D ^ } ] o ^ À ] o v l } } W } µ } Á o l h ð l î ô l î ì í ... · ì î ð ï d } ] o ] o r...

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017 Group Description Group Code Proc/Svc Code Proc Short Description Modifier Code (See last page for modifier code description) Bathroom aids, toileting, and supplies SA875 E0160 Sitz type bath or equipment - NU RR UE E0161 Sitz bath/equipment w/faucet - NU RR UE E0162 Sitz bath chair - NU RR UE E0163 Commode chair with fixed arm - NU RR UE E0165 Commode chair with detacharm - NU RR E0167 Commode chair pail or pan - NU RR UE E0168 Heavyduty/wide commode chair - NU RR E0170 Commode chair electric - RR E0171 Commode chair non-electric - RR E0172 Seat lift mechanism toilet - E0175 Commode chair foot rest E0240 Bath/shower chair - NU E0241 Bath tub wall rail - E0243 Toilet rail - E0244 Toilet seat raised - E0245 Tub stool or bench - E0246 Transfer tub rail attachment - NU E0247 Trans bench w/wo comm open - NU E0248 HDtrans bench w/wo comm open - NU E0275 Bed pan standard - E0276 Bed pan fracture - E0325 Urinal male jug-type - E0326 Urinal female jug-type - E1310 Whirlpool non-portable - NU RR UE Communication devices and supplies SA876 E2500 SGD DIGITIZED PRE-REC <=8MIN - E2502 SGD PREREC MSG >8MIN <=20MIN - E2504 SGD PREREC MSG>20MIN <=40MIN - E2506 SGD PREREC MSG > 40 MIN - E2508 SGD SPELLING PHYS CONTACT - E2510 SGD W MULTI METHODS MSG/ACCS - E2511 SGD sftwre prgrm for PC/PDA - NU RR UE E2512 SGD accessory, mounting sys - 1 of 43

Transcript of D ^ } ] o ^ À ] o v l } } W } µ } Á o l h ð l î ô l î ì í ... · ì î ð ï d } ] o ] o r...

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

Bathroom aids, toileting, and supplies SA875 E0160 Sitz type bath or equipment -NURRUE

E0161 Sitz bath/equipment w/faucet -NURRUE

E0162 Sitz bath chair -NURRUE

E0163 Commode chair with fixed arm -NURRUE

E0165 Commode chair with detacharm -NURR

E0167 Commode chair pail or pan -NURRUE

E0168 Heavyduty/wide commode chair -NURR

E0170 Commode chair electric -RR

E0171 Commode chair non-electric -RR

E0172 Seat lift mechanism toilet -E0175 Commode chair foot restE0240 Bath/shower chair -

NUE0241 Bath tub wall rail -E0243 Toilet rail -E0244 Toilet seat raised -E0245 Tub stool or bench -E0246 Transfer tub rail attachment -

NUE0247 Trans bench w/wo comm open -

NUE0248 HDtrans bench w/wo comm open -

NUE0275 Bed pan standard -E0276 Bed pan fracture -E0325 Urinal male jug-type -E0326 Urinal female jug-type -E1310 Whirlpool non-portable -

NURRUE

Communication devices and supplies SA876 E2500 SGD DIGITIZED PRE-REC <=8MIN -E2502 SGD PREREC MSG >8MIN <=20MIN -E2504 SGD PREREC MSG>20MIN <=40MIN -E2506 SGD PREREC MSG > 40 MIN -E2508 SGD SPELLING PHYS CONTACT -E2510 SGD W MULTI METHODS MSG/ACCS -E2511 SGD sftwre prgrm for PC/PDA -

NURRUE

E2512 SGD accessory, mounting sys -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

Communication devices and supplies SA876 E2599 SGD ACCESSORY NOC -Diabetic equipment and supplies SA877 A4230 Infus insulin pump non needl -

A4231 Infusion insulin pump needle -A4232 Syringe w/needle insulin 3cc -A4233 Alkalin batt for glucose mon -A4234 J-cell batt for glucose mon -A4235 Lithium batt for glucose mon -A4236 Silvr oxide batt glucose mon -A4245 Alcohol wipes per box -A4252 Blood ketone test or strip -A4253 Blood glucose/reagent strips -

KSKX

A4255 Glucose monitor platforms -A5500 Diab shoe for density insert -A5501 Diabetic custom molded shoe -A5503 Diabetic shoe w/roller/rockr -A5504 Diabetic shoe with wedge -A5505 Diab shoe w/metatarsal bar -A5506 Diabetic shoe w/off set heel -A5507 Modification diabetic shoe -A5508 Diabetic deluxe shoe -A5510 Compression form shoe insert -A5512 Multi den insert direct form -A5513 Multi den insert custom mold -A6531 Compression stocking BK30-40 -A6545 Grad comp non-elastic BK -E0607 Blood glucose monitor home -E2100 Bld glucose monitor w voice -E2101 Bld glucose monitor w lance -

NURRUE

Hospital beds and supplies SA878 E0250 Hosp bed fixed ht w/ mattres -RR

E0251 Hosp bed fixd ht w/o mattres -RR

E0255 Hospital bed var ht w/ mattr -RR

E0256 Hospital bed var ht w/o matt -RR

E0260 Hosp bed semi-electr w/ matt -RR

E0261 Hosp bed semi-electr w/o mat -RR

E0265 Hosp bed total electr w/ mat -RR

E0266 Hosp bed total elec w/o matt -RR

E0270 Hospital bed institutional t -E0271 Mattress innerspring -

NUE0272 Mattress foam rubber -E0277 Powered pres-redu air mattrs -

NURR

E0280 Bed cradle -NURRUE

E0290 Hosp bed fx ht w/o rails w/m -RR

E0291 Hosp bed fx ht w/o rail w/o -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

E0291 Hosp bed fx ht w/o rail w/o RRE0292 HOSP BED VAR HT NO SR W/MATT -

NURR

E0293 HOSP BED VAR HT NO SR NO MAT -NURR

E0294 Hosp bed semi-elect w/ mattr -NURR

E0295 Hosp bed semi-elect w/o matt -NURR

E0296 Hosp bed total elect w/ matt -NURR

E0297 Hosp bed total elect w/o mat -NURR

E0300 Enclosed ped crib hosp grade -NURR

E0301 HD hosp bed, 350-600 lbs -RR

E0302 Ex hd hosp bed > 600 lbs -RR

E0303 Hosp bed hvy dty xtra wide -NURR

E0304 Hosp bed xtra hvy dty x wide -NURR

E0305 Rails bed side half length -NURR

E0310 Rails bed side full length -NURR

E0316 Bed safety enclosure -E0328 Ped hospital bed, manual -E0329 Ped hospital bed semi/elect -E0350 Control unit bowel system -E0352 Disposable pack w/bowel syst -E0371 Nonpower mattress overlay -

NURR

E0372 Powered air mattress overlay -NURR

E0373 Nonpowered pressure mattress -NURR

Miscellaneous SA879 94005 Home vent mgmt supervision -22263247555659667677

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

Miscellaneous SA879 94005 Home vent mgmt supervision QKSTTCXEXPXSXU

94760 Measure blood oxygen level -22263247555659667677QKSTTCXEXPXSXU

94772 Breath recording, infant -22263247555659667677QKSTTCXEXPXSXU

A4206 1 CC sterile syringe&needle -A4207 2 CC sterile syringe&needle -A4208 3 CC sterile syringe&needle -A4209 5+ CC sterile syringe&needle -A4210 Nonneedle injection device -A4211 Supp for self-adm injections -A4213 20+ CC syringe only -A4215 Sterile needle -A4216 Sterile water/saline, 10 ml -A4217 Sterile water/saline, 500 ml -A4220 Infusion pump refill kit -A4221 SUPP NON-INSULIN INF CATH/WK -A4222 Infusion supplies with pump -A4223 Infusion supplies w/o pump -A4244 Alcohol or peroxide per pint -A4246 Betadine/phisohex solution -A4247 Betadine/iodine swabs/wipes -A4248 CHLORHEXIDINE ANTISEPT -A4250 Urine reagent strips/tablets -A4256 Calibrator solution/chips -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A4258 Lancet device each -A4259 Lancets per box -

KSKX

A4265 Paraffin -A4281 Replacement breastpump tube -A4282 Replacement breastpump adpt -A4283 Replacement breastpump cap -A4284 Replcmnt breast pump shield -A4285 Replcmnt breast pump bottle -A4286 Replcmnt breastpump lok ring -A4290 Sacral nerve stim test lead -A4458 Reusable enema bag -A4461 Surgicl dress hold non-reuse -A4463 Surgical dress holder reuse -A4465 Non-elastic extremity binder -A4467 BELT STRAP SLEEV GRMNT COVER -A4490 Above knee surgical stocking -A4495 Thigh length surg stocking -A4500 Below knee surgical stocking -A4510 Full length surg stocking -A4520 Incontinence garment anytype -A4554 Disposable underpads -A4556 Electrodes, pair -

NUA4557 Lead wires, pair -A4558 Conductive gel or paste -

NUA4559 Coupling gel or paste -A4561 Pessary rubber, any type -A4562 Pessary, non rubber,any type -A4565 SLINGS -A4570 Splint -A4595 TENS suppl 2 lead per month -A4600 Sleeve, inter limb comp dev -A4602 REPLACE LITHIUM BATTERY 1.5V -A4605 Trach suction cath close sys -

NUA4606 Oxygen probe used w oximeter -

NUA4630 Repl bat t.e.n.s. own by pt -

NUA4633 Uvl replacement bulb -

NUA4634 Replacement bulb th lightbox -A4639 INFRARED HT SYS REPLCMNT PAD -A4640 Alternating pressure pad -

RAA4649 Surgical supplies -

A1A2A3A4A5A6A7A8A9

A4670 Automatic bp monitor, dial -A4928 SURGICAL MASK -A4930 STERILE, GLOVES PER PAIR -A4931 REUSABLE ORAL THERMOMETER -A4932 Reusable rectal thermometer -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A6530 Compression stocking BK18-30 -A6531 Compression stocking BK30-40 -A6532 Compression stocking BK40-50 -A6533 Gc stocking thighlngth 18-30 -A6534 Gc stocking thighlngth 30-40 -A6535 Gc stocking thighlngth 40-50 -A6536 Gc stocking full lngth 18-30 -A6537 Gc stocking full lngth 30-40 -A6538 Gc stocking full lngth 40-50 -A6539 Gc stocking waistlngth 18-30 -A6540 Gc stocking waistlngth 30-40 -A6541 Gc stocking waistlngth 40-50 -A6544 Gc stocking garter belt -A9180 Lice treatment, topical -A9276 Disposable sensor, CGM sys -A9277 External transmitter, CGM -A9278 External receiver, CGM sys -E0181 Press pad alternating w/ pum -

NURR

E0182 Replace pump, alt press pad -E0184 Dry pressure mattress -E0185 Gel pressure mattress pad -

NURR

E0186 Air pressure mattress -NURR

E0188 Synthetic sheepskin pad -E0189 Lambswool sheepskin pad -E0190 Positioning cushion -E0191 Protector heel or elbow -E0193 Powered air flotation bed -

RRE0194 Air fluidized bed -

NURR

E0196 Gel pressure mattress -E0197 AIR PRESSURE PAD FOR MATTRES -

NURR

E0198 WATER PRESSURE PAD FOR MATTR -E0199 Dry pressure pad for mattres -E0225 Hydrocollator unit -

NURRUE

E0232 Warming card for NWT -E0235 Paraffin bath unit portable -

RRE0236 Pump for water circulating p -

NURRUE

E0239 Hydrocollator unit portable -NURRUE

E0274 Over-bed table -E0600 Suction pump portab hom modl -

RRTW

E0601 CONT AIRWAY PRESSURE DEVICE -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

E0601 CONT AIRWAY PRESSURE DEVICE MSNURARR

E0619 Apnea monitor w recorder -RR

E0621 Patient lift sling or seat -E0627 SEAT LIFT MECH, ELECTRIC ANY -

NURRUE

E0629 SEAT LIFT MECH, NON-ELECTRIC -NURRUE

E0630 Patient lift hydraulic -NURR

E0635 Patient lift electric -NURR

E0636 PT support & positioning sys -RR

E0637 Combination sit to stand sys -NURR

E0638 Standing frame sys -NU

E0639 Moveable patient lift system -E0640 Fixed patient lift system -E0641 Multi-position stnd fram sys -E0642 Dynamic standing frame -E0650 Pneuma compresor non-segment -

NURR

E0651 Pneum compressor segmental -NURRUE

E0652 Pneum compres w/cal pressure -NURRUE

E0655 Pneumatic appliance half arm -E0656 SEGMENTAL PNEUMATIC TRUNK -

NURRUE

E0657 SEGMENTAL PNEUMATIC CHEST -NURRUE

E0660 Pneumatic appliance full leg -E0665 Pneumatic appliance full arm -E0666 Pneumatic appliance half leg -E0667 Seg pneumatic appl full leg -

NURRUE

E0668 Seg pneumatic appl full arm -NURRUE

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

E0669 Seg pneumatic appli half leg -NURRUE

E0671 Pressure pneum appl full leg -NURRUE

E0672 Pressure pneum appl full arm -NURRUE

E0673 Pressure pneum appl half leg -NURRUE

E0675 Pneumatic compression device -RR

E0691 Uvl pnl 2 sq ft or less -NURRUE

E0692 Uvl sys panel 4 ft -NURRUE

E0693 Uvl sys panel 6 ft -NURRUE

E0694 Uvl md cabinet sys 6 ft -NURRUE

E0700 Safety equipment -E0705 Transfer device -E0720 Tens two lead -

NUE0731 Conductive garment for tens/ -

NUE0740 NON-IMPLANT PELV FLR E-STIM -

NURR

E0744 Neuromuscular stim for scoli -RR

E0747 Elec osteogen stim not spine -E0748 Elec osteogen stim spinal -E0749 Elec osteogen stim implanted -

RRE0760 Osteogen ultrasound stimltor -E0762 Trans elec jt stim dev sys -

NURRUE

E0765 Nerve stimulator for tx n&v -NURRUE

E0776 Iv pole -NURR

E0779 Amb infusion pump mechanical -NU

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

E0779 Amb infusion pump mechanical RRE0780 Mech amb infusion pump <8hrs -

NUE0781 External ambulatory infus pu -

NURR

E0784 Ext amb infusn pump insulin -NURR

E0791 Parenteral infusion pump sta -NURR

E0830 Ambulatory traction device -E0840 Tract frame attach headboard -E0849 CERVICAL PNEUM TRAC EQUIP -

NURRUE

E0850 Traction stand free standing -E0855 CERVICAL TRACTION EQUIPMENT -

NURRUE

E0856 CERVIC COLLAR W AIR BLADDERS -NURRUE

E0860 Tract equip cervical tract -E0870 Tract frame attach footboard -E0880 Trac stand free stand extrem -E0890 Traction frame attach pelvic -E0900 Trac stand free stand pelvic -E0910 Trapeze bar attached to bed -

NURR

E0911 HD trapeze bar attach to bed -NURR

E0912 HD trapeze bar free standing -NURR

E0920 Fracture frame attached to b -NURR

E0930 Fracture frame free standing -NURR

E0935 Cont pas motion exercise dev -RR

E0936 CPM device, other than knee -RR

E0940 Trapeze bar free standing -NURR

E0941 Gravity assisted traction de -NURR

E0942 Cervical head harness/halter -E0944 Pelvic belt/harness/boot -E0945 Belt/harness extremity -E0946 Fracture frame dual w cross -

NURR

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

E0947 Fracture frame attachmnts pe -E0948 Fracture frame attachmnts ce -E1031 Rollabout chair with casters -

NUE1037 Transport chair, ped size -

RRE1038 Transport chair pt wt<=300lb -

RRE1039 Transport chair pt wt >300lb -

RRE1399 Durable medical equipment mi -

NURR

E2000 Gastric suction pump hme mdl -RR

E2402 Neg press wound therapy pump -RR

S1040 Cranial remolding orthosis -S8431 Compression bandage -

A1A2A3A4A5A6A7A8A9

T5001 Position seat spec orth need -NURR

T5999 Supply, nos -Mobility Aids and supplies SA880 A4635 Underarm crutch pad -

A4636 Handgrip for cane etc -A4637 Repl tip cane/crutch/walker -E0100 Cane adjust/fixed with tip -E0105 Cane adjust/fixed quad/3 pro -E0110 Crutch forearm pair -E0111 Crutch forearm each -E0112 Crutch underarm pair wood -E0113 Crutch underarm each wood -E0114 Crutch underarm pair no wood -E0116 Crutch underarm each no wood -E0117 UNDERARM SPRINGASSIST CRUTCH -E0118 Crutch substitute -E0130 Walker rigid adjust/fixed ht -E0135 Walker folding adjust/fixed -E0140 WALKER W TRUNK SUPPORT -E0141 Rigid wheeled walker adj/fix -E0143 Walker folding wheeled w/o s -E0144 ENCLOSED WALKER W REAR SEAT -E0147 Walker variable wheel resist -E0148 Heavyduty walker no wheels -E0149 HEAVY DUTY WHEELED WALKER -E0153 Forearm crutch platform atta -E0154 Walker platform attachment -E0155 Walker wheel attachment,pair -E0156 Walker seat attachment -E0157 Walker crutch attachment -E0158 Walker leg extenders set of4 -E0159 Brake for wheeled walker -E1800 Adjust elbow ext/flex device -

RR

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

E1801 SPS elbow device -RR

E1802 Adjst forearm pro/sup device -RR

E1805 Adjust wrist ext/flex device -RR

E1806 SPS wrist device -RR

E1810 Adjust knee ext/flex device -RR

E1811 SPS knee device -RR

E1815 Adjust ankle ext/flex device -RR

E1816 SPS ankle device -RR

E1818 SPS forearm device -RR

E1820 Soft interface material -NURRUE

E1821 Replacement interface SPSD -NURRUE

E1825 Adjust finger ext/flex devc -RR

E1830 Adjust toe ext/flex device -RR

E1840 Adj shoulder ext/flex device -RR

E1902 AAC non-electronic board -E8000 Posterior gait trainer -E8001 Upright gait trainer -E8002 Anterior gait trainer -

Nutrition equipment and supplies SA881 97804 Medical nutrition, group -22263247555659667677QKSTXEXPXSXU

B4164 Parenteral 50% dextrose solu -B4168 Parenteral sol amino acid 3. -B4172 Parenteral sol amino acid 5. -B4176 Parenteral sol amino acid 7- -B4178 Parenteral sol amino acid > -B4180 Parenteral sol carb > 50% -B4185 Parenteral sol 10 gm lipids -B4189 Parenteral sol amino acid & -B4193 Parenteral sol 52-73 gm prot -B4197 Parenteral sol 74-100 gm pro -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

B4199 Parenteral sol > 100gm prote -B4216 Parenteral nutrition additiv -B4220 Parenteral supply kit premix -B4222 Parenteral supply kit homemi -B4224 Parenteral administration ki -B5000 PARENTERAL SOL RENAL-AMIROSY -B5100 PARENTERAL SOLUTION HEPATIC -B5200 PARENTERAL SOL HEPATIC FREAM -B9004 Parenteral infus pump portab -

NURR

B9006 Parenteral infus pump statio -NURR

B9999 Parenteral supp not othrws c -Orthotic equipment and supplies SA882 A4280 Brst prsths adhsv attchmnt -

A9283 Foot press off load supp dev -L0112 Cranial cervical orthosis -L0113 Cranial cervical torticollis -L0120 CERV FLEX N/ADJ FOAM PRE OTS -L0130 Flex thermoplastic collar mo -L0140 Cervical semi-rigid adjustab -L0150 Cerv semi-rig adj molded chn -L0160 CERV SR WIRE OCC/MAN PRE OTS -L0170 Cervical collar molded to pt -L0172 CERV COL SR FOAM 2PC PRE OTS -L0174 CERV SR 2PC THOR EXT PRE OTS -L0180 Cer post col occ/man sup adj -L0190 Cerv collar supp adj cerv ba -L0200 Cerv col supp adj bar & thor -L0220 Thor rib belt custom fabrica -L0450 TLSO FLEX TRUNK/THOR PRE OTS -L0452 tlso flex custom fab thoraci -L0454 TLSO TRNK SJ-T9 PRE CST -L0456 TLSO FLEX TRNK SJ-SS PRE CST -L0458 TLSO 2Mod symphis-xipho pre -L0460 TLSO 2 SHL SYMPHYS-STERN CST -L0462 TLSO 3Mod sacro-scap pre -L0464 TLSO 4Mod sacro-scap pre -L0466 TLSO R FRAM SOFT ANT PRE CST -L0468 TLSO RIG FRAM PELVIC PRE CST -L0470 TLSO rigid frame pre subclav -L0472 TLSO rigid frame hyperex pre -L0480 TLSO rigid plastic custom fa -L0482 TLSO rigid lined custom fab -L0484 TLSO rigid plastic cust fab -L0486 TLSO rigidlined cust fab two -L0488 TLSO rigid lined pre one pie -L0490 TLSO rigid plastic pre one -L0491 TLSO 2 piece rigid shell -L0492 TLSO 3 piece rigid shell -L0621 SIO FLEX PELVIC/SACR PRE OTS -L0622 SIO flex pelvisacral custom -L0623 SIO RIG PNL PELV/SAC PRE OTS -L0624 SIO panel custom -L0625 LO FLEX L1-BELOW L5 PRE OTS -L0626 LO SAG RIG PNL STAYS PRE CST -L0627 LO SAG RI AN/POS PNL PRE CST -L0628 LSO FLEX NO RI STAYS PRE OTS -L0629 LSO flex w/rigid stays cust -L0630 LSO R POST PNL SJ-T9 PRE CST -L0631 LSO SAG R AN/POS PNL PRE CST -L0632 LSO sag rigid frame cust -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

L0633 LSO SC R POS/LAT PNL PRE CST -L0634 LSO flexion control custom -L0635 LSO sagit rigid panel prefab -L0636 LSO sagittal rigid panel cus -L0637 LSO SC R ANT/POS PNL PRE CST -L0638 LSO sag-coronal panel custom -L0639 LSO S/C SHELL/PANEL PREFAB -L0640 LSO s/c shell/panel custom -L0700 Ctlso a-p-l control molded -L0710 Ctlso a-p-l control w/ inter -L0810 Halo cervical into jckt vest -L0820 Halo cervical into body jack -L0830 Halo cerv into milwaukee typ -L0859 MRI compatible system -L0861 Halo repl liner/interface -L0970 Tlso corset front -L0972 Lso corset front -L0974 Tlso full corset -L0976 Lso full corset -L0978 Axillary crutch extension -L0980 PERONEAL STRAPS PAIR PRE OTS -L0982 STOCKING SUP GRIPS 4 PRE OTS -L0984 PROTECT BODY SOCK EA PRE OTS -L0999 Add to spinal orthosis NOS -L1000 Ctlso milwauke initial model -L1001 CTLSO infant immobilizer -L1005 Tension based scoliosis orth -L1010 Ctlso axilla sling -L1020 Kyphosis pad -L1025 Kyphosis pad floating -L1030 Lumbar bolster pad -L1040 Lumbar or lumbar rib pad -L1050 Sternal pad -L1060 Thoracic pad -L1070 Trapezius sling -L1080 Outrigger -L1085 Outrigger bil w/ vert extens -L1090 Lumbar sling -L1100 Ring flange plastic/leather -L1110 Ring flange plas/leather mol -L1120 Covers for upright each -L1200 Furnsh initial orthosis only -L1210 Lateral thoracic extension -L1220 Anterior thoracic extension -L1230 Milwaukee type superstructur -L1240 Lumbar derotation pad -L1250 Anterior asis pad -L1260 Anterior thoracic derotation -L1270 Abdominal pad -L1280 Rib gusset (elastic) each -L1290 Lateral trochanteric pad -L1300 Body jacket mold to patient -L1310 Post-operative body jacket -L1499 Spinal orthosis NOS -L1600 HO FLEX FREJKA W/COV PRE CST -L1610 HO FREJKA COV ONLY PRE CST -L1620 HO FLEX PAVLIK HARNS PRE CST -L1630 Abduct control hip semi-flex -L1640 Pelv band/spread bar thigh c -L1650 HO abduction hip adjustable -L1652 HO bi thighcuffs w sprdr bar -L1660 HO abduction static plastic -L1680 Pelvic & hip control thigh c -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

L1685 Post-op hip abduct custom fa -L1686 HO post-op hip abduction -L1690 Combination bilateral HO -L1700 Leg perthes orth toronto typ -L1710 Legg perthes orth newington -L1720 Legg perthes orthosis trilat -L1730 Legg perthes orth scottish r -L1755 Legg perthes patten bottom t -L1810 KO ELASTIC WITH JOINTS -L1820 Ko elas w/ condyle pads & jo -L1830 KO IMMOB CANVAS LONG PRE OTS -

LTRT

L1831 Knee orth pos locking joint -L1832 KO ADJ JNT POS R SUP PRE CST -L1834 Ko w/0 joint rigid molded to -L1836 KO RIGID W/O JOINTS PRE OTS -L1840 Ko derot ant cruciate custom -L1843 KO SINGLE UPRIGHT PRE CST -L1844 Ko w/adj jt rot cntrl molded -L1845 KO DOUBLE UPRIGHT PRE CST -L1846 Ko w adj flex/ext rotat mold -L1847 KO DBL UPRIGHT W/AIR PRE CST -L1850 KO SWEDISH TYPE PRE OTS -L1860 Ko supracondylar socket mold -L1900 Afo sprng wir drsflx calf bd -L1902 Afo ankle gauntlet pre ots -L1904 Afo molded ankle gauntlet -L1906 AFO MULTILIG ANK SUP PRE OTS -L1907 AFO SUPRAMALLEOLAR CUSTOM -L1910 Afo sing bar clasp attach sh -L1920 Afo sing upright w/ adjust s -L1930 Afo plastic -L1932 Afo rig ant tib prefab TCF/= -L1940 Afo molded to patient plasti -L1945 Afo molded plas rig ant tib -L1950 Afo spiral molded to pt plas -L1951 AFO spiral prefabricated -L1960 Afo pos solid ank plastic mo -L1970 Afo plastic molded w/ankle j -L1971 AFO w/ankle joint, prefab -L1980 Afo sing solid stirrup calf -L1990 Afo doub solid stirrup calf -L2000 Kafo sing fre stirr thi/calf -L2005 KAFO sng/dbl mechanical act -L2010 Kafo sng solid stirrup w/o j -L2020 Kafo dbl solid stirrup band/ -L2030 Kafo dbl solid stirrup w/o j -L2034 KAFO pla sin up w/wo k/a cus -L2035 KAFO plastic pediatric size -L2036 Kafo plas doub free knee mol -L2037 Kafo plas sing free knee mol -L2038 Kafo w/o joint multi-axis an -L2040 Hkafo torsion bil rot straps -L2050 Hkafo torsion cable hip pelv -L2060 Hkafo torsion ball bearing j -L2070 Hkafo torsion unilat rot str -L2080 Hkafo unilat torsion cable -L2090 Hkafo unilat torsion ball br -L2106 Afo tib fx cast plaster mold -L2108 Afo tib fx cast molded to pt -L2112 Afo tibial fracture soft -L2114 Afo tib fx semi-rigid -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

L2116 Afo tibial fracture rigid -L2126 Kafo fem fx cast thermoplas -L2128 Kafo fem fx cast molded to p -L2132 Kafo femoral fx cast soft -L2134 Kafo fem fx cast semi-rigid -L2136 Kafo femoral fx cast rigid -L2180 Plas shoe insert w ank joint -L2182 Drop lock knee -L2184 Limited motion knee joint -L2186 Adj motion knee jnt lerman t -L2188 Quadrilateral brim -L2190 Waist belt -L2192 Pelvic band & belt thigh fla -L2200 Limited ankle motion ea jnt -L2210 Dorsiflexion assist each joi -L2220 Dorsi & plantar flex ass/res -L2230 Split flat caliper stirr & p -L2232 Rocker bottom, contact AFO -L2240 Round caliper and plate atta -L2250 Foot plate molded stirrup at -L2260 Reinforced solid stirrup -L2265 Long tongue stirrup -L2270 Varus/valgus strap padded/li -L2275 Plastic mod low ext pad/line -L2280 Molded inner boot -L2300 Abduction bar jointed adjust -L2310 Abduction bar-straight -L2320 Non-molded lacer -L2330 Lacer molded to patient mode -L2335 Anterior swing band -L2340 Pre-tibial shell molded to p -L2350 Prosthetic type socket molde -L2360 Extended steel shank -L2370 Patten bottom -L2375 Torsion ank & half solid sti -L2380 Torsion straight knee joint -L2385 Straight knee joint heavy du -L2387 Add LE poly knee custom KAFO -L2390 Offset knee joint each -L2395 Offset knee joint heavy duty -L2397 Suspension sleeve lower ext -L2405 Knee joint drop lock ea jnt -L2415 Knee joint cam lock each joi -L2425 Knee disc/dial lock/adj flex -L2430 Knee jnt ratchet lock ea jnt -L2492 Knee lift loop drop lock rin -L2500 Thi/glut/ischia wgt bearing -L2510 Th/wght bear quad-lat brim m -L2520 Th/wght bear quad-lat brim c -L2525 Th/wght bear nar m-l brim mo -L2526 Th/wght bear nar m-l brim cu -L2530 Thigh/wght bear lacer non-mo -L2540 Thigh/wght bear lacer molded -L2550 Thigh/wght bear high roll cu -L2570 Hip clevis type 2 posit jnt -L2580 Pelvic control pelvic sling -L2600 Hip clevis/thrust bearing fr -L2610 Hip clevis/thrust bearing lo -L2620 Pelvic control hip heavy dut -L2622 Hip joint adjustable flexion -L2624 Hip adj flex ext abduct cont -L2627 Plastic mold recipro hip & c -L2628 Metal frame recipro hip & ca -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

L2630 Pelvic control band & belt u -L2640 Pelvic control band & belt b -L2650 Pelv & thor control gluteal -L2660 Thoracic control thoracic ba -L2670 Thorac cont paraspinal uprig -L2680 Thorac cont lat support upri -L2750 Plating chrome/nickel pr bar -L2755 Carbon graphite lamination -L2760 Extension per extension per -L2768 Ortho sidebar disconnect -L2780 Non-corrosive finish -L2785 Drop lock retainer each -L2795 Knee control full kneecap -L2800 Knee cap medial or lateral p -L2810 Knee control condylar pad -L2820 Soft interface below knee se -L2830 Soft interface above knee se -L2840 Tibial length sock fx or equ -L2850 Femoral lgth sock fx or equa -L2861 Torsion mechanism knee/ankle -L2999 Lower extremity orthosis NOS -L3000 Ft insert ucb berkeley shell -L3001 Foot insert remov molded spe -L3002 Foot insert plastazote or eq -L3003 Foot insert silicone gel eac -L3010 Foot longitudinal arch suppo -L3020 Foot longitud/metatarsal sup -L3030 Foot arch support remov prem -L3031 Foot lamin/prepreg composite -L3040 Ft arch suprt premold longit -L3050 Foot arch supp premold metat -L3060 Foot arch supp longitud/meta -L3070 Arch suprt att to sho longit -L3080 Arch supp att to shoe metata -L3090 Arch supp att to shoe long/m -L3100 HALLUS-VALGUS NT DYN PRE OTS -L3140 Abduction rotation bar shoe -L3150 Abduct rotation bar w/o shoe -L3160 Shoe styled positioning dev -L3170 FOOT PLAS HEEL STABI PRE OTS -L3201 Oxford w supinat/pronat inf -L3202 Oxford w/ supinat/pronator c -L3203 Oxford w/ supinator/pronator -L3204 Hightop w/ supp/pronator inf -L3206 Hightop w/ supp/pronator chi -L3207 Hightop w/ supp/pronator jun -L3208 Surgical boot each infant -L3209 Surgical boot each child -L3211 Surgical boot each junior -L3212 Benesch boot pair infant -L3213 Benesch boot pair child -L3214 Benesch boot pair junior -L3215 Orthopedic ftwear ladies oxf -L3216 Orthoped ladies shoes dpth i -L3217 Ladies shoes hightop depth i -L3219 Orthopedic mens shoes oxford -L3221 Orthopedic mens shoes dpth i -L3222 Mens shoes hightop depth inl -L3224 Woman''s shoe oxford brace -L3225 Man''s shoe oxford brace -L3230 Custom shoes depth inlay -L3250 Custom mold shoe remov prost -L3251 Shoe molded to pt silicone s -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

L3252 Shoe molded plastazote cust -L3253 Shoe molded plastazote cust -L3254 Orth foot non-stndard size/w -L3255 Orth foot non-standard size/ -L3257 Orth foot add charge split s -L3260 Ambulatory surgical boot eac -L3265 Plastazote sandal each -L3300 Sho lift taper to metatarsal -L3310 Shoe lift elev heel/sole neo -L3320 Shoe lift elev heel/sole cor -L3330 Lifts elevation metal extens -L3332 Shoe lifts tapered to one-ha -L3334 Shoe lifts elevation heel /i -L3340 Shoe wedge sach -L3350 Shoe heel wedge -L3360 Shoe sole wedge outside sole -L3370 Shoe sole wedge between sole -L3380 Shoe clubfoot wedge -L3390 Shoe outflare wedge -L3400 Shoe metatarsal bar wedge ro -L3410 Shoe metatarsal bar between -L3420 Full sole/heel wedge btween -L3430 Sho heel count plast reinfor -L3440 Heel leather reinforced -L3450 Shoe heel sach cushion type -L3455 Shoe heel new leather standa -L3460 Shoe heel new rubber standar -L3465 Shoe heel thomas with wedge -L3470 Shoe heel thomas extend to b -L3480 Shoe heel pad & depress for -L3485 Shoe heel pad removable for -L3500 Ortho shoe add leather insol -L3510 Orthopedic shoe add rub insl -L3520 O shoe add felt w leath insl -L3530 Ortho shoe add half sole -L3540 Ortho shoe add full sole -L3550 O shoe add standard toe tap -L3560 O shoe add horseshoe toe tap -L3570 O shoe add instep extension -L3580 O shoe add instep velcro clo -L3590 O shoe convert to sof counte -L3595 Ortho shoe add march bar -L3600 Trans shoe calip plate exist -L3610 Trans shoe caliper plate new -L3620 Trans shoe solid stirrup exi -L3630 Trans shoe solid stirrup new -L3640 Shoe dennis browne splint bo -L3649 Orthopedic shoe modifica NOS -L3650 SO 8 ABD RESTRAINT PRE OTS -L3660 SO 8 AB RSTR CAN/WEB PRE OTS -L3670 SO ACRO/CLAV CAN WEB PRE OTS -L3671 SO CAP DESIGN W/O JNTS CF -L3675 SO VEST CANVAS/WEB PRE OTS -L3677 SO HARD PLAS STABILI PRE CST -L3702 EO w/o joints CF -L3710 EO ELAS W/METAL JNTS PRE OTS -L3720 Forearm/arm cuffs free motio -L3730 Forearm/arm cuffs ext/flex a -L3740 Cuffs adj lock w/ active con -L3760 EO withjoint, Prefabricated -L3762 EO RIGID W/O JOINTS PRE OTS -L3763 EWHO rigid w/o jnts CF -L3764 EWHO w/joint(s) CF -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

L3765 EWHFO rigid w/o jnts CF -L3766 EWHFO w/joint(s) CF -L3806 WHFO w/joint(s) custom fab -L3807 WHFO W/O JOINTS PRE CST -L3808 WHFO, rigid w/o joints -L3891 Torsion mechanism wrist/elbo -L3900 Hinge extension/flex wrist/f -L3901 Hinge ext/flex wrist finger -L3904 Whfo electric custom fitted -L3905 WHO w/nontorsion jnt(s) CF -L3906 WHO w/o joints CF -L3908 WHO COCK-UP NONMOLDE PRE OTS -L3912 HFO FLEXION GLOVE PRE OTS -L3913 HFO w/o joints CF -L3915 WHO NONTORSION JNTS PRE CST -L3917 METACARP FX ORTHOSIS PRE CST -L3919 HO w/o joints CF -L3921 HFO w/joint(s) CF -L3923 HFO WITHOUT JOINTS PRE CST -L3925 FO PIP DIP JNT/SPRNG PRE OTS -L3927 FO PIP DIP NO JT SPR PRE OTS -L3929 HFO NONTORSION JNTS PRE CST -L3931 WHFO nontorsion joint prefab -L3933 FO w/o joints CF -L3935 FO nontorsion joint CF -L3956 Add joint upper ext orthosis -L3960 Sewho airplan desig abdu pos -L3961 SEWHO cap design w/o jnts CF -L3962 Sewho erbs palsey design abd -L3967 SEWHO airplane w/o jnts CF -L3971 SEWHO cap design w/jnt(s) CF -L3973 SEWHO airplane w/jnt(s) CF -L3975 SEWHFO cap design w/o jnt CF -L3976 SEWHFO airplane w/o jnts CF -L3977 SEWHFO cap desgn w/jnt(s) CF -L3978 SEWHFO airplane w/jnt(s) CF -L3980 UP EXT FX ORTHOS HUMERAL NOS -L3982 Upper ext fx orthosis rad/ul -L3984 Upper ext fx orthosis wrist -L3995 Sock fracture or equal each -L3999 Upper limb orthosis NOS -L4000 Repl girdle milwaukee orth -L4002 Replace strap, any orthosis -L4010 Replace trilateral socket br -L4020 Replace quadlat socket brim -L4030 Replace socket brim cust fit -L4040 Replace molded thigh lacer -L4045 Replace non-molded thigh lac -L4050 Replace molded calf lacer -L4055 Replace non-molded calf lace -L4060 Replace high roll cuff -L4070 Replace prox & dist upright -L4080 Repl met band kafo-afo prox -L4090 Repl met band kafo-afo calf/ -L4100 Repl leath cuff kafo prox th -L4110 Repl leath cuff kafo-afo cal -L4130 Replace pretibial shell -L4205 Ortho dvc repair per 15 min -L4210 Orth dev repair/repl minor p -L4350 ANKLE CONTROL ORTHO PRE OTS -L4360 PNEUMAT WALKING BOOT PRE CST -L4370 PNEUM FULL LEG SPLNT PRE OTS -L4386 NON-PNEUM WALK BOOT PRE CST -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

L4392 Replace AFO soft interface -L4394 Replace foot drop spint -L4396 STATIC OR DYNAMI AFO PRE CST -L4398 FOOT DROP SPLINT PRE OTS -

Ostomy care SA883 A4361 Ostomy face plate -A4362 Solid skin barrier -A4363 Ostomy clamp, replacement -A4366 Ostomy vent -A4367 Ostomy belt -A4368 Ostomy filter -A4369 Skin barrier liquid per oz -A4371 Skin barrier powder per oz -A4372 Skin barrier solid 4x4 equiv -A4373 Skin barrier with flange -A4375 Drainable plastic pch w fcpl -A4376 Drainable rubber pch w fcplt -A4377 Drainable plstic pch w/o fp -A4378 Drainable rubber pch w/o fp -A4379 Urinary plastic pouch w fcpl -A4380 Urinary rubber pouch w fcplt -A4381 Urinary plastic pouch w/o fp -A4382 Urinary hvy plstc pch w/o fp -A4383 Urinary rubber pouch w/o fp -A4384 Ostomy faceplt/silicone ring -A4385 Ost skn barrier sld ext wear -A4387 Ost clsd pouch w att st barr -A4388 Drainable pch w ex wear barr -A4389 Drainable pch w st wear barr -A4390 Drainable pch ex wear convex -A4391 Urinary pouch w ex wear barr -A4392 Urinary pouch w st wear barr -A4393 Urine pch w ex wear bar conv -A4394 Ostomy pouch liq deodorant -A4395 Ostomy pouch solid deodorant -A4396 Peristomal hernia supprt blt -A4397 Irrigation supply sleeve -A4398 Ostomy irrigation bag -A4399 Ostomy irrig cone/cath w brs -A4400 Ostomy irrigation set -A4402 Lubricant per ounce -A4404 Ostomy ring each -A4405 Nonpectin based ostomy paste -A4406 Pectin based ostomy paste -A4407 ="Ext wear ost skn barr <=4sq"" -A4408 ="Ext wear ost skn barr >4sq"" -A4409 Ost skn barr convex <=4 sq i -A4410 Ost skn barr extnd >4 sq -A4411 Ost skn barr extnd =4sq -A4412 Ost pouch drain high output -A4413 2 pc drainable ost pouch -A4414 Ost sknbar w/o conv<=4 sq in -A4415 Ost skn barr w/o conv >4 sqi -A4416 Ost pch clsd w barrier/filtr -A4417 Ost pch w bar/bltinconv/fltr -A4418 Ost pch clsd w/o bar w filtr -A4419 Ost pch for bar w flange/flt -A4420 Ost pch clsd for bar w lk fl -A4421 Ostomy supply misc -A4422 Ost pouch absorbent material -A4423 Ost pch for bar w lk fl/fltr -A4424 Ost pch drain w bar & filter -A4425 Ost pch drain for barrier fl -A4426 Ost pch drain 2 piece system -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A4427 Ost pch drain/barr lk flng/f -A4428 Urine ost pouch w faucet/tap -A4429 Urine ost pouch w bltinconv -A4430 Ost urine pch w b/bltin conv -A4431 Ost pch urine w barrier/tapv -A4432 Os pch urine w bar/fange/tap -A4433 Urine ost pch bar w lock fln -A4434 Ost pch urine w lock flng/ft -A5051 Pouch clsd w barr attached -A5052 Clsd ostomy pouch w/o barr -A5053 Clsd ostomy pouch faceplate -A5054 Clsd ostomy pouch w/flange -A5055 Stoma cap -A5061 Pouch drainable w barrier at -A5062 Drnble ostomy pouch w/o barr -A5063 Drain ostomy pouch w/flange -A5071 Urinary pouch w/barrier -A5072 Urinary pouch w/o barrier -A5073 Urinary pouch on barr w/flng -A5081 STOMA PLUG OR SEAL, ANY TYPE -A5082 Continent stoma catheter -A5083 Stoma absorptive cover -A5093 Ostomy accessory convex inse -

Respiratory equipment and supplies SA884 A4218 Sterile saline or water -A4450 Non-waterproof tape -

A1A2A3A4A5A6A7A8A9

A4452 Waterproof tape -A1A2A3A4A5A6A7A8A9

A4481 Tracheostoma filter -A4483 Moisture exchanger -A4558 Conductive gel or paste -

NUA4604 Tubing with heating element -A4606 Oxygen probe used w oximeter -

NUA4608 TRANSTRACHEAL OXYGEN CATH -A4611 HEAVY DUTY BATTERY -

NUA4612 BATTERY CABLES -

NUA4613 BATTERY CHARGER -A4614 Hand-held PEFR meter -

NUA4615 Cannula nasal -

NUA4616 Tubing (oxygen) per foot -

NU

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A4617 Mouth piece -NU

A4618 Breathing circuits -NU

A4619 Face tent -NU

A4620 Variable concentration mask -NU

A4623 Tracheostomy inner cannula -NU

A4624 Tracheal suction tube -A1A2A3A4A5A6A7A8A9NU

A4625 Trach care kit for new trach -NU

A4626 Tracheostomy cleaning brush -A4627 Spacer bag/reservoir -

NUA4628 Oropharyngeal suction cath -

NUA4629 Tracheostomy care kit -

NUA7000 Disposable canister for pump -

NUTW

A7001 Nondisposable pump canister -NU

A7002 Tubing used w suction pump -NU

A7003 Nebulizer administration set -NUTW

A7004 Disposable nebulizer sml vol -NU

A7005 Nondisposable nebulizer set -NU

A7006 Filtered nebulizer admin set -NU

A7007 Lg vol nebulizer disposable -NU

A7008 Disposable nebulizer prefill -NU

A7009 Nebulizer reservoir bottle -NU

A7010 Disposable corrugated tubing -NU

A7012 Nebulizer water collec devic -NU

A7013 Disposable compressor filter -NU

A7014 Compressor nondispos filter -NU

A7015 Aerosol mask used w nebulize -NU

A7016 Nebulizer dome & mouthpiece -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A7016 Nebulizer dome & mouthpiece NUA7017 Nebulizer not used w oxygen -

NURRUE

A7018 Water distilled w/nebulizer -NU

A7020 INTERFACE, COUGH STIM DEVICE -A7025 REPLACE CHEST COMPRESS VEST -A7027 Combination oral/nasal mask -

NUA7028 Repl oral cushion combo mask -

NUA7029 Repl nasal pillow comb mask -

NUA7030 CPAP full face mask -

NUA7031 Replacement facemask interfa -

NUA7032 Replacement nasal cushion -

NUA7033 Replacement nasal pillows -

NUA7034 Nasal application device -

NUA7035 Pos airway press headgear -

NUA7036 Pos airway press chinstrap -

NUA7037 Pos airway pressure tubing -

NUA7038 Pos airway pressure filter -

NUA7039 Filter, non disposable w pap -

NUA7044 PAP oral interface -

NUA7045 Repl exhalation port for PAP -

NURRUE

A7046 Repl water chamber, PAP dev -NU

A7501 Tracheostoma valve w diaphra -A7502 Replacement diaphragm/fplate -A7503 HMES filter holder or cap -A7504 Tracheostoma HMES filter -A7505 HMES or trach valve housing -A7506 HMES/trachvalve adhesivedisk -A7507 Integrated filter & holder -A7508 Housing & Integrated Adhesiv -A7509 Heat & moisture exchange sys -

NUA7520 Trach/laryn tube non-cuffed -

NUA7521 Trach/laryn tube cuffed -

NUA7522 Trach/laryn tube stainless -

NUA7523 Tracheostomy shower protect -A7524 Tracheostoma stent/stud/bttn -A7525 Tracheostomy mask -

NU

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A7526 Tracheostomy tube collar -NU

A7527 Trach/laryn tube plug/stop -A8000 Soft protect helmet prefab -A8001 Hard protect helmet prefab -A8002 Soft protect helmet custom -A8003 Hard protect helmet custom -A8004 Repl soft interface, helmet -A9284 Non-electronic spirometer -E0424 Stationary compressed gas 02 -

MSRR

E0425 Gas system stationary compre -E0430 Oxygen system gas portable -E0431 Portable gaseous 02 -

MSRR

E0433 Portable liquid oxygen sys -RR

E0434 Portable liquid 02 -MSRR

E0435 Oxygen system liquid portabl -E0439 Stationary liquid 02 -

MSRR

E0440 Oxygen system liquid station -E0441 Stationary O2 contents, gas -

NUE0442 Stationary O2 contents, liq -

NUE0443 Portable 02 contents, gas -

NUE0444 Portable 02 contents, liquid -

NUE0445 Oximeter non-invasive -

RRE0446 TOPICAL OX DELIVER SYS, NOS -E0455 Oxygen tent excl croup/ped t -E0457 CHEST SHELL -E0459 CHEST WRAP -E0470 RAD w/o backup non-inv intfc -

NURR

E0471 RAD w/backup non inv intrfc -MSRR

E0472 RAD w backup invasive intrfc -MSRR

E0480 Percussor elect/pneum home m -NU

E0481 Intrpulmnry percuss vent sys -E0482 Cough stimulating device -

RRE0483 Chest compression gen system -

RRE0484 Non-elec oscillatory pep dvc -

NURRUE

E0487 Electronic spirometer -E0500 Ippb all types -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

E0500 Ippb all types RRE0550 Humidif extens supple w ippb -

RRE0555 Humidifier for use w/ regula -E0560 Humidifier supplemental w/ i -

NURRUE

E0561 Humidifier nonheated w PAP -NURRUE

E0562 Humidifier heated used w PAP -NU

E0565 Compressor air power source -RR

E0570 Nebulizer with compression -NURR

E0572 Aerosol compressor adjust pr -RR

E0574 Ultrasonic generator w svneb -RR

E0575 Nebulizer ultrasonic -RR

E0580 Nebulizer for use w/ regulat -NURRUE

E0585 Nebulizer w/ compressor & he -RR

E0605 Vaporizer room type -E0618 Apnea monitor -

RRE1352 O2 FLOW REG POS INSPIR PRESS -E1354 Wheeled cart, port cyl/conc -E1355 Oxygen supplies stand/rack -E1356 Batt pack/cart, port conc -E1357 Battery charger, port conc -E1358 DC POWER ADAPTER, PORT CONC -E1372 Oxy suppl heater for nebuliz -

NURRUE

E1390 Oxygen concentrator -MSRR

E1391 Oxygen concentrator, dual -RR

E1392 Portable oxygen concentrator -MSRR

E1405 O2/water vapor enrich w/heat -RR

E1406 O2/water vapor enrich w/o he -RR

K0462 Temporary replacement eqpmnt -RR

K0740 Repair/svc oxygen equipment -L8501 Tracheostomy speaking valve -

K0K1K2

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

L8501 Tracheostomy speaking valve K3K4

S8185 Flutter device -NU

S8186 Swivel adaptor -S8189 Trach supply noc -S8210 Mucus trap -S8265 Haberman feeder -S8999 Resuscitation bag -

Urinary/incontinence equipment SA885 A4310 Insert tray w/o bag/cath -A4311 Catheter w/o bag 2-way latex -A4312 Cath w/o bag 2-way silicone -A4313 Catheter w/bag 3-way -A4314 Cath w/drainage 2-way latex -A4315 Cath w/drainage 2-way silcne -A4316 Cath w/drainage 3-way -A4320 Irrigation tray -A4321 Cath therapeutic irrig agent -A4322 Irrigation syringe -A4326 Male external catheter -A4327 Fem urinary collect dev cup -A4328 Fem urinary collect pouch -A4330 Stool collection pouch -A4331 Extension drainage tubing -A4332 Lube sterile packet -A4333 Urinary cath anchor device -A4334 Urinary cath leg strap -A4335 Incontinence supply -A4336 Urethral insert -A4338 Indwelling catheter latex -A4340 Indwelling catheter special -A4344 Cath indw foley 2 way silicn -A4346 Cath indw foley 3 way -A4349 Disposable male external cat -A4351 Straight tip urine catheter -A4352 Coude tip urinary catheter -A4353 Intermittent urinary cath -A4354 Cath insertion tray w/bag -A4355 Bladder irrigation tubing -A4356 Ext ureth clmp or compr dvc -A4357 Bedside drainage bag -A4358 Urinary leg or abdomen bag -A4360 Disposable ext urethral dev -A5102 Bedside drain btl w/wo tube -A5105 Urinary suspensory -A5112 Urinary leg bag -A5113 Latex leg strap -

RAA5114 Foam/fabric leg strap -

RAA5120 Skin barrier, wipe or swab -A5121 Solid skin barrier 6x6 -A5122 Solid skin barrier 8x8 -A5126 Disk/foam pad +or- adhesive -T4521 Adult size brief/diaper sm -T4522 Adult size brief/diaper med -T4523 Adult size brief/diaper lg -T4524 Adult size brief/diaper xl -T4525 Adult size pull-on sm -

59T4526 Adult size pull-on med -

59T4527 Adult size pull-on lg -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

T4527 Adult size pull-on lg 59T4528 Adult size pull-on xl -

59T4529 Ped size brief/diaper sm/med -T4530 Ped size brief/diaper lg -T4531 Ped size pull-on sm/med -

59T4532 Ped size pull-on lg -

59T4533 Youth size brief/diaper -T4534 Youth size pull-on -

59T4535 Disposable liner/shield/pad -

59T4536 Reusable pull-on any size -

NURR

T4537 Reusable underpad bed size -NURR

T4538 Diaper serv reusable diaper -RR

T4539 Reuse diaper/brief any size -NU

T4540 Reusable underpad chair size -T4541 Large disposable underpad -T4542 Small disposable underpad -T4543 ADULT DISP BRIEF/DIAP ABV XL -T4544 ADLT DISP UND/PULL ON ABV XL -

59Wheelchairs and accessories SA886 E0950 Tray -

E0951 Loop heel -E0952 Toe loop/holder, each -E0955 CUSHIONED HEADREST -E0956 W/c lateral trunk/hip suppor -E0957 W/c medial thigh support -E0958 Whlchr att- conv 1 arm drive -E0959 Amputee adapter -E0960 W/c shoulder harness/straps -E0961 Wheelchair brake extension -E0966 Wheelchair head rest extensi -

NURRUE

E0967 MAN WC RIM/PROJECTION REP EA -E0968 Wheelchair commode seat -

RRE0969 Wheelchair narrowing device -

NURRUE

E0970 Wheelchair no. 2 footplates -E0971 Wheelchair anti-tipping devi -E0973 W/Ch access det adj armrest -E0974 W/Ch access anti-rollback -E0978 W/C acc,saf belt pelv strap -E0980 Wheelchair safety vest -E0981 Seat upholstery, replacement -E0982 Back upholstery, replacement -E0983 Add pwr joystick -E0984 ADD PWR TILLER -E0985 W/C SEAT LIFT MECHANISM -E0986 MAN W/C PUSH-RIM POWR SYSTEM -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

E0990 Wheelchair elevating leg res -E0992 Wheelchair solid seat insert -E0994 Wheelchair arm rest -E0995 WC CALF REST, PAD REPLACEMNT -E1002 PWR SEAT TILT -E1003 PWR SEAT RECLINE -E1004 PWR SEAT RECLINE MECH -E1005 PWR SEAT RECLINE PWR -E1006 PWR SEAT COMBO W/O SHEAR -E1007 PWR SEAT COMBO W/SHEAR -E1008 PWR SEAT COMBO PWR SHEAR -E1009 Add mech leg elevation -E1010 ADD PWR LEG ELEVATION -E1011 Ped wc modify width adjustm -E1014 RECLINING BACK ADD PED W/C -E1015 Shock absorber for man w/c -E1016 Shock absorber for power w/c -E1017 HD shck absrbr for hd man wc -E1018 HD shck absrber for hd powwc -E1020 Residual limb support system -E1028 W/C MANUAL SWINGAWAY -E1029 W/C VENT TRAY FIXED -E1030 W/C VENT TRAY GIMBALED -E1037 Transport chair, ped size -

RRE1038 Transport chair pt wt<=300lb -

RRE1039 Transport chair pt wt >300lb -

RRE1050 Whelchr fxd full length arms -

RRE1060 Wheelchair detachable arms -

RRE1070 Wheelchair detachable foot r -

RRE1083 Hemi-wheelchair fixed arms -

RRE1084 Hemi-wheelchair detachable a -

RRE1085 Hemi-wheelchair fixed arms -E1086 Hemi-wheelchair detachable a -E1087 Wheelchair lightwt fixed arm -

RRE1088 Wheelchair lightweight det a -

RRE1089 Wheelchair lightwt fixed arm -E1090 Wheelchair lightweight det a -E1092 Wheelchair wide w/ leg rests -E1093 Wheelchair wide w/ foot rest -

RRE1100 Whchr s-recl fxd arm leg res -

RRE1110 Wheelchair semi-recl detach -

RRE1130 Whlchr stand fxd arm ft rest -E1140 Wheelchair standard detach a -E1150 Wheelchair standard w/ leg r -

RRE1160 Wheelchair fixed arms -

RRE1161 MANUAL ADULT WC W TILTINSPAC -

NUE1170 Whlchr ampu fxd arm leg rest -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

E1170 Whlchr ampu fxd arm leg rest RRE1171 Wheelchair amputee w/o leg r -

RRE1172 Wheelchair amputee detach ar -

RRE1180 Wheelchair amputee w/ foot r -

RRE1190 Wheelchair amputee w/ leg re -

RRE1195 Wheelchair amputee heavy dut -

RRE1200 Wheelchair amputee fixed arm -

RRE1220 Whlchr special size/constrc -E1221 Wheelchair spec size w foot -

RRE1222 Wheelchair spec size w/ leg -

RRE1223 Wheelchair spec size w foot -

RRE1224 Wheelchair spec size w/ leg -

RRE1225 Manual semi-reclining back -E1226 Manual fully reclining back -E1227 Wheelchair spec sz spec ht a -E1228 Wheelchair spec sz spec ht b -E1229 Pediatric wheelchair NOS -

NUE1231 Rigid ped w/c tilt-in-space -

NUE1232 FOLDING PED WC TILT-IN-SPACE -

NUE1233 RIG PED WC TLTNSPC W/O SEAT -

NUE1234 FLD PED WC TLTNSPC W/O SEAT -

NUE1235 RIGID PED WC ADJUSTABLE -

NUE1236 FOLDING PED WC ADJUSTABLE -

NUE1237 RGD PED WC ADJSTABL W/O SEAT -

NURR

E1238 FLD PED WC ADJSTABL W/O SEAT -NU

E1239 Ped power wheelchair NOS -NU

E1240 Whchr litwt det arm leg rest -RR

E1250 Wheelchair lightwt fixed arm -E1260 Wheelchair lightwt foot rest -E1270 Wheelchair lightweight leg r -

RRE1280 Whchr h-duty det arm leg res -

RRE1285 Wheelchair heavy duty fixed -E1290 Wheelchair hvy duty detach a -E1295 Wheelchair heavy duty fixed -

RRE1296 Wheelchair special seat heig -

NURRUE

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

E1297 Wheelchair special seat dept -E1298 Wheelchair spec seat depth/w -E2201 Man w/ch acc seat w>=20o<24o -E2202 Seat width 24-27 in -E2203 Frame depth less than 22 in -E2204 Frame depth 22 to 25 in -E2205 Manual wc accessory, handrim -E2206 MAN WC WHL LOCK COMP REPL EA -E2207 Crutch and cane holder -E2208 Cylinder tank carrier -E2209 Arm trough each -E2210 Wheelchair bearings -E2211 Pneumatic propulsion tire -E2212 Pneumatic prop tire tube -E2213 Pneumatic prop tire insert -E2214 Pneumatic caster tire each -E2215 Pneumatic caster tire tube -E2216 Foam filled propulsion tire -E2217 Foam filled caster tire each -E2218 Foam propulsion tire each -E2219 Foam caster tire any size ea -E2220 SOLID PROPULS TIRE, REPL, EA -E2221 SOLID CASTER TIRE REPL, EACH -E2222 SOLID CASTER INTEG WHL, REPL -E2224 PROPULSION WHL EXCL TIRE REP -E2225 Caster wheel excludes tire -E2226 Caster fork replacement only -E2227 GEAR REDUCTION DRIVE WHEEL -E2228 MWC ACC, WHEELCHAIR BRAKE -

NURRUE

E2230 MANUAL STANDING SYSTEM -E2231 Solid seat support base -E2291 Planar back for ped size wc -E2292 Planar seat for ped size wc -E2293 Contour back for ped size wc -E2294 Contour seat for ped size wc -E2295 Ped dynamic seating frame -E2300 PWR SEAT ELEVATION SYS -E2301 PWR STANDING -E2310 ELECTRO CONNECT BTW CONTROL -E2311 ELECTRO CONNECT BTW 2 SYS -E2312 MINI-PROP REMOTE JOYSTICK -E2313 PWC HARNESS, EXPAND CONTROL -E2321 HAND INTERFACE JOYSTICK -E2322 MULT MECH SWITCHES -E2323 Special joystick handle -E2324 Chin cup interface -E2325 SIP AND PUFF INTERFACE -E2326 BREATH TUBE KIT -E2327 HEAD CONTROL INTERFACE MECH -E2328 HEAD/EXTREMITY CONTROL INTER -E2329 HEAD CONTROL NONPROPORTIONAL -E2330 HEAD CONTROL PROXIMITY SWITC -E2331 Attendant control -E2340 W/c wdth 20-23 in seat frame -E2341 W/c wdth 24-27 in seat frame -E2342 W/c dpth 20-21 in seat frame -E2343 W/c dpth 22-25 in seat frame -E2351 ELECTRONIC SGD INTERFACE -E2360 22nf nonsealed leadacid -E2361 22nf sealed leadacid battery -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

E2362 Gr24 nonsealed leadacid -NURRUE

E2363 Gr24 sealed leadacid battery -E2364 U1nonsealed leadacid battery -

NURRUE

E2365 U1 sealed leadacid battery -E2366 Battery charger, single mode -E2367 Battery charger, dual mode -E2368 PWR WC DRIVEWHEEL MOTOR REPL -E2369 PWR WC DRIVEWHEEL GEAR REPL -E2370 PWR WC DR WH MOTOR/GEAR COMB -E2371 Gr27 sealed leadacid battery -E2372 Gr27 non-sealed leadacid -E2373 HAND/CHIN CTRL SPEC JOYSTICK -E2374 HAND/CHIN CTRL STD JOYSTICK -E2375 NON-EXPANDABLE CONTROLLER -E2376 EXPANDABLE CONTROLLER, REPL -E2377 EXPANDABLE CONTROLLER, INITL -E2381 Pneum drive wheel tire -E2382 Tube, pneum wheel drive tire -E2383 Insert, pneum wheel drive -E2384 Pneumatic caster tire -E2385 Tube, pneumatic caster tire -E2386 Foam filled drive wheel tire -E2387 Foam filled caster tire -E2388 Foam drive wheel tire -E2389 Foam caster tire -E2390 Solid drive wheel tire -E2391 Solid caster tire -E2392 Solid caster tire, integrate -E2394 Drive wheel excludes tire -E2395 Caster wheel excludes tire -E2396 Caster fork -E2397 Pwc acc, lith-based battery -

NURRUE

E2601 Gen w/c cushion wdth < 22 in -E2602 Gen w/c cushion wdth >=22 in -E2603 Skin protect wc cus wd <22in -E2604 Skin protect wc cus wd>=22in -E2605 Position wc cush wdth <22 in -E2606 Position wc cush wdth>=22 in -E2607 Skin pro/pos wc cus wd <22in -E2608 Skin pro/pos wc cus wd>=22in -E2609 Custom fabricate w/c cushion -E2610 Powered w/c cushion -E2611 Gen use back cush wdth <22in -E2612 Gen use back cush wdth>=22in -E2613 Position back cush wd <22in -E2614 Position back cush wd>=22in -E2615 Pos back post/lat wdth <22in -E2616 Pos back post/lat wdth>=22in -E2617 Custom fab w/c back cushion -E2619 Replace cover w/c seat cush -E2620 WC planar back cush wd <22in -E2621 WC planar back cush wd>=22in -E2622 ADJ SKIN PRO W/C CUS WD<22IN -E2623 ADJ SKIN PRO WC CUS WD>=22IN -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

E2624 ADJ SKIN PRO/POS CUS<22IN -E2625 ADJ SKIN PRO/POS WC CUS>=22 -K0001 Standard wheelchair -

NURR

K0002 Stnd hemi (low seat) whlchr -NURR

K0003 Lightweight wheelchair -NURR

K0004 High strength ltwt whlchr -NU

K0005 Ultralightweight wheelchair -NU

K0006 Heavy duty wheelchair -NURR

K0007 Extra heavy duty wheelchair -NU

K0009 OTHER MANUAL WHEELCHAIR/BASE -NU

K0010 Stnd wt frame power whlchr -NURR

K0011 Stnd wt pwr whlchr w control -NURR

K0012 Ltwt portbl power whlchr -NURR

K0015 DETACH NON-ADJ HT ARMRST REP -K0017 DETACH ADJUST ARMREST BASE -K0018 DETACH ADJUST ARMRST UPPER -K0019 ARM PAD REPL, EACH -K0020 Fixed adjust armrest pair -K0037 HI MOUNT FLIP-UP FTREST REPL -K0038 Leg strap each -K0039 Leg strap h style each -K0040 Adjustable angle footplate -K0041 Large size footplate each -K0042 STANDARD SIZE FTPLATE REP EA -K0043 FTRST LOWR EXTEN TUBE REP EA -K0044 FTRST UPR HANGER BRAC REP EA -K0045 FTRST COMPL ASSEMBLY REPL EA -K0046 ELEV LGRST LWR EXTEN REPL EA -K0047 ELEV LEGRST UPR HANGR REP EA -K0050 RATCHET ASSEMBLY REPLACEMENT -K0051 CAM REL ASM FT/LEGRST REP EA -K0052 SWINGAWAY DETACH FTREST REPL -K0053 Elevate footrest articulate -K0056 Seat ht <17 or >=21 ltwt wc -K0065 Spoke protectors -K0069 RR WHL COMPL SOL TIRE REP EA -K0070 RR WHL COMPL PNE TIRE REP EA -K0071 FR CSTR COMP PNE TIRE REP EA -K0072 FR CSTR SEMI-PNE TIRE REP EA -K0073 Caster pin lock each -K0077 FR CSTR ASMB SOL TIRE REP EA -K0098 DRIVE BELT FOR PWC, REPL -K0105 Iv hanger -K0108 W/c component-accessory NOS -K0195 Elevating whlchair leg rests -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

K0195 Elevating whlchair leg rests RRK0601 Repl batt silver oxide 1.5 v -K0602 Repl batt silver oxide 3 v -K0603 Repl batt alkaline 1.5 v -K0604 Repl batt lithium 3.6 v -K0605 Repl batt lithium 4.5 v -K0669 SEAT/BACK CUS NO DMEPDAC VER -K0672 Removable soft interface LE -K0733 12-24hr sealed lead acid -K0738 Portable gas oxygen system -

MSRR

K0800 POV group 1 std up to 300lbs -K0801 POV group 1 hd 301-450 lbs -K0802 POV group 1 vhd 451-600 lbs -K0806 POV group 2 std up to 300lbs -K0807 POV group 2 hd 301-450 lbs -K0808 POV group 2 vhd 451-600 lbs -K0812 Power operated vehicle NOC -K0813 PWC gp 1 std port seat/back -K0814 PWC gp 1 std port cap chair -K0815 PWC gp 1 std seat/back -K0816 PWC gp 1 std cap chair -K0820 PWC gp 2 std port seat/back -K0821 PWC gp 2 std port cap chair -K0822 PWC gp 2 std seat/back -K0823 PWC gp 2 std cap chair -K0824 PWC gp 2 hd seat/back -K0825 PWC gp 2 hd cap chair -K0826 PWC gp 2 vhd seat/back -K0827 PWC gp vhd cap chair -K0828 PWC gp 2 xtra hd seat/back -K0829 PWC gp 2 xtra hd cap chair -K0830 PWC gp2 std seat elevate s/b -K0831 PWC gp2 std seat elevate cap -K0835 PWC gp2 std sing pow opt s/b -K0836 PWC gp2 std sing pow opt cap -K0837 PWC gp 2 hd sing pow opt s/b -K0838 PWC gp 2 hd sing pow opt cap -K0839 PWC gp2 vhd sing pow opt s/b -K0840 PWC gp2 xhd sing pow opt s/b -K0841 PWC gp2 std mult pow opt s/b -K0842 PWC gp2 std mult pow opt cap -K0843 PWC gp2 hd mult pow opt s/b -K0848 PWC gp 3 std seat/back -K0849 PWC gp 3 std cap chair -K0850 PWC gp 3 hd seat/back -K0851 PWC gp 3 hd cap chair -K0852 PWC gp 3 vhd seat/back -K0853 PWC gp 3 vhd cap chair -K0854 PWC gp 3 xhd seat/back -K0855 PWC gp 3 xhd cap chair -K0856 PWC gp3 std sing pow opt s/b -K0857 PWC gp3 std sing pow opt cap -K0858 PWC gp3 hd sing pow opt s/b -K0859 PWC gp3 hd sing pow opt cap -K0860 PWC gp3 vhd sing pow opt s/b -K0861 PWC gp3 std mult pow opt s/b -K0862 PWC gp3 hd mult pow opt s/b -K0863 PWC gp3 vhd mult pow opt s/b -K0864 PWC gp3 xhd mult pow opt s/b -

RRK0868 PWC gp 4 std seat/back -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

Wheelchairs and accessories SA886 K0869 PWC gp 4 std cap chair -K0870 PWC gp 4 hd seat/back -K0871 PWC gp 4 vhd seat/back -K0877 PWC gp4 std sing pow opt s/b -K0878 PWC gp4 std sing pow opt cap -K0879 PWC gp4 hd sing pow opt s/b -K0880 PWC gp4 vhd sing pow opt s/b -K0884 PWC gp4 std mult pow opt s/b -K0885 PWC gp4 std mult pow opt cap -K0886 PWC gp4 hd mult pow s/b -K0890 PWC gp5 ped sing pow opt s/b -K0891 PWC gp5 ped mult pow opt s/b -K0898 Power wheelchair NOC -K0899 Pow mobil dev no dmepdac -

Wound care SA887 A4364 Adhesive, liquid or equal -A4450 Non-waterproof tape -

A1A2A3A4A5A6A7A8A9

A4452 Waterproof tape -A1A2A3A4A5A6A7A8A9

A4455 Adhesive remover per ounce -A4456 Adhesive remover, wipes -A5056 1 pc ost pouch w filter -A5057 1 pc ost pou w built-in conv -A5131 Appliance cleaner -A6000 Wound warming wound cover -A6010 Collagen based wound filler -A6011 Collagen gel/paste wound fil -A6021 Collagen dressing <=16 sq in -

A1A2A3A4A5A6A7A8A9

A6022 Collagen drsg>16<=48 sq in -A1A2A3A4A5A6A7A8A9

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A6023 Collagen dressing >48 sq in -A1A2A3A4A5A6A7A8A9

A6024 Collagen dsg wound filler -A1A2A3A4A5A6A7A8A9

A6025 Silicone gel sheet, each -A6154 Wound pouch each -

A1A2A3A4A5A6A7A8A9

A6196 Alginate dressing <=16 sq in -A1A2A3A4A5A6A7A8A9

A6197 Alginate drsg >16 <=48 sq in -A1A2A3A4A5A6A7A8A9

A6198 alginate dressing > 48 sq in -A1A2A3A4A5A6A7A8A9

A6199 Alginate drsg wound filler -A1

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A6199 Alginate drsg wound filler A2A3A4A5A6A7A8A9

A6203 Composite drsg <= 16 sq in -A1A2A3A4A5A6A7A8A9

A6204 Composite drsg >16<=48 sq in -A1A2A3A4A5A6A7A8A9

A6205 Composite drsg > 48 sq in -A1A2A3A4A5A6A7A8A9

A6206 Contact layer <= 16 sq in -A1A2A3A4A5A6A7A8A9

A6207 Contact layer >16<= 48 sq in -A1A2A3A4A5A6A7A8A9

A6208 Contact layer > 48 sq in -A1A2A3A4

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A6208 Contact layer > 48 sq in A5A6A7A8A9

A6209 Foam drsg <=16 sq in w/o bdr -A1A2A3A4A5A6A7A8A9

A6210 Foam drg >16<=48 sq in w/o b -A1A2A3A4A5A6A7A8A9

A6211 Foam drg > 48 sq in w/o brdr -A1A2A3A4A5A6A7A8A9

A6212 Foam drg <=16 sq in w/border -A1A2A3A4A5A6A7A8A9

A6213 Foam drg >16<=48 sq in w/bdr -A1A2A3A4A5A6A7A8A9

A6214 Foam drg > 48 sq in w/border -A1A2A3A4A5A6A7

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A6214 Foam drg > 48 sq in w/border A8A9

A6215 Foam dressing wound filler -A1A2A3A4A5A6A7A8A9

A6216 Non-sterile gauze<=16 sq in -A1A2A3A4A5A6A7A8A9

A6217 Non-sterile gauze>16<=48 sq -A1A2A3A4A5A6A7A8A9

A6218 Non-sterile gauze > 48 sq in -A1A2A3A4A5A6A7A8A9

A6219 Gauze <= 16 sq in w/border -A1A2A3A4A5A6A7A8A9

A6220 Gauze >16 <=48 sq in w/bordr -A1A2A3A4A5A6A7A8A9

A6221 Gauze > 48 sq in w/border -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A6221 Gauze > 48 sq in w/border A1A2A3A4A5A6A7A8A9

A6222 Gauze <=16 in no w/sal w/o b -A1A2A3A4A5A6A7A8A9

A6223 Gauze >16<=48 no w/sal w/o b -A1A2A3A4A5A6A7A8A9

A6224 Gauze > 48 in no w/sal w/o b -A1A2A3A4A5A6A7A8A9

A6228 Gauze <= 16 sq in water/sal -A1A2A3A4A5A6A7A8A9

A6229 Gauze >16<=48 sq in watr/sal -A1A2A3A4A5A6A7A8A9

A6230 Gauze > 48 sq in water/salne -A1A2A3

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A6230 Gauze > 48 sq in water/salne A4A5A6A7A8A9

A6231 Hydrogel dsg<=16 sq in -A6232 Hydrogel dsg>16<=48 sq in -A6233 Hydrogel dressing >48 sq in -A6234 Hydrocolld drg <=16 w/o bdr -

A1A2A3A4A5A6A7A8A9

A6235 Hydrocolld drg >16<=48 w/o b -A1A2A3A4A5A6A7A8A9

A6236 Hydrocolld drg > 48 in w/o b -A1A2A3A4A5A6A7A8A9

A6237 Hydrocolld drg <=16 in w/bdr -A1A2A3A4A5A6A7A8A9

A6238 Hydrocolld drg >16<=48 w/bdr -A1A2A3A4A5A6A7A8A9

A6239 Hydrocolld drg > 48 in w/bdr -A6240 Hydrocolld drg filler paste -A6241 Hydrocolloid drg filler dry -A6242 Hydrogel drg <=16 in w/o bdr -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A6243 Hydrogel drg >16<=48 w/o bdr -A6244 Hydrogel drg >48 in w/o bdr -

A1A2A3A4A5A6A7A8A9

A6245 Hydrogel drg <= 16 in w/bdr -A1A2A3A4A5A6A7A8A9

A6246 Hydrogel drg >16<=48 in w/b -A1A2A3A4A5A6A7A8A9

A6247 Hydrogel drg > 48 sq in w/b -A1A2A3A4A5A6A7A8A9

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A6248 Hydrogel drsg gel filler -A1A2A3A4A5A6A7A8A9

A6250 Skin seal protect moisturizr -A6251 Absorpt drg <=16 sq in w/o b -

A1A2A3A4A5A6A7A8A9

A6252 Absorpt drg >16 <=48 w/o bdr -A1A2A3A4A5A6A7A8A9

A6253 Absorpt drg > 48 sq in w/o b -A1A2A3A4A5A6A7A8A9

A6254 Absorpt drg <=16 sq in w/bdr -A1A2A3A4A5A6A7A8A9

A6255 Absorpt drg >16<=48 in w/bdr -A6256 Absorpt drg > 48 sq in w/bdr -A6257 Transparent film <= 16 sq in -A6258 Transparent film >16<=48 in -A6259 Transparent film > 48 sq in -A6260 Wound cleanser any type/size -A6261 Wound filler gel/paste /oz -

A1A2A3A4A5

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A6261 Wound filler gel/paste /oz A6A7A8A9

A6262 Wound filler dry form / gram -A1A2A3A4A5A6A7A8A9

A6266 Impreg gauze no h20/sal/yard -A6402 Sterile gauze <= 16 sq in -

A1A2A3A4A5A6A7A8A9

A6403 Sterile gauze>16 <= 48 sq in -A1A2A3A4A5A6A7A8A9

A6404 Sterile gauze > 48 sq in -A1A2A3A4A5A6A7A8A9

A6407 Packing strips, non-impreg -A6410 Sterile eye pad -A6411 Non-sterile eye pad -A6412 Occlusive eye patch -A6413 Adhesive bandage, first-aid -A6441 ="Pad band w>=3" <5"/yd" -A6442 ="Conform band n/s w<3"/yd" -A6443 ="Conform band n/s w>=3"<5"/yd" -A6444 ="Conform band n/s w>=5"/yd" -A6445 ="Conform band s w <3"/yd" -A6446 ="Conform band s w>=3" <5"/yd" -A6447 ="Conform band s w >=5"/yd" -A6448 ="Lt compres band <3"/yd" -A6449 ="Lt compres band >=3" <5"/yd" -A6450 ="Lt compres band >=5"/yd" -A6451 ="Mod compres band w>=3"<5"/yd" -A6452 ="High compres band w>=3"<5"yd" -A6453 ="Self-adher band w <3"/yd" -

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DME Social Services Blanket Code to Procedure Crosswalk Updated 4/28/2017

Group Description Group Code Proc/Svc Code Proc Short Description

Modifier Code(See last page for modifier code description)

A6454 ="Self-adher band w>=3" <5"/yd" -A6455 ="Self-adher band >=5"/yd" -A6456 ="Zinc paste band w >=3"<5"/yd" -A6457 Tubular dressing -A6501 Compres burngarment bodysuit -A6502 Compres burngarment chinstrp -A6503 Compres burngarment facehood -A6504 Cmprsburngarment glove-wrist -A6505 Cmprsburngarment glove-elbow -A6506 Cmprsburngrmnt glove-axilla -A6507 Cmprs burngarment foot-knee -A6508 Cmprs burngarment foot-thigh -A6509 Compres burn garment jacket -A6510 Compres burn garment leotard -A6511 Compres burn garment panty -A6512 Compres burn garment, noc -A6513 Compress burn mask face/neck -A6549 G compression stocking -A6550 Neg pres wound ther drsg set -

Mdfr Short Description Modifier CodeNo modifier -UNUSUAL PROCEDURAL SERVICES 22PROFESSIONAL COMPONENT 26MANDATED SERVICES 32ANESTHESIA BY SURGEON 47POSTOPERATIVE MANAGEMNT ONLY 55Preoperative management only 56STAGED/REL PROC SM MD POSTOP 59SURGICAL TEAM 66REPEAT PROCEDURE BY SAME MD 76REPEAT PROCEDURE ANOTHER MD 77Dressing for one wound A1Dressing for two wounds A2Dressing for three wounds A3Dressing for four wounds A4Dressing for five wounds A5Dressing for six wounds A6Dressing for seven wounds A7Dressing for eight wounds A8Dressing for nine or more wounds A9LWR EXT PROST FUNCTNL LVL 0 K0LWR EXT PROST FUNCTNL LVL 1 K1LWR EXT PROST FUNCTNL LVL 2 K2LWR EXT PROST FUNCTNL LVL 3 K3Lwr ext prost functnl lvl 4 K4Glucose monitor supply KSDOCUMENTATION ON FILE KXLeft side LT6-MO MAINT/SVC FEE PARTS/LBR MSNew equipment NUMED DIR 2-4 CNCRNT ANES PROC QKREPLACEMENT OF DME ITEM RARENTAL (DME) RRRight side RTRelated to trauma or injury STTECHNICAL COMPONENT TCBack-up equipment TWUsed durable med equipment UESEPARATE ENCOUNTER XESEPARATE PRACTITIONER XPSEPARATE ORGAN/STRUCTURE XSUNUSUAL SEPARATE SERVICE XU

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