Table Of Contentsdocshare04.docshare.tips/files/12982/129829075.pdf · IX - ENTERAL NUTRITION ... X...

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Table Of Contents I - IMPORTANT PHONE NUMBERS, ADDRESSES AND WEBSITES .........................................................................5

GLOSSARY OF TERMS/DEFINITIONS........................................................................................................................................5 II - MEDICARE DOCUMENTATION REQUIREMENTS ...............................................................................................8 III - MEDICARE ELIGIBILITY AND THE ID CARD......................................................................................................9

ELIGIBILITY............................................................................................................................................................................9 MEDICARE HEALTH INSURANCE CLAIM (HIC) NUMBER .......................................................................................................9

IV - CLAIMS FILING ..........................................................................................................................................................10 FIELD DEFINITIONS ..............................................................................................................................................................10 ALLWIN TRANSMITS.............................................................................................................................................................11 UNDERSTANDING ALLWIN DATA ON-LINE REJECTIONS.......................................................................................................14 VERSION 5.1 NCPDP FIELD LOCATIONS .............................................................................................................................15

V - NEBULIZERS & INHALATION SOLUTIONS..........................................................................................................16 COVERAGE AND PAYMENT RULES........................................................................................................................................16 DOCUMENTATION REQUIREMENTS.......................................................................................................................................16 CLAIMS TRANSMISSION........................................................................................................................................................17 HCPCS CODES.....................................................................................................................................................................18

VI - DIABETIC SUPPLIES..................................................................................................................................................21 COVERAGE AND PAYMENT RULES........................................................................................................................................21 CODING GUIDELINES ............................................................................................................................................................22 DOCUMENTATION REQUIREMENTS.......................................................................................................................................22 CLAIMS TRANSMISSION........................................................................................................................................................23 HCPCS CODES.....................................................................................................................................................................24

VII - OSTOMY SUPPLIES ..................................................................................................................................................25 COVERAGE AND PAYMENT RULES........................................................................................................................................25 CODING GUIDELINES ............................................................................................................................................................25 DOCUMENTATION REQUIREMENTS.......................................................................................................................................25 CLAIMS TRANSMISSION........................................................................................................................................................26

VIII - IMMUNOSUPPRESSIVE DRUGS...........................................................................................................................30 COVERAGE AND PAYMENT RULES........................................................................................................................................30 CODING GUIDELINES ............................................................................................................................................................30 DOCUMENTATION REQUIREMENTS.......................................................................................................................................31 CLAIM TRANSMISSION..........................................................................................................................................................31 HCPCS CODES.....................................................................................................................................................................31

IX - ENTERAL NUTRITION ..............................................................................................................................................33 COVERAGE AND PAYMENT RULES........................................................................................................................................33 CODING GUIDELINES ............................................................................................................................................................33 DOCUMENTATION REQUIREMENTS.......................................................................................................................................33 CLAIM TRANSMISSION..........................................................................................................................................................34 HCPCS CODES.....................................................................................................................................................................35

X - ORAL ANTI-CANCER DRUGS ...................................................................................................................................37 COVERAGE AND PAYMENT RULES........................................................................................................................................37 CODING GUIDELINES ............................................................................................................................................................37 DOCUMENTATION REQUIREMENTS.......................................................................................................................................38 CLAIMS TRANSMISSION........................................................................................................................................................38

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XI - ORAL ANTI-EMETIC DRUGS...................................................................................................................................39 COVERAGE AND PAYMENT RULES........................................................................................................................................39 CODING GUIDELINES ............................................................................................................................................................39 DOCUMENTATION REQUIREMENTS.......................................................................................................................................40 CLAIM TRANSMISSION..........................................................................................................................................................40 HCPCS CODES.....................................................................................................................................................................40

XIII - UROLOGICAL SUPPLIES.......................................................................................................................................42 COVERAGE AND PAYMENT RULES........................................................................................................................................42 CODING GUIDELINES ............................................................................................................................................................42 DOCUMENTATION REQUIREMENTS.......................................................................................................................................43 CLAIM TRANSMISSION..........................................................................................................................................................44 HCPCS CODES.....................................................................................................................................................................44

XIV - SURGICAL DRESSINGS..........................................................................................................................................46 COVERAGE AND PAYMENT RULES........................................................................................................................................46 CODING GUIDELINES ............................................................................................................................................................47 DOCUMENTATION REQUIREMENTS.......................................................................................................................................49 CLAIM TRANSMISSION..........................................................................................................................................................50 HCPCS CODES.....................................................................................................................................................................50

XV - WALKERS, CANES AND CRUTCHES....................................................................................................................56 COVERAGE AND PAYMENT RULES........................................................................................................................................56 CODING GUIDELINES ............................................................................................................................................................56 HCPCS CODES.....................................................................................................................................................................58

XVI - SEAT LIFT MECHANISMS .....................................................................................................................................59 COVERAGE AND PAYMENT RULES........................................................................................................................................59 CODING GUIDELINES ............................................................................................................................................................59 DOCUMENTATION REQUIREMENTS.......................................................................................................................................59 CLAIM TRANSMISSION..........................................................................................................................................................59 HCPCS CODES.....................................................................................................................................................................60

XVII - HOSPITAL BEDS.....................................................................................................................................................61 COVERAGE AND PAYMENT RULES........................................................................................................................................61 ACCESSORIES .......................................................................................................................................................................61 CODING GUIDELINES ............................................................................................................................................................62 DOCUMENTATION REQUIREMENTS.......................................................................................................................................63 CLAIM TRANSMISSION..........................................................................................................................................................63 HCPCS CODES.....................................................................................................................................................................63

XVIII - MANUAL WHEELCHAIRS ..................................................................................................................................66 COVERAGE AND PAYMENT RULES........................................................................................................................................66 CODING GUIDELINES ............................................................................................................................................................67 DOCUMENTATION REQUIREMENTS.......................................................................................................................................68 CLAIM TRANSMISSION..........................................................................................................................................................68 HCPCS CODES.....................................................................................................................................................................68

XIX - MOTORIZED WHEELCHAIRS..............................................................................................................................70 COVERAGE AND PAYMENT RULES........................................................................................................................................70 CODING GUIDELINES ............................................................................................................................................................70 DOCUMENTATION REQUIREMENTS.......................................................................................................................................71 CLAIMS TRANSMISSION........................................................................................................................................................71 HCPCS CODES.....................................................................................................................................................................71

XX - WHEELCHAIR ACCESSORIES...............................................................................................................................73

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COVERAGE AND PAYMENT RULES........................................................................................................................................73 CODING GUIDELINES ............................................................................................................................................................74 DOCUMENTATION REQUIREMENTS.......................................................................................................................................79 CLAIM TRANSMISSION..........................................................................................................................................................79 HCPCS CODES.....................................................................................................................................................................79

XXI - OXYGEN .....................................................................................................................................................................85 COVERAGE AND PAYMENT RULES........................................................................................................................................85 CODING GUIDELINES ............................................................................................................................................................88 DOCUMENTATION REQUIREMENTS.......................................................................................................................................88 CLAIM TRANSMISSION..........................................................................................................................................................90 HCPCS CODES.....................................................................................................................................................................90

XXII - APPENDIX I..............................................................................................................................................................93 SUPPLEMENTAL INSURANCE BILLING......................................................................................................................93 COMPLEMENTARY CROSSOVER INSURANCE COMPANIES .....................................................................................................95 OCNA NUMBER LIST...........................................................................................................................................................98

XXIII - APPENDIX II – NON-COVERED HCPCS ........................................................................................................115 XXIV - APPENDIX III – CMN COMPLETION .............................................................................................................119

CERTIFICATES OF MEDICAL NECESSITY.............................................................................................................................119 XXV - APPENDIX IV – MEDICARE AS SECONDARY PAYER QUESTIONNAIRE (SHORT FORM)...............124

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I - Important Phone Numbers, Addresses and Websites Glossary of Terms/Definitions DMEPOS

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Jurisdiction of DMEPOS Regional Carriers

Claims jurisdiction is determined by the state in which the beneficiary permanently resides. The following table is a listing of the four DMERC regions and their contact information. The image below the table is a map representation of the four DMERC regions.

REGION DMERC PHONE NUMBER Region A HealthNow NY Connecticut, Delaware, Maine, Massachusetts, New York, New Hampshire, New Jersey, Pennsylvania, Rhode Island and Vermont

P.O. Box 6800 Wilkes-Barre, PA 18773-6800

(866) 419-9458 Beneficiary Line: (800)842-2052

Region B AdminaStar Federal Inc. District of Columbia, Illinois, Indiana, Maryland, Michigan, Minnesota, Ohio, Virginia, West Virginia and Wisconsin

P.O. Box 7078 Indianapolis, IN 46207-7078

(877) 299-7900 Beneficiary Line: (800)270-2313

Region C Palmetto GBA Alabama, Arkansas, Colorado, Florida, Georgia, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas and the Virgin Islands

Medicare DMERC Operations P.O. Box 100141 Columbia, SC 29202-3141

VRU: (866) 238-9650 Live Customer Service:(866) 270-4909 Beneficiary Line: (800)583-2236

Region D Connecticut General Life Insurance Co. (CIGNA Medicare)

Alaska, Arizona, California, Guam/American Samoa, Hawaii, Idaho, Iowa, Kansas, the Marianna Islands, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah , Washington and Wyoming

P.O. Box 690 Nashville, TN 37202

VRU: (877) 320-0390 Live Customer Service:(866) 243-7272 Beneficiary Line: (800)899-7095

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National Supplier Clearinghouse The National Supplier Clearinghouse (NSC) is the national entity contracted by the Centers for Medicare & Medicaid Services (CMS) that issues Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) supplier authorization numbers. The NSC provides DMEPOS supplier applications, verifies application information, and administers file activity. See below for information on Medicare Enrollment & Reenrollment Guidelines. Phone – (866)238-9652 Website – www.pgba.com

SADMERC

The SADMERC HCPCS Unit offers guidance to manufacturers and suppliers on the proper use of the Healthcare Common Procedure Coding System (HCPCS), the means by which durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) services are identified for Medicare billing. Phone – (877) 735-1326 Website – www.pgba.com

Medicare Websites

Region A – www.umd.nycpic.com Region B – www.adminastar.com Region C – www.pgba.com Region D – www.cignamedicare.com

Diagnosis Code Website

www.allwin.net UPIN Number Website

upin.ecare.com www.upinregistry.com

Medicare Initial Enrollment & Reenrollment

To Enroll or Reenroll as a Medicare Provider / Supplier, you must complete the Federal Health Care Provider/Supplier Enrollment Application--CMS 855B.

Complete Section 8-Billing Agency with the following information: Legal Business Name NOW Technology

Doing Business Name Allwin Data One West Pack Sq., Ste. 1400 Asheville, NC 28801 Phone: 800-879-6153 Fax: 828-250-9553 www.allwin.net

Tax ID # 31-1573823 Complete Section 8C by checking the Yes/No Boxes as it applies to you. Question 4 will always be answered “NO”.

Check Section 9 as “Does Not Apply” and skip to section 10

You are allowed 30 days to reenroll or your Medicare provider number will be deactivated. To request an extension or make inquiries, call NSC at 866-238-9652 and ask for Provider Enrollment.

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DMERC Place of Service (POS) Definition All claims filed through Allwin Data to the DMERC must include a two digit place of service code in the Patient Location/Place of Service field in your pharmacy software system. Claims filed without POS information (or with an invalid POS code) will default to POS code of 12 (Home). Only the following POS codes should be submitted to the DMERCs.

POS Code Definition

04 Homeless Shelter 12 Home 13 Assisted Living Facility 14 Group Home 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 54 Intermediate Care Facility/Mentally Retarded 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center 65 End Stage Renal Disease Treatment Facility

The following POS codes are valid for the following categories of durable medical equipment.

POS Code Category 04,12, 13, 14, 33, 54, 55, 56 Inexpensive or other routinely purchased DME 04, 12, 13, 33, 54, 55, 56 Items requiring frequent and substantial servicing 04, 12, 13, 14, 31, 32, 33, 54, 55, 56 04, 12, 13, 14, 33, 54, 55, 56

Customized items • Prosthetic and orthotics • DME

04, 12, 13, 14, 33, 54, 55, 56 Capped Rental Items 04, 12, 13, 14, 33, 54, 55, 56 Oxygen and oxygen equipment 04, 12, 13, 14, 31, 32, 33, 54, 55, 56 General prosthetic and orthotic devices, 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

04, 12, 13, 14, 31, 32, 33, 54, 55, 56 Surgical dressings 04, 12, 13, 14, 31, 32, 33, 54 Drugs (oral anticancer, immunosuppressive) 04, 12, 13, 14, 33, 54, 55, 56 Drugs administered through DME such as nebulizers and

external infusion pump

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II - Medicare Documentation Requirements First The pharmacy must have a dispensing order from the treating physician. This order may be faxed, written or verbal, and must contain the following: • A description of the item • The beneficiary's name • The name of the physician • The date of the order

Second The pharmacy must have a detailed written order that should be retained in the patient's file, and it is a good idea to attach the dispensing order to the detailed written order. The detailed written order must include the following: • Patient's name; • A description of the item (the description can be either a narrative or a brand name/model number) and the length of

need; • If the order is for accessories or supplies that will be provided on a periodic basis, it must include appropriate

information on the quantity used, frequency of change or use, and length of need; • If the order is a drug, it must specify the name of the drug, concentration (if applicable), dosage, frequency of

administration, and duration of infusion (if applicable); • Patient's diagnosis (policy applicable); • The expected start date of the order; • The physician's signature and date. Third The pharmacy must have the beneficiary sign an Assignment of Benefits for each Detailed Written Order that the pharmacy is going to accept assignment for. This Assignment of Benefits agreement must be kept in the patient's file. A new Assignment of Benefits agreement is required with each new written order, however, not with refills of an existing Detailed Written Order.

***All three of these items previously listed should be on file before the pharmacy bills the claim to Allwin Data***

Fourth A delivery slip which has been signed and dated by the beneficiary, or authorized representative, is required in order to verify the DMEPOS item(s) received. An acceptable delivery slip must include the patient's name, the quantity and detailed description of the item(s) being delivered, brand name and serial number. Note: The date of service on the claim must be the date of delivery.

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III - Medicare Eligibility and the ID Card Eligibility The Social Security Administration (SSA) determines Medicare eligibility. Medicare Part A basically covers hospitalization expenses, and Part B covers treatment at a doctor’s office and any DMEPOS (Durable Medical Equipment Prosthetics, Orthotics, and Supplies) filled at the pharmacy level. Medicare Part B is a voluntary program for which the insured must pay a monthly premium, therefore, individuals who do not want coverage may refuse Medicare Part B enrollment. The effective date of Medicare Part B coverage depends on the month in which enrollment takes place. An individual’s Medicare Part B coverage ends when the individual requests disenrollment, does not pay premiums, dies, or when hospital insurance entitlement ends for those less than 65 years of age. In order for an individual to be eligible for medical insurance (Medicare Part B), he or she must be a U.S. citizen and/or:

1. 65 years of age, 2. Under age 65 with permanent kidney failure, or 3. Under age 65 and permanently disabled and entitled to SSA benefits.

Medicare Health Insurance Claim (HIC) Number The HIC number is the Social Security number that indicates that the beneficiary is eligible for Medicare benefits. This HIC number is shown on his or her Medicare card. NOTE: The Medicare identification number may be different than the beneficiary’s social security number, nor does the number always end with the letter A or B. The format of the Social Security Administration (SSA) issued Medicare number is 000-00-0000 followed by a letter, two letters, or a letter-number combination. A Railroad Retiree Benefit issued number may be a nine digit or six digit number with one or more alphas in front. The Medicare number is probably the most important piece of information you can have about your Medicare patient. Your claims cannot be paid if the Medicare number is missing or incorrect. The Medicare beneficiary’s name and number should be entered on the claim exactly as it appears on the Medicare card to prevent unnecessary rejections from Medicare. We recommend a copy of the Medicare card be obtained and incorporated in the patient’s file for accuracy of claim submissions.

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IV - Claims Filing Field Definitions BIN Numbers

The standard BIN Number for Medicare transactions to Allwin Data is 004766. Those pharmacies using Envoy as a switch should use the BIN Number indicated in the chart below:

Processor Control # Envoy BIN #

USMCA 005200 USMCAASG 005730 USMCANON 005917

USNONCOVER 002522 Processor Control Number

Allwin Data offers 4 unique Processor Control Numbers to insure each claim processes as the pharmacy intended. Below the 4 Processor Control Numbers are listed along with the way each processes a claim.

USMCA Claims will process according to how your pharmacy was set up upon initially enrolling with Allwin Data

USMCAASG Claims will process as assigned regardless of how your pharmacy is set up in the Allwin system. 20% or “ 0” coinsurance depending upon the existence of supplemental insurance.

USMCANON Claims will process as unassigned regardless of how your pharmacy is set up in the Allwin system. 100% patient pay amount to the beneficiary. Medicare will reimburse the beneficiary.

USNONCOVER Used when billing non-covered Medicare item that Medicaid or another insurance requires a Medicare rejection before assuming coverage.

Note: Pharmacies registered with Medicare as a Participating Provider must always accept assignment (USMCAASG or USMCA). If you are unsure of how your pharmacy is set up with Medicare, you can call the National Supplier Clearinghouse (see pg. 3). Note: Pharmacies must always accept assignment on any claim for a drug or biological billed to Medicare. (Inhalation Solutions, Immunosuppressive Drugs, Anti-Cancer Drugs, and Anti-Emetic Drugs)

Pharmacy ID Number

When transmitting claims to Allwin Data use your NABP Number. Allwin Data will convert your NABP# based on the particular plan being billed.

NDC Numbers and Procedure/HCPCS Codes

For most products Medicare does not accept NDC #’s to identify an item on a claim. Medicare only recognizes HCPCS (Procedure) codes as a valid product identifier. Allwin Data will accept your NDC# on a claim transaction and convert it to a payable HCPCS code before transmitting the claim to Medicare, provided there is a link established in our system between the NDC# and HCPCS code. Establishing this link may sometimes require a call to Allwin Data. However, there will be occasions when it is necessary for the pharmacy to transmit a HCPCS code to Allwin Data, therefore, the pharmacy should be familiar with the location and use of their HCPCS code field. The pharmacy’s software vendor should be helpful in locating and using this field. The NCPDP location of this field and many others can be found in the chart at the end of this section, and will be useful when talking to your software vendor. Note: If you have the HCPCS code, but no NDC#, Allwin Data will always accept an NDC# in the following format: Using HCPCS A5061, drop the A, add 5 “0”s in front of 5061, and 2 “0”s behind 5061, leaving an NDC# of 00000506100, Allwin will accept this format as a valid NDC#.

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Modifiers Medicare requires modifiers on most HCPCS codes. These modifiers generally represent additional information without having to actually include all the documentation necessary for claim payment. Allwin Data automatically attaches the proper modifiers to most all HCPCS codes. However, there are a few instances when it will be necessary for the pharmacy to include the modifier and HCPCS code with the claim. The primary examples are listed below and covered in greater detail in the Medical Policies Section where necessary.

• Billing for any item that can be used for a left or right body member

For example, when billing for a Left Breast Prostheses, the pharmacy would transmit the HCPCS code for a Breast Prostheses and the LT modifier to indicate the left breast, as shown here – L8020LT. If billing for both the left and right, the pharmacy would then transmit the HCPCS code with an XT modifier and a quantity of two.

• Compounding inhalation solutions It is necessary to use the KP and KQ modifiers to indicate that the drug being billed is part of a compound. These modifiers dictate the amount at which Medicare will reimburse for each drug and must be used in such a way that the lowest price is returned to the beneficiary.

• Renting an item that is available for purchase, such as a walker or cane Allwin will automatically attach modifiers to DME indicating purchase. In the instance a pharmacy wishes to transmit a claim for a rental, it will be necessary for the pharmacy to transmit the HCPCS code and the RR modifier, to indicate the intention to rent. For example, to indicate a standard cane rental you would transmit E0100RR. These will have to be repeated each month during the rental period. This policy does not apply to Capped Rental Items such as wheelchairs, hospital beds, and nebulizers.

• Billing for surgical dressings being used on more than one wound Medicare’s monthly limits on surgical dressings are based per wound. Therefore the Allwin system defaults to modifier A1, indicating 1 wound. Should the pharmacy be billing for surgical dressings being used on more than one wound, the pharmacy will need to transmit the HCPCS code plus the proper modifier, A2 – A9. For example, A6402A2.

• Billing a capped rental item through Allwin Data that is not the first month of the rental period When a pharmacy is transmitting a claim for a capped rental item to Allwin Data for the first time, and the claim is for any other month in the rental period other than the first, the pharmacy should use the chart below to determine what HCPCS/modifier combination to use. The example used is a Nebulizer.

Month You Transmit Allwin Transmits Meaning Months 2&3 E0570KI E0570RRKI Months 4-10 E0570KJ E0570RRKJ

Months 11-13 E0570BP E0570RRKJBP Patient Purchase Months 11-15 E0570BR E0570RRKJBR Patient Rent Months 11-15 E0570BU E0570RRKJBU Patient Undecided

Diagnosis Codes

All Medicare claims transmitted to Allwin Data require a diagnosis code. This code should be indicated on the order from the doctor, or at the very least a narrative description of the diagnosis should be written on the order. If all the pharmacy has is a narrative diagnosis, the actual code may be found by using the diagnosis code search on www.allwin.net, or by calling the prescribing physician.

Doctor ID Numbers

The doctor identification number required on a claim by Medicare is the UPIN (Unique Physician Identifier Number). This number is one alpha character followed by 5 numeric characters, and can be obtained from the website listed in Section I or by calling the doctor’s office. Because most Pharmacy Billing Systems are set up to transmit only the DEA #, Allwin Data has developed a conversion file in which we will accept the DEA# and convert it to the correct UPIN before transmitting the claim to Medicare. Allwin currently has the majority of these DEA #s and UPINs linked in our system. However, occasionally, a pharmacy will have to call an Allwin Data

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representative and have a DEA# linked to a UPIN in order for a claim to process. This is especially the case with a newly enrolled pharmacy in an area not previously served by Allwin Data.

Medicare Supplemental Insurance

Many Medicare beneficiaries have supplemental insurance that will cover the Medicare co-pays and deductible. It is the pharmacy’s responsibility to determine the existence of supplemental coverage. Once the beneficiary’s supplemental coverage has been established, the pharmacy would indicate this coverage by entering the OCNA # of that particular insurance company in the Group Field of the Medicare claim (see Supplemental Insurance Billing list on pg. 93 of this manual). In the instance where there is no supplemental coverage the Group Field would simply be left blank. There are two distinct types of supplemental coverage that are important to differentiate between. This difference is explained in greater detail at the beginning of Appendix I, where you will also find all of the OCNA codes listed.

Billing Medicare as Secondary

There are generally only three instances in which a pharmacy would bill Medicare as secondary:(use form on pg. 116 to help in determining primary insurance) Working Aged Patients 65 years or older who have Employer Group Health Plan coverage through their own employment or employment of a spouse. An EGHP is a health insurance or benefit plan that is offered through an employer of 20 or more employees. Disabled Patients under age 65 entitled to Medicare on the basis of permanent disability that have health insurance coverage under a Large Group Health Plan (LGHP) either through a family member or from their own current employment. An LGHP is a health insurance or benefit plan that is offered through an employer who has 100 or more employees or is part of a multi-employer trust or association, which has at least one employer of 100 or more employees. End Stage Renal Disease (ESRD) For patients under age 65 (including dependent children) who are entitled to Medicare solely on the basis of ESRD and who have health insurance coverage under the Employer Group Health Plan (EGHP) as a result of the patient or any family member's current or former employment, the EGHP may be offered by an employer of any size. Medicare is the secondary payer for ESRD beneficiaries for the first 30 months of their Medicare eligibility. Eligibility is determined by the first month that Medicare could have, upon application, made payments on behalf of the beneficiary. NOTE: These instances basically state that unless a beneficiary is still working or their spouse is still working, Medicare is always primary.

Medicare as Secondary Billing Procedure

Should a situation arise in which a pharmacy needs to bill Medicare as secondary, it will be necessary for the pharmacy to call an Allwin Data Representative and provide them with some information concerning the beneficiary’s primary insurance before the claim will process.

Once Allwin Data has loaded the beneficiary’s primary insurance info into the system, the following steps need to be taken in order for the claim to transmit:

1. Type the word “SECONDARY” in the Group Field of your Medicare claim. 2. Enter the number “2” in the Other Coverage Code Field. The amount the other insurance paid should

automatically appear in the Other Insurance Amount Field. 3. If the primary insurance paid $0.00, enter the number “3” in the Other Coverage Code Field.

Once these fields are populated Allwin Data will be able to correctly transmit the claim.

Quantities Dispensed and Medicare Billing Units

The quantities a pharmacy bills and the billing units Medicare requires to pay a claim are sometimes very different. This is especially true in the cases of Diabetic Supplies, Enteral Nutrition, and Inhalation Solutions. In most cases, Allwin Data has in place quantity conversions for Medicare claims so the pharmacy can continue billing quantities as they always have. However, if you feel that the price being returned does not adequately reflect the quantities

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dispensed a custom conversion may be required for the product being billed. The quantity conversions Allwin Data currently use for different items are discussed in greater detail in the Medical Policies Section. The safest way to avoid a claim being filed with an erroneous quantity is to always pay close attention to allowable price Allwin Data returns for the claim. Most often if a quantity is misrepresented the allowable price Allwin Data returns will be too low.

Billing Capped Rental Items

Many popular items covered by Medicare are available as rental items only. These items include, but are not limited to, nebulizers, wheelchairs, and hospital beds. When the pharmacy is billing for these items it will be necessary to submit a claim to Allwin Data each month during the rental period. Medicare will pay for a Capped Rental Item for up to 15 months, in the 10th month of the rental period the pharmacy should have the beneficiary sign a Rental/Purchase Option Form. Should the beneficiary chose to continue renting Medicare will make payments through the 15th month, and reimburse a servicing fee every 6 months after the 15th month. Should the beneficiary choose the purchase option, Medicare will make payments through the 13th month, after which it becomes the property of the beneficiary. In this instance (purchase option) it will be necessary for the pharmacy to transmit the HCPCS code along with a BP modifier in the 11th month’s billing.

Medicare Deductible and Coinsurance

Medicare pays only 80% of their allowable cost on everything they cover. In 2005, Medicare has a $110 deductible each beneficiary must meet at the beginning of each calendar year before any coverage will take effect. Many supplemental insurance companies pick up the 20% Medicare coinsurance and the $110 Medicare deductible. All State Medicaid plans pick up the entire 20% co-pay and the $110 deductible. To find out if a supplemental plan covers the $110 deductible you may call that insurance company for confirmation of your patient’s benefits. Due to privacy issues Allwin Data can never know for sure if a beneficiary has meet their $110 deductible, however, Allwin Data does offer a deductible tracking service in which we will return a full patient pay amount on each claim until $110 is spent through the Allwin Data system. For more information on this option please contact an Allwin Data Representative.

There are only 3 different coinsurance percentages Allwin Data will reply with on a transmitted claim and is important to understand what they mean, as these coinsurance amounts dictate who will receive reimbursement and from where the reimbursement is coming.

100% coinsurance Pharmacy collects full amount from the patient. Reimbursement will be sent directly to the beneficiary’s residence.

20% coinsurance Pharmacy collects the 20% amount returned by Allwin Data from the patient. Medicare will reimburse the pharmacy the other 80%.

$0.00 coinsurance Patient pays nothing. Pharmacy will receive 80% from Medicare and the other 20% from the patient’s supplemental insurance indicated in the Group Field.

Reversing Claims

Allwin Data batches all claims every Friday at midnight for transmission to Medicare. Once Friday midnight has passed there is no way to reverse a claim filed during the previous week until remittance advice on the claim has been received. Calling Medicare is the only option if a change needs to be made to a claim after it has been batched.

Receiving Medicare Payment

Upon enrolling with Allwin Data for Medicare billing, the pharmacy’s first check from Medicare should arrive within 6 weeks, after that initial check, all subsequent checks should arrive on more routine (7-10 days) basis. To check on the status of a particular claim, the pharmacy can call the DMERC and use the automated response system. The phone number for your region can be found on page 3.

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Understanding Allwin Data On-line Rejections Invalid Prescriber ID

Allwin Data offers the service of cross-referencing a physician’s DEA# with the Medicare required UPIN. To remedy this rejection you may either transmit the UPIN or call Allwin Data to link the DEA# to the UPIN. To expedite this call have the DEA# and UPIN handy. An excellent resource for the UPIN is the website upin.ecare.com or a call to the physician’s office. The UPIN format is one letter and five digits.

Invalid NDC Number

There are a couple different reasons you may be receiving this rejection. First of all verify that the product being billed is a Medicare covered item by referring to the non-covered items list beginning on page 115. If it is a covered item then the NDC# will most likely need to be cross referenced with the HCPCS code by calling Allwin Data. To expedite this process, please have the NDC# and HCPCS code handy. An excellent resource for the HCPCS codes is SADMERC at 877-735-1326.

Invalid Diagnosis Code

Medicare requires that each diagnosis code be brought out to its greatest specificity. For example, the general diagnosis code for asthma is 493. This code would need to be brought out to its greatest specificity to reflect the type of asthma the patient has (i.e. 493.00, 493.01, 493.02, etc.). However, this does not mean that all codes must have five digits. For instance, 496 is a valid code reflecting COPD. You can check the validity of the diagnosis code you are submitting using the Allwin Data website. Make sure not to include any leading or following zeros unless indicated in the ICD-9 coding. If you have validated the ICD-9 code and you are still receiving a rejection it may be that the product you are billing is not covered for that particular diagnosis. Keep in mind that the ICD-9 code, or at least a diagnosis description, should be included on the order and the physician should approve any changes.

Refilled Too Soon

This rejection is commonly encountered when billing more frequently than the Medicare utilization guidelines. When billing for glucose test strips or lancets you may use a “07” in your Rx Denial Override field if you have documentation to support the medical necessity for testing in excess of these guidelines. A prescription stating the frequency of testing is sufficient. For all other products a “02” may be used to override our frequency edits if there is a prescription on file supporting the medical necessity of the frequency/quantity. To increase the likelihood of payment from Medicare you may call Allwin Data to request that a narrative be attached to the claim describing the medical necessity. Any rejected portion should be sent to the DMERC review department for payment.

Invalid Metric Quantity

This rejection is encountered when billing for quantities in excess of the Medicare guidelines. When billing for glucose test strips or lancets you may use a “07” in your Rx Denial Override field if you have documentation to support the medical necessity for testing in excess of these guidelines. A prescription stating the frequency of testing is sufficient. For all other products a “02” may be used to override our quantity edits if there is a prescription on file supporting the medical necessity of the frequency/quantity. To increase the likelihood of payment from Medicare you may call Allwin Data to request that a narrative be attached to the claim describing the medical necessity. Any rejected portion should be sent to the DMERC review department for payment.

Patient First Name Invalid

You will encounter this rejection when billing Medicare as a secondary payer. First refer to the section on Medicare as a Secondary Payer on pg. 9 of this manual, to determine if Medicare is in fact secondary. This section will also instruct you to call Allwin Data with the beneficiary’s primary payer information.

Invalid Group Number

This is another rejection you may encounter when billing Medicare as a secondary payer. Refer to the section of this manual on Medicare as a Secondary Payer, pg. 9.

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Supporting Documentation Required Some products require a Certificate of Medical Necessity (CMN) to be reimbursed by Medicare. A completed CMN may be entered on our website or faxed into us. Please allow 24 hours if the CMN is faxed. If you are still receiving this rejection after waiting 24 hours there may have been missing or invalid information. Call Allwin Data to have the CMN updated. If Medicare already has the CMN on file due to a prior billing using billing methods other than Allwin Data you may override our reject message with a “03” in the Rx Denial Override field. Only use this override if you have received remittance reflecting payment of this item for this patient.

Invalid Cardholder ID Number

The format of the Social Security Administration (SSA) issued Medicare number is 000-00-0000 followed by a letter, two letters, or a letter-number combination. A Railroad Retiree Benefit issued number may be a nine digit or six digit number with one or more alphas in front. This ID# must be submitted exactly as it reads on the beneficiary’s card.

Version 5.1 NCPDP Field Locations

When talking with your software vendor, use the following chart to locate important fields used in Medicare claims transmission:

Field Field Number Field Identifier Product/Service ID 407 D7

Prescriber ID 411 DB Group ID 301 C1

Eligibility Clarification 309 C9 Other Coverage Code 308 C8 Usual & Customary 426 DQ Gross Amount Due 430 DU

Submission Clarification Code (Rx Denial Override)

420 DK

Quantity Dispensed 442 E7 Processor Control # 104 A4

Diagnosis Code 424 DO

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V - Nebulizers & Inhalation Solutions Coverage and Payment Rules A small volume nebulizer (A7003, A7004, A7005) and related compressor (E0570, E0571) are covered when: a) It is medically necessary to administer beta-adrenergics, anticholinergics, corticosteroids, and cromolyn for the

management of obstructive pulmonary disease (ICD-9 diagnosis codes 491.0 - 505), or b) It is medically necessary to administer gentamicin, tobramycin, amikacin, or dornase alfa to a patient with cystic fibrosis

(ICD-9 diagnosis code 277.00) or c) It is medically necessary to administer pentamidine to patients with HIV (ICD-9 diagnosis code 042), pneumocystosis

(ICD-9 diagnosis code 136.3), and complications of organ transplants (ICD-9 diagnosis codes 996.80-996.89), or d) It is medically necessary to administer mucolytics (other than dornase alpha) for persistent thick or tenacious pulmonary

secretions (ICD-9 diagnosis codes 480.0-505, and 786.4).

Use of inhalation drugs, other than those listed above, will be denied as not medically necessary. If none of the drugs used with a nebulizer are covered, the nebulizer and its accessories/supplies will be denied as not medically necessary. When a concentrated form of an inhalation drug is dispensed, separate saline solution (J7051 or A4216, A4217) used to dilute it will be separately reimbursed. Saline dispensed for the dilution of concentrated nebulizer drugs must be billed on the same day as the drug(s) being diluted. If the unit dose form of the drug is dispensed, separate saline solution (J7051 or A4216, A4217) will be denied as not medically necessary. Water or saline in 1000 ml quantities (A7018) are not appropriate for use by patients to dilute inhalation drugs and will therefore be denied as not medically necessary if used for this purpose. These codes are only medically necessary when used in a large volume nebulizer (A7017 or E0585). Nebulizers are billable to Medicare as rental items only. Inhalation Solutions should be billed as 30-day supplies, and refilled every 30 days as such. A monthly dispensing fee (E0590) for each covered drug or combination of drugs used in a nebulizer will be paid in addition to payment for the drug or drugs. This dispensing fee will be based on the drug dispensed, and not on the number of unit dose vials dispensed. Also, if two or more drugs are combined in single unit dose vials, only one dispensing fee will be paid per drug combination per month. The dispensing fee(s) must be billed on the same day as the dispensed inhalation drug(s). A dispensing fee is not separately billable or payable for saline, whether used as a dilutant or for humidification therapy. Documentation Requirements An order for all equipment, accessories, drugs, and other supplies related to nebulizer therapy must be signed and dated by the ordering physician and kept on file by the supplier. The order for any drug must clearly specify the type of solution to be dispensed to the patient and the administration instructions for that solution. The type of solution is described by a combination of (a) the name of the drug and the concentration of the drug in the dispensed solution and the volume of solution in each

container, or (b) the name of the drug and the number of milligrams/grams of drug in the dispensed solution and the volume of solution

in that container.

Examples of (a) would be: albuterol 0.083% 3 ml; or albuterol 0.5% 20 ml; or cromolyn 20 mg/2 ml. Examples of (b) would be: albuterol 1.25 mg. in 3 ml. saline; or albuterol 2.5 mg. and cromolyn 20 mg. in 3 ml. saline. Administration instructions must specify the amount of solution and frequency of use. Examples would be: 3 ml. qid and prn - max 6 doses/24 hr.; or one ampule q 4 hr prn; or 0.5 ml. diluted with saline to 3.0 ml. tid and prn. A new order is required if there is a change in the

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type of solution dispensed or the administration instructions. For all inhalation drugs, a new order is required at least every 12 months even if the prescription has not changed. A narrative diagnosis and/or an ICD-9 diagnosis code describing the condition must be present on each order. An ICD-9 code describing the condition that necessitates nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs. If more than one beta-adrenergic or more than one anticholinergic inhalation drug is billed during the same month, each claim must be accompanied by a copy of the prescription(s) and physician narrative documentation supporting the medical necessity of concurrent use. When billing for quantities of nebulized inhalation drugs or nebulizer accessories and supplies greater than those described in the policy as the usual maximum amounts, each claim must be accompanied by a physician’s narrative documentation supporting the medical necessity for the higher utilization. Contact Allwin Data to have this narrative documentation electronically attached to the claim. Claims Transmission Allwin Data can accept Inhalation Solution quantities in all units a pharmacy may wish to transmit in a claim. Allwin Data currently defaults to reading most inhalation solution quantities as milliliters and will convert them to the proper Medicare billing units. Should a pharmacy wish to send a quantity other than milliliters, please contact Allwin Data about setting up a conversion specific to your store and drug. The exceptions to the milliliter default are as follows:

• Any quantity of Ipratropium [J7644] less than 74 mgs will be read as mgs. • Any quantity of compounded Ipratropium [J7644KP] will be read as mgs. • Any quantity of compounded Albuterol [J7619KQ] will be read as mgs.

Remember, Allwin Data can set your store up for any particular drug to be transmitted in the quantity you wish, even the three listed above. These examples are simply the quantities our system defaults to for our conversions. Duoneb may be billed through Allwin using the drug’s NDC or the procedure code, J7621. The billed quantity should reflect the total number of milliliters dispensed. Allwin will convert the billed units to the appropriate Medicare units. Since the addition of procedure code J7621 was effective as of 01/01/2004 the billing procedure is different if you wish to bill for a date of service prior to this. If the date of service is prior to 01/01/04 the claim will need to be billed under two separate prescriptions. One prescription will be for Albuterol (J7619KQ) in mg units and the other for Ipratropium (J7644KP) in mg units. Xopenex must be billed using the NDC# in mL units. Unfortunately, Medicare does not reimburse appropriately for this product (currently, the reimbursement is $0.88 per mg). The claim cannot be billed as unassigned and the patient cannot be charged the difference. You do have the right to refuse to dispense the product as long as you do not bill Medicare for Xopenex on any future claims. If the patient wishes to pay cash for the product, Allwin suggests having the patient sign a waiver showing their agreement of these terms. The reason reimbursement is so low is because Medicare does not recognize the medical benefits of Xopenex over Albuterol. Allwin also suggests you notify the physician of the low reimbursement and request that the prescription be changed to Albuterol. For nebulizers Allwin Data will automatically attach all required capped rental modifiers. Should you begin processing through Allwin Data halfway through a capped rental period, refer to the section regarding modifiers beginning on page 8, for the proper way to transmit your claim.

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HCPCS Codes Inhalation Solutions

HCPCS Description Quantity Notes A7018 WATER, DISTILLED, USED WITH LARGE VOLUME NEBULIZER, 1000

ML 18L/mo A4216

SALINE SOLUTION, PER 10 ML, METERED DOSE DISPENSER, FOR USE WITH INHALATION DRUGS 60units/mo

A4217 STERILE WATER/SALINE PER 500 ML

A7020 STERILE WATER OR STERILE SALINE, 1000 ML, USED WITH LARGE VOLUME NEBULIZER 18L/mo

E0590 DISPENSING FEE COVERED DRUG ADMINISTERED THROUGH DME NEBULIZER 1 per drug/mo

J2545 PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, PER 300 MG, ADMINISTERED THROUGH A DME 300 mg/mo

J7051 STERILE SALINE OR WATER, UP TO 5 CC 186units/mo J7608 ACETYLCYSTEINE, INHALATION SOLUTION ADMINISTERED

THROUGH DME, UNIT DOSE FORM, PER GRAM 74grams/mo J7618 ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED

ISOMERS, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL) 465mg/mo

J7619 ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL) 465mg/mo

J7621 ALBUTEROL, ALL FORMULATIONS, INCLUDING SEPARATED ISOMERS, UP TO 5 MG (ALBUTEROL) OR 2.5 MG (LEVOALBUTEROL), AND IPRATROPIUM BROMIDE, UP TO 1 MG, COMPOUNDED INHALATION SOLUTION, ADMINISTERED THROUGH DME IC

J7622 BECLOMETHASONE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM IC

J7624 BETAMETHASONE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM IC

J7626 BUDESONIDE INHALATION SOLUTION, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 0.25 TO 0.50 MG IC

J7628 BITOLTEROL MESYLATE, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM 434mg/mo

J7629 BITOLTEROL MESYLATE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM 434mg/mo

J7631 CROMOLYN SODIUM, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS 248units/mo

J7633 BUDESONIDE, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM IC

J7635 ATROPINE, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM 186mg/mo

J7636 ATROPINE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM 186mg/mo

J7637 DEXAMETHASONE, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM IC

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J7638 DEXAMETHASONE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM IC

J7639 DORNASE ALPHA, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM 78mg/mo

J7641 FLUNISOLIDE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE, PER MILLIGRAM IC

J7642 GLYCOPYRROLATE, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM 75mg/mo

J7643 GLYCOPYRROLATE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM 75mg/mo

J7644 IPRATROPIUM BROMIDE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM 93mg/mo

J7648 ISOETHARINE HCL, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM 930mg/mo

J7649 ISOETHARINE HCL, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM 930mg/mo

J7658 ISOPROTERENOL HCL, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM 450/mg/mo

J7659 ISOPROTERENOL HCL, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM 450mg/mo

J7668 METAPROTERENOL SULFATE, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 10 MILLIGRAMS 280units/mo

J7669 METAPROTERENOL SULFATE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS 280units/mo

J7680 TERBUTALINE SULFATE, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM 186mg/mo

J7681 TERBUTALINE SULFATE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM 186mg/mo

J7682 TOBRAMYCIN, UNIT DOSE FORM, 300 MG, INHALATION SOLUTION, ADMINISTERED THROUGH DME IC

J7683 TRIAMCINOLONE, INHALATION SOLUTION ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM IC

J7684 TRIAMCINOLONE, INHALATION SOLUTION ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM IC

J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTERED THROUGH DME IC NARR

• IC = Individually Considered on a claim-by-claim basis. We recommend you call and ask an Allwin Data

Representative to include a narrative as to the dosage, condition of patient, and expected length of need when billing for those drugs that are Individually considered.

Nebulizers Equipment HCPCS Description Quantity Notes E0565 Compressor, air power source, for equipment which is not self-contained or

cylinder driven CR

E0570 Nebulizer with compressor CR E0571 Aerosol compressor, battery powered, for use with small volume nebulizer CR/NARR

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E0572 Aerosol compressor, adjustable pressure, light duty for intermittent use CR E0574 Ultrasonic generator with small volume ultrasonic nebulizer CR/NMN E0575 Nebulizer, ultrasonic, large volume CR/NC E0585 Nebulizer, with compressor and heater CR Accessories HCPCS Description Quantity Notes A4619 Face tent 1/ month A7525 Tracheostomy mask 1/ month A7526 Tracheostomy tube collar/holder, each A7003 Administration set, small volume non-filtered pneumatic nebulizer, disposable 2/month A7004 Small volume non-filtered pneumatic nebulizer, disposable 2/month A7005 Administration set, small volume non-filtered pneumatic nebulizer, non-

disposable 1/6 months

A7006 Administration set, small volume filtered pneumatic nebulizer 1/month A7007 Large volume nebulizer, disposable, unfilled, used with aerosol compressor NC A7008 Large volume nebulizer, disposable, pre-filled, used with aerosol compressor NC A7009 Reservoir bottle, non-disposable, used with large volume ultrasonic nebulizer A7010 Corrugated tubing, disposable, used with large volume nebulizer, 100 feet 1/ 2 months A7011 Corrugated tubing, non-disposable, used with large volume nebulizer, 10 feet 1/ year A7012 Water collection device, used with large volume nebulizer 2/ month A7013 Filter, disposable, used with aerosol compressor 2 /month A7014 Filter, non-disposable, used with aerosol compressor or ultrasonic generator 1/ 3 months A7015 Aerosol mask, used with DME nebulizer 1 / month A7016 Dome and mouthpiece, used with small volume ultrasonic nebulizer 2 / year A7017 Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with

oxygen 1 / 3 years

E0580 Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter

E1372 Immersion external heater for nebulizer 1 / 3 years

Explanations of Notes Column NMN Not Medically Necessary, payment will be based on the allowance for

the least costly medical appropriate alternative.

NC Not Covered.

NARR Narrative required. Call Allwin Data with the appropriate information.

CR Capped Rental item.

CMN Certificate of Medical Neccessity required.

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VI - Diabetic Supplies Coverage and Payment Rules Home blood glucose monitors are covered for patients who are diabetics and who can better control their blood glucose levels by checking these levels and appropriately contacting their attending physician for advice and treatment. To be eligible for coverage, the patient must meet all of the following basic criteria: 1. The patient has diabetes (ICD-9 codes 250.00-250.93) which is being treated by a physician; and 2. The glucose monitor and related accessories and supplies have been ordered by the physician who is treating the

patient's diabetes and the treating physician maintains records reflecting the care provided including, but not limited to, evidence of medical necessity for the prescribed frequency of testing; and

3. The patient (or the patient's caregiver) has successfully completed training or is scheduled to begin training in the use of the monitor, test strips, and lancing devices; and

4. The patient (or the patient's caregiver) is capable of using the test results to assure the patient's appropriate glycemic control; and

5. The device is designed for home use. For all glucose monitors and related accessories and supplies, if the basic coverage criteria (1)-(5) are not met, the items will be denied as not medically necessary. Home blood glucose monitors with special features (E2100, E2101) are covered to enable the visually impaired to use the equipment without assistance. Codes E2100 or E2101 are covered when the basic coverage criteria are met and the treating physician certifies that the patient has a severe visual impairment (i.e., best corrected visual acuity of 20/200 or worse in both eyes) requiring use of this special monitoring system. Code E2101 is also covered for those with impairment of manual dexterity when the basic coverage criteria is met and the treating physician certifies that the patient has an impairment of manual dexterity severe enough to require the use of this special monitoring system. Coverage of E2101 for patients with manual dexterity impairments is not dependent upon a visual impairment. The medical necessity for a laser skin-piercing device (E0620) has not been established. If an E0620 is ordered for use with a covered home blood glucose monitor, payment will be based on the allowance for the least costly medically appropriate alternative (A4258). In addition, since E0620 is not medically necessary, replacement lens shield cartridges (A4257) are also considered not medically necessary. If A4257 is ordered for use with an E0620, payment will be based on the allowance for the least costly medically appropriate alternative (A4259). For a patient who is not currently being treated with insulin injections, more than 100 test strips and up to 100 lancets every 3 months are covered if the treating physician has seen and evaluated the patient’s diabetes within the last 6 months and specifically ordered a frequency of testing that exceeds the utilization guidelines and has documented in the patient's medical record the specific reason for the additional materials for that particular patient. For a patient who is currently being treated with insulin injections, more than 100 test strips and up to 100 lancets every month are covered if the treating physician has seen and evaluated the patient’s diabetes within the last 6 months and specifically ordered a frequency of testing that exceeds the utilization guidelines and has documented in the patient's medical record the specific reason for the additional materials for that particular patient. Any diagnosis code ending with an odd number indicates the patient is Type I diabetic (usually insulin treated). Diagnosis codes ending in an even number indicate the patient is Type II diabetic (usually not insulin treated). “Insulin-treated” means that the patient is receiving insulin injections to treat their diabetes. Insulin does not exist in an oral form and therefore patients taking oral medication to treat their diabetes are not insulin-treated.

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Medicare does not pay for syringes, needles, and alcohol wipes, or insulin injected by syringe. Insulin will be covered only when it is administered using an external insulin infusion pump, and will require a narrative stating whether or not the beneficiary owns his or her own pump. A supplier should not dispense more than a 3-month supply of test strips or lancets at a time. A beneficiary or their caregiver must specifically request refills of glucose monitor supplies before they are dispensed. The supplier must not automatically dispense a quantity of supplies on a predetermined regular basis, even if the beneficiary has "authorized" this in advance. Coding Guidelines For glucose test strips (A4253), 1 unit of service = 50 strips. For lancets (A4259), 1 unit of service = 100 lancets. Allwin Data will accept a quantity that indicates the number of boxes (per 50 strips) or the total number of strips dispensed. . Allwin Data will accept a quantity that indicates the number of boxes (per 100 lancets) or the total number of lancets dispensed. Blood glucose test or reagent strips that use a visual reading and are not used in a glucose monitor must be coded A9270 (non-covered item or service). Do not use code A4253 for these items. Documentation Requirements General Requirements An order to refill is the act of replenishing quantities of previously ordered items during the time period in which the current order is valid. An order refill does not have to be approved by the ordering physician as it is assumed that the ordering physician has approved that quantity of product. An order renewal is the act of obtaining an order for an additional period of time beyond that previously ordered by the physician. Physician Requirements Claims for diabetic testing supplies must be supported by a valid order. The order may be in the form of a written, faxed, or electronic order and must state to the supplier: 1. The item(s) to be dispensed 2. The quantity of item(s) to be dispensed The frequency of testing ("as needed" is not acceptable) 3. Whether the patient has insulin-treated or non-insulin-treated diabetes; 4. A physician signature; 5. A signature date; and, 6. A start date of the order - only required if the start date is different than the signature date. For verbal orders, the physician must sign and return to the supplier a written, faxed, or electronic confirmation of the verbal order. On this confirmation the item(s) to be dispensed, frequency of testing, and start date (if applicable) may be written by the supplier, but the confirmation must be reviewed, signed, and dated by the physician. Orders are valid for up to 12 months if the physician does not indicate an earlier expiration date. Renewal orders must contain the same information as initial orders and be submitted to the supplier using one of the methods acceptable for initial orders. The DMERC expects that physician records will reflect the care provided to the patient including, but not limited to evidence of the medical necessity for the prescribed frequency of testing. Physicians are not required to fill out additional forms from suppliers or to provide additional information to suppliers unless specifically requested of the supplier by the DMERC.

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Supplier Requirements If a DMERC requests a supplier to justify quantity billed, the supplier must provide all documentation listed under physician requirements above and any other information requested by the DMERC. At the beneficiary's request, suppliers may refill orders without consulting the treating physician as long as the order remains valid and allows for refills. Under no circumstances may suppliers automatically dispense supplies on a predetermined basis even if the beneficiary has authorized this in advance. Upon expiration of the order, the supplier may contact the physician to renew the order. However, the request for renewal may only be made with the beneficiary’s continued monthly use of the supply and only with the beneficiary's request for refill or renewal. A supplier may not dispense more than a 3-month supply of diabetic testing supplies at a time. Suppliers should not dispense a quantity of supplies exceeding a beneficiary’s expected utilization (e.g., testing once a day would require approximately 100 strips in a 3-month period). Suppliers share responsibility for providing care that is reasonable and necessary. To this end, suppliers should only provide supplies in quantities needed and at appropriate times. Suppliers should also stay attuned to atypical utilization patterns on behalf of their clients and verify with ordering physicians that the atypical utilization is, in fact, warranted. In response to DMERC requests, suppliers may need to collect specific information from physicians in order to corroborate the care provided. While the DMERC does not prohibit suppliers from creating data collection forms in order to gather this information, the DMERCs will not rely on these forms to prove the medical necessity of services provided. The DMERCs should expect physician notes, prescriptions, and medical charts to corroborate the care provided. Suppliers should assure that they do not attribute any self-generated forms or data collection requests to the Medicare Program, the Centers for Medicare & Medicaid Services (CMS), or the DMERCs. The supplier is required to have a new written order from the treating physician every 12 months; however, if the patient is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every 6 months. Claims Transmission The Allwin Data system allows for the dispensing of 100 test strips and 100 lancets every 30 days for an insulin treated patient. In cases where the pharmacy has specific documentation from the physician that the patient must test their blood more than three times daily, the pharmacy will have to override the Allwin Data system by placing a “07” in the Denial Override Field. This “07” is equivalent to a Medically Necessary Override in the Allwin Data System, and the pharmacy must have the documentation to support using the “07” override. The Allwin Data system allows for the dispensing of 100 test strips and 100 lancets every 90 days for a non-insulin treated patient. In cases where the pharmacy has specific documentation from the physician that the patient must test their blood more than once daily, the pharmacy will have to override the Allwin Data system by placing a “07” in the Denial Override Field. This “07” is equivalent to a Medically Necessary Override in the Allwin Data System, and the pharmacy must have the documentation to support using the “07” override. In those cases in which the pharmacy is billing for more than 100 test strips or lancets a “07” in the Denial Override Field will be necessary. However, the pharmacy can only ever bill for a maximum of a three-month supply at a time. Allwin Data will automatically attach all required modifiers based on the diagnosis code transmitted with all diabetic supply claims. Allwin Data will automatically convert all diabetic supply claims to the proper Medicare billing units. 1 unit of strips is equal to 50 strips and 1 unit of lancets is equal to 100 lancets.

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HCPCS Codes HCPCS Description Quantity Notes E0607 Home blood glucose monitor 1 / 5years E0620 Skin piercing device for collection of capillary blood, laser, each 1 / 5years A4258 E2100 Blood glucose monitor with integrated voice synthesizer 1 / 5years NARR E2101 Blood glucose monitor with integrated lancing/blood sample collection 1 / 5years NARR A4253 Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips A4254 Replacement battery, any type, for use with medically necessary home blood glucose monitor

owned by patient, each

A4255 Platforms for home blood glucose monitor, 50 per box A4256 Normal, low and high calibrator solution/chips A4257 Replacement lens shield cartridge for use with laser skin piercing device, each A4259 A4258 Spring-powered device for lancet, each 1 / 5years A4259 Lancets, per box of 100

Explanations of Notes Column

NMN Not Medically Necessary, payment will be based on the allowance for the least costly medical appropriate alternative.

NC Not Covered.




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VII - Ostomy Supplies Coverage and Payment Rules Ostomy supplies are covered for use on patients with a surgically created opening (stoma) to divert urine, or fecal contents outside the body. Ostomy supplies are appropriately used for colostomies V44.3, V55.3, ileostomies V44.2, V55.2 or urinary ostomies V44.6, V55.6. Use for other conditions will be denied as noncovered. Provision of ostomy supplies should be limited to a one-month supply for a patient in a nursing facility and a 3-month supply for a patient at home. When a liquid barrier is necessary, either liquid or spray (A4369) or individual wipes (A5119) is appropriate. The use of both is not medically necessary. Patients with continent stomas may use the following means to prevent/manage drainage: stoma cap (A5055), stoma plug (A5081) or gauze pads (A6216). No more than one type of supply would be medically necessary on a given day. Patients with urinary ostomies may use either a bag (A4357) or bottle (A5102) for drainage at night. It is not medically necessary to have both. A pouch cover should be coded A9270 and will be denied as a non-covered item. Coding Guidelines Code A4400 (Ostomy irrigation set), for an irrigation kit, is not valid for claims submitted to the DMERC. If an irrigation kit is supplied, the individual components should be billed using individual codes, A4367, A4397, A4398, and A4399. The following table lists codes for faceplate systems. When supplying a pouch with faceplate attached (Column I) a claim may not be made for a component product from Column II provided at the same time.

Column I Column II A4375 A4361, A4377 A4376 A4361, A4378 A4379 A4361, A4381, A4382 A4380 A4361, A4383

Documentation Requirements The supplier must keep an order for ostomy supplies, which has been signed and dated by the treating physician, on file. The order must include the type(s) of supplies ordered and the approximate quantity to be used per unit of time. An ICD-9 diagnosis code describing the type of ostomy (V44.2, V44.3, V44.6, V55.2, V55.3, or V55.6) must be included on the initial order to a supplier. A new order is required if there is an increase in the quantity of the supply used per month and/or the type of supply used. . The add-on codes do not need to be specifically listed on the physician's order. When supplies used are greater than the usual maximum quantity, there must be adequate documentation in the patient's medical records corroborating the medical necessity of this amount. This documentation must be entered in the form of a narrative in the Allwin Data system. The DMERC may request copies of the patient's medical records that corroborate the order and any additional documentation that pertains to the medical necessity of items and quantities billed.

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Claims Transmission Allwin Data will reject any ostomy supply claim that exceeds Medicare’s allowable monthly quantity. When you are billing for more than a one month supply you may use a “02” in your denial override field to get the claim through the Allwin system. (i.e. When 20 pouches a month are allowed, you may use the override to bill for 60 in a 3-month period.) In those cases where the pharmacy wishes to bill for more than the usual quantity allowed by Medicare it will be necessary to call Allwin and have a narrative attached to the claim explaining medical necessity, this narrative information may also be added at the Allwin Data website. If you are unsure of which codes to use you can check the most recent Hollister or Convatec catalogs, call the SADMERC, or use the Manufacturer Code look-up on the Allwin Data website. HCPCS Codes HCPCS Description Quantity Notes

A4331

EXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH CONNECTOR/ADAPTOR, FOR USE WITH URINARY LEG BAG OR UROSTOMY POUCH, EACH

A4357 BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH OR WITHOUT ANTI-REFLUX DEVICE, WITH OR WITHOUT TUBE, EACH 2

A4361 OSTOMY FACEPLATE, EACH 3 / 6mo A4362 SKIN BARRIER; SOLID, 4 X 4 OR EQUIVALENT; EACH 20 A4364 ADHESIVE, LIQUID OR EQUAL, ANY TYPE, PER OZ 4 A4365 ADHESIVE REMOVER WIPES, ANY TYPE, PER 50 A4367 OSTOMY BELT, EACH 1 A4368 OSTOMY FILTER, ANY TYPE, EACH A4369 OSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUSH, ETC), PER OZ 2 A4371 OSTOMY SKIN BARRIER, POWDER, PER OZ 10 / 6mo

A4372 OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, WITH BUILT-IN CONVEXITY, EACH

A4373 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDIAN), WITH BUILT-IN CONVEXITY, ANY SIZE, EACH

A4375 OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, PLASTIC, EACH

A4376 OSTOMY POUCH, DRAINABLE, WITH FACEPLATE ATTACHED, RUBBER, EACH A4377 OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, PLASTIC, EACH 10 A4378 OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, RUBBER, EACH A4378 OSTOMY POUCH, DRAINABLE, FOR USE ON FACEPLATE, RUBBER, EACH A4379 OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, PLASTIC, EACH A4380 OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, RUBBER, EACH A4381 OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, PLASTIC 10

A4382 OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, HEAVY PLASTIC, EACH

A4383 OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, RUBBER, EACH A4384 OSTOMY FACEPLATE EQUIVALENT, SILICONE RING, EACH

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A4385 OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, EACH

A4387 OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH

A4388 OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, (1 PIECE), EACH

A4389 OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH

A4390 OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH

A4391 OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED (1 PIECE), EACH

A4392 OSTOMY POUCH, URINARY, WITH STANDARD WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH

A4393 OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH

A4394 OSTOMY DEODORANT FOR USE IN OSTOMY POUCH, LIQUID, PER FLUID OUNCE

A4395 OSTOMY DEODORANT FOR USE IN OSTOMY POUCH, SOLID, PER TABLET A4396 OSTOMY BELT WITH PERISTOMAL HERNIA SUPPORT A4397 IRRIGATION SUPPLY; SLEEVE, EACH 4 A4398 OSTOMY IRRIGATION SUPPLY; BAG, EACH 2 / 6mo A4399 OSTOMY IRRIGATION SUPPLY; CONE/CATHETER, INCLUDING BRUSH 2 / 6mo A4402 LUBRICANT, PER OUNCE 4 A4404 OSTOMY RING, EACH 10 A4405 OSTOMY SKIN BARRIER, NON-PECTIN BASED, PASTE, PER OUNCE 4 A4406 OSTOMY SKIN BARRIER, PECTIN-BASED, PASTE, PER OUNCE 4

A4407

OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE, OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH

A4408

OSTOMY SKIN BARRIER, WTIH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH

A4409

OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH

A4410

OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH

A4413 OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECE SYSTEM), WITH FILTER, EACH

A4414 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH 20

A4415 OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4X4 INCHES, EACH 20

A4421 OSTOMY SUPPLY; MISCELLANEOUS NARR

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A4422 OSTOMY ABSORBENT MATERIAL (SHEET/PAD/CRYSTAL PACKET) FOR USE IN OSTOMY POUCH TO THICKEN LIQUID STOMAL OUTPUT, EACH

A4450 TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES 40 A4452 TAPE, WATERPROOF, PER 18 SQUARE INCHES 40

A4455 ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE 16 / 6mo

A5051 OSTOMY POUCH, CLOSED; WITH BARRIER ATTACHED (1 PIECE), EACH 60 A5052 OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED (1 PIECE), EACH A5053 OSTOMY POUCH, CLOSED; FOR USE ON FACEPLATE, EACH 60

A5054 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH FLANGE (2 PIECE), EACH 60

A5055 STOMA CAP 31 A5061 OSTOMY POUCH, DRAINABLE; WITH BARRIER ATTACHED, (1 PIECE), EACH

A5062 OSTOMY POUCH, DRAINABLE; WITHOUT BARRIER ATTACHED (1 PIECE), EACH 20

A5063 OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH FLANGE (2 PIECE SYSTEM), EACH 20

A5071 OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED (1 PIECE), EACH 20 A5072 OSTOMY POUCH, URINARY; WITHOUT BARRIER ATTACHED (1 PIECE), EACH 20

A5073 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH FLANGE (2 PIECE), EACH 20

A5081 CONTINENT DEVICE; PLUG FOR CONTINENT STOMA 31 A5082 CONTINENT DEVICE; CATHETER FOR CONTINENT STOMA 1 A5093 OSTOMY ACCESSORY; CONVEX INSERT 10

A5102 BEDSIDE DRAINAGE BOTTLE WITH OR WITHOUT TUBING, RIGID OR EXPANDABLE, EACH 2 / 6mo

A5119 SKIN BARRIER; WIPES, BOX PER 50 3 / 6mo A5121 SKIN BARRIER; SOLID, 6 X 6 OR EQUIVALENT, EACH 20 A5122 SKIN BARRIER; SOLID, 8 X 8 OR EQUIVALENT, EACH 20 A5126 ADHESIVE OR NON-ADHESIVE; DISK OR FOAM PAD 20

A5131 APPLIANCE CLEANER, INCONTINENCE AND OSTOMY APPLIANCES, PER 16 OZ. 1

A6216 GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 60

A9270 NON-COVERED ITEM OR SERVICE NC

A4416 OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH 60

A4417 OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FILTER (1 PIECE), EACH 60

A4418 OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH 60

A4419 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH FLANGE, WITH FILTER (2 PIECE), EACH 60

A4420 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACH 60

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A4423 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2 PIECE), EACH 60

A4424 OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH 20

A4425 OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH FLANGE, WITH FILTER (2 PIECE SYSTEM), EACH 20

A4426 OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE SYSTEM), EACH

A4427 OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2 PIECE SYSTEM), EACH 20

A4428 OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH

A4429 OSTOMY POUCH, URINARY, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH

A4430

OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH

A4431 OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH 20

A4432 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH FLANGE, WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH 20

A4433 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACH 20

A4434 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH 20



NC Not Covered.




Updated Winter 2004

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VIII - Immunosuppressive Drugs Coverage and Payment Rules All Immunosuppressive Drug claims require a DIF 08.02 to be completed by the supplier and processed through the Allwin Data system before transmitting a claim. A blank form can be requested by calling the Allwin helpdesk or by downloading from the Allwin website. A completed DIF can be entered on the Allwin website or faxed in to Allwin for entry. Prescription drugs used in immunosuppressive therapy are covered if all of the following criteria (1-5) are met: 1. Immunosuppressive drugs are prescribed following a kidney, heart, liver, bone marrow/stem cell, lung, heart/lung

transplant, whole organ pancreas transplant performed concurrent with or subsequent to a kidney transplant because of diabetic nephropathy (performed on or after July 1, 1999), or intestinal transplant (performed on or after April 1, 2001); and,

2. The transplant met Medicare coverage criteria in effect at the time (e.g., approved facility for kidney, heart, intestinal, liver, lung, or heart/lung transplant; national and/or local medical necessity criteria; etc.); and,

3. The patient was enrolled in Medicare Part A at the time of the transplant and is enrolled in Medicare Part B at the time that the drugs are dispensed (Question #8 must be answered YES); and,

4. The drugs are medically necessary to prevent or treat rejection of an organ transplant in the particular patient; and, 5. The drugs are furnished on or after the date of discharge from the hospital following a covered organ transplant (The

initial date on the DIF must be equal to or later than the date of discharge following the transplant). Immunosuppressive drug coverage is still limited to 36 months for beneficiaries whose Medicare entitlement is based solely on end-stage renal disease (ESRD). Generally a kidney transplant beneficiary who is under 65 and has a Medicare ID# ending in T. Immunosuppressive drugs are non-covered for the treatment of patients with non-transplant related diagnoses (e.g., rheumatoid arthritis, connective tissue diseases, vasculitis). Parenteral cyclosporine (J7516), antithymocyte globulin (J7504, J7511), muromonab-CD3 (J7505), tacrolimus (J7525) and daclizumab (J7513) are not proven to be safe when administered in the home setting and therefore they will be denied as not medically necessary when provided in that setting. Coverage of parenteral azathioprine (J7501) or methylprednisolone (J2920, J2930) is limited to those situations in which the medication cannot be tolerated or absorbed if taken orally and is self-administered by the patient. There is no coverage under the immunosuppressive drug benefit for supplies used in conjunction with the administration of parenteral immunosuppressive drugs. The dosage, frequency and route of administration must conform to generally accepted medical practice. Coding Guidelines For all immunosuppressive drugs, the number of units billed must accurately reflect the definition of one unit of service in each code narrative. For example, if fifty 10 mg prednisone tablets are dispensed, bill J7506, 100 units (1 unit of J7506 = 5 mg). If fifty 2.5 mg prednisone tablets are dispensed, bill J7506, 25 units. When dispensing 500 mg Mycophenolate, 10 mg Prednisone, .5/5 mg Tacrolimus, or 2.5 mg Predisone, transmit only the NDC# with the claim, Allwin Data will make the proper quantity conversion before transmitting the claim to Medicare. In those cases where a pharmacy is dispensing both 250mg Mycophenolate and 500mg Mycophenolate, or 2 strengths of Prednisone, or .5 and 1 mg Tacrolimus, the quantities will have to combined and sent to Allwin Data as one claim.

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Documentation Requirements The supplier must keep an order for the drug(s) that has been signed and dated by the treating physician on file. A new order is required if a new drug(s) is added to the patient's immunosuppressive regimen or if there is a change in dose or frequency of administration of an already allowed drug. A DMERC Information Form (DIF), DMERC 08.02, must be completed and kept on file by the supplier. A revised DIF is required if the physician prescribing the drugs changes or if the patient has another transplant. An initial DIF is needed if a different drug is prescribed in addition to or in replacement of existing drugs. Claim Transmission Upon completing the DIF, the pharmacy has two ways to get the DIF to Allwin Data before the claim can be transmitted. The pharmacy may enter the DIF using the Allwin Data website and transmit the claim upon acceptance of the DIF by the Allwin system, or the pharmacy may fax the DIF to Allwin Data for processing. Please allow 24 hrs for processing when the DIF is faxed to Allwin Data. As mentioned above in the Coding Guidelines, when billing for two different strengths of a drug that only has one HCPCS code, for billing purposes the pharmacy can send only one claim reflecting the total amount dispensed in terms of the recognized HCPCS code. Example: Dispensing 50 tablets of 500mg Cellcept and 50 tablets of 250mg Cellcept. Medicare only has a code for the 250mg Cellcept so the claim must reflect the total amount of tablets dispensed based on the 250mg tablets. In this case the 50 500mg tablets would have to be shown as 100 250mg tablets, therefore the claim would show a total of 150 250mg tablets dispensed.

HCPCS Codes HCPCS Description Quantity Notes J2920 INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP

TO 40 MG CMN

J2930 INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG

CMN

J7500 AZATHIOPRINE, ORAL, 50 MG CMN J7501 AZATHIOPRINE, PARENTERAL, 100 MG CMN J7502 CYCLOSPORINE, ORAL, 100 MG CMN J7504 LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE

GLOBULIN, EQUINE, PARENTERAL, 250 MG CMN

J7505 MUROMONAB-CD3, PARENTERAL, 5 MG CMN J7506 PREDNISONE, ORAL, PER 5 MG CMN J7507 TACROLIMUS, ORAL, PER 1 MG CMN J7509 METHYLPREDNISOLONE ORAL, PER 4 MG CMN J7510 PREDNISOLONE ORAL, PER 5 MG CMN J7511 LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE

GLOBULIN, RABBIT, PARENTERAL, 25MG CMN

J7513 DACLIZUMAB, PARENTERAL, 25 MG CMN J7515 CYCLOSPORINE, ORAL, 25 MG CMN J7516 CYCLOSPORINE, PARENTERAL, 250 MG CMN J7517 MYCOPHENOLATE MOFETIL, ORAL, PER 250 MG CMN J7520 SIROLIMUS, ORAL, 1 MG CMN

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J7525 TACROLIMUS, PARENTERAL, 5 MG CMN J7599 IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED CMN J8530 CYCLOPHOSPHAMIDE; ORAL, 25 MG CMN J8610 METHOTREXATE; ORAL, 2.5 MG CMN

Explanations of Notes Column NMN Not Medically Necessary, payment will be based on the allowance for

the least costly medical appropriate alternative.

NC Not Covered.




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IX - Enteral Nutrition Coverage and Payment Rules Enteral nutrition is the provision of nutritional requirements through a tube into the stomach or small intestine. Enteral nutrition is covered for a patient who has (a) permanent non-function or disease of the structures that normally permit food to reach the small bowel or (b) disease of the small bowel which impairs digestion and absorption of an oral diet, either of which requires tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with the patient's overall health status. The patient must have a permanent impairment. Permanence does not require a determination that there is no possibility that the patient's condition may improve sometime in the future. If the judgement of the attending physician, substantiated in the medical record, is that the condition is of long and indefinite duration (ordinarily at least 3 months), the test of permanence is considered met. Enteral nutrition will be denied as non-covered in situations involving temporary impairments. The patient's condition could be either anatomic (e.g., obstruction due to head and neck cancer or reconstructive surgery, etc.) or due to a motility disorder (e.g., severe dysphagia following a stroke, etc.). Enteral nutrition is non-covered for patients with a functioning gastrointestinal tract whose need for enteral nutrition is due to reasons such as anorexia or nausea associated with mood disorder, end-stage disease, etc. The patient must require tube feedings to maintain weight and strength commensurate with the patient's overall health status. Adequate nutrition must not be possible by dietary adjustment and/or oral supplements. Coverage is possible for patients with partial impairments - e.g., a patient with dysphagia who can swallow small amounts of food or a patient with Crohn's disease who requires prolonged infusion of enteral nutrients to overcome a problem with absorption. Enteral nutrition products that are administered orally and related supplies are non-covered. If the coverage requirements for enteral nutrition are met, medically necessary nutrients, administration supplies, and equipment are covered. No more than one month's supply of enteral nutrients, equipment or supplies is allowed for one month's prospective billing. Claims submitted retroactively, however, may include multiple months. Valid CMN’S 1. Question #7 and #8 on the CMN must be answered YES 2. Question #13 on the CMN must be answered 1, 2, or 3 3. Coverage does not exist for enteral nutrition that is administered orally 4. Length of Need must be equal to or greater than 3 months 5. The diagnosis code provided by the doctor on the CMN should reflect a condition in the beneficiary that makes it

difficult, if not impossible to swallow. Examples would be mouth/throat cancer, dysphasia, gastro paresis, Alzheimer’s, Parkinson’s, etc..

Coding Guidelines When enteral nutrition is covered, dressings used in conjunction with a gastrostomy or enterostomy tube are included in the supply kit code (B4034-B4036) and should not be billed separately using dressing codes. Documentation Requirements A Certificate of Medical Necessity (CMN) which has been completed, signed, and dated by the treating physician must be kept on file by the supplier and made available to the DMERC on request. The CMN may act as a substitute for a written order if it contains all of the required elements of an order. The CMN for Enteral Nutrition is HCFA Form 853. The initial claim must include a copy of the CMN.

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A new Initial certification for enteral nutrients is required when (1) a formula billed with a different code which has not been previously certified is ordered, or (2) enteral nutrition services are resumed after they have not been required for two consecutive months. A new Initial Certification for a pump (B9000 or B9002) is required if enteral nutrition services involving use of a pump are resumed after they have not been required for two consecutive months. An Initial Certification is also required for a pump if a patient receiving enteral nutrition by the syringe or gravity method is changed to administration using a pump. (In this latter situation, a Revised Certification is required for the nutrient which indicates the change to the pump method of administration - Question #13 on the CMN.) In addition to the reason listed above, a Revised Certification is required when, for a formula which has been previously certified, (1) the number of calories per day is changed, or (2) number of days per week administered is changed, or (3) the method of administration (syringe, gravity, pump) changes, or (4) route of administration is changed from tube feedings to oral feedings (if billing for denial), or (5) if a Category IV or V enteral nutrient being provided is changed. The initial date listed in Section A of a Revised CMN for codes B4154 or B4155 must match the initial date on the certification record for code B4154 or B4155 which has been set up by the DMERC. Regularly scheduled recertifications are not required. However, a recertification is required if the physician indicates a length of need of less than lifetime (i.e., less than 99 months) on the CMN and subsequently orders a greater length of need. Recertification may also be requested on an individual basis at the discretion of the DMERC. The Initial Certification must be accompanied by adequate documentation to support the medical necessity of the following orders, if applicable: 1. the need for special nutrients (B4151, B4153-B4156), 2. the need for a pump. If two Category IV or two Category V nutrients are being provided at the same time, they should be billed on a single claim line with the units of service reflecting the total calories of both nutrients. Claim Transmission Upon receiving the completed CMN from the physician the pharmacy has two ways to get the CMN to Allwin Data before the claim can be transmitted. The pharmacy may enter the CMN using the Allwin Data website and transmit the claim upon acceptance of the CMN by the Allwin system, or the pharmacy may fax the CMN to Allwin Data for processing. Please allow 24 hrs for processing when the CMN is faxed to Allwin Data. Because Medicare pays enteral claims per 100 calories and all enteral products have different caloric values, Allwin Data requires the pharmacy use only the product’s NDC# for claims processing. This will insure the correct quantity conversion based solely on the specific product being dispensed. All claims should be billed as 30-day supplies and quantities should reflect the total number of cans dispensed. If you wish to submit units other than total number of cans dispensed please call the Allwin helpdesk to request a quantity conversion specifically for your store. Common Enteral Nutrition HCPCS Codes

Product Name HCPCS BOOST B4150

BOOST PLUS B4152 ENSURE B4150

ENSURE PLUS B4152 GLUCERNA B4154

ISOCAL B4150 JEVITY B4150

JEVITY PLUS B4150 NUTREN 1.0 B4150

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NUTREN 1.5 B4152 OSMOLITE B4150

PULMOCARE B4154 RESOURCE B4150 TWOCAL B4152

ULTRACAL B4150 HCPCS Codes HCPCS Description Quantity Notes

A5200 PERCUTANEOUS CATHETER/TUBE ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT

A9270 NON-COVERED ITEM OR SERVICE NC B4034 ENTERAL FEEDING SUPPLY KIT; SYRINGE, PER DAY B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAY B4036 ENTERAL FEEDING SUPPLY KIT; GRAVITY FED, PER DAY B4081 NASOGASTRIC TUBING WITH STYLET 3 / 3mos B4082 NASOGASTRIC TUBING WITHOUT STYLET 3 / 3mos B4083 STOMACH TUBE - LEVINE TYPE 3 / 3mos

B4086 GASTROSTOMY / JEJUNOSTOMY TUBE, ANY MATERIAL, ANY TYPE, (STANDARD OR LOW PROFILE), EACH 1 / 3mos

B4100 FOOD THICKENER, ADMINISTERED ORALLY, PER OUNCE NC

B4150

ENTERAL FORMULAE; CATEGORY I; SEMI-SYNTHETIC INTACT PROTEIN/PROTEIN ISOLATES, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT CMN

B4151

ENTERAL FORMULAE; CATEGORY I; NATURAL INTACT PROTEIN/PROTEIN ISOLATES, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT CMN

B4152

ENTERAL FORMULAE; CATEGORY II; INTACT PROTEIN/PROTEIN ISOLATES (CALORICALLY DENSE), ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT CMN

B4153

ENTERAL FORMULAE; CATEGORY III; HYDROLIZED PROTEIN/AMINO ACIDS, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT CMN

B4154

ENTERAL FORMULAE; CATEGORY IV; DEFINED FORMULA FOR SPECIAL METABOLIC NEED, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT CMN

B4155

ENTERAL FORMULAE; CATEGORY V; MODULAR COMPONENTS, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT

B4156

ENTERAL FORMULAE; CATEGORY VI; STANDARDIZED NUTRIENTS, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT CMN

B9000 ENTERAL NUTRITION INFUSION PUMP - WITHOUT ALARM CMN B9002 ENTERAL NUTRITION INFUSION PUMP - WITH ALARM CMN B9998 NOC FOR ENTERAL SUPPLIES NARR E0776 IV POLE

Updated Winter 2004

Page 36



NC Not Covered.




Updated Winter 2004

Page 37

X - Oral Anti-Cancer Drugs Coverage and Payment Rules An oral anticancer drug is covered if all of the following criteria (1-6) are met: 1. It is a drug or biological that has been approved by the Food and Drug Administration (FDA), and 2. It has the same ingredients as a non-self-administrable anticancer chemotherapeutic drug or biological that is covered

when furnished incident to a physician's service. The oral anticancer drug and the non-self-administrable drug must have the same chemical/generic name as indicated by the FDA's Approved Drug Products (Orange Book), Physician's Desk Reference (PDR), or an authoritative drug compendium, or It is a prodrug which, when ingested, is metabolized into the same active ingredient which is found in the non-self-administrable form of the drug, and

3. It is used for the same indications, including unlabeled uses, as the non-self-administrable form of the drug, and 4. It is prescribed by a physician or other practitioner licensed under state law to prescribe such drugs as anticancer

chemotherapeutic agents, and 5. It is prescribed for the treatment of cancer (ICD-9 codes 140.0-208.9, 236.1, 273.3), and 6. It is reasonable and necessary for the individual patient.

A drug that is not available in an injectable form does not meet criterion 2. If an oral anticancer drug is used for immunosuppression (rather than the treatment of cancer), criterion 5 is not met and the drug cannot be covered under the oral anticancer drug benefit. (If the drug is used for immunosuppression following organ transplant, refer to the Immunosuppressive Drugs policy.) If criteria 1, 2, 3, 4, or 5 are not met, the drug will be denied as noncovered. If criteria 1-5 are met but criterion 6 is not met, the drug will be denied as not medically necessary. Coding Guidelines Anticancer Drugs are billed using the NDC# only, there are no HCPCS codes for covered anti-cancer drugs. Anticancer Drugs require no modifier. For all NDC codes, 1 unit of service = 1 tablet or 1 capsule. National Drugs Codes (NDCs) may be billed only when the drug is used as an oral anticancer drug. If cyclophosphamide or methotrexate is prescribed as an oral immunosuppressive drug following an organ transplant, code J8530 or J8610 respectively must be used. (Refer to the Immunosuppressive Drugs policy for additional information.) If cyclophosphamide or methotrexate is prescribed as an oral immunosuppressive drug for other conditions (e.g., lupus, rheumatoid arthritis, etc.), a claim should not be submitted to Medicare (unless requested by the beneficiary) because there is no statutory benefit for oral immunosuppressive drugs in these conditions. Covered Drugs

Busulfan, 2 mg Methotrexate 5mg Capecitabine 150mg Methotrexate 7.5mg Capecitabine 500mg Methotrexate 10mg Cyclophosphamide 25mg Methotrexate 15mg Cyclophosphamide 50mg Temozolomide 5mg Etoposide 50mg Temozolomide 20mg Melphalan 2mg Temozolomide 100mg Methotrexate 2.5mg Temozolomide 250mg

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Documentation Requirements A detailed written order for each drug must be signed and dated by the treating physician and kept on file by the supplier. The physician must enter a narrative diagnosis and/or ICD-9-CM diagnosis code describing the condition for which the drug is ordered on the order. A new detailed written order is required whenever there is a change in dosage or in the directions for administering the drug. The ICD-9-CM diagnosis code describing the condition for which the drug is used must be included on each claim. Claims Transmission Send claims using only the NDC #. Only diagnosis codes listed in Coverage and Payment Rules are valid for claim payment. A claim should be billed as a 30-day supply; there are no specific restrictions on quantities allowed, but claim should represent written order from physician.

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XI - Oral Anti-Emetic Drugs Coverage and Payment Rules An oral antiemetic drug billed with codes Q0163-Q0181 is covered if all of the following criteria (1-4) are met:

1. The drug has been approved by the Food and Drug Administration (FDA) for use as an antiemetic, and 2. The drug has been ordered by the treating physician as part of a cancer chemotherapy regimen, and 3. The drug is used as a full therapeutic replacement for an intravenous antiemetic drug that would otherwise have been

administered at the time of the chemotherapy treatment, and 4. The initial dose of the oral antiemetic drug is administered within 2 hours of the administration of the chemotherapy

drug.

If criteria 1, 2, 3, or 4 are not met, oral antiemetic drugs billed using codes Q0163-Q0181 will be denied as non-covered. If all of the above criteria (1-4) are met, the quantity of oral antiemetic drugs covered for each episode of chemotherapy cannot exceed the initial loading dose plus 48 hours of therapy. However, for the drugs granisetron (Q0166) and dolasetron (Q0180), the quantity of drugs covered for each episode of chemotherapy is limited to the initial loading dose plus 24 hours of therapy. Quantities of drugs in excess of these amounts are non-covered.

Criterion 3 is not met when the chemotherapy drug is an oral drug or when the chemotherapy drug is administered intravenously in the home setting because the type and dosage of chemotherapy drugs administered in these situations do not require intravenous anti-emetic drugs. If the anti-emetic is being used in conjunction with an oral anti-cancer in the home refer to criteria below. Anti-emetic Drugs Used With Oral Anticancer Drugs A self-administered antiemetic drug billed with code K0415 or K0416 is covered if all of the following criteria are met: 1. It is used in conjunction with a covered oral anticancer drug, and 2. It is likely that administration of the covered oral anticancer drug will induce emesis if the antiemetic drug is not

administered, and 3. The antiemetic drug is administered within 2 hours before the covered oral anticancer drug is administered.

Oral antiemetics are covered under the oral anticancer drug benefit for the sole purpose of allowing the absorption of the covered oral anticancer drug. Therefore, coverage is limited to doses of antiemetic drugs which are administered during the two hours before administration of the covered oral anticancer drug. Doses of antiemetic drugs administered after the administration of the oral anticancer drug (e.g., to treat nausea or vomiting which is caused by the oral anticancer drug or other etiology) are noncovered. If criterion 1 or 3 is not met, the antiemetic drug will be denied as noncovered. If criteria 1 and 3 are met but criterion 2 is not met, the antiemetic drug will be denied as not medically necessary. Coding Guidelines For codes K0415 and K0416, 1 unit of service = 1 mg. Code K0415 or K0416 may be billed only when the antiemetic drug is used in conjunction with a covered oral anticancer drug. Suppliers may bill only for quantities of antiemetic drugs that are to be used within 2 hours before the covered oral anticancer drug.

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Documentation Requirements A detailed written order for each drug must be signed and dated by the treating physician and kept on file by the supplier. The physician must enter a narrative diagnosis and/or ICD-9-CM diagnosis code describing the patient’s cancer diagnosis on the order. There must also be a statement on the order that indicates that the oral anti-emetic drug is a full therapeutic replacement for an intravenous anti-emetic drug and is used as part of a cancer chemotherapy regimen. This order must be available to the DMERC on request. The supplier may bill using code Q0163-Q0181 only if they have a written order with the specified attestation. Claims for codes K0415 or K0416 must be accompanied by a narrative containing the following information: 1. Anti-emetic name 2. Anti-emetic strength 3. Dosage directions for anti-emetic 4. Manufacturer of Anti-emetic 5. Anti-emetic NDC # 6. Oral anti-cancer name 7. Oral anti-cancer strength 8. Oral anti-cancer method of administration Claim Transmission Allwin will always prompt the pharmacy for supporting narrative documentation required on all anti-emetic claims. This is done to make the pharmacy aware of the 2-day supply limitations on these drugs. Once the pharmacy has confirmed only a 2-day supply will be dispensed, and the patient’s chemotherapy regimen is being administered intravenously in a facility, a “03” in the denial override field will allow for transmission of the claim through the Allwin system without a narrative. All claims for K0415 and K0416, oral anti-emetics used in conjunction with oral anti-cancers, will require a narrative to be transmitted with the claim. This can be done by calling an Allwin representative with the necessary narrative information. The information required in the narrative is listed above in the Documentation Requirements. HCPCS Codes

HCPCS Description Quantity Notes Q0163 Diphenhydramine hydrochloride 50mg, oral , FDA approved prescription anti-emetic, for

use as a complete therapeutic substitute for an IV anti-emetic at time of chemotherapy treatment not to exceed a 48 hour dosage regimen

Q0164 Prochlorperazine maleate 5mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0165 Prochlorperazine maleate 10mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0166 Granisetron hydrochloride 1mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen

Q0167 Dronabinol 2.5mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0168 Dronabinol 5mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

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Q0169 Promethazine hydrochloride 12.5mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0170 Promethazine hydrochloride 25mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0171 Chlorpromazine hydrochloride 10mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0172 Chlorpromazine hydrochloride 25mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0173 Trimethobenzamide hydrochloride 250mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0174 Thiethylperazine maleate 10mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0175 Perphenazine 4mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0176 Perphenazine 8mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0177 Hydroxyzine pamoate 25mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0178 Hydroxyzine pamoate 50mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0179 Ondansetron hydrochloride 8mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0180 Dolasetron mesylate 100mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen

Q0181 Unspecified oral dosage form, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

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XIII - Urological Supplies Coverage and Payment Rules Urinary catheters and external urinary collection devices are covered to drain or collect urine for a patient who has permanent urinary incontinence (ICD-9 788.30) or permanent urinary retention (ICD-9 788.20). Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected in that patient within 3 months. If the catheter or the external urinary collection device meets the coverage criteria then the related supplies that are necessary for their effective use are also covered. Urological supplies that are used for purposes not related to the covered use of catheters or external urinary collection devices (i.e., drainage and/or collection of urine from the bladder) will be denied as noncovered. The patient must have a permanent impairment of urination. This does not require a determination that there is no possibility that the patient's condition may improve sometime in the future. If the medical record, including the judgement of the attending physician, indicates the condition is of long and indefinite duration (ordinarily at least 3 months), the test of permanence is considered met. Catheters and related supplies will be denied as noncovered in situations in which it is expected that the condition will be temporary. The use of a urological supply for the treatment of chronic urinary tract infection or other bladder condition in the absence of permanent urinary incontinence or retention is noncovered. Since the patient's urinary system is functioning, the criteria for coverage under the prosthetic benefit provision are not met. The medical necessity for use of a greater quantity of supplies than the amounts specified in the policy must be well documented in the patient's medical record and may be requested by the DMERC. Coding Guidelines A meatal cup female external urinary collection device (A4327) is a plastic cup which is held in place around the female urethra by suction or pressure and is connected to a urinary drainage container such as a bag or bottle. A pouch type female external collection device (A4328) is a plastic pouch which is attached to the periurethral area with adhesive and which can be connected to a urinary drainage container such as a bag or bottle. A urinary catheter anchoring device described by code A4333 has an adhesive surface which attaches to the patient's skin and a mechanism for releasing and re-anchoring the catheter multiple times without changing the anchoring device. A urinary catheter anchoring device described by code A4334 is a strap which goes around a patient's leg and has a mechanism for releasing and re-anchoring the catheter multiple times without changing the anchoring device. A urinary intermittent catheter with insertion supplies (A4353) is a kit which includes a catheter, lubricant, gloves, antiseptic solution, applicators, drape, and a tray or bag in a sterile package intended for single use. Therapeutic agent for urinary irrigation (A4321) is defined as a solution containing agents in addition to saline or sterile water (for example acetic acid or hydrogen peroxide) which is used for the treatment or prevention of urinary catheter obstruction. Procedure code A4347 is not valid for claims submitted to the DMERC. When billing for male external catheters, use code A4324 or A4325 and one unit of service for each catheter supplied. Irrigation solutions containing antibiotics and chemotherapeutic agents should be coded A9270. Irrigating solutions such as acetic acid or hydrogen peroxide which are used for the treatment or prevention of urinary obstruction should be coded A4321.

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Adhesive strips or tape used with code A4325 (Male external catheter, with adhesive strip, each) should not be billed separately. Adhesive strips and tape used in conjunction with code A4324 (Male external catheter, with adhesive coating, each) should be billed with code A4335. Adhesive catheter anchoring devices that are used with indwelling urethral catheters are billed using codes A4333 and A4334, respectively. An anchoring device used with a percutaneous catheter/tube (e.g., suprapubic tube, nephrostomy tube) is billed using code A5200. Replacement leg straps (A5113, A5114) are used with a urinary leg bag (A4358, A5105, or A5112). These codes are not used for a leg strap for an indwelling catheter. When codes A4450 and A4452 are used with Urological Supplies they must be billed with the AU modifier. For this policy, codes A4450 and A4452 and A4217 are the only two codes for which the AU modifier may be used. An external catheter that contains a barrier for attachment should be coded using A4335. Codes for ostomy barriers (A5119, A4369-A4371) should not be used for skin care products used in the management of urinary incontinence. A percutaneous catheter/tube anchoring device (A5200) is a dressing with adhesive that is designed to be applied directly over the cutaneous opening through which the catheter/tube passes. This dressing has a hole through which the catheter/tube passes and a mechanism for firmly anchorin the catheter/tube to the dressing. In the following table, the Column I code includes the items identified by the codes in Column II. The Column I code must be used instead of multiple Column II codes when the items are provided at the same time.

Column I Column II A4310 A4332 A4311 A4310, A4332, A4338 A4312 A4310, A4332, A4344 A4313 A4310, A4332, A4346 A4314 A4310, A4311, A4331, A4332, A4338, A4354, A4357 A4315 A4310, A4312, A4331, A4332, A4344, A4354, A4357 A4316 A4310, A4313, A4331, A4332, A4346, A4354, A4357 A4325 A4450, A4452 A4353 A4310, A4332, A4351, A4352 A4354 A4310, A4331, A4332, A4357 A4357 A4331 A4358 A4331, A5113, A5114 A5112 A5113, A5114 A5105 A4331, A4358, A4359, A5112, A5113, A5114 If a code exists that includes multiple products, that code should be used in lieu of the individual codes. Documentation Requirements When billing for quantities of supplies greater than those described in the policy as the usual replacement frequency (e.g., more than one indwelling catheter per month, more than two bedside drainage bags per month, more than 35 male external catheters per month, etc.), the claim must include documentation supporting the medical necessity for the higher utilization. This can be done by calling an Allwin representative with the necessary narrative information. The initial claim for catheters or kits used for sterile intermittent catheterization in the home must be accompanied by documentation supporting the medical necessity for sterile technique.

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Claim Transmission Allwin Data will reject any urological supply claim that exceeds Medicare’s allowable monthly quantity. In those cases where the pharmacy wishes to bill for more than the usual quantity allowed by Medicare we suggest you call Allwin Data to have a narrative attached to the claim. This narrative information may also be added at the Allwin Data website. HCPCS Codes HCPCS Description Quantity Notes

A4310 INSERTION TRAY WITHOUT DRAINAGE BAG AND WITHOUT CATHETER (ACCESSORIES ONLY) 1

A4311

INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.) 1

A4312 INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE 1

A4313 INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, THREE-WAY, FOR CONTINUOUS IRRIGATION 1

A4314

INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.) 1

A4315 INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE 1

A4316 INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, THREE-WAY, FOR CONTINUOUS IRRIGATION 1

A4320 IRRIGATION TRAY WITH BULB OR PISTON SYRINGE, ANY PURPOSE A4321 THERAPEUTIC AGENT FOR URINARY CATHETER IRRIGATION NC A4322 IRRIGATION SYRINGE, BULB OR PISTON, EACH A4324 MALE EXTERNAL CATHETER, WITH ADHESIVE COATING, EACH 35 A4325 MALE EXTERNAL CATHETER, WITH ADHESIVE STRIP, EACH 35

A4326 MALE EXTERNAL CATHETER SPECIALTY TYPE, EG; INFLATABLE, FACEPLATE, ETC., EACH

A4327 FEMALE EXTERNAL URINARY COLLECTION DEVICE; MEATAL CUP, EACH 4 A4328 FEMALE EXTERNAL URINARY COLLECTION DEVICE; POUCH, EACH 30

A4331

EXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH CONNECTOR/ADAPTOR, FOR USE WITH URINARY LEG BAG OR UROSTOMY POUCH, EACH

A4332 LUBRICANT, INDIVIDUAL STERILE PACKET, FOR INSERTION OF URINARY CATHETER, EACH

A4333 URINARY CATHETER ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT, EACH 12

A4334 URINARY CATHETER ANCHORING DEVICE, LEG STRAP, EACH 1 A4335 INCONTINENCE SUPPLY; MISCELLANEOUS

A4338 INDWELLING CATHETER; FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH 1

A4340 INDWELLING CATHETER; SPECIALTY TYPE, EG; COUDE, MUSHROOM, WING, ETC.), EACH 1

A4344 INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE, EACH 1

A4346 INDWELLING CATHETER; FOLEY TYPE, THREE WAY FOR CONTINUOUS IRRIGATION, EACH 1

A4347 MALE EXTERNAL CATHETER WITH OR WITHOUT ADHESIVE, WITH OR WITHOUT ANTI-REFLUX DEVICE; PER DOZEN

Use A4324 or A4325

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A4348 MALE EXTERNAL CATHETER WITH INTEGRAL COLLECTION COMPARTMENT, EXTENDED WEAR, EACH (E.G., 2 PER MONTH)

A4351

INTERMITTENT URINARY CATHETER; STRAIGHT TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH 4

A4352

INTERMITTENT URINARY CATHETER; COUDE (CURVED) TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMERIC, OR HYDROPHILIC, ETC.), EACH 4

A4353 INTERMITTENT URINARY CATHETER, WITH INSERTION SUPPLIES 1 A4354 INSERTION TRAY WITH DRAINAGE BAG BUT WITHOUT CATHETER 1

A4355 IRRIGATION TUBING SET FOR CONTINUOUS BLADDER IRRIGATION THROUGH A THREE-WAY INDWELLING FOLEY CATHETER, EACH

A4356 EXTERNAL URETHRAL CLAMP OR COMPRESSION DEVICE (NOT TO BE USED FOR CATHETER CLAMP), EACH 1 / 3mo

A4357 BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH OR WITHOUT ANTI-REFLUX DEVICE, WITH OR WITHOUT TUBE, EACH 1

A4358 URINARY DRAINAGE BAG, LEG OR ABDOMEN, VINYL, WITH OR WITHOUT TUBE, WITH STRAPS, EACH 2

A4359 URINARY SUSPENSORY WITHOUT LEG BAG, EACH NC A4365 ADHESIVE REMOVER WIPES, ANY TYPE, PER 50 NC A4402 LUBRICANT, PER OUNCE 8 A4450 TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES A4452 TAPE, WATERPROOF, PER 18 SQUARE INCHES

A4455 ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE NC

A5102 BEDSIDE DRAINAGE BOTTLE WITH OR WITHOUT TUBING, RIGID OR EXPANDABLE, EACH

A5105 URINARY SUSPENSORY; WITH LEG BAG, WITH OR WITHOUT TUBE A5112 URINARY LEG BAG; LATEX 1 A5113 LEG STRAP; LATEX, REPLACEMENT ONLY, PER SET A5114 LEG STRAP; FOAM OR FABRIC, REPLACEMENT ONLY, PER SET A5131 APPLIANCE CLEANER, INCONTINENCE AND OSTOMY APPLIANCES, PER 16 OZ.

A5200 PERCUTANEOUS CATHETER/TUBE ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT

A9270 NON-COVERED ITEM OR SERVICE NC

Explanations of Notes Column NMN Not Medically Necessary, payment will be based on the allowance for the least costly

medical appropriate alternative.

NC Not Covered.




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XIV - SURGICAL DRESSINGS 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). The surgical procedure or debridement must be performed by a physician or other healthcare professional to the extent permissible under State law. 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 noncovered. Surgical dressings are covered for as long as they are medically necessary. Dressings over a percutaneous catheter or tube (e.g., intravascular, epidural, nephrostomy, etc.) are 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 Dressings benefit are: a) Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure; or b) A Stage I pressure ulcer; or c) A first degree burn; or d) Wounds caused by trauma which do not require surgical closure or debridement - e.g., skin tear or abrasion; or e) A venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter or needle.

A silicone gel sheet (A6025) use for the treatment of keloids or other scars does not meet the definition of the surgical dressing benefit and will be denied as noncovered. 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 were not being used. When a wound cover with an adhesive border is being used, no other dressing is needed on top of it and additional tape is usually not required. Reasons for use of additional tape must 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 is rarely medically necessary and the reasons must be well documented. An exception is an alginate or other fiber gelling dressing wound cover or a saline, water, or hydrogel impregnated gauze dressing which might need an additional wound cover. 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 judgment should be used to avoid their use with primary dressings which require more frequent dressing changes. When claims are submitted for these dressings for changes greater than once every other day, the quantity in excess of that amount will be denied as not medically

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necessary. While a highly exudative wound might require such a combination initially, with continued proper management the wound usually progresses to a point where the appropriate selection of these products results in the less frequent dressing changes which they are designed to allow. An example of an inappropriate combination is the use of a specialty absorptive dressing on top of non-impregnated gauze being used as a primary dressing. Dressing size must be based on and appropriate to the size of the wound. For wound covers, the pad size is usually about 2 inches greater than the dimensions of the wound. For example, a 5 cm x 5 cm (2 in. x 2 in.) wound requires a 4 in. x 4 in. pad size. The following are examples of wound care items which are noncovered under the surgical dressing benefit: skin sealants or barriers (A6250), wound cleansers (A6260) or irrigating solutions, solutions used to moisten gauze (e.g., saline), silicone gel sheets, 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 (e.g., an antibiotic-impregnated dressing which requires a prescription) is considered a drug and is noncovered under the Surgical Dressings benefit. 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. When surgical dressings are provided in kits, only those components of the kit that meet the definition of a surgical dressing, that are ordered by the physician, and that are medically necessary are covered. Coding Guidelines Composite dressings (A6200-A6205) 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 or other fiber gelling dressing, foam, hydrocolloid, or hydrogel, and (c) either a semi-adherent or nonadherent property over the wound site. Contact layers (A6206-A6208) 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 (A6222-A6233, A6266, A6456) are woven or non-woven materials into which substances such as iodinated agents, petrolatum, zinc paste, crystalline sodium chloride, chlorhexadine gluconate (CHG), bismuth tribromophenate (BTP), water, aqueous saline, hydrogel, or other agents have been incorporated into the dressing material by the manufacturer. Specialty absorptive dressings (A6251-A6256) are unitized multi-layer 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 (A6154) is a waterproof collection device with a drainable port that adheres to the skin around a wound. Code A6025 should only be used for gel sheets used for the treatment of keloids or other scars. Hydrogel sheets used in the treatment of wounds are billed with codes A6242-A6247. 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., A4221 with a covered

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infusion pump, B4224 with parenteral nutrition, B4034-B4036 with enteral nutrition, A4625 or A4629 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) are billed separately using the appropriate surgical dressing code. Wound fillers are dressing materials which are placed into open wounds to eliminate dead space, absorb exudate, or maintain a moist wound surface. 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 - i.e., collagen wound filler (A6010, A6011, A6024), alginate or other fiber gelling wound filler (A6199), foam wound filler (A6215), hydrocolloid wound filler (A6240, A6241), hydrogel wound filler (A6248), and non-impregnated packing strips (A6407). Wound fillers not falling into any of these categories are coded as A6261 or A6262. The units of service for wound fillers are 1 gram, 1 fluid ounce, 6 inch length, or one yard 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 code. For example, some pastes or gels are labeled as grams (instead of fluid ounces), some wound fillers are labeled as cc. or ml. (instead of fluid ounces or grams), some are described by linear dimensions (instead of grams). In these situations, the supplier must contact the manufacturer to determine the appropriate conversion factor or unit of service which corresponds to the code. 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. 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 A6237, " ... pad size 16 sq. inch or less..." Products containing multiple materials are categorized according to the clinically predominant component (e.g., alginate, collagen, 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. Multi-component 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. Impregnated dressings that are listed in the FDA Orange Book must be billed using code A9270 and must not be billed using codes A6222-A6224, A6231-A6233, or A6266. Elastic bandages are those that contain fibers of rubber (latex, neoprene), spandex, or elastane. Roll bandages that do not contain these fibers are considered non-elastic bandages even though many of them (e.g., gauze bandages) are stretchable. Codes A6442-A6447 describe roll gauze-type bandages made either of cotton or of synthetic materials such as nylon, viscose, polyester, rayon, polyamide. These bandages are stretchable, but do not contain elastic fibers. These codes include short-stretch bandages. Codes A6448 - A6450 describe ACE type elastic bandages. Codes A6451 and A6452 describe elastic bandages that produce moderate or high compression that is sustained typically for one week. They are commonly included in multi-layer compression bandage systems. Suppliers billing these new codes must be able to provide, on request from the DMERC, documentation from the manufacturer verifying that the performance characteristics specified in the code narratives have

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been met. When multi-layer compression bandage systems are used for the treatment of a venous stasis ulcer, each component is billed using a specific code for the component - e.g., moderate or high compression bandages (A6451, A6452), conforming bandages (A6443, A6444), self-adherent bandages (A6454), and padding bandages (A6441), zinc paste impregnated bandage (A6456). For the compression stocking codes L8110 and L8120, one unit of service is generally for one stocking. However, if a manufacturer has a product consisting of two components which are designed to be worn simultaneously on the same leg, the two components must be billed as one claim line with one unit of service – e.g., a product which consists of an unzippered liner and a zippered stocking. Modifiers A1 – A9 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. 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 A2 modifier must be used with that HCPCS code. The Allwin Data system will always default to using A1 as the modifier on surgical dressing claims, in the instance that a beneficiary has more than one wound the pharmacy will need to transmit the proper A2-A9 modifier directly following the appropriate HCPCS code for the item. If the dressing is not being used as a primary or secondary dressing on a surgical or debrided wound, do not use modifiers A1-A9. When dressings are provided in non-covered situations (e.g., use of gauze in the cleansing of a wound or intact skin), a GY modifier must be added to the code and a brief description of the reason for non-coverage included -- e.g., "A6216GY -- used for wound cleansing." These items can be billed through the Allwin system by using a Processor Control Number of USNONCOVER. When multi-layer compression bandage systems are used for the treatment of a venous stasis ulcer, each component is billed using a specific code for the component, if available -- e.g., non-sterile elastic roll gauze (A6263), non-sterile non-elastic roll gauze (A6264), elastic bandage (A4460). If there is no specific code to describe the component, use code A4649. Impregnated roll gauze dressings designed for the treatment of venous stasis ulcers are coded using A6266. Documentation Requirements An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available to the DMERC upon request. 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) must be obtained from the physician, nursing home, or home care nurse. The source of that information and date obtained must 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

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within this timeframe and what other monitoring methods were used to evaluate the patient's need for dressings. Evaluation is 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 HA0 record of an electronic claim. When surgical dressings are billed, the appropriate modifier (A1 – A9, AW, EY, or GY) must be added to the code when applicable. If A9 is used, information must be submitted with the claim indicating the number of wounds. When codes A4649, A6261 or A6262 are billed, the claim must include a narrative description of the item (including size of the product provided), the manufacturer, the brand name or number, and information justifying the medical necessity for the item. Claim Transmission Allwin Data will reject any surgical dressing claim that exceeds Medicare’s allowable monthly quantity for one wound. In those cases where the pharmacy wishes to bill for more than the usual quantity allowed by Medicare it will be necessary to call Allwin and have a narrative attached to the claim explaining medical necessity, this narrative information may also be added at the Allwin Data website. All claims for tape must be billed per 18 sq. inches of tape. If necessary the pharmacy can have Allwin Data input a quantity conversion so that the pharmacy may bill in total number of rolls. HCPCS Codes HCPCS Description (All quantity limitations are based per wound) Quantity Notes A4450** TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES A4452** TAPE, WATERPROOF, PER 18 SQUARE INCHES A4462 ABDOMINAL DRESSING HOLDER, EACH A4649 SURGICAL SUPPLY; MISCELLANEOUS NARR

A6010 COLLAGEN BASED WOUND FILLER, DRY FORM, PER GRAM OF COLLAGEN

A6011 COLLAGEN BASED WOUND FILLER, GEL/PASTE, PER GRAM OF COLLAGEN

A6021 COLLAGEN DRESSING, PAD SIZE 16 SQ. IN. OR LESS, EACH

A6022 COLLAGEN DRESSING, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH

A6023 COLLAGEN DRESSING, PAD SIZE MORE THAN 48 SQ. IN., EACH A6024 COLLAGEN DRESSING WOUND FILLER, PER 6 INCHES A6154 WOUND POUCH, EACH 12

A6196 ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, EACH DRESSING 30

A6197

ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING 30

A6198 ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., EACH DRESSING 30

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A6199 ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND FILLER, PER 6 INCHES 30

A6200 COMPOSITE DRESSING, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 12

A6201 COMPOSITE DRESSING, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 12

A6202 COMPOSITE DRESSING, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 12

A6203 COMPOSITE DRESSING, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 12

A6204

COMPOSITE DRESSING, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 12

A6205 COMPOSITE DRESSING, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 12

A6206 CONTACT LAYER, 16 SQ. IN. OR LESS, EACH DRESSING 4

A6207 CONTACT LAYER, MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING 4

A6208 CONTACT LAYER, MORE THAN 48 SQ. IN., EACH DRESSING 4

A6209 FOAM DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 12

A6210

FOAM DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 12

A6211 FOAM DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 12

A6212 FOAM DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 12

A6213

FOAM DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 12

A6214 FOAM DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 12

A6215 FOAM DRESSING, WOUND FILLER, PER GRAM 60

A6216 GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 90

A6217

GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 90

A6218 GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 90

A6219 GAUZE, NON-IMPREGNATED, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 30

A6220

GAUZE, NON-IMPREGNATED, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 30

A6221 GAUZE, NON-IMPREGNATED, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 30

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A6222

GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 30

A6223

GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, PAD SIZE MORE THAN 16 SQUARE INCHES, BUT LESS THAN OR EQUAL TO 48 SQUARE INCHES, WITHOUT ADHESIVE BORDER, EACH DRESSING 30

A6224

GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, PAD SIZE MORE THAN 48 SQUARE INCHES, WITHOUT ADHESIVE BORDER, EACH DRESSING 30

A6228* GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 90 NMN

A6229*

GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, PAD SIZE MORE THAT 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 90 NMN

A6230* GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 90 NMN

A6231 GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND CONTACT, PAD SIZE 16 SQ. IN. OR LESS, EACH DRESSING 12

A6232

GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND CONTACT, PAD SIZE GREATER THAN 16 SQ. IN., BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING 12

A6233 GAUZE, IMPREGNATED, HYDROGEL FOR DIRECT WOUND CONTACT, PAD SIZE MORE THAN 48 SQ. IN., EACH DRESSING 12

A6234 HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 12

A6235

HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 12

A6236 HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 12

A6237 HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 12

A6238

HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 12

A6239 HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 12

A6240 HYDROCOLLOID DRESSING, WOUND FILLER, PASTE, PER FLUID OUNCE 24 A6241 HYDROCOLLOID DRESSING, WOUND FILLER, DRY FORM, PER GRAM 24

A6242 HYDROGEL DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 30

A6243

HYDROGEL DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 30

A6244 HYDROGEL DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 30

A6245 HYDROGEL DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 12

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A6246

HYDROGEL DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 12

A6247 HYDROGEL DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 12

A6248 HYDROGEL DRESSING, WOUND FILLER, GEL, PER FLUID OUNCE 3

A6250 SKIN SEALANTS, PROTECTANTS, MOISTURIZERS, OINTMENTS, ANY TYPE, ANY SIZE NC

A6251 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 30

A6252

SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 30

A6253 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 30

A6254 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 15

A6255

SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 15

A6256 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 15

A6257 TRANSPARENT FILM, 16 SQ. IN. OR LESS, EACH DRESSING 12

A6258 TRANSPARENT FILM, MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING 12

A6259 TRANSPARENT FILM, MORE THAN 48 SQ. IN., EACH DRESSING 12 A6260 WOUND CLEANSERS, ANY TYPE, ANY SIZE NC

A6261 WOUND FILLER, GEL/PASTE, PER FLUID OUNCE, NOT ELSEWHERE CLASSIFIED NARR

A6262 WOUND FILLER, DRY FORM, PER GRAM, NOT ELSEWHERE CLASSIFIED NARR

A6266 GAUZE, IMPREGNATED, OTHER THAN WATER, NORMAL SALINE, OR ZINC PASTE, ANY WIDTH, PER LINEAR YARD 5

A6402 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 90

A6403

GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 16 SQ. IN. LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 90

A6404 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 90

A6407 GAUZE, PACKING STRIPS, NON-IMPREGNATED, LESS THAN OR EQUAL TO 2 INCHES, PER LINEAR YARD

A6410 EYE PAD, STERILE, EACH A6411 EYE PAD, NON-STERILE, EACH A6412 EYE PATCH, OCCLUSIVE, EACH

A6441

PADDING BANDAGE, NON-ELASTIC, NON-WOVEN/NON-KNITTED, WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES, PER YARD 4

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A6442 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON-STERILE, WIDTH LESS THAN 3 INCHES, PER YARD

A6443

CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON-STERILE, WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES PER YARD 4

A6444 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NON-STERILE, WIDTH GREATER THAN OR EQUAL TO 5 INCHES, PER YARD 4

A6446

CONFORMING BANDAGE, NON-ELASTIC, KNITTED/ WOVEN, STERILE, WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES, PER YARD 4

A6447 CONFORMING BANDAGE, NON-ELASTIC, KNITTED/ WOVEN, STERILE, WIDTH GREATER THAN OR EQUAL TO 5 INCHES, PER YARD 4

A6449

LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES, PER YARD = ONE UNIT 4

A6450 LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL TO 5 INCHES, PER YARD 4

A6451

MODERATE COMPRESSION BANDAGE, ELASTIC, KNITTED/ WOVEN, LOAD RESISTANCE OF 1.25 TO 1.34 FOOT POUNDS AT 50% MAXIMUM STRETCH, WIDTH GREATER THAN OR EQUAL TO 3 INCHES OR LESS THAN 5 INCHES, PER YARD 4

A6452

HIGH COMPRESSION BANDAGE, ELASTIC, KNITTED/ WOVEN, LOAD RESISTANCE GREATER THAN OR EQUAL TO 1.35 FOOT POUNDS AT 50% MAXIMUM STRETCH, WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES, PER YARD 4

A6454

SELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/ NON-WOVEN, WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES, PER YARD

A6456

ZINC PASTE IMPREGNATED BANDAGE, NON-ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES, PER YARD

A6501 COMPRESSION BURN GARMENT, BODYSUIT (HEAD TO FOOT), CUSTOM FABRICATED

A6502 COMPRESSION BURN GARMENT, CHIN STRAP, CUSTOM FABRICATED A6503 COMPRESSION BURN GARMENT, FACIAL HOOD, CUSTOM FABRICATED

A6504 COMPRESSION BURN GARMENT, GLOVE TO WRIST, CUSTOM FABRICATED

A6505 COMPRESSION BURN GARMENT, GLOVE TO ELBOW, CUSTOM FABRICATED

A6506 COMPRESSION BURN GARMENT, GLOVE TO AXILLA, CUSTOM FABRICATED

A6507 COMPRESSION BURN GARMENT, FOOT TO KNEE LENGTH, CUSTOM FABRICATED

A6508 COMPRESSION BURN GARMENT, FOOT TO THIGH LENGTH, CUSTOM FABRICATED

A6509 COMPRESSION BURN GARMENT, UPPER TRUNK TO WAIST INCLUDING ARM OPENINGS (VEST), CUSTOM FABRICATED

A6510 COMPRESSION BURN GARMENT, TRUNK, INCLUDING ARMS DOWN TO LEG OPENINGS (LEOTARD), CUSTOM FABRICATED

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A6511 COMPRESSION BURN GARMENT, LOWER TRUNK INCLUDING LEG OPENINGS (PANTY), CUSTOM FABRICATED

A6512 COMPRESSION BURN GARMENT, NOT OTHERWISE CLASSIFIED A9270 NON-COVERED ITEM OR SERVICE NC K0620 TUBULAR ELASTIC DRESSING, ANY WIDTH, PER LINEAR YARD *There is no medical necessity for these dressings compared to non-impregnated gauze that 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 non-covered under the Surgical Dressings benefit. **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 must be documented. Tape change is determined by the frequency of change of the wound cover. Quantities of tape submitted must 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.



NC Not Covered.




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XV - WALKERS, CANES AND CRUTCHES Coverage and Payment Rules A standard walker (E0130, E0135, E0141, E0143) and related accessories are covered if both of the following criteria are met: 1. It is prescribed by a physician for a patient with a medical condition impairing ambulation and there is a potential for

ambulation; and 2. There is a need for greater stability and security than provided by a cane or crutches.

A heavy duty walker (E0148, E0149) is covered for patients who meet coverage criteria for a standard walker and who weigh more than 300 pounds. If a E0148 or E0149 walker is provided and the patient does not weigh more than 300 pounds but does meet coverage criteria for a standard walker, payment will be based on the allowance for the least costly medically appropriate alternative, E0135 or E0143 respectively. A heavy duty, multiple braking system, variable wheel resistance walker (E0147) is covered for patients who meet coverage criteria for a standard walker and who are unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand. Obesity, by itself, is not a sufficient reason for an E0147 walker. If an E0147 walker is provided and the coverage criteria for a standard walker are met but the additional coverage criteria for an E0147 are not met, payment will be based on the allowance for the least costly medically appropriate alternative, E0143 or E0149 depending on the patient's weight. The medical necessity for a walker with an enclosed frame (E0144) compared to a standard folding wheeled walker, E0143, has not been established. Therefore, if the basic coverage criteria for a walker are met and code E0144 is billed, payment will be based on the allowance for the least costly medically appropriate alternative, E0143. Enhancement accessories of walkers will be denied as noncovered. Leg extensions (E0158) are covered only for patients 6 feet tall or more. Canes (E0100, E0105) and crutches (E0110 - E0116) are covered when prescribed by a physician for a patient with a condition causing impaired ambulation and there is a potential for ambulation. The medical necessity for an underarm, articulating, spring assisted crutch (E0117) has not been established. If an E0117 is ordered, payment will be based on the allowance for the least costly medically appropriate alternative, E0116. A white cane for a blind person is noncovered since it is a "self-help" item. Coding Guidelines A wheeled walker (E0141, E0143, E0149) is one with either 2, 3, or 4 wheels. It may be fixed height or adjustable height. It may or may not include glide-type brakes (or equivalent). The wheels may be fixed or swivel. A glide-type brake consists of a spring mechanism (or equivalent) which raises the leg post of the walker off the ground when the patient is not pushing down on the frame. Code E0144 describes a folding wheeled walker which has a frame that completely surrounds the patient and an attached seat in the back. A heavy duty walker (E0148, E0149) is one which is labeled as capable of supporting patients who weigh more than 300 pounds. It may be fixed height or adjustable height. It may be rigid or folding.

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Code E0147 describes a 4-wheeled, adjustable height, folding-walker that has all of the following characteristics: 1. Capable of supporting patients who weigh greater than 350 pounds, 2. Hand operated brakes that cause the wheels to lock when the hand levers are released, 3. The hand brakes can be set so that either or both can lock both wheels, 4. The pressure required to operate each hand brake is individually adjustable, 5. There is an additional braking mechanism on the front crossbar, 6. At least two wheels have brakes that can be independently set through tension adjustability to give varying resistance.

The only walkers that may be billed using code E0147 are those products listed in the Product Classification List on the SADMERC Web site. An enhancement accessory is one which does not contribute significantly to the therapeutic function of the walker. It may include, but is not limited to style, color, hand operated brakes (other than those described in code E0147), or basket (or equivalent). A4636, A4637, and E0159 are only used to bill for replacement items for covered, patient-owned walkers. Codes E0154, E0156, E0157, and E0158 can be used for accessories provided with the initial issue of a walker or for replacement components. Code E0155 can be used for replacements on covered, patient-owned wheeled walkers or when wheels are subsequently added to a covered, patient-owned nonwheeled walker (E0130, E0135). Code E0155 cannot be used for wheels provided at the time of, or within one month of, the initial issue of a nonwheeled walker. Hemi-walkers must be billed using code E0130 or E0135, not E1399. Use code A9270 when an enhancement accessory of a walker is billed. A gait trainer is a term used to describe certain devices that are used to support a patient during ambulation. Gait trainers are billed using one of the codes for walkers. If a gait trainer has a feature described by one of the walker attachment codes (E0154-E0157) that code may be separately billed. Other unique features of gait trainers are not separately payable and may not be billed with code E1399. If a supplier chooses to bill separately for a feature of a gait trainer that is not described by a specific HCPCS code, then code A9900 must be used. A Column II code is included in the allowance for the corresponding Column I code when provided at the same time and must not be billed separately at the time of billing the Column I code.

Column I Column II E0130 A4636, A4637 E0135 A4636, A4637 E0140 A4636, A4637, E0155, E0159 E0141 A4636, A4637, E0155, E0159 E0143 A4636, A4637, E0155, E0159 E0144 A4636, A4637, E0155, E0156, E0159 E0147 A4636, E0155, E0159 E0148 A4636, A4637 E0149 A4636, A4637, E0155, E0159

Documentation Requirements If E0147 is billed, the claim must include the manufacturer's name, the model name/number, and documentation from the treating physician giving a description of the functional limitations which preclude the patient using another type of wheeled walker and the diagnosis causing this limitation. When code E1399 is billed, the claim must include a narrative description of the item, the manufacturer, the model name or

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number (if applicable), and information justifying the medical necessity for the item. HCPCS Codes

HCPCS Description Quantity Notes A4636 Replacement, handgrip, cane, crutch or walker, each A4637 Replacement tip, cane, crutch, or walker, each A9270 Non-covered item or service NC E0130 Walker, rigid (pickup), adjustable or fixed height 1 / 5yrs E0135 Walker, folding (pickup), adjustable or fixed height 1 / 5yrs E0141 Rigid walker, wheeled, without seat 1 / 5yrs E0143 Folding walker, wheeled, without seat 1 / 5yrs E0144 Enclosed, framed folding walker, wheeled, with posterior seat 1 / 5yrs NMN E0147 Heavy duty, multiple braking system, variable wheel resistance walker 1 / 5yrs NARR E0148 Walker, heavy duty, without wheels, rigid or folding, any type, each 1 / 5yrs NARR E0149 Walker, heavy duty, wheeled, rigid or folding, any type, each 1 / 5yrs NARR E0154 Platform attachment, walker, each E0155 Wheel attachment, rigid pickup walker, per pair E0156 Seat attachment, walker E0157 Crutch attachment, walker, each E0158 Leg extensions for a walker, per set of four (4) E0159 Brake attachment for wheeled walker, replacement, each E1399 Durable medical equipment, miscellaneous NARR E0100 Cane, Includes Canes of All Materials, Adjustable or Fixed with Tips 1 / 5yrs E0105 Cane, Quad or Three Prong, Includes Canes of All Materials, Adjustable or Fixed with

Tips 1 / 5yrs

E0110 Crutches, Forearm, Includes Crutches of Various Materials, Adjustable or Fixed, Pair, Complete with Tips and Handgrips

1 / 5yrs

E0111 Crutch, Forearm, Includes Crutches of Various Material, Adjustable or Fixed, Each, with Tip and Handgrips

1 / 5yrs

E0112 Crutches, Underarm, Wood Adjustable or Fixed, Pair, with Pads, Tips and Handgrips 1 / 5yrs E0113 Crutch, Underarm, Wood Adjustable or Fixed, Each, with Pad, Tip and Handgrip 1 / 5yrs E0114 Crutches Underarm, Aluminum, Adjustable or Fixed, Pair, with Pads, Tips and

Handgrips 1 / 5yrs

E0116 Crutches Underarm, Aluminum, Adjustable or Fixed, Each, with Pads, Tip and Handgrip 1 / 5yrs



NC Not Covered.




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XVI - SEAT LIFT MECHANISMS Coverage and Payment Rules A seat lift mechanism is covered if all of the following criteria are met: 1. The patient must have severe arthritis of the hip or knee or have a severe neuromuscular disease. 2. The seat lift mechanism must be a part of the physician's course of treatment and be prescribed to effect improvement, or

arrest or retard deterioration in the patient's condition. 3. The patient must be completely incapable of standing up from a regular armchair or any chair in their home. (The fact

that a patient has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism. Almost all patients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.)

4. Once standing, the patient must have the ability to ambulate. Coverage of seat lift mechanisms is limited to those types which operate smoothly, can be controlled by the patient, and effectively assist a patient in standing up and sitting down without other assistance. Excluded from coverage is the type of lift which operates by spring release mechanism with a sudden, catapult-like motion and jolts the patient from a seated to a standing position. Coverage is limited to the seat lift mechanism, even if it is incorporated into a chair (E0627). Payment for a seat lift mechanism incorporated into a chair (E0627) is based on the allowance for the least costly alternative (E0628, E0629). The physician ordering the seat lift mechanism must be the treating physician or a consulting physician for the disease or condition resulting in the need for a seat lift. The physician's record must document that all appropriate therapeutic modalities (e.g., medication, physical therapy) have been tried and failed to enable the patient to transfer from a chair to a standing position. Valid CMN’S 1. Either question #1 or question #2 must be answered yes for coverage to exist 2. Question #3 must be answered yes for coverage to exist 3. Question #4 must be answered yes for coverage to exist Coding Guidelines When providing a seat lift mechanism which is incorporated into a chair as a complete unit at the time of purchase, suppliers must bill the item using the established HCPCS code, E0627. In this situation, the supplier may bill the seat lift mechanism using E0627 and A9270 for the chair. However, if the seat lift mechanism, electric or non-electric, is supplied as an individual unit to be incorporated into a chair that a patient owns, the supplier must bill using the appropriate code for the seat lift mechanism for use with patient owned furniture, E0628 or E0629. Documentation Requirements A Certificate of Medical Necessity (CMN), which has been completed, signed and dated by the treating physician, must be kept on file by the supplier, and made available to the DMERC upon request. The CMN may act as a substitute for a written order if it contains all of the required elements of an order. The CMN for seat lift mechanism is HCFA form 849. The initial claim must include a copy of the CMN. Claim Transmission Upon receiving the completed CMN from the physician the pharmacy has two ways to get the CMN to Allwin Data before the claim can be transmitted. The pharmacy may enter the CMN using the Allwin Data website and transmit the claim upon acceptance of the CMN by the Allwin system, or the pharmacy may fax the CMN to Allwin Data for processing. Please

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allow 24 hrs for processing when the CMN is faxed to Allwin Data. The chair component may be billed using Processor Control Number USNONCOVER as HCPCS A9270. Narrative information will need to be attached to the claim by calling an Allwin representative or entering the information on the Allwin website. HCPCS Codes

HCPCS Description Quantity Notes E0627 Seat Lift Mechanism Incorporated into a Combination Lift-Chair Mechanism 1 / 5yrs CMN E0628 Separate Seat Lift Mechanism for Use With Patient Owned Furniture-Electric 1 / 5yrs CMN E0629 Separate Seat Lift Mechanism for Use with Patient Owned Furniture (Non-electric) 1 / 5yrs CMN



NC Not Covered.




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XVII - HOSPITAL BEDS Coverage and Payment Rules A fixed height hospital bed (E0250, E0251, E0290, and E0291) is covered if one or more of the following criteria are met: 1. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed.

Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed, or 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart

failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out, or

4. The patient requires traction equipment, which can only be attached to a hospital bed.

A variable height hospital bed (E0255, E0256, E0292, E0293) is covered if the patient meets one of the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position. A semi-electric hospital bed (E0260, E0261, E0294, and E0295) is covered if the patient meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate need for a change in body position. A heavy duty extra wide hospital bed (E0301, E0303) is covered if the patient meets one of the criteria for a fixed height hospital bed and the patient's weight is more than 350 pounds, but does not exceed 600 pounds. An extra heavy duty hospital bed (E0302, E0304) is covered if the patient meets one of the criteria for a hospital bed and the patient's weight exceeds 600 pounds. A total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. For any of the above hospital beds (plus those coded E1399 - see Coding Guidelines), if documentation does not support the medical necessity of the type of bed billed, payment will be based on the allowance for the least costly medically appropriate alternative. If the patient does not meet any of the coverage criteria for any type of hospital bed it will be denied as not medically necessary. Accessories Trapeze equipment (E0910,E0940) is covered if the patient needs this device to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed. E0910 is noncovered when used on an ordinary bed. A bed cradle (E0280) is covered when it is necessary to prevent contact with the bed coverings. A bed cradle (E0280) is covered when it is necessary to prevent contact with the bed coverings. Side rails (E0305, E0310) are covered when they are required by the patient's condition and they are an integral part of, or an accessory to, a hospital bed. If a patient's condition requires a replacement innerspring mattress (E0271) or foam rubber mattress (E0272) it will be covered for a patient owned hospital bed. A bed board (E0273, E0315) is noncovered since it is not primarily medical in nature.

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An over bed table (E0274, E0315) is noncovered because it is not primarily medical in nature. Valid CMN’s 1. A fixed height hospital bed (E0250, E0251, E0290, E0291) is covered when one or more of questions 1, 3, 4, or 5 are

answered YES on CMN 01.02A. 2. A variable height hospital bed (E0255, E0256, E0292, E0293) is covered when one or more of questions 1, 3, 4, or 5 are

answered YES, and question 6 is answered YES on CMN 01.02A. 3. A semi-electric hospital bed (E0260, E0261, E0294, E0295) is covered when one or more of questions 1, 3, 4, or 5 are

answered YES, and question 7 is answered YES on CMN 01.02A. 4. A total electric hospital bed (E0265, E0266, E0296, E0297) is not covered; the height adjustment feature is a

convenience feature. If this bed is billed, payment will be based on the least costly alternative. 5. A heavy duty extra wide hospital bed (E0303) is covered when or more of questions 1, 3, 4, or 5 are answered YES on

CMN01.02A and the patient weighs more than 350 pounds, but less than 600 pounds. 6. A extra heavy duty hospital bed (E0304) is covered when or more of questions 1, 3, 4, or 5 is answered YES on

CMN01.02A and the patient weighs more than 600 pounds. Coding Guidelines A fixed height hospital bed is one with manual head and leg elevation adjustments but no height adjustment. A variable height hospital bed is one with manual height adjustment and with manual head and leg elevation adjustments. A semi-electric bed is one with manual height adjustment and with electric head and leg elevation adjustments. A total electric bed is one with electric height adjustment and with electric head and leg elevation adjustments. E0301 and E0303 are hospital beds that are capable of supporting a patient who weighs more than 350 pounds, but no more than 600 pounds. E0302 and E0304 are hospital beds that are capable of supporting a patient who weighs more than 600 pounds. E0316 is a safety enclosure used to prevent a patient from leaving the bed. An ordinary bed is one, which is typically sold as furniture. It may consist of a frame, box spring and mattress. It is a fixed height and has no head or leg elevation adjustments. E1399 should be used for products not described by the specific HCPCS codes above, for example - a heavy (or extra heavy) duty bed without a mattress (as when used with a support surface for the treatment of pressure ulcers). A Column II code is included in the allowance for the corresponding Column I code when provided at the same time and must not be billed separately at the time of billing the Column I code.

Column I Column II E0250 E0271, E0272, E0305, E0310 E0251 E0305, E0310 E0255 E0271, E0272, E0305, E0310 E0256 E0305, E0310 E0260 E0271, E0272, E0305, E0310 E0261 E0305, E0310 E0265 E0271, E0272, E0305, E0310 E0266 E0305, E0310 E0290 E0271, E0272

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E0292 E0271, E0272 E0294 E0271, E0272 E0296 E0271, E0272 E0301 E0305, E0310 E0302 E0305, E0310 E0303 E0271, E0272, E0305, E0310 E0304 E0271, E0272, E0305, E0310 When mattress or bedside rails are provided at the same time as a hospital bed, use the single code that combines these items. Documentation Requirements The supplier must keep on file a Certificate of Medical Necessity (CMN) that has been completed, signed and dated by the treating physician. If there is also a written order for a hospital bed and accessories, it must be signed and dated by the treating physician and kept on file by the supplier. The initial claim for a hospital bed must include a copy of the CMN if filed hard copy. A claim for code E1399 must be accompanied by: • A Hospital Bed CMN, HCFA Form 841, that must include the patient's weight; and, • The manufacturer and model/product name/number of the bed; and, • Information that describes the necessity for the bed. Claim Transmission Upon receiving the completed CMN from the physician the pharmacy has two ways to get the CMN to Allwin Data before the claim can be transmitted. The pharmacy may enter the CMN using the Allwin Data website and transmit the claim upon acceptance of the CMN by the Allwin system, or the pharmacy may fax the CMN to Allwin Data for processing. Please allow 24 hrs for processing when the CMN is faxed to Allwin Data. Allwin Data will automatically attach all required capped rental modifiers. Should you begin processing through Allwin Data halfway through a capped rental period, Allwin Data will attach the proper capped-rental modifiers only if the claim shows a date written that is accurate with the beginning of the rental period. If you are unsure of what date is showing up in the date written field please call Allwin Data following your first transmission of a capped rental item in the middle of the rental period.

HCPCS Codes Fixed Height Beds HCPCS Description Quantity Notes E0250 Hospital bed, fixed height, with any type side rails, with mattress CMN/CRE0251 Hospital bed, fixed height, with any type side rails, without mattress CMN/CRE0290 Hospital bed, fixed height, without side rails, with mattress CMN/CRE0291 Hospital bed, fixed height, without side rails, without mattress CMN/CR Variable Height Beds HCPCS Description Quantity Notes E0255 Hospital bed, variable height (hi-lo), with any type side rails, with mattress CMN/CRE0256 Hospital bed, variable height (hi-lo), with any type side rails, without mattress CMN/CR

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E0292 Hospital bed, variable height (hi-lo), without side rails, with mattress CMN/CRE0293 Hospital bed, variable height (hi-lo), without side rails, without mattress CMN/CR Semi-Electric Beds HCPCS Description Quantity Notes E0260 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with

mattress CMN/CR

E0261 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress

CMN/CR

E0294 Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress CMN/CRE0295 Hospital bed, semi-electric (head and foot adjustment), without side rails, without

mattress CMN/CR

Total Electric Beds HCPCS Description Quantity Notes E0265 Hospital bed, total electric (head, foot, and height adjustments), with any type side

rails, with mattress CMN/NMN

E0266 Hospital bed, total electric (head, foot, and height adjustments), with any type side

rails, without mattress CMN/NMN

E0296 Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress

CMN/NMN

E0297 Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress

CMN/NMN

Heavy Duty Beds

HCPCS Description Quantity Notes E0303 Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but

less than or equal to 600 pounds, with any type side rails, with mattress CMN

E0304 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress.

CMN

Accessories

HCPCS Description Quantity Notes E0271 Mattress, innerspring E0272 Mattress, foam rubber E0273 Bed board NC E0274 Over-bed table E0280 Bed cradle, any type E0305 Bedside rails, half-length E0310 Bedside rails, full length E0315 Bed accessory: board or table or support device, any type NC E0316 Safety enclosure frame/canopy for use with hospital bed, any type E0910 Trapeze bars, a/k/a patient helper, attached to bed, with grab bar E0940 Trapeze bar, free standing, complete with grab bar Miscellaneous

HCPCS Description Quantity Notes E1399 Durable medical equipment, miscellaneous NARR

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NC Not Covered.




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XVIII - MANUAL WHEELCHAIRS Coverage and Payment Rules A wheelchair is covered if the patient's condition is such that without the use of a wheelchair, he would otherwise be bed or chair confined. An individual may qualify for a wheelchair and still be considered bed confined. This basic requirement must be met for coverage of any wheelchair. An upgrade that is beneficial primarily in allowing the patient to perform leisure or recreational activities will be noncovered. Payment will be based on the allowance for the least costly medically acceptable alternative. Payment is made for only one wheelchair at a time. Backup chairs are denied as not medically necessary. One month's rental of a wheelchair is covered if a patient-owned wheelchair is being repaired. Reimbursement for wheelchair codes includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support services such as emergency services, delivery, set-up, education, and on-going assistance with use of the wheelchair. A standard hemi-wheelchair (K0002) is covered when the patient requires a lower seat height (17" to 18") because of short stature or to enable the patient to place his/her feet on the ground for propulsion. A lightweight wheelchair (K0003) is covered when a patient: a) Cannot self-propel in a standard wheelchair using arms and/or legs and b) The patient can and does self-propel in a lightweight wheelchair.

A high strength lightweight wheelchair (K0004) is covered when a patient meets the criteria in (1) and/or (2): 1. The patient self-propels the wheelchair while engaging in frequent activities that cannot be performed in a standard or

lightweight wheelchair. 2. The patient requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-

wheelchair, and spends at least two hours per day in the wheelchair.

A high strength lightweight wheelchair is rarely medically necessary if the expected duration of need is less than three months (e.g., post-operative recovery). Coverage of an ultralightweight wheelchair (K0005) is determined on an individual consideration basis. If a K0005 wheelchair base is determined to be not medically necessary but criteria are met for a less costly wheelchair, payment will be based on the least costly alternative (K0001 - K0004). However, since K0005 is in a different payment category it will be denied as not medically necessary if billed as a purchase. A heavy duty wheelchair (K0006) is covered if the patient weighs more than 250 pounds or the patient has severe spasticity. An extra heavy duty wheelchair (K0007) is covered if the patient weighs more than 300 pounds. When the stated coverage criteria relating to medical necessity are not met, a claim will be considered for coverage if there is additional documentation which justifies the medical necessity for the item in the individual case. If the documentation does not support the medical necessity of the wheelchair which is billed, but does support the medical necessity of a lower level wheelchair, payment will be based on the allowance for the least costly medically acceptable alternative. Valid CMN’s 1. Question #1 must be answered YES for a standard wheelchair (K0001) to be covered.

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2. Question #1 and #9 must be answered YES, and question #8 must be answered NO for a lightweight wheelchair to be covered.

Coding Guidelines Adult manual wheelchairs (K0001-K0009, E1161) are those which have a seat width and a seat depth of 15" or greater. In addition, specific codes are defined by the following characteristics: Standard wheelchair (K0001) Weight: Greater than 36 lbs. Seat Height: 19" or greater Weight capacity: 250 pounds or less Standard hemi (low seat) wheelchair (K0002) Weight: Greater than 36 lbs Seat Height: Less than 19" Weight capacity: 250 pounds or less Lightweight wheelchair (K0003) Weight: 34-36 lbs Weight capacity: 250 pounds or less High strength, lightweight wheelchair (K0004) Weight: Less than 34 lbs Lifetime Warranty on side frames and crossbraces Ultra lightweight wheelchair (K0005) Weight: Less than 30 lbs Adjustable rear axle position Lifetime Warranty on side frames and crossbraces Heavy duty wheelchair (K0006) Weight capacity: Greater than 250 pounds Extra heavy duty wheelchair (K0007) Weight capacity: Greater than 300 pounds Adult tilt-in-space wheelchair (E1161) Ability to tilt the frame of the wheelchair greater than or equal to 45 degrees from horizontal while maintaining the same back to seat angle. Lifetime Warranty: On side frames and crossbraces Wheelchair "poundage" (lbs.) represents the weight of the usual configuration of the wheelchair with a seat and back but without frontriggings. The following features are included in the allowance for all adult manual wheelchairs: Seat Width: 15" - 19" Seat Depth: 15" – 19" Arm Style: Fixed, swingaway, or detachable; fixed height Footrests: Fixed, swingaway, or detachable Codes K0003-K0007 and E1161 include any seat height. Refer to the medical policy on Wheelchair Options and Accessories for information on other features included in the allowance for the wheelchair base.

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A manual wheelchair with a seat width and/or depth of 14" or less is considered a pediatric size wheelchair and is billed with codes E1231-E1238. Codes E1050 - E1060, E1070 - E1200, E1220 - E1224, E1240 - E1295 should only be used to bill for maintenance and service for an item for which the initial claim was paid by the local carrier prior to transition to the DMERC. Wheelchairs with individualized features which meet the needs of a particular patient are billed by selecting the correct code for the wheelchair base and then using appropriate codes for wheelchair options and accessories. (Refer to the Wheelchair Options and Accessories policy.) If the frame of the wheelchair is modified in a unique way to accommodate the patient, bill the code for the wheelchair base and bill the modification with code K0108 (wheelchair component or accessory, not otherwise specified). Documentation Requirements A Certificate of Medical Necessity (CMN), which has been completed, signed, and dated by the treating physician, must be kept on file by the supplier, and made available to the DMERC on request. The CMN for manual wheelchairs is HCFA Form 844. The initial claim must include a copy of the CMN. Initial claims for K0005 must include a description of the patient's routine activities. This may include what types of activities the patient frequently encounters, and whether the patient is fully independent in the use of the wheelchair. Describe the features of the K0005 base which are needed compared to the K0004 base. This information should be attached to a hard copy claim or entered in the narrative field of an electronic claim. When code K0009 is billed, the claim must include a narrative description of the item, the manufacturer, the model name or number (if applicable), and information justifying the medical necessity for the item. Documentation for individual consideration might include information on the patient's diagnosis, the patient's abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency, and nature of the activities the patient performs, etc.), the duration of the condition, the expected prognosis, and past experience using similar equipment. Claim Transmission Upon receiving the completed CMN from the physician the pharmacy has two ways to get the CMN to Allwin Data before the claim can be transmitted. The pharmacy may enter the CMN using the Allwin Data website and transmit the claim upon acceptance of the CMN by the Allwin system, or the pharmacy may fax the CMN to Allwin Data for processing. Please allow 24 hrs for processing when the CMN is faxed to Allwin Data. Allwin Data will automatically attach all required capped rental modifiers. Should you begin processing through Allwin Data halfway through a capped rental period, Allwin Data will attach the proper capped-rental modifiers only if the claim shows a date written that is accurate with the beginning of the rental period. If you are unsure of what date is showing up in the date written field please call Allwin Data following your first transmission of a capped rental item in the middle of the rental period. HCPCS Codes

HCPCS Description Quantity Notes K0001 Standard wheelchair CMN / CR K0002 Standard hemi (low seat) wheelchair CMN / CR K0003 Lightweight wheelchair CMN / CR K0004 High strength, lightweight wheelchair CMN / CR K0005 Ultra lightweight wheelchair CMN K0006 Heavy duty wheelchair CMN / CR K0007 Extra heavy duty wheelchair CMN / CR

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K0009 Other manual wheelchair/base CMN



NC Not Covered.




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XIX - MOTORIZED WHEELCHAIRS

Coverage and Payment Rules A power wheelchair is covered when all of the following criteria are met: 1. The patient's condition is such that without the use of a wheelchair the patient would otherwise be bed or chair confined,

and; 2. The patient's condition is such that a wheelchair is medically necessary and the patient is unable to operate a wheelchair

manually and; 3. The patient is capable of safely operating the controls for the power wheelchair.

A patient who requires a power wheelchair usually is totally nonambulatory and has severe weakness of the upper extremities due to a neurologic or muscular disease/condition. If the documentation does not support the medical necessity of a power wheelchair but does support the medical necessity of a manual wheelchair, payment is based on the allowance for the least costly medically appropriate alternative. However, if the power wheelchair has been purchased, and the manual wheelchair on which payment is based is in the capped rental category, the power wheelchair will be denied as not medically necessary. Options that are beneficial primarily in allowing the patient to perform leisure or recreational activities are noncovered. Payment is made for only one wheelchair at a time. Backup chairs are denied as not medically necessary. One month's rental of a wheelchair is covered if a patient-owned wheelchair is being repaired. Reimbursement for the wheelchair codes includes all labor charges involved in the assembly of the wheelchair and all covered additions or modifications. Reimbursement also includes support services, such as emergency services, delivery, set-up, education, and on-going assistance with use of the wheelchair. Coding Guidelines Motorized/power wheelchair bases K0010, K0011, and K0012 are characterized by: A seat width and a seat depth of 15" or greater. In addition, a lightweight power wheelchair (K0012) is characterized by: Weight less than 80 lbs. with back and seat but without frontriggings or battery Folding back or collapsible frame Code K0014 is used for an adult power wheelchair base if it has a patient weight capacity of greater than or equal to 350 pounds and has programmable controls. A power wheelchair with a seat width or depth of 14" or less is considered a pediatric power wheelchair base and is coded K0014. The following features are included in the allowance for K0010-K0012 and adult K0014 power wheelchair bases: Seat Width: 15"-19" Seat Depth: 15"-19" Arm Style: Fixed, swingaway, or detachable; fixed height Footrests: Fixed, swingaway, or detachable Wheelchairs with individualized features which meet the needs of a particular patient are billed by selecting the correct code for the wheelchair base and then using appropriate codes for wheelchair options and accessories. (Refer to the Wheelchair Options and Accessories policy.) If the frame of the wheelchair is modified in a unique way to accommodate the patient,

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bill the code for the wheelchair base and bill the modification with code K0108 (wheelchair component or accessory, not otherwise specified). Codes K0010 - K0014 are not used for manual wheelchairs with add-on power packs. Use the appropriate code for the manual wheelchair base provided (K0001 - K0009) and code E0983. Codes E1210 - E1220 should only be used to bill for maintenance and service for an item for which the initial claim was paid to the local carrier prior to the transition to the DMERC. Documentation Requirements A Certificate of Medical Necessity (CMN), which has been completed, signed, and dated by the treating physician, must be kept on file by the supplier and made available to the DMERC on request. The CMN for power wheelchairs is HCFA Form 843. This applies to the power add-on code K0460 as well as to the power wheelchair bases K0010-K0014. The initial claim must include a copy of the CMN. When billing K0014, the claim must include documentation indicating the brand name and model name/number of the base, and a statement documenting the medical necessity of this base for the particular patient including why another base (K0010-K0012) was not acceptable. Claims Transmission Upon receiving the completed CMN from the physician the pharmacy has two ways to get the CMN to Allwin Data before the claim can be transmitted. The pharmacy may enter the CMN using the Allwin Data website and transmit the claim upon acceptance of the CMN by the Allwin system, or the pharmacy may fax the CMN to Allwin Data for processing. Please allow 24 hrs for processing when the CMN is faxed to Allwin Data. Since a motorized wheelchair can be billed as a purchase or a capped rental item you will need to indicate your intention to bill as a purchase. This can be done by placing the “NU” modifier immediately following the appropriate HCPCS code. Otherwise Allwin will assume that the item is being billed as a capped rental. Allwin Data will automatically attach all required capped rental modifiers. Should you begin processing through Allwin Data halfway through a capped rental period, Allwin Data will attach the proper capped-rental modifiers only if the claim shows a date written that is accurate with the beginning of the rental period. If you are unsure of what date is showing up in the date written field please call Allwin Data following your first transmission of a capped rental item in the middle of the rental period. HCPCS Codes

HCPCS Description Quantity Notes K0010 STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR CMN K0011 STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR

WITH PROGRAMMABLE CONTROL PARAMETERS FOR SPEED ADJUSTMENT, TREMOR DAMPENING, ACCELERATION CONTROL AND BRAKING

CMN

K0012 LIGHTWEIGHT PORTABLE MOTORIZED/POWER WHEELCHAIR CMN K0014 OTHER MOTORIZED/POWER WHEELCHAIR BASE CMN E0983 POWER ADD-ON, TO CONVERT MANUAL WHEELCHAIR TO

MOTORIZED WHEELCHAIR, JOYSTICK CONTROL

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NC Not Covered.




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XX - WHEELCHAIR ACCESSORIES

Coverage and Payment Rules Options and accessories for wheelchairs are covered if the following criteria are met: 1. The patient has a wheelchair that meets Medicare coverage criteria, and 2. The patient's condition is such that without the use of a wheelchair, he would otherwise be bed or chair confined (an

individual may qualify for a wheelchair and still be considered bed confined), and; 3. The options/accessories are necessary for the patient to perform one or more of the following activities:

• Function in the home; • Perform instrumental activities of daily living.

An option/accessory that is beneficial primarily in allowing the patient to perform leisure or recreational activities is noncovered. The medical necessity for all options and accessories must be documented in the patient's medical record and be available to the DMERC on request. Adjustable arm height option (E0973,K0017, K0018, K0020) is covered if the patient requires an arm height that is different than that available using nonadjustable arms and the patient spends at least 2 hours per day in the wheelchair. An arm trough (K0106) is covered if patient has quadriplegia, hemiplegia, or uncontrolled arm movements. Elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if: 1. The patient has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the

knee; or 2. The patient has significant edema of the lower extremities that requires having an elevating legrest; or 3. The patient meets the criteria for and has a reclining back on the wheelchair. A nonstandard seat width and/or depth (E2201-E2204, E2340-E2343) is covered only if the patient's dimensions justify the need. Up to two batteries (E2360-E2365) at any one time are allowed if required for a power wheelchair. A dual mode battery charger (E2367) is not medically necessary; when it is provided as a replacement, payment is based on the allowance for the least costly medically appropriate alternative, E2366. An electronic interface (E2351) to allow a speech generating device to be operated by the power wheelchair control interface is covered if the patient has a covered speech generating device. (Refer to the medical policy on Speech Generating Devices for details.) Anti-rollback device (E0974) is covered if the patient propels himself/ herself and needs the device because of ramps. A safety belt/pelvic strap (E0978) is covered if the patient has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning. One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware (E1028) would be to move the component out of the way so that a patient could perform a slide transfer to a chair or bed. A fully reclining back option (E1226) is covered if the patient spends at least 2 hours per day in the wheelchair and has one or more of the following conditions/needs: 1. Quadriplegia;

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2. Fixed hip angle; 3. Trunk or lower extremity casts/braces that require the reclining back feature for positioning; 4. Excess extensor tone of the trunk muscles; and/or 5. The need to rest in a recumbent position two or more times during the day and transfer between wheelchair and bed is

very difficult. A crutch and cane holder (K0102) is not medically necessary. Coding Guidelines A table in the Appendices section defines the bundling guidelines for wheelchair bases and options/accessories. Codes listed in Column II are not separately payable from the wheelchair base and must not be billed separately at the time of initial purchase or rental of the wheelchair. A replacement option/accessory for a power operated vehicle (POV) is billed using a wheelchair option/accessory code. All options and accessories provided at the time of initial issue of a POV are not separately billable. The RP modifier is used when an option or accessory is provided either as a replacement for the same part which has been worn or damaged (e.g., replacing a tire of the same type) or as an upgrade subsequent to providing the wheelchair base (e.g., replacing a standard seat of a power wheelchair with a power seating system). In both of these situations, the new item is placed on the existing wheelchair base. The RP modifier must not be used if the accessory is provided at the same time as the wheelchair base, even if the option/accessory is the same as one that the patient had on a prior wheelchair. Miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific HCPCS code and are not included in another code should be coded K0108. If multiple miscellaneous accessories are provided, each should be billed on a separate claim line using code K0108. When billing more than one line item with code K0108, ensure that the additional information can be matched to the appropriate line item on the claim. It is also helpful to reference the line item to the submitted charge. If a supplier chooses to bill separately for a component that is included in another code, code A9900 must be used. The right (RT) and left (LT) modifiers must be used when appropriate. When the same code for bilateral items (left and right) are billed on the same date of service, bill both items on the same claim line using the LTRT modifiers and 2 units of service. Codes E0953, E0954, E0969-E0970, E0977, E0980, E0994, E0996-E1001, E1227, E1296-E1298 are not valid for claims submitted to the DMERC. Codes E0968 and E1228 should only be used to bill for maintenance and service for an item for which the initial claim was paid by the local carrier prior to transition to the DMERC. Suppliers should contact the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) for guidance on the correct coding of these items. FOOTREST/ LEGREST: Elevating legrests that are used with a wheelchair that is purchased or owned by the patient are coded E0990. This code is per legrest. Elevating legrests that are used with a capped rental wheelchair base should be coded K0195. This code is per pair of legrests. NONSTANDARD SEAT FRAME DIMENSIONS: For all adult wheelchairs (E1161, K0001-K0009, K0010-K0014), payment for seat widths and/or seat depths of 15-19 inches are included in the payment for the base code. These seat dimensions should not be separately billed. Codes E2201-E2204 and E2340-E2343 describe seat widths and/or depths of 20 inches or more for manual or power wheelchairs. REAR WHEELS FOR MANUAL WHEELCHAIRS:

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A push-rim activated power assist (E0986) is an option for a manual wheelchair in which sensors in specially designed wheels determine the force that is exerted by the patient on the wheel. Additional propulsive and/or braking force is then provided by motors in each wheel. Batteries are included. Code K0064 (flat free insert) is used to describe either 1) a removable ring of firm material that is placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured or 2) nonremovable foam material in a foam filled rubber tire. It should not be used for a solid self-skinning polyurethane tire. POWER SEATING SYSTEMS: A power tilt seating system (E1002) includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway detachable legrests; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to tilt to greater than or equal to 45 degrees from horizontal; back height of at least 20 inches; ability for the supplier to adjust the seat to back angle; ability to support patient weight of at least 250 pounds. A power recline seating system (E1003-E1005) includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height arm rests; fixed or swingaway detachable legrests; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to recline to greater than or equal to 150 degrees from horizontal; back height of at least 20 inches; ability to support patient weight of at least 250 pounds. A power tilt and recline seating system (E1006-E1008) includes: a solid seat platform and a solid back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or swingaway detachable legrests; fixed or flip-up footplates; two motors and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to tilt to greater than or equal to 45 degrees from horizontal; ability to recline to greater than or equal to 150 degrees from horizontal; back height of at least 20 inches; ability to support patient weight of at least 250 pounds. A mechanical shear reduction feature (E1004 and E1007) consists of two separate back panels. As the posterior back panel reclines or raises there is a mechanical linkage between the two panels which allows the patient's back to stay in contact with the anterior panel without sliding along that panel. A power shear reduction feature (E1005 and E1008) consists of two separate back panels. As the posterior back panel reclines or raises there is a separate motor which controls the linkage between the two panels and allows the patient's back to stay in contact with the anterior panel without sliding along that panel. A mechanically linked leg elevation feature (E1009) involves a pushrod which connects the legrest to a power recline seating system. With this feature, when the back reclines, the legrest elevates; when the back raises, the legrest lowers. A power leg elevation feature (E1010) involves a dedicated motor and related electronics with or without variable speed programmability which allows the legrest to be raised and lowered independently of the recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with the power tilt and/or recline control(s). A power seat elevation system (E2300) includes: a motor and related electronics with or without variable speed programmability; a switch control which is independent of the power wheelchair drive control interface; any hardware that is needed to attach the seating system to the wheelchair base. It must provide a seat elevation of at least 6 inches. A power standing system (E2301) includes: a solid seat platform and a solid back; detachable or flip-up fixed height armrests; hinged legrests; anterior knee supports; fixed or flip-up footplates; a motor and related electronics with or without variable speed programmability; a basic switch control which is independent of the power wheelchair drive control

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interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not include a headrest. It must have the following features: ability to move the patient to a standing position; ability to support patient weight of at least 250 pounds. Codes E2310 and E2311 describe the electronic components that allow the patient to control two or more of the following motors from a single interface (e.g., proportional joystick, touchpad, or nonproportional interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, power seat elevation, power standing. It includes a function selection switch which allows the patient to select the motor that is being controlled and an indicator feature to visually show which function has been selected. When the wheelchair drive function has been selected, the indicator feature may also show the direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for fixed mounting hardware for the control box and for the display box (if present). Codes E1019 (Power seating system, heavy duty feature, patient weight capacity greater than 250 pounds and less than or equal to 400 pounds) and E1021 (Power seating system, extra heavy duty feature, weight capacity greater than 400 pounds) are invalid for claim submission to the DMERC. POWER WHEELCHAIR DRIVE CONTROL SYSTEMS: The term interface in the code narrative and definitions describes the mechanism for controlling the movement of a power wheelchair. Examples of interfaces include, but are not limited to, joystick, sip and puff, chin control, head control, etc. A proportional interface is one in which the direction and amount of movement by the patient controls the direction and speed of the wheelchair. One example of a proportional interface is a standard joystick. A nonproportional interface is one which involves a number of switches. Selecting a particular switch determines the direction of the wheelchair, but the speed is pre-programmed. One example of a nonproportional interface is a sip-and-puff mechanism. The term controller describes the electronics that connect the interface to the motor and gears in the power wheelchair base. A switch is an electronic device which turns power to a particular function either "on" or "off". The external component of a switch may be either mechanical or nonmechanical. Mechanical switches involve physical contact in order to be activated. Examples of the external components of mechanical switches include, but are not limited to, toggle, button, ribbon, etc. Examples of the external components of nonmechanical switches include, but are not limited to, proximity, infrared, etc. Some of the codes include multiple switches. In those situations, each functional switch may have its own external component or multiple functional switches may be integrated into a single external switch component or multiple functional switches may be integrated into the wheelchair control interface without having a distinct external switch component. A stop switch allows for an emergency stop when a wheelchair with a nonproportional interface is operating in the latched mode. (Latched mode is when the wheelchair continues to move without the patient having to continually activate the interface.) This switch is sometimes referred to as a kill switch. A direction change switch allows the patient to change the direction that is controlled by another separate switch or by a mechanical proportional head control interface. For example, it allows a switch to initiate forward movement one time and backward movement another time. A function selection switch allows the patient to determine what operation is being controlled by the interface at any particular time. Operations may include, but are not limited to, drive forward, drive backward, tilt forward, recline backward, etc. The interfaces described by codes E2320-E2322, E2325, and E2327-E2330 must have programmable control parameters for speed adjustment, tremor dampening, acceleration control, and braking. A remote joystick (E2320, E2321) is one in which the joystick itself is separate from the controller box (i.e., the box containing the electronics that connects the interface to the motor and gears). These codes include remote joysticks that are used for hand control as well as joysticks that are used for chin control. Code E2320 includes either a standard proportional

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remote joystick stick or a proportional remote joystick in which small movements of the joystick are sufficient to control the wheelchair. The latter type of joysticks are sometimes referred to as mini-proportional, compact, or short throw joysticks. When code E2320 or E2321 is used for a chin control interface, the chin cup is billed separately with code E2324. Code E2320 also describes a touchpad which is an interface similar to the pad-type mouse found on portable computers. Code E2322 describes a system of 3-5 mechanical switches which are activated by the patient touching the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch, if provided, are included in the allowance for the code. Code E2323 includes prefabricated joystick handles that have shapes other than a straight stick – e.g., U shape or T shape – or that have some other nonstandard feature – e.g., flexible shaft. A sip and puff interface (E2325) is a nonproportional interface in which the patient holds a tube in their mouth and controls the wheelchair by either sucking in (sip) or blowing out (puff). A mechanical stop switch is included in the allowance for the code. E2325 does not include the breath tube kit which is described by code E2326. A proportional, mechanical head control interface (E2327) is one in which a headrest is attached to a joystick-like device. The direction and amount of movement of the patient's head pressing on the headrest control the direction and speed of the wheelchair. A mechanical direction control switch is included in the code. A proportional, electronic head control interface (E2328) is one in which a patient's head movements are sensed by a box placed behind the patient's head. The direction and amount of movement of the patient's head (which does not come in contact with the box) control the direction and speed of the wheelchair. A proportional, electronic extremity control interface (E2328) is one in which the direction and amount of movement of the patient's arm or leg control the direction and speed of the wheelchair. A nonproportional, contact switch head control interface (E2329) is one in which a patient activates one of three mechanical switches placed around the back and sides of their head. These switches are activated by pressure of the head against the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch is included in the allowance for the code. A nonproportional, proximity switch head control interface (E2330) is one in which a patient activates one of three switches placed around the back and sides of their head. These switches are activated by movement of the head toward the switch, though the head does not touch the switch. The switch that is selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch is included in the allowance for the code. An attendant control (E2331) is one which allows a caregiver to drive the wheelchair instead of the patient. The attendant control is usually mounted on one of the rear canes of the wheelchair. This code is limited to proportional control devices, usually a joystick. OTHER POWER WHEELCHAIR ACCESSORIES: Codes K0093 and K0097 (flat free insert, power wheelchair) are used to describe either 1) a removable ring of firm material that is placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured or 2) nonremovable foam material in a foam filled rubber tire. It should not be used for a solid self-skinning polyurethane tire. Code E2351 describes an electronic interface used with a speech generating device. An electronic interface that is used to allow lights or other electrical devices to be operated using the power wheelchair control interface must be billed with code A9270 (non-covered item). MISCELLANEOUS: Code E1028 is used for swingaway hardware used with interfaces described by codes E2320 and E2321, swingaway or flip-down hardware for head control interfaces E2327-E2330, and swingaway hardware for an indicator display box that is

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related to the multi-motor electronic connection codes E2310 or E2311. Code E1028 is not to be used for swing away hardware used with a sip and puff interface (E2325) because swingaway hardware is included in the allowance for that code. See Wheelchair Seating Policy article for information concerning uses of E1028 for positioning accessories. Code E1029 describes a ventilator tray which is attached in a fixed position to the wheelchair base or back. Code E1030 describes a ventilator tray which is attached to the seat back and is articulated so that the tray will remain horizontal when the seat back is raised or lowered. Code E1225 describes a manually operated reclining back that can recline greater than 15 degrees but less than 80 degrees. Code E1226 describes a manually operated reclining back that recline 80 degrees or greater. These codes may be used for a manual reclining back that is used on either a manual or a power wheelchair. APPENDIX: A Column II code is included in the allowance for the corresponding Column I code when provided at the same time. When multiple nonbolded codes are listed in column I, all the bolded codes in column II relate to each nonbolded code in column I.

Column I Column II Power Operated Vehicle (E1230) (All options and accessories) Manual Wheelchair Base (E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009)

E0981, E0982, E0995, K0015, K0017, K0018, K0019, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0052, K0060, K0061, K0066, K0069, K0070, K0071, K0072, K0076, K0077, K0081, K0452

Power Wheelchair Base (K0010, K0011, K0012, K0014)

E0971, E0981, E0982, E0995, E2366, E2367, K0015, K0017, K0018, K0019, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0081, K0090, K0092, K0094, K0096, K0098, K0099, K0452

E0973 K0017, K0018, K0019 E0990 E0995, K0042, K0043, K0044, K0045, K0046, K0047 Power tilt and/or recline seating systems (E1002, E1003, E1004, E1005, E1006, E1007, E1008)

E0973, K0015, K0017, K0018, K0019, K0020, K0023, K0024, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052

E1009, E1010 E0990, E0995, K0042. K0043, K0044, K0045, K0046, K0047, K0052, K0053, K0195

E2325 E1028 K0039 K0038 K0045 K0043, K0044 K0046 K0043 K0047 K0044 K0053 E0990, E0995, K0042, K0043, K0044, K0045, K0046,

K0047 K0069 K0066 K0070 K0067, K0068 K0071 K0074, K0078 K0072 K0075 K0077 K0076 K0090 K0091 K0092 K0090, K0091 K0096 K0094, K0095 K0195 E0995, K0042, K0043, K0044, K0045, K0046, K0047

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Documentation Requirements Wheelchair options/accessories which require a Certificate of Medical Necessity (CMN) are: E0973, E0990, K0017, K0018, K0020, E1226, K0046, K0047, K0053, and K0195. For these items, a CMN which has been completed, signed and dated by the treating physician must be kept on file by the supplier and made available to the DMERC on request. For these items, the CMN may act as a substitute for a written order if it contains all of the required elements of an order. Depending on the type of wheelchair, the CMN for these options/accessories is either HCFA Form 843 (power wheelchairs) or HCFA Form 844 (manual wheelchairs). For these items, the initial claim must include a copy of the CMN. When billing option/accessory codes as a replacement (modifier RP), documentation of the medical necessity for the item, make and model name of the wheelchair base it is being added to, and the date of purchase of the wheelchair must be submitted with the claim. When code K0108 is billed, the claim must include a narrative description of the item, the manufacturer, the model name or number (if applicable), and information justifying the medical necessity for the item. If a formal wheelchair evaluation has been performed, it would be appropriate to include this information as documentation. Documentation for individual consideration might include information on the patient's diagnosis, the patient's abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency and nature of the activities the patient performs, etc.), the duration of the condition, the expected prognosis, past experience using similar equipment. Claim Transmission Allwin Data will automatically attach all required capped rental modifiers. Should you begin processing through Allwin Data halfway through a capped rental period, Allwin Data will attach the proper capped-rental modifiers only if the claim shows a date written that is accurate with the beginning of the rental period. If you are unsure of what date is showing up in the date written field please call Allwin Data following your first transmission of a capped rental item in the middle of the rental period. Upon receiving the completed CMN (for those accessories that require it) from the physician the pharmacy has two ways to get the CMN to Allwin Data before the claim can be transmitted. The pharmacy may enter the CMN using the Allwin Data website and transmit the claim upon acceptance of the CMN by the Allwin system, or the pharmacy may fax the CMN to Allwin Data for processing. Please allow 24 hrs for processing when the CMN is faxed to Allwin Data. For those items that require specific LT or RT modifiers the pharmacy will have to transmit this information with the claim. HCPCS Codes ARM OF CHAIR HCPCS Description Quantity Notes

E0973 WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH CMN

K0015 DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH K0017 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, BASE, EACH CMN K0018 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER PORTION, EACH CMN K0019 ARM PAD, EACH K0020 FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR CMN

L3964

SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L3965

SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, ADJUSTABLE RANCHO TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

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L3966

SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, RECLINING, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L3968

SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, FRICTION ARM SUPPORT (FRICTION DAMPENING TO PROXIMAL AND DISTAL JOINTS), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L3969

SHOULDER ELBOW ORTHOSIS, MOBILE ARM SUPPORT, MONOSUSPENSION ARM AND HAND SUPPORT, OVERHEAD ELBOW FOREARM HAND SLING SUPPORT, YOKE TYPE SUSPENSION SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L3970 SEO, ADDITION TO MOBILE ARM SUPPORT, ELEVATING PROXIMAL ARM

L3972 SEO, ADDITION TO MOBILE ARM SUPPORT, OFFSET OR LATERAL ROCKER ARM WITH ELASTIC BALANCE CONTROL

L3974 SEO, ADDITION TO MOBILE ARM SUPPORT, SUPINATOR BACK OF CHAIR HCPCS Description Quantity Notes E0971 ANTI-TIPPING DEVICE WHEELCHAIRS NC E1014 RECLINING BACK, ADDITION TO PEDIATRIC WHEELCHAIR

E1025 LATERAL THORACIC SUPPORT, NON-CONTOURED, FOR PEDIATRIC WHEELCHAIR, EACH (INCLUDES HARDWARE)

E1026 LATERAL THORACIC SUPPORT, CONTOURED, FOR PEDIATRIC WHEELCHAIR, EACH (INCLUDES HARDWARE)

E1027 LATERAL/ANTERIOR SUPPORT, FOR PEDIATRIC WHEELCHAIR, EACH (INCLUDES HARDWARE)

E0966 HOOK-ON HEADREST EXTENSION SEAT HCPCS Description Quantity Notes K0650 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES,

ANY DEPTH K0651 GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR

GREATER, ANY DEPTH K0652 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22

INCHES, ANY DEPTH K0653 SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR

GREATER, ANY DEPTH K0654 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES,

ANY DEPTH K0655 POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR

GREATER, ANY DEPTH K0656 SKIN PROTECTION AND POSITIONING WHEELCHAIR CUSHION, WIDTH LESS

THAN 22 INCHES, ANY DEPTH K0657 SKIN PROTECTION AND POSITIONING WHEELCHAIR CUSHION, WIDTH 22

INCHES OR GREATER, ANY DEPTH K0658 CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZE K0659 WHEELCHAIR SEAT CUSHION POWERED K0660 GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES,

ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE K0661 GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR

GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

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K0662 POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

K0663 POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

K0664 POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

K0665 POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

K0666 CUSTOM FABRICATED WHEELCHAIR BACK CUSHION, ANY SIZE, INCLUDING ANY TYPE MOUNTING HARDWARE

K0668 REPLACEMENT COVER FOR WHEELCHAIR SEAT CUSHION OR BACK CUSHION, EACH

E0992 SOLID SEAT INSERT, PLANAR SEAT, SINGLE DENSITY FOAM FOOTREST/LEGREST HCPCS Description Quantity Notes E0951 LOOP HEEL, EACH NC E0952 TOE LOOP/HOLDER, EACH

E0990 WHEELCHAIR ACCESSORY, ELEVATING LEGREST, COMPLETE ASSEMBLY, EACH CMN

E0995 WHEELCHAIR ACCESSORY, CALF REST/PAD, EACH E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR K0037 HIGH MOUNT FLIP-UP FOOTREST, EACH K0038 LEG STRAP, EACH K0039 LEG STRAP, H STYLE, EACH K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH K0041 LARGE SIZE FOOTPLATE, EACH K0042 STANDARD SIZE FOOTPLATE, EACH K0043 FOOTREST, LOWER EXTENSION TUBE, EACH K0044 FOOTREST, UPPER HANGER BRACKET, EACH K0045 FOOTREST, COMPLETE ASSEMBLY K0046 ELEVATING LEGREST, LOWER EXTENSION TUBE, EACH CMN K0047 ELEVATING LEGREST, UPPER HANGER BRACKET, EACH CMN K0050 RATCHET ASSEMBLY K0051 CAM RELEASE ASSEMBLY, FOOTREST OR LEGREST, EACH K0052 SWINGAWAY, DETACHABLE FOOTRESTS, EACH K0053 ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH CMN

K0195 ELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE) CMN

SEAT WIDTH, DEPTH, HEIGHT HCPCS Description Quantity Notes E1011 MODIFICATION TO PEDIATRIC WHEELCHAIR, WIDTH ADJUSTMENT

PACKAGE (NOT TO BE DISPENSED WITH INITIAL CHAIR) E2201 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH

GREATER THAN OR EQUAL TO 20 IN & LESS THAN 24 INCHES E2202 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH,

24-27 INCHES

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E2203 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN 22 INCHES

E2204 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES

K0056 SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH, LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR

HANDRIMS WITHOUT PROJECTIONS HCPCS Description Quantity Notes K0059 PLASTIC COATED HANDRIM, EACH K0060 STEEL HANDRIM, EACH K0061 ALUMINUM HANDRIM, EACH HANDRIMS WITH PROJECTIONS HCPCS Description Quantity Notes E0967 HANDRIM WITH PROJECTIONS, EACH REAR WHEELS HCPCS Description Quantity Notes K0064 ZERO PRESSURE TUBE (FLAT FREE INSERTS), ANY SIZE, EACH K0065 SPOKE PROTECTORS, EACH K0066 SOLID TIRE, ANY SIZE, EACH K0067 PNEUMATIC TIRE, ANY SIZE, EACH K0068 PNEUMATIC TIRE TUBE, EACH K0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR

MOLDED, EACH K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR

MOLDED, EACH MOTORIZED/POWER WHEELCHAIR PARTS HCPCS Description Quantity Notes K0090 REAR WHEEL TIRE FOR POWER WHEELCHAIR, ANY SIZE, EACH

K0091 REAR WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE FOR POWER WHEELCHAIR, ANY SIZE, EACH

K0092 REAR WHEEL ASSEMBLY FOR POWER WHEELCHAIR, COMPLETE, EACH

K0093 REAR WHEEL, ZERO PRESSURE TIRE TUBE (FLAT FREE INSERT) FOR POWER WHEELCHAIR, ANY SIZE, EACH

K0094 WHEEL TIRE FOR POWER BASE, ANY SIZE, EACH

K0095 WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE FOR EACH BASE, ANY SIZE, EACH

K0096 WHEEL ASSEMBLY FOR POWER BASE, COMPLETE, EACH

K0097 WHEEL ZERO PRESSURE TIRE TUBE (FLAT FREE INSERT) FOR POWER BASE, ANY SIZE, EACH

K0098 DRIVE BELT FOR POWER WHEELCHAIR K0099 FRONT CASTER FOR POWER WHEELCHAIR, EACH BATTERIES/CHARGERS FOR MOTORIZED/POWER WHEELCHAIRS HCPCS Description Quantity Notes E2360 22 NF NON-SEALED LEAD ACID BATTERY, EACH

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E2361 22 NF SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL, ABSORBED GLASS MAT)

E2362 GROUP 24 NON-SEALED LEAD ACID BATTERY, EACH

E2363 GROUP 24 SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL ABSORBED GLASS MAT)

E2364 U-1 NON-SEALED LEAD ACID BATTERY, EACH

E2365 U-1 SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL, ABSORBED GLASS MAT)

E2366 BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY ONE BATTERY TYPE, SEALED OR NON-SEALED

E2367 BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER BATTERY TYPE, SEALED OR NON-SEALED

FRONT CASTERS HCPCS Description Quantity Notes K0071 FRONT CASTER ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, EACH

K0072 FRONT CASTER ASSEMBLY, COMPLETE, WITH SEMI-PNEUMATIC TIRE, EACH

K0073 CASTER PIN LOCK,EACH K0074 PNEUMATIC CASTER TIRE, ANY SIZE, EACH K0075 SEMI-PNEUMATIC CASTER TIRE, ANY SIZE, EACH K0076 SOLID CASTER TIRE, ANY SIZE, EACH K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACH K0078 PNEUMATIC CASTER TIRE TUBE, EACH WHEEL LOCK HCPCS Description Quantity Notes E0961 WHEEL LOCK EXTENSION (HANDLE), EACH K0081 WHEEL LOCK ASSEMBLY, COMPLETE, EACH MISCELLANEOUS ACCESSORIES HCPCS Description Quantity Notes

E0958 WHEELCHAIR ATTACHMENT TO CONVERT ANY WHEELCHAIR TO ONE ARM DRIVE

E0959

WHEELCHAIR ADAPTER FOR AMPUTEE, PAIR (DEVICE USED TO COMPENSATE FOR TRANSFER OF WEIGHT DUE TO LOST LIMBS TO MAINTAIN PROPER BALANCE)

E1015 SHOCK ABSORBER FOR MANUAL WHEELCHAIR, EACH E0972 TRANSFER BOARD OR DEVICE, EACH E0974 ANTI-ROLLBACK DEVICE, EACH E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH

E1017 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MANUAL WHEELCHAIR, EACH

E1018 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR, EACH

E1226 MANUAL WHEELCHAIR ACCESSORY, FULLY RECLINING BACK, EACH K0102 CRUTCH AND CANE HOLDER, EACH NC K0104 CYLINDER TANK CARRIER, EACH

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K0105 IV HANGER, EACH K0106 ARM TROUGH, EACH E0950 WHEELCHAIR TRAY E0981 SEAT UPHOLSTERY, REPLACEMENT ONLY, EACH E0982 BACK UPHOLSTERY, REPLACEMENT ONLY, EACH E0985 WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM K0108 WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED K0452 WHEELCHAIR BEARINGS, ANY TYPE



NC Not Covered.




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XXI - Oxygen

Coverage and Payment Rules Home oxygen therapy is covered only if all of the following conditions are met: 1. The treating physician has determined that the patient has a severe lung disease or hypoxia-related symptoms that might

be expected to improve with oxygen therapy, and 2. The patient's blood gas study meets the criteria stated below, and 3. The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory

services, and 4. The qualifying blood gas study was obtained under the following conditions:

• If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the one obtained closest to, but no earlier than 2 days prior to the hospital discharge date, or

• If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the patient is in a chronic stable state – i.e., not during a period of acute illness or an exacerbation of their underlying disease, and

5. Alternative treatment measures have been tried or considered and deemed clinically ineffective. Group I criteria include any of the following: 1. An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake), or 2. An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, for at least 5 minutes

taken during sleep for a patient who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89% while awake, or

3. A decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent, for at least 5 minutes taken during sleep associated with symptoms or signs reasonably attributable to hypoxemia (e.g., cor pulmonale, "P" pulmonale on EKG, documented pulmonary hypertension and erythrocytosis), or

4. An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise for a patient who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent during the day while at rest. In this case, oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.

Initial coverage for patients meeting Group I criteria is limited to 12 months or the physician-specified length of need, whichever is shorter. (Refer to the Documentation portion of this section for information on recertification.) Group II criteria include the presence of (a) an arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake), during sleep for at least 5 minutes, or during exercise (as described under Group I criteria) and (b) any of the following: 1. Dependent edema suggesting congestive heart failure, or 2. Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool

scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVF), or 3. Erythrocythemia with a hematocrit greater than 56 percent. Initial coverage for patients meeting Group II criteria is limited to 3 months or the physician specified length of need, whichever is shorter. (Refer to the Documentation portion of this section for information on recertification.) Group III includes patients with arterial PO2 levels at or above 60 mm Hg or arterial blood oxygen saturations at or above 90 percent. For these patients there is a rebuttable presumption of noncoverage. For all the sleep oximetry criteria described above, the 5 minutes does not have to be continuous.

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If all of the coverage conditions specified above are not met, the oxygen therapy will be denied as not medically necessary. Oxygen therapy will also be denied as not medically necessary if any of the following conditions are present: 1. Angina pectoris in the absence of hypoxemia. This condition is generally not the result of a low oxygen level in the

blood and there are other preferred treatments. 2. Dyspnea without cor pulmonale or evidence of hypoxemia. 3. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the

absence of systemic hypoxemia. There is no evidence that increased PO2 will improve the oxygenation of tissues with impaired circulation.

4. Terminal illnesses that do not affect the respiratory system. The qualifying blood gas study must be one that complies with the Fiscal Intermediary or Local Carrier policy on the standards for conducting the test and is covered under Medicare Part A or Part B. This includes a requirement that the test be performed by a provider who is qualified to bill Medicare for the test – i.e., a Part A provider, a laboratory, an Independent Diagnostic Testing Facility (IDTF), or a physician. A supplier is not considered a qualified provider or a qualified laboratory for purposes of this policy. Blood gas studies performed by a supplier are not acceptable. In addition, the qualifying blood gas study may not be paid for by any supplier. This prohibition does not extend to blood gas studies performed by a hospital certified to do such tests. For sleep oximetry studies, the oximeter provided to the patient must be tamper-proof and must have the capability to download data that allows documentation of the duration of oxygen desaturation below a specified value. The qualifying blood gas study may be performed while the patient is on oxygen as long as the reported blood gas values meet the Group I or Group II criteria. For Initial Certifications, the blood gas study reported on the Certificate of Medical Necessity (CMN) must be the most recent study obtained prior to the Initial Date indicated in Section A of the CMN and this study must be obtained within 30 days prior to that Initial Date. There is an exception for patients who were on oxygen in a Medicare HMO and who transition to fee-for-service Medicare. For those patients, the blood gas study does not have to be obtained 30 days prior to the Initial Date, but must be the most recent test obtained while in the HMO. For patients initially meeting Group I criteria, the most recent blood gas study prior to the thirteenth month of therapy must be reported on the Recertification CMN. An exception would be situations in which the initial test was performed at rest/awake and on room air and the most recent test was performed on oxygen and was nonqualifying. In those situations, report the most recent at rest/awake test on room air. For patients initially meeting Group I criteria, if the estimated length of need on the Initial CMN is less than lifetime and the physician wants to extend coverage, a repeat blood gas study must be performed within 30 days prior to the date of the Revised Certification. For patients initially meeting Group II criteria, the most recent blood gas study which was performed between the 61st and 90th day following Initial Certification must be reported on the Recertification CMN. An exception would be situations in which the initial test was performed at rest/awake and on room air and the most recent test was performed on oxygen and was nonqualifying. In those situations, report the most recent at rest/awake test on room air. If a qualifying test is not obtained between the 61st and 90th day of home oxygen therapy, but the patient continues to use oxygen and a test is obtained at a later date, if that test meets Group I or II criteria, coverage would resume beginning with the date of that test. For patients initially meeting Group II criteria, if the estimated length of need on the Initial CMN is less than lifetime and the physician wants to extend coverage, a repeat blood gas study must be performed within 30 days prior to the date of the Revised Certification. For any Revised CMN, the blood gas study reported on the CMN must be the most recent test performed prior to the Revised date. A repeat blood gas study may be requested at any time at the discretion of the DMERC. When both arterial blood gas (ABG) and oximetry tests have been performed on the same day under the same conditions

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(i.e., at rest/awake, during exercise, or during sleep), the ABG result will be used to determine if the coverage criteria were met. If an ABG test at rest/awake is nonqualifying, but an exercise or sleep oximetry test on the same day is qualifying, the oximetry test result will determine coverage. The patient must be seen and evaluated by the treating physician within 30 days prior to the date of Initial Certification. The patient must be seen and re-evaluated by the treating physician within 90 days prior to the date of any Recertification. If the patient is not seen and re-evaluated within 90 days prior to Recertification but is subsequently seen, payment can be made for dates of service between the scheduled Recertification date and the physician visit date if the blood gas study criteria are met. Portable Oxygen Systems: A portable oxygen system is covered if the patient is mobile within the home and the qualifying blood gas study was performed while at rest (awake) or during exercise. If the only qualifying blood gas study was performed during sleep, portable oxygen will be denied as not medically necessary. If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the stationary system. (See exception in Liter Flow Greater Than 4 LPM.) If a portable oxygen system is covered, the supplier must provide whatever quantity of oxygen the patient uses; Medicare's reimbursement is the same, regardless of the quantity of oxygen dispensed. Liter Flow Greater Than 4 LPM: If basic oxygen coverage criteria have been met, a higher allowance for a stationary system for a flow rate of greater than 4 liters per minute (LPM) will be paid only if a blood gas study performed while the patient is on 4 LPM meets Group I or II criteria. If a flow rate greater than 4 LPM is billed and the coverage criterion for the higher allowance is not met, payment will be limited to the standard fee schedule allowance. If a patient qualifies for additional payment for greater than 4 LPM of oxygen and also meets the requirements for portable oxygen, payment will be made for either the stationary system (at the higher allowance) or the portable system (at the standard fee schedule allowance for a portable system), but not both. In this situation, if both a stationary system and a portable system are billed for the same rental month, the portable oxygen system will be denied as not separately payable. Oxygen Contents: Oxygen contents are included in the allowance for rented oxygen systems. Stationary oxygen contents (E0441, E0442) are separately payable only when the coverage criteria for home oxygen have been met and they are used with a patient owned stationary gaseous or liquid system respectively. Portable contents (E0443, E0444) are separately payable only when the coverage criteria for home oxygen have been met and: a) The beneficiary owns a concentrator and rents or owns a portable system, or b) The beneficiary rents or owns a portable system and has no stationary system (concentrator, gaseous, or liquid). If the criteria for separate payment of contents are met, they are separately payable regardless of the date that the stationary or portable system was purchased. Oxygen Accessories: Accessories, including but not limited to, cannulas (A4615), humidifiers (E0555), masks (A4620, A7525), mouthpieces (A4617), nebulizer for humidification (E0580), oxygen conserving devices (A9900), regulators (E1353), transtracheal catheters (A4608), and tubing (A4616) are included in the allowance for rented systems. The supplier must provide any accessory ordered by the physician. Accessories are separately payable only when they are used with a patient-owned system that was purchased prior to June 1, 1989. Accessories used with a patient-owned system that was purchased on or

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after June 1, 1989 will be denied as noncovered. Travel Oxygen: If a beneficiary travels out of their supplier's usual service area, it is the beneficiary's responsibility to arrange for oxygen during their travels. Medicare will only pay one supplier for oxygen during any one rental month. Oxygen services furnished by an airline to a beneficiary are noncovered. Payment for oxygen furnished by an airline is the responsibility of the beneficiary and not the responsibility of the supplier. Miscellaneous: Only rented oxygen systems (E0424, E0431, E0434, E0439, E1390RR) are eligible for coverage. Purchased oxygen systems (E0425, E0430, E0435, E0440, E1390NU, E1390UE) will be denied as noncovered. Emergency or stand-by oxygen systems will be denied as not medically necessary since they are precautionary and not therapeutic in nature. Oximeters (E0445) and replacement probes (A4606) will be denied as noncovered because they are monitoring devices that provide information to physicians to assist in managing the patient's treatment. Topical hyperbaric oxygen chambers (A4575) will be denied as not medically necessary. Respiratory therapists' services are noncovered under the DME benefit. Coding Guidelines For gaseous or liquid oxygen systems or contents, report one unit of service for one month rental. Do not report in cubic feet or pounds. The appropriate modifier must be used if the prescribed flow rate is less than 1 LPM (QE) or greater than 4 LPM (QF or QG). These modifiers may only be used with stationary gaseous (E0424) or liquid (E0439) systems or with an oxygen concentrator (E1390). They must not be used with codes for portable systems or oxygen contents. Claims for oxygen contents and/or oxygen accessories should not be submitted in situations in which they are not separately payable (see above). Documentation Requirements Initial CMN is Required:

• With the first claim to the DMERC for home oxygen (even if the patient was on oxygen prior to Medicare eligibility or oxygen was initially covered by a Medicare HMO).

• When an Initial CMN does not meet coverage criteria and the patient was subsequently retested and meets coverage criteria. The Initial Date on this new CMN is the date of the subsequent qualifying blood gas study.

• When there has been a change in the patient's condition that has caused a break in medical necessity of at least 60 days plus whatever days remain in the rental month during which the need for oxygen ended. (This indication does not apply if there was just a break in billing because the patient was in a hospital, nursing facility, hospice, or Medicare HMO, but the patient continued to need oxygen during that time.)

• When a Group I patient with a length of need less than or equal to 12 months was not retested prior to Revised Certification/ Recertification, but a qualifying study was subsequently performed. The Initial Date on this new CMN is the date of the subsequent qualifying blood gas study.

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• When the patient initially qualified in Group II, repeat blood gas studies were not performed between the 61st and 90th day of coverage, but a qualifying study was subsequently performed. The Initial Date on this new CMN may not be any earlier than the date of the subsequent qualifying blood gas study.

• When there was a change of supplier due to an acquisition and the previous supplier did not file a recertification when it was due and the requirements for the recertification were not met when it was due. The Initial Date on this new CMN is the date of the subsequent qualifying blood gas study.

The blood gas study reported on the Initial CMN must be the most recent study obtained prior to the Initial Date and this study must be obtained within 30 days prior to that Initial Date. There is an exception for patients who were on oxygen in a Medicare HMO and who transition to fee-for-service Medicare. For those patients, the blood gas study does not have to be obtained 30 days prior to the Initial Date, but must be the most recent test obtained while in the HMO. Recertification CMN is Required:

• 3 months after Initial Certification (i.e., with the fourth month's claim) - if oxygen test results on the Initial Certification are in Group II. The blood gas study reported must be the most recent study which was performed between the 61st and 90th day following the Initial Date.

• 12 months after Initial Certification (i.e., with the thirteenth month's claim) - if oxygen test results on the Initial Certification are in Group I. The blood gas study reported must be the most recent blood gas study prior to the thirteenth month of therapy.

• In other situations at the discretion of the DMERC. The blood gas study reported must be the most recent study which was performed within 30 days prior to the Recertification Date.

If a Group I patient with a lifetime length of need was not seen and evaluated by the physician within 90 days prior to the 12 month Recertification but was subsequently seen, the date on Recertification CMN should be the date of the physician visit. If there was a change of supplier due to an acquisition and the previous supplier did not file a recertification when it was due but all the requirements for the recertification were met when it was due, a Recertification CMN would be filed with the recertification date being 12 or 3 months after the Initial Date depending on whether the Initial Certification was based on Group I or Group II criteria. Revised CMN is Required:

• When the prescribed maximum flow rate changes from one of the following categories to another: (a) less than 1 LPM, (b) 1-4 LPM, (c) greater than 4 LPM. If the change is from category (a) or (b) to category (c), a repeat blood gas study with the patient on 4 LPM must be performed within 30 days prior to the start of the greater than 4 LPM flow.

• When a portable oxygen system is added subsequent to Initial Certification of a stationary system. In this situation, there is no requirement for a repeat blood gas study unless the initial qualifying study was performed during sleep, in which case a repeat blood gas study must be performed while the patient is at rest (awake) or during exercise within 30 days prior to the Revised Date.

• When a stationary system is added subsequent to Initial Certification of a portable system. In this situation, there is no requirement for a repeat blood gas study.

• When the length of need expires – if the physician specified less than lifetime length of need on the most recent CMN. In this situation, a blood gas study must be performed within 30 days prior to the Revised Date.

• When there is a new treating physician but the oxygen order is the same. In this situation, there is no requirement for a repeat blood gas study. Note: In this situation, the Revised CMN does not have to be submitted with the claim but must be kept on file by the supplier.

If there is a new supplier, that supplier must be able to provide the DMERC with an original CMN on request. (An original CMN is a CMN which has a physician's original signature on it. It is not necessarily an Initial CMN or the first CMN for that patient.) If the supplier obtains a new CMN, it would be considered a Revised CMN. In this situation, if the oxygen order is the same, the CMN does not have to be submitted with the claim.

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Submission of a Revised CMN does not change the Recertification schedule specified above. If the indications for a Revised CMN are met at the same time that a Recertification CMN is due, file the CMN as a Recertification CMN. Miscellaneous: In the following situations, a new order must be obtained and kept on file by the supplier, but neither a new CMN nor a repeat blood gas study are required:

• Prescribed maximum flow rate changes but remains within one of the following categories: (a) less than 1 LPM, (b) 1-4 LPM, (c) greater than 4 LPM.

• Change from one type of system to another (i.e., concentrator, liquid, gaseous). A new CMN is not required just because a patient changes from Medicare secondary to Medicare primary. A new CMN is not required just because the supplier changes assignment status on the submitted claim. Claim Transmission Upon receiving the completed CMN from the physician the pharmacy may fax the CMN to Allwin Data for processing. Please allow 24 hrs to process. When billing for a stationary gaseous oxygen system (E0424), stationary liquid oxygen system (E0439), or an oxygen concentrator (E1390) and the patient’s prescribed flow rate is less than 1 LPM a QE modifier must be indicated on the claim. If the patient’s prescribed flow rate is greater than 4 LPM a QF or QG modifier must be indicated on the claim. This is done by transmitting the HCPCS code with the appropriate modifier directly after it. HCPCS Codes Equipment HCPCS Description Quantity Notes E0424 STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM,

RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING

E0425 STATIONARY COMPRESSED GAS SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING

E0430 PORTABLE GASEOUS OXYGEN SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING

E0431 PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING

E0434 PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, HUMIDIFIER, FLOWMETER, REFILL ADAPTOR, CONTENTS GAUGE, CANNULA OR MASK, AND TUBING

E0435 PORTABLE LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, FLOWMETER, HUMIDIFIER, CONTENTS GAUGE, CANNULA OR MASK, TUBING AND REFILL ADAPTOR

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E0439 STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, & TUBING

E0440 STATIONARY LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES USE OF RESERVOIR, CONTENTS INDICATOR, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING

E0441 OXYGEN CONTENTS, GASEOUS (FOR USE WITH OWNED GASEOUS STATIONARY SYSTEMS OR WHEN BOTH A STATIONARY AND PORTABLE GASEOUS SYSTEM ARE OWNED), 1 MONTH'S SUPPLY = 1 UNIT

E0442 OXYGEN CONTENTS, LIQUID (FOR USE WITH OWNED LIQUID STATIONARY SYSTEMS OR WHEN BOTH A STATIONARY AND PORTABLE LIQUID SYSTEM ARE OWNED), 1 MONTH'S SUPPLY = 1 UNIT

E0443 PORTABLE OXYGEN CONTENTS, GASEOUS (FOR USE ONLY WITH PORTABLE GASEOUS SYSTEMS WHEN NO STATIONARY GAS OR LIQUID SYSTEM IS USED), 1 MONTH'S SUPPLY = 1 UNIT

E0444 PORTABLE OXYGEN CONTENTS, LIQUID (FOR USE ONLY WITHPORTABLE LIQUID SYSTEMS WHEN NO STATIONARY GAS OR LIQUID SYSTEM IS USED), 1 MONTH'S SUPPLY = 1 UNIT

E0445 OXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON-INVASIVELY

E1390 OXYGEN CONCENTRATOR, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE

Accessories

HCPCS Description Quantity Notes A4575 TOPICAL HYPERBARIC OXYGEN CHAMBER, DISPOSABLE A4606 OXYGEN PROBE FOR USE WITH OXIMETER DEVICE,

REPLACEMENT

A4608 TRANSTRACHEAL OXYGEN CATHETER, EACH A4615 CANNULA, NASAL A4616 TUBING (OXYGEN), PER FOOT A4617 MOUTH PIECE A4619 FACE TENT A4620 VARIABLE CONCENTRATION MASK A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR

SERVICE COMPONENT OF ANOTHER HCPCS CODE

E0455 OXYGEN TENT, EXCLUDING CROUP OR PEDIATRIC TENTS E0555 HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC

BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER

E0580 NEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER

E1353 REGULATOR E1355 STAND/RACK



NC Not Covered.


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Explanations of Notes Column CR Capped Rental item.


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XXII - APPENDIX I SUPPLEMENTAL INSURANCE BILLING Before using the Allwin Data system to indicate supplemental insurance coverage for a patient, it is important to determine how your pharmacy is set up with the National Supplier Clearinghouse. There are two specific types of Medicare providers, Participating Providers and Non-Participating Providers. The type of provider you are will determine when and if your supplemental insurance claims will be crossed over by Medicare. If you are unsure of what type of provider you are you can call the National Supplier Clearinghouse @ (866)238-9652. Non-Participating Providers For Non-Participating Providers, Medicare will only cross over supplemental insurance claims to those companies listed below as Complementary Insurance Companies. There are a few different ways to indicate in the claim the existence of a Complementary Insurance Company.

1. You can use the word “MEDIGAP” in the Group Field 2. For Medicaid, use the states postal abbreviation followed by “MEDCO”, for example, in Mississippi you would

put “MSMEDCO” in the Group Field. 3. If one of the companies listed in the Complementary Insurance Company list has an OCNA #, you can put that

OCNA# in the Group Field. 4. For TRICARE, you would put the word “TRICARE” in the Group Field. Only those companies listed in the Complementary Insurance Companies list will crossover for Non-Participating Providers.

Participating Providers For Participating Providers Medicare will cross over supplemental insurance claims to all companies listed in the Complementary Insurance Companies list, as well as all companies in the OCNA# List. There are a few different ways to indicate in the claim the existence of supplemental insurance.

1. You can use the word “MEDIGAP” in the Group Field for any company in the Complementary Insurance Companies list, or if the company also exists in the OCNA# List, you may use that companies OCNA#.

2. For Medicaid, use the states postal abbreviation followed by “MEDCO”, for example, in Mississippi you would put “MSMEDCO” in the Group Field.

3. For TRICARE, you would put the word “TRICARE” in the Group Field. 4. If the company is listed in the OCNA# List, use that specific OCNA# in the Group Field.

IMPORTANT Medicare will not automatically forward the coinsurance to Medicaid in Michigan and South Carolina. You may bill the coinsurance electronically to SC Medicaid through Allwin Data. Allwin Data will generate a HCFA form for the MI Medicaid coinsurance if you are enrolled in Allwin’s Manual Billing Service. The following Medicaids will only crossover if the pharmacy has called Allwin Data to have the patient’s Medicaid ID# added to our files: Vermont, New Hampshire, Maine, and Massachusetts. Allwin Data’s Manual Billing Service for Non-Participating Providers Allwin Data’s Manual Billing Service enables Non-Participating providers to send supplemental insurance claims to non-Complementary Insurance Companies. Non-Participating providers must enroll with Allwin Data’s Manual Billing Service to bill non-Complementary insurers as supplemental. This can be done by calling 800-879-6153. To determine your participation status, call the NSC at 866-238-9652 or log on to the following link: http://www.medicare.gov/supplier/Home.asp#NewSearch.

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Transmitting Supplemental Insurance Claims via Allwin’s Manual Billing Service Once enrolled with the Manual Billing service, providers use their system’s Group Number field to transmit OCNA Number and Cardholder ID in the following format: XXXX-ZZZZZZZZZZ DASH OCNA# SUPPLEMENTAL CARDHOLDER ID The OCNA#s that can be used in the Group Number field are listed on the OCNA Number List that follows. What happens next? Once the claim is successfully transmitted, Allwin will electronically transmit the Medicare portion, and will print out a hard-copy HCFA 1500 indicating “signature on file.” This paperwork will then be sent to you so that you may attach the Medicare remittance and send to the supplemental.

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Complementary Crossover Insurance Companies PLAN REGION AARP A,B,C,D Acordia Senior of the SE, Inc C AEGON B AETNA LIFE & CASUALTY A,B,C,D AFLAC A,B AIAG-UNION BANKERS B Aid Association for Lutherans D American Family Life Assurance C AMERICAN GEN. GRP. INSURANCE A,D American General Life Ins. Co. D American Insurance Amin. Group C AMERICAN NAT. INS. CO. B AMERICAN NAT. LIFE INS (STANDARD LIFE) A AMERICAN POSTAL WORKERS UNION (APWU) A,B,C,D American Republic A,B,C,D ANTHEM INSURANCE COMPANIES, INC B,D Bankers Fidelity Life D BANKERS LIFE & CASUALTY B BCBS Alabama A,B,C BCBS Anthem C BCBS ANTHEM (CMIC) B BCBS ANTHEM (FACETS) B BCBS ANTHEM NEW HAMPSHIRE A BCBS Arizona D BCBS Arkansas B BCBS Colorado C BCBS Colorado(FEP) C BCBS CONNECTICUT A BCBS DELAWARE A BCBS EMPIRE OF NY A,C BCBS FEP A BCBS Florida C BCBS HIGHMARK A,D BCBS Horizon of NJ C BCBS Iowa D BCBS Kansas D BCBS Louisiana C BCBS MARYLAND B BCBS MICHIGAN A,B,C,D BCBS MINNESOTA B,C BCBS MISSOURI A,D BCBS Nebraska D BCBS Nevada D

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BCBS New Hampshire C BCBS NEW JERSEY B BCBS New Mexico C BCBS North Carolina C BCBS North Dakota D BCBS Oklahoma A,B,C BCBS RHODE ISLAND A BCBS South Carolina (FEP) C BCBS South Carolina (over 65) C BCBS Texas C BCBS VIRGINIA B BCBS VIRGINIA (FEP) B BCBS WESTERN NY A BCBS Wisconsin B,C,D BENEFIT PLANNERS B Benefit Planners Ltd. C Blue Shield of California D Blue Shield of Idaho (FEP) D C.A.R.E. A Carefirst C CATERPILLAR INC B Celtic Life Ins D Central States A,C,D CLAIM PRO (ANTHEM INS CO) B Claims Administration Corp. (Mailhandlers) B,C Companion Life C Continental General D Continental Life Insurance C Dallas General Life Insurance C ELECTRONIC DATA SYSTEMS A Fortis Inc/Time D FORTIS INSURANCE COMPANY A GE Capital Ins D Government Employee Hospital Association (GEHA) A,B,C,D Group Health Inc. (GHI) A,C GROUP HOSPITAL MEDICAL SERVICES B HARRINGTON BENEFIT SERVICES B Health Data Management (HDM) B,C Heritage Health Plans C Highmark Services D Humana B,D J.F. MOLLOY & ASSOC. B King County D King County (FEP) D KIRKE-VAN ORSDEL INC. A,B KPS D

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KVI D LOCKHEED-MARTEN B MEDICAL MUTUAL OF OHIO A,B Medical Service Corp A,D Michigan Employed Benefit Services D Monumental Insurance Company C,D Mutual of Omaha A,B,C,D NAT ASSOC LETTER CARRIERS (NALC) A,B,C,D NORTH AMER INS CO. A,D NorthWest Medical D Olympic Health Management A,B,C,D Oxford Life Ins D Peoples Benefit Life Ins. Co. C,D Physicians Mutual A,B,C,D Pierce County D Pierce County (FEP) D Pioneer Life A,B,C,D Premera BC D Principal Financial Group D PROVIDIAN LIFE/HEALTH A Regence Blue Shield (Utah Only) D SAMBA B Savers Life Ins D Seabury and Smith Inc. C SECURITY HEALTH PLAN OF WISCONSIN B SPECIAL AGENTS MUT BENEFIT A Standard Life and Accident A,C State Farm D State Mutual Ins D TRICARE A,B,C,D Triple-S (Seguros de Servicio de Salud de Puerto Rico) C Unicare B,C,D Union Fidelity Life Ins. Co. A,C,D UNITED AMERICAN INS. CO. A,B,C,D UNITED COMMERCIAL TRAVELERS OF AMERICA B United HealthCare A,B,C,D United Teachers C USAA D USAA Life Insurance C USAble Life Ins D WEA INSURANCE COMPANY B WELLMARK B Westport Benefits D World Ins D WorldNet B,C,D

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OCNA Number List Insurance Plan Name City St OCNA Code Region(s)A AND H CLAIMS CHICAGO IL 60630A001 ABCD A HERBERT AGENCY INC NEW YORK NY 53066A001 C AAA LIFE INSURANCE CO HEATHROW FL 32740A001 C AAL DES MOINES IA 50306A004 D AARP MONTGOMERYVILLE PA 18936A001 BCD AARP FT WASHINGTON PA 18936A002 AD ACADEMY LIFE INS CO ATLANTA GA 30328A001 BCD ACCORDIA GOVT BENEFITS/AICI INDIANAPOLIS IN 46250A001 ABCD ACCORDIA SENIOR BENEFITS/ ANTHEM INS CO INDIANAPOLIS IN 46254A001 AC ACCORDIA/BCBS OF KY LOUISVILLE KY 40233B001 A ACEDEMY LIFE BRISTOL TN 37625A002 A ACORDIA BENEFITS ANAHEIM CA 92806A001 B ACORDIA LOCAL GOV SER INDIANAPOLIS IN 46240A001 B ACORDIA SENIOR BENEFITS INDIANAPOLIS IN 46207A001 B ADMINASTAR INC/ANTHEM DOCUMENT MGMT LOUISVILLE KY 40299A001 CD ADMINISTAR LOUISVILLE KY 40223A001 D ADMINISTRATIVE SERVICES INC ATLANTA GA 30345A001 B ADVANCED INS SERVICES MEMPHIS TN 38103A001 D ADVANCED INSURANCE ADM LITLE ROCK AR 72211A001 C AEGON MEDICARE SUPPLEMENT MOOSIC PA 18507A001 C AETNA LIFE AND CASUALTY MIDDLETOWN CT 06457A001 A AFLAC (AMER FAMILY LIFE ASSU) COLUMBUS GA 31999A001 BC AFLAC NEW YORK ALBANY NY 12205A001 A AGENCY SERVICES/AMERICARE MEMPHIS TN 37215A002 BD AGIA, INC. CARPINTERIA CA 93013A001 AC AGRICULTURAL INS ADMIN LEWISTON ID 83501A001 ABCD AIAG CLEARWATER FL 75201A001 C AID ASSOC FOR LUTHERANS APPLETON WI 54919A001 BCD AIG LIFE INS CO WILMINGTON DE 19801A001 ABCD AIROMD MAILHANDLERS INS ROCKVILLE MD 20855A001 BD ALLIANCE HEALTH BEN PLAN WASHINGTON DC 20065A001 ABCD ALLIANZ LIFE INSURANCE CO MINNEAPOLIS MN 55403A001 C ALTA HEALTH STRATEGIES BALTIMORE MD 21201A001 BC ALTA HLTH STRATEGIES SALT LAKE CITY UT 84130A001 A AMALGAMATED LIFE AND - 79 CHICAGO IL 60607A001 ABCD AMER BANKERS INS CO OF FL MIAMI FL 33157A001 ABD AMER COMBINED LIFE CLEARWATER FL 19047A001 BCD AMER COMMUNITY MUTUAL LIVONIA MI 48152A001 ACD AMER EXCHANGE LIFE INS CO/COMMUNITY MUTUAL RYE BROOK NY 75221A001 ABCD AMER HOECHSST PER WESTERN SPRINGS IL 60558A001 ABCD AMER INCOME LIFE INS WACO TX 76702A001 CD AMER INCOME LIFE INS WACO TX 76702A002 AB AMER INS CO OF TX FT WORTH TX 75266A001 D AMER LIFE INS CO COLUMBUS GA 31999A002 A AMER MANUFACTURERS MUTUAL LONG GROVE IL 60049A001 AC AMER PROGRESS LANDHIC OF NY RYE BROOK NY 10509A001 ABCD AMER PROTECTIVE LIFE INS CLEVELAND MS 38732A001 ABCD AMER TRAVELLERS INS DES MOINES IA 19020A001 BCD AMERICAN ASSOCIATION LAKEWOOD CA 90712A001 ABCD

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AMERICAN BANKERS INS FORT WORTH TX 76101A001 BD AMERICAN CAPITAL INS CO HOUSTON TX 77242A001 CD AMERICAN FAMILY MUTUAL INS CO MADISON WI 53783A001 ABCD AMERICAN GENERAL NASHVILLE TN 37250A001 ACD AMERICAN GENERAL LIFE AND ACCIDENT NASHVILLE TN 37202A001 B AMERICAN HARDWARE MUTUAL MINNEAPOLIS MN 55440A001 BCD AMERICAN INDEP LIFE INS CO KING OF PRUSSIA PA 19406A001 BCD AMERICAN INS CO OF TX DALLAS TX 75266A002 B AMERICAN INTEGRITY INS HARRISBURG PA 19101A001 BC AMERICAN LIFE AND ACC DALLAS TX 75221A002 BCD AMERICAN LIFE AND HEALTH MISSION VIEJO CA 92691A001 C AMERICAN MOTORISTS INS CO LONG GROVE IL 60049A002 AC AMERICAN NATIONAL INS CO GALVESTON TX 77553A001 BCD AMERICAN PATRIOT HEALTH CLEARWATER FL 33755A001 C AMERICAN PIONEER LIFE INS RYE BROOK NY 32804A001 AC AMERICAN REPUBLIC INS CO DES MOINES IA 50301A001 ABCD AMERICAN SERVICE LIFE INS CO FORT WORTH TX 76107A001 ABCD AMERICAN STD LIFE AND ACC CO ENID OK 73702A001 BD AMERICAN TRAVELLERS INS WARRINGTON PA 18976A001 B AMERICARE PROTECTION DES MOINES IA 50301A002 C AMF, INC. DES MOINES IA 50306A003 D AMOCO CASUALTY AND INDEM OMAHA NE 68102A001 ABC AMVETS INS PLAN MINNEAPOLIS MN 43216A001 BCD AON SELECT, INC. HARSHAM PA 64111A001 D AON SELECT, INC./NETWORK AMERICA LIFE HORSHAM PA 19044N001 AC APPALACHIAN LIFE INS CO HUNTINGTON WV 25701A001 ABCD APWU HEALTH PLAN SILVER SPRING MD 20904A001 A ARMCO MED INS SVC CT WORTHIGNTON OH 43805A001 B ASSOC DOCTORS HEALTH AND LIFE BIRMINGHAM AL 35202A001 B ASSOC DOCTORS HLTH AND LIFE TREVOSE PA 35289A001 BCD ASSOC MUTUAL HOSP SERV MI WARREN MI 48091A001 AC ASSOCIATED LIFE INS CO INDIANAPOLIS IN 46206A001 B ATCHISON TOPEKA TOPEKA KS 66612A001 ABCD ATLANTIC AMER INS CO ATLANTA GA 30319A001 ABCD ATLANTIC AMER LIFE INS ATLANTA GA 30219A002 B ATLANTIC AMER LIFE INS ATLANTA GA 30319A002 CD ATLANTIC AMER/BANKERS FIDEL ATLANTA GA 31319A003 B ATLANTIC AND PACIFIC INS CO ATLANTA GA 30359A001 B ATLANTIC COAST INS CO GAINESVILLE GA 30503A001 AB ATLANTIC INS CO OF SA AUSTIN TX 78714A001 BC AUSA MASTERCARE DES MOINES IA 50306A002 D AUSA MASTERCARE INS DES MOINES IA 50306A001 D AUTO OWNERS LIFE INS CO LANSING MI 48909A001 BCD AWARE GOLD ST PAUL MN 55164A001 BCD BADGER METER DES MOINES IA 50306B001 D BANKERS COMMER LIFE INS HOUSTON TX 75240B001 ABCD BANKERS FIDELITY LIFE INS ATLANTA GA 30319B001 C BANKERS FIDELITY LIFE INS/ATLANTIC AMERICAN ATLANTA GA 30319A003 BC BANKERS LIFE AND CASUALTY CHICAGO IL 02888B001 BD BANKERS LIFE AND CASUALTY CHICAGO IL 60630B001 ABCD BANKERS LIFE AND CASUALTY/CNA CHICAGO IL 60630B002 A BANKERS MULTIPLE LINE DALLAS TX 75221B001 BC BANKERS UNITED LIFE ASSUR SCRANTON PA 18504B001 AC

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BC OF PA/HIGHMARK PITTSBURGH PA 15242B001 ABCD BCBS CT-CONST HLTH CARE NORTH HAVEN CT 06473C001 A BCBS MOUNTAIN STATE CHARLESTON WV 25325B001 ABCD BCBS OF ALABAMA BIRMINGHAM AL 35244B001 ABC BCBS OF ARIZONA PHOENIX AZ 85069B001 ABCD BCBS OF ARKANSAS LITTLE ROCK AR 72203B001 ABCD BCBS OF CALIFORNIA WOODLAND HLS CA 91365B001 ABCD BCBS OF CALIFORNIA VAN NUYS CA 91470B001 ABCD BCBS OF CALIFORNIA OAKLAND CA 94612B001 B BCBS OF CALIFORNIA/UNICARE OXNARD CA 93031B002 AC BCBS OF CENTRAL NY SYRACUSE NY 13221B001 ABCD BCBS OF COLORADO DENVER CO 80203B001 ABCD BCBS OF COLORADO DENVER CO 80203B002 C BCBS OF CONNECTICUT NORTH HAVEN CT 06473B001 ABCD BCBS OF DELAWARE WILMINGTON DE 19801B001 BCD BCBS OF DELAWARE WILMINGTON DE 19899B001 A BCBS OF FED EMP. CLAIMS NORTH HAVEN CT 06473B002 A BCBS OF FED EMP. CLAIMS NORTH HAVEN CT 06473B003 A BCBS OF FLORIDA JACKSONVILLE FL 32202B001 ABCD BCBS OF FLORIDA WINTER HAVEN FL 33883B001 A BCBS OF GEORGIA COLUMBUS GA 31908B001 ABCD BCBS OF GREENVILLE GREENVILLE SC 29615B002 A BCBS OF ILLINOIS CHICAGO IL 60601B001 ABCD BCBS OF INDIANA INDIANAPOLIS IN 46204B001 C BCBS OF IOWA DES MOINES IA 50309B001 ABCD BCBS OF KANSAS TOPEKA KS 66629B001 ABCD BCBS OF KANSAS CITY KANSAS CITY KS 64141B001 ABCD BCBS OF KY/ANTHEM DOC MGT LOUISVILLE KY 40223B001 ABCD BCBS OF LOUISIANA BATON ROUGE LA 70898B001 ABCD BCBS OF MAINE SO PORTLAND ME 04106B001 ABCD BCBS OF MARYLAND OWING MILLS MD 21117B001 ABCD BCBS OF MASSACHUSETTS N QUINCY MA 02171B001 ABCD BCBS OF MEMPHIS MEMPHIS TN 38101B001 ABCD BCBS OF MICHIGAN NEW HUDSON MI 48226B001 ABCD BCBS OF MINNESOTA SAINT PAUL MN 55164B001 BCD BCBS OF MINNESOTA ST PAUL MN 55164B002 A BCBS OF MISSISSIPPI JACKSON MS 39215B001 ABCD BCBS OF MISSOURI SAINT LOUIS MO 63108B001 ABCD BCBS OF MONTANA HELENA MT 59604B001 ABCD BCBS OF NATIONAL CAPITAL AR WASHINGTON DC 20065B001 ABCD BCBS OF NEBRASKA OMAHA NE 68180B001 ABCD BCBS OF NEVADA RENO NV 89520B001 ABC BCBS OF NEW HAMPSHIRE MANCHESTER NH 03306B001 ABCD BCBS OF NEW JERSEY NEWARK NJ 07101B001 A BCBS OF NEW JERSEY NEWARK NJ 08206B001 ABCD BCBS OF NEW JERSEY NEWARK NJ 08206B002 C BCBS OF NEW MEXICO ALBUQUERQUE NM 87112B001 ABCD BCBS OF NEW MEXICO ALBUQUERQUE NM 87112B002 C BCBS OF NEW YORK MIDDLETOWN NY 10943B001 A BCBS OF NEW YORK UTICA NY 13502B001 B BCBS OF NEW YORK (NE) ALBANY NY 12205B001 ABCD BCBS OF NEW YORK (WEST) BUFFALO NY 14240B001 ABCD BCBS OF NEW YORK (WEST) BUFFALO NY 14240B002 D

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BCBS OF NEW YORK UTICA-WATERTOWN UTICA NY 13501B001 ACD BCBS OF NEW YORK/EMPIRE NEW YORK NY 10156B001 ABCD BCBS OF NORTH CAROLINA DURHAM NC 27702B001 ABCD BCBS OF NORTH DAKOTA FARGO ND 58121B001 ABD BCBS OF OHIO TOLEDO OH 43697B001 ABCD BCBS OF OHIO/MEDICAL MUTUAL CLEVELAND OH 44115B001 ABCD BCBS OF OKLAHOMA TULSA OK 74102B001 ABCD BCBS OF OREGON PORTLAND OR 97207B001 ABCD BCBS OF PENNSYLVANIA CAMPHILL PA 17011B001 B BCBS OF RHODE ISLAND PROVIDENCE RI 02903B001 ABCD BCBS OF ROCHESTER ROCHESTER NY 14604B001 C BCBS OF SOUTH CAROLINA COLUMBIA SC 29219B001 ABCD BCBS OF SOUTH DAKOTA SIOUX FALLS SD 57104B001 ABCD BCBS OF TENNESSEE CHATTANOOGA TN 37402B001 ABCD BCBS OF TEXAS SAN ANTONIO TX 78228B001 ABCD BCBS OF UTAH SALT LAKE CITY UT 84130B001 ABCD BCBS OF VERMONT MONTPELIER VT 05601B001 ABCD BCBS OF VIRGINIA ROANOKE VA 23230B001 BCD BCBS OF VIRGINIA ROANOKE VA 24045B001 A BCBS OF WASHINGTON DC WASHINGTON DC 20024B001 A BCBS OF WESTERN PA CAMP HILL PA 15222B001 C BCBS OF WISCONSIN MILWAUKEE WI 53203B001 BCD BCBS OF WISCONSIN OSHKOSH WI 54901B001 D BCBS OF WYOMING CHEYENNE WY 82003B001 ABCD BCBS UNITED OF WISCONSIN MILWAUKEE WI 53201U001 AC BCBS/TRIGON MUTUAL INS CO ROANOKE VA 24031B001 D BD OF PENSIONS - PRESBY C PHILADELPHIA PA 19101B001 ABCD BELL UNIT CHICAGO IL 60690B001 ABCD BENEFICIAL LIFE INS CO PORTLAND OR 97207B002 ABCD BENEFIT PLANNERS LTD BOERNE TX 78006B001 C BENEFIT TRUST LIFE INS LAKE FOREST IL 60045B001 ABCD BENEFIT TRUST LIFE TRUSTMARK INSURANCE BOARDMAN OH 63127B001 ABCD BLUE CROSS KINGS COUNTY SEATTLE WA 98111B002 ABCD BLUE CROSS OF ARIZONA PHOENIX AZ 85002B001 ABCD BLUE CROSS OF CALIFORNIA OXNARD CA 93031B001 BCD BLUE CROSS OF IDAHO BOISE ID 83707B001 ABCD BLUE CROSS OF MINNESOTA ROSEVILLE MN 55113B001 A BLUE CROSS OF NEW YORK ALBANY NY 12212B001 A BLUE CROSS OF OHIO (SW) CINCINNATI OH 45206B001 A BLUE CROSS OF PA-INDEPEND PHILADELPHIA PA 19103B001 ABCD BLUE CROSS OF TENNESSEE NASHVILLE TN 37212B001 ABCD BLUE CROSS OF VIRGINIA ROANOKE VA 24031B002 A BLUE CROSS OF WASHINGTON SEATTLE WA 98111B001 ABCD BLUE SHIELD NORTH DAKOTA FARGO ND 58103B001 ABCD BLUE SHIELD OF CALIFORNIA SAN FRANCISCO CA 94120B001 BCD BLUE SHIELD OF CALIFORNIA PLACERVILLE CA 95667B001 BCD BLUE SHIELD OF IDAHO LEWISTON ID 83501B001 B BLUE SHIELD OF IDAHO LEWISTON ID 86501B001 AC BLUE SHIELD OF OREGON PORTLAND OR 97207B003 A C M LIFE INS CO HARTFORD CT 06105C001 BD C. A. R. E. TEMPLE TX 76503C001 A CAL FARM BUR HEALTH INS PRO SACREMENTO CA 95851C001 ABCD CAPITAL SECURITY INS CO DURHAM NC 27702C001 AC

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CAREAMERICA LIFE INS CO CHATSWORTH CA 91311C001 ABD CAREFIRST OWING MILLS MD 21117C001 C CARLE CARE URBANA IL 61801C001 ABCD CATHOLIC GOLDEN AGE INS SCRANTON PA 18202C001 B CATHOLIC GOLDEN AGE INS SCRANTON PA 18505C001 ACD CELTIC LIFE INS CO BEDFORD PARK IL 60499C001 BCD CENTRAL BENEFITS COLUMBUS OH 43216C001 ABCD CENTRAL MASS HEALTH WORCESTER MA 01608C001 ABCD CENTRAL RESERVE LIFE INS STRONGSVILLE OH 44136C001 ABC CENTRAL SECURITY LIFE INS RICHARDSON TX 75083C001 ABCD CENTRAL STATES OMAHA NE 66134C001 AC CENTRAL STATES HEALTH AND LIFE CHICAGO IL 60631C001 BD CENTRAL STATES INS DES PLAINES IL 60017C001 B CENTRAL STATES OF OMAHA OMAHA NE 68134C001 BCD CERTIFIED LIFE INS CO CHICAGO IL 60630C001 ABCD CERTIFIED LIFE INS CO DALLAS TX 75265C001 BC CHRISTIAN FIDELITY LIFE WAXAHACHIE TX 75165C001 ABCD CINCINNATI LIFE INS CO CINCINNATI OH 45250C001 ABCD CITIZENS INS CO OF AMER AUSTIN TX 78767C001 ABD CITY OF OAK CREEK DES MOINES IA 50306C001 D CIVIL SRVC EMPLOYEES INS SAN FRANCISCO CA 94103C001 A CLALLAM COUNTY PHYS SVC PORT ANGELES WA 98362C001 AC CLINICIANS HEALTH NETWORK BAKERSFIELD CA 93301C001 ABCD CNA/CONTINENTAL CASUALTY ATLANTA GA 30345C001 ABCD CNA/CONTINENTAL CASUALTY NASHVILLE TN 37230C001 BC CNA/CONTINENTAL CASUALTY CHICAGO IL 60630C002 BCD COASTAL STATES OKLAHOMA CITY OK 73125C001 BD COLONIAL SPARTANSBURG SC 29306C001 AB COLONIAL INSURANCE CO CLEVELAND OH 44114C001 AC COLONIAL LIFE ATLANTA GA 29202C001 C COLONIAL LIFE CHARLESTON SC 29402C001 AB COLONIAL PENN INS CO PHILADELPHIA PA 19103C001 B COLONIAL PENN LIFE INS GREENVILLE SC 29601C001 BC COLORADO PIPE IND INS DENVER CO 80531C001 A COMBINED AMERICAN CHICAGO IL 60606C002 BC COMBINED INS CO OF AMER BELLINGHAM WA 60606C001 CD COMBINED UNDERWRITERS LIF TYLER TX 75710C001 BC COMMERCIAL LIFE INS SVANNAH GA 31401C001 B COMMONWEALTH INS CO COLUMBUS OH 43235C001 BD COMMONWEALTH NATIONAL LIFE CLEVELAND MS 38732C001 BCD COMMUNITY FINANCIAL AND INSURANCE CORP. MADISON WI 53705C001 A COMMUNITY MUTUAL INS WORTHINGTON OH 43085C001 A COMMUNITY MUTUAL INS CINCINNATI OH 45206C001 BCD COMPANION HEALTH CARE COLUMBIA SC 29223C001 BC COMPANION LIFE COLUMBIA SC 29202C002 AC COMPCARE HEALTH SERVICES INS CO MILWAUKEE WE 53203C001 B COMPCARE HLTH SVCS INS CO MILWAUKEE WI 53202C001 A COMPCARE HLTH SVCS INS CO MILWAUKEE WI 53202C002 CD COMPLETE HEALTH BIRMINGHAM AL 35202C001 BCD COMPLETE HEALTH, INC./SENIOR PARTNERS BIRMINGHAM AL 35205S001 AC CONESTOGA LIFE ASSUR CO LANCASTER PA 17604C001 AC CONFEDERATION LIFE INS CO NO CHARLESTON SC 29418C001 AB CONSECO DIRECT LIFE INS/COLONIAL LIFE PHILADELPHIA PA 19181C001 CD

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CONSECO SENIOR HEALTH INS CLEARWATER FL 33757C001 C CONSECO SENIOR HEALTH INS CLEARWATER FL 33767C001 C CONSUMER UNITED INS CO WASHINGTON DC 20063C001 ABC CONTINENTAL AMER LIFE WILMINGTON DE 19850C001 B CONTINENTAL ASSURANCE ATLANTA GA 30326C001 AB CONTINENTAL CASUALTY CHICAGO IL 60604C001 ABCD CONTINENTAL GENERAL INS WICHITA KS 67201C001 BCD CONTINENTAL GENERAL INS OMAHA NE 68114C001 B CONTINENTAL GENERAL INS OMAHA NE 68124C001 CD CONTINENTAL LIFE BRENTWOOD TN 37024C001 ABC COOPERATIVA DE SEGUROS SANJUAN PR 00936C001 ABCD CORNING GROUP INS DEPT CORNING NY 14830C001 BD CORPORATE LIFE INS CO WEST CHESTER PA 19381C001 BD CORROON AND BLACK NASHVILLE TN 37230C002 A COSMOPOLITAN LIFE INS CO WOODLAND HILLS CA 91365C001 ABD COUNTRY LIFE INS CO BLOOMINGTON IL 61702C001 AC CROLEY LIFE INS CO GILMER TX 75644C001 AB CRUS AZUL DE PUERTO RICO SANJUAN PR 00936C002 ABCD CUNA MUTUAL INS CO PELHAM AL 35124C001 ABD CUSTOM CARE CHARLOTTE NC 28235C001 AB DAIRY FARMERS OF AMERICA DES MOINES IA 50306D001 D DALLAS GENERAL LIFE DALLAS TX 75221D001 ABCD DEANCARE MADISON WI 53705D001 ABCD DIRECT OLIN STATFORD CT 06497D001 AB DIRECT RESPONSE INS ADMIN CHANHASSEN MN 55438D001 D DURHAM LIFE INS CO RALEIGH NC 27611D001 ABCD EARLY AMER LIFE INS CO EAGAN MN 55121E001 ABC EASTERN INS CO COLUMBIA SC 29219E001 A EASTERN INS CO/AM FAM LIFE/EQUALIZER COLUMBUS GA 31999E001 AC EASY CHOICE USA CHARLESTON WV 25301E001 ABCD EBA KANSAS CIY MO 64193E001 AB EDS FEDERAL CORP TOPEKA KS 66604E001 ABD EDS MEDICAL SACRAMENTO CA 95852E001 B EDUCATORS MUTUAL MURRAY UT 84107E001 B EGIP OKLAHOMA CITY OK 73124E001 ABD ELECTRIC MUTUAL BENEFIT SALT LAKE CITY UT 84127E001 ABCD ELECTRONICS DATA SYSTEM CHEYENNE WY 82003E001 B EMPIRE BCBS OF NEW YORK NEW YORK NY 10016B001 ABCD EQUALIZER DETROIT MI 48226E001 AB EQUITABLE LIFE ASSN SOC EASTON PA 18042E001 C EQUITABLE LIFE ASSN SOC O EASTON PA 18942E001 B EQUITABLE LIFE ASSN SOC O SALT LAKE CTY UT 84110E001 BCD EQUITABLE LIFE ASSURANCE GREAT FALLS MT 59405E001 A EQUITABLE LIFE ASSURANCE SHAWNNE MISSION KS 66205E001 B EQUITABLE LIFE ASSURANCE ALBUQUERQUE NM 87190E001 BD EQUITABLE LIFE INS CO CLEARWATER FL 33755E001 C EXECUTIVE FUND INS CO SANTA MONICA CA 90403E001 BCD EXECUTIVE FUND LIFE INS RALEIGH NC 27605E001 C FARM FAMILY LIFE INS CO ALBANY NY 12201F001 BCD FARMERS STOCKMAN INS SPOKANE WA 99210F001 BCD FED LIFE INS CO RIVERWOODS IL 60015C001 AB FEDERAL HOME COMPANIES BATTLE CREEK MI 49017F001 BC FEDERAL HOME LIFE MILWAUKEE WI 53214F001 ABCD

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FEDERAL HOME LIFE INS ORLANDO FL 32887F001 BCD FEDERAL KEMPER INS CO DECATUR IL 62526F001 B FELRA BALTIMORE MD 21212F001 B FHP LIFE INS CO SANTAANA CA 92708F001 ABC FIC INS GROUP AUSTIN TX 78714F001 ABCD FIREMAN’S FUND EMPL INS MINNEAPOLIS MN 55440F001 ABD FIRST CENTENNIAL LIFE INS FORT COLLINS CO 80522F001 ABC FIRST CONTINENTAL LIFE PITTSBURGH PA 15230F001 ABCD FIRST HEALTH OF AZ INC SUN CITY AZ 85351F001 AB FIRST NATIONAL LIFE INS PENSACOLA FL 32591F001 C FIRST NATIONAL LIFE INS MONTGOMERY AL 36104F001 BCD FLEET RESERVE ASSOC ALEXANDRIA VA 20037F001 BC FLEET RESERVE ASSOC - FRA DES MOINES IA 50306F002 D FLEET RESERVEASSOC W DES MOINES IA 50398F001 D FLIGHT-CARE DES MOINES IA 50306F001 D FOREMOSE LIFE INS CO GRAND RAPIDS MI 49501F001 ABCD FORTIS BENEFITS KANSAS CITY MI 64141P002 A FORTIS INSURANCE COMPANY/TIME MILWAUKEE WI 53201T001 AB FOUNDATION HEALTH PLAN FRENSO CA 93712F001 ABCD FOUNDATION HEALTH PLAN CARMICHAEL CA 95608F001 ABCD FOUNDATION HEALTH PLAN RANCHO CORDOVA CA 95670F001 ABCD FOUNDATION HLTH PLAN SACRAMENTO CA 95865F001 ACD FRA INSURANCE PLANS DES MOINES IA 50306F003 D FUTURE FINANCIAL MILWAUKEE WI 53223F001 ABC GE CAPITAL ASSUARANCE CO SEATTLE WA 98111G001 C GE LIFE ADN ANNUNITY CLEARWATER FL 32887G001 C GENERAL AMER LIFE ST LOUIS MO 65178G001 AB GEORGIA LIFE AND HEALTH INS CO ATLANTA GA 30301G001 ABD GERBER LIFE INS FREMONT MI 49412G001 C GERBER LIFE INS CO GRAND RAPIDS MI 10601G001 ABCD GH BENEFIT PLAN DES MOINES IA 50306G001 AB GIDDINGS AND LEWIS DES MOINES IA 50306G002 D GILSBAR, INC. COVINGTON LA 70433G001 C GLOBE LIFE AND ACCIDENT INS DALLAS TX 55221U001 B GLOBE LIFE AND ACCIDENT INS DALLAS TX 75221G001 C GOLDEN CARE MEMPHIS TN 38119G001 ABCD GOLDEN INS CO COLUMBIA SC 29202G001 AB GOLDEN RULE INS CO INDIANAPOLIS IN 46278G001 CD GOLDEN RULE INS CO LAWRENCEVILLE IL 62439G001 ABCD GOLDEN STATE MUTUAL LIFE LOS ANGELES CA 90018G001 A GOLDSTAR HEALTH CARE DELAWARE OH 43015G001 AC GOLDSTAR HEALTH CARE DELAWARE OH 46015G001 B GOLDSTAR HEALTH CARE HOUSTON TX 77006G001 C GOOD SAM INS CO SANTA BARBARA CA 93121G001 ABCD GOVERNMENT WIDE INDEM BOISE ID 83707G001 B GRANGE MUTUAL NAMPA ID 85653G001 A GRAYS HARBOR MED BUREAU ABERDEEN WA 98520G001 ABCD GREAT AMER ORLANDO FL 32803G001 ABC GREAT AMER RESERVE INS CO CARMEL IN 46032G001 ABCD GREAT FIDELITY LIFE INS FORT WAYNE IN 46801G001 BCD GREAT MIDWEST LIFE INS CO DALLAS TX 75218G001 ABCD GREAT REPUBLIC INS CO SEATTLE WA 98119G001 ABCD GREAT WESTERN LIFE COLUMBUS OH 43215G001 BD

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GREAT WESTERN LIFE CLAYTON MO 63105G001 B GREAT WESTERN LIFE DENVER CO 80201G001 BD GREATER LACROSSE HLTH WAUSAU WI 54402G001 ACD GREATER MARSHFIELD OFFICE MARSHFIELD WI 54449G001 C GREDE FOUNDRIES INC DES MOINES IA 50306G003 D GROUP HEALTH COOP/S CTRL MADISON WI 53715G001 B GROUP HEALTH INC NEW YORK NY 10036G001 ABCD GROUP HEALTH OF SPOKANE SPOKANE WA 92204G001 B GROUP HEALTH OF SPOKANE SPOKANE WA 99204G001 A GROUP HEALTH SRVS OF OK TULSA OK 74102G001 C GROUP LIFE AND HEALTH INS RICHARDSON TX 75080G001 C GROUP MGMNT SERVICES INC NEW BERLIN WI 53151G001 ABC GUARANTEE RESERVE LIFE CALUMET CITY IL 60409G001 ABCD GUARANTEE TRUST LIFE INS GLENVIEW IL 60025G001 ABCD GUARDIAN LIFE APPLETON WI 54913G001 ABD GULF SOUTH HEALTH PLAN BATON ROUGE LA 70898G001 AB GVMNT EMP HOSP ASSOC INC INDEPENDENCE MO 64111G001 A HARBOR INS CO LOS ANGELES CA 90010H001 ABC HARTFORD ACC AND INDEMNITY DES MOINES IA 50398H001 BCD HARTFORD INS CO ALEXANDRIA VA 22312H001 BCD HARTFORD INS CO SHAWNEE MISSION KS 66201H001 B HARTFORD INS CO/KING COUNTY BLUE SHIELD DES MOINES IA 50398H002 BD HARTFORD INSURANCE DES MOINES IA 50306H001 D HARTFORD LIFE AND ACC CO HARTFORD CT 06104H001 BC HARTFORD LIFE AND ACCIDENT HARTFORD CT 06115H001 D HARVEST LIFE INS CO ORLANDO FL 32887H001 BCD HAWKEYE NATIONAL LIFE INS CO W DES MOINES IA 50266H001 ABC HEALTH ABENEFIT PLAN PISCATAWAY NJ 08854H001 B HEALTH ADVANTAGE FLORENCE SC 29501H001 B HEALTH AND LIFE INS ROCKFORD IL 61105H001 BCD HEALTH CARE GREENACRES WA 99016H001 ABCD HEALTH CARE BENEFIT COLUMBIA SC 29260H001 ABCD HEALTH CARE BENEFIT CHICAGO IL 60685H001 ABCD HEALTH CARE SERVICE CHICAGO IL 60601H001 ABCD HEALTH DATA MANAGEMENT OMAHA NE 68154H001 CD HEALTH FIRST PPO GREENVILLE SC 29605H001 BD HEALTH LINK SAINT LOUIS MO 63132H001 BC HEALTH PARTNERS ALABAMA BIRMINGHAM AL 35209H001 ABCD HEALTHCARE MGMNT SVC/ME SENIOR COMP PLAN LONG BEACH CA 90802H001 AC HEALTHGUARD SERVICES BELLINGHAM WA 98227H001 ABCD HEALTHGUARD SERVICES INC EUGENE OR 97440H001 ABC HERITAGE HEALTH PLANS GRAND PRAIRIE TX 75050H001 C HIGHMARK/BLUE SHIELD OF PA CAMP HILL PA 17089B001 ABCD HILL COUNTRY LIFE INS CO AUSTIN TX 78720H001 ABCD HILL COUNTRY OF MONTANA BOZEMAN MT 59771H001 B HMO MIDWEST HUDSON WI 54016H001 AC HMO OF WISCONSIN SIOUX CITY WI 53583H001 AC HOLY FAMILY SOCIETY OF US JOLIET IL 60434H001 BD HOME BENEFICIAL LIFE INS RICHMOND VA 23261H001 ABC HORACE MANN LIFE INS CO SPRINGFIELD IL 62715H001 AC HORIZON BCBS OF NJ NEWARK NJ 07105H001 C HUMANA CARE PLUS LOUISVILLE KY 40201H002 BCD HUMANA GOLD CLAIMS DENVER CO 80210H001 ABC

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HUMANA HEALTH CARE PLANS JACKSONVILLE FL 32245H001 ABC HUMANA HEALTH CARE PLANS LOUISVILLE KY 40201H001 AD HUMANA INC. LEXINGTON KY 78229H001 ABCD IASD HEALTH SERVICES CORP DES MOINES IA 50309I001 C ICI HEALTH CLAIMS SERVICES BOCAROPON FL 33427I001 ABD IDEALIFE INSURANCE CO CLEARWATER FL 34618I001 A IGG ASSOCIATION OMAHA NE 68175I001 ABCD IHC SENIOR CARE SALT LAKE CITY UT 84111I001 ABCD ILLINOIS CENTRAL GULF LANSING MI 48909I001 AB INDEPENDENCE BC/BS CAMP HILL PA 17089I001 C INDEPENDENT LIFE JACKSONVILLE FL 32276I001 C INDUSTRIAL CASUALTY INS OAK PARK IL 60301I001 BCD INTEGRITY NATIONAL LIFE INS LOUISVILLE KY 40232I001 BCD INTER COUNTY HOSP PLAN IN HORSHAM PA 19044I001 ABD INTERCONTINENTAL LIFE INS AUSTIN TX 78714I001 ACD INTERCONTINETAL LIFE INS PHILADELPHIA PA 19101I001 B INTERGROUP PREPAID SCVS O TUCSON AZ 85710I001 ABC INTL BENEFITS SERVICES CO FORT WORTH TX 76109I001 ABCD INVESTORS CONSOLIDATED IN DURHAM NC 27702I001 ABCD INVESTORS DIVERSIFIED INS BATON ROUGE LA 70816I001 AB INVESTORS HERITAGE LIFE FRANKFORT KY 40602I001 ABCD ITT HARTFORD SIMSBURY CT 06104I001 C ITT LIFE INS CORP MINNEAPOLIS MN 55441I001 ABCD J C STEELE AND SONS INC DURHAM NC 27702J001 ABCD JC PENNY LIFE INS CO DALLAS TX 75221J001 ABD JEFERSON LIFE INS CO DALLAS TX 75243J001 ABCD JEFFERSON PILOT FINANCIAL GREENSBORO NC 27420J001 C JOCKEY INTERNATIONAL INC DES MOINES IA 50306J001 D JOINT BENEFIT TRUST LIVERMORE CA 94551J001 ABC KAISER GROWN HEALTH PLAN WAHSINGTON DC 20016H001 B KAISER GROWN HLTH PLAN ROCKVILLE MD 20016K001 ACD KAISER PERMANENTE LOS ANGELEA CA 90041K001 BCD KANAWHA INS CO LANCASTER SC 29721K001 ABCD KEYSTONE INS CO PHILADELPHIA PA 19103K001 BCD KING COUNTY BLUE SHIELD SEATTLE WA 50398K001 CD KING COUNTY BLUE SHIELD/KIRKE VAN ORSDEL DES MOINES IA 50398K002 ACD KIRKE VAN ORSDEL DES MOINES IA 50306K001 C KIRKE VAN ORSDEL DES MOINES IA 50306K002 D KIRKE VAN ORSDEL DES MOINES IA 50306K003 D KIRKE VAN ORSDEL DES MOINES IA 50306K004 D KIRKE VAN ORSDEL INC DES MOINES IA 50306K005 D KIRKE VAN ORSDEL INC DES MOINES IA 50306K006 D KIRKE VAN ORSDEL INC DES MOINES IA 50306K007 D KIRKE-VAN ORSDEL DES MOINES IA 50309K001 D KIRKE-VAN ORSDEL INC W DES MOINES IA 50398K003 D KIRKE-VAN ORSDEL, INC WEST DES MOINES IA 50398A002 A KITSAP PHYSICIANS SERVICE BREMERTON WA 98310K001 ABCD KLAMATH MEDICAL KLAMATH FALL OR 97601K001 BCD LA-Z-BOY INCORPORATED DES MOINES IA 50306L001 D LEGAL SECURITY LIFE INS DALLAS TX 75185L001 ABC LIBERTY LIFE INS CO GREENVILLE SV 29602L001 ABCD LIBERTY MUTUAL INS CO LONG BEACH CA 90804L001 BD LIBERTY NATIONAL LIFE INS CO BIRMINGHAM AL 35202L001 B

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LIBERTY NATL LIFE INS CO BIRMINGHAM AL 35207L001 ACD LIFE / HEALTH OF AMERICA FORT WORTH TX 76102L001 AC LIFE AND HLTH INS CO OF AME PHILADELPHIA PA 19103L001 BCD LIFE INS CO OF CONNECTICUT SIOUX FALLS SD 57193L001 ABCD LIFE INS CO OF GEORGIA BIRMINGHAM AL 30348L001 B LIFE INS CO OF GEORGIA LANGHORNE PA 35289L001 CD LIFE INS CO OF VIRGINIA TREVOSE PA 19053L001 ABCD LIFE INSURANCE CO OF VA RICHMOND VA 23240L001 C LIFE INSURANCE OF VA DANVILLE VA 24540L001 ABCD LIFE INVESTIRS CO CEDAR RAPIDS IA 52402L001 ACD LIFE INVESTORS CO CEDAR RAPIDS IA 52102L001 B LIFE INVESTORS INS CO SCRANTON PA 18504L001 AC LIFE OF AMERICA HOUSTON TX 77019L001 ABCD LIFE OF GEORGIA FORT WASHINGTON PA 35209L001 BC LIFE OF GEORGIA INS COLUMBUS GA 31999L001 BCD LINCOLN LIFE AND CAS CO LINCOLN NE 68501L001 ABCD LINCOLN MUT LIFE AND CAS IN FARGO ND 58107L001 ABCD LINCOLN NATIONAL INS FREDRICK MD 21701L001 ABD LUMBERMENS MUTUAL CASLTY LONG GROVE IL 60049L001 AC LUTHERAN BROTHERHOOD INS MINNEAPOLIS MN 55415L001 ABCD M AND I INSURANCE PLANS DES MOINES IA 50306M003 D M AND M INSURANCE PLANS DES MOINES IA 50306M004 D M PHYSICIANS MUTUAL OMAHA NE 68131M002 D MARICOPA MANAGED CARE SYS PHOENIX AZ 85034M001 AB MARITIME ASSOC HOUSTON TX 77034M001 ABD MARKET EMPLOYEES ASSOC CHARLOTTE NC 28222M001 ABD MARSH AND MCCLELLAN GRP CHICAGO IL 60606M002 ABCD MASSACHUSETTS MUTUAL WASHINGTON DC 20063M002 B MASTERCARE DES MOINES IA 50306M001 CD MAXICARE CHARLOTTE NC 28217M001 ABD MEAD DES MOINES IA 50306M005 D MEDCENTERS SENIOR LINK MINNEAPOLIS MN 55435M001 ABD MEDI PAK/BCBS ARKANSAS LITTLE ROCK AR 72203M001 BC MEDI PAK/BCBS ARKANSAS LITTLE ROCK AR 77203M001 ACD MEDICAL ASSOC HMO DUBUQUE IA 52001C001 A MEDICAL ASSOC HMO DUBUQUE IA 52001M001 B MEDICAL SERV ADMIN OF MI DES MOINES IA 50309M001 ABC MEDICAL SERVICE ASSOC. CAMP HILL PA 17089M001 C MEDICAL SERVICE CORP SPOKANE WA 99220M001 ABCD MEDICAL SERVICE OF D C WASHINGTON DC 20065M001 ABCD MEDICARE-AID RALEIGH NC 27622M001 ABD MEDICO LIFE INS CO OMAHA NE 68103M001 ACD MEDICOMP PORTLAND ME 04104M001 B MEDICOMP GREENVILLE SC 29609M001 ABCD MEDIPLUS DES MOINES IA 50306M002 D MEDIPLUS DES MOINES IA 50398M001 BCD MEDIPLUS DES MOINES IA 50398M002 D MEDIPLUS CAROL STREAM IL 60197M002 D MEMORIAL LIFE INS CO WAUSAU WI 54402M001 BD MENNONITE MUTUAL AID GOSHEN IN 46526M001 ABCD METROPOLITAN LIFE INS PITTSBURGH PA 15230M001 A METROPOLITAN LIFE INS AURORA IL 60507M001 A METROPOLITAN LIFE INS/UNITED HEALTHCARE BRIDGEWATER NJ 08807M001 ABD

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MID AMER MUT LIFE INS CO SAINT PAUL MN 55113M001 BCD MID AMERICA MUTUAL LIFE CHICAGO IL 60606M001 BC MID SOUTH INS CO FAYETTEVILLE NC 28302M001 BCD MII LIFE INCORPORATED SAINT PAUL MN 55164M001 ABCD MILICARE - FLEET RESERVE W DES MOINES IA 20063M001 BCD MILICARE/FLEETRESERVE FAIRFAX VA 20063M003 D MINNESOTA COMP HEALTH SAINT PAUL MN 55164M002 ABCD MINNESOTA PROTECTIVE LIFE OMAHA NE 68114M001 ABCD MONTGOMERY WARD LIFE INS CAROL STREAM IL 60197M001 ABCD MONUMENTAL GENERAL INS SCRANTON PA 18504M001 ABCD MONUMENTAL LIFE BALTIMORE MD 21201M001 C MONY HOUSTON TX 77006M001 ABCD MOUNTAIN STATE BCBS WHEELING WV 26003M001 ABCD MPS OF MICHIGAN DETROIT MI 48266M001 ABCD MUTUAL BENEFIT CO COLUMBIA SC 29260M001 ABD MUTUAL INS. NATIONWIDE COLUMBUS OH 43216M001 C MUTUAL LIFE INS CO WASHINGTON DC 20037M001 ABCD MUTUAL LIFE INS CO FAIRFIELD AL 35064M001 ABCD MUTUAL LIFE INS CO OF NY PURCHASE NY 10577M001 ABCD MUTUAL OF NEW YORK NEW YORK NY 10019M001 ABCD MUTUAL OF OMAHA/STANDARD LIFE OMAHA NE 68131M001 ABCD MUTUAL PROT MEDICO LIFE OMAHA NE 68172M001 BCD MUTUAL PROTECTIVE OMAHA NE 68124M001 C MUTUAL SERVICE LIFE INS SAINT PAUL MN 55164M003 ABC N CENTRAL 65 PLUS WAUSAW WI 54402N001 BCD NALC - HEALTH BENEFIT PLN ASHBURN VA 22093N001 A NATIONAL BENEFIT CORP KANSAS CITY MO 64111N001 ABCD NATIONAL CASUALTY INS SAINT LOUIS MO 63101N001 BC NATIONAL COUNCIL SR CITIZEN IRVINGTON NY 10533N001 ABD NATIONAL FARMERS UNION LIFE DENVER CO 80231N001 AB NATIONAL FINANCIAL INS CO DALLAS TX 75266N001 BD NATIONAL FINANCIAL/FOUNDATION LIFE FORT WORTH TX 76102N001 BCD NATIONAL GROUP LIFE ROCKFORD IL 61105N001 AC NATIONAL HERITAGE INS AUSTIN TX 78720N001 ABD NATIONAL HOME LIFE ASSUR BINGHAMTON NY 13901N001 B NATIONAL HOME LIFE ASSUR VALLEY FORGE PA 19493N001 BCD NATIONAL LIBERTY GROUP VALLEY FORGE PA 19493N002 BCD NATIONAL LIFE AND ACCIDENT EVANSVILLE IN 47701N001 C NATIONAL SECURITY INS CO POTTSVILLE PA 17901N001 AB NATIONAL STATES INS DES MOINES IA 50306N001 AB NATIONAL STATES INS CO ST LOUIS MO 63141N001 BD NATIONAL TRAVELERS LIFE DES MOINES IA 50309N001 ABC NATIONAL VISION PHOENIX AZ 85060N001 ABCD NATIONWIDE LIFE INS CO COLUMBUS OH 43216N001 ABCD NATL BENEFIT LIFE INS CO NEW YORK NY 10016N001 ABCD NATL FARMERS UNION LIFE KANSAS CITY MO 64199N001 ABCD NATL HEALTH INS CO DALLAS TX 75261N001 ABC NATL LIFE OCEANSIDE CA 92049N001 AB NATL LIFE AND ACC NASHVILLE TN 37250N001 A NATL LIFE INS CO OF TEXAS ARLINGTON TX 76015N001 ABCD NAUS - UNISERVICE ROCKVILLE MD 20852N001 AD NAUS – UNISERVICE ROCKVILLE MD 28052N001 B NEW ERA LIFE INS CO HOUSTON TX 77210N001 AC

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NEW YORK LIFE ATLANTA GA 30348N001 BD NEW YORK LIFE INS OMAHA NE 68131N001 B NORTH AMER INS CO MADISON WI 53744N001 ABCD NORTH AMER INS CO MINNEAPOLIS MN 55440N001 B NORTH AMER INS CO KANSAS CITY MO 64111N002 BCD NORTH AMERICAN LIFE DES MOINES IA 50306N002 D NORTH ATLANTIC CAS AND SURE INDIANAPOLIS IN 46206N001 ABCD NORTH CAROLINA MUTUAL NASHVILLE TN 37202N001 ABD NORTHWESTERN NATIONAL LIFE JACKSON MN 56143N001 B NORTHWESTERN PUBLIC SERV HURON SD 57350N001 BD NW WASHINGTON MEDICAL BUR BELLINGHAM WA 98227N001 D OCR CLAIMS CHICO CA 95927O001 A OKLAHOMA STATE INS OKLAHOMA CITY OK 73124O001 AB OLD AMER INS CO KANSAS CITY MO 64141O001 ABCD OLD SOUTHERN LIFE INS CO MONTGOMERY AL 36101O001 AB OLD SURETY LIFE INS CO OKLAHOMA CITY OK 73154O001 ABCD OLYMPIC HEALTH MANAGEMENT BELLINGHAM WA 98227O001 ACD OREGON PACIFIC STATES PORTLAND OR 97207O001 ABCD OXFORD LIFE INSURANCE MADISON WI 53744O001 C OXFORD LIFE INSURANCE COM OMAHA NE 68154O001 D PACC HEALTH PLANS CLACKAMAS OK 97015P001 AC PACIFIC HEALTH ADM HUNTINGTON BCH CA 92647P001 C PACIFIC HEALTH AND LIFE INS BEND OR 97701P001 AC PACIFIC HERITAGE ASSURANC OMAHA NB 68172P001 AC PACIFIC HOSPITAL ASSOC EUGENE OR 97401P001 ABCD PACIFIC MUTUAL LIFE GLENDALE CA 91203P001 AB PACIFIC MUTUAL LIFE FEDERAL WAY WA 98003P001 AB PACIFIC NORTHWEST LIFE PORTLAND OR 97207P001 ABCD PACIFICARE LIFE ASSURANCE COSTA MESA CA 92708P001 C PANHANDLE EASTERN CORP HOUSTON TX 77251P001 ABD PARK AND SHOP INS SHEBOYGAN WI 53801P001 ABCD PATRICK CUDAHY, INC. DES MOINES IA 50306P001 D PAUL REVERE LIFE INS CO WORCHESTER MA 01608P001 ABCD PEARCE IND HOUSTON TX 77235P001 ABCD PEHP SALT LAKE CITY UT 84102P001 ABC PEIA HEALTH ECON CORP CHARLESTON WV 25362P001 B PEKIN LIFE INS CO PEKIN IL 61558P001 ABCD PENINSULAR LIFE INS CO RALEIGH NC 27605P001 ABCD PENN GENERAL SERVICES OF GA ATLANTA GA 30358P001 ABC PENN TREATY LIFE INS CO ALLENTOWN PA 18105P001 BCD PENNSYLVANIA AMER HATTSBORO PA 19034P001 BD PENNSYLVANIA LIFE INS SANTA MONICA CA 90406P001 BC PEOPLES BENEFIT LIFE INS FRAZER PA 19493P002 C PEOPLES LIFE - NORTH AMERICAN INS CO MADISON WI 53703P001 C PEOPLES LIFE INS GREENVILLE SC 29609P001 ABCD PEOPLES LIFE INS CO/UNITED HEALTHCARE ROLLING MEADOWS IL 60008P001 ABCD PEOPLES SECURITY INS DANVILLE VA 24540P001 ABCD PEOPLES SECURITY LIFE INS/PUBLIC SAVINGS LIFE DURHAM NC 27702P001 ABCD PERSONALCARE INS AIL INC CHAMPAIGN IL 61820P001 AC PFL LIFE INSURANCE CO SCRANTON PA 18504P001 C PFWB BENEVOLENT ASSO DUNN NC 28335P001 ABCD PHILADELPHIA AMER LIFE CO HOUSTON TX 77210P001 C PHYSICIANS HEALTH PLAN MINNEAPOLIS MN 55440P001 B

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PHYSICIANS LIABILITY INS OKLAHOMA CITY OK 73126P001 A PHYSICIANS MUTUAL INS CO OMAHA NE 68131P001 ABD PIERCE COUNTY MED BUREAU TACOMA WA 98401P001 ABD PIERCE COUNTY MEDICAL BUR TACOMA WA 98101P001 D PILGRIM LIFE INS CO FOLCROFT PA 19032P001 B PILOT LIFE INS CO NASHVILLE TN 37220P001 B PIONEER LIFE INS CO ROCKFORD IL 61105P001 ABCD PLAN 65 OF KANSAS TOPEKA KS 66629P001 ABCD PREFERRED ADMINISTRATIVE MADISON WI 53715P001 BCD PREFERRED BANKERS LIFE DALLAS TX 75205P001 ABC PREFERRED CHOICE SAN DIEGO CA 92196P001 BD PREFERRED HEALTH CARE WICHITA KS 67214P001 ABCD PREFERRED LIFE INS CO OF NY NEW YORK NY 10019P001 ABCD PREFERRED RISK LIFE W DES MOINES IA 50265P001 BCD PREMERA BLUE CROSS SEATTLE WA 98111P001 D PRESIDENTIAL LIFE DALLAS TX 75228P001 ABCD PRIME CARE PLUS COLUMBUS OH 43235P001 ABD PRIME HEALTH KANSAS CITY MO 64134P001 ABCD PRINCIPAL FINANCIAL GROUP WALLINGFORD CT 06492P001 C PRINCIPAL FINANCIAL GROUP BALA CYNWYD PA 19004P001 C PRINCIPAL FINANCIAL GROUP JACKSONVILLE FL 32256P001 C PRINCIPAL FINANCIAL GROUP TAMPA FL 33607P001 C PRINCIPAL FINANCIAL GROUP TAMPA FL 33631P001 C PRINCIPAL FINANCIAL GROUP COLUMBUS OH 43229P001 C PRINCIPAL FINANCIAL GROUP AMES IA 50014P001 C PRINCIPAL FINANCIAL GROUP WEST DES MOINES IA 50265P002 C PRINCIPAL FINANCIAL GROUP WEST DES MOINES IA 50266P001 C PRINCIPAL FINANCIAL GROUP CEDAR RAPIDS IA 52402P001 C PRINCIPAL FINANCIAL GROUP WEST ALLIS WI 53227P001 C PRINCIPAL FINANCIAL GROUP AURORA IL 60504P001 C PRINCIPAL FINANCIAL GROUP SPRINGFIELD MO 65802P001 C PRINCIPAL FINANCIAL GROUP COLORADO SPRING CO 66210P001 C PRINCIPAL FINANCIAL GROUP BROOKLYN MN 73134P001 C PRINCIPAL FINANCIAL GROUP SAN ANTONIO TX 78279P001 C PRINCIPAL FINANCIAL GROUP SALT LAKE CITY UT 84157P001 C PRINCIPAL FINANCIAL GROUP PHOENIX AZ 85021P001 C PRINCIPAL FINANCIAL GROUP FRESNO CA 93711P001 C PRINCIPAL FINANCIAL GROUP PORTLAND OR 97204P001 C PRINCIPAL FINANCIAL GROUP SEATTLE WA 98188P001 C PRINCIPAL FINANCIAL GRP COLORADO SPRING CO 80920P001 AC PRINCIPAL HEALTH CARE KANSAS CITY MO 64141P001 BCD PRINCIPAL MUTUAL INS BROOKLYN MN 55430P001 BCD PRINCIPAL MUTUAL LIFE OMAHA NE 68154P001 ABCD PROTECTED HOME MUT LIFE SHARON PA 16146P001 ABCD PROTECTIVE LIFE INS CO BIRMINGHAM AL 35202P001 AB PROVIDENCE LIFE MEMPHIS TN 38187P001 B PROVIDENTIAL LIFE INS CO LITTLE ROCK AR 72203P001 ABCD PROVIDERS FIDELITY LIFE BLUE BELL PA 19422P001 ABCD PROVIDIAN LIFE AND HEALTH LOUISVILLE KY 19493P001 C PROVIDIAN LIFE/HEALTH FRAZIER PA 19355N001 A PRUDENTIAL INSURANCE CO ROSELAND NJ 07068P001 A PYRAMID LIFE INS CO SHAWNEE MISSION KS 66202P001 ABCD QUAL-MED INC ALBUQUERQUE NM 87110Q001 ABCD

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R E HARRINGTON INC CHARLOTTE NC 28226R001 ABD R J REYNOLDS TOBACCO ATLANTA GA 30348R001 A RAND MCNALLY GREENVILLE SC 29609R001 ABD REGENCE BCBS OF OREGON KLAMATH FALLS OR 97601R001 D REGENCE BLUE SHIELD SEATTLE WA 99362R001 C REGENCE BLUESHIELD SEATTLE WA 98401R001 C REGENCE WASHINGTON HEALTH/KING CTY MEDICAL SEATTLE WA 98101K001 ABC RELIABLE LIFE INS CO WEBSTER GRV MO 63119R001 ABCD RESERVE NATIONAL LIFE IN OKLAHOMA CITY OK 73118R001 ABCD RETIRED OFFICERS ASSOC ALEXANDRIA VA 22314R001 D RETIRED OFFICERS ASSOC DES MOINES IA 50306R001 D RHONE POULENE OF WY GREEN RIVER WY 82935R001 BCD RHULEN INS CO MONTICELLO NY 12701R001 ABCD RISK MANAGEMENT INC FRESNO CA 93794R001 AB ROCKWELL AUTOMATION DES MOINES IA 50306R002 D RURAL SECURITY LIFE INS MADISON WI 53705R001 AB SAN ANTONIO REG CLAIM CTR SAN ANTONIO TX 78216S001 ABCD SAVERS LIFE INS CO WINSTON SALEM NC 27103S001 BC SDC - SYSTEM DEVELOPMENT/SENIOR SECURITY LIFE OKLAHOMA CITY OK 73154S002 ABCD SEABURY AND SMITH WEST DES MOINES IA 50398S001 C SECURE CARE VALLEY FORGE PA 19493S001 BCD SECURE HORIZONS HEALTH PLAN CYPRESS CA 90630S001 ABCD SECURITY GENERAL INS/PROVIDENT CLAIM OFFICE CHATANOOGA TN 37422S001 B SECURITY GENERAL LIFE INS OKLAHOMA CITY OK 73154S001 AB SECURITY HEALTH PLAN OF WI MARSHFIELD WI 54449S001 ABCD SECURITY LIFE INS CO HOUSTON TX 77019S001 ABCD SECURITY NATIONAL LIFE INS CO SALT LAKE CITY UT 84157S001 ABCD SECURITY TRUST LIFE INS DURHAM NC 27702S001 BCD SEGUROS DE SERVICIO DE SAN JUAN PR 00936S001 ABCD SELECTCARE LINWOOD NJ 08221S001 B SENIOR CARE CANYON COUNTRY CA 91351S001 BD SENIOR SECURITY LIFE INS OKLAHOMA CITY OK 73154S003 ACD SENTRY LIFE INS STEVENS POINT WI 54481S001 ABCD SEVENTYH DAY ADVENTISTS DES MOINES IA 50306S003 D SHELTER LIFE INS CO COLUMBIA MO 65218S001 ABCD SIEBE TEMP AND APPL CONTROL DES MOINES IA 50306S002 D SIERRA HEALTH AND LIFE INS LAS VEGAS NV 89114S001 ABCD SIGN AND DISPLAY INS PLAN DES MOINES IA 50306S004 D SKAGIT CTY MED BUREAU INC MOUNT VERNON WA 98273S001 ABCD SOUTH ATLANTIC LIFE JACKSONVILLE FL 33101S001 ABD SOUTH ATLANTIC LIFE SKOKIE IL 60076S001 ABD SOUTH DAKOTA BLUE SHIELD SIOUX FALLS SD 57104S001 AC SOUTHERN FARM BUREAU LIFE JACKSON CITY MS 39205S001 ABCD SOUTHERN HEALTH PLAN MEMPHIS TN 38101S001 ABCD SOUTHLAND LIFE INS CO BIRMINGHAM AL 35289S001 ABC SOUTHWEST ADMINISTRATOR ALHAMBRA CA 90057S001 ABC SOUTHWEST HOME LIFE INS DALLAS TX 75221S001 AC SOUTHWEST SERVICE LIFE FT WORTH TX 76180S001 D SOUTHWEST SERVICES LIFE FORT WORTH TX 76118S001 ABCD SOUTHWESTERN GENERAL LIFE DALLAS TX 75266S001 AB SPECIAL AGTS MUT BENEFIT ROCKVILLE MD 20852S001 A ST MICHAELS PA MILWAUKEE WI 53209S001 ABC STANDARD GUARANTY INS ATLANTA GA 30327S001 AB

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STANDARD LIFE AND ACC INS C OKLAHOMACITY OK 73125S001 ABCD STATE FARM HEALTH INS FREDERICK MD 21709S001 AC STATE FARM HLTH INS CO LINCOLN NE 68501S001 ACD STATE FARM INS CO WAYNE NJ 07477S001 ABCD STATE FARM INS CO CONCORDVILLE PA 19339S001 C STATE FARM INS CO CHARLOTTESVILLE VA 22901S001 B STATE FARM INS CO CHARLOTTESVILLE VA 22909S001 ACD STATE FARM INS CO CHILHOWIE VA 24319S001 ABCD STATE FARM INS CO BLUEFIELD VA 24605S001 ABCD STATE FARM INS CO ELIZABETHTOWN NC 28337S001 ABCD STATE FARM INS CO WHITEVILLE NC 28472S001 ABCD STATE FARM INS CO LENIOR NC 28645S001 ABCD STATE FARM INS CO DELUTH GA 30136S001 ABD STATE FARM INS CO JACKSONVILLE FL 32232S001 ABD STATE FARM INS CO MURFREESBOURO TN 37131S001 ABCD STATE FARM INS CO NEWARK OH 43055S001 C STATE FARM INS CO NEWARK OH 43093S001 C STATE FARM INS CO WEST LAFAYETTE IN 47906S001 C STATE FARM INS CO MARSHALL MI 49069S001 C STATE FARM INS CO ST PAUL MN 55161S001 ABD STATE FARM INS CO BLOOMINGTON IL 61709S001 BCD STATE FARM INS CO BLOOMINGTON IL 61710S001 C STATE FARM INS CO COLUMBIA MO 65217S001 A STATE FARM INS CO MONROE LA 71208S001 ABCD STATE FARM INS CO TULSA OK 74146S001 C STATE FARM INS CO DALLAS TX 75252S001 C STATE FARM INS CO DALLAS TX 75379S001 C STATE FARM INS CO GOODING ID 83330S001 ABCD STATE FARM INS CO WESTLAKE VILLAG CA 91363S001 C STATE FARM INS CO COSTA MESA CA 92626S001 C STATE FARM INS CO SANTA ANA CA 92799S001 C STATE FARM INS CO BAKERSFIELD CA 93311S001 C STATE FARM INS CO BAKERSFIELD CA 93399S001 C STATE FARM INS CO ROHNERT PARK CA 94926S001 C STATE FARM INS CO SALEM OR 97303S001 ABD STATE FARM MUT AUTO INS BALLSTON SPA NY 12020S001 AC STATE FARM MUT AUTO INS BIRMINGHAM AL 35297S001 AC STATE FARM MUT AUTO INS WEST LAFAYETTE IN 47905S001 AC STATE FARM MUT AUTO INS AUSTIN TX 78729S001 A STATE FARM MUT INS WINTER HAVEN FL 33888S001 A STATE FARM MUTUAL AUTO GREELEY CO 80638S001 AC STATE FARM MUTUAL AUTO TEMPE AZ 85289S001 AC STATE GROUP BENEFITS BATON ROUGE LA 70804S001 ABD STATE MUTUAL CO WORCHESTER MA 01653S001 AB STATE MUTUAL INSURANCE CO ROME GA 30162S001 C STATES GENERAL LIFE INS DALLAS TX 75214S001 ABC STATESMAN NATL LIFE HOUSTON TX 77006S001 ABCD STATEWIDE INS CO MONROE NC 28110S001 ABCD STIRLING AND STIRLING MILFORD CT 06460S001 D SUMMIT NATIONAL LIFE INS CO LANCASTER PA 17601S001 BD SURGICAL CARE MILWAUKEE WI 53201S001 ABCD SVEDALA INDUSTRIES DES MOINES IA 50306S001 D T AND N COMPANY DES MOINES IA 50306T002 D

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TAKE CARE HEALTH PLAN CONCORD CA 94524T001 ABCD TEAM-CARE HEALTH CHOICE MEMPHIS TN 38174T001 ABD TENNECO JACKSONVILLE FL 32276T001 ABD TEXAS IMPERIAL LIFE HOUSTON TX 77242T001 C THE PRINCIPAL FINANCIAL OMAHA NE 68154T001 C TRANSAMERICA ACC LIFE UPLAND CA 91785T001 ABD TRANSAMERICA INS WOODLAND HILLS CA 91367T001 ABC TRANSPORT LIFE FORT WORTH TX 76102T001 ABCD TRAVELERS INC CO HAMDEN CT 06517T001 B TRAVELERS OMAHA OMAHA NE 68175T001 BD TRIGON BCBS ROANOKE VA 24031T001 BCD TRIGON MUTUAL INS CO/BCBS VA WYTHEVILLE VA 24382B001 A TROA GROUP HLTH INS DES MOINES IA 50306T001 BCD TRS CARE NASHVILLE TN 37202T001 A TRUSTMARK INS CO LAKE FOREST IL 55116T001 C TRUSTMARK INS CO LAKE FOREST IL 60045T001 D U S HEALTH AND LIFE INS/IDEALIFE CLEARWATER FL 34618U001 AC UNDERWRITERS LIFE INS CO DALLAS TX 75238U001 B UNICARE ANDOVER MA 93031U001 C UNION BANKERS INS CO DALLAS TX 75265U001 BCD UNION BANKERS-RR CLAIMS/UAIAG DALLAS TX 75201U001 AC UNION CARE LIFE INS CO WASHINGTON DC 20001U001 BCD UNION FIDELITY LIFE INS/COMBINED INS OF AMER TREVOSE PA 19047C001 ABCD UNION FIDELITY/MUTUAL LIFE ALPHARETTA GA 19049U001 BCD UNION LABOR LIFE WASHINGTON DC 20006U001 BCD UNION LABOR LIFE INS CO NEW YORK NY 10010U001 BD UNION LOCAL 662 DES MOINES IA 50306U002 D UNISYS BENEFITS OFFICE LONDON KY 84130U001 A UNIT DROP FORGE CO INC DES MOINES IA 50306U001 D UNITED AMER INS CO DALLAS TX 75221U001 ABCD UNITED ASSURANCE CO OF PA SOUDERTON PA 19047U002 ABCD UNITED COMMERCIAL TRAVLRS COLUMBUS OH 43215U001 BCD UNITED FAMILY LIFE INS ATLANTA GA 30301U001 BCD UNITED FARM BUREAU FAM INDIANAPOLIS IN 46206U001 ABCD UNITED FOUNDERS LIFE BIRMINGHAM AL 35202U001 ABCD UNITED FOUNDERS LIFE INS OKLAHOMA CITY OK 73112U001 ABD UNITED GENERAL LIFE CLEARWATER FL 34616U001 BCD UNITED GENERAL LIFE INS CLEARWATER FL 33743U001 ABCD UNITED HEALTHCARE OF ALABAMA, INC BIRMINGHAM AL 35255U001 C UNITED HERITAGE MUTUAL NAMPA ID 83653U001 ABCD UNITED INVESTORS LIFE INS DALLAS TX 75221U002 A UNITED LIFE OF NORTH AMER VIENNA VA 22182U001 AB UNITED METHODIST GROUP OMAHA NE 68175U001 ABCD UNITED NATIONAL LIFE INS GLENVIEW IL 60025U001 AC UNITED OF OMAHA LANGHORNE PA 19047U001 B UNITED OF OMAHA TREVOSE PA 19049U003 A UNITED SEC ASSURANCE CO SOUDERTON PA 18964U001 ABD UNITED TEACHER ASSOC AUSTIN TX 78755U001 ACD UNITED TECHNOLOGIES HARTFORD CT 06146U001 ABCD UNIVERSAL FIDELITY LIFE DUNCAN OK 73533U001 ABCD UNIVERSAL LIFE INS CO RICHMOND VA 23222U001 ABD US GUARDIAN HEALTH INS CO DALLAS TX 75244U001 AB USAA LIFE INS CO SAN ANTONIO TX 78288U001 ABCD

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USABLE LIFE LITTLE ROCK AK 72203U001 ABCD VALLEY HEALTH PLAN EAU CLAIRE WI 54702V001 ABCD VASA NORTH ATLANTIC INDIANAPOLIS IN 46206V001 C VASA/VARIABLE PROTECTION CLEVELAND OH 44130V001 C VETERANS ADMINISTRATION PHOENIX AZ 85012V001 AB VETERANS LIFE INS CO VALLEY FORGE PA 19493V001 ABCD VFW MDGAP/NO AMER INS/PA HORSHAM PA 64111V001 ABCD VICTORY LIFE INS CO MURFREESBORO TN 37133V001 ABCD VIRGINIA HEALTH AND AS ASSOC EMPORIA VA 23847V001 BCD VIRGINIA MUTUAL INS CO RICHMOND VA 23225V001 BC VIRGINIA SURETY CO INC CLEARWATER FL 33755V001 C VULCAN LIFE INS CO BIRMINGHAM AL 35201V001 AB WALLA WALLA VALLEY MED WALLA WALLA WA 99362W001 ABD WASHINGTON NATIONAL INS EVANSTON IL 60201W001 BD WASHINGTON NATL INS LINCOLNSHIRE IL 60069W001 C WC KUMMEROW AND CO CRYSTAL LAKE IL 60014W001 ABC WEA INSURANCE GROUP MADISON WI 53708W002 AB WEST BEND INSURANCE PLAN DES MOINES IA 50306W002 D WESTERN AMER LIFE INS CO RICHARDSON TX 75083W001 AC WESTERN FARM BUREAU INS DENVER CO 80217W001 ABCD WESTERN FIDELITY INS FORT WORTH TX 76101W001 ABCD WHATCOM MEDICAL BUREAU BELLINGHAM WA 98227W001 ABCD WIS HEALTH ORG/WISCONSIN PHYSICIANS MILWAUKEE WI 53212W001 ABCD WISCONSIN PHYSICIANS SERV MADISON WI 53701W001 ABCD WIT AND CO INSURANCE PLANS DES MOINES IA 50306W001 D WORLD INS CO OMAHA NE 68130W001 BCD WORLD LIFE AND HEALTH INS CO HARRISBURG PA 17105W001 BC WORLD NET SERVICES CORP PENSACOLA FL 32501W001 C

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XXIII - APPENDIX II – Non-covered HCPCS

Item HCPCS Code Coverage Guidelines (MCM or Title 18 SSA)

A9270 Air Cleaner (includes electrostatic machines)

11/10/2000

Not primarily medical in nature/environmental control equipment/2100.1 B.2 1861(n) of the Act

Air Conditioners A9270 Convenience item/not primarily medical in nature/2100.1 B.2 1861(n) of the Act

Bathtub Lifts E0625 Convenience item/not primarily medical in nature/2100.1 B.2 1861(n) of the Act.

E0241 Bathtub wall rail

Bathtub Seat/Stool/Bench/Rails Equipment

E0242 Bathtub rail, floor base E0243 Toilet rail E0245 Tub stool or bench

Comfort or convenience item/hygienic equipment/not primarily medical in nature/2100.1 B.2 1861(n) of the Act.

Bed Accessory: Board, Table or Support Device, any type

E0315 Convenience item/not primarily medical in nature/2100.1 B.2 1861(n) of the Act.

A9270 Bed Baths (home type)

8/30/1999

Hygienic equipment/not primarily medical in nature. 1861(n) of the Act.

Bedboards E0273-bed board overbed board/table-E0274

Not primarily medical in nature/2100.1 B.2 1861(n) of the Act.

Bed Lifter (bed elevator) E0315 Not primarily medical in nature/2100.1 B.2 1861(n) of the Act.

Bed Lounge (power or manual) A9270 Comfort or convenience item/not primarily medical in nature/2100.1 B.2 1861(n) of the Act.

Bed Oscillating A9270 Institutional equipment/inappropriate for home use/2100.1 B.2

Bed Table (Over bed table) E0274 Comfort or convenience item/hygienic equipment/not primarily medical in nature/2100.1 B.2 1861(n) of the Act.

A9270 Bidet Toilet Seats

7/26/1999

Not medical equipment

Biofeedback Therapy for the Treatment of Urinary Incontinence

E0746 CIM 35-27.1Home use of biofeedback therapy is not covered.

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Note: this is NOT the MONITOR

Blood Glucose ANALYZER

A9270

Unsuitable for home use/60-11

Carafes A9270 Convenience item/not primarily medical in nature. 1861(n) of the Act.

Clitoral Therapy Device A9270 CMS Benefit Category Determination December 7, 2001

Dehumidifiers (room or central heating system type)

A9270 Not primarily medical in nature/environmental control equipment/2100.1 B.2 1861(n) of the Act.

Diapers A4360 Supplies expendable in nature/2100.1.A

Diabetic Shoe Inserts (Molded by the Patient's Body Heat and Weight)

A5510 CMS Benefit Category Determination November 14, 2001

Diathermy Machines A9270 Inappropriate for home use/35.41/35-3

Disposable Sheets and Bags A4335 and A4554

Nonreuseable disposable supplies/2100.1A 1861(n) of the Act.

Electric Air Cleaners A9270 Not primarily medical in nature/environmental control equipment/2100.1 B.2 1861(n) of the Act.

Electrostatic Machines A9270 Not primarily medical in nature/environmental control equipment/2100.1 B.2 1861(n) of the Act.

Elastic Stockings A9270 and L8100-L8239

Nonreuseable disposable supplies/2100.1A . 1861(n) of the Act.

Electrostimulation in the treatment of wounds

A9270 Non-proven therapy. CIM 35-98

Emesis Basin A9270 Nonreuseable disposable supplies/2100.1A . 1861(n) of the Act.

Elevators A9270 Convenience item/not primarily medical in nature./2100.1 B.2. 1861(n) of the Act

Esophageal Dilator A9270 Physician instrument; inappropriate for patient use

Exercise Equipment A9300 Not primarily medical in nature/2100.1 B.2

Fabric Supports A9270 Nonreuseable supplies; not rental-type. 1861(n) of the Act. CIM 35-34

Face Masks (surgical) A9270 Nonreuseable disposable supplies/2100.1A . 1861(n) of the Act.

Grab Bars E0241-E0243 Self-help device/not primarily medical in nature/2100.1 B.2 1861(n) of the Act.

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Heat and Massage Foam A9270 Self-help device/not primarily medical in nature/2100.1 B.2 1861(n) and 1862(a)(6) of the Act.

Heating and Cooling Plants A9270 Environmental control equipment/not medical in nature/2100.1 B.2 1861(n) of the Act.

Humidifiers (room or central heating system types)

A9270 Not primarily medical in nature/environmental control equipment/2100.1 B.2 1861(n) of the Act.

Incontinent Pads A4554 Disposable under pads, all sizes (e.g., Chux's) or A4360 Adult incontinence garmet (e.g. brief, diaper)

Nonreuseable supply/hygienic item/2130.A. 1861(n) of the Act.

Injectors (hypodermic jet pressure powered devices for insulin injections)

A4210 Noncovered self-administered drug supply. 1861(s)(2)(A) of the Act.

Insulin except used in a pump J1820, K0548 Self Administered Drug. MCM 2049

Leotards A9270 Nonreuseable supplies; not rental-type. 1861(n) of the Act.

Massage Devices A9270 Personal comfort item/not primarily medical in nature. 1861(n) and 1862(a)(6) of the Act.

Metered Dose Inhaler A9270 Self administered Drug. MCM 2049.

Non-contact wound warming device and accessories

E0231, E0232, A6000

CMS Benefit Determination.

Oscillating Beds A9270 Institutional equipment--inappropriate for home use.

Overbed Tables E0274 Not primarily medical in nature/2100.1 B.2 1861(n) of the Act.

Paraffin Bath Units (standard) non-portable

A9270 Institutional equipment/2110.3

Parallel Bars A9300 Support exercise equipment/2100.1.B.2

Patient Lift, Kartop, bathroom or toilet

E0625 Not primarily medical in nature/personal comfort item. 1861(n) and 1862(a)(6) of the Act.

Portable Room Heaters A9270 Environmental control equipment/not primarily medical in nature 2100.1 B.2 1861(n) of the Act.

Portable Whirlpool Pumps E1300 Not primarily medical in nature/personal comfort item. 1861(n) and 1862(a)(6) of the Act.

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Preset Portable Oxygen Units A9270 Emergency, first aid, or precautionary equipment; essentially not therapeutic in nature.

Pressure Leotards A9270 Nonreuseable supplies; not rental-type. 1861(n) of the Act.

Pulse Tachometer A9270 Not reasonable or necessary for monitoring pulse of homebound patient with or without cardiac pacemaker

Raised Toilet Seats E0244 Convenience item/hygienic equipment/not primarily medical in nature

Sauna Baths A9270 Not primarily medical in nature/personal comfort item/1862(a)(6) of the Act/2100.1 B.2

Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler

A4627 Supply used with self administered drug. MCM 2049.

Spare Tanks of Oxygen A9270 Convenience or precautionary supply.

Speech Teaching Machine A9270 Educational equipment; not primarily medical in nature. 1861(n) of the Act.

Stairway Elevators A9270 Convenience item/not primarily medical in nature/2100.1B.2

Standing Table A9270 Convenience item/not primarily medical in nature

Support Hose A9270 and L8100-8239

Nonreuseable supplies; not rental-type. 1861(n) of the Act.

Surgical Stocking A4490, A4495, A4500, A4510

Nonreuseable supplies; not rental-type/MCM 2133. 1861(n) of the Act.

Telephone Alert Systems A9270 Emergency communication systems/do not serve a diagnostic or therapeutic purpose

Telephone Arms A9270 Convenience item/not medical in nature

Toilet Seats A9270 Not medical equipment. 1861(n) of the Act.

Treadmill Exerciser A9300 Exercise equipment/not primarily medical in nature/2100.1 B.2

White Cane A9270 Self-help item/60-3, per cane/crutches policy

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XXIV - APPENDIX III – CMN Completion Certificates Of Medical Necessity OVERVIEW A Certificate of Medical Necessity (CMN) or DMERC Information Form (DIF) is required to help document the medical necessity and other coverage criteria for selected DMEPOS items. The ‘Documentation’ section of the medical policy shows which items require one of these forms. Sixteen forms have been developed by the DMERCs. Fourteen of the forms have been assigned a HCFA form number, HCFA 841-854. The HCFA form number is in the bottom left corner of the form. The CMNs/DIF also have a DMERC form number that consists of two numbers before a decimal and two numbers after a decimal (e.g., DMERC 03.02). The numbers after the decimal identify the version or sequence of revisions to the CMN. (For example, DMERC 03.02 is a revision of a prior CMN that was numbered 03.01.) Version .02 and .03 hard copy CMNs have been formatted so that only a single type of equipment is on each CMN. In situations where there had been different devices on the same CMN, the hard copy version .02 and .03 CMNs have a letter after the version number. For example, the CMN for seat lift mechanisms is DMERC 07.02A and that for power operated vehicles is DMERC 07.02B. The current CMNs/DIF are: HCFA Form DMERC Form Items Addressed

484 DMERC 484.2 (11/99) Oxygen

841 DMERC 01.02A Hospital Beds

842 DMERC 01.02B Support Surfaces

843 DMERC 02.03A Motorized Wheelchairs

844 DMERC 02.03B Manual Wheelchairs

845 DMERC 03.02 Continuous Positive Airway Pressure (CPAP) Devices

846 DMERC 04.03B Lymphedema Pumps (Pneumatic Compression Devices)

847 DMERC 04.03C Osteogenesis Stimulators

848 DMERC 06.02B Transcutaneous Electrical Nerve Stimulators (TENS)

849 DMERC 07.02A Seat Lift Mechanisms

850 DMERC 07.02B Power Operated Vehicles

DMERC 08.02 (7/00) Immunosuppressive Drugs

851 DMERC 09.02 Infusion Pumps

852 DMERC 10.02A Parenteral Nutrition

853 DMERC 10.02B Enteral Nutrition

854 DMERC 11.01 Section C Continuation Form DMERC 08.02 for Immunosuppressive Drugs has been designated a DMERC Information Form (DIF) rather than a CMN. That is because this form can be completed and signed by the supplier, rather than requiring physician completion. It has no Section C or D. CMN COMPLETION Instructions on the backs of the CMNs/DIF should be reviewed and followed. A few highlights are listed.

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In Section A, at least the patient’s name, address, telephone and HIC number, the supplier’s name, address, telephone and NSC number, and the HCPCS codes must be completed by the supplier before the CMN is sent to the physician. The codes that require a CMN/DIF are listed later in this section. These are the codes that should be listed in Section A of the CMN/DIF. Section B may not be completed by the supplier on HCFA forms 484 and 841-853. Section B may be completed by the physician, the physician’s employee or another clinician involved in the care of the patient (e.g., nurse, physical or occupational therapist, etc.) as long as that person is not the supplier. Section C on HCFA forms 484 and 841-854 reflects the requirements from the 1994 Amendments to the Social Security Act. It provides an opportunity for the ordering physician to review and confirm a detailed description of the items provided. It also indicates the supplier’s charge and what the Medicare fee schedule allowance will be, if applicable. Section C contains a blank space that can be formatted in different ways. However the following guidelines must be met: The description of the item provided must include not only those items listed in Section A of the CMN, but also any accessories, options, supplies or drugs which are related to the item and which are provided by the supplier. There should be a narrative description for each related item billed on a separate claim line. The exact HCPCS description is not required; a reasonable, abbreviated descriptor may be substituted. For every item listed, the supplier must always specify their submitted charge. For purchased equipment, accessories and options, the full charge must be specified. For rental equipment, accessories and options, the supplier must specify “per month” or “/month.” For accessories, supplies, nutrients, or drugs which are replaced regularly, the supplier must specify what time span the charge represents - e.g., per day, per week, per month, etc. The supplier must list the Medicare fee schedule amount for each item, accessory and option, if applicable. The fee schedule allowance should reflect the same time span and quantity used in the submitted charge column. If the Medicare allowed amount is determined by methods other than a fee schedule (e.g., for drugs, parenteral and enteral nutrients, PEN supplies, miscellaneous codes, etc.), a NA (not applicable) should be put in the Medicare allowed charge column. The supplier must complete section C before the CMN is sent to the physician. Samples of Section C formats are given in Examples 1 and 2. Suppliers may use other formats as long as the required information is presented. Form 854 (Section C Continuation Form) may only be used in conjunction with HCFA forms 843 (Motorized Wheelchairs) or 844 (Manual Wheelchairs). Section C of forms 843 or 844 should list the wheelchair base and the 4-6 most costly options/accessories. Form 854 is used for additional options/accessories. Satisfactory completion of Section C will be assessed in post-payment audits. Civil monetary penalties can be assessed for failure to comply. Section D contains the physician’s attestation statement, physician’s signature, and date. The physician who signs the CMN must be the physician who is actively/presently treating the patient. Claims submitted with CMNs lacking a physician signature will be denied. Suppliers billing electronically must indicate presence of the physician’s signature in the usual way. The date in Section D must be the date that the physician signs the CMN. Both the signature and date must be personally entered by the physician and may not be a stamp or other substitute. For codes requiring a CMN or DIF, the CMN or DIF must accompany claims for purchase of these items (including replacement), for the first month rental of equipment, for the initial provision of PEN nutrients and supplies, and for any required revised certifications or re-certifications. Submitting CMNs/DIF when they are not required (e.g., subsequent months on rental items, oxygen, or PEN nutrients when there is no change in the order and no requirement for re-certification) may cause claims processing problems/delays and is discouraged. Because HCFA forms 484 and 841-854 have been approved by the Office of Management and Budget (OMB), when a CMN is submitted with a paper claim, the hard copy CMN must be an exact reproduction of the HCFA form.

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A nurse practitioner or clinical nurse specialist may complete Section B and sign Section D if they are treating the beneficiary for the condition for which the item is needed, and they are practicing independently of a physician, and they bill Medicare for other covered services using their own provider number, and they are permitted to do all of the above in the state in which the services are rendered. Suppliers are encouraged to mail or deliver a two-sided CMN to the physician and to have the physician mail the completed CMN back to the supplier. However, it is permissible to fax a CMN from the supplier to the physician. If this is done, the supplier must also fax the instructions that are on the back of the CMN. The physician may fax the completed CMN to the supplier. However, the original CMN (i.e., the CMN with the original answers in Section B and the original physician signature and date in Section D) must be retained either in the supplier’s files or in the physician’s files. The DMERC may request to see the original CMN at any time. If the original CMN is not available, the items on the CMN will be considered not medically necessary and a denial or overpayment will be initiated. If any change is made to the CMN after the physician has completed Section B and signed the CMN, the physician must line through the correction, sign the correction in full, and date the change – or the supplier may choose to have the physician complete a new CMN. If the original or faxed CMN has been altered without this physician verification, the items on the CMN will be considered not medically necessary and a denial or overpayment will be initiated. For items that require a CMN, the supplier must have a fully completed original or faxed CMN in their records before they submit a claim to the DMERC. When a CMN/DIF is submitted hard copy, the supplier must include a copy of only the front side. When a CMN is submitted electronically, only information from sections A, B, and D is transmitted. HCFA forms 484 and 841-854 can serve as the physician order if the narrative description in Section C is sufficiently detailed. Refer to Section XVII, Medical Policy, subsection Documentation, and subsection Orders for requirements for the content of detailed written orders. For items which require a written order prior to delivery and which have a CMN (i.e., air fluidized beds, TENS, POVs, seat lift mechanisms), suppliers may utilize a completed and physician-signed CMN for this purpose, if the CMN is signed and dated prior to delivery of the item. Otherwise, a separate order in addition to a subsequently completed and signed CMN would be necessary. The physician is encouraged, although not required, to keep a copy of the CMN in their patient’s medical record. CMNs are a standardized means of submitting some medical necessity information to the DMERCs. A CMN does not by itself provide sufficient documentation of medical necessity, even though the treating physician signs it. There must be clinical information in the patient’s medical record that substantiates the answers on the CMN and supports the medical necessity for the item in the individual case. Suppliers are encouraged to remind physicians that it is the physician’s responsibility to determine both the medical need for, and the utilization of, all health care services. Suppliers are also encouraged to remind physicians that it is the physician’s responsibility to ensure that the information on the CMN relating to the beneficiary’s condition is correct and is supported by information in the patient’s medical record. Original CMNs will be audited periodically to validate proper completion and transmission to the DMERC. Individual claims will be reviewed to verify that the answers on CMNs are supported by information in the patient’s medical record. SECTION C EXAMPLES Example 1: Item: Codes: HCPCS Description:

A K0004 High strength, lightweight wheelchair.

B K0195 Elevating leg rests, pair.

C K0028 Fully reclining back.

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Item: Codes: HCPCS Description:

D K0025 Hook-on headset extension.

E K0020 Fixed, adjustable height armrests, pair. Item: Quantity: Supplier’s Charge: Medicare Fee Schedule Allowance:

A 1 $115.00/Month $110.31/Month

B 1 $11.00/Month $9.95/Month

C 1 $428.93 $407.60

D 1 $60.00 $56.90

E 1 $45.00 $40.82 Example 2: Item: Codes: HCPCS Description:

A E0781 Ambulatory infusion pump

B A4222 Supplies for external drug infusion pump, per cassette or bag.

C A4221 Supplies for maintenance of drug infusion catheter, per week.

D J2270 Morphine Sulfate, 10 mg. Item: Quantity: Supplier’s Charge: Medicare Fee Schedule Allowance:

A 1 $747.30/Month $235.28/Month

B 3/Wk $153.30/Week $121.44/Week

C 1/Wk $30.00/Week $20.39/Week

D 168/Wk $300.00/Week N/A * * An N/A (not applicable) entry means that Medicare payment will be determined by a method other than a fee schedule. An N/A does not indicate that Medicare will deny the item.

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HCPCS CODES REQUIRING A CMN OR A DIF The following codes are those that currently require a CMN/DIF and that should be listed in Section A of the CMN/DIF. The description of related additional items must also be listed in Section C of HCFA forms 484 and 841-854. For narrative descriptions, refer to the HCPCS Chapter of this Supplier Manual. B4150 B4151 B4152 B4153 B4154 B4155 B4156 B4164 B4168 B4176 B4178 B4180 B4184 B4186 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B9000

B9002 B9004 B9006 E0194 E0250 E0251 E0255 E0256 E0260 E0261 E0265 E0266 E0290 E0291 E0292 E0293 E0294 E0295 E0296 E0297 E0303 E0304 E0424 E0431 E0434

E0439 E0441 E0442 E0443 E0444 E0627 E0628 E0629 E0650 E0651 E0652 E0655 E0660 E0665 E0666 E0667 E0668 E0669 E0671 E0672 E0673 E0720 E0730 E0748 E0776

E0779 E0780 E0781 E0784 E0791 E0973 E0982 E0983 E0990 E1226 E1230 E1390 E1405 E1406 J7920 J2930 J7500 J7501 J7502 J7506 J7507 J7509 J7510 J7513 J7515

J7517 J7520 K0001 K0002 K0003 K0004 K0005 K0006 K0007 K0009 K0010 K0011 K0012 K0014 K0017 K0018 K0020 K0046 K0047 K0053 K0195 K0455

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XXV - APPENDIX IV – Medicare As Secondary Payer Questionnaire (Short Form) Beneficiary Name: __________________________________________ Age: _____________ HICN: ___________________________________________________ 1 1. Is this illness/injury covered by Worker’s Compensation? If yes, note employer/insurer

name, address and claim number (if available) in #9 and file claim with them. If no, go to #2.

YES NO

2 Is this illness/injury covered under the Federal Black Lung Program? If yes, file claim with them. If no, go to #3.

YES NO

3 Is this illness/injury the result of an auto accident? If yes, enter the responsible auto insurer in #9 and file claim with them. If no, go to #4.

YES NO

4 Is another party’s liability insurance, non-liability insurance, or no-fault insurance liable for this illness/injury? If yes, enter information in #9 and file claim with them. If no, go to #5.

YES NO

5 Is this patient covered by an employer group health plan (EGHP), including Federal Employee Health Benefits? If yes, go to #6. If no, Medicare is primary.

YES NO

6 Is this patient or his/her spouse actively employed by an employer of 20 or more employees? If yes, enter information in #9 and file claim with them. If no, go to #7.

YES NO

7a Is the patient under 65 and entitled to Medicare due to a disability? If yes, go to #7b. If no, go to #8.

YES NO

7b Is the patient or his/her spouse or parent actively employed by, or is the patient considered an employee of an employer having 100 or more employees? If yes, enter LGHP data in #9 and file claim with them. If no, go to #8a.

YES NO

8a Is the patient entitled to Medicare solely on the basis of End Stage Renal Disease (ESRD)? If yes, go to #8b. If no, Medicare is primary.

YES NO

8b Has the patient completed the ESRD coordination period? If yes, Medicare is primary. If no, enter the EGHP date in #9 and file claim with them.

YES NO

9 Name of insurance company: _______________________________________________________________

Name of insured: _________________________________________________________________________ Patient’s relationship to insured: _____________________________________________________________ Insured’s policy number: ___________________________________________________________________ Insurer’s address: _________________________________________________________________________ ______________________________________________________________________________________ Employer name:________________________________________________________________________ Employer address: ________________________________________________________________________ ______________________________________________________________________________________ Name of attorney(s) involved: _______________________________________________________________

Updated Winter 2004

Page 125

NOTES

Updated Winter 2004

Page 126

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