016.06.07 Ark. Code R. 047
The following medical supplies procedure codes may be billed by Medicaid-enrolled Home Health and Prosthetics providers for ARKids First-B participants.
Procedure Code | Required Modifier(s) | Description |
A4206 | NU | Syringe with needle, sterile [LESS THAN] or = tolcc |
A4207 | NU | Syringe with needle, sterile 2 cc, each |
A4209 | NU | Syringe with needle, sterile 5 cc or greater, each |
A4216 | NU | Sterile water/saline, 10 ml |
A4217 | NU | Sterile water/saline, 500 ml |
A4221* | NU | Supplies for maintenance of drug infusion catheter per week |
A4222* | NU | Supplies for external drug infusion pump per cassette or bag |
A4253 A4253 | NU NU, U1 | Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
A4256 | NU | Normal, low and high calibrator solution/chips |
A4259 A4259 | NU NU, U2 | Lancets, per box |
A4265 | NU | Paraffin |
A4310 | NU | Insertion tray without drainage bag and without catheter |
A4311 | NU | Insertion tray without drainage bag with indwelling catheter |
A4312 | NU | Insertion tray without drainage bag with indwelling catheter |
A4313 | NU | Insertion tray without drainage bag with indwelling catheter |
A4314 | NU | Insertion tray with drainage bag with indwelling catheter |
A4315 | NU | Insertion tray with drainage bag with indwelling catheter |
A4316 | NU | Insertion tray with drainage bag with indwelling catheter |
A4320 | NU | Irrigation tray with bulb or piston syringe, any purpose |
A4322 | NU | Irrigation syringe, bulb or piston |
A4326 | NU | Male external catheter specialty type, e.g.; inflatable, |
A4327 | NU | Female external urinary collection device; metal cup, each |
A4328 | NU | Female external urinary collection device; pouch, each |
A4330 | NU | Perianal fecal collection pouch with adhesive |
A4331 | NU | External drainage tube, any type/length, for urine leg bag/urostomy pouch, ea |
A4338 | NU | Indwelling catheter; foley type, two-way latex with coating |
A4340 | NU | Indwelling catheter; specialty type, e.g.; Coude, mushroom |
A4344 | NU | Indwelling catheter; foley type, two-way, all silicone |
A4346 | NU | Indwelling catheter; foley type, three way for continuous |
A4349 | NU | Male external catheter w/integral collection compartment |
A4351 A4351 | NU NU, U1 | Intermittent urinary catheter, disposable straight tip |
A4352 A4352 | NU NU.U1 | Intermittent urinary catheter disposable Coude (curved) |
A4353 A4353 | NU NU.U2 | Urinary intermittent catheter with insertion supplies |
A4354 | NU | Insertion tray with drainage bag but without catheter |
A4355 | NU | Irrigation tubing set for continuous bladder irrigation |
A4356 | NU | External urethral clamp or compression device (not to be used for catheter clamp), each |
A4357 | NU | Bedside drainage bag, day or night, with or without anti reflux |
A4358 | NU | Urinary leg bag; vinyl, with or without tube |
A4361 | NU | Ostomy faceplate |
A4362 | NU | Skin barrier; solid, 4 x 4 or equivalent, each |
A4364 | NU | Adhesive for ostomy or catheter; liquid (spray, brush, etc.) |
A4365 | NU | Adhesive remover wipes, any type, per 50 |
A4367 | NU | Ostomy belt |
A4368 | NU | Ostomy filters, any type, each |
A4369 | NU | Ostomy skin barrier liquid spray, brush, etc. |
A4371 | NU | Ostomy skin barrier powder, per oz |
A4394 | NU | Ostomy deodorant, all types, per ounce |
A4397 | NU | Irrigation supply; sleeve |
A4398 | NU | Irrigation supply; bags |
A4399 | NU | Irrigation supply; cone/catheter |
A4400 | NU | Ostomy irrigation set |
A4402 | NU | Lubricant |
A4404 | NU | Ostomy rings |
A4405 | NU | Ostomy skin barrier, non-pectin based paste, per oz. |
A4406 | NU | Ostomy skin barrier, non-pectin based paste, per oz. |
A4407 | NU | Ostomy skin barrier w/flange, ext wear, w/built in convexity 4x4 or[LESS THAN], ea |
A4414 | NU | Ostomy skin barrier, w/flange (solid, flexible or accordion), w/o built in convexity, 4x4 or[LESS THAN], ea |
A4452 | NU | Tape non-waterproof per 18 sq in |
A4455 | NU | Adhesive remover or solvent (for tape, cement or other adhesive), per oz |
A4483 | NU | Moisture exchanger, disposable, for use with invasive mechanical ventilation |
A4558 | NU | Conductive paste or gel |
A4561 | NU, U1 | Pessary, rubber, any type |
A4562 | NU | Pessary, non-rubber, any type |
A4623 | NU | Tracheostomy, inner cannula (replacement only) |
A4624 | NU | Tracheal suction catheter, any type, each |
A4625 | NU | Tracheostomy care or cleaning starter kit |
A4626 | NU | Tracheostomy cleaning brush, each |
A4628 | NU | Oropharyngeal suction catheter each |
A4629 | NU | Tracheostomy care kit for the established tracheostomy |
A4772 | NU | Dextrostick or glucose test stripes per box |
A4927 | NU | Gloves sterile or non-sterile per pair |
A5051 | NU | Pouch, closed; with barrier attached (1 piece) |
A5052 | NU | Pouch, closed; with barrier attached (1 piece) |
A5053 | NU | Pouch, closed; for use on faceplate |
A5054 | NU | Pouch, closed; for use on barrier with flange (2 piece) |
A5055 | NU | Stoma cap |
A5061 | NU | Pouch, drainable; with barrier attached (1 piece) |
A5062 | NU | Pouch, drainable; without barrier attached (1 piece) |
A5063 | NU | Pouch, drainable; for use on barrier with flange (2 piece) |
A5071 | NU | Pouch, urinary; with barrier attached (1 piece) |
A5072 | NU | Pouch, urinary; without barrier attached (1 piece) |
A5073 | NU | Pouch, urinary; for use on barrier with flange (2 piece) |
A5081 | NU | Continent device; plug for continent stoma |
A5082 | NU | Continent device; catheter for continent stoma |
A5093 | NU | Ostomy accessory; convex insert |
A5102 | NU | Bedside drainage bottle; rigid or expandable |
A5105 | NU | Urinary suspensory; with orw/o leg bag, with or without tube |
A5112 | NU | Urinary leg bag; latex |
A5113 | NU | Leg strap; latex, per set |
A5114 | NU | Leg strap; foam or fabric, per set |
A5120 | NU | Skin barrier, wipes or swabs, each |
A5121 | NU | Skin barrier; solid, 6 x 6 or equivalent, each |
A5122 | NU | Skin barrier; solid, 8 x 8 or equivalent, each |
A5126 | NU | Adhesive; disc or foam pad |
A5131 | NU | Appliance cleaner, incontinence and ostomy appliances, 16 oz |
A6154 | NU | Wound pouch each |
A6196 | NU | Alginate dressing, each (16 square inches or less) |
A6197 | NU | Alginate dressing, each (more than 16, but less than 48 square inches) |
A6198 | NU | Alginate dressing, each (more than 48 square inches) |
A6203 | NU | Composite dressing, each (16 square inches or less) |
A6204 | NU | Composite dressing, each (more than 16, but less than 48 square inches) |
A6205 | NU | Composite dressing, each (more than 48 square ins) |
A6209 | NU | Foam dressing, each (16 square inches or less) |
A6211 | NU | Foam dressing, wound cover pad each (more than 48 square inches) |
A6212 | NU | Foam dressing, wound cover pad each (16 sq in or less) |
A6213 | NU | Foam dressing, each (more than 16, but less than 48 square inches) |
A6216 | NU | Gauze non-impregnated, non-sterile, pad size 16 square inches or less) w/o adhesive border |
A6219 | NU | Gauze, non-impregnated pad size 16 sq in or less with adhesive border |
A6220 | NU | Gauze, non-impregnated pad size [GREATER THAN]16 sq in but [LESS THAN] 48 sq in |
A6221 | NU | Gauze, non-impregnated, pad size [GREATER THAN] 48 sq in |
A6228 | NU | Gauze, impregnated, water or NS pad size 16 sq in or less |
A6229 | NU | Gauze, impregnated, water or NS, pad size [GREATER THAN] 16 in but [LESS THAN] 48 sq in |
A6230 | NU | Gauze, impregnated, water or NS, pad size [GREATER THAN] 48 sq in |
A6234 | NU | Hydrocolloid dressing, each (16 square inches or less) |
A6235 | NU | Hydrocolloid dressing, each (more than 16, but less than 48 square inches) |
A6237 | NU | Hydrocolloid dressing, wound cover, pad size 16 sq in or less with adhesive |
A6238 | NU, U1 | Hydrocolloid dressing, each (more than 48 square inches) |
A6241 | NU | Hydrocolloid dressing, wound cover, pad size 16 sq in or less w/o adhesive |
A6242 | NU | Hydrogel dressing, each (16 square inches or less) |
A6243 | NU | Hydrogel dressing, each (more than 16, but less than 48 square inches) |
A6244 | NU | Hydrogel dressing, each (more than 48 square inches) |
A6245 | NU | Hydrogel dressing, each (16 square inches or less) |
A6246 | NU | Hydrogel dressing, each (more than 16, but less than 48 square inches) |
A6247 | NU | Hydrogel dressing, each (more than 48 square inches) |
A6248 | NU | Hydrogel dressing, each (1 ounce), wound filler, gel |
A6257 | NU | Transparent film, each (16 square inches or less) |
A6258 | NU | Transparent film, each (more than 16, but less than 48 square inches) |
A6259 | NU | Transparent film, each (more than 48 square inches) |
A6403 | NU | Gauze, non-impregnated, sterile, pad size more than 16 sq in but = to or[LESS THAN]48 sq in |
A6404 | NU, | Gauze, non-impregnated, sterile, pad size = to or [GREATER THAN]48 sq in |
A6441 | NU | Padding Bandage, non-elastic, width [GREATER THAN] or = I in & [LESS THAN] 5 in per yd |
A6442 | NU | Conform bandage, non-elastic, non-sterile, width [LESS THAN] 3 in, per yd |
A6443 | NU | Conform bandage, non-elastic, non-sterile, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, pery |
A6444 | NU | Conform bandage, non-elastic, non-sterile, width [GREATER THAN] or= 5 in, per yd |
A6445 | NU | Conform bandage, non-elastic, sterile, width [LESS THAN] 3 in, per yd |
A6446 | NU | Conform bandage, non-elastic, sterile, width [GREATER THAN] or = 3 in and [LESS THAN] 5 in, per yd |
A6447 | NU | Conform bandage, non-elastic, sterile, width [GREATER THAN] or = 5 in, per yd |
A6448 | NU | Light compression bandage, elastic, width [LESS THAN] 3 in, per yd |
A6449 | NU | Gauze elastic, all types, per roll (linear yard) |
A6450 | NU | Light compression bandage, elastic width [GREATER THAN] or = 5 in, per yd |
A6451 | NU | Mod compress bandage, elastic, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd |
A6452 | NU | High compress bandage, elastic, with [GREATER THAN] or = 3 in & [LESS THAN] 5 in per yd |
A6453 | NU | Self-adherent bandage, elastic, width [LESS THAN] 3 in, per yd |
A6454 | NU | Self-adherent bandage, elastic, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd |
A6455 | NU | Self-adherent bandage, elastic, width [GREATER THAN] or= 5 in, per yd |
A6549* ** | NU | Stocking, gradient compression; not otherwise specified |
A7520 | NU | Trach/Laryngectomy tube, non-cuffed, PVC, silicone or equal, each |
A7521 | NU | Trach/Laryngectomy tube, cuffed, PVC, silicone or equal, ea |
A7522 | NU | Trach/Laryngectomy tube, stainless steel or equal, reusable, ea |
B4086 | NU | Gastrostomy/jejunostomy tube any material any type |
B4100** | NU | Food thickener, administered orally, peroz. |
E0776 | NU | IV pole |
NOTE: *A4221, A4222 and A6549 must be prior authorized. Form AFMC-103 must be used for the request for prior authorization. View or print form AFMC-103 and instructions for completion.
**The costs of B4100 and A6549 are not subject to the $125 medical supplies monthly benefit limit.
The following DME HCPCS procedure codes may be billed with appropriate modifiers by Medicaid-enrolled prosthetics providers for ARKids First-B participants.
HCPCS code | Modifiers | Description | Payment Method |
A4213 | NU | Syringes, sterile, 20 cc or greater, each | Purchase only |
A4230 | NU | Infusion set for external insulin pump, non-needle cannula type | Purchase only |
A4231* | NU | Infusion set for external insulin pump, needle (ea) | Purchase only |
A4232* | NU | Syringe w/needle for external insulin pump sterile (ea) | Purchase only |
A4627 | NU, UB | Spacer bag or reservoir, with or without mask, for use with metered dose inhaler | Purchase only |
A4627 | NU | Spacer bag or reservoir, with mask, for use with metered inhaler | Purchase only |
A4635 | NU UE | Underarm pad, crutch, replacement, each | Purchase only |
A4636 | NU UE | Replacement, handgrip, cane, crutch or walker, each | Purchase only |
A4637 | NU UE | Replacement, tip, cane, crutch or walker, each | Purchase only |
A4670 | NU | Electronic blood pressure monitor and cuff | Rental only |
A6021 A6022 A6023 A6024 | NU NU NU NU | Polyskin/Collagen dressing 16 sq in or less Polyskin/Collagen dressing [GREATER THAN]16 sq in but [LESS THAN]48 sq in Polyskin/Collagen dressing 48 sq in or[GREATER THAN] Polyskin/Collagen dressing wound filler per 6 in | Purchase only |
A7034* A7034* A | RR | CPAP (continuous positive airway pressure) device, nasal (includes necessary accessory items) Note: Complete medical data pertinent to the request must be submitted with a prior authorization request. | Rental only |
A7045 | NU | Exhalation port w/wo swivel used w/accessories for positive airway device, replacement only | Purchase only |
A7046 | NU | Water chamber for humidifier, replacement, each | Purchase only |
A7524 | NU | Tracheostoma stent/stud/button, each | Purchase only |
A7525 | NU | Tracheostomy mask, each | Purchase only |
E0100 | NU | Cane includes canes of all materials, adjustable | Purchase only |
E0105 | NU UE | Cane, quad or three prong, includes canes of all materials, adjustable or fixed, with tips | Purchase only |
E0110 | NU UE | Crutches, forearm, includes crutches of various materials, complete, pair | Purchase only |
E0111 | NU UE | Crutch, forearm, includes crutches of various materials, complete, each | Purchase only |
E0112 | NU UE | Crutches, underarm, wood, adjustable or fixed, pair | Purchase only |
E0113 | NU UE | Crutches, underarm, wood, adjustable or fixed, each | Purchase only |
E0114 | NU UE | Crutches underarm, aluminum, adjustable or fixed, pair | Purchase only |
E0116 | NU | Crutch, underarm, aluminum, adjustable or fixed, each | Purchase only |
E0130 | NU UE | Walker, rigid adjust, or fixed height | Purchase only |
E0135 | NU UE | Walker, folding (pickup), adjustable or fixed height | Purchase only |
E0141 | NU UE | Walker, wheeled, without seat | Purchase only |
E0143 | NU UE | Folding walker, wheeled without seat | Purchase only |
E0147 | NU UE | Heavy duty, multiple breaking system, variable | Purchase only |
E0153 | NU UE | Platform attachment, forearm crutch, each | Purchase only |
E0154 | NU | Platform attachment, walker each | Purchase only |
E0155 | NU | Wheel attachment, rigid pickup walker, per | Purchase only |
E0156 | NU | Seat attachment, walker | Purchase only |
E0157 | NU UE | Crutch attachment, walker | Purchase only |
E0158 | NU UE | Leg extensions for a walker | Purchase only |
E0159 | NU | Brake attachment for wheeled walker, replacement, each | Purchase only |
E0161 | NU UE | Sitz type bath, portable, fits over commode seat | Purchase only |
E0163 | NU UE | Commode chair, stationary with fixed arms | Purchase only |
E0167 | NU UE | Pail or pan for use with commode chair | Purchase only |
E0175 | NU UE | Footrest, for use with commode chair, each | Purchase only |
E0181A | NU UE | Pressure pad, alternating with pump | Capped rental |
E0182 | NU | Pump for alternating pressure pad | Purchase only |
E0184 | NU UE | Floatation mattress, dry | Purchase only |
E0185 | NU UE | Decubitus care pad, floatation or gel pad with foam leveling | Purchase only |
E0186* | NU | Air pressure mattress | Purchase only |
E0187* | NU | Water pressure mattress | Purchase only |
E0189 | NU UE | Lambswool sheepskin pad, any size | Purchase only |
E0190 | NU UE | Decubitus care mattress | Purchase only |
E0191 | NU UE | Heel or elbow protector, each | Purchase only |
E0196 | NU | Gel pressure mattress | Purchase only |
E0197 | NU UE | Air pressure pad for mattress, standard mattress length and width | Purchase only |
E0198* | NU | Water pressure pad for mattress, standard mattress length and width | Purchase only |
E0200A | NU UE | Heat lamp, without stand (table model) | Capped rental |
E0202 | NU UE | Phototherapy (bilirubin) light with photometer | Rental only |
E0205A | NU UE | Heat lamp, with stand, includes bulb or infrared | Capped rental |
E0217A | NU UE | Water circulating heat pad with pump | Capped rental |
E0225A | NU UE | Hydrocollator unit, includes pads | Capped rental |
E0235 | NU UE | Paraffin bath unit, portable | Purchase only |
E0236A | NU UE | Pump for water circulating pad | Capped rental |
E0238 | NU UE | Non-electric heat pad, moist | Purchase only |
E0239A | NU | Hydrocollator unit, portable | Capped rental |
E0244 | NU | Raised toilet seat (manufacturer's invoice must be attached to paper claim) | Purchase only Manually priced |
E0249 | NU UE | Pad for water circulating heat unit | Purchase only |
E0250A | NU | Hospital bed, with side rails fixed height, w/mattress | Capped rental |
E0255A | NU | Hospital bed, with side rails, variable heights, hi-lo, w/mattress | Capped rental |
E0260A | RR KH UE | Hospital bed, semi-electric (head and foot adjustment) with any type side rails.w/mattress | Capped rental |
E0271A | NU UE | Mattress, innerspring | Capped rental |
E0272A | NU UE | Mattress, foam rubber | Capped rental |
E0273 | NU UE | Bed board | Purchase only |
E0275 | NU UE | Bed pan, standard, metal or plastic | Purchase only |
E0276 | NU | Bed pan, fracture, metal or plastic | Purchase only |
E0280 | NU UE | Bed cradle, any type | Purchase only |
E0325 | NU UE | Urinal; male, jug-type, any material | Purchase only |
E0326 | NU UE | Urinal; female jug type, any material | Purchase only |
E0424A | NU | Stationary compressed gas system rental includes contents | Rental only |
E0430A | NU | Portable gaseous oxygen system, includes contents | Rental only |
E0435A | NU | Oxygen system, liquid, portable, includes portable container | Rental only |
E0439A | NU | Stationary liquid oxygen system rental includes contents | Rental only |
E0443 | NU | Portable oxygen contents gaseous one month's supply | Purchase only |
E0444 | NU | Portable oxygen contents liquid one month's supply | Purchase only |
E0445A | NU | Pulse oximeter (including 4 disposable probes) | Rental only |
E0480A | NU UE | Percussor, electric or pneumatic, home model | Capped rental |
E0483 | UB | Replacement Pulmonary vest - vest only The manufacturer's invoice must be attached to the claim form. | Purchase only |
E0483 | RR | High-frequency chest-wall oscillation air-pulse generator system, includes hoses and vest | Rental only |
E0560 | NU UE | Cascade humidification | Purchase only |
E0565A | NU UE | Compressor, air power source for equipment which is not self contained or cylinder driven | Capped rental |
E0570 | NU UE | Nebulizer with compressor | Purchase only |
E0575 | NU UE | Ultrasonic nebulizer | Capped rental |
E0585A | NU UE | Nebulizer, with compressor and heater | Capped rental |
E0600 | NU UE | Suction pump | Rental only |
E0605 | NU UE | Vaporizer room type | Purchase only |
E0606| | NU UE | Postural drainage board | Capped rental |
E0607 | NU UE | Home blood glucose monitor | Purchase only |
E0630A | NU UE | Patient lift, hydraulic, with seat or sling | Capped rental |
E0650A | NU UE | Pneumatic compressor, non-segmental | Capped rental |
E0667A | NU | Pneumatic appliance (leg) | Capped rental |
E0668A | NU | Pneumatic appliance (arm) | Capped rental |
E0691A | NU | Ultraviolet light therapy system panel, bulbs/lamps/timer/eye protect [LESS THAN] 2sq ft treat area | Rental only |
E0692A | NU | Ultraviolet light therapy panel, bulbs/lamps/timer/eye protection, 4 ft panel | Rental only |
E0693A | NU | Ultraviolet light therapy system panel, bulbs/lamps/timer/eye protection, 6 ft panel | Rental only |
E0694A | NU | Ultraviolet light therapy system panel, bulbs/lamps/timer/eye protection, 6 ft cabinet | Rental only |
E0720A | NU UE | TENS, two leads, localized stimulation | Capped rental |
E0730A | NU UE | TENS, four leads, larger area/multiple nerve stimulation | Capped rental |
E0740 | NU UE | Replacement batteries for medically necessary TENS | Purchase only |
E0745A | NU UE | Neuromuscular stimulator, electronic shock unit | Capped rental |
E0747A | NU | Osteogenesis stimulator | Rental only |
E0760* | NU | Osteogenesis stimulator, low intensity ultrasound, non-invasive | Rental only |
E0779 E0779| | RR | Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home | Rental only |
E0840 | NU UE | Traction frame attached to headboard, simple cervical traction | Purchase only |
E0850 | NU UE | Traction stand, free standing cervical traction | Purchase only |
E0860 | NU | Traction equipment, over door, cervical | Purchase only |
E0870 | NU UE | Traction frame attached to footboard, extremity traction | Purchase only |
E0880 | NU UE | Traction stand, free standing, extremity, traction | Purchase only |
E0890 | NU UE | Traction frame, attached to footboard, pelvic traction | Purchase only |
E0900 | NU | Traction stand, free standing, pelvic traction | Purchase only |
E0910A | NU UE | Trapeze bars, attached to bed, complete with grab bar | Capped rental |
E0920* A | NU UE | Fracture frame attached to bed, includes weights | Capped rental |
E0930A | NU UE | Fracture frame, free standing, includes weights | Capped rental |
E0935A | NU UE | Passive motion exercise device | Capped rental |
E0936 | NU | Continuous passive motion exercise device | Capped Rental |
Bill on paper | for use other than knee | ||
E0940A | NU UE | Trapeze bar, free standing, complete with grab bar | Capped rental |
E0941A | NU UE | Gravity assisted traction device, any type | Capped rental |
E0942 | NU UE | Cervical head harness/halter | Purchase only |
E0944 | NU UE | Pelvic belt/harness/boot | Purchase only |
E0945 | NU UE | Extremity belt/harness | Purchase only |
E0946 | NU UE | Fracture frame, dual with cross bars, attached | Purchase only |
E0947 | NU UE | Fracture frame, attachments for complex pelvic | Purchase only |
E0948 | NU UE | Fracture frame, attachments for complex cervical | Purchase only |
E1130A | NU UE | Standard wheelchair, fixed full length arms, fixed or swing away detachable footrests | Capped rental |
E1140 | NU | W/chair detachable arms, desk or full length | Capped rental |
E1150 | NU | W/chair detachable arms, desk or full length | Capped rental |
E1160 | NU | W/chair, fixed full length arms, swing away | Capped rental |
E1224**A | NU UE | Footrest wheelchair with detachable arm | Capped rental |
E1340 Bill on paper | NU | Durable medical equipment parts only. Repairs/parts will not be approved for more than the allowed purchase price of new equipment. The manufacturer's invoice for all parts must be attached to the repair claim | Manually priced |
E1340 | NU, U1 | Labor only (a maximum of 20 units per date of service is allowed) (1 unit = 15 minutes of labor) | N/A - Labor charges only |
E1340 | NU, U4 | Maintenance for capped rental items | N/A - Labor charges only |
E1390A | NU | Oxygen concentrator manufacturer specified maximum flow rate | Rental only |
E1391*A | NU | 02 concentrator, dual delivery port, 85% or [GREATER THAN] 02 concentration, each | Rental only |
E2601 | NU | General use wheelchair seat cushion, width less than 22 in., any depth | Purchase only |
E2602 | NU | General use wheelchair seat cushion, width 22 in. or greater, any depth | Purchase only |
E2611 | NU | General use wheelchair seat cushion, width 22 in. or greater, any depth | Purchase only |
E2612 | NU | General use wheelchair seat cushion, width 22 in. or greater, any depth | Purchase only |
Z0428 Bill on paper | NU | Unlisted durable medical equipment, $500.00 and over. The manufacturer's invoice must be attached to the claim form. | Manually priced |
Z1825 Bill on paper | NU | Unlisted durable medical equipment, under $500.00. The manufacturer's invoice must be attached to the claim form. | Manually priced |
Z2211 Bill on paper | NU | Power kit/batteries | Purchase only |
NOTES: Codes denoted with an asterisk * (A4231, A4232, A7034, E0186, E0187,
E0198, E0760, E0920, and E1391) must be prior authorized. Form AFMC-103 must be used for the request for prior authorization. View or print form AFMC-103 and instructions for completion.
** Code E1224 must be prior authorized through the Division of Medical Services, Utilization Review. Form DMS-679 must be used for the request for prior authorization. View or print form DMS-679 and instructions for completion.
Codes denoted with A symbol are approved for special circumstance "Initial" billing (See Section 242.111 of the Prosthetics Medicaid Provider Manual for details regarding "initial" billing). These codes must be billed WITHOUT A MODIFIER to indicate the "Initial" bill circumstance applies -EXCEPTION - if a modifier KH is specifically indicated, that modifier must be used.
016.06.07 Ark. Code R. 047