarification Other Coverage Code Usual & Customary Gross Amount Due Submission Clarification Code (Rx Denial Override) Quantity Dispensed Processor Control # Diagnosis Code Field Number 407 411 301 309 308 426 430 420 442 104 424 Field Identifier D7 DB C1 C9 C8 DQ DU DK E7 A4 DO Page 15 . Please allow 24 hours if the CMN is faxed. This ID# must be submitted exactly as it reads on the beneficiary’s card. If Medicare already has the CMN on file due to a prior billing using billing methods other than Allwin Data you may override our reject message with a “03” in the Rx Denial Override field. Version 5. Only use this override if you have received remittance reflecting payment of this item for this patient. A Railroad Retiree Benefit issued number may be a nine digit or six digit number with one or more alphas in front.1 NCPDP Field Locations When talking with your software vendor. two letters. Call Allwin Data to have the CMN updated. A completed CMN may be entered on our website or faxed into us. These codes are only medically necessary when used in a large volume nebulizer (A7017 or E0585).25 mg. A4217) will be denied as not medically necessary. in 3 ml. A4217) used to dilute it will be separately reimbursed.80-996. A7004. pneumocystosis (ICD-9 diagnosis code 136. Examples of (a) would be: albuterol 0. the nebulizer and its accessories/supplies will be denied as not medically necessary. If the unit dose form of the drug is dispensed.Updated Winter 2004 V .5 mg. or one ampule q 4 hr prn.Nebulizers & Inhalation Solutions Coverage and Payment Rules A small volume nebulizer (A7003. Water or saline in 1000 ml quantities (A7018) are not appropriate for use by patients to dilute inhalation drugs and will therefore be denied as not medically necessary if used for this purpose. separate saline solution (J7051 or A4216. only one dispensing fee will be paid per drug combination per month.00) or c) It is medically necessary to administer pentamidine to patients with HIV (ICD-9 diagnosis code 042). A7005) and related compressor (E0570.. The dispensing fee(s) must be billed on the same day as the dispensed inhalation drug(s). diluted with saline to 3. and complications of organ transplants (ICD-9 diagnosis codes 996. or 0. or cromolyn 20 mg/2 ml. The type of solution is described by a combination of (a) the name of the drug and the concentration of the drug in the dispensed solution and the volume of solution in each container.89). Documentation Requirements An order for all equipment. tid and prn. other than those listed above. or b) It is medically necessary to administer gentamicin. or (b) the name of the drug and the number of milligrams/grams of drug in the dispensed solution and the volume of solution in that container. or albuterol 2. This dispensing fee will be based on the drug dispensed. drugs. and refilled every 30 days as such. anticholinergics. and not on the number of unit dose vials dispensed. or albuterol 0. Saline dispensed for the dilution of concentrated nebulizer drugs must be billed on the same day as the drug(s) being diluted. If none of the drugs used with a nebulizer are covered.0 ml. qid and prn . in 3 ml. whether used as a dilutant or for humidification therapy.0 . if two or more drugs are combined in single unit dose vials. amikacin. Nebulizers are billable to Medicare as rental items only. Inhalation Solutions should be billed as 30-day supplies. and cromolyn for the management of obstructive pulmonary disease (ICD-9 diagnosis codes 491.4). separate saline solution (J7051 or A4216. accessories.505).083% 3 ml. and other supplies related to nebulizer therapy must be signed and dated by the ordering physician and kept on file by the supplier.0-505. When a concentrated form of an inhalation drug is dispensed.max 6 doses/24 hr. Also.5% 20 ml. saline. E0571) are covered when: a) It is medically necessary to administer beta-adrenergics. A dispensing fee is not separately billable or payable for saline. Examples of (b) would be: albuterol 1. tobramycin.5 ml. or d) It is medically necessary to administer mucolytics (other than dornase alpha) for persistent thick or tenacious pulmonary secretions (ICD-9 diagnosis codes 480. Examples would be: 3 ml. corticosteroids. will be denied as not medically necessary. saline. The order for any drug must clearly specify the type of solution to be dispensed to the patient and the administration instructions for that solution. and cromolyn 20 mg. Use of inhalation drugs. A monthly dispensing fee (E0590) for each covered drug or combination of drugs used in a nebulizer will be paid in addition to payment for the drug or drugs. or dornase alfa to a patient with cystic fibrosis (ICD-9 diagnosis code 277. Administration instructions must specify the amount of solution and frequency of use.3). A new order is required if there is a change in the Page 16 . and 786. the reimbursement is $0. One prescription will be for Albuterol (J7619KQ) in mg units and the other for Ipratropium (J7644KP) in mg units. Allwin also suggests you notify the physician of the low reimbursement and request that the prescription be changed to Albuterol. Should a pharmacy wish to send a quantity other than milliliters. Allwin Data can set your store up for any particular drug to be transmitted in the quantity you wish. If more than one beta-adrenergic or more than one anticholinergic inhalation drug is billed during the same month. If the patient wishes to pay cash for the product. J7621. If the date of service is prior to 01/01/04 the claim will need to be billed under two separate prescriptions. A narrative diagnosis and/or an ICD-9 diagnosis code describing the condition must be present on each order. The reason reimbursement is so low is because Medicare does not recognize the medical benefits of Xopenex over Albuterol. You do have the right to refuse to dispense the product as long as you do not bill Medicare for Xopenex on any future claims. Allwin Data currently defaults to reading most inhalation solution quantities as milliliters and will convert them to the proper Medicare billing units. each claim must be accompanied by a copy of the prescription(s) and physician narrative documentation supporting the medical necessity of concurrent use. Xopenex must be billed using the NDC# in mL units. Page 17 . For nebulizers Allwin Data will automatically attach all required capped rental modifiers.Updated Winter 2004 type of solution dispensed or the administration instructions. Should you begin processing through Allwin Data halfway through a capped rental period. Since the addition of procedure code J7621 was effective as of 01/01/2004 the billing procedure is different if you wish to bill for a date of service prior to this. For all inhalation drugs. Duoneb may be billed through Allwin using the drug’s NDC or the procedure code. Unfortunately. please contact Allwin Data about setting up a conversion specific to your store and drug. a new order is required at least every 12 months even if the prescription has not changed. Claims Transmission Allwin Data can accept Inhalation Solution quantities in all units a pharmacy may wish to transmit in a claim. Any quantity of compounded Albuterol [J7619KQ] will be read as mgs. Allwin will convert the billed units to the appropriate Medicare units. for the proper way to transmit your claim. accessories. Allwin suggests having the patient sign a waiver showing their agreement of these terms. refer to the section regarding modifiers beginning on page 8. An ICD-9 code describing the condition that necessitates nebulizer therapy must be included on each claim for equipment. These examples are simply the quantities our system defaults to for our conversions. Medicare does not reimburse appropriately for this product (currently. The exceptions to the milliliter default are as follows: • • • Any quantity of Ipratropium [J7644] less than 74 mgs will be read as mgs. each claim must be accompanied by a physician’s narrative documentation supporting the medical necessity for the higher utilization. Any quantity of compounded Ipratropium [J7644KP] will be read as mgs. and/or drugs. even the three listed above. Remember. The claim cannot be billed as unassigned and the patient cannot be charged the difference. The billed quantity should reflect the total number of milliliters dispensed. Contact Allwin Data to have this narrative documentation electronically attached to the claim. When billing for quantities of nebulized inhalation drugs or nebulizer accessories and supplies greater than those described in the policy as the usual maximum amounts.88 per mg). INHALATION SOLUTION ADMINISTERED THROUGH DME. UP TO 5 CC 186units/mo ACETYLCYSTEINE. ALL FORMULATIONS INCLUDING SEPARATED ISOMERS. PER 300 MG. COMPOUNDED IC INHALATION SOLUTION.5 MG (LEVOALBUTEROL).5 MG (LEVALBUTEROL) 465mg/mo ALBUTEROL.5 MG 465mg/mo (LEVALBUTEROL) ALBUTEROL. 0. ALL FORMULATIONS INCLUDING SEPARATED ISOMERS. ALL FORMULATIONS. 1000 ML. PER 10 MILLIGRAMS 248units/mo BUDESONIDE. PER MILLIGRAM 186mg/mo DEXAMETHASONE. CONCENTRATED FORM. ADMINISTERED THROUGH A DME 300 mg/mo STERILE SALINE OR WATER. PER 1 MG (ALBUTEROL) OR PER 0. PER MILLIGRAM 186mg/mo ATROPINE. INHALATION SOLUTION ADMINISTERED THROUGH DME. PER GRAM 74grams/mo ALBUTEROL.25 MILLIGRAM IC ATROPINE. UP TO 1 MG. CONCENTRATED FORM. PER MILLIGRAM IC Notes J7619 J7621 J7622 J7624 J7626 J7628 J7629 J7631 J7633 J7635 J7636 J7637 Page 18 .Updated Winter 2004 HCPCS Codes Inhalation Solutions HCPCS A7018 A4216 A4217 A7020 E0590 J2545 J7051 J7608 J7618 Description Quantity WATER. 1000 ML 18L/mo SALINE SOLUTION. CONCENTRATED FORM. INHALATION SOLUTION ADMINISTERED THROUGH DME. USED WITH LARGE VOLUME NEBULIZER. UNIT DOSE FORM. PER MILLIGRAM 434mg/mo BITOLTEROL MESYLATE. ADMINISTERED THROUGH DME BECLOMETHASONE. UNIT DOSE FORM. UNIT DOSE FORM. FOR USE WITH INHALATION DRUGS 60units/mo STERILE WATER/SALINE PER 500 ML STERILE WATER OR STERILE SALINE. CONCENTRATED FORM. INHALATION SOLUTION ADMINISTERED THROUGH DME. CONCENTRATED FORM. PER MILLIGRAM IC BUDESONIDE INHALATION SOLUTION. INHALATION SOLUTION ADMINISTERED THROUGH DME. PER 0. PER MILLIGRAM 434mg/mo CROMOLYN SODIUM. INHALATION SOLUTION ADMINISTERED THROUGH DME.50 MG IC BITOLTEROL MESYLATE. UNIT DOSE. UP TO 5 MG (ALBUTEROL) OR 2. INHALATION SOLUTION ADMINISTERED THROUGH DME. UNIT DOSE FORM. USED WITH LARGE VOLUME NEBULIZER 18L/mo DISPENSING FEE COVERED DRUG ADMINISTERED THROUGH DME 1 per drug/mo NEBULIZER PENTAMIDINE ISETHIONATE. INHALATION SOLUTION ADMINISTERED THROUGH DME. UNIT DOSE FORM. ADMINISTERED THROUGH DME. INHALATION SOLUTION ADMINISTERED THROUGH DME. INHALATION SOLUTION ADMINISTERED THROUGH DME. INHALATION SOLUTION. DISTILLED. INCLUDING SEPARATED ISOMERS. UNIT DOSE FORM.25 TO 0. PER 10 ML. AND IPRATROPIUM BROMIDE. PER 1 MG (ALBUTEROL) OR PER 0. INHALATION SOLUTION ADMINISTERED THROUGH DME. PER MILLIGRAM IC BETAMETHASONE. INHALATION SOLUTION ADMINISTERED THROUGH DME. METERED DOSE DISPENSER. UNIT DOSE FORM. PER MILLIGRAM ISOPROTERENOL HCL. UNIT DOSE FORM. PER MILLIGRAM ISOPROTERENOL HCL. 300 MG. INHALATION SOLUTION ADMINISTERED THROUGH DME. PER 10 MILLIGRAMS TERBUTALINE SULFATE. UNIT DOSE FORM. UNIT DOSE FORM. PER MILLIGRAM DORNASE ALPHA. INHALATION SOLUTION ADMINISTERED THROUGH DME. INHALATION SOLUTION ADMINISTERED THROUGH DME IC 78mg/mo IC 75mg/mo 75mg/mo 93mg/mo 930mg/mo 930mg/mo 450/mg/mo 450mg/mo 280units/mo 280units/mo 186mg/mo 186mg/mo IC IC IC IC NARR IC = Individually Considered on a claim-by-claim basis. and expected length of need when billing for those drugs that are Individually considered. INHALATION SOLUTION ADMINISTERED THROUGH DME. INHALATION SOLUTION ADMINISTERED THROUGH DME. CONCENTRATED FORM. CONCENTRATED FORM. INHALATION SOLUTION ADMINISTERED THROUGH DME. PER MILLIGRAM TOBRAMYCIN. INHALATION SOLUTION ADMINISTERED THROUGH DME. INHALATION SOLUTION ADMINISTERED THROUGH DME. UNIT DOSE FORM. INHALATION SOLUTION. INHALATION SOLUTION ADMINISTERED THROUGH DME. INHALATION SOLUTION ADMINISTERED THROUGH DME. UNIT DOSE FORM. PER MILLIGRAM FLUNISOLIDE.Updated Winter 2004 J7638 J7639 J7641 J7642 J7643 J7644 J7648 J7649 J7658 J7659 J7668 J7669 J7680 J7681 J7682 J7683 J7684 J7699 • DEXAMETHASONE. INHALATION SOLUTION ADMINISTERED THROUGH DME. PER 10 MILLIGRAMS METAPROTERENOL SULFATE. PER MILLIGRAM GLYCOPYRROLATE. air power source. PER MILLIGRAM ISOETHARINE HCL. CONCENTRATED FORM. PER MILLIGRAM GLYCOPYRROLATE. UNIT DOSE FORM. UNIT DOSE. INHALATION SOLUTION ADMINISTERED THROUGH DME. CONCENTRATED FORM. UNIT DOSE FORM. CONCENTRATED FORM. PER MILLIGRAM IPRATROPIUM BROMIDE. Nebulizers Equipment HCPCS E0565 E0570 E0571 Description Compressor. INHALATION SOLUTION ADMINISTERED THROUGH DME. PER MILLIGRAM TERBUTALINE SULFATE. INHALATION SOLUTION ADMINISTERED THROUGH DME. UNIT DOSE FORM. CONCENTRATED FORM. PER MILLIGRAM METAPROTERENOL SULFATE. condition of patient. for use with small volume nebulizer Quantity Notes CR CR CR/NARR Page 19 . UNIT DOSE FORM. for equipment which is not self-contained or cylinder driven Nebulizer with compressor Aerosol compressor. We recommend you call and ask an Allwin Data Representative to include a narrative as to the dosage. PER MILLIGRAM NOC DRUGS. INHALATION SOLUTION ADMINISTERED THROUGH DME. ADMINISTERED THROUGH DME TRIAMCINOLONE. PER MILLIGRAM TRIAMCINOLONE. battery powered. UNIT DOSE FORM. PER MILLIGRAM ISOETHARINE HCL. INHALATION SOLUTION ADMINISTERED THROUGH DME. INHALATION SOLUTION ADMINISTERED THROUGH DME. used with large volume nebulizer Filter. disposable. Call Allwin Data with the appropriate information. small volume filtered pneumatic nebulizer Large volume nebulizer. used with aerosol compressor Large volume nebulizer. pre-filled. 10 feet Water collection device. used with small volume ultrasonic nebulizer Nebulizer. Certificate of Medical Neccessity required. nondisposable Administration set. disposable. used with aerosol compressor or ultrasonic generator Aerosol mask. glass or autoclavable plastic. used with large volume nebulizer. not used with oxygen Nebulizer.Updated Winter 2004 E0572 E0574 E0575 E0585 Aerosol compressor. used with large volume nebulizer. used with aerosol compressor Reservoir bottle. Narrative required. light duty for intermittent use Ultrasonic generator with small volume ultrasonic nebulizer Nebulizer. Not Covered. used with DME nebulizer Dome and mouthpiece. payment will be based on the allowance for the least costly medical appropriate alternative. disposable Administration set. with compressor and heater CR CR/NMN CR/NC CR Accessories HCPCS A4619 A7525 A7526 A7003 A7004 A7005 A7006 A7007 A7008 A7009 A7010 A7011 A7012 A7013 A7014 A7015 A7016 A7017 E0580 E1372 Description Face tent Tracheostomy mask Tracheostomy tube collar/holder. disposable Small volume non-filtered pneumatic nebulizer. non-disposable. each Administration set. used with large volume ultrasonic nebulizer Corrugated tubing. 100 feet Corrugated tubing. ultrasonic. large volume Nebulizer. non-disposable. for use with regulator or flowmeter Immersion external heater for nebulizer Quantity 1/ month 1/ month 2/month 2/month 1/6 months 1/month NC NC 1/ 2 months 1/ year 2/ month 2 /month 1/ 3 months 1 / month 2 / year 1 / 3 years Notes 1 / 3 years Explanations of Notes Column NMN NC NARR CR CMN Not Medically Necessary. durable. unfilled. bottle type. bottle type. used with aerosol compressor Filter. Capped Rental item. small volume non-filtered pneumatic nebulizer. disposable. disposable. Page 20 . adjustable pressure. durable. glass or autoclavable plastic. small volume non-filtered pneumatic nebulizer. non-disposable. To be eligible for coverage. payment will be based on the allowance for the least costly medically appropriate alternative (A4258). For all glucose monitors and related accessories and supplies. Any diagnosis code ending with an odd number indicates the patient is Type I diabetic (usually insulin treated). E2101) are covered to enable the visually impaired to use the equipment without assistance.. Codes E2100 or E2101 are covered when the basic coverage criteria are met and the treating physician certifies that the patient has a severe visual impairment (i. “Insulin-treated” means that the patient is receiving insulin injections to treat their diabetes.93) which is being treated by a physician. best corrected visual acuity of 20/200 or worse in both eyes) requiring use of this special monitoring system. and 2.Diabetic Supplies Coverage and Payment Rules Home blood glucose monitors are covered for patients who are diabetics and who can better control their blood glucose levels by checking these levels and appropriately contacting their attending physician for advice and treatment. The patient has diabetes (ICD-9 codes 250. If an E0620 is ordered for use with a covered home blood glucose monitor. and 5. payment will be based on the allowance for the least costly medically appropriate alternative (A4259). but not limited to.e. more than 100 test strips and up to 100 lancets every month are covered if the treating physician has seen and evaluated the patient’s diabetes within the last 6 months and specifically ordered a frequency of testing that exceeds the utilization guidelines and has documented in the patient's medical record the specific reason for the additional materials for that particular patient. and 3. The medical necessity for a laser skin-piercing device (E0620) has not been established. if the basic coverage criteria (1)-(5) are not met. replacement lens shield cartridges (A4257) are also considered not medically necessary. evidence of medical necessity for the prescribed frequency of testing. Page 21 . the patient must meet all of the following basic criteria: 1. and lancing devices. Coverage of E2101 for patients with manual dexterity impairments is not dependent upon a visual impairment. The patient (or the patient's caregiver) is capable of using the test results to assure the patient's appropriate glycemic control. For a patient who is currently being treated with insulin injections. since E0620 is not medically necessary. In addition. the items will be denied as not medically necessary. For a patient who is not currently being treated with insulin injections. Code E2101 is also covered for those with impairment of manual dexterity when the basic coverage criteria is met and the treating physician certifies that the patient has an impairment of manual dexterity severe enough to require the use of this special monitoring system. Home blood glucose monitors with special features (E2100. Insulin does not exist in an oral form and therefore patients taking oral medication to treat their diabetes are not insulin-treated.Updated Winter 2004 VI . If A4257 is ordered for use with an E0620. and 4. test strips. The glucose monitor and related accessories and supplies have been ordered by the physician who is treating the patient's diabetes and the treating physician maintains records reflecting the care provided including. more than 100 test strips and up to 100 lancets every 3 months are covered if the treating physician has seen and evaluated the patient’s diabetes within the last 6 months and specifically ordered a frequency of testing that exceeds the utilization guidelines and has documented in the patient's medical record the specific reason for the additional materials for that particular patient.00-250. The patient (or the patient's caregiver) has successfully completed training or is scheduled to begin training in the use of the monitor. Diagnosis codes ending in an even number indicate the patient is Type II diabetic (usually not insulin treated). The device is designed for home use. Documentation Requirements General Requirements An order to refill is the act of replenishing quantities of previously ordered items during the time period in which the current order is valid.only required if the start date is different than the signature date. The DMERC expects that physician records will reflect the care provided to the patient including. 1 unit of service = 100 lancets. but the confirmation must be reviewed. and dated by the physician. and will require a narrative stating whether or not the beneficiary owns his or her own pump. Allwin Data will accept a quantity that indicates the number of boxes (per 100 lancets) or the total number of lancets dispensed. The supplier must not automatically dispense a quantity of supplies on a predetermined regular basis. A beneficiary or their caregiver must specifically request refills of glucose monitor supplies before they are dispensed. and start date (if applicable) may be written by the supplier. and. even if the beneficiary has "authorized" this in advance. 6. and alcohol wipes. Insulin will be covered only when it is administered using an external insulin infusion pump. or electronic order and must state to the supplier: 1. For verbal orders. 2. A start date of the order . Do not use code A4253 for these items. A supplier should not dispense more than a 3-month supply of test strips or lancets at a time. 1 unit of service = 50 strips. On this confirmation the item(s) to be dispensed. A physician signature. or electronic confirmation of the verbal order. Physician Requirements Claims for diabetic testing supplies must be supported by a valid order.Updated Winter 2004 Medicare does not pay for syringes. faxed. The order may be in the form of a written. 4. needles. Allwin Data will accept a quantity that indicates the number of boxes (per 50 strips) or the total number of strips dispensed. Renewal orders must contain the same information as initial orders and be submitted to the supplier using one of the methods acceptable for initial orders. For lancets (A4259). 3. faxed. . but not limited to evidence of the medical necessity for the prescribed frequency of testing. Page 22 . 5. Blood glucose test or reagent strips that use a visual reading and are not used in a glucose monitor must be coded A9270 (non-covered item or service). signed. Physicians are not required to fill out additional forms from suppliers or to provide additional information to suppliers unless specifically requested of the supplier by the DMERC. the physician must sign and return to the supplier a written. frequency of testing. An order renewal is the act of obtaining an order for an additional period of time beyond that previously ordered by the physician. or insulin injected by syringe. A signature date. The item(s) to be dispensed The quantity of item(s) to be dispensed The frequency of testing ("as needed" is not acceptable) Whether the patient has insulin-treated or non-insulin-treated diabetes. Coding Guidelines For glucose test strips (A4253). Orders are valid for up to 12 months if the physician does not indicate an earlier expiration date. An order refill does not have to be approved by the ordering physician as it is assumed that the ordering physician has approved that quantity of product. the supplier must provide all documentation listed under physician requirements above and any other information requested by the DMERC.g. 1 unit of strips is equal to 50 strips and 1 unit of lancets is equal to 100 lancets. or the DMERCs. the supplier may contact the physician to renew the order. the pharmacy will have to override the Allwin Data system by placing a “07” in the Denial Override Field.Updated Winter 2004 Supplier Requirements If a DMERC requests a supplier to justify quantity billed. In cases where the pharmacy has specific documentation from the physician that the patient must test their blood more than once daily. new documentation must be present at least every 6 months. the pharmacy will have to override the Allwin Data system by placing a “07” in the Denial Override Field. if the patient is regularly using quantities of supplies that exceed the utilization guidelines. and the pharmacy must have the documentation to support using the “07” override. Suppliers should not dispense a quantity of supplies exceeding a beneficiary’s expected utilization (e. The DMERCs should expect physician notes. and medical charts to corroborate the care provided. The supplier is required to have a new written order from the treating physician every 12 months. Allwin Data will automatically attach all required modifiers based on the diagnosis code transmitted with all diabetic supply claims. Suppliers should also stay attuned to atypical utilization patterns on behalf of their clients and verify with ordering physicians that the atypical utilization is. testing once a day would require approximately 100 strips in a 3-month period). The Allwin Data system allows for the dispensing of 100 test strips and 100 lancets every 90 days for a non-insulin treated patient. Upon expiration of the order. suppliers should only provide supplies in quantities needed and at appropriate times. In cases where the pharmacy has specific documentation from the physician that the patient must test their blood more than three times daily. Suppliers share responsibility for providing care that is reasonable and necessary. In those cases in which the pharmacy is billing for more than 100 test strips or lancets a “07” in the Denial Override Field will be necessary. Claims Transmission The Allwin Data system allows for the dispensing of 100 test strips and 100 lancets every 30 days for an insulin treated patient. warranted. the Centers for Medicare & Medicaid Services (CMS). however. Page 23 . the DMERCs will not rely on these forms to prove the medical necessity of services provided. Under no circumstances may suppliers automatically dispense supplies on a predetermined basis even if the beneficiary has authorized this in advance. in fact. Allwin Data will automatically convert all diabetic supply claims to the proper Medicare billing units. A supplier may not dispense more than a 3-month supply of diabetic testing supplies at a time. the pharmacy can only ever bill for a maximum of a three-month supply at a time. This “07” is equivalent to a Medically Necessary Override in the Allwin Data System. However. the request for renewal may only be made with the beneficiary’s continued monthly use of the supply and only with the beneficiary's request for refill or renewal. suppliers may refill orders without consulting the treating physician as long as the order remains valid and allows for refills. At the beneficiary's request. While the DMERC does not prohibit suppliers from creating data collection forms in order to gather this information. In response to DMERC requests.. To this end. and the pharmacy must have the documentation to support using the “07” override. prescriptions. However. suppliers may need to collect specific information from physicians in order to corroborate the care provided. Suppliers should assure that they do not attribute any self-generated forms or data collection requests to the Medicare Program. This “07” is equivalent to a Medically Necessary Override in the Allwin Data System. Call Allwin Data with the appropriate information. payment will be based on the allowance for the least costly medical appropriate alternative. Narrative required. each Spring-powered device for lancet. each Blood glucose monitor with integrated voice synthesizer Blood glucose monitor with integrated lancing/blood sample collection Blood glucose test or reagent strips for home blood glucose monitor. Certificate of Medical Neccessity required. low and high calibrator solution/chips Replacement lens shield cartridge for use with laser skin piercing device. Capped Rental item. any type.Updated Winter 2004 HCPCS Codes HCPCS E0607 E0620 E2100 E2101 A4253 A4254 A4255 A4256 A4257 A4258 A4259 Description Home blood glucose monitor Skin piercing device for collection of capillary blood. Not Covered. each Platforms for home blood glucose monitor. Page 24 . per 50 strips Replacement battery. per box of 100 Quantity 1 / 5years 1 / 5years 1 / 5years 1 / 5years Notes A4258 NARR NARR A4259 1 / 5years Explanations of Notes Column NMN NC NARR CR CMN Not Medically Necessary. each Lancets. 50 per box Normal. laser. for use with medically necessary home blood glucose monitor owned by patient. V55.6. This documentation must be entered in the form of a narrative in the Allwin Data system. V44. which has been signed and dated by the treating physician. Provision of ostomy supplies should be limited to a one-month supply for a patient in a nursing facility and a 3-month supply for a patient at home. No more than one type of supply would be medically necessary on a given day. A4397. When a liquid barrier is necessary. or fecal contents outside the body. Ostomy supplies are appropriately used for colostomies V44.3. the individual components should be billed using individual codes. Patients with continent stomas may use the following means to prevent/manage drainage: stoma cap (A5055). The order must include the type(s) of supplies ordered and the approximate quantity to be used per unit of time. there must be adequate documentation in the patient's medical records corroborating the medical necessity of this amount. A4378 A4361. The DMERC may request copies of the patient's medical records that corroborate the order and any additional documentation that pertains to the medical necessity of items and quantities billed. and A4399. The use of both is not medically necessary. on file. ileostomies V44. When supplying a pouch with faceplate attached (Column I) a claim may not be made for a component product from Column II provided at the same time. stoma plug (A5081) or gauze pads (A6216). V44. Page 25 . When supplies used are greater than the usual maximum quantity. A4398.6) must be included on the initial order to a supplier.Ostomy Supplies Coverage and Payment Rules Ostomy supplies are covered for use on patients with a surgically created opening (stoma) to divert urine. . A4367. V55. It is not medically necessary to have both. A pouch cover should be coded A9270 and will be denied as a non-covered item. The add-on codes do not need to be specifically listed on the physician's order. V55. Coding Guidelines Code A4400 (Ostomy irrigation set). for an irrigation kit.3. An ICD-9 diagnosis code describing the type of ostomy (V44.3. V55. Use for other conditions will be denied as noncovered.2.6.6. either liquid or spray (A4369) or individual wipes (A5119) is appropriate. A4377 A4361. or V55. A new order is required if there is an increase in the quantity of the supply used per month and/or the type of supply used. The following table lists codes for faceplate systems. Patients with urinary ostomies may use either a bag (A4357) or bottle (A5102) for drainage at night.2.3.Updated Winter 2004 VII . A4381. V55. is not valid for claims submitted to the DMERC. A4383 Documentation Requirements The supplier must keep an order for ostomy supplies. A4382 A4361.2 or urinary ostomies V44. Column I A4375 A4376 A4379 A4380 Column II A4361.2. If an irrigation kit is supplied. ANY LENGTH. EACH OSTOMY POUCH. PLASTIC. EACH OSTOMY POUCH. DAY OR NIGHT. EACH OSTOMY POUCH. FOR USE ON FACEPLATE. ANY TYPE. EACH OSTOMY POUCH. WITH OR WITHOUT ANTI-REFLUX DEVICE. WITH FACEPLATE ATTACHED. WITH CONNECTOR/ADAPTOR. WITH FLANGE (SOLID. When you are billing for more than a one month supply you may use a “02” in your denial override field to get the claim through the Allwin system. EACH OSTOMY SKIN BARRIER. EACH 10 10 2 10 / 6mo 1 3 / 6mo 20 4 Notes A4331 A4357 A4361 A4362 A4364 A4365 A4367 A4368 A4369 A4371 A4372 A4373 A4375 A4376 A4377 A4378 A4378 A4379 A4380 A4381 A4382 A4383 A4384 Page 26 . PLASTIC. SILICONE RING. ETC). FOR USE WITH URINARY LEG BAG OR UROSTOMY POUCH. LIQUID (SPRAY. LIQUID OR EQUAL. call the SADMERC. FOR USE ON FACEPLATE. HEAVY PLASTIC. ANY TYPE. FLEXIBLE OR ACCORDIAN). EACH OSTOMY POUCH. (i. DRAINABLE. RUBBER. WITH BUILT-IN CONVEXITY.Updated Winter 2004 Claims Transmission Allwin Data will reject any ostomy supply claim that exceeds Medicare’s allowable monthly quantity. URINARY. EACH OSTOMY POUCH. EACH OSTOMY SKIN BARRIER. or use the Manufacturer Code look-up on the Allwin Data website. EACH OSTOMY FACEPLATE EQUIVALENT. When 20 pouches a month are allowed. EACH OSTOMY POUCH. SOLID. RUBBER. RUBBER. EACH BEDSIDE DRAINAGE BAG. FOR USE ON FACEPLATE. BRUSH. EACH OSTOMY POUCH. URINARY.) In those cases where the pharmacy wishes to bill for more than the usual quantity allowed by Medicare it will be necessary to call Allwin and have a narrative attached to the claim explaining medical necessity. PLASTIC. RUBBER. EACH SKIN BARRIER. URINARY. PER OZ OSTOMY SKIN BARRIER. FOR USE ON FACEPLATE. URINARY. EACH 2 OSTOMY FACEPLATE. WITH OR WITHOUT TUBE. DRAINABLE. PLASTIC OSTOMY POUCH. PER OZ OSTOMY SKIN BARRIER. POWDER. ANY SIZE. WITH FACEPLATE ATTACHED. EACH ADHESIVE. DRAINABLE. URINARY. WITH FACEPLATE ATTACHED.e. ANY TYPE. DRAINABLE. SOLID 4X4 OR EQUIVALENT. WITH FACEPLATE ATTACHED. 4 X 4 OR EQUIVALENT. DRAINABLE. PER OZ ADHESIVE REMOVER WIPES. If you are unsure of which codes to use you can check the most recent Hollister or Convatec catalogs. WITH BUILT-IN CONVEXITY. this narrative information may also be added at the Allwin Data website. you may use the override to bill for 60 in a 3-month period. HCPCS Codes HCPCS Description Quantity EXTENSION DRAINAGE TUBING. FOR USE ON FACEPLATE. ANY TYPE. FOR USE ON FACEPLATE. EACH OSTOMY POUCH. EACH OSTOMY FILTER. RUBBER. PER 50 OSTOMY BELT. EXTENDED WEAR. URINARY. NON-PECTIN BASED. WITH EXTENDED WEAR BARRIER ATTACHED. FLEXIBLE OR ACCORDION). WITH BUILT-IN CONVEXITY (1 PIECE). EACH OSTOMY SKIN BARRIER. HIGH OUTPUT. EACH OSTOMY DEODORANT FOR USE IN OSTOMY POUCH. URINARY. WITHOUT BUILT-IN CONVEXITY. DRAINABLE. WTIH FLANGE (SOLID. EACH OSTOMY POUCH. FLEXIBLE OR ACCORDION). EACH OSTOMY SKIN BARRIER. WITH BUILT-IN CONVEXITY (1 PIECE). WITH FLANGE (SOLID. WITH BUILT-IN CONVEXITY (1 PIECE). FLEXIBLE OR ACCORDION). PECTIN-BASED. EXTENDED WEAR. WITHOUT BUILT-IN CONVEXITY. EXTENDED WEAR. WITHOUT BUILT-IN CONVEXITY. DRAINABLE. WITH BUILT-IN CONVEXITY. FLEXIBLE OR ACCORDION). EXTENDED WEAR. WITH BARRIER ATTACHED. WITH BUILT-IN CONVEXITY (1 PIECE). DRAINABLE. WITHOUT BUILT-IN CONVEXITY. PASTE. WITH EXTENDED WEAR BARRIER ATTACHED. EACH OSTOMY POUCH. EACH OSTOMY POUCH. EACH OSTOMY SKIN BARRIER. WITHOUT BUILT-IN CONVEXITY. EACH OSTOMY POUCH. PER OUNCE OSTOMY SKIN BARRIER. BAG. SLEEVE. EACH OSTOMY SKIN BARRIER. 4 X 4 INCHES OR SMALLER. 4 X 4 INCHES OR SMALLER. FOR USE ON A BARRIER WITH FLANGE (2 PIECE SYSTEM). WITH EXTENDED WEAR BARRIER ATTACHED. EXTENDED WEAR. EACH OSTOMY POUCH. EACH OSTOMY IRRIGATION SUPPLY. URINARY. MISCELLANEOUS 4 2 / 6mo 2 / 6mo 4 10 4 4 A4385 A4387 A4388 A4389 A4390 A4391 A4392 A4393 A4394 A4395 A4396 A4397 A4398 A4399 A4402 A4404 A4405 A4406 A4407 A4408 A4409 A4410 A4413 A4414 A4415 A4421 20 20 NARR Page 27 . PASTE. WITH BUILT-IN CONVEXITY (1 PIECE). LARGER THAN 4 X 4 INCHES. CONE/CATHETER. FLEXIBLE. LIQUID. CLOSED. EACH OSTOMY POUCH.Updated Winter 2004 OSTOMY SKIN BARRIER. PER TABLET OSTOMY BELT WITH PERISTOMAL HERNIA SUPPORT IRRIGATION SUPPLY. EACH OSTOMY SUPPLY. WITH FILTER. PER OUNCE OSTOMY SKIN BARRIER. WITH EXTENDED WEAR BARRIER ATTACHED (1 PIECE). DRAINABLE. WITH STANDARD WEAR BARRIER ATTACHED. EACH OSTOMY POUCH. EACH OSTOMY SKIN BARRIER. WITH FLANGE (SOLID. 4 X 4 INCHES OR SMALLER. (1 PIECE). EACH OSTOMY POUCH. EACH OSTOMY SKIN BARRIER. FLEXIBLE OR ACCORDION). WITH FLANGE (SOLID. PER OUNCE OSTOMY RING. SOLID. WITH FLANGE (SOLID. EACH OSTOMY IRRIGATION SUPPLY. OR ACCORDION). WITH BARRIER ATTACHED. WITH FLANGE (SOLID. INCLUDING BRUSH LUBRICANT. LARGER THAN 4 X 4 INCHES. SOLID 4X4 OR EQUIVALENT. PER FLUID OUNCE OSTOMY DEODORANT FOR USE IN OSTOMY POUCH. WITH BUILT-IN CONVEXITY. LARGER THAN 4X4 INCHES. OR LESS. DRAINABLE. EACH OSTOMY POUCH. NON-WATERPROOF. PER 16 OZ. IN. FOR USE ON FACEPLATE. FOR USE ON BARRIER WITH FLANGE (2 PIECE SYSTEM). 8 X 8 OR EQUIVALENT. WITH FILTER (1 PIECE). 6 X 6 OR EQUIVALENT. EACH OSTOMY POUCH. WITH BARRIER ATTACHED (1 PIECE). GAUZE. WITHOUT BARRIER ATTACHED. PER OUNCE OSTOMY POUCH. EACH 60 60 31 40 40 16 / 6mo 60 A4422 A4450 A4452 A4455 A5051 A5052 A5053 A5054 A5055 A5061 A5062 A5063 A5071 A5072 A5073 A5081 A5082 A5093 A5102 A5119 A5121 A5122 A5126 A5131 A6216 A9270 A4416 A4417 A4418 A4419 A4420 20 20 20 20 20 31 1 10 2 / 6mo 3 / 6mo 20 20 20 1 60 NC 60 60 60 60 60 Page 28 . BOX PER 50 SKIN BARRIER. EACH SKIN BARRIER. EACH OSTOMY POUCH. EACH SKIN BARRIER. EACH DRESSING NON-COVERED ITEM OR SERVICE OSTOMY POUCH. PER 18 SQUARE INCHES TAPE. CLOSED. PER 18 SQUARE INCHES ADHESIVE REMOVER OR SOLVENT (FOR TAPE. EACH OSTOMY POUCH. PAD SIZE 16 SQ. EACH OSTOMY POUCH. CATHETER FOR CONTINENT STOMA OSTOMY ACCESSORY. FOR USE ON BARRIER WITH FLANGE (2 PIECE). EACH OSTOMY POUCH. NON-IMPREGNATED. WITHOUT BARRIER ATTACHED (1 PIECE). URINARY. DRAINABLE. FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE). PLUG FOR CONTINENT STOMA CONTINENT DEVICE. SOLID. EACH OSTOMY POUCH. INCONTINENCE AND OSTOMY APPLIANCES. URINARY. CLOSED. WITH BARRIER ATTACHED.Updated Winter 2004 OSTOMY ABSORBENT MATERIAL (SHEET/PAD/CRYSTAL PACKET) FOR USE IN OSTOMY POUCH TO THICKEN LIQUID STOMAL OUTPUT. WITHOUT BARRIER ATTACHED (1 PIECE). DISK OR FOAM PAD APPLIANCE CLEANER. WITH BARRIER ATTACHED. WITH FILTER (1 PIECE). EACH STOMA CAP OSTOMY POUCH. WITH BARRIER ATTACHED. CEMENT OR OTHER ADHESIVE). WITHOUT ADHESIVE BORDER. FOR USE ON BARRIER WITH FLANGE (2 PIECE). EACH OSTOMY POUCH. WITHOUT BARRIER ATTACHED (1 PIECE). EACH CONTINENT DEVICE. WITH FILTER (1 PIECE). CLOSED. CLOSED. EACH OSTOMY POUCH. EACH OSTOMY POUCH. RIGID OR EXPANDABLE. FOR USE ON BARRIER WITH FLANGE. EACH OSTOMY POUCH. WIPES. EACH TAPE. SOLID. CLOSED. DRAINABLE. URINARY. CLOSED. (1 PIECE). EACH OSTOMY POUCH. CLOSED. NON-STERILE. CLOSED. WITH BUILT-IN CONVEXITY. CLOSED. WITH FILTER (2 PIECE). WATERPROOF. CONVEX INSERT BEDSIDE DRAINAGE BOTTLE WITH OR WITHOUT TUBING. WITH BARRIER ATTACHED (1 PIECE). EACH ADHESIVE OR NON-ADHESIVE. URINARY. WITH FILTER (2 PIECE SYSTEM). FOR USE ON BARRIER WITH FLANGE. EACH Explanations of Notes Column NMN NC NARR CR CMN Not Medically Necessary. FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE). payment will be based on the allowance for the least costly medical appropriate alternative. FOR USE ON BARRIER WITH FLANGE. WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE). WITH EXTENDED WEAR BARRIER ATTACHED. WITH FILTER (1 PIECE). WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE). A4423 A4424 A4425 A4426 A4427 A4428 A4429 60 20 20 20 A4430 A4431 A4432 A4433 A4434 20 20 20 20 Page 29 . FOR USE ON BARRIER WITH LOCKING FLANGE. FOR USE ON BARRIER WITH LOCKING FLANGE. EACH OSTOMY POUCH. WITH EXTENDED WEAR BARRIER ATTACHED. EACH OSTOMY POUCH. URINARY. DRAINABLE. WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE). Certificate of Medical Neccessity required. EACH OSTOMY POUCH. WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE). DRAINABLE. Capped Rental item. EACH OSTOMY POUCH. EACH OSTOMY POUCH. WITH BARRIER ATTACHED. EACH OSTOMY POUCH. WITH BUILT-IN CONVEXITY. EACH OSTOMY POUCH. DRAINABLE. EACH OSTOMY POUCH. WITH FILTER (2 PIECE). EACH OSTOMY POUCH. URINARY. Call Allwin Data with the appropriate information. URINARY. WITH BARRIER ATTACHED. DRAINABLE. WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE). FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE SYSTEM). WITH BUILT-IN CONVEXITY. Narrative required. URINARY. WITH BARRIER ATTACHED. Not Covered. WITH FILTER (2 PIECE SYSTEM). URINARY. FOR USE ON BARRIER WITH LOCKING FLANGE. CLOSED. EACH OSTOMY POUCH. WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE). URINARY. EACH OSTOMY POUCH.Updated Winter 2004 OSTOMY POUCH. Prescription drugs used in immunosuppressive therapy are covered if all of the following criteria (1-5) are met: 1. or 2. .g. bill J7506. transmit only the NDC# with the claim. muromonab-CD3 (J7505). Allwin Data will make the proper quantity conversion before transmitting the claim to Medicare.5 mg Predisone. whole organ pancreas transplant performed concurrent with or subsequent to a kidney transplant because of diabetic nephropathy (performed on or after July 1. vasculitis). The drugs are furnished on or after the date of discharge from the hospital following a covered organ transplant (The initial date on the DIF must be equal to or later than the date of discharge following the transplant). or . and. frequency and route of administration must conform to generally accepted medical practice. liver.5 mg prednisone tablets are dispensed. lung.5 and 1 mg Tacrolimus. 3. If fifty 2. The dosage. Coverage of parenteral azathioprine (J7501) or methylprednisolone (J2920. A completed DIF can be entered on the Allwin website or faxed in to Allwin for entry. intestinal. the number of units billed must accurately reflect the definition of one unit of service in each code narrative. Immunosuppressive drug coverage is still limited to 36 months for beneficiaries whose Medicare entitlement is based solely on end-stage renal disease (ESRD). Immunosuppressive drugs are prescribed following a kidney. or heart/lung transplant. and.). 10 mg Prednisone. if fifty 10 mg prednisone tablets are dispensed. approved facility for kidney. The patient was enrolled in Medicare Part A at the time of the transplant and is enrolled in Medicare Part B at the time that the drugs are dispensed (Question #8 must be answered YES). 5. J7511). heart. or intestinal transplant (performed on or after April 1.5/5 mg Tacrolimus. 2. or 2 strengths of Prednisone. Immunosuppressive drugs are non-covered for the treatment of patients with non-transplant related diagnoses (e. bill J7506. connective tissue diseases. tacrolimus (J7525) and daclizumab (J7513) are not proven to be safe when administered in the home setting and therefore they will be denied as not medically necessary when provided in that setting. heart. the quantities will have to combined and sent to Allwin Data as one claim. and. 2001). When dispensing 500 mg Mycophenolate. The drugs are medically necessary to prevent or treat rejection of an organ transplant in the particular patient. lung. The transplant met Medicare coverage criteria in effect at the time (e.. In those cases where a pharmacy is dispensing both 250mg Mycophenolate and 500mg Mycophenolate.Immunosuppressive Drugs Coverage and Payment Rules All Immunosuppressive Drug claims require a DIF 08. liver. There is no coverage under the immunosuppressive drug benefit for supplies used in conjunction with the administration of parenteral immunosuppressive drugs.g. bone marrow/stem cell. J2930) is limited to those situations in which the medication cannot be tolerated or absorbed if taken orally and is self-administered by the patient. For example. 100 units (1 unit of J7506 = 5 mg). Page 30 . and. Coding Guidelines For all immunosuppressive drugs. heart/lung transplant. antithymocyte globulin (J7504. national and/or local medical necessity criteria. rheumatoid arthritis.. Generally a kidney transplant beneficiary who is under 65 and has a Medicare ID# ending in T. Parenteral cyclosporine (J7516). 25 units. A blank form can be requested by calling the Allwin helpdesk or by downloading from the Allwin website.Updated Winter 2004 VIII . 4.02 to be completed by the supplier and processed through the Allwin Data system before transmitting a claim. etc. 1999). EQUINE.02. must be completed and kept on file by the supplier. Please allow 24 hrs for processing when the DIF is faxed to Allwin Data. when billing for two different strengths of a drug that only has one HCPCS code. A revised DIF is required if the physician prescribing the drugs changes or if the patient has another transplant. 1 MG Quantity Notes CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN Page 31 . DMERC 08. PARENTERAL. for billing purposes the pharmacy can send only one claim reflecting the total amount dispensed in terms of the recognized HCPCS code. ORAL. PER 5 MG LYMPHOCYTE IMMUNE GLOBULIN. PARENTERAL. ANTITHYMOCYTE GLOBULIN. As mentioned above in the Coding Guidelines. Medicare only has a code for the 250mg Cellcept so the claim must reflect the total amount of tablets dispensed based on the 250mg tablets. PARENTERAL. 5 MG PREDNISONE. A DMERC Information Form (DIF). ORAL. 25 MG CYCLOSPORINE. ORAL. PER 1 MG METHYLPREDNISOLONE ORAL. The pharmacy may enter the DIF using the Allwin Data website and transmit the claim upon acceptance of the DIF by the Allwin system. 100 MG CYCLOSPORINE. PARENTERAL. PER 250 MG SIROLIMUS. METHYLPREDNISOLONE SODIUM SUCCINATE. UP TO 125 MG AZATHIOPRINE. PER 5 MG TACROLIMUS. 100 MG LYMPHOCYTE IMMUNE GLOBULIN. METHYLPREDNISOLONE SODIUM SUCCINATE. 25 MG CYCLOSPORINE. In this case the 50 500mg tablets would have to be shown as 100 250mg tablets. 250 MG MUROMONAB-CD3. ANTITHYMOCYTE GLOBULIN. PARENTERAL. A new order is required if a new drug(s) is added to the patient's immunosuppressive regimen or if there is a change in dose or frequency of administration of an already allowed drug. Example: Dispensing 50 tablets of 500mg Cellcept and 50 tablets of 250mg Cellcept.Updated Winter 2004 Documentation Requirements The supplier must keep an order for the drug(s) that has been signed and dated by the treating physician on file. RABBIT. An initial DIF is needed if a different drug is prescribed in addition to or in replacement of existing drugs. HCPCS Codes HCPCS J2920 J2930 J7500 J7501 J7502 J7504 J7505 J7506 J7507 J7509 J7510 J7511 J7513 J7515 J7516 J7517 J7520 Description INJECTION. Claim Transmission Upon completing the DIF. 25MG DACLIZUMAB. ORAL. ORAL. therefore the claim would show a total of 150 250mg tablets dispensed. UP TO 40 MG INJECTION. 50 MG AZATHIOPRINE. the pharmacy has two ways to get the DIF to Allwin Data before the claim can be transmitted. PARENTERAL. ORAL. PER 4 MG PREDNISOLONE ORAL. or the pharmacy may fax the DIF to Allwin Data for processing. 250 MG MYCOPHENOLATE MOFETIL. ORAL. ORAL. Certificate of Medical Neccessity required. Narrative required.5 MG CMN CMN CMN CMN Explanations of Notes Column NMN NC NARR CR CMN Not Medically Necessary. Call Allwin Data with the appropriate information. 25 MG METHOTREXATE. ORAL. Capped Rental item. payment will be based on the allowance for the least costly medical appropriate alternative. Page 32 . 5 MG IMMUNOSUPPRESSIVE DRUG. Not Covered. NOT OTHERWISE CLASSIFIED CYCLOPHOSPHAMIDE.Updated Winter 2004 J7525 J7599 J8530 J8610 TACROLIMUS. 2. PARENTERAL. ) or due to a motility disorder (e. Enteral nutrition is non-covered for patients with a functioning gastrointestinal tract whose need for enteral nutrition is due to reasons such as anorexia or nausea associated with mood disorder. dysphasia. If the judgement of the attending physician. Coding Guidelines When enteral nutrition is covered. Coverage is possible for patients with partial impairments . If the coverage requirements for enteral nutrition are met. substantiated in the medical record. equipment or supplies is allowed for one month's prospective billing.e. The patient must have a permanent impairment. obstruction due to head and neck cancer or reconstructive surgery. Alzheimer’s.g. administration supplies.Enteral Nutrition Coverage and Payment Rules Enteral nutrition is the provision of nutritional requirements through a tube into the stomach or small intestine. if not impossible to swallow. The patient's condition could be either anatomic (e. Documentation Requirements A Certificate of Medical Necessity (CMN) which has been completed. The CMN may act as a substitute for a written order if it contains all of the required elements of an order.).. 4. may include multiple months. etc. The CMN for Enteral Nutrition is HCFA Form 853. Page 33 . and equipment are covered. Claims submitted retroactively.. The patient must require tube feedings to maintain weight and strength commensurate with the patient's overall health status.Updated Winter 2004 IX . Enteral nutrition products that are administered orally and related supplies are non-covered. however. Examples would be mouth/throat cancer. The initial claim must include a copy of the CMN. Enteral nutrition will be denied as non-covered in situations involving temporary impairments. severe dysphagia following a stroke. 5. 2. gastro paresis. is that the condition is of long and indefinite duration (ordinarily at least 3 months). etc. Valid CMN’S 1. Question #7 and #8 on the CMN must be answered YES Question #13 on the CMN must be answered 1. end-stage disease.g. medically necessary nutrients.. the test of permanence is considered met. a patient with dysphagia who can swallow small amounts of food or a patient with Crohn's disease who requires prolonged infusion of enteral nutrients to overcome a problem with absorption. etc. Enteral nutrition is covered for a patient who has (a) permanent non-function or disease of the structures that normally permit food to reach the small bowel or (b) disease of the small bowel which impairs digestion and absorption of an oral diet. or 3 Coverage does not exist for enteral nutrition that is administered orally Length of Need must be equal to or greater than 3 months The diagnosis code provided by the doctor on the CMN should reflect a condition in the beneficiary that makes it difficult. 2. Parkinson’s. No more than one month's supply of enteral nutrients.g. 3. signed. Adequate nutrition must not be possible by dietary adjustment and/or oral supplements. Permanence does not require a determination that there is no possibility that the patient's condition may improve sometime in the future.. dressings used in conjunction with a gastrostomy or enterostomy tube are included in the supply kit code (B4034-B4036) and should not be billed separately using dressing codes. etc. either of which requires tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with the patient's overall health status. and dated by the treating physician must be kept on file by the supplier and made available to the DMERC on request. Claim Transmission Upon receiving the completed CMN from the physician the pharmacy has two ways to get the CMN to Allwin Data before the claim can be transmitted. or (3) the method of administration (syringe.Updated Winter 2004 A new Initial certification for enteral nutrients is required when (1) a formula billed with a different code which has not been previously certified is ordered. (In this latter situation. Common Enteral Nutrition HCPCS Codes Product Name BOOST BOOST PLUS ENSURE ENSURE PLUS GLUCERNA ISOCAL JEVITY JEVITY PLUS NUTREN 1. or (2) number of days per week administered is changed. Allwin Data requires the pharmacy use only the product’s NDC# for claims processing. This will insure the correct quantity conversion based solely on the specific product being dispensed.Question #13 on the CMN. (1) the number of calories per day is changed. Please allow 24 hrs for processing when the CMN is faxed to Allwin Data. they should be billed on a single claim line with the units of service reflecting the total calories of both nutrients. pump) changes. or (5) if a Category IV or V enteral nutrient being provided is changed. or (2) enteral nutrition services are resumed after they have not been required for two consecutive months. the need for special nutrients (B4151. The initial date listed in Section A of a Revised CMN for codes B4154 or B4155 must match the initial date on the certification record for code B4154 or B4155 which has been set up by the DMERC. All claims should be billed as 30-day supplies and quantities should reflect the total number of cans dispensed. The Initial Certification must be accompanied by adequate documentation to support the medical necessity of the following orders. An Initial Certification is also required for a pump if a patient receiving enteral nutrition by the syringe or gravity method is changed to administration using a pump. for a formula which has been previously certified. or the pharmacy may fax the CMN to Allwin Data for processing.e. gravity. The pharmacy may enter the CMN using the Allwin Data website and transmit the claim upon acceptance of the CMN by the Allwin system.) In addition to the reason listed above. Recertification may also be requested on an individual basis at the discretion of the DMERC. If two Category IV or two Category V nutrients are being provided at the same time. 2. A new Initial Certification for a pump (B9000 or B9002) is required if enteral nutrition services involving use of a pump are resumed after they have not been required for two consecutive months. However. a Revised Certification is required for the nutrient which indicates the change to the pump method of administration . Because Medicare pays enteral claims per 100 calories and all enteral products have different caloric values. If you wish to submit units other than total number of cans dispensed please call the Allwin helpdesk to request a quantity conversion specifically for your store.. Regularly scheduled recertifications are not required.0 HCPCS B4150 B4152 B4150 B4152 B4154 B4150 B4150 B4150 B4150 Page 34 . the need for a pump. a Revised Certification is required when. a recertification is required if the physician indicates a length of need of less than lifetime (i. or (4) route of administration is changed from tube feedings to oral feedings (if billing for denial). if applicable: 1. less than 99 months) on the CMN and subsequently orders a greater length of need. B4153-B4156). ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE. NATURAL INTACT PROTEIN/PROTEIN ISOLATES. MODULAR COMPONENTS. PER DAY ENTERAL FEEDING SUPPLY KIT. ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE. GRAVITY FED. 100 CALORIES = 1 UNIT ENTERAL FORMULAE. PER OUNCE ENTERAL FORMULAE. 100 CALORIES = 1 UNIT ENTERAL FORMULAE. (STANDARD OR LOW PROFILE). ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE. CATEGORY I. ANY TYPE.WITH ALARM NOC FOR ENTERAL SUPPLIES IV POLE 3 / 3mos 3 / 3mos 3 / 3mos 1 / 3mos NC Quantity Notes NC B4150 CMN B4151 CMN B4152 CMN B4153 CMN B4154 CMN B4155 B4156 B9000 B9002 B9998 E0776 CMN CMN CMN NARR Page 35 . ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE. HYDROLIZED PROTEIN/AMINO ACIDS. 100 CALORIES = 1 UNIT ENTERAL FORMULAE. INTACT PROTEIN/PROTEIN ISOLATES (CALORICALLY DENSE). ANY MATERIAL. CATEGORY II. ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE. 100 CALORIES = 1 UNIT ENTERAL FORMULAE. PER DAY NASOGASTRIC TUBING WITH STYLET NASOGASTRIC TUBING WITHOUT STYLET STOMACH TUBE . SYRINGE. ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE. SEMI-SYNTHETIC INTACT PROTEIN/PROTEIN ISOLATES. STANDARDIZED NUTRIENTS.WITHOUT ALARM ENTERAL NUTRITION INFUSION PUMP . DEFINED FORMULA FOR SPECIAL METABOLIC NEED. EACH FOOD THICKENER. CATEGORY V. ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE. 100 CALORIES = 1 UNIT ENTERAL FORMULAE. CATEGORY IV. CATEGORY VI. PER DAY ENTERAL FEEDING SUPPLY KIT. ADHESIVE SKIN ATTACHMENT NON-COVERED ITEM OR SERVICE ENTERAL FEEDING SUPPLY KIT. CATEGORY III.LEVINE TYPE GASTROSTOMY / JEJUNOSTOMY TUBE.5 OSMOLITE PULMOCARE RESOURCE TWOCAL ULTRACAL B4152 B4150 B4154 B4150 B4152 B4150 HCPCS Codes HCPCS A5200 A9270 B4034 B4035 B4036 B4081 B4082 B4083 B4086 B4100 Description PERCUTANEOUS CATHETER/TUBE ANCHORING DEVICE. 100 CALORIES = 1 UNIT ENTERAL NUTRITION INFUSION PUMP . CATEGORY I. 100 CALORIES = 1 UNIT ENTERAL FORMULAE. ADMINISTERED ORALLY. PUMP FED.Updated Winter 2004 NUTREN 1. Updated Winter 2004 Explanations of Notes Column NMN NC NARR CR CMN Not Medically Necessary. payment will be based on the allowance for the least costly medical appropriate alternative. Narrative required. Not Covered. Page 36 . Call Allwin Data with the appropriate information. Capped Rental item. Certificate of Medical Neccessity required. the drug will be denied as noncovered. there are no HCPCS codes for covered anti-cancer drugs. lupus. and 3.5mg Methotrexate 10mg Methotrexate 15mg Temozolomide 5mg Temozolomide 20mg Temozolomide 100mg Temozolomide 250mg Page 37 . A drug that is not available in an injectable form does not meet criterion 2. is metabolized into the same active ingredient which is found in the non-selfadministrable form of the drug. If cyclophosphamide or methotrexate is prescribed as an oral immunosuppressive drug following an organ transplant. It is reasonable and necessary for the individual patient. It is a drug or biological that has been approved by the Food and Drug Administration (FDA).. For all NDC codes. Coding Guidelines Anticancer Drugs are billed using the NDC# only.).g. a claim should not be submitted to Medicare (unless requested by the beneficiary) because there is no statutory benefit for oral immunosuppressive drugs in these conditions. If criteria 1-5 are met but criterion 6 is not met. It is prescribed for the treatment of cancer (ICD-9 codes 140. 2. when ingested. (If the drug is used for immunosuppression following organ transplant.Updated Winter 2004 X . and 4. (Refer to the Immunosuppressive Drugs policy for additional information.) If criteria 1. Physician's Desk Reference (PDR). 3. 2 mg Capecitabine 150mg Capecitabine 500mg Cyclophosphamide 25mg Cyclophosphamide 50mg Etoposide 50mg Melphalan 2mg Methotrexate 2.9. 236. etc. including unlabeled uses. The oral anticancer drug and the non-self-administrable drug must have the same chemical/generic name as indicated by the FDA's Approved Drug Products (Orange Book). It is prescribed by a physician or other practitioner licensed under state law to prescribe such drugs as anticancer chemotherapeutic agents. the drug will be denied as not medically necessary.3). rheumatoid arthritis. 273. code J8530 or J8610 respectively must be used. and 2. or an authoritative drug compendium. If an oral anticancer drug is used for immunosuppression (rather than the treatment of cancer). It has the same ingredients as a non-self-administrable anticancer chemotherapeutic drug or biological that is covered when furnished incident to a physician's service.1. and 5.0-208. Covered Drugs Busulfan.5mg Methotrexate 5mg Methotrexate 7. as the non-self-administrable form of the drug.) If cyclophosphamide or methotrexate is prescribed as an oral immunosuppressive drug for other conditions (e. criterion 5 is not met and the drug cannot be covered under the oral anticancer drug benefit. It is used for the same indications. 4. or It is a prodrug which. or 5 are not met.Oral Anti-Cancer Drugs Coverage and Payment Rules An oral anticancer drug is covered if all of the following criteria (1-6) are met: 1. Anticancer Drugs require no modifier. 1 unit of service = 1 tablet or 1 capsule. and 6. refer to the Immunosuppressive Drugs policy. National Drugs Codes (NDCs) may be billed only when the drug is used as an oral anticancer drug. The physician must enter a narrative diagnosis and/or ICD-9-CM diagnosis code describing the condition for which the drug is ordered on the order. there are no specific restrictions on quantities allowed. Only diagnosis codes listed in Coverage and Payment Rules are valid for claim payment. but claim should represent written order from physician.Updated Winter 2004 Documentation Requirements A detailed written order for each drug must be signed and dated by the treating physician and kept on file by the supplier. The ICD-9-CM diagnosis code describing the condition for which the drug is used must be included on each claim. A new detailed written order is required whenever there is a change in dosage or in the directions for administering the drug. Claims Transmission Send claims using only the NDC #. Page 38 . A claim should be billed as a 30-day supply. If criteria 1 and 3 are met but criterion 2 is not met. The initial dose of the oral antiemetic drug is administered within 2 hours of the administration of the chemotherapy drug. However. Quantities of drugs in excess of these amounts are non-covered. Anti-emetic Drugs Used With Oral Anticancer Drugs A self-administered antiemetic drug billed with code K0415 or K0416 is covered if all of the following criteria are met: 1. If the anti-emetic is being used in conjunction with an oral anti-cancer in the home refer to criteria below. If criterion 1 or 3 is not met. and 4. 2. The drug has been approved by the Food and Drug Administration (FDA) for use as an antiemetic. or 4 are not met. Page 39 .g. Suppliers may bill only for quantities of antiemetic drugs that are to be used within 2 hours before the covered oral anticancer drug. It is likely that administration of the covered oral anticancer drug will induce emesis if the antiemetic drug is not administered. and 2. to treat nausea or vomiting which is caused by the oral anticancer drug or other etiology) are noncovered. and 3.Oral Anti-Emetic Drugs Coverage and Payment Rules An oral antiemetic drug billed with codes Q0163-Q0181 is covered if all of the following criteria (1-4) are met: 1. If criteria 1. Doses of antiemetic drugs administered after the administration of the oral anticancer drug (e. The drug has been ordered by the treating physician as part of a cancer chemotherapy regimen. It is used in conjunction with a covered oral anticancer drug. oral antiemetic drugs billed using codes Q0163-Q0181 will be denied as non-covered. for the drugs granisetron (Q0166) and dolasetron (Q0180). the antiemetic drug will be denied as noncovered. Criterion 3 is not met when the chemotherapy drug is an oral drug or when the chemotherapy drug is administered intravenously in the home setting because the type and dosage of chemotherapy drugs administered in these situations do not require intravenous anti-emetic drugs.. Coding Guidelines For codes K0415 and K0416. Therefore. The drug is used as a full therapeutic replacement for an intravenous antiemetic drug that would otherwise have been administered at the time of the chemotherapy treatment. the quantity of drugs covered for each episode of chemotherapy is limited to the initial loading dose plus 24 hours of therapy. the antiemetic drug will be denied as not medically necessary. The antiemetic drug is administered within 2 hours before the covered oral anticancer drug is administered. coverage is limited to doses of antiemetic drugs which are administered during the two hours before administration of the covered oral anticancer drug. and 3. 1 unit of service = 1 mg. and 2. 3.Updated Winter 2004 XI . Code K0415 or K0416 may be billed only when the antiemetic drug is used in conjunction with a covered oral anticancer drug. Oral antiemetics are covered under the oral anticancer drug benefit for the sole purpose of allowing the absorption of the covered oral anticancer drug. If all of the above criteria (1-4) are met. the quantity of oral antiemetic drugs covered for each episode of chemotherapy cannot exceed the initial loading dose plus 48 hours of therapy. There must also be a statement on the order that indicates that the oral anti-emetic drug is a full therapeutic replacement for an intravenous anti-emetic drug and is used as part of a cancer chemotherapy regimen. The physician must enter a narrative diagnosis and/or ICD-9-CM diagnosis code describing the patient’s cancer diagnosis on the order. FDA approved prescription anti-emetic. The supplier may bill using code Q0163-Q0181 only if they have a written order with the specified attestation. for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment. FDA approved prescription anti-emetic. 2. will require a narrative to be transmitted with the claim. not to exceed a 24 hour dosage regimen Dronabinol 2. FDA approved prescription anti-emetic. All claims for K0415 and K0416. for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment. oral. The information required in the narrative is listed above in the Documentation Requirements. HCPCS Codes HCPCS Q0163 Description Quantity Diphenhydramine hydrochloride 50mg. 6. oral. a “03” in the denial override field will allow for transmission of the claim through the Allwin system without a narrative.Updated Winter 2004 Documentation Requirements A detailed written order for each drug must be signed and dated by the treating physician and kept on file by the supplier. oral.5mg. and the patient’s chemotherapy regimen is being administered intravenously in a facility. oral . 7. not to exceed a 48 hour dosage regimen Granisetron hydrochloride 1mg. Once the pharmacy has confirmed only a 2-day supply will be dispensed. This can be done by calling an Allwin representative with the necessary narrative information. for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment. FDA approved prescription anti-emetic. This is done to make the pharmacy aware of the 2-day supply limitations on these drugs. not to exceed a 48 hour dosage regimen Notes Q0164 Q0165 Q0166 Q0167 Q0168 Page 40 . oral. for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment. FDA approved prescription anti-emetic. oral anti-emetics used in conjunction with oral anti-cancers. 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 5mg. not to exceed a 48 hour dosage regimen Prochlorperazine maleate 10mg. 5. 8. 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 5mg. Anti-emetic name Anti-emetic strength Dosage directions for anti-emetic Manufacturer of Anti-emetic Anti-emetic NDC # Oral anti-cancer name Oral anti-cancer strength Oral anti-cancer method of administration Claim Transmission Allwin will always prompt the pharmacy for supporting narrative documentation required on all anti-emetic claims. This order must be available to the DMERC on request. oral. Claims for codes K0415 or K0416 must be accompanied by a narrative containing the following information: 1. 3. 4. for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment. for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment. for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment. FDA approved prescription anti-emetic. FDA approved prescription anti-emetic. oral. 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 8mg. FDA approved prescription anti-emetic. not to exceed a 48 hour dosage regimen Hydroxyzine pamoate 50mg. oral. 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 10mg. not to exceed a 24 hour dosage regimen Unspecified oral dosage form. oral. not to exceed a 48 hour dosage regimen Trimethobenzamide hydrochloride 250mg. not to exceed a 48 hour dosage regimen Q0170 Q0171 Q0172 Q0173 Q0174 Q0175 Q0176 Q0177 Q0178 Q0179 Q0180 Q0181 Page 41 . for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment.Updated Winter 2004 Q0169 Promethazine hydrochloride 12. not to exceed a 48 hour dosage regimen Dolasetron mesylate 100mg. not to exceed a 48 hour dosage regimen Promethazine hydrochloride 25mg. FDA approved prescription anti-emetic. FDA approved prescription anti-emetic.5mg. not to exceed a 48 hour dosage regimen Thiethylperazine maleate 10mg. FDA approved prescription anti-emetic. for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment. oral. oral. FDA approved prescription anti-emetic. for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment. for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment. oral. not to exceed a 48 hour dosage regimen Chlorpromazine hydrochloride 25mg. FDA approved prescription anti-emetic. oral. oral. not to exceed a 48 hour dosage regimen Perphenazine 8mg. 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 4mg. not to exceed a 48 hour dosage regimen Hydroxyzine pamoate 25mg. FDA approved prescription anti-emetic. for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment. FDA approved prescription anti-emetic. FDA approved prescription anti-emetic. oral. oral. FDA approved prescription anti-emetic. FDA approved prescription anti-emetic. for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment. oral. for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment. oral. 30) or permanent urinary retention (ICD-9 788. the test of permanence is considered met. drape. Catheters and related supplies will be denied as noncovered in situations in which it is expected that the condition will be temporary. The use of a urological supply for the treatment of chronic urinary tract infection or other bladder condition in the absence of permanent urinary incontinence or retention is noncovered. If the catheter or the external urinary collection device meets the coverage criteria then the related supplies that are necessary for their effective use are also covered. Urological supplies that are used for purposes not related to the covered use of catheters or external urinary collection devices (i. indicates the condition is of long and indefinite duration (ordinarily at least 3 months). and a tray or bag in a sterile package intended for single use. The medical necessity for use of a greater quantity of supplies than the amounts specified in the policy must be well documented in the patient's medical record and may be requested by the DMERC. When billing for male external catheters. Coding Guidelines A meatal cup female external urinary collection device (A4327) is a plastic cup which is held in place around the female urethra by suction or pressure and is connected to a urinary drainage container such as a bag or bottle. Procedure code A4347 is not valid for claims submitted to the DMERC. Page 42 . Irrigation solutions containing antibiotics and chemotherapeutic agents should be coded A9270. Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected in that patient within 3 months. A urinary intermittent catheter with insertion supplies (A4353) is a kit which includes a catheter. Irrigating solutions such as acetic acid or hydrogen peroxide which are used for the treatment or prevention of urinary obstruction should be coded A4321.e. lubricant. Since the patient's urinary system is functioning. Therapeutic agent for urinary irrigation (A4321) is defined as a solution containing agents in addition to saline or sterile water (for example acetic acid or hydrogen peroxide) which is used for the treatment or prevention of urinary catheter obstruction. A urinary catheter anchoring device described by code A4333 has an adhesive surface which attaches to the patient's skin and a mechanism for releasing and re-anchoring the catheter multiple times without changing the anchoring device. This does not require a determination that there is no possibility that the patient's condition may improve sometime in the future.20). A urinary catheter anchoring device described by code A4334 is a strap which goes around a patient's leg and has a mechanism for releasing and re-anchoring the catheter multiple times without changing the anchoring device. gloves. applicators.Updated Winter 2004 XIII . use code A4324 or A4325 and one unit of service for each catheter supplied. drainage and/or collection of urine from the bladder) will be denied as noncovered. If the medical record. the criteria for coverage under the prosthetic benefit provision are not met. including the judgement of the attending physician..Urological Supplies Coverage and Payment Rules Urinary catheters and external urinary collection devices are covered to drain or collect urine for a patient who has permanent urinary incontinence (ICD-9 788. A pouch type female external collection device (A4328) is a plastic pouch which is attached to the periurethral area with adhesive and which can be connected to a urinary drainage container such as a bag or bottle. The patient must have a permanent impairment of urination. antiseptic solution. A4331. A4332. A4332. that code should be used in lieu of the individual codes.). Page 43 . An external catheter that contains a barrier for attachment should be coded using A4335. A4332. A4332. A4452 A4310.. A4332. A4357 A4450. A4357 A4310. or A5112). A percutaneous catheter/tube anchoring device (A5200) is a dressing with adhesive that is designed to be applied directly over the cutaneous opening through which the catheter/tube passes. etc. A4338. codes A4450 and A4452 and A4217 are the only two codes for which the AU modifier may be used. more than two bedside drainage bags per month. Codes for ostomy barriers (A5119. A5114 A5113. A5113. An anchoring device used with a percutaneous catheter/tube (e. A4351. A5114) are used with a urinary leg bag (A4358.Updated Winter 2004 Adhesive strips or tape used with code A4325 (Male external catheter. more than 35 male external catheters per month. A4346 A4310.g.. A4357 A4310. Adhesive strips and tape used in conjunction with code A4324 (Male external catheter. A5114 If a code exists that includes multiple products. with adhesive coating. each) should be billed with code A4335. A4357 A4331 A4331. A5113. These codes are not used for a leg strap for an indwelling catheter. Adhesive catheter anchoring devices that are used with indwelling urethral catheters are billed using codes A4333 and A4334. A5105. A4369-A4371) should not be used for skin care products used in the management of urinary incontinence. suprapubic tube. Column I A4310 A4311 A4312 A4313 A4314 A4315 A4316 A4325 A4353 A4354 A4357 A4358 A5112 A5105 Column II A4332 A4310. nephrostomy tube) is billed using code A5200. A4346. A4331. A4332. Documentation Requirements When billing for quantities of supplies greater than those described in the policy as the usual replacement frequency (e. more than one indwelling catheter per month. A4332. A4311. This can be done by calling an Allwin representative with the necessary narrative information. each) should not be billed separately. the claim must include documentation supporting the medical necessity for the higher utilization. In the following table. A4354. A4331. respectively. The initial claim for catheters or kits used for sterile intermittent catheterization in the home must be accompanied by documentation supporting the medical necessity for sterile technique. A4354. A4352 A4310.g. A4332. The Column I code must be used instead of multiple Column II codes when the items are provided at the same time. A4344 A4310. A4312. A4358. For this policy. When codes A4450 and A4452 are used with Urological Supplies they must be billed with the AU modifier. Replacement leg straps (A5113. A4354. with adhesive strip. A4359. the Column I code includes the items identified by the codes in Column II. A4331. A5114 A4331. A4338 A4310. A4344. A4313. This dressing has a hole through which the catheter/tube passes and a mechanism for firmly anchorin the catheter/tube to the dressing. A5112. INDIVIDUAL STERILE PACKET. EACH URINARY CATHETER ANCHORING DEVICE. SILICONE. TWO-WAY. INFLATABLE. FOLEY TYPE. FOLEY TYPE. SILICONE.). FOLEY TYPE. HCPCS Codes HCPCS A4310 A4311 A4312 A4313 A4314 A4315 A4316 A4320 A4321 A4322 A4324 A4325 A4326 A4327 A4328 A4331 A4332 A4333 A4334 A4335 A4338 A4340 A4344 A4346 A4347 Description INSERTION TRAY WITHOUT DRAINAGE BAG AND WITHOUT CATHETER (ACCESSORIES ONLY) INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER. EG. PER DOZEN Quantity Notes 1 1 1 1 1 1 1 NC 35 35 4 30 12 1 1 1 1 1 Use A4324 or A4325 Page 44 . THREE-WAY. This narrative information may also be added at the Allwin Data website. ANY LENGTH. EACH LUBRICANT. LEG STRAP. FOR USE WITH URINARY LEG BAG OR UROSTOMY POUCH. ADHESIVE SKIN ATTACHMENT. MEATAL CUP. ETC. SILICONE. FOLEY TYPE. WITH ADHESIVE STRIP. ALL SILICONE. TWO-WAY LATEX WITH COATING (TEFLON. FOR CONTINUOUS IRRIGATION INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER. ETC. In those cases where the pharmacy wishes to bill for more than the usual quantity allowed by Medicare we suggest you call Allwin Data to have a narrative attached to the claim. FOLEY TYPE. ANY TYPE. THREE WAY FOR CONTINUOUS IRRIGATION. WITH OR WITHOUT ANTI-REFLUX DEVICE. ALL SILICONE INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER.. THREE-WAY. EACH MALE EXTERNAL CATHETER SPECIALTY TYPE. EACH INDWELLING CATHETER. MUSHROOM. EACH MALE EXTERNAL CATHETER WITH OR WITHOUT ADHESIVE. EG. SILICONE ELASTOMER OR HYDROPHILIC. ETC. SILICONE ELASTOMER OR HYDROPHILIC. ANY PURPOSE THERAPEUTIC AGENT FOR URINARY CATHETER IRRIGATION IRRIGATION SYRINGE. FOLEY TYPE. TWO-WAY LATEX WITH COATING (TEFLON. WITH ADHESIVE COATING. MISCELLANEOUS INDWELLING CATHETER. ALL SILICONE INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER. FOR CONTINUOUS IRRIGATION IRRIGATION TRAY WITH BULB OR PISTON SYRINGE. EACH INCONTINENCE SUPPLY. ETC. WING. COUDE. FACEPLATE. EACH INDWELLING CATHETER. EACH INDWELLING CATHETER.) INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER. EACH EXTENSION DRAINAGE TUBING. EACH FEMALE EXTERNAL URINARY COLLECTION DEVICE.Updated Winter 2004 Claim Transmission Allwin Data will reject any urological supply claim that exceeds Medicare’s allowable monthly quantity. OR HYDROPHILIC.). EACH FEMALE EXTERNAL URINARY COLLECTION DEVICE. EACH MALE EXTERNAL CATHETER. FOLEY TYPE. WITH CONNECTOR/ADAPTOR. SPECIALTY TYPE. ETC. FOLEY TYPE. TWO-WAY. FOLEY TYPE. TWO-WAY LATEX WITH COATING (TEFLON. EACH URINARY CATHETER ANCHORING DEVICE. TWO-WAY. EACH MALE EXTERNAL CATHETER. FOR INSERTION OF URINARY CATHETER. SILICONE ELASTOMER. POUCH.) INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER. BULB OR PISTON. REPLACEMENT ONLY. EACH URINARY DRAINAGE BAG. EACH ADHESIVE REMOVER WIPES. payment will be based on the allowance for the least costly medical appropriate alternative. CEMENT OR OTHER ADHESIVE). Certificate of Medical Neccessity required. ETC. WITH INSERTION SUPPLIES 1 INSERTION TRAY WITH DRAINAGE BAG BUT WITHOUT CATHETER 1 IRRIGATION TUBING SET FOR CONTINUOUS BLADDER IRRIGATION THROUGH A THREE-WAY INDWELLING FOLEY CATHETER. COUDE (CURVED) TIP. SILICONE. PER 18 SQUARE INCHES TAPE. DAY OR NIGHT. PER SET LEG STRAP. EXTENDED WEAR. EACH 4 INTERMITTENT URINARY CATHETER. PER 16 OZ.). STRAIGHT TIP.. EACH URINARY SUSPENSORY. WITH OR WITHOUT 2 TUBE. A4348 A4351 A4352 A4353 A4354 A4355 A4356 A4357 A4358 A4359 A4365 A4402 A4450 A4452 A4455 A5102 A5105 A5112 A5113 A5114 A5131 A5200 A9270 NC NC NC NC Page 45 . EACH 4 INTERMITTENT URINARY CATHETER. Capped Rental item. WITH OR WITHOUT COATING (TEFLON. OR HYDROPHILIC. PER OUNCE 8 TAPE. 2 PER MONTH) INTERMITTENT URINARY CATHETER. SILICONE. WITH OR WITHOUT TUBE. EACH 1 / 3mo BEDSIDE DRAINAGE BAG. EACH EXTERNAL URETHRAL CLAMP OR COMPRESSION DEVICE (NOT TO BE USED FOR CATHETER CLAMP).). SILICONE ELASTOMER. PERCUTANEOUS CATHETER/TUBE ANCHORING DEVICE. REPLACEMENT ONLY. Narrative required. PER OUNCE BEDSIDE DRAINAGE BOTTLE WITH OR WITHOUT TUBING. Not Covered.Updated Winter 2004 MALE EXTERNAL CATHETER WITH INTEGRAL COLLECTION COMPARTMENT. LEG OR ABDOMEN. LATEX. EACH (E. VINYL. SILICONE ELASTOMERIC. WATERPROOF. PER 50 LUBRICANT. LATEX 1 LEG STRAP. WITH OR WITHOUT ANTI-REFLUX 1 DEVICE. ETC. Call Allwin Data with the appropriate information. OR HYDROPHILIC. FOAM OR FABRIC.G. WITH LEG BAG. WITH OR WITHOUT COATING (TEFLON. PER 18 SQUARE INCHES ADHESIVE REMOVER OR SOLVENT (FOR TAPE. EACH URINARY SUSPENSORY WITHOUT LEG BAG. ANY TYPE. RIGID OR EXPANDABLE. PER SET APPLIANCE CLEANER. WITH OR WITHOUT TUBE URINARY LEG BAG. WITH STRAPS. NON-WATERPROOF. INCONTINENCE AND OSTOMY APPLIANCES. ADHESIVE SKIN ATTACHMENT NON-COVERED ITEM OR SERVICE Explanations of Notes Column NMN NC NARR CR CMN Not Medically Necessary. A silicone gel sheet (A6025) use for the treatment of keloids or other scars does not meet the definition of the surgical dressing benefit and will be denied as noncovered. or to cover wounds to allow for autolytic debridement are covered although the agents themselves are noncovered. An exception is an alginate or other fiber gelling dressing wound cover or a saline. Surgical dressings are covered for as long as they are medically necessary. and transparent film.g.Updated Winter 2004 XIV . It may not be appropriate to use some combinations of a hydrating dressing on the same wound at the same time as an absorptive dressing (e..g... Use of more than one type of wound filler or more than one type of wound cover in a single wound is rarely medically necessary and the reasons must be well documented. or A first degree burn.g. irrigation or wet-to-dry dressings). chemical (e. skin tear or abrasion. They are medically necessary when debridement of a wound is medically necessary. when used as secondary dressings.. (Refer to Coding Guidelines) Examples of situations in which dressings are noncovered under the Surgical Dressings benefit are: a) b) c) d) e) Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure. or treated by. When a wound cover with an adhesive border is being used. Surgical dressings used in conjunction with investigational wound healing therapy (e. hydrogel and alginate). intravascular.. Reasons for use of additional tape must be well documented.e. appropriate clinical judgment should be used to avoid their use with primary dressings which require more frequent dressing changes. nephrostomy. platelet derived wound healing formula) may be covered if all applicable coverage criteria are met based on the number and type of surgical dressings that are appropriate to treat the wound if the investigational therapy were not being used.g. application of occlusive dressings to an open wound). water. no other dressing is needed on top of it and additional tape is usually not required. blood sample) other than the site of an indwelling catheter or needle.e. to cover chemical debriding agents. Debridement of a wound may be any type of debridement (examples given are not allinclusive): surgical (e. or autolytic (e. Surgical dressings include both primary dressings (i.. or A venipuncture or arterial puncture site (e. or 2. The surgical procedure or debridement must be performed by a physician or other healthcare professional to the extent permissible under State law. therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin) or secondary dressings (i. When claims are submitted for these dressings for changes greater than once every other day. or A Stage I pressure ulcer.g.) are covered as long as the catheter or tube remains in place and after removal until the wound heals. topical application of enzymes).. a surgical procedure.g. They are medically necessary for the treatment of a wound caused by. etc..g.. sharp instrument or laser). or hydrogel impregnated gauze dressing which might need an additional wound cover. are meant to be changed at frequencies less than daily.g.e.SURGICAL DRESSINGS Coverage and Payment Rules Surgical dressings are covered when either of the following criteria are met: 1. Dressings over a percutaneous catheter or tube (e.g. Because composite dressings. Dressings used for mechanical debridement.. the quantity in excess of that amount will be denied as not medically Page 46 . materials that serve a therapeutic or protective function and that are needed to secure a primary dressing). epidural. foam and hydrocolloid wound covers. mechanical (e. An adhesive border is usually more binding than that obtained with separate taping and is therefore indicated for use with wounds requiring less frequent dressing changes. or Wounds caused by trauma which do not require surgical closure or debridement .. durable medical equipment (infusion pumps) or prosthetic devices (parenteral and enteral nutrition. When surgical dressings are provided in kits. enzymatic debriding agents. These may or may not have an adhesive border. saline). weekly) in the early phases of wound treatment and/or with heavily draining wounds. Dressing size must be based on and appropriate to the size of the wound. No more than a one month's supply of dressings may be provided at one time. A6456) are woven or non-woven materials into which substances such as iodinated agents. For example. and (b) highly absorptive layers of fibers such as absorbent cellulose. Dressing needs may change frequently (e. Impregnated gauze dressings (A6222-A6233. that are ordered by the physician. wound cleansers (A6260) or irrigating solutions. with continued proper management the wound usually progresses to a point where the appropriate selection of these products results in the less frequent dressing changes which they are designed to allow. An even smaller quantity may be appropriate in the situations described above.) wound requires a 4 in. or rayon. Surgical dressings must be tailored to the specific needs of an individual patient. or hydrogel. For wound covers.. Hydrogel sheets used in the treatment of wounds are billed with codes A6242-A6247. the likelihood of change.. solutions used to moisten gauze (e. x 4 in. The quantity and type of dressings dispensed at any one time must take into account the current status of the wound(s). aqueous saline. A4221 with a covered Page 47 .g.. pad size. chlorhexadine gluconate (CHG). crystalline sodium chloride. and that are medically necessary are covered.e.e. An example of an inappropriate combination is the use of a specialty absorptive dressing on top of non-impregnated gauze being used as a primary dressing.g. the pad size is usually about 2 inches greater than the dimensions of the wound. Suppliers are also expected to have a mechanism for determining the quantity of dressings that the patient is actually using and to adjust their provision of dressings accordingly. gauze or other dressings used to cleanse or debride a wound but not left on the wound. foam. Coding Guidelines Composite dressings (A6200-A6205) are products combining physically distinct components into a single dressing that provides multiple functions. x 2 in. A wound pouch (A6154) is a waterproof collection device with a drainable port that adheres to the skin around a wound.g. While a highly exudative wound might require such a combination initially. only those components of the kit that meet the definition of a surgical dressing. Contact layers (A6206-A6208) are thin non-adherent sheets placed directly on an open wound bed to protect the wound tissue from direct contact with other agents or dressings applied to the wound. unless there is documentation to support the necessity of greater quantities in the home setting in an individual case.g.. but are not limited to: (a) a bacterial barrier. topical antibiotics. They are porous to allow wound fluid to pass through for absorption by an overlying dressing. an antibioticimpregnated dressing which requires a prescription) is considered a drug and is noncovered under the Surgical Dressings benefit. or other agents have been incorporated into the dressing material by the manufacturer. hydrocolloid. (b) an absorptive layer other than an alginate or other fiber gelling dressing.and are included in supply allowance codes .g. water. A6266. and the recent use of dressings. Specialty absorptive dressings (A6251-A6256) are unitized multi-layer dressings which provide (a) either a semi-adherent quality or nonadherent layer. topical antiseptics. bismuth tribromophenate (BTP). When dressings are covered under other benefits . a 5 cm x 5 cm (2 in. cotton.. Also. The following are examples of wound care items which are noncovered under the surgical dressing benefit: skin sealants or barriers (A6250). silicone gel sheets. hydrogel. any item listed in the latest edition of the Orange Book (e. tracheostomy ) . zinc paste. and (c) either a semi-adherent or nonadherent property over the wound site.Updated Winter 2004 necessary. petrolatum. These functions must include. Code A6025 should only be used for gel sheets used for the treatment of keloids or other scars. if a single dressing is divided into multiple portion/pieces. pillows. 1/2 fluid ounce). (instead of fluid ounces or grams). spiral.. Wound fillers come in hydrated forms (e. some pastes or gels are labeled as grams (instead of fluid ounces). 1 fluid ounce.. the code to be used is determined by the pad size. the units on the package do not correspond to the units of the code. If the individual product is packaged as a fraction of a unit (e. hydrogel). Roll bandages that do not contain these fibers are considered non-elastic bandages even though many of them (e. A6241). A6231-A6233. polyester. or maintain a moist wound surface. collagen wound filler (A6010. x 6 in. Codes A6442-A6447 describe roll gauze-type bandages made either of cotton or of synthetic materials such as nylon. gauze. beads). The units of service for wound fillers are 1 gram. Gauze or gauze-like products are typically manufactured as a single piece of material folded into a several ply gauze pad. or ml. These bandages are stretchable. etc.. and non-impregnated packing strips (A6407). For example. pad size 16 sq. powder.. alginate or other fiber gelling wound filler (A6199). Elastic bandages are those that contain fibers of rubber (latex. Dressings over infusion access entry sites not used in conjunction with covered use of infusion pumps.. the supplier must contact the manufacturer to determine the appropriate conversion factor or unit of service which corresponds to the code. collagen. hydrogel wound filler (A6248). granules.they may not be separately billed using the surgical dressing codes. rayon.. B4034-B4036 with enteral nutrition. A6024). absorb exudate. not by the outside adhesive border dimensions. border on each side is coded as A6237. Codes A6451 and A6452 describe elastic bandages that produce moderate or high compression that is sustained typically for one week.g. the code and quantity billed must represent the originally manufactured size and quantity. B4224 with parenteral nutrition.i. if eleven (11) 1/2 oz.. some wound fillers are labeled as cc. spandex. Multi-component products may not be unbundled and billed as the separate components of the dressing. or other forms such as rope. pad surrounded by a 1 in. some are described by linear dimensions (instead of grams). In these situations. For all dressings. or over catheter/tube entry sites into a body cavity (other than tracheostomy) are billed separately using the appropriate surgical dressing code. pastes. bill 6 units (11 x 1/2 = 5.A6450 describe ACE type elastic bandages. documentation from the manufacturer verifying that the performance characteristics specified in the code narratives have Page 48 . foam wound filler (A6215). gauze bandages) are stretchable. hydrocolloid wound filler (A6240. x 4 in. on request from the DMERC. 6 inch length. " . which has a 4 in. For certain materials.e. Wound fillers not falling into any of these categories are coded as A6261 or A6262. hydrocolloid. but do not contain elastic fibers.g.g." Products containing multiple materials are categorized according to the clinically predominant component (e. viscose. Some wound covers are available both without and with an adhesive border. unique codes have been established . dry forms (e. Impregnated dressings that are listed in the FDA Orange Book must be billed using code A9270 and must not be billed using codes A6222-A6224. polyamide. inch or less. foam.. For some wound fillers. A6011.5. or elastane. Other multi-component wound dressings not containing these specified components may be classified as composite or specialty absorptive dressings if the definition of these categories has been met. or A6266. Coding must be based on the functional size of the pad as it is commonly used in clinical practice. Codes A6448 . A wound cover with adhesive border is one which has an integrated cover and distinct adhesive border designed to adhere tightly to the skin. For example. tubes of a wound filler are dispensed. A4625 or A4629 with a tracheostomy . Wound fillers are dressing materials which are placed into open wounds to eliminate dead space. gels). Wound covers are flat dressing pads.. For example. They are commonly included in multi-layer compression bandage systems. round to 6). a hydrocolloid dressing with outside dimensions of 6 in. determine the units billed by multiplying the number dispensed times the individual product size and rounding to the nearest whole number. Suppliers billing these new codes must be able to provide. alginate.g.g. These codes include short-stretch bandages. For wound covers with an adhesive border. or one yard depending on the product.. neoprene).Updated Winter 2004 infusion pump. e. Current clinical information which supports the reasonableness and necessity of the type and quantity of surgical dressings provided must be present in the patient's medical records. if a manufacturer has a product consisting of two components which are designed to be worn simultaneously on the same leg. (b) the size of the dressing (if appropriate). Information defining the number of surgical/debrided wounds being treated with a dressing. A6452).g. self-adherent bandages (A6454). When multi-layer compression bandage systems are used for the treatment of a venous stasis ulcer. do not use modifiers A1-A9. nursing home. use code A4649. a product which consists of an unzippered liner and a zippered stocking. When dressings are provided in non-covered situations (e. hydrogel wound filler. However a new order is required at least every 3 months for each dressing being used even if the quantity used has remained the same or decreased. Modifiers A1 – A9 have been established to indicate that a particular item is being used as a primary or secondary dressing on a surgical or debrided wound and also to indicate the number of wounds on which that dressing is being used. or home care nurse. non-sterile elastic roll gauze (A6263). hydrocolloid wound cover.. and (e) the expected duration of need.g. and made available to the DMERC upon request. one unit of service is generally for one stocking. and padding bandages (A6441).g..." These items can be billed through the Allwin system by using a Processor Control Number of USNONCOVER. The modifier number must correspond to the number of wounds on which the dressing is being used. the reason for dressing use (e. the two components must be billed as one claim line with one unit of service – e. the A2 modifier must be used with that HCPCS code. debrided wound. a GY modifier must be added to the code and a brief description of the reason for non-coverage included -. each component is billed using a specific code for the component . in the instance that a beneficiary has more than one wound the pharmacy will need to transmit the proper A2-A9 modifier directly following the appropriate HCPCS code for the item. (d) the frequency of dressing change. Documentation Requirements An order for each item billed must be signed and dated by the treating physician. When multi-layer compression bandage systems are used for the treatment of a venous stasis ulcer. For example. etc. The source of that information and date obtained must be documented in the supplier's records. and whether the dressing is being used as a primary or secondary dressing or for some noncovered use (e. if available -. kept on file by the supplier. each component is billed using a specific code for the component. if the patient has four (4) wounds but a particular dressing is only used on two (2) of them. Evaluation of a patient's wound(s) must be performed at least on a monthly basis unless there is documentation in the medical record which justifies why an evaluation could not be done Page 49 . moderate or high compression bandages (A6451.).. surgical wound.g. zinc paste impregnated bandage (A6456).Updated Winter 2004 been met. A new order is needed if a new dressing is added or if the quantity of an existing dressing to be used is increased. "A6216GY -.. conforming bandages (A6443. elastic bandage (A4460). Impregnated roll gauze dressings designed for the treatment of venous stasis ulcers are coded using A6266. If there is no specific code to describe the component.e.g. If the dressing is not being used as a primary or secondary dressing on a surgical or debrided wound. However.e.).g. use of gauze in the cleansing of a wound or intact skin). A new order is not routinely needed if the quantity of dressings used is decreased... For the compression stocking codes L8110 and L8120. non-sterile non-elastic roll gauze (A6264). The Allwin Data system will always default to using A1 as the modifier on surgical dressing claims.g.. A6444). not the total number of wounds treated.g. wound cleansing) must be obtained from the physician. The order must specify (a) the type of dressing (e. (c) the number/amount to be used at one time (if more than one).used for wound cleansing. etc. However a brief statement documenting the medical necessity of any quantity billed which exceeds the quantity needed for the usual dressing change frequency stated in the policy must be submitted with the claim.. EY. When codes A4649. EACH ALGINATE OR OTHER FIBER GELLING DRESSING. OR LESS. GEL/PASTE. IN. The evaluation may be performed by a nurse. IN. PER GRAM OF COLLAGEN COLLAGEN DRESSING.. its location. If A9 is used. PAD SIZE 16 SQ. EACH SURGICAL SUPPLY. WOUND COVER.) and depth. and any other relevant information. burn. If necessary the pharmacy can have Allwin Data input a quantity conversion so that the pharmacy may bill in total number of rolls.g. PER 18 SQUARE INCHES TAPE. OR LESS. WATERPROOF. PER 6 INCHES WOUND POUCH. BUT LESS THAN OR EQUAL TO 48 SQ. its size (length x width in cm. IN. surgical wound. PAD SIZE MORE THAN 48 SQ. PER 18 SQUARE INCHES ABDOMINAL DRESSING HOLDER. WOUND COVER. IN. BUT LESS THAN OR EQUAL TO 48 SQ. the claim must include a narrative description of the item (including size of the product provided). EACH DRESSING ALGINATE OR OTHER FIBER GELLING DRESSING. When surgical dressings are billed. This evaluation must include the type of each wound (e. weekly) in patients in a nursing facility or in patients with heavily draining or infected wounds. MISCELLANEOUS COLLAGEN BASED WOUND FILLER. All claims for tape must be billed per 18 sq. information must be submitted with the claim indicating the number of wounds.g. this narrative information may also be added at the Allwin Data website. EACH COLLAGEN DRESSING. and information justifying the medical necessity for the item. EACH COLLAGEN DRESSING WOUND FILLER. or GY) must be added to the code when applicable. EACH DRESSING Page 50 12 30 NARR Quantity Notes A6197 A6198 30 30 . IN. PAD SIZE MORE THAN 16 SQ. EACH COLLAGEN DRESSING. WOUND COVER. physician or other health care professional. IN... Claim Transmission Allwin Data will reject any surgical dressing claim that exceeds Medicare’s allowable monthly quantity for one wound. AW. etc). inches of tape. PAD SIZE MORE THAN 48 SQ. the manufacturer. HCPCS Codes HCPCS A4450** A4452** A4462 A4649 A6010 A6011 A6021 A6022 A6023 A6024 A6154 A6196 Description (All quantity limitations are based per wound) TAPE. NON-WATERPROOF. the brand name or number. This information does not have to be routinely submitted with each claim. IN. DRY FORM. Evaluation is expected on a more frequent basis (e. PAD SIZE MORE THAN 16 SQ. the amount of drainage. A6261 or A6262 are billed.Updated Winter 2004 within this timeframe and what other monitoring methods were used to evaluate the patient's need for dressings. PAD SIZE 16 SQ. PER GRAM OF COLLAGEN COLLAGEN BASED WOUND FILLER. the appropriate modifier (A1 – A9. pressure ulcer. In those cases where the pharmacy wishes to bill for more than the usual quantity allowed by Medicare it will be necessary to call Allwin and have a narrative attached to the claim explaining medical necessity. EACH DRESSING ALGINATE OR OTHER FIBER GELLING DRESSING... IN. This statement may be attached to a hard copy claim or entered in the HA0 record of an electronic claim. WITH ANY SIZE ADHESIVE BORDER. WITHOUT ADHESIVE BORDER. IN. PAD SIZE MORE THAN 16 SQ.. IN.. WITHOUT ADHESIVE BORDER. WOUND COVER. PAD SIZE 16 SQ. EACH DRESSING GAUZE. IN. WITHOUT ADHESIVE BORDER. IN. IN. EACH DRESSING FOAM DRESSING. EACH DRESSING GAUZE. PAD SIZE 16 SQ. EACH DRESSING GAUZE. MORE THAN 48 SQ. OR LESS. NON-IMPREGNATED. PAD SIZE MORE THAN 16 SQ. PAD SIZE 16 SQ. BUT LESS THAN OR EQUAL TO 48 SQ. PAD SIZE MORE THAN 16 SQ.Updated Winter 2004 ALGINATE OR OTHER FIBER GELLING DRESSING.. WOUND FILLER. WITH ANY SIZE ADHESIVE BORDER. BUT LESS THAN OR EQUAL TO 48 SQ.. WITHOUT ADHESIVE BORDER. BUT LESS THAN OR EQUAL TO 48 SQ. NON-IMPREGNATED. IN. IN. EACH DRESSING CONTACT LAYER. PAD SIZE 16 SQ. OR LESS. WOUND COVER. IN. PAD SIZE MORE THAN 16 SQ. WITH ANY SIZE ADHESIVE BORDER.. EACH DRESSING COMPOSITE DRESSING.. PAD SIZE MORE THAN 48 SQ. OR LESS. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN. WITH ANY SIZE ADHESIVE BORDER. WITH ANY SIZE ADHESIVE BORDER.. IN. IN. EACH DRESSING COMPOSITE DRESSING. OR LESS. PER GRAM GAUZE. WOUND COVER. NON-IMPREGNATED. PAD SIZE 16 SQ. EACH DRESSING CONTACT LAYER. PAD SIZE MORE THAN 48 SQ. PAD SIZE MORE THAN 48 SQ. IN. EACH DRESSING FOAM DRESSING. NON-STERILE. IN. IN. WITH ANY SIZE ADHESIVE BORDER. IN. WOUND FILLER. PAD SIZE MORE THAN 48 SQ. IN. OR LESS.. EACH DRESSING FOAM DRESSING.. BUT LESS THAN OR EQUAL TO 48 SQ. PAD SIZE MORE THAN 16 SQ. 16 SQ. MORE THAN 16 SQ. NON-IMPREGNATED. EACH DRESSING FOAM DRESSING. NON-IMPREGNATED. OR LESS. EACH DRESSING FOAM DRESSING. BUT LESS THAN OR EQUAL TO 48 SQ.. EACH DRESSING FOAM DRESSING.. WITH ANY SIZE ADHESIVE BORDER. NON-STERILE. OR LESS. IN. EACH DRESSING COMPOSITE DRESSING. EACH DRESSING GAUZE. IN. WITHOUT ADHESIVE BORDER. WITH ANY SIZE ADHESIVE BORDER. EACH DRESSING CONTACT LAYER. IN. EACH DRESSING FOAM DRESSING. PAD SIZE 16 SQ. EACH DRESSING COMPOSITE DRESSING. NON-IMPREGNATED.. IN. IN. PAD SIZE MORE THAN 16 SQ. WITHOUT ADHESIVE BORDER. PAD SIZE MORE THAN 48 SQ. WITHOUT ADHESIVE BORDER. WOUND COVER. NON-STERILE.. IN. WITH ANY SIZE ADHESIVE BORDER. IN. EACH DRESSING GAUZE. WITHOUT ADHESIVE BORDER. WITHOUT ADHESIVE BORDER. IN. IN. WOUND COVER. WOUND COVER.. EACH DRESSING A6199 A6200 A6201 A6202 A6203 30 12 12 12 12 A6204 A6205 A6206 A6207 A6208 A6209 12 12 4 4 4 12 A6210 A6211 A6212 12 12 12 A6213 A6214 A6215 A6216 12 12 60 90 A6217 A6218 A6219 90 90 30 A6220 A6221 30 30 Page 51 . IN. EACH DRESSING COMPOSITE DRESSING. PAD SIZE MORE THAN 48 SQ. IN. PER 6 INCHES COMPOSITE DRESSING. BUT LESS THAN OR EQUAL TO 48 SQ. HYDROGEL FOR DIRECT WOUND CONTACT. EACH DRESSING GAUZE. BUT LESS THAN OR EQUAL TO 48 SQ. WITH ANY SIZE ADHESIVE BORDER. WATER OR NORMAL SALINE. WOUND COVER. IMPREGNATED.. IMPREGNATED WITH OTHER THAN WATER. IN. WOUND FILLER. PAD SIZE 16 SQ. WITHOUT ADHESIVE BORDER. IN. WOUND COVER. PAD SIZE MORE THAN 16 SQUARE INCHES. PAD SIZE 16 SQ. EACH DRESSING GAUZE. WITHOUT ADHESIVE BORDER. OR LESS. IN. WITH ANY SIZE ADHESIVE BORDER. PER GRAM HYDROGEL DRESSING. EACH DRESSING HYDROCOLLOID DRESSING. PAD SIZE 16 SQ.Updated Winter 2004 GAUZE. WATER OR NORMAL SALINE. EACH DRESSING GAUZE. NORMAL SALINE. IN. WITHOUT ADHESIVE BORDER. IN. EACH DRESSING HYDROGEL DRESSING. EACH DRESSING GAUZE... PAD SIZE MORE THAN 16 SQ.. FOR DIRECT WOUND CONTACT. WITHOUT ADHESIVE BORDER. IMPREGNATED WITH OTHER THAN WATER. WITHOUT ADHESIVE BORDER. WITHOUT ADHESIVE BORDER. WITHOUT ADHESIVE BORDER. IN. PAD SIZE 16 SQ. EACH DRESSING HYDROCOLLOID DRESSING. OR HYDROGEL. IN. WATER OR NORMAL SALINE. PAD SIZE MORE THAT 16 SQ. PAD SIZE MORE THAN 48 SQ. EACH DRESSING HYDROGEL DRESSING. IMPREGNATED. PAD SIZE MORE THAN 48 SQ. EACH DRESSING GAUZE. PAD SIZE 16 SQ. PAD SIZE 16 SQ. IMPREGNATED WITH OTHER THAN WATER. IMPREGNATED. IN. WITH ANY SIZE ADHESIVE BORDER. IN... NORMAL SALINE. PAD SIZE MORE THAN 48 SQ. FOR DIRECT WOUND CONTACT. PAD SIZE GREATER THAN 16 SQ. OR LESS. OR LESS. IN. WITHOUT ADHESIVE BORDER. EACH DRESSING HYDROCOLLOID DRESSING. PASTE. IMPREGNATED. BUT LESS THAN OR EQUAL TO 48 SQ. EACH DRESSING A6222 30 A6223 30 A6224 A6228* 30 90 NMN A6229* A6230* A6231 90 90 12 NMN NMN A6232 A6233 A6234 12 12 12 A6235 A6236 A6237 12 12 12 A6238 A6239 A6240 A6241 A6242 12 12 24 24 30 A6243 A6244 A6245 30 30 12 Page 52 . PAD SIZE MORE THAN 48 SQUARE INCHES. WOUND COVER. PAD SIZE MORE THAN 48 SQ. BUT LESS THAN OR EQUAL TO 48 SQUARE INCHES. EACH DRESSING HYDROCOLLOID DRESSING.. WOUND COVER. BUT LESS THAN OR EQUAL TO 48 SQ. IN. WOUND COVER. IN. IN. PAD SIZE MORE THAN 48 SQ. EACH DRESSING GAUZE. WOUND COVER. WOUND COVER.. EACH DRESSING GAUZE. WOUND FILLER. IN. IN. WITHOUT ADHESIVE BORDER. WOUND COVER. EACH DRESSING GAUZE. OR LESS. IN. DRY FORM. BUT LESS THAN OR EQUAL TO 48 SQ. IN. IN. HYDROGEL. WITHOUT ADHESIVE BORDER.. IMPREGNATED. EACH DRESSING HYDROCOLLOID DRESSING. BUT LESS THAN OR EQUAL TO 48 SQ. WITH ANY SIZE ADHESIVE BORDER. OR LESS. PAD SIZE MORE THAN 16 SQ. IN. EACH DRESSING HYDROGEL DRESSING. IN.. OR LESS. OR HYDROGEL. PAD SIZE MORE THAN 16 SQ. PAD SIZE 16 SQ. WOUND COVER. IN. EACH DRESSING HYDROCOLLOID DRESSING. WOUND COVER. HYDROGEL. WITHOUT ADHESIVE BORDER. EACH DRESSING HYDROCOLLOID DRESSING. OR HYDROGEL. IMPREGNATED. IN.. PER FLUID OUNCE HYDROCOLLOID DRESSING. OR LESS. WITHOUT ADHESIVE BORDER. NORMAL SALINE. WOUND COVER. STERILE. ANY WIDTH.. EACH DRESSING HYDROGEL DRESSING. EACH DRESSING SPECIALTY ABSORPTIVE DRESSING. ANY SIZE SPECIALTY ABSORPTIVE DRESSING. EACH DRESSING HYDROGEL DRESSING. NORMAL SALINE. EACH EYE PAD. NOT ELSEWHERE CLASSIFIED WOUND FILLER. IN. WITHOUT ADHESIVE BORDER. ANY TYPE. EACH DRESSING GAUZE. LESS THAN OR EQUAL TO 2 INCHES.. EACH DRESSING WOUND CLEANSERS. IN. MOISTURIZERS. PAD SIZE 16 SQ. IN. WITHOUT ADHESIVE BORDER. IN. IN. WITH ANY SIZE ADHESIVE BORDER. WOUND COVER. EACH DRESSING SPECIALTY ABSORPTIVE DRESSING. WOUND COVER. EACH EYE PATCH. OR ZINC PASTE. PAD SIZE MORE THAN 48 SQ. IN. EACH DRESSING TRANSPARENT FILM. ANY SIZE WOUND FILLER. WITHOUT ADHESIVE BORDER. IN. WOUND FILLER. OR LESS.. NOT ELSEWHERE CLASSIFIED GAUZE. IN. WITH ANY SIZE ADHESIVE BORDER. DRY FORM. WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES. IN.. PACKING STRIPS. STERILE. PER FLUID OUNCE SKIN SEALANTS. PAD SIZE MORE THAN 48 SQ. BUT LESS THAN OR EQUAL TO 48 SQ. PAD SIZE MORE THAN 16 SQ. IN. EACH DRESSING SPECIALTY ABSORPTIVE DRESSING. PAD SIZE 16 SQ. WITH ANY SIZE ADHESIVE BORDER. EACH DRESSING GAUZE. BUT LESS THAN OR EQUAL TO 48 SQ. WITHOUT ADHESIVE BORDER. WITH ANY SIZE ADHESIVE BORDER. IMPREGNATED.Updated Winter 2004 HYDROGEL DRESSING. LESS THAN OR EQUAL TO 48 SQ.. PER GRAM. PER LINEAR YARD GAUZE. GEL. NON-IMPREGNATED. STERILE. IN. OTHER THAN WATER. PAD SIZE 16 SQ. OR LESS. WOUND COVER. IN. WOUND COVER. NON-IMPREGNATED. WOUND COVER. EACH DRESSING TRANSPARENT FILM. BUT LESS THAN OR EQUAL TO 48 SQ. IN. OR LESS. PAD SIZE MORE THAN 48 SQ. NON-IMPREGNATED. EACH PADDING BANDAGE. PAD SIZE MORE THAN 48 SQ. OR LESS. WOUND COVER. PAD SIZE MORE THAN 16 SQ. NON-IMPREGNATED. EACH DRESSING SPECIALTY ABSORPTIVE DRESSING. NON-WOVEN/NON-KNITTED. PER YARD A6246 A6247 A6248 A6250 A6251 12 12 3 NC 30 A6252 A6253 A6254 30 30 15 A6255 A6256 A6257 A6258 A6259 A6260 A6261 A6262 A6266 A6402 15 15 12 12 12 NC NARR NARR 5 90 A6403 A6404 A6407 A6410 A6411 A6412 90 90 A6441 4 Page 53 . IN. PER FLUID OUNCE. EACH DRESSING SPECIALTY ABSORPTIVE DRESSING.. PAD SIZE MORE THAN 16 SQ. WITHOUT ADHESIVE BORDER. EACH DRESSING GAUZE. OCCLUSIVE.. BUT LESS THAN OR EQUAL TO 48 SQ. IN. MORE THAN 48 SQ. WITH ANY SIZE ADHESIVE BORDER. PROTECTANTS. PAD SIZE MORE THAN 16 SQ.. IN. 16 SQ. OINTMENTS.. ANY TYPE. IN. IN. NON-ELASTIC. NON-STERILE. GEL/PASTE. STERILE. IN. EACH DRESSING TRANSPARENT FILM. WOUND COVER. PER LINEAR YARD EYE PAD. WITHOUT ADHESIVE BORDER. MORE THAN 16 SQ.. WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES. KNITTED/ WOVEN. NON-ELASTIC. NON-ELASTIC. PER YARD CONFORMING BANDAGE. WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES. WIDTH GREATER THAN OR EQUAL TO 5 INCHES. PER YARD MODERATE COMPRESSION BANDAGE. NON-KNITTED/ NON-WOVEN. PER YARD CONFORMING BANDAGE. CUSTOM FABRICATED COMPRESSION BURN GARMENT. WIDTH GREATER THAN OR EQUAL TO 5 INCHES. PER YARD CONFORMING BANDAGE. GLOVE TO ELBOW.35 FOOT POUNDS AT 50% MAXIMUM STRETCH. NONSTERILE. ELASTIC. CUSTOM FABRICATED COMPRESSION BURN GARMENT. WIDTH GREATER THAN OR EQUAL TO 3 INCHES OR LESS THAN 5 INCHES. CUSTOM FABRICATED COMPRESSION BURN GARMENT. FOOT TO KNEE LENGTH. CUSTOM FABRICATED COMPRESSION BURN GARMENT. GLOVE TO WRIST. PER YARD SELF-ADHERENT BANDAGE. NON-ELASTIC. CUSTOM FABRICATED COMPRESSION BURN GARMENT. ELASTIC. ELASTIC. STERILE. CUSTOM FABRICATED A6442 A6443 A6444 4 4 A6446 A6447 4 4 A6449 A6450 4 4 A6451 4 A6452 4 A6454 A6456 A6501 A6502 A6503 A6504 A6505 A6506 A6507 A6508 A6509 A6510 Page 54 . INCLUDING ARMS DOWN TO LEG OPENINGS (LEOTARD). NONSTERILE. NON-ELASTIC. KNITTED/ WOVEN. GLOVE TO AXILLA. KNITTED/WOVEN. FOOT TO THIGH LENGTH. NON-ELASTIC. UPPER TRUNK TO WAIST INCLUDING ARM OPENINGS (VEST). PER YARD HIGH COMPRESSION BANDAGE. CUSTOM FABRICATED COMPRESSION BURN GARMENT. ELASTIC. PER YARD ZINC PASTE IMPREGNATED BANDAGE. LOAD RESISTANCE GREATER THAN OR EQUAL TO 1. CUSTOM FABRICATED COMPRESSION BURN GARMENT. PER YARD COMPRESSION BURN GARMENT.Updated Winter 2004 CONFORMING BANDAGE. WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES PER YARD CONFORMING BANDAGE. NONSTERILE.25 TO 1. STERILE.34 FOOT POUNDS AT 50% MAXIMUM STRETCH. KNITTED/ WOVEN. KNITTED/ WOVEN. FACIAL HOOD. TRUNK. KNITTED/WOVEN. KNITTED/WOVEN. WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES. ELASTIC. WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES. KNITTED/WOVEN. CUSTOM FABRICATED COMPRESSION BURN GARMENT. PER YARD = ONE UNIT LIGHT COMPRESSION BANDAGE. PER YARD LIGHT COMPRESSION BANDAGE. KNITTED/WOVEN. WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES. KNITTED/WOVEN. NON-ELASTIC. LOAD RESISTANCE OF 1. WIDTH LESS THAN 3 INCHES. WIDTH GREATER THAN OR EQUAL TO 5 INCHES. BODYSUIT (HEAD TO FOOT). CUSTOM FABRICATED COMPRESSION BURN GARMENT. CHIN STRAP. NOT OTHERWISE CLASSIFIED NON-COVERED ITEM OR SERVICE TUBULAR ELASTIC DRESSING. up to 3 units per dressing change. Not Covered. for wound covers measuring greater than 48 square inches. Additional tape is usually not required when a wound cover with an adhesive border is used. When these dressings are billed. Call Allwin Data with the appropriate information. CUSTOM FABRICATED COMPRESSION BURN GARMENT. Quantities of tape submitted must reasonably reflect the size of the wound cover being secured. The medical necessity for tape in these situations must be documented. payment will be based on the least costly medically appropriate alternative. Tape change is determined by the frequency of change of the wound cover. up to 4 units per dressing change. Narrative required. sterile non-impregnated gauze. for wound covers measuring 16 to 48 square inches. Bulk saline or sterile water is non-covered under the Surgical Dressings benefit. LOWER TRUNK INCLUDING LEG OPENINGS (PANTY). Page 55 . Certificate of Medical Neccessity required.Updated Winter 2004 COMPRESSION BURN GARMENT. PER LINEAR YARD NC A6511 A6512 A9270 K0620 *There is no medical necessity for these dressings compared to non-impregnated gauze that is moistened with bulk saline or sterile water. ANY WIDTH. Usual use for wound covers measuring 16 square inches or less is up to 2 units per dressing change. payment will be based on the allowance for the least costly medical appropriate alternative. Capped Rental item. Explanations of Notes Column NMN NC NARR CR CMN Not Medically Necessary. **Tape is covered when needed to hold on a wound cover. elastic roll gauze or non-elastic roll gauze. A white cane for a blind person is noncovered since it is a "self-help" item. E0149) is one which is labeled as capable of supporting patients who weigh more than 300 pounds. Page 56 . Obesity. E0116. E0143. A heavy duty. A heavy duty walker (E0148. variable wheel resistance walker (E0147) is covered for patients who meet coverage criteria for a standard walker and who are unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand. E0143. or 4 wheels. 3. payment will be based on the allowance for the least costly medically appropriate alternative. E0143. It may or may not include glide-type brakes (or equivalent). payment will be based on the allowance for the least costly medically appropriate alternative. Code E0144 describes a folding wheeled walker which has a frame that completely surrounds the patient and an attached seat in the back. The medical necessity for an underarm. has not been established. It is prescribed by a physician for a patient with a medical condition impairing ambulation and there is a potential for ambulation. and 2. E0149) is one with either 2. If an E0117 is ordered. Therefore. Leg extensions (E0158) are covered only for patients 6 feet tall or more. payment will be based on the allowance for the least costly medically appropriate alternative. Coding Guidelines A wheeled walker (E0141. E0149) is covered for patients who meet coverage criteria for a standard walker and who weigh more than 300 pounds. There is a need for greater stability and security than provided by a cane or crutches. articulating. Canes (E0100. It may be fixed height or adjustable height. is not a sufficient reason for an E0147 walker. if the basic coverage criteria for a walker are met and code E0144 is billed. It may be fixed height or adjustable height. A heavy duty walker (E0148.WALKERS. If a E0148 or E0149 walker is provided and the patient does not weigh more than 300 pounds but does meet coverage criteria for a standard walker. CANES AND CRUTCHES Coverage and Payment Rules A standard walker (E0130. The wheels may be fixed or swivel. E0105) and crutches (E0110 . multiple braking system. E0143) and related accessories are covered if both of the following criteria are met: 1. The medical necessity for a walker with an enclosed frame (E0144) compared to a standard folding wheeled walker. If an E0147 walker is provided and the coverage criteria for a standard walker are met but the additional coverage criteria for an E0147 are not met. E0143 or E0149 depending on the patient's weight. E0135. E0135 or E0143 respectively. Enhancement accessories of walkers will be denied as noncovered.Updated Winter 2004 XV . by itself. E0141.E0116) are covered when prescribed by a physician for a patient with a condition causing impaired ambulation and there is a potential for ambulation. It may be rigid or folding. A glide-type brake consists of a spring mechanism (or equivalent) which raises the leg post of the walker off the ground when the patient is not pushing down on the frame. spring assisted crutch (E0117) has not been established. payment will be based on the allowance for the least costly medically appropriate alternative. and documentation from the treating physician giving a description of the functional limitations which preclude the patient using another type of wheeled walker and the diagnosis causing this limitation. There is an additional braking mechanism on the front crossbar. and E0159 are only used to bill for replacement items for covered. 6. E0156. 4. If a gait trainer has a feature described by one of the walker attachment codes (E0154-E0157) that code may be separately billed. A Column II code is included in the allowance for the corresponding Column I code when provided at the same time and must not be billed separately at the time of billing the Column I code. Hemi-walkers must be billed using code E0130 or E0135. Hand operated brakes that cause the wheels to lock when the hand levers are released. E0157. but is not limited to style. Codes E0154. The pressure required to operate each hand brake is individually adjustable. A4637. the initial issue of a nonwheeled walker. and E0158 can be used for accessories provided with the initial issue of a walker or for replacement components. E0135). E0159 A4636. Other unique features of gait trainers are not separately payable and may not be billed with code E1399. the manufacturer. It may include. A4637. E0159 Documentation Requirements If E0147 is billed. folding-walker that has all of the following characteristics: 1. If a supplier chooses to bill separately for a feature of a gait trainer that is not described by a specific HCPCS code. A4637 A4636. A4637. patient-owned wheeled walkers or when wheels are subsequently added to a covered. The hand brakes can be set so that either or both can lock both wheels. E0155. A gait trainer is a term used to describe certain devices that are used to support a patient during ambulation. the model name or Page 57 . hand operated brakes (other than those described in code E0147). E0159 A4636. E0155. patient-owned nonwheeled walker (E0130. The only walkers that may be billed using code E0147 are those products listed in the Product Classification List on the SADMERC Web site. Use code A9270 when an enhancement accessory of a walker is billed. 3. Column I E0130 E0135 E0140 E0141 E0143 E0144 E0147 E0148 E0149 Column II A4636. When code E1399 is billed. A4637. or within one month of. not E1399. E0156. then code A9900 must be used. E0155. A4637 A4636. color. A4636. E0155. Capable of supporting patients who weigh greater than 350 pounds. or basket (or equivalent). E0155. the claim must include a narrative description of the item. A4637. the model name/number. Gait trainers are billed using one of the codes for walkers. A4637. E0159 A4636. adjustable height. Code E0155 can be used for replacements on covered. the claim must include the manufacturer's name. E0155. An enhancement accessory is one which does not contribute significantly to the therapeutic function of the walker. patient-owned walkers. 2. At least two wheels have brakes that can be independently set through tension adjustability to give varying resistance. A4637 A4636. 5. Code E0155 cannot be used for wheels provided at the time of. E0159 A4636. E0159 A4636.Updated Winter 2004 Code E0147 describes a 4-wheeled. rigid (pickup). Underarm. payment will be based on the allowance for the least costly medical appropriate alternative. Forearm. with 1 / 5yrs Tip and Handgrips Crutches. adjustable or fixed height 1 / 5yrs Rigid walker. each Durable medical equipment. rigid pickup walker. Tips and Handgrips 1 / 5yrs Crutch. walker Crutch attachment. any type. or walker. Each. Forearm.Updated Winter 2004 number (if applicable). any type. Aluminum. miscellaneous Cane. adjustable or fixed height 1 / 5yrs Walker. with Pads. walker. rigid or folding. Adjustable or Fixed. Tip and Handgrip 1 / 5yrs Crutches Underarm. Each. each 1 / 5yrs Walker. without wheels. wheeled. Adjustable or Fixed with Tips 1 / 5yrs Cane. Includes Crutches of Various Materials. with Pad. wheeled. Certificate of Medical Neccessity required. rigid or folding. Includes Canes of All Materials. Adjustable or Fixed. each Non-covered item or service Walker. cane. crutch. walker. Pair. cane. Includes Canes of All Materials. multiple braking system. and information justifying the medical necessity for the item. heavy duty. Tip and Handgrip 1 / 5yrs Notes NC NMN NARR NARR NARR NARR E0111 E0112 E0113 E0114 E0116 Explanations of Notes Column NMN NC NARR CR CMN Not Medically Necessary. Narrative required. variable wheel resistance walker 1 / 5yrs Walker. folding (pickup). Underarm. each Leg extensions for a walker. Tips and 1 / 5yrs Handgrips Crutches Underarm. with Pads. framed folding walker. Aluminum. each 1 / 5yrs Platform attachment. handgrip. Capped Rental item. per set of four (4) Brake attachment for wheeled walker. Includes Crutches of Various Material. replacement. Adjustable or Fixed. heavy duty. Page 58 . wheeled. without seat 1 / 5yrs Folding walker. each Wheel attachment. Adjustable or Fixed. crutch or walker. Quad or Three Prong. Call Allwin Data with the appropriate information. Pair. Each. per pair Seat attachment. HCPCS Codes HCPCS A4636 A4637 A9270 E0130 E0135 E0141 E0143 E0144 E0147 E0148 E0149 E0154 E0155 E0156 E0157 E0158 E0159 E1399 E0100 E0105 E0110 Description Quantity Replacement. with Pads. each Replacement tip. Pair. Adjustable or Fixed with 1 / 5yrs Tips Crutches. wheeled. Wood Adjustable or Fixed. Wood Adjustable or Fixed. without seat 1 / 5yrs Enclosed. 1 / 5yrs Complete with Tips and Handgrips Crutch. Not Covered. with posterior seat 1 / 5yrs Heavy duty. The pharmacy may enter the CMN using the Allwin Data website and transmit the claim upon acceptance of the CMN by the Allwin system. Question #3 must be answered yes for coverage to exist 3. (The fact that a patient has difficulty or is even incapable of getting up from a chair. Claim Transmission Upon receiving the completed CMN from the physician the pharmacy has two ways to get the CMN to Allwin Data before the claim can be transmitted. the patient must have the ability to ambulate. The CMN for seat lift mechanism is HCFA form 849. the supplier must bill using the appropriate code for the seat lift mechanism for use with patient owned furniture. is supplied as an individual unit to be incorporated into a chair that a patient owns.) 4. Almost all patients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms. E0629).g. E0627. particularly a low chair. if the seat lift mechanism. is not sufficient justification for a seat lift mechanism. Payment for a seat lift mechanism incorporated into a chair (E0627) is based on the allowance for the least costly alternative (E0628. However. the supplier may bill the seat lift mechanism using E0627 and A9270 for the chair. The physician's record must document that all appropriate therapeutic modalities (e. In this situation.SEAT LIFT MECHANISMS Coverage and Payment Rules A seat lift mechanism is covered if all of the following criteria are met: 1. Documentation Requirements A Certificate of Medical Necessity (CMN). can be controlled by the patient. 3. The initial claim must include a copy of the CMN. and made available to the DMERC upon request. Coverage of seat lift mechanisms is limited to those types which operate smoothly. 2. physical therapy) have been tried and failed to enable the patient to transfer from a chair to a standing position. catapult-like motion and jolts the patient from a seated to a standing position. The CMN may act as a substitute for a written order if it contains all of the required elements of an order.. medication. Question #4 must be answered yes for coverage to exist Coding Guidelines When providing a seat lift mechanism which is incorporated into a chair as a complete unit at the time of purchase. Please Page 59 . suppliers must bill the item using the established HCPCS code. The physician ordering the seat lift mechanism must be the treating physician or a consulting physician for the disease or condition resulting in the need for a seat lift. Valid CMN’S 1. Excluded from coverage is the type of lift which operates by spring release mechanism with a sudden. signed and dated by the treating physician. E0628 or E0629. must be kept on file by the supplier. which has been completed. Coverage is limited to the seat lift mechanism. The patient must be completely incapable of standing up from a regular armchair or any chair in their home. electric or non-electric. or the pharmacy may fax the CMN to Allwin Data for processing. Either question #1 or question #2 must be answered yes for coverage to exist 2. Once standing.Updated Winter 2004 XVI . and effectively assist a patient in standing up and sitting down without other assistance. The patient must have severe arthritis of the hip or knee or have a severe neuromuscular disease. or arrest or retard deterioration in the patient's condition. even if it is incorporated into a chair (E0627). The seat lift mechanism must be a part of the physician's course of treatment and be prescribed to effect improvement. Page 60 . Call Allwin Data with the appropriate information. Not Covered. The chair component may be billed using Processor Control Number USNONCOVER as HCPCS A9270. Narrative information will need to be attached to the claim by calling an Allwin representative or entering the information on the Allwin website. payment will be based on the allowance for the least costly medical appropriate alternative. Capped Rental item.Updated Winter 2004 allow 24 hrs for processing when the CMN is faxed to Allwin Data. HCPCS Codes HCPCS E0627 E0628 E0629 Description 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) Quantity 1 / 5yrs 1 / 5yrs 1 / 5yrs Notes CMN CMN CMN Explanations of Notes Column NMN NC NARR CR CMN Not Medically Necessary. Narrative required. Certificate of Medical Neccessity required. or to get in or out of bed. Page 61 . and E0295) is covered if the patient meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate need for a change in body position. A heavy duty extra wide hospital bed (E0301. Pillows or wedges must have been considered and ruled out. E0261.HOSPITAL BEDS Coverage and Payment Rules A fixed height hospital bed (E0250. E0910 is noncovered when used on an ordinary bed. to change body position for other medical reasons. E0294. chronic pulmonary disease. wheelchair or standing position. payment will be based on the allowance for the least costly medically appropriate alternative. An extra heavy duty hospital bed (E0302. A bed cradle (E0280) is covered when it is necessary to prevent contact with the bed coverings. E0310) are covered when they are required by the patient's condition and they are an integral part of. The patient requires traction equipment.E0940) is covered if the patient needs this device to sit up because of a respiratory condition. A semi-electric hospital bed (E0260. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain. If a patient's condition requires a replacement innerspring mattress (E0271) or foam rubber mattress (E0272) it will be covered for a patient owned hospital bed. Accessories Trapeze equipment (E0910. or an accessory to. or 4. A variable height hospital bed (E0255. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed. but does not exceed 600 pounds. E0292. A total electric hospital bed (E0265. and E0291) is covered if one or more of the following criteria are met: 1. if documentation does not support the medical necessity of the type of bed billed. E0290. E0293) is covered if the patient meets one of the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to chair. a hospital bed.see Coding Guidelines). or 3. or 2. E0256. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. E0304) is covered if the patient meets one of the criteria for a hospital bed and the patient's weight exceeds 600 pounds. the height adjustment feature is a convenience feature. E0296. A bed cradle (E0280) is covered when it is necessary to prevent contact with the bed coverings. or problems with aspiration. Side rails (E0305. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure. E0251. which can only be attached to a hospital bed. E0303) is covered if the patient meets one of the criteria for a fixed height hospital bed and the patient's weight is more than 350 pounds. and E0297) is not covered. If the patient does not meet any of the coverage criteria for any type of hospital bed it will be denied as not medically necessary. E0315) is noncovered since it is not primarily medical in nature. A bed board (E0273.Updated Winter 2004 XVII . E0266. For any of the above hospital beds (plus those coded E1399 . E0310 E0305. but less than 600 pounds. It may consist of a frame. Column I E0250 E0251 E0255 E0256 E0260 E0261 E0265 E0266 E0290 Column II E0271. E0292.02A. or 5 are answered YES. An ordinary bed is one. E0291) is covered when one or more of questions 1. 3. If this bed is billed. 4. E1399 should be used for products not described by the specific HCPCS codes above. or 5 are answered YES on CMN01. 6. Valid CMN’s 1. box spring and mattress.02A. E0310 E0271. 5. the height adjustment feature is a convenience feature. 4. E0290. E0272. E0310 E0305. 4. E0261. E0305.Updated Winter 2004 An over bed table (E0274. A semi-electric hospital bed (E0260. E0310 E0271. E0297) is not covered. E0302 and E0304 are hospital beds that are capable of supporting a patient who weighs more than 600 pounds.a heavy (or extra heavy) duty bed without a mattress (as when used with a support surface for the treatment of pressure ulcers). A fixed height hospital bed (E0250. for example . or 5 are answered YES. E0293) is covered when one or more of questions 1. 4. 4. E0296.02A and the patient weighs more than 600 pounds. 2. or 5 are answered YES on CMN 01. A variable height hospital bed is one with manual height adjustment and with manual head and leg elevation adjustments. E0310 E0271. E0272.02A and the patient weighs more than 350 pounds. Coding Guidelines A fixed height hospital bed is one with manual head and leg elevation adjustments but no height adjustment. which is typically sold as furniture. A total electric hospital bed (E0265. It is a fixed height and has no head or leg elevation adjustments. 3. A extra heavy duty hospital bed (E0304) is covered when or more of questions 1. A variable height hospital bed (E0255. 3. E0294. E0266. or 5 is answered YES on CMN01. A total electric bed is one with electric height adjustment and with electric head and leg elevation adjustments. 3.02A. E0251. E0305. E0310 E0305. E0295) is covered when one or more of questions 1. E0301 and E0303 are hospital beds that are capable of supporting a patient who weighs more than 350 pounds. 4. E0316 is a safety enclosure used to prevent a patient from leaving the bed. 3. E0272. and question 6 is answered YES on CMN 01. A heavy duty extra wide hospital bed (E0303) is covered when or more of questions 1. E0310 E0271. E0256. E0305. A semi-electric bed is one with manual height adjustment and with electric head and leg elevation adjustments. payment will be based on the least costly alternative. but no more than 600 pounds. E0272 Page 62 . and question 7 is answered YES on CMN 01. E0315) is noncovered because it is not primarily medical in nature. E0305. E0310 E0305. A Column II code is included in the allowance for the corresponding Column I code when provided at the same time and must not be billed separately at the time of billing the Column I code. 3. E0272. without mattress Quantity Notes CMN/CR CMN/CR CMN/CR CMN/CR Variable Height Beds HCPCS E0255 E0256 Description Hospital bed. Information that describes the necessity for the bed. and. E0310 When mattress or bedside rails are provided at the same time as a hospital bed. E0272. Please allow 24 hrs for processing when the CMN is faxed to Allwin Data. E0305. Allwin Data will attach the proper capped-rental modifiers only if the claim shows a date written that is accurate with the beginning of the rental period. fixed height. E0310 E0305. with mattress Hospital bed. The initial claim for a hospital bed must include a copy of the CMN if filed hard copy. with any type side rails. Documentation Requirements The supplier must keep on file a Certificate of Medical Necessity (CMN) that has been completed. with mattress Hospital bed. with any type side rails. E0272 E0271.Updated Winter 2004 E0292 E0294 E0296 E0301 E0302 E0303 E0304 E0271. fixed height. use the single code that combines these items. fixed height. HCFA Form 841. E0310 E0271. If you are unsure of what date is showing up in the date written field please call Allwin Data following your first transmission of a capped rental item in the middle of the rental period. with any type side rails. The manufacturer and model/product name/number of the bed. or the pharmacy may fax the CMN to Allwin Data for processing. without side rails. The pharmacy may enter the CMN using the Allwin Data website and transmit the claim upon acceptance of the CMN by the Allwin system. variable height (hi-lo). and. with any type side rails. Allwin Data will automatically attach all required capped rental modifiers. without side rails. with mattress Hospital bed. without mattress Quantity Notes CMN/CR CMN/CR Page 63 . without mattress Hospital bed. it must be signed and dated by the treating physician and kept on file by the supplier. If there is also a written order for a hospital bed and accessories. A claim for code E1399 must be accompanied by: • • • A Hospital Bed CMN. Claim Transmission Upon receiving the completed CMN from the physician the pharmacy has two ways to get the CMN to Allwin Data before the claim can be transmitted. signed and dated by the treating physician. that must include the patient's weight. E0272 E0271. variable height (hi-lo). Should you begin processing through Allwin Data halfway through a capped rental period. E0272. fixed height. E0305. E0310 E0271. HCPCS Codes Fixed Height Beds HCPCS E0250 E0251 E0290 E0291 Description Hospital bed. E0272 E0305. and height adjustments). without side rails. foam rubber Bed board Over-bed table Bed cradle. extra wide. with mattress Hospital bed. without side rails. with any type side rails. without side rails. with weight capacity greater than 600 pounds. without side rails. free standing. without mattress Quantity Notes CMN/CR CMN/CR CMN/CR CMN/CR Total Electric Beds HCPCS E0265 E0266 E0296 E0297 Description Hospital bed. extra wide. with any type side rails. total electric (head. total electric (head. with mattress Hospital bed. with any type side rails. total electric (head. and height adjustments). without mattress Hospital bed. with any type side rails. semi-electric (head and foot adjustment). a/k/a patient helper. foot. without side rails. without mattress Quantity Notes CMN/NMN CMN/NMN CMN/NMN CMN/NMN Heavy Duty Beds HCPCS E0303 E0304 Description Quantity Hospital bed. foot.Updated Winter 2004 E0292 E0293 Hospital bed. Notes CMN CMN Accessories HCPCS E0271 E0272 E0273 E0274 E0280 E0305 E0310 E0315 E0316 E0910 E0940 Description Mattress. innerspring Mattress. with mattress. with grab bar Trapeze bar. with mattress Hospital bed. semi-electric (head and foot adjustment). full length Bed accessory: board or table or support device. with mattress Hospital bed. with mattress Hospital bed. with weight capacity greater than 350 pounds. attached to bed. and height adjustments). variable height (hi-lo). any type Trapeze bars. without side rails. without mattress CMN/CR CMN/CR Semi-Electric Beds HCPCS E0260 E0261 E0294 E0295 Description Hospital bed. with any type side rails. with mattress Hospital bed. semi-electric (head and foot adjustment). half-length Bedside rails. heavy duty. but less than or equal to 600 pounds. foot. any type Safety enclosure frame/canopy for use with hospital bed. extra heavy duty. foot. miscellaneous Quantity Notes NARR Page 64 . any type Bedside rails. and height adjustments). semi-electric (head and foot adjustment). without mattress Hospital bed. variable height (hi-lo). with any type side rails. total electric (head. complete with grab bar Quantity Notes NC NC Miscellaneous HCPCS E1399 Description Durable medical equipment. Updated Winter 2004 Explanations of Notes Column NMN NC NARR CR CMN Not Medically Necessary. Page 65 . Certificate of Medical Neccessity required. Capped Rental item. Call Allwin Data with the appropriate information. Not Covered. payment will be based on the allowance for the least costly medical appropriate alternative. Narrative required. A high strength lightweight wheelchair is rarely medically necessary if the expected duration of need is less than three months (e. If the documentation does not support the medical necessity of the wheelchair which is billed. An individual may qualify for a wheelchair and still be considered bed confined. depth. Backup chairs are denied as not medically necessary. The patient self-propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or lightweight wheelchair. An extra heavy duty wheelchair (K0007) is covered if the patient weighs more than 300 pounds. Question #1 must be answered YES for a standard wheelchair (K0001) to be covered. and spends at least two hours per day in the wheelchair. Payment will be based on the allowance for the least costly medically acceptable alternative.g.. An upgrade that is beneficial primarily in allowing the patient to perform leisure or recreational activities will be noncovered. Payment is made for only one wheelchair at a time. Reimbursement for wheelchair codes includes all labor charges involved in the assembly of the wheelchair. education. If a K0005 wheelchair base is determined to be not medically necessary but criteria are met for a less costly wheelchair. However. The patient requires a seat width. 2. delivery. Page 66 . One month's rental of a wheelchair is covered if a patient-owned wheelchair is being repaired. payment will be based on the least costly alternative (K0001 . A lightweight wheelchair (K0003) is covered when a patient: a) Cannot self-propel in a standard wheelchair using arms and/or legs and b) The patient can and does self-propel in a lightweight wheelchair. he would otherwise be bed or chair confined. or height that cannot be accommodated in a standard.K0004).Updated Winter 2004 XVIII . A heavy duty wheelchair (K0006) is covered if the patient weighs more than 250 pounds or the patient has severe spasticity. a claim will be considered for coverage if there is additional documentation which justifies the medical necessity for the item in the individual case.MANUAL WHEELCHAIRS Coverage and Payment Rules A wheelchair is covered if the patient's condition is such that without the use of a wheelchair. A high strength lightweight wheelchair (K0004) is covered when a patient meets the criteria in (1) and/or (2): 1. This basic requirement must be met for coverage of any wheelchair. When the stated coverage criteria relating to medical necessity are not met. Valid CMN’s 1. post-operative recovery). Coverage of an ultralightweight wheelchair (K0005) is determined on an individual consideration basis. lightweight or hemiwheelchair. and on-going assistance with use of the wheelchair. Reimbursement also includes support services such as emergency services. set-up. A standard hemi-wheelchair (K0002) is covered when the patient requires a lower seat height (17" to 18") because of short stature or to enable the patient to place his/her feet on the ground for propulsion. since K0005 is in a different payment category it will be denied as not medically necessary if billed as a purchase. but does support the medical necessity of a lower level wheelchair. payment will be based on the allowance for the least costly medically acceptable alternative. specific codes are defined by the following characteristics: Standard wheelchair (K0001) Weight: Greater than 36 lbs. swingaway. lightweight wheelchair (K0004) Weight: Less than 34 lbs Lifetime Warranty on side frames and crossbraces Ultra lightweight wheelchair (K0005) Weight: Less than 30 lbs Adjustable rear axle position Lifetime Warranty on side frames and crossbraces Heavy duty wheelchair (K0006) Weight capacity: Greater than 250 pounds Extra heavy duty wheelchair (K0007) Weight capacity: Greater than 300 pounds Adult tilt-in-space wheelchair (E1161) Ability to tilt the frame of the wheelchair greater than or equal to 45 degrees from horizontal while maintaining the same back to seat angle. swingaway. Seat Height: 19" or greater Weight capacity: 250 pounds or less Standard hemi (low seat) wheelchair (K0002) Weight: Greater than 36 lbs Seat Height: Less than 19" Weight capacity: 250 pounds or less Lightweight wheelchair (K0003) Weight: 34-36 lbs Weight capacity: 250 pounds or less High strength. Lifetime Warranty: On side frames and crossbraces Wheelchair "poundage" (lbs. The following features are included in the allowance for all adult manual wheelchairs: Seat Width: 15" . fixed height Footrests: Fixed.) represents the weight of the usual configuration of the wheelchair with a seat and back but without frontriggings. and question #8 must be answered NO for a lightweight wheelchair to be covered. or detachable Codes K0003-K0007 and E1161 include any seat height. Coding Guidelines Adult manual wheelchairs (K0001-K0009. In addition. Page 67 . Question #1 and #9 must be answered YES.19" Seat Depth: 15" – 19" Arm Style: Fixed.Updated Winter 2004 2. or detachable. E1161) are those which have a seat width and a seat depth of 15" or greater. Refer to the medical policy on Wheelchair Options and Accessories for information on other features included in the allowance for the wheelchair base. g.E1060. and whether the patient is fully independent in the use of the wheelchair.). must be kept on file by the supplier.E1295 should only be used to bill for maintenance and service for an item for which the initial claim was paid by the local carrier prior to transition to the DMERC.) If the frame of the wheelchair is modified in a unique way to accommodate the patient. the claim must include a narrative description of the item. When code K0009 is billed. E1220 . signed. The pharmacy may enter the CMN using the Allwin Data website and transmit the claim upon acceptance of the CMN by the Allwin system. Please allow 24 hrs for processing when the CMN is faxed to Allwin Data. not otherwise specified). Documentation for individual consideration might include information on the patient's diagnosis. lightweight wheelchair Ultra lightweight wheelchair Heavy duty wheelchair Extra heavy duty wheelchair Page 68 Quantity Notes CMN / CR CMN / CR CMN / CR CMN / CR CMN CMN / CR CMN / CR .E1200.Updated Winter 2004 A manual wheelchair with a seat width and/or depth of 14" or less is considered a pediatric size wheelchair and is billed with codes E1231-E1238. The CMN for manual wheelchairs is HCFA Form 844. E1070 .E1224. frequency. and nature of the activities the patient performs. Codes E1050 . which has been completed. the manufacturer. and made available to the DMERC on request. bill the code for the wheelchair base and bill the modification with code K0108 (wheelchair component or accessory. degree of independence/dependence. or the pharmacy may fax the CMN to Allwin Data for processing. and dated by the treating physician. Allwin Data will attach the proper capped-rental modifiers only if the claim shows a date written that is accurate with the beginning of the rental period. This may include what types of activities the patient frequently encounters. Documentation Requirements A Certificate of Medical Necessity (CMN). The initial claim must include a copy of the CMN. and past experience using similar equipment. and information justifying the medical necessity for the item. E1240 . Claim Transmission Upon receiving the completed CMN from the physician the pharmacy has two ways to get the CMN to Allwin Data before the claim can be transmitted. Wheelchairs with individualized features which meet the needs of a particular patient are billed by selecting the correct code for the wheelchair base and then using appropriate codes for wheelchair options and accessories. Initial claims for K0005 must include a description of the patient's routine activities. Should you begin processing through Allwin Data halfway through a capped rental period. the expected prognosis. Allwin Data will automatically attach all required capped rental modifiers. the patient's abilities and limitations as they relate to the equipment (e. (Refer to the Wheelchair Options and Accessories policy. Describe the features of the K0005 base which are needed compared to the K0004 base.. HCPCS Codes HCPCS K0001 K0002 K0003 K0004 K0005 K0006 K0007 Description Standard wheelchair Standard hemi (low seat) wheelchair Lightweight wheelchair High strength. This information should be attached to a hard copy claim or entered in the narrative field of an electronic claim. etc. the model name or number (if applicable). If you are unsure of what date is showing up in the date written field please call Allwin Data following your first transmission of a capped rental item in the middle of the rental period. the duration of the condition. Updated Winter 2004 K0009 Other manual wheelchair/base Explanations of Notes Column NMN NC NARR CR CMN Not Medically Necessary. payment will be based on the allowance for the least costly medical appropriate alternative. Not Covered. Certificate of Medical Neccessity required. Narrative required. Call Allwin Data with the appropriate information. CMN Page 69 . Capped Rental item. and. and on-going assistance with use of the wheelchair. The patient's condition is such that without the use of a wheelchair the patient would otherwise be bed or chair confined. Payment is made for only one wheelchair at a time. swingaway. If the documentation does not support the medical necessity of a power wheelchair but does support the medical necessity of a manual wheelchair. A patient who requires a power wheelchair usually is totally nonambulatory and has severe weakness of the upper extremities due to a neurologic or muscular disease/condition. fixed height Footrests: Fixed. Reimbursement also includes support services. Backup chairs are denied as not medically necessary. delivery. swingaway. education. The following features are included in the allowance for K0010-K0012 and adult K0014 power wheelchair bases: Seat Width: 15"-19" Seat Depth: 15"-19" Arm Style: Fixed. the power wheelchair will be denied as not medically necessary.MOTORIZED WHEELCHAIRS Coverage and Payment Rules A power wheelchair is covered when all of the following criteria are met: 1. A power wheelchair with a seat width or depth of 14" or less is considered a pediatric power wheelchair base and is coded K0014. Coding Guidelines Motorized/power wheelchair bases K0010. Options that are beneficial primarily in allowing the patient to perform leisure or recreational activities are noncovered. Page 70 . or detachable Wheelchairs with individualized features which meet the needs of a particular patient are billed by selecting the correct code for the wheelchair base and then using appropriate codes for wheelchair options and accessories. However. One month's rental of a wheelchair is covered if a patient-owned wheelchair is being repaired. 2. and K0012 are characterized by: A seat width and a seat depth of 15" or greater. (Refer to the Wheelchair Options and Accessories policy. Reimbursement for the wheelchair codes includes all labor charges involved in the assembly of the wheelchair and all covered additions or modifications. set-up. and the manual wheelchair on which payment is based is in the capped rental category. 3. K0011. a lightweight power wheelchair (K0012) is characterized by: Weight less than 80 lbs. In addition. The patient is capable of safely operating the controls for the power wheelchair. if the power wheelchair has been purchased. payment is based on the allowance for the least costly medically appropriate alternative.) If the frame of the wheelchair is modified in a unique way to accommodate the patient. The patient's condition is such that a wheelchair is medically necessary and the patient is unable to operate a wheelchair manually and. or detachable. such as emergency services.Updated Winter 2004 XIX . with back and seat but without frontriggings or battery Folding back or collapsible frame Code K0014 is used for an adult power wheelchair base if it has a patient weight capacity of greater than or equal to 350 pounds and has programmable controls. Updated Winter 2004 bill the code for the wheelchair base and bill the modification with code K0108 (wheelchair component or accessory.E1220 should only be used to bill for maintenance and service for an item for which the initial claim was paid to the local carrier prior to the transition to the DMERC.K0014 are not used for manual wheelchairs with add-on power packs. TREMOR DAMPENING. This can be done by placing the “NU” modifier immediately following the appropriate HCPCS code.K0009) and code E0983. not otherwise specified). Codes K0010 . must be kept on file by the supplier and made available to the DMERC on request. The initial claim must include a copy of the CMN. ACCELERATION CONTROL AND BRAKING LIGHTWEIGHT PORTABLE MOTORIZED/POWER WHEELCHAIR OTHER MOTORIZED/POWER WHEELCHAIR BASE POWER ADD-ON.WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR WITH PROGRAMMABLE CONTROL PARAMETERS FOR SPEED ADJUSTMENT. The pharmacy may enter the CMN using the Allwin Data website and transmit the claim upon acceptance of the CMN by the Allwin system. TO CONVERT MANUAL WHEELCHAIR TO MOTORIZED WHEELCHAIR. Use the appropriate code for the manual wheelchair base provided (K0001 . Please allow 24 hrs for processing when the CMN is faxed to Allwin Data. the claim must include documentation indicating the brand name and model name/number of the base. Should you begin processing through Allwin Data halfway through a capped rental period. signed. and dated by the treating physician. which has been completed. JOYSTICK CONTROL Quantity Notes CMN CMN K0012 K0014 E0983 CMN CMN Page 71 . Allwin Data will attach the proper capped-rental modifiers only if the claim shows a date written that is accurate with the beginning of the rental period. Documentation Requirements A Certificate of Medical Necessity (CMN). Since a motorized wheelchair can be billed as a purchase or a capped rental item you will need to indicate your intention to bill as a purchase. Claims Transmission Upon receiving the completed CMN from the physician the pharmacy has two ways to get the CMN to Allwin Data before the claim can be transmitted. The CMN for power wheelchairs is HCFA Form 843. Codes E1210 . HCPCS Codes HCPCS K0010 K0011 Description STANDARD . This applies to the power add-on code K0460 as well as to the power wheelchair bases K0010-K0014.WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR STANDARD . and a statement documenting the medical necessity of this base for the particular patient including why another base (K0010-K0012) was not acceptable. If you are unsure of what date is showing up in the date written field please call Allwin Data following your first transmission of a capped rental item in the middle of the rental period. or the pharmacy may fax the CMN to Allwin Data for processing. Otherwise Allwin will assume that the item is being billed as a capped rental. Allwin Data will automatically attach all required capped rental modifiers. When billing K0014. Updated Winter 2004 Explanations of Notes Column NMN NC NARR CR CMN Not Medically Necessary. Certificate of Medical Neccessity required. Capped Rental item. Not Covered. Narrative required. Call Allwin Data with the appropriate information. Page 72 . payment will be based on the allowance for the least costly medical appropriate alternative. K0017. (Refer to the medical policy on Speech Generating Devices for details. A safety belt/pelvic strap (E0978) is covered if the patient has weak upper body muscles. An electronic interface (E2351) to allow a speech generating device to be operated by the power wheelchair control interface is covered if the patient has a covered speech generating device. A dual mode battery charger (E2367) is not medically necessary. K0047. K0053. or 3. An option/accessory that is beneficial primarily in allowing the patient to perform leisure or recreational activities is noncovered. Quadriplegia.Updated Winter 2004 XX . or 2.WHEELCHAIR ACCESSORIES Coverage and Payment Rules Options and accessories for wheelchairs are covered if the following criteria are met: 1. The medical necessity for all options and accessories must be documented in the patient's medical record and be available to the DMERC on request. hemiplegia. Elevating legrests (E0990. A fully reclining back option (E1226) is covered if the patient spends at least 2 hours per day in the wheelchair and has one or more of the following conditions/needs: 1. upper body instability or muscle spasticity which requires use of this item for proper positioning. Up to two batteries (E2360-E2365) at any one time are allowed if required for a power wheelchair. and 2. A nonstandard seat width and/or depth (E2201-E2204. K0046. The patient meets the criteria for and has a reclining back on the wheelchair. E2366. The options/accessories are necessary for the patient to perform one or more of the following activities: • Function in the home. or uncontrolled arm movements. The patient's condition is such that without the use of a wheelchair.) Anti-rollback device (E0974) is covered if the patient propels himself/ herself and needs the device because of ramps. and. K0018. 3. payment is based on the allowance for the least costly medically appropriate alternative. he would otherwise be bed or chair confined (an individual may qualify for a wheelchair and still be considered bed confined). retractable. Adjustable arm height option (E0973. Page 73 . • Perform instrumental activities of daily living. when it is provided as a replacement. An arm trough (K0106) is covered if patient has quadriplegia. or removable hardware (E1028) would be to move the component out of the way so that a patient could perform a slide transfer to a chair or bed. E2340-E2343) is covered only if the patient's dimensions justify the need. K0020) is covered if the patient requires an arm height that is different than that available using nonadjustable arms and the patient spends at least 2 hours per day in the wheelchair. The patient has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee. The patient has significant edema of the lower extremities that requires having an elevating legrest. K0195) are covered if: 1. The patient has a wheelchair that meets Medicare coverage criteria. One example (not all-inclusive) of a covered indication for swingaway. When the same code for bilateral items (left and right) are billed on the same date of service. replacing a standard seat of a power wheelchair with a power seating system). 4. This code is per legrest. E0996-E1001. Elevating legrests that are used with a capped rental wheelchair base should be coded K0195. E0977.Updated Winter 2004 2. 3.g. K0001-K0009. In both of these situations. K0010-K0014). 5. Suppliers should contact the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) for guidance on the correct coding of these items. When billing more than one line item with code K0108. Coding Guidelines A table in the Appendices section defines the bundling guidelines for wheelchair bases and options/accessories. E1227.. code A9900 must be used. ensure that the additional information can be matched to the appropriate line item on the claim. FOOTREST/ LEGREST: Elevating legrests that are used with a wheelchair that is purchased or owned by the patient are coded E0990. Fixed hip angle. Excess extensor tone of the trunk muscles. The RP modifier is used when an option or accessory is provided either as a replacement for the same part which has been worn or damaged (e. REAR WHEELS FOR MANUAL WHEELCHAIRS: Page 74 . A replacement option/accessory for a power operated vehicle (POV) is billed using a wheelchair option/accessory code. even if the option/accessory is the same as one that the patient had on a prior wheelchair. Miscellaneous options. E0980. and/or The need to rest in a recumbent position two or more times during the day and transfer between wheelchair and bed is very difficult. payment for seat widths and/or seat depths of 15-19 inches are included in the payment for the base code. the new item is placed on the existing wheelchair base. Codes listed in Column II are not separately payable from the wheelchair base and must not be billed separately at the time of initial purchase or rental of the wheelchair. or replacement parts for wheelchairs that do not have a specific HCPCS code and are not included in another code should be coded K0108. Codes E2201E2204 and E2340-E2343 describe seat widths and/or depths of 20 inches or more for manual or power wheelchairs. Trunk or lower extremity casts/braces that require the reclining back feature for positioning. each should be billed on a separate claim line using code K0108.g. A crutch and cane holder (K0102) is not medically necessary. accessories. bill both items on the same claim line using the LTRT modifiers and 2 units of service. E0969-E0970. E0954. The RP modifier must not be used if the accessory is provided at the same time as the wheelchair base. replacing a tire of the same type) or as an upgrade subsequent to providing the wheelchair base (e. E0994. These seat dimensions should not be separately billed. E1296-E1298 are not valid for claims submitted to the DMERC. The right (RT) and left (LT) modifiers must be used when appropriate. It is also helpful to reference the line item to the submitted charge. This code is per pair of legrests. All options and accessories provided at the time of initial issue of a POV are not separately billable. NONSTANDARD SEAT FRAME DIMENSIONS: For all adult wheelchairs (E1161. If multiple miscellaneous accessories are provided. Codes E0953.. Codes E0968 and E1228 should only be used to bill for maintenance and service for an item for which the initial claim was paid by the local carrier prior to transition to the DMERC. If a supplier chooses to bill separately for a component that is included in another code. As the posterior back panel reclines or raises there is a mechanical linkage between the two panels which allows the patient's back to stay in contact with the anterior panel without sliding along that panel. With this feature. a motor and related electronics with or without variable speed programmability. any hardware that is needed to attach the seating system to the wheelchair base. It must have the following features: ability to tilt to greater than or equal to 45 degrees from horizontal. anterior knee supports. back height of at least 20 inches. when the back reclines. a switch control which is independent of the power wheelchair drive control interface. fixed or flip-up footplates. fixed or flipup footplates. ability to support patient weight of at least 250 pounds. when the back raises. a basic switch control which is independent of the power wheelchair drive control Page 75 . two motors and related electronics with or without variable speed programmability. fixed or swingaway detachable legrests. a switch control which is independent of the power wheelchair drive control interface. back height of at least 20 inches. It does not include a headrest. fixed or flip-up footplates. As the posterior back panel reclines or raises there is a separate motor which controls the linkage between the two panels and allows the patient's back to stay in contact with the anterior panel without sliding along that panel. back height of at least 20 inches. ability to support patient weight of at least 250 pounds. any frame width and depth. a switch control which is independent of the power wheelchair drive control interface. fixed or swingaway detachable legrests. a motor and related electronics with or without variable speed programmability. any frame width and depth. any hardware that is needed to attach the seating system to the wheelchair base.Updated Winter 2004 A push-rim activated power assist (E0986) is an option for a manual wheelchair in which sensors in specially designed wheels determine the force that is exerted by the patient on the wheel. ability for the supplier to adjust the seat to back angle. A mechanically linked leg elevation feature (E1009) involves a pushrod which connects the legrest to a power recline seating system. detachable or flip-up fixed height or adjustable height armrests. A power seat elevation system (E2300) includes: a motor and related electronics with or without variable speed programmability. the legrest elevates. It does not include a headrest. It does not include a headrest. A mechanical shear reduction feature (E1004 and E1007) consists of two separate back panels. It must have the following features: ability to recline to greater than or equal to 150 degrees from horizontal. hinged legrests. It includes a switch control which may or may not be integrated with the power tilt and/or recline control(s). Additional propulsive and/or braking force is then provided by motors in each wheel. It must have the following features: ability to tilt to greater than or equal to 45 degrees from horizontal. POWER SEATING SYSTEMS: A power tilt seating system (E1002) includes: a solid seat platform and a solid back. the legrest lowers. detachable or flip-up fixed height armrests. a motor and related electronics with or without variable speed programmability. any hardware that is needed to attach the seating system to the wheelchair base. any hardware that is needed to attach the seating system to the wheelchair base. any frame width and depth. A power tilt and recline seating system (E1006-E1008) includes: a solid seat platform and a solid back. It should not be used for a solid self-skinning polyurethane tire. Batteries are included. ability to support patient weight of at least 250 pounds. a switch control which is independent of the power wheelchair drive control interface. It must provide a seat elevation of at least 6 inches. Code K0064 (flat free insert) is used to describe either 1) a removable ring of firm material that is placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured or 2) nonremovable foam material in a foam filled rubber tire. A power shear reduction feature (E1005 and E1008) consists of two separate back panels. fixed or flip-up footplates. detachable or flip-up fixed height or adjustable height armrests. detachable or flip-up fixed height or adjustable height arm rests. A power leg elevation feature (E1010) involves a dedicated motor and related electronics with or without variable speed programmability which allows the legrest to be raised and lowered independently of the recline and/or tilt of the seating system. A power standing system (E2301) includes: a solid seat platform and a solid back. ability to recline to greater than or equal to 150 degrees from horizontal. fixed or swingaway detachable legrests. A power recline seating system (E1003-E1005) includes: a solid seat platform and a solid back. but are not limited to. tremor dampening.. head control. In those situations. The external component of a switch may be either mechanical or nonmechanical. tilt forward. drive backward. extra heavy duty feature. POWER WHEELCHAIR DRIVE CONTROL SYSTEMS: The term interface in the code narrative and definitions describes the mechanism for controlling the movement of a power wheelchair. power shear reduction. or nonproportional interface): power wheelchair drive. It does not include a headrest.g. but are not limited to. sip and puff. infrared. These codes include remote joysticks that are used for hand control as well as joysticks that are used for chin control. the indicator feature may also show the direction that has been selected (forward. power seat elevation. It must have the following features: ability to move the patient to a standing position. A direction change switch allows the patient to change the direction that is controlled by another separate switch or by a mechanical proportional head control interface. chin control. The interfaces described by codes E2320-E2322. A remote joystick (E2320. (Latched mode is when the wheelchair continues to move without the patient having to continually activate the interface. it allows a switch to initiate forward movement one time and backward movement another time. but are not limited to. Examples of the external components of nonmechanical switches include. drive forward. Operations may include. toggle. power leg elevation. Examples of interfaces include. Payment for the code includes an allowance for fixed mounting hardware for the control box and for the display box (if present). For example. One example of a proportional interface is a standard joystick. patient weight capacity greater than 250 pounds and less than or equal to 400 pounds) and E1021 (Power seating system. reverse. ribbon. One example of a nonproportional interface is a sip-and-puff mechanism. power tilt. E2321) is one in which the joystick itself is separate from the controller box (i. A function selection switch allows the patient to determine what operation is being controlled by the interface at any particular time. right).Updated Winter 2004 interface. A proportional interface is one in which the direction and amount of movement by the patient controls the direction and speed of the wheelchair. button. power recline. When the wheelchair drive function has been selected. and E2327-E2330 must have programmable control parameters for speed adjustment. E2325. power standing. The term controller describes the electronics that connect the interface to the motor and gears in the power wheelchair base.e. any hardware that is needed to attach the seating system to the wheelchair base. but the speed is pre-programmed. left. Code E2320 includes either a standard proportional Page 76 . Codes E1019 (Power seating system. A nonproportional interface is one which involves a number of switches. Selecting a particular switch determines the direction of the wheelchair. This indicator feature may be in a separate display box or may be integrated into the wheelchair interface. A stop switch allows for an emergency stop when a wheelchair with a nonproportional interface is operating in the latched mode. etc.. ability to support patient weight of at least 250 pounds. acceleration control. touchpad. etc. and braking. It includes a function selection switch which allows the patient to select the motor that is being controlled and an indicator feature to visually show which function has been selected. but are not limited to. proportional joystick. recline backward. Some of the codes include multiple switches. Examples of the external components of mechanical switches include. proximity. joystick. Mechanical switches involve physical contact in order to be activated. each functional switch may have its own external component or multiple functional switches may be integrated into a single external switch component or multiple functional switches may be integrated into the wheelchair control interface without having a distinct external switch component. heavy duty feature. etc. weight capacity greater than 400 pounds) are invalid for claim submission to the DMERC. etc. the box containing the electronics that connects the interface to the motor and gears). A switch is an electronic device which turns power to a particular function either "on" or "off". Codes E2310 and E2311 describe the electronic components that allow the patient to control two or more of the following motors from a single interface (e.) This switch is sometimes referred to as a kill switch. An electronic interface that is used to allow lights or other electrical devices to be operated using the power wheelchair control interface must be billed with code A9270 (non-covered item). MISCELLANEOUS: Code E1028 is used for swingaway hardware used with interfaces described by codes E2320 and E2321. The direction and amount of movement of the patient's head (which does not come in contact with the box) control the direction and speed of the wheelchair. A proportional. swingaway or flipdown hardware for head control interfaces E2327-E2330. E2325 does not include the breath tube kit which is described by code E2326. Code E2351 describes an electronic interface used with a speech generating device. or short throw joysticks. though the head does not touch the switch. mechanical head control interface (E2327) is one in which a headrest is attached to a joystick-like device. This code is limited to proportional control devices. The switch that is selected determines the direction of the wheelchair.Updated Winter 2004 remote joystick stick or a proportional remote joystick in which small movements of the joystick are sufficient to control the wheelchair. OTHER POWER WHEELCHAIR ACCESSORIES: Codes K0093 and K0097 (flat free insert. The latter type of joysticks are sometimes referred to as mini-proportional. A mechanical stop switch is included in the allowance for the code. The switch that is selected determines the direction of the wheelchair. electronic extremity control interface (E2328) is one in which the direction and amount of movement of the patient's arm or leg control the direction and speed of the wheelchair. These switches are activated by movement of the head toward the switch. contact switch head control interface (E2329) is one in which a patient activates one of three mechanical switches placed around the back and sides of their head. When code E2320 or E2321 is used for a chin control interface. proximity switch head control interface (E2330) is one in which a patient activates one of three switches placed around the back and sides of their head. A nonproportional. A mechanical stop switch and a mechanical direction change switch is included in the allowance for the code. electronic head control interface (E2328) is one in which a patient's head movements are sensed by a box placed behind the patient's head. Code E2322 describes a system of 3-5 mechanical switches which are activated by the patient touching the switch. flexible shaft. Code E2323 includes prefabricated joystick handles that have shapes other than a straight stick – e. These switches are activated by pressure of the head against the switch. It should not be used for a solid self-skinning polyurethane tire..g. A mechanical stop switch and a mechanical direction change switch is included in the allowance for the code. A proportional. if provided. the chin cup is billed separately with code E2324. and swingaway hardware for an indicator display box that is Page 77 . compact. A nonproportional. The switch that is selected determines the direction of the wheelchair. Code E2320 also describes a touchpad which is an interface similar to the pad-type mouse found on portable computers. The attendant control is usually mounted on one of the rear canes of the wheelchair. A sip and puff interface (E2325) is a nonproportional interface in which the patient holds a tube in their mouth and controls the wheelchair by either sucking in (sip) or blowing out (puff). A proportional. power wheelchair) are used to describe either 1) a removable ring of firm material that is placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured or 2) nonremovable foam material in a foam filled rubber tire. The direction and amount of movement of the patient's head pressing on the headrest control the direction and speed of the wheelchair. An attendant control (E2331) is one which allows a caregiver to drive the wheelchair instead of the patient. are included in the allowance for the code.. A mechanical stop switch and a mechanical direction change switch. U shape or T shape – or that have some other nonstandard feature – e. A mechanical direction control switch is included in the code.g. usually a joystick. Updated Winter 2004 related to the multi-motor electronic connection codes E2310 or E2311. Code E1028 is not to be used for swing away hardware used with a sip and puff interface (E2325) because swingaway hardware is included in the allowance for that code. See Wheelchair Seating Policy article for information concerning uses of E1028 for positioning accessories. Code E1029 describes a ventilator tray which is attached in a fixed position to the wheelchair base or back. Code E1030 describes a ventilator tray which is attached to the seat back and is articulated so that the tray will remain horizontal when the seat back is raised or lowered. Code E1225 describes a manually operated reclining back that can recline greater than 15 degrees but less than 80 degrees. Code E1226 describes a manually operated reclining back that recline 80 degrees or greater. These codes may be used for a manual reclining back that is used on either a manual or a power wheelchair. APPENDIX: A Column II code is included in the allowance for the corresponding Column I code when provided at the same time. When multiple nonbolded codes are listed in column I, all the bolded codes in column II relate to each nonbolded code in column I. Column I Power Operated Vehicle (E1230) Manual Wheelchair Base (E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009) Power Wheelchair Base (K0010, K0011, K0012, K0014) Column II (All options and accessories) E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0452 E0971, E0981, E0982, E0995, E2366, E2367, K0015, K0017, K0018, K0019, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0081, K0090, K0092, K0094, K0096, K0098, K0099, K0452 K0017, K0018, K0019 E0995, K0042, K0043, K0044, K0045, K0046, K0047 E0973, K0015, K0017, K0018, K0019, K0020, K0023, K0024, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052 E0990, E0995, K0042. K0043, K0044, K0045, K0046, K0047, K0052, K0053, K0195 E1028 K0038 K0043, K0044 K0043 K0044 E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047 K0066 K0067, K0068 K0074, K0078 K0075 K0076 K0091 K0090, K0091 K0094, K0095 E0995, K0042, K0043, K0044, K0045, K0046, K0047 E0973 E0990 Power tilt and/or recline seating systems (E1002, E1003, E1004, E1005, E1006, E1007, E1008) E1009, E1010 E2325 K0039 K0045 K0046 K0047 K0053 K0069 K0070 K0071 K0072 K0077 K0090 K0092 K0096 K0195 Page 78 Updated Winter 2004 Documentation Requirements Wheelchair options/accessories which require a Certificate of Medical Necessity (CMN) are: E0973, E0990, K0017, K0018, K0020, E1226, K0046, K0047, K0053, and K0195. For these items, a CMN which has been completed, signed and dated by the treating physician must be kept on file by the supplier and made available to the DMERC on request. For these items, the CMN may act as a substitute for a written order if it contains all of the required elements of an order. Depending on the type of wheelchair, the CMN for these options/accessories is either HCFA Form 843 (power wheelchairs) or HCFA Form 844 (manual wheelchairs). For these items, the initial claim must include a copy of the CMN. When billing option/accessory codes as a replacement (modifier RP), documentation of the medical necessity for the item, make and model name of the wheelchair base it is being added to, and the date of purchase of the wheelchair must be submitted with the claim. When code K0108 is billed, the claim must include a narrative description of the item, the manufacturer, the model name or number (if applicable), and information justifying the medical necessity for the item. If a formal wheelchair evaluation has been performed, it would be appropriate to include this information as documentation. Documentation for individual consideration might include information on the patient's diagnosis, the patient's abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency and nature of the activities the patient performs, etc.), the duration of the condition, the expected prognosis, past experience using similar equipment. Claim Transmission Allwin Data will automatically attach all required capped rental modifiers. Should you begin processing through Allwin Data halfway through a capped rental period, Allwin Data will attach the proper capped-rental modifiers only if the claim shows a date written that is accurate with the beginning of the rental period. If you are unsure of what date is showing up in the date written field please call Allwin Data following your first transmission of a capped rental item in the middle of the rental period. Upon receiving the completed CMN (for those accessories that require it) from the physician the pharmacy has two ways to get the CMN to Allwin Data before the claim can be transmitted. The pharmacy may enter the CMN using the Allwin Data website and transmit the claim upon acceptance of the CMN by the Allwin system, or the pharmacy may fax the CMN to Allwin Data for processing. Please allow 24 hrs for processing when the CMN is faxed to Allwin Data. For those items that require specific LT or RT modifiers the pharmacy will have to transmit this information with the claim. HCPCS Codes ARM OF CHAIR HCPCS E0973 K0015 K0017 K0018 K0019 K0020 L3964 L3965 Description Quantity WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH DETACHABLE, ADJUSTABLE HEIGHT ARMREST, BASE, EACH DETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER PORTION, EACH ARM PAD, EACH FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR 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 Page 79 Notes CMN CMN CMN CMN Updated Winter 2004 SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, RECLINING, PREFABRICATED, 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 SEO, ADDITION TO MOBILE ARM SUPPORT, OFFSET OR LATERAL ROCKER ARM WITH ELASTIC BALANCE CONTROL SEO, ADDITION TO MOBILE ARM SUPPORT, SUPINATOR L3966 L3968 L3969 L3970 L3972 L3974 BACK OF CHAIR HCPCS E0971 E1014 E1025 E1026 E1027 E0966 Description ANTI-TIPPING DEVICE WHEELCHAIRS RECLINING BACK, ADDITION TO PEDIATRIC WHEELCHAIR LATERAL THORACIC SUPPORT, NON-CONTOURED, FOR PEDIATRIC WHEELCHAIR, EACH (INCLUDES HARDWARE) LATERAL THORACIC SUPPORT, CONTOURED, FOR PEDIATRIC WHEELCHAIR, EACH (INCLUDES HARDWARE) LATERAL/ANTERIOR SUPPORT, FOR PEDIATRIC WHEELCHAIR, EACH (INCLUDES HARDWARE) HOOK-ON HEADREST EXTENSION Quantity Notes NC SEAT HCPCS K0650 K0651 K0652 K0653 K0654 K0655 K0656 K0657 K0658 K0659 K0660 K0661 Description Quantity 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 CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH SKIN PROTECTION AND POSITIONING WHEELCHAIR 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 Page 80 Notes EACH ADJUSTABLE ANGLE FOOTPLATE. ANY HEIGHT. EACH WHEELCHAIR ACCESSORY. H STYLE. POSTERIOR-LATERAL. ELEVATING LEGREST. EACH RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR HIGH MOUNT FLIP-UP FOOTREST. INCLUDING ANY TYPE MOUNTING HARDWARE POSITIONING WHEELCHAIR BACK CUSHION. HEIGHT HCPCS E1011 E2201 E2202 Description Quantity MODIFICATION TO PEDIATRIC WHEELCHAIR. NONSTANDARD SEAT FRAME WIDTH. FOOTREST OR LEGREST. ANY HEIGHT. 24-27 INCHES Page 81 Notes . EACH LARGE SIZE FOOTPLATE. WIDTH 22 INCHES OR GREATER. WIDTH ADJUSTMENT PACKAGE (NOT TO BE DISPENSED WITH INITIAL CHAIR) MANUAL WHEELCHAIR ACCESSORY. WIDTH LESS THAN 22 INCHES. EACH FOOTREST. EACH ELEVATING FOOTRESTS. ARTICULATING (TELESCOPING). PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE) Quantity Notes NC CMN CMN CMN CMN CMN SEAT WIDTH. COMPLETE ASSEMBLY ELEVATING LEGREST. POSTERIOR. INCLUDING ANY TYPE MOUNTING HARDWARE POSITIONING WHEELCHAIR BACK CUSHION. EACH STANDARD SIZE FOOTPLATE. EACH LEG STRAP. UPPER HANGER BRACKET. EACH TOE LOOP/HOLDER. WIDTH 22 INCHES OR GREATER. INCLUDING ANY TYPE MOUNTING HARDWARE REPLACEMENT COVER FOR WHEELCHAIR SEAT CUSHION OR BACK CUSHION. EACH SWINGAWAY. INCLUDING ANY TYPE MOUNTING HARDWARE CUSTOM FABRICATED WHEELCHAIR BACK CUSHION. EACH FOOTREST. WIDTH GREATER THAN OR EQUAL TO 20 IN & LESS THAN 24 INCHES MANUAL WHEELCHAIR ACCESSORY. ANY SIZE.Updated Winter 2004 K0662 K0663 K0664 K0665 K0666 K0668 E0992 POSITIONING WHEELCHAIR BACK CUSHION. DEPTH. DETACHABLE FOOTRESTS. NONSTANDARD SEAT FRAME. EACH RATCHET ASSEMBLY CAM RELEASE ASSEMBLY. INCLUDING ANY TYPE MOUNTING HARDWARE POSITIONING WHEELCHAIR BACK CUSHION. POSTERIOR-LATERAL. ANY HEIGHT. EACH LEG STRAP. CALF REST/PAD. EACH SOLID SEAT INSERT. WIDTH LESS THAN 22 INCHES. EACH ELEVATING LEGREST. SINGLE DENSITY FOAM FOOTREST/LEGREST HCPCS E0951 E0952 E0990 E0995 E1020 K0037 K0038 K0039 K0040 K0041 K0042 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0052 K0053 K0195 Description LOOP HEEL. EACH ELEVATING LEG RESTS. UPPER HANGER BRACKET. EACH WHEELCHAIR ACCESSORY. COMPLETE ASSEMBLY. LOWER EXTENSION TUBE. PLANAR SEAT. ANY HEIGHT. LOWER EXTENSION TUBE. EACH FOOTREST. POSTERIOR. NONSTANDARD SEAT FRAME DEPTH. COMPLETE. EACH SPOKE PROTECTORS. COMPLETE. ANY SIZE. EACH REAR WHEEL. EACH PNEUMATIC TIRE. EACH Quantity Notes MOTORIZED/POWER WHEELCHAIR PARTS HCPCS K0090 K0091 K0092 K0093 K0094 K0095 K0096 K0097 K0098 K0099 Description Quantity REAR WHEEL TIRE FOR POWER WHEELCHAIR. 20 TO LESS THAN 22 INCHES MANUAL WHEELCHAIR ACCESSORY. ANY SIZE. WITH PNEUMATIC TIRE. EACH REAR WHEEL ASSEMBLY. ANY SIZE. EACH PNEUMATIC TIRE TUBE. ANY SIZE. SPOKES OR MOLDED. ZERO PRESSURE TIRE TUBE (FLAT FREE INSERT) FOR POWER WHEELCHAIR. EACH Notes BATTERIES/CHARGERS FOR MOTORIZED/POWER WHEELCHAIRS HCPCS E2360 Description 22 NF NON-SEALED LEAD ACID BATTERY. WITH SOLID TIRE. EACH WHEEL TIRE FOR POWER BASE. EACH WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE FOR EACH BASE. COMPLETE. ANY SIZE. ANY SIZE. ANY SIZE. EACH DRIVE BELT FOR POWER WHEELCHAIR FRONT CASTER FOR POWER WHEELCHAIR. EACH SOLID TIRE. EACH STEEL HANDRIM. EACH WHEEL ASSEMBLY FOR POWER BASE. COMPLETE. EACH WHEEL ZERO PRESSURE TIRE TUBE (FLAT FREE INSERT) FOR POWER BASE.Updated Winter 2004 E2203 E2204 K0056 MANUAL WHEELCHAIR ACCESSORY. LIGHTWEIGHT. EACH Quantity Notes HANDRIMS WITH PROJECTIONS HCPCS E0967 Description HANDRIM WITH PROJECTIONS. EACH REAR WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE FOR POWER WHEELCHAIR. ANY SIZE. ANY SIZE. SPOKES OR MOLDED. EACH Quantity Notes REAR WHEELS HCPCS K0064 K0065 K0066 K0067 K0068 K0069 K0070 Description ZERO PRESSURE TUBE (FLAT FREE INSERTS). EACH ALUMINUM HANDRIM. EACH Page 82 Quantity Notes . 22 TO 25 INCHES SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH. OR ULTRALIGHTWEIGHT WHEELCHAIR HANDRIMS WITHOUT PROJECTIONS HCPCS K0059 K0060 K0061 Description PLASTIC COATED HANDRIM. EACH REAR WHEEL ASSEMBLY. NONSTANDARD SEAT FRAME DEPTH. EACH REAR WHEEL ASSEMBLY FOR POWER WHEELCHAIR. FOR USE WITH EITHER BATTERY TYPE.G. EACH Quantity Notes MISCELLANEOUS ACCESSORIES HCPCS E0958 Description Quantity WHEELCHAIR ATTACHMENT TO CONVERT ANY WHEELCHAIR TO ONE ARM DRIVE WHEELCHAIR ADAPTER FOR AMPUTEE. COMPLETE. EACH GROUP 24 SEALED LEAD ACID BATTERY. EACH (E. FOR USE WITH ONLY ONE BATTERY TYPE. PAIR (DEVICE USED TO COMPENSATE FOR TRANSFER OF WEIGHT DUE TO LOST LIMBS TO MAINTAIN PROPER BALANCE) SHOCK ABSORBER FOR MANUAL WHEELCHAIR. ANY SIZE. SEALED OR NON-SEALED E2361 E2362 E2363 E2364 E2365 E2366 E2367 FRONT CASTERS HCPCS K0071 K0072 K0073 K0074 K0075 K0076 K0077 K0078 Description FRONT CASTER ASSEMBLY. WITH SOLID TIRE. WITH SEMI-PNEUMATIC TIRE. EACH U-1 SEALED LEAD ACID BATTERY. SINGLE MODE. EACH PNEUMATIC CASTER TIRE TUBE. GEL CELL. EACH FRONT CASTER ASSEMBLY. DUAL MODE. EACH MANUAL WHEELCHAIR ACCESSORY. SEALED OR NON-SEALED BATTERY CHARGER. EACH NC Notes E0959 E1015 E0972 E0974 E1016 E1017 E1018 E1226 K0102 K0104 Page 83 . EACH SOLID CASTER TIRE. ANY SIZE. EACH Quantity Notes WHEEL LOCK HCPCS E0961 K0081 Description WHEEL LOCK EXTENSION (HANDLE). EACH (E. EACH WHEEL LOCK ASSEMBLY. EACH SHOCK ABSORBER FOR POWER WHEELCHAIR. EACH FRONT CASTER ASSEMBLY. EACH (E.Updated Winter 2004 22 NF SEALED LEAD ACID BATTERY.EACH PNEUMATIC CASTER TIRE. EACH SEMI-PNEUMATIC CASTER TIRE. WITH PNEUMATIC TIRE.G. EACH HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR. COMPLETE. ABSORBED GLASS MAT) GROUP 24 NON-SEALED LEAD ACID BATTERY. EACH TRANSFER BOARD OR DEVICE.G. COMPLETE. EACH HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MANUAL WHEELCHAIR. EACH ANTI-ROLLBACK DEVICE. EACH CYLINDER TANK CARRIER. EACH CASTER PIN LOCK. EACH CRUTCH AND CANE HOLDER.. GEL CELL.. COMPLETE. ANY SIZE. FULLY RECLINING BACK. GEL CELL ABSORBED GLASS MAT) U-1 NON-SEALED LEAD ACID BATTERY.. ABSORBED GLASS MAT) BATTERY CHARGER. Not Covered. SEAT LIFT MECHANISM WHEELCHAIR COMPONENT OR ACCESSORY. ANY TYPE Explanations of Notes Column NMN NC NARR CR CMN Not Medically Necessary. EACH ARM TROUGH.Updated Winter 2004 K0105 K0106 E0950 E0981 E0982 E0985 K0108 K0452 IV HANGER. NOT OTHERWISE SPECIFIED WHEELCHAIR BEARINGS. payment will be based on the allowance for the least costly medical appropriate alternative. Certificate of Medical Neccessity required. REPLACEMENT ONLY. EACH WHEELCHAIR TRAY SEAT UPHOLSTERY. Narrative required. EACH BACK UPHOLSTERY. REPLACEMENT ONLY. Capped Rental item. Call Allwin Data with the appropriate information. EACH WHEELCHAIR ACCESSORY. Page 84 . cor pulmonale. The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services.Oxygen Coverage and Payment Rules Home oxygen therapy is covered only if all of the following conditions are met: 1.) Group II criteria include the presence of (a) an arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake). during sleep for at least 5 minutes. Dependent edema suggesting congestive heart failure. or 3. or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II. gated blood pool scan. A decrease in arterial PO2 more than 10 mm Hg. documented pulmonary hypertension and erythrocytosis).. or an arterial oxygen saturation at or below 88 percent. Initial coverage for patients meeting Group I criteria is limited to 12 months or the physician-specified length of need. For all the sleep oximetry criteria described above. or 4. for at least 5 minutes taken during sleep associated with symptoms or signs reasonably attributable to hypoxemia (e. and 3. or a decrease in arterial oxygen saturation more than 5 percent. or during exercise (as described under Group I criteria) and (b) any of the following: 1. Page 85 . whichever is shorter. echocardiogram. The treating physician has determined that the patient has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy. Group I criteria include any of the following: 1. Alternative treatment measures have been tried or considered and deemed clinically ineffective. An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake). or AVF). the 5 minutes does not have to be continuous. or • If the qualifying blood gas study is not performed during an inpatient hospital stay. and 2. for at least 5 minutes taken during sleep for a patient who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89% while awake. Erythrocythemia with a hematocrit greater than 56 percent. (Refer to the Documentation portion of this section for information on recertification. Pulmonary hypertension or cor pulmonale. oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.e. taken during exercise for a patient who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent during the day while at rest.g. The qualifying blood gas study was obtained under the following conditions: • If the qualifying blood gas study is performed during an inpatient hospital stay. whichever is shorter. or 3. and 5. An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent. or 2. In this case. For these patients there is a rebuttable presumption of noncoverage. determined by measurement of pulmonary artery pressure. not during a period of acute illness or an exacerbation of their underlying disease. III. the reported test must be performed while the patient is in a chronic stable state – i. or 2.) Group III includes patients with arterial PO2 levels at or above 60 mm Hg or arterial blood oxygen saturations at or above 90 percent. "P" pulmonale on EKG. An arterial PO2 at or below 55 mm Hg.Updated Winter 2004 XXI . (Refer to the Documentation portion of this section for information on recertification.. Initial coverage for patients meeting Group II criteria is limited to 3 months or the physician specified length of need. The patient's blood gas study meets the criteria stated below. but no earlier than 2 days prior to the hospital discharge date. and 4. the reported test must be the one obtained closest to. For patients initially meeting Group II criteria. For patients initially meeting Group I criteria. the blood gas study reported on the CMN must be the most recent test performed prior to the Revised date. For Initial Certifications. In addition. the most recent blood gas study which was performed between the 61st and 90th day following Initial Certification must be reported on the Recertification CMN. a repeat blood gas study must be performed within 30 days prior to the date of the Revised Certification. An exception would be situations in which the initial test was performed at rest/awake and on room air and the most recent test was performed on oxygen and was nonqualifying. The qualifying blood gas study must be one that complies with the Fiscal Intermediary or Local Carrier policy on the standards for conducting the test and is covered under Medicare Part A or Part B. When both arterial blood gas (ABG) and oximetry tests have been performed on the same day under the same conditions Page 86 . 2. an Independent Diagnostic Testing Facility (IDTF).. the oxygen therapy will be denied as not medically necessary. An exception would be situations in which the initial test was performed at rest/awake and on room air and the most recent test was performed on oxygen and was nonqualifying. but must be the most recent test obtained while in the HMO.e. A repeat blood gas study may be requested at any time at the discretion of the DMERC. the most recent blood gas study prior to the thirteenth month of therapy must be reported on the Recertification CMN. For patients initially meeting Group I criteria.Updated Winter 2004 If all of the coverage conditions specified above are not met. Dyspnea without cor pulmonale or evidence of hypoxemia. report the most recent at rest/awake test on room air. For sleep oximetry studies. 4. if the estimated length of need on the Initial CMN is less than lifetime and the physician wants to extend coverage. There is no evidence that increased PO2 will improve the oxygenation of tissues with impaired circulation. if the estimated length of need on the Initial CMN is less than lifetime and the physician wants to extend coverage. There is an exception for patients who were on oxygen in a Medicare HMO and who transition to fee-for-service Medicare. In those situations. the blood gas study reported on the Certificate of Medical Necessity (CMN) must be the most recent study obtained prior to the Initial Date indicated in Section A of the CMN and this study must be obtained within 30 days prior to that Initial Date. The qualifying blood gas study may be performed while the patient is on oxygen as long as the reported blood gas values meet the Group I or Group II criteria. report the most recent at rest/awake test on room air. the qualifying blood gas study may not be paid for by any supplier. For those patients. If a qualifying test is not obtained between the 61st and 90th day of home oxygen therapy. Terminal illnesses that do not affect the respiratory system. For patients initially meeting Group II criteria. or a physician. a laboratory. This condition is generally not the result of a low oxygen level in the blood and there are other preferred treatments. A supplier is not considered a qualified provider or a qualified laboratory for purposes of this policy. This prohibition does not extend to blood gas studies performed by a hospital certified to do such tests. coverage would resume beginning with the date of that test. For any Revised CMN. In those situations. but the patient continues to use oxygen and a test is obtained at a later date. 3. Oxygen therapy will also be denied as not medically necessary if any of the following conditions are present: 1. if that test meets Group I or II criteria. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the absence of systemic hypoxemia. a repeat blood gas study must be performed within 30 days prior to the date of the Revised Certification. Angina pectoris in the absence of hypoxemia. Blood gas studies performed by a supplier are not acceptable. the oximeter provided to the patient must be tamper-proof and must have the capability to download data that allows documentation of the duration of oxygen desaturation below a specified value. the blood gas study does not have to be obtained 30 days prior to the Initial Date. This includes a requirement that the test be performed by a provider who is qualified to bill Medicare for the test – i. a Part A provider. E0442) are separately payable only when the coverage criteria for home oxygen have been met and they are used with a patient owned stationary gaseous or liquid system respectively. Accessories used with a patient-owned system that was purchased on or Page 87 . or b) The beneficiary rents or owns a portable system and has no stationary system (concentrator. a higher allowance for a stationary system for a flow rate of greater than 4 liters per minute (LPM) will be paid only if a blood gas study performed while the patient is on 4 LPM meets Group I or II criteria. a portable oxygen system is usually separately payable in addition to the stationary system. The patient must be seen and evaluated by the treating physician within 30 days prior to the date of Initial Certification. If coverage criteria are met. regulators (E1353). cannulas (A4615). E0444) are separately payable only when the coverage criteria for home oxygen have been met and: a) The beneficiary owns a concentrator and rents or owns a portable system. Portable contents (E0443. at rest/awake. payment will be limited to the standard fee schedule allowance. the portable oxygen system will be denied as not separately payable. Portable Oxygen Systems: A portable oxygen system is covered if the patient is mobile within the home and the qualifying blood gas study was performed while at rest (awake) or during exercise. Stationary oxygen contents (E0441. including but not limited to. A7525). Liter Flow Greater Than 4 LPM: If basic oxygen coverage criteria have been met. If a patient qualifies for additional payment for greater than 4 LPM of oxygen and also meets the requirements for portable oxygen. If a flow rate greater than 4 LPM is billed and the coverage criterion for the higher allowance is not met. if both a stationary system and a portable system are billed for the same rental month. (See exception in Liter Flow Greater Than 4 LPM. 1989. humidifiers (E0555). The patient must be seen and re-evaluated by the treating physician within 90 days prior to the date of any Recertification.e.Updated Winter 2004 (i. or liquid). payment will be made for either the stationary system (at the higher allowance) or the portable system (at the standard fee schedule allowance for a portable system). oxygen conserving devices (A9900). Oxygen Accessories: Accessories. Accessories are separately payable only when they are used with a patient-owned system that was purchased prior to June 1. portable oxygen will be denied as not medically necessary. masks (A4620. transtracheal catheters (A4608). If an ABG test at rest/awake is nonqualifying.) If a portable oxygen system is covered. gaseous. but an exercise or sleep oximetry test on the same day is qualifying. or during sleep). If the only qualifying blood gas study was performed during sleep. payment can be made for dates of service between the scheduled Recertification date and the physician visit date if the blood gas study criteria are met. The supplier must provide any accessory ordered by the physician. Oxygen Contents: Oxygen contents are included in the allowance for rented oxygen systems. the ABG result will be used to determine if the coverage criteria were met. If the criteria for separate payment of contents are met. the oximetry test result will determine coverage. In this situation. Medicare's reimbursement is the same. they are separately payable regardless of the date that the stationary or portable system was purchased. nebulizer for humidification (E0580). and tubing (A4616) are included in the allowance for rented systems. mouthpieces (A4617). but not both. If the patient is not seen and re-evaluated within 90 days prior to Recertification but is subsequently seen. during exercise. the supplier must provide whatever quantity of oxygen the patient uses.. regardless of the quantity of oxygen dispensed. Oximeters (E0445) and replacement probes (A4606) will be denied as noncovered because they are monitoring devices that provide information to physicians to assist in managing the patient's treatment. report one unit of service for one month rental. E1390UE) will be denied as noncovered. They must not be used with codes for portable systems or oxygen contents. Coding Guidelines For gaseous or liquid oxygen systems or contents. Emergency or stand-by oxygen systems will be denied as not medically necessary since they are precautionary and not therapeutic in nature. When an Initial CMN does not meet coverage criteria and the patient was subsequently retested and meets coverage criteria. E0435. 1989 will be denied as noncovered. but the patient continued to need oxygen during that time. Topical hyperbaric oxygen chambers (A4575) will be denied as not medically necessary. Respiratory therapists' services are noncovered under the DME benefit. E0430. These modifiers may only be used with stationary gaseous (E0424) or liquid (E0439) systems or with an oxygen concentrator (E1390). Payment for oxygen furnished by an airline is the responsibility of the beneficiary and not the responsibility of the supplier. E0439. E1390NU. E0434. Documentation Requirements Initial CMN is Required: • • • With the first claim to the DMERC for home oxygen (even if the patient was on oxygen prior to Medicare eligibility or oxygen was initially covered by a Medicare HMO). Oxygen services furnished by an airline to a beneficiary are noncovered. When there has been a change in the patient's condition that has caused a break in medical necessity of at least 60 days plus whatever days remain in the rental month during which the need for oxygen ended. but a qualifying study was subsequently performed. it is the beneficiary's responsibility to arrange for oxygen during their travels. Travel Oxygen: If a beneficiary travels out of their supplier's usual service area. Do not report in cubic feet or pounds. E1390RR) are eligible for coverage. nursing facility. E0440. The Initial Date on this new CMN is the date of the subsequent qualifying blood gas study. (This indication does not apply if there was just a break in billing because the patient was in a hospital. Medicare will only pay one supplier for oxygen during any one rental month. The Initial Date on this new CMN is the date of the subsequent qualifying blood gas study. hospice.Updated Winter 2004 after June 1. Purchased oxygen systems (E0425. • Page 88 . Miscellaneous: Only rented oxygen systems (E0424. Claims for oxygen contents and/or oxygen accessories should not be submitted in situations in which they are not separately payable (see above). The appropriate modifier must be used if the prescribed flow rate is less than 1 LPM (QE) or greater than 4 LPM (QF or QG). E0431. or Medicare HMO.) When a Group I patient with a length of need less than or equal to 12 months was not retested prior to Revised Certification/ Recertification. When there was a change of supplier due to an acquisition and the previous supplier did not file a recertification when it was due and the requirements for the recertification were not met when it was due. If the change is from category (a) or (b) to category (c). In this situation. with the thirteenth month's claim) . but a qualifying study was subsequently performed.if oxygen test results on the Initial Certification are in Group I. Page 89 . there is no requirement for a repeat blood gas study. For those patients.. The blood gas study reported on the Initial CMN must be the most recent study obtained prior to the Initial Date and this study must be obtained within 30 days prior to that Initial Date.e. a repeat blood gas study with the patient on 4 LPM must be performed within 30 days prior to the start of the greater than 4 LPM flow. the Revised CMN does not have to be submitted with the claim but must be kept on file by the supplier. In other situations at the discretion of the DMERC. In this situation. If there was a change of supplier due to an acquisition and the previous supplier did not file a recertification when it was due but all the requirements for the recertification were met when it was due. 12 months after Initial Certification (i. the blood gas study does not have to be obtained 30 days prior to the Initial Date.if oxygen test results on the Initial Certification are in Group II. The blood gas study reported must be the most recent study which was performed within 30 days prior to the Recertification Date. If a Group I patient with a lifetime length of need was not seen and evaluated by the physician within 90 days prior to the 12 month Recertification but was subsequently seen. Note: In this situation. It is not necessarily an Initial CMN or the first CMN for that patient. When a stationary system is added subsequent to Initial Certification of a portable system. (b) 1-4 LPM. The Initial Date on this new CMN is the date of the subsequent qualifying blood gas study. The Initial Date on this new CMN may not be any earlier than the date of the subsequent qualifying blood gas study. the date on Recertification CMN should be the date of the physician visit. (An original CMN is a CMN which has a physician's original signature on it. Revised CMN is Required: • When the prescribed maximum flow rate changes from one of the following categories to another: (a) less than 1 LPM. the CMN does not have to be submitted with the claim. In this situation. a blood gas study must be performed within 30 days prior to the Revised Date. if the oxygen order is the same.) If the supplier obtains a new CMN. with the fourth month's claim) .e. When a portable oxygen system is added subsequent to Initial Certification of a stationary system. repeat blood gas studies were not performed between the 61st and 90th day of coverage. When there is a new treating physician but the oxygen order is the same. but must be the most recent test obtained while in the HMO. a Recertification CMN would be filed with the recertification date being 12 or 3 months after the Initial Date depending on whether the Initial Certification was based on Group I or Group II criteria.. When the length of need expires – if the physician specified less than lifetime length of need on the most recent CMN. there is no requirement for a repeat blood gas study. The blood gas study reported must be the most recent study which was performed between the 61st and 90th day following the Initial Date. that supplier must be able to provide the DMERC with an original CMN on request. • • • • If there is a new supplier.Updated Winter 2004 • • When the patient initially qualified in Group II. Recertification CMN is Required: • • • 3 months after Initial Certification (i. In this situation. In this situation. there is no requirement for a repeat blood gas study unless the initial qualifying study was performed during sleep. it would be considered a Revised CMN. (c) greater than 4 LPM. There is an exception for patients who were on oxygen in a Medicare HMO and who transition to fee-for-service Medicare. The blood gas study reported must be the most recent blood gas study prior to the thirteenth month of therapy. in which case a repeat blood gas study must be performed while the patient is at rest (awake) or during exercise within 30 days prior to the Revised Date. REFILL ADAPTOR. Claim Transmission Upon receiving the completed CMN from the physician the pharmacy may fax the CMN to Allwin Data for processing. SUPPLY RESERVOIR. HUMIDIFIER. CONTENTS. CANNULA OR MASK. INCLUDES PORTABLE CONTAINER. PURCHASE. FLOWMETER. (c) greater than 4 LPM. HUMIDIFIER. stationary liquid oxygen system (E0439). AND TUBING PORTABLE GASEOUS OXYGEN SYSTEM. RENTAL. CANNULA OR MASK. REGULATOR. HUMIDIFIER. A new CMN is not required just because a patient changes from Medicare secondary to Medicare primary. INCLUDES REGULATOR. FLOWMETER. TUBING AND REFILL ADAPTOR Quantity Notes E0425 E0430 E0431 E0434 E0435 Page 90 . AND TUBING PORTABLE GASEOUS OXYGEN SYSTEM. REGULATOR. FLOWMETER. FLOWMETER. NEBULIZER. a new order must be obtained and kept on file by the supplier. gaseous). HUMIDIFIER. RENTAL. Change from one type of system to another (i.Updated Winter 2004 Submission of a Revised CMN does not change the Recertification schedule specified above. Miscellaneous: In the following situations. INCLUDES REGULATOR.. INCLUDES CONTAINER. AND TUBING STATIONARY COMPRESSED GAS SYSTEM. PURCHASE. FLOWMETER.e. If the patient’s prescribed flow rate is greater than 4 LPM a QF or QG modifier must be indicated on the claim. CONTENTS GAUGE. CANNULA OR MASK. Please allow 24 hrs to process. AND TUBING PORTABLE LIQUID OXYGEN SYSTEM. PURCHASE. or an oxygen concentrator (E1390) and the patient’s prescribed flow rate is less than 1 LPM a QE modifier must be indicated on the claim. SUPPLY RESERVOIR. CANNULA OR MASK. CONTENTS GAUGE. file the CMN as a Recertification CMN. INCLUDES PORTABLE CONTAINER. concentrator. If the indications for a Revised CMN are met at the same time that a Recertification CMN is due. HUMIDIFIER. CANNULA OR MASK. CANNULA OR MASK. INCLUDES PORTABLE CONTAINER. RENTAL. NEBULIZER. AND TUBING PORTABLE LIQUID OXYGEN SYSTEM. A new CMN is not required just because the supplier changes assignment status on the submitted claim. liquid. HCPCS Codes Equipment HCPCS E0424 Description STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM. HUMIDIFIER. FLOWMETER. but neither a new CMN nor a repeat blood gas study are required: • • Prescribed maximum flow rate changes but remains within one of the following categories: (a) less than 1 LPM. When billing for a stationary gaseous oxygen system (E0424). (b) 1-4 LPM. This is done by transmitting the HCPCS code with the appropriate modifier directly after it. NEBULIZER. AND TUBING OXYGEN CONTENTS. DURABLE. REGULATOR. FLOWMETER. RENTAL. CONTENTS. LIQUID (FOR USE WITH OWNED LIQUID STATIONARY SYSTEMS OR WHEN BOTH A STATIONARY AND PORTABLE LIQUID SYSTEM ARE OWNED). GLASS OR AUTOCLAVABLE PLASTIC BOTTLE TYPE. 1 MONTH'S SUPPLY = 1 UNIT PORTABLE OXYGEN CONTENTS. CONTENTS INDICATOR. GLASS OR AUTOCLAVABLE PLASTIC. LIQUID (FOR USE ONLY WITH PORTABLE LIQUID SYSTEMS WHEN NO STATIONARY GAS OR LIQUID SYSTEM IS USED). 1 MONTH'S SUPPLY = 1 UNIT OXYGEN CONTENTS. INCLUDES CONTAINER. CANNULA OR MASK. GASEOUS (FOR USE WITH OWNED GASEOUS STATIONARY SYSTEMS OR WHEN BOTH A STATIONARY AND PORTABLE GASEOUS SYSTEM ARE OWNED). FOR USE WITH REGULATOR OR FLOWMETER NEBULIZER. PER FOOT MOUTH PIECE FACE TENT VARIABLE CONCENTRATION MASK MISCELLANEOUS DME SUPPLY. & TUBING STATIONARY LIQUID OXYGEN SYSTEM. BOTTLE TYPE. 1 MONTH'S SUPPLY = 1 UNIT PORTABLE OXYGEN CONTENTS. FLOWMETER. REPLACEMENT TRANSTRACHEAL OXYGEN CATHETER.Updated Winter 2004 E0439 E0440 STATIONARY LIQUID OXYGEN SYSTEM. CANNULA OR MASK. CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE E0441 E0442 E0443 E0444 E0445 E1390 Accessories HCPCS A4575 A4606 A4608 A4615 A4616 A4617 A4619 A4620 A9900 E0455 E0555 E0580 E1353 E1355 Description TOPICAL HYPERBARIC OXYGEN CHAMBER. GASEOUS (FOR USE ONLY WITH PORTABLE GASEOUS SYSTEMS WHEN NO STATIONARY GAS OR LIQUID SYSTEM IS USED). INCLUDES USE OF RESERVOIR. NEBULIZER. Not Covered. DISPOSABLE OXYGEN PROBE FOR USE WITH OXIMETER DEVICE. payment will be based on the allowance for the least costly medical appropriate alternative. 1 MONTH'S SUPPLY = 1 UNIT OXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON-INVASIVELY OXYGEN CONCENTRATOR. AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE OXYGEN TENT. Quantity Notes Page 91 . HUMIDIFIER. PURCHASE. Narrative required. Call Allwin Data with the appropriate information. REGULATOR. EACH CANNULA. FOR USE WITH REGULATOR OR FLOWMETER REGULATOR STAND/RACK Explanations of Notes Column NMN NC NARR Not Medically Necessary. HUMIDIFIER. DURABLE. ACCESSORY. EXCLUDING CROUP OR PEDIATRIC TENTS HUMIDIFIER. NASAL TUBING (OXYGEN). Certificate of Medical Neccessity required. Page 92 .Updated Winter 2004 Explanations of Notes Column CR CMN Capped Rental item. Updated Winter 2004 XXII . you may use that companies OCNA#. or if the company also exists in the OCNA# List. use that specific OCNA# in the Group Field. 4. You may bill the coinsurance electronically to SC Medicaid through Allwin Data. There are a few different ways to indicate in the claim the existence of a Complementary Insurance Company. and Massachusetts. 1. 1. you can put that OCNA# in the Group Field.medicare. You can use the word “MEDIGAP” in the Group Field for any company in the Complementary Insurance Companies list. Participating Providers For Participating Providers Medicare will cross over supplemental insurance claims to all companies listed in the Complementary Insurance Companies list.gov/supplier/Home. If one of the companies listed in the Complementary Insurance Company list has an OCNA #. 3. If the company is listed in the OCNA# List. This can be done by calling 800-879-6153. There are two specific types of Medicare providers. use the states postal abbreviation followed by “MEDCO”. Allwin Data’s Manual Billing Service for Non-Participating Providers Allwin Data’s Manual Billing Service enables Non-Participating providers to send supplemental insurance claims to nonComplementary Insurance Companies. There are a few different ways to indicate in the claim the existence of supplemental insurance.asp#NewSearch. for example. For Medicaid. Only those companies listed in the Complementary Insurance Companies list will crossover for Non-Participating Providers. 3. Participating Providers and Non-Participating Providers. If you are unsure of what type of provider you are you can call the National Supplier Clearinghouse @ (866)238-9652. in Mississippi you would put “MSMEDCO” in the Group Field. Non-Participating Providers For Non-Participating Providers. it is important to determine how your pharmacy is set up with the National Supplier Clearinghouse. 4. as well as all companies in the OCNA# List. For Medicaid. You can use the word “MEDIGAP” in the Group Field 2. you would put the word “TRICARE” in the Group Field. The following Medicaids will only crossover if the pharmacy has called Allwin Data to have the patient’s Medicaid ID# added to our files: Vermont. use the states postal abbreviation followed by “MEDCO”. The type of provider you are will determine when and if your supplemental insurance claims will be crossed over by Medicare. New Hampshire. Non-Participating providers must enroll with Allwin Data’s Manual Billing Service to bill non-Complementary insurers as supplemental. Allwin Data will generate a HCFA form for the MI Medicaid coinsurance if you are enrolled in Allwin’s Manual Billing Service. Page 93 . for example. IMPORTANT Medicare will not automatically forward the coinsurance to Medicaid in Michigan and South Carolina. Maine. you would put the word “TRICARE” in the Group Field. 2.APPENDIX I SUPPLEMENTAL INSURANCE BILLING Before using the Allwin Data system to indicate supplemental insurance coverage for a patient. For TRICARE. For TRICARE. To determine your participation status. in Mississippi you would put “MSMEDCO” in the Group Field. Medicare will only cross over supplemental insurance claims to those companies listed below as Complementary Insurance Companies. call the NSC at 866238-9652 or log on to the following link: http://www. providers use their system’s Group Number field to transmit OCNA Number and Cardholder ID in the following format: XXXX-ZZZZZZZZZZ DASH OCNA# SUPPLEMENTAL CARDHOLDER ID The OCNA#s that can be used in the Group Number field are listed on the OCNA Number List that follows. Allwin will electronically transmit the Medicare portion.” This paperwork will then be sent to you so that you may attach the Medicare remittance and send to the supplemental. Page 94 . and will print out a hard-copy HCFA 1500 indicating “signature on file. What happens next? Once the claim is successfully transmitted.Updated Winter 2004 Transmitting Supplemental Insurance Claims via Allwin’s Manual Billing Service Once enrolled with the Manual Billing service. C. Co. Group AMERICAN NAT.C.C C B B A D B C C A A A.D B. CO.D D D Page 95 . GRP.C.B. INC Bankers Fidelity Life BANKERS LIFE & CASUALTY BCBS Alabama BCBS Anthem BCBS ANTHEM (CMIC) BCBS ANTHEM (FACETS) BCBS ANTHEM NEW HAMPSHIRE BCBS Arizona BCBS Arkansas BCBS Colorado BCBS Colorado(FEP) BCBS CONNECTICUT BCBS DELAWARE BCBS EMPIRE OF NY BCBS FEP BCBS Florida BCBS HIGHMARK BCBS Horizon of NJ BCBS Iowa BCBS Kansas BCBS Louisiana BCBS MARYLAND BCBS MICHIGAN BCBS MINNESOTA BCBS MISSOURI BCBS Nebraska BCBS Nevada REGION A.D A.B.B. AMERICAN NAT.B.C.B.C A C A.D D C B A A. American Insurance Amin.Updated Winter 2004 Complementary Crossover Insurance Companies PLAN AARP Acordia Senior of the SE.D D B A.C.D C D D C B A. Inc AEGON AETNA LIFE & CASUALTY AFLAC AIAG-UNION BANKERS Aid Association for Lutherans American Family Life Assurance AMERICAN GEN. INS.C A.B.D A.D B.B B D C A.D C B A. INSURANCE American General Life Ins. LIFE INS (STANDARD LIFE) AMERICAN POSTAL WORKERS UNION (APWU) American Republic ANTHEM INSURANCE COMPANIES. E.D B C D D A C B D A.D B B.C.D A. MOLLOY & ASSOC. (Mailhandlers) Companion Life Continental General Continental Life Insurance Dallas General Life Insurance ELECTRONIC DATA SYSTEMS Fortis Inc/Time FORTIS INSURANCE COMPANY GE Capital Ins Government Employee Hospital Association (GEHA) Group Health Inc. King County King County (FEP) KIRKE-VAN ORSDEL INC.B D Page 96 .C.C A C C C B B A B.D B D D A.Updated Winter 2004 BCBS New Hampshire BCBS NEW JERSEY BCBS New Mexico BCBS North Carolina BCBS North Dakota BCBS Oklahoma BCBS RHODE ISLAND BCBS South Carolina (FEP) BCBS South Carolina (over 65) BCBS Texas BCBS VIRGINIA BCBS VIRGINIA (FEP) BCBS WESTERN NY BCBS Wisconsin BENEFIT PLANNERS Benefit Planners Ltd. Blue Shield of California Blue Shield of Idaho (FEP) C.C B B B.R.A.C.F.B.C C D C C A D A D A. (GHI) GROUP HOSPITAL MEDICAL SERVICES HARRINGTON BENEFIT SERVICES Health Data Management (HDM) Heritage Health Plans Highmark Services Humana J. KPS C B C C D A.C C D B.B. Carefirst CATERPILLAR INC Celtic Life Ins Central States CLAIM PRO (ANTHEM INS CO) Claims Administration Corp. C.D Page 97 .Updated Winter 2004 KVI LOCKHEED-MARTEN MEDICAL MUTUAL OF OHIO Medical Service Corp Michigan Employed Benefit Services Monumental Insurance Company Mutual of Omaha NAT ASSOC LETTER CARRIERS (NALC) NORTH AMER INS CO.C D D A.C.C.B. SECURITY HEALTH PLAN OF WISCONSIN SPECIAL AGENTS MUT BENEFIT Standard Life and Accident State Farm State Mutual Ins TRICARE Triple-S (Seguros de Servicio de Salud de Puerto Rico) Unicare Union Fidelity Life Ins.B. UNITED COMMERCIAL TRAVELERS OF AMERICA United HealthCare United Teachers USAA USAA Life Insurance USAble Life Ins WEA INSURANCE COMPANY WELLMARK Westport Benefits World Ins WorldNet D B A.D A.C.D D D A. NorthWest Medical Olympic Health Management Oxford Life Ins Peoples Benefit Life Ins.B.D D C.D D D A D B D C B A A.C.B A. Co.C.D D A. Physicians Mutual Pierce County Pierce County (FEP) Pioneer Life Premera BC Principal Financial Group PROVIDIAN LIFE/HEALTH Regence Blue Shield (Utah Only) SAMBA Savers Life Ins Seabury and Smith Inc.D A.B.C.D D C.C.D A.D A.D A. Co.B.D C B.D A.C.B. UNITED AMERICAN INS.C. CO.B.D B A.C.B.D C D C D B B D D B. CARPINTERIA AGRICULTURAL INS ADMIN LEWISTON AIAG CLEARWATER AID ASSOC FOR LUTHERANS APPLETON AIG LIFE INS CO WILMINGTON AIROMD MAILHANDLERS INS ROCKVILLE ALLIANCE HEALTH BEN PLAN WASHINGTON ALLIANZ LIFE INSURANCE CO MINNEAPOLIS ALTA HEALTH STRATEGIES BALTIMORE ALTA HLTH STRATEGIES SALT LAKE CITY AMALGAMATED LIFE AND . INC.79 CHICAGO AMER BANKERS INS CO OF FL MIAMI AMER COMBINED LIFE CLEARWATER AMER COMMUNITY MUTUAL LIVONIA AMER EXCHANGE LIFE INS CO/COMMUNITY MUTUAL RYE BROOK AMER HOECHSST PER WESTERN SPRINGS AMER INCOME LIFE INS WACO AMER INCOME LIFE INS WACO AMER INS CO OF TX FT WORTH AMER LIFE INS CO COLUMBUS AMER MANUFACTURERS MUTUAL LONG GROVE AMER PROGRESS LANDHIC OF NY RYE BROOK AMER PROTECTIVE LIFE INS CLEVELAND AMER TRAVELLERS INS DES MOINES AMERICAN ASSOCIATION LAKEWOOD St IL NY FL IA PA PA GA IN IN KY TN CA IN IN KY KY GA TN AR PA CT GA NY TN CA ID FL WI DE MD DC MN MD UT IL FL FL MI NY IL TX TX TX GA IL NY MS IA CA OCNA Code 60630A001 53066A001 32740A001 50306A004 18936A001 18936A002 30328A001 46250A001 46254A001 40233B001 37625A002 92806A001 46240A001 46207A001 40299A001 40223A001 30345A001 38103A001 72211A001 18507A001 06457A001 31999A001 12205A001 37215A002 93013A001 83501A001 75201A001 54919A001 19801A001 20855A001 20065A001 55403A001 21201A001 84130A001 60607A001 33157A001 19047A001 48152A001 75221A001 60558A001 76702A001 76702A002 75266A001 31999A002 60049A001 10509A001 38732A001 19020A001 90712A001 Region(s) ABCD C C D BCD AD BCD ABCD AC A A B B B CD D B D C C A BC A BD AC ABCD C BCD ABCD BD ABCD C BC A ABCD ABD BCD ACD ABCD ABCD CD AB D A AC ABCD ABCD BCD ABCD Page 98 .Updated Winter 2004 OCNA Number List Insurance Plan Name City A AND H CLAIMS CHICAGO A HERBERT AGENCY INC NEW YORK AAA LIFE INSURANCE CO HEATHROW AAL DES MOINES AARP MONTGOMERYVILLE AARP FT WASHINGTON ACADEMY LIFE INS CO ATLANTA ACCORDIA GOVT BENEFITS/AICI INDIANAPOLIS ACCORDIA SENIOR BENEFITS/ ANTHEM INS CO INDIANAPOLIS ACCORDIA/BCBS OF KY LOUISVILLE ACEDEMY LIFE BRISTOL ACORDIA BENEFITS ANAHEIM ACORDIA LOCAL GOV SER INDIANAPOLIS ACORDIA SENIOR BENEFITS INDIANAPOLIS ADMINASTAR INC/ANTHEM DOCUMENT MGMT LOUISVILLE ADMINISTAR LOUISVILLE ADMINISTRATIVE SERVICES INC ATLANTA ADVANCED INS SERVICES MEMPHIS ADVANCED INSURANCE ADM LITLE ROCK AEGON MEDICARE SUPPLEMENT MOOSIC AETNA LIFE AND CASUALTY MIDDLETOWN AFLAC (AMER FAMILY LIFE ASSU) COLUMBUS AFLAC NEW YORK ALBANY AGENCY SERVICES/AMERICARE MEMPHIS AGIA. INC./NETWORK AMERICA LIFE APPALACHIAN LIFE INS CO APWU HEALTH PLAN ARMCO MED INS SVC CT ASSOC DOCTORS HEALTH AND LIFE ASSOC DOCTORS HLTH AND LIFE ASSOC MUTUAL HOSP SERV MI ASSOCIATED LIFE INS CO ATCHISON TOPEKA ATLANTIC AMER INS CO ATLANTIC AMER LIFE INS ATLANTIC AMER LIFE INS ATLANTIC AMER/BANKERS FIDEL ATLANTIC AND PACIFIC INS CO ATLANTIC COAST INS CO ATLANTIC INS CO OF SA AUSA MASTERCARE AUSA MASTERCARE INS AUTO OWNERS LIFE INS CO AWARE GOLD BADGER METER BANKERS COMMER LIFE INS BANKERS FIDELITY LIFE INS BANKERS FIDELITY LIFE INS/ATLANTIC AMERICAN BANKERS LIFE AND CASUALTY BANKERS LIFE AND CASUALTY BANKERS LIFE AND CASUALTY/CNA BANKERS MULTIPLE LINE BANKERS UNITED LIFE ASSUR FORT WORTH HOUSTON MADISON NASHVILLE NASHVILLE MINNEAPOLIS KING OF PRUSSIA DALLAS HARRISBURG DALLAS MISSION VIEJO LONG GROVE GALVESTON CLEARWATER RYE BROOK DES MOINES FORT WORTH ENID WARRINGTON DES MOINES DES MOINES OMAHA MINNEAPOLIS HARSHAM HORSHAM HUNTINGTON SILVER SPRING WORTHIGNTON BIRMINGHAM TREVOSE WARREN INDIANAPOLIS TOPEKA ATLANTA ATLANTA ATLANTA ATLANTA ATLANTA GAINESVILLE AUSTIN DES MOINES DES MOINES LANSING ST PAUL DES MOINES HOUSTON ATLANTA ATLANTA CHICAGO CHICAGO CHICAGO DALLAS SCRANTON TX 76101A001 TX 77242A001 WI 53783A001 TN 37250A001 TN 37202A001 MN 55440A001 PA 19406A001 TX 75266A002 PA 19101A001 TX 75221A002 CA 92691A001 IL 60049A002 TX 77553A001 FL 33755A001 NY 32804A001 IA 50301A001 TX 76107A001 OK 73702A001 PA 18976A001 IA 50301A002 IA 50306A003 NE 68102A001 MN 43216A001 PA 64111A001 PA 19044N001 WV 25701A001 MD 20904A001 OH 43805A001 AL 35202A001 PA 35289A001 MI 48091A001 IN 46206A001 KS 66612A001 GA 30319A001 GA 30219A002 GA 30319A002 GA 31319A003 GA 30359A001 GA 30503A001 TX 78714A001 IA 50306A002 IA 50306A001 MI 48909A001 MN 55164A001 IA 50306B001 TX 75240B001 GA 30319B001 GA 30319A003 IL 02888B001 IL 60630B001 IL 60630B002 TX 75221B001 PA 18504B001 BD CD ABCD ACD B BCD BCD B BC BCD C AC BCD C AC ABCD ABCD BD B C D ABC BCD D AC ABCD A B B BCD AC B ABCD ABCD B CD B B AB BC D D BCD BCD D ABCD C BC BD ABCD A BC AC Page 99 . AON SELECT.Updated Winter 2004 AMERICAN BANKERS INS AMERICAN CAPITAL INS CO AMERICAN FAMILY MUTUAL INS CO AMERICAN GENERAL AMERICAN GENERAL LIFE AND ACCIDENT AMERICAN HARDWARE MUTUAL AMERICAN INDEP LIFE INS CO AMERICAN INS CO OF TX AMERICAN INTEGRITY INS AMERICAN LIFE AND ACC AMERICAN LIFE AND HEALTH AMERICAN MOTORISTS INS CO AMERICAN NATIONAL INS CO AMERICAN PATRIOT HEALTH AMERICAN PIONEER LIFE INS AMERICAN REPUBLIC INS CO AMERICAN SERVICE LIFE INS CO AMERICAN STD LIFE AND ACC CO AMERICAN TRAVELLERS INS AMERICARE PROTECTION AMF. INC. AMOCO CASUALTY AND INDEM AMVETS INS PLAN AON SELECT. INC. Updated Winter 2004 BC OF PA/HIGHMARK BCBS CT-CONST HLTH CARE BCBS MOUNTAIN STATE BCBS OF ALABAMA BCBS OF ARIZONA BCBS OF ARKANSAS BCBS OF CALIFORNIA BCBS OF CALIFORNIA BCBS OF CALIFORNIA BCBS OF CALIFORNIA/UNICARE BCBS OF CENTRAL NY BCBS OF COLORADO BCBS OF COLORADO BCBS OF CONNECTICUT BCBS OF DELAWARE BCBS OF DELAWARE BCBS OF FED EMP. CLAIMS BCBS OF FLORIDA BCBS OF FLORIDA BCBS OF GEORGIA BCBS OF GREENVILLE BCBS OF ILLINOIS BCBS OF INDIANA BCBS OF IOWA BCBS OF KANSAS BCBS OF KANSAS CITY BCBS OF KY/ANTHEM DOC MGT BCBS OF LOUISIANA BCBS OF MAINE BCBS OF MARYLAND BCBS OF MASSACHUSETTS BCBS OF MEMPHIS BCBS OF MICHIGAN BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MISSISSIPPI BCBS OF MISSOURI BCBS OF MONTANA BCBS OF NATIONAL CAPITAL AR BCBS OF NEBRASKA BCBS OF NEVADA BCBS OF NEW HAMPSHIRE BCBS OF NEW JERSEY BCBS OF NEW JERSEY BCBS OF NEW JERSEY BCBS OF NEW MEXICO BCBS OF NEW MEXICO BCBS OF NEW YORK BCBS OF NEW YORK BCBS OF NEW YORK (NE) BCBS OF NEW YORK (WEST) BCBS OF NEW YORK (WEST) PITTSBURGH NORTH HAVEN CHARLESTON BIRMINGHAM PHOENIX LITTLE ROCK WOODLAND HLS VAN NUYS OAKLAND OXNARD SYRACUSE DENVER DENVER NORTH HAVEN WILMINGTON WILMINGTON NORTH HAVEN NORTH HAVEN JACKSONVILLE WINTER HAVEN COLUMBUS GREENVILLE CHICAGO INDIANAPOLIS DES MOINES TOPEKA KANSAS CITY LOUISVILLE BATON ROUGE SO PORTLAND OWING MILLS N QUINCY MEMPHIS NEW HUDSON SAINT PAUL ST PAUL JACKSON SAINT LOUIS HELENA WASHINGTON OMAHA RENO MANCHESTER NEWARK NEWARK NEWARK ALBUQUERQUE ALBUQUERQUE MIDDLETOWN UTICA ALBANY BUFFALO BUFFALO Page 100 PA 15242B001 CT 06473C001 WV 25325B001 AL 35244B001 AZ 85069B001 AR 72203B001 CA 91365B001 CA 91470B001 CA 94612B001 CA 93031B002 NY 13221B001 CO 80203B001 CO 80203B002 CT 06473B001 DE 19801B001 DE 19899B001 CT 06473B002 CT 06473B003 FL 32202B001 FL 33883B001 GA 31908B001 SC 29615B002 IL 60601B001 IN 46204B001 IA 50309B001 KS 66629B001 KS 64141B001 KY 40223B001 LA 70898B001 ME 04106B001 MD 21117B001 MA 02171B001 TN 38101B001 MI 48226B001 MN 55164B001 MN 55164B002 MS 39215B001 MO 63108B001 MT 59604B001 DC 20065B001 NE 68180B001 NV 89520B001 NH 03306B001 NJ 07101B001 NJ 08206B001 NJ 08206B002 NM 87112B001 NM 87112B002 NY 10943B001 NY 13502B001 NY 12205B001 NY 14240B001 NY 14240B002 ABCD A ABCD ABC ABCD ABCD ABCD ABCD B AC ABCD ABCD C ABCD BCD A A A ABCD A ABCD A ABCD C ABCD ABCD ABCD ABCD ABCD ABCD ABCD ABCD ABCD ABCD BCD A ABCD ABCD ABCD ABCD ABCD ABC ABCD A ABCD C ABCD C A B ABCD ABCD D . CLAIMS BCBS OF FED EMP. PRESBY C BELL UNIT BENEFICIAL LIFE INS CO BENEFIT PLANNERS LTD BENEFIT TRUST LIFE INS BENEFIT TRUST LIFE TRUSTMARK INSURANCE BLUE CROSS KINGS COUNTY BLUE CROSS OF ARIZONA BLUE CROSS OF CALIFORNIA BLUE CROSS OF IDAHO BLUE CROSS OF MINNESOTA BLUE CROSS OF NEW YORK BLUE CROSS OF OHIO (SW) BLUE CROSS OF PA-INDEPEND BLUE CROSS OF TENNESSEE BLUE CROSS OF VIRGINIA BLUE CROSS OF WASHINGTON BLUE SHIELD NORTH DAKOTA BLUE SHIELD OF CALIFORNIA BLUE SHIELD OF CALIFORNIA BLUE SHIELD OF IDAHO BLUE SHIELD OF IDAHO BLUE SHIELD OF OREGON C M LIFE INS CO C. CAL FARM BUR HEALTH INS PRO CAPITAL SECURITY INS CO UTICA NEW YORK DURHAM FARGO TOLEDO CLEVELAND TULSA PORTLAND CAMPHILL PROVIDENCE ROCHESTER COLUMBIA SIOUX FALLS CHATTANOOGA SAN ANTONIO SALT LAKE CITY MONTPELIER ROANOKE ROANOKE WASHINGTON CAMP HILL MILWAUKEE OSHKOSH CHEYENNE MILWAUKEE ROANOKE PHILADELPHIA CHICAGO PORTLAND BOERNE LAKE FOREST BOARDMAN SEATTLE PHOENIX OXNARD BOISE ROSEVILLE ALBANY CINCINNATI PHILADELPHIA NASHVILLE ROANOKE SEATTLE FARGO SAN FRANCISCO PLACERVILLE LEWISTON LEWISTON PORTLAND HARTFORD TEMPLE SACREMENTO DURHAM Page 101 NY 13501B001 NY 10156B001 NC 27702B001 ND 58121B001 OH 43697B001 OH 44115B001 OK 74102B001 OR 97207B001 PA 17011B001 RI 02903B001 NY 14604B001 SC 29219B001 SD 57104B001 TN 37402B001 TX 78228B001 UT 84130B001 VT 05601B001 VA 23230B001 VA 24045B001 DC 20024B001 PA 15222B001 WI 53203B001 WI 54901B001 WY 82003B001 WI 53201U001 VA 24031B001 PA 19101B001 IL 60690B001 OR 97207B002 TX 78006B001 IL 60045B001 OH 63127B001 WA 98111B002 AZ 85002B001 CA 93031B001 ID 83707B001 MN 55113B001 NY 12212B001 OH 45206B001 PA 19103B001 TN 37212B001 VA 24031B002 WA 98111B001 ND 58103B001 CA 94120B001 CA 95667B001 ID 83501B001 ID 86501B001 OR 97207B003 CT 06105C001 TX 76503C001 CA 95851C001 NC 27702C001 ACD ABCD ABCD ABD ABCD ABCD ABCD ABCD B ABCD C ABCD ABCD ABCD ABCD ABCD ABCD BCD A A C BCD D ABCD AC D ABCD ABCD ABCD C ABCD ABCD ABCD ABCD BCD ABCD A A A ABCD ABCD A ABCD ABCD BCD BCD B AC A BD A ABCD AC . A. R. E.Updated Winter 2004 BCBS OF NEW YORK UTICA-WATERTOWN BCBS OF NEW YORK/EMPIRE BCBS OF NORTH CAROLINA BCBS OF NORTH DAKOTA BCBS OF OHIO BCBS OF OHIO/MEDICAL MUTUAL BCBS OF OKLAHOMA BCBS OF OREGON BCBS OF PENNSYLVANIA BCBS OF RHODE ISLAND BCBS OF ROCHESTER BCBS OF SOUTH CAROLINA BCBS OF SOUTH DAKOTA BCBS OF TENNESSEE BCBS OF TEXAS BCBS OF UTAH BCBS OF VERMONT BCBS OF VIRGINIA BCBS OF VIRGINIA BCBS OF WASHINGTON DC BCBS OF WESTERN PA BCBS OF WISCONSIN BCBS OF WISCONSIN BCBS OF WYOMING BCBS UNITED OF WISCONSIN BCBS/TRIGON MUTUAL INS CO BD OF PENSIONS . COMMUNITY MUTUAL INS COMMUNITY MUTUAL INS COMPANION HEALTH CARE COMPANION LIFE COMPCARE HEALTH SERVICES INS CO COMPCARE HLTH SVCS INS CO COMPCARE HLTH SVCS INS CO COMPLETE HEALTH COMPLETE HEALTH./SENIOR PARTNERS CONESTOGA LIFE ASSUR CO CONFEDERATION LIFE INS CO CONSECO DIRECT LIFE INS/COLONIAL LIFE CHATSWORTH OWING MILLS URBANA SCRANTON SCRANTON BEDFORD PARK COLUMBUS WORCESTER STRONGSVILLE RICHARDSON OMAHA CHICAGO DES PLAINES OMAHA CHICAGO DALLAS WAXAHACHIE CINCINNATI AUSTIN DES MOINES SAN FRANCISCO PORT ANGELES BAKERSFIELD ATLANTA NASHVILLE CHICAGO OKLAHOMA CITY SPARTANSBURG CLEVELAND ATLANTA CHARLESTON PHILADELPHIA GREENVILLE DENVER CHICAGO BELLINGHAM TYLER SVANNAH COLUMBUS CLEVELAND MADISON WORTHINGTON CINCINNATI COLUMBIA COLUMBIA MILWAUKEE MILWAUKEE MILWAUKEE BIRMINGHAM BIRMINGHAM LANCASTER NO CHARLESTON PHILADELPHIA CA 91311C001 MD 21117C001 IL 61801C001 PA 18202C001 PA 18505C001 IL 60499C001 OH 43216C001 MA 01608C001 OH 44136C001 TX 75083C001 NE 66134C001 IL 60631C001 IL 60017C001 NE 68134C001 IL 60630C001 TX 75265C001 TX 75165C001 OH 45250C001 TX 78767C001 IA 50306C001 CA 94103C001 WA 98362C001 CA 93301C001 GA 30345C001 TN 37230C001 IL 60630C002 OK 73125C001 SC 29306C001 OH 44114C001 GA 29202C001 SC 29402C001 PA 19103C001 SC 29601C001 CO 80531C001 IL 60606C002 WA 60606C001 TX 75710C001 GA 31401C001 OH 43235C001 MS 38732C001 WI 53705C001 OH 43085C001 OH 45206C001 SC 29223C001 SC 29202C002 WE 53203C001 WI 53202C001 WI 53202C002 AL 35202C001 AL 35205S001 PA 17604C001 SC 29418C001 PA 19181C001 ABD C ABCD B ACD BCD ABCD ABCD ABC ABCD AC BD B BCD ABCD BC ABCD ABCD ABD D A AC ABCD ABCD BC BCD BD AB AC C AB B BC A BC CD BC B BD BCD A A BCD BC AC B A CD BCD AC AC AB CD Page 102 .Updated Winter 2004 CAREAMERICA LIFE INS CO CAREFIRST CARLE CARE CATHOLIC GOLDEN AGE INS CATHOLIC GOLDEN AGE INS CELTIC LIFE INS CO CENTRAL BENEFITS CENTRAL MASS HEALTH CENTRAL RESERVE LIFE INS CENTRAL SECURITY LIFE INS CENTRAL STATES CENTRAL STATES HEALTH AND LIFE CENTRAL STATES INS CENTRAL STATES OF OMAHA CERTIFIED LIFE INS CO CERTIFIED LIFE INS CO CHRISTIAN FIDELITY LIFE CINCINNATI LIFE INS CO CITIZENS INS CO OF AMER CITY OF OAK CREEK CIVIL SRVC EMPLOYEES INS CLALLAM COUNTY PHYS SVC CLINICIANS HEALTH NETWORK CNA/CONTINENTAL CASUALTY CNA/CONTINENTAL CASUALTY CNA/CONTINENTAL CASUALTY COASTAL STATES COLONIAL COLONIAL INSURANCE CO COLONIAL LIFE COLONIAL LIFE COLONIAL PENN INS CO COLONIAL PENN LIFE INS COLORADO PIPE IND INS COMBINED AMERICAN COMBINED INS CO OF AMER COMBINED UNDERWRITERS LIF COMMERCIAL LIFE INS COMMONWEALTH INS CO COMMONWEALTH NATIONAL LIFE COMMUNITY FINANCIAL AND INSURANCE CORP. INC. Updated Winter 2004 CONSECO SENIOR HEALTH INS CONSECO SENIOR HEALTH INS CONSUMER UNITED INS CO CONTINENTAL AMER LIFE CONTINENTAL ASSURANCE CONTINENTAL CASUALTY CONTINENTAL GENERAL INS CONTINENTAL GENERAL INS CONTINENTAL GENERAL INS CONTINENTAL LIFE COOPERATIVA DE SEGUROS CORNING GROUP INS DEPT CORPORATE LIFE INS CO CORROON AND BLACK COSMOPOLITAN LIFE INS CO COUNTRY LIFE INS CO CROLEY LIFE INS CO CRUS AZUL DE PUERTO RICO CUNA MUTUAL INS CO CUSTOM CARE DAIRY FARMERS OF AMERICA DALLAS GENERAL LIFE DEANCARE DIRECT OLIN DIRECT RESPONSE INS ADMIN DURHAM LIFE INS CO EARLY AMER LIFE INS CO EASTERN INS CO EASTERN INS CO/AM FAM LIFE/EQUALIZER EASY CHOICE USA EBA EDS FEDERAL CORP EDS MEDICAL EDUCATORS MUTUAL EGIP ELECTRIC MUTUAL BENEFIT ELECTRONICS DATA SYSTEM EMPIRE BCBS OF NEW YORK EQUALIZER EQUITABLE LIFE ASSN SOC EQUITABLE LIFE ASSN SOC O EQUITABLE LIFE ASSN SOC O EQUITABLE LIFE ASSURANCE EQUITABLE LIFE ASSURANCE EQUITABLE LIFE ASSURANCE EQUITABLE LIFE INS CO EXECUTIVE FUND INS CO EXECUTIVE FUND LIFE INS FARM FAMILY LIFE INS CO FARMERS STOCKMAN INS FED LIFE INS CO FEDERAL HOME COMPANIES FEDERAL HOME LIFE CLEARWATER CLEARWATER WASHINGTON WILMINGTON ATLANTA CHICAGO WICHITA OMAHA OMAHA BRENTWOOD SANJUAN CORNING WEST CHESTER NASHVILLE WOODLAND HILLS BLOOMINGTON GILMER SANJUAN PELHAM CHARLOTTE DES MOINES DALLAS MADISON STATFORD CHANHASSEN RALEIGH EAGAN COLUMBIA COLUMBUS CHARLESTON KANSAS CIY TOPEKA SACRAMENTO MURRAY OKLAHOMA CITY SALT LAKE CITY CHEYENNE NEW YORK DETROIT EASTON EASTON SALT LAKE CTY GREAT FALLS SHAWNNE MISSION ALBUQUERQUE CLEARWATER SANTA MONICA RALEIGH ALBANY SPOKANE RIVERWOODS BATTLE CREEK MILWAUKEE Page 103 FL 33757C001 FL 33767C001 DC 20063C001 DE 19850C001 GA 30326C001 IL 60604C001 KS 67201C001 NE 68114C001 NE 68124C001 TN 37024C001 PR 00936C001 NY 14830C001 PA 19381C001 TN 37230C002 CA 91365C001 IL 61702C001 TX 75644C001 PR 00936C002 AL 35124C001 NC 28235C001 IA 50306D001 TX 75221D001 WI 53705D001 CT 06497D001 MN 55438D001 NC 27611D001 MN 55121E001 SC 29219E001 GA 31999E001 WV 25301E001 MO 64193E001 KS 66604E001 CA 95852E001 UT 84107E001 OK 73124E001 UT 84127E001 WY 82003E001 NY 10016B001 MI 48226E001 PA 18042E001 PA 18942E001 UT 84110E001 MT 59405E001 KS 66205E001 NM 87190E001 FL 33755E001 CA 90403E001 NC 27605E001 NY 12201F001 WA 99210F001 IL 60015C001 MI 49017F001 WI 53214F001 C C ABC B AB ABCD BCD B CD ABC ABCD BD BD A ABD AC AB ABCD ABD AB D ABCD ABCD AB D ABCD ABC A AC ABCD AB ABD B B ABD ABCD B ABCD AB C B BCD A B BD C BCD C BCD BCD AB BC ABCD . GLOBE LIFE AND ACCIDENT INS GLOBE LIFE AND ACCIDENT INS GOLDEN CARE GOLDEN INS CO GOLDEN RULE INS CO GOLDEN RULE INS CO GOLDEN STATE MUTUAL LIFE GOLDSTAR HEALTH CARE GOLDSTAR HEALTH CARE GOLDSTAR HEALTH CARE GOOD SAM INS CO GOVERNMENT WIDE INDEM GRANGE MUTUAL GRAYS HARBOR MED BUREAU GREAT AMER GREAT AMER RESERVE INS CO GREAT FIDELITY LIFE INS GREAT MIDWEST LIFE INS CO GREAT REPUBLIC INS CO GREAT WESTERN LIFE ORLANDO DECATUR BALTIMORE SANTAANA AUSTIN MINNEAPOLIS FORT COLLINS PITTSBURGH SUN CITY PENSACOLA MONTGOMERY ALEXANDRIA DES MOINES W DES MOINES DES MOINES GRAND RAPIDS KANSAS CITY MILWAUKEE FRENSO CARMICHAEL RANCHO CORDOVA SACRAMENTO DES MOINES MILWAUKEE SEATTLE CLEARWATER ST LOUIS ATLANTA FREMONT GRAND RAPIDS DES MOINES DES MOINES COVINGTON DALLAS DALLAS MEMPHIS COLUMBIA INDIANAPOLIS LAWRENCEVILLE LOS ANGELES DELAWARE DELAWARE HOUSTON SANTA BARBARA BOISE NAMPA ABERDEEN ORLANDO CARMEL FORT WAYNE DALLAS SEATTLE COLUMBUS Page 104 FL 32887F001 IL 62526F001 MD 21212F001 CA 92708F001 TX 78714F001 MN 55440F001 CO 80522F001 PA 15230F001 AZ 85351F001 FL 32591F001 AL 36104F001 VA 20037F001 IA 50306F002 IA 50398F001 IA 50306F001 MI 49501F001 MI 64141P002 WI 53201T001 CA 93712F001 CA 95608F001 CA 95670F001 CA 95865F001 IA 50306F003 WI 53223F001 WA 98111G001 FL 32887G001 MO 65178G001 GA 30301G001 MI 49412G001 MI 10601G001 IA 50306G001 IA 50306G002 LA 70433G001 TX 55221U001 TX 75221G001 TN 38119G001 SC 29202G001 IN 46278G001 IL 62439G001 CA 90018G001 OH 43015G001 OH 46015G001 TX 77006G001 CA 93121G001 ID 83707G001 ID 85653G001 WA 98520G001 FL 32803G001 IN 46032G001 IN 46801G001 TX 75218G001 WA 98119G001 OH 43215G001 BCD B B ABC ABCD ABD ABC ABCD AB C BCD BC D D D ABCD A AB ABCD ABCD ABCD ACD D ABC C C AB ABD C ABCD AB D C B C ABCD AB CD ABCD A AC B C ABCD B A ABCD ABC ABCD BCD ABCD ABCD BD . INC.Updated Winter 2004 FEDERAL HOME LIFE INS FEDERAL KEMPER INS CO FELRA FHP LIFE INS CO FIC INS GROUP FIREMAN’S FUND EMPL INS FIRST CENTENNIAL LIFE INS FIRST CONTINENTAL LIFE FIRST HEALTH OF AZ INC FIRST NATIONAL LIFE INS FIRST NATIONAL LIFE INS FLEET RESERVE ASSOC FLEET RESERVE ASSOC .FRA FLEET RESERVEASSOC FLIGHT-CARE FOREMOSE LIFE INS CO FORTIS BENEFITS FORTIS INSURANCE COMPANY/TIME FOUNDATION HEALTH PLAN FOUNDATION HEALTH PLAN FOUNDATION HEALTH PLAN FOUNDATION HLTH PLAN FRA INSURANCE PLANS FUTURE FINANCIAL GE CAPITAL ASSUARANCE CO GE LIFE ADN ANNUNITY GENERAL AMER LIFE GEORGIA LIFE AND HEALTH INS CO GERBER LIFE INS GERBER LIFE INS CO GH BENEFIT PLAN GIDDINGS AND LEWIS GILSBAR. Updated Winter 2004 GREAT WESTERN LIFE GREAT WESTERN LIFE GREATER LACROSSE HLTH GREATER MARSHFIELD OFFICE GREDE FOUNDRIES INC GROUP HEALTH COOP/S CTRL GROUP HEALTH INC GROUP HEALTH OF SPOKANE GROUP HEALTH OF SPOKANE GROUP HEALTH SRVS OF OK GROUP LIFE AND HEALTH INS GROUP MGMNT SERVICES INC GUARANTEE RESERVE LIFE GUARANTEE TRUST LIFE INS GUARDIAN LIFE GULF SOUTH HEALTH PLAN GVMNT EMP HOSP ASSOC INC HARBOR INS CO HARTFORD ACC AND INDEMNITY HARTFORD INS CO HARTFORD INS CO HARTFORD INS CO/KING COUNTY BLUE SHIELD HARTFORD INSURANCE HARTFORD LIFE AND ACC CO HARTFORD LIFE AND ACCIDENT HARVEST LIFE INS CO HAWKEYE NATIONAL LIFE INS CO HEALTH ABENEFIT PLAN HEALTH ADVANTAGE HEALTH AND LIFE INS HEALTH CARE HEALTH CARE BENEFIT HEALTH CARE BENEFIT HEALTH CARE SERVICE HEALTH DATA MANAGEMENT HEALTH FIRST PPO HEALTH LINK HEALTH PARTNERS ALABAMA HEALTHCARE MGMNT SVC/ME SENIOR COMP PLAN HEALTHGUARD SERVICES HEALTHGUARD SERVICES INC HERITAGE HEALTH PLANS HIGHMARK/BLUE SHIELD OF PA HILL COUNTRY LIFE INS CO HILL COUNTRY OF MONTANA HMO MIDWEST HMO OF WISCONSIN HOLY FAMILY SOCIETY OF US HOME BENEFICIAL LIFE INS HORACE MANN LIFE INS CO HORIZON BCBS OF NJ HUMANA CARE PLUS HUMANA GOLD CLAIMS CLAYTON DENVER WAUSAU MARSHFIELD DES MOINES MADISON NEW YORK SPOKANE SPOKANE TULSA RICHARDSON NEW BERLIN CALUMET CITY GLENVIEW APPLETON BATON ROUGE INDEPENDENCE LOS ANGELES DES MOINES ALEXANDRIA SHAWNEE MISSION DES MOINES DES MOINES HARTFORD HARTFORD ORLANDO W DES MOINES PISCATAWAY FLORENCE ROCKFORD GREENACRES COLUMBIA CHICAGO CHICAGO OMAHA GREENVILLE SAINT LOUIS BIRMINGHAM LONG BEACH BELLINGHAM EUGENE GRAND PRAIRIE CAMP HILL AUSTIN BOZEMAN HUDSON SIOUX CITY JOLIET RICHMOND SPRINGFIELD NEWARK LOUISVILLE DENVER MO 63105G001 CO 80201G001 WI 54402G001 WI 54449G001 IA 50306G003 WI 53715G001 NY 10036G001 WA 92204G001 WA 99204G001 OK 74102G001 TX 75080G001 WI 53151G001 IL 60409G001 IL 60025G001 WI 54913G001 LA 70898G001 MO 64111G001 CA 90010H001 IA 50398H001 VA 22312H001 KS 66201H001 IA 50398H002 IA 50306H001 CT 06104H001 CT 06115H001 FL 32887H001 IA 50266H001 NJ 08854H001 SC 29501H001 IL 61105H001 WA 99016H001 SC 29260H001 IL 60685H001 IL 60601H001 NE 68154H001 SC 29605H001 MO 63132H001 AL 35209H001 CA 90802H001 WA 98227H001 OR 97440H001 TX 75050H001 PA 17089B001 TX 78720H001 MT 59771H001 WI 54016H001 WI 53583H001 IL 60434H001 VA 23261H001 IL 62715H001 NJ 07105H001 KY 40201H002 CO 80210H001 B BD ACD C D B ABCD B A C C ABC ABCD ABCD ABD AB A ABC BCD BCD B BD D BC D BCD ABC B B BCD ABCD ABCD ABCD ABCD CD BD BC ABCD AC ABCD ABC C ABCD ABCD B AC AC BD ABC AC C BCD ABC Page 105 . Updated Winter 2004 HUMANA HEALTH CARE PLANS HUMANA HEALTH CARE PLANS HUMANA INC. IASD HEALTH SERVICES CORP ICI HEALTH CLAIMS SERVICES IDEALIFE INSURANCE CO IGG ASSOCIATION IHC SENIOR CARE ILLINOIS CENTRAL GULF INDEPENDENCE BC/BS INDEPENDENT LIFE INDUSTRIAL CASUALTY INS INTEGRITY NATIONAL LIFE INS INTER COUNTY HOSP PLAN IN INTERCONTINENTAL LIFE INS INTERCONTINETAL LIFE INS INTERGROUP PREPAID SCVS O INTL BENEFITS SERVICES CO INVESTORS CONSOLIDATED IN INVESTORS DIVERSIFIED INS INVESTORS HERITAGE LIFE ITT HARTFORD ITT LIFE INS CORP J C STEELE AND SONS INC JC PENNY LIFE INS CO JEFERSON LIFE INS CO JEFFERSON PILOT FINANCIAL JOCKEY INTERNATIONAL INC JOINT BENEFIT TRUST KAISER GROWN HEALTH PLAN KAISER GROWN HLTH PLAN KAISER PERMANENTE KANAWHA INS CO KEYSTONE INS CO KING COUNTY BLUE SHIELD KING COUNTY BLUE SHIELD/KIRKE VAN ORSDEL KIRKE VAN ORSDEL KIRKE VAN ORSDEL KIRKE VAN ORSDEL KIRKE VAN ORSDEL KIRKE VAN ORSDEL INC KIRKE VAN ORSDEL INC KIRKE VAN ORSDEL INC KIRKE-VAN ORSDEL KIRKE-VAN ORSDEL INC KIRKE-VAN ORSDEL, INC KITSAP PHYSICIANS SERVICE KLAMATH MEDICAL LA-Z-BOY INCORPORATED LEGAL SECURITY LIFE INS LIBERTY LIFE INS CO LIBERTY MUTUAL INS CO LIBERTY NATIONAL LIFE INS CO JACKSONVILLE LOUISVILLE LEXINGTON DES MOINES BOCAROPON CLEARWATER OMAHA SALT LAKE CITY LANSING CAMP HILL JACKSONVILLE OAK PARK LOUISVILLE HORSHAM AUSTIN PHILADELPHIA TUCSON FORT WORTH DURHAM BATON ROUGE FRANKFORT SIMSBURY MINNEAPOLIS DURHAM DALLAS DALLAS GREENSBORO DES MOINES LIVERMORE WAHSINGTON ROCKVILLE LOS ANGELEA LANCASTER PHILADELPHIA SEATTLE DES MOINES DES MOINES DES MOINES DES MOINES DES MOINES DES MOINES DES MOINES DES MOINES DES MOINES W DES MOINES WEST DES MOINES BREMERTON KLAMATH FALL DES MOINES DALLAS GREENVILLE LONG BEACH BIRMINGHAM FL 32245H001 KY 40201H001 KY 78229H001 IA 50309I001 FL 33427I001 FL 34618I001 NE 68175I001 UT 84111I001 MI 48909I001 PA 17089I001 FL 32276I001 IL 60301I001 KY 40232I001 PA 19044I001 TX 78714I001 PA 19101I001 AZ 85710I001 TX 76109I001 NC 27702I001 LA 70816I001 KY 40602I001 CT 06104I001 MN 55441I001 NC 27702J001 TX 75221J001 TX 75243J001 NC 27420J001 IA 50306J001 CA 94551J001 DC 20016H001 MD 20016K001 CA 90041K001 SC 29721K001 PA 19103K001 WA 50398K001 IA 50398K002 IA 50306K001 IA 50306K002 IA 50306K003 IA 50306K004 IA 50306K005 IA 50306K006 IA 50306K007 IA 50309K001 IA 50398K003 IA 50398A002 WA 98310K001 OR 97601K001 IA 50306L001 TX 75185L001 SV 29602L001 CA 90804L001 AL 35202L001 ABC AD ABCD C ABD A ABCD ABCD AB C C BCD BCD ABD ACD B ABC ABCD ABCD AB ABCD C ABCD ABCD ABD ABCD C D ABC B ACD BCD ABCD BCD CD ACD C D D D D D D D D A ABCD BCD D ABC ABCD BD B Page 106 Updated Winter 2004 LIBERTY NATL LIFE INS CO LIFE / HEALTH OF AMERICA LIFE AND HLTH INS CO OF AME LIFE INS CO OF CONNECTICUT LIFE INS CO OF GEORGIA LIFE INS CO OF GEORGIA LIFE INS CO OF VIRGINIA LIFE INSURANCE CO OF VA LIFE INSURANCE OF VA LIFE INVESTIRS CO LIFE INVESTORS CO LIFE INVESTORS INS CO LIFE OF AMERICA LIFE OF GEORGIA LIFE OF GEORGIA INS LINCOLN LIFE AND CAS CO LINCOLN MUT LIFE AND CAS IN LINCOLN NATIONAL INS LUMBERMENS MUTUAL CASLTY LUTHERAN BROTHERHOOD INS M AND I INSURANCE PLANS M AND M INSURANCE PLANS M PHYSICIANS MUTUAL MARICOPA MANAGED CARE SYS MARITIME ASSOC MARKET EMPLOYEES ASSOC MARSH AND MCCLELLAN GRP MASSACHUSETTS MUTUAL MASTERCARE MAXICARE MEAD MEDCENTERS SENIOR LINK MEDI PAK/BCBS ARKANSAS MEDI PAK/BCBS ARKANSAS MEDICAL ASSOC HMO MEDICAL ASSOC HMO MEDICAL SERV ADMIN OF MI MEDICAL SERVICE ASSOC. MEDICAL SERVICE CORP MEDICAL SERVICE OF D C MEDICARE-AID MEDICO LIFE INS CO MEDICOMP MEDICOMP MEDIPLUS MEDIPLUS MEDIPLUS MEDIPLUS MEMORIAL LIFE INS CO MENNONITE MUTUAL AID METROPOLITAN LIFE INS METROPOLITAN LIFE INS METROPOLITAN LIFE INS/UNITED HEALTHCARE BIRMINGHAM FORT WORTH PHILADELPHIA SIOUX FALLS BIRMINGHAM LANGHORNE TREVOSE RICHMOND DANVILLE CEDAR RAPIDS CEDAR RAPIDS SCRANTON HOUSTON FORT WASHINGTON COLUMBUS LINCOLN FARGO FREDRICK LONG GROVE MINNEAPOLIS DES MOINES DES MOINES OMAHA PHOENIX HOUSTON CHARLOTTE CHICAGO WASHINGTON DES MOINES CHARLOTTE DES MOINES MINNEAPOLIS LITTLE ROCK LITTLE ROCK DUBUQUE DUBUQUE DES MOINES CAMP HILL SPOKANE WASHINGTON RALEIGH OMAHA PORTLAND GREENVILLE DES MOINES DES MOINES DES MOINES CAROL STREAM WAUSAU GOSHEN PITTSBURGH AURORA BRIDGEWATER Page 107 AL 35207L001 TX 76102L001 PA 19103L001 SD 57193L001 AL 30348L001 PA 35289L001 PA 19053L001 VA 23240L001 VA 24540L001 IA 52402L001 IA 52102L001 PA 18504L001 TX 77019L001 PA 35209L001 GA 31999L001 NE 68501L001 ND 58107L001 MD 21701L001 IL 60049L001 MN 55415L001 IA 50306M003 IA 50306M004 NE 68131M002 AZ 85034M001 TX 77034M001 NC 28222M001 IL 60606M002 DC 20063M002 IA 50306M001 NC 28217M001 IA 50306M005 MN 55435M001 AR 72203M001 AR 77203M001 IA 52001C001 IA 52001M001 IA 50309M001 PA 17089M001 WA 99220M001 DC 20065M001 NC 27622M001 NE 68103M001 ME 04104M001 SC 29609M001 IA 50306M002 IA 50398M001 IA 50398M002 IL 60197M002 WI 54402M001 IN 46526M001 PA 15230M001 IL 60507M001 NJ 08807M001 ACD AC BCD ABCD B CD ABCD C ABCD ACD B AC ABCD BC BCD ABCD ABCD ABD AC ABCD D D D AB ABD ABD ABCD B CD ABD D ABD BC ACD A B ABC C ABCD ABCD ABD ACD B ABCD D BCD D D BD ABCD A A ABD Updated Winter 2004 MID AMER MUT LIFE INS CO MID AMERICA MUTUAL LIFE MID SOUTH INS CO MII LIFE INCORPORATED MILICARE - FLEET RESERVE MILICARE/FLEETRESERVE MINNESOTA COMP HEALTH MINNESOTA PROTECTIVE LIFE MONTGOMERY WARD LIFE INS MONUMENTAL GENERAL INS MONUMENTAL LIFE MONY MOUNTAIN STATE BCBS MPS OF MICHIGAN MUTUAL BENEFIT CO MUTUAL INS. NATIONWIDE MUTUAL LIFE INS CO MUTUAL LIFE INS CO MUTUAL LIFE INS CO OF NY MUTUAL OF NEW YORK MUTUAL OF OMAHA/STANDARD LIFE MUTUAL PROT MEDICO LIFE MUTUAL PROTECTIVE MUTUAL SERVICE LIFE INS N CENTRAL 65 PLUS NALC - HEALTH BENEFIT PLN NATIONAL BENEFIT CORP NATIONAL CASUALTY INS NATIONAL COUNCIL SR CITIZEN NATIONAL FARMERS UNION LIFE NATIONAL FINANCIAL INS CO NATIONAL FINANCIAL/FOUNDATION LIFE NATIONAL GROUP LIFE NATIONAL HERITAGE INS NATIONAL HOME LIFE ASSUR NATIONAL HOME LIFE ASSUR NATIONAL LIBERTY GROUP NATIONAL LIFE AND ACCIDENT NATIONAL SECURITY INS CO NATIONAL STATES INS NATIONAL STATES INS CO NATIONAL TRAVELERS LIFE NATIONAL VISION NATIONWIDE LIFE INS CO NATL BENEFIT LIFE INS CO NATL FARMERS UNION LIFE NATL HEALTH INS CO NATL LIFE NATL LIFE AND ACC NATL LIFE INS CO OF TEXAS NAUS - UNISERVICE NAUS – UNISERVICE NEW ERA LIFE INS CO SAINT PAUL CHICAGO FAYETTEVILLE SAINT PAUL W DES MOINES FAIRFAX SAINT PAUL OMAHA CAROL STREAM SCRANTON BALTIMORE HOUSTON WHEELING DETROIT COLUMBIA COLUMBUS WASHINGTON FAIRFIELD PURCHASE NEW YORK OMAHA OMAHA OMAHA SAINT PAUL WAUSAW ASHBURN KANSAS CITY SAINT LOUIS IRVINGTON DENVER DALLAS FORT WORTH ROCKFORD AUSTIN BINGHAMTON VALLEY FORGE VALLEY FORGE EVANSVILLE POTTSVILLE DES MOINES ST LOUIS DES MOINES PHOENIX COLUMBUS NEW YORK KANSAS CITY DALLAS OCEANSIDE NASHVILLE ARLINGTON ROCKVILLE ROCKVILLE HOUSTON Page 108 MN 55113M001 IL 60606M001 NC 28302M001 MN 55164M001 IA 20063M001 VA 20063M003 MN 55164M002 NE 68114M001 IL 60197M001 PA 18504M001 MD 21201M001 TX 77006M001 WV 26003M001 MI 48266M001 SC 29260M001 OH 43216M001 DC 20037M001 AL 35064M001 NY 10577M001 NY 10019M001 NE 68131M001 NE 68172M001 NE 68124M001 MN 55164M003 WI 54402N001 VA 22093N001 MO 64111N001 MO 63101N001 NY 10533N001 CO 80231N001 TX 75266N001 TX 76102N001 IL 61105N001 TX 78720N001 NY 13901N001 PA 19493N001 PA 19493N002 IN 47701N001 PA 17901N001 IA 50306N001 MO 63141N001 IA 50309N001 AZ 85060N001 OH 43216N001 NY 10016N001 MO 64199N001 TX 75261N001 CA 92049N001 TN 37250N001 TX 76015N001 MD 20852N001 MD 28052N001 TX 77210N001 BCD BC BCD ABCD BCD D ABCD ABCD ABCD ABCD C ABCD ABCD ABCD ABD C ABCD ABCD ABCD ABCD ABCD BCD C ABC BCD A ABCD BC ABD AB BD BCD AC ABD B BCD BCD C AB AB BD ABC ABCD ABCD ABCD ABCD ABC AB A ABCD AD B AC NORTH AMERICAN INS CO PEOPLES LIFE INS PEOPLES LIFE INS CO/UNITED HEALTHCARE PEOPLES SECURITY INS PEOPLES SECURITY LIFE INS/PUBLIC SAVINGS LIFE PERSONALCARE INS AIL INC PFL LIFE INSURANCE CO PFWB BENEVOLENT ASSO PHILADELPHIA AMER LIFE CO PHYSICIANS HEALTH PLAN ATLANTA OMAHA MADISON MINNEAPOLIS KANSAS CITY DES MOINES INDIANAPOLIS NASHVILLE JACKSON HURON BELLINGHAM CHICO OKLAHOMA CITY KANSAS CITY MONTGOMERY OKLAHOMA CITY BELLINGHAM PORTLAND MADISON OMAHA CLACKAMAS HUNTINGTON BCH BEND OMAHA EUGENE GLENDALE FEDERAL WAY PORTLAND COSTA MESA HOUSTON SHEBOYGAN DES MOINES WORCHESTER HOUSTON SALT LAKE CITY CHARLESTON PEKIN RALEIGH ATLANTA ALLENTOWN HATTSBORO SANTA MONICA FRAZER MADISON GREENVILLE ROLLING MEADOWS DANVILLE DURHAM CHAMPAIGN SCRANTON DUNN HOUSTON MINNEAPOLIS GA 30348N001 NE 68131N001 WI 53744N001 MN 55440N001 MO 64111N002 IA 50306N002 IN 46206N001 TN 37202N001 MN 56143N001 SD 57350N001 WA 98227N001 CA 95927O001 OK 73124O001 MO 64141O001 AL 36101O001 OK 73154O001 WA 98227O001 OR 97207O001 WI 53744O001 NE 68154O001 OK 97015P001 CA 92647P001 OR 97701P001 NB 68172P001 OR 97401P001 CA 91203P001 WA 98003P001 OR 97207P001 CA 92708P001 TX 77251P001 WI 53801P001 IA 50306P001 MA 01608P001 TX 77235P001 UT 84102P001 WV 25362P001 IL 61558P001 NC 27605P001 GA 30358P001 PA 18105P001 PA 19034P001 CA 90406P001 PA 19493P002 WI 53703P001 SC 29609P001 IL 60008P001 VA 24540P001 NC 27702P001 IL 61820P001 PA 18504P001 NC 28335P001 TX 77210P001 MN 55440P001 BD B ABCD B BCD D ABCD ABD B BD D A AB ABCD AB ABCD ACD ABCD C D AC C AC AC ABCD AB AB ABCD C ABD ABCD D ABCD ABCD ABC B ABCD ABCD ABC BCD BD BC C C ABCD ABCD ABCD ABCD AC C ABCD C B Page 109 . PAUL REVERE LIFE INS CO PEARCE IND PEHP PEIA HEALTH ECON CORP PEKIN LIFE INS CO PENINSULAR LIFE INS CO PENN GENERAL SERVICES OF GA PENN TREATY LIFE INS CO PENNSYLVANIA AMER PENNSYLVANIA LIFE INS PEOPLES BENEFIT LIFE INS PEOPLES LIFE . INC.Updated Winter 2004 NEW YORK LIFE NEW YORK LIFE INS NORTH AMER INS CO NORTH AMER INS CO NORTH AMER INS CO NORTH AMERICAN LIFE NORTH ATLANTIC CAS AND SURE NORTH CAROLINA MUTUAL NORTHWESTERN NATIONAL LIFE NORTHWESTERN PUBLIC SERV NW WASHINGTON MEDICAL BUR OCR CLAIMS OKLAHOMA STATE INS OLD AMER INS CO OLD SOUTHERN LIFE INS CO OLD SURETY LIFE INS CO OLYMPIC HEALTH MANAGEMENT OREGON PACIFIC STATES OXFORD LIFE INSURANCE OXFORD LIFE INSURANCE COM PACC HEALTH PLANS PACIFIC HEALTH ADM PACIFIC HEALTH AND LIFE INS PACIFIC HERITAGE ASSURANC PACIFIC HOSPITAL ASSOC PACIFIC MUTUAL LIFE PACIFIC MUTUAL LIFE PACIFIC NORTHWEST LIFE PACIFICARE LIFE ASSURANCE PANHANDLE EASTERN CORP PARK AND SHOP INS PATRICK CUDAHY. Updated Winter 2004 PHYSICIANS LIABILITY INS PHYSICIANS MUTUAL INS CO PIERCE COUNTY MED BUREAU PIERCE COUNTY MEDICAL BUR PILGRIM LIFE INS CO PILOT LIFE INS CO PIONEER LIFE INS CO PLAN 65 OF KANSAS PREFERRED ADMINISTRATIVE PREFERRED BANKERS LIFE PREFERRED CHOICE PREFERRED HEALTH CARE PREFERRED LIFE INS CO OF NY PREFERRED RISK LIFE PREMERA BLUE CROSS PRESIDENTIAL LIFE PRIME CARE PLUS PRIME HEALTH PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GRP PRINCIPAL HEALTH CARE PRINCIPAL MUTUAL INS PRINCIPAL MUTUAL LIFE PROTECTED HOME MUT LIFE PROTECTIVE LIFE INS CO PROVIDENCE LIFE PROVIDENTIAL LIFE INS CO PROVIDERS FIDELITY LIFE PROVIDIAN LIFE AND HEALTH PROVIDIAN LIFE/HEALTH PRUDENTIAL INSURANCE CO PYRAMID LIFE INS CO QUAL-MED INC OKLAHOMA CITY OMAHA TACOMA TACOMA FOLCROFT NASHVILLE ROCKFORD TOPEKA MADISON DALLAS SAN DIEGO WICHITA NEW YORK W DES MOINES SEATTLE DALLAS COLUMBUS KANSAS CITY WALLINGFORD BALA CYNWYD JACKSONVILLE TAMPA TAMPA COLUMBUS AMES WEST DES MOINES WEST DES MOINES CEDAR RAPIDS WEST ALLIS AURORA SPRINGFIELD COLORADO SPRING BROOKLYN SAN ANTONIO SALT LAKE CITY PHOENIX FRESNO PORTLAND SEATTLE COLORADO SPRING KANSAS CITY BROOKLYN OMAHA SHARON BIRMINGHAM MEMPHIS LITTLE ROCK BLUE BELL LOUISVILLE FRAZIER ROSELAND SHAWNEE MISSION ALBUQUERQUE Page 110 OK 73126P001 NE 68131P001 WA 98401P001 WA 98101P001 PA 19032P001 TN 37220P001 IL 61105P001 KS 66629P001 WI 53715P001 TX 75205P001 CA 92196P001 KS 67214P001 NY 10019P001 IA 50265P001 WA 98111P001 TX 75228P001 OH 43235P001 MO 64134P001 CT 06492P001 PA 19004P001 FL 32256P001 FL 33607P001 FL 33631P001 OH 43229P001 IA 50014P001 IA 50265P002 IA 50266P001 IA 52402P001 WI 53227P001 IL 60504P001 MO 65802P001 CO 66210P001 MN 73134P001 TX 78279P001 UT 84157P001 AZ 85021P001 CA 93711P001 OR 97204P001 WA 98188P001 CO 80920P001 MO 64141P001 MN 55430P001 NE 68154P001 PA 16146P001 AL 35202P001 TN 38187P001 AR 72203P001 PA 19422P001 KY 19493P001 PA 19355N001 NJ 07068P001 KS 66202P001 NM 87110Q001 A ABD ABD D B B ABCD ABCD BCD ABC BD ABCD ABCD BCD D ABCD ABD ABCD C C C C C C C C C C C C C C C C C C C C C AC BCD BCD ABCD ABCD AB B ABCD ABCD C A A ABCD ABCD . SYSTEM DEVELOPMENT/SENIOR SECURITY LIFE OKLAHOMA CITY SEABURY AND SMITH WEST DES MOINES SECURE CARE VALLEY FORGE SECURE HORIZONS HEALTH PLAN CYPRESS SECURITY GENERAL INS/PROVIDENT CLAIM OFFICE CHATANOOGA SECURITY GENERAL LIFE INS OKLAHOMA CITY SECURITY HEALTH PLAN OF WI MARSHFIELD SECURITY LIFE INS CO HOUSTON SECURITY NATIONAL LIFE INS CO SALT LAKE CITY SECURITY TRUST LIFE INS DURHAM SEGUROS DE SERVICIO DE SAN JUAN SELECTCARE LINWOOD SENIOR CARE CANYON COUNTRY SENIOR SECURITY LIFE INS OKLAHOMA CITY SENTRY LIFE INS STEVENS POINT SEVENTYH DAY ADVENTISTS DES MOINES SHELTER LIFE INS CO COLUMBIA SIEBE TEMP AND APPL CONTROL DES MOINES SIERRA HEALTH AND LIFE INS LAS VEGAS SIGN AND DISPLAY INS PLAN DES MOINES SKAGIT CTY MED BUREAU INC MOUNT VERNON SOUTH ATLANTIC LIFE JACKSONVILLE SOUTH ATLANTIC LIFE SKOKIE SOUTH DAKOTA BLUE SHIELD SIOUX FALLS SOUTHERN FARM BUREAU LIFE JACKSON CITY SOUTHERN HEALTH PLAN MEMPHIS SOUTHLAND LIFE INS CO BIRMINGHAM SOUTHWEST ADMINISTRATOR ALHAMBRA SOUTHWEST HOME LIFE INS DALLAS SOUTHWEST SERVICE LIFE FT WORTH SOUTHWEST SERVICES LIFE FORT WORTH SOUTHWESTERN GENERAL LIFE DALLAS SPECIAL AGTS MUT BENEFIT ROCKVILLE ST MICHAELS PA MILWAUKEE STANDARD GUARANTY INS ATLANTA Page 111 NC 28226R001 GA 30348R001 SC 29609R001 OR 97601R001 WA 99362R001 WA 98401R001 WA 98101K001 MO 63119R001 OK 73118R001 VA 22314R001 IA 50306R001 WY 82935R001 NY 12701R001 CA 93794R001 IA 50306R002 WI 53705R001 TX 78216S001 NC 27103S001 OK 73154S002 IA 50398S001 PA 19493S001 CA 90630S001 TN 37422S001 OK 73154S001 WI 54449S001 TX 77019S001 UT 84157S001 NC 27702S001 PR 00936S001 NJ 08221S001 CA 91351S001 OK 73154S003 WI 54481S001 IA 50306S003 MO 65218S001 IA 50306S002 NV 89114S001 IA 50306S004 WA 98273S001 FL 33101S001 IL 60076S001 SD 57104S001 MS 39205S001 TN 38101S001 AL 35289S001 CA 90057S001 TX 75221S001 TX 76180S001 TX 76118S001 TX 75266S001 MD 20852S001 WI 53209S001 GA 30327S001 ABD A ABD D C C ABC ABCD ABCD D D BCD ABCD AB D AB ABCD BC ABCD C BCD ABCD B AB ABCD ABCD ABCD BCD ABCD B BD ACD ABCD D ABCD D ABCD D ABCD ABD ABD AC ABCD ABCD ABC ABC AC D ABCD AB A ABC AB .Updated Winter 2004 R E HARRINGTON INC CHARLOTTE R J REYNOLDS TOBACCO ATLANTA RAND MCNALLY GREENVILLE REGENCE BCBS OF OREGON KLAMATH FALLS REGENCE BLUE SHIELD SEATTLE REGENCE BLUESHIELD SEATTLE REGENCE WASHINGTON HEALTH/KING CTY MEDICAL SEATTLE RELIABLE LIFE INS CO WEBSTER GRV RESERVE NATIONAL LIFE IN OKLAHOMA CITY RETIRED OFFICERS ASSOC ALEXANDRIA RETIRED OFFICERS ASSOC DES MOINES RHONE POULENE OF WY GREEN RIVER RHULEN INS CO MONTICELLO RISK MANAGEMENT INC FRESNO ROCKWELL AUTOMATION DES MOINES RURAL SECURITY LIFE INS MADISON SAN ANTONIO REG CLAIM CTR SAN ANTONIO SAVERS LIFE INS CO WINSTON SALEM SDC . Updated Winter 2004 STANDARD LIFE AND ACC INS C STATE FARM HEALTH INS STATE FARM HLTH INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM MUT AUTO INS STATE FARM MUT AUTO INS STATE FARM MUT AUTO INS STATE FARM MUT AUTO INS STATE FARM MUT INS STATE FARM MUTUAL AUTO STATE FARM MUTUAL AUTO STATE GROUP BENEFITS STATE MUTUAL CO STATE MUTUAL INSURANCE CO STATES GENERAL LIFE INS STATESMAN NATL LIFE STATEWIDE INS CO STIRLING AND STIRLING SUMMIT NATIONAL LIFE INS CO SURGICAL CARE SVEDALA INDUSTRIES T AND N COMPANY OKLAHOMACITY FREDERICK LINCOLN WAYNE CONCORDVILLE CHARLOTTESVILLE CHARLOTTESVILLE CHILHOWIE BLUEFIELD ELIZABETHTOWN WHITEVILLE LENIOR DELUTH JACKSONVILLE MURFREESBOURO NEWARK NEWARK WEST LAFAYETTE MARSHALL ST PAUL BLOOMINGTON BLOOMINGTON COLUMBIA MONROE TULSA DALLAS DALLAS GOODING WESTLAKE VILLAG COSTA MESA SANTA ANA BAKERSFIELD BAKERSFIELD ROHNERT PARK SALEM BALLSTON SPA BIRMINGHAM WEST LAFAYETTE AUSTIN WINTER HAVEN GREELEY TEMPE BATON ROUGE WORCHESTER ROME DALLAS HOUSTON MONROE MILFORD LANCASTER MILWAUKEE DES MOINES DES MOINES Page 112 OK 73125S001 MD 21709S001 NE 68501S001 NJ 07477S001 PA 19339S001 VA 22901S001 VA 22909S001 VA 24319S001 VA 24605S001 NC 28337S001 NC 28472S001 NC 28645S001 GA 30136S001 FL 32232S001 TN 37131S001 OH 43055S001 OH 43093S001 IN 47906S001 MI 49069S001 MN 55161S001 IL 61709S001 IL 61710S001 MO 65217S001 LA 71208S001 OK 74146S001 TX 75252S001 TX 75379S001 ID 83330S001 CA 91363S001 CA 92626S001 CA 92799S001 CA 93311S001 CA 93399S001 CA 94926S001 OR 97303S001 NY 12020S001 AL 35297S001 IN 47905S001 TX 78729S001 FL 33888S001 CO 80638S001 AZ 85289S001 LA 70804S001 MA 01653S001 GA 30162S001 TX 75214S001 TX 77006S001 NC 28110S001 CT 06460S001 PA 17601S001 WI 53201S001 IA 50306S001 IA 50306T002 ABCD AC ACD ABCD C B ACD ABCD ABCD ABCD ABCD ABCD ABD ABD ABCD C C C C ABD BCD C A ABCD C C C ABCD C C C C C C ABD AC AC AC A A AC AC ABD AB C ABC ABCD ABCD D BD ABCD D D . INC UNITED HERITAGE MUTUAL UNITED INVESTORS LIFE INS UNITED LIFE OF NORTH AMER UNITED METHODIST GROUP UNITED NATIONAL LIFE INS UNITED OF OMAHA UNITED OF OMAHA UNITED SEC ASSURANCE CO UNITED TEACHER ASSOC UNITED TECHNOLOGIES UNIVERSAL FIDELITY LIFE UNIVERSAL LIFE INS CO US GUARDIAN HEALTH INS CO USAA LIFE INS CO CONCORD MEMPHIS JACKSONVILLE HOUSTON OMAHA UPLAND WOODLAND HILLS FORT WORTH HAMDEN OMAHA ROANOKE WYTHEVILLE DES MOINES NASHVILLE LAKE FOREST LAKE FOREST CLEARWATER DALLAS ANDOVER DALLAS DALLAS WASHINGTON TREVOSE ALPHARETTA WASHINGTON NEW YORK DES MOINES LONDON DES MOINES DALLAS SOUDERTON COLUMBUS ATLANTA INDIANAPOLIS BIRMINGHAM OKLAHOMA CITY CLEARWATER CLEARWATER BIRMINGHAM NAMPA DALLAS VIENNA OMAHA GLENVIEW LANGHORNE TREVOSE SOUDERTON AUSTIN HARTFORD DUNCAN RICHMOND DALLAS SAN ANTONIO CA TN FL TX NE CA CA TX CT NE VA VA IA TN IL IL FL TX MA TX TX DC PA GA DC NY IA KY IA TX PA OH GA IN AL OK FL FL AL ID TX VA NE IL PA PA PA TX CT OK VA TX TX 94524T001 38174T001 32276T001 77242T001 68154T001 91785T001 91367T001 76102T001 06517T001 68175T001 24031T001 24382B001 50306T001 37202T001 55116T001 60045T001 34618U001 75238U001 93031U001 75265U001 75201U001 20001U001 19047C001 19049U001 20006U001 10010U001 50306U002 84130U001 50306U001 75221U001 19047U002 43215U001 30301U001 46206U001 35202U001 73112U001 34616U001 33743U001 35255U001 83653U001 75221U002 22182U001 68175U001 60025U001 19047U001 19049U003 18964U001 78755U001 06146U001 73533U001 23222U001 75244U001 78288U001 ABCD ABD ABD C C ABD ABC ABCD B BD BCD A BCD A C D AC B C BCD AC BCD ABCD BCD BCD BD D A D ABCD ABCD BCD BCD ABCD ABCD ABD BCD ABCD C ABCD A AB ABCD AC B A ABD ACD ABCD ABCD ABD AB ABCD Page 113 .Updated Winter 2004 TAKE CARE HEALTH PLAN TEAM-CARE HEALTH CHOICE TENNECO TEXAS IMPERIAL LIFE THE PRINCIPAL FINANCIAL TRANSAMERICA ACC LIFE TRANSAMERICA INS TRANSPORT LIFE TRAVELERS INC CO TRAVELERS OMAHA TRIGON BCBS TRIGON MUTUAL INS CO/BCBS VA TROA GROUP HLTH INS TRS CARE TRUSTMARK INS CO TRUSTMARK INS CO U S HEALTH AND LIFE INS/IDEALIFE UNDERWRITERS LIFE INS CO UNICARE UNION BANKERS INS CO UNION BANKERS-RR CLAIMS/UAIAG UNION CARE LIFE INS CO UNION FIDELITY LIFE INS/COMBINED INS OF AMER UNION FIDELITY/MUTUAL LIFE UNION LABOR LIFE UNION LABOR LIFE INS CO UNION LOCAL 662 UNISYS BENEFITS OFFICE UNIT DROP FORGE CO INC UNITED AMER INS CO UNITED ASSURANCE CO OF PA UNITED COMMERCIAL TRAVLRS UNITED FAMILY LIFE INS UNITED FARM BUREAU FAM UNITED FOUNDERS LIFE UNITED FOUNDERS LIFE INS UNITED GENERAL LIFE UNITED GENERAL LIFE INS UNITED HEALTHCARE OF ALABAMA. Updated Winter 2004 USABLE LIFE VALLEY HEALTH PLAN VASA NORTH ATLANTIC VASA/VARIABLE PROTECTION VETERANS ADMINISTRATION VETERANS LIFE INS CO VFW MDGAP/NO AMER INS/PA VICTORY LIFE INS CO VIRGINIA HEALTH AND AS ASSOC VIRGINIA MUTUAL INS CO VIRGINIA SURETY CO INC VULCAN LIFE INS CO WALLA WALLA VALLEY MED WASHINGTON NATIONAL INS WASHINGTON NATL INS WC KUMMEROW AND CO WEA INSURANCE GROUP WEST BEND INSURANCE PLAN WESTERN AMER LIFE INS CO WESTERN FARM BUREAU INS WESTERN FIDELITY INS WHATCOM MEDICAL BUREAU WIS HEALTH ORG/WISCONSIN PHYSICIANS WISCONSIN PHYSICIANS SERV WIT AND CO INSURANCE PLANS WORLD INS CO WORLD LIFE AND HEALTH INS CO WORLD NET SERVICES CORP LITTLE ROCK EAU CLAIRE INDIANAPOLIS CLEVELAND PHOENIX VALLEY FORGE HORSHAM MURFREESBORO EMPORIA RICHMOND CLEARWATER BIRMINGHAM WALLA WALLA EVANSTON LINCOLNSHIRE CRYSTAL LAKE MADISON DES MOINES RICHARDSON DENVER FORT WORTH BELLINGHAM MILWAUKEE MADISON DES MOINES OMAHA HARRISBURG PENSACOLA AK 72203U001 WI 54702V001 IN 46206V001 OH 44130V001 AZ 85012V001 PA 19493V001 PA 64111V001 TN 37133V001 VA 23847V001 VA 23225V001 FL 33755V001 AL 35201V001 WA 99362W001 IL 60201W001 IL 60069W001 IL 60014W001 WI 53708W002 IA 50306W002 TX 75083W001 CO 80217W001 TX 76101W001 WA 98227W001 WI 53212W001 WI 53701W001 IA 50306W001 NE 68130W001 PA 17105W001 FL 32501W001 ABCD ABCD C C AB ABCD ABCD ABCD BCD BC C AB ABD BD C ABC AB D AC ABCD ABCD ABCD ABCD ABCD D BCD BC C Page 114 . Updated Winter 2004 XXIII - APPENDIX II – Non-covered HCPCS Item HCPCS Code Coverage Guidelines (MCM or Title 18 SSA) Not primarily medical in nature/environmental control equipment/2100.1 B.2 1861(n) of the Act Air Cleaner (includes electrostatic A9270 machines) Air Conditioners 11/10/2000 A9270 Convenience item/not primarily medical in nature/2100.1 B.2 1861(n) of the Act E0625 Convenience item/not primarily medical in nature/2100.1 B.2 1861(n) of the Act. Bathtub Lifts Bathtub Seat/Stool/Bench/Rails Equipment E0241 Bathtub Comfort or convenience item/hygienic equipment/not primarily wall rail medical in nature/2100.1 B.2 1861(n) of the Act. E0242 Bathtub rail, floor base E0243 Toilet rail E0245 Tub stool or bench E0315 Convenience item/not primarily medical in nature/2100.1 B.2 1861(n) of the Act. A9270 Hygienic equipment/not primarily medical in nature. 1861(n) of the Act. Bed Accessory: Board, Table or Support Device, any type Bed Baths (home type) Bedboards 8/30/1999 E0273-bed Not primarily medical in nature/2100.1 B.2 1861(n) of the Act. board overbed board/tableE0274 E0315 Not primarily medical in nature/2100.1 B.2 1861(n) of the Act. Bed Lifter (bed elevator) Bed Lounge (power or manual) Bed Oscillating Bed Table (Over bed table) A9270 A9270 E0274 Comfort or convenience item/not primarily medical in nature/2100.1 B.2 1861(n) of the Act. Institutional equipment/inappropriate for home use/2100.1 B.2 Comfort or convenience item/hygienic equipment/not primarily medical in nature/2100.1 B.2 1861(n) of the Act. Bidet Toilet Seats Biofeedback Therapy for the Treatment of Urinary Incontinence A9270 Not medical equipment 7/26/1999 E0746 CIM 35-27.1Home use of biofeedback therapy is not covered. Page 115 Updated Winter 2004 Blood Glucose ANALYZER Note: this is NOT the MONITOR A9270 A9270 A9270 A9270 Unsuitable for home use/60-11 Carafes Clitoral Therapy Device Dehumidifiers (room or central heating system type) Diapers Convenience item/not primarily medical in nature. 1861(n) of the Act. CMS Benefit Category Determination December 7, 2001 Not primarily medical in nature/environmental control equipment/2100.1 B.2 1861(n) of the Act. Supplies expendable in nature/2100.1.A CMS Benefit Category Determination November 14, 2001 A4360 Diabetic Shoe Inserts (Molded by A5510 the Patient's Body Heat and Weight) Diathermy Machines Disposable Sheets and Bags Electric Air Cleaners Electrostatic Machines Elastic Stockings Electrostimulation in the treatment of wounds Emesis Basin Elevators Esophageal Dilator Exercise Equipment Fabric Supports Face Masks (surgical) Grab Bars A9270 A4335 and A4554 A9270 A9270 Inappropriate for home use/35.41/35-3 Nonreuseable disposable supplies/2100.1A 1861(n) of the Act. Not primarily medical in nature/environmental control equipment/2100.1 B.2 1861(n) of the Act. Not primarily medical in nature/environmental control equipment/2100.1 B.2 1861(n) of the Act. A9270 and Nonreuseable disposable supplies/2100.1A . 1861(n) of the Act. L8100-L8239 A9270 A9270 A9270 A9270 A9300 A9270 A9270 Non-proven therapy. CIM 35-98 Nonreuseable disposable supplies/2100.1A . 1861(n) of the Act. Convenience item/not primarily medical in nature./2100.1 B.2. 1861(n) of the Act Physician instrument; inappropriate for patient use Not primarily medical in nature/2100.1 B.2 Nonreuseable supplies; not rental-type. 1861(n) of the Act. CIM 35-34 Nonreuseable disposable supplies/2100.1A . 1861(n) of the Act. E0241-E0243 Self-help device/not primarily medical in nature/2100.1 B.2 1861(n) of the Act. Page 116 Updated Winter 2004 Heat and Massage Foam A9270 Self-help device/not primarily medical in nature/2100.1 B.2 1861(n) and 1862(a)(6) of the Act. Environmental control equipment/not medical in nature/2100.1 B.2 1861(n) of the Act. Not primarily medical in nature/environmental control equipment/2100.1 B.2 1861(n) of the Act. Heating and Cooling Plants Humidifiers (room or central heating system types) Incontinent Pads A9270 A9270 A4554 Nonreuseable supply/hygienic item/2130.A. 1861(n) of the Act. Disposable under pads, all sizes (e.g., Chux's) or A4360 Adult incontinence garmet (e.g. brief, diaper) Noncovered self-administered drug supply. 1861(s)(2)(A) of the Act. Injectors (hypodermic jet pressure A4210 powered devices for insulin injections) Insulin except used in a pump Leotards Massage Devices Metered Dose Inhaler Non-contact wound warming device and accessories Oscillating Beds Overbed Tables Paraffin Bath Units (standard) non-portable Parallel Bars J1820, K0548 Self Administered Drug. MCM 2049 A9270 A9270 A9270 Nonreuseable supplies; not rental-type. 1861(n) of the Act. Personal comfort item/not primarily medical in nature. 1861(n) and 1862(a)(6) of the Act. Self administered Drug. MCM 2049. E0231, E0232, CMS Benefit Determination. A6000 A9270 E0274 A9270 A9300 Institutional equipment--inappropriate for home use. Not primarily medical in nature/2100.1 B.2 1861(n) of the Act. Institutional equipment/2110.3 Support exercise equipment/2100.1.B.2 Not primarily medical in nature/personal comfort item. 1861(n) and 1862(a)(6) of the Act. Environmental control equipment/not primarily medical in nature 2100.1 B.2 1861(n) of the Act. Not primarily medical in nature/personal comfort item. 1861(n) and 1862(a)(6) of the Act. Patient Lift, Kartop, bathroom or E0625 toilet Portable Room Heaters Portable Whirlpool Pumps A9270 E1300 Page 117 Not reasonable or necessary for monitoring pulse of homebound patient with or without cardiac pacemaker Convenience item/hygienic equipment/not primarily medical in nature Not primarily medical in nature/personal comfort item/1862(a)(6) of the Act/2100. bag or reservoir. MCM 2049. Raised Toilet Seats Sauna Baths E0244 A9270 Spacer.1B.1 B. 1861(n) of the Act. 1861(n) of the Act. with or A4627 without mask. 1861(n) of the Act.2 Supply used with self administered drug. 1861(n) of the A4500. first aid. A9270 A9270 A9270 A9300 A9270 Emergency communication systems/do not serve a diagnostic or therapeutic purpose Convenience item/not medical in nature Not medical equipment. Educational equipment.1 B.Updated Winter 2004 Preset Portable Oxygen Units Pressure Leotards Pulse Tachometer A9270 A9270 A9270 Emergency. A4510 Act. or precautionary equipment. for use with metered dose inhaler Spare Tanks of Oxygen Speech Teaching Machine Stairway Elevators Standing Table Support Hose Surgical Stocking A9270 A9270 A9270 A9270 A9270 and L8100-8239 Convenience or precautionary supply. 1861(n) of the Act. Nonreuseable supplies.2 Convenience item/not primarily medical in nature Nonreuseable supplies. not rental-type. Convenience item/not primarily medical in nature/2100. not primarily medical in nature. not rental-type/MCM 2133. A4495. Exercise equipment/not primarily medical in nature/2100. per cane/crutches policy Telephone Alert Systems Telephone Arms Toilet Seats Treadmill Exerciser White Cane Page 118 . not rental-type. essentially not therapeutic in nature. A4490.2 Self-help item/60-3. Nonreuseable supplies. 01 Oxygen Hospital Beds Support Surfaces Motorized Wheelchairs Manual Wheelchairs Continuous Positive Airway Pressure (CPAP) Devices Lymphedema Pumps (Pneumatic Compression Devices) Osteogenesis Stimulators Transcutaneous Electrical Nerve Stimulators (TENS) Seat Lift Mechanisms Power Operated Vehicles Immunosuppressive Drugs Infusion Pumps Parenteral Nutrition Enteral Nutrition Section C Continuation Form Items Addressed DMERC 08. (For example.02A DMERC 10. the hard copy version . DMERC 03.Updated Winter 2004 XXIV .02B.02 for Immunosuppressive Drugs has been designated a DMERC Information Form (DIF) rather than a CMN. the CMN for seat lift mechanisms is DMERC 07.) Version .03A DMERC 02.02 and .g.03B DMERC 04. HCFA 841-854.03 CMNs have a letter after the version number.02B DMERC 02. A few highlights are listed.02 and .02A DMERC 01.03B DMERC 03.02 DMERC 10. For example. That is because this form can be completed and signed by the supplier. Sixteen forms have been developed by the DMERCs. DMERC 03. CMN COMPLETION Instructions on the backs of the CMNs/DIF should be reviewed and followed.02B DMERC 11.02). The numbers after the decimal identify the version or sequence of revisions to the CMN. It has no Section C or D. The ‘Documentation’ section of the medical policy shows which items require one of these forms.01.02A DMERC 07. Page 119 .02B DMERC 07. Fourteen of the forms have been assigned a HCFA form number.02B DMERC 08.02 DMERC 04. The HCFA form number is in the bottom left corner of the form. rather than requiring physician completion.APPENDIX III – CMN Completion Certificates Of Medical Necessity OVERVIEW A Certificate of Medical Necessity (CMN) or DMERC Information Form (DIF) is required to help document the medical necessity and other coverage criteria for selected DMEPOS items. The current CMNs/DIF are: HCFA Form 484 841 842 843 844 845 846 847 848 849 850 851 852 853 854 DMERC Form DMERC 484. The CMNs/DIF also have a DMERC form number that consists of two numbers before a decimal and two numbers after a decimal (e.02 is a revision of a prior CMN that was numbered 03.2 (11/99) DMERC 01.02A and that for power operated vehicles is DMERC 07.03 hard copy CMNs have been formatted so that only a single type of equipment is on each CMN. In situations where there had been different devices on the same CMN..02 (7/00) DMERC 09.03C DMERC 06. and for any required revised certifications or re-certifications. for the first month rental of equipment. physician’s signature. supplies. Both the signature and date must be personally entered by the physician and may not be a stamp or other substitute.Updated Winter 2004 In Section A. Suppliers may use other formats as long as the required information is presented. the CMN or DIF must accompany claims for purchase of these items (including replacement). Page 120 . It also indicates the supplier’s charge and what the Medicare fee schedule allowance will be. Civil monetary penalties can be assessed for failure to comply. the supplier must specify “per month” or “/month. options. Section C contains a blank space that can be formatted in different ways. The fee schedule allowance should reflect the same time span and quantity used in the submitted charge column. The exact HCPCS description is not required. or drugs which are replaced regularly.” For accessories. but also any accessories. Form 854 (Section C Continuation Form) may only be used in conjunction with HCFA forms 843 (Motorized Wheelchairs) or 844 (Manual Wheelchairs). address. and the HCPCS codes must be completed by the supplier before the CMN is sent to the physician. oxygen. accessory and option. nurse. and date. The supplier must complete section C before the CMN is sent to the physician.. the hard copy CMN must be an exact reproduction of the HCFA form. Form 854 is used for additional options/accessories.g. physical or occupational therapist. a reasonable. etc. However the following guidelines must be met: The description of the item provided must include not only those items listed in Section A of the CMN. supplies or drugs which are related to the item and which are provided by the supplier. PEN supplies. The physician who signs the CMN must be the physician who is actively/presently treating the patient. For every item listed.g. subsequent months on rental items. The date in Section D must be the date that the physician signs the CMN. Samples of Section C formats are given in Examples 1 and 2. for drugs. Section C of forms 843 or 844 should list the wheelchair base and the 4-6 most costly options/accessories. Satisfactory completion of Section C will be assessed in post-payment audits. the supplier’s name. per month.. For codes requiring a CMN or DIF. or PEN nutrients when there is no change in the order and no requirement for recertification) may cause claims processing problems/delays and is discouraged. For rental equipment. the full charge must be specified. If the Medicare allowed amount is determined by methods other than a fee schedule (e.g. There should be a narrative description for each related item billed on a separate claim line. telephone and NSC number. address. per week. nutrients. etc. Claims submitted with CMNs lacking a physician signature will be denied. Section B may not be completed by the supplier on HCFA forms 484 and 841-853. Section D contains the physician’s attestation statement. the supplier must specify what time span the charge represents . Submitting CMNs/DIF when they are not required (e. accessories and options.. These are the codes that should be listed in Section A of the CMN/DIF. miscellaneous codes. the supplier must always specify their submitted charge. Section B may be completed by the physician.e. It provides an opportunity for the ordering physician to review and confirm a detailed description of the items provided.). the physician’s employee or another clinician involved in the care of the patient (e. Section C on HCFA forms 484 and 841-854 reflects the requirements from the 1994 Amendments to the Social Security Act. per day. etc. if applicable. accessories and options. Because HCFA forms 484 and 841-854 have been approved by the Office of Management and Budget (OMB).) as long as that person is not the supplier. Suppliers billing electronically must indicate presence of the physician’s signature in the usual way. for the initial provision of PEN nutrients and supplies. abbreviated descriptor may be substituted.g. a NA (not applicable) should be put in the Medicare allowed charge column. The codes that require a CMN/DIF are listed later in this section. telephone and HIC number. The supplier must list the Medicare fee schedule amount for each item.. if applicable. For purchased equipment. at least the patient’s name. parenteral and enteral nutrients. when a CMN is submitted with a paper claim. A CMN does not by itself provide sufficient documentation of medical necessity.. the physician must line through the correction. the items on the CMN will be considered not medically necessary and a denial or overpayment will be initiated. subsection Documentation. If the original CMN is not available. The physician is encouraged. If the original or faxed CMN has been altered without this physician verification. The DMERC may request to see the original CMN at any time.e.e. Original CMNs will be audited periodically to validate proper completion and transmission to the DMERC. Suppliers are encouraged to remind physicians that it is the physician’s responsibility to determine both the medical need for. For items that require a CMN. When a CMN/DIF is submitted hard copy. even though the treating physician signs it. sign the correction in full.Updated Winter 2004 A nurse practitioner or clinical nurse specialist may complete Section B and sign Section D if they are treating the beneficiary for the condition for which the item is needed. a separate order in addition to a subsequently completed and signed CMN would be necessary.. However. and date the change – or the supplier may choose to have the physician complete a new CMN. all health care services. Suppliers are also encouraged to remind physicians that it is the physician’s responsibility to ensure that the information on the CMN relating to the beneficiary’s condition is correct and is supported by information in the patient’s medical record. Refer to Section XVII. Otherwise. If this is done. pair. and they are practicing independently of a physician. When a CMN is submitted electronically. There must be clinical information in the patient’s medical record that substantiates the answers on the CMN and supports the medical necessity for the item in the individual case. the supplier must have a fully completed original or faxed CMN in their records before they submit a claim to the DMERC. Elevating leg rests. and they bill Medicare for other covered services using their own provider number. HCFA forms 484 and 841-854 can serve as the physician order if the narrative description in Section C is sufficiently detailed. SECTION C EXAMPLES Example 1: Item: A B C Codes: K0004 K0195 K0028 HCPCS Description: High strength. air fluidized beds. TENS. and subsection Orders for requirements for the content of detailed written orders. The physician may fax the completed CMN to the supplier. Individual claims will be reviewed to verify that the answers on CMNs are supported by information in the patient’s medical record. only information from sections A. CMNs are a standardized means of submitting some medical necessity information to the DMERCs. seat lift mechanisms). the original CMN (i. Medical Policy. B. suppliers may utilize a completed and physician-signed CMN for this purpose. the items on the CMN will be considered not medically necessary and a denial or overpayment will be initiated. and D is transmitted. Fully reclining back. For items which require a written order prior to delivery and which have a CMN (i. and they are permitted to do all of the above in the state in which the services are rendered. POVs. However. lightweight wheelchair. Page 121 . If any change is made to the CMN after the physician has completed Section B and signed the CMN. if the CMN is signed and dated prior to delivery of the item. to keep a copy of the CMN in their patient’s medical record. the CMN with the original answers in Section B and the original physician signature and date in Section D) must be retained either in the supplier’s files or in the physician’s files. the supplier must also fax the instructions that are on the back of the CMN. Suppliers are encouraged to mail or deliver a two-sided CMN to the physician and to have the physician mail the completed CMN back to the supplier. it is permissible to fax a CMN from the supplier to the physician. although not required. and the utilization of. the supplier must include a copy of only the front side. 39/Week N/A * * An N/A (not applicable) entry means that Medicare payment will be determined by a method other than a fee schedule. Morphine Sulfate.93 $60.00/Week $300. Supplier’s Charge: $115.60 $56.90 $40.Updated Winter 2004 Item: D E Item: A B C D E Codes: K0025 K0020 Quantity: 1 1 1 1 1 HCPCS Description: Hook-on headset extension.95/Month $407. Page 122 . Supplies for maintenance of drug infusion catheter.00/Month $428. An N/A does not indicate that Medicare will deny the item.44/Week $20.31/Month $9.30/Month $153. adjustable height armrests. per cassette or bag.00/Month $11.28/Month $121.82 Example 2: Item: A B C D Item: A B C D Codes: E0781 A4222 A4221 J2270 Quantity: 1 3/Wk 1/Wk 168/Wk HCPCS Description: Ambulatory infusion pump Supplies for external drug infusion pump.00 Medicare Fee Schedule Allowance: $110.00 $45. per week. Supplier’s Charge: $747.00/Week Medicare Fee Schedule Allowance: $235. 10 mg. pair.30/Week $30. Fixed. refer to the HCPCS Chapter of this Supplier Manual. For narrative descriptions. B4150 B4151 B4152 B4153 B4154 B4155 B4156 B4164 B4168 B4176 B4178 B4180 B4184 B4186 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B9000 B9002 B9004 B9006 E0194 E0250 E0251 E0255 E0256 E0260 E0261 E0265 E0266 E0290 E0291 E0292 E0293 E0294 E0295 E0296 E0297 E0303 E0304 E0424 E0431 E0434 E0439 E0441 E0442 E0443 E0444 E0627 E0628 E0629 E0650 E0651 E0652 E0655 E0660 E0665 E0666 E0667 E0668 E0669 E0671 E0672 E0673 E0720 E0730 E0748 E0776 E0779 E0780 E0781 E0784 E0791 E0973 E0982 E0983 E0990 E1226 E1230 E1390 E1405 E1406 J7920 J2930 J7500 J7501 J7502 J7506 J7507 J7509 J7510 J7513 J7515 J7517 J7520 K0001 K0002 K0003 K0004 K0005 K0006 K0007 K0009 K0010 K0011 K0012 K0014 K0017 K0018 K0020 K0046 K0047 K0053 K0195 K0455 Page 123 .Updated Winter 2004 HCPCS CODES REQUIRING A CMN OR A DIF The following codes are those that currently require a CMN/DIF and that should be listed in Section A of the CMN/DIF. The description of related additional items must also be listed in Section C of HCFA forms 484 and 841-854. Is this illness/injury covered under the Federal Black Lung Program? If yes. or no-fault insurance liable for this illness/injury? If yes. If no. including Federal Employee Health Benefits? If yes. go to #8a. If no. go to #8. Has the patient completed the ESRD coordination period? If yes. go to #2. If no. go to #3. If no. If no. If no. or is the patient considered an employee of an employer having 100 or more employees? If yes. Medicare is primary.Updated Winter 2004 APPENDIX IV – Medicare As Secondary Payer Questionnaire (Short Form) XXV Beneficiary Name: __________________________________________ Age: _____________ HICN: ___________________________________________________ 1 2 3 4 5 6 7a 7b 8a 8b 9 1. If no. Medicare is primary. Is the patient under 65 and entitled to Medicare due to a disability? If yes. Medicare is primary. file claim with them. go to #6. enter LGHP data in #9 and file claim with them. Is this patient or his/her spouse actively employed by an employer of 20 or more employees? If yes. Is this illness/injury covered by Worker’s Compensation? If yes. enter information in #9 and file claim with them. Is the patient entitled to Medicare solely on the basis of End Stage Renal Disease (ESRD)? If yes. go to #8b. go to #7. Is this illness/injury the result of an auto accident? If yes. YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO Name of insurance company: _______________________________________________________________ Name of insured: _________________________________________________________________________ Patient’s relationship to insured: _____________________________________________________________ Insured’s policy number: ___________________________________________________________________ Insurer’s address: _________________________________________________________________________ ______________________________________________________________________________________ Employer name:________________________________________________________________________ Employer address: ________________________________________________________________________ ______________________________________________________________________________________ Name of attorney(s) involved: _______________________________________________________________ Page 124 . If no. address and claim number (if available) in #9 and file claim with them. Is another party’s liability insurance. enter the responsible auto insurer in #9 and file claim with them. non-liability insurance. go to #5. go to #7b. Is this patient covered by an employer group health plan (EGHP). If no. go to #4. If no. enter the EGHP date in #9 and file claim with them. note employer/insurer name. Is the patient or his/her spouse or parent actively employed by. enter information in #9 and file claim with them. Updated Winter 2004 NOTES Page 125 . Updated Winter 2004 Page 126 .