Transcription
dura cd1Durable Medical Equipment (DME): Billing Codes andReimbursement RatesPage updated: September 2020This section lists the HCPCS codes and maximum allowances for Durable MedicalEquipment (DME). Refer to the Durable Medical Equipment (DME): An Overview section inthe appropriate Part 2 manual for general policy information.Note: Per California Code of Regulations (CCR), Title 22, Section 51321(g): Authorizationfor durable medical equipment shall be limited to the lowest cost item that meets thepatient’s medical needs.AuthorizationAuthorization is required for all oxygen contents, oxygen equipment and respiratoryequipment except for all of the following, which require authorization only for quantitiesexceeding the stated billing limit: A7005 (administration set, with small volume non-filtered pneumatic nebulizer,non-disposable) – billing limit of one every 6 months. E0484 (oscillatory positive expiratory pressure device, non-electric, any type, each)– billing limit of two per 12 months.Authorization is required for all other DME products exceeding the following threshold limits(cumulative cost of related items within a group): Rental: 50 Purchasing: 100 Repair or maintenance: 250This policy also applies to daily amounts that exceed the respective dollar limits for rental,purchase, repair or maintenance for an individual item or combination of similar group DMEitems.Rentals and PurchasesReimbursement for rental or purchase of DME includes the following policies.Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd2Page updated: September 2020Rental Rate Includes SuppliesDME rental rates include reimbursement for equipment-related supplies. Supplies are notseparately reimbursable, except as noted.Rental PeriodUnless otherwise noted, DME rental is based on a rental period of one calendar month, withthe beginning date of rental as the date of service.Rental Reimbursement CapFor information about the DME rental reimbursement cap, refer to theDurable Medical Equipment (DME): Bill for DME section in the appropriate Part 2 manual.GuaranteesPurchased equipment is to be guaranteed for at least six months from the date of purchase.Out-of-guarantee repairs are to be guaranteed for at least three months from the date ofsuch repair. Reimbursement will not be allowed for parts or labor during a guarantee periodif the need for repair is due to a defect in material or workmanshipBilling CodesRefer to the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC)Product Classification Lists at www.palmettogba.com or call the SADMERC/HCPCS helpline at 1-877-735-1326 to determine proper billing codes for DME items.Codes and RatesReimbursement for purchased DME is subject to the Upper Billing Limit defined in CaliforniaCode of Regulations, Title 22, Section 51008.1. Claims submitted are not to exceed anamount that is the lesser of: The usual charges made to the general public, or The net purchase price of the item, which shall be documented in provider’s books andrecords, plus no more than a 100 percent mark-up.Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd3Page updated: September 2020For more information regarding the maximum allowable DME purchase billing amounts, referto “Net Purchase Price” in the Durable Medical Equipment (DME): Bill for DME section.The following listed rates are the maximum amounts allowed for each procedure code:Note: If the net purchase price of the item, plus a 100 percent mark-up, adds up to less thanthe maximum amount indicated for the code on the pages that follow, the billedamount is to be the net purchase price, plus the 100 percent mark-up, i.e., not themaximum amount allowable listed.Ambulation DevicesCanes and CrutchesTable of HCPCS Codes, Descriptions and Cost for Canes and CrutchesHCPCS CodeDescriptionA4635Underarm pad, crutch,replacement, eachReplacement handgrip, cane,crutch or walker, eachReplacement tip, cane, crutch orwalker, eachCane, includes canes of allmaterials, adjustable or fixed, withtipCane, quad or three prong,includes canes of all materials,adjustable or fixed, with tipsCrutches, forearm, adjustable orfixed, with tips and handgrips, pairA4636A4637E0100E0105E0110Monthly Rental Purchase(in dollars)(in ›4.7515.997.0937.5012.7962.07Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd4Page updated: September 2020Table of HCPCS Codes, Descriptions and Cost for Canes and Crutches (continued)HCPCS CodeDescriptionE0112Crutches, underarm, wood,adjustable or fixed, pair, with pads,tips and handgripsCrutches, underarm, non-wood,adjustable or fixed, pair, with pads,tips and handgripsCrutch, underarm, articulating,spring assisted, eachE0114E0117Monthly Rental(in dollars)7.94Purchase(in dollars)53.756.8637.7515.41154.17WalkersTable of HCPCS Codes, Descriptions and Cost for WalkersHCPCS CodeDescriptionE0130Rigid (pick-up), adjustable or fixedheightFolding (pick-up), adjustable orfixed heightWalker w/trunk support, adjustableor fixed heightRigid walker, wheeled, adjustableor fixed heightFolding walker, wheeledWalker, enclosed, four sidedframed, rigid or folding, wheeledwith posterior seatWalker, heavy duty, multiplebraking system, variable ly Rental(in dollars)‹‹8.61››Purchase(in �›254.7628.41279.69Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd5Page updated: September 2020Table of HCPCS Codes, Descriptions and Cost for Walkers (continued)HCPCS CodeDescriptionE0148Walker, heavy duty, withoutwheels, rigid or folding, any type,eachWalker, heavy duty, wheeled, rigidor folding, any typePlatform attachment, forearmcrutch, eachPlatform attachment, walker, eachWheel attachment, rigid pick-upwalker, per pairSeat attachment, walkerCrutch attachment, walker, eachLeg extensions, per set of fourBrake attachment for wheeledwalker, replacement, y Rental(in dollars)‹‹8.58››Purchase(in 6››‹‹21.99››‹‹13.35››Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd6Page updated: August 2021Bathroom EquipmentTable of HCPCS Codes, Descriptions and Cost for Bathroom EquipmentHCPCS CodeDescriptionE0163E0165Commode chair with fixed arms‹‹Commode chair, mobile orstationary, with detachable arms››Pail or pan for use with commodechair, replacement onlyCommode chair, extra wide and/orheavy duty, stationary, or mobile,with or without arms, any type,eachCommode chair with integratedseat lift mechanism, electric, anytypeCommode chair with integratedseat lift mechanism, non-electric,any typeBath/shower chair, with or withoutwheels, any sizeE0167E0168 E0170 E0171E0240Monthly Rental(in dollars)13.5013.02Purchase(in 123.14277.63N/ABy ReportPart 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd7Page updated: September 2020‹‹Table of HCPCS Codes, Descriptions and Cost for Bathroom Equipment(continued)››HCPCS CodeDescriptionBathtub wall rail, eachBathtub rail, floor baseMonthly Rental‹‹(in se‹‹(in dollars)››14.62By ReportE0241E0242E0243Toilet rail, each‹‹N/A››42.76E0244Raised toilet seat‹‹N/A››46.04E0245Tub stool or bench‹‹N/A››55.07E0246Transfer tub rail attachment‹‹N/A››37.08E0247Transfer bench for tub or toilet with ‹‹N/A››or without commode openingTransfer bench, heavy duty, for tub ‹‹N/A››or toilet with or without commodeopening81.42E0248By ReportPart 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd8Page updated: September 2020Decubitus Care EquipmentTable of HCPCS Codes, Descriptions and Cost for Decubitus Care EquipmentHCPCS CodeDescriptionMonthly Rental(in dollars)N/APurchase(in dollars)45.18A4640Replacement pad for use withmedically necessary alternatingpressure pad owned by patientPressure pad, alternating withpumpReplacement pump for alternatingpressure padDry pressure 186Gel or gel-like pressure pad formattress, standard mattress lengthand widthAir pressure mattress16.24194.88E0187Water pressure mattress18.57222.82E0188Synthetic sheepskin pad2.4721.14E0189Lambswool sheepskin pad4.5041.57E0193Powered air flotation bed (low airloss therapy) (daily rental)24.09By ReportE0181E0182E0184E0185Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd9Page updated: August 2021Table of HCPCS Codes, Descriptions and Cost for Decubitus Care Equipment(continued)HCPCS CodeDescriptionE0194E0196E0197Air fluidized bed (daily rental)Gel pressure mattressAir pressure pad for mattress,standard mattress length and widthWater pressure pad for mattress,standard mattress length and widthDry pressure pad for mattress,standard mattress length and widthPhototherapy (bilirubin) light withphotometer (daily rental)Electric heat pad, standardPowered pressure-reducing airmattress (daily rental)Nonpowered advanced pressurereducing overlay for mattress,standard mattress length and width(daily rental)Powered air overlay for mattress,standard mattress length and width(daily rental)Nonpowered advanced pressurereducing mattress (daily 373Monthly Rental(in dollars)55.0025.9913.50Purchase(in dollars)By Report311.90134.9618.61179.652.5525.64By ReportN/A››2.4618.7626.11By Report10.62By Report13.70By Report14.76By ReportPart 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd10Page updated: September 2020Hospital Beds and AccessoriesTable of HCPCS Codes, Descriptions and Cost for Hospital Beds and AccessoriesHCPCS CodeDescriptionE0271E0272E0273E0291Mattress, innerspringMattress, foam rubberBed boardHospital bed, fixed height, withoutside rails, without mattressHospital bed, variable height, hi-lo,without side rails, without mattressHospital bed, semi-electric (headand foot adjustment), without siderails, without mattressHospital bed, total electric (head,foot, and height adjustments),without side rails, without mattressPediatric crib, hospital grade, fullyenclosedHospital bed, heavy duty, extrawide, with weight capacity greaterthan 350 pounds, but less than orequal to 600 pounds, with any typeside rails, with mattressE0293E0295E0297E0300E0303Monthly Rental(in dollars)‹‹14.43››‹‹14.38››By Report35.33Purchase(in dollars)‹‹128.57››‹‹140.19››By ��‹184.80››2,785.63Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd11Page updated: September 2020Table of HCPCS Codes, Descriptions and Cost for Hospital Beds and Accessories(continued)HCPCS CodeDescriptionE0304Hospital bed, extra heavy duty,extra wide, with weight capacitygreater than 600 pounds, with anytype side rails, with mattressBed side rails, half lengthBed side rails, full lengthSafety enclosure frame/canopy foruse with hospital bed, any typeHospital bed, pediatric, manual,360 degree side enclosures, top ofheadboard, footboard, and siderails up to 24 in. above the spring,includes, mattressHospital bed, pediatric, electric orsemi-electric, 360 degree sideenclosures, top of headboard,footboard, and side rails up to 24in. above the spring, includesmattressE0305E0310E0316E0328E0329Monthly Rental(in dollars)‹‹512.23››Purchase(in 155.50170.78‹‹123.34››1,950.43By ReportBy ReportBy ReportBy ReportPart 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd12Page updated: September 2020Traction and Trapeze EquipmentTable of HCPCS Codes, Descriptions and Cost for Traction and Trapeze EquipmentHCPCS CodeDescriptionE0840Traction frame, attached toheadboard, cervical tractionTraction equipment, cervical, freestanding stand/frame, pneumatic,applying traction force to otherthan mandibleTraction stand, freestanding,cervical tractionTraction equipment, overdoor,cervicalTraction frame, attached tofootboard, extremity traction(e.g. Buck’s)Traction stand, freestanding,extremity tractionTraction frame, attached tofootboard, pelvic tractionTraction stand, freestanding, pelvictractionTrapeze bars, A/K/A patienthelper, attached to bed, with grabbarTrapeze bar, heavy duty, forpatient weight capacity greaterthan 250 pounds, attached to bed,with grab barTrapeze bar, heavy duty, forpatient weight capacity greaterthan 250 pounds, free standing,with grab bar Monthly Rental(in dollars)13.06Purchase(in 8.91Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd13Page updated: September 2020Table of HCPCS Codes, Descriptions and Cost for Traction and Trapeze Equipment(continued)HCPCS CodeDescriptionMonthly Rental(in dollars)31.38Purchase(in dollars)376.51E0920E0942Fracture frame, attached to bed,includes weightsFracture frame, free standing,includes weightsContinuous passive motionexercise device for use on kneeonly (daily rental)Continuous passive motionexercise device for use other thanknee (daily rental)Trapeze bar, free standing,complete with grab barCervical head harness/halter32.96395.5215.97N/ABy ic belt/harness/boot3.1331.20E0945Extremity belt/harness3.5535.46E0947Fracture frame, attachments forcomplex pelvic tractionFracture frame, attachments forcomplex cervical E0948Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd14Page updated: September 2020Oxygen and Related Respiratory EquipmentTable of HCPCS Codes, Descriptions and Cost for Oxygen and Related RespiratoryEquipmentHCPCS CodeDescriptionMonthly Rental(in dollars)N/APurchase(in dollars)8.26A4556 A4615Electrodes (e.g., apnea monitor),per pairLead wires (e.g., apnea monitor),per pairShoulder sling or vest design,abduction restrainerTubing with integrated heatingelement for use with positiveairway pressure deviceCannula, nasalN/A‹‹12.66››N/ABy ReportN/A‹‹43.84››N/A0.64 A4619Face tentN/A0.97 A4620Variable concentration maskN/A0.56 A7005Administration set, with smallvolume nonfiltered pneumaticnebulizer, non-disposableAerosol mask, used with DMEnebulizerInterface for cough stimulatingdevice, includes all components,replacement onlyCombination oral/nasal mask,used with continuous positiveairway pressure device, eachOral cushion for combinationoral/nasal mask, replacement only,eachNasal pillows for combinationoral/nasal mask, replacement ‹‹16.00››A4557A4566 A4604 A7015 A7020 A7027 A7028 A7029Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd15Page updated: September 2020Table of HCPCS Codes, Descriptions and Cost for Oxygen and Related RespiratoryEquipment (continued)HCPCS CodeDescription A7030Full face mask used with positiveairway pressure device, eachFace mask interface, replacementfor full face mask, eachCushion for use on nasal maskinterface, replacement only, eachPillow for use on nasal cannulatype interface, replacement only,pairNasal interface used with positiveairway pressure device, with orwithout headstrapHeadgear used with positiveairway pressure deviceChinstrap used with positiveairway pressure deviceTubing used with positive airwaypressure deviceFilter, disposable, used withpositive airway pressure deviceFilter, non-disposable, used withpositive airway pressure deviceOral interface used with positiveairway pressure device, each A7031 A7032 A7033 A7034 A7035 A7036 A7037 A7038 A7039 A7044Monthly Rental(in dollars)N/APurchase(in 84.03››Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd16Page updated: September 2020Table of HCPCS Codes, Descriptions and Cost for Oxygen and Related RespiratoryEquipment (continued)HCPCS CodeDescription A7045Exhalation port with or withoutswivel used with accessories forpositive airway devices,replacement onlyWater chamber for humidifier,used with positive airway pressuredevice, replacement, eachStationary compressed gaseousoxygen system, rental; includescontainer, contents, regulator,flowmeter, humidifier, nebulizer,cannula or mask and tubingStationary compressed gassystem, purchase; includesregulator, flowmeter, humidifier,nebulizer, cannula or mask, andtubingPortable gaseous oxygen system,purchase; includes regulator,flowmeter, humidifier, cannula ormask, and tubingPortable gaseous oxygen system,rental; includes portable container,regulator, flowmeter, humidifier,cannula or mask, and tubingPortable liquid oxygen system,rental; home liquefier used to fillportable liquid oxygen containers,includes portable containers,regulator, flowmeter, humidifier,cannula or mask and tubing, withor without supply reservoir andcontents gauge A7046§ E0424 E0425 E0430§ E0431§ E0433Monthly Rental(in dollars)N/APurchase(in �107.77››N/AN/ABy ReportN/ABy Report‹‹19.20››N/A‹‹35.46››N/APart 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd17Page updated: September 2020Table of HCPCS Codes, Descriptions and Cost for Oxygen and Related RespiratoryEquipment (continued)HCPCS CodeDescription§ E0434Portable liquid oxygen system,rental; includes portable container,supply reservoir, humidifier,flowmeter, refill adapter, contentsgauge, cannula or mask, andtubingPortable liquid oxygen system,purchase; includes portablecontainer, supply reservoir,flowmeter, humidifier, contentsgauge, cannula or mask, tubingand refill adapterStationary liquid oxygen system,rental; includes container,contents, regulator, flowmeter,humidifier, nebulizer, cannula ormask, and tubingStationary liquid oxygen system,purchase; includes use ofreservoir, contents indicator,regulator, flowmeter, humidifier,nebulizer, cannula or mask, andtubingStationary oxygen contents,gaseous, 1 month’s supply 1 unitStationary oxygen contents, liquid,1 month’s supply 1 unitPortable oxygen contents,gaseous, 1 month’s supply 1 unit(modifier NU)Portable oxygen contents,gaseous, 1 month’s supply 1 unit(modifier SC) E0435§ E0439 E0440 E0441 E0442 E0443 E0443Monthly Rental(in dollars)24.34Purchase(in dollars)N/AN/ABy Report‹‹107.77››N/AN/ABy ��‹49.35››N/A16.87Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd18Page updated: September 2020Table of HCPCS Codes, Descriptions and Cost for Oxygen and Related RespiratoryEquipment (continued)HCPCS CodeDescription E0444Portable oxygen contents, liquid, 1month’s supply 1 unit (modifierNU)Portable oxygen contents, liquid, 1month’s supply 1 unit (modifierSC)Home ventilator, any type, usedwith invasive interfaceHome ventilator, any type, usedwith non-invasive interfaceHome ventilator; multi-functionrespiratory device, also performsany or all of the additionalfunctions of oxygen concentration,drug nebulization, aspiration, andcough stimulation, includes allaccessories, components andsupplies for all functions.Respiratory assist device, bi-levelpressure capability, without backuprate feature, used with noninvasiveinterface, e.g., nasal or facial mask(intermittent assist device withcontinuous positive airwaypressure device)Respiratory assist device, bi-levelpressure capability, withback-up rate feature, used withnoninvasive interface, e.g., nasalor facial mask (intermittent assistdevice with continuous positiveairway pressure device) E0444† E0465† § E0466† § E0467§ E0470§ E0471Monthly Rental(in dollars)N/APurchase(in �›6,164.88Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd19Page updated: September 2021Table of HCPCS Codes, Descriptions and Cost for Oxygen and Related RespiratoryEquipment (continued)HCPCS CodeDescription§ E0472Respiratory assist device, bi-levelpressure capability, with backuprate feature, used with invasiveinterface, e.g., tracheostomy tube(intermittent assist device withcontinuous positive airwaypressure device)Percussor, electric or pneumatic,home modelIntrapulmonary percussiveventilation system and relatedaccessoriesCough stimulating device,alternating positive and negativeairway pressure‹‹High frequency chest walloscillation system, includes allaccessories and supplies, each››Oscillatory positive expiratorypressure device, non-electric, anytypeSpirometer, electronic, includes allaccessoriesHumidifier, durable, glass orautoclavable plastic bottle type, foruse with regulator or flowmeterHumidifier, non-heated, used withpositive airway pressure deviceHumidifier, heated, used withpositive airway pressure deviceCompressor, air power source forequipment which is notself-contained or cylinder drivenNebulizer, with compressor§ E0480‹‹ † E0481››§ E0482§ E0483§ E0484 E0487§ E0555§ E0561§ E0562§ E0565§ E0570Monthly Rental(in dollars)428.17Purchase(in dollars)6,164.8834.55414.62By ReportN/A327.73N/A410.96N/AN/A29.54By ReportBy ReportN/ABy t 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd20Page updated: September 2020Table of HCPCS Codes, Descriptions and Cost for Oxygen and Related RespiratoryEquipment (continued)HCPCS CodeDescription§ E0600Respiratory suction pump, homemodel, portable or stationary,electricContinuous positive airwaypressure (CPAP) deviceApnea monitor, without recordingfeatureApnea monitor, with recordingfeatureRegulatorOxygen accessory, wheeled cartfor portable cylinder or portableconcentrator, any type,replacement only, eachStand/rack§ E0601§ E0618§ E0619 E1353 E1354 E1355Monthly Rental(in dollars)36.63Purchase(in dollars)439.58‹‹59.53››609.55208.80By Report208.80By ReportN/ABy Report26.30By ReportBy Report18.94Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd21Page updated: September 2020Table of HCPCS Codes, Descriptions and Cost for Oxygen and Related RespiratoryEquipment (continued)HCPCS CodeDescription E1356Oxygen accessory, batterypack/cartridge for portableconcentrator, any type,replacement only, eachOxygen accessory, battery chargerfor portable concentrator, any type,replacement only, eachOxygen accessory, DC poweradapter for portable concentrator,any type, replacement only, eachOxygen concentrator, singledelivery port, capable of delivering85 percent or greater oxygenconcentration at the prescribedflow rateOxygen concentrator, dual deliveryport, capable of delivering 85percent or greater oxygenconcentration at the prescribedflow rate, eachPortable oxygen concentrator,rentalPortable gaseous oxygen system,rental; home compressor used tofill portable oxygen cylinders;includes portable containers,regulator, flowmeter, humidifier,cannula or mask, and tubing) E1357 E1358§ E1390§ E1391§ E1392§ K0738Monthly Rental(in dollars)N/APurchase(in dollars)By ReportN/ABy ReportN/ABy rt 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd22Page updated: September 2020Wheelchairs, Modifications and AccessoriesFor items included in the reimbursement for the initial wheelchair, refer to “WheelchairAccessories Not Separately Reimbursable” in the Durable Medical Equipment (DME): Billfor Wheelchairs and Wheelchair Accessories section of the Part 2 manual.Power Operated Vehicles‹‹Table of HCPCS Codes, Descriptions and Cost for Power Operated Vehicles››HCPCS CodeDescription E1230K0800Three or four wheeledGroup 1 standard, patient weightcapacity up to and including 300poundsGroup 1 heavy duty, patient weightcapacity 301 to 450 poundsGroup 1 very heavy duty, patientweight capacity 451 to 600 poundsGroup 2 standard, patient weightcapacity up to and including 300poundsGroup 2 heavy duty, patient weightcapacity 301 to 450 poundsGroup 2 very heavy duty, patientweight capacity 451 to 600 poundsNot otherwise classifiedK0801K0802K0806K0807K0808K0812Monthly Rental‹‹(in n .18119.691196.90181.621816.18281.002810.01By ReportBy ReportPart 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd23Page updated: September 2020Transport ChairsTable of HCPCS Codes, Descriptions and Cost for Transport ChairsHCPCS CodeDescriptionE1031Rollabout chair, any and all typeswith casters five inches or greaterMulti-positional patient transfer‹‹663.00››system, with integrated seat,operated by caregiver, patientweight capacity up to and including300 lbs.Multi-positional patient transfer763.34system, extra-wide, with integratedseat, operated by caregiver,patient weight capacity greaterthan 300 lbs.Transport chair, pediatric size‹‹118.80›› E1035 E1036E1037E1038Transport chair, adult size, patientweight capacity less than 250poundsTransport chair, adult size, heavyduty, patient weight capacity 250pounds or greaterE1039Monthly Rental(in dollars)‹‹51.49››Purchase(in dollars)604.567,726.32By �›410.40Manual WheelchairsTable of HCPCS Codes, Descriptions and Cost for Manual WheelchairsHCPCS CodeDescriptionE1161Manual adult size wheelchair,includes tilt in spaceStandard wheelchairK0001K0002Standard hemi (low seat)wheelchairMonthly Rental(in dollars)236.61Purchase(in ››871.92Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd24Page updated: September 2020Table of HCPCS Codes, Descriptions and Cost for Manual Wheelchairs (continued)HCPCS CodeDescriptionMonthly Rental(in (in dollars)943.801,363.08K0003K0004K0005Lightweight wheelchairHigh strength, lightweightwheelchairUltralightweight wheelchair181.781,817.84K0006Heavy-duty wheelchair‹‹94.95››1,279.20K0007Extra heavy-duty wheelchair‹‹144.74››2,034.00 K0008Custom manual wheelchair/baseN/ABy Report K0009Other manual wheelchair/baseBy ReportBy ReportPower WheelchairsTable of HCPCS Codes, Descriptions and Cost for Power WheelchairsHCPCS CodeDescription K0010Standard-weight framemotorized/power wheelchairStandard-weight framemotorized/power wheelchair withprogrammable control parametersfor speed adjustment, tremordampening, acceleration controland braking(For Medi-Cal, purchase or rentalof this code is restricted to an iBOTMobility System.)Lightweight portablemotorized/power wheelchairCustom motorized/powerwheelchair baseOther motorized/power wheelchairbase K0011 K0012 K0013 K0014Monthly Rental(in dollars)N/APurchase(in dollars)N/A504.605,046.00N/AN/AN/ABy ReportN/AN/APart 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd25Page updated: September 2020Table of HCPCS Codes, Descriptions and Cost for Power Wheelchairs (continued)Group 1HCPCS CodeDescriptionK0813Standard, portable, sling/solid seatand back, patient weight capacityup to and including 300 poundsStandard, portable, captain’s chair, ‹‹373.50››patient weight capacity up to andincluding 300 pounds‹‹420.21››Standard, sling/solid seat andback, patient weight capacity up toand including 300 poundsStandard captain’s chair, patient‹‹397.62››weight capacity up to and including300 poundsK0814K0815K0816Monthly Rental(in dollars)‹‹318.44››Purchase(in dollars)2,894.883,705.364,219.564,040.88Table of HCPCS Codes, Descriptions and Cost for Power Wheelchairs (continued)Group 2HCPCS CodeDescriptionK0820Standard, portable, sling/solidseat/back, patient weight capacityup to and including 300 poundsStandard, portable, captain’s chair,patient weight capacity up to andincluding 300 poundsStandard, sling/solid seat/back,patient weight capacity up to andincluding 300 poundsStandard, captain’s chair, patientweight capacity up to and including300 poundsHeavy duty, sling/solid seat/back,patient weight capacity 301 to 450poundsK0821K0822K0823K0824Monthly Rental(in dollars)‹‹334.47››Purchase(in 587.54››5,811.24Part 2 – Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates
dura cd26Page updated: September 2020Table of HCPCS Codes, Descriptions and Cost for Power Wheelchairs (continued)Group 2 (continued)HCPCS 0837DescriptionMonthly Rental(in dollars)Heavy duty, captain’s chair, patient ‹‹540.40››weight capacity 301 to 450 poundsVery heavy duty, sling/solid‹‹851.15››seat/back, patient weight capacity451 to 600 pounds‹‹732.74››Very heavy duty, captain’s chair,patient weight capacity 451 to 600poundsExtra heavy duty, sling/solid‹‹990.72››seat/back, patient weight capacity601 pounds or moreExtra heavy duty, captain’s chair,‹‹935.40››patient weight capacity 601pounds or moreStandard, seat elevator, sling/solid 391.41seat/back, patient weight capacityup to and including 300 poundsStandard, seat elevator, captain’s391.41chair, patient weight capacity up toand including 300 poundsStandard, single power option,‹‹477.44››sling/solid seat/back, patientweight capacity up to and including300 poundsStandard, single power option,‹‹495.15››captain’
Repair or maintenance: 250 This policy also applies to daily amounts that exceed the respective dollar limits for rental, purchase, repair or maintenance for an individual item or combination of similar group DME items. Rentals and Purchases Reimbursement for r
