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Page 1 of 66NYS Medicaid DME Services Fee 4364A4366A4367A4368A4369A4371DESCRIPTIONSTERILE WATER, SALINE AND/OR DEXTROSE, DSTERILE WATER/SALINE,500 MLSUPPLIES FOR MAINTENANCE OF DRUG INFUSIOINFUSION SET FOR EXTERNAL INSULIN PUMP,INFUSION SET FOR EXTERNAL INSULIN PUMP,REPLACEMENT BATTERY, ALKALINE (OTHER THAREPLACEMENT BATTERY, ALKALINE, J CELL, FREPLACEMENT BATTERY, LITHIUM, FOR USE WIALCOHOL OR PEROXIDE, PER PINTALCOHOL WIPES, PER BOXBETADINE OR PHISOHEX SOLUTION, PER PINTURINE TEST OR REAGENT STRIPS OR TABLETSBLOOD KETONE TEST OR REAGENT STRIP, EACHBLOOD GLUCOSE TEST OR REAGENT STRIPS FORNORMAL, LOW AND HIGH CALIBRATOR SOLUTIONSPRING-POWERED DEVICE FOR LANCET, EACHLANCETS, PER BOX OF 100PARAFFIN, PER POUNDCONTRACEPTIVE SUPPLY, CONDOM, MALE, EACHCONTRACEPTIVE SUPPLY, CONDOM, FEMALE, EAINSERTION TRAY WITHOUT DRAINAGE BAG ANDINSERTION TRAY WITHOUT DRAINAGE BAG WITHINSERTION TRAY WITH DRAINAGE BAG WITH INIRRIGATION TRAY WITH BULB OR PISTON SYRIIRRIGATION SYRINGE, BULB OR PISTON, EACHMALE EXTERNAL CATHETER WITH INTEGRAL COLEXTENSION DRAINAGE TUBING, ANY TYPE, ANYURINARY CATHETER ANCHORING DEVICE, ADHESURINARY CATHETER ANCHORING DEVICE, LEG SINCONTINENCE SUPPLY MISCINDWELLING CATHETER; FOLEY TYPE, TWO-WAYINDWELLING CATHETER, FOLEY TYPE, TWO-WAYINDWELLING CATHETER; FOLEY TYPE, THREE WMALE EXTERNAL CATHETER, WITH OR WITHOUTINTERMITTENT URINARY CATHETER; STRAIGHTINTERMITTENT URINARY CATHETER; COUDE (CUINTERMITTENT URINARY CATHETER, WITH INSEINSERTION TRAY WITH DRAINAGE BAG BUT WITEXTERNAL URETHRAL CLAMP OR COMPRESSION DBEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITHURINARY DRAINAGE BAG, LEG OR ABDOMEN, VIOSTOMY FACE PLATE, EACHSKIN BARRIER; SOLID, 4 X 4 OR EQUIVALENTOSTOMY CLAMP, ANY TYPE, REPLACEMENT ONLYADHESIVE, LIQUID OR EQUAL, ANY TYPE, PEOSTOMY VENT, ANY TYPE, EACHOSTOMY BELT, EACHOSTOMY FILTER,ANY TYPE, EACHOSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUSOSTOMY SKIN BARRIER,POWDER,PER 301525520105402221PA66666666111666666666
Page 2 of 66NYS Medicaid DME Services Fee 4420A4421A4422A4423A4424A4425DESCRIPTIONOSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVAOSTOMY SKIN BARRIER, WITH FLANGE (SOLID,OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTAOSTOMY POUCH, DRAINABLE, WITH FACEPLATEOSTOMY POUCH, DRAINABLE, FOR USE ON FACEOSTOMY POUCH, DRAINABLE, FOR USE ON FACEOSTOMY POUCH, URINARY, WITH FACEPLATE ATOSTOMY POUCH, URINARY, WITH FACEPLATE ATOSTOMY POUCH, URINARY, FOR USE ON FACEPLOSTOMY POUCH, URINARY, FOR USE ON FACEPLOSTOMY POUCH, URINARY, FOR USE ON FACEPLOSTOMY FACEPLATE EQUIVALENT, SILICONE RING, EAOSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVAOSTOMY POUCH, CLOSED, WITH BARRIER ATTACOSTOMY POUCH, DRAINABLE, WITH EXTENDED WOSTOMY POUCH, DRAINABLE, WITH BARRIER ATOSTOMY POUCH, DRAINABLE, WITH EXTENDED WOSTOMY POUCH, URINARY, WITH EXTENDED WEAOSTOMY POUCH, URINARY, WITH STANDARD WEAOSTOMY POUCH, URINARY, WITH EXTENDED WEAOSTOMY DEODORANT, WITH OR WITHOUT LUBRICOSTOMY DEODORANT FOR USE IN OSTOMY POUCHOSTOMY BELT W/PERISTOMAL HERNIA SUPPORTIRRIGATION SUPPLY SLEEVE EACHOSTOMY IRRIGATION SUPPLY; BAG, EACHOSTOMY IRRIGATION SUPPLY; CONE/CATHETER,OSTOMY IRRIGATION SET EACHLUBRICANT, PER OUNCEOSTOMY RING, EACHOSTOMY SKIN BARRIER, NON-PECTIN BASED, POSTOMY SKIN BARRIER, PECTIN-BASED, PASTEOSTOMY SKIN BARRIER, WITH FLANGE (SOLID,OSTOMY SKIN BARRIER, WTIH FLANGE (SOLID,OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVAOSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOOSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOOSTOMY SKIN BARRIER, WITH FLANGE (SOLID,OSTOMY SKIN BARRIER, WITH FLANGE (SOLID,OSTOMY POUCH, CLOSED, WITH BARRIER ATTACOSTOMY POUCH, CLOSED, WITH BARRIER ATTACOSTOMY POUCH, CLOSED; WITHOUT BARRIER ATOSTOMY POUCH, CLOSED; FOR USE ON BARRIEROSTOMY POUCH, CLOSED; FOR USE ON BARRIEROSTOMY SUPPLY; MISCELLANEOUSOSTOMY ABSORBENT MATERIAL (SHEET/PAD/CRYSTOSTOMY POUCH, CLOSED; FOR USE ON BARRIEROSTOMY POUCH, DRAINABLE, WITH BARRIER ATOSTOMY POUCH, DRAINABLE; FOR USE ON 6666666666666666666666616666
Page 3 of 66NYS Medicaid DME Services Fee 4637A4640A4649A4660A4670A4670DESCRIPTIONOSTOMY POUCH, DRAINABLE; FOR USE ON BARROSTOMY POUCH, DRAINABLE; FOR USE ON BARROSTOMY POUCH, URINARY, WITH EXTENDED WEAR BAOSTOMY POUCH, URINARY, WITH BARRIER ATTACHEOSTOMY POUCH, URINARY, WITH EXTENDED WEAR BOSTOMY POUCH, URINARY; WITH BARRIER ATTACHEDOSTOMY POUCH, URINARY; FOR USE ON BARRIER WITOSTOMY POUCH, URINARY; FOR USE ON BARRIER WITOSTOMY POUCH, URINARY; FOR USE ON BARRIER WITOSTOMY POUCH, DRAINABLE, HIGH OUTPUT,TAPE, NON-WATERPROOF, PER 18 SQUARE INCHTAPE, WATERPROOF, PER 18 SQUARE INCHESADHESIVE REMOVER OR SOLVENT (FOR TAPE, CADHESIVE REMOVER, WIPES, ANY TYPE, EACHENEMA BAG WITH TUBING, REUSABLESURGICAL DRESSING HOLDER, REUSABLE, EACHTRACHEOSTOMA FILTER, ANY TYPE, ANY SIZE,SURGICAL STOCKINGS THIGH LENGTH, EACHSURGICAL STOCKINGS BELOW KNEE LENGTH, EASURGICAL STOCKINGS FULL LENGTH, EACHDISPOSABLE UNDERPADS, ALL SIZESELECTRODES, (E.G., APNEA MONITOR), PER PLEAD WIRES, (E.G., APNEA MONITOR), PER PSLINGSSPLINTTOPICAL HYPERBARIC OXYGEN CHAMBER, DISPOREPLACEMENT BATTERY FOR EXTERNAL INFUSIOTRACHEAL SUCTION CATHETER, CLOSED SYSTEMPEAK EXPIRATORY FLOW RATE METER, HAND HECANNULA NASALTUBING,(OXYGEN),PER FOOTBREATHING CIRCUITSFACE TENTVARIABLE CONCENTRATION MASKTRACHEOSTOMY, INNER CANNULATRACHEAL SUCTION CATHETER, ANY TYPE OTHETRACHEOSTOMY CARE KIT FOR NEW TRACHEOSTOTRACHEOSTOMY CLEANING BRUSH EAOROPHARYNGEAL SUCTION CATHETER, EACHTRACHEOSTOMY CARE KIT FOR ESTABLISHED TRREPLACEMENT BATTERIES, MEDICALLY NECESSAREPLACEMENT BATTERY FOR EXTERNAL INFUSIOUNDERARM PAD,CRUTCH,REPLACEMENT EACHREPLACEMENT, HANDGRIP, CANE, CRUTCH, ORREPLACEMENT, TIP, CANE, CRUTCH, WALKER,REPLACEMENT PAD FOR USE WITH MEDICALLYSURGICAL SUPPLY MISCSPHYGMOMANOMETER/BLOOD PRESSURE APPARATUAUTOMATIC BLOOD PRESSURE MONITOR - SEMI AUTOAUTOMATIC BLOOD PRESSURE MONITOR- FULLY 0111PA66666666666666666666161611
Page 4 of 66NYS Medicaid DME Services Fee 6023A6024A6196A6197A6198A6199DESCRIPTIONGLOVES, NON-STERILE, PER 100GLOVES,STERILE PER PAIRORAL THERMOMETER, REUSABLE, ANY TYPE, EARECTAL THERMOMETER, REUSABLE, ANY TYPE,OSTOMY POUCH, CLOSED; WITH BARRIER ATTACOSTOMY POUCH, CLOSED; WITHOUT BARRIER ATOSTOMY POUCH, CLOSED; FOR USE ON FACEPLAOSTOMY POUCH, CLOSED; FOR USE ON BARRIERSTOMA CAP EACHOSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAROSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAROSTOMY POUCH, DRAINABLE; WITH BARRIER ATOSTOMY POUCH, DRAINABLE; WITHOUT BARRIEROSTOMY POUCH, DRAINABLE; FOR USE ON BARROSTOMY POUCH, URINARY; WITH BARRIER ATTAOSTOMY POUCH, URINARY; WITHOUT BARRIER AOSTOMY POUCH, URINARY; FOR USE ON BARRIECONTINENT DEVICE; PLUG FOR CONTINENT STOCONTINENT DEVICE; CATHETER FOR CONTINENTCONTINENT DEVICE, STOMA ABSORPTIVE COVEROSTOMY ACCESSORY CONVEX INSERTURINARY SUSPENSORY WITH LEG BAG, WITH ORURINARY DRAINAGE BAG, LEG OR ABDOMEN, LALEG STRAP; LATEX, REPLACEMENT ONLY, PERLEG STRAP; FOAM OR FABRIC, REPLACEMENTSKIN BARRIER, WIPES OR SWABS, EACHSKIN BARRIER; SOLID, 6 X 6 OR EQUIVALENTSKIN BARRIER; SOLID, 8 X 8 OR EQUIVALENTADHESIVE OR NON-ADHESIVE; DISK OR FOAMAPPLIANCE CLEANER, INCONTINENCE AND OSTOPERCUTANEOUS CATHETER/TUBE ANCHORING DEVFOR DIABETICS ONLY, FITTINGFOR DIABETICS ONLY, FITTING, CUSTOM PREPARATIOFOR DIABETICS ONLY, MODIFICATION (OF OFF-THE-SFOR DIABETICS ONLY, MODIFICATION ) OF OFF-THE-SFOR DIABETICS ONLY, MODIFICATION OF OFF-THE-SHDEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITFOR DIABETICS ONLY, NOT OTHERWISE SPECIFIED MFOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, DFOR DIABETICS ONLY, MULTIPLE DENSITY INSERT, CUCOLLAGEN BASED WOUND FILLER, DRY FORM, SCOLLAGEN BASED WOUND FILLER, GEL/PASTE,COLLAGEN DRESSING, STERILE, SIZE 16 SQUARECOLLAGEN DRESSING, STERILE, SIZE MORE THACOLLAGEN DRESSING, STERILE, SIZE MORE THACOLLAGEN DRESSING WOUND FILLER, STERILE,ALGINATE OR OTHER FIBER GELLING DRESSINGALGINATE OR OTHER FIBER GELLING DRESSINGALGINATE OR OTHER FIBER GELLING DRESSINGALGINATE OR OTHER FIBER GELLING 6666666666666666
Page 5 of 66NYS Medicaid DME Services Fee 6253A6254A6255A6256A6257A6258DESCRIPTIONCOMPOSITE DRESSING, STERILE, PAD SIZE 16COMPOSITE DRESSING, STERILE, PAD SIZE MOCOMPOSITE DRESSING, STERILE, PAD SIZE MOCONTACT LAYER, STERILE, 16 SQ. IN. OR LECONTACT LAYER, STERILE, MORE THAN 16 SQ.CONTACT LAYER, STERILE, MORE THAN 48 SQ.FOAM DRESSING, WOUND COVER, STERILE, PADFOAM DRESSING, WOUND COVER, STERILE, PADFOAM DRESSING, WOUND COVER, STERILE, PADFOAM DRESSING, WOUND COVER, STERILE, PADFOAM DRESSING, WOUND COVER, STERILE, PADFOAM DRESSING, WOUND COVER, STERILE, PADGAUZE NON-IMP NON-STER UP TO 1A6216; MORE THAN 16 UP TO 48SQA6216; MORE THAN 48 SQ INGAUZE, NON-IMPREGNATED, STERILE, PAD SIZGAUZE, NON-IMPREGNATED, STERILE, PAD SIZGAUZE, NON-IMPREGNATED, STERILE, PAD SIZGAUZE, IMPREGNATED WITH OTHER THAN WATERGAUZE, IMPREGNATED WITH OTHER THAN WATERGAUZE, IMPREGNATED WITH OTHER THAN WATERGAUZE, IMPREGNATED, WATER OR NORMAL SALIGAUZE, IMPREGNATED, WATER OR NORMAL SALIGAUZE, IMPREGNATED, WATER OR NORMAL SALIGAUZE, IMPREGNATED, HYDROGEL, FOR DIRECTGAUZE, IMPREGNATED, HYDROGEL, FOR DIRECTGAUZE, IMPREGNATED, HYDROGEL, FOR DIRECTHYDROCOLLOID DRESSING, WOUND COVER, STERHYDROCOLLOID DRESSING, WOUND COVER, STERHYDROCOLLOID DRESSING, WOUND COVER, STERHYDROCOLLOID DRESSING, WOUND COVER, STERHYDROCOLLOID DRESSING, WOUND COVER, STERHYDROCOLLOID DRESSING, WOUND COVER, STERHYDROCOLLOID DRESSING, WOUND FILLER, PASHYDROCOLLOID DRESSING, WOUND FILLER, DRYHYDROGEL DRESSING, WOUND COVER, STERILE,HYDROGEL DRESSING, WOUND COVER, STERILE,HYDROGEL DRESSING, WOUND COVER, STERILE,HYDROGEL DRESSING, WOUND COVER, STERILE,HYDROGEL DRESSING, WOUND COVER, STERILE,HYDROGEL DRESSING, WOUND COVER, STERILE,HYDROGEL DRESSING, WOUND FILLER, GEL, PESPECIALTY ABSORPTIVE DRESSING, WOUND COVSPECIALTY ABSORPTIVE DRESSING, WOUND COVSPECIALTY ABSORPTIVE DRESSING, WOUND COVSPECIALTY ABSORPTIVE DRESSING, WOUND COVSPECIALTY ABSORPTIVE DRESSING, WOUND COVSPECIALTY ABSORPTIVE DRESSING, WOUND COVTRANSPARENT FILM, STERILE, 16 SQ. IN. ORTRANSPARENT FILM, STERILE, MORE THAN .850.351.16RENTALFEEBRMAXUNITS 03030
Page 6 of 66NYS Medicaid DME Services Fee 6534A6535A6536A6537DESCRIPTIONTRANSPARENT FILM, STERILE, MORE THAN 48WOUND FILLER, GEL/PASTE, PER FLUID OUNCEWOUND FILLER, DRY FORM, PER GRAM, NOT OTGAUZE, IMPREGNATED, OTHER THAN WATER, NOGAUZE, NON-IMPREGNATED, STERILE, PAD SIZGAUZE, NON-IMPREGNATED, STERILE, PAD SIZGAUZE, NON-IMPREGNATED, STERILE, PAD SIZPACKING STRIPS, NON-IMPREGNATED, STERILEEYE PAD, STERILE, EACHEYE PAD,NON-STERILE, EACHEYE PATCH, OCCLUSIVE, EACHPADDING BANDAGE, NON-ELASTIC, NON-WOVEN/CONFORMING BANDAGE, NON-ELASTIC, KNITTEDCONFORMING BANDAGE, NON-ELASTIC, KNITTEDCONFORMING BANDAGE, NON-ELASTIC, KNITTEDCONFORMING BANDAGE, NON-ELASTIC, KNITTEDCONFORMING BANDAGE, NON-ELASTIC, KNITTEDCONFORMING BANDAGE, NON-ELASTIC, KNITTEDLIGHT COMPRESSION BANDAGE, ELASTIC, KNITLIGHT COMPRESSION BANDAGE, ELASTIC, KNITLIGHT COMPRESSION BANDAGE, ELASTIC, KNITMODERATE COMPRESSION BANDAGE, ELASTIC, KHIGH COMPRESSION BANDAGE, ELASTIC, KNITTSELF-ADHERENT BANDAGE, ELASTIC, NON-KNITSELF-ADHERENT BANDAGE, ELASTIC, NON-KNITSELF-ADHERENT BANDAGE, ELASTIC, NON-KNITZINC PASTE IMPREGNATED BANDAGE, NON-ELASTUBULAR DRESSING WITH OR WITHOUT ELASTICCOMPRESSION BURN GARMENT, BODYSUIT (HEADCOMPRESSION BURN GARMENT, CHIN STRAP, CUCOMPRESSION BURN GARMENT, FACIAL HOOD, CCOMPRESSION BURN GARMENT, GLOVE TO WRISTCOMPRESSION BURN GARMENT, GLOVE TO ELBOWCOMPRESSION BURN GARMENT, GLOVE TO AXILLCOMPRESSION BURN GARMENT, FOOT TO KNEE LCOMPRESSION BURN GARMENT, FOOT TO THIGHCOMPRESSION BURN GARMENT, UPPER TRUNK TOCOMPRESSION BURN GARMENT, TRUNK, INCLUDICOMPRESSION BURN GARMENT, LOWER TRUNK INCOMPRESSION BURN GARMET NOCGRADIENT COMPRESSION STOCKING, BELOW KNEGRADIENT COMPRESSION STOCKING, BELOW KNEGRADIENT COMPRESSION STOCKING, BELOW KNEGRADIENT COMPRESSION STOCKING, THIGH LENGRADIENT COMPRESSION STOCKING, THIGH LENGRADIENT COMPRESSION STOCKING, THIGH LENGRADIENT COMPRESSION STOCKING, FULL LENGGRADIENT COMPRESSION STOCKING, FULL 2222PA11111111111111166666666
Page 7 of 66NYS Medicaid DME Services Fee 9275A9282A9900A9999B4034DESCRIPTIONGRADIENT COMPRESSION STOCKING, FULL LENGGRADIENT COMPRESSION STOCKING, WAIST LENGRADIENT COMPRESSION STOCKING, WAIST LENGRADIENT COMPRESSION STOCKING, WAIST LENGRADIENT COMPRESSION STOCKING, GARTER BEGRADIENT COMPRESSION STOCKING/SLEEVE, NOCANISTER, DISPOSABLE, USED WITH SUCTIONTUBING, USED WITH SUCTION PUMP, EACHADMINISTRATION SET, WITH SMALL VOLUME NOSMALL VOLUME NONFILTERED PNEUMATIC NEBULADMINISTRATION SET, WITH SMALL VOLUME NOLARGE VOLUME NEBULIZER, DISPOSABLE, UNFIFILTER, DISPOSABLE, USED WITH AEROSOL COFILTER, NONDISPOSABLE, USED WITH AEROSOLAEROSOL MASK, USED WITH DME NEBULIZERHIGH FREQUENCY CHEST WALL OSCILLATION SYHIGH FREQUENCY CHEST WALL OSCILLATION SYCOMBINATION ORAL/NASAL MASK, USED WITH CORAL CUSHION FOR COMBINATION ORAL/NASALNASAL PILLOWS FOR COMBINATION ORAL/NASALFULL FACE MASK USED WITH POSITIVE AIRWAYFACE MASK INTERFACE, REPLACEMENT FOR FULCUSHION FOR USE ON NASAL MASK INTERFACE,PILLOW FOR USE ON NASAL CANNULA TYPE INTNASAL INTERFACE (MASK OR CANNULA TYPE) UHEADGEAR USED WITH POSITIVE AIRWAY PRESSCHINSTRAP USED WITH POSITIVE AIRWAY PRESTUBING USED WITH POSITIVE AIRWAY PRESSURFILTER, DISPOSABLE, USED WITH POSITIVE AFILTER, NON DISPOSABLE, USED WITH POSITIORAL INTERFACE USED WITH POSITIVE AIRWAYEXHALATION PORT WITH OR WITHOUT SWIVEL UTRACHEOSTOMY/LARYNGECTOMY TUBE, NON-CUFFTRACHEOSTOMY/LARYNGECTOMY TUBE, CUFFED,TRACHEOSTOMY/LARYNGECTOMY TUBE, STAINLESTRACH SHOWER PROTECTOR,EACHTRACHEOSTOMA STENT/STUD/BUTTON, EACHTRACHEOSTOMY MASK,EACHHELMET, PROTECTIVE, SOFT, PREFABRICATED,HELMET, PROTECTIVE, HARD, PREFABRICATED,HELMET, PROTECTIVE, SOFT, CUSTOM FABRICAHELMET, PROTECTIVE, HARD, CUSTOM FABRICASOFT INTERFACE FOR HELMET, REPLACEMENT OHOT WATER BOTTLE, ICE CAP OR COLLAR, HEAHOME GLUCOSE DISPOSABLE MONITOR, INCLUDEWIG, ANY TYPE, EACHMISCELLANEOUS DME SUPPLY, ACCESSORY, ANDMISCELLANEOUS DME SUPPLY OR ACCESSORY, NENTERAL FEEDING SUPPLY KIT; SYRINGE A66666166666666666666666666161116
Page 8 of 66NYS Medicaid DME Services Fee 0156E0157E0159E0160E0163E0165DESCRIPTIONENTERAL FEEDING SUPPLY KIT; PUMP FED, PEENTERAL FEEDING SUPPLY KIT; GRAVITY FED,NASOGASTRIC TUBING WITH STYLETNASOGASTRIC TUBING WITHOUT STYLETSTOMACH TUBE-LEVINE TYPEGASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD,GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFILFOOD THICKENER, ADMINISTERED ORALLY, PERENTERAL FORMULA, MANUFACTURED BLENDERIZEENTERAL FORMULA, NUTRITIONALLY COMPLETEENTERAL FORMULA, NUTRITIONALLY COMPLETE,ENTERAL FORMULA, NUTRITIONALLY COMPLETE,ENTERAL FORMULA, NUTRITIONALLY COMPLETE,ENTERAL FORMULA, NUTRITIONALLY INCOMPLETENTERAL FORMULA, NUTRITIONALLY COMPLETE,ENTERAL FORMULA, FOR PEDIATRICS, NUTRITIENTERAL FORMULA, FOR PEDIATRICS, NUTRITIENTERAL FORMULA, FOR PEDIATRICS, NUTRITIENTERAL FORMULA, FOR PEDIATRICS, HYDROLYENTERAL FORMULA, FOR PEDIATRICS, SPECIALENTERAL NUTRITION INFUSION PUMP - WITH APARENTERAL NUTRITION INFUSION PUMP, PORTPARENTERAL NUTRITION INFUSION PUMP, STATNOC FOR ENTERAL SUPPLIESCANE, INCLUDES CANES OF ALL MATERIALS, ACANE, QUAD OR THREE PRONG, INCLUDES CANECRUTCHES, FOREARM, INCLUDES CRUTCHES OFCRUTCH FOREARM, INCLUDES CRUTCHES OF VARCRUTCHES UNDERARM, WOOD, ADJUSTABLE OR FCRUTCH UNDERARM, WOOD, ADJUSTABLE OR FIXCRUTCHES UNDERARM, OTHER THAN WOOD, ADJUCRUTCH, UNDERARM, OTHER THAN WOOD, ADJUSWALKER, RIGID (PICKUP), ADJUSTABLE OR FIWALKER, FOLDING (PICKUP), ADJUSTABLE ORWALKER, WITH TRUNK SUPPORT, ADJUSTABLE OWALKER, RIGID, WHEELED, ADJUSTABLE OR FIWALKER, FOLDING, WHEELED, ADJUSTABLE ORWALKER, ENCLOSED, FOUR SIDED FRAMED, RIGWALKER, HEAVY DUTY, MULTIPLE BRAKING SYSWALKER, HEAVY DUTY, WITHOUT WHEELS, RIGIWALKER, HEAVY DUTY, WHEELED, RIGID OR FOPLATFORM ATTACHMENT, FOREARM CRUTCH, EACPLATFORM ATTACHMENT,WALKER,EACHWHEEL ATTACHMENT, RIGID PICK-UP WALKER,SEAT ATTACHMENT, WALKERCRUTCH ATTACHMENT, WALKER, EACHBRAKE ATTACHMENT FOR WHEELED WALKER, REPSITZ TYPE BATH OR EQUIPMENT, PORTABLE, UCOMMODE CHAIR, MOBILE OR STATIONARY, WITCOMMODE CHAIR, MOBILE OR STATIONARY, 8.362039.92RENTALFEEBR SCBR SCBR SCBR SCBR 666444444444444666166661666666666666666
Page 9 of 66NYS Medicaid DME Services Fee 0325E0326E0328E0371E0372E0424DESCRIPTIONPAIL OR PAN FOR USE WITH COMMODE CHAIR,COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DFOOT REST, FOR USE WITH COMMODE CHAIR, EPOWERED PRESSURE REDUCING MATTRESS OVERLPUMP FOR ALTERNATING PRESSURE PAD, FOR RDRY PRESSURE MATTRESSGEL OR GEL-LIKE PRESSURE PAD FOR MATTRESAIR PRESSURE MATTRESSWATER PRESSURE MATTRESSSYNTHETIC SHEEPSKIN PADPOSITIONING CUSHION/PILLOW/WEDGE, ANY SHHEEL OR ELBOW PROTECTOR EACHPOWERED AIR FLOTATION BED (LOW AIR LOSSGEL PRESSURE MATTRESSAIR PRESSURE PAD FOR MATTRESS, STANDARDWATER PRESSURE PAD FOR MATTRESS, STANDARDRY PRESSURE PAD FOR MATTRESS, STANDARDPHOTOTHERAPY (BILIRUBIN) LIGHT WITH PHOTELECTRIC HEAT PAD, STANDARDELECTRIC HEAT PAD MOISTPARAFFIN BATH UNIT, PORTABLE (SEE MEDICABATH/SHOWER CHAIR, WITH OR WITHOUT WHEELBATHTUB WALL RAIL EACHTOILET RAIL EACHRAISED TOILET SEATTUB STOOL OR BENCHTRANSFER TUB RAIL ATTACHMENTTRANSFER BENCH FOR TUB OR TOILET WITH ORTRANSFER BENCH, HEAVY DUTY, FOR TUB OR THOSPITAL BED, FIXED HEIGHT, WITH ANY TYPHOSPITAL BED, VARIABLE HEIGHT, HI-LO, WIHOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOHOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOTMATTRESS, INNERSPRINGMATTRESS, FOAM RUBBERTABLE, OVERBEDBED PAN STANDARD METAL OR PLASTICBED PAN FRACTURE METAL OR PLASTICPOWERED PRESSURE-REDUCING AIR MATTRESSHOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WIHOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIBED SIDE RAILS, HALF LENGTHBED SIDE RAILS, FULL LENGTHSAFETY ENCLOSURE FRAME/CANOPY FOR USE WIURINAL MALE JUG-TYPE ANY MATERIALURINAL FEMALE JUG-TYPE ANY MATERIALHOSPITAL BED, PEDIATRIC, MANUAL, 360 DEGNONPOWERED ADVANCED PRESSURE REDUCING OVPOWERED AIR OVERLAY FOR MATTRESS, STANDASTATIONARY COMPRESSED GASEOUS OXYGEN 6666666666666166666666666666666661666666
Page 10 of 66NYS Medicaid DME Services Fee E GASEOUS OXYGEN SYSTEM, RENTAL;30.42PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; I45.00STATIONARY LIQUID OXYGEN SYSTEM, RENTAL;72.50OXIMETER DEVICE FOR MEASURING BLOOD OXYG165.00HOME VENTILATOR, ANY TYPE, USED WITH INVASIVE INTERFACE 731.00HOME VENTILATOR, ANY TYPE, USED WITH NON- INVASIVE INTE 731.00RESPIRATORY ASSIST DEVICE, BI-LEVEL PRES2088.50RESPIRATORY ASSIST DEVICE, BI-LEVEL PRES190.00RESPIRATORY ASSIST DEVICE, BI-LEVEL PRES190.00PERCUSSOR, ELECTRIC OR PNEUMATIC, HOME M355.56INTRAPULMONARY PERCUSSIVE VENTILATION SY190.00COUGH STIMULATING DEVICE, ALTERNATING PO190.00HIGH FREQUENCY CHEST WALL OSCILLATION AI195.00IPPB MACHINE, ALL TYPES, WITH BUILT-IN1524.17HUMIDIFIER, DURABLE FOR EXTENSIVE SUPPLE136.64HUMIDIFIER, NON-HEATED, USED WITH POSITI96.74HUMIDIFIER, HEATED, USED WITH POSITIVE A186.33COMPRESSOR, AIR POWER SOURCE FOR EQUIPME377.69NEBULIZER, WITH COMPRESSOR117.89NEBULIZER; ULTRASONIC433.91NEBULIZER, DURABLE, GLASS OR AUTOCLAVABL105.38RESPIRATORY SUCTION PUMP, HOME MODEL, PO290.66CONTINUOUS AIRWAY PRESSURE (CPAP) DEVICE496.20BREAST PUMP, MANUAL, ANY TYPE31.71BREAST PUMP ELECTRIC (AC/DC), ANY TYPE173.47BREAST PUMP, HOSPITAL GRADE, ELECTRIC (A38.61VAPORIZER,ROOM TYPE16.73HOME BLOOD GLUCOSE MONITOR0.00APNEA MONITOR W/RECORDING FEATURE190.00SLING OR SEAT,PATIENT LIFT, CANVAS OR NYLON76.59SEPARATE SEAT LIFT MECHANISM FOR USE WIT189.00SEPARATE SEAT LIFT MECHANISM FOR USE WIT133.50PATIENT LIFT, HYDRAULIC OR MECHANICAL, I1035.36COMBINATION SIT TO STAND SYSTEM, ANY SIZ3229.11STANDING FRAME SYSTEM, ONE POSITION (E.G1273.22STANDING FRAME SYSTEM, MULTI-POSITION (E1663.88STANDING FRAME SYSTEM, MOBILE (DYNAMIC SPNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME531.06NON-SEGMENTAL PNEUMATIC APPLIANCE FOR US56.04NON-SEGMENTAL PNEUMATIC APPLIANCE FOR US166.98NON-SEGMENTAL PNEUMATIC APPLIANCE FOR US135.15NON-SEGMENTAL PNEUMATIC APPLIANCE FOR US89.56SAFETY EQUIPMENT, DEVICE OR ACCESSORY, A15.15TRANSFER DEVICE, ANY TYPE, EACH37.22RESTRAINTS, ANY TYPE (BODY, CHEST, WRIST13.65TRANSCUTANEOUS ELECTRICAL NERVE STIMULAT76.25OSTEOGENESIS STIMULATOR, ELECTRICAL, NON3,300.00OSTEOGENESIS STIMULATOR, ELECTRICAL, NON3,300.00OSTEOGENESIS STIMULATOR, LOW INTENSITY U2,700.00IV 6666661661666666
Page 11 of 66NYS Medicaid DME Services Fee 1012E1014E1020E1028E1161E1225DESCRIPTIONAMBULATORY INFUSION PUMP, SINGLE OR MULTEXTERNAL AMBULATORY INFUSION PUMP, INSULPARENTERAL INFUSION PUMP, STATIONARY, SITRACTION EQUIPMENT, CERVICAL, FREE-STANDCERVICAL TRACTION EQUIPMENT NOT REQUIRINTRACTION EQUIPMENT, OVERDOOR, CERVICALTRACTION FRAME, ATTACHED TO FOOTBOARD, PTRACTION STAND, FREE STANDING, PELVIC TRTRAPEZE BARS, A/K/A PATIENT HELPER, ATTATRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEITRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEITRAPEZE BAR, FREE STANDING, COMPLETE WITPELVIC BELT/HARNESS/BOOTFRACTURE, FRAME, DUAL WITH CROSS BARS, AWHEELCHAIR ACCESSORY, TRAY, EACHHEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHTOE LOOP/HOLDER, ANY TYPE, EACHWHEELCHAIR ACCESSORY, HEADREST, CUSHIONEWHEELCHAIR ACCESSORY, LATERAL TRUNK OR HWHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPOMANUAL WHEELCHAIR ACCESSORY, ONE-ARM DRIMANUAL WHEELCHAIR ACCESSORY, ADAPTER FORWHEELCHAIR ACCESSORY, SHOULDER HARNESS/SMANUAL WHEELCHAIR ACCESSORY, WHEEL LOCKMANUAL WHEELCHAIR ACCESSORY, HEADREST EXMANUAL WHEELCHAIR ACCESSORY, HAND RIM WIMANUAL WHEELCHAIR ACCESSORY, ANTI-TIPPINWHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT,MANUAL WHEELCHAIR ACCESSORY, ANTI-ROLLBAWHEELCHAIR ACCESSORY, POSITIONING BELT/SMANUAL WHEELCHAIR ACCESSORY, PUSH ACTIVAWHEELCHAIR ACCESSORY, ELEVATING LEG RESTMANUAL WHEELCHAIR ACCESSORY, SOLID SEATWHEELCHAIR ACCESSORY, CALF REST/PAD, EACWHEELCHAIR ACCESSORY, POWER SEATING SYSTWHEELCHAIR ACCESSORY, POWER SEATING SYSTWHEELCHAIR ACCESSORY, POWER SEATING SYSTWHEELCHAIR ACCESSORY, POWER SEATNG SYSTEWHEELCHAIR ACCESSORY, POWER SEATING SYSTWHEELCHAIR ACCESSORY, POWER SEATING SYSTWHEELCHAIR ACCESSORY, POWER SEATING SYSTWHEELCHAIR ACCESSORY, ADDITION TO POWERWHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYMODIFICATION TO PEDIATRIC SIZE WHEELCHAIWHEELCHAIR ACCESSORY,ADDITION TO POWER SEATING SYSTRECLINING BACK, ADDITION TO PEDIATRIC SIRESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHWHEELCHAIR ACCESSORY, MANUAL SWINGAWAY,MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TWHEELCHAIR ACCESSORY, MANUAL 666166666666616661111111111166161
Page 12 of 66NYS Medicaid DME Services Fee 2323E2324E2325E2326E2327E2328DESCRIPTIONWHEELCHAIR ACCESSORY, MANUAL FULLY RECLISPECIAL BACK HEIGHT FOR WHEELCHAIRWHEELCHAIR, PEDIATRIC SIZE, NOT OTHERWISWHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACWHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SPACSPECIAL WHEELCHAIR SEAT DEPTH AND/OR WIDOXYGEN CONCENTRATOR, SINGLE DELIVERY PORPORTABLE OXYGEN CONCENTRATOR, RENTALDURABLE MEDICAL EQUIPMENT,MISCPositioning bath chair, small/mediumPositioning bath chair, largePositioning bath chair tub stand additionPositioning bath chair shower stand additionBLOOD GLUCOSE MONITOR WITH INTEGRATED VOMANUAL WHEELCHAIR ACCESSORY, NONSTANDARDMANUAL WHEELCHAIR ACCESSORY, NONSTANDARDMANUAL WHEELCHAIR ACCESSORY, NONSTANDARDMANUAL WHEELCHAIR ACCESSORY, NONSTANDARDMANUAL WHEELCHAIR ACCESSORY, HANDRIM WITMANUAL WHEELCHAIR ACCESSORY, WHEEL LOCKWHEELCHAIR ACCESSORY, CRUTCH AND CANE HOARM TROUGH, WITH OR WITHOUT HAND SUPPORTWHEELCHAIR ACCESSORY, BEARINGS, ANY TYPEMANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PMANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNMANUAL WHEELCHAIR ACCESSORY, INSERT FORMANUAL WHEELCHAIR ACCESSORY, PNEUMATIC CMANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNMANUAL WHEELCHAIR ACCESSORY, FOAM PROPULMANUAL WHEELCHAIR A
tracheostomy care kit for new tracheosto 4.25: 90 a4626 : tracheostomy cleaning brush ea 1.51: 2 a4628 : oropharyngeal suction catheter, each 2.02: 5 . nys medicaid dme services fee schedule effective 1-jul-16 code description fee: rental fee br max units pa a4927 gloves, non-sterile, per 100 4.55: 1 6: a4930 gloves,sterile per pair:
