December 1995 DMERC Medicare Advisory
Page 95-145
Palmetto Government Benefits Administrators
DMERC
MEDICARE ADVISORY
Durable Medical Equipment Regional Carrier P.O. Box 100141 Columbia, SC 29202-3141
DECEMBER 1995
PAGE 95-145
ISSUE 14
ATTENTION PHYSICIANS AND SUPPLIERS
IN THIS ISSUE:
Categories Established For Payment Of
Temporary Level II Codes ................................................ 95-190
Certificates Of Medical Necessity: Legislative
Changes Involving CMNs .........................................95-163-164
CMN Version .02 Implementation Schedule Change ................ 95-145
Cochlear Implant (L8619) ........................................................ 95-192
Complementary/Supplemental Policies Update ........................ 95-189
DMERC Medicare Advisory Update ..................................95-182-183
Electronic Data Interchange .............................................95-188-189
Enteral Nutrients - Level III: Code Deletions ............................. 95-162
Enteral/Parenteral Nutrition Certification Requirements ....95-178-179
External Infusion Pump Covered Drugs .................................. 95-161
HCFA 1500 (12/90) Form Orders ............................................ 95-182
HCPCS Codes Requiring A CMN/DIF - Update ..................95-166-169
Hearing Request Form ............................................................ 95-180
Inherent Reasonableness Notice ....................................95-195-196
Join HCFA In Saving Medicare Trust Funds .....................95-170-177
Medical Policies ....................................................................... 95-146
External Infusion Pumps ...........................................95-146-151
Surgical Dressings ...................................................95-152-160
Medicare Anti-Fraud Unit .................................................95-185-187
Modifier Replacement .............................................................. 95-163
National Supplier Clearinghouse (NSC) Re-Enrollment ............ 95-182
Nebulizer Drugs And Saline .................................................... 95-162
Neoral Soft Gel/Oral Solution .................................................. 95-161
Ombudsmen Addresses And Their Territories ....................... 95-218
Palmetto GBA Region C DMERC Contacts ............................... 95-219
Place Of Service Clarification, Item 24b .................................. 95-169
Professional Relations Update ................................................ 95-181
Q & A ...................................................................................... 95-165
Remittance Code Update ......................................................... 95-162
RIK Fluid Mattress ................................................................... 95-162
Span Dates Needed When Filing Claims ................................. 95-190
Supplier Satisfaction Survey .................................................. 95-189
Support Surfaces: Powered Air Overlay - Coding Guidelines 95-161
Workshop Notice..................................................................... 95-184
1995 Fee Schedule Updates ................................................... 95-194
Drug Pricing ..................................................................... 95-194
1996 Fee Schedule Corrections ............................................. 95-196
1996 Fee Schedules ........................................................95-197-217
1996 HCPCS Update: Additions, Changes And Deletions95-191-193
NOTICE
CMN VERSION .02 IMPLEMENTATION SCHEDULE CHANGE
Version .02 CMNs may be submitted with claims received by the DMERC on or after 10/1/95. Version
.02 CMNs will be required with claims received by the DMERC on or after 4/1/96. The current .01 versions
will not be acceptable as certifying medical necessity with claims received on or after 4/1/96.
NOTE: This is an update to previously published implementation instructions which indicated 7/1/96 as
the implementation date of the version .02 CMNs.
Workshop
Reminder
Alabama
Arkansas
Colorado
Florida
Palmetto GBA will be holding the next series of workshops covering a DMERC update, in January and February
of 1996. Separate invitations were mailed to all Region C billers the end of November 1995. A list of the dates
and locations along with a short agenda appears on page 95-184 of this advisory for your reference. If you
have not received your separate invitation, please contact the Dedicated Work Teams at (803) 691-4300. They
will be happy to send you a copy.
Georgia
Kentucky
Louisiana
Mississippi
New Mexico
North Carolina
Oklahoma
Puerto Rico
South Carolina
Tennessee
Texas
Virgin Islands
Page 95-146
MEDICAL POLICIES
December 1995 DMERC Medicare Advisory
The following DMERC Medical Policy releases include a revised DMERC Medical
Policy on External Infusion Pumps, including a Home Parenteral Inotropic Therapy
Data Collection Form, and a Medical Policy on Surgical Dressings. Also included in
this section are new coding guidelines for the Support Surfaces Policy. These revised
Medical Policies will also be published in the next Palmetto GBA DMEPOS Supplier
Manual revision.
EXTERNAL
INFUSION PUMPS
REGION C DMERC REGIONAL MEDICAL REVIEW POLICY
SUBJECT: External Infusion Pumps
HCPCS CODES:
The appearance of a code in this section does not necessarily indicate coverage.
Equipment:
E0781 - Ambulatory infusion pump, single or multiple channels, with administrative equipment, worn by patient
E0782 - Infusion pump, implantable
E0791 - Parenteral infusion pump, stationary, single or multi-channel
E0776 - IV pole
E1399 - Durable medical equipment miscellaneous
K0284 - External infusion pump, mechanical, reusable, for extended drug infusion
Supplies:
A4305 - Disposable drug delivery system, flow rate of 50 ml or greater per hour
A4306 - Disposable drug delivery system, flow rate of 5 ml or less per hour
A9270 - Noncovered item or service
K0110 - Supplies for the maintenance of a drug infusion catheter, per week
K0111 - Supplies for external drug infusion pump, per cassette or bag
Drugs:
J0895 - Injection, deferoxamine mesylate, 500 mg per 5 cc
J1170 - Injection, hydromorphone, up to 4 mg
J1250 - Injection, dobutamine hydrochloride, per 250 mg
J1455 - Injection, foscarnet sodium, per 1000 mg
J1570 - Injection, ganciclovir sodium, 500 mg
J2175 - Injection, meperidine, per 100 mg
J2260 - Injection, milrinone lactate, per 5 ml
J2270 - Injection, morphine sulfate, up to 10 mg
J2275 - Injection, morphine sulfate (preservative-free sterile solution), per 10 mg
J3010 - Injection, fentanyl citrate, up to 2 ml
J3370 - Injection, vancomycin HCL, up to 500 mg
J7799 - NOC drugs, other than inhalation drugs, administered through DME
J9000 - Doxorubicin HCL, 10 mg
J9010 - Doxorubicin HCL, 50 mg
J9040 - Bleomycin sulfate, 15 units
J9065 - Injection, cladribine, per 1 mg
J9100 - Cytarabine, 100 mg
J9110 - Cytarabine, 500 mg
J9190 - Fluorouracil, 500 mg
J9200 - Floxuridine, 500 mg
J9360 - Vinblastine sulfate, 1 mg
J9370 - Vincristine sulfate, 1 mg
J9875 - Vincristine sulfate, 2 mg
J9380 - Vincristine sulfate, 5 mg
XX009 - Dobutamine, 250 mg
December 1995 DMERC Medicare Advisory
Page 95-147
BENEFITS CATEGORY: Durable Medical Equipment
REFERENCE: Coverage Issues Manual 60-14
DEFINITIONS:
An ambulatory infusion pump (E0781) is an electrical device which is used to deliver solutions containing parenteral
medication under pressure at a regulated flow rate. It is small, portable and designed to be carried by the patient.
A stationary infusion pump (E0791) is an electrical device which serves the same purpose as an ambulatory pump but is
larger and typically mounted on a pole.
An infusion controller (E1399) is an electrical device which regulates the flow of parenteral solutions under gravity pressure.
A reusable mechanical infusion pump (K0284) is a non-electric device used to deliver solutions containing parenteral
medication under pressure at a constant predetermined flow rate. It is small, portable and designed to be carried by the
patient. It must be capable of a single infusion cycle of at least 8 hours.
A disposable drug delivery system (A4305, A4306) is a device used to deliver solutions containing parenteral medication
under pressure generated from the elastic properties of the container. It is commonly called an elastomeric infusion pump.
Code K0110 includes dressings for the catheter site and flush solutions not directly related to drug infusion. The catheter
site may be a peripheral intravenous line, a peripherally inserted central catheter (PICC), a centrally inserted intravenous
line with either an external or subcutaneous port, or an epidural catheter.
Code K0111 includes the cassette or bag, diluting solutions, tubing and other administration supplies, port cap changes,
compounding charges, and preparation charges.
COVERAGE AND PAYMENT RULES:
An infusion pump is indicated for the administration of parenteral medication in the home setting when both of the following
criteria are met:
1. Parenteral administration of the medication in the home is reasonable and necessary, and
2. An infusion pump is necessary to safely administer the medication.
An external infusion pump is covered for the following indications:
1. In the subcutaneous administration of deferoxamine for the treatment of chronic iron overload.
2. Chemotherapy for the treatment of primary hepatocellular carcinoma or colorectal cancer where this disease is
unresectable or where the patient refuses surgical excision of the tumor.
3. Morphine when used in the treatment of intractable pain caused by cancer.
Additional uses of an infusion pump are covered for the administration of parenteral medication in the home setting if the
patient meets:
a) criteria 1, 2, and 3, or
b) criteria 1, 4, and 5
Criteria:
1) Parenteral administration of the medication in the home is reasonable and necessary.
2) The drug is administered by a prolonged infusion of at least 8 hours because of proven improved clinical efficacy.
3) The therapeutic regimen is proven or generally accepted to have significant advantages over (a) intermittent bolus
administration regimens or (b) infusions lasting less than 8 hours.
4) The drug is administered by intermittent infusion (each episode of infusion lasting less than 8 hours) which does
not require the patient to return to the physician’s office prior to the beginning of each infusion.
5) Systemic toxicity or adverse effects of the drug is unavoidable without infusing it at a strictly controlled rate as
indicated in the Physicians Desk Reference, American Medical Association’s Drug Evaluations, or the U.S.
Pharmacopeia Drug Information
Page 95-148
December 1995 DMERC Medicare Advisory
The criteria for additional uses of infusion pumps as described in a) and b) above are met in the following situations:
A. Administration of cladribine, fluorouracil, cytarabine, bleomycin, floxuridine, doxorubicin, vincristine or vinblastine
by continuous infusion over at least 8 hours when the regimen is proven or generally accepted to have significant
advantages over intermittent administration regimens. This does not apply to primary hepatocellular carcinoma or
liver metastases from colorectal carcinoma.
B. Administration of narcotic analgesics (except meperidine) in place of morphine to a patient with intractable pain
caused by cancer who has not responded to an adequate oral/transdermal therapeutic regimen and/or cannot
tolerate oral/transdermal narcotic analgesics.
C. Administration of the following antibiotics or antiviral drugs: foscarnet, amphotericin B, vancomycin, acyclovir, and
ganciclovir.
D. Administration of parenteral inotropic therapy, using the drugs dobutamine, milrinone and/or dopamine for patients
with congestive heart failure and depressed cardiac function if a patient has all of the following conditions:
1) Dyspnea at rest despite treatment with maximum or near maximum tolerated doses of digoxin, a loop diuretic,
and an angiotensin converting enzyme inhibitor or another vasodilator (e.g. hydralazine or isosorbide dinitrate),
used simultaneously (unless allergic or intolerant), and
2) Doses are within the following ranges (lower doses will be covered only if part of a weaning or tapering protocol
from higher dose levels):
a) Dobutamine 2.5 - 10 mcg/kg/min
b) Milrinone 0.375 - 0.750 mcg/kg/min
c) Dopamine < 2 mcg/kg/min, and
3) Invasive hemodynamic studies performed within 6 months prior to the initiation of home inotropic therapy show
(a) cardiac index (CI) is less than or equal to 2.2 liters/min/meter squared and/or pulmonary capillary wedge
pressure (PCWP) is greater than or equal to 20 mm Hg before inotrope infusion on maximum medical
management and (b) at least a 20 % increase in CI and/or at least a 20 % decrease in PCWP during inotrope
infusion at the dose initially prescribed for home infusion, and
4) An improvement in patient well being, (less dyspnea, improved diuresis, improved renal function and/or reduction
in weight) with the absence of dyspnea at rest at the time of discharge and the capability of outpatient evaluation
by the prescribing physician at least monthly, and
5) In the case of continuous infusion, there is documented deterioration in clinical status when the drug(s) is
tapered or discontinued under observation in a hospital, or
In the case of intermittent infusions, there is documentation of repeated hospitalizations for congestive heart
failure despite maximum medical management, and
6) Any life threatening arrhythmia is controlled prior to hospital discharge and there is no need for routine
electrocardiographic monitoring at home, and
7) The patient is maintained on the lowest practical dose and efforts to decrease the dose of the drug(s) or the
frequency/duration of infusion are documented during the first 3 months of therapy, and
8) The patient’s cardiac symptoms, vital signs, weight, lab values, and response to therapy are routinely assessed
and documented in the patient’s medical record.
External infusion pumps and related drugs and supplies will be denied as not medically necessary when these criteria are
not met unless there is documentation justifying medical necessity in the individual case.
When an infusion pump is covered, the medication necessitating the use of the pump and necessary supplies are also
covered. When a pump has been purchased by the Medicare program, other insurer, or the patient, or the rental cap has
been reached, the medication necessitating the use of the pump, and supplies are covered as long as the coverage criteria
for the pump are met.
Disposable drug delivery systems, including elastomeric infusion pumps (A4305, A4306) are noncovered devices because
they do not meet the Medicare definition of durable medical equipment. Medication and supplies used with disposable drug
delivery systems are also noncovered items.
December 1995 DMERC Medicare Advisory
Page 95-149
An external infusion pump and related medication and supplies will be denied as not medically necessary in the home setting
in the following situations:
1.
Heparin for the treatment of thromboembolic disease and/or pulmonary embolism,
2.
Insulin for the treatment of diabetes mellitus.
An infusion controller device (E1399) is not medically necessary.
An IV pole (E0776) is covered only when a stationary infusion pump (E0791) is covered. It is considered not medically
necessary if it is billed with an ambulatory infusion pump (E0781).
Supplies for the maintenance of a parenteral drug infusion catheter (K0110) are covered during the period of covered use of
an infusion pump. They are also covered for the weeks in between covered infusion pump use, not to exceed 4 weeks per
episode.
Supplies used with an external infusion pump, K0111, are covered. Allowance is based on the number of cassettes or bags
prepared. For intermittent infusions, no more than one cassette or bag is covered for each dose of medication. For continuous
infusion, the concentration of the drug and the size of the cassette or bag should be maximized to result in the fewest
cassettes or bags in keeping with good pharmacologic and medical practice. Medications and supplies that are dispensed
but not used for completely unforeseen circumstances (e.g., emergency admission to hospital, drug toxicity, etc.) are
covered. Suppliers are expected to anticipate changing needs for drugs (e.g. planned hospital admissions, drug level testing
with possible dosage change, etc.) in their drug and supply preparation and delivery schedule.
The DMERC does not process claims for implantable infusion pumps or medications and supplies used in conjunction with
implantable infusion pumps. Claims for these items must be submitted to the local carrier.
RELATED CLINICAL INFORMATION
The Center for Disease Control and Prevention (CDC) has determined that use of vancomycin may increase the possibility
of emergence of vancomycin-resistant staphylococci and enterococci. Since the presence of these organisms has a
significant negative public health impact, use of vancomycin should be limited to those situations in which it is clearly
necessary. The CDC outlined appropriate and inappropriate uses of vancomycin. Of the appropriate uses listed, use of
vancomycin administered through an infusion pump in the home setting would usually be limited to the following:
1.
Treatment of serious infections due to beta-lactam resistant gram positive microorganisms
2.
Treatment of infections due to gram positive microorganisms in patients with serious allergy to beta-lactam
antimicrobials
CODING GUIDELINES:
Supplies (including dressings) used in conjunction with an durable infusion pump (E0781, E0791, K0284) are included in
codes K0110 or K0111. Other codes should not be used for the separate billing of these supplies.
Use codes K0110 and K0111 only for supplies related to durable infusion pumps. Charges for supplies for noncovered infusion
therapy via disposable pump or without a pump may be billed under code A9270.
Medication used in a durable infusion pump should be coded using the appropriate HCPCS codes. If the medication does
not have a distinct code, then use the unclassified drug code J7799. Do not use codes A4610 or J9999. If there is no distinct
HCPCS code for the drug billed, and the drug is not administered via an infusion pump, use code A9270.
Use code J2275 only for morphine sulfate that is labeled “preservative free.” Morphine sulfate that is not labeled “preservative
free” must be coded J2270.
For disposable drug delivery systems (e.g. elastomeric) with a flow rate of more than 5 ml per hour and less than 50 ml per
hour, use code A9270.
Page 95-150
December 1995 DMERC Medicare Advisory
DOCUMENTATION:
An order for the item which has been signed and dated by the ordering physician and a certificate of medical necessity (CMN)
which has been filled out, signed and dated by the ordering physician must be kept on file by the supplier. The CMN for
external infusion pumps is DMERC 09.
The initial claim must include a copy of the CMN if filed hard copy. If the claim is filed electronically, the information on the
CMN must be transcribed exactly into the GUO record. (See DMEPOS National Standard Format Matrix for details.) If
additional medical necessity information is included, it must be transcribed into the HAO record.
If an inotropic drug is ordered, the initial claim must include a copy of the order (prescription and documentation from the
ordering physician) which includes information relating to each of the criteria (D1-D8) defined in the Coverage and Payment
Rules section. This must include the before and after inotropic drug infusion values defined in D3. A suggested form for
collecting this information is attached. Questions pertaining to medical necessity on any form used to collect this information
may not be completed by the supplier or by anyone in a financial relationship with the supplier. If coverage criteria stated
in the policy are not met, the claim should be accompanied by a copy of a letter from the physician giving details of the
patient’s history (e.g. dates of past hospitalization for heart failure, prior use of parenteral inotropics and the results, etc.)
If invasive hemodynamic studies were not performed, the claim should be accompanied by a letter from the attending
physician explaining the rationale for not performing the tests accompanied by any other documentation deemed appropriate
to explain this exception.
Refer to the Supplier Manual for more information on orders, CMNs, medical records and supplier documentation.
EFFECTIVE DATE: Claims received by the DMERC on or after April 1, 1996.
This is a revision to a previously published policy.
NOTE: The Home Parenteral Inotropic Therapy Data Collection Form found on the following page is a recommended form
only. If you do not use this form, please be sure to provide us with all the information requested on the form when
filing claims for Home Parenteral Inotropic Therapy.
December 1995 DMERC Medicare Advisory
Page 95-151
HOME PARENTERAL INOTROPIC THERAPY: DATA COLLECTION FORM
Patient’s name:
HIC #:
Information below may not be completed by the supplier nor anyone in a financial relationship with the supplier.
1) Results of invasive hemodynamic monitoring:
Cardiac
Index
Wedge
Pressure
Date
Before inotrope infusion
On inotrope infusion
Drug
Dose
mcg/kg/min
2) Cardiac medications (digoxin, diuretics, vasodilators) immediately prior to inotrope infusion (list name, dose, frequency):
3) Does this represent maximum tolerated doses of these medications?
4) Breathing status
(check one in each column)
Prior to
inotrope infusion
At time
of discharge
No dyspnea on exertion
Dyspnea on moderate exertion
Dyspnea on mild exertion
Dyspnea at rest
5) Initial home prescription: Drug
hrs/day
Surgical Dressings
days/week (or every
mcg/kg/min
days)
6) If continuous infusion is prescribed, have attempts to discontinue inotrope infusion in the hospital failed?
7) If intermittent infusion is prescribed, have there been repeated hospitalizations for heart failure during which parenteral
inotropes were required?
8) Is the patient capable of going to the physician for outpatient evaluation?
9) Is routine electrocardiographic monitoring required in the home?
The above statements and any additional explanations included separately are true and accurate and there is documentation
present in the patient’s medical record to support these statements.
Physician Signature:
Date:
Physician Name Printed/Typed:
UPIN #:
Physician Specialty:
Page 95-152
December 1995 DMERC Medicare Advisory
SURGICAL
DRESSINGS
REGION C DMERC REGIONAL MEDICAL REVIEW POLICY
SUBJECT: Surgical Dressings
HCPCS CODES:
The appearance of a code in this section does not necessarily indicate coverage.
A4460
A4649
A6020
K0154
K0196
K0197
K0198
K0199
K0203
K0204
-
K0205
K0206
K0207
K0208
K0209
K0210
-
K0211 K0212 K0213 K0214
K0215
K0216
K0217
-
K0218 K0219 K0220 K0221 K0222 K0223 K0224 K0228 K0229 K0230 K0234 K0235 -
Elastic bandage, per roll (e.g., compression bandage)
Surgical supplies, miscellaneous
Collagen based wound dressing, wound cover, each dressing
Wound pouch, each
Alginate dressing, wound cover, pad size 16 sq. in. or less, each dressing
Alginate dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., each dressing
Alginate dressing, wound cover, pad size more than 48 sq. in., each dressing
Alginate dressing, wound filler, per 6 inches
Composite dressing, pad size 16 sq. in. or less, with any size adhesive border, each dressing
Composite dressing, pad size more than 16 but less than or equal to 48 sq. in., with any size adhesive border,
each dressing
Composite dressing, pad size more than 48 sq. in., with any size adhesive border, each dressing
Contact layer, 16 sq. in. or less, each dressing
Contact layer, more than 16 but less than or equal to 48 sq. in., each dressing
Contact layer, more than 48 sq. in., each dressing
Foam dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing
Foam dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., without adhesive border,
each dressing
Foam dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing
Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing
Foam dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., with any size adhesive
border, each dressing
Foam dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing
Foam dressing, wound filler, per gram
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing
Gauze, non-impregnated, non-sterile, pad size more than 16 but less than or equal to 48 sq. in., without adhesive
border, each dressing
Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in., without adhesive border, each dressing
Gauze, non-impregnated, pad size 16 sq. in. or less, with any size adhesive border, each dressing
Gauze, non-impregnated, pad size more than 16 but less than or equal to 48 sq. in., with any size adhesive
border, each dressing
Gauze, non-impregnated, pad size more than 48 sq. in., with any size adhesive border, each dressing
Gauze, impregnated, other than water or normal saline, pad size 16 sq. in. or less, without adhesive border,
each dressing
Gauze, impregnated, other than water or normal saline, pad size more than 16 but less than or equal to 48 sq.
in., without adhesive border, each dressing
Gauze, impregnated, other than water or normal saline, pad size more than 48 sq. in., without adhesive border,
each dressing
Gauze, impregnated, water or normal saline, pad size 16 sq. in. or less, without adhesive border, each dressing
Gauze, impregnated, water or normal saline, pad size more than 16 but less than or equal to 48 sq. in., without
adhesive border, each dressing
Gauze, impregnated, water or normal saline, pad size more than 48 sq. in., without adhesive border, each
dressing
Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing
Hydrocolloid dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., without adhesive
border, each dressing
December 1995 DMERC Medicare Advisory
K0236 K0237 K0238 K0239
K0240
K0241
K0242
K0243
-
K0244 K0245 K0246 K0247
K0248
K0249
K0250
K0251
K0252
-
K0253 K0254 K0255 K0256 K0257
K0258
K0259
K0260
K0261
K0262
K0263
K0264
K0265
K0266
K0402
K0403
-
K0404 K0405 K0406 -
Page 95-153
Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing
Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing
Hydrocolloid dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., with any size
adhesive border, each dressing
Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing
Hydrocolloid dressing, wound filler, paste, per fluid ounce
Hydrocolloid dressing, wound filler, dry form, per gram
Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing
Hydrogel dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., without adhesive
border, each dressing
Hydrogel dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing
Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing
Hydrogel dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., with any size
adhesive border, each dressing
Hydrogel dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing
Hydrogel dressing, wound filler, gel, per fluid ounce
Hydrogel dressing, wound filler, dry form, per gram
Skin sealants, protectants, moisturizers, any type, any size
Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing
Specialty absorptive dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., without
adhesive border, each dressing
Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each
dressing
Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each
dressing
Specialty absorptive dressing, wound cover, pad size more than 16 but less than or equal to 48 sq. in., with
any size adhesive border, each dressing
Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each
dressing
Transparent film, 16 sq. in. or less, each dressing
Transparent film, more than 16 but less than or equal to 48 sq. in., each dressing
Transparent film, more than 48 sq. in., each dressing
Wound cleansers, any type, any size
Wound filler, not elsewhere classified, gel/paste, per fluid ounce
Wound filler, not elsewhere classified, dry form, per gram
Gauze, elastic, non-sterile, all types. per linear yard
Gauze, non-elastic, non-sterile, per linear yard
Tape, all types, per 18 square inches
Gauze, impregnated, other than water or normal saline, any width, per linear yard
Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing
Gauze, non-impregnated, sterile, pad size more than 16 but less than or equal to 48 sq. in., without adhesive
border, each dressing
Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing
Gauze, elastic, sterile, all types, per linear yard
Gauze, non-elastic, sterile, per linear yard
HCPCS MODIFIERS:
X1
X2
X3
X4
X5
X6
X7
X8
X9
ZY
-
Dressing used as a primary or secondary dressing on one surgical or debrided wound
Dressing used as a primary or secondary dressing on two surgical or debrided wounds
Dressing used as a primary or secondary dressing on three surgical or debrided wounds
Dressing used as a primary or secondary dressing on four surgical or debrided wounds
Dressing used as a primary or secondary dressing on five surgical or debrided wounds
Dressing used as a primary or secondary dressing on six surgical or debrided wounds
Dressing used as a primary or secondary dressing on seven surgical or debrided wounds
Dressing used as a primary or secondary dressing on eight surgical or debrided wounds
Dressing used as a primary or secondary dressing on nine or more surgical or debrided wounds
Potentially non-covered item or service billed for denial or at a beneficiary’s request (not to be used for medical
necessity denials)
Page 95-154
December 1995 DMERC Medicare Advisory
BENEFIT CATEGORY: Surgical Dressings
DEFINITIONS:
Wound fillers are dressing materials which are placed into open wounds to eliminate dead space, absorb exudate, or maintain
a moist wound surface.
Wound covers are flat dressing pads. A wound cover with adhesive border is one which has an integrated cover and distinct
adhesive border designed to adhere tightly to the skin.
A surgical dressing kit is defined as non-individualized, standardized packaging containing repetitive quantities of dressings
not related to the individual medical needs of a beneficiary, or whose contents have not each been prescribed for the care
of the specific wounds of that beneficiary, or that contain materials in addition to surgical dressings.
Composite dressings are products combining physically distinct components into a single dressing that provides multiple
functions. These functions must include, but are not limited to: (a) a bacterial barrier, (b) an absorptive layer other than an
alginate, foam, hydrocolloid, or hydrogel, (c) either a semi-adherent or nonadherent property over the wound site, and (d)
an adhesive border.
Contact layers 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. They are porous to allow wound fluid to pass through for
absorption by an overlying dressing.
Impregnated gauze dressings are woven or non-woven materials in which substances such as iodinated agents, petrolatum,
zinc compounds, crystalline sodium chloride, chlorhexadine gluconate (CHG), bismuth tribromophenate (BTP), water,
aqueous saline, or other agents have been incorporated into the dressing material by the manufacturer. However, when the
dressing and the substance with which it is impregnated are listed in combination in the FDA Orange Book (e.g. an antibiotic
impregnated dressing which requires a prescription), then the entire item is considered a drug which is noncovered under
the surgical dressing benefit and should not be coded using K0222-K0224.
Specialty absorptive dressings are unitized multilayer dressings which provide (a) either a semi-adherent quality or
nonadherent layer, and (b) highly absorptive layers of fibers such as absorbent cellulose, cotton, or rayon. These may or
may not have an adhesive border.
A wound pouch is a waterproof collection device with a drainable port that adheres to the skin around a wound.
The staging of pressure ulcers used in this policy is as follows:
Stage I - nonblanchable erythema of intact skin
Stage II - partial thickness skin loss involving epidermis and/or dermis
Stage III - full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but
not through, underlying fascia
Stage IV - full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or
supporting structures
COVERAGE AND PAYMENT RULES:
Surgical dressings are covered when either of the following criteria are met:
1) They are medically necessary for the treatment of a wound caused by, or treated by, a surgical procedure; or
2) They are medically necessary when debridement of a wound is medically necessary.
Surgical dressings include both primary dressings (i.e. 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.e. materials that serve a therapeutic
or protective function and that are needed to secure a primary dressing). Items such as adhesive tape, roll gauze, or elastic
bandages are examples of secondary dressings. Elastic stockings, support hose, foot coverings, leotards, knee supports,
December 1995 DMERC Medicare Advisory
Page 95-155
surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily
covered as surgical dressings. In the very rare situation when one of these items might possibly be used as a secondary
dressing, it should be coded A4649 and individual consideration will be given to claims submitted with additional
documentation demonstrating that the item is medically necessary, serves a therapeutic or protective function, and is
needed to secure the primary dressing. If an alternative secondary dressing item (e.g., adhesive tape) is effective in securing
the primary dressing, the aforementioned items would not be covered.
The surgical procedure or debridement must be performed by a physician or other health care professional to the extent
permissible under State law. Surgical dressings must be ordered by a physician or a Nurse Practitioner, Clinical Nurse
Specialist, Certified Nurse-Midwife or Physician’s Assistant who was acting within the scope of his or her legal authority
as defined by State law or regulation.
Debridement of a wound may be any type of debridement (examples given are not all-inclusive): surgical (e.g. sharp
instrument or laser), mechanical (e.g. irrigation or wet-to-dry dressings), chemical (e.g. topical application of enzymes), or
autolytic (e.g. application of occlusive dressings to an open wound). Dressings used for mechanical debridement, to cover
chemical debriding agents, or to cover wounds to allow for autolytic debridement are covered although the agents themselves
are non-covered.
Surgical dressings are covered for as long as they are medically necessary. Dressings over a percutaneous catheter or tube
(e.g. intravascular, epidural, nephrotomy, etc.) would be covered as long as the catheter or tube remains in place and after
removal until the wound heals. (Refer to Coding Guidelines)
Examples of situations in which dressings are noncovered under the surgical dressing benefit are:
a)
b)
c)
d)
e)
drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure;
a Stage I pressure ulcer;
a first degree burn;
wounds caused by trauma which do not require surgical closure or debridement - e.g. skin tear or abrasion;
a venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter or needle
Surgical dressing codes billed without modifiers X1 - X9 (See Coding Guidelines) are non-covered under the Surgical Dressing
Benefit. Certain dressings may be covered under other benefits (e.g., see Ostomy Supply Policy).
If a physician, Certified Nurse Midwife, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist applies surgical
dressings as part of a professional service that is billed to Medicare, the surgical dressings are considered incident to the
professional services of the health care practitioner and are not separately payable. Claims for these dressings should not
be submitted to the DMERC. Claims for the professional service which includes the dressings should be submitted to the
local carrier. If dressing changes are sent home with the patient, claims for these may be submitted to the DMERC. In this
situation, use the place of service corresponding to the patient’s residence, and Place of Service Office (POS=11) should
not be used.
Surgical dressings used in conjunction with investigational wound healing therapy (e.g., 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 was not being used.
When a wound cover with an adhesive border is being used, no other dressing would be used on top of it and additional tape
is usually not required. Reasons for use of additional tape would have to be well documented. 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.
Use of more than one type of wound filler or more than one type of wound cover in a single wound would rarely be medically
necessary and the reasons would have to be well documented.
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., hydrogel and alginate).
Because composite dressings, foam and hydrocolloid wound covers, and transparent film, when used as secondary
dressings, are meant to be changed at frequencies less than daily, appropriate clinical judgement should be used to avoid
Page 95-156
December 1995 DMERC Medicare Advisory
their use with primary dressings which would require more frequent dressing changes. When claims are submitted for these
dressing for changes greater than once every other day, the quantity in excess of that amount will be denied as not medically
necessary. While a highly exudative wound might require such a combination initially, with continued proper management
the wound should progress to a point where the appropriate selection of these products should result in the less frequent
dressing changes which they are designed to allow. An example of an inappropriate combination would be the use of a
specialty absorptive dressing on top of non-impregnated gauze being used as a primary dressing.
Dressing size should be based on and appropriate to the size of the wound. For wound covers, the pad size should usually
be about 2 inches greater than the dimensions of the wound. For example, a 5 cm X 5 cm (2 in. X 2 in.) wound would require
a 4 in. X 4 in. pad size.
The following are examples of wound care items which would not be covered under the surgical dressing benefit: skin sealants
or barriers, wound cleansers or irrigating solutions, solutions used to moisten gauze (e.g. saline), topical antiseptics, topical
antibiotics, enzymatic debriding agents, gauze or other dressings used to cleanse or debride a wound but not left on the
wound. Also any item listed in the latest edition of the Orange Book is considered a drug and is not covered under the surgical
dressing benefit. In general, Medicare Part B does not cover self-administered drugs. All of the above items will be denied
as noncovered supplies. Codes K0250 and K0260 have been established to describe some of these products. These codes
will be denied as noncovered.
The quantity and type of dressings dispensed at any one time must take into account the current status of the wound(s),
the likelihood of change, and the recent use of dressings. Dressing needs may change frequently (e.g. weekly) in the early
phases of wound treatment and/or with heavily draining wounds. 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.
No more than a one month’s supply of dressings may be provided at one time, unless there is documentation to support
the necessity of greater quantities in the home setting in an individual case. An even smaller quantity may be appropriate
in the situations described above.
Surgical dressings must be tailored to the specific needs of an individual patient. This cannot be accomplished when
dressings are provided as kits or trays containing fixed quantities and/or multiple types of dressings. Dressings must be
individually provided to meet the needs of a specific patient. When surgical dressing kits as defined in this policy are used
for the provision of surgical dressings, all components of the kit billed are denied as not medically necessary.
The following are some specific coverage guidelines for individual products when the products themselves are necessary
in the individual patient. The medical necessity for more frequent change of dressing should be documented in the patient’s
medical record and submitted with the claim to the DMERC (see Documentation section).
Alginate dressing (K0196-K0198)
Alginate dressing covers are covered for moderately to highly exudative full thickness wounds (e.g., stage III or IV ulcers);
and alginate fillers for moderately to highly exudative full thickness wound cavities (e.g., stage III or IV ulcers). They are not
medically necessary on dry wounds or wounds covered with eschar. Usual dressing change is up to once per day. One wound
cover sheet of the approximate size of the wound or up to 2 units of wound filler (1 unit = 6 inches of alginate rope) would
usually be used at each dressing change. It is usually inappropriate to use alginates in combination with hydrogels.
Composite dressing (K0203-K0205)
Usual composite dressing change is up to 3 times per week, one wound cover per dressing change.
Contact layer (K0206-K0208)
Contact layer dressings are used to line the entire wound; they are not intended to be changed with each dressing change.
Usual dressing change is up to once per week.
December 1995 DMERC Medicare Advisory
Page 95-157
Foam dressing (K0209-K0215)
Foam dressings are covered when used on full thickness wounds (e.g., stage III or IV ulcers) with moderate to heavy exudate.
Usual dressing change for a foam wound cover used as a primary dressing is up to 3 times per week. When a foam wound
cover is used as a secondary dressing for wounds with very heavy exudate, dressing change may be up to 3 times per week.
Usual dressing change for foam wound fillers is up to once per day.
Gauze, non-impregnated (K0216-K0221, K0402-K0404)
Usual non-impregnated gauze dressing change is up to 3 times per day for a dressing without a border and once per day
for a dressing with a border. It is usually not necessary to stack more than 2 gauze pads on top of each other in any one
area.
Gauze, impregnated, other than water or normal saline (K0222-K0224)
Usual dressing change for gauze dressings impregnated with other than water or normal saline is up to once per day.
Gauze, impregnated, water or normal saline (K0228-K0230)
There is no medical necessity for these dressings compared to non-impregnated gauze which is moistened with bulk saline
or sterile water. When these dressings are billed, payment will be based on the least costly medically appropriate alternative,
sterile non-impregnated gauze. Bulk saline or sterile water is noncovered under the surgical dressing benefit.
Hydrocolloid dressing (K0234-K0241)
Hydrocolloid dressings are covered for use on wounds with light to moderate exudate. Usual dressing change for hydrocolloid
wound covers or hydrocolloid wound fillers is up to 3 times per week.
Hydrogel dressing (K0242-K0248)
Hydrogel dressings are covered when used on full thickness wounds with minimal or no exudate (e.g., stage III or IV ulcers).
Hydrogel dressings are not usually medically necessary for stage II ulcers . Documentation must substantiate the medical
necessity for use of hydrogel dressings for stage II ulcers (e.g., location of ulcer is sacro-coccygeal area). Usual dressing
change for hydrogel wound covers without adhesive border or hydrogel wound fillers is up to once per day. Usual dressing
change for hydrogel wound covers with adhesive border is up to 3 times per week.
The quantity of hydrogel filler used for each wound should not exceed the amount needed to line the surface of the wound.
Additional amounts used to fill a cavity are not medically necessary. Documentation must substantiate the medical
necessity for code K0248 billed in excess of 3 units (fluid ounces) per wound in 30 days.
Use of both a hydrogel filler and a hydrogel cover on the same wound at the same time is not medically necessary. The cover
is denied as not medically necessary.
Specialty absorptive dressing (K0251-K0256)
Specialty absorptive dressings are covered when used for moderately or highly exudative wounds (e.g., stage III or IV ulcers).
Usual specialty absorptive dressing change is up to once per day for a dressing without an adhesive border and up to every
other day for a dressing with a border.
Transparent film (K0257-K0259)
Transparent film dressings are covered when used on open partial thickness wounds with minimal exudate or closed wounds.
Usual dressing change is up to 3 times per week.
Wound filler, not elsewhere classified (K0261-K0262)
Usual dressing change is up to once per day.
Page 95-158
December 1995 DMERC Medicare Advisory
Wound pouch (K0154)
Usual dressing change is up to 3 times per week.
Tape (K0265)
Tape is covered when needed to hold on a wound cover, elastic roll gauze or non-elastic roll gauze. Additional tape is usually
not required when a wound cover with an adhesive border is used. The medical necessity for tape in these situations would
need to be documented. Tape change is determined by the frequency of change of the wound cover. Quantities of tape
submitted should reasonably reflect the size of the wound cover being secured. Usual use for wound covers measuring 16
square inches or less is up to 2 units per dressing change; for wound covers measuring 16 to 48 square inches, up to 3 units
per dressing change; for wound covers measuring greater than 48 square inches, up to 4 units per dressing change.
Elastic bandage (A4460)
Elastic bandages are covered when used as a secondary dressing to hold wound cover dressings in place. When an elastic
bandage is used over a wound cover with adhesive border or over a wound cover which is held in place by tape, elastic roll
gauze or non-elastic roll gauze, or transparent film, the elastic bandage is noncovered. Elastic bandages are also noncovered
when used for strains, sprains, edema, or situations other than as a secondary surgical dressing.
Most elastic bandages are reusable. Usual frequency of replacement would be no more than one per week.
Gauze, elastic (K0263, K0405)
Elastic gauze dressing change is determined by the frequency of change of the selected primary dressing. When a dressing
is secured with tape or has an adhesive border, overlying elastic gauze is denied as noncovered.
Gauze, non-elastic (K0264, K0406)
Non-elastic gauze dressing change is determined by the frequency of change of the selected primary dressing. When a
dressing is secured with tape or has adhesive border, overlying non-elastic gauze is denied as noncovered.
CODING GUIDELINES:
Codes A4190-A4205, A4454 and K0152 are not valid for claims submitted to the DMERC. Codes K0196-K0248, K0250K0266 or K0402-K0406 should be used instead. Code K0249 is not valid for claims submitted to the DMERC. Code K0262
should be used instead.
Codes K0402-K0406 are valid for claims with date of service on or after 1/1/96. The revised narrative description for codes
K0216-K0218 and K0263-K0264 (i.e. specifying non-sterile dressing) is effective for dates of service on or after 1/1/96. For
claims with dates of service prior to 1/1/96, codes K0216-K0218, K0263, and K0264 will continue to be used for either sterile
or non-sterile products, even for claims submitted on or after 1/1/96.
When dressings are covered under other benefits - e.g. durable medical equipment (infusion pumps) or prosthetic devices
(parenteral and enteral nutrition, tracheostomy ) - and are included in supply allowance codes - e.g. K0110 with a covered
infusion pump, B4224 with parenteral nutrition, B4034-B4036 with enteral nutrition, A4625 or K0165 with a tracheostomy
- they may not be separately billed using the surgical dressing codes.
Dressings over infusion access entry sites not used in conjunction with covered use of infusion pumps, or over catheter/tube
entry sites into a body cavity (other than tracheostomy) should be billed separately using the appropriate surgical dressing
code.
Wound fillers come in hydrated forms (e.g. pastes, gels), dry forms (e.g. powder, granules, beads), or other forms such as
rope, spiral, pillows, etc. For certain materials, unique codes have been established - e.g. alginate wound filler (K0199), foam
wound filler (K0215), hydrocolloid wound filler (K0240-K0241), and hydrogel wound filler (K0248). Wound fillers not falling
into any of these categories would be coded as K0261 or K0262.
December 1995 DMERC Medicare Advisory
Page 95-159
The units of service for wound fillers are 1 gram, 1 fluid ounce, or 6 inch length depending on the product. If the individual
product is packaged as a fraction of a unit (e.g. 1/2 fluid ounce), determine the units billed by multiplying the number
dispensed times the individual product size and rounding to the nearest whole number. For example, if eleven (11) 1/2 oz.
tubes of a wound filler are dispensed, bill 6 units ( 11 X 1/2 = 5.5; round to 6).
For some wound fillers, the units on the package do not correspond to the units of the new code. For example, some pastes
or gels are labelled as grams (instead of fluid ounces), some wound fillers are labelled as cc. or ml. (instead of fluid ounces
or grams), some are described by linear dimensions (instead of grams). In these situations, the supplier should contact the
manufacturer to determine the appropriate conversion factor or unit of service which corresponds to the new code.
Some wound covers are available both without and with an adhesive border. For wound covers with an adhesive border, the
code to be used is determined by the pad size, not by the outside adhesive border dimensions. For example, a hydrocolloid
dressing with outside dimensions of 6 in. X 6 in. which has a 4 in. X 4 in. pad surrounded by a 1 in. border on each side is
coded as K0237, “ ... pad size 16 sq. inch or less ...”
Products containing multiple materials are categorized according to the clinically predominant component (e.g., alginate,
foam, gauze, hydrocolloid, hydrogel). 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. Multicomponent products may not be unbundled and billed as the separate components of the dressing.
Gauze or gauze-like products are typically manufactured as a single piece of material folded into a several ply gauze pad.
Coding must be based on the functional size of the pad as it is commonly used in clinical practice.
For all dressings, if a single dressing is divided into multiple portion/pieces, the code and quantity billed must represent the
originally manufactured size and quantity.
Paste or powder commonly used with ostomies will continue to be coded using codes K0138 (Skin barrier; paste, per oz.)
and K0139 (Skin barrier; powder, per oz.) and not one of the wound filler codes. (See Ostomy Supplies policy for details.)
Modifiers (X1 - X9) 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. For example,
X1 Dressing used as a primary or secondary dressing on one surgical or debrided wound.
X2 Dressing used as a primary or secondary dressing on two surgical or debrided wounds.
X9 Dressing used as a primary or secondary dressing on nine or more surgical or debrided wounds.
The modifier number must correspond to the number of wounds on which the dressing is being used, not the total number
of wounds treated. For example, if the patient has four (4) wounds but a particular dressing is only used on two (2) of them,
the X2 modifier should be used with that HCPCS code.
If the dressing is not being used as a primary or secondary dressing on a surgical or debrided wound, do not use
modifiers X1-X9. When dressings are provided in non-covered situations (e.g., use of gauze in the cleansing of a
wound or intact skin), a ZY modifier must be added to the code and a brief description of the reason for non-coverage
included - e.g. “K0216ZY - used for wound cleansing.”
When dressing codes are billed for items covered under another benefit (e.g., gauze for a continent ostomy which is covered
under the prosthetic device benefit) claims must be billed according to the documentation requirements specified in the
applicable policy (See Ostomy Supplies policy for details.)
A supplier wanting to know which code to use for a particular dressing should refer to the Surgical Dressing Product
Classification List published separately or contact the Statistical Analysis DME Regional Carrier (SADMERC)
Palmetto Government Benefits Administrators. Surgical dressings listed under specific codes in the Surgical Dressing
Product Classification List should not be coded using the miscellaneous code A4649. Impregnated roll gauze dressings
designed for the treatment of venous stasis ulcers are examples of dressings that would be properly coded using A4649.
Page 95-160
December 1995 DMERC Medicare Advisory
DOCUMENTATION:
An order for surgical dressings must be signed and dated by the patient’s attending physician, by a consulting physician
for the condition resulting in the need for the dressing, or by a Nurse Practitioner, Clinical Nurse Specialist, Certified NurseMidwife or Physician’s Assistant who is directly involved with the care of the patient. The order from a nonphysician must
be countersigned by the physician when required by State law. This order must be kept on file by the supplier.
The order must specify (a) the type of dressing (e.g. hydrocolloid wound cover, hydrogel wound filler, etc.), (b) the size of
the dressing (if appropriate), (c) the number/amount to be used at one time (if more than one), (d) the frequency of dressing
change, and (e) the expected duration of need.
A new order is needed if a new dressing is added or if the quantity of an existing dressing to be used is increased. A new
order is not routinely needed if the quantity of dressings used is decreased. 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.
Information defining the number of surgical/debrided wounds being treated with a dressing, the reason for dressing use (e.g.
surgical wound, debrided wound, etc.), and whether the dressing is being used as a primary or secondary dressing or for
some noncovered use (e.g. wound cleansing) should be obtained from the physician, nursing home, or home care nurse.
The source of that information and date obtained should be documented in the supplier’s records.
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. 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
within this time frame and what other monitoring methods were used to evaluate the patient’s need for dressings. Evaluation
would be expected on a more frequent basis (e.g. weekly) in patients in a nursing facility or in patients with heavily draining
or infected wounds. The evaluation may be performed by a nurse, physician or other health care professional. This evaluation
must include the type of each wound (e.g. surgical wound, pressure ulcer, burn, etc.), its location, its size (length X width
in cm.) and depth, the amount of drainage, and any other relevant information. This information does not have to be routinely
submitted with each claim. 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
This statement may be attached to a hard copy claim or entered in the HAO record of an electronic claim.
When surgical dressings are billed, the appropriate modifier (X1-X9 or ZY) must be added to the code when applicable. If
X9 is used, information must be submitted with the claim indicating the number of wounds. If ZY is used, a brief description
of the reason for non-coverage (e.g., “K0216ZY - used for wound cleansing”) must be included. These statements should
be included with a hard copy claim or entered into the HAO record.
When codes A4649, A6020, K0261 or K0262 are used for a dressing, the appropriate modifier to indicate the number of
wounds should be used and the claim must include the brand name, product number and size of the product provided. When
code A4649 is used for a dressing, the claim should also include a statement describing the medical necessity for that
dressing in that patient.
* EFFECTIVE DATE: Claims received by the DMERC on or after October 1, 1995.
This is a revision to a previously published policy.
* Changes In the Surgical Dressings Policy
New surgical dressing codes distinguishing sterile from non-sterile dressings have been introduced into the regional medical
policy for surgical dressings. The definitions for codes K0216-K0218 have been changed to reflect non-sterile dressings,
while codes K0402-K0406 have been added. There has been a corresponding change in the "Coding Guidelines" section,
describing proper billing, using these new codes.
December 1995 DMERC Medicare Advisory
SUPPORT SURFACES:
POWERED AIR
OVERLAY - CODING
GUIDELINES
Page 95-161
A new code for support surfaces is being proposed. The proposed code narrative is,
“Powered air overlay.” This code will describe a powered pressure reducing mattress
overlay (low air loss, powered flotation without low air loss, or alternating pressure)
which is characterized by all of the following:
1) An air pump or blower which provides either sequential inflation and deflation of the
air cells or a low interface pressure throughout the overlay, and
2) Inflated cell height of the air cells through which air is being circulated is 3.5 inches
or greater, and
3) Height of the air chambers, proximity of the air chambers to one another, frequency
of air cycling (for alternating pressure overlays), and air pressure provide adequate
patient lift, reduce pressure, and prevent bottoming out, and
4) A surface designed to reduce friction and shear.
Until this code is established, these products may be billed using code E0277. All of
the coverage and documentation requirements for code E0277 will apply, including the
use of the ZX modifier when appropriate. See DMERC medical policy on Pressure
Reducing Support Surfaces - Group 2, for more information.
Powered overlays that have a cell height of greater than or equal to 2.5 inches,
but less than 3.5 inches should be coded as E0180 or E0181 if they meet all the
other characteristics defined in the policy on Pressure Reducing Support Surfaces Group 1.
NEORAL SOFT
GEL/ORAL
SOLUTION
Effective September 1, 1995, the immunosuppressive drug, Neoral Soft Gel/Oral
Solution, will be covered for kidney, liver and heart transplants. Neoral is a new
formulation of Cyclosporine based microemulsion technology, designed to provide
increased and more reliable absorption of the medication.
To submit claims for Neoral, use HCPCS code K0121 [Cyclosporine, oral, 25 mg
(Sandimmune)].
EXTERNAL INFUSION
PUMP COVERED
DRUGS
Region C will cover the use of milrinone and dopamine in external infusion pumps when
used to treat congestive heart failure (see revised External Infusion Pump Policy, which
can be found on page 95-146 in this issue of the advisory). The same criteria that would
have justified coverage of dobutamine must be fulfilled. The suggested DMERC
information gathering sheet should be completed and signed by the ordering physician
and returned to the DMERC with the claim. If the criteria for covering dobutamine are
met and milrinone or dopamine have been ordered by the physician instead of
dobutamine, then the use of these other inotropic agents may be approved. Although
the medical policy revision is effective April 1, 1996, the effective date of this change
is October 1, 1995.
Page 95-162
NEBULIZER DRUGS
AND SALINE
December 1995 DMERC Medicare Advisory
Saline solution, HCPCS code J7051 (Sterile saline or water, up to 5 cc) is eligible for
coverage by the DMERC when billed in conjunction with the following Nebulizer Drug
codes:
J7610
Acetylcysteine, 10%, per ml, inhalation solution administered through DME
(Mucomyst, Mucosol)
J7615
Acetylcysteine, 20%, per ml, inhalation solution administered through DME
(Mucomyst, Mucosol)
J7625
Albuterol Sulfate, 0.083%, per ml, inhalation solution administered through
DME (Proventil, Ventolin)
J7627
Bitolterol mesylate, 0.2%, per 10 ml, inhalation solution administered through
DME (Tornalate)
J7640
Epinephrine, 2.25%, per ml, inhalation solution administered through DME
J7675
Metaproterenol sulfate, 5.0% per ml, inhalation solution administered through
DME (Alupent, Metaprel)
J7699
NOC drugs - Terbutaline
RIK FLUID MATTRESS
Claims for a RIK Fluid Mattress should be submitted to Palmetto GBA using HCPCS
code E1399 (Durable Medical Equipment, Miscellaneous). Please be sure when filing
for the RIK Fluid Mattress and using this miscellaneous code to include with the claim
all materials documenting medical necessity for the mattress.
ENTERAL
NUTRIENTS LEVEL III: CODE
DELETIONS
Effective January 1, 1996, the following codes will be deleted:
XX054
XX060
XX063
XX067
Category IV Enteral Product, 100 calories = 1 unit, TraumAid HBC
Category V Enteral Product, 100 calories = 1 unit, Controlyte
Category V Enteral Product, 100 calories = 1 unit, Lipomul
Category V Enteral Product, 100 calories = 1 unit, Nutrisource
According to research done by the Statistical Analysis Durable Medical Equipment
Regional Carrier (SADMERC) with the manufacturers, these Level III nutrients have not
been manufactured for several years.
REMITTANCE CODE
UPDATE
Effective January 1, 1996, you may begin seeing new remittance code and modifier
messages on your standard electronic and paper remittance notices. Be sure to read
all remittance code and modifier messages/descriptions, to accurately interpret the
disposition of your claim.
December 1995 DMERC Medicare Advisory
MODIFIER
REPLACEMENT
Page 95-163
Effective April 1, 1996, the modifier GA will replace modifier ZU. The nomenclature for
the GA modifier is identical to the nomenclature for the ZU modifier. Effective October
1, 1995, you may begin using the GA modifier in place of the ZU modifier. Claims
received on or after April 1, 1996 with the ZU modifier will be denied.
GA - Advance notice of possible medical necessity denial on file
CERTIFICATES OF
MEDICAL
NECESSITY:
LEGISLATIVE
CHANGES
INVOLVING CMNs
Why You Have Received this Information
The Health Care Financing Administration (HCFA) is providing you with this information
to advise you of the provisions and requirements of Section 1834 of the Social Security
Act , as amended in 1994. The law restricts information that suppliers may provide to
physicians in CMNs, and requires suppliers to include relevant charge information for
items and services they list on CMNs. These amendments supersede those of the
Omnibus Budget Reconciliation Act of 1990 (OBRA 1990). The provisions apply to any
CMN revised by the DMERCs in 1995.
What the Law Prohibits
Section 1834 of the Act was amended in 1994 to allow suppliers to complete certain
informational elements on CMNs when sending the forms to physicians. The
information that suppliers may provide is limited to the following:
t
t
t
An identification (name) of the supplier and the beneficiary receiving the
medical equipment and supplies,
A description of the medical equipment and supplies,
Any other administrative information (other than information relating to the
beneficiary's medical condition) permitted by the Secretary.
Section 1834 of the Act prohibits the supplier or any employee of the supplier from
completing the medical portion of the CMN. A clinician (not necessarily the attending
physician) who is familiar with the medical condition of the beneficiary may complete
the medical section. This does not apply to a physician who is also the supplier of the
item.
What the Law Requires
If a supplier is required to submit a CMN for the purpose of documenting medical
necessity of a particular type of equipment or supplies (including) those used in the prior
authorization process), the supplier must list on the CMN the fee schedule amount and
the supplier's charge for the medical equipment or supplies being furnished before
sending the CMN to the physician. If the item is not subject to a fee schedule amount,
then the supplier must list his/her usual charge for the item. If the CMN lists more than
one item, the supplier must itemize for each item the applicable fee schedule amount
and charges on the CMN. Similarly, if an item includes accessories or supplies that
are essential to the operation of the item, charges for these accessories must be listed.
If the item is capped rental, the supplier must show the monthly rental fee. If a CMN
is accompanied by other forms before being forwarded to a physician, the charge
information may be listed. This applies to both participating and nonparticipating
suppliers.
CMNs and all attachments to them must be kept on file by suppliers for at least seven
years after processing.
Page 95-164
CMNs:
LEGISLATIVE
CHANGES (Cont'd)
December 1995 DMERC Medicare Advisory
Items Subject to the Provisions
The following items are subject to the above prohibition and requirement:
t
t
t
t
t
Durable Medical Equipment,
Prosthetic Devices
Orthotics and Prosthetics,
Surgical Dressings, and
Such other items as the Secretary may determine.
Items Not Included in the Provisions
The provisions involving the CMN requirements and prohibitions do not apply to the
following items:
t
t
t
t
t
Home Dialysis Supplies and Equipment,
Immunosuppressive Drugs,
Therapeutic Shoes for Diabetics,
Oral Drugs prescribed for use as an Anti-Cancer Therapeutic Agent,
and
Self-Administered Erythropoietin.
DME Regional Carriers are authorized to determine, based on analysis of the utilization
trends for equipment and supplies, any additional items that may require a CMN. Any
new CMN will be implemented under the current provisions unless the item is among
those not included in the provisions.
December 1995 DMERC Medicare Advisory
Q&A
Page 95-165
Providing answers to your questions/concerns
on an on-going basis.
These questions were submitted to Palmetto GBA by Region C suppliers, and the answers are being published so that
all may benefit.
Revised CMNs (Version .02)
1.
2.
3.
4.
5.
6.
7.
Q
Instructions for completing Section B of the CMNs state that the information cannot be provided by either the supplier
or "anyone in a financial relationship with the supplier." Is this prohibition intended to apply to both clinicians and
physicians? Specifically, can a physician employed by a nursing home (NH) complete an initial or revised CMN
for a NH patient when the NH is also the supplier of the item being certified?
A
If the ordering physician is the patient's attending physician, then that physician, or a direct employee of that
physician, may complete Section B of a version .02 CMN. If the ordering physician is a consultant, and there is
another attending physician who is managing the general care of the patient and who does not have a financial
relationship with the supplier, then the physician with the financial relationship should not fill out Section B. Section
B may never be filled out by a non-physician clinician who has a financial relationship with the supplier.
Q
When must suppliers begin submitting the physician-signed attachment to the HCFA-484 (Oxygen) form?
A
Since only version .02 of the CMNs will be accepted after April 01, 1996, all HCFA-484 forms submitted after this
date must have the physician-signed attachment.
Q
Do suppliers have to send physicians the CMNs with instructions on the back, or can they just send the front pages
of the CMNs.
A
Suppliers must provide physicians with both the front and back pages of the CMNs. The instructions on the back
pages are essential to both physicians and suppliers.
Q
In Section C of the version .02 CMNs, can the supplier list the ICD-9-CM code in addition to the narrative diagnosis?
A
Yes. The requirement for "narrative" in Section C is to enable the physician to review the diagnosis/es without having
to look up the definition in the ICD-9-CM reference. Supplying the ICD-9-CM in addition to the narrative would not
preclude this purpose.
Q
Is the supplier prohibited from filling in the physician's name, address, UPIN and phone number in the boxes at the
bottom of Page 1 of the version .02 CMN?
A
The supplier may fill in the physician's name and address only. The supplier may not fill in the physician's UPIN
or telephone number.
Q
Are nurse practitioners in rural areas considered to be "MDs" for the purpose of signing a CMN?
A
Nurse practitioner services are covered by Medicare Part B only if they are provided "in collaboration with an MD."
Thus, a nurse practitioner cannot sign a CMN as a physician; the "collaborating MD" must sign.
Q
Can residents complete and sign CMNs or must they be counter-signed by the attending physician?
A
Residents are licensed physicians and, therefore, can complete and sign CMNs.
Page 95-166
December 1995 DMERC Medicare Advisory
HCPCS CODES REQUIRING A CMN/DIF - UPDATE
Effective for claims received on or after January 1, 1996, the following codes have been added or deleted, as noted, from the
list of HCPCS codes requiring a Certificate of Medical Necessity (CMN)/DMERC Information Form (DIF). A complete and
revised chart of HCPCS codes requiring a CMN/DIF appears beginning this page through page 95-169 of this Advisory.
Effective January 1, 1996, the following list of HCPCS codes requiring a CMN/DIF replaces all previously published lists of
this information.
Additions (Listed in Bold):
E0748, J7503, J7509, J7510, J7599, K0412
Deletions (Listed with a strikethru):
E0180, E0181, E0277
HCPCS
CODE
HCPCS
DESCRIPTION
B4150
B4151
B4152
Category I, Semi-Synthetic: Intact, Protein/Protein Isolates, (100 calories = 1 unit)
Enteral Nutrition Formulae, Category 1B, Blenderized: Intact, Protein/Protein Isolates - Naturalized, (100 calories = 1 unit)
Enteral Nutrition Formulae, Category II - Intact, Protein/Protein Isolates, (Calorically Dense),
(100 calories = 1 unit)
Enteral Nutrition Formulae, Category III, Hydrolyzed Protein/Amino Acid, (100 calories = 1 unit)
Enteral Nutrition Formulae, Category IV: defined formula for special metabolic need,
(100 calories = 1 unit)
Enteral Nutrition Formulae, Category V: modular components (protein, carbohydrates, fat),
(100 calories = 1 unit)
Enteral Nutrition Formulae, Category VI - Standard, (100 calories = 1 unit)
Parenteral Nutrition Solution, Dextrose, 50% or less (500 ml = 1 unit) Home Mix
Parenteral Nutrition Solution, Amino Acid, 3.5% or less (500 ml = 1 unit) Home Mix
Parenteral Nutrition Solution, Amino Acid, 5.5% through 7% (500 ml = 1 unit) Home Mix
Parenteral Nutrition Solution, Amino Acid, 7.5% through 8.5% (500 ml = 1 unit) Home Mix
Parenteral Nutrition Solution, Amino Acid, greater than 8.5% (500 ml = 1 unit) Home Mix
Parenteral Nutrition Solution, Dextrose, greater than 50% (500 ml = 1 unit) Home Mix
Parenteral Nutrition Solution, 10% with Administration set (500 ml = 1 unit)
Parenteral Nutrition Solution, 20% with Administration set (500 ml = 1 unit)
Parenteral Nutrition Solution: Compounded Amino Acid & Carbohydrates with electrolytes, trace
elements and vitamins, including preparation, any strength, 10 to 51 grams of protein - Pre-Mix
Parenteral Nutrition Solution: Compounded Amino Acid & Carbohydrates with electrolytes, trace
elements and vitamins, including preparation, any strength, 52 to 73 grams of protein - Pre-Mix
Parenteral Nutrition Solution: Compounded Amino Acid & Carbohydrates with electrolytes, trace
elements and vitamins, including preparation, any strength, 74 to 100 grams of protein - Pre-Mix
Parenteral Nutrition Solution: Compounded Amino Acid & Carbohydrates with electrolytes, trace
elements and vitamins, including preparation, any strength, over 100 grams of protein - Pre-Mix
Parenteral Nutrition; Additives (Vitamins, Trace elements and Electrolytes ) Home Mix, per day
Parenteral Nutrition Solution; Compounded Amino Acid and Carbohydrates with electrolytes, trace elements and vitamins,
including preparation, any strength, per gram, Renal, Aminosyn RF, Nephramine, Renamine Pre-Mix
Parenteral Nutrition Solution; Compounded Amino Acid & Carbohydrates with electrolytes, trace elements & vitamins, including
preparation, any strength, per gram, Stress-Branch chains amino
acids - Pre-Mix
Parenteral Nutrition Solution; Compounded Amino Acid & Carbohydrates with electrolytes, trace elements & vitamins, including
preparation, any strength, per gram, Stress-Branch chains amino
acids - Pre-Mix
Enteral Nutrition Pump, no alarm
Enteral Nutrition Pump with alarm
Parenteral Nutrition Pump - Portable
Parenteral Nutrition Pump - Stationary
Pressure pad, alternating, with pump
Pressure pad, alternating, with pump, heavy-duty
Air Fluidized Bed
Hospital bed, fixed height, with any type side rails, with mattress
Hospital bed, fixed height, with any type side rails, without mattress
Hospital bed, variable height, hi-lo, with any type side rails, with mattress
Hospital bed, variable height, hi-lo, with any type side rails, without mattress
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress
Hospital bed, total electric, (head, foot and height adjustments), with any type side rails, with mattress
Hospital bed, total electric, (head, foot and height adjustments), with any type side rails, without mattress
Alternating Pressure Mattress
Hospital bed, fixed height, without side rails, with mattress
Hospital bed, fixed height, without side rails, without mattress
Hospital bed, variable height, hi-lo, without side rails, with mattress
Hospital bed, variable height, hi-lo, without side rails, without mattress
Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress
B4153
B4154
B4155
B4156
B4164
B4168
B4172
B4176
B4178
B4180
B4184
B4186
B4189
B4193
B4197
B4199
B4216
B5000
B5100
B5200
B9000
B9002
B9004
B9006
E0180
E0181
E0194
E0250
E0251
E0255
E0256
E0260
E0261
E0265
E0266
E0277
E0290
E0291
E0292
E0293
E0294
December 1995 DMERC Medicare Advisory
Page 95-167
HCPCS CODES REQUIRING A CMN/DIF - UPDATE (Cont'd)
HCPCS
CODE
E0295
E0296
E0297
E0424
E0431
E0434
E0439
E0441
E0442
E0443
E0444
E0601
E0627
E0628
E0629
E0650
E0651
E0652
E0655
E0660
E0665
E0666
E0667
E0668
E0669
E0670
E0671
E0672
E0673
E0720
E0730
E0731
E0747
E0776
E0748
E0781
E0791
E1230
E1400
E1401
E1402
E1403
E1404
E1405
E1406
J2920
J2930
J7503
J7507
J7508
J7509
J7510
J7599
K0001
K0002
K0003
K0004
K0005
HCPCS
DESCRIPTION
Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress
Hospital bed, total electric, (head, foot and height adjustments), without side rails, with mattress
Hospital bed, total electric, (head, foot and height adjustments), without side rails, without mattress
Stationary compressed gaseous oxygen system, rental; includes contents (per unit) regulator, flow meter, humidifier,
nebulizer, cannula or mask and tubing; one unit = 50 cu. ft.
Portable gaseous oxygen system, rental; includes regulator, flowmeter, humidifier, cannula or mask and tubing
Portable liquid oxygen system, rental; includes portable container supply reservoir, humidifier, flowmeter, refill adaptor,
contents gauge, cannula or mask, and tubing
Stationary liquid oxygen system, rental; includes use of reservoir, contents (per unit), regulator, flowmeter, humidifier,
nebulizer, cannula or mask, and tubing; one unit = 50 lbs.
Oxygen contents, gaseous, per unit (for use with owned stationary gaseous systems or when both a stationary and
portable gaseous are owned; one unit = 50 cu. ft.)
Oxygen contents, liquid, per unit (for use with owned liquid stationary systems or when both a stationary and portable liquid
system are owned; one unit = 10 lbs.)
Portable oxygen contents, gaseous, per unit (for use only with portable gaseous systems when no stationary gas or liquid
system is used; one unit = 5 cu.ft.)
Portable oxygen contents, liquid per unit (for use only with portable liquid systems when no stationary gas or liquid system is
used; one unit = 1 lbs.)
Continuous airway pressure (CPAP) device
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
Pneumatic compressor, non-segmental home model
Pneumatic compressor, segmental home model without calibrated gradient pressure
Pneumatic compressor, segmental home model with calibrated gradient pressure
Non-segmental pneumatic appliance for use with pneumatic compressor, half arm
Non-segmental pneumatic appliance for use with pneumatic compressor, full leg
Non-segmental pneumatic appliance for use with pneumatic compressor, full arm
Non-segmental pneumatic appliance for use with pneumatic compressor, half leg
Segmental pneumatic appliance for use with pneumatic compressor, full leg
Segmental pneumatic appliance for use with pneumatic compressor, full arm
Segmental pneumatic appliance for use with pneumatic compressor, half leg
Segmental pneumatic appliance for use with pneumatic compressor, half arm
Segmental gradient pressure pneumatic appliance, full leg
Segmental gradient pressure pneumatic appliance, full arm
Segmental gradient pressure pneumatic appliance, half leg
TENS, two-lead, localized stimulation
TENS, four-lead, larger area/multiple nerve stimulation
Form fitting conductive garment for delivery of TENS or NINES (with conductive fibers separated from the patient’s skin by
layers of fabric)
Osteogenesis stimulator, non-invasive
IV pole
Osteogenic stimulator, noninvasive, spinal applications
Ambulatory infusion pump, single or multiple channels, with administrative equipment, worn by patient
Parenteral infusion pump, stationary, single or multichannel
Power operated vehicle (three or four wheel nonhighway) specify brand name and model number
Oxygen concentrator, manufacturer specified maximum flow rate does not exceed 2 liters per minute,
at 85 percent or greater concentration
Oxygen concentrator, manufacturer specified maximum flow rate greater than 2 liters per minute, does
not exceed 3 liters per minute, at 85 percent or greater concentration
Oxygen concentrator, manufacturer specified maximum flow rate greater than 3 liters per minute, does
not exceed 4 liters per minute, at 85 percent or greater concentration
Oxygen concentrator, manufacturer specified maximum flow rate greater than 4 liters per minute, does
not exceed 5 liters per minute, at 85 percent or greater concentration
Oxygen concentrator, manufacturer specified maximum flow rate greater than 5 liters per minute, at 85 percent or greater
concentration
Oxygen and water vapro enriching system with heated delivery
Oxygen and water vapro enriching system without heated delivery
Methylprednisolone sodium succinate up to 40 mg.
Methylprednisolone sodium succinate up to 125 mg.
Cyclosporine-oral, sol; 100 mg/ml, 50 ml, each (Sandimmune)
Tacrolimus, oral, per 1 mg
Tacrolimus, oral, per 5 mg
Methylprednisolone oral, per 4 mg
Prednisolone oral, per 5 mg
Immunosuppressive drug, not otherwise classified
Standard wheelchair
Standard hemi (low seat) wheelchair
Lightweight wheelchair
High strength lightweight wheelchair
Ultralightweight wheelchair
Page 95-168
December 1995 DMERC Medicare Advisory
HCPCS CODES REQUIRING A CMN/DIF - UPDATE (Cont'd)
HCPCS
CODE
HCPCS
DESCRIPTION
K0006
K0007
K0008
K0009
K0010
K0011
Heavy-duty wheelchair
Extra heavy-duty wheelchair
Custom manual wheelchair/base
Other manual wheelchair/base
Standard-weight frame motorized/power wheelchair
Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor
dampening, acceleration control and breaking
Lightweight portable motorized/power wheelchair
Custom motorized/power wheelchair base
Other motorized/power wheelchair base
Detachable, adjustable height armrest, complete assembly, each
Detachable, adjustable height armrest, base each
Detachable, adjustable height armrest, upper portion each
Fixed, adjustable height armrest, pair
Fully reclining back
Elevating leg rest, lower extension tube, each
Elevating leg rest, upper hanger bracket, each
Elevating leg rest, complete assembly
Elevating footrest, articulating (telescoping), each
One-arm drive attachment
Arm trough, each
Azathioprine - oral, tab, 50 mg.
Azathioprine - parenteral, 100 mg.
Cyclosporine - oral, 25 mg
Cyclosporine - parenteral, 250 mg
Lymphocyte immune globulin, antithmocyte globulin - parenteral, 250 mg
Monoclonal antibodies - parenteral, 5 mg
Prednisone - oral, 5 mg
Methylprednisonal - oral, 4 mg
Prednisolone - oral, 5 mg
CPAP device with humidifier
Elevating leg rest, pair (for use with capped rental wheelchair base)
External infusion pump, mechanical, reusable, for extended drug infusion
Mycophenolate mofetil, oral, 250 mg
Immunosuppressive drug, not otherwise classified
Category IV Enteral Product, 100 calories = one unit, Accupep HPF
Category IV Enteral Product, 100 calories = one unit, Aminaid
Category IV Enteral Product, 100 calories = one unit, Entera OPD
Category IV Enteral Product, 100 calories = one unit, Glucerna
Category IV Enteral Product, 100 calories = one unit, Hepatic Aid
Category IV Enteral Product, 100 calories = one unit, Impact
Category IV Enteral Product, 100 calories = one unit, Impact with fiber
Category IV Enteral Product, 100 calories = one unit, Immunaid
Category IV Enteral Product, 100 calories = one unit, Lipisorb
Category IV Enteral Product, 100 calories = one unit, Nepro
Category IV Enteral Product, 100 calories = one unit, Replete
Category IV Enteral Product, 100 calories = one unit, Replete with fiber
Category IV Enteral Product, 100 calories = one unit, NutriHep
Category IV Enteral Product, 100 calories = one unit, Nutrivent
Category IV Enteral Product, 100 calories = one unit, Peptamen
Category IV Enteral Product, 100 calories = one unit, Perative
Category IV Enteral Product, 100 calories = one unit, Pregestimil
Category IV Enteral Product, 100 calories = one unit, Protain XL
Category IV Enteral Product, 100 calories = one unit, Provide
Category IV Enteral Product, 100 calories = one unit, Pulmocare
Category IV Enteral Product, 100 calories = one unit, Reabilan HN
Category IV Enteral Product, 100 calories = one unit, Suplena (Replena)
Category IV Enteral Product, 100 calories = one unit, Stresstein
Category IV Enteral Product, 100 calories = one unit, Traumacal
Category IV Enteral Product, 100 calories = one unit, TraumAid HBC
Category IV Enteral Product, 100 calories = one unit, Travasorb Hepatic
Category IV Enteral Product, 100 calories = one unit, Travasorb MCT
Category IV Enteral Product, 100 calories = one unit, Travasorb Renal
Category IV Enteral Product, 100 calories = one unit, Vivonex T.E.N.
Category IV Enteral Product, 100 calories = one unit, Casec
Category IV Enteral Product, 100 calories = one unit, Controlyte
Category IV Enteral Product, 100 calories = one unit, Elementra
K0012
K0013
K0014
K0016
K0017
K0018
K0020
K0028
K0046
K0047
K0048
K0053
K0101
K0106
K0119
K0120
K0121
K0122
K0123
K0124
K0125
K0166
K0167
K0193
K0195
K0284
K0412
XX010
XX030
XX031
XX032
XX033
XX034
XX035
XX036
XX037
XX038
XX039
XX040
XX041
XX042
XX043
XX044
XX045
XX046
XX047
XX048
XX049
XX050
XX051
XX052
XX053
XX054
XX055
XX056
XX057
XX058
XX059
XX060
XX061
December 1995 DMERC Medicare Advisory
Page 95-169
HCPCS CODES REQUIRING A CMN/DIF - UPDATE (Cont'd)
HCPCS
CODE
HCPCS
DESCRIPTION
XX062
XX063
XX064
XX065
XX066
XX067
XX068
XX069
XX070
XX071
XX072
XX073
XX074
XX075
XX076
XX077
Category IV Enteral Product, 100 calories = one unit, Fibrad
Category IV Enteral Product, 100 calories = one unit, Lipomul
Category IV Enteral Product, 100 calories = one unit, MCT Oil
Category IV Enteral Product, 100 calories = one unit, Microlipid
Category IV Enteral Product, 100 calories = one unit, Moducal
Category IV Enteral Product, 100 calories = one unit, Nutrisource
Category IV Enteral Product, 100 calories = one unit, Polycose
Category IV Enteral Product, 100 calories = one unit, Promod
Category IV Enteral Product, 100 calories = one unit, Promix
Category IV Enteral Product, 100 calories = one unit, Propac
Category IV Enteral Product, 100 calories = one unit, Sumacal
Category IV Enteral Product, 100 calories = one unit, Advera
Category IV Enteral Product, 100 calories = one unit, Crucial
Category IV Enteral Product, 100 calories = one unit, Diabetisource
Category IV Enteral Product, 100 calories = one unit, Isosource VHN
Category IV Enteral Product, 100 calories = one unit, Vivonex Plus
PLACE OF SERVICE
CLARIFICATION,
ITEM 24B
All claims filed to the DMERC must include a two digit POS code in Item 24b of the
HCFA-1500 (12/90) form. Claims filed without POS information (or with an invalid POS
code) will cause processing delays. Only the following POS codes should be
submitted to the DMERCs.
POS
12
31
32
33
*54
65
Definition
Home
Skilled Nursing Facility
Nursing Facility
Custodial Care Facility
Intermediate Care Facility/Mentally Retarded
End Stage Renal Disease Treatment Facility
DMERCs do not have jurisdiction over equipment/items provided for use in a physician's
office. The POS code should indicate where the patient is to use the equipment/item
(i.e., patient's home), as opposed to where it was issued (i.e., physician's office).
The following POS codes are valid for the following categories of Durable Medical
Equipment.
I. Inexpensive or other routinely purchased DME
12, 33, 54
II. Items requiring frequent and substantial servicing
12. 33, 54
III. Customized items
a. Prosthetic and orthotics 12,31,32,33, 54
b. DME 12,33, 54
IV. Capped Rental Items
12, 33, 54
V. Oxygen and Oxygen equipment
12, 33, 54
VI. General prosthetic and orthotic devices
12, 31, 32, 33, 54,65
P & O supplies, parenteral and enteral nutrition
related items and supplies (these include IV poles used to
administer PEN (E0776XA), urinary incontinence
and ostomy supplies
VII. Surgical Dressings 12, 31, 32, 33, 54
VIII.Drugs (oral anticancer, those administered through DME)
12, 33, 54
* The addition of place of service code 54 to this chart is a correction. This chart
supercedes all previously published copies of this information.
Page 95-170
December 1995 DMERC Medicare Advisory
JOIN HCFA IN SAVING MEDICARE TRUST FUNDS
The Health Care Financing Administration (HCFA) is continuing efforts to reduce costs and administrative waste. As of
4/l/96, a new editing process will be implemented for assigned claims which will save the Medicare Trust Fund millions of
dollars. For some time, the denial of claims with incomplete or invalid information has resulted in claims surfacing
inappropriately into the appeals process. This practice has not only been costly, it has resulted in an inappropriate use of
the appeals system.
This new editing process will return paper or electronic claims to you as unprocessable if the claim contains certain
incomplete or invalid information. No appeal rights will be afforded to these claims, or portion of these claims, because no
“initial determination” can be made; rendering the claim unprocessable.
This new editing process not only saves Medicare Trust Funds, there is little change and no additional administrative burden
for you. You will not be denied any services you are accustomed to. You will be able to correct an unprocessable claim
under the new editing system with the same ease as you did under the current system. If you are accustomed to submitting
corrections via the telephone, on a development letter, as a new claim, or in any format, that process will continue. However,
you will not be granted a review because “returned” claims have no appeal rights.
One caution: Please correct “returned” claims promptly because only when that is done will you have met your legal obligation
for submitting a Medicare claim. If you are a non-participating provider and currently bill beneficiaries prior to submitting
a claim, you may continue to do so.
What does Return as Unprocessable mean?
Returning a claim as unprocessable does not mean your DMERC will physically return every claim you submit with
incomplete or invalid information. The term “return as unprocessable” is used to refer to the many processes utilized by your
DMERC today for notifying you that your claim cannot be processed, and that it must be corrected or resubmitted. Some
(not all) of the various techniques for returning claims as unprocessable include:
1.
Incomplete or invalid information is detected at the front-end of your DMERC’s claims processing system. The claim
is returned to you either electronically or in a hardcopy/checklist type form explaining errors and how to correct them.
2.
Incomplete or invalid information is detected at the front-end of the claims processing system and is suspended and
developed by your DMERC. If corrections are submitted within a 45 day period, the claim is processed. Otherwise,
the suspended portion is “returned as unprocessable” and you are notified by means of the remittance notice.
3.
Incomplete or invalid information is detected within the claims processing system and is rejected through the remittance
process by your DMERC. You are notified of any error(s) through the remittance notice, as well as how to correct it.
NOTE: An incomplete claim is a claim with missing, required information (e.g., no UPIN). An invalid claim is a claim that
contains complete and necessary information; however, the information is illogical or incorrect (e.g. incorrect UPIN).
What information will be provided to assist you in correcting a claim?
To assist you in furnishing the appropriate corrections, the following information will be supplied (as long as it is on the
received claim):
1.
2.
3.
4.
Beneficiary’s name;
HIC number;
Dates of service;
Patient account or control number
An explanation of the errors will also be provided. This explanation will either be in the form of a description or a code.
December 1995 DMERC Medicare Advisory
Page 95-171
Which Incomplete or Invalid Information will be Returned as Unprocessable?
The following information will be returned as unprocessable if it is not completed and/or entered accurately on the claim.
Please note that a required data element must always be present on a claim (Refer to Table I), a conditional data element
must be present when certain conditions exist (Refer to Table II).
To assist you in completing your claim: for paper claims, refer to the Regional DMERC Supplier Manuals; for electronic
claims, refer to the DMERC National Standard Format Matrix. Please verify that your printing specifications are correct on
a claim. Claims will be returned as unprocessable if the required information is submitted incorrectly.
Special Note: If you do not submit information for a required or conditional field(s) because the information is normally kept
on file with your DMERC, and can be supplied by your DMERC, then the claim will not be returned as
unprocessable.
Table I
Claims will be Returned as Unprocessable if the following information is Incomplete/Invalid
HCFA
1500
NSF
PAPER
EMC
*STATUS **DMERC ACTION
DATE
ELEMENT
1A
DA0-18.0
Insured I.D. Number
Insured I.D. Number
R
Rejected Via Remittance
2
CA0-04.0
Patient Name
Patient Last Name
R
Rejected Via Remittance
Patient First Name
R
Rejected Via Remittance
Insured Last Name
C
Rejected Via Remittance
Insured First Name
C
Rejected Via Remittance
SAME
C
Rejected Via Remittance
Insured Address Line1
C
Rejected Via Remittance
DA2-06.0
Insured City
C
Rejected Via Remittance
DA2-07.0
Insured State
C
Rejected Via Remittance
DA2-08.0
Insured Zip Code
C
Rejected Via Remittance
DA2-09.0
Insured Telephone Number
C
Rejected Via Remittance
Group Number
R
Rejected Via Remittance
Source of Payment
R
Rejected Via Remittance
Insured Employer Name
C
Rejected Via Remittance
Group Name
C
Rejected Via Remittance
CA0-05.0
4
DA0-19.0
Insured Name
DA0-20.0
6
DA0-17.0
Patient Relationship
To Insured
7
11
DA2-04.0
DA0-10.0
Insured’s Address
Insured’s Policy
Group Number
DA0-05.0
11B
DA2-12.0
Employer’s or
School Name
11C
DA0-11.0
Insurance Plan or
Program Name
Page 95-172
December 1995 DMERC Medicare Advisory
Table I (Cont'd)
HCFA
1500
12
NSF
DA0-16.0
PAPER
Patient Signature
EMC
*STATUS **DMERC ACTION
DATE
ELEMENT
Patient Signature Source
R
Rejected Via Remittance
Release of Information
R
Rejected Via Remittance
C
Rejected Via Remittance
Source
EA0-13.0
Indicator
14
EA0-07.0
Date of Current
Accident/Symptom Date
Illness, etc.
OR
Rejected Via Remittance
GCO-05.0
17
EA0-22.0
Name of Refer/
Refer/Ordering Provider
Ordering Provider
Last Name
C
Rejected Via Remittance
C
Rejected Via Remittance
OR
17A
FB1-13.0
Rejected Via Remittance
ID No. of Refer/Ordering Refer/Ordering Provider I.D.
C
Rejected Via Remittance
Provider
OR
19
20
21
Rejected Via Remittance
EA0-20.0
Referring Provider I.D.
C
Rejected Via Remittance
FB1-09.0
Refer/Ordering Provider UPIN
C
Rejected Via Remittance
C
Rejected Via Remittance
EA0-46.0
Reserved for Local Use Date Last Seen
FB1-22.0
Supervising Provider UPIN
C
Rejected Via Remittance
GC0-06.0
Date of Last X-Ray
C
Rejected Via Remittance
Laboratory Indicator
C
Rejected Via Remittance
EA0-29.0
Lab Charges
C
Rejected Via Remittance
FA0-26.0
Purchased Service Indicator
C
Rejected Via Remittance
FB0-05.0
Purchased Service Charge
C
Rejected Via Remittance
Diagnosis-1
C
Rejected Via Remittance
EA0-31.0
Diagnosis-2
C
Rejected Via Remittance
EA0-32.0
Diagnosis-3
C
Rejected Via Remittance
EA0-33.0
Diagnosis-4
C
Rejected Via Remittance
EA0-28.0
EA0-30.0
Outside Lab
Diagnosis
24A
FA0-05.0
Dates of Service(s)
Service From Date
R
Rejected Via Remittance
24B
FA0-07.0
Place of Service
Place of Service
R
Rejected Via Remittance
24D
FA0-09.0
Procedures, Services,
HCPCS Procedure Code
R
Rejected Via Remittance
FA0-10.0
HCPCS Modifier-1
C
Rejected Via Remittance
FA0-11.0
HCPCS Modifier-2
C
Rejected Via Remittance
FA0-12.0
HCPCS Modifier-3
C
Rejected Via Remittance
FA0-36.0
HCPCS Modifier-4
C
Rejected Via Remittance
Line Charges
R
Rejected Via Remittance
etc.
24F
FA0-13.0
$Charges
December 1995 DMERC Medicare Advisory
Page 95-173
Table I (Cont'd)
HCFA
1500
NSF
PAPER
EMC
*STATUS
DATE
**DMERC ACTION
ELEMENT
24G
FA0-18.0
Days or Units of Service Units of Service
R
OR
Rejected Via Remittance
Rejected Via Remittance
FA0-19.0
R
Rejected Via Remittance
24K
FA0-23.0
Reserved for Local Use Rendering Provider I.D.
C
Rejected Via Remittance
31
EA0-35.0
Provider Signature
Provider Signature Indicator
R
Rejected Via Remittance
Facility/laboratory Name
C
Rejected Via Remittance
Indicator
32
EA0-37.0
Facility Name and Ad
AND/OR
AND/OR
EA1-04.0
Facility/Laboratory
Rejected Via Remittance
C
Rejected Via Remittance
I.D. Number
OR
Rejected Via Remittance
FB0-11.0
Laboratory I.D.
FA0-31.0
Mammography Certification
Rejected Via Remittance
C
Rejected Via Remittance
R
Rejected Via Remittance
R
Rejected Via Remittance
Number
33
BA0-19.0
Provider’s Billing Name Provider Last Name
And Address
BA0-20.0
Provider First Name
OR
Rejected Via Remittance
BA0-18.0
Payer Organ. Name (EMC)
R
Rejected Via Remittance
BA0-09.0
Provider Medicare Number
R
Rejected Via Remittance
(batch)
BA1-13.0
Provider’s Pay-To Address 1
R
Rejected Via Remittance
BA1-15.0
Provider’s Pay-To City
R
Rejected Via Remittance
BA1-16.0
Provider’s Pay-To State
R
Rejected Via Remittance
BA1-17.0
Provider’s Pay-To Zip Code
R
Rejected Via Remittance
BA1-18.0
Provider’s Pay-To Telephone
R
Rejected Via Remittance
Number
* R = Required - Information which MUST always be on a claim.
C = Conditional - Information which is required on a claim if certain conditions exist.
** Lists the action each Medicare Carrier or DMERC will take on a claim returned as unprocessable.
Page 95-174
December 1995 DMERC Medicare Advisory
TABLE II:
LIST OF CONDITIONAL EDITS
NOTE: Items from the HCFA-1500 form have been provided. These items are referred to as fields. Refer to Table I which
crosswalks HCFA-1500 items with records and fields on the National Standard Format.
Your claim will be returned or rejected as unprocessable:
1.
If a service was ordered or referred by a physician (other than those services specified below) and the physician’s name
and/or UPIN (or surrogate) is not present in Fields 17 or 17A.
2.
If a physician extender or other limited licensed practitioner refers a patient for consultative services, but the name and/
or UPIN of the supervising physician is not entered in Fields 17 or 17A.
3.
For diagnostic tests subject to purchase price limitations
- If a “YES” or “NO” is not indicated in Field 20.
- If the “YES” box is checked in Field 20 and the purchase price is not entered under the word “$CHARGES”.
- If the “YES” box is checked and the purchase price is entered under $CHARGES, but Field 32 is blank (no name
or PIN number is provided or the word “SAME”).
4.
If a diagnosis in Field 21 is missing or incorrect.
5.
If modifiers “QB” and “QU” are entered in Field 24D to refer to a Health Professional Shortage Area, but Field 32 is left
blank, or contains no facility/laboratory name or carrier assigned PIN, or does not contain the word “SAME.”
6.
If a performing physician/supplier/or other practitioner is a member of a group practice and does not enter his or her carrier
assigned Provider Identification Number (PIN) in Field 24K and the group number in Field 33.
7.
If a primary insurer to Medicare is indicated in Field 11, but Fields 4, 6, and 7 are incomplete.
8.
If there is insurance primary to Medicare that is indicated in Field 11 by either an insured/group policy number or the
FECA number, but the insurance/program name in Field 11C is incomplete.
9.
For chiropractor claims:
a) If the x-ray date (s) is not entered in Field 19.
b) If the initial date “actual” treatment began is not entered in Field 14. NOTE: Record GCO, Field 5 of the NSF.
10. For certified registered nurse anesthetist (CRNA) and anesthesia assistant (AA) claims, if the CRNA or AA is employed
by a group (such as a hospital, physician, or ASC) and they do not enter the group’s name or billing number in Field
33 and their personal PIN number in Field 24K.
11. For durable medical, orthotic, and prosthetic claims, if the name or PIN of the location where the order was accepted
is not entered in Field 32.
12. For physicians who maintain dialysis patients and receive a monthly capitation payment:
a) If the physician is a member of a professional corporation, similar group, or clinic, and the attending physician’s
PIN is not entered in Field 24K.
b) If the name or PIN of the facility involved with the patient’s maintenance of care and training is not entered in
Field 32.
13. For foot care claims, if the date the patient was last seen and the attending physician’s UPIN are not present in
Field 19.
14. For immunosuppressive drug claims, if a referring/ordering physician was used and their name and/or UPIN are not
present in Fields 17 or 17A.
15. For all laboratory services, if the services of a referring/ ordering physician are used and his or her name and/or UPIN
are not present in Fields 17 or 17A.
December 1995 DMERC Medicare Advisory
Page 95-175
TABLE II (Cont'd)
16. For laboratory services performed by participating hospital-leased laboratory or an independent laboratory (including
services to a patient at home or in an institution), if the name or PIN of the laboratory where services were performed
is not in Field 32.
17. For independent laboratory services involving EKG tracing and the procurement of specimens from a patient at home
or in an institution, if a prescribing physician does not validate any laboratory service(s) performed at home or in an
institution by entering the appropriate annotation in Field 19 (i.e. - “Homebound).
18. For mammography “screening” and “diagnostic” claims, if a qualified screening center does not accurately enter their
six-digit, FDA-approved facility identification number in Field 32 when billing the technical or global component.
19. For physician assistant, nurse practitioner, and clinical nurse specialist claims, if services are performed in a hospital
setting but neither the hospitals name or PIN is entered accurately in Field 32.
20. For parenteral and enteral nutrition claims, if the services of an ordering/referring physicians are used and their name
and/or UPIN is not present in Field 17 or 17A.
21. For portable X-Ray services claims, if the ordering physician’s name and/or UPIN are not entered in Fields 17 or 17A.
22. For radiology and pathology claims for hospital inpatients, if the referring/ordering physician’s name and/or UPIN (if
appropriate) are not entered in Fields 17 or 17A.
23. For outpatient services provided by a qualified, independent physical or occupational therapist:
a) If the UPIN of the attending physician is not present in Field 19.
b) If the date the patient was last seen by the attending physician is not present in Field 19.
24. If a HCPCS modifier must be associated with a HCPCS procedure code or if the HCPCS modifier is invalid.
If my claim is returned as unprocessable through the remittance notice, how will I be notified of the error(s)?
Table III contains the Medicare Inpatient Adjudication (MIA)/ Medicare Outpatient Adjudication (MOA)/Reference Remark
Codes that will be used if your claim is returned as unprocessable through the remittance process. Please note that MIA/
MOA Code MA130 will be present on the remittance notice for any claim returned for incomplete or invalid information.
TABLE III:
Incomplete or Invalid Information Codes
MA36
Incomplete/invalid patient’s name.
MA51
Incomplete/Invalid procedure code(s) and/or rates.
Refer to the HCFA Common Procedure Coding System.
If an appropriate procedure code does not exist, refer to Item 19 on the HCFA instructions.
MA52
Incomplete/invalid date(s) of service.
MA53
Did not complete or enter the appropriate number of days or unit(s) of service.
MA58
Incomplete release of information indicator.
MA60
Incomplete/invalid patient’s relationship to insured.
MA61
Did not complete or enter correctly the patient’s social security or health insurance claim number.
Page 95-176
December 1995 DMERC Medicare Advisory
TABLE III (Cont'd)
MA75
Our records indicate neither a patient’s or authorized representatives signature was submitted on the claim. Since
this information is not on file, please resubmit.
MA76
Incomplete/invalid patient’s diagnosis and condition.
MA77
Incomplete/invalid place of service(s). Refer to Section 2010.3 in the HCFA-1500 instructions.
MA78
Did not complete or enter accurately an appropriate HCPCS modifier(s).
MA79
Did not complete or enter the appropriate charge for each listed service.
MA81
Our records indicate neither a physician or supplier signature is on the claim or on file.
MA82
Did not complete or enter the correct physician/ supplier’s Medicare number or billing name, address, city, state,
zip code, and phone number.
MA83
Did not indicate whether Medicare is the primary or secondary payer. Refer to Item 11 in the HCFA-1500 instructions
for assistance.
MA84
Our records indicate that a primary payer exists (other than Medicare); however, you did not complete or enter
accurately the employer’s name and/or the retirement date.
MA85
Our records indicate that a primary payer exists (other than Medicare); however, you did not complete or enter
accurately the insurance plan or group/program name.
MA86
Our records indicate that there is insurance primary to Medicare; however, you either did not complete or enter
accurately the group number of the primary insurer.
MA87
Our records indicate that a primary payer exists (other than Medicare); however, you did not complete or enter
accurately the correct insured’s name.
MA88
Our records indicate that a primary payer exists (other than Medicare); however, you did not complete or enter
accurately the insured’s address and/or telephone number.
MA89
Our records indicate that a primary payer exists (other than Medicare); however, you did not complete or enter the
appropriate patient’s relationship to the insured.
MA91
Our records indicate that there is insurance primary to Medicare; however, you either did not complete or enter
accurately the employer location of the primary insurer.
MA92
Our records indicate that there is insurance primary to Medicare; however, you did not complete or enter accurately
the required information.
Refer to the HCFA-1500 instructions on how to complete MSP information.
MA93
Our records indicate that there is insurance primary to Medicare and is indicated properly on the claim; however,
paper submissions require a copy of the primary payer’s EOB to be attached to the claim.
MA99
Our records indicate that a Medigap policy exists; however, you did not complete or enter accurately any of the
required information. Refer to the HCFA-1500 instructions on how to complete a mandated medigap transfer.
MA100 Did not complete or enter accurately the date of current illness, injury, or pregnancy.
MA102 Did not complete or enter accurately the referring/ ordering/supervising physician’s name and/or their UPIN (or
surrogate).
MA104 Did not complete or enter accurately the date the patient was last seen and/or the UPIN of their attending physician.
December 1995 DMERC Medicare Advisory
Page 95-177
TABLE III (Cont'd)
MA110 Our records indicate that you billed diagnostic test(s) subject to price limitations; however, you did not indicate
whether the test(s) were performed by an outside entity or if “no purchased tests are included on the claim.
MA111 Our records indicate that you billed diagnostic test(s) subject to price limitations and indicated that the test (s) were
performed by an outside entity; however, you did not indicate the purchase price of the test(s) and/or the performing
laboratory’s name and address.
MA112 Our records indicate that the performing physician/ supplier is a member of a group practice; however,- you did not
complete or enter accurately their carrier assigned PIN.
MA114 Did not complete or enter accurately the name and address, or the carrier assigned PIN, of the entity where services
were furnished.
MA115 Our records indicate that you billed one or more services in a Health Professional Shortage Area (HPSA); however,
you did not enter the physical location where the service(s) was rendered.
MA116 Did not complete the statement “Homebound, on the claim to validate whether laboratory services where performed
at home or in an institution.
CHIROPRACTOR CLAIMS:
MA121 Did not complete or enter accurately the date the X-Ray was performed.
MA122 Did not complete or enter accurately the initial date "actual" treatment occurred.
MAMMOGRAPHY SCREENING:
MA128 Did not complete or enter accurately the six digit FDA approved. certification number.
REQUIRED CODE:
MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is
unprocessable. Please submit the correct information to the appropriate fiscal intermediary or carrier.
Page 95-178
ENTERAL/
PARENTERAL
NUTRITION
CERTIFICATION
REQUIREMENTS
December 1995 DMERC Medicare Advisory
Certification, recertification and revision for enteral/parenteral nutritional therapy is
established with the DMERC by applying each CMN to a specific HCPCS code. The
certification process does not apply just to the therapy or to the patient, but to the
HCPCS code itself. The following instructions address submission of CMNs to the
DMERC for enteral/parenteral nutrition by type and time frame, and should be adhered
to when submitting claims for enteral/parenteral nutrition.
Initial certifications of medical necessity (CMNs) are required:
Initial
t
For all enteral formulae/parenteral solution, specified by HCPCS code, regardless
of whether the formula/solution is prescribed at the onset of therapy or at a later date
with a prescription change.
Example A:
Mrs. Jones began enteral therapy on 10/1/94. She was initially prescribed Jevity,
HCPCS code B4150. An initial CMN had to be submitted for Mrs. Jones for B4150.
On 12/15/94, Mrs. Jones’ prescription changed to Compleat B, code B4151. An
initial CMN must be submitted for B4151 with an initial date of 12/15/94, because
the HCPCS has changed and B4151 is a new code for Mrs. Jones.
Example B:
Mr. Smith began enteral therapy on 10/1/94. Jevity, HCPCS code B4150, was
initially prescribed. An initial CMN had to be submitted for Mr. Smith for B4150. On
12/15/94, Mr. Smith’s prescription changed to Osmolite, code B4150. Neither an
initial nor a revision CMN is needed for B4150, because an initial CMN is already
on file for Mr. Smith for code B4150. The updated prescription information specific
to the formula being furnished should be included on the next scheduled recertification CMN.
t
For all enteral/parenteral pumps, specified by HCPCS code, regardless of whether
the pump was prescribed at the onset of therapy or at a later date with a prescription
change.
Example A:
Mrs. Jones began parenteral therapy on 10/1/94. Her initial prescription specified
pump administration, HCPCS code B9006. An initial CMN had to be submitted for
Mrs. Jones for B9006.
Example B:
Mr. Smith began enteral therapy on 10/1/94. His initial prescription specified gravity
administration. A CMN was not needed for the gravity method, only for the nutrient.
On 12/15/94, Mr. Smith’s prescription changed to a pump administration method,
requiring a pump with alarm, HCPCS code B9002. An initial CMN must be
submitted for code B9002 with an initial date of 12/15/94, because code B9002 is
a new code for Mr. Smith.
t
For all enteral formulae/parenteral solution and/or enteral/parenteral pumps when
the patient has incurred a break in therapy of at least 60 days. A break in therapy
is defined as a period of time during which the patient is not tube-fed.
Example A:
Mrs. White suffered a stroke on 1/1/95. As a result, she experienced paralysis that
precluded swallowing, and began enteral therapy on 1/10/95. An initial CMN was
submitted for the formula and for a pump with an initial date of 1/10/95. After 6
months of enteral therapy, Mrs. White improved and was able to resume normal
feedings. On 11/1/95, Mrs. White suffered a second stroke and was prescribed
enteral therapy once again beginning 11/5/95. The time period between 7/10/95 (the
ending date for the initial enteral period of need) and 11/5/95 is greater than 60 days
and reflects a period of time during which Mrs. White was not tube-fed, i.e., a break
in therapy. An initial CMN for the formulae and/or pump is needed for the therapy
with an initial date of 11/5/95.
NOTE: Initial dates on all initial CMNs should be the start date for the HCPCS code
being certified.
December 1995 DMERC Medicare Advisory
ENTERAL/
PARENTERAL
NUTRITION
CERTIFICATION
REQUIREMENTS
(Cont'd)
Page 95-179
Recertification certificates of medical necessity (CMNs) are required:
t
For every HCPCS code requiring a CMN after 3, 9 and 24 months have elapsed from
the initial date on the initial CMN for that same HCPCS code.
Example:
Mrs. Jones began enteral therapy on 10/1/94. Her initial date of certification for
pump feeding, HCPCS code B9002, is 10/1/94. The recertification for the pump is
due, therefore, on 1/1/95. Although Mrs. Jones began enteral therapy on 10/1/94
with Jevity, code B4150, her prescription changed to Compleat B, code B4151, on
12/15/94. The recertification for the nutrient, Compleat B, is due 3/15/95 (90 days
after the start of B4151).
Recertification
NOTE: Recertification dates on all recertification CMNs should be exactly 3, 9 or 24
months from the initial date on the initial CMN for each certified HCPCS code.
Recertification schedules are not altered by revision CMNs.
Revision
Revision certificates of medical necessity (CMNs) are required:
t
For all prescription changes that do not involve HCPCS codes requiring CMNs as
follows:
Changes to methods of infusion i.e., changes from one type of feeding to another.
Changes to the calories prescribed per day.
Changes to the frequency of infusion i.e., the number of days per week the patient
is tube-fed.
NOTE: Revised dates on all revision CMNs should be the date of the prescription
change.
Refer to page 95-166 of this Advisory for the complete list of HCPCS requiring a CMN.
Page 95-180
HEARING REQUEST
FORM
December 1995 DMERC Medicare Advisory
The following DMERC Hearing Request form was developed to expedite the processing
of your hearing requests. All the information on the form is necessary for us to promptly
complete your request. Although this form is not mandatory, completion of this form
submitted to us as your request may enable us to respond to you more quickly.
ü
q
q
q
q
q
q
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December 1995 DMERC Medicare Advisory
PROFESSIONAL
RELATIONS UPDATE:
Adds New Staff
Page 95-181
Leslie Epperly is the new ombudsman for South Carolina. She brings with her valuable
Medicare experience in processing DME claims and conducting training seminars.
Beginning her Medicare experience as a Medical Claims Processor, Leslie is aware
of what it takes to file Medicare claims and stay on top of claims filing and coding
procedures. Applying her Medical Claims Processor background, Leslie obtained the
position of DME Review Analyst with an insurance company in Georgia. In this position,
she added to her Medicare background post pay review analysis. Her responsibilities
also included conducting training seminars for DME suppliers, providers and hospitals
throughout the state of Georgia. Leslie’s skills enabled her to quickly be promoted to
Congressional Review Analyst. In this position she was the Liaison for Congressional/
Senate staff for Georgia Medicare. As a liaison, Leslie maintained her responsibilities
of training and claims analysis and added to them, investigating fraudulent claims, data
collection and hearings analysis. Leslie then applied her experience as a Customer
Service Supervisor at a billing service. She then moved to a Regional Medical Center
where she was a Health Systems Analyst, primarily responsible for monitoring
administrative activities and making recommendations for efficiency improvements.
Leslie is currently located at Palmetto GBA’s home office in Columbia, SC. She looks
forward to applying her Medicare experience as the new ombudsman for South
Carolina. Leslie can be reached at (803) 735-1034, Extension 35714.
Leslie Epperly
Changes in
Ombudsman Address
& Telephone Number
Ombudsmen Services
The following ombudsmen have changed either their address, telephone number, or
both. The map of ombudsmen and their territories on page 95-218 of this advisory has
also been updated. Please make note of these changes when contacting your area
ombudsman.
Ombudsman
Cris Taylor
Territory
CO/NM
New Address
8200 S. Quebec St.
Suite A-3, #305
Englewood, CO 80112
New Telephone #
(303) 683-4309
Vince Temples
GA
-----
(770) 663-7644
Keith Smith
North FL
-----
(904) 886-2887
Sharon Briggman
NC
P.O. Box 97424
Raleigh, NC 97624-7424
(919) 846-3552
Adie Fuentes
PR/VI
Ave. Esmeralda #53
Call Box 50
Urb. Munoz Rivera
Guaynabo, PR 00969
(803) 735-1034
Ext. 35780
Palmetto GBA has ombudsmen strategically located throughout Region C. The
primary objective of the ombudsmen is to educate suppliers who file claims to
Palmetto GBA. The mechanisms Palmetto GBA uses to provide this training include
workshops which are held throughout the region, on-site visits to suppliers’ offices,
association meetings, as well as telephone and written contacts. Most of these
functions require the ombudsmen to be out of the office traveling several days a week.
Consequently, routine inquiries such as claim status, claim adjustments and general
coverage and coding questions can be answered more quickly by contacting Palmetto
GBA’s Dedicated Work Teams at (803) 691-4300. For inquiries of more detailed
nature, suppliers should leave a message for their ombudsman and understand a
return call may take a day or two. Please allow ample time for your calls to be returned
before contacting another ombudsman or other DMERC personnel. Also, please keep
in mind the ombudsmen are not able to conduct medical reviews and should not be
contacted in lieu of submitting a request for a review.
When ombudsmen anticipate being unavailable by telephone for an extended period
of time, their voice mail message will indicate so and refer you to another Palmetto
GBA staff member when immediate assistance is required.
Palmetto GBA representatives enjoy making one-on-one personal contacts with the
supplier community and look forward to being able to continue to serve their
educational needs.
Page 95-182
HCFA 1500 (12/90)
FORM ORDERS
December 1995 DMERC Medicare Advisory
For ordering HCFA 1500 (12/90) forms, the Government Printing Office has a new
telephone number. The new telephone number is (202) 512-1800. Please use this new
telephone number when ordering your next supply of HCFA 1500 (12/90).
Government Printing Office:
(202) 512-1800
NATIONAL SUPPLIER
CLEARINGHOUSE
(NSC)
RE-ENROLLMENT
The NSC began the supplier re-enrollment process in November 1995. One third of the
suppliers currently on file will be sent a re-enrollment package between November 1995
and March 1996. The package will consist of a letter, copy of the most current data
on the supplier record, attestation statement and supplier standards compliance
request. Copies of the re-enrollment package will be sent to each DMERC, HCFA
Central and Regional offices.
Participating Supplier
Survey
The participating supplier survey was produced and mailed in November 1995.
Approximately 92,000 suppliers will receive a survey package.
Should you have any questions regarding the NSC re-enrollment please contact the
NSC directly.
National Supplier Clearinghouse (NSC):
DMERC MEDICARE
ADVISORY UPDATE
t
(803)754-3951
DMERC Medical Policy Correction: The Urological Policy on page 95-50 of the
June 1995 issue of the DMERC Medicare Advisory inadvertently left out three
covered codes under the guidelines table titled, Usual Maximum Quantity of
Supplies. These items are A4314 (Insertion tray with drainage bag with indwelling
catheter, Foley type, two-way latex with coating), A4315 (Insertion tray with
drainage bag with indwelling catheter, Foley type, two-way, all silicone), and A4316
(Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, for
continuous irrigation). These items would be logically included with those codes
already listed, and would also be allowed at the rate of 2 per month, above which
extra medical necessity documentation should be included with the claim. The
Usual Maximum Quantity of Supplies chart on page 95-50 should read as follows:
Usual Maximum Quantity Supplies
t
Code
#/mo.
#/3 mo.
A4314
A4315
A4316
A4357
A4358
A5102
A5112
2
2
2
2
2
—
—
—
—
—
—
—
1
1
DMERC Medical Policy Clarification: The Lower Limb Prostheses medical
policy more specifically page 94-215, of the December 1994 issue of the DMERC
Medicare Advisory, requires clarification. Under the title “Knees”, the second
paragraph beginning with, “Fluid and pneumatic knees…” should read as follows:
Fluid, pneumatic and certain mechanical knees (L5610-L5616, L5722-L5780,
L5822-L5840) are covered for patients with a functional Level 3 or above.
December 1995 DMERC Medicare Advisory
DMERC MEDICARE
ADVISORY UPDATE
(Cont'd)
Lymphedema
Pumps/Pneumatic
Compressors
Page 95-183
Lymphedema Pump Chart Correction: The Lymphedema Pump Chart on page
95-137 of the September 1995 issue of the DMERC Medicare Advisory inadvertently
has missing and misplaced information regarding the Manufacturer/Brand Names,
Huntleigh, Lympha Press and Chattanooga. For clarification this chart is being
reprinted below in its entirety with all corrections in place. Our apologies for any
inconvenience.
It has been brought to our attention that there is some confusion throughout the supplier
community as to which HCPCS code should be used to properly bill for the various
lymphedema pumps available. The following grid is provided to offer clarification in this
area.
Manufacturer/Brand Name
Bio Compressions Systems/Sequential Circulator
Model Name/No.
HCPCS Code
2000
3000
3001
3004
E0651
E0652
E0652
E0652
Flowplus (AC330)
Flowpress (AC300)
Flowtron
Lymphatron
Lymphatron (AC340)
Lymphatron Trio (AC350)
E0650
E0651
E0650
E0651
E0651
E0652
Jobst/Extremity Pump
Clinical Model
System 7000
System 7500 (II)
E0650
E0650
E0651
Kendall
Home Rx (5550)
E0651
Lympha Press
103A
103M
201A - Mini
201-M
E0651
E0652
E0651
E0652
Talley/Hemaflow 2 Pump
Intermittent
Sequential
E0650
E0651
Huntleigh
Talley/Multicom
100
200
300
300G
500 ('93 & '94 model)
Talley/Multipulse
1000
E0652
II
IV
E0652
E0652
PresSsion
PresSion 4328 CGS
PresSion 4330 VGS
4320
4322
E0651
E0651
E0652
E0650
E0650
Advantage
2100
E0652
Thera-Con
Sequential
E0652
Wright Linear Pump
Chattanooga
* Talley/Multicom model '92 or before = E0651
E0650
E0650
E0651
E0652
E0652 *
Page 95-184
December 1995 DMERC Medicare Advisory
WORKSHOP NOTICE
DMERC Update Workshops
Palmetto Government Benefits Administrators (Palmetto GBA), the Medicare Region C Durable Medical Equipment
Regional Carrier (DMERC), is sponsoring a series of full day DMERC Update Workshops, throughout the South and
Southwest region from January 9, 1996 through February 15, 1996. The agenda for each of our DMERC Update Workshops
will consist of the following:
8:30 - Registration
9:00 a.m. - Updates on CMN Revisions
Medical Policies
12 noon - 1:30 p.m. - Lunch Break (On your own)
1:30 p.m. - 4:00 p.m. - New Remittance Notices
Changes to the Appeals Process
1996 HCPCS
1996 Pricing
To Register:
Invitations for these workshops have already been mailed to all suppliers. The registration form can be found in the workshop
invitation. If you have not yet received your invitation, please contact the DMERC Region C Dedicated Work Team at (803)
691-4300 and they will be happy to send you another invitation to the DMERC Update Workshops.
The cost for attending each workshop is $40.00 per person. All persons attending these workshops must register and pay
in advance. We cannot accept cash at the door.
What to Expect:
Each individual attending a workshop can expect to receive comprehensive workshop materials, as well as complimentary
coffee, tea, assorted sodas and a continental breakfast. The ombudsmen staff will conduct each full day workshop and will
be available to answer your questions.
NOTE: Specific resolution of individual claim denials will not be possible due to our inability to gain access to our processing
system in meeting room facilities.
DATE
CITY/STATE
SPECIALTY WORKSHOP LOCATIONS
PHONE
January 1996
Jan. 9
Jackson, MS
Jan. 11
Raleigh, NC
Jan. 11
Houston, TX
Jan. 12
Houston, TX
Jan. 12
Denver, CO
Jan. 15
San Antonio, TX
Jan. 16
San Antonio, TX
Jan. 16
San Juan, PR
Jan. 17
Nashville, TN
Jan. 23
Tulsa, OK
Jan. 24
Ft. Lauderdale, FL
Jan. 25
Ft. Lauderdale, FL
Jan. 24
Birmingham, AL
Jan. 25
Birmingham, AL
Jan. 30
Albuquerque, NM
Jan. 30
Orlando, FL
Jan. 31
Orlando, FL
Jan. 31
Atlanta, GA
Ramada Plaza Hotel, 1001 County Line Road, 39211
North Raleigh Hilton, 3415 Wake Forest Road, 27609
Wyndham Greenspoint, 12400 Greenspoint Drive, 77060
Wyndham Greenspoint, 12400 Greenspoint Drive, 77060
Adam's Mark Denver, 1550 Court Place, 80202
Hyatt Regency, 123 Losoya Street, 78205
Hyatt Regency, 123 Losoya Street, 78205
Caribe Hilton, Calle Los Rosales, San Geronimo Ground, 00904
Loews Vanderbilt Plaza, 2100 W. End Avenue, 37203
Doubletree Hotel at Warrens Place, 6100 S. Yale, 74136
Ft. Lauderdale Marina Marriott, 1881 SE 17th Street, 33316
Ft. Lauderdale Marina Marriott, 1881 SE 17th Street, 33316
The Radisson Hotel, 808 South 20th Street, 35205
The Radisson Hotel, 808 South 20th Street, 35205
Albuquerque Marriott, 2101 Louisiana Boulevard, 87110
Orlando Marriott Downtown, 400 West Livingston Street, 32801
Orlando Marriott Downtown, 400 West Livingston Street, 32801
Wyndham Garden Hotel, 3340 Peachtree Road NE, 30326
(601)
(919)
(713)
(713)
(303)
(210)
(210)
(809)
(615)
(918)
(305)
(305)
(205)
(205)
(505)
(407)
(407)
(404)
February 1996
Feb. 1
Asheville, NC
Feb. 1
Little Rock, AR
Asheville-Radisson Hotel, One Thomas Wolfe Plaza, 28801
Robinson Convention Center, #7 State House Plaza, 72201
(704) 252-8211
(501) 376-4781
Feb. 6
Feb. 6
Feb. 8
Feb. 13
Feb. 13
Feb. 14
Feb. 14
Feb. 15
Radisson Plaza Hotel, 369 West Vine Street, 40507
Hyatt Regency, 2 West Bay Street, 31401
Embassy Suites Hotel, 200 Stoneridge Drive, 29210
Adam's Mark Hotel, 939 Ridgelake Boulevard, 38128
Dallas Grand Hotel, 1914 Commerce Street, 75201
Dallas Grand Hotel, 1914 Commerce Street, 75201
The Monteleone Hotel, 214 Royal Street, 70140
Holiday Inn I-95 North, 14670 Duval Road, 32229
957-2800
872-2323
875-2222
875-2222
893-3333
222-1234
222-1234
721-0303
320-1700
495-1000
463-4000
463-4000
933-9000
933-9000
881-6800
843-6664
843-6664
231-1234
[Managed by Doubletree Hotel (formerly Camelot Hotel)]
Lexington, KY
Savannah, GA
Columbia, SC
Memphis, TN
Dallas, TX
Dallas, TX
New Orleans, LA
Jacksonville, FL
(606)
(912)
(803)
(901)
(214)
(214)
(504)
(904)
231-9000
238-1234
252-8700
684-6664
747-7000
747-7000
523-3341
741-4404
December 1995 DMERC Medicare Advisory
Page 95-185
MEDICARE
ANTI-FRAUD UNIT
The effort to prevent, detect and eliminate fraud, abuse and waste is a cooperative
one that involves beneficiaries, Medicare contractors, providers, physicians suppliers and numerous federal and state law enforcement organizations. As a part of
this cooperative effort Palmetto Government Benefits Administrators (Palmetto
GBA) has greatly strengthened the capabilities of its Anti-Fraud Unit. We have
added additional investigators and implemented new statistical and data analysis
procedures that will enhance our ability to proactively detect fraudulent billing
practices. In cooperation with the Health Care Financing Administration (HCFA) our
approach to Anti-Fraud consists of three-prongs: prevention, early detection, and
cooperation with enforcement agencies.
Prevention
The primary prevention goals concentrate on paying claims only for covered services
thereby avoiding opportunities for fraud and abuse. This also reduces the need to
recover payments on a postpayment basis, after we discover erroneous reimbursements.
Educating providers, beneficiaries and our contractor staff is the most effective way to
prevent fraud and abuse.
t
Providers receive information from various departments in Medicare but primarily
through our Provider Education Department about covered services, proper coding
and billing. Well-informed providers make the correct coding choices eliminating
the need for claims reviews. Our dedicated representatives hold training sessions
for providers on how to correctly prepare and submit forms for processing.
t
Beneficiaries are educated through our Outreach Program to review their Explanation of Medicare Benefits (EOMB) to make sure the services and charges are
correct. They are encouraged to call the Beneficiary Services Department with any
questions or discrepancies on the EOMB.
t
Contractor staff benefits from information provided by HCFA and other sources
regarding trends in fraudulent activity and “best practices” in detection and pursuit.
Detection
We have enhanced data analysis and statistical systems to identify and monitor
services that may be vulnerable to abuse. By identifying abusive patterns of services
to beneficiaries, we can prevent the occurrence of future of problems.
Cooperation with
Enforcement Agencies
As a Medicare contractor we work closely with all agencies that have major responsibility for enforcement actions, referring cases and supporting their activities. These
agencies include the Office of the Inspector General (OIG), the Department of Justice,
the FBI, and local US Attorneys. When cases are developed which are appropriate for
civil or criminal action they are referred to the OIG. Ultimately these cases may be
prosecuted by federal or state authorities or other investigative agencies.
Definitions
Fraud is intentional deception or misrepresentation that the individual makes,
knowing it to be false and that could result in some unauthorized benefit to them.
The most frequent kind of fraud arises from a false statement or misrepresentation that
is material to entitlement or payment under the Medicare program. The violator may
be a participating provider, a supplier of durable medical equipment, a beneficiary, or
some other person or business entity, including a carrier employee.
Page 95-186
Kickbacks, Bribes,
Rebates
December 1995 DMERC Medicare Advisory
Knowingly and willfully soliciting or receiving remuneration directly or indirectly, overtly
or covertly, in cash or in kind: (1) in return for referring an individual to someone who
will furnish for any item or service Medicare or Medicaid may pay for in whole or in part,
or (2) in return for purchasing, leasing, ordering or arranging for or recommending
purchasing, leasing or ordering any good facility, service or item Medicare or Medicaid
may pay for in whole or in part. Anyone engaging in this activity will be guilty of
a felony.
Knowingly and willfully offering or paying any remuneration directly or indirectly, overtly
or covertly,’ in cash or in kind to any person to induce someone: (1) to refer an individual
to one who will furnish or arrange for any item or service Medicare or Medicaid may pay
for in whole or in part, or, (2) to purchase, lease, order or arrange for or recommend
purchasing, leasing or ordering any good, facility, service or item Medicare or Medicaid
may pay for in whole or in part. Anyone engaging in this activity will be guilty of
a felony.
Provider Agreement
In accordance with Section 1866 of the Social Security Act (Health Insurance
Benefit Agreement), the provider agrees to furnish the information the Medicare
Carrier needs to determine the appropriateness of reimbursement on behalf of a
beneficiary for the period in which payment is to be made, or any previous period.
Providers are required to supply information to the Medicare Carrier on demand.
Social Security Act Section 1866 (a)(1) requires providers to agree to limit their
charges to beneficiaries to the cost of non-covered services and the deductible and
coinsurance amounts allowed under federal law.
Breach of Provider
Agreement
Each provider participating in the Medicare Program must comply with Title VI of the
Civil Rights Act of 1964 and meet eligibility requirements of Title XVIII of the Social
Security Act.
Administrative remedies are usually invoked to correct abusive practice. Examples
include:
t
t
t
t
t
Educational contact
Removal from Periodic Interim Payment
Withdrawal of Favorable Waiver Presumption
Withholding of Payments/Recovery of Overpayment
Referral to State Licensing Boards of Medical/Professional
Societies or the Peer Review Organization
HCFA and/or OIG have the authority to suspend, exclude, or terminate payment to
practitioners, providers and supplier of Medicare services.
Sanctions
Sanctions for violation of Medicare law may include involuntary termination or
suspension of the Medicare Provider Agreement and exclusion or suspension under
Federal and/or State Health Care Programs. See Public Law 100-93, the “Medicare
and Medicaid Patient and Program Protection Act of 1987.”
Penalties
Section 208 of the Social Security Act provides penalties for obtaining or attempting
to obtain services or payments by fraudulent means. When Medicare was enacted,
Congress specifically extended these penalties to Title XVIII (Medicare) by Section
1872 of the Act.
The Social Security Amendments of 1972 repealed the application of the Section
1872 penalty provisions to the Medicare program and substituted new provisions
applicable to the Medicare and Medicaid program when an item or service is
December 1995 DMERC Medicare Advisory
Penalties (Cont'd)
Page 95-187
furnished under an approved state plan. These new penalty provisions, contained in
sections 1877 and 1909 of the Act, apply to any acts, statements or representations
under Medicare or Medicaid that occur on or after October 30, 1972. Originally, violation
of the provisions of these sections was misdemeanors. But the Medicare-Medicaid
Anti-Fraud and Abuse Amendments, enacted October 25, 1977, upgraded most
fraudulent acts from misdemeanors to felonies and increased maximum penalties from
a $10,000 fine, one-year imprisonment or both to a $25,000 fine, five year imprisonment
or both.
Under the False Claims Act, (31 U.S.C. 231) a penalty of $2,000 may be assessed
for each claim.
Reporting Fraudulent
Activity
We recognize that the vast majority of providers are as interested as we are in deterring
fraudulent activity in Medicare. We appreciate any input you can provide to assist us
in identifying those few providers who are involved in inappropriate billings.
If you identify potential schemes to defraud the Medicare program,
Please call:
Medicare Anti-Fraud Hotline (803) 788-5414
or
Sandra Anthony, Medicare Fraud and Abuse Information Coordinator
(803) 788-0222, ext. 41393
Or write to:
Medicare Anti-Fraud Unit
Palmetto Government Benefits Administrators
Post Office Box 100236
Columbia, South Carolina 29202-3236
Fraud Alert*
Some Durable Medical Equipment suppliers are allegedly billing for orthotic L codes
when in fact they are delivering seating systems which are not covered by Medicare.
The following codes are reportedly being billed:
L0120
L0130
L0170
L0400
L1500
L1640
L2184
L2210
L2220
L2250
L3936
L3970
*
Cervical, flexible, non-adjustable (foam collar)
Cervical, flexible, thermoplastic collar, molded to patient
Cervical, collar, molded to patient
TLSO, anterior-posterior-lateral-control molded to patient model, with interface
material
Thoracic-hip-knee-ankle orthosis, mobility frame (Newington, Parapodium
types)
HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh
cuffs
Addition to lower extremity fracture orthosis, limited motion knee joint
Addition to lower extremity, dorsiflexion assist (Plantar flexion resist)
Addition to lower extremity, dorsiflexion and plantar flexion
Addition to lower extremity, foot plate, molded to patient model
Wrist-hand-finger orthoses-custom fitted, palmer
SEWHO, addition to mobile arm support, elevation proximal arm
This alert is provided for educational and informational purposes only. It is
intended to assist parties in obtaining information concerning potential fraud and
abuse and to alert affected parties tot he nature of the suspected fraud. It is not
intended to be used as a basis for the denial of claims or any adverse action against
any provider or supplier. This alert is not intended to indicate, suggest or imply
that any particular individual or entity or group of individuals or entities, are
associated with the activity described therein.
Page 95-188
December 1995 DMERC Medicare Advisory
ELECTRONIC
DATA
INTERCHANGE
On-line beneficiary eligibility inquiry is now available to Region C participating
suppliers. By keying ELGB on a clear screen in Claims Status Inquiry (CSI), electronic
submitters can access eligibility data such as Medicare Secondary Payer and
deductible information. While the actual submission of a claim is always the final
determination of beneficiary eligibility, this new electronic feature is expected to be an
aid to participating suppliers.
EDI Update
Direct deposit is catching on in Medicare circles! Electronic Funds Transfer (EFT) is
an increasingly popular feature for Palmetto GBA electronic submitters. The only
requirements for EFT are to receive electronic remittances and to submit at least 90%
of claims electronically. Medicare payments are automatically posted to a supplier’s
checking or savings account within 48 working hours of the electronic remittance
check date. In the case of an overpayment, the recoupment usually takes place before
the funds are deposited into the account.
As a growing number of suppliers take advantage of CSI’s many features, one question
keeps recurring: “How often are the screens updated?” The answer: EVERDAY! The
VPIQ screens (e.g.., claims on the payment floor, pending, resolved, etc.) are updated
five days per week, Monday through Friday. Crossover eligibility (XOCS), beneficiary
eligibility (ELGB), and PAME (last three payments) also retrieve data from our system
each working day.
PACES users received the latest Version 3.0 in November, 1995. This early
distribution of Palmetto GBA’s updated claims entry software helps submitters
implement the new CMNs at their convenience before HCFA’s April 1, 1995 deadline.
For an annual fee of $25.00 plus a one-time communications software charge, PACES
is a wonderful way to enter the world of electronic billing. Call the EDI Help Line at (803)
788-9751 for more information about PACES and Palmetto GBA’s other electronic
services.
Electronic Funds
Transfer (EFT)
Clarification
Qualification Criteria
Palmetto GBA offers the option of Electronic Funds Transfer (EFT) to its DMERC
electronic submitters. Any submitter wishing to take advantage of EFT must first meet
the following criteria:
The submitter must have submitted at least 90% of total claims electronically over the
90-day period prior to application.
The submitter must be receiving Electronic Remittance Notices (ERTs).
Enrollment Procedures
To enroll in the Electronic Funds Transfer program, complete the EFT enrollment form
found in your “Getting Certified for Electronic claims Transmission” package. If you
cannot locate your package, forms may be obtained from Palmetto GBA by contacting
the EDI Help-Line at (803) 788-9751.
Complete the Letter of Credit of Advancing Funds - Authorization Agreement for
Electronic Funds Transfer form found in the package, or EFT enrollment form, along
with a voided check, and return it to:
Government Finance Bank Reconciliation
Palmetto Government Benefits Administrators
I-20 at Alpine Road
Columbia, SC 29219
Allow at least 30 days from the date you mailed your enrollment forms for enrollment
processing, which includes evaluation of eligibility requirements and pre-notification
testing with the Automated Clearing House, National Bank of Detroit (ACH - NBD).
Please do not call and request enrollment status until this time period has expired.
December 1995 DMERC Medicare Advisory
EDI Qualification
Criteria (Cont'd)
Page 95-189
Approval notification will be made by letter, which will include the date on which EFT
will commence. Thirty days after the date EFT begins, you will no longer receive
hardcopy remittances, only Electronic Remittance Notices (ERNs).
If approval is not granted, you will be notified by letter as to the additional information
required prior to approval.
EFT Termination
Palmetto GBA monitors all electronic submissions and can identify those submitters
who fall below the 90% requirement for two or more consecutive months, or for three
or more non-consecutive months within a 12-month period. Submitters falling below
the requirement criteria will have Electronic Funds Transfer functionality terminated.
For questions regarding Electronic Funds Transfer and other EDI benefits, please
contact the EDI Help-Line.
EDI Help-Line (803)788-9751
SUPPLIER
SATISFACTION
SURVEY
COMPLEMENTARY/
SUPPLEMENTAL
POLICIES UPDATE
Supplier Satisfaction Surveys are being conducted with a random group (approximately
10%) of region c suppliers. If you should receive a Supplier Satisfaction Survey, we
would appreciate your prompt input and response. Results of the survey responses will
be published in a future issue of the DMERC Medicare Advisory.
Non-Medigap Medicare Supplemental policies are Medicare supplement policies that
do not meet the definition of Medigap policies. Often these policies are referred to as
Complementary Coverage policies.
Do not list these Non-Medigap Medicare Supplemental policies on the HCFA-1500
(12/90) form. If we have an agreement with a Non-Medigap Medicare Supplemental
insurer, Palmetto GBA will automatically forward the Medicare claim information to
that insurer and indicate that we did so on your Medicare remittance.
The most current list of these insurers as of November 29, 1995 is shown below.
Acordia Senior of the Southeast,
Incorporated
Aetna Life and Casualty Insurance
American Family Life Assurance (AFLAC)
American Postal Workers Union
American Republic Insurance
Bankers Life and Casualty
BCBS of Alabama
BCBS of Arkansas
BCBS of Colorado
BCBS of Florida
BCBS of Louisiana
BCBS of Michigan
BCBS of New Mexico
BCBS of North Carolina
BCBS of Oklahoma
BCBS of South Carolina (Over 65 Plan)
BCBS of South Carolina (FEP)
BCBS of Texas
Government Employee Hospital
Association
Group Health Incorporated
Humana Health Care Plan
Kirke-Van Orsdel, Incorporated
La Cruz Azul de Puerto Rico
Mutual of Omaha
National Association of Letter Carriers
Olympic Health Management Systems
Physicians Mutual
Pioneer Life
Serguros de Servicio de Salud, Inc.
(Triple-S, Inc.)
Standard life and Accident Insurance
Company
The Prudential Insurance Company (AARP)
Union Fidelity (ASO) American General
United American Insurance Company
USAA Life Insurance Company
USAble life Insurance
Page 95-190
SPAN DATES
NEEDED WHEN
FILING CLAIMS
December 1995 DMERC Medicare Advisory
The following items require the use of span dates (i.e., a span of time between the from
and to dates of service). Failure to use span dates will result in incorrect payment for
the following items:
Parenteral and Enteral Nutrition Formula/Solution
B4150 - B4156
B4164 - B4216
B5000 - B5200
XX030 - XX077
(Enteral)
(Parenteral)
(Parenteral)
(Enteral)
Supply Kits
B4034 - B4036 (Enteral)
B4220 - B4224 (Parenteral)
Continuous Passive Motion (CPM) Device
E0935
Infusion Pump Supplies
K0110 - K0111
When using span dates, do not span the end of a calendar year. The from and to date
must fall within the same calendar year per claim. For example, when billing for a 30
day supply of enteral nutrition for the 1995 claim from December 15, 1995 through
January 14, 1996, two separate claims must be submitted. The from and to date should
be indicated in the following manner:
Date of Service
From
To
12/15/95 - 12/31/95
The claim for the period beginning January 1, 1996 thru January 14, 1996, should be
filed on or after January 1, 1996, as follows:
Date of Service
From
1/1/96
CATEGORIES
ESTABLISHED FOR
PAYMENT OF
TEMPORARY LEVEL II
CODES
-
To
1/14/96
HCPCS Code
Category
K0268
K0269
K0270
K0271-K0276, K0279
K0283
K0285
K0400
K0402-K0406
K0407-K0411
IRP* DME
Capped Rental DME
Capped Rental DME
P & O/Ostomy Supplies
DME Supplies
IC**
P&O
Surgical Dressing
P & O/Urologicals
*
**
IRP IC
-
Inexpensive and Routinely Purchased
Individually Considered
December 1995 DMERC Medicare Advisory
Page 95-191
1996 HCPCS UPDATE: ADDITIONS, CHANGES AND DELETIONS
The following are additions, changes and deletions to the HCPCS for 1996. Deleted HCPCS for 1996 will be accepted through
March 31, 1996 as a 90-day grace period. Claims received on or after April 1, 1996 must contain the new and correct codes as
they are outlined in the following.
HCPCS 1996 Additions
GA
Waiver Of Liability Statement On File
A4254
Replacement Battery, Any Type, For Use With Medically Necessary Home Blood Glucose Monitor Owned By
Patient, Each
(Effective 1/1/96 This Replaces HCPCS Code K0267)
A4258
Spring-Powered Device For Lancet, Each
(Effective 1/1/96 This Replaces HCPCS Code K0131)
A4575
Topical Hyperbaric Oxygen Chamber, Disposable
A4595
Tens Supplies, 2 Lead, Per Month
A4628
Oropharyngeal Suction Catheter, Each
(Effective 1/1/96 This Replaces HCPCS Code K0164)
A4629
Tracheostomy Care Kit For Established Tracheostomy
(Effective 1/1/96 This Replaces HCPCS Code K0165)
A6020
Collagen Based Wound Dressing, Wound Cover, Each Dressing
B4085
Gastrostomy Tube, Silicone With Sliding Ring, Each
(Effective 1/1/96 This Replaces HCPCS Code K0147)
E0748
Osteogenic Stimulator, Noninvasive, Spinal Applications
E0784
External Ambulatory Infusion Pump, Insulin
E1800
Dynamic Adjustable Elbow Extension/Flexion Device
E1805
Dynamic Adjustable Wrist Extension/Flexion Device
E1810
Dynamic Adjustable Knee Extension/Flexion Device
E1815
Dynamic Adjustable Ankle Extension/Flexion Device
E1820
Soft Interface Material, Dynamic Adjustable Extension/Flexion Device
E1825
Dynamic Adjustable Finger Extension/Flexion Device
E1830
Dynamic Adjustable Toe Extension/Flexion Device
J0713
Injection, Ceftazidime, Per 500 Mg
J1095
Injection, Dexamethasone Acetate, Per 8 Mg
J1250
Injection, Dobutamine Hydrochloride, Per 250 Mg
J2300
Injection, Nalbuphine Hydrochloride, Per 10 Mg
J3305
Injection, Trimetrexate Glucoronate, Per 25 Mg
J3480
Injection, Potassium Chloride, Per 2 Meq
J7509
Methylprednisolone Oral, Per 4 Mg
J7510
Prednisolone Oral, Per 5 Mg
These HCPCS codes are not available for DMERC use
Page 95-192
December 1995 DMERC Medicare Advisory
HCPCS 1996 Additions (Cont'd)
J7599
Immunosuppressive Drug, Not Otherwise Classified
J9015
Aldesleukin, Per Single Use Vial
J9266
Pegaspargase, Per Single Dose Vial
K0400 Adhesive Skin Support Attachment For Use With External Breast Prosthesis, Each
K0401 For Diabetics Only, Deluxe Feature Of Off-The Shelf Depth Inlay Shoe Or Custom Molded Shoe, Per Shoe
K0402 Gauze, Non-Impregnated, Sterile, Pad Size 16 Sq. In. Or Less, Without Adhesive Border, Each Dressing
K0403 Gauze, Non-Impregnated, Sterile, Pad Size More Than 16 But Less Than Or Equal To 48 Sq. In., Without Adhesive
Border, Each Dressing
K0404 Gauze, Non-Impregnated, Sterile, Pad Size More Than 48 Sq. In., Without Adhesive Border, Each Dressing
K0405 Gauze, Elastic, Sterile, All Types, Per Linear Yard
K0406 Gauze, Non-Elastic, Sterile, Per Linear Yard
K0407 Urinary Catheter Anchoring Device, Adhesive Skin Attachment
K0408 Urinary Catheter Anchoring Device, Leg Strap
K0409 Sterile Water Irrigation Solution, 1000 Ml
K0410 Male External Catheter, With Adhesive Coating, Each
K0411 Male External Catheter, With Adhesive Strip, Each
K0412 Mycophenolate Mofetil, Oral, 250 Mg
L1885
KO, Single Or Double Upright, Thigh And Calf, With Functional Active Resistance Control
L5617
Addition To Lower Extremity, Quick Change Self-Aligning Unit, Above Knee Or Below Knee, Each
L5845
Addition, Endoskeletal, Knee-Shin System, Stance Flexion Feature, Adjustable
L5846
Addition, Endoskeletal, Knee-Shin System, Microprocessor Control Feature, Swing Phase Only
L5930
Additional, Endoskeletal System, High Activity Knee Control Frame
L5985
All Endoskeletal Lower Extremity Prostheses, Dynamic Prosthetic Pylon
*L8619 Cochlear Implant External Speech Processor, Replacement
V2531 Contact Lens, Scleral, Gas Permeable, Per Lens (For Contact Lens Modification, See 92325)
V2781 Progressive Lens, Per Lens
(Effective 1/1/96 This Replaces HCPCS Code K0162)
* (Effective 1/1/96 Jurisdiction Of This Code Will Be Under The Local Carrier.)
December 1995 DMERC Medicare Advisory
Page 95-193
HCPCS 1996 Description Changes
Additional nomenclature will be bolded
Deleted nomenclature will be marked with a (Strikethru)
K0125 Prednisone - Oral, (Tab) 5 Mg (Deltasone)
K0263 Gauze, Elastic, Non-Sterile, All Types, Per Linear Yard
K0264 Gauze, Non-Elastic, Non-Sterile, Per Linear Yard
HCPCS 1996 Deletions
J2100
Injection, Luminal Sodium, Up To 120 Mg
J3500
Vitamin Therapy
K0117 Unlisted Item, Orthotic Seating, Back Module
K0118 Tens Supplies - One Month Supply For Tens, 2 Lead
(Effective 1/1/96 Use HCPCS Code A4595)
K0131 Spring-Powered Device For Lancet
(Effective 1/1/96 Use HCPCS Code A4258)
K0132 Male External Catheter With Or Without Adhesive, With Or Without Anti-Reflux Device, Each
K0133 Intermittent Urinary Catheter, Disposable; Straight Tip
K0134 Intermittent Urinary Catheter, Disposable; Coude (Curved) Tip
K0135 Intermittent Urinary Catheter, Reusable; Straight Tip
K0136 Intermittent Urinary Catheter, Reusable; Coude (Curved) Tip
K0147 Gastrostomy Tube, Silicone With Sliding Ring
(Effective 1/1/96 Use HCPCS Code B4085)
K0162 Progressive Lens, Each Lens
(Effective 1/1/96 Use HCPCS Code V2781)
K0164 Oropharyngeal Suction Catheter, Each
(Effective 1/1/96 Use HCPCS Code A4628)
K0165 Tracheostomy Care Kit For Established Tracheostomy
(Effective 1/1/96 Use HCPCS Code A4629)
K0166
Methylprednisolone - Oral, 4 Mg
(Effective 1/1/96 Use HCPCS Code J7509)
K0167
Prednisolone - Oral, 5 Mg
(Effective 1/1/96 Use HCPCS Code J7510)
K0267
Replacement Battery, Any Type, For Use With Medically Necessary Home Blood Glucose Monitor Owned By
Patient, Each
(Effective 1/1/96 Use HCPCS Code A4254)
Page 95-194
December 1995 DMERC Medicare Advisory
1995 FEE SCHEDULE
UPDATES
*Category HCPCS Modifier
CR
CR
K0011
K0012
RR
RR
The following fee schedule matrix contains updates to the schedule previously
published in the December 1994 issue of the DMERC Medicare Advisory.
AL
AR
CO
FL
GA
KY
LA
MS
NM
NC
OK
PR
SC
TN
TX
VI
449.89
288.86
457.03
293.43
457.03
293.43
420.58
270.02
445.66
286.13
457.03
293.43
451.34
289.77
411.73
264.35
406.16
260.77
457.03
293.43
457.03
293.43
538.83
345.95
442.44
284.06
430.74
276.56
457.03
293.43
457.03
293.43
* Category Key
CR - Capped Rental
Drug Pricing - Effective
January 1, 1996
Immunosuppressive
Drugs
J7500
J7502
J7506
J7507
J7508
K0119
K0120
K0121
K0125
K0166
K0167
117.89
280.32
4.51
2.18
10.92
1.18
91.96
1.32
0.05
0.52
0.03
Epoetin Alpha (EPO)
Q9920 - Q9940
$10.00
Infusion
Therapy Drugs
J0640
J0895
J1170
J1455
J1570
J2175
J2270
J2275
J2920
J2930
J3010
J3370
J9000
J9010
J9040
J9065
J9100
J9110
J9190
J9200
J9245
J9360
J9370
J9375
J9380
XX009
21.53
9.95
1.07
12.19
34.80
0.69
0.74
12.73
4.50
12.50
3.67
10.88
45.08
225.40
291.49
48.00
5.88
23.00
2.03
122.94
270.93
4.32
25.44
38.25
156.21
45.79
Nebulizer Drugs
J2545
J7051
J7610
J7615
J7620
J7625
J7627
J7630
J7640
J7650
J7651
J7652
J7653
J7654
J7655
J7660
J7665
J7670
J7672
J7675
XX001
Atrovent 0.02% UD*
109.17
0.24
1.23
1.37
0.41
0.69
4.55
0.70
0.69
0.28
0.20
0.26
0.32
0.40
0.58
1.91
2.40
1.23
1.23
1.34
0.24
1.87
NOTE: As a reminder, all drugs reimbursable as DMEPOS items, (i.e., immunotherapy, bronchodilator drugs, and all other
DMEPOS drugs), are reimbursable based on the national average wholesale price of the drugs. If a drug has multiple
sources, the median of the average national wholesale generic prices is used (DMERC Region C Supplier Manual,
7/95 Revision, page 6.4)
December 1995 DMERC Medicare Advisory
Page 95-195
INHERENT REASONABLENESS NOTICE
The Region C DMERC has reviewed the Local Carrier base fees for the following codes and determined that they are either
deficient or excessive. We have provided information reflecting our proposed changes for your review.
The law, under section 1842(b)(8)(A) of the Social Security Act, allows the application of inherent reasonableness to reasonable charges that are determined to be either grossly excessive or grossly deficient. The 1989 local carrier base fees were
developed using 1986 reasonable charge data. Therefore, revisions to establish a realistic and equitable fee must be applied
to the 1986 and January 1, 1987 time period. Our base fee revisions are derived using retail catalog price lists for this same
period. If sources are not available, we use the earliest available catalogs that contain sources for codes under review.
The revised base fees will be indexed to the current fee screen year (1996) using the annual covered item update factors
provided below. In addition, national floor and ceiling limitations will be applied prior to establishing the final fees.
You have thirty days to submit any comments regarding these changes. Your comments must be received by February 29,
1996. Remember, it is not HCFA's intention to pay for deluxe or personal comfort items. When submitting comments
include supporting documentation that best reflects the 1986/87 historical charge data base period. Please send all comments to:
PGBA
DMEPOS Inherent Reasonableness
Medicare Reimbursement
P.O. Box 100141
Columbia, SC 29202-3141
Code Description
A4338 Indwelling catheter; Foley type, two-way latex
with coating.
A5062 Pouch, drainable; without barrier attached
(one piece).
*
State
AR
CO
FL
KY
LA
MS
PR
SC
AL
AR
CO
FL
KY
LA
MS
NM
OK
PR
TX
VI
Current
1989
Base Fee
$11.91
$12.56
$ 6.92
$ 6.71
$12.25
$ 6.92
$ 6.56
$11.92
$
$
$
$
$
$
$
$
$
$
$
$
1.16
1.14
2.10
2.11
1.21
1.18
1.38
2.10
2.10
2.47
2.62
2.36
Revised
Current
1989
1996
Base Fee Allowance
$10.02
$12.08*
$10.06
$12.13*
$ 9.45
$11.38*
$ 9.92
$11.96*
$10.30
$12.41*
$10.02
$12.07*
$10.40
$12.55
$ 9.92
$11.96*
$
$
$
$
$
$
$
$
$
$
$
$
1.73
1.72
1.73
1.62
1.70
1.77
1.72
1.71
1.71
1.78
1.62
1.78
$
$
$
$
$
$
$
$
$
$
$
$
2.09*
2.08*
2.09*
1.95*
2.06*
2.14*
2.08*
2.07*
2.07*
2.15
1.95*
2.15*
The current 1996 Fee is the end result of calculations described in paragraph 3 above. These are not the final fees for
1996. Final Fees will be limited by the National floors and ceilings.
Page 95-196
December 1995 DMERC Medicare Advisory
INHERENT REASONABLENESS NOTICE (Cont'd)
A5063 Pouch, drainable; for use on barrier with flange
(two piece system).
*
AR
CO
FL
GA
KY
LA
NM
NC
OK
SC
$
$
$
$
$
$
$
$
$
$
2.87
2.73
2.47
2.16
2.41
2.95
2.44
2.34
2.44
2.21
$
$
$
$
$
$
$
$
$
$
1.76
1.77
1.66
1.73
1.74
1.81
1.75
1.71
1.75
1.74
$
$
$
$
$
$
$
$
$
$
2.13*
2.14*
2.01*
2.09*
2.10*
2.18*
2.11*
2.07*
2.11*
2.10*
The current 1996 Fee is the end result of calculations described in paragraph 3 above. These are not the final fees for
1996. Final Fees will be limited by the National floors and ceilings.
Covered Item Update Factors
DME/Other
Prosthetics and Orthotics
1989
1.7%
1.7%
1990
0%
0%
1991
3.7%
0%
1992
3.7%
4.7%
1993
3.1%
3.1%
1994
3.0%
0%
1995
2.5%
0%
1996
3.0%
3.0%
1996 FEE SCHEDULE CORRECTIONS
The DMERCs have corrected base fees for the following codes. These corrections could result in changes to the final fee
schedule calculations for 1996. These fee schedule calculations were not available at the time of this publication. 1996 Fee
Schedules for the following codes will be published in the next issue of the DMERC Medicare Advisory.
A4259 A4326 A4327 A4328 A4329 A4340 A4357 A4398 A4399 A5051 A5052 A5055 A5061 A5064 A5065 A5071 A5072 A5073 A5074 A5075 A5102 A5112 E0180 E0181 E0193 E0277 E0781 K0011 K0012 K0195 -
Lancets, per box of 100.
Male external catheter specialty type (e.g., inflatable, faceplate, etc., each).
Female external urinary collection device; metal cup, each.
Female external urinary collection device; pouch, each.
External catheter starter set, male/female, includes catheters/urinary collection device, bag/pouch and accessories
(tubing, clamps, etc.), 7 day supply.
Indwelling catheter; specialty type, (e.g., coude, mushroom, wing, etc.).
Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube.
Irrigation supply; bags (each bag).
Irrigation supply; cone/catheter (includes brush).
Pouch, closed; with barrier attached (one piece).
Pouch, closed; without barrier attached (one piece)
Stoma cap.
Pouch, drainable; with barrier attached (one piece).
Pouch, drainable; with faceplate attached; rubber or plastic.
Pouch, drainable; for use on faceplate; plastic or rubber.
Pouch, urinary; with barrier attached (one piece).
Pouch, urinary; without barrier attached (one piece).
Pouch, urinary; for use on barrier with flange (two piece).
Pouch, urinary; with faceplate attached, plastic or rubber.
Pouch, urinary; for use on faceplate; plastic or rubber.
Bedside drainage bottle, rigid or expandable.
Urinary leg bag; latex.
Pressure pad, alternating with pump.
Pressure pad, alternating with pump, heavy duty.
Powered air flotation bed (low air loss therapy).
Alternating pressure mattress.
Ambulatory infusion pump, single or multiple channels, with administrative equipment, worn by patient.
Supplies for external drug infusion pump, per cassette or bag
Trunk support device, vest type, with inner frame, prefabricated
Elevating leg rest, pair (for use with capped rental wheelchair base)
December 1995 DMERC Medicare Advisory
1996 FEE SCHEDULES
Note:
The 1996 Update Factor for Durable Medical Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) is a 3.0% increase. The following is the 1996 fee schedule matrix.
Fee schedules for HCPCS deleted in 1996 have been included and are valid through March 31, 1996. Deleted 1996
HCPCS may not be used on or after April 1, 1996.
*Category HCPCS Modifier
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
Page 95-197
E0145
E0146
E0165
E0166
E0182
E0186
E0187
E0194
E0196
E0202
E0235
E0236
E0250
E0251
E0255
E0256
E0260
E0261
E0265
E0266
E0290
E0291
E0292
E0293
E0294
E0295
E0296
E0297
E0305
E0452
E0459
E0462
E0480
E0550
E0565
E0570
E0585
E0600
E0601
E0606
E0608
E0630
E0635
E0744
E0745
E0749
E0791
E0910
E0920
E0930
E0940
E0941
E0946
E0958
E0968
E1031
E1050
E1060
E1070
E1083
E1084
E1085
E1086
E1087
E1088
E1089
E1090
E1091
E1092
E1093
E1100
E1110
E1130
E1140
E1150
E1160
E1170
E1171
E1172
E1180
E1190
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
AL
AR
CO
FL
GA
KY
LA
MS
NM
NC
OK
PR
SC
TN
TX
VI
19.25
16.62
16.36
19.25
19.25
19.25
16.36
16.36
19.25
19.25
19.25
41.49
19.25
16.36
19.25
19.25
17.63
17.67
15.02
17.67
17.67
15.18
17.67
15.11
15.02
15.02
17.67
15.38
17.67
15.02
17.67
15.02
14.65
14.65
17.24
17.24
17.24
17.24
14.65
14.65
14.65
14.65
17.24
21.66
17.24
14.65
17.24
17.24
24.56
24.56
24.57
24.56
24.56
27.10
24.56
26.91
28.89
28.89
28.07
40.97
25.68
28.89
28.89
28.89
21.58
20.66
24.30
20.66
20.66
20.66
20.66
20.66
23.30
20.66
24.30
30.68
20.66
20.66
20.66
20.82
16.01
16.01
18.83
18.83
16.01
16.01
16.19
16.01
16.01
16.01
16.01
44.92
16.01
16.01
18.83
18.83
21.54
18.31
21.54
18.83
18.31
21.28
18.31
18.31
18.31
18.31
19.16
44.92
18.31
18.31
21.54
21.54
3,019.54 3,019.54 3,019.54 2,663.47 2,566.61 2,566.61 3,019.54 3,019.54 2,566.61 2,639.75 2,738.05 2,511.00 2,566.61 2,670.34 2,751.74 2,566.61
30.15
25.63
30.15
30.15
25.63
25.63
25.63
25.63
27.30
30.15
30.15
44.92
25.63
25.63
30.15
30.15
58.09
58.09
50.83
49.38
49.38
49.38
58.09
58.09
58.09
58.09
58.09
208.73
58.09
58.09
58.09
58.09
14.06
16.01
16.01
16.01
16.01
16.01
16.01
16.01
13.61
15.29
15.17
18.04
15.16
13.61
16.01
16.01
34.90
41.06
34.90
34.90
36.55
34.90
41.06
41.06
38.37
41.06
41.06
32.77
41.06
41.06
41.06
35.75
77.10
90.71
89.19
90.71
78.97
77.10
77.92
77.10
79.70
84.71
90.71
122.26
79.13
77.10
90.71
77.10
58.43
68.74
66.55
68.74
59.20
58.43
64.14
68.22
58.43
68.74
58.43
92.80
58.43
59.45
68.74
62.70
92.65
109.00
109.00
104.18
93.43
93.38
101.95
92.65
99.16
97.78
109.00
155.57
92.65
101.46
109.00
109.00
65.73
77.33
77.33
73.19
65.73
65.73
77.33
65.73
77.33
73.82
77.33
115.99
65.73
65.73
77.33
77.33
132.44
155.81
155.81
132.44
134.04
135.04
149.22
132.44
133.92
132.44
155.81
229.44
132.44
132.44
155.81
155.81
108.00
127.06
127.06
108.00
108.00
108.00
127.06
108.00
116.05
108.00
127.06
180.38
108.00
108.00
127.06
127.06
157.65
185.47
185.47
157.65
157.65
164.80
185.47
172.62
172.28
185.47
171.16
264.96
157.65
166.85
185.47
185.47
142.78
164.78
153.57
140.06
140.06
157.16
149.22
140.06
164.78
163.07
141.71
235.33
140.06
145.99
164.78
164.78
58.95
67.26
69.35
69.35
58.95
58.95
69.35
58.95
58.95
61.05
69.35
92.59
60.47
58.95
69.35
68.34
42.82
50.38
50.38
50.38
42.82
42.82
50.38
48.56
42.82
45.24
42.82
66.89
42.82
42.82
50.38
50.38
66.28
77.98
77.98
73.35
66.28
66.28
77.98
66.28
77.98
66.28
77.98
121.65
66.28
66.28
77.98
77.98
56.41
66.37
66.37
62.45
56.41
56.41
66.37
60.71
66.02
56.41
66.37
102.00
56.41
56.41
66.37
66.37
103.05
121.23
121.23
103.05
103.05
103.05
121.23
103.05
118.69
103.05
121.23
186.04
103.05
103.05
121.23
121.23
100.44
118.16
118.16
100.44
100.44
100.44
118.16
100.44
100.83
100.44
118.16
88.00
100.44
100.44
118.16
118.16
129.50
152.35
152.35
129.50
129.50
129.50
152.35
129.50
152.25
152.35
139.36
202.98
129.50
129.50
152.35
152.35
110.96
130.54
130.54
110.96
110.96
114.99
130.54
110.96
130.54
130.54
124.58
177.19
110.96
110.96
130.54
130.54
14.03
14.03
15.82
14.03
14.03
16.51
14.03
16.51
16.51
14.03
16.51
9.31
14.03
14.03
16.51
14.03
219.02
238.08
238.08
216.14
238.08
238.08
238.08
215.37
228.89
238.08
238.08
101.93
238.08
238.08
238.08
238.08
40.14
41.42
46.91
43.59
44.41
40.14
40.14
40.14
40.14
40.14
40.14
50.41
40.14
40.14
40.14
47.22
242.44
237.25
239.93
270.38
270.38
270.38
229.82
270.38
270.38
256.73
270.38
181.19
242.96
270.38
270.38
229.82
40.77
34.96
37.12
34.65
40.09
40.77
34.65
34.65
40.77
36.43
40.77
40.88
34.65
34.65
40.77
34.65
39.53
39.53
46.50
46.50
46.50
39.53
39.53
46.50
39.53
46.50
39.53
76.87
41.69
46.50
46.50
46.50
48.12
48.12
48.12
48.12
56.61
48.12
48.12
48.12
56.61
56.61
56.61
27.82
48.12
56.61
56.61
56.61
16.02
15.56
16.34
18.31
18.31
17.46
15.56
16.97
15.71
17.84
18.31
41.48
18.31
18.19
18.31
18.31
27.66
32.54
32.54
31.40
27.66
32.54
32.54
27.66
28.15
27.66
32.54
45.10
32.54
29.66
32.54
32.54
36.11
36.11
42.48
42.48
37.77
36.11
36.11
36.11
40.53
42.48
36.78
39.99
37.77
36.11
42.48
42.48
103.65
88.10
90.87
88.10
103.65
103.37
88.10
93.15
103.65
103.65
103.65
108.89
103.65
103.65
95.36
103.65
19.18
18.09
20.33
18.09
21.28
20.72
18.09
21.28
21.21
21.28
21.28
20.57
19.23
21.28
18.67
19.45
221.11
260.13
254.03
221.11
260.13
221.11
221.11
260.13
260.13
260.13
260.13
321.97
260.13
260.13
221.11
260.13
87.33
94.53
94.53
80.35
85.20
85.56
94.53
80.35
86.29
94.53
94.53
91.31
83.02
94.53
94.53
94.53
96.50
113.53
96.50
96.50
113.53
113.53
113.53
113.53
113.53
113.53
113.53
192.60
113.53
113.53
113.53
106.43
83.02
84.02
84.96
84.96
84.96
84.96
79.05
72.22
83.80
72.48
84.96
124.41
81.17
72.22
72.22
84.96
83.02
70.59
82.31
83.05
83.05
83.05
70.59
70.59
76.57
72.48
83.05
84.73
76.11
70.59
83.05
82.37
204.05
237.65
237.65
202.00
202.00
231.75
237.65
237.65
213.54
202.00
237.65
408.08
204.50
202.00
237.65
212.16
249.38
255.21
293.39
249.38
249.38
293.39
249.38
249.38
293.39
293.39
293.39
183.65
279.88
293.39
293.39
249.38
15.77
18.55
18.38
18.55
17.45
18.55
17.41
16.39
15.77
15.77
17.95
17.70
18.55
16.27
18.55
18.55
36.39
36.39
40.43
42.81
38.04
42.81
36.58
36.39
36.39
42.81
36.39
59.16
36.39
42.81
42.81
42.81
36.03
38.57
38.60
42.39
36.03
36.03
36.03
36.03
37.29
42.39
42.39
43.79
36.03
42.39
42.39
37.54
27.42
32.26
32.26
28.59
27.42
28.66
27.42
27.42
27.48
27.42
32.26
34.69
27.42
27.42
32.26
32.26
34.57
36.74
37.11
40.28
40.28
40.28
36.58
34.24
40.28
40.28
40.28
42.72
40.28
40.28
40.28
40.28
46.66
46.66
48.99
47.54
46.66
46.66
46.66
46.66
46.66
49.91
46.66
57.95
46.66
46.66
46.66
49.66
35.58
40.49
40.49
35.92
39.80
40.49
40.49
36.58
36.68
40.49
40.49
49.91
40.49
36.30
37.02
40.22
14.41
14.14
16.63
16.63
15.99
14.14
14.14
16.63
16.41
16.63
16.63
20.41
16.48
15.16
16.63
16.62
39.84
46.87
46.87
39.84
39.84
39.84
39.84
39.84
39.84
39.84
46.87
31.87
39.84
39.84
46.87
39.84
86.97
94.49
83.79
80.32
80.32
85.63
94.49
80.32
94.49
88.42
94.49
107.20
80.32
80.32
92.81
94.22
99.42
116.97
116.97
99.42
99.42
116.97
101.62
99.42
116.97
103.24
116.97
124.71
99.42
99.42
116.97
102.32
86.38
101.62
99.42
86.38
86.38
101.62
101.62
86.38
101.62
93.69
99.44
147.86
101.62
86.38
99.43
96.46
73.05
73.05
73.05
62.09
62.09
73.05
73.05
62.09
73.05
64.60
72.23
76.21
73.05
62.09
62.09
73.05
91.02
77.93
91.02
77.37
91.02
91.02
85.12
77.37
91.02
84.12
91.02
96.58
91.02
77.37
91.02
85.50
63.15
64.21
64.21
54.58
64.21
64.21
64.21
54.58
64.21
54.58
54.58
63.82
64.21
54.58
64.21
59.00
77.98
77.93
77.98
66.66
66.28
77.98
77.98
66.28
77.98
70.89
76.14
84.20
77.98
66.28
77.98
77.98
99.77
104.42
102.01
99.77
99.77
99.77
101.01
99.77
117.38
116.18
117.38
160.59
109.93
117.38
117.38
117.38
118.91
118.91
132.18
118.91
127.73
118.91
118.91
118.91
139.89
123.19
139.89
193.21
133.40
139.89
139.89
139.89
94.80
94.80
94.80
94.80
98.28
94.80
94.80
94.80
111.53
98.51
111.53
140.29
100.55
111.53
111.53
111.29
107.39
107.39
107.39
107.39
107.39
124.41
107.39
107.39
126.34
117.55
126.34
172.89
126.34
126.34
126.34
126.34
75.59
65.75
74.28
77.35
77.01
77.35
65.75
65.75
65.75
77.35
65.75
116.93
77.35
74.81
65.75
77.35
101.36
101.36
101.36
101.36
119.25
107.28
107.33
116.70
119.25
119.25
119.25
158.33
119.25
119.25
119.25
119.25
102.55
102.55
87.17
87.17
87.17
87.30
87.17
100.05
102.55
102.55
87.17
145.29
102.55
90.08
102.55
102.55
81.87
96.32
88.02
81.87
81.87
81.87
86.95
81.87
96.32
81.87
96.32
119.00
81.87
81.87
96.32
90.46
84.48
94.32
80.17
80.17
80.17
80.17
80.17
80.17
94.32
94.32
94.32
99.07
94.31
90.21
94.32
89.59
36.83
43.33
43.33
36.83
36.83
42.78
43.33
36.83
39.62
36.83
43.33
60.96
41.46
36.83
43.33
41.08
57.54
66.65
66.65
56.65
62.33
56.65
62.72
56.65
57.02
58.09
63.58
84.77
63.03
56.65
66.65
64.99
65.93
75.69
75.69
64.41
69.44
65.67
68.75
64.34
68.63
67.37
65.71
95.07
69.10
64.34
75.69
75.69
49.29
57.99
57.99
49.71
49.29
52.79
57.36
49.29
53.62
49.29
55.74
73.32
53.92
49.29
57.99
57.99
82.87
82.87
82.87
70.44
70.44
82.87
70.44
70.44
82.87
70.44
82.87
137.22
70.44
70.44
82.87
76.65
64.97
74.37
74.37
63.21
65.78
63.21
74.37
63.21
74.37
63.21
74.37
109.54
63.21
63.21
74.37
71.14
77.25
90.88
87.57
77.25
90.88
77.25
90.88
77.25
90.88
78.24
90.88
102.87
77.86
90.88
90.88
90.88
79.93
94.03
84.73
79.93
79.93
94.03
79.93
79.93
94.03
81.84
94.03
113.14
79.93
94.03
94.03
94.03
92.34
108.63
92.34
92.34
92.34
108.63
94.23
92.34
108.63
92.34
108.63
141.57
92.34
108.63
108.63
108.63
IN - Inexpensive/Routinely Purchased
OX - Oxygen
OS - Ostomy
SD - Surgical Dressing
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
Page 95-198
December 1995 DMERC Medicare Advisory
*Category HCPCS Modifier
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
FS
FS
FS
FS
FS
FS
FS
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
E1195
E1200
E1210
E1211
E1212
E1213
E1221
E1222
E1223
E1224
E1225
E1228
E1240
E1250
E1260
E1270
E1280
E1285
E1290
E1295
K0001
K0002
K0003
K0004
K0006
K0007
K0010
K0101
K0193
K0194
K0284
E0450
E0453
E0457
E0460
E0500
E0575
E0935
A4254
A4254
A4254
A4611
A4611
A4611
A4612
A4612
A4612
A4613
A4613
A4613
A4618
A4618
A4618
A4631
A4631
A4631
A4635
A4635
A4635
A4636
A4636
A4636
A4637
A4637
A4637
A4640
A4640
A4640
E0100
E0100
E0100
E0105
E0105
E0105
E0110
E0110
E0110
E0111
E0111
E0111
E0112
E0112
E0112
E0113
E0113
E0113
E0114
E0114
E0114
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
AL
AR
CO
FL
GA
KY
LA
MS
NM
NC
101.62
68.62
381.22
330.07
319.90
344.04
44.07
62.90
68.68
75.30
35.65
26.00
95.58
70.51
86.48
62.25
121.79
95.45
103.16
95.80
43.08
75.92
83.13
105.40
101.25
164.41
335.97
35.58
113.89
209.10
15.29
752.79
506.46
63.73
644.09
101.86
95.36
17.93
6.11
0.62
4.59
182.28
18.90
136.71
74.16
7.55
56.56
133.80
13.39
96.77
7.01
0.80
5.26
83.81
8.87
59.20
4.04
0.57
2.67
3.48
0.34
2.77
1.67
0.24
1.27
58.75
5.98
41.62
19.55
4.69
15.59
45.57
6.99
35.13
61.19
12.61
53.38
44.14
6.65
33.10
29.18
7.83
22.26
16.66
4.06
12.51
37.21
6.77
28.13
99.08
80.73
324.04
330.07
319.90
344.04
40.11
62.83
68.68
75.30
40.15
25.43
95.58
60.95
86.48
73.24
103.52
95.12
98.70
95.80
50.68
75.92
83.13
105.40
98.91
164.93
335.97
40.49
98.06
231.10
15.53
864.54
506.46
54.17
680.64
101.86
95.36
19.79
6.11
0.62
4.59
182.28
18.90
136.71
74.16
7.55
56.56
133.80
13.39
96.77
8.25
0.94
6.19
93.80
9.57
69.65
4.04
0.59
2.67
3.32
0.34
2.42
1.97
0.28
1.49
49.94
5.42
37.40
19.55
4.69
15.59
45.57
6.99
35.13
71.99
12.61
53.99
49.42
7.82
38.10
34.33
9.21
26.19
19.16
4.06
14.38
43.78
6.77
33.09
116.57
68.62
324.04
388.32
376.35
404.75
44.07
62.90
68.68
72.20
40.83
22.10
85.96
70.51
86.48
70.11
121.79
111.90
116.12
112.70
50.68
75.92
83.13
105.40
116.36
164.93
395.26
40.49
98.06
231.10
15.53
752.79
521.02
55.31
680.64
86.58
84.62
21.09
6.11
0.62
4.59
182.28
18.90
136.71
74.16
7.55
56.56
113.73
11.38
82.25
8.25
0.94
6.19
92.84
9.29
69.65
4.75
0.64
3.14
3.90
0.40
2.85
1.97
0.24
1.49
58.75
5.98
41.62
19.55
5.52
15.59
44.11
8.22
35.13
61.19
12.61
45.89
47.76
6.65
38.13
34.02
9.21
25.51
17.01
4.78
12.75
43.78
7.96
33.09
99.08
68.62
324.04
330.07
319.90
344.04
37.46
53.47
58.38
64.01
35.65
22.10
81.24
59.93
73.51
62.25
103.52
95.12
98.70
95.80
43.08
64.53
70.66
105.40
98.91
153.69
335.97
35.92
98.06
205.97
14.28
885.64
506.46
54.17
680.64
101.86
93.89
21.09
6.11
0.62
4.59
175.31
17.53
131.47
74.16
7.55
56.56
121.29
12.13
90.98
7.01
0.80
5.26
93.80
9.57
69.65
4.04
0.54
2.67
3.32
0.34
2.42
1.67
0.24
1.27
49.94
5.08
35.46
19.55
4.69
15.59
45.57
6.99
35.13
67.44
13.34
50.58
42.01
6.65
32.41
29.18
7.83
22.26
16.66
4.06
12.51
38.65
6.77
28.97
99.08
68.62
353.40
336.82
319.90
344.04
44.07
62.35
68.68
75.30
37.68
22.10
95.58
70.51
86.22
73.24
106.08
111.90
116.12
112.70
43.64
64.53
82.08
105.40
116.36
162.85
335.97
39.80
108.53
231.10
15.14
885.64
595.84
54.17
680.64
86.58
93.50
17.93
6.11
0.62
4.59
154.94
16.07
116.20
70.96
7.11
53.21
113.73
11.38
82.25
7.59
0.80
5.72
84.12
8.72
63.09
4.04
0.54
2.67
3.32
0.34
2.42
1.67
0.24
1.27
58.75
5.98
41.62
19.55
4.69
15.51
45.57
6.99
35.13
61.19
12.61
45.89
45.63
6.65
34.23
29.18
7.83
22.26
16.66
4.06
12.51
37.21
6.77
28.13
116.57
77.72
324.04
334.03
319.90
344.04
37.46
53.47
58.38
64.01
41.94
26.00
81.24
59.93
73.51
70.07
121.79
95.12
110.58
95.80
46.25
75.92
70.66
121.05
103.99
164.93
335.97
40.49
108.48
231.10
15.53
885.64
595.84
54.17
680.64
98.65
95.36
21.09
6.11
0.62
4.59
169.01
16.91
126.75
63.04
6.42
48.08
133.80
13.39
96.77
8.25
0.82
6.19
93.80
9.57
69.65
4.75
0.64
3.14
3.90
0.40
2.85
1.97
0.28
1.49
58.75
5.98
41.62
16.62
4.69
13.25
44.61
6.99
33.45
69.42
12.61
52.08
42.01
7.82
32.41
34.33
8.09
25.80
17.23
4.06
12.93
40.96
6.77
30.74
107.33
77.55
324.04
330.07
319.90
344.04
37.46
57.36
62.72
75.30
37.75
23.93
81.24
70.51
86.48
71.64
103.52
95.12
98.70
95.80
49.79
75.92
83.13
105.40
98.91
164.93
335.97
40.49
98.06
223.28
15.33
776.70
506.46
54.17
680.64
86.58
81.06
20.33
6.11
0.62
4.59
182.28
18.90
136.71
74.16
7.55
56.56
133.80
13.39
96.77
8.25
0.94
6.19
79.73
8.13
59.20
4.04
0.60
2.67
3.90
0.40
2.85
1.97
0.28
1.49
49.94
5.42
37.40
19.55
4.69
15.59
45.57
6.99
35.13
71.99
12.61
53.99
42.01
6.65
32.41
34.33
7.83
26.19
18.25
4.06
13.70
43.78
7.74
33.09
99.08
68.62
325.47
330.07
319.90
344.04
44.07
62.90
68.68
75.30
37.62
22.10
81.24
59.93
73.51
62.25
103.52
95.12
98.70
95.80
43.08
64.53
70.66
105.40
98.91
150.45
335.97
36.58
98.06
196.44
14.00
752.79
536.89
63.73
680.64
86.58
81.06
17.93
6.11
0.62
4.59
175.31
17.53
131.47
74.16
7.55
56.56
133.80
13.39
96.77
7.01
0.80
5.26
79.73
8.13
59.20
4.75
0.64
3.14
3.90
0.40
2.85
1.97
0.27
1.49
49.94
5.08
35.38
16.62
4.69
14.84
45.57
6.99
35.13
68.24
12.61
51.18
42.01
6.65
32.41
34.33
7.83
26.19
19.60
4.06
14.72
43.78
6.77
33.09
116.57
80.73
381.22
388.32
319.90
404.75
37.46
53.47
58.38
68.61
39.71
22.10
95.58
69.09
86.48
73.24
121.79
105.94
116.12
112.70
44.57
75.92
83.13
124.00
116.36
148.39
395.26
36.68
101.30
231.10
13.79
853.76
506.46
54.17
680.64
101.86
91.06
17.93
6.11
0.62
4.59
154.94
16.07
116.20
74.16
7.55
56.56
129.03
12.92
96.77
8.19
0.82
6.15
93.80
9.57
69.65
4.04
0.60
2.67
3.32
0.34
2.42
1.67
0.24
1.27
58.75
5.98
41.62
19.55
4.69
15.59
45.57
6.99
35.13
71.99
12.61
53.99
49.42
6.65
37.39
29.18
7.83
22.26
19.60
4.06
14.72
37.21
6.77
28.13
99.08
69.48
324.04
336.68
319.90
344.04
37.46
53.47
58.38
64.01
35.65
22.10
83.68
59.93
74.09
66.54
116.32
106.70
109.55
102.45
43.08
67.70
70.66
115.48
108.84
164.93
335.97
40.49
113.53
231.10
15.53
885.64
595.84
58.41
680.64
94.97
81.06
19.48
6.11
0.62
4.59
154.94
16.07
116.20
74.16
7.43
55.62
113.73
11.38
82.25
7.01
0.80
5.26
93.80
9.57
69.65
4.04
0.54
2.67
3.37
0.34
2.53
1.97
0.28
1.49
52.96
5.42
36.93
16.62
4.69
13.25
44.14
6.99
33.10
69.44
12.61
52.09
42.01
6.65
32.41
31.19
7.83
23.39
16.66
4.06
12.51
37.21
6.77
28.13
IN - Inexpensive/Routinely Purchased
OX - Oxygen
OS - Ostomy
SD - Surgical Dressing
OK
PR
116.57
119.57
80.73
116.93
381.22
407.94
388.32
407.94
376.35
387.65
404.75
395.02
37.46
57.12
55.74
68.77
59.02
79.80
65.71
90.50
40.29
45.96
25.53
27.00
95.58
102.52
66.31
69.20
86.48
90.08
73.24
80.79
106.97
192.60
105.94
117.21
116.12
179.67
102.19
159.97
50.68
68.01
71.99
81.47
80.78
84.26
124.00
169.60
116.36
164.12
164.93
196.89
395.26
393.84
40.49
49.91
115.37
146.08
231.10
111.90
15.53
18.31
885.64 1,472.51
506.46
692.44
54.17
60.29
680.64
747.90
101.86
89.22
95.36
95.65
17.93
15.72
6.11
7.31
0.62
0.73
4.59
5.50
154.94
245.95
16.07
30.75
116.20
184.47
74.16
30.14
7.55
3.77
56.56
22.62
129.03
97.91
12.92
12.25
96.77
73.45
8.17
8.98
0.82
1.12
6.13
6.74
93.80
119.54
9.57
14.94
69.65
89.65
4.75
5.14
0.64
0.65
3.14
3.86
3.90
2.20
0.40
0.28
2.85
1.66
1.67
2.50
0.28
0.32
1.49
1.87
58.75
70.62
5.98
8.83
41.62
52.96
19.55
31.83
4.69
3.98
15.59
23.88
45.57
56.34
6.99
7.03
34.17
42.26
71.99
92.19
14.84
11.53
53.99
69.14
49.42
45.85
7.82
5.74
37.06
34.38
34.33
41.56
7.83
5.19
26.19
31.17
19.60
20.78
4.06
2.60
14.72
15.60
43.78
57.77
6.77
7.22
33.09
43.34
SC
TN
TX
VI
99.08
68.62
324.04
333.46
319.90
344.04
44.07
61.32
68.68
75.30
37.05
22.10
95.58
59.93
86.48
69.66
105.63
95.12
99.82
95.80
47.58
75.92
83.13
124.00
98.91
161.69
335.97
40.49
115.37
231.10
15.04
752.79
595.84
56.65
661.41
101.86
95.36
17.93
6.11
0.62
4.59
169.01
16.91
126.75
74.16
7.43
55.62
121.29
12.13
90.98
8.25
0.82
6.19
81.61
8.17
61.21
4.04
0.54
2.67
3.32
0.34
2.42
1.97
0.24
1.49
49.94
5.08
35.38
18.42
4.69
13.80
45.57
6.99
35.13
71.99
12.61
53.99
45.61
6.65
34.21
29.18
7.83
22.26
16.66
4.06
12.51
43.78
6.77
33.09
116.57
80.73
324.04
330.07
319.90
344.04
38.85
53.47
59.36
64.01
35.65
22.10
81.24
68.54
86.48
62.25
103.52
111.90
116.12
112.70
43.08
64.53
83.13
124.00
116.36
157.39
335.97
36.30
113.07
231.10
14.64
885.64
595.84
54.17
680.64
86.59
95.36
17.93
6.11
0.62
4.59
154.94
16.07
116.20
63.04
6.42
48.08
117.92
11.80
88.45
7.01
0.80
5.26
93.80
9.57
69.65
4.04
0.56
2.67
3.32
0.34
2.42
1.67
0.24
1.27
53.85
5.40
40.40
19.55
4.69
15.59
44.75
6.99
34.96
64.74
12.61
48.53
42.01
6.65
32.41
29.18
7.83
22.26
16.66
4.06
12.51
42.93
6.77
32.19
116.57
80.73
324.04
330.07
319.90
344.04
44.07
60.13
68.68
75.30
35.65
26.00
95.58
70.51
86.48
73.24
121.79
111.90
112.39
112.70
50.68
75.92
83.13
124.00
116.36
164.93
335.97
37.02
109.52
231.10
15.53
885.64
506.46
63.73
680.64
101.86
95.36
21.09
6.11
0.62
4.59
182.28
18.90
136.71
74.16
7.55
56.56
113.73
11.38
82.25
7.01
0.80
5.26
85.45
9.33
64.10
4.04
0.59
2.67
3.32
0.34
2.42
1.74
0.25
1.31
49.94
5.08
35.38
18.19
4.69
13.65
44.29
6.99
35.06
66.22
12.61
49.66
42.01
6.65
32.41
34.33
7.83
26.19
16.98
4.06
12.74
38.19
6.77
28.64
116.57
80.73
324.04
373.51
319.90
344.04
44.07
62.90
67.28
64.01
41.94
22.10
87.59
59.93
80.32
65.29
121.79
105.39
116.12
112.70
47.84
75.53
74.44
124.00
116.36
162.81
335.97
40.22
115.37
196.44
15.14
885.64
595.84
54.17
578.54
101.86
95.36
17.93
6.11
0.62
4.59
154.94
16.07
116.20
66.14
6.61
49.59
133.74
13.38
96.77
8.25
0.94
6.19
93.80
9.57
69.65
4.75
0.58
3.13
3.90
0.39
2.85
1.67
0.24
1.31
51.61
5.40
37.47
19.55
5.52
15.59
45.57
8.22
35.13
71.99
12.61
53.99
47.00
6.65
35.24
34.33
7.83
26.19
19.60
4.78
14.72
40.81
7.17
30.94
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
December 1995 DMERC Medicare Advisory
*Category HCPCS Modifier
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
E0116
E0116
E0116
E0130
E0130
E0130
E0135
E0135
E0135
E0141
E0141
E0141
E0142
E0142
E0142
E0143
E0143
E0143
E0147
E0147
E0147
E0153
E0153
E0153
E0154
E0154
E0154
E0155
E0155
E0155
E0156
E0156
E0156
E0157
E0157
E0157
E0158
E0158
E0158
E0160
E0160
E0160
E0161
E0161
E0161
E0162
E0162
E0162
E0163
E0163
E0163
E0164
E0164
E0164
E0167
E0167
E0167
E0175
E0175
E0175
E0176
E0176
E0176
E0177
E0177
E0177
E0178
E0178
E0178
E0179
E0179
E0179
E0184
E0184
E0184
E0185
E0185
E0185
E0191
E0191
E0191
E0192
E0192
E0192
E0197
E0197
E0197
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
AL
AR
21.88
4.26
16.46
65.17
13.27
50.78
77.09
13.76
59.68
106.97
17.64
80.23
159.57
24.52
121.53
111.56
17.03
80.93
341.19
34.12
255.58
64.38
6.87
48.27
63.50
7.26
49.71
28.82
3.03
21.59
24.52
3.13
18.41
69.72
8.34
52.34
29.85
3.05
22.54
26.07
3.42
19.54
24.33
3.31
18.23
117.54
12.05
89.11
102.33
19.27
78.91
143.07
23.99
107.30
9.47
1.00
7.66
61.45
6.15
45.22
84.47
11.16
62.79
83.71
9.58
62.79
104.87
11.84
78.64
9.44
0.99
7.43
153.55
22.79
117.77
252.26
35.44
193.60
9.27
0.94
6.93
342.09
36.17
228.92
187.18
24.11
153.50
25.74
5.01
19.37
65.17
13.27
50.78
77.79
13.61
59.68
106.97
17.64
80.23
159.57
20.84
121.53
111.56
17.03
83.48
376.58
38.25
286.14
64.38
6.70
48.27
65.42
7.80
49.71
24.90
3.03
18.97
24.52
3.13
18.41
76.01
8.34
57.01
27.09
2.80
20.31
26.07
3.42
19.54
24.33
3.31
18.23
135.18
14.18
104.84
102.33
19.27
78.91
143.07
20.84
108.05
11.14
1.18
8.39
52.23
5.23
38.44
99.38
13.13
73.87
98.48
11.27
73.87
112.59
13.13
84.44
9.93
1.00
7.47
180.65
19.37
135.50
252.26
35.44
193.60
8.70
0.87
6.52
337.90
33.78
253.44
174.75
24.11
153.50
CO
21.88
5.01
16.46
65.17
15.61
50.78
71.31
16.01
59.68
106.97
20.75
80.23
159.57
20.84
121.53
111.56
20.04
83.48
320.09
32.51
243.22
55.50
7.27
41.63
62.72
7.23
49.71
28.79
3.57
22.32
20.84
2.66
15.65
76.01
8.34
57.01
27.09
2.80
20.31
30.67
4.02
22.99
20.68
2.81
15.50
135.18
14.18
104.84
98.30
22.67
78.91
168.32
24.52
126.24
9.47
1.18
7.13
61.45
6.15
45.22
97.98
11.16
73.49
86.05
9.58
64.53
112.59
11.91
84.44
11.10
1.16
8.74
153.55
19.37
117.77
296.78
35.44
222.57
9.27
0.94
6.93
359.09
35.96
269.32
205.59
28.37
180.59
FL
21.88
4.26
16.46
65.17
15.61
50.78
77.79
16.01
56.15
106.55
20.75
79.37
135.63
24.52
103.30
104.86
20.04
80.77
320.09
37.10
243.22
54.72
6.18
41.03
55.61
6.87
42.25
26.96
3.03
20.21
20.84
2.66
15.65
64.61
7.09
48.46
25.37
2.80
19.16
26.07
3.42
19.54
24.33
3.05
18.23
135.18
14.18
104.84
99.47
22.67
78.91
143.07
23.04
107.30
9.48
1.00
7.13
61.45
6.15
45.22
99.38
13.13
73.51
83.71
9.58
62.79
99.38
13.93
73.51
11.10
1.16
8.74
180.65
22.79
138.55
275.89
35.44
206.91
8.58
0.85
6.44
359.09
35.99
269.32
174.75
24.11
153.50
GA
21.88
4.26
16.46
65.17
15.61
50.78
70.12
16.01
55.08
103.38
17.64
77.54
159.57
20.84
121.53
103.38
17.03
77.54
320.09
32.51
243.22
56.01
6.18
41.99
65.42
6.76
49.06
28.40
3.03
21.27
24.52
3.13
18.41
67.14
7.09
50.35
29.85
3.29
22.54
26.07
3.42
19.54
24.33
2.81
18.23
114.90
12.05
89.11
102.33
21.58
74.49
143.07
20.84
107.30
9.47
1.00
7.83
61.45
6.15
45.22
99.38
13.13
73.87
98.48
11.27
73.87
112.59
13.93
84.44
11.10
1.16
8.74
180.65
20.96
138.55
269.35
35.44
202.00
7.88
0.80
5.89
359.09
36.17
269.32
174.75
24.11
153.50
IN - Inexpensive/Routinely Purchased
OX - Oxygen
Page 95-199
KY
22.06
4.26
16.56
55.39
15.07
43.16
66.12
16.01
50.73
95.58
20.75
71.70
159.39
24.52
119.55
96.76
20.04
72.56
320.09
32.51
243.22
64.38
7.27
48.27
65.42
7.87
49.71
29.29
3.03
22.32
24.34
2.66
18.24
64.61
7.09
48.46
25.37
2.80
19.16
26.07
3.42
19.54
20.68
2.81
15.50
114.90
12.05
89.11
99.51
20.31
73.22
143.07
20.84
107.30
9.47
1.00
7.13
61.45
6.15
45.22
99.38
13.13
73.87
98.48
11.27
73.87
112.59
13.93
84.44
9.44
0.99
7.43
153.55
19.37
117.77
252.26
35.44
193.60
9.27
0.94
6.93
359.09
36.17
269.32
174.75
24.11
153.50
LA
MS
25.74
4.26
19.37
65.17
13.27
50.78
76.92
13.61
59.68
106.97
17.64
80.23
159.57
20.84
119.67
111.56
17.03
83.48
376.58
38.25
286.14
64.38
6.70
48.27
65.42
7.95
49.71
24.90
3.03
18.97
24.52
3.13
18.41
76.01
8.34
57.01
27.09
2.80
20.31
30.67
4.02
22.99
24.33
3.31
18.23
135.18
13.77
104.84
93.69
19.27
73.66
143.07
20.84
107.30
9.47
1.00
7.13
52.23
5.23
38.44
99.38
13.13
73.87
98.48
11.27
73.87
112.59
13.93
84.44
9.93
1.00
7.47
180.65
19.37
138.55
252.26
35.44
193.60
8.94
0.89
6.72
347.48
34.74
260.61
174.75
24.11
153.50
24.43
4.26
19.37
55.58
14.55
45.44
66.12
14.40
50.73
106.94
20.75
80.21
159.57
20.84
121.53
101.62
17.03
76.23
376.58
38.25
286.14
64.38
6.79
48.27
65.42
7.95
49.71
24.90
3.03
18.97
24.52
3.13
18.41
64.61
7.09
48.46
25.37
3.29
19.16
30.67
3.42
22.99
24.33
3.31
18.23
135.18
14.16
104.84
92.36
19.27
74.57
143.07
24.52
107.30
11.14
1.12
8.37
61.45
6.15
45.22
99.38
13.13
73.87
98.48
11.27
73.87
112.59
13.82
84.44
9.44
0.99
7.43
180.65
22.79
138.55
252.26
35.44
193.60
8.92
0.89
6.70
324.91
32.50
243.70
174.75
24.11
153.50
NM
25.74
4.26
19.37
65.17
13.27
50.78
77.79
13.61
59.68
104.35
17.64
78.25
135.63
20.84
103.30
111.53
17.03
83.48
376.58
37.67
282.44
57.29
6.18
42.98
65.42
7.95
49.71
29.29
3.17
22.32
24.52
2.76
18.41
76.01
8.34
57.01
29.85
3.25
22.54
26.07
3.42
19.54
20.68
2.81
15.50
114.90
12.05
89.11
102.33
19.27
77.14
168.32
21.61
126.24
11.14
1.18
8.39
61.45
6.15
45.22
99.38
11.27
73.87
98.48
11.27
73.87
112.59
11.84
84.44
9.70
0.99
7.43
153.55
19.37
117.77
296.78
39.87
227.77
9.27
0.94
6.93
359.09
36.17
269.32
174.75
24.11
153.50
OS - Ostomy
SD - Surgical Dressing
NC
OK
PR
SC
TN
TX
VI
21.88
4.26
16.46
61.32
13.63
45.99
77.79
13.63
59.68
106.97
18.41
80.23
156.20
20.84
117.15
98.44
20.04
70.96
376.58
38.25
286.14
64.38
7.27
48.27
65.42
6.76
49.71
24.90
3.03
18.97
21.95
2.66
16.46
76.01
8.21
57.01
28.21
2.83
21.14
26.07
3.42
19.54
24.33
2.81
18.23
114.90
12.05
89.11
87.37
19.27
67.07
168.32
21.95
126.24
10.72
1.07
8.04
61.45
6.15
45.22
84.47
11.16
72.62
88.49
9.58
66.35
95.70
11.84
71.77
11.10
1.16
8.74
180.65
22.79
138.55
296.78
39.03
227.77
7.88
0.80
5.89
359.09
36.17
269.32
174.75
24.11
153.50
25.74
4.26
19.37
65.17
13.27
50.78
76.58
13.61
57.43
106.97
17.64
80.23
145.62
20.84
109.22
107.53
17.03
80.64
376.58
37.67
282.44
57.29
6.18
42.98
65.42
6.76
49.07
29.29
3.14
22.32
24.52
3.13
18.41
75.84
7.58
56.89
29.85
3.29
22.54
26.07
3.42
19.54
20.68
2.81
15.50
114.90
12.05
89.11
102.33
19.27
78.91
164.82
20.84
123.61
9.64
1.00
7.22
61.45
6.15
45.22
98.48
11.16
73.87
98.48
9.84
73.87
98.48
11.84
73.87
9.70
0.99
7.43
153.55
19.37
117.77
296.78
41.69
227.77
9.27
0.94
6.93
359.09
36.17
269.32
174.75
24.11
153.50
28.89
3.63
21.66
84.36
10.55
73.16
112.31
13.47
63.18
135.36
16.93
101.53
145.37
18.17
109.05
141.26
17.65
105.94
434.99
54.37
326.24
82.84
10.37
62.13
75.04
9.38
56.28
41.69
5.20
31.27
115.89
14.48
86.92
70.53
8.82
52.90
37.08
4.64
27.80
5.52
0.69
4.14
27.54
3.45
20.65
236.46
29.57
177.32
134.84
16.87
101.13
230.73
28.85
173.06
12.96
1.61
9.71
64.75
8.09
48.56
149.99
18.63
112.49
149.99
18.63
112.49
149.99
18.63
112.49
42.91
5.37
32.18
214.50
26.82
160.88
650.92
81.36
488.19
11.76
1.45
8.82
434.04
54.27
325.53
108.98
13.63
81.75
25.74
4.26
19.37
61.50
13.27
49.13
69.96
13.61
52.47
97.62
17.64
73.21
135.63
20.84
103.30
98.00
17.03
73.51
320.09
32.51
243.22
58.75
6.18
44.07
65.42
6.76
49.71
27.06
3.03
20.29
24.34
2.66
18.24
76.01
8.30
57.01
29.85
3.05
22.54
26.07
3.42
19.54
23.56
2.81
17.66
130.74
13.07
98.06
102.33
19.27
78.91
143.07
20.84
107.30
10.60
1.00
7.94
52.23
5.23
38.44
92.07
11.16
64.85
92.07
9.58
64.85
95.70
11.84
71.77
9.67
0.99
7.43
180.65
22.79
138.55
252.26
35.44
193.60
7.88
0.80
5.89
318.79
30.74
239.10
174.75
24.11
153.50
21.88
4.26
16.46
60.05
14.79
50.78
77.79
14.79
59.68
90.92
17.64
69.11
135.63
20.84
103.30
111.16
17.03
83.37
376.58
38.25
286.14
64.38
7.27
48.27
64.21
6.76
48.43
25.08
3.03
18.97
21.95
2.66
16.46
76.01
8.21
57.01
25.37
2.80
19.16
26.07
3.42
19.54
24.33
2.81
18.23
135.18
14.18
104.84
99.52
19.98
76.32
168.32
24.52
126.24
11.00
1.09
8.26
61.45
6.15
45.22
99.38
13.13
73.87
95.35
9.58
71.50
95.70
11.84
71.77
11.10
1.16
8.74
180.65
22.79
138.55
296.78
41.69
227.77
7.88
0.80
5.89
359.09
36.17
269.32
174.75
24.11
153.50
21.88
4.26
16.46
60.56
13.27
48.20
77.79
13.61
59.68
98.49
17.64
73.88
144.62
24.52
108.47
107.44
17.03
75.50
376.58
38.25
286.14
64.38
7.27
48.27
65.42
7.95
49.71
29.29
3.57
22.32
20.84
2.66
15.65
64.61
7.09
48.46
28.77
3.29
21.59
26.07
3.42
19.54
20.68
2.81
15.50
114.90
12.05
89.11
102.33
22.67
78.91
168.32
24.52
126.24
11.08
1.11
8.39
61.45
6.15
45.22
99.38
11.16
73.87
98.48
11.14
73.87
112.59
13.93
84.44
9.44
0.99
7.43
153.55
22.79
117.77
296.78
41.69
227.77
8.69
0.87
6.51
306.55
30.78
229.91
174.75
24.11
153.50
21.88
5.01
16.46
63.57
13.27
50.78
77.79
15.54
59.68
106.97
17.64
80.23
135.63
20.84
103.30
111.56
20.04
83.48
336.25
34.12
254.49
64.38
6.72
48.27
58.66
6.76
45.43
24.90
3.03
18.97
24.52
3.13
18.41
66.45
7.09
49.85
25.37
2.80
19.16
30.67
4.02
22.99
24.33
3.05
18.23
135.18
14.18
104.84
102.33
19.27
78.91
168.32
24.52
126.24
11.14
1.16
8.39
52.23
5.23
38.44
99.38
13.13
73.87
98.48
11.27
73.87
112.59
13.93
84.44
10.74
1.07
8.06
180.65
22.79
138.55
296.78
41.69
227.77
7.88
0.80
5.89
347.60
36.17
257.70
174.75
24.11
153.50
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
Page 95-200
December 1995 DMERC Medicare Advisory
*Category HCPCS Modifier
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
E0198
E0198
E0198
E0199
E0199
E0199
E0200
E0200
E0200
E0205
E0205
E0205
E0210
E0210
E0210
E0215
E0215
E0215
E0220
E0220
E0220
E0225
E0225
E0225
E0230
E0230
E0230
E0237
E0237
E0237
E0238
E0238
E0238
E0239
E0239
E0239
E0249
E0249
E0249
E0271
E0271
E0271
E0272
E0272
E0272
E0275
E0275
E0275
E0276
E0276
E0276
E0280
E0280
E0280
E0310
E0310
E0310
E0325
E0325
E0325
E0326
E0326
E0326
E0560
E0560
E0560
E0605
E0605
E0605
E0607
E0607
E0607
E0609
E0609
E0609
E0610
E0610
E0610
E0615
E0615
E0615
E0621
E0621
E0621
E0627
E0627
E0627
E0628
E0628
E0628
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
AL
174.75
18.10
132.61
27.13
2.72
20.34
73.56
9.98
55.19
153.05
16.84
114.78
25.74
2.42
19.30
55.87
5.85
41.91
6.68
0.71
5.00
306.51
30.21
229.88
7.87
0.89
5.89
458.13
44.71
343.59
25.09
2.46
18.44
417.37
41.74
313.04
78.55
8.64
58.91
206.01
21.40
160.94
159.60
16.66
119.14
14.20
1.48
10.65
11.14
1.23
8.30
35.44
3.81
26.59
165.21
20.25
136.31
7.97
1.19
5.52
8.40
1.11
6.44
136.83
17.08
102.66
20.84
2.42
17.16
61.99
6.20
46.48
507.25
50.73
380.46
195.21
22.26
146.40
444.27
54.28
333.21
75.71
7.29
57.07
312.99
31.30
234.75
312.99
31.30
234.75
AR
CO
FL
GA
KY
LA
MS
NM
NC
OK
PR
SC
TN
TX
174.75
18.10
132.61
25.28
2.52
18.96
73.56
9.98
55.19
180.06
19.81
135.04
25.74
2.42
19.30
65.73
6.88
49.30
6.68
0.71
5.00
345.72
34.57
259.28
7.36
0.76
5.53
460.65
51.29
345.46
25.09
2.52
18.44
354.76
35.48
266.08
81.87
8.64
61.39
206.01
21.40
160.94
187.77
19.60
140.16
12.07
1.26
9.05
12.34
1.45
9.77
35.44
3.81
26.59
180.14
20.44
136.31
9.38
1.40
6.21
9.75
1.03
7.30
159.14
18.65
119.36
21.43
2.42
17.16
61.99
6.20
46.48
596.77
59.68
447.60
187.60
19.79
140.71
377.63
46.14
283.23
89.07
8.58
67.14
306.40
30.64
229.80
306.40
30.64
229.80
205.59
21.29
156.01
29.74
2.97
22.31
73.56
9.98
55.19
180.06
19.81
135.04
30.28
2.85
22.71
65.73
6.88
49.30
6.68
0.71
5.00
360.60
35.54
270.45
7.36
0.76
5.53
460.65
51.29
345.46
21.33
2.14
15.67
417.37
41.74
313.04
92.41
10.16
69.31
206.01
20.09
160.94
182.69
18.25
137.02
14.20
1.48
10.65
12.34
1.45
9.77
35.44
3.81
26.59
153.12
21.12
136.31
7.97
1.19
5.28
8.29
0.94
6.21
135.27
15.85
101.46
24.52
2.85
20.19
61.99
6.20
46.48
560.04
50.73
380.46
220.70
22.07
165.54
444.27
54.28
333.21
89.07
7.29
67.14
312.99
31.30
234.75
312.99
31.30
234.75
205.59
21.29
156.01
28.55
2.86
21.40
62.53
8.48
46.91
153.05
16.84
114.78
25.74
2.44
19.30
55.87
5.85
41.91
6.68
0.71
5.00
306.51
30.21
229.88
7.87
0.82
5.89
391.55
43.60
293.64
21.33
2.14
15.67
417.37
41.74
313.04
78.55
8.64
58.91
175.11
18.19
136.80
177.19
17.72
132.89
12.07
1.26
9.05
10.97
1.23
8.30
34.33
3.45
25.75
170.63
17.95
127.97
8.28
1.19
6.21
9.75
1.11
7.30
141.02
18.41
105.76
24.09
2.83
18.06
61.99
6.20
46.48
507.25
50.73
380.46
220.70
23.28
165.54
444.27
53.96
333.21
78.72
7.88
59.04
312.99
31.30
234.75
312.99
31.30
234.75
174.75
18.10
132.61
29.74
2.97
22.31
73.56
9.98
55.19
180.06
19.81
135.04
27.02
2.69
20.25
55.87
5.85
41.91
7.86
0.83
5.88
360.60
35.54
270.45
6.81
0.76
5.10
458.13
45.80
343.59
25.09
2.52
18.44
417.37
41.74
313.04
92.41
10.16
69.31
188.39
18.85
141.31
187.77
19.60
140.16
14.20
1.48
10.65
12.34
1.45
9.77
35.44
3.81
26.59
180.14
20.17
135.14
7.97
1.19
5.28
8.55
0.94
6.42
135.27
17.08
101.46
20.84
2.42
17.16
61.99
6.20
46.48
507.25
50.73
380.46
195.21
19.79
146.40
444.27
54.28
333.21
75.71
7.29
57.07
312.99
31.30
234.75
312.99
31.30
234.75
205.59
21.29
156.01
29.74
2.97
22.31
73.56
9.01
55.19
153.05
19.29
114.78
25.74
2.50
19.30
55.87
5.85
41.91
6.68
0.71
5.00
360.60
35.54
270.45
6.69
0.76
5.01
460.65
48.04
345.46
25.09
2.52
18.44
369.23
36.93
276.94
78.55
8.64
58.91
189.27
18.92
141.98
187.77
18.83
140.16
14.20
1.44
10.65
12.34
1.44
9.77
30.12
3.24
22.60
154.37
21.12
115.86
9.38
1.40
6.21
9.75
1.11
7.30
143.06
15.85
107.28
24.52
2.85
20.19
61.99
6.20
46.48
596.77
59.68
447.60
195.21
23.28
146.40
444.27
54.28
333.21
75.71
7.29
57.07
312.99
31.30
234.75
312.99
31.30
234.75
174.75
18.10
132.61
25.28
2.52
18.96
73.56
9.98
55.19
180.06
19.81
135.04
29.26
2.85
21.95
65.73
6.88
49.30
6.68
0.71
5.00
355.49
35.54
266.63
7.59
0.76
5.72
460.65
51.29
345.46
25.09
2.52
18.44
354.76
35.48
266.08
84.18
8.64
63.15
178.55
18.19
136.80
187.77
19.60
140.16
12.07
1.26
9.05
12.34
1.45
9.77
35.44
3.81
26.59
180.14
20.55
136.31
9.38
1.40
6.21
9.75
1.07
7.30
159.14
16.36
119.36
22.05
2.42
17.16
61.99
6.20
46.48
596.77
59.68
447.60
187.60
19.79
140.71
377.63
46.14
283.23
89.07
8.58
67.14
306.40
30.64
229.80
306.40
30.64
229.80
174.75
18.10
132.61
25.28
2.52
18.96
62.53
8.48
46.91
153.05
16.84
114.78
25.96
2.59
19.47
55.87
5.85
41.91
7.86
0.83
5.88
360.60
35.54
270.45
7.87
0.89
5.89
458.13
44.72
343.59
25.09
2.52
18.44
417.37
41.74
313.04
78.55
8.64
58.91
175.11
18.19
149.17
159.60
16.66
119.14
14.20
1.48
10.65
12.34
1.45
9.77
30.12
3.24
22.60
162.46
18.91
121.86
9.38
1.19
6.21
9.75
0.98
7.30
157.62
15.85
118.21
24.52
2.83
20.19
61.99
6.20
46.48
596.77
59.68
447.60
220.70
23.28
165.54
444.27
54.28
333.21
89.07
8.58
67.14
306.85
30.69
230.12
306.85
30.69
230.12
174.75
18.10
132.61
27.94
2.81
20.96
70.06
8.48
52.53
180.06
19.81
135.04
25.74
2.42
19.30
55.87
5.85
41.91
7.86
0.83
5.88
360.60
35.54
270.45
7.87
0.89
5.89
460.65
46.06
345.46
21.33
2.14
15.67
355.63
35.56
266.75
78.55
8.64
58.91
206.01
21.40
160.94
187.77
19.60
140.16
14.20
1.48
10.65
12.34
1.45
9.77
30.12
3.24
22.60
180.14
18.05
135.36
9.38
1.19
6.21
8.29
0.94
6.21
159.14
17.30
119.36
20.84
2.42
17.16
61.99
6.20
46.48
596.77
59.68
447.60
194.01
19.79
145.53
377.63
46.14
283.23
89.07
8.58
67.14
306.85
30.69
230.12
306.85
30.69
230.12
202.77
20.28
152.09
25.28
2.52
18.96
73.56
9.98
55.19
180.06
19.81
135.04
25.74
2.42
19.30
65.73
6.57
49.30
7.86
0.83
5.88
360.60
35.54
270.45
7.34
0.76
5.52
460.65
51.29
345.46
24.57
2.47
18.44
354.76
35.48
266.08
92.41
10.16
69.31
206.01
21.40
160.94
187.77
19.60
140.16
13.58
1.36
10.18
10.49
1.23
8.30
30.12
3.24
22.60
165.03
17.95
125.90
7.97
1.19
5.28
8.29
0.94
6.21
151.59
15.85
113.70
20.84
2.42
17.16
61.99
6.20
46.48
588.54
58.85
441.42
195.21
19.79
146.40
444.27
54.28
333.21
78.06
7.83
58.56
312.99
31.30
234.75
312.99
31.30
234.75
174.75
18.10
132.61
27.94
2.81
20.96
70.06
8.48
52.53
180.06
19.81
135.04
25.74
2.47
19.30
55.87
5.85
41.91
7.86
0.83
5.88
360.60
35.54
270.45
7.87
0.89
5.89
460.65
46.06
345.46
21.33
2.14
15.67
355.63
41.74
266.75
78.55
10.16
58.91
206.01
21.40
160.94
187.77
19.60
140.16
14.20
1.48
10.65
12.34
1.45
9.77
30.12
3.24
22.60
180.14
21.12
136.31
9.38
1.40
6.21
8.29
0.94
6.21
159.14
17.30
119.36
20.84
2.42
17.16
61.99
6.20
46.48
596.77
59.68
447.60
188.35
19.79
141.29
377.63
46.14
283.23
89.07
8.58
67.14
306.85
30.69
230.12
306.85
30.69
230.12
540.29
67.54
405.22
87.80
10.97
65.86
154.49
19.30
115.86
241.31
30.16
180.97
27.95
3.50
20.97
101.15
16.58
75.86
7.52
0.94
0.00
444.61
55.58
333.46
12.82
1.61
9.64
411.52
51.45
308.63
28.94
3.63
21.70
365.80
45.72
274.37
117.79
14.73
88.34
320.76
38.40
240.58
217.76
27.22
163.34
14.46
1.80
10.86
18.10
2.26
13.57
58.65
7.31
43.99
182.36
22.80
136.75
10.41
1.31
7.82
7.34
0.93
5.52
170.17
21.27
127.63
14.60
1.82
10.94
70.68
7.08
53.00
706.24
88.28
529.70
469.35
58.67
352.02
469.35
58.67
352.01
86.72
10.86
65.03
368.20
46.02
276.15
368.20
46.02
276.15
174.75
18.10
132.61
25.90
2.59
19.45
73.56
9.98
55.19
180.06
19.81
135.04
25.74
2.42
19.30
55.87
5.85
41.91
7.86
0.83
5.88
354.05
30.21
265.54
7.87
0.83
5.89
458.13
43.60
343.59
25.09
2.52
18.44
417.37
41.74
313.04
85.45
8.64
64.10
206.01
18.19
160.94
187.77
16.66
140.16
14.20
1.26
10.65
10.49
1.23
8.30
35.44
3.81
26.59
180.14
17.96
136.31
7.97
1.19
5.28
8.70
0.94
6.52
135.27
15.85
101.46
24.09
2.42
18.06
61.99
6.20
46.48
588.54
58.85
441.42
195.21
19.79
146.40
444.27
54.28
333.21
75.71
7.33
57.07
312.99
31.30
234.75
312.99
31.30
234.75
205.59
20.81
156.01
29.74
2.97
22.31
73.56
9.98
55.19
180.06
19.80
135.04
25.74
2.42
19.30
65.73
6.88
49.30
7.86
0.83
5.88
360.60
35.54
270.45
7.56
0.76
5.67
460.65
51.29
345.46
25.09
2.18
16.34
354.76
35.48
266.08
92.41
10.16
69.31
206.01
21.40
160.94
187.77
19.60
140.16
13.25
1.33
9.93
10.49
1.23
8.30
35.44
3.81
26.59
180.14
18.11
134.87
7.97
1.19
5.28
8.29
0.94
6.21
147.29
15.85
110.48
24.52
2.83
20.19
61.99
6.20
46.48
596.77
59.68
447.60
220.70
23.28
165.54
444.27
54.28
333.21
78.06
7.83
58.56
312.99
31.30
234.75
312.99
31.30
234.75
174.75
18.10
132.61
28.96
2.89
21.72
73.56
9.98
55.19
180.06
19.81
135.04
25.74
2.42
19.30
65.73
6.88
49.30
7.86
0.83
5.88
360.60
35.54
270.45
7.87
0.89
5.89
460.65
51.29
345.46
21.33
2.14
15.67
417.37
41.74
313.04
92.41
10.16
69.31
191.01
19.11
143.26
171.67
17.17
128.75
14.20
1.48
10.65
12.34
1.45
9.77
35.44
3.81
26.59
169.26
20.80
136.31
9.38
1.40
6.21
9.75
1.11
7.30
159.14
17.21
119.36
24.52
2.85
20.19
61.99
6.20
46.48
507.25
50.73
380.46
220.70
23.28
165.54
444.27
54.28
333.21
89.07
8.58
67.14
306.86
30.64
230.12
306.86
30.64
230.12
IN - Inexpensive/Routinely Purchased
OX - Oxygen
OS - Ostomy
SD - Surgical Dressing
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
VI
174.75
18.10
132.61
29.74
2.97
22.31
73.56
9.98
55.19
180.06
19.81
135.04
25.74
2.42
19.30
55.87
5.85
41.91
6.68
0.71
5.00
360.60
35.54
270.45
6.69
0.76
5.01
391.55
43.60
293.64
21.33
2.14
15.67
354.76
35.48
266.08
78.55
8.64
58.91
175.11
18.19
136.80
159.60
16.66
119.14
12.97
1.31
9.73
12.34
1.45
9.77
35.44
3.81
26.59
153.12
17.95
115.86
7.97
1.19
5.28
8.87
0.94
6.64
159.14
18.65
119.36
24.52
2.85
20.19
61.99
6.20
46.48
510.79
59.68
417.84
220.70
23.28
165.54
405.60
46.14
300.87
75.71
7.33
57.07
305.27
30.52
228.96
305.27
30.52
228.96
December 1995 DMERC Medicare Advisory
*Category HCPCS Modifier
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
E0629
E0629
E0629
E0650
E0650
E0650
E0651
E0651
E0651
E0652
E0652
E0652
E0655
E0655
E0655
E0660
E0660
E0660
E0665
E0665
E0665
E0666
E0666
E0666
E0667
E0667
E0667
E0668
E0668
E0668
E0669
E0669
E0669
E0671
E0671
E0671
E0672
E0672
E0672
E0673
E0673
E0673
E0690
E0690
E0690
E0747
E0747
E0747
E0748
E0748
E0748
E0776
E0776
E0776
E0782
E0782
E0782
E0840
E0840
E0840
E0850
E0850
E0850
E0860
E0860
E0860
E0870
E0870
E0870
E0880
E0880
E0880
E0890
E0890
E0890
E0900
E0900
E0900
E0942
E0942
E0942
E0943
E0943
E0943
E0944
E0944
E0944
E0945
E0945
E0945
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
AL
306.85
30.69
230.12
668.25
70.08
501.19
852.16
87.05
639.12
4,918.94
486.15
3,685.90
100.14
10.42
75.20
148.22
14.72
111.16
125.46
13.05
95.46
128.12
13.16
96.11
300.41
33.92
225.31
410.00
40.47
307.50
170.09
17.01
127.59
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,264.45
130.58
946.10
3,126.62
312.67
2,298.98
3,251.51
325.15
2,438.64
112.91
14.71
83.06
3,588.05
358.81
2,691.04
62.27
12.87
46.72
82.86
12.78
62.14
30.39
5.13
26.02
91.73
10.57
69.11
103.62
15.55
74.94
111.72
25.89
89.99
101.04
21.79
84.47
15.65
1.84
11.73
21.82
2.56
16.35
36.40
3.68
29.89
34.96
3.49
27.06
AR
306.40
30.64
229.80
664.54
82.45
498.41
852.16
87.05
639.12
4,918.94
486.15
3,685.90
100.14
11.76
75.20
148.22
15.43
111.16
127.11
13.05
95.46
128.12
13.21
96.11
300.41
33.92
225.31
407.35
40.47
305.52
170.09
17.01
127.59
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,074.78
110.99
804.19
3,272.71
325.22
2,431.57
3,251.51
325.15
2,438.64
112.91
14.71
83.06
3,112.77
311.28
2,334.58
58.47
12.87
43.87
97.48
13.39
73.11
35.75
5.13
27.38
91.73
10.57
69.11
99.01
15.55
74.94
111.72
25.89
89.99
118.87
21.79
89.18
15.65
1.84
11.73
21.82
2.56
16.35
36.18
3.63
27.14
34.96
3.49
27.06
CO
306.85
30.69
230.12
648.46
70.08
486.92
852.16
87.05
639.12
4,478.43
447.82
3,358.81
100.14
11.76
75.20
148.22
15.43
111.16
113.48
11.34
85.11
122.60
12.27
91.97
255.35
28.83
191.51
348.50
34.40
261.38
170.09
17.01
127.59
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,074.78
110.99
804.19
3,272.71
325.22
2,431.57
3,251.51
325.15
2,438.64
132.83
16.59
97.72
3,049.84
304.99
2,287.38
57.79
15.14
43.32
82.86
11.38
62.14
35.75
5.13
27.38
91.73
10.57
69.11
99.01
18.29
74.94
94.96
25.89
76.49
101.04
21.79
75.80
18.41
2.17
13.80
25.67
3.01
19.24
42.57
4.27
31.93
41.13
4.11
31.84
FL
306.85
30.69
230.12
617.71
76.12
475.20
852.16
87.05
639.12
4,918.94
486.15
3,685.90
95.79
10.00
71.84
126.57
13.12
94.92
116.95
11.69
87.71
128.12
12.99
96.11
300.41
33.92
225.31
410.00
40.47
307.50
161.51
16.16
121.14
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,264.45
130.58
946.10
3,272.71
325.22
2,431.57
3,251.51
325.15
2,438.64
132.83
15.94
97.72
3,588.05
358.81
2,691.04
67.99
15.14
50.96
97.48
13.39
73.11
34.64
5.13
27.38
91.73
12.43
69.11
116.48
18.29
88.17
94.96
28.77
76.49
101.04
25.63
75.80
18.41
1.98
13.80
25.67
3.01
19.24
36.18
3.63
27.14
34.96
3.49
27.06
GA
306.85
30.69
230.12
568.01
74.09
426.01
852.16
87.05
639.12
4,918.94
486.15
3,685.90
87.59
10.00
75.20
148.22
15.12
111.16
124.38
12.43
95.46
128.12
13.21
96.11
300.41
33.92
225.31
410.00
40.47
307.50
167.96
16.79
125.98
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,264.45
130.58
946.10
3,272.71
325.22
2,431.57
3,251.51
325.15
2,438.64
112.91
14.71
83.06
3,588.05
358.81
2,691.04
65.92
15.14
49.44
82.86
11.38
62.14
33.58
5.13
25.17
91.73
10.57
69.11
99.01
15.55
74.94
94.96
30.29
76.49
101.04
21.79
75.80
15.95
1.84
11.96
25.67
3.01
19.24
41.58
4.16
31.19
34.96
3.49
27.06
IN - Inexpensive/Routinely Purchased
OX - Oxygen
Page 95-201
KY
306.85
30.69
230.12
600.92
70.08
450.68
852.16
87.05
639.12
4,438.13
443.88
3,328.60
90.42
10.00
67.83
148.22
15.43
111.16
127.11
13.05
95.46
128.12
13.21
96.11
300.41
33.92
225.31
410.00
40.47
307.50
169.59
16.96
127.19
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,264.45
130.58
946.10
2,781.80
276.44
2,066.83
3,251.51
325.15
2,438.64
112.91
14.71
83.06
3,588.05
358.81
2,691.04
57.79
15.14
43.32
97.48
11.38
73.11
34.44
6.04
25.81
107.92
11.09
81.30
116.48
18.29
88.17
110.93
25.89
83.20
118.87
25.63
89.18
18.41
2.17
13.80
25.67
2.76
19.24
38.95
3.89
29.22
41.13
4.11
31.84
LA
306.40
30.64
229.80
668.25
82.45
501.19
852.16
87.05
639.12
4,918.94
486.15
3,685.90
100.14
11.76
75.20
148.22
15.43
111.16
127.11
13.05
95.46
128.12
13.21
96.11
300.41
33.92
225.31
410.00
40.47
307.50
170.09
17.01
127.59
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,074.78
110.99
804.19
3,272.71
325.22
2,431.57
3,251.51
325.15
2,438.64
112.91
17.31
83.06
3,200.88
320.08
2,400.65
60.13
12.87
45.10
82.86
11.38
62.14
35.75
6.04
27.38
91.73
10.57
69.11
99.01
15.55
74.94
111.72
30.46
89.99
118.87
25.63
89.18
15.65
1.84
11.73
21.82
2.56
16.35
36.18
3.63
27.14
34.96
3.49
27.06
MS
306.85
30.69
230.12
568.01
70.08
426.01
852.16
87.05
639.12
4,181.10
413.23
3,133.02
85.12
10.00
63.92
148.22
14.95
111.16
108.04
11.09
81.14
108.90
11.23
81.69
255.35
28.83
191.51
348.50
34.40
261.38
170.09
17.01
127.59
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,264.45
130.58
946.10
3,272.71
325.22
2,431.57
3,251.51
325.15
2,438.64
132.83
14.95
97.72
3,588.05
358.81
2,691.04
67.99
15.14
50.96
97.48
13.39
73.11
35.75
5.77
27.38
91.73
12.43
69.11
99.01
15.55
74.94
94.96
25.89
76.49
101.04
21.79
75.80
15.65
1.84
11.73
21.82
2.56
16.35
36.40
3.68
29.89
34.96
3.49
27.06
NM
306.85
30.69
230.12
668.25
82.45
501.19
852.16
85.52
639.12
4,918.94
486.15
3,685.90
100.14
11.76
75.20
146.79
14.70
110.09
127.11
13.05
95.46
128.12
13.21
96.11
300.41
31.48
225.31
410.00
40.47
307.50
170.09
17.01
127.59
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,264.45
126.44
946.10
3,272.71
318.79
2,390.95
3,251.51
325.15
2,438.64
130.09
14.71
97.57
3,588.05
358.81
2,691.04
63.23
12.87
47.43
82.86
11.38
62.14
35.75
5.13
26.92
107.92
12.43
81.30
99.01
15.55
74.94
111.72
25.89
89.99
118.87
21.79
89.18
15.65
1.84
11.73
24.97
2.56
18.73
36.18
3.63
27.14
34.96
3.49
27.06
OS - Ostomy
SD - Surgical Dressing
NC
306.85
30.69
230.12
589.01
70.08
441.76
852.16
87.05
639.12
4,918.94
486.15
3,685.90
89.63
10.00
67.22
148.22
15.02
111.16
122.00
12.21
91.51
120.23
12.01
90.18
300.41
33.92
225.31
410.00
40.47
307.50
166.36
16.63
124.76
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,264.45
130.58
946.10
3,272.71
325.22
2,431.57
3,251.51
325.15
2,438.64
132.83
14.71
97.72
3,588.05
358.81
2,691.04
57.79
12.87
43.32
87.04
11.38
65.27
31.52
5.13
23.64
91.73
10.57
69.11
99.01
15.55
74.94
94.96
25.89
76.49
101.04
21.79
75.80
15.65
1.84
11.73
25.67
3.01
19.24
38.65
3.86
28.97
39.76
3.98
29.82
OK
306.85
30.69
230.12
668.25
82.45
501.19
780.44
78.04
585.33
4,918.94
486.15
3,685.90
100.14
11.76
75.20
146.79
15.43
110.09
127.11
13.05
95.46
128.12
13.21
96.11
287.13
28.83
215.34
410.00
40.47
307.50
169.99
17.00
127.49
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,261.46
126.14
946.10
3,272.71
318.79
2,390.95
3,251.51
325.15
2,438.64
116.28
14.71
87.22
3,588.05
358.81
2,691.04
58.14
12.87
43.61
82.86
11.38
62.14
35.75
5.13
27.38
107.92
12.43
81.30
99.01
15.55
74.94
111.72
25.89
89.99
118.87
21.79
89.18
18.41
2.17
13.80
22.10
2.56
16.59
42.57
4.26
31.93
34.96
3.49
27.06
PR
368.20
46.02
276.15
647.40
80.93
80.93
875.46
109.44
656.60
5,873.82
734.24
4,405.38
88.64
11.03
65.85
161.85
20.23
121.39
125.06
15.64
93.80
116.24
14.52
87.18
404.63
50.58
303.47
348.30
38.65
289.53
193.82
19.38
145.36
462.36
46.26
346.84
359.36
35.93
269.51
298.59
29.87
223.93
717.64
89.69
538.25
3,186.87
470.49
635.26
3,901.79
390.17
2,926.36
133.89
16.73
100.44
348.78
43.60
261.59
108.50
30.14
81.39
106.53
13.32
79.89
25.47
3.19
19.13
140.75
17.60
105.56
129.80
16.23
97.37
102.41
12.79
76.81
113.21
14.15
84.91
4.10
0.50
3.06
32.41
4.06
24.32
51.49
6.44
38.63
42.68
5.35
32.01
SC
306.85
30.69
230.12
568.01
70.08
426.01
852.16
87.05
639.12
4,918.94
486.15
3,685.90
99.12
10.00
74.36
148.22
15.43
111.16
123.36
12.33
92.51
128.12
13.21
96.11
300.41
33.92
225.31
410.00
40.47
307.50
169.59
16.96
127.19
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,264.45
130.58
946.10
3,272.71
325.22
2,431.57
3,251.51
325.15
2,438.64
112.91
14.71
83.06
3,588.05
358.81
2,691.04
67.99
12.87
43.32
82.86
11.38
62.14
35.75
6.02
27.38
91.73
10.57
69.11
99.01
15.55
74.94
99.53
30.46
76.49
101.04
21.79
75.80
18.41
2.17
13.80
21.82
2.56
16.35
42.57
4.27
31.93
41.13
4.11
31.84
TN
306.85
30.69
230.12
568.01
82.45
426.01
852.16
87.05
639.12
4,918.94
486.15
3,685.90
85.52
10.00
64.15
135.93
13.60
101.94
127.11
13.05
95.46
125.60
12.58
94.20
300.41
33.92
225.31
410.00
40.47
307.50
170.09
17.01
127.59
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,264.45
130.58
946.10
3,272.71
325.22
2,431.57
3,251.51
325.15
2,438.64
123.90
14.71
92.93
3,588.05
358.81
2,691.04
57.79
12.87
43.32
89.30
11.38
66.99
31.65
5.13
24.79
91.73
10.57
69.11
99.01
15.55
74.94
94.96
25.89
76.49
101.04
21.79
75.80
15.65
1.84
11.73
25.67
3.01
19.24
40.24
4.03
30.18
34.96
3.49
27.06
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
TX
306.85
30.64
230.12
648.51
74.64
486.40
852.16
85.22
639.12
4,918.94
486.15
3,685.90
97.00
10.00
72.73
148.22
15.09
111.16
127.11
12.80
95.46
128.12
13.14
96.11
300.41
33.92
225.31
410.00
40.47
307.50
161.51
16.16
121.14
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,074.78
110.99
804.19
3,272.71
325.22
2,431.57
3,251.51
325.15
2,438.64
112.91
14.71
83.06
3,200.88
320.08
2,400.65
57.79
14.22
43.32
97.48
11.38
73.11
30.39
5.13
23.27
107.92
12.43
81.30
103.24
15.55
77.43
111.72
25.89
89.99
109.44
21.79
82.07
18.41
2.17
13.80
25.67
3.01
19.24
36.18
3.63
27.14
34.96
3.49
27.06
VI
260.82
26.09
195.60
604.25
72.62
456.13
724.34
81.39
543.25
4,666.93
466.67
3,320.62
90.63
11.76
67.95
147.56
14.85
111.16
127.11
12.82
95.46
122.89
12.02
95.17
300.41
33.92
225.31
348.50
34.40
261.38
169.59
16.96
127.19
385.38
38.54
289.03
299.45
29.95
224.60
248.82
24.88
186.63
1,264.45
130.58
946.10
3,252.29
325.22
2,431.57
3,251.51
325.15
2,438.64
112.91
14.71
83.06
3,588.05
358.81
2,691.04
67.99
15.14
50.96
97.48
13.39
73.11
30.39
5.13
23.38
107.92
12.43
81.30
99.01
15.55
74.94
111.72
30.46
89.99
117.06
21.79
87.68
15.65
1.84
11.73
23.31
2.56
17.48
36.18
3.63
27.14
34.96
3.49
27.06
Page 95-202
December 1995 DMERC Medicare Advisory
*Category HCPCS Modifier
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
E0947
E0947
E0947
E0948
E0948
E0948
E0950
E0950
E0950
E0951
E0951
E0951
E0952
E0952
E0952
E0953
E0953
E0953
E0954
E0954
E0954
E0959
E0959
E0959
E0961
E0961
E0961
E0962
E0962
E0962
E0963
E0963
E0963
E0964
E0964
E0964
E0965
E0965
E0965
E0966
E0966
E0966
E0967
E0967
E0967
E0969
E0969
E0969
E0970
E0970
E0970
E0971
E0971
E0971
E0972
E0972
E0972
E0973
E0973
E0973
E0974
E0974
E0974
E0975
E0975
E0975
E0976
E0976
E0976
E0977
E0977
E0977
E0978
E0978
E0978
E0979
E0979
E0979
E0980
E0980
E0980
E0990
E0990
E0990
E0991
E0991
E0991
E0992
E0992
E0992
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
AL
AR
CO
FL
GA
KY
LA
MS
NM
NC
OK
PR
SC
TN
TX
VI
478.30
49.61
358.72
475.13
47.81
356.35
96.45
9.66
72.34
14.86
1.54
11.14
14.86
1.55
11.14
32.29
3.73
23.11
33.00
4.38
24.75
69.73
7.00
52.78
23.46
2.88
17.60
55.19
5.52
39.54
61.01
5.88
49.56
62.53
6.30
46.91
66.84
6.69
51.66
58.47
6.53
43.88
104.21
12.58
78.17
145.33
13.98
109.00
37.99
3.39
28.49
51.85
6.93
38.89
51.14
5.20
37.45
90.67
8.64
68.01
62.31
6.55
46.73
39.24
3.90
29.44
39.61
3.90
29.70
51.59
4.97
38.71
35.29
3.51
26.48
26.64
2.67
19.98
26.07
2.59
22.07
108.96
12.27
85.13
36.74
3.68
32.09
75.04
7.29
56.29
478.30
49.61
358.72
462.63
46.25
326.27
81.98
8.21
61.49
14.86
1.54
11.14
17.48
1.82
13.11
32.50
3.17
24.37
38.82
4.38
29.12
82.04
8.24
62.09
27.60
2.88
20.71
55.19
5.52
41.39
65.93
6.70
49.56
73.56
7.41
55.19
78.64
7.87
59.00
62.50
6.53
46.88
122.60
12.58
91.97
123.53
12.23
92.65
37.99
3.39
28.49
61.00
6.93
45.75
51.14
5.20
37.45
90.67
8.64
68.01
62.31
6.55
46.73
46.16
4.59
34.63
40.36
4.04
30.26
60.69
5.85
45.54
35.59
3.55
26.71
26.64
2.67
19.98
26.07
2.59
19.45
92.62
10.43
72.36
42.57
4.08
31.93
88.28
8.58
66.22
562.70
58.36
422.02
544.27
54.41
383.85
96.45
9.66
72.34
15.16
1.54
11.36
14.86
1.55
11.14
37.96
3.73
27.19
33.61
3.72
25.20
82.04
8.24
62.09
27.60
2.85
20.71
55.19
5.52
41.39
61.25
6.13
45.95
66.18
6.61
49.63
66.84
6.69
50.15
66.22
6.29
49.66
104.21
10.69
78.17
134.87
13.48
101.16
44.69
3.99
33.52
60.43
6.05
45.31
51.14
5.20
37.45
106.67
10.16
80.01
62.31
6.55
46.73
45.82
4.59
34.35
45.82
4.59
34.35
51.59
5.06
38.71
36.73
3.68
28.46
31.34
3.14
23.51
30.67
3.05
22.88
108.96
12.27
85.13
41.98
3.47
31.50
85.40
8.54
64.06
478.30
49.61
358.72
462.63
46.25
326.27
81.98
8.21
61.49
17.48
1.81
13.11
17.48
1.82
13.11
37.96
3.73
27.19
33.00
3.72
24.75
69.73
7.00
52.78
23.46
2.45
17.60
49.66
4.97
37.24
64.16
6.42
48.13
71.51
7.16
53.64
78.06
7.83
58.56
60.69
6.07
45.54
107.90
10.79
80.93
145.33
14.39
109.00
44.69
3.99
33.52
55.84
5.89
41.91
49.53
4.96
37.14
90.67
8.64
68.01
62.31
6.55
46.73
46.16
4.59
34.63
46.60
4.59
34.94
51.59
4.97
38.71
35.29
3.51
26.48
26.64
2.67
19.98
26.07
2.59
19.45
108.96
12.05
85.13
42.57
4.08
32.09
84.46
8.45
63.35
498.48
50.47
373.86
498.48
49.86
373.86
81.98
8.21
61.49
17.48
1.81
13.11
14.86
1.55
11.14
33.96
3.38
23.88
38.82
4.38
29.12
71.38
7.15
53.54
23.46
2.45
17.60
55.19
5.52
41.39
64.43
6.44
48.31
64.71
6.47
49.56
66.84
6.69
50.15
60.84
6.08
45.63
104.21
10.69
78.17
145.33
14.39
109.00
44.69
3.99
33.52
61.00
6.16
45.75
51.14
5.20
37.45
106.67
10.16
80.01
73.31
7.71
54.98
46.16
4.59
34.63
46.60
4.59
34.94
60.69
5.85
45.54
41.52
4.13
31.15
31.34
3.14
23.51
26.07
2.59
19.45
108.96
10.90
85.13
36.18
3.47
28.94
75.04
7.43
56.29
562.70
58.36
422.02
544.27
54.41
383.85
96.45
9.66
72.34
15.32
1.54
11.49
14.86
1.55
11.14
37.96
3.73
27.19
33.00
3.72
24.75
82.04
8.24
62.09
23.46
2.45
17.60
46.91
4.69
35.18
56.56
5.70
42.41
64.10
6.42
48.08
69.12
6.90
51.84
60.29
6.04
45.22
114.63
11.46
85.98
143.88
14.39
107.90
37.99
3.39
28.49
61.00
6.93
45.75
51.14
5.20
37.45
90.67
8.64
68.01
67.47
6.76
50.59
46.16
4.59
34.63
46.60
4.59
34.94
60.69
5.85
45.54
41.52
4.13
31.15
31.34
3.14
23.51
30.67
3.05
22.88
108.96
12.27
85.13
42.57
4.08
32.09
76.79
7.67
57.59
478.30
49.61
358.72
462.63
46.25
326.27
81.98
8.21
61.49
14.86
1.54
11.14
17.48
1.82
13.11
33.40
3.34
25.05
38.82
4.38
29.12
82.04
8.24
62.09
27.60
2.88
20.71
55.19
5.52
41.39
65.93
6.70
49.56
73.56
7.41
55.19
78.64
7.87
59.00
64.41
6.44
48.30
122.60
12.58
91.97
123.53
12.23
92.65
37.99
3.39
28.49
61.00
6.93
45.75
51.14
5.20
37.45
90.67
8.64
68.01
62.31
6.55
46.73
40.10
4.02
30.07
40.10
4.02
30.07
60.69
5.85
45.54
36.60
3.67
27.46
26.64
2.67
19.98
26.07
2.59
19.45
108.96
12.17
85.13
42.57
4.08
32.09
88.28
8.58
66.22
478.30
49.61
358.72
475.13
47.81
356.35
96.45
9.66
72.34
14.86
1.54
11.14
17.48
1.82
13.11
32.27
3.17
23.11
33.00
3.72
24.75
80.58
8.05
60.43
23.46
2.45
17.60
55.19
5.52
41.39
65.93
6.70
49.56
73.56
7.41
55.19
78.64
7.87
59.00
56.29
5.55
42.21
122.60
12.58
91.97
145.33
14.39
109.00
37.99
3.39
28.49
61.00
6.93
45.75
51.14
5.20
37.45
90.67
8.64
68.01
73.31
7.71
54.98
39.24
3.90
29.44
39.61
3.90
29.70
60.69
5.85
45.54
41.52
4.13
31.15
31.34
3.14
23.51
30.23
3.02
22.68
92.62
10.43
72.36
36.18
3.47
27.28
87.08
8.58
65.31
562.70
58.36
422.02
507.73
50.77
380.81
96.45
9.66
72.34
17.48
1.81
13.11
17.48
1.82
13.11
37.96
3.73
27.19
33.00
3.72
24.75
82.04
8.24
62.09
23.46
2.45
17.60
55.19
5.52
41.39
65.93
6.70
49.56
73.56
7.41
55.19
78.64
7.87
59.00
66.22
6.53
49.66
120.74
12.06
90.55
145.33
14.39
109.00
38.81
3.88
29.10
61.00
6.93
45.75
51.14
5.20
37.45
90.67
8.64
68.01
73.31
7.71
54.98
39.24
3.90
29.44
39.61
3.90
29.70
60.69
5.85
45.54
35.29
3.51
26.48
28.53
2.86
21.39
30.08
3.01
22.55
108.04
10.80
81.03
38.47
3.85
28.87
84.51
8.45
63.40
490.15
49.61
367.60
490.15
47.81
367.60
96.45
9.66
72.34
16.35
1.65
12.27
17.48
1.82
13.11
37.96
3.73
27.19
38.82
4.38
29.12
79.29
7.93
59.47
23.46
2.45
17.60
55.19
5.52
41.39
65.93
6.70
49.56
73.56
7.41
55.19
78.64
7.87
59.00
64.98
6.50
48.74
104.21
10.69
78.17
145.33
14.39
109.00
37.99
3.39
28.49
51.85
5.89
38.89
51.14
5.20
37.45
106.67
10.16
80.01
62.31
6.55
46.73
39.24
3.90
29.44
39.61
3.90
29.70
53.96
5.41
40.47
40.47
4.05
30.35
31.06
3.12
23.28
26.07
2.59
19.45
102.23
10.43
76.67
42.57
4.08
32.09
88.28
8.58
66.22
562.70
58.36
422.02
506.51
50.65
379.89
96.45
9.66
72.34
17.48
1.81
13.11
17.48
1.82
13.11
37.96
3.73
27.19
33.00
3.72
24.75
82.04
8.24
62.09
27.60
2.88
20.71
55.19
5.52
41.39
65.93
6.70
49.56
73.56
7.41
55.19
78.64
7.87
59.00
66.22
6.53
49.66
112.43
11.26
84.34
142.60
14.26
106.94
44.69
3.99
33.52
61.00
6.93
45.75
51.14
5.20
37.45
90.67
8.64
68.01
73.31
7.71
54.98
39.24
3.90
29.44
39.61
3.90
29.70
60.69
5.85
45.54
36.14
3.63
27.10
30.00
3.00
22.51
30.50
3.04
22.88
108.96
12.27
85.13
40.85
4.08
30.64
88.28
8.58
66.22
727.03
90.88
545.26
724.64
90.57
543.48
105.94
13.25
79.45
19.37
2.43
14.52
19.37
2.43
14.52
46.17
5.78
34.64
37.75
4.73
28.31
97.12
12.15
72.83
18.39
2.29
13.79
54.83
6.85
41.12
61.69
7.71
46.28
90.49
11.31
67.87
97.12
12.15
72.83
79.94
10.01
59.96
133.41
16.67
100.05
187.60
23.46
140.70
64.01
8.00
48.01
96.44
12.21
73.19
56.89
7.13
42.66
105.46
13.16
79.08
95.64
11.96
71.73
46.34
5.79
34.76
46.34
5.79
34.76
50.52
6.31
37.90
54.44
6.81
40.83
41.20
5.15
30.89
31.63
3.96
23.73
168.78
21.09
126.57
37.08
4.64
27.80
108.72
13.60
81.55
530.42
53.06
397.81
530.42
53.06
383.85
81.98
8.21
61.49
17.48
1.81
13.11
17.48
1.82
13.11
35.61
3.56
26.72
38.82
4.38
29.12
75.31
7.54
56.49
27.60
2.88
20.71
54.71
5.47
41.04
65.67
6.57
49.25
71.45
7.16
53.59
74.68
7.48
56.02
61.16
6.11
45.88
104.21
10.69
78.17
145.33
14.39
109.00
37.99
3.39
28.49
51.85
5.89
38.89
51.14
5.20
37.45
106.67
10.16
80.01
62.31
6.55
46.73
46.16
4.59
34.63
46.60
4.59
34.94
60.69
5.85
45.54
41.20
4.12
30.89
31.34
3.14
23.51
26.07
2.59
19.45
105.15
10.51
78.87
36.18
3.47
27.28
76.60
7.64
57.46
490.15
49.61
367.60
490.15
47.81
367.60
96.45
9.66
72.34
15.79
1.58
11.85
14.86
1.55
11.14
32.27
3.17
23.15
33.00
3.72
24.75
79.29
7.93
59.47
23.46
2.45
17.60
54.35
5.44
40.77
65.80
6.58
49.34
73.56
7.41
55.19
78.64
7.87
59.00
65.39
6.53
49.05
112.04
11.21
84.03
145.18
14.39
108.88
42.54
3.99
31.91
51.85
5.89
38.89
51.14
5.14
37.45
100.59
10.06
75.45
72.75
7.26
54.56
39.24
3.90
29.44
39.61
3.90
29.70
53.96
5.41
40.47
37.09
3.71
27.80
28.66
2.87
21.05
26.07
2.59
19.45
102.23
10.43
76.67
42.57
4.08
32.09
87.55
8.58
65.67
478.30
49.61
358.72
462.63
46.25
326.27
96.45
9.66
72.34
14.86
1.54
11.14
15.64
1.57
11.72
32.27
3.17
23.11
33.00
3.72
24.75
80.24
8.03
60.19
26.16
2.88
19.61
46.91
4.69
35.18
56.04
5.70
42.13
62.53
6.30
46.91
66.84
6.69
50.15
66.22
6.53
49.66
122.60
12.58
91.97
132.24
13.24
99.18
44.69
3.99
33.52
51.85
5.89
38.89
43.47
4.42
31.87
90.67
8.64
68.01
73.31
7.71
54.98
39.24
3.90
29.44
46.60
4.59
34.94
51.59
4.97
38.71
40.71
4.08
30.52
30.05
3.00
22.53
28.72
2.87
21.55
104.15
10.43
78.13
36.18
3.47
27.28
75.04
7.29
56.29
562.70
58.36
422.02
544.27
54.41
383.85
81.98
8.21
61.49
17.48
1.81
13.11
17.48
1.82
13.11
34.58
3.47
25.95
38.82
4.38
29.12
79.72
7.92
62.09
23.46
2.45
17.60
55.19
5.52
41.39
65.93
6.70
48.48
62.53
7.11
47.12
70.00
7.87
53.87
66.22
6.53
49.66
122.60
12.58
91.97
136.62
14.39
107.01
37.99
3.49
28.49
61.00
5.89
45.75
48.82
5.00
37.45
94.82
9.13
80.01
67.31
6.97
52.39
45.04
4.50
33.78
39.61
3.90
29.70
60.69
5.85
45.54
41.31
4.13
31.00
31.34
3.14
23.51
26.07
2.59
19.45
108.96
11.34
85.13
36.18
3.53
27.28
75.04
7.49
56.29
IN - Inexpensive/Routinely Purchased
OX - Oxygen
OS - Ostomy
SD - Surgical Dressing
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
December 1995 DMERC Medicare Advisory
*Category HCPCS Modifier
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
E0993
E0993
E0993
E0994
E0994
E0994
E0995
E0995
E0995
E0996
E0996
E0996
E0997
E0997
E0997
E0998
E0998
E0998
E0999
E0999
E0999
E1000
E1000
E1000
E1001
E1001
E1001
E1065
E1065
E1065
E1066
E1066
E1066
E1069
E1069
E1069
E1226
E1226
E1226
E1227
E1227
E1227
E1230
E1230
E1230
E1296
E1296
E1296
E1297
E1297
E1297
E1298
E1298
E1298
E1310
E1310
E1310
E1372
E1372
E1372
E1375
E1375
E1375
E1700
E1700
E1700
K0005
K0005
K0005
K0015
K0015
K0015
K0016
K0016
K0016
K0017
K0017
K0017
K0018
K0018
K0018
K0019
K0019
K0019
K0020
K0020
K0020
K0021
K0021
K0021
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
Page 95-203
AL
AR
CO
FL
GA
KY
LA
MS
NM
NC
OK
PR
SC
TN
TX
VI
36.67
3.66
27.63
13.91
1.40
10.44
23.98
2.41
17.97
22.49
2.46
17.92
61.71
6.61
46.29
30.19
3.13
22.66
106.67
10.67
68.01
28.39
3.68
22.69
77.33
8.12
58.00
2,697.49
245.23
2,023.12
244.60
24.52
160.93
88.60
8.91
66.45
506.27
52.11
379.68
257.48
25.75
193.13
1,977.57
196.32
1,659.75
456.20
46.34
342.15
97.06
10.78
72.79
393.08
40.22
294.81
1,693.59
144.86
1,270.20
128.58
18.67
95.17
211.65
38.72
160.92
319.96
31.38
239.97
1,715.36
171.53
1,286.51
168.59
16.87
126.44
90.67
8.64
68.01
47.42
4.74
35.56
26.49
2.64
19.88
15.99
1.60
11.99
43.10
4.32
32.32
51.85
7.05
38.89
43.14
4.30
32.50
16.36
1.65
12.28
28.21
2.83
21.14
26.46
2.55
20.23
61.71
6.18
46.29
30.19
3.13
22.66
90.67
9.07
68.01
33.40
3.68
25.05
90.98
9.55
68.24
2,292.87
208.45
1,719.65
244.60
24.52
183.45
88.60
8.91
66.45
506.27
52.11
379.68
218.86
21.89
164.16
2,098.60
206.40
1,659.75
456.20
46.34
342.15
97.06
10.78
72.79
393.08
40.22
294.81
1,992.46
170.42
1,494.35
151.27
21.97
111.97
183.84
32.91
137.90
271.97
26.67
203.97
1,715.36
171.53
1,286.51
168.59
16.87
126.44
90.67
8.64
68.01
47.42
4.74
35.56
26.49
2.64
19.88
15.99
1.60
11.99
43.10
4.32
32.32
61.00
7.05
45.75
43.14
4.30
32.50
16.36
1.65
12.28
28.21
2.83
21.14
26.46
2.55
20.23
52.45
5.62
39.35
35.52
3.68
26.66
90.67
9.07
68.01
33.40
3.68
25.05
90.98
9.55
68.24
2,292.87
208.45
1,719.65
244.60
20.84
183.45
104.24
10.48
78.18
430.33
44.29
322.73
218.86
21.89
164.16
1,783.81
175.44
1,659.75
456.20
46.34
342.15
97.06
10.78
72.79
334.12
34.19
250.59
1,992.46
170.42
1,494.35
151.27
21.97
111.97
179.90
32.91
136.78
301.41
30.14
239.97
1,715.36
171.53
1,286.51
168.59
16.87
126.44
106.67
10.16
80.01
47.42
4.74
35.56
26.49
2.64
19.88
15.99
1.60
11.99
43.10
4.32
32.32
60.43
6.05
45.31
43.14
4.30
32.50
16.36
1.65
12.28
23.98
2.41
17.97
26.46
2.55
20.23
52.45
5.62
39.35
35.52
3.68
26.66
106.67
10.67
80.01
28.39
3.13
21.29
90.98
9.55
68.24
2,608.60
245.23
1,956.43
244.60
24.52
183.45
104.24
10.48
78.18
430.33
44.29
322.73
257.48
25.75
193.13
1,783.81
177.56
1,410.79
456.20
46.34
342.15
97.06
10.78
72.79
348.84
34.88
261.64
1,693.59
144.86
1,270.20
128.58
18.67
95.17
185.50
32.91
139.13
319.96
31.38
239.97
1,715.36
171.53
1,286.51
168.59
16.87
126.44
90.67
8.64
68.01
47.42
4.74
35.56
26.49
2.64
19.88
15.17
1.52
11.37
43.10
4.32
32.32
55.84
5.99
41.91
38.84
3.88
28.95
13.91
1.40
10.44
28.21
2.83
21.14
26.46
2.55
20.23
61.71
6.55
46.29
30.19
3.13
22.66
106.67
10.67
80.01
28.39
3.13
21.29
77.33
8.12
58.00
2,292.87
216.23
1,719.65
207.91
20.84
155.93
88.60
8.91
66.45
506.27
52.11
379.68
257.48
25.75
193.13
2,098.60
206.40
1,589.21
456.20
46.34
342.15
97.06
10.78
72.79
393.08
40.22
294.81
1,992.46
170.42
1,494.35
128.58
18.67
95.17
210.66
32.91
158.00
319.96
31.38
239.97
1,715.36
171.53
1,286.51
168.59
16.87
126.44
106.67
10.16
80.01
47.42
4.74
35.56
26.49
2.64
19.88
15.77
1.58
11.83
43.10
4.32
32.32
61.00
6.16
45.75
43.14
4.30
32.50
16.36
1.65
12.28
25.76
2.58
19.31
22.49
2.17
17.20
52.45
5.62
39.35
30.19
3.13
22.66
106.67
10.67
80.01
28.39
3.13
21.29
77.33
8.12
58.00
2,697.49
245.23
2,023.12
244.60
24.52
183.45
104.24
10.48
78.18
506.27
52.11
379.68
237.42
23.75
178.06
2,098.60
204.01
1,659.75
387.77
39.39
290.83
93.05
9.32
69.79
393.08
40.22
294.81
1,992.46
170.42
1,494.35
136.74
18.67
102.57
211.65
32.91
160.92
319.96
31.38
239.97
1,715.36
171.53
1,286.51
168.59
16.87
126.44
90.67
8.64
68.01
47.42
4.74
35.56
26.49
2.64
19.88
15.93
1.59
11.95
43.10
4.32
32.32
61.00
7.05
45.75
43.14
4.30
32.50
15.38
1.55
11.54
28.21
2.83
21.14
26.46
2.55
20.23
61.71
6.36
46.29
30.19
3.13
22.66
90.67
9.07
68.01
33.40
3.68
25.05
79.06
8.12
59.29
2,292.87
208.45
1,719.65
244.60
24.52
183.45
104.24
10.48
78.18
506.27
52.11
379.68
218.86
21.89
164.16
1,863.39
186.34
1,659.75
456.20
46.34
342.15
97.06
10.78
72.79
393.08
40.22
294.81
1,992.46
170.42
1,494.35
151.27
21.97
111.97
183.84
32.91
137.90
271.97
26.67
203.97
1,715.36
171.53
1,286.51
168.59
16.87
126.44
90.67
8.64
68.01
47.42
4.74
35.56
26.49
2.64
19.88
15.99
1.60
11.99
43.10
4.32
32.32
61.00
7.05
45.75
36.67
3.66
27.63
13.91
1.40
10.44
23.98
2.41
17.97
26.46
2.55
20.23
61.71
6.61
46.29
35.52
3.68
26.66
106.67
10.67
80.01
28.39
3.13
21.29
82.47
8.25
61.87
2,292.87
208.45
1,719.65
244.60
24.52
183.45
88.60
8.91
66.45
506.27
52.11
379.68
257.48
25.75
193.13
1,783.81
175.44
1,410.79
456.20
45.62
342.15
97.06
9.71
72.79
393.08
40.22
294.81
1,992.46
170.42
1,494.35
128.58
18.67
95.17
211.65
38.72
160.92
319.96
31.38
239.97
1,715.36
171.53
1,286.51
168.59
16.87
126.44
90.67
8.64
68.01
47.42
4.74
35.56
26.49
2.64
19.88
15.99
1.60
11.99
43.10
4.32
32.32
61.00
7.05
45.75
43.14
4.30
32.50
16.36
1.65
12.28
28.21
2.83
21.14
26.46
2.55
20.23
52.45
5.62
39.35
30.19
3.13
22.66
90.67
9.07
68.01
33.40
3.68
25.05
90.98
9.11
68.24
2,685.85
245.23
2,014.38
207.91
20.84
155.93
104.24
10.48
78.18
506.27
52.11
379.68
257.48
25.75
193.13
2,064.09
206.40
1,548.08
456.20
46.34
342.15
82.50
9.16
61.87
393.08
40.22
294.81
1,693.59
168.05
1,270.20
137.52
18.67
103.14
182.60
32.91
136.96
319.96
31.38
239.97
1,715.36
171.53
1,286.51
168.59
16.87
126.44
90.67
8.64
68.01
47.42
4.74
35.56
26.49
2.64
19.88
15.99
1.60
11.99
43.10
4.32
32.32
61.00
7.05
45.75
43.14
4.30
32.50
15.54
1.56
11.66
26.76
2.67
20.09
26.46
2.55
20.23
61.71
6.61
46.29
30.19
3.13
22.66
90.67
9.07
68.01
28.40
3.13
21.30
88.67
8.87
66.50
2,618.39
208.45
1,719.65
207.91
20.84
155.93
104.24
10.48
78.18
430.33
44.29
322.73
257.48
25.75
193.13
1,783.81
175.44
1,410.79
426.08
42.62
319.58
87.09
9.16
65.32
393.08
40.22
294.81
1,992.46
170.42
1,494.35
134.45
18.67
100.83
210.66
32.91
158.00
319.96
31.38
239.97
1,715.36
171.53
1,286.51
168.59
16.87
126.44
106.67
10.16
80.01
47.42
4.74
35.56
26.49
2.64
19.88
15.63
1.57
11.71
43.10
4.32
32.32
51.85
5.99
38.89
38.73
3.87
29.04
16.36
1.65
12.28
28.21
2.83
21.14
26.46
2.55
20.23
61.71
6.61
46.29
35.52
3.68
26.66
90.67
9.07
68.01
33.40
3.68
25.05
90.98
9.11
68.24
2,685.24
245.23
2,013.93
207.91
20.84
155.93
104.24
10.48
78.18
506.27
52.11
379.68
257.48
25.75
193.13
2,098.60
206.40
1,659.75
456.20
46.34
342.15
82.50
9.16
61.87
393.08
40.22
294.81
1,704.24
170.42
1,278.18
137.52
18.67
103.14
180.79
32.91
136.78
319.96
31.38
239.97
1,715.36
171.53
1,286.51
168.59
16.87
126.44
90.67
8.64
68.01
47.42
4.74
35.56
26.49
2.64
19.88
15.97
1.59
11.97
43.10
4.32
32.32
61.00
7.05
45.75
37.08
4.64
27.80
11.33
1.42
8.48
44.43
5.55
45.34
32.96
4.12
24.72
82.84
10.37
62.13
46.00
5.76
34.49
116.97
14.63
87.74
35.02
4.38
26.30
114.33
14.28
85.75
3,105.29
388.16
2,328.96
374.76
46.84
281.08
89.75
11.22
67.30
646.66
80.83
484.99
308.97
38.63
237.78
2,493.95
311.74
1,870.44
478.19
59.77
358.63
108.40
13.54
81.30
367.84
45.98
275.88
2,361.43
295.17
1,771.06
162.04
20.26
121.53
223.28
27.91
167.48
405.80
50.72
304.37
1,721.60
172.16
1,291.23
202.31
20.23
151.74
105.35
13.16
79.08
56.90
5.69
42.67
31.80
3.19
23.83
18.20
1.81
13.66
51.72
5.16
38.81
96.44
12.21
73.18
41.66
4.18
31.23
16.36
1.65
12.28
28.21
2.83
21.14
26.46
2.55
20.23
59.36
5.92
44.52
35.52
3.55
26.66
106.67
10.67
80.01
28.39
3.13
21.29
77.33
8.12
58.00
2,292.87
208.45
1,719.65
207.91
20.84
155.93
88.60
8.91
66.45
430.33
44.29
322.73
257.48
25.75
193.13
1,783.81
175.44
1,410.79
387.77
39.39
290.83
82.50
9.16
61.87
386.24
38.65
289.68
1,992.46
170.42
1,494.35
128.58
18.67
95.17
211.65
38.72
160.92
301.41
30.14
226.05
1,715.36
171.53
1,286.51
168.59
16.87
126.44
106.67
10.16
80.01
47.42
4.74
35.56
26.49
2.64
19.88
15.93
1.59
11.95
43.10
4.32
32.32
51.85
5.99
38.89
43.14
4.30
32.50
16.08
1.61
12.06
28.21
2.83
21.14
26.46
2.55
20.23
61.71
6.61
46.29
30.19
3.13
22.66
106.67
10.67
80.01
28.40
3.13
21.30
85.97
8.59
64.48
2,618.39
245.23
1,963.80
207.91
20.84
155.93
104.24
10.48
78.18
506.27
52.11
379.68
257.48
25.75
193.13
1,869.85
186.99
1,410.79
402.17
40.21
301.64
84.19
9.16
63.16
393.08
40.22
294.81
1,992.46
170.42
1,494.35
149.30
18.67
111.97
211.65
32.91
160.92
319.96
31.38
239.97
1,715.36
171.53
1,286.51
168.59
16.87
126.44
100.59
10.06
75.45
47.42
4.74
35.56
26.49
2.64
19.88
15.99
1.60
11.99
43.10
4.32
32.32
51.85
5.99
38.89
40.45
4.04
30.34
13.91
1.40
10.44
23.98
2.41
17.97
22.49
2.17
17.20
52.45
5.62
39.35
30.19
3.13
22.66
90.67
9.07
68.01
28.39
3.13
21.29
77.33
8.12
58.00
2,292.87
208.45
1,719.65
244.60
24.52
183.45
100.18
10.03
75.15
430.33
44.29
322.73
218.86
21.89
164.16
1,937.36
206.40
1,453.01
387.77
39.39
290.83
82.50
9.16
61.87
334.12
34.19
250.59
1,992.46
157.40
1,494.35
151.27
21.97
111.97
179.90
32.91
136.78
271.97
26.67
203.97
1,715.36
171.53
1,286.51
168.59
16.87
126.44
90.67
8.64
68.01
47.42
4.74
35.56
26.49
2.64
19.88
15.17
1.52
11.37
43.10
4.32
32.32
51.85
5.99
38.89
36.67
3.66
27.63
13.91
1.40
10.44
23.98
2.41
17.97
22.91
2.28
17.20
53.28
5.62
39.95
31.99
3.20
23.99
106.67
10.43
80.01
28.39
3.13
21.29
79.70
8.12
59.77
2,682.60
245.23
2,011.95
239.63
23.97
183.45
104.24
10.48
78.18
506.27
52.11
379.68
257.48
25.75
193.13
2,098.60
206.40
1,659.75
387.77
39.39
290.83
82.50
9.16
61.87
343.86
34.38
257.89
1,992.46
162.47
1,494.35
151.27
18.67
111.97
179.90
32.91
136.78
319.96
31.38
239.97
1,715.36
171.53
1,286.51
168.59
16.87
126.44
94.82
9.13
80.01
47.42
4.74
35.56
26.49
2.64
19.88
15.17
1.52
11.37
43.10
4.32
32.32
61.00
5.99
45.75
IN - Inexpensive/Routinely Purchased
OX - Oxygen
OS - Ostomy
SD - Surgical Dressing
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
Page 95-204
December 1995 DMERC Medicare Advisory
*Category HCPCS Modifier
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
K0022
K0022
K0022
K0023
K0023
K0023
K0024
K0024
K0024
K0025
K0025
K0025
K0026
K0026
K0026
K0027
K0027
K0027
K0028
K0028
K0028
K0029
K0029
K0029
K0030
K0030
K0030
K0031
K0031
K0031
K0032
K0032
K0032
K0033
K0033
K0033
K0034
K0034
K0034
K0035
K0035
K0035
K0036
K0036
K0036
K0037
K0037
K0037
K0038
K0038
K0038
K0039
K0039
K0039
K0040
K0040
K0040
K0041
K0041
K0041
K0042
K0042
K0042
K0043
K0043
K0043
K0044
K0044
K0044
K0045
K0045
K0045
K0046
K0046
K0046
K0047
K0047
K0047
K0048
K0048
K0048
K0049
K0049
K0049
K0050
K0050
K0050
K0051
K0051
K0051
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
AL
AR
CO
FL
GA
KY
LA
MS
NM
NC
OK
PR
SC
TN
TX
VI
39.61
3.94
29.70
87.31
8.73
65.49
103.36
10.35
77.53
58.47
6.53
43.88
36.67
3.66
27.63
36.67
3.66
27.63
506.27
52.11
379.68
39.24
3.90
29.44
75.04
7.29
56.29
33.68
3.37
24.97
36.74
3.68
32.09
36.74
3.68
32.09
14.86
1.54
11.14
24.04
2.41
18.04
14.86
1.55
11.14
37.99
3.39
28.49
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
28.72
2.86
21.55
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.42
39.41
18.12
1.81
13.60
70.96
7.12
53.21
108.96
12.27
85.13
23.98
2.41
17.97
30.16
3.01
22.63
48.81
4.90
36.60
40.36
4.04
30.26
87.31
8.73
65.49
103.36
10.35
77.53
62.50
6.53
46.88
43.14
4.30
32.50
43.14
4.30
32.50
506.27
52.11
379.68
46.16
4.59
34.63
88.28
8.58
66.22
33.68
3.37
24.97
42.57
4.08
31.93
42.57
4.08
31.93
14.86
1.54
11.14
24.04
2.41
18.04
17.48
1.82
13.11
37.99
3.39
28.49
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
30.91
3.11
23.20
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.42
39.41
18.12
1.81
13.60
70.96
7.12
53.21
92.62
10.43
72.36
28.21
2.83
21.14
30.16
3.01
22.63
48.81
4.90
36.60
45.82
4.59
34.35
87.31
8.73
65.49
103.36
10.35
77.53
66.22
6.29
49.66
43.14
4.30
32.50
43.14
4.30
32.50
430.33
44.29
322.73
45.82
4.59
34.35
85.40
8.54
64.06
36.23
3.63
27.90
41.98
3.47
31.50
41.98
3.47
31.50
15.16
1.54
11.36
24.04
2.41
18.04
14.86
1.55
11.14
44.69
3.99
33.52
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
33.79
3.37
25.35
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.42
39.41
18.12
1.81
13.60
70.96
7.12
53.21
108.96
12.27
85.13
28.21
2.83
21.14
30.16
3.01
22.63
48.81
4.90
36.60
46.60
4.64
34.94
83.15
8.32
62.36
98.43
9.83
73.83
60.69
6.07
45.54
43.14
4.30
32.50
43.14
4.30
32.50
430.33
44.29
322.73
46.16
4.59
34.63
84.46
8.45
63.35
33.68
3.37
24.97
42.57
4.08
32.09
42.57
4.08
32.09
17.48
1.81
13.11
23.13
2.30
17.35
17.48
1.82
13.11
44.69
3.99
33.52
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
33.79
3.37
25.35
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.26
39.41
18.12
1.81
13.60
70.96
7.12
53.21
108.96
12.05
85.13
23.98
2.41
17.97
30.16
3.01
22.63
48.81
4.90
36.60
46.60
4.64
34.94
86.48
8.66
64.86
102.36
10.23
76.78
60.84
6.08
45.63
38.84
3.88
28.95
38.84
3.88
28.95
506.27
52.11
379.68
46.16
4.59
34.63
75.04
7.43
56.29
39.62
3.97
29.38
36.18
3.47
28.94
36.18
3.47
28.94
17.48
1.81
13.11
24.04
2.41
18.04
14.86
1.55
11.14
44.69
3.99
33.52
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
33.79
3.37
25.35
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.42
39.41
18.12
1.81
13.60
70.96
7.12
53.21
108.96
10.90
85.13
28.21
2.83
21.14
30.16
3.01
22.63
48.81
4.90
36.60
46.60
4.64
34.94
87.31
8.73
65.49
103.36
10.35
77.53
60.29
6.04
45.22
43.14
4.30
32.50
43.14
4.30
32.50
506.27
52.11
379.68
46.16
4.59
34.63
76.79
7.67
57.59
39.62
3.97
29.38
42.57
4.08
32.09
42.57
4.08
32.09
15.32
1.54
11.49
24.04
2.41
18.04
14.86
1.55
11.14
37.99
3.39
28.49
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
31.16
3.13
23.36
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.42
39.41
18.12
1.81
13.60
70.96
7.12
53.21
108.96
12.27
85.13
25.76
2.58
19.31
30.16
3.01
22.63
48.81
4.90
36.60
40.10
4.02
30.07
87.31
8.73
65.49
103.36
10.35
77.53
64.41
6.44
48.30
43.14
4.30
32.50
43.14
4.30
32.50
506.27
52.11
379.68
40.10
4.02
30.07
88.28
8.58
66.22
33.68
3.37
24.97
42.57
4.08
32.09
42.57
4.08
32.09
14.86
1.54
11.14
24.04
2.41
18.04
17.48
1.82
13.11
37.99
3.39
28.49
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
31.80
3.19
23.84
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.42
39.41
18.12
1.81
13.60
70.96
7.12
53.21
108.96
12.17
85.13
28.21
2.83
21.14
30.16
3.01
22.63
48.81
4.90
36.60
39.61
3.94
29.70
87.31
8.73
65.49
103.36
10.35
77.53
56.29
5.55
42.21
36.67
3.66
27.63
36.67
3.66
27.63
506.27
52.11
379.68
39.24
3.90
29.44
87.08
8.58
65.31
39.62
3.97
29.38
36.18
3.47
27.28
36.18
3.47
27.28
14.86
1.54
11.14
24.04
2.41
18.04
17.48
1.82
13.11
37.99
3.39
28.49
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
28.72
2.86
21.55
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.42
39.41
18.12
1.81
13.60
70.96
7.12
53.21
92.62
10.43
72.36
23.98
2.41
17.97
30.16
3.01
22.63
48.81
4.90
36.60
39.61
3.94
29.70
87.31
8.73
65.49
103.36
10.35
77.53
66.22
6.53
49.66
43.14
4.30
32.50
43.14
4.30
32.50
506.27
52.11
379.68
39.24
3.90
29.44
84.51
8.45
63.40
33.68
3.37
24.97
38.47
3.85
28.87
38.47
3.85
28.87
17.48
1.81
13.11
24.04
2.41
18.04
17.48
1.82
13.11
38.81
3.88
29.10
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
33.79
3.37
25.35
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.42
39.41
18.12
1.81
13.60
70.96
7.12
53.21
108.04
10.80
81.03
28.21
2.83
21.14
30.16
3.01
22.63
48.81
4.90
36.60
39.61
3.94
29.70
85.65
8.56
64.23
101.38
10.14
76.03
64.98
6.50
48.74
43.14
4.30
32.50
43.14
4.30
32.50
430.33
44.29
322.73
39.24
3.90
29.44
88.28
8.58
66.22
38.47
3.84
28.87
42.57
4.08
32.09
42.57
4.08
32.09
16.35
1.65
12.27
23.82
2.40
17.86
17.48
1.82
13.11
37.99
3.39
28.49
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
28.72
2.86
21.55
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.42
39.41
18.12
1.81
13.60
70.96
7.12
53.21
102.23
10.43
76.67
26.76
2.67
20.09
30.16
3.01
22.63
48.81
4.90
36.60
39.61
3.94
29.70
87.31
8.73
65.49
103.36
10.35
77.53
66.22
6.53
49.66
38.73
3.87
29.04
38.73
3.87
29.04
506.27
52.11
379.68
39.24
3.90
29.44
88.28
8.58
66.22
34.84
3.48
26.13
40.85
4.08
30.64
40.85
4.08
30.64
17.48
1.81
13.11
24.04
2.41
18.04
17.48
1.82
13.11
44.69
3.99
33.52
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
33.79
3.37
25.35
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.42
39.41
18.12
1.81
13.60
70.96
7.12
53.21
108.96
12.27
85.13
28.21
2.83
21.14
30.16
3.01
22.63
48.81
4.90
36.60
46.34
5.79
34.77
99.79
9.99
74.84
118.12
11.82
88.59
79.94
10.01
59.96
37.08
4.64
27.80
37.08
4.64
27.80
646.66
80.83
484.99
46.34
5.79
34.77
227.48
28.42
170.62
51.65
6.43
38.75
37.08
4.64
27.80
37.08
4.64
27.80
19.37
2.43
14.52
27.76
2.79
20.82
19.37
2.43
14.52
64.01
8.00
48.02
27.03
2.69
20.26
60.01
6.00
45.01
83.13
8.32
62.35
58.94
5.89
44.21
64.01
8.00
48.02
21.73
2.17
16.32
18.52
1.85
13.88
63.04
6.30
47.27
21.73
2.17
16.32
85.15
8.51
63.87
168.78
21.09
126.57
44.43
5.55
45.36
36.19
3.63
27.14
58.57
5.86
43.92
46.60
4.64
34.94
87.31
8.73
65.49
103.36
10.35
77.53
61.16
6.11
45.88
41.66
4.18
31.23
41.66
4.18
31.23
430.33
44.29
322.73
46.16
4.59
34.63
76.60
7.64
57.46
39.17
3.90
29.38
36.18
3.47
27.28
36.18
3.47
27.28
17.48
1.81
13.11
24.04
2.41
18.04
17.48
1.82
13.11
37.99
3.39
28.49
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
33.79
3.37
25.35
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.42
39.41
18.12
1.81
13.60
70.96
7.12
53.21
105.15
10.51
78.87
28.21
2.83
21.14
30.16
3.01
22.63
48.81
4.90
36.60
39.61
3.94
29.70
87.31
8.73
65.49
103.36
10.35
77.53
65.39
6.53
49.05
43.14
4.30
32.50
43.14
4.30
32.50
506.27
52.11
379.68
39.24
3.90
29.44
87.55
8.58
65.67
35.31
3.52
26.38
42.57
4.08
32.09
42.57
4.08
32.09
15.79
1.58
11.85
24.04
2.41
18.04
14.86
1.55
11.14
42.54
3.99
31.91
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
33.79
3.37
25.35
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.42
39.41
18.12
1.81
13.60
70.96
7.12
53.21
102.23
10.43
76.67
28.21
2.83
21.14
30.16
3.01
22.63
48.81
4.90
36.60
46.60
4.64
34.94
83.15
8.32
62.36
98.43
9.83
73.83
66.22
6.53
49.66
40.45
4.04
30.34
40.45
4.04
30.34
430.33
44.29
322.73
39.24
3.90
29.44
75.04
7.29
56.29
38.45
3.84
28.86
36.18
3.47
27.28
36.18
3.47
27.28
14.86
1.54
11.14
23.13
2.30
17.35
15.64
1.57
11.72
44.69
3.99
33.52
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
33.79
3.37
25.35
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.26
39.41
18.12
1.81
13.60
70.96
7.12
53.21
104.15
10.43
78.13
23.98
2.41
17.97
30.16
3.01
22.63
48.81
4.90
36.60
39.61
3.94
29.70
77.21
7.71
57.91
91.81
9.18
68.86
66.22
6.53
49.66
36.67
3.66
27.63
36.67
3.66
27.63
506.27
52.11
379.68
45.04
4.50
33.79
75.04
7.49
56.29
39.62
3.97
29.38
36.18
3.54
27.28
36.18
3.54
27.28
17.48
1.81
13.11
24.04
2.41
18.04
17.48
1.82
13.11
37.99
3.49
28.49
22.51
2.25
16.89
49.99
5.01
37.49
69.28
6.92
51.95
49.10
4.92
36.83
33.79
3.37
25.35
18.12
1.81
13.60
15.44
1.55
11.58
52.53
5.26
39.41
18.12
1.81
13.60
70.96
7.12
53.21
108.96
11.34
85.13
23.98
2.41
17.97
30.16
3.01
22.63
48.81
4.90
36.60
IN - Inexpensive/Routinely Purchased
OX - Oxygen
OS - Ostomy
SD - Surgical Dressing
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
December 1995 DMERC Medicare Advisory
*Category HCPCS Modifier
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
K0052
K0052
K0052
K0053
K0053
K0053
K0054
K0054
K0054
K0055
K0055
K0055
K0056
K0056
K0056
K0057
K0057
K0057
K0058
K0058
K0058
K0059
K0059
K0059
K0060
K0060
K0060
K0061
K0061
K0061
K0062
K0062
K0062
K0063
K0063
K0063
K0064
K0064
K0064
K0065
K0065
K0065
K0066
K0066
K0066
K0067
K0067
K0067
K0068
K0068
K0068
K0069
K0069
K0069
K0070
K0070
K0070
K0071
K0071
K0071
K0072
K0072
K0072
K0073
K0073
K0073
K0074
K0074
K0074
K0075
K0075
K0075
K0076
K0076
K0076
K0077
K0077
K0077
K0078
K0078
K0078
K0079
K0079
K0079
K0080
K0080
K0080
K0081
K0081
K0081
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
AL
AR
CO
FL
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.53
3.66
27.41
56.61
5.67
42.45
75.58
7.56
56.67
28.22
2.83
21.15
41.25
4.12
30.93
22.49
2.46
17.92
32.29
3.73
23.11
5.46
0.56
4.10
92.70
9.66
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
32.29
3.23
24.22
28.39
3.68
22.69
33.00
4.38
24.75
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
46.94
5.77
23.44
123.68
13.12
93.45
37.74
3.77
28.30
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.53
3.66
27.41
56.61
5.67
42.45
75.58
7.56
56.67
28.22
2.83
21.15
41.25
4.12
30.93
26.46
2.55
20.23
32.50
3.17
24.37
5.46
0.56
4.10
92.70
9.66
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
32.29
3.23
24.22
33.40
3.68
25.05
38.82
4.38
29.12
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
55.22
5.77
27.58
123.68
13.12
93.45
37.74
3.77
28.30
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.53
3.66
27.41
56.61
5.67
42.45
75.58
7.56
56.67
28.22
2.83
21.15
41.25
4.12
30.93
26.46
2.55
20.23
37.96
3.73
27.19
5.46
0.56
4.10
92.70
9.66
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
32.29
3.23
24.22
33.40
3.68
25.05
33.61
3.72
25.20
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
55.22
5.69
27.58
123.68
13.12
93.45
37.74
3.77
28.30
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.53
3.66
27.41
56.59
5.65
42.45
75.58
7.56
56.67
28.21
2.83
21.14
41.25
4.12
30.93
26.46
2.55
20.23
37.96
3.73
27.19
5.46
0.56
4.10
92.70
9.27
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
31.06
3.12
23.28
28.39
3.13
21.29
33.00
3.72
24.75
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
46.94
4.90
27.58
123.68
13.12
93.45
37.74
3.77
28.30
Page 95-205
GA
KY
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.53
3.66
27.41
56.61
5.67
42.45
75.58
7.56
56.67
28.22
2.83
21.15
41.25
4.12
30.93
26.46
2.55
20.23
33.96
3.38
23.88
5.46
0.56
4.10
92.70
9.66
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
32.29
3.23
24.22
28.39
3.13
21.29
38.82
4.38
29.12
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
46.94
4.90
27.58
145.50
15.44
109.94
37.74
3.77
28.30
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.53
3.66
27.41
56.61
5.67
42.45
75.58
7.56
56.67
28.22
2.83
21.15
41.25
4.12
30.93
22.49
2.17
17.20
37.96
3.73
27.19
5.46
0.56
4.10
92.70
9.66
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
32.29
3.23
24.22
28.39
3.13
21.29
33.00
3.72
24.75
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
46.94
4.90
27.58
134.90
13.49
101.19
37.74
3.77
28.30
IN - Inexpensive/Routinely Purchased
OX - Oxygen
LA
MS
NM
NC
OK
PR
SC
TN
TX
VI
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.53
3.66
27.41
56.61
5.67
42.45
75.58
7.56
56.67
28.22
2.83
21.15
41.25
4.12
30.93
26.46
2.55
20.23
33.40
3.34
25.05
5.46
0.56
4.10
92.70
9.66
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
32.29
3.23
24.22
33.40
3.68
25.05
38.82
4.38
29.12
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
55.22
5.77
27.58
123.68
13.12
93.45
37.74
3.77
28.30
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.53
3.66
27.41
56.61
5.67
42.45
75.58
7.56
56.67
28.22
2.83
21.15
41.25
4.12
30.93
26.46
2.55
20.23
32.27
3.17
23.11
5.46
0.56
4.10
92.70
9.66
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
32.29
3.23
24.22
28.39
3.13
21.29
33.00
3.72
24.75
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
46.94
4.90
23.44
145.50
15.44
109.94
37.74
3.77
28.30
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.53
3.66
27.41
56.61
5.67
42.45
75.58
7.56
56.67
28.22
2.83
21.15
41.25
4.12
30.93
26.46
2.55
20.23
37.96
3.73
27.19
5.46
0.56
4.10
92.70
9.66
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
32.29
3.23
24.22
33.40
3.68
25.05
33.00
3.72
24.75
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
46.94
4.90
24.25
145.50
15.44
109.94
37.74
3.77
28.30
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.53
3.66
27.41
56.61
5.67
42.45
75.58
7.56
56.67
28.22
2.83
21.15
41.25
4.12
30.93
26.46
2.55
20.23
37.96
3.73
27.19
5.46
0.56
4.10
92.70
9.54
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
31.98
3.20
23.99
28.40
3.13
21.30
38.82
4.38
29.12
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
46.94
4.90
23.47
123.68
13.12
93.45
37.74
3.77
28.30
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.53
3.66
27.41
56.61
5.67
42.45
75.58
7.56
56.67
28.22
2.83
21.15
41.25
4.12
30.93
26.46
2.55
20.23
37.96
3.73
27.19
5.46
0.56
4.10
92.70
9.66
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
32.29
3.23
24.22
33.40
3.68
25.05
33.00
3.72
24.75
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
55.22
5.77
27.58
145.50
15.44
109.94
37.74
3.77
28.30
102.93
10.29
77.20
113.58
11.35
85.19
116.48
11.65
87.37
105.89
10.58
79.41
105.89
10.58
79.41
138.26
13.83
103.71
67.20
6.73
50.39
35.31
3.53
26.48
30.90
3.09
23.19
43.85
4.38
32.89
67.91
6.79
50.95
90.68
9.06
68.01
33.84
3.39
25.37
49.50
4.96
37.11
32.96
4.12
45.36
46.17
4.61
34.63
6.55
0.66
4.91
111.23
11.12
83.44
203.94
20.39
152.94
121.63
12.17
91.21
73.21
7.31
54.93
37.27
3.73
27.94
35.02
3.50
26.30
37.75
4.73
28.30
28.46
2.85
21.34
65.51
6.55
49.14
10.68
1.08
8.00
18.39
2.29
13.79
95.64
11.96
71.72
45.31
4.54
33.98
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.53
3.66
27.41
56.61
5.67
42.45
75.58
7.56
56.67
28.22
2.83
21.15
41.25
4.12
30.93
26.46
2.55
20.23
35.61
3.56
26.72
5.46
0.56
4.10
92.70
9.66
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
32.29
3.23
24.22
28.39
3.13
21.29
38.82
4.38
29.12
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
55.22
5.77
27.58
123.68
13.12
93.45
37.74
3.77
28.30
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.53
3.66
27.41
56.61
5.67
42.45
75.58
7.56
56.67
28.22
2.83
21.15
41.25
4.12
30.93
26.46
2.55
20.23
32.27
3.17
23.15
5.46
0.56
4.10
92.70
9.66
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
32.29
3.23
24.22
28.40
3.13
21.30
33.00
3.72
24.75
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
46.94
4.90
23.44
145.50
14.53
109.11
37.74
3.77
28.30
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.53
3.66
27.41
56.59
5.65
42.45
75.58
7.56
56.67
28.21
2.83
21.14
41.25
4.12
30.93
22.49
2.17
17.20
32.27
3.17
23.11
5.46
0.56
4.10
92.70
9.27
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
31.06
3.12
23.28
28.39
3.13
21.29
33.00
3.72
24.75
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
52.35
5.77
27.58
145.50
15.44
109.94
37.74
3.77
28.30
85.77
8.57
64.32
94.65
9.46
70.99
97.09
9.71
72.81
88.24
8.82
66.19
88.24
8.82
66.19
115.24
11.53
86.42
56.01
5.60
42.00
29.43
2.94
22.07
25.75
2.58
19.30
36.51
3.66
27.40
56.59
5.65
42.45
75.58
7.56
56.67
28.21
2.83
21.14
41.25
4.12
30.93
22.91
2.28
17.20
34.58
3.47
25.96
5.46
0.56
4.10
92.70
9.27
69.53
169.95
17.00
127.46
101.36
10.14
76.01
61.01
6.10
45.76
32.29
3.23
24.22
28.39
3.13
21.29
38.82
4.38
29.12
23.71
2.39
17.79
54.60
5.46
40.94
8.91
0.89
6.66
46.94
4.90
23.44
134.61
13.97
104.77
37.74
3.77
28.30
OS - Ostomy
SD - Surgical Dressing
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
Page 95-206
December 1995 DMERC Medicare Advisory
*Category HCPCS Modifier
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
K0082
K0082
K0082
K0083
K0083
K0083
K0084
K0084
K0084
K0085
K0085
K0085
K0086
K0086
K0086
K0087
K0087
K0087
K0088
K0088
K0088
K0089
K0089
K0089
K0090
K0090
K0090
K0091
K0091
K0091
K0092
K0092
K0092
K0093
K0093
K0093
K0094
K0094
K0094
K0095
K0095
K0095
K0096
K0096
K0096
K0097
K0097
K0097
K0098
K0098
K0098
K0099
K0099
K0099
K0100
K0100
K0100
K0102
K0102
K0102
K0103
K0103
K0103
K0104
K0104
K0104
K0105
K0105
K0105
K0106
K0106
K0106
K0107
K0107
K0107
K0115
K0115
K0115
K0116
K0116
K0116
K0164
K0168
K0169
K0170
K0171
K0172
K0173
K0174
K0175
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
NU
NU
NU
NU
NU
NU
NU
NU
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
AL
AR
CO
FL
GA
KY
LA
MS
NM
NC
OK
PR
SC
TN
TX
VI
88.60
88.60
104.24
104.24
88.60
104.24
104.24
88.60
104.24
104.24
104.24
89.75
88.60
104.24
100.18
104.24
8.91
8.91
10.48
10.48
8.91
10.48
10.48
8.91
10.48
10.48
10.48
11.22
8.91
10.48
10.03
10.48
66.45
66.45
78.18
78.18
66.45
78.18
78.18
66.45
78.18
78.18
78.18
67.30
66.45
78.18
75.15
78.18
129.41
129.41
129.41
129.41
129.41
129.41
129.41
129.41
129.41
129.41
129.41
155.29
129.41
129.41
129.41
129.41
12.95
12.95
12.95
12.95
12.95
12.95
12.95
12.95
12.95
12.95
12.95
15.53
12.95
12.95
12.95
12.95
97.07
97.07
97.07
97.07
97.07
97.07
97.07
97.07
97.07
97.07
97.07
116.47
97.07
97.07
97.07
97.07
85.34
85.34
85.34
85.34
85.34
85.34
85.34
85.34
85.34
85.34
85.34
102.41
85.34
85.34
85.34
85.34
8.54
8.54
8.54
8.54
8.54
8.54
8.54
8.54
8.54
8.54
8.54
10.23
8.54
8.54
8.54
8.54
64.01
64.01
64.01
64.01
64.01
64.01
64.01
64.01
64.01
64.01
64.01
76.81
64.01
64.01
64.01
64.01
172.59
172.59
172.59
172.59
172.59
172.59
172.59
172.59
172.59
172.59
172.59
207.09
172.59
172.59
172.59
172.59
17.27
17.27
17.27
17.27
17.27
17.27
17.27
17.27
17.27
17.27
17.27
20.71
17.27
17.27
17.27
17.27
129.43
129.43
129.43
129.43
129.43
129.43
129.43
129.43
129.43
129.43
129.43
155.05
129.43
129.43
129.43
129.43
88.60
88.60
104.24
104.24
88.60
104.24
104.24
88.60
104.24
104.24
104.24
89.75
88.60
104.24
100.18
104.24
8.91
8.91
10.48
10.48
8.91
10.48
10.48
8.91
10.48
10.48
10.48
11.22
8.91
10.48
10.03
10.48
66.45
66.45
78.18
78.18
66.45
78.18
78.18
66.45
78.18
78.18
78.18
67.30
66.45
78.18
75.15
78.18
104.08
104.08
104.08
104.08
104.08
104.08
104.08
104.08
104.08
104.08
104.08
124.92
104.08
104.08
104.08
104.08
10.41
10.41
10.41
10.41
10.41
10.41
10.41
10.41
10.41
10.41
10.41
12.49
10.41
10.41
10.41
10.41
78.07
78.07
78.07
78.07
78.07
78.07
78.07
78.07
78.07
78.07
78.07
93.69
78.07
78.07
78.07
78.07
244.60
244.60
244.60
244.60
207.91
244.60
244.60
244.60
207.91
207.91
207.91
374.76
207.91
207.91
244.60
239.63
24.52
24.52
20.84
24.52
20.84
24.52
24.52
24.52
20.84
20.84
20.84
46.84
20.84
20.84
24.52
23.96
160.93
183.45
183.45
183.45
155.93
183.45
183.45
183.45
155.93
155.93
155.93
281.08
155.93
155.93
183.45
183.45
70.05
70.05
70.05
70.05
70.05
70.05
70.05
70.05
70.05
70.05
70.05
84.06
70.05
70.05
70.05
70.05
6.99
6.99
6.99
6.99
6.99
6.99
6.99
6.99
6.99
6.99
6.99
8.40
6.99
6.99
6.99
6.99
52.53
52.53
52.53
52.53
52.53
52.53
52.53
52.53
52.53
52.53
52.53
63.03
52.53
52.53
52.53
52.53
70.68
70.68
70.68
70.68
70.68
70.68
70.68
70.68
70.68
70.68
70.68
84.83
70.68
70.68
70.68
70.68
7.08
7.08
7.08
7.08
7.08
7.08
7.08
7.08
7.08
7.08
7.08
8.49
7.08
7.08
7.08
7.08
53.02
53.02
53.02
53.02
53.02
53.02
53.02
53.02
53.02
53.02
53.02
63.64
53.02
53.02
53.02
53.02
19.27
19.27
19.27
19.27
19.27
19.27
19.27
19.27
19.27
19.27
19.27
23.12
19.27
19.27
19.27
19.27
1.93
1.93
1.93
1.93
1.93
1.93
1.93
1.93
1.93
1.93
1.93
2.31
1.93
1.93
1.93
1.93
14.45
14.45
14.45
14.45
14.45
14.45
14.45
14.45
14.45
14.45
14.45
17.35
14.45
14.45
14.45
14.45
225.58
225.58
225.58
225.58
225.58
225.58
225.58
225.58
225.58
225.58
225.58
270.71
225.58
225.58
225.58
225.58
22.55
22.55
22.55
22.55
22.55
22.55
22.55
22.55
22.55
22.55
22.55
27.07
22.55
22.55
22.55
22.55
169.19
169.19
169.19
169.19
169.19
169.19
169.19
169.19
169.19
169.19
169.19
203.03
169.19
169.19
169.19
169.19
140.92
140.92
140.92
140.92
140.92
140.92
140.92
140.92
140.92
140.92
140.92
169.12
140.92
140.92
140.92
140.92
14.09
14.09
14.09
14.09
14.09
14.09
14.09
14.09
14.09
14.09
14.09
16.92
14.09
14.09
14.09
14.09
105.69
105.69
105.69
105.69
105.69
105.69
105.69
105.69
105.69
105.69
105.69
126.83
105.69
105.69
105.69
105.69
45.92
45.92
45.92
45.92
45.92
45.92
45.92
45.92
45.92
45.92
45.92
55.08
45.92
45.92
45.92
45.92
4.60
4.60
4.60
4.60
4.60
4.60
4.60
4.60
4.60
4.60
4.60
5.51
4.60
4.60
4.60
4.60
34.44
34.44
34.44
34.44
34.44
34.44
34.44
34.44
34.44
34.44
34.44
41.33
34.44
34.44
34.44
34.44
45.92
45.92
45.92
45.92
45.92
45.92
45.92
45.92
45.92
45.92
45.92
55.08
45.92
45.92
45.92
45.92
4.60
4.60
4.60
4.60
4.60
4.60
4.60
4.60
4.60
4.60
4.60
5.51
4.60
4.60
4.60
4.60
34.44
34.44
34.44
34.44
34.44
34.44
34.44
34.44
34.44
34.44
34.44
41.33
34.44
34.44
34.44
34.44
254.50
254.50
254.50
254.50
254.50
254.50
254.50
254.50
254.50
254.50
254.50
305.41
254.50
254.50
254.50
254.50
25.44
25.44
25.44
25.44
25.44
25.44
25.44
25.44
25.44
25.44
25.44
30.53
25.44
25.44
25.44
25.44
190.88
190.88
190.88
190.88
190.88
190.88
190.88
190.88
190.88
190.88
190.88
229.04
190.88
190.88
190.88
190.88
58.53
58.53
58.53
56.28
58.53
58.53
58.53
58.53
58.53
57.96
58.53
67.54
58.53
58.53
56.28
58.53
5.86
5.86
5.86
5.63
5.86
5.86
5.86
5.86
5.86
5.80
5.86
6.76
5.86
5.86
5.63
5.86
43.90
43.90
43.90
42.21
43.90
43.90
43.90
43.90
43.90
43.47
43.90
50.66
43.90
43.90
42.21
43.90
25.09
25.09
25.09
24.50
25.09
25.09
25.09
25.09
25.09
25.09
25.09
29.40
25.09
25.09
24.50
25.09
2.51
2.51
2.51
2.46
2.51
2.51
2.51
2.51
2.51
2.51
2.51
2.95
2.51
2.51
2.46
2.51
18.84
18.84
18.84
18.38
18.84
18.84
18.84
18.84
18.84
18.84
18.84
22.05
18.84
18.84
18.38
18.84
75.07
75.07
75.07
75.07
75.07
75.07
75.07
75.07
75.07
75.07
75.07
90.06
75.07
75.07
75.07
75.07
7.52
7.52
7.52
7.52
7.52
7.52
7.52
7.52
7.52
7.52
7.52
9.00
7.52
7.52
7.52
7.52
56.30
56.30
56.30
56.30
56.30
56.30
56.30
56.30
56.30
56.30
56.30
67.55
56.30
56.30
56.30
56.30
69.73
82.04
82.04
69.73
71.38
82.04
82.04
80.58
82.04
79.29
82.04
97.12
75.31
79.29
80.24
79.72
7.00
8.24
8.24
7.00
7.15
8.24
8.24
8.05
8.24
7.93
8.24
12.15
7.54
7.93
8.03
7.92
52.78
62.09
62.09
52.78
53.54
62.09
62.09
60.43
62.09
59.47
62.09
72.83
56.49
59.47
60.19
62.09
40.22
40.22
40.22
40.22
40.22
40.22
40.22
40.22
40.22
40.22
40.22
48.27
40.22
40.22
40.22
40.22
4.03
4.03
4.03
4.03
4.03
4.03
4.03
4.03
4.03
4.03
4.03
4.81
4.03
4.03
4.03
4.03
30.17
30.17
30.17
30.17
30.17
30.17
30.17
30.17
30.17
30.17
30.17
36.21
30.17
30.17
30.17
30.17
51.14
51.14
51.14
49.53
51.14
51.14
51.14
51.14
51.14
51.14
51.14
56.89
51.14
51.14
43.47
48.82
5.20
5.20
5.20
4.96
5.20
5.20
5.20
5.20
5.20
5.20
5.20
7.13
5.20
5.14
4.42
5.00
37.45
37.45
37.45
37.14
37.45
37.45
37.45
37.45
37.45
37.45
37.45
42.66
37.45
37.45
31.87
37.45
110.21
110.21
110.21
110.21
110.21
110.21
110.21
110.21
110.21
110.21
110.21
132.24
110.21
110.21
110.21
110.21
11.01
11.01
11.01
11.01
11.01
11.01
11.01
11.01
11.01
11.01
11.01
13.21
11.01
11.01
11.01
11.01
82.67
82.67
82.67
82.67
82.67
82.67
82.67
82.67
82.67
82.67
82.67
99.19
82.67
82.67
82.67
82.67
92.26
92.26
92.26
92.26
92.26
92.26
92.26
92.26
92.26
92.26
92.26
110.69
92.26
92.26
92.26
92.26
9.21
9.21
9.21
9.21
9.21
9.21
9.21
9.21
9.21
9.21
9.21
11.07
9.21
9.21
9.21
9.21
69.19
69.19
69.19
69.19
69.19
69.19
69.19
69.19
69.19
69.19
69.19
83.05
69.19
69.19
69.19
69.19
99.43
99.43
99.43
99.43
99.43
99.43
99.43
99.43
99.43
99.43
99.43
119.33
99.43
99.43
99.43
99.43
9.96
9.96
9.96
9.96
9.96
9.96
9.96
9.96
9.96
9.96
9.96
11.94
9.96
9.96
9.96
9.96
74.58
74.58
74.58
74.58
74.58
74.58
74.58
74.58
74.58
74.58
74.58
89.50
74.58
74.58
74.58
74.58
96.45
81.98
96.45
81.98
81.98
96.45
81.98
96.45
96.45
96.45
96.45
105.94
81.98
96.45
96.45
81.98
9.66
8.21
9.66
8.21
8.21
9.66
8.21
9.66
9.66
9.66
9.66
13.25
8.21
9.66
9.66
8.21
72.34
61.49
72.34
61.49
61.49
72.34
61.49
72.34
72.34
72.34
72.34
79.45
61.49
72.34
72.34
61.49
806.65
806.65
806.65
806.65
806.65
806.65
806.65
806.65
806.65
806.65
806.65
968.01
806.65
806.65
806.65
806.65
80.68
80.68
80.68
80.68
80.68
80.68
80.68
80.68
80.68
80.68
80.68
96.80
80.68
80.68
80.68
80.68
605.00
605.00
605.00
605.00
605.00
605.00
605.00
605.00
605.00
605.00
605.00
726.02
605.00
605.00
605.00
605.00
1,683.68 1,683.68 1,683.68 1,683.68 1,683.68 1,683.68 1,683.68 1,683.68 1,683.68 1,683.68 1,683.68 2,020.44 1,683.68 1,683.68 1,683.68 1,683.68
168.38
168.38
168.38
168.38
168.38
168.38
168.38
168.38
168.38
168.38
168.38
202.04
168.38
168.38
168.38
168.38
1,262.77 1,262.77 1,262.77 1,262.77 1,262.77 1,262.77 1,262.77 1,262.77 1,262.77 1,262.77 1,262.77 1,515.34 1,262.77 1,262.77 1,262.77 1,262.77
3.47
3.47
3.47
3.40
3.47
3.47
3.47
3.47
3.47
3.47
3.47
4.09
3.47
3.47
3.40
3.40
2.54
2.54
2.54
2.41
2.50
2.52
2.54
2.54
2.53
2.48
2.53
2.88
2.52
2.54
2.41
2.53
1.42
1.42
1.42
1.42
1.42
1.42
1.42
1.42
1.42
1.42
1.42
1.13
1.42
1.42
1.42
1.42
24.31
24.31
24.31
24.31
24.31
24.31
24.31
24.31
24.31
24.31
24.31
18.90
24.31
24.31
24.31
25.79
8.85
8.85
8.85
8.80
8.85
8.85
8.85
8.85
8.85
8.85
8.85
10.56
8.85
8.85
8.80
7.55
4.11
4.08
4.10
3.85
4.00
4.04
4.20
4.08
4.05
3.96
4.05
4.61
4.04
4.14
3.85
3.69
8.67
8.67
8.67
8.67
8.67
8.67
8.67
8.67
8.67
8.67
8.67
8.10
8.67
8.67
8.67
10.20
38.77
38.41
38.58
36.23
37.68
38.04
39.01
38.41
38.23
37.32
38.12
43.48
38.04
39.01
36.23
35.17
18.61
18.61
18.61
18.61
18.61
18.61
18.61
18.61
18.61
18.61
18.61
19.80
18.61
18.61
18.61
21.63
IN - Inexpensive/Routinely Purchased
OX - Oxygen
OS - Ostomy
SD - Surgical Dressing
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
December 1995 DMERC Medicare Advisory
*Category HCPCS Modifier
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
OS
K0177
K0178
K0179
K0180
K0181
K0182
K0183
K0184
K0185
K0186
K0187
K0188
K0189
K0190
K0191
K0192
K0267
K0268
K0268
K0268
A4214
A4310
A4311
A4312
A4313
A4314
A4315
A4316
A4320
A4322
A4323
A4330
A4338
A4344
A4346
A4347
A4351
A4352
A4354
A4355
A4356
A4358
A4359
A4361
A4362
A4363
A4364
A4367
A4397
A4400
A4402
A4404
A4454
A4455
A4622
A4623
A4625
A4626
A4630
A5053
A5054
A5062
A5063
A5081
A5082
A5093
A5105
A5113
A5114
A5119
A5121
A5122
A5123
A5126
A5131
K0132
K0133
K0134
K0135
K0136
K0137
K0138
K0139
K0165
K0277
K0278
K0279
K0280
K0281
K0407
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
NU
RR
UE
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
Page 95-207
AL
AR
CO
FL
GA
KY
LA
MS
NM
NC
OK
PR
SC
TN
TX
VI
3.51
0.65
4.16
1.74
6.47
0.31
74.57
22.85
34.45
14.75
38.05
5.00
12.09
8.85
27.63
3.02
6.10
99.28
9.91
74.46
1.59
6.46
13.77
14.43
14.61
20.21
20.81
22.40
4.94
2.88
6.92
6.63
11.83
14.69
18.18
16.05
1.68
5.95
10.94
7.70
42.33
5.78
24.16
17.04
2.73
3.10
2.64
6.18
4.45
38.55
1.48
1.33
2.06
1.32
53.14
5.17
6.43
2.72
5.80
1.37
1.33
2.05
2.07
3.05
9.38
1.81
32.15
3.71
7.05
10.07
6.25
11.83
5.26
1.22
14.72
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
3.51
0.65
4.16
1.74
6.41
0.31
74.57
22.85
34.12
14.60
37.70
5.00
12.09
8.85
27.39
3.02
6.10
99.28
9.91
74.46
1.62
6.30
13.77
16.73
17.17
23.46
23.48
23.48
4.94
2.86
8.14
6.06
11.83
14.86
15.45
18.88
1.59
5.06
10.94
8.27
42.33
6.16
28.42
16.61
3.21
3.65
2.72
6.47
4.45
45.35
1.48
1.57
2.24
1.32
53.14
6.08
6.43
2.97
5.80
1.61
1.57
2.05
2.43
2.59
11.03
1.68
35.48
4.36
8.29
8.94
6.93
11.93
5.26
1.23
12.51
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
3.51
0.65
4.16
1.74
6.43
0.31
74.57
22.85
34.28
14.69
37.89
5.00
12.09
8.85
27.51
3.02
6.10
99.28
9.91
74.46
1.62
7.17
12.18
14.22
14.61
23.46
24.48
26.35
4.90
2.84
7.23
6.63
11.83
14.72
18.18
18.38
1.43
5.80
10.94
8.27
35.98
6.16
28.42
16.55
3.21
3.65
2.72
6.82
4.45
38.55
1.48
1.57
2.06
1.32
52.11
6.08
6.43
2.97
5.80
1.61
1.57
2.41
2.43
3.05
11.03
1.81
33.48
4.36
8.29
9.35
6.93
11.93
5.26
1.23
14.72
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
3.34
0.65
4.02
1.74
6.05
0.31
71.02
21.56
32.19
14.36
35.56
4.76
12.09
8.44
26.09
3.02
6.10
99.28
9.91
74.46
1.62
6.09
11.70
16.73
14.61
19.94
20.81
22.4
4.94
3.02
7.47
6.63
10.06
14.86
18.18
16.05
1.68
5.06
9.30
7.03
42.33
6.16
26.92
17.04
3.14
3.65
2.43
6.82
3.83
38.55
1.31
1.57
2.42
1.12
53.14
6.08
6.43
2.52
5.80
1.56
1.56
2.41
2.43
3.05
9.38
1.81
32.15
4.36
7.48
10.07
5.89
11.93
4.47
1.05
12.51
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
3.48
0.65
4.16
1.74
6.27
0.31
73.87
22.41
33.49
14.36
37.00
4.95
12.09
8.78
26.85
3.02
6.10
99.28
9.91
74.46
1.62
6.44
13.77
14.22
14.61
21.65
20.81
26.35
4.37
3.02
7.64
6.63
10.06
12.63
15.45
17.79
1.67
5.86
9.30
7.54
42.33
6.02
24.16
14.96
2.73
3.65
2.31
6.25
4.09
38.55
1.26
1.57
2.06
1.32
53.14
5.82
6.43
2.97
4.93
1.38
1.57
2.41
2.22
2.59
11.03
1.81
37.82
4.36
7.05
10.07
5.89
11.93
4.47
1.23
14.72
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
3.51
0.65
4.16
1.74
6.33
0.31
74.57
22.63
33.79
14.46
37.34
5.00
12.09
8.85
27.12
3.02
6.10
99.28
9.91
74.46
1.62
6.30
13.77
16.42
17.19
23.46
24.48
26.35
4.94
2.57
6.92
6.63
10.06
14.86
18.18
18.88
1.43
5.06
10.94
8.27
42.33
5.24
28.07
17.04
2.95
3.10
2.72
6.82
3.78
43.39
1.26
1.38
2.42
1.12
45.17
5.17
6.43
2.52
5.80
1.37
1.38
2.05
2.43
2.89
9.38
1.81
32.96
3.71
7.05
9.14
6.93
11.93
5.26
1.05
14.70
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
3.51
0.65
4.16
1.74
6.58
0.31
74.57
22.85
35.09
15.02
38.05
5.00
12.17
8.85
28.16
3.02
6.10
99.28
9.91
74.46
1.62
7.11
13.77
16.73
17.19
23.46
23.46
23.46
4.94
2.94
8.14
6.06
11.83
14.86
18.18
17.95
1.59
5.06
10.94
8.27
42.33
6.16
28.42
14.48
3.21
3.65
2.72
6.16
4.45
45.35
1.48
1.57
2.29
1.32
53.14
6.08
6.43
2.97
5.80
1.61
1.57
2.05
2.43
2.59
11.03
1.68
36.45
4.36
8.29
8.94
6.93
11.93
5.26
1.23
12.51
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
3.51
0.65
4.16
1.74
6.41
0.31
74.57
22.85
34.12
14.60
37.70
5.00
12.09
8.85
27.39
3.02
6.10
99.28
9.91
74.46
1.62
6.09
13.77
16.73
17.19
19.94
24.48
26.35
4.20
2.57
7.85
5.64
10.06
13.58
16.11
16.05
1.57
5.95
10.94
8.27
38.60
5.51
27.30
17.04
2.73
3.10
2.72
5.80
4.05
38.55
1.26
1.35
2.06
1.32
53.14
5.17
5.47
2.96
5.80
1.37
1.37
2.05
2.07
2.59
9.38
1.74
37.82
4.36
7.05
9.42
6.93
11.93
5.26
1.23
14.72
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
3.51
0.65
4.16
1.74
6.38
0.31
74.57
22.74
33.96
14.52
37.52
5.00
12.09
8.85
27.25
3.02
6.10
99.28
9.91
74.46
1.62
7.17
13.77
16.73
17.19
21.81
21.81
22.40
4.94
3.02
8.14
5.64
10.06
14.86
18.18
18.88
1.68
5.09
10.06
7.03
42.33
6.16
27.00
14.48
2.73
3.32
2.72
6.74
3.78
45.35
1.28
1.57
2.06
1.12
45.17
5.17
6.43
2.97
4.93
1.37
1.33
2.41
2.43
2.59
11.03
1.70
35.48
3.71
8.29
9.54
6.93
11.93
5.26
1.05
14.72
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
3.46
0.65
4.13
1.74
6.22
0.31
73.16
22.20
33.18
14.36
36.63
4.91
12.09
8.70
26.62
3.02
6.10
99.28
9.91
74.46
1.62
6.09
13.77
16.73
17.19
23.46
24.48
26.35
4.20
3.02
7.95
6.61
10.09
13.31
15.45
16.05
1.43
5.52
10.94
8.27
42.09
6.16
25.96
17.04
3.21
3.15
2.31
5.80
3.78
38.55
1.26
1.33
2.06
1.12
47.37
5.17
5.47
2.52
5.80
1.37
1.57
2.41
2.41
2.69
10.42
1.54
37.82
3.71
7.05
9.41
6.93
11.63
4.47
1.05
13.42
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
3.51
0.65
4.16
1.74
6.36
0.31
74.57
22.69
33.88
14.50
37.44
5.00
12.09
8.85
27.18
3.02
6.10
99.28
9.91
74.46
1.62
7.17
13.77
16.73
17.19
22.73
22.73
22.73
4.94
3.02
8.14
5.64
10.06
14.86
18.18
18.88
1.68
5.09
10.51
7.03
35.98
6.16
27.00
14.48
2.73
3.32
2.72
6.82
3.78
45.35
1.28
1.57
2.06
1.12
45.17
5.17
6.43
2.97
4.93
1.37
1.33
2.41
2.43
2.59
11.03
1.70
35.48
3.71
8.29
9.54
6.93
11.93
5.26
1.05
14.72
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
4.02
0.45
4.82
2.13
7.24
0.27
85.23
25.86
38.63
16.53
42.68
5.72
13.39
10.12
30.99
2.51
7.30
119.13
11.92
89.34
1.15
16.43
10.45
23.82
17.31
23.82
23.82
23.82
5.50
25.00
6.33
1.17
7.91
25.25
16.04
16.97
8.51
8.51
16.43
21.95
30.57
5.16
25.81
9.55
3.25
6.95
6.10
6.79
7.17
52.21
2.94
1.66
1.09
1.06
2.82
2.82
41.09
1.17
4.42
1.17
1.28
2.97
2.20
1.40
1.40
1.17
18.78
5.82
5.82
6.76
3.83
13.12
4.05
1.66
46.96
1.51
1.91
3.84
1.81
10.74
2.62
3.71
3.97
5.02
4.91
7.17
9.79
3.55
0.16
2.24
3.51
0.65
4.16
1.74
6.33
0.31
74.57
22.63
33.79
14.46
37.34
5.00
12.09
8.85
27.12
3.02
6.10
99.28
9.91
74.46
1.62
6.09
13.77
16.73
17.19
23.46
24.48
25.43
4.94
2.84
6.92
6.62
11.83
13.21
15.45
17.78
1.68
5.95
10.94
7.73
39.08
5.24
28.42
17.04
3.21
3.10
2.38
6.38
4.10
38.55
1.48
1.57
2.06
1.30
53.14
5.17
5.47
2.52
5.80
1.37
1.33
2.05
2.28
2.59
9.38
1.72
32.15
4.36
7.05
9.84
6.93
11.93
5.26
1.05
12.51
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
3.51
0.65
4.16
1.74
6.51
0.31
74.57
22.85
34.68
14.84
38.05
5.00
12.09
8.85
27.84
3.02
6.10
99.28
9.91
74.46
1.58
6.82
13.24
16.73
17.19
22.55
24.48
26.35
4.23
2.59
6.92
5.64
10.06
13.6
18.18
16.05
1.43
5.06
10.94
8.27
42.33
5.24
25.95
17.04
2.90
3.10
2.41
5.80
3.78
38.55
1.26
1.33
2.06
1.12
49.29
5.17
5.47
2.52
5.80
1.37
1.35
2.05
2.07
2.97
9.38
1.54
37.82
3.71
7.05
9.41
6.93
10.14
4.47
1.05
13.43
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
3.34
0.65
4.02
1.74
6.05
0.31
71.02
21.56
32.19
14.36
35.56
4.76
12.09
8.44
26.09
3.02
6.10
99.28
9.91
74.46
1.62
6.09
11.96
16.73
17.19
23.46
23.84
26.35
4.20
2.57
8.14
6.58
11.83
12.63
15.45
16.92
1.68
5.93
10.94
8.27
35.98
5.24
28.42
17.04
2.99
3.65
2.50
6.33
4.45
45.35
1.48
1.57
2.42
1.12
51.95
5.18
6.43
2.52
5.80
1.52
1.52
2.41
2.07
2.59
11.03
1.81
37.82
3.71
8.29
10.07
6.61
10.14
5.26
1.23
14.72
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
3.32
0.69
3.75
1.53
6.05
0.36
67.28
20.64
32.86
16.89
36.38
4.25
14.22
7.73
27.68
3.21
6.10
99.28
9.91
74.46
1.38
7.17
12.55
14.22
17.19
22.64
24.48
26.35
4.54
2.83
6.92
5.64
10.06
14.86
16.48
16.05
1.43
5.95
9.30
8.27
35.98
5.83
28.26
14.48
3.21
3.49
2.72
6.36
3.93
38.55
1.48
1.57
2.06
1.12
45.17
6.08
6.43
2.97
4.93
1.53
1.49
2.41
2.07
3.05
9.38
1.65
37.82
4.36
8.29
10.00
5.89
10.57
4.47
1.05
14.72
1.31
1.62
3.29
1.56
9.19
2.24
3.18
3.39
4.30
4.08
5.95
8.17
2.96
0.12
2.04
IN - Inexpensive/Routinely Purchased
OX - Oxygen
OS - Ostomy
SD - Surgical Dressing
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
Page 95-208
December 1995 DMERC Medicare Advisory
* CategoryHCPCSModifier
OS
OS
OS
OS
OX
OX
OX
OX
OX
OX
OX
OX
OX
OX
OX
OX
OX
OX
OX
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
K0408
K0409
K0410
K0411
E0424
E0431
E0434
E0439
E0441
E0442
E0443
E0444
E1400
E1401
E1402
E1403
E1404
E1405
E1406
A4560
E0750
K0112
K0113
K0114
K0126
K0127
K0128
K0129
K0130
K0163
K0400
L0100
L0110
L0120
L0130
L0140
L0150
L0160
L0170
L0172
L0174
L0180
L0190
L0200
L0210
L0220
L0300
L0310
L0315
L0317
L0320
L0330
L0340
L0350
L0360
L0370
L0380
L0390
L0400
L0410
L0420
L0430
L0440
L0500
L0510
L0515
L0520
L0530
L0540
L0550
L0560
L0565
L0600
L0610
L0620
L0700
L0710
L0810
L0820
L0830
L0860
L0900
L0910
L0920
L0930
L0940
L0950
L0960
L0970
L0972
L0974
RR
RR
RR
RR
NU
NU
NU
NU
RR
RR
RR
RR
RR
RR
RR
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
AL
AR
CO
FL
GA
KY
LA
MS
NM
NC
OK
PR
SC
TN
TX
4.58
5.88
2.01
1.67
317.97
49.77
49.77
317.97
226.49
226.49
25.30
25.30
317.97
317.97
317.97
317.97
317.97
345.63
333.99
17.44
6337.49
214.76
131.00
668.29
114.73
17.00
12.39
121.12
55.76
391.36
4.45
408.35
120.47
20.19
146.00
50.39
84.02
119.62
506.19
102.63
184.37
250.77
377.47
346.61
35.97
82.21
135.70
253.59
176.50
239.45
275.86
345.85
551.05
767.44
1132.39
309.08
433.77
955.74
1095.61
1277.47
1265.49
1003.89
818.71
101.16
205.91
122.84
302.10
278.06
300.07
900.49
985.29
982.53
64.35
174.49
290.96
1553.87
1696.14
1801.90
1457.67
2104.71
817.67
133.94
267.54
151.90
311.02
107.31
275.36
61.82
76.71
78.41
160.22
4.58
5.88
2.01
1.67
317.97
49.97
49.97
317.97
226.49
226.49
25.30
25.30
317.97
317.97
317.97
317.97
317.97
350.51
333.53
23.26
8320.62
214.73
130.97
668.24
114.72
16.98
12.38
121.11
55.75
391.33
4.45
417.80
128.57
17.81
109.50
43.84
72.54
140.16
459.11
94.60
184.37
276.27
357.76
399.74
39.62
109.61
116.65
235.21
176.50
304.61
287.33
332.65
438.17
714.03
967.97
298.71
417.78
1029.23
1040.82
1192.80
1287.10
1095.60
829.43
102.71
185.00
122.84
283.05
278.06
299.48
918.73
969.90
876.74
67.03
173.39
287.37
1377.37
1483.75
1838.19
1550.64
2484.46
1090.22
119.78
233.36
113.92
253.94
132.58
232.81
61.82
97.60
89.22
134.89
4.58
5.88
2.01
1.67
275.17
42.47
42.47
275.17
192.52
192.52
25.30
25.30
275.17
275.17
275.17
275.17
275.17
307.71
291.51
22.54
8449.99
212.05
129.35
659.88
113.29
16.77
12.24
119.59
55.06
390.26
4.45
425.02
96.43
17.81
109.50
48.52
72.54
105.12
432.86
88.52
215.66
248.70
345.23
374.92
29.72
82.21
116.65
221.25
176.50
291.03
262.00
307.66
438.17
642.47
1118.01
271.40
417.67
1187.64
1327.99
1433.28
1452.21
1017.25
751.94
91.02
185.00
133.91
279.57
356.79
357.78
1040.29
1164.57
752.66
76.59
173.39
284.18
1372.73
1601.87
1808.71
1564.77
2104.71
1090.22
107.47
233.36
113.92
253.94
106.13
231.06
46.37
102.28
74.30
120.17
4.58
5.88
2.01
1.67
296.16
49.97
49.97
296.16
192.52
192.52
25.30
25.30
296.16
296.16
296.16
296.16
296.16
327.56
314.47
17.44
6337.49
214.76
131.00
668.29
114.73
17.00
12.39
121.12
55.76
391.36
4.45
408.35
120.47
20.19
146.00
50.39
84.02
119.62
506.19
102.63
184.37
250.77
377.47
346.61
35.97
82.21
135.70
253.59
176.50
239.45
275.86
345.85
551.05
767.44
1132.39
309.08
433.77
955.74
1095.61
1277.47
1265.49
1003.89
818.71
101.16
205.91
122.84
302.10
278.06
300.07
900.49
985.29
982.53
64.35
174.49
290.96
1553.87
1696.14
1801.90
1457.67
2104.71
817.67
133.94
267.54
151.90
311.02
107.31
275.36
61.82
76.71
78.41
160.22
4.58
5.88
2.01
1.67
317.97
49.97
49.97
317.97
226.49
226.49
29.40
29.40
317.97
317.97
317.97
317.97
317.97
345.63
336.28
17.44
6337.49
214.76
131.00
668.29
114.73
17.00
12.39
121.12
55.76
391.36
4.45
408.35
120.47
20.19
146.00
50.39
84.02
119.62
506.19
102.63
184.37
250.77
377.47
346.61
35.97
82.21
135.70
253.59
176.50
239.45
275.86
345.85
551.05
767.44
1132.39
309.08
433.77
955.74
1095.61
1277.47
1265.49
1003.89
818.71
101.16
205.91
122.84
302.10
278.06
300.07
900.49
985.29
982.53
64.35
174.49
290.96
1553.87
1696.14
1801.90
1457.67
2104.71
817.67
133.94
267.54
151.90
311.02
107.31
275.36
61.82
76.71
78.41
160.22
4.58
5.88
2.01
1.67
317.97
42.47
42.47
317.97
192.52
192.52
25.30
25.30
317.97
317.97
317.97
317.97
317.97
350.51
335.43
17.44
6337.49
214.76
131.00
668.29
114.73
17.00
12.39
121.12
55.76
391.36
4.45
408.35
120.47
20.19
146.00
50.39
84.02
119.62
506.19
102.63
184.37
250.77
377.47
346.61
35.97
82.21
135.70
253.59
176.50
239.45
275.86
345.85
551.05
767.44
1132.39
309.08
433.77
955.74
1095.61
1277.47
1265.49
1003.89
818.71
101.16
205.91
122.84
302.10
278.06
300.07
900.49
985.29
982.53
64.35
174.49
290.96
1553.87
1696.14
1801.9
1457.67
2104.71
817.67
133.94
267.54
151.90
311.02
107.31
275.36
61.82
76.71
78.41
160.22
4.58
5.88
2.01
1.67
291.91
49.97
49.97
291.91
219.51
219.51
25.30
25.30
291.91
291.91
291.91
291.91
291.91
324.45
307.47
23.26
8320.62
214.73
130.97
668.24
114.72
16.98
12.38
121.11
55.75
391.33
4.45
417.80
128.57
17.81
109.50
43.84
72.54
140.16
459.11
94.60
184.37
276.27
357.76
399.74
39.62
109.61
116.65
235.21
176.50
304.61
287.33
332.65
438.17
714.03
967.97
298.71
417.78
1029.23
1040.82
1192.80
1287.10
1095.60
829.43
102.71
185.00
122.84
283.05
278.06
299.48
918.73
969.90
876.74
67.03
173.39
287.37
1377.37
1483.75
1838.19
1550.64
2484.46
1090.22
119.78
233.36
113.92
253.94
132.58
232.81
61.82
97.60
89.22
134.89
4.58
5.88
2.01
1.67
271.47
42.47
42.47
271.47
192.52
192.52
25.30
25.30
271.47
271.47
271.47
271.47
271.47
299.13
288.44
17.44
6337.49
214.76
131.00
668.29
114.73
17.00
12.39
121.12
55.76
391.36
4.45
408.35
120.47
20.19
146.00
50.39
84.02
119.62
506.19
102.63
184.37
250.77
377.47
346.61
35.97
82.21
135.70
253.59
176.50
239.45
275.86
345.85
551.05
767.44
1132.39
309.08
433.77
955.74
1095.61
1277.47
1265.49
1003.89
818.71
101.16
205.91
122.84
302.10
278.06
300.07
900.49
985.29
982.53
64.35
174.49
290.96
1553.87
1696.14
1801.90
1457.67
2104.71
817.67
133.94
267.54
151.90
311.02
107.31
275.36
61.82
76.71
78.41
160.22
4.58
5.88
2.01
1.67
285.37
49.02
49.02
285.37
195.89
195.89
29.76
29.76
285.37
285.37
285.37
285.37
285.37
313.52
301.08
23.26
8320.62
214.73
130.97
668.24
114.72
16.98
12.38
121.11
55.75
391.33
4.45
417.80
128.57
17.81
109.50
43.84
72.54
140.16
459.11
94.60
184.37
276.27
357.76
399.74
39.62
109.61
116.65
235.21
176.50
304.61
287.33
332.65
438.17
714.03
967.97
298.71
417.78
1029.23
1040.82
1192.80
1287.10
1095.60
829.43
102.71
185.00
122.84
283.05
278.06
299.48
918.73
969.90
876.74
67.03
173.39
287.37
1377.37
1483.75
1838.19
1550.64
2484.46
1090.22
119.78
233.36
113.92
253.94
132.58
232.81
61.82
97.60
89.22
134.89
4.58
5.88
2.01
1.67
290.24
42.47
42.47
290.24
205.41
205.41
25.30
25.30
290.24
290.24
290.24
290.24
290.24
317.90
308.08
17.44
6337.49
214.76
131.00
668.29
114.73
17.00
12.39
121.12
55.76
391.36
4.45
408.35
120.47
20.19
146.00
50.39
84.02
119.62
506.19
102.63
184.37
250.77
377.47
346.61
35.97
82.21
135.70
253.59
176.50
239.45
275.86
345.85
551.05
767.44
1132.39
309.08
433.77
955.74
1095.61
1277.47
1265.49
1003.89
818.71
101.16
205.91
122.84
302.10
278.06
300.07
900.49
985.29
982.53
64.35
174.49
290.96
1553.87
1696.14
1801.9
1457.67
2104.71
817.67
133.94
267.54
151.90
311.02
107.31
275.36
61.82
76.71
78.41
160.22
4.58
5.88
2.01
1.67
275.78
43.65
43.65
275.78
225.82
225.82
25.30
25.30
275.78
275.78
275.78
275.78
275.78
308.32
294.09
23.26
8320.62
214.73
130.97
668.24
114.72
16.98
12.38
121.11
55.75
391.33
4.45
417.80
128.57
17.81
109.50
43.84
72.54
140.16
459.11
94.60
184.37
276.27
357.76
399.74
39.62
109.61
116.65
235.21
176.50
304.61
287.33
332.65
438.17
714.03
967.97
298.71
417.78
1029.23
1040.82
1192.80
1287.10
1095.60
829.43
102.71
185.00
122.84
283.05
278.06
299.48
918.73
969.90
876.74
67.03
173.39
287.37
1377.37
1483.75
1838.19
1550.64
2484.46
1090.22
119.78
233.36
113.92
253.94
132.58
232.81
61.82
97.60
89.22
134.89
5.03
6.48
2.2
1.83
404.83
50.92
50.92
404.83
191.12
191.12
53.78
53.78
404.83
404.83
404.83
404.83
404.83
449.92
446.31
27.50
7597.89
250.18
152.62
778.52
133.65
19.78
14.44
141.09
64.95
455.91
4.75
473.65
96.74
33.35
428.61
83.39
94.51
106.74
426.39
88.95
144.54
278.42
384.60
384.60
22.24
105.63
151.80
333.56
389.14
400.26
161.23
767.17
388.15
764.61
886.73
722.70
294.64
1194.08
1389.80
1556.58
2168.09
1167.43
611.51
177.89
282.68
94.51
333.01
189.02
222.37
1017.68
997.31
833.88
65.58
155.12
200.80
943.62
1003.32
1582.69
1027.35
1791.72
827.22
91.83
191.13
91.83
250.17
138.99
326.88
61.16
47.70
47.70
77.72
4.58
5.88
2.01
1.67
312.15
48.06
48.06
312.15
200.75
200.75
25.30
25.30
312.15
312.15
312.15
312.15
312.15
344.69
330.46
17.44
6337.49
214.76
131.00
668.29
114.73
17.00
12.39
121.12
55.76
391.36
4.45
408.35
120.47
20.19
146.00
50.39
84.02
119.62
506.19
102.63
184.37
250.77
377.47
346.61
35.97
82.21
135.70
253.59
176.50
239.45
275.86
345.85
551.05
767.44
1132.39
309.08
433.77
955.74
1095.61
1277.47
1265.49
1003.89
818.71
101.16
205.91
122.84
302.10
278.06
300.07
900.49
985.29
982.53
64.35
174.49
290.96
1553.87
1696.14
1801.9
1457.67
2104.71
817.67
133.94
267.54
151.90
311.02
107.31
275.36
61.82
76.71
78.41
160.22
4.58
5.88
2.01
1.67
317.97
42.47
42.47
317.97
212.6
212.6
25.30
25.30
317.97
317.97
317.97
317.97
317.97
347.63
336.16
17.44
6337.49
214.76
131.00
668.29
114.73
17.00
12.39
121.12
55.76
391.36
4.45
408.35
120.47
20.19
146.00
50.39
84.02
119.62
506.19
102.63
184.37
250.77
377.47
346.61
35.97
82.21
135.70
253.59
176.50
239.45
275.86
345.85
551.05
767.44
1132.39
309.08
433.77
955.74
1095.61
1277.47
1265.49
1003.89
818.71
101.16
205.91
122.84
302.1
278.06
300.07
900.49
985.29
982.53
64.35
174.49
290.96
1553.87
1696.14
1801.9
1457.67
2104.71
817.67
133.94
267.54
151.90
311.02
107.31
275.36
61.82
76.71
78.41
160.22
4.58
5.88
2.01
1.67
317.97
49.97
49.97
317.97
221.34
221.34
25.30
25.30
317.97
317.97
317.97
317.97
317.97
350.51
336.28
23.26
8320.62
214.73
130.97
668.24
114.72
16.98
12.38
121.11
55.75
391.33
4.45
417.80
128.57
17.81
109.50
43.84
72.54
140.16
459.11
94.60
184.37
276.27
357.76
399.74
39.62
109.61
116.65
235.21
176.50
304.61
287.33
332.65
438.17
714.03
967.97
298.71
417.78
1029.23
1040.82
1192.80
1287.10
1095.6
829.43
102.71
185
122.84
283.05
278.06
299.48
918.73
969.9
876.74
67.03
173.39
287.37
1377.37
1483.75
1838.19
1550.64
2484.46
1090.22
119.78
233.36
113.92
253.94
132.58
232.81
61.82
97.6
89.22
134.89
IN - Inexpensive/Routinely Purchased
OX - Oxygen
OS - Ostomy
SD - Surgical Dressing
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
VI
4.58
5.88
2.01
1.67
317.97
49.96
49.96
317.97
226.49
226.49
29.76
29.76
317.97
317.97
317.97
317.97
317.97
350.51
336.28
17.44
6913.99
208.47
127.16
648.76
111.37
16.49
12.03
117.57
54.13
368.84
4.75
453.24
96.43
17.81
146.00
42.97
83.01
112.47
432.86
98.22
184.37
272.21
364.60
351.09
37.76
103.60
136.63
295.00
226.02
278.77
250.77
307.66
438.17
682.99
1012.92
325.01
556.90
1153.94
1285.96
1277.58
1358.34
997.67
754.84
94.91
218.91
148.17
306.26
278.06
367.18
986.27
989.93
752.66
64.93
173.39
378.9
1356.95
1408.6
1758.14
1449.83
2104.71
817.67
107.47
239.79
113.92
271.79
106.13
260.02
46.37
79.41
76.54
120.17
December 1995 DMERC Medicare Advisory
* CategoryHCPCSModifier
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
L0976
L0978
L0980
L0982
L0984
L1000
L1010
L1020
L1025
L1030
L1040
L1050
L1060
L1070
L1080
L1085
L1090
L1100
L1110
L1120
L1200
L1210
L1220
L1230
L1240
L1250
L1260
L1270
L1280
L1290
L1300
L1310
L1500
L1510
L1520
L1600
L1610
L1620
L1630
L1640
L1650
L1660
L1680
L1685
L1686
L1700
L1710
L1720
L1730
L1750
L1755
L1800
L1810
L1815
L1820
L1825
L1830
L1832
L1834
L1840
L1844
L1845
L1846
L1850
L1855
L1858
L1860
L1870
L1880
L1885
L1900
L1902
L1904
L1906
L1910
L1920
L1930
L1940
L1945
L1950
L1960
L1970
L1980
L1990
L2000
L2010
L2020
L2030
L2036
L2037
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
AL
143.09
129.20
11.71
12.77
40.74
1362.67
54.87
74.98
85.21
56.93
68.53
59.34
66.93
68.42
47.39
131.71
61.52
108.60
183.96
29.31
1166.46
175.63
148.70
381.55
65.66
64.66
66.44
66.34
59.15
67.05
1121.18
1153.69
1274.90
806.56
1915.72
86.49
29.47
97.02
115.80
309.71
164.23
114.87
944.36
996.46
668.49
1161.05
1364.77
1008.15
760.63
132.05
1107.10
59.53
87.36
80.07
87.02
38.79
72.80
544.09
640.10
672.84
1122.08
676.00
847.26
193.19
826.71
908.56
749.33
770.07
475.07
746.82
202.99
55.13
315.63
92.23
179.50
234.65
158.78
358.82
658.95
499.93
372.03
550.26
246.33
316.50
680.78
620.60
783.72
679.94
1245.28
1147.61
AR
126.32
132.33
15.61
14.57
40.74
1481.48
53.07
73.55
83.69
56.93
59.54
72.02
69.90
68.38
38.46
116.18
68.80
118.58
172.94
31.33
1209.48
175.63
169.95
381.55
56.27
54.60
54.93
52.82
57.91
52.76
1292.34
1244.93
1396.74
806.56
1830.23
115.32
30.55
89.92
113.74
356.64
163.77
153.16
966.76
798.36
612.26
1151.31
1480.47
1098.30
869.38
132.05
1062.66
59.53
71.79
67.35
96.58
49.21
58.72
408.07
521.02
758.33
1120.11
628.67
776.38
223.40
737.56
853.90
734.04
751.21
514.98
746.76
232.54
71.44
315.63
80.72
202.22
242.96
211.70
339.87
621.32
501.65
372.03
477.59
257.49
299.19
680.78
664.82
783.72
687.43
1308.50
1117.94
CO
136.16
129.20
11.71
10.93
44.73
1587.91
45.05
58.01
83.69
42.70
52.36
55.88
64.19
60.40
47.74
103.31
66.44
106.73
171.42
28.81
1261.14
234.17
155.04
507.14
52.11
48.49
50.78
52.00
57.91
52.76
1393.34
1475.44
1396.90
1035.82
1562.47
88.45
29.47
89.92
113.74
379.98
175.10
114.87
817.79
798.36
690.07
1024.97
1199.85
884.44
760.91
132.05
1062.66
44.65
67.76
65.02
95.17
36.91
62.00
408.07
550.37
617.15
1204.78
566.61
712.60
220.02
737.56
888.44
720.22
702.41
480.14
748.60
197.45
53.58
315.63
107.63
181.48
295.13
173.32
331.94
639.31
540.88
372.03
501.75
265.60
299.19
705.34
726.11
783.72
679.94
1366.99
1117.94
FL
143.09
129.20
11.71
12.77
40.74
1362.67
54.87
74.98
85.21
56.93
68.53
59.34
66.93
68.42
47.39
131.71
61.52
108.60
183.96
29.31
1166.46
175.63
148.70
381.55
65.66
64.66
66.44
66.34
59.15
67.05
1121.18
1153.69
1274.90
806.56
1915.72
86.49
29.47
97.02
115.80
309.71
164.23
114.87
944.36
996.46
668.49
1161.05
1364.77
1008.15
760.63
132.05
1107.10
59.53
87.36
80.07
87.02
38.79
72.80
544.09
640.10
672.84
1122.08
676.00
847.26
193.19
826.71
908.56
749.33
770.07
475.07
746.82
202.99
55.13
315.63
92.23
179.50
234.65
158.78
358.82
658.95
499.93
372.03
550.26
246.33
316.50
680.78
620.60
783.72
679.94
1245.28
1147.61
Page 95-209
GA
KY
LA
MS
NM
NC
143.09
129.20
11.71
12.77
40.74
1362.67
54.87
74.98
85.21
56.93
68.53
59.34
66.93
68.42
47.39
131.71
61.52
108.60
183.96
29.31
1166.46
175.63
148.70
381.55
65.66
64.66
66.44
66.34
59.15
67.05
1121.18
1153.69
1274.90
806.56
1915.72
86.49
29.47
97.02
115.80
309.71
164.23
114.87
944.36
996.46
668.49
1161.05
1364.77
1008.15
760.63
132.05
1107.10
59.53
87.36
80.07
87.02
38.79
72.80
544.09
640.10
672.84
1122.08
676.00
847.26
193.19
826.71
908.56
749.33
770.07
475.07
746.82
202.99
55.13
315.63
92.23
179.50
234.65
158.78
358.82
658.95
499.93
372.03
550.26
246.33
316.50
680.78
620.60
783.72
679.94
1245.28
1147.61
143.09
129.20
11.71
12.77
40.74
1362.67
54.87
74.98
85.21
56.93
68.53
59.34
66.93
68.42
47.39
131.71
61.52
108.60
183.96
29.31
1166.46
175.63
148.70
381.55
65.66
64.66
66.44
66.34
59.15
67.05
1121.18
1153.69
1274.9
806.56
1915.72
86.49
29.47
97.02
115.80
309.71
164.23
114.87
944.36
996.46
668.49
1161.05
1364.77
1008.15
760.63
132.05
1107.10
59.53
87.36
80.07
87.02
38.79
72.80
544.09
640.10
672.84
1122.08
676.00
847.26
193.19
826.71
908.56
749.33
770.07
475.07
746.82
202.99
55.13
315.63
92.23
179.50
234.65
158.78
358.82
658.95
499.93
372.03
550.26
246.33
316.50
680.78
620.60
783.72
679.94
1245.28
1147.61
126.32
132.33
15.61
14.57
40.74
1481.48
53.07
73.55
83.69
56.93
59.54
72.02
69.90
68.38
38.46
116.18
68.80
118.58
172.94
31.33
1209.48
175.63
169.95
381.55
56.27
54.60
54.93
52.82
57.91
52.76
1292.34
1244.93
1396.74
806.56
1830.23
115.32
30.55
89.92
113.74
356.64
163.77
153.16
966.76
798.36
612.26
1151.31
1480.47
1098.30
869.38
132.05
1062.66
59.53
71.79
67.35
96.58
49.21
58.72
408.07
521.02
758.33
1120.11
628.67
776.38
223.40
737.56
853.90
734.04
751.21
514.98
746.76
232.54
71.44
315.63
80.72
202.22
242.96
211.70
339.87
621.32
501.65
372.03
477.59
257.49
299.19
680.78
664.82
783.72
687.43
1308.50
1117.94
143.09
129.20
11.71
12.77
40.74
1362.67
54.87
74.98
85.21
56.93
68.53
59.34
66.93
68.42
47.39
131.71
61.52
108.60
183.96
29.31
1166.46
175.63
148.70
381.55
65.66
64.66
66.44
66.34
59.15
67.05
1121.18
1153.69
1274.90
806.56
1915.72
86.49
29.47
97.02
115.80
309.71
164.23
114.87
944.36
996.46
668.49
1161.05
1364.77
1008.15
760.63
132.05
1107.10
59.53
87.36
80.07
87.02
38.79
72.80
544.09
640.10
672.84
1122.08
676.00
847.26
193.19
826.71
908.56
749.33
770.07
475.07
746.82
202.99
55.13
315.63
92.23
179.50
234.65
158.78
358.82
658.95
499.93
372.03
550.26
246.33
316.50
680.78
620.60
783.72
679.94
1245.28
1147.61
126.32
132.33
15.61
14.57
40.74
1481.48
53.07
73.55
83.69
56.93
59.54
72.02
69.90
68.38
38.46
116.18
68.80
118.58
172.94
31.33
1209.48
175.63
169.95
381.55
56.27
54.60
54.93
52.82
57.91
52.76
1292.34
1244.93
1396.74
806.56
1830.23
115.32
30.55
89.92
113.74
356.64
163.77
153.16
966.76
798.36
612.26
1151.31
1480.47
1098.30
869.38
132.05
1062.66
59.53
71.79
67.35
96.58
49.21
58.72
408.07
521.02
758.33
1120.11
628.67
776.38
223.40
737.56
853.9
734.04
751.21
514.98
746.76
232.54
71.44
315.63
80.72
202.22
242.96
211.70
339.87
621.32
501.65
372.03
477.59
257.49
299.19
680.78
664.82
783.72
687.43
1308.50
1117.94
143.09
129.20
11.71
12.77
40.74
1362.67
54.87
74.98
85.21
56.93
68.53
59.34
66.93
68.42
47.39
131.71
61.52
108.60
183.96
29.31
1166.46
175.63
148.70
381.55
65.66
64.66
66.44
66.34
59.15
67.05
1121.18
1153.69
1274.90
806.56
1915.72
86.49
29.47
97.02
115.80
309.71
164.23
114.87
944.36
996.46
668.49
1161.05
1364.77
1008.15
760.63
132.05
1107.10
59.53
87.36
80.07
87.02
38.79
72.80
544.09
640.10
672.84
1122.08
676.00
847.26
193.19
826.71
908.56
749.33
770.07
475.07
746.82
202.99
55.13
315.63
92.23
179.50
234.65
158.78
358.82
658.95
499.93
372.03
550.26
246.33
316.50
680.78
620.60
783.72
679.94
1245.28
1147.61
IN - Inexpensive/Routinely Purchased
OX - Oxygen
OS - Ostomy
SD - Surgical Dressing
OK
126.32
132.33
15.61
14.57
40.74
1481.48
53.07
73.55
83.69
56.93
59.54
72.02
69.90
68.38
38.46
116.18
68.80
118.58
172.94
31.33
1209.48
175.63
169.95
381.55
56.27
54.60
54.93
52.82
57.91
52.76
1292.34
1244.93
1396.74
806.56
1830.23
115.32
30.55
89.92
113.74
356.64
163.77
153.16
966.76
798.36
612.26
1151.31
1480.47
1098.30
869.38
132.05
1062.66
59.53
71.79
67.35
96.58
49.21
58.72
408.07
521.02
758.33
1120.11
628.67
776.38
223.40
737.56
853.90
734.04
751.21
514.98
746.76
232.54
71.44
315.63
80.72
202.22
242.96
211.70
339.87
621.32
501.65
372.03
477.59
257.49
299.19
680.78
664.82
783.72
687.43
1308.50
1117.94
PR
77.72
47.70
10.19
10.19
50.20
1701.12
29.80
38.92
189.02
41.81
29.90
29.90
47.70
40.03
11.90
107.85
41.81
53.70
107.50
16.79
1075.03
1164.65
1224.25
1642.43
48.63
37.32
37.32
42.97
59.93
44.09
1639.96
1313.93
1111.84
1778.94
2779.60
192.68
28.29
92.72
99.53
667.10
110.80
107.43
833.88
945.07
889.48
1056.24
1223.02
250.17
878.35
54.26
1223.02
70.10
79.05
77.83
101.51
21.49
74.60
945.07
1056.24
889.48
1307.14
644.87
683.79
277.96
995.10
1223.02
949.61
975.31
555.92
797.50
205.69
50.04
344.67
83.39
344.67
444.73
131.44
889.48
455.86
716.69
889.48
753.35
238.95
722.70
728.88
745.83
1084.05
836.10
2390.45
1728.34
SC
143.09
129.20
11.71
12.77
40.74
1362.67
54.87
74.98
85.21
56.93
68.53
59.34
66.93
68.42
47.39
131.71
61.52
108.60
183.96
29.31
1166.46
175.63
148.70
381.55
65.66
64.66
66.44
66.34
59.15
67.05
1121.18
1153.69
1274.90
806.56
1915.72
86.49
29.47
97.02
115.80
309.71
164.23
114.87
944.36
996.46
668.49
1161.05
1364.77
1008.15
760.63
132.05
1107.10
59.53
87.36
80.07
87.02
38.79
72.80
544.09
640.10
672.84
1122.08
676.00
847.26
193.19
826.71
908.56
749.33
770.07
475.07
746.82
202.99
55.13
315.63
92.23
179.50
234.65
158.78
358.82
658.95
499.93
372.03
550.26
246.33
316.50
680.78
620.60
783.72
679.94
1245.28
1147.61
TN
143.09
129.20
11.71
12.77
40.74
1362.67
54.87
74.98
85.21
56.93
68.53
59.34
66.93
68.42
47.39
131.71
61.52
108.60
183.96
29.31
1166.46
175.63
148.70
381.55
65.66
64.66
66.44
66.34
59.15
67.05
1121.18
1153.69
1274.90
806.56
1915.72
86.49
29.47
97.02
115.80
309.71
164.23
114.87
944.36
996.46
668.49
1161.05
1364.77
1008.15
760.63
132.05
1107.10
59.53
87.36
80.07
87.02
38.79
72.80
544.09
640.10
672.84
1122.08
676.00
847.26
193.19
826.71
908.56
749.33
770.07
475.07
746.82
202.99
55.13
315.63
92.23
179.50
234.65
158.78
358.82
658.95
499.93
372.03
550.26
246.33
316.50
680.78
620.60
783.72
679.94
1245.28
1147.61
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
TX
126.32
132.33
15.61
14.57
40.74
1481.48
53.07
73.55
83.69
56.93
59.54
72.02
69.90
68.38
38.46
116.18
68.80
118.58
172.94
31.33
1209.48
175.63
169.95
381.55
56.27
54.60
54.93
52.82
57.91
52.76
1292.34
1244.93
1396.74
806.56
1830.23
115.32
30.55
89.92
113.74
356.64
163.77
153.16
966.76
798.36
612.26
1151.31
1480.47
1098.30
869.38
132.05
1062.66
59.53
71.79
67.35
96.58
49.21
58.72
408.07
521.02
758.33
1120.11
628.67
776.38
223.40
737.56
853.90
734.04
751.21
514.98
746.76
232.54
71.44
315.63
80.72
202.22
242.96
211.70
339.87
621.32
501.65
372.03
477.59
257.49
299.19
680.78
664.82
783.72
687.43
1308.50
1117.94
VI
107.32
129.20
11.71
10.93
43.94
1362.67
45.05
58.01
111.59
42.70
52.36
55.88
64.19
60.40
37.14
103.31
67.52
109.58
171.42
26.66
1051.64
234.17
198.26
508.73
52.60
48.49
50.78
52.00
62.20
52.76
1494.90
1488.92
1274.9
1075.42
1995.12
86.49
32.21
99.53
113.74
361.88
155.39
114.87
817.79
798.36
816.35
1024.97
1199.85
884.44
779.98
176.06
1093.79
44.65
72.09
65.02
98.77
36.91
69.60
544.09
589.89
694.55
1097.42
689.53
915.85
212.17
983.41
880.37
877.22
865.65
560.39
797.50
181.07
70.11
326.40
81.53
223.30
251.01
158.78
421.33
621.32
666.58
496.04
633.45
276.50
356.79
767.67
827.46
851.45
873.02
1660.37
1469.14
Page 95-210
* CategoryHCPCSModifier
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
L2038
L2040
L2050
L2060
L2070
L2080
L2090
L2102
L2104
L2106
L2108
L2112
L2114
L2116
L2122
L2124
L2126
L2128
L2132
L2134
L2136
L2180
L2182
L2184
L2186
L2188
L2190
L2192
L2200
L2210
L2220
L2230
L2240
L2250
L2260
L2265
L2270
L2275
L2280
L2300
L2310
L2320
L2330
L2335
L2340
L2350
L2360
L2370
L2375
L2380
L2385
L2390
L2395
L2397
L2405
L2415
L2425
L2435
L2492
L2500
L2510
L2520
L2525
L2526
L2530
L2540
L2550
L2570
L2580
L2600
L2610
L2620
L2622
L2624
L2627
L2628
L2630
L2640
L2650
L2660
L2670
L2680
L2750
L2760
L2770
L2780
L2785
L2795
L2800
L2810
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
December 1995 DMERC Medicare Advisory
AL
AR
959.62
122.56
326.44
418.97
120.35
256.65
316.37
312.24
331.28
456.35
717.14
340.50
389.58
513.29
550.49
683.38
913.27
1150.91
541.43
649.16
793.75
78.61
61.52
110.86
122.84
268.03
69.60
239.32
31.91
51.79
59.45
51.51
56.13
238.50
134.55
79.04
36.05
87.71
325.82
183.92
82.58
138.10
263.55
155.04
365.86
598.07
34.73
172.30
75.84
82.63
89.90
73.47
112.18
78.68
35.81
164.35
122.22
122.01
68.45
211.75
566.90
309.20
1060.83
571.77
157.71
283.76
192.76
426.25
404.07
137.84
163.00
179.46
205.83
279.82
1152.80
1354.22
166.20
225.56
80.55
125.10
114.49
105.03
56.11
40.78
41.44
48.23
28.36
57.03
71.60
52.43
959.62
119.16
379.26
438.80
90.94
257.95
312.62
390.64
440.41
561.65
780.29
380.17
440.11
527.27
711.57
764.80
803.73
1150.91
610.80
763.95
864.91
104.81
76.98
100.04
101.04
235.13
67.21
264.72
42.55
45.12
58.64
54.19
56.13
238.50
138.84
105.38
36.05
87.70
303.92
240.95
110.10
150.66
279.32
152.48
371.97
637.30
46.31
196.97
101.12
110.17
116.06
73.47
140.02
78.67
39.51
126.46
123.04
111.08
76.41
246.91
560.01
353.55
818.18
459.73
159.00
301.84
192.76
426.25
311.51
183.79
217.33
209.99
274.44
238.67
1150.61
1124.51
196.53
258.37
97.03
151.10
152.65
140.04
73.76
54.37
55.25
45.42
21.27
65.72
71.60
58.36
CO
959.62
154.85
353.76
397.25
90.26
241.42
327.20
316.83
331.28
456.35
816.64
313.15
392.78
477.83
550.49
657.50
902.55
1150.91
700.07
649.16
892.16
102.37
65.50
91.08
120.98
201.02
60.70
239.32
42.55
60.16
71.22
56.18
56.13
282.35
153.86
79.04
39.57
99.99
303.92
180.71
89.62
176.23
290.49
159.99
299.98
698.54
38.60
172.30
75.84
110.17
119.87
97.96
124.79
86.44
45.54
127.59
146.04
111.08
85.70
211.75
487.54
330.92
919.92
595.49
210.28
322.09
257.02
319.69
407.43
149.68
170.64
179.46
205.83
222.26
1534.15
1499.34
221.60
225.56
80.55
166.80
152.65
140.04
56.11
54.37
55.25
45.42
21.27
57.03
78.52
52.43
FL
959.62
122.56
326.44
418.97
120.35
256.65
316.37
312.24
331.28
456.35
717.14
340.50
389.58
513.29
550.49
683.38
913.27
1150.91
541.43
649.16
793.75
78.61
61.52
110.86
122.84
268.03
69.60
239.32
31.91
51.79
59.45
51.51
56.13
238.5
134.55
79.04
36.05
87.71
325.82
183.92
82.58
138.10
263.55
155.04
365.86
598.07
34.73
172.30
75.84
82.63
89.90
73.47
112.18
78.68
35.81
164.35
122.22
122.01
68.45
211.75
566.90
309.20
1060.83
571.77
157.71
283.76
192.76
426.25
404.07
137.84
163.00
179.46
205.83
279.82
1152.80
1354.22
166.20
225.56
80.55
125.10
114.49
105.03
56.11
40.78
41.44
48.23
28.36
57.03
71.60
52.43
GA
959.62
122.56
326.44
418.97
120.35
256.65
316.37
312.24
331.28
456.35
717.14
340.50
389.58
513.29
550.49
683.38
913.27
1150.91
541.43
649.16
793.75
78.61
61.52
110.86
122.84
268.03
69.60
239.32
31.91
51.79
59.45
51.51
56.13
238.50
134.55
79.04
36.05
87.71
325.82
183.92
82.58
138.10
263.55
155.04
365.86
598.07
34.73
172.30
75.84
82.63
89.90
73.47
112.18
78.68
35.81
164.35
122.22
122.01
68.45
211.75
566.90
309.20
1060.83
571.77
157.71
283.76
192.76
426.25
404.07
137.84
163.00
179.46
205.83
279.82
1152.80
1354.22
166.20
225.56
80.55
125.10
114.49
105.03
56.11
40.78
41.44
48.23
28.36
57.03
71.60
52.43
IN - Inexpensive/Routinely Purchased
OX - Oxygen
KY
959.62
122.56
326.44
418.97
120.35
256.65
316.37
312.24
331.28
456.35
717.14
340.50
389.58
513.29
550.49
683.38
913.27
1150.91
541.43
649.16
793.75
78.61
61.52
110.86
122.84
268.03
69.60
239.32
31.91
51.79
59.45
51.51
56.13
238.50
134.55
79.04
36.05
87.71
325.82
183.92
82.58
138.10
263.55
155.04
365.86
598.07
34.73
172.30
75.84
82.63
89.90
73.47
112.18
78.68
35.81
164.35
122.22
122.01
68.45
211.75
566.90
309.20
1060.83
571.77
157.71
283.76
192.76
426.25
404.07
137.84
163.00
179.46
205.83
279.82
1152.80
1354.22
166.20
225.56
80.55
125.10
114.49
105.03
56.11
40.78
41.44
48.23
28.36
57.03
71.60
52.43
LA
959.62
119.16
379.26
438.80
90.94
257.95
312.62
390.64
440.41
561.65
780.29
380.17
440.11
527.27
711.57
764.80
803.73
1150.91
610.80
763.95
864.91
104.81
76.98
100.04
101.04
235.13
67.21
264.72
42.55
45.12
58.64
54.19
56.13
238.50
138.84
105.38
36.05
87.70
303.92
240.95
110.10
150.66
279.32
152.48
371.97
637.30
46.31
196.97
101.12
110.17
116.06
73.47
140.02
78.67
39.51
126.46
123.04
111.08
76.41
246.91
560.01
353.55
818.18
459.73
159.00
301.84
192.76
426.25
311.51
183.79
217.33
209.99
274.44
238.67
1150.61
1124.51
196.53
258.37
97.03
151.10
152.65
140.04
73.76
54.37
55.25
45.42
21.27
65.72
71.60
58.36
MS
959.62
122.56
326.44
418.97
120.35
256.65
316.37
312.24
331.28
456.35
717.14
340.50
389.58
513.29
550.49
683.38
913.27
1150.91
541.43
649.16
793.75
78.61
61.52
110.86
122.84
268.03
69.60
239.32
31.91
51.79
59.45
51.51
56.13
238.50
134.55
79.04
36.05
87.71
325.82
183.92
82.58
138.10
263.55
155.04
365.86
598.07
34.73
172.30
75.84
82.63
89.90
73.47
112.18
78.68
35.81
164.35
122.22
122.01
68.45
211.75
566.90
309.20
1060.83
571.77
157.71
283.76
192.76
426.25
404.07
137.84
163.00
179.46
205.83
279.82
1152.80
1354.22
166.20
225.56
80.55
125.10
114.49
105.03
56.11
40.78
41.44
48.23
28.36
57.03
71.60
52.43
NM
959.62
119.16
379.26
438.80
90.94
257.95
312.62
390.64
440.41
561.65
780.29
380.17
440.11
527.27
711.57
764.80
803.73
1150.91
610.80
763.95
864.91
104.81
76.98
100.04
101.04
235.13
67.21
264.72
42.55
45.12
58.64
54.19
56.13
238.50
138.84
105.38
36.05
87.70
303.92
240.95
110.10
150.66
279.32
152.48
371.97
637.30
46.31
196.97
101.12
110.17
116.06
73.47
140.02
78.67
39.51
126.46
123.04
111.08
76.41
246.91
560.01
353.55
818.18
459.73
159.00
301.84
192.76
426.25
311.51
183.79
217.33
209.99
274.44
238.67
1150.61
1124.51
196.53
258.37
97.03
151.10
152.65
140.04
73.76
54.37
55.25
45.42
21.27
65.72
71.60
58.36
OS - Ostomy
SD - Surgical Dressing
NC
959.62
122.56
326.44
418.97
120.35
256.65
316.37
312.24
331.28
456.35
717.14
340.50
389.58
513.29
550.49
683.38
913.27
1150.91
541.43
649.16
793.75
78.61
61.52
110.86
122.84
268.03
69.60
239.32
31.91
51.79
59.45
51.51
56.13
238.50
134.55
79.04
36.05
87.71
325.82
183.92
82.58
138.10
263.55
155.04
365.86
598.07
34.73
172.30
75.84
82.63
89.90
73.47
112.18
78.68
35.81
164.35
122.22
122.01
68.45
211.75
566.90
309.20
1060.83
571.77
157.71
283.76
192.76
426.25
404.07
137.84
163.00
179.46
205.83
279.82
1152.80
1354.22
166.20
225.56
80.55
125.10
114.49
105.03
56.11
40.78
41.44
48.23
28.36
57.03
71.60
52.43
OK
959.62
119.16
379.26
438.80
90.94
257.95
312.62
390.64
440.41
561.65
780.29
380.17
440.11
527.27
711.57
764.80
803.73
1150.91
610.80
763.95
864.91
104.81
76.98
100.04
101.04
235.13
67.21
264.72
42.55
45.12
58.64
54.19
56.13
238.50
138.84
105.38
36.05
87.70
303.92
240.95
110.10
150.66
279.32
152.48
371.97
637.30
46.31
196.97
101.12
110.17
116.06
73.47
140.02
78.67
39.51
126.46
123.04
111.08
76.41
246.91
560.01
353.55
818.18
459.73
159.00
301.84
192.76
426.25
311.51
183.79
217.33
209.99
274.44
238.67
1150.61
1124.51
196.53
258.37
97.03
151.10
152.65
140.04
73.76
54.37
55.25
45.42
21.27
65.72
71.60
58.36
PR
SC
TN
TX
VI
1223.02
88.20
367.48
528.13
100.06
305.76
305.76
400.26
472.53
530.35
583.72
389.14
617.06
744.94
650.43
694.91
945.07
1056.24
833.88
1000.66
1667.77
55.59
27.80
38.92
61.16
72.28
50.04
216.82
38.92
38.92
55.59
29.80
14.88
203.47
433.62
94.51
94.51
108.10
384.44
35.80
35.80
149.27
250.83
83.39
333.56
776.51
56.54
255.73
50.04
33.35
29.80
44.48
44.48
96.95
27.80
47.70
71.70
47.70
72.28
131.44
836.10
500.33
2223.68
1334.21
209.03
298.63
83.39
298.63
358.35
59.76
77.72
119.43
105.63
150.10
1234.15
1223.02
472.53
477.83
29.80
47.70
29.80
29.80
23.91
29.36
11.97
23.91
27.24
40.14
61.16
50.04
959.62
122.56
326.44
418.97
120.35
256.65
316.37
312.24
331.28
456.35
717.14
340.50
389.58
513.29
550.49
683.38
913.27
1150.91
541.43
649.16
793.75
78.61
61.52
110.86
122.84
268.03
69.60
239.32
31.91
51.79
59.45
51.51
56.13
238.50
134.55
79.04
36.05
87.71
325.82
183.92
82.58
138.10
263.55
155.04
365.86
598.07
34.73
172.30
75.84
82.63
89.90
73.47
112.18
78.68
35.81
164.35
122.22
122.01
68.45
211.75
566.90
309.20
1060.83
571.77
157.71
283.76
192.76
426.25
404.07
137.84
163.00
179.46
205.83
279.82
1152.80
1354.22
166.20
225.56
80.55
125.10
114.49
105.03
56.11
40.78
41.44
48.23
28.36
57.03
71.60
52.43
959.62
122.56
326.44
418.97
120.35
256.65
316.37
312.24
331.28
456.35
717.14
340.50
389.58
513.29
550.49
683.38
913.27
1150.91
541.43
649.16
793.75
78.61
61.52
110.86
122.84
268.03
69.60
239.32
31.91
51.79
59.45
51.51
56.13
238.50
134.55
79.04
36.05
87.71
325.82
183.92
82.58
138.10
263.55
155.04
365.86
598.07
34.73
172.30
75.84
82.63
89.90
73.47
112.18
78.68
35.81
164.35
122.22
122.01
68.45
211.75
566.90
309.20
1060.83
571.77
157.71
283.76
192.76
426.25
404.07
137.84
163.00
179.46
205.83
279.82
1152.80
1354.22
166.20
225.56
80.55
125.10
114.49
105.03
56.11
40.78
41.44
48.23
28.36
57.03
71.60
52.43
959.62
119.16
379.26
438.80
90.94
257.95
312.62
390.64
440.41
561.65
780.29
380.17
440.11
527.27
711.57
764.80
803.73
1150.91
610.80
763.95
864.91
104.81
76.98
100.04
101.04
235.13
67.21
264.72
42.55
45.12
58.64
54.19
56.13
238.50
138.84
105.38
36.05
87.70
303.92
240.95
110.10
150.66
279.32
152.48
371.97
637.30
46.31
196.97
101.12
110.17
116.06
73.47
140.02
78.67
39.51
126.46
123.04
111.08
76.41
246.91
560.01
353.55
818.18
459.73
159.00
301.84
192.76
426.25
311.51
183.79
217.33
209.99
274.44
238.67
1150.61
1124.51
196.53
258.37
97.03
151.10
152.65
140.04
73.76
54.37
55.25
45.42
21.27
65.72
71.60
58.36
1260.65
119.16
327.79
412.57
90.85
256.15
294.32
392.23
399.31
585.52
870.34
397.74
519.03
571.02
662.10
739.22
1071.64
1386.57
721.91
865.55
1058.33
78.61
61.52
83.14
111.11
268.03
63.12
305.42
33.07
49.29
62.35
51.51
56.13
238.50
179.40
79.04
36.86
84.60
350.41
240.95
82.58
165.27
351.40
152.48
326.04
794.85
46.31
229.73
75.84
82.63
89.90
78.32
105.01
79.23
37.87
123.26
146.70
111.08
77.99
211.75
567.48
380.96
941.69
459.73
205.52
289.88
234.26
319.69
357.40
137.84
190.21
239.28
205.83
237.99
1399.87
1445.39
202.43
300.74
82.69
125.10
141.41
131.45
66.02
50.16
48.84
54.69
25.04
64.09
71.60
52.43
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
December 1995 DMERC Medicare Advisory
* CategoryHCPCSModifier
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
L2820
L2830
L2840
L2850
L2860
L3215
L3219
L3224
L3225
L3650
L3660
L3670
L3700
L3710
L3720
L3730
L3740
L3800
L3805
L3810
L3815
L3820
L3825
L3830
L3835
L3840
L3845
L3850
L3855
L3860
L3890
L3900
L3901
L3902
L3904
L3906
L3907
L3908
L3910
L3912
L3914
L3916
L3918
L3920
L3922
L3924
L3926
L3928
L3930
L3932
L3934
L3936
L3938
L3940
L3942
L3944
L3946
L3948
L3950
L3952
L3954
L3960
L3962
L3963
L3964
L3965
L3966
L3968
L3969
L3970
L3972
L3974
L3980
L3982
L3984
L3985
L3986
L3995
L4000
L4010
L4020
L4030
L4040
L4045
L4050
L4055
L4060
L4070
L4080
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
AL
58.28
65.54
36.58
41.55
265.10
78.94
90.80
39.47
45.41
39.32
67.51
94.09
45.85
95.22
475.10
625.43
702.86
131.34
210.13
42.56
39.52
67.87
48.18
55.60
60.28
41.28
53.32
76.16
82.32
111.92
265.10
1026.06
1150.47
1770.49
2342.09
277.07
372.89
39.36
290.72
63.14
63.58
83.41
56.39
67.25
77.14
82.46
67.80
40.03
41.35
35.86
31.64
58.51
61.54
70.61
48.83
80.42
65.99
44.19
104.05
115.30
72.53
541.40
563.73
1426.08
621.46
1060.76
642.94
818.40
680.71
262.91
183.56
113.28
203.05
250.86
267.78
397.39
459.61
22.48
875.60
492.72
615.47
338.88
273.98
220.17
277.09
179.42
213.31
203.51
71.73
AR
58.28
63.05
39.10
44.72
265.08
78.94
92.52
39.47
46.27
42.67
67.51
77.11
61.13
97.59
498.34
728.90
935.93
131.34
242.86
42.56
46.83
73.23
53.68
59.46
75.20
55.04
57.25
81.78
92.29
140.12
265.08
858.51
1055.48
1765.62
1923.39
259.52
333.63
39.36
263.25
81.87
56.30
111.22
59.59
72.04
78.58
80.35
66.05
45.01
49.86
38.25
34.73
61.02
64.86
74.87
56.61
70.63
69.49
36.20
120.27
130.52
72.53
588.54
471.25
1095.74
498.46
801.97
631.47
793.34
530.35
207.53
185.97
151.04
241.77
272.84
237.36
383.88
386.04
28.01
904.40
462.21
675.90
442.03
288.09
220.17
277.09
182.77
213.31
237.79
67.89
CO
77.71
84.07
29.32
53.37
266.55
82.07
109.53
41.04
54.75
38.95
88.10
74.27
45.85
81.19
429.59
592.07
701.95
175.12
248.22
56.75
52.69
90.49
56.76
68.05
67.53
50.93
70.48
87.81
96.71
124.10
266.55
849.85
1352.35
2102.86
2564.52
268.59
333.63
39.36
290.95
62.29
56.30
83.41
51.47
64.32
64.23
70.03
60.98
38.22
40.41
30.87
31.64
58.51
61.26
70.61
52.34
64.50
58.20
36.20
98.50
109.31
72.53
482.69
471.25
1095.74
498.46
795.57
631.47
699.24
510.53
197.18
183.56
113.28
203.05
251.05
259.77
383.88
368.14
21.48
970.56
488.29
578.12
338.88
286.00
265.00
277.09
179.42
284.41
188.89
67.89
FL
58.28
65.54
36.58
41.55
265.10
78.94
90.80
39.47
45.41
39.32
67.51
94.09
45.85
95.22
475.10
625.43
702.86
131.34
210.13
42.56
39.52
67.87
48.18
55.60
60.28
41.28
53.32
76.16
82.32
111.92
265.10
1026.06
1150.47
1770.49
2342.09
277.07
372.89
39.36
290.72
63.14
63.58
83.41
56.39
67.25
77.14
82.46
67.80
40.03
41.35
35.86
31.64
58.51
61.54
70.61
48.83
80.42
65.99
44.19
104.05
115.30
72.53
541.40
563.73
1426.08
621.46
1060.76
642.94
818.40
680.71
262.91
183.56
113.28
203.05
250.86
267.78
397.39
459.61
22.48
875.60
492.72
615.47
338.88
273.98
220.17
277.09
179.42
213.31
203.51
71.73
Page 95-211
GA
KY
LA
58.28
65.54
36.58
41.55
265.10
78.94
90.80
39.47
45.41
39.32
67.51
94.09
45.85
95.22
475.10
625.43
702.86
131.34
210.13
42.56
39.52
67.87
48.18
55.60
60.28
41.28
53.32
76.16
82.32
111.92
265.10
1026.06
1150.47
1770.49
2342.09
277.07
372.89
39.36
290.72
63.14
63.58
83.41
56.39
67.25
77.14
82.46
67.80
40.03
41.35
35.86
31.64
58.51
61.54
70.61
48.83
80.42
65.99
44.19
104.05
115.30
72.53
541.40
563.73
1426.08
621.46
1060.76
642.94
818.40
680.71
262.91
183.56
113.28
203.05
250.86
267.78
397.39
459.61
22.48
875.60
492.72
615.47
338.88
273.98
220.17
277.09
179.42
213.31
203.51
71.73
58.28
65.54
36.58
41.55
265.10
78.94
90.80
39.47
45.41
39.32
67.51
94.09
45.85
95.22
475.10
625.43
702.86
131.34
210.13
42.56
39.52
67.87
48.18
55.60
60.28
41.28
53.32
76.16
82.32
111.92
265.10
1026.06
1150.47
1770.49
2342.09
277.07
372.89
39.36
290.72
63.14
63.58
83.41
56.39
67.25
77.14
82.46
67.80
40.03
41.35
35.86
31.64
58.51
61.54
70.61
48.83
80.42
65.99
44.19
104.05
115.30
72.53
541.40
563.73
1426.08
621.46
1060.76
642.94
818.40
680.71
262.91
183.56
113.28
203.05
250.86
267.78
397.39
459.61
22.48
875.60
492.72
615.47
338.88
273.98
220.17
277.09
179.42
213.31
203.51
71.73
58.28
63.05
39.10
44.72
265.08
78.94
92.52
39.47
46.27
42.67
67.51
77.11
61.13
97.59
498.34
728.90
935.93
131.34
242.86
42.56
46.83
73.23
53.68
59.46
75.20
55.04
57.25
81.78
92.29
140.12
265.08
858.51
1055.48
1765.62
1923.39
259.52
333.63
39.36
263.25
81.87
56.30
111.22
59.59
72.04
78.58
80.35
66.05
45.01
49.86
38.25
34.73
61.02
64.86
74.87
56.61
70.63
69.49
36.20
120.27
130.52
72.53
588.54
471.25
1095.74
498.46
801.97
631.47
793.34
530.35
207.53
185.97
151.04
241.77
272.84
237.36
383.88
386.04
28.01
904.40
462.21
675.90
442.03
288.09
220.17
277.09
182.77
213.31
237.79
67.89
IN - Inexpensive/Routinely Purchased
OX - Oxygen
MS
58.28
65.54
36.58
41.55
265.10
78.94
90.80
39.47
45.41
39.32
67.51
94.09
45.85
95.22
475.10
625.43
702.86
131.34
210.13
42.56
39.52
67.87
48.18
55.60
60.28
41.28
53.32
76.16
82.32
111.92
265.10
1026.06
1150.47
1770.49
2342.09
277.07
372.89
39.36
290.72
63.14
63.58
83.41
56.39
67.25
77.14
82.46
67.80
40.03
41.35
35.86
31.64
58.51
61.54
70.61
48.83
80.42
65.99
44.19
104.05
115.30
72.53
541.40
563.73
1426.08
621.46
1060.76
642.94
818.40
680.71
262.91
183.56
113.28
203.05
250.86
267.78
397.39
459.61
22.48
875.60
492.72
615.47
338.88
273.98
220.17
277.09
179.42
213.31
203.51
71.73
NM
NC
58.28
63.05
39.10
44.72
265.08
78.94
92.52
39.47
46.27
42.67
67.51
77.11
61.13
97.59
498.34
728.90
935.93
131.34
242.86
42.56
46.83
73.23
53.68
59.46
75.20
55.04
57.25
81.78
92.29
140.12
265.08
858.51
1055.48
1765.62
1923.39
259.52
333.63
39.36
263.25
81.87
56.30
111.22
59.59
72.04
78.58
80.35
66.05
45.01
49.86
38.25
34.73
61.02
64.86
74.87
56.61
70.63
69.49
36.20
120.27
130.52
72.53
588.54
471.25
1095.74
498.46
801.97
631.47
793.34
530.35
207.53
185.97
151.04
241.77
272.84
237.36
383.88
386.04
28.01
904.40
462.21
675.90
442.03
288.09
220.17
277.09
182.77
213.31
237.79
67.89
58.28
65.54
36.58
41.55
265.10
78.94
90.80
39.47
45.41
39.32
67.51
94.09
45.85
95.22
475.10
625.43
702.86
131.34
210.13
42.56
39.52
67.87
48.18
55.60
60.28
41.28
53.32
76.16
82.32
111.92
265.10
1026.06
1150.47
1770.49
2342.09
277.07
372.89
39.36
290.72
63.14
63.58
83.41
56.39
67.25
77.14
82.46
67.80
40.03
41.35
35.86
31.64
58.51
61.54
70.61
48.83
80.42
65.99
44.19
104.05
115.30
72.53
541.40
563.73
1426.08
621.46
1060.76
642.94
818.40
680.71
262.91
183.56
113.28
203.05
250.86
267.78
397.39
459.61
22.48
875.60
492.72
615.47
338.88
273.98
220.17
277.09
179.42
213.31
203.51
71.73
OS - Ostomy
SD - Surgical Dressing
OK
58.28
63.05
39.10
44.72
265.08
78.94
92.52
39.47
46.27
42.67
67.51
77.11
61.13
97.59
498.34
728.90
935.93
131.34
242.86
42.56
46.83
73.23
53.68
59.46
75.20
55.04
57.25
81.78
92.29
140.12
265.08
858.51
1055.48
1765.62
1923.39
259.52
333.63
39.36
263.25
81.87
56.30
111.22
59.59
72.04
78.58
80.35
66.05
45.01
49.86
38.25
34.73
61.02
64.86
74.87
56.61
70.63
69.49
36.20
120.27
130.52
72.53
588.54
471.25
1095.74
498.46
801.97
631.47
793.34
530.35
207.53
185.97
151.04
241.77
272.84
237.36
383.88
386.04
28.01
904.40
462.21
675.90
442.03
288.09
220.17
277.09
182.77
213.31
237.79
67.89
PR
233.49
233.49
33.35
44.48
308.79
177.89
161.23
88.95
80.62
55.59
65.72
83.39
23.91
29.80
226.91
262.73
722.70
161.23
226.14
29.80
35.80
60.83
52.53
49.02
47.70
35.80
41.81
53.70
59.76
83.67
308.79
537.56
716.69
936.53
1370.09
222.37
500.33
29.17
197.11
38.25
1084.05
47.70
31.14
38.25
41.81
44.20
47.70
23.91
29.80
23.91
23.91
41.81
40.14
61.16
40.58
46.59
83.39
35.8
56.14
62.04
47.70
418.18
334.44
1167.43
917.28
906.15
789.40
1011.78
644.87
350.22
242.40
242.40
750.49
750.49
119.43
194.58
131.44
33.35
778.29
667.10
833.88
667.10
800.53
250.17
667.10
305.76
177.89
177.89
83.39
SC
58.28
65.54
36.58
41.55
265.10
78.94
90.80
39.47
45.41
39.32
67.51
94.09
45.85
95.22
475.10
625.43
702.86
131.34
210.13
42.56
39.52
67.87
48.18
55.60
60.28
41.28
53.32
76.16
82.32
111.92
265.10
1026.06
1150.47
1770.49
2342.09
277.07
372.89
39.36
290.72
63.14
63.58
83.41
56.39
67.25
77.14
82.46
67.80
40.03
41.35
35.86
31.64
58.51
61.54
70.61
48.83
80.42
65.99
44.19
104.05
115.30
72.53
541.40
563.73
1426.08
621.46
1060.76
642.94
818.40
680.71
262.91
183.56
113.28
203.05
250.86
267.78
397.39
459.61
22.48
875.60
492.72
615.47
338.88
273.98
220.17
277.09
179.42
213.31
203.51
71.73
TN
58.28
65.54
36.58
41.55
265.10
78.94
90.80
39.47
45.41
39.32
67.51
94.09
45.85
95.22
475.10
625.43
702.86
131.34
210.13
42.56
39.52
67.87
48.18
55.60
60.28
41.28
53.32
76.16
82.32
111.92
265.10
1026.06
1150.47
1770.49
2342.09
277.07
372.89
39.36
290.72
63.14
63.58
83.41
56.39
67.25
77.14
82.46
67.80
40.03
41.35
35.86
31.64
58.51
61.54
70.61
48.83
80.42
65.99
44.19
104.05
115.30
72.53
541.40
563.73
1426.08
621.46
1060.76
642.94
818.40
680.71
262.91
183.56
113.28
203.05
250.86
267.78
397.39
459.61
22.48
875.60
492.72
615.47
338.88
273.98
220.17
277.09
179.42
213.31
203.51
71.73
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
TX
58.28
63.05
39.10
44.72
265.08
78.94
92.52
39.47
46.27
42.67
67.51
77.11
61.13
97.59
498.34
728.90
935.93
131.34
242.86
42.56
46.83
73.23
53.68
59.46
75.20
55.04
57.25
81.78
92.29
140.12
265.08
858.51
1055.48
1765.62
1923.39
259.52
333.63
39.36
263.25
81.87
56.30
111.22
59.59
72.04
78.58
80.35
66.05
45.01
49.86
38.25
34.73
61.02
64.86
74.87
56.61
70.63
69.49
36.20
120.27
130.52
72.53
588.54
471.25
1095.74
498.46
801.97
631.47
793.34
530.35
207.53
185.97
151.04
241.77
272.84
237.36
383.88
386.04
28.01
904.40
462.21
675.90
442.03
288.09
220.17
277.09
182.77
213.31
237.79
67.89
VI
66.95
77.65
34.70
44.62
262.52
86.90
97.62
43.46
48.80
44.75
69.10
88.05
53.06
84.75
572.78
772.15
865.96
131.34
278.85
42.56
40.80
67.87
44.04
55.60
60.28
41.28
53.32
101.54
76.77
105.09
262.52
849.85
1167.72
1599.87
1923.39
268.19
391.66
52.48
267.98
62.29
74.82
83.41
51.47
74.31
64.23
70.03
68.28
45.82
42.23
30.87
31.64
59.31
61.26
70.61
48.83
64.50
58.20
42.32
98.50
109.31
72.53
495.12
471.25
1196.01
603.57
795.57
740.97
884.04
523.82
262.91
191.03
151.04
232.16
326.92
241.81
511.84
428.38
28.64
855.80
531.17
737.29
451.84
323.96
220.17
369.46
179.42
213.31
188.89
69.38
Page 95-212
* CategoryHCPCSModifier
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
L4090
L4100
L4110
L4130
L4310
L4320
L4350
L4360
L4370
L4380
L5000
L5010
L5020
L5050
L5060
L5100
L5105
L5150
L5160
L5200
L5210
L5220
L5230
L5250
L5270
L5280
L5300
L5310
L5320
L5330
L5340
L5400
L5410
L5420
L5430
L5450
L5460
L5500
L5505
L5510
L5520
L5530
L5535
L5540
L5560
L5570
L5580
L5585
L5590
L5595
L5600
L5610
L5611
L5613
L5614
L5616
L5617
L5618
L5620
L5622
L5624
L5626
L5628
L5629
L5630
L5631
L5632
L5634
L5636
L5637
L5638
L5639
L5640
L5642
L5643
L5644
L5645
L5646
L5647
L5648
L5649
L5650
L5651
L5652
L5653
L5654
L5655
L5656
L5658
L5660
L5661
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
December 1995 DMERC Medicare Advisory
AL
63.50
71.62
56.93
391.74
273.93
110.36
70.57
197.45
126.71
77.68
378.42
913.99
1552.16
1716.98
1975.03
1720.77
2484.12
2511.11
2731.28
2615.58
1735.17
1972.34
2720.25
3710.18
3693.73
3665.42
2350.24
3486.91
3536.01
4518.03
4666.98
973.80
298.76
1193.39
359.83
292.71
390.01
918.39
1270.15
1041.05
1028.30
1235.10
1212.62
1294.25
1389.80
1444.90
1686.81
2075.91
1718.98
3036.81
3264.45
1480.46
1152.10
1801.26
2843.77
1206.57
404.59
214.05
198.80
259.24
259.97
340.93
364.54
227.25
320.92
314.18
175.35
217.51
182.21
206.58
359.85
801.72
457.24
443.03
1112.97
422.35
570.55
391.79
568.81
470.78
1705.9
349.08
858.74
311.76
416.17
237.14
200.94
269.60
259.99
435.19
435.15
AR
76.68
78.74
62.99
388.09
282.66
83.12
61.70
185.85
126.71
72.09
481.72
1093.82
1643.2
2068.53
2337.33
2032.67
2484.12
2961.02
3115.33
2707.48
2001.25
2514.18
2980.03
4034.37
3833.48
4172.96
2355.36
3303.47
3436.13
5027.09
5207.50
1019.82
398.35
1305.99
479.77
388.43
519.89
1026.16
1658.30
1219.95
1371.07
1416.95
1419.70
1522.22
1830.69
1807.50
2018.21
2024.85
1981.16
2879.24
3179.53
1715.83
1152.10
1774.60
2843.50
1363.36
404.55
216.01
265.07
345.65
346.63
380.66
410.82
303.00
369.89
418.91
158.77
217.51
182.21
275.44
360.95
801.72
457.24
456.93
1197.01
503.85
571.69
508.57
568.81
554.75
1737.40
409.63
1144.98
363.73
426.01
281.89
219.30
271.80
259.99
464.27
435.15
CO
60.61
70.00
57.68
382.71
365.24
110.82
59.99
200.55
138.99
72.09
361.29
955.03
1675.65
1780.26
2412.98
1661.94
2725.09
2781.34
3063.01
2362.22
1870.29
2155.04
3627.00
4660.38
4251.15
4828.93
2078.80
3317.31
3031.92
4984.84
5316.49
877.58
298.76
1222.40
359.83
350.34
410.34
1209.82
1408.26
1205.42
1028.30
1353.29
1212.62
1452.56
1698.14
1837.70
2064.16
2069.60
2195.36
2879.24
3179.53
1917.24
1536.13
2196.94
3119.53
1275.22
405.56
201.10
198.80
259.24
260.78
340.93
345.25
227.25
350.46
314.18
195.19
290.02
242.94
206.58
464.00
1068.96
609.65
590.71
1483.96
563.14
760.73
507.46
694.51
627.71
1515.93
465.44
1144.98
415.68
554.89
238.41
189.67
273.73
298.03
418.87
435.15
FL
63.50
71.62
56.93
391.74
273.93
110.36
70.57
197.45
126.71
77.68
378.42
913.99
1552.16
1716.98
1975.03
1720.77
2484.12
2511.11
2731.28
2615.58
1735.17
1972.34
2720.25
3710.18
3693.73
3665.42
2350.24
3486.91
3536.01
4518.03
4666.98
973.80
298.76
1193.39
359.83
292.71
390.01
918.39
1270.15
1041.05
1028.30
1235.10
1212.62
1294.25
1389.80
1444.90
1686.81
2075.91
1718.98
3036.81
3264.45
1480.46
1152.10
1801.26
2843.77
1206.57
404.59
214.05
198.80
259.24
259.97
340.93
364.54
227.25
320.92
314.18
175.35
217.51
182.21
206.58
359.85
801.72
457.24
443.03
1112.97
422.35
570.55
391.79
568.81
470.78
1705.90
349.08
858.74
311.76
416.17
237.14
200.94
269.60
259.99
435.19
435.15
GA
63.50
71.62
56.93
391.74
273.93
110.36
70.57
197.45
126.71
77.68
378.42
913.99
1552.16
1716.98
1975.03
1720.77
2484.12
2511.11
2731.28
2615.58
1735.17
1972.34
2720.25
3710.18
3693.73
3665.42
2350.24
3486.91
3536.01
4518.03
4666.98
973.80
298.76
1193.39
359.83
292.71
390.01
918.39
1270.15
1041.05
1028.30
1235.10
1212.62
1294.25
1389.80
1444.90
1686.81
2075.91
1718.98
3036.81
3264.45
1480.46
1152.10
1801.26
2843.77
1206.57
404.59
214.05
198.80
259.24
259.97
340.93
364.54
227.25
320.92
314.18
175.35
217.51
182.21
206.58
359.85
801.72
457.24
443.03
1112.97
422.35
570.55
391.79
568.81
470.78
1705.90
349.08
858.74
311.76
416.17
237.14
200.94
269.60
259.99
435.19
435.15
IN - Inexpensive/Routinely Purchased
OX - Oxygen
KY
LA
63.50
71.62
56.93
391.74
273.93
110.36
70.57
197.45
126.71
77.68
378.42
913.99
1552.16
1716.98
1975.03
1720.77
2484.12
2511.11
2731.28
2615.58
1735.17
1972.34
2720.25
3710.18
3693.73
3665.42
2350.24
3486.91
3536.01
4518.03
4666.98
973.80
298.76
1193.39
359.83
292.71
390.01
918.39
1270.15
1041.05
1028.30
1235.10
1212.62
1294.25
1389.80
1444.90
1686.81
2075.91
1718.98
3036.81
3264.45
1480.46
1152.10
1801.26
2843.77
1206.57
404.59
214.05
198.80
259.24
259.97
340.93
364.54
227.25
320.92
314.18
175.35
217.51
182.21
206.58
359.85
801.72
457.24
443.03
1112.97
422.35
570.55
391.79
568.81
470.78
1705.90
349.08
858.74
311.76
416.17
237.14
200.94
269.60
259.99
435.19
435.15
76.68
78.74
62.99
388.09
282.66
83.12
61.70
185.85
126.71
72.09
481.72
1093.82
1643.20
2068.53
2337.33
2032.67
2484.12
2961.02
3115.33
2707.48
2001.25
2514.18
2980.03
4034.37
3833.48
4172.96
2355.36
3303.47
3436.13
5027.09
5207.50
1019.82
398.35
1305.99
479.77
388.43
519.89
1026.16
1658.30
1219.95
1371.07
1416.95
1419.70
1522.22
1830.69
1807.50
2018.21
2024.85
1981.16
2879.24
3179.53
1715.83
1152.10
1774.60
2843.50
1363.36
404.55
216.01
265.07
345.65
346.63
380.66
410.82
303.00
369.89
418.91
158.77
217.51
182.21
275.44
360.95
801.72
457.24
456.93
1197.01
503.85
571.69
508.57
568.81
554.75
1737.40
409.63
1144.98
363.73
426.01
281.89
219.30
271.80
259.99
464.27
435.15
MS
63.50
71.62
56.93
391.74
273.93
110.36
70.57
197.45
126.71
77.68
378.42
913.99
1552.16
1716.98
1975.03
1720.77
2484.12
2511.11
2731.28
2615.58
1735.17
1972.34
2720.25
3710.18
3693.73
3665.42
2350.24
3486.91
3536.01
4518.03
4666.98
973.80
298.76
1193.39
359.83
292.71
390.01
918.39
1270.15
1041.05
1028.30
1235.10
1212.62
1294.25
1389.80
1444.90
1686.81
2075.91
1718.98
3036.81
3264.45
1480.46
1152.10
1801.26
2843.77
1206.57
404.59
214.05
198.80
259.24
259.97
340.93
364.54
227.25
320.92
314.18
175.35
217.51
182.21
206.58
359.85
801.72
457.24
443.03
1112.97
422.35
570.55
391.79
568.81
470.78
1705.90
349.08
858.74
311.76
416.17
237.14
200.94
269.60
259.99
435.19
435.15
NM
76.68
78.74
62.99
388.09
282.66
83.12
61.70
185.85
126.71
72.09
481.72
1093.82
1643.20
2068.53
2337.33
2032.67
2484.12
2961.02
3115.33
2707.48
2001.25
2514.18
2980.03
4034.37
3833.48
4172.96
2355.36
3303.47
3436.13
5027.09
5207.50
1019.82
398.35
1305.99
479.77
388.43
519.89
1026.16
1658.30
1219.95
1371.07
1416.95
1419.70
1522.22
1830.69
1807.50
2018.21
2024.85
1981.16
2879.24
3179.53
1715.83
1152.10
1774.60
2843.50
1363.36
404.55
216.01
265.07
345.65
346.63
380.66
410.82
303.00
369.89
418.91
158.77
217.51
182.21
275.44
360.95
801.72
457.24
456.93
1197.01
503.85
571.69
508.57
568.81
554.75
1737.40
409.63
1144.98
363.73
426.01
281.89
219.30
271.80
259.99
464.27
435.15
OS - Ostomy
SD - Surgical Dressing
NC
63.50
71.62
56.93
391.74
273.93
110.36
70.57
197.45
126.71
77.68
378.42
913.99
1552.16
1716.98
1975.03
1720.77
2484.12
2511.11
2731.28
2615.58
1735.17
1972.34
2720.25
3710.18
3693.73
3665.42
2350.24
3486.91
3536.01
4518.03
4666.98
973.80
298.76
1193.39
359.83
292.71
390.01
918.39
1270.15
1041.05
1028.30
1235.10
1212.62
1294.25
1389.80
1444.90
1686.81
2075.91
1718.98
3036.81
3264.45
1480.46
1152.10
1801.26
2843.77
1206.57
404.59
214.05
198.80
259.24
259.97
340.93
364.54
227.25
320.92
314.18
175.35
217.51
182.21
206.58
359.85
801.72
457.24
443.03
1112.97
422.35
570.55
391.79
568.81
470.78
1705.90
349.08
858.74
311.76
416.17
237.14
200.94
269.60
259.99
435.19
435.15
OK
PR
76.68
83.39
78.74
100.06
62.99
100.06
388.09
305.76
282.66
667.10
83.12
55.59
61.70
46.36
185.85
214.58
126.71
124.53
72.09
85.61
481.72
583.72
1093.82
583.72
1643.20
806.30
2068.53 2223.68
2337.33
597.30
2032.67 2223.68
2484.12 3891.44
2961.02 3891.44
3115.33 4002.63
2707.48 3446.71
2001.25 3224.34
2514.18 3113.15
2980.03 2779.60
4034.37 7226.96
3833.48 10619.29
4172.96 7449.33
2355.36 3001.97
3303.47 4780.92
3436.13 4711.98
5027.09 8672.35
5207.50 10619.29
1019.82
507.67
398.35
155.21
1305.99
776.51
479.77 2779.60
388.43
215.03
519.89
268.73
1026.16 1334.21
1658.30 2334.87
1219.95 1778.94
1371.07 1778.94
1416.95
704.56
1419.70 1867.89
1522.22 1834.53
1830.69 2668.42
1807.50
764.38
2018.21 1015.33
2024.85 2668.42
1981.16 2668.42
2879.24 4447.36
3179.53 5003.29
1715.83 2223.68
1152.10 1167.43
1774.60 1473.20
2843.50 3504.62
1363.36
833.88
404.55
432.04
216.01
186.59
265.07
282.68
345.65
722.70
346.63
395.71
380.66
889.48
410.82
756.05
303.00
333.56
369.89
215.03
418.91
500.33
158.77
59.82
217.51
83.67
182.21
59.82
275.44
722.70
360.95
89.62
801.72 2112.50
457.24
179.23
456.93
209.03
1197.01
806.09
503.85
238.95
571.69
472.53
508.57
388.15
568.81
539.25
554.75
477.78
1737.40
1111.84
409.63
778.29
1144.98
778.29
363.73
833.88
426.01
1111.84
281.89
277.96
219.30
611.51
271.80
378.80
259.99
611.51
464.27
303.11
435.15
411.38
SC
63.50
71.62
56.93
391.74
273.93
110.36
70.57
197.45
126.71
77.68
378.42
913.99
1552.16
1716.98
1975.03
1720.77
2484.12
2511.11
2731.28
2615.58
1735.17
1972.34
2720.25
3710.18
3693.73
3665.42
2350.24
3486.91
3536.01
4518.03
4666.98
973.80
298.76
1193.39
359.83
292.71
390.01
918.39
1270.15
1041.05
1028.30
1235.10
1212.62
1294.25
1389.80
1444.90
1686.81
2075.91
1718.98
3036.81
3264.45
1480.46
1152.10
1801.26
2843.77
1206.57
404.59
214.05
198.80
259.24
259.97
340.93
364.54
227.25
320.92
314.18
175.35
217.51
182.21
206.58
359.85
801.72
457.24
443.03
1112.97
422.35
570.55
391.79
568.81
470.78
1705.90
349.08
858.74
311.76
416.17
237.14
200.94
269.60
259.99
435.19
435.15
TN
63.50
71.62
56.93
391.74
273.93
110.36
70.57
197.45
126.71
77.68
378.42
913.99
1552.16
1716.98
1975.03
1720.77
2484.12
2511.11
2731.28
2615.58
1735.17
1972.34
2720.25
3710.18
3693.73
3665.42
2350.24
3486.91
3536.01
4518.03
4666.98
973.80
298.76
1193.39
359.83
292.71
390.01
918.39
1270.15
1041.05
1028.30
1235.10
1212.62
1294.25
1389.80
1444.90
1686.81
2075.91
1718.98
3036.81
3264.45
1480.46
1152.10
1801.26
2843.77
1206.57
404.59
214.05
198.80
259.24
259.97
340.93
364.54
227.25
320.92
314.18
175.35
217.51
182.21
206.58
359.85
801.72
457.24
443.03
1112.97
422.35
570.55
391.79
568.81
470.78
1705.90
349.08
858.74
311.76
416.17
237.14
200.94
269.60
259.99
435.19
435.15
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
TX
76.68
78.74
62.99
388.09
282.66
83.12
61.70
185.85
126.71
72.09
481.72
1093.82
1643.20
2068.53
2337.33
2032.67
2484.12
2961.02
3115.33
2707.48
2001.25
2514.18
2980.03
4034.37
3833.48
4172.96
2355.36
3303.47
3436.13
5027.09
5207.50
1019.82
398.35
1305.99
479.77
388.43
519.89
1026.16
1658.30
1219.95
1371.07
1416.95
1419.70
1522.22
1830.69
1807.50
2018.21
2024.85
1981.16
2879.24
3179.53
1715.83
1152.10
1774.60
2843.50
1363.36
404.55
216.01
265.07
345.65
346.63
380.66
410.82
303.00
369.89
418.91
158.77
217.51
182.21
275.44
360.95
801.72
457.24
456.93
1197.01
503.85
571.69
508.57
568.81
554.75
1737.40
409.63
1144.98
363.73
426.01
281.89
219.30
271.80
259.99
464.27
435.15
VI
72.14
86.98
75.03
333.00
326.27
98.45
59.99
192.8
126.71
89.14
361.29
1105.11
1417.10
1749.23
2633.38
1812.29
3027.45
2789.10
2731.28
2363.26
2313.56
2111.71
2720.25
3962.96
3677.68
3640.90
2018.35
3126.82
3014.47
4210.23
4618.14
860.62
298.76
1086.92
479.77
324.08
389.92
918.39
1243.73
1041.05
1256.32
1235.10
1356.35
1294.25
1623.98
1635.73
1854.03
1829.56
1907.61
3178.49
3516.29
1480.46
1152.10
1752.43
2970.47
1206.57
432.04
211.94
235.20
345.65
300.36
340.93
356.48
303.00
324.18
418.91
172.95
255.00
242.94
263.55
418.68
1021.33
609.65
528.70
1112.97
422.35
570.55
414.86
595.40
523.23
1361.45
465.44
858.74
311.76
416.17
251.16
244.02
346.65
279.89
412.25
436.42
December 1995 DMERC Medicare Advisory
* CategoryHCPCSModifier
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
L5662
L5663
L5664
L5665
L5666
L5667
L5668
L5669
L5670
L5672
L5674
L5675
L5676
L5677
L5678
L5680
L5682
L5684
L5686
L5688
L5690
L5692
L5694
L5695
L5696
L5697
L5698
L5699
L5700
L5701
L5702
L5704
L5705
L5706
L5707
L5710
L5711
L5712
L5714
L5716
L5718
L5722
L5724
L5726
L5728
L5780
L5785
L5790
L5795
L5810
L5811
L5812
L5816
L5818
L5822
L5824
L5828
L5830
L5840
L5845
L5846
L5850
L5855
L5910
L5920
L5925
L5930
L5940
L5950
L5960
L5962
L5964
L5966
L5970
L5972
L5974
L5976
L5978
L5979
L5980
L5981
L5982
L5984
L5985
L5986
L6000
L6010
L6020
L6050
L6055
L6100
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
Page 95-213
AL
AR
CO
FL
GA
KY
LA
MS
NM
NC
OK
PR
SC
TN
TX
404.51
492.74
474.74
366.13
50.06
1197.21
80.72
798.34
194.03
213.23
47.22
68.50
259.13
352.57
28.40
236.99
447.20
34.42
36.53
43.68
69.97
95.02
129.73
119.76
132.31
57.40
93.88
169.10
2048.81
2460.48
3112.87
383.28
684.85
671.35
885.08
267.41
373.75
313.19
321.68
521.17
651.40
688.18
1079.33
1243.92
1701.5
818.69
460.20
514.15
1023.68
348.14
521.51
404.23
611.78
686.70
1217.69
1096.61
2019.31
1356.87
1727.39
2715.75
3919.79
91.48
245.81
258.98
379.40
320.35
2433.95
358.68
560.84
689.36
453.67
669.68
853.34
145.22
271.26
166.64
400.46
208.67
1631.62
2651.27
2141.86
413.39
407.36
204.19
453.12
950.10
1057.32
985.78
1358.36
1893.20
1376.23
411.06
566.16
490.49
391.31
66.74
1197.10
96.28
798.34
258.71
213.23
60.94
82.60
337.48
470.09
37.86
233.40
456.27
38.48
38.64
54.92
77.15
126.70
172.97
155.48
158.74
57.40
85.58
133.33
2048.62
2460.25
3112.58
383.24
684.79
671.29
884.99
306.06
387.67
406.27
343.25
606.72
669.35
650.70
1439.11
1658.56
1771.96
943.26
414.22
685.54
1023.68
384.39
569.40
430.87
693.06
694.92
1217.69
1306.32
2019.31
1489.20
1727.23
2715.49
3919.42
121.97
245.78
345.31
505.87
320.35
2433.73
478.24
741.77
919.14
453.64
669.68
853.34
162.75
306.37
189.53
434.06
243.36
1631.62
2804.34
2141.66
447.57
480.76
204.17
478.33
1070.28
1076.82
1071.12
1645.50
2029.82
1688.23
424.66
561.34
501.91
366.13
50.06
1348.33
72.21
872.19
258.71
284.30
48.60
62.36
320.47
352.57
36.96
265.72
447.20
35.09
43.16
43.68
69.97
98.33
144.61
141.76
132.31
62.53
74.59
133.33
2029.11
2708.25
3732.76
423.44
718.97
709.41
978.78
303.48
373.37
308.12
362.93
694.90
868.54
718.24
1128.11
1243.92
2048.16
821.84
371.52
514.15
767.76
386.52
675.53
497.26
810.83
915.60
1346.80
1462.14
2270.72
1356.87
2023.12
2722.22
3929.12
121.97
292.77
345.31
502.40
320.35
2439.75
478.24
578.03
689.36
535.48
756.70
962.27
162.36
314.82
168.95
432.39
208.67
1975.05
3535.03
2310.06
551.18
431.32
204.67
604.16
950.10
1125.67
1002.12
1461.78
2023.82
1446.90
404.51
492.74
474.74
366.13
50.06
1197.21
80.72
798.34
194.03
213.23
47.22
68.50
259.13
352.57
28.40
236.99
447.20
34.42
36.53
43.68
69.97
95.02
129.73
119.76
132.31
57.40
93.88
169.10
2048.81
2460.48
3112.87
383.28
684.85
671.35
885.08
267.41
373.75
313.19
321.68
521.17
651.40
688.18
1079.33
1243.92
1701.50
818.69
460.20
514.15
1023.68
348.14
521.51
404.23
611.78
686.70
1217.69
1096.61
2019.31
1356.87
1727.39
2715.75
3919.79
91.48
245.81
258.98
379.40
320.35
2433.95
358.68
560.84
689.36
453.67
669.68
853.34
145.22
271.26
166.64
400.46
208.67
1631.62
2651.27
2141.86
413.39
407.36
204.19
453.12
950.10
1057.32
985.78
1358.36
1893.20
1376.23
404.51
492.74
474.74
366.13
50.06
1197.21
80.72
798.34
194.03
213.23
47.22
68.50
259.13
352.57
28.40
236.99
447.20
34.42
36.53
43.68
69.97
95.02
129.73
119.76
132.31
57.40
93.88
169.10
2048.81
2460.48
3112.87
383.28
684.85
671.35
885.08
267.41
373.75
313.19
321.68
521.17
651.40
688.18
1079.33
1243.92
1701.50
818.69
460.20
514.15
1023.68
348.14
521.51
404.23
611.78
686.70
1217.69
1096.61
2019.31
1356.87
1727.39
2715.75
3919.79
91.48
245.81
258.98
379.40
320.35
2433.95
358.68
560.84
689.36
453.67
669.68
853.34
145.22
271.26
166.64
400.46
208.67
1631.62
2651.27
2141.86
413.39
407.36
204.19
453.12
950.10
1057.32
985.78
1358.36
1893.20
1376.23
404.51
492.74
474.74
366.13
50.06
1197.21
80.72
798.34
194.03
213.23
47.22
68.50
259.13
352.57
28.40
236.99
447.20
34.42
36.53
43.68
69.97
95.02
129.73
119.76
132.31
57.40
93.88
169.10
2048.81
2460.48
3112.87
383.28
684.85
671.35
885.08
267.41
373.75
313.19
321.68
521.17
651.40
688.18
1079.33
1243.92
1701.5
818.69
460.2
514.15
1023.68
348.14
521.51
404.23
611.78
686.70
1217.69
1096.61
2019.31
1356.87
1727.39
2715.75
3919.79
91.48
245.81
258.98
379.40
320.35
2433.95
358.68
560.84
689.36
453.67
669.68
853.34
145.22
271.26
166.64
400.46
208.67
1631.62
2651.27
2141.86
413.39
407.36
204.19
453.12
950.10
1057.32
985.78
1358.36
1893.20
1376.23
411.06
566.16
490.49
391.31
66.74
1197.10
96.28
798.34
258.71
213.23
60.94
82.60
337.48
470.09
37.86
233.40
456.27
38.48
38.64
54.92
77.15
126.70
172.97
155.48
158.74
57.40
85.58
133.33
2048.62
2460.25
3112.58
383.24
684.79
671.29
884.99
306.06
387.67
406.27
343.25
606.72
669.35
650.70
1439.11
1658.56
1771.96
943.26
414.22
685.54
1023.68
384.39
569.40
430.87
693.06
694.92
1217.69
1306.32
2019.31
1489.20
1727.23
2715.49
3919.42
121.97
245.78
345.31
505.87
320.35
2433.73
478.24
741.77
919.14
453.64
669.68
853.34
162.75
306.37
189.53
434.06
243.36
1631.62
2804.34
2141.66
447.57
480.76
204.17
478.33
1070.28
1076.82
1071.12
1645.50
2029.82
1688.23
404.51
492.74
474.74
366.13
50.06
1197.21
80.72
798.34
194.03
213.23
47.22
68.50
259.13
352.57
28.40
236.99
447.20
34.42
36.53
43.68
69.97
95.02
129.73
119.76
132.31
57.40
93.88
169.10
2048.81
2460.48
3112.87
383.28
684.85
671.35
885.08
267.41
373.75
313.19
321.68
521.17
651.40
688.18
1079.33
1243.92
1701.50
818.69
460.20
514.15
1023.68
348.14
521.51
404.23
611.78
686.70
1217.69
1096.61
2019.31
1356.87
1727.39
2715.75
3919.79
91.48
245.81
258.98
379.4
320.35
2433.95
358.68
560.84
689.36
453.67
669.68
853.34
145.22
271.26
166.64
400.46
208.67
1631.62
2651.27
2141.86
413.39
407.36
204.19
453.12
950.10
1057.32
985.78
1358.36
1893.20
1376.23
411.06
566.16
490.49
391.31
66.74
1197.10
96.28
798.34
258.71
213.23
60.94
82.60
337.48
470.09
37.86
233.40
456.27
38.48
38.64
54.92
77.15
126.70
172.97
155.48
158.74
57.40
85.58
133.33
2048.62
2460.25
3112.58
383.24
684.79
671.29
884.99
306.06
387.67
406.27
343.25
606.72
669.35
650.70
1439.11
1658.56
1771.96
943.26
414.22
685.54
1023.68
384.39
569.40
430.87
693.06
694.92
1217.69
1306.32
2019.31
1489.20
1727.23
2715.49
3919.42
121.97
245.78
345.31
505.87
320.35
2433.73
478.24
741.77
919.14
453.64
669.68
853.34
162.75
306.37
189.53
434.06
243.36
1631.62
2804.34
2141.66
447.57
480.76
204.17
478.33
1070.28
1076.82
1071.12
1645.50
2029.82
1688.23
404.51
492.74
474.74
366.13
50.06
1197.21
80.72
798.34
194.03
213.23
47.22
68.50
259.13
352.57
28.40
236.99
447.20
34.42
36.53
43.68
69.97
95.02
129.73
119.76
132.31
57.40
93.88
169.10
2048.81
2460.48
3112.87
383.28
684.85
671.35
885.08
267.41
373.75
313.19
321.68
521.17
651.40
688.18
1079.33
1243.92
1701.50
818.69
460.20
514.15
1023.68
348.14
521.51
404.23
611.78
686.70
1217.69
1096.61
2019.31
1356.87
1727.39
2715.75
3919.79
91.48
245.81
258.98
379.40
320.35
2433.95
358.68
560.84
689.36
453.67
669.68
853.34
145.22
271.26
166.64
400.46
208.67
1631.62
2651.27
2141.86
413.39
407.36
204.19
453.12
950.10
1057.32
985.78
1358.36
1893.2
1376.23
411.06
566.16
490.49
391.31
66.74
1197.10
96.28
798.34
258.71
213.23
60.94
82.60
337.48
470.09
37.86
233.40
456.27
38.48
38.64
54.92
77.15
126.70
172.97
155.48
158.74
57.40
85.58
133.33
2048.62
2460.25
3112.58
383.24
684.79
671.29
884.99
306.06
387.67
406.27
343.25
606.72
669.35
650.70
1439.11
1658.56
1771.96
943.26
414.22
685.54
1023.68
384.39
569.40
430.87
693.06
694.92
1217.69
1306.32
2019.31
1489.2
1727.23
2715.49
3919.42
121.97
245.78
345.31
505.87
320.35
2433.73
478.24
741.77
919.14
453.64
669.68
853.34
162.75
306.37
189.53
434.06
243.36
1631.62
2804.34
2141.66
447.57
480.76
204.17
478.33
1070.28
1076.82
1071.12
1645.50
2029.82
1688.23
326.45
408.97
408.97
389.14
60.50
1475.41
74.60
968.70
113.07
119.43
17.90
38.92
528.13
138.99
11.11
229.48
416.94
17.90
23.91
68.07
66.71
66.82
142.47
110.06
124.38
56.54
116.37
59.76
2524.92
3032.27
3836.26
472.36
844.00
827.36
1090.76
395.76
366.91
372.92
149.27
209.03
209.03
555.92
1334.21
937.71
1879.01
501.66
416.94
667.10
889.48
277.96
806.09
528.13
361.35
778.29
833.88
1056.24
2617.27
1243.05
2128.80
2900.01
4185.72
75.61
302.92
500.33
1000.66
433.77
2599.08
667.10
722.70
1362.00
559.09
797.09
979.38
194.58
194.58
277.96
578.16
133.27
1995.46
4047.10
2639.59
191.38
289.08
218.05
191.38
669.00
669.00
692.79
716.69
2034.67
826.12
404.51
492.74
474.74
366.13
50.06
1197.21
80.72
798.34
194.03
213.23
47.22
68.50
259.13
352.57
28.40
236.99
447.20
34.42
36.53
43.68
69.97
95.02
129.73
119.76
132.31
57.40
93.88
169.10
2048.81
2460.48
3112.87
383.28
684.85
671.35
885.08
267.41
373.75
313.19
321.68
521.17
651.40
688.18
1079.33
1243.92
1701.50
818.69
460.20
514.15
1023.68
348.14
521.51
404.23
611.78
686.70
1217.69
1096.61
2019.31
1356.87
1727.39
2715.75
3919.79
91.48
245.81
258.98
379.40
320.35
2433.95
358.68
560.84
689.36
453.67
669.68
853.34
145.22
271.26
166.64
400.46
208.67
1631.62
2651.27
2141.86
413.39
407.36
204.19
453.12
950.10
1057.32
985.78
1358.36
1893.20
1376.23
404.51
492.74
474.74
366.13
50.06
1197.21
80.72
798.34
194.03
213.23
47.22
68.50
259.13
352.57
28.40
236.99
447.20
34.42
36.53
43.68
69.97
95.02
129.73
119.76
132.31
57.40
93.88
169.10
2048.81
2460.48
3112.87
383.28
684.85
671.35
885.08
267.41
373.75
313.19
321.68
521.17
651.40
688.18
1079.33
1243.92
1701.50
818.69
460.20
514.15
1023.68
348.14
521.51
404.23
611.78
686.70
1217.69
1096.61
2019.31
1356.87
1727.39
2715.75
3919.79
91.48
245.81
258.98
379.40
320.35
2433.95
358.68
560.84
689.36
453.67
669.68
853.34
145.22
271.26
166.64
400.46
208.67
1631.62
2651.27
2141.86
413.39
407.36
204.19
453.12
950.10
1057.32
985.78
1358.36
1893.20
1376.23
411.06
566.16
490.49
391.31
66.74
1197.10
96.28
798.34
258.71
213.23
60.94
82.60
337.48
470.09
37.86
233.40
456.27
38.48
38.64
54.92
77.15
126.70
172.97
155.48
158.74
57.40
85.58
133.33
2048.62
2460.25
3112.58
383.24
684.79
671.29
884.99
306.06
387.67
406.27
343.25
606.72
669.35
650.70
1439.11
1658.56
1771.96
943.26
414.22
685.54
1023.68
384.39
569.40
430.87
693.06
694.92
1217.69
1306.32
2019.31
1489.20
1727.23
2715.49
3919.42
121.97
245.78
345.31
505.87
320.35
2433.73
478.24
741.77
919.14
453.64
669.68
853.34
162.75
306.37
189.53
434.06
243.36
1631.62
2804.34
2141.66
447.57
480.76
204.17
478.33
1070.28
1076.82
1071.12
1645.50
2029.82
1688.23
IN - Inexpensive/Routinely Purchased
OX - Oxygen
OS - Ostomy
SD - Surgical Dressing
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
VI
378.03
503.80
503.80
366.13
56.23
1170.38
75.25
897.46
200.75
213.23
45.70
61.95
259.13
352.57
28.40
278.73
466.19
35.33
48.71
58.24
74.03
95.02
129.73
135.63
143.73
57.40
93.65
136.01
1994.73
2474.64
3118.90
406.72
745.65
727.29
977.12
270.64
406.36
352.17
310.24
521.17
651.40
645.62
1344.27
1243.92
1893.19
818.69
371.52
514.15
767.76
359.72
521.51
404.23
608.12
735.95
1509.84
1357.72
2467.54
1456.14
1624.93
2900.01
4185.72
95.84
220.83
283.32
379.40
240.26
2599.08
389.65
631.70
915.10
420.32
728.99
939.06
145.22
252.01
166.64
505.31
208.67
1631.62
3481.54
2218.99
413.39
407.36
218.05
453.12
971.73
1110.16
985.78
1584.73
2065.15
1834.97
Page 95-214
* CategoryHCPCSModifier
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
L6110
L6120
L6130
L6200
L6205
L6250
L6300
L6310
L6320
L6350
L6360
L6370
L6380
L6382
L6384
L6386
L6388
L6400
L6450
L6500
L6550
L6570
L6580
L6582
L6584
L6586
L6588
L6590
L6600
L6605
L6610
L6615
L6616
L6620
L6623
L6625
L6628
L6629
L6630
L6632
L6635
L6637
L6640
L6641
L6642
L6645
L6650
L6655
L6660
L6665
L6670
L6672
L6675
L6676
L6680
L6682
L6684
L6686
L6687
L6688
L6689
L6690
L6691
L6692
L6700
L6705
L6710
L6715
L6720
L6725
L6730
L6735
L6740
L6745
L6750
L6755
L6765
L6770
L6775
L6780
L6790
L6795
L6800
L6805
L6806
L6807
L6808
L6809
L6810
L6825
L6830
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
December 1995 DMERC Medicare Advisory
AL
AR
CO
FL
GA
KY
LA
MS
NM
NC
OK
PR
SC
TN
TX
VI
1459.73
1701.10
1851.12
1950.78
2603.98
2043.96
2664.08
2300.31
1256.61
2800.87
2518.95
1507.28
873.41
1314.05
1817.82
287.16
314.36
1659.25
2216.71
2319.15
2787.65
3129.78
1194.88
1082.23
1697.23
1588.33
2087.02
1982.37
134.13
132.44
127.19
137.04
50.78
219.26
611.58
434.55
342.55
104.63
154.12
53.52
125.95
268.65
238.66
114.71
155.48
287.01
298.00
58.58
65.64
32.93
36.41
144.50
85.87
99.28
165.91
183.43
249.26
562.86
412.46
409.98
491.20
535.27
247.74
399.89
370.94
217.76
246.80
245.14
610.03
295.34
486.55
213.08
302.77
265.81
266.59
267.27
282.40
267.92
299.43
335.02
323.11
901.98
724.52
243.29
942.28
804.61
664.43
282.41
137.91
812.39
968.34
1792.09
2020.55
1872.33
2278.00
2603.98
2362.30
2844.70
2284.05
1374.11
2800.87
2277.63
1587.94
938.67
1113.61
1380.50
319.65
357.26
1793.54
2204.62
2224.48
2726.74
3129.78
1175.03
1089.74
1591.95
1566.30
2156.42
2114.85
178.84
176.58
144.62
138.83
59.01
239.87
481.66
507.08
369.13
126.94
205.49
46.46
158.20
308.27
257.93
139.47
166.07
288.01
302.41
66.22
73.81
43.91
45.72
127.23
89.20
93.79
221.21
216.60
249.26
463.42
412.46
487.51
510.13
553.50
246.83
508.78
494.58
279.34
270.57
286.78
813.37
364.29
596.06
240.56
303.77
285.66
280.70
287.52
345.53
295.37
382.06
358.12
430.81
1024.63
791.12
304.28
1057.68
804.61
702.60
306.25
177.84
837.28
1113.23
1493.26
1874.83
2022.73
2180.42
2670.52
1941.35
2846.61
2169.95
1302.77
3270.78
2277.63
1452.38
832.66
1131.74
1569.39
287.16
361.53
2212.33
2939.50
2890.65
3615.63
3762.01
1345.12
1312.21
1463.61
1522.81
2021.16
2027.10
134.13
132.44
121.19
139.61
46.38
243.28
458.69
380.31
456.73
131.08
154.12
61.94
148.13
262.57
209.74
115.44
155.48
228.27
242.05
53.71
67.23
32.93
34.29
144.60
85.87
101.24
175.72
191.54
272.27
422.15
549.95
378.80
642.42
491.69
246.83
500.33
494.58
259.84
312.53
326.86
813.37
381.13
512.11
277.64
370.39
338.90
326.62
315.64
307.74
319.12
358.50
372.64
334.28
909.16
893.01
254.63
942.28
898.12
775.20
348.16
157.43
832.39
1291.12
1459.73
1701.10
1851.12
1950.78
2603.98
2043.96
2664.08
2300.31
1256.61
2800.87
2518.95
1507.28
873.41
1314.05
1817.82
287.16
314.36
1659.25
2216.71
2319.15
2787.65
3129.78
1194.88
1082.23
1697.23
1588.33
2087.02
1982.37
134.13
132.44
127.19
137.04
50.78
219.26
611.58
434.55
342.55
104.63
154.12
53.52
125.95
268.65
238.66
114.71
155.48
287.01
298.00
58.58
65.64
32.93
36.41
144.50
85.87
99.28
165.91
183.43
249.26
562.86
412.46
409.98
491.20
535.27
247.74
399.89
370.94
217.76
246.80
245.14
610.03
295.34
486.55
213.08
302.77
265.81
266.59
267.27
282.40
267.92
299.43
335.02
323.11
901.98
724.52
243.29
942.28
804.61
664.43
282.41
137.91
812.39
968.34
1459.73
1701.10
1851.12
1950.78
2603.98
2043.96
2664.08
2300.31
1256.61
2800.87
2518.95
1507.28
873.41
1314.05
1817.82
287.16
314.36
1659.25
2216.71
2319.15
2787.65
3129.78
1194.88
1082.23
1697.23
1588.33
2087.02
1982.37
134.13
132.44
127.19
137.04
50.78
219.26
611.58
434.55
342.55
104.63
154.12
53.52
125.95
268.65
238.66
114.71
155.48
287.01
298.00
58.58
65.64
32.93
36.41
144.50
85.87
99.28
165.91
183.43
249.26
562.86
412.46
409.98
491.20
535.27
247.74
399.89
370.94
217.76
246.80
245.14
610.03
295.34
486.55
213.08
302.77
265.81
266.59
267.27
282.40
267.92
299.43
335.02
323.11
901.98
724.52
243.29
942.28
804.61
664.43
282.41
137.91
812.39
968.34
1459.73
1701.10
1851.12
1950.78
2603.98
2043.96
2664.08
2300.31
1256.61
2800.87
2518.95
1507.28
873.41
1314.05
1817.82
287.16
314.36
1659.25
2216.71
2319.15
2787.65
3129.78
1194.88
1082.23
1697.23
1588.33
2087.02
1982.37
134.13
132.44
127.19
137.04
50.78
219.26
611.58
434.55
342.55
104.63
154.12
53.52
125.95
268.65
238.66
114.71
155.48
287.01
298.00
58.58
65.64
32.93
36.41
144.50
85.87
99.28
165.91
183.43
249.26
562.86
412.46
409.98
491.20
535.27
247.74
399.89
370.94
217.76
246.80
245.14
610.03
295.34
486.55
213.08
302.77
265.81
266.59
267.27
282.40
267.92
299.43
335.02
323.11
901.98
724.52
243.29
942.28
804.61
664.43
282.41
137.91
812.39
968.34
1792.09
2020.55
1872.33
2278.00
2603.98
2362.30
2844.70
2284.05
1374.11
2800.87
2277.63
1587.94
938.67
1113.61
1380.50
319.65
357.26
1793.54
2204.62
2224.48
2726.74
3129.78
1175.03
1089.74
1591.95
1566.30
2156.42
2114.85
178.84
176.58
144.62
138.83
59.01
239.87
481.66
507.08
369.13
126.94
205.49
46.46
158.20
308.27
257.93
139.47
166.07
288.01
302.41
66.22
73.81
43.91
45.72
127.23
89.20
93.79
221.21
216.60
249.26
463.42
412.46
487.51
510.13
553.50
246.83
508.78
494.58
279.34
270.57
286.78
813.37
364.29
596.06
240.56
303.77
285.66
280.70
287.52
345.53
295.37
382.06
358.12
430.81
1024.63
791.12
304.28
1057.68
804.61
702.60
306.25
177.84
837.28
1113.23
1459.73
1701.10
1851.12
1950.78
2603.98
2043.96
2664.08
2300.31
1256.61
2800.87
2518.95
1507.28
873.41
1314.05
1817.82
287.16
314.36
1659.25
2216.71
2319.15
2787.65
3129.78
1194.88
1082.23
1697.23
1588.33
2087.02
1982.37
134.13
132.44
127.19
137.04
50.78
219.26
611.58
434.55
342.55
104.63
154.12
53.52
125.95
268.65
238.66
114.71
155.48
287.01
298.00
58.58
65.64
32.93
36.41
144.50
85.87
99.28
165.91
183.43
249.26
562.86
412.46
409.98
491.20
535.27
247.74
399.89
370.94
217.76
246.80
245.14
610.03
295.34
486.55
213.08
302.77
265.81
266.59
267.27
282.40
267.92
299.43
335.02
323.11
901.98
724.52
243.29
942.28
804.61
664.43
282.41
137.91
812.39
968.34
1792.09
2020.55
1872.33
2278.00
2603.98
2362.30
2844.70
2284.05
1374.11
2800.87
2277.63
1587.94
938.67
1113.61
1380.50
319.65
357.26
1793.54
2204.62
2224.48
2726.74
3129.78
1175.03
1089.74
1591.95
1566.30
2156.42
2114.85
178.84
176.58
144.62
138.83
59.01
239.87
481.66
507.08
369.13
126.94
205.49
46.46
158.20
308.27
257.93
139.47
166.07
288.01
302.41
66.22
73.81
43.91
45.72
127.23
89.20
93.79
221.21
216.60
249.26
463.42
412.46
487.51
510.13
553.50
246.83
508.78
494.58
279.34
270.57
286.78
813.37
364.29
596.06
240.56
303.77
285.66
280.70
287.52
345.53
295.37
382.06
358.12
430.81
1024.63
791.12
304.28
1057.68
804.61
702.60
306.25
177.84
837.28
1113.23
1459.73
1701.10
1851.12
1950.78
2603.98
2043.96
2664.08
2300.31
1256.61
2800.87
2518.95
1507.28
873.41
1314.05
1817.82
287.16
314.36
1659.25
2216.71
2319.15
2787.65
3129.78
1194.88
1082.23
1697.23
1588.33
2087.02
1982.37
134.13
132.44
127.19
137.04
50.78
219.26
611.58
434.55
342.55
104.63
154.12
53.52
125.95
268.65
238.66
114.71
155.48
287.01
298.00
58.58
65.64
32.93
36.41
144.50
85.87
99.28
165.91
183.43
249.26
562.86
412.46
409.98
491.20
535.27
247.74
399.89
370.94
217.76
246.80
245.14
610.03
295.34
486.55
213.08
302.77
265.81
266.59
267.27
282.40
267.92
299.43
335.02
323.11
901.98
724.52
243.29
942.28
804.61
664.43
282.41
137.91
812.39
968.34
1792.09
2020.55
1872.33
2278.00
2603.98
2362.30
2844.70
2284.05
1374.11
2800.87
2277.63
1587.94
938.67
1113.61
1380.50
319.65
357.26
1793.54
2204.62
2224.48
2726.74
3129.78
1175.03
1089.74
1591.95
1566.30
2156.42
2114.85
178.84
176.58
144.62
138.83
59.01
239.87
481.66
507.08
369.13
126.94
205.49
46.46
158.20
308.27
257.93
139.47
166.07
288.01
302.41
66.22
73.81
43.91
45.72
127.23
89.20
93.79
221.21
216.60
249.26
463.42
412.46
487.51
510.13
553.50
246.83
508.78
494.58
279.34
270.57
286.78
813.37
364.29
596.06
240.56
303.77
285.66
280.70
287.52
345.53
295.37
382.06
358.12
430.81
1024.63
791.12
304.28
1057.68
804.61
702.60
306.25
177.84
837.28
1113.23
836.10
895.86
913.83
1164.37
2724.01
1194.45
1552.80
824.21
585.28
1851.50
895.86
669.00
1223.02
2001.31
2334.87
833.88
271.37
812.31
1164.55
1194.45
1552.80
1851.50
2334.87
1556.58
2001.31
1778.94
3446.71
4225.00
89.62
77.72
71.71
71.71
44.47
155.21
83.39
167.22
38.92
61.16
14.35
38.92
89.62
61.16
89.62
196.79
389.14
203.14
250.83
56.15
59.82
14.35
27.46
333.56
111.94
101.66
455.86
567.04
373.14
794.96
889.48
883.90
1028.44
1084.05
472.53
667.10
179.23
191.22
197.12
197.12
388.15
215.03
215.03
179.23
197.12
197.12
197.12
197.12
197.12
197.12
209.03
215.03
238.94
501.66
531.46
173.17
1556.58
1334.21
1094.06
818.31
138.99
1084.05
1223.02
1459.73
1701.1
1851.12
1950.78
2603.98
2043.96
2664.08
2300.31
1256.61
2800.87
2518.95
1507.28
873.41
1314.05
1817.82
287.16
314.36
1659.25
2216.71
2319.15
2787.65
3129.78
1194.88
1082.23
1697.23
1588.33
2087.02
1982.37
134.13
132.44
127.19
137.04
50.78
219.26
611.58
434.55
342.55
104.63
154.12
53.52
125.95
268.65
238.66
114.71
155.48
287.01
298.00
58.58
65.64
32.93
36.41
144.50
85.87
99.28
165.91
183.43
249.26
562.86
412.46
409.98
491.20
535.27
247.74
399.89
370.94
217.76
246.8
245.14
610.03
295.34
486.55
213.08
302.77
265.81
266.59
267.27
282.40
267.92
299.43
335.02
323.11
901.98
724.52
243.29
942.28
804.61
664.43
282.41
137.91
812.39
968.34
1459.73
1701.10
1851.12
1950.78
2603.98
2043.96
2664.08
2300.31
1256.61
2800.87
2518.95
1507.28
873.41
1314.05
1817.82
287.16
314.36
1659.25
2216.71
2319.15
2787.65
3129.78
1194.88
1082.23
1697.23
1588.33
2087.02
1982.37
134.13
132.44
127.19
137.04
50.78
219.26
611.58
434.55
342.55
104.63
154.12
53.52
125.95
268.65
238.66
114.71
155.48
287.01
298.00
58.58
65.64
32.93
36.41
144.50
85.87
99.28
165.91
183.43
249.26
562.86
412.46
409.98
491.20
535.27
247.74
399.89
370.94
217.76
246.80
245.14
610.03
295.34
486.55
213.08
302.77
265.81
266.59
267.27
282.40
267.92
299.43
335.02
323.11
901.98
724.52
243.29
942.28
804.61
664.43
282.41
137.91
812.39
968.34
1792.09
2020.55
1872.33
2278.00
2603.98
2362.30
2844.70
2284.05
1374.11
2800.87
2277.63
1587.94
938.67
1113.61
1380.50
319.65
357.26
1793.54
2204.62
2224.48
2726.74
3129.78
1175.03
1089.74
1591.95
1566.30
2156.42
2114.85
178.84
176.58
144.62
138.83
59.01
239.87
481.66
507.08
369.13
126.94
205.49
46.46
158.20
308.27
257.93
139.47
166.07
288.01
302.41
66.22
73.81
43.91
45.72
127.23
89.20
93.79
221.21
216.60
249.26
463.42
412.46
487.51
510.13
553.50
246.83
508.78
494.58
279.34
270.57
286.78
813.37
364.29
596.06
240.56
303.77
285.66
280.70
287.52
345.53
295.37
382.06
358.12
430.81
1024.63
791.12
304.28
1057.68
804.61
702.60
306.25
177.84
837.28
1113.23
1946.30
2114.37
2288.26
1950.78
2927.61
2023.63
3233.52
2308.85
1222.01
3734.50
2277.63
1936.50
990.07
1411.72
1817.82
382.88
314.36
1931.20
2218.63
2286.24
2726.74
3332.85
1120.53
990.07
1502.70
1346.78
2063.15
1921.66
178.84
176.58
119.05
131.43
54.08
216.81
458.69
380.31
342.55
125.31
154.12
46.46
144.50
262.57
267.07
152.95
207.31
230.78
277.21
57.15
65.64
38.13
42.27
146.57
97.19
104.33
209.09
224.22
318.30
428.34
419.76
389.78
642.42
552.57
263.54
405.60
370.94
217.76
246.80
245.14
610.03
295.34
528.27
213.08
277.79
254.18
251.24
250.52
261.74
252.32
298.96
319.57
331.57
884.98
724.52
285.57
1092.96
829.96
699.51
353.76
133.38
787.10
968.34
IN - Inexpensive/Routinely Purchased
OX - Oxygen
OS - Ostomy
SD - Surgical Dressing
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
December 1995 DMERC Medicare Advisory
* CategoryHCPCSModifier
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
L6835
L6840
L6845
L6850
L6855
L6860
L6865
L6867
L6868
L6870
L6872
L6873
L6875
L6880
L6890
L6895
L6900
L6905
L6910
L6915
L6920
L6925
L6930
L6935
L6940
L6945
L6950
L6955
L6960
L6965
L6970
L6975
L7010
L7015
L7020
L7025
L7030
L7035
L7040
L7045
L7160
L7165
L7170
L7180
L7185
L7186
L7190
L7191
L7260
L7261
L7266
L7272
L7274
L7360
L7362
L7364
L7366
L8000
L8010
L8020
L8030
L8300
L8310
L8320
L8330
L8400
L8410
L8415
L8420
L8430
L8435
L8440
L8460
L8465
L8470
L8480
L8485
L8490
L8500
L8501
Q0134
V2020
V2100
V2101
V2102
V2103
V2104
V2105
V2106
V2107
V2108
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
AL
843.52
615.44
584.95
530.66
626.64
476.97
260.57
696.64
171.44
169.97
673.46
334.50
555.80
360.58
121.62
447.42
1276.81
1269.58
1085.63
547.34
4772.19
6424.17
4801.78
6523.87
6273.84
7665.89
7131.10
8540.46
9674.20
10317.89
10751.44
11758.60
2611.69
4150.17
2433.32
2455.58
3754.96
2514.80
2015.92
1155.79
11000.83
11387.96
5321.67
23359.28
5255.24
6325.19
5519.80
6609.45
1407.28
2561.78
943.97
1634.69
4107.07
170.63
179.15
284.94
383.82
31.46
44.73
163.02
235.83
69.63
107.09
46.78
46.35
13.55
15.41
15.33
17.92
19.71
17.69
37.48
52.18
46.51
4.77
6.58
7.95
95.01
471.92
104.81
338.31
57.66
28.01
29.51
41.87
24.32
26.94
32.98
33.45
35.18
34.11
Page 95-215
AR
CO
FL
GA
KY
LA
MS
NM
NC
OK
921.95
649.71
608.14
502.83
648.41
526.62
236.89
789.03
228.59
170.90
778.35
446.00
693.81
477.20
131.81
399.29
1105.62
1049.87
1034.57
447.64
5240.10
5533.10
5625.88
6188.39
7031.10
7953.82
7475.41
9380.61
9249.77
13512.56
13734.60
13808.32
3482.26
5533.56
3244.43
3274.10
4725.51
3353.06
2687.89
1541.05
10244.47
11693.09
5590.42
29208.69
5661.06
8170.28
7202.63
8684.75
1876.37
3003.15
734.68
1622.00
4517.58
172.20
207.08
377.25
511.76
26.82
43.38
162.47
238.53
60.31
95.23
43.97
47.08
11.25
16.48
16.72
14.88
16.32
17.24
31.60
54.95
39.16
5.74
7.52
7.96
95.01
555.92
86.38
319.30
48.12
34.34
39.35
43.75
26.02
30.76
30.14
35.99
38.81
38.07
1112.45
734.72
612.28
557.31
746.63
633.67
264.82
686.98
171.44
206.78
834.38
334.50
555.80
419.41
129.94
408.11
1080.09
1049.87
1022.80
447.64
5800.96
6256.54
6095.03
6543.77
8365.12
9731.83
9508.13
11387.28
11484.92
12443.30
12596.91
13496.32
2611.69
4200.35
2497.01
2455.58
4115.47
2580.87
2015.92
1155.79
10970.51
13199.50
4399.27
25531.16
4564.16
8272.09
5774.57
8475.39
1641.08
3108.95
707.98
1589.89
4744.63
162.60
238.87
284.94
383.82
26.88
57.83
143.45
254.54
68.82
111.01
38.22
35.31
11.25
15.67
16.92
13.91
17.57
15.04
29.91
47.66
34.88
6.36
8.77
9.52
99.50
471.92
86.38
319.30
52.53
37.34
39.35
55.37
30.11
34.31
29.32
32.54
33.37
40.60
843.52
615.44
584.95
530.66
626.64
476.97
260.57
696.64
171.44
169.97
673.46
334.50
555.80
360.58
121.62
447.42
1276.81
1269.58
1085.63
547.34
4772.19
6424.17
4801.78
6523.87
6273.84
7665.89
7131.10
8540.46
9674.20
10317.89
10751.44
11758.60
2611.69
4150.17
2433.32
2455.58
3754.96
2514.80
2015.92
1155.79
11000.83
11387.96
5321.67
23359.28
5255.24
6325.19
5519.8
6609.45
1407.28
2561.78
943.97
1634.69
4107.07
170.63
179.15
284.94
383.82
31.46
44.73
163.02
235.83
69.63
107.09
46.78
46.35
13.55
15.41
15.33
17.92
19.71
17.69
37.48
52.18
46.51
4.77
6.58
7.95
95.01
471.92
104.81
338.31
57.66
28.01
29.51
41.87
24.32
26.94
32.98
33.45
35.18
34.11
843.52
615.44
584.95
530.66
626.64
476.97
260.57
696.64
171.44
169.97
673.46
334.50
555.80
360.58
121.62
447.42
1276.81
1269.58
1085.63
547.34
4772.19
6424.17
4801.78
6523.87
6273.84
7665.89
7131.10
8540.46
9674.20
10317.89
10751.44
11758.60
2611.69
4150.17
2433.32
2455.58
3754.96
2514.80
2015.92
1155.79
11000.83
11387.96
5321.67
23359.28
5255.24
6325.19
5519.8
6609.45
1407.28
2561.78
943.97
1634.69
4107.07
170.63
179.15
284.94
383.82
31.46
44.73
163.02
235.83
69.63
107.09
46.78
46.35
13.55
15.41
15.33
17.92
19.71
17.69
37.48
52.18
46.51
4.77
6.58
7.95
95.01
471.92
104.81
338.31
57.66
28.01
29.51
41.87
24.32
26.94
32.98
33.45
35.18
34.11
843.52
615.44
584.95
530.66
626.64
476.97
260.57
696.64
171.44
169.97
673.46
334.50
555.80
360.58
121.62
447.42
1276.81
1269.58
1085.63
547.34
4772.19
6424.17
4801.78
6523.87
6273.84
7665.89
7131.10
8540.46
9674.20
10317.89
10751.44
11758.60
2611.69
4150.17
2433.32
2455.58
3754.96
2514.80
2015.92
1155.79
11000.83
11387.96
5321.67
23359.28
5255.24
6325.19
5519.8
6609.45
1407.28
2561.78
943.97
1634.69
4107.07
170.63
179.15
284.94
383.82
31.46
44.73
163.02
235.83
69.63
107.09
46.78
46.35
13.55
15.41
15.33
17.92
19.71
17.69
37.48
52.18
46.51
4.77
6.58
7.95
95.01
471.92
104.81
338.31
57.66
28.01
29.51
41.87
24.32
26.94
32.98
33.45
35.18
34.11
921.95
649.71
608.14
502.83
648.41
526.62
236.89
789.03
228.59
170.9
778.35
446.00
693.81
477.20
131.81
399.29
1105.62
1049.87
1034.57
447.64
5240.10
5533.10
5625.88
6188.39
7031.10
7953.82
7475.41
9380.61
9249.77
13512.56
13734.60
13808.32
3482.26
5533.56
3244.43
3274.10
4725.51
3353.06
2687.89
1541.05
10244.47
11693.09
5590.42
29208.69
5661.06
8170.28
7202.63
8684.75
1876.37
3003.15
734.68
1622.00
4517.58
172.20
207.08
377.25
511.76
26.82
43.38
162.47
238.53
60.31
95.23
43.97
47.08
11.25
16.48
16.72
14.88
16.32
17.24
31.60
54.95
39.16
5.74
7.52
7.96
95.01
555.92
86.38
319.30
48.12
34.34
39.35
43.75
26.02
30.76
30.14
35.99
38.81
38.07
843.52
615.44
584.95
530.66
626.64
476.97
260.57
696.64
171.44
169.97
673.46
334.50
555.80
360.58
121.62
447.42
1276.81
1269.58
1085.63
547.34
4772.19
6424.17
4801.78
6523.87
6273.84
7665.89
7131.10
8540.46
9674.20
10317.89
10751.44
11758.60
2611.69
4150.17
2433.32
2455.58
3754.96
2514.80
2015.92
1155.79
11000.83
11387.96
5321.67
23359.28
5255.24
6325.19
5519.8
6609.45
1407.28
2561.78
943.97
1634.69
4107.07
170.63
179.15
284.94
383.82
31.46
44.73
163.02
235.83
69.63
107.09
46.78
46.35
13.55
15.41
15.33
17.92
19.71
17.69
37.48
52.18
46.51
4.77
6.58
7.95
95.01
471.92
104.81
338.31
57.66
28.01
29.51
41.87
24.32
26.94
32.98
33.45
35.18
34.11
921.95
649.71
608.14
502.83
648.41
526.62
236.89
789.03
228.59
170.90
778.35
446.00
693.81
477.20
131.81
399.29
1105.62
1049.87
1034.57
447.64
5240.10
5533.10
5625.88
6188.39
7031.10
7953.82
7475.41
9380.61
9249.77
13512.56
13734.60
13808.32
3482.26
5533.56
3244.43
3274.10
4725.51
3353.06
2687.89
1541.05
10244.47
11693.09
5590.42
29208.69
5661.06
8170.28
7202.63
8684.75
1876.37
3003.15
734.68
1622.00
4517.58
172.20
207.08
377.25
511.76
26.82
43.38
162.47
238.53
60.31
95.23
43.97
47.08
11.25
16.48
16.72
14.88
16.32
17.24
31.60
54.95
39.16
5.74
7.52
7.96
95.01
555.92
86.38
319.30
48.12
34.34
39.35
43.75
26.02
30.76
30.14
35.99
38.81
38.07
843.52
615.44
584.95
530.66
626.64
476.97
260.57
696.64
171.44
169.97
673.46
334.50
555.80
360.58
121.62
447.42
1276.81
1269.58
1085.63
547.34
4772.19
6424.17
4801.78
6523.87
6273.84
7665.89
7131.10
8540.46
9674.20
10317.89
10751.44
11758.60
2611.69
4150.17
2433.32
2455.58
3754.96
2514.80
2015.92
1155.79
11000.83
11387.96
5321.67
23359.28
5255.24
6325.19
5519.8
6609.45
1407.28
2561.78
943.97
1634.69
4107.07
170.63
179.15
284.94
383.82
31.46
44.73
163.02
235.83
69.63
107.09
46.78
46.35
13.55
15.41
15.33
17.92
19.71
17.69
37.48
52.18
46.51
4.77
6.58
7.95
95.01
471.92
104.81
338.31
57.66
28.01
29.51
41.87
24.32
26.94
32.98
33.45
35.18
34.11
921.95
649.71
608.14
502.83
648.41
526.62
236.89
789.03
228.59
170.90
778.35
446.00
693.81
477.20
131.81
399.29
1105.62
1049.87
1034.57
447.64
5240.10
5533.10
5625.88
6188.39
7031.10
7953.82
7475.41
9380.61
9249.77
13512.56
13734.60
13808.32
3482.26
5533.56
3244.43
3274.10
4725.51
3353.06
2687.89
1541.05
10244.47
11693.09
5590.42
29208.69
5661.06
8170.28
7202.63
8684.75
1876.37
3003.15
734.68
1622.00
4517.58
172.20
207.08
377.25
511.76
26.82
43.38
162.47
238.53
60.31
95.23
43.97
47.08
11.25
16.48
16.72
14.88
16.32
17.24
31.60
54.95
39.16
5.74
7.52
7.96
95.01
555.92
86.38
319.30
48.12
34.34
39.35
43.75
26.02
30.76
30.14
35.99
38.81
38.07
IN - Inexpensive/Routinely Purchased
OX - Oxygen
OS - Ostomy
SD - Surgical Dressing
PR
1223.02
1111.84
1111.84
917.28
1223.02
328.55
268.73
1901.25
237.46
160.57
1956.84
1778.94
686.83
680.89
500.33
191.13
3613.49
2779.6
2334.68
611.51
6115.12
9005.91
7004.6
7616.11
7894.06
10284.53
10284.53
10619.29
10619.29
10619.29
10619.29
10619.29
4558.54
7226.96
2721.69
2959.72
6226.31
2721.69
2282.96
1084.94
10619.29
10299.99
6671.04
10619.29
10619.29
10619.29
10619.29
10619.29
2334.87
2390.45
889.48
2112.50
5920.55
283.54
548.41
548.41
604.95
33.35
51.26
213.91
241.52
100.06
155.21
27.80
38.92
17.90
19.13
18.09
27.80
27.80
18.09
35.80
77.83
22.62
2.44
3.68
9.81
103.07
500.33
88.95
319.93
33.92
33.92
33.92
33.92
33.92
33.92
33.92
33.92
33.92
33.92
SC
TN
TX
843.52
615.44
584.95
530.66
626.64
476.97
260.57
696.64
171.44
169.97
673.46
334.50
555.80
360.58
121.62
447.42
1276.81
1269.58
1085.63
547.34
4772.19
6424.17
4801.78
6523.87
6273.84
7665.89
7131.10
8540.46
9674.20
10317.89
10751.44
11758.60
2611.69
4150.17
2433.32
2455.58
3754.96
2514.80
2015.92
1155.79
11000.83
11387.96
5321.67
23359.28
5255.24
6325.19
5519.80
6609.45
1407.28
2561.78
943.97
1634.69
4107.07
170.63
179.15
284.94
383.82
31.46
44.73
163.02
235.83
69.63
107.09
46.78
46.35
13.55
15.41
15.33
17.92
19.71
17.69
37.48
52.18
46.51
4.77
6.58
7.95
95.01
471.92
104.81
338.31
57.66
28.01
29.51
41.87
24.32
26.94
32.98
33.45
35.18
34.11
843.52
615.44
584.95
530.66
626.64
476.97
260.57
696.64
171.44
169.97
673.46
334.50
555.80
360.58
121.62
447.42
1276.81
1269.58
1085.63
547.34
4772.19
6424.17
4801.78
6523.87
6273.84
7665.89
7131.10
8540.46
9674.20
10317.89
10751.44
11758.60
2611.69
4150.17
2433.32
2455.58
3754.96
2514.80
2015.92
1155.79
11000.83
11387.96
5321.67
23359.28
5255.24
6325.19
5519.80
6609.45
1407.28
2561.78
943.97
1634.69
4107.07
170.63
179.15
284.94
383.82
31.46
44.73
163.02
235.83
69.63
107.09
46.78
46.35
13.55
15.41
15.33
17.92
19.71
17.69
37.48
52.18
46.51
4.77
6.58
7.95
95.01
471.92
104.81
338.31
57.66
28.01
29.51
41.87
24.32
26.94
32.98
33.45
35.18
34.11
921.95
649.71
608.14
502.83
648.41
526.62
236.89
789.03
228.59
170.90
778.35
446.00
693.81
477.20
131.81
399.29
1105.62
1049.87
1034.57
447.64
5240.10
5533.10
5625.88
6188.39
7031.10
7953.82
7475.41
9380.61
9249.77
13512.56
13734.60
13808.32
3482.26
5533.56
3244.43
3274.10
4725.51
3353.06
2687.89
1541.05
10244.47
11693.09
5590.42
29208.69
5661.06
8170.28
7202.63
8684.75
1876.37
3003.15
734.68
1622.00
4517.58
172.20
207.08
377.25
511.76
26.82
43.38
162.47
238.53
60.31
95.23
43.97
47.08
11.25
16.48
16.72
14.88
16.32
17.24
31.60
54.95
39.16
5.74
7.52
7.96
95.01
555.92
86.38
319.30
48.12
34.34
39.35
43.75
26.02
30.76
30.14
35.99
38.81
38.07
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
VI
843.52
586.01
677.5
492.69
626.72
491.57
310.45
766.31
181.74
190.53
814.47
353.86
708.83
480.77
162.16
399.29
1269.22
1254.09
1303.96
447.64
4772.19
5509.42
4801.78
5612.55
6651.20
7457.10
7131.10
8540.46
8613.69
10134.42
10429.24
11427.15
2611.69
4224.82
2694.53
2816.13
4466.31
2657.73
2181.75
1155.79
11628.71
12698.44
4192.81
25705.14
5127.54
7811.60
7202.63
8076.46
1407.28
2561.78
707.98
1591.50
4489.29
216.80
199.82
379.92
511.76
26.34
46.46
171.50
231.27
60.31
126.27
38.22
35.31
15.00
18.17
17.19
16.10
18.64
15.72
38.69
47.66
34.88
4.77
6.58
8.00
114.19
543.42
86.38
317.23
44.83
37.34
39.35
45.56
32.42
35.92
39.10
43.19
41.26
41.08
Page 95-216
* CategoryHCPCSModifier
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
V2109
V2110
V2111
V2112
V2113
V2114
V2115
V2116
V2117
V2118
V2200
V2201
V2202
V2203
V2204
V2205
V2206
V2207
V2208
V2209
V2210
V2211
V2212
V2213
V2214
V2215
V2216
V2217
V2218
V2219
V2220
V2300
V2301
V2302
V2303
V2304
V2305
V2306
V2307
V2308
V2309
V2310
V2311
V2312
V2313
V2314
V2315
V2316
V2317
V2318
V2319
V2320
V2410
V2430
V2500
V2501
V2502
V2503
V2510
V2511
V2512
V2513
V2520
V2521
V2522
V2523
V2530
V2531
V2623
V2624
V2625
V2626
V2627
V2628
V2700
V2710
V2715
V2718
V2730
V2740
V2741
V2742
V2743
V2744
V2750
V2755
V2760
V2770
V2780
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
December 1995 DMERC Medicare Advisory
AL
39.21
45.76
40.36
39.81
55.01
48.66
52.89
47.41
54.67
52.43
36.66
39.96
47.02
36.99
40.11
44.01
53.57
44.72
45.26
49.78
64.06
54.62
59.44
60.95
65.32
70.71
73.33
67.43
72.32
31.84
25.82
47.61
55.20
60.50
50.10
52.45
64.31
59.96
59.46
63.44
74.21
81.64
77.75
68.54
93.54
102.47
113.76
106.66
114.79
104.90
35.51
37.47
64.12
83.46
58.12
88.53
109.06
104.35
79.34
114.00
134.71
113.09
74.57
129.83
126.35
107.68
159.48
391.53
641.88
43.53
281.95
178.88
1024.15
234.15
31.33
45.85
8.31
20.42
15.08
10.00
7.26
8.23
9.16
15.65
18.20
13.14
11.46
14.80
11.94
AR
36.51
35.06
41.04
53.08
57.11
64.81
70.52
48.09
72.89
52.43
42.34
44.60
50.66
41.57
42.32
44.17
45.14
42.05
46.68
46.17
52.77
52.81
54.53
58.26
59.88
68.28
66.65
73.79
72.32
36.79
33.65
55.30
72.41
72.76
52.55
51.30
63.71
76.43
57.45
59.77
66.86
61.23
76.58
72.38
75.61
76.85
85.32
79.99
93.24
104.90
40.07
49.96
75.65
87.61
72.66
88.53
109.06
100.45
104.93
136.07
179.62
150.79
90.28
138.05
168.47
131.59
203.29
391.50
855.84
57.10
274.28
190.21
1035.56
269.39
37.88
56.87
9.39
23.33
20.11
10.00
9.60
7.16
11.33
14.94
18.20
15.84
12.69
15.29
8.96
CO
35.45
34.98
36.47
39.81
45.47
59.67
63.07
47.02
56.70
52.43
39.29
46.08
60.93
39.23
40.74
47.49
44.92
45.77
49.23
49.89
53.20
70.42
72.71
73.44
69.81
62.20
76.36
62.21
72.32
42.46
26.70
51.68
55.01
58.64
49.19
52.75
58.94
66.30
56.17
58.51
61.97
61.23
63.71
64.07
71.56
76.85
85.32
86.88
86.09
104.90
35.51
37.47
85.49
87.93
61.50
108.19
122.13
100.45
88.58
114.00
134.71
113.09
74.57
144.41
126.35
107.68
173.58
392.47
679.17
55.37
348.99
142.66
1182.41
290.08
36.95
55.28
8.31
20.42
15.08
7.50
8.44
7.16
12.22
11.74
13.65
12.55
15.28
14.27
8.96
FL
39.21
45.76
40.36
39.81
55.01
48.66
52.89
47.41
54.67
52.43
36.66
39.96
47.02
36.99
40.11
44.01
53.57
44.72
45.26
49.78
64.06
54.62
59.44
60.95
65.32
70.71
73.33
67.43
72.32
31.84
25.82
47.61
55.20
60.50
50.10
52.45
64.31
59.96
59.46
63.44
74.21
81.64
77.75
68.54
93.54
102.47
113.76
106.66
114.79
104.90
35.51
37.47
64.12
83.46
58.12
88.53
109.06
104.35
79.34
114.00
134.71
113.09
74.57
129.83
126.35
107.68
159.48
391.53
641.88
43.53
281.95
178.88
1024.15
234.15
31.33
45.85
8.31
20.42
15.08
10.00
7.26
8.23
9.16
15.65
18.20
13.14
11.46
14.80
11.94
GA
KY
39.21
45.76
40.36
39.81
55.01
48.66
52.89
47.41
54.67
52.43
36.66
39.96
47.02
36.99
40.11
44.01
53.57
44.72
45.26
49.78
64.06
54.62
59.44
60.95
65.32
70.71
73.33
67.43
72.32
31.84
25.82
47.61
55.20
60.50
50.10
52.45
64.31
59.96
59.46
63.44
74.21
81.64
77.75
68.54
93.54
102.47
113.76
106.66
114.79
104.90
35.51
37.47
64.12
83.46
58.12
88.53
109.06
104.35
79.34
114.00
134.71
113.09
74.57
129.83
126.35
107.68
159.48
391.53
641.88
43.53
281.95
178.88
1024.15
234.15
31.33
45.85
8.31
20.42
15.08
10.00
7.26
8.23
9.16
15.65
18.20
13.14
11.46
14.80
11.94
39.21
45.76
40.36
39.81
55.01
48.66
52.89
47.41
54.67
52.43
36.66
39.96
47.02
36.99
40.11
44.01
53.57
44.72
45.26
49.78
64.06
54.62
59.44
60.95
65.32
70.71
73.33
67.43
72.32
31.84
25.82
47.61
55.20
60.50
50.10
52.45
64.31
59.96
59.46
63.44
74.21
81.64
77.75
68.54
93.54
102.47
113.76
106.66
114.79
104.90
35.51
37.47
64.12
83.46
58.12
88.53
109.06
104.35
79.34
114.00
134.71
113.09
74.57
129.83
126.35
107.68
159.48
391.53
641.88
43.53
281.95
178.88
1024.15
234.15
31.33
45.85
8.31
20.42
15.08
10.00
7.26
8.23
9.16
15.65
18.20
13.14
11.46
14.80
11.94
IN - Inexpensive/Routinely Purchased
OX - Oxygen
LA
36.51
35.06
41.04
53.08
57.11
64.81
70.52
48.09
72.89
52.43
42.34
44.60
50.66
41.57
42.32
44.17
45.14
42.05
46.68
46.17
52.77
52.81
54.53
58.26
59.88
68.28
66.65
73.79
72.32
36.79
33.65
55.30
72.41
72.76
52.55
51.30
63.71
76.43
57.45
59.77
66.86
61.23
76.58
72.38
75.61
76.85
85.32
79.99
93.24
104.90
40.07
49.96
75.65
87.61
72.66
88.53
109.06
100.45
104.93
136.07
179.62
150.79
90.28
138.05
168.47
131.59
203.29
391.50
855.84
57.10
274.28
190.21
1035.56
269.39
37.88
56.87
9.39
23.33
20.11
10.00
9.60
7.16
11.33
14.94
18.20
15.84
12.69
15.29
8.96
MS
39.21
45.76
40.36
39.81
55.01
48.66
52.89
47.41
54.67
52.43
36.66
39.96
47.02
36.99
40.11
44.01
53.57
44.72
45.26
49.78
64.06
54.62
59.44
60.95
65.32
70.71
73.33
67.43
72.32
31.84
25.82
47.61
55.20
60.50
50.10
52.45
64.31
59.96
59.46
63.44
74.21
81.64
77.75
68.54
93.54
102.47
113.76
106.66
114.79
104.90
35.51
37.47
64.12
83.46
58.12
88.53
109.06
104.35
79.34
114.00
134.71
113.09
74.57
129.83
126.35
107.68
159.48
391.53
641.88
43.53
281.95
178.88
1024.15
234.15
31.33
45.85
8.31
20.42
15.08
10.00
7.26
8.23
9.16
15.65
18.20
13.14
11.46
14.80
11.94
NM
36.51
35.06
41.04
53.08
57.11
64.81
70.52
48.09
72.89
52.43
42.34
44.60
50.66
41.57
42.32
44.17
45.14
42.05
46.68
46.17
52.77
52.81
54.53
58.26
59.88
68.28
66.65
73.79
72.32
36.79
33.65
55.30
72.41
72.76
52.55
51.30
63.71
76.43
57.45
59.77
66.86
61.23
76.58
72.38
75.61
76.85
85.32
79.99
93.24
104.90
40.07
49.96
75.65
87.61
72.66
88.53
109.06
100.45
104.93
136.07
179.62
150.79
90.28
138.05
168.47
131.59
203.29
391.50
855.84
57.10
274.28
190.21
1035.56
269.39
37.88
56.87
9.39
23.33
20.11
10.00
9.60
7.16
11.33
14.94
18.20
15.84
12.69
15.29
8.96
OS - Ostomy
SD - Surgical Dressing
NC
39.21
45.76
40.36
39.81
55.01
48.66
52.89
47.41
54.67
52.43
36.66
39.96
47.02
36.99
40.11
44.01
53.57
44.72
45.26
49.78
64.06
54.62
59.44
60.95
65.32
70.71
73.33
67.43
72.32
31.84
25.82
47.61
55.20
60.50
50.10
52.45
64.31
59.96
59.46
63.44
74.21
81.64
77.75
68.54
93.54
102.47
113.76
106.66
114.79
104.90
35.51
37.47
64.12
83.46
58.12
88.53
109.06
104.35
79.34
114.00
134.71
113.09
74.57
129.83
126.35
107.68
159.48
391.53
641.88
43.53
281.95
178.88
1024.15
234.15
31.33
45.85
8.31
20.42
15.08
10.00
7.26
8.23
9.16
15.65
18.20
13.14
11.46
14.80
11.94
OK
36.51
35.06
41.04
53.08
57.11
64.81
70.52
48.09
72.89
52.43
42.34
44.60
50.66
41.57
42.32
44.17
45.14
42.05
46.68
46.17
52.77
52.81
54.53
58.26
59.88
68.28
66.65
73.79
72.32
36.79
33.65
55.30
72.41
72.76
52.55
51.30
63.71
76.43
57.45
59.77
66.86
61.23
76.58
72.38
75.61
76.85
85.32
79.99
93.24
104.90
40.07
49.96
75.65
87.61
72.66
88.53
109.06
100.45
104.93
136.07
179.62
150.79
90.28
138.05
168.47
131.59
203.29
391.50
855.84
57.10
274.28
190.21
1035.56
269.39
37.88
56.87
9.39
23.33
20.11
10.00
9.60
7.16
11.33
14.94
18.20
15.84
12.69
15.29
8.96
PR
33.92
33.92
46.08
46.08
46.08
46.08
54.62
56.54
62.20
62.20
42.12
42.12
42.12
42.12
42.12
42.12
42.12
42.12
42.12
42.12
42.12
53.43
53.43
42.12
53.43
53.43
67.57
73.51
75.15
6.28
56.54
57.67
57.67
57.21
57.67
57.67
57.67
57.67
57.67
57.67
57.67
57.67
68.98
68.98
68.98
68.98
115.68
108.28
108.34
152.33
30.57
67.85
99.22
142.92
226.15
254.43
253.53
141.18
226.15
253.53
253.53
226.15
226.15
254.43
254.43
227.15
143.65
418.11
528.13
56.24
216.70
129.75
735.26
562.26
33.98
90.45
57.10
29.40
4.43
9.04
9.04
9.04
9.04
9.04
28.07
9.32
5.89
22.62
22.62
SC
39.21
45.76
40.36
39.81
55.01
48.66
52.89
47.41
54.67
52.43
36.66
39.96
47.02
36.99
40.11
44.01
53.57
44.72
45.26
49.78
64.06
54.62
59.44
60.95
65.32
70.71
73.33
67.43
72.32
31.84
25.82
47.61
55.20
60.50
50.10
52.45
64.31
59.96
59.46
63.44
74.21
81.64
77.75
68.54
93.54
102.47
113.76
106.66
114.79
104.90
35.51
37.47
64.12
83.46
58.12
88.53
109.06
104.35
79.34
114.00
134.71
113.09
74.57
129.83
126.35
107.68
159.48
391.53
641.88
43.53
281.95
178.88
1024.15
234.15
31.33
45.85
8.31
20.42
15.08
10.00
7.26
8.23
9.16
15.65
18.20
13.14
11.46
14.80
11.94
TN
39.21
45.76
40.36
39.81
55.01
48.66
52.89
47.41
54.67
52.43
36.66
39.96
47.02
36.99
40.11
44.01
53.57
44.72
45.26
49.78
64.06
54.62
59.44
60.95
65.32
70.71
73.33
67.43
72.32
31.84
25.82
47.61
55.20
60.50
50.10
52.45
64.31
59.96
59.46
63.44
74.21
81.64
77.75
68.54
93.54
102.47
113.76
106.66
114.79
104.90
35.51
37.47
64.12
83.46
58.12
88.53
109.06
104.35
79.34
114.00
134.71
113.09
74.57
129.83
126.35
107.68
159.48
391.53
641.88
43.53
281.95
178.88
1024.15
234.15
31.33
45.85
8.31
20.42
15.08
10.00
7.26
8.23
9.16
15.65
18.20
13.14
11.46
14.80
11.94
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
TX
36.51
35.06
41.04
53.08
57.11
64.81
70.52
48.09
72.89
52.43
42.34
44.60
50.66
41.57
42.32
44.17
45.14
42.05
46.68
46.17
52.77
52.81
54.53
58.26
59.88
68.28
66.65
73.79
72.32
36.79
33.65
55.30
72.41
72.76
52.55
51.30
63.71
76.43
57.45
59.77
66.86
61.23
76.58
72.38
75.61
76.85
85.32
79.99
93.24
104.90
40.07
49.96
75.65
87.61
72.66
88.53
109.06
100.45
104.93
136.07
179.62
150.79
90.28
138.05
168.47
131.59
203.29
391.50
855.84
57.10
274.28
190.21
1035.56
269.39
37.88
56.87
9.39
23.33
20.11
10.00
9.60
7.16
11.33
14.94
18.20
15.84
12.69
15.29
8.96
VI
45.69
46.64
48.62
53.08
58.34
64.81
54.62
51.72
60.93
59.92
48.88
52.93
60.05
49.32
50.62
55.19
55.77
51.32
53.00
53.88
57.56
59.80
60.73
63.01
76.75
71.35
65.83
70.81
92.81
39.94
34.43
60.30
58.23
59.06
57.56
62.06
64.04
65.71
63.35
63.41
65.24
66.32
63.95
64.35
72.48
82.63
102.96
104.63
100.28
139.86
40.69
49.96
79.07
103.02
77.50
118.04
145.42
133.93
90.33
152.00
179.62
150.79
99.43
173.11
168.47
134.22
159.48
418.11
828.75
43.53
264.65
142.66
1130.50
220.99
36.11
61.13
11.08
25.28
15.08
9.72
9.38
9.55
9.92
11.89
14.65
11.88
12.13
17.90
8.96
December 1995 DMERC Medicare Advisory
* CategoryHCPCSModifier
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SD
SU
SU
SU
SU
SU
SU
SU
SU
SU
SU
SU
SU
SU
SU
TE
A4460
K0154
K0196
K0197
K0199
K0203
K0204
K0207
K0209
K0210
K0211
K0212
K0214
K0216
K0217
K0219
K0220
K0222
K0223
K0224
K0229
K0234
K0235
K0236
K0237
K0238
K0240
K0241
K0242
K0243
K0244
K0245
K0246
K0247
K0248
K0249
K0251
K0252
K0253
K0254
K0255
K0257
K0258
K0259
K0263
K0264
K0265
K0266
K0402
K0403
K0405
K0406
A4253
A4256
A4556
A4557
A4558
A4624
E0731
E1701
E1702
K0110
K0111
K0118
K0131
K0283
E0720
TE
E0730
AL
AR
CO
FL
Page 95-217
GA
KY
LA
MS
NM
NC
OK
TX
VI
NU
0.94
13.34
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.40
0.31
0.74
39.70
10.62
11.26
18.49
5.06
2.44
330.95
9.84
20.67
21.00
43.36
26.73
16.74
0.32
341.07
0.94
13.34
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.40
0.31
0.74
39.70
9.03
11.26
19.58
5.06
2.44
330.95
9.84
17.79
21.00
43.36
26.73
16.74
0.32
341.07
0.94
13.34
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.40
0.31
0.74
33.75
10.62
11.26
19.58
5.06
2.44
330.95
9.84
20.93
21.00
43.36
26.73
16.74
0.32
338.34
0.94
12.93
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.40
0.31
0.74
39.70
9.80
10.05
19.58
4.80
2.44
330.95
9.34
18.77
21.00
41.69
26.73
16.74
0.32
341.07
0.94
13.34
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.40
0.31
0.74
36.60
9.03
11.26
19.58
5.06
2.44
330.95
9.34
18.77
21.00
43.36
26.73
16.74
0.32
341.07
0.94
13.34
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.40
0.31
0.74
38.53
10.20
9.64
19.58
5.06
2.07
330.95
9.84
20.29
21.00
43.36
26.73
16.74
0.32
298.83
0.94
13.34
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.40
0.31
0.74
39.70
9.03
11.26
19.58
4.30
2.44
330.95
9.84
17.79
21.00
43.36
26.73
16.74
0.32
304.05
0.94
13.34
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.40
0.31
0.74
39.70
10.62
9.57
16.64
4.58
2.07
330.95
8.36
17.79
21.00
43.36
26.73
16.74
0.32
341.07
0.94
13.34
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.40
0.31
0.74
34.15
10.62
11.26
19.47
4.30
2.07
330.95
9.84
19.86
21.00
43.36
26.73
16.74
0.32
341.07
0.94
13.32
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.40
0.31
0.74
34.26
10.62
9.57
19.58
5.06
2.07
330.95
9.84
20.93
21.00
42.96
26.73
16.74
0.32
341.07
0.94
13.34
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.47
0.31
0.74
33.75
10.02
11.26
16.64
5.06
2.07
330.95
9.84
20.17
21.00
43.36
26.73
16.74
0.32
289.91
PR
0.84
14.61
8.19
18.31
5.86
3.72
6.93
8.17
8.35
22.18
32.69
10.82
11.46
0.06
0.47
1.08
2.85
2.38
2.68
4.03
4.03
7.27
18.75
30.33
8.81
25.38
13.65
2.84
6.76
13.71
43.73
8.06
11.04
26.48
18.08
0.97
2.22
3.63
7.09
1.36
3.36
1.71
4.78
12.18
0.32
0.56
0.14
2.14
0.14
0.40
0.36
0.88
36.63
9.37
6.57
15.64
1.80
1.17
345.58
10.58
26.58
25.21
50.02
32.06
20.11
0.37
*202.22
SC
0.94
13.34
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.40
0.31
0.74
39.70
10.62
9.57
19.58
4.30
2.44
330.95
9.84
20.92
21.00
43.36
26.73
16.74
0.32
341.07
TN
0.94
13.34
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.40
0.31
0.74
39.70
10.62
9.57
16.90
4.30
2.07
330.95
9.84
20.93
21.00
43.36
26.73
16.74
0.32
334.97
0.94
12.93
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.40
0.31
0.74
35.60
10.62
11.26
19.58
4.30
2.44
281.31
9.38
17.79
21.00
41.69
26.73
16.74
0.32
324.52
0.94
13.34
6.82
15.25
4.90
3.10
5.78
6.81
6.95
18.48
27.25
9.00
9.55
0.05
0.40
0.89
2.39
1.97
2.24
3.35
3.35
6.07
15.61
25.28
7.33
21.15
11.36
2.38
5.63
11.43
36.44
6.74
9.20
22.06
15.07
0.80
1.85
3.02
5.89
1.13
2.81
1.42
3.99
10.15
0.27
0.45
0.12
1.78
0.12
0.40
0.31
0.74
39.70
9.03
11.26
17.69
4.30
2.07
281.31
9.84
20.93
21.00
43.36
26.73
16.74
0.32
314.57
NU
343.83
337.63
341.07
343.83
343.83
311.73
304.05
343.83
343.83
343.83
322.62
*331.07
343.83
334.97
331.94
315.72
*These codes have undergone a price calculation reduction. This reduction is reflected in the allowable amounts listed.
*Category Key
CR - Capped Rental
PO - Prosthetic/Orthotic
IN - Inexpensive/Routinely Purchased
OX - Oxygen
OS - Ostomy
SD - Surgical Dressing
SU - Supply
TE - TENS
FS - Frequent/Substantial Servicing
Page 95-218
December 1995 DMERC Medicare Advisory
Ombudsmen Addresses and Their Territories
(Updated as of 12/1/95)
Leslie Epperly
Sharon Briggman Teresa Camfield
Dana Causey
P.O. Box 100141
Columbia, SC 29202-3141
(803) 735-1034, Ext. 35714
P.O. Box 97424
Raleigh, NC 97624-7424
(919) 846-3552
P.O. Box 7891
Horseshoe Bay, TX 78657
(210) 598-4882
P.O. Box 1806
Murray, KY 42071
(502) 753-3511
NC
SC
KY
TX
Adie Fuentes
Elaine Hensley
Wanda Mosley
Teresita Ortiz
Ave. Esmeralda #53
Call Box 50
Urb. Munoz Rivera
Guaynabo, PR 00969
(803) 735-1034, Ext. 35780
4647T Hwy. 280 E., Box 127
Birmingham, AL 35242
(205) 408-9489
5103 S. Sheridan Place, #570
Tulsa, OK 74145
(918) 627-7375
P.O. Box 100141
Columbia, SC 29202-3141
(803) 735-1034, Ext. 37282
PR
OK
AL
VI
AR
FL
Alison Santoro
Bobby Smith
Keith Smith
Cris Taylor
7051 Highway 70 S., #226
Nashville, TN 37221
(615) 353-8851
P.O. Box 9225
Jackson, MS 39286
(601) 898-0067
10991-55 San Jose Blvd.
Suite 139
Jacksonville, FL 32223
(904) 886-2887
8200 S. Quebec St.
Suite A-3, #305
Englewood, CO 80112
(303) 683-4309
MS
TN
FL
CO
LA
NM
Vince Temples
Sheri Thompson
P.O. Box 767337
Roswell, GA 30076
(770) 663-7644
P.O. Box 100141
Columbia, SC 29202-3141
(803) 735-1034, Ext. 35726
GA
OUT OF
REGION C
Florida is covered by two ombudsmen.
Keith Smith covers the northern portion of Florida (includes Pinellas, Hillsborough, Polk, Osceola and Bryam
counties, and all points north).
Teresita Ortiz covers the southern portion of Florida (includes Manatee, Hardee, Highlands, Okeechobee and
Indian River counties, and all points south).
Ombudsmen are those who investigate reported complaints, report findings, and help to
achieve equitable settlements, through training and education of the supplier community.
December 1995 DMERC Medicare Advisory
REGION C
DIRECTORY
Palmetto GBA Region
C DMERC Contacts
Page 95-219
Please retain the list below as your new DMERC telephone directory.
Dedicated Work Teams
and DMERC General
Information
(803) 691-4300
Professional Relations (PR)
Palmetto GBA
Professional Relations,
Medicare Region C DMERC
P.O. Box 100141
Columbia, SC 29202-3141
PR General Information Number:
(803) 735-1034
Individual extensions in Professional Relations may be reached by adding the number three
in front of the person's extension. (Ombudsmen addresses and telephone numbers can
be found in this advisory in the Professional Relations section.)
Anti-Fraud Unit
Anti-Fraud Hot-Line:
Palmetto GBA
Anti-Fraud Unit, Medicare Region C DMERC
P.O. Box 100236
Columbia, SC 29202-3236
(803) 788-5414
Individual extensions in the Anti-Fraud Unit may be reached by adding the number four in
front of the person's extension.
National Numbers
Hearings
Palmetto GBA
Hearings Department,
Medicare Region C DMERC
P.O. Box 100249
Columbia, SC 29202
Written Prior Authorization
Palmetto GBA
Prior Authorization Dept.,
Medicare Region C DMERC
P.O. Box 100235
Columbia, SC 29202-3235
Electronic Data Interchange
(EDI)
EDI Help-Line:
Palmetto GBA
Electronic Data Interchange,
Medicare Region C DMERC
P.O. Box 100145
Columbia, SC 29202-3145
(803) 788-9751
DMERC Region A
DMERC Region B
DMERC Region D
(717) 735-9445
(317) 577-5722
(615) 251-8182
National Supplier
Clearinghouse (NSC)
Palmetto GBA
National Supplier Clearinghouse
P.O. Box 100142
Columbia, SC 29202-3142
803) 754-3951
Statistical Analysis Durable
Medical Equipment Regional
Carrier (SADMERC)
Palmetto GBA
Statistical Analysis Durable Medical
Regional Carrier (SADMERC)
P.O. Box 100143
Columbia, SC 29202-3143
(803) 736-6809
HCPCS Help-Line:
Page 95-220
December 1995 DMERC Medicare Advisory
GLOSSARY
AARP
AKA
ALJ
ANSI
ARU
AWP
CMN
CPAP
CPM
CWF
DME
DMEPOS
DMERC
DOB
EDI
EFT
EMC
EOB
EOMB
EPO
ERN
ESRD
FDA
GHP
HCFA
HCPCS
HCT
HICN
HAØ Record
ICD-9-CM
IPPB
MCM
MSP
NDC
NSC
NSF
NTIS
OBRA 93
OCNA
OIG
OSA
P&O
Palmetto GBA
PDR
PEN
POS
POV
RMRP
RRB
SAC
SADMERC
TENS
UPIN
American Association of Retired Persons
Also Known As
Administrative Law Judge
American National Standards Institute
Audio Response Unit
Average Wholesale Price
Certificate of Medical Necessity
Continuous Positive Airway Pressure
Continuous Passive Motion
Common Working File
Durable Medical Equipment
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
Durable Medical Equipment Regional Carrier
Date of Birth
Electronic Data Interchange
Electronic Funds Transfer
Electronic Media Claim
Explanation of Benefits
Explanation of Medicare Benefits
Epoetin Alpha
Electronic Remittance Notice
End-Stage Renal Disease
Food and Drug Administration
Group Health Plan
Health Care Financing Administration
HCFA Common Procedure Coding System
Hematocrit
Health Insurance Claim Number
NSF record that allows electronic submission of extra narrative data.
International Classification of Diseases-9th Revision-Clinical Modification
Intermittent Positive Pressure Breathing
Medicare Carrier's Manual
Medicare Secondary Payer
National Drug Code
National Supplier Clearinghouse
National Standard Format
National Technical Information Service
Omnibus Budget Reconciliation Act of 1993
Other Carrier Name & Address
Office of Inspector General
Obstructed Sleep Apnea
Prosthetics & Orthotics
Palmetto Government Benefits Administrators
Physician's Desk Reference
Parenteral and Enteral Nutrition
Place of Service
Power Operated Vehicle
Regional Medical Review Policies
Railroad Retirement Board
Supplier Advisory Committee
Statistical Analysis Durable Medical Equipment Regional Carrier
Transcutaneous Electrical Nerve Stimulator
Unique Physician Identification Number
The Region C DMERC Medicare Advisory is published by Palmetto Government Benefits Administrator's Professional Relations
Department for suppliers and providers of DMEPOS.