016-06-05 Ark. Code R. § 15
The following procedure codes must be used to bill for ventilator equipment and supplies:
Procedure Code | Modifier(s) | Description | PA Req'd | Max. Units | Capped Rental, Purchase or Rental Only |
A4483 | Nasal Prosthesis | No | N/A | Purchase | |
E02501 | Hospital bed, fixed height, with any type side rails, with mattress | Yes* | 1 per day (1 day = 1 unit) | Capped Rental | |
E02551 | Hospital bed, variable height, hi-lo, with any type side rails, with mattress | Yes* | 1 per day (1 day = 1 unit) | Capped Rental | |
E02601 | Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress | Yes* | 1 per day (1 day = 1 unit) | Capped Rental | |
E04241 | Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator flowmeter, humidifier, nebulizer, cannula or mask, and tubing | Yes* | 1 per day (1 day = 1 unit) | Rental Only | |
E04301 | Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing | Yes* | 1 per day (1 day = 1 unit) | Rental Only | |
E04351 | Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing, and refill adapter | Yes* | 1 per day (1 day = 1 unit) | Rental Only | |
E04391 | Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing | Yes* | 1 per day (1 day = 1 unit) | Rental Only |
E0450 | Positive Pressure Ventilator and Accessories (New Equipment) - Includes circuits, humidifier, low-pressure alarm, back-up emergency power, resuscitator bag, emergency call, 24 hours/day, 7 day/week availability and in-service training (used with invasive interface, e.g., tracheostomy tube) | Yes | 1 per day (1 day = 1 unit) | Rental Only | |
E04501 | UB | Positive Pressure Ventilator Supplies -Includes suction catheter kits, trach kits, trach tubes, sterile water and all respiratory care supplies (used with invasive interface, e.g., tracheostomy tube) | Yes | 1 per day (1 day = 1 unit) | Purchase |
E0450 | UE | Positive Pressure Ventilator and Accessories (Used Equipment) - Includes circuits, humidifier, low pressure alarm, backup emergency power, resuscitator bag, emergency call, 24 hours/day, 7 day/week availability and in-service training (used with invasive interface, e.g., tracheostomy tube) | Yes | 1 per day (1 day = 1 unit) | Rental Only |
E0500 | IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source | Yes | 1 per day | Rental Only | |
E05701 | Nebulizer, with compressor | Yes* | 1 per day (1 day = 1 unit) | Purchase Only | |
E06001 | Respiratory suction pump, home model, portable or stationary, electric | No | 1 per day (1 day = 1 unit) | Rental Only |
E06001 | U1 | Suction pump, home model, portable (Used Equipment) | Yes | 1 per day (1 day = 1 unit) | Rental Only |
E1390 | Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate | Yes* | 1 per day | Rental Only | |
G02372 | EP, UA | Respiratory therapy services for ventilator-dependent patients | Yes | Frequency of visits as prescribed | N/A |
G02382 | EP, UA |
* Prior authorization is not required when another insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.
016.06.05 Ark. Code R. § 015