Allwin Medicare Manual 332045

Updated Winter 2004

Table Of Contents I - IMPORTANT PHONE NUMBERS, ADDRESSES AND WEBSITES .........................................................................5 GLOSSARY OF /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 NDP FIELD LOCATIONS .............................................................................................................................15 V - NEBULIZERS & INHALATION SOLUTIONS..........................................................................................................16 COVERAGE AND PAYMENT RULES ........................................................................................................................................16 DOCUMENTATION REQUIREMENTS .......................................................................................................................................16 CLAIMS TRANSMISSION ........................................................................................................................................................17 HCS CODES.....................................................................................................................................................................18 VI - DIABETIC SUPPLIES..................................................................................................................................................21 COVERAGE AND PAYMENT RULES ........................................................................................................................................21 CODING GUIDELINES ............................................................................................................................................................22 DOCUMENTATION REQUIREMENTS .......................................................................................................................................22 CLAIMS TRANSMISSION ........................................................................................................................................................23 HCS 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 HCS CODES.....................................................................................................................................................................31 IX - ENTERAL NUTRITION ..............................................................................................................................................33 COVERAGE AND PAYMENT RULES ........................................................................................................................................33 CODING GUIDELINES ............................................................................................................................................................33 DOCUMENTATION REQUIREMENTS .......................................................................................................................................33 CLAIM TRANSMISSION..........................................................................................................................................................34 HCS CODES.....................................................................................................................................................................35 X - ORAL ANTI-CANCER DRUGS ...................................................................................................................................37 COVERAGE AND PAYMENT RULES ........................................................................................................................................37 CODING GUIDELINES ............................................................................................................................................................37 DOCUMENTATION REQUIREMENTS .......................................................................................................................................38 CLAIMS TRANSMISSION ........................................................................................................................................................38 Page 2

Updated Winter 2004 XI - ORAL ANTI-EMETIC DRUGS...................................................................................................................................39 COVERAGE AND PAYMENT RULES ........................................................................................................................................39 CODING GUIDELINES ............................................................................................................................................................39 DOCUMENTATION REQUIREMENTS .......................................................................................................................................40 CLAIM TRANSMISSION..........................................................................................................................................................40 HCS CODES.....................................................................................................................................................................40 XIII - UROLOGICAL SUPPLIES.......................................................................................................................................42 COVERAGE AND PAYMENT RULES ........................................................................................................................................42 CODING GUIDELINES ............................................................................................................................................................42 DOCUMENTATION REQUIREMENTS .......................................................................................................................................43 CLAIM TRANSMISSION..........................................................................................................................................................44 HCS CODES.....................................................................................................................................................................44 XIV - SURGICAL DRESSINGS ..........................................................................................................................................46 COVERAGE AND PAYMENT RULES ........................................................................................................................................46 CODING GUIDELINES ............................................................................................................................................................47 DOCUMENTATION REQUIREMENTS .......................................................................................................................................49 CLAIM TRANSMISSION..........................................................................................................................................................50 HCS CODES.....................................................................................................................................................................50 XV - WALKERS, CANES AND CRUTCHES....................................................................................................................56 COVERAGE AND PAYMENT RULES ........................................................................................................................................56 CODING GUIDELINES ............................................................................................................................................................56 HCS CODES.....................................................................................................................................................................58 XVI - SEAT LIFT MECHANISMS .....................................................................................................................................59 COVERAGE AND PAYMENT RULES ........................................................................................................................................59 CODING GUIDELINES ............................................................................................................................................................59 DOCUMENTATION REQUIREMENTS .......................................................................................................................................59 CLAIM TRANSMISSION..........................................................................................................................................................59 HCS CODES.....................................................................................................................................................................60 XVII - HOSPITAL BEDS .....................................................................................................................................................61 COVERAGE AND PAYMENT RULES ........................................................................................................................................61 ACCESSORIES .......................................................................................................................................................................61 CODING GUIDELINES ............................................................................................................................................................62 DOCUMENTATION REQUIREMENTS .......................................................................................................................................63 CLAIM TRANSMISSION..........................................................................................................................................................63 HCS CODES.....................................................................................................................................................................63 XVIII - MANUAL WHEELCHAIRS ..................................................................................................................................66 COVERAGE AND PAYMENT RULES ........................................................................................................................................66 CODING GUIDELINES ............................................................................................................................................................67 DOCUMENTATION REQUIREMENTS .......................................................................................................................................68 CLAIM TRANSMISSION..........................................................................................................................................................68 HCS CODES.....................................................................................................................................................................68 XIX - MOTORIZED WHEELCHAIRS..............................................................................................................................70 COVERAGE AND PAYMENT RULES ........................................................................................................................................70 CODING GUIDELINES ............................................................................................................................................................70 DOCUMENTATION REQUIREMENTS .......................................................................................................................................71 CLAIMS TRANSMISSION ........................................................................................................................................................71 HCS CODES.....................................................................................................................................................................71 XX - WHEELCHAIR ACCESSORIES...............................................................................................................................73 Page 3

Updated Winter 2004 COVERAGE AND PAYMENT RULES ........................................................................................................................................73 CODING GUIDELINES ............................................................................................................................................................74 DOCUMENTATION REQUIREMENTS .......................................................................................................................................79 CLAIM TRANSMISSION..........................................................................................................................................................79 HCS CODES.....................................................................................................................................................................79 XXI - OXYGEN .....................................................................................................................................................................85 COVERAGE AND PAYMENT RULES ........................................................................................................................................85 CODING GUIDELINES ............................................................................................................................................................88 DOCUMENTATION REQUIREMENTS .......................................................................................................................................88 CLAIM TRANSMISSION..........................................................................................................................................................90 HCS CODES.....................................................................................................................................................................90 XXII - APPENDIX I..............................................................................................................................................................93 SUPPLEMENTAL INSURANCE BILLING......................................................................................................................93 COMPLEMENTARY CROSSOVER INSURANCE COMPANIES .....................................................................................................95 OCNA NUMBER LIST ...........................................................................................................................................................98 XXIII - APPENDIX II – NON-COVERED HCS ........................................................................................................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 /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 information. The image below the table is a map representation of the four DMERC regions. REGION Region A Connecticut, Delaware, Maine, Massachusetts, New York, New Hampshire, New Jersey, Pennsylvania, Rhode Island and Vermont Region B District of Columbia, Illinois, Indiana, Maryland, Michigan, Minnesota, Ohio, Virginia, West Virginia and Wisconsin

DMERC HealthNow NY P.O. Box 6800 Wilkes-Barre, PA 18773-6800 aStar Federal Inc. P.O. Box 7078 Indianapolis, IN 46207-7078

Region C Palmetto GBA Alabama, Arkansas, Colorado, Florida, Georgia, Kentucky, Medicare DMERC Operations Louisiana, Mississippi, New Mexico, North Carolina, P.O. Box 100141 Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas and Columbia, SC 29202-3141 the Virgin Islands Connecticut General Life Insurance Co. (CIGNA Medicare) Alaska, Arizona, California, Guam/American Samoa, Hawaii, P.O. Box 690 Idaho, Iowa, Kansas, the Marianna Islands, Missouri, Montana, Nashville, TN 37202 Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah , Washington and Wyoming

PHONE NUMBER (866) 419-9458 Beneficiary Line: (800)842-2052 (877) 299-7900 Beneficiary Line: (800)270-2313 VRU: (866) 238-9650 Live Customer Service:(866) 270-4909 Beneficiary Line: (800)583-2236

Region D

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

Updated Winter 2004

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 isters file activity. See below for information on Medicare Enrollment & Reenrollment Guidelines. Phone – (866)238-9652 Website – www.pgba.com SERC The SERC HCS Unit offers guidance to manufacturers and suppliers on the proper use of the Healthcare Common Procedure Coding System (HCS), 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.nyic.com Region B – www.astar.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 04 12 13 14 31 32 33 54 55 56 65

Definition Homeless Shelter Home Assisted Living Facility Group Home Skilled Nursing Facility Nursing Facility Custodial Care Facility Intermediate Care Facility/Mentally Retarded Residential Substance Abuse Treatment Facility Psychiatric Residential Treatment Center End Stage Renal Disease Treatment Facility

The following POS codes are valid for the following categories of durable medical equipment. POS Code 04,12, 13, 14, 33, 54, 55, 56 04, 12, 13, 33, 54, 55, 56 04, 12, 13, 14, 31, 32, 33, 54, 55, 56 04, 12, 13, 14, 33, 54, 55, 56 04, 12, 13, 14, 33, 54, 55, 56 04, 12, 13, 14, 33, 54, 55, 56 04, 12, 13, 14, 31, 32, 33, 54, 55, 56

04, 12, 13, 14, 31, 32, 33, 54, 55, 56 04, 12, 13, 14, 31, 32, 33, 54 04, 12, 13, 14, 33, 54, 55, 56

Category Inexpensive or other routinely purchased DME Items requiring frequent and substantial servicing Customized items • Prosthetic and orthotics • DME Capped Rental Items Oxygen and oxygen equipment General prosthetic and orthotic devices, P & O supplies, parenteral and enteral nutrition-related items and supplies (these include IV poles used to ister PEN (E0776XA), urinary incontinence and ostomy supplies Surgical dressings Drugs (oral anticancer, immunosuppressive) Drugs istered 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 istration, 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 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 istration (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 , 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 s, 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 istration (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 # USMCA USMCAASG USMCANON USNONCOVER

Envoy BIN # 005200 005730 005917 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 ed 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/HCS Codes For most products Medicare does not accept NDC #’s to identify an item on a claim. Medicare only recognizes HCS (Procedure) codes as a valid product identifier. Allwin Data will accept your NDC# on a claim transaction and convert it to a payable HCS code before transmitting the claim to Medicare, provided there is a link established in our system between the NDC# and HCS 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 HCS code to Allwin Data, therefore, the pharmacy should be familiar with the location and use of their HCS code field. The pharmacy’s software vendor should be helpful in locating and using this field. The NDP 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 HCS code, but no NDC#, Allwin Data will always accept an NDC# in the following format: Using HCS 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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Updated Winter 2004 Modifiers Medicare requires modifiers on most HCS 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 HCS codes. However, there are a few instances when it will be necessary for the pharmacy to include the modifier and HCS 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 HCS 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 HCS 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 HCS 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 HCS 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 HCS/modifier combination to use. The example used is a Nebulizer. Month Months 2&3 Months 4-10 Months 11-13 Months 11-15 Months 11-15

You Transmit E0570KI E0570KJ E0570BP E0570BR E0570BU

Allwin Transmits E0570RRKI E0570RRKJ E0570RRKJBP E0570RRKJBR E0570RRKJBU

Meaning Patient Purchase Patient Rent 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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Updated Winter 2004 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. 2. 3.

Type the word “SECONDARY” in the Group Field of your Medicare claim. 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. 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 Page 12

Updated Winter 2004 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 HCS 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 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 20% coinsurance $0.00 coinsurance

Pharmacy collects full amount from the patient. Reimbursement will be sent directly to the beneficiary’s residence. Pharmacy collects the 20% amount returned by Allwin Data from the patient. Medicare will reimburse the pharmacy the other 80%. 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 ed 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 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 HCS code by calling Allwin Data. To expedite this process, please have the NDC# and HCS code handy. An excellent resource for the HCS codes is SERC 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 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 ing 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 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 ing 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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Updated Winter 2004

ing 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 istration (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 NDP Field Locations When talking with your software vendor, use the following chart to locate important fields used in Medicare claims transmission: Field Product/Service ID Prescriber ID Group ID Eligibility Clarification Other Coverage Code Usual & Customary Gross Amount Due Submission Clarification Code (Rx Denial Override) Quantity Dispensed Processor Control # Diagnosis Code

Field Number 407 411 301 309 308 426 430 420

Field Identifier D7 DB C1 C9 C8 DQ DU DK

442 104 424

E7 A4 DO

Page 15

Updated Winter 2004

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 ister 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 ister 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 ister 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 ister 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 istration 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. istration 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

Page 16

Updated Winter 2004 type of solution dispensed or the istration 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 ing 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 ing the medical necessity for the higher utilization. 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 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.

, 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 . 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.

Page 17

Updated Winter 2004

HCS Codes Inhalation Solutions HCS A7018 A4216 A4217 A7020 E0590 J2545 J7051 J7608 J7618

J7619

J7621

J7622 J7624 J7626 J7628 J7629 J7631 J7633 J7635 J7636 J7637

Description Quantity WATER, DISTILLED, USED WITH LARGE VOLUME NEBULIZER, 1000 ML 18L/mo SALINE SOLUTION, PER 10 ML, METERED DOSE DISPENSER, FOR USE WITH INHALATION DRUGS 60units/mo STERILE WATER/SALINE PER 500 ML STERILE WATER OR STERILE SALINE, 1000 ML, USED WITH LARGE VOLUME NEBULIZER 18L/mo DISPENSING FEE COVERED DRUG ISTERED THROUGH DME 1 per drug/mo NEBULIZER PENTAMIDINE ISETHIONATE, INHALATION SOLUTION, PER 300 MG, ISTERED THROUGH A DME 300 mg/mo STERILE SALINE OR WATER, UP TO 5 CC 186units/mo ACETYLCYSTEINE, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM 74grams/mo ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION ISTERED THROUGH DME, CONCENTRATED FORM, PER 1 MG (ALBUTEROL) OR PER 0.5 MG 465mg/mo (LEVALBUTEROL) ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL) 465mg/mo ALBUTEROL, ALL FORMULATIONS, INCLUDING SEPARATED ISOMERS, UP TO 5 MG (ALBUTEROL) OR 2.5 MG (LEVOALBUTEROL), AND IPRATROPIUM BROMIDE, UP TO 1 MG, COMPOUNDED IC INHALATION SOLUTION, ISTERED THROUGH DME BECLOMETHASONE, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM IC BETAMETHASONE, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM IC BUDESONIDE INHALATION SOLUTION, ISTERED THROUGH DME, UNIT DOSE FORM, 0.25 TO 0.50 MG IC BITOLTEROL MESYLATE, INHALATION SOLUTION ISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM 434mg/mo BITOLTEROL MESYLATE, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM 434mg/mo CROMOLYN SODIUM, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS 248units/mo BUDESONIDE, INHALATION SOLUTION ISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM IC ATROPINE, INHALATION SOLUTION ISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM 186mg/mo ATROPINE, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM 186mg/mo DEXAMETHASONE, INHALATION SOLUTION ISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM IC

Page 18

Notes

Updated Winter 2004 J7638 J7639 J7641 J7642 J7643 J7644 J7648 J7649 J7658 J7659 J7668 J7669 J7680 J7681 J7682 J7683 J7684 J7699 •

DEXAMETHASONE, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM DORNASE ALPHA, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM FLUNISOLIDE, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE, PER MILLIGRAM GLYCOPYRROLATE, INHALATION SOLUTION ISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM GLYCOPYRROLATE, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM IPRATROPIUM BROMIDE, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM ISOETHARINE HCL, INHALATION SOLUTION ISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM ISOETHARINE HCL, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM ISOPROTERENOL HCL, INHALATION SOLUTION ISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM ISOPROTERENOL HCL, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM METAPROTERENOL SULFATE, INHALATION SOLUTION ISTERED THROUGH DME, CONCENTRATED FORM, PER 10 MILLIGRAMS METAPROTERENOL SULFATE, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS TERBUTALINE SULFATE, INHALATION SOLUTION ISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM TERBUTALINE SULFATE, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM TOBRAMYCIN, UNIT DOSE FORM, 300 MG, INHALATION SOLUTION, ISTERED THROUGH DME TRIAMCINOLONE, INHALATION SOLUTION ISTERED THROUGH DME, CONCENTRATED FORM, PER MILLIGRAM TRIAMCINOLONE, INHALATION SOLUTION ISTERED THROUGH DME, UNIT DOSE FORM, PER MILLIGRAM NOC DRUGS, INHALATION SOLUTION ISTERED THROUGH DME

IC 78mg/mo IC 75mg/mo 75mg/mo 93mg/mo 930mg/mo 930mg/mo 450/mg/mo 450mg/mo 280units/mo 280units/mo 186mg/mo 186mg/mo IC IC IC 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 HCS E0565 E0570 E0571

Description Compressor, air power source, for equipment which is not self-contained or cylinder driven Nebulizer with compressor Aerosol compressor, battery powered, for use with small volume nebulizer

Page 19

Quantity

Notes CR CR CR/NARR

Updated Winter 2004 E0572 E0574 E0575 E0585

Aerosol compressor, adjustable pressure, light duty for intermittent use Ultrasonic generator with small volume ultrasonic nebulizer Nebulizer, ultrasonic, large volume Nebulizer, with compressor and heater

CR CR/NMN CR/NC CR

Accessories HCS A4619 A7525 A7526 A7003 A7004 A7005 A7006 A7007 A7008 A7009 A7010 A7011 A7012 A7013 A7014 A7015 A7016 A7017 E0580 E1372

Description Face tent Tracheostomy mask Tracheostomy tube collar/holder, each istration set, small volume non-filtered pneumatic nebulizer, disposable Small volume non-filtered pneumatic nebulizer, disposable istration set, small volume non-filtered pneumatic nebulizer, nondisposable istration set, small volume filtered pneumatic nebulizer Large volume nebulizer, disposable, unfilled, used with aerosol compressor Large volume nebulizer, disposable, pre-filled, used with aerosol compressor Reservoir bottle, non-disposable, used with large volume ultrasonic nebulizer Corrugated tubing, disposable, used with large volume nebulizer, 100 feet Corrugated tubing, non-disposable, used with large volume nebulizer, 10 feet Water collection device, used with large volume nebulizer Filter, disposable, used with aerosol compressor Filter, non-disposable, used with aerosol compressor or ultrasonic generator Aerosol mask, used with DME nebulizer Dome and mouthpiece, used with small volume ultrasonic nebulizer Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with oxygen Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter Immersion external heater for nebulizer

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.

Page 20

Quantity 1/ month 1/ month

Notes

2/month 2/month 1/6 months 1/month NC NC 1/ 2 months 1/ year 2/ month 2 /month 1/ 3 months 1 / month 2 / year 1 / 3 years

1 / 3 years

Updated Winter 2004

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 ing 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.

Page 21

Updated Winter 2004 Medicare does not pay for syringes, needles, and alcohol wipes, or insulin injected by syringe. Insulin will be covered only when it is istered 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 ed 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. 2. 3. 4. 5. 6.

The item(s) to be dispensed The quantity of item(s) to be dispensed The frequency of testing ("as needed" is not acceptable) Whether the patient has insulin-treated or non-insulin-treated diabetes; A physician signature; A signature date; and, 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. Page 22

Updated Winter 2004

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 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 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 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 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.

Page 23

Updated Winter 2004

HCS Codes HCS E0607 E0620 E2100 E2101 A4253 A4254 A4255 A4256 A4257 A4258 A4259

Description Home blood glucose monitor Skin piercing device for collection of capillary blood, laser, each Blood glucose monitor with integrated voice synthesizer Blood glucose monitor with integrated lancing/blood sample collection Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips Replacement battery, any type, for use with medically necessary home blood glucose monitor owned by patient, each Platforms for home blood glucose monitor, 50 per box Normal, low and high calibrator solution/chips Replacement lens shield cartridge for use with laser skin piercing device, each Spring-powered device for lancet, each Lancets, per box of 100



NC

Not Covered.

NARR


CR

Capped Rental item.

CMN


Page 24

Quantity 1 / 5years 1 / 5years 1 / 5years 1 / 5years

Notes A4258 NARR NARR

A4259 1 / 5years

Updated Winter 2004

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 A4375 A4376 A4379 A4380

Column II A4361, A4377 A4361, A4378 A4361, A4381, A4382 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.

Page 25

Updated Winter 2004

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 SERC, or use the Manufacturer Code look-up on the Allwin Data website.

HCS Codes HCS

A4357

Description Quantity EXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH CONNECTOR/ADAPTOR, FOR USE WITH URINARY LEG BAG OR UROSTOMY POUCH, EACH BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH OR WITHOUT ANTI-REFLUX DEVICE, WITH OR WITHOUT TUBE, EACH 2

A4361

OSTOMY FACEPLATE, EACH

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

A4368

OSTOMY FILTER, ANY TYPE, EACH

A4369

OSTOMY SKIN BARRIER, LIQUID (SPRAY, BRUSH, ETC), PER OZ

A4371

A4375

OSTOMY SKIN BARRIER, POWDER, PER OZ OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, WITH BUILT-IN CONVEXITY, EACH OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDIAN), WITH BUILT-IN CONVEXITY, ANY SIZE, EACH 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

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 A4382

OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, PLASTIC 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

A4331

A4372 A4373

3 / 6mo

1

Page 26

2 10 / 6mo

10

10

Notes

Updated Winter 2004

A4394

OSTOMY SKIN BARRIER, SOLID 4X4 OR EQUIVALENT, EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, EACH OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, (1 PIECE), EACH OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH OSTOMY POUCH, DRAINABLE, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED (1 PIECE), EACH OSTOMY POUCH, URINARY, WITH STANDARD WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY (1 PIECE), EACH 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

A4397

IRRIGATION SUPPLY; SLEEVE, EACH

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

4

A4415

OSTOMY SKIN BARRIER, PECTIN-BASED, PASTE, PER OUNCE OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE, OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH OSTOMY SKIN BARRIER, WTIH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITH BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), EXTENDED WEAR, WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4 X 4 INCHES, EACH OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, FOR USE ON A BARRIER WITH FLANGE (2 PIECE SYSTEM), WITH FILTER, EACH OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, 4 X 4 INCHES OR SMALLER, EACH OSTOMY SKIN BARRIER, WITH FLANGE (SOLID, FLEXIBLE OR ACCORDION), WITHOUT BUILT-IN CONVEXITY, LARGER THAN 4X4 INCHES, EACH

A4421

OSTOMY SUPPLY; MISCELLANEOUS

A4385 A4387 A4388 A4389 A4390 A4391 A4392 A4393

A4407

A4408

A4409

A4410 A4413 A4414

4

20 20 NARR

Page 27

Updated Winter 2004

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

40

A4455

TAPE, WATERPROOF, PER 18 SQUARE INCHES ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE

A5051

OSTOMY POUCH, CLOSED; WITH BARRIER ATTACHED (1 PIECE), EACH

A5052

OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED (1 PIECE), EACH

A5053

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

60

A5055

STOMA CAP

31

A5061

20

A5063

OSTOMY POUCH, DRAINABLE; WITH BARRIER ATTACHED, (1 PIECE), EACH OSTOMY POUCH, DRAINABLE; WITHOUT BARRIER ATTACHED (1 PIECE), EACH OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH FLANGE (2 PIECE SYSTEM), EACH

A5071

OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED (1 PIECE), EACH

20

A5072

20

A5073

OSTOMY POUCH, URINARY; WITHOUT BARRIER ATTACHED (1 PIECE), EACH 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

10

A5102

OSTOMY ACCESSORY; CONVEX INSERT 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 APPLIANCE CLEANER, INCONTINENCE AND OSTOMY APPLIANCES, PER 16 OZ. GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING

20

A5054

A5062

A5131 A6216 A9270 A4416 A4417 A4418 A4419 A4420

NON-COVERED ITEM OR SERVICE OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH OSTOMY POUCH, CLOSED, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FILTER (1 PIECE), EACH OSTOMY POUCH, CLOSED; WITHOUT BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH FLANGE, WITH FILTER (2 PIECE), EACH OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACH

Page 28

16 / 6mo 60

60

20

1 60 NC 60 60 60 60 60

Updated Winter 2004 OSTOMY POUCH, CLOSED; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2 PIECE), EACH OSTOMY POUCH, DRAINABLE, WITH BARRIER ATTACHED, WITH FILTER (1 PIECE), EACH OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH FLANGE, WITH FILTER (2 PIECE SYSTEM), EACH OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE SYSTEM), EACH OSTOMY POUCH, DRAINABLE; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FILTER (2 PIECE SYSTEM), EACH OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH OSTOMY POUCH, URINARY, WITH BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-IN CONVEXITY, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITH VALVE (1 PIECE), EACH OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH FLANGE, WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACH OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE, WITH FAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH

A4423 A4424 A4425 A4426 A4427 A4428 A4429

A4430 A4431 A4432 A4433 A4434



NC

Not Covered.

NARR


CR

Capped Rental item.

CMN


Page 29

60 20 20

20

20 20 20 20

Updated Winter 2004

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 ing 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 istered 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-istered by the patient. There is no coverage under the immunosuppressive drug benefit for supplies used in conjunction with the istration of parenteral immunosuppressive drugs. The dosage, frequency and route of istration 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.

Page 30

Updated Winter 2004

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 istration 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 HCS code, for billing purposes the pharmacy can send only one claim reflecting the total amount dispensed in of the recognized HCS 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.

HCS Codes HCS J2920 J2930 J7500 J7501 J7502 J7504 J7505 J7506 J7507 J7509 J7510 J7511 J7513 J7515 J7516 J7517 J7520

Description INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 MG INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 MG AZATHIOPRINE, ORAL, 50 MG AZATHIOPRINE, PARENTERAL, 100 MG CYCLOSPORINE, ORAL, 100 MG LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, EQUINE, PARENTERAL, 250 MG MUROMONAB-CD3, PARENTERAL, 5 MG PREDNISONE, ORAL, PER 5 MG TACROLIMUS, ORAL, PER 1 MG METHYLPREDNISOLONE ORAL, PER 4 MG PREDNISOLONE ORAL, PER 5 MG LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT, PARENTERAL, 25MG DACLIZUMAB, PARENTERAL, 25 MG CYCLOSPORINE, ORAL, 25 MG CYCLOSPORINE, PARENTERAL, 250 MG MYCOPHENOLATE MOFETIL, ORAL, PER 250 MG SIROLIMUS, ORAL, 1 MG

Page 31

Quantity

Notes CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN CMN

Updated Winter 2004 J7525 J7599 J8530 J8610

TACROLIMUS, PARENTERAL, 5 MG IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED CYCLOPHOSPHAMIDE; ORAL, 25 MG METHOTREXATE; ORAL, 2.5 MG



NC

Not Covered.

NARR


CR

Capped Rental item.

CMN


Page 32

CMN CMN CMN CMN

Updated Winter 2004

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 istered orally and related supplies are non-covered. If the coverage requirements for enteral nutrition are met, medically necessary nutrients, istration 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. 2. 3. 4. 5.

Question #7 and #8 on the CMN must be answered YES Question #13 on the CMN must be answered 1, 2, or 3 Coverage does not exist for enteral nutrition that is istered orally Length of Need must be equal to or greater than 3 months 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. Page 33

Updated Winter 2004

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 istration using a pump. (In this latter situation, a Revised Certification is required for the nutrient which indicates the change to the pump method of istration - 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 istered is changed, or (3) the method of istration (syringe, gravity, pump) changes, or (4) route of istration 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 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 HCS Codes Product Name BOOST BOOST PLUS ENSURE ENSURE PLUS GLUCERNA ISOCAL JEVITY JEVITY PLUS NUTREN 1.0

HCS B4150 B4152 B4150 B4152 B4154 B4150 B4150 B4150 B4150

Page 34

Updated Winter 2004 NUTREN 1.5 OSMOLITE PULMOCARE RESOURCE TWOCAL ULTRACAL

B4152 B4150 B4154 B4150 B4152 B4150

HCS Codes HCS A5200

Description PERCUTANEOUS CATHETER/TUBE ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT

A9270

NON-COVERED ITEM OR SERVICE

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 GASTROSTOMY / JEJUNOSTOMY TUBE, ANY MATERIAL, ANY TYPE, (STANDARD OR LOW PROFILE), EACH

3 / 3mos

B4086 B4100

Quantity

Notes

NC

1 / 3mos NC

B4156

FOOD THICKENER, ISTERED ORALLY, PER OUNCE ENTERAL FORMULAE; CATEGORY I; SEMI-SYNTHETIC INTACT PROTEIN/PROTEIN ISOLATES, ISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT ENTERAL FORMULAE; CATEGORY I; NATURAL INTACT PROTEIN/PROTEIN ISOLATES, ISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT ENTERAL FORMULAE; CATEGORY II; INTACT PROTEIN/PROTEIN ISOLATES (CALORICALLY DENSE), ISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT ENTERAL FORMULAE; CATEGORY III; HYDROLIZED PROTEIN/AMINO ACIDS, ISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT ENTERAL FORMULAE; CATEGORY IV; DEFINED FORMULA FOR SPECIAL METABOLIC NEED, ISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT ENTERAL FORMULAE; CATEGORY V; MODULAR COMPONENTS, ISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT ENTERAL FORMULAE; CATEGORY VI; STANDARDIZED NUTRIENTS, ISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT

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

B4150

B4151

B4152

B4153

B4154

B4155

Page 35

CMN

CMN

CMN

CMN

CMN

CMN

Updated Winter 2004



NC

Not Covered.

NARR


CR

Capped Rental item.

CMN


Page 36

Updated Winter 2004

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 istration (FDA), and 2. It has the same ingredients as a non-self-istrable anticancer chemotherapeutic drug or biological that is covered when furnished incident to a physician's service. The oral anticancer drug and the non-self-istrable 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-selfistrable form of the drug, and 3. It is used for the same indications, including unlabeled uses, as the non-self-istrable 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 HCS 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 Capecitabine 150mg Capecitabine 500mg Cyclophosphamide 25mg Cyclophosphamide 50mg Etoposide 50mg Melphalan 2mg Methotrexate 2.5mg

Methotrexate 5mg Methotrexate 7.5mg Methotrexate 10mg Methotrexate 15mg Temozolomide 5mg Temozolomide 20mg Temozolomide 100mg Temozolomide 250mg

Page 37

Updated Winter 2004

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 istering 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.

Page 38

Updated Winter 2004

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 istration (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 istered at the time of the chemotherapy treatment, and 4. The initial dose of the oral antiemetic drug is istered within 2 hours of the istration 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 istered intravenously in the home setting because the type and dosage of chemotherapy drugs istered 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-istered 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 istration of the covered oral anticancer drug will induce emesis if the antiemetic drug is not istered, and 3. The antiemetic drug is istered within 2 hours before the covered oral anticancer drug is istered. 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 istered during the two hours before istration of the covered oral anticancer drug. Doses of antiemetic drugs istered after the istration 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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Updated Winter 2004

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. 2. 3. 4. 5. 6. 7. 8.

Anti-emetic name Anti-emetic strength Dosage directions for anti-emetic Manufacturer of Anti-emetic Anti-emetic NDC # Oral anti-cancer name Oral anti-cancer strength Oral anti-cancer method of istration

Claim Transmission Allwin will always prompt the pharmacy for ing 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 istered 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.

HCS Codes HCS Q0163

Q0164

Q0165

Q0166

Q0167

Q0168

Description Quantity 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 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 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 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 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 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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Notes

Updated Winter 2004 Q0169

Q0170

Q0171

Q0172

Q0173

Q0174

Q0175

Q0176

Q0177

Q0178

Q0179

Q0180

Q0181

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 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 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 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 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 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 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 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 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 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 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 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 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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Updated Winter 2004

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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Updated Winter 2004 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 es. This dressing has a hole through which the catheter/tube es 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 A4310 A4311 A4312 A4313 A4314 A4315 A4316 A4325 A4353 A4354 A4357 A4358 A5112 A5105

Column II A4332 A4310, A4332, A4338 A4310, A4332, A4344 A4310, A4332, A4346 A4310, A4311, A4331, A4332, A4338, A4354, A4357 A4310, A4312, A4331, A4332, A4344, A4354, A4357 A4310, A4313, A4331, A4332, A4346, A4354, A4357 A4450, A4452 A4310, A4332, A4351, A4352 A4310, A4331, A4332, A4357 A4331 A4331, A5113, A5114 A5113, A5114 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 ing 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 ing the medical necessity for sterile technique.

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Updated Winter 2004

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.

HCS Codes HCS

A4346

Description INSERTION TRAY WITHOUT DRAINAGE BAG AND WITHOUT CATHETER (ACCESSORIES ONLY) INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.) INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE INSERTION TRAY WITHOUT DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, THREE-WAY, FOR CONTINUOUS IRRIGATION INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.) INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE INSERTION TRAY WITH DRAINAGE BAG WITH INDWELLING CATHETER, FOLEY TYPE, THREE-WAY, FOR CONTINUOUS IRRIGATION IRRIGATION TRAY WITH BULB OR PISTON SYRINGE, ANY PURPOSE THERAPEUTIC AGENT FOR URINARY CATHETER IRRIGATION IRRIGATION SYRINGE, BULB OR PISTON, EACH MALE EXTERNAL CATHETER, WITH ADHESIVE COATING, EACH MALE EXTERNAL CATHETER, WITH ADHESIVE STRIP, EACH MALE EXTERNAL CATHETER SPECIALTY TYPE, EG; INFLATABLE, FACEPLATE, ETC., EACH FEMALE EXTERNAL URINARY COLLECTION DEVICE; MEATAL CUP, EACH FEMALE EXTERNAL URINARY COLLECTION DEVICE; POUCH, EACH EXTENSION DRAINAGE TUBING, ANY TYPE, ANY LENGTH, WITH CONNECTOR/ADAPTOR, FOR USE WITH URINARY LEG BAG OR UROSTOMY POUCH, EACH LUBRICANT, INDIVIDUAL STERILE PACKET, FOR INSERTION OF URINARY CATHETER, EACH URINARY CATHETER ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT, EACH URINARY CATHETER ANCHORING DEVICE, LEG STRAP, EACH INCONTINENCE SUPPLY; MISCELLANEOUS INDWELLING CATHETER; FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH INDWELLING CATHETER; SPECIALTY TYPE, EG; COUDE, MUSHROOM, WING, ETC.), EACH INDWELLING CATHETER, FOLEY TYPE, TWO-WAY, ALL SILICONE, EACH INDWELLING CATHETER; FOLEY TYPE, THREE WAY FOR CONTINUOUS IRRIGATION, EACH

A4347

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

A4310 A4311 A4312 A4313 A4314 A4315 A4316 A4320 A4321 A4322 A4324 A4325 A4326 A4327 A4328 A4331 A4332 A4333 A4334 A4335 A4338 A4340 A4344

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Quantity Notes 1 1 1 1 1 1 1 NC 35 35

4 30

12 1

1 1 1 1 Use A4324 or A4325

Updated Winter 2004

A4348 A4351 A4352 A4353 A4354 A4355 A4356 A4357 A4358 A4359 A4365 A4402 A4450 A4452 A4455 A5102 A5105 A5112 A5113 A5114 A5131 A5200 A9270

MALE EXTERNAL CATHETER WITH INTEGRAL COLLECTION COMPARTMENT, EXTENDED WEAR, EACH (E.G., 2 PER MONTH) INTERMITTENT URINARY CATHETER; STRAIGHT TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH 4 INTERMITTENT URINARY CATHETER; COUDE (CURVED) TIP, WITH OR WITHOUT COATING (TEFLON, SILICONE, SILICONE ELASTOMERIC, OR HYDROPHILIC, ETC.), EACH 4 INTERMITTENT URINARY CATHETER, WITH INSERTION SUPPLIES 1 INSERTION TRAY WITH DRAINAGE BAG BUT WITHOUT CATHETER 1 IRRIGATION TUBING SET FOR CONTINUOUS BLADDER IRRIGATION THROUGH A THREE-WAY INDWELLING FOLEY CATHETER, EACH EXTERNAL URETHRAL CLAMP OR COMPRESSION DEVICE (NOT TO BE USED FOR CATHETER CLAMP), EACH 1 / 3mo BEDSIDE DRAINAGE BAG, DAY OR NIGHT, WITH OR WITHOUT ANTI-REFLUX 1 DEVICE, WITH OR WITHOUT TUBE, EACH URINARY DRAINAGE BAG, LEG OR ABDOMEN, VINYL, WITH OR WITHOUT 2 TUBE, WITH STRAPS, EACH URINARY SUSPENSORY WITHOUT LEG BAG, EACH ADHESIVE REMOVER WIPES, ANY TYPE, PER 50 LUBRICANT, PER OUNCE 8 TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES TAPE, WATERPROOF, PER 18 SQUARE INCHES ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE BEDSIDE DRAINAGE BOTTLE WITH OR WITHOUT TUBING, RIGID OR EXPANDABLE, EACH URINARY SUSPENSORY; WITH LEG BAG, WITH OR WITHOUT TUBE URINARY LEG BAG; LATEX 1 LEG STRAP; LATEX, REPLACEMENT ONLY, PER SET LEG STRAP; FOAM OR FABRIC, REPLACEMENT ONLY, PER SET APPLIANCE CLEANER, INCONTINENCE AND OSTOMY APPLIANCES, PER 16 OZ. PERCUTANEOUS CATHETER/TUBE ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT NON-COVERED ITEM OR SERVICE Explanations of Notes Column NMN NC NARR CR CMN

Not Medically Necessary, payment will be based on the allowance for the least costly medical appropriate alternative. Not Covered. Narrative required. Call Allwin Data with the appropriate information. Capped Rental item. Certificate of Medical Neccessity required.

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NC NC

NC

NC

Updated Winter 2004

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 allinclusive): 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) b) c) d) e)

Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure; or A Stage I pressure ulcer; or A first degree burn; or Wounds caused by trauma which do not require surgical closure or debridement - e.g., skin tear or abrasion; or 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 Page 46

Updated Winter 2004 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 antibioticimpregnated 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 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 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. layers (A6206-A6208) are thin non-adherent sheets placed directly on an open wound bed to protect the wound tissue from direct with other agents or dressings applied to the wound. They are porous to allow wound fluid to 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 Page 47

Updated Winter 2004 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 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 ing that the performance characteristics specified in the code narratives have Page 48

Updated Winter 2004 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 HCS 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 HCS 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 s 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 Page 49

Updated Winter 2004 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.

HCS Codes HCS

Description (All quantity limitations are based per wound)

A4450**

TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES

A4452**

TAPE, WATERPROOF, PER 18 SQUARE INCHES

A4462

ABDOMINAL DRESSING HOLDER, EACH

A4649

SURGICAL SUPPLY; MISCELLANEOUS COLLAGEN BASED WOUND FILLER, DRY FORM, PER GRAM OF COLLAGEN COLLAGEN BASED WOUND FILLER, GEL/PASTE, PER GRAM OF COLLAGEN

A6010 A6011 A6021 A6022

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

A6196

A6197 A6198

Page 50

Quantity

Notes

NARR

12 30

30 30

Updated Winter 2004

A6199 A6200 A6201 A6202 A6203

A6204 A6205 A6206 A6207 A6208 A6209

A6210 A6211 A6212

A6213 A6214 A6215 A6216

A6217 A6218 A6219

A6220 A6221

ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND FILLER, PER 6 INCHES COMPOSITE DRESSING, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING COMPOSITE DRESSING, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING COMPOSITE DRESSING, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING COMPOSITE DRESSING, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 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 COMPOSITE DRESSING, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING LAYER, 16 SQ. IN. OR LESS, EACH DRESSING LAYER, MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING LAYER, MORE THAN 48 SQ. IN., EACH DRESSING FOAM DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 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 FOAM DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING FOAM DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 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 FOAM DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING FOAM DRESSING, WOUND FILLER, PER GRAM GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 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 GAUZE, NON-IMPREGNATED, NON-STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING GAUZE, NON-IMPREGNATED, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 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 GAUZE, NON-IMPREGNATED, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

Page 51

30 12 12 12 12

12 12 4 4 4 12

12 12 12

12 12 60 90

90 90 30

30 30

Updated Winter 2004

A6239

GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 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 GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, PAD SIZE MORE THAN 48 SQUARE INCHES, WITHOUT ADHESIVE BORDER, EACH DRESSING GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 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 GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND , PAD SIZE 16 SQ. IN. OR LESS, EACH DRESSING GAUZE, IMPREGNATED, HYDROGEL, FOR DIRECT WOUND , PAD SIZE GREATER THAN 16 SQ. IN., BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING GAUZE, IMPREGNATED, HYDROGEL FOR DIRECT WOUND , PAD SIZE MORE THAN 48 SQ. IN., EACH DRESSING HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 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 HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 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 HYDROCOLLOID DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

A6240

HYDROCOLLOID DRESSING, WOUND FILLER, PASTE, PER FLUID OUNCE

24

A6241

HYDROCOLLOID DRESSING, WOUND FILLER, DRY FORM, PER GRAM HYDROGEL DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 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 HYDROGEL DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING HYDROGEL DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

24

A6222

A6223

A6224 A6228*

A6229* A6230* A6231

A6232 A6233 A6234

A6235 A6236 A6237

A6238

A6242

A6243 A6244 A6245

Page 52

30

30

30 90

NMN

90

NMN

90

NMN

12

12 12 12

12 12 12

12 12

30

30 30 12

Updated Winter 2004

A6246 A6247 A6248 A6250 A6251

A6252 A6253 A6254

A6255 A6256 A6257

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 HYDROGEL DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING HYDROGEL DRESSING, WOUND FILLER, GEL, PER FLUID OUNCE SKIN SEALANTS, PROTECTANTS, MOISTURIZERS, OINTMENTS, ANY TYPE, ANY SIZE SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING 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 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING 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 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, PAD SIZE MORE THAN 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING

12 12 3 NC 30

30 30 15

15 15

A6258

TRANSPARENT FILM, 16 SQ. IN. OR LESS, EACH DRESSING 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 WOUND FILLER, GEL/PASTE, PER FLUID OUNCE, NOT ELSEWHERE CLASSIFIED

A6261 A6262

A6407

WOUND FILLER, DRY FORM, PER GRAM, NOT ELSEWHERE CLASSIFIED GAUZE, IMPREGNATED, OTHER THAN WATER, NORMAL SALINE, OR ZINC PASTE, ANY WIDTH, PER LINEAR YARD GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 16 SQ. IN. LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING 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 PADDING BANDAGE, NON-ELASTIC, NON-WOVEN/NON-KNITTED, WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES, PER YARD

A6266 A6402

A6403 A6404

A6441

Page 53

12

NC NARR NARR 5 90

90 90

4

Updated Winter 2004

A6501

CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NONSTERILE, WIDTH LESS THAN 3 INCHES, PER YARD CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NONSTERILE, WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES PER YARD CONFORMING BANDAGE, NON-ELASTIC, KNITTED/WOVEN, NONSTERILE, WIDTH GREATER THAN OR EQUAL TO 5 INCHES, PER YARD CONFORMING BANDAGE, NON-ELASTIC, KNITTED/ WOVEN, STERILE, WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES, PER YARD CONFORMING BANDAGE, NON-ELASTIC, KNITTED/ WOVEN, STERILE, WIDTH GREATER THAN OR EQUAL TO 5 INCHES, PER YARD LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES, PER YARD = ONE UNIT LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL TO 5 INCHES, PER YARD 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 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 SELF-ADHERENT BANDAGE, ELASTIC, NON-KNITTED/ NON-WOVEN, WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES, PER YARD ZINC PASTE IMPREGNATED BANDAGE, NON-ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL TO 3 INCHES AND LESS THAN 5 INCHES, PER YARD 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 COMPRESSION BURN GARMENT, GLOVE TO WRIST, CUSTOM FABRICATED COMPRESSION BURN GARMENT, GLOVE TO ELBOW, CUSTOM FABRICATED COMPRESSION BURN GARMENT, GLOVE TO AXILLA, CUSTOM FABRICATED COMPRESSION BURN GARMENT, FOOT TO KNEE LENGTH, CUSTOM FABRICATED COMPRESSION BURN GARMENT, FOOT TO THIGH LENGTH, CUSTOM FABRICATED COMPRESSION BURN GARMENT, UPPER TRUNK TO WAIST INCLUDING ARM OPENINGS (VEST), CUSTOM FABRICATED COMPRESSION BURN GARMENT, TRUNK, INCLUDING ARMS DOWN TO LEG OPENINGS (LEOTARD), CUSTOM FABRICATED

A6442

A6443 A6444

A6446 A6447

A6449 A6450

A6451

A6452

A6454

A6456

A6504 A6505 A6506 A6507 A6508 A6509 A6510

Page 54

4 4

4 4

4 4

4

4

Updated Winter 2004

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

K0620

TUBULAR ELASTIC DRESSING, ANY WIDTH, PER LINEAR YARD

NC

*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.

Explanations of Notes Column NMN NC NARR CR CMN


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Updated Winter 2004

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 ing 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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Updated Winter 2004 Code E0147 describes a 4-wheeled, adjustable height, folding-walker that has all of the following characteristics: 1. 2. 3. 4. 5. 6.

Capable of ing patients who weigh greater than 350 pounds, Hand operated brakes that cause the wheels to lock when the hand levers are released, The hand brakes can be set so that either or both can lock both wheels, The pressure required to operate each hand brake is individually adjustable, There is an additional braking mechanism on the front crossbar, 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 SERC 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 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 HCS 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 E0130 E0135 E0140 E0141 E0143 E0144 E0147 E0148 E0149

Column II A4636, A4637 A4636, A4637 A4636, A4637, E0155, E0159 A4636, A4637, E0155, E0159 A4636, A4637, E0155, E0159 A4636, A4637, E0155, E0156, E0159 A4636, E0155, E0159 A4636, A4637 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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Updated Winter 2004 number (if applicable), and information justifying the medical necessity for the item.

HCS Codes HCS A4636 A4637 A9270 E0130 E0135 E0141 E0143 E0144 E0147 E0148 E0149 E0154 E0155 E0156 E0157 E0158 E0159 E1399 E0100 E0105 E0110

E0111

E0112 E0113 E0114 E0116

Description Quantity Replacement, handgrip, cane, crutch or walker, each Replacement tip, cane, crutch, or walker, each Non-covered item or service Walker, rigid (pickup), adjustable or fixed height 1 / 5yrs Walker, folding (pickup), adjustable or fixed height 1 / 5yrs Rigid walker, wheeled, without seat 1 / 5yrs Folding walker, wheeled, without seat 1 / 5yrs Enclosed, framed folding walker, wheeled, with posterior seat 1 / 5yrs Heavy duty, multiple braking system, variable wheel resistance walker 1 / 5yrs Walker, heavy duty, without wheels, rigid or folding, any type, each 1 / 5yrs Walker, heavy duty, wheeled, rigid or folding, any type, each 1 / 5yrs Platform attachment, walker, each Wheel attachment, rigid pickup walker, per pair Seat attachment, walker Crutch attachment, walker, each Leg extensions for a walker, per set of four (4) Brake attachment for wheeled walker, replacement, each Durable medical equipment, miscellaneous Cane, Includes Canes of All Materials, Adjustable or Fixed with Tips 1 / 5yrs Cane, Quad or Three Prong, Includes Canes of All Materials, Adjustable or Fixed with 1 / 5yrs Tips Crutches, Forearm, Includes Crutches of Various Materials, Adjustable or Fixed, Pair, 1 / 5yrs Complete with Tips and Handgrips Crutch, Forearm, Includes Crutches of Various Material, Adjustable or Fixed, Each, with 1 / 5yrs Tip and Handgrips Crutches, Underarm, Wood Adjustable or Fixed, Pair, with Pads, Tips and Handgrips 1 / 5yrs Crutch, Underarm, Wood Adjustable or Fixed, Each, with Pad, Tip and Handgrip 1 / 5yrs Crutches Underarm, Aluminum, Adjustable or Fixed, Pair, with Pads, Tips and 1 / 5yrs Handgrips Crutches Underarm, Aluminum, Adjustable or Fixed, Each, with Pads, Tip and Handgrip 1 / 5yrs



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Notes

NC

NMN NARR NARR NARR

NARR

Updated Winter 2004

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 HCS 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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Updated Winter 2004 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 HCS A9270. Narrative information will need to be attached to the claim by calling an Allwin representative or entering the information on the Allwin website.

HCS Codes HCS E0627 E0628 E0629

Description Seat Lift Mechanism Incorporated into a Combination Lift-Chair Mechanism Separate Seat Lift Mechanism for Use With Patient Owned Furniture-Electric Separate Seat Lift Mechanism for Use with Patient Owned Furniture (Non-electric)

Quantity 1 / 5yrs 1 / 5yrs 1 / 5yrs



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Notes CMN CMN CMN

Updated Winter 2004

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 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 with the bed coverings. A bed cradle (E0280) is covered when it is necessary to prevent 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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Updated Winter 2004

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 ing a patient who weighs more than 350 pounds, but no more than 600 pounds. E0302 and E0304 are hospital beds that are capable of ing 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 HCS codes above, for example - a heavy (or extra heavy) duty bed without a mattress (as when used with a 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 E0250 E0251 E0255 E0256 E0260 E0261 E0265 E0266 E0290

Column II E0271, E0272, E0305, E0310 E0305, E0310 E0271, E0272, E0305, E0310 E0305, E0310 E0271, E0272, E0305, E0310 E0305, E0310 E0271, E0272, E0305, E0310 E0305, E0310 E0271, E0272

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Updated Winter 2004 E0292 E0294 E0296 E0301 E0302 E0303 E0304

E0271, E0272 E0271, E0272 E0271, E0272 E0305, E0310 E0305, E0310 E0271, E0272, E0305, E0310 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.

HCS Codes Fixed Height Beds HCS E0250 E0251 E0290 E0291

Description Hospital bed, fixed height, with any type side rails, with mattress Hospital bed, fixed height, with any type side rails, without mattress Hospital bed, fixed height, without side rails, with mattress Hospital bed, fixed height, without side rails, without mattress

Quantity

Notes CMN/CR CMN/CR CMN/CR CMN/CR

Quantity

Notes CMN/CR CMN/CR

Variable Height Beds HCS E0255 E0256

Description Hospital bed, variable height (hi-lo), with any type side rails, with mattress Hospital bed, variable height (hi-lo), with any type side rails, without mattress

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Updated Winter 2004 E0292 E0293

Hospital bed, variable height (hi-lo), without side rails, with mattress Hospital bed, variable height (hi-lo), without side rails, without mattress

CMN/CR CMN/CR

Semi-Electric Beds HCS E0260 E0261 E0294 E0295

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

Quantity

Notes CMN/CR CMN/CR CMN/CR CMN/CR

Total Electric Beds HCS E0265 E0266 E0296 E0297

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

Quantity

Notes CMN/NMN CMN/NMN CMN/NMN CMN/NMN

Heavy Duty Beds HCS E0303 E0304

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

Notes CMN CMN

Accessories HCS E0271 E0272 E0273 E0274 E0280 E0305 E0310 E0315 E0316 E0910 E0940

Description Mattress, innerspring Mattress, foam rubber Bed board Over-bed table Bed cradle, any type Bedside rails, half-length Bedside rails, full length Bed accessory: board or table or device, any type Safety enclosure frame/canopy for use with hospital bed, any type Trapeze bars, a/k/a patient helper, attached to bed, with grab bar Trapeze bar, free standing, complete with grab bar

Quantity

Notes

NC

NC

Miscellaneous HCS E1399

Description Durable medical equipment, miscellaneous

Quantity

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Notes NARR

Updated Winter 2004



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Updated Winter 2004

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 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 hemiwheelchair, 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 the medical necessity of the wheelchair which is billed, but does 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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Updated Winter 2004 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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Updated Winter 2004 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.

HCS Codes HCS K0001 K0002 K0003 K0004 K0005 K0006 K0007

Description Standard wheelchair Standard hemi (low seat) wheelchair Lightweight wheelchair High strength, lightweight wheelchair Ultra lightweight wheelchair Heavy duty wheelchair Extra heavy duty wheelchair

Quantity

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Notes CMN / CR CMN / CR CMN / CR CMN / CR CMN CMN / CR CMN / CR

Updated Winter 2004 K0009

Other manual wheelchair/base

CMN Explanations of Notes Column

NMN NC NARR CR CMN


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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 the medical necessity of a power wheelchair but does 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 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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Updated Winter 2004 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 HCS 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.

HCS Codes HCS K0010 K0011

K0012 K0014 E0983

Description STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR STANDARD - WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR WITH PROGRAMMABLE CONTROL PARAMETERS FOR SPEED ADJUSTMENT, TREMOR DAMPENING, ACCELERATION CONTROL AND BRAKING LIGHTWEIGHT PORTABLE MOTORIZED/POWER WHEELCHAIR OTHER MOTORIZED/POWER WHEELCHAIR BASE POWER ADD-ON, TO CONVERT MANUAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, JOYSTICK CONTROL

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Quantity

Notes CMN CMN

CMN CMN

Updated Winter 2004 Explanations of Notes Column NMN NC NARR CR CMN


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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; Page 73

Updated Winter 2004 2. 3. 4. 5.

Fixed hip angle; Trunk or lower extremity casts/braces that require the reclining back feature for positioning; Excess extensor tone of the trunk muscles; and/or 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 HCS 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 the Statistical Analysis Durable Medical Equipment Regional Carrier (SERC) 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 E2201E2204 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 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 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 flipup 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 patient weight of at least 250 pounds. A mechanical shear reduction feature (E1004 and E1007) consists of two separate back s. As the posterior back reclines or raises there is a mechanical linkage between the two s which allows the patient's back to stay in with the anterior without sliding along that . A power shear reduction feature (E1005 and E1008) consists of two separate back s. As the posterior back reclines or raises there is a separate motor which controls the linkage between the two s and allows the patient's back to stay in with the anterior without sliding along that . 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 s; 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 Page 75

Updated Winter 2004 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 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 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 Page 76

Updated Winter 2004 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 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, 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 flipdown hardware for head control interfaces E2327-E2330, and swingaway hardware for an indicator display box that is Page 77

Updated Winter 2004 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 Power Operated Vehicle (E1230) Manual Wheelchair Base (E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009) Power Wheelchair Base (K0010, K0011, K0012, K0014)

E0973 E0990 Power tilt and/or recline seating systems (E1002, E1003, E1004, E1005, E1006, E1007, E1008) E1009, E1010 E2325 K0039 K0045 K0046 K0047 K0053 K0069 K0070 K0071 K0072 K0077 K0090 K0092 K0096 K0195

Column II (All options and accessories) 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 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 K0017, K0018, K0019 E0995, K0042, K0043, K0044, K0045, K0046, K0047 E0973, K0015, K0017, K0018, K0019, K0020, K0023, K0024, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052 E0990, E0995, K0042. K0043, K0044, K0045, K0046, K0047, K0052, K0053, K0195 E1028 K0038 K0043, K0044 K0043 K0044 E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047 K0066 K0067, K0068 K0074, K0078 K0075 K0076 K0091 K0090, K0091 K0094, K0095 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.

HCS Codes ARM OF CHAIR HCS E0973 K0015 K0017 K0018 K0019 K0020 L3964 L3965

Description Quantity WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH DETACHABLE, NON-ADJUSTABLE HEIGHT ARMREST, EACH DETACHABLE, ADJUSTABLE HEIGHT ARMREST, BASE, EACH DETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER PORTION, EACH ARM PAD, EACH FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR SHOULDER ELBOW ORTHOSIS, MOBILE ARM ATTACHED TO WHEELCHAIR, BALANCED, ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ELBOW ORTHOSIS, MOBILE ARM ATTACHED TO WHEELCHAIR, BALANCED, ADJUSTABLE RANCHO TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT Page 79

Notes CMN CMN CMN CMN

Updated Winter 2004

L3966

L3968

L3969 L3970 L3972 L3974

SHOULDER ELBOW ORTHOSIS, MOBILE ARM ATTACHED TO WHEELCHAIR, BALANCED, RECLINING, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ELBOW ORTHOSIS, MOBILE ARM ATTACHED TO WHEELCHAIR, BALANCED, FRICTION ARM (FRICTION DAMPENING TO PROXIMAL AND DISTAL TS), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT SHOULDER ELBOW ORTHOSIS, MOBILE ARM , MONOSUSPENSION ARM AND HAND , OVERHEAD ELBOW FOREARM HAND SLING , YOKE TYPE SUSPENSION , PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT SEO, ADDITION TO MOBILE ARM , ELEVATING PROXIMAL ARM SEO, ADDITION TO MOBILE ARM , OFFSET OR LATERAL ROCKER ARM WITH ELASTIC BALANCE CONTROL SEO, ADDITION TO MOBILE ARM , SUPINATOR

BACK OF CHAIR HCS E0971 E1014 E1025 E1026 E1027 E0966

Description ANTI-TIPPING DEVICE WHEELCHAIRS RECLINING BACK, ADDITION TO PEDIATRIC WHEELCHAIR LATERAL THORACIC , NON-CONTOURED, FOR PEDIATRIC WHEELCHAIR, EACH (INCLUDES HARDWARE) LATERAL THORACIC , CONTOURED, FOR PEDIATRIC WHEELCHAIR, EACH (INCLUDES HARDWARE) LATERAL/ANTERIOR , FOR PEDIATRIC WHEELCHAIR, EACH (INCLUDES HARDWARE) HOOK-ON HEADREST EXTENSION

Quantity

Notes NC

Description Quantity GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH SKIN PROTECTION AND POSITIONING WHEELCHAIR CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH SKIN PROTECTION AND POSITIONING WHEELCHAIR CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZE WHEELCHAIR SEAT CUSHION POWERED GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

Notes

SEAT HCS K0650 K0651 K0652 K0653 K0654 K0655 K0656 K0657 K0658 K0659 K0660 K0661

Page 80

Updated Winter 2004 K0662 K0663 K0664 K0665 K0666 K0668 E0992

POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE CUSTOM FABRICATED WHEELCHAIR BACK CUSHION, ANY SIZE, INCLUDING ANY TYPE MOUNTING HARDWARE REPLACEMENT COVER FOR WHEELCHAIR SEAT CUSHION OR BACK CUSHION, EACH SOLID SEAT INSERT, PLANAR SEAT, SINGLE DENSITY FOAM

FOOTREST/LEGREST HCS E0951 E0952 E0990 E0995 E1020 K0037 K0038 K0039 K0040 K0041 K0042 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0052 K0053 K0195

Description LOOP HEEL, EACH TOE LOOP/HOLDER, EACH WHEELCHAIR ACCESSORY, ELEVATING LEGREST, COMPLETE ASSEMBLY, EACH WHEELCHAIR ACCESSORY, CALF REST/PAD, EACH RESIDUAL LIMB SYSTEM FOR WHEELCHAIR HIGH MOUNT FLIP-UP FOOTREST, EACH LEG STRAP, EACH LEG STRAP, H STYLE, EACH ADJUSTABLE ANGLE FOOTPLATE, EACH LARGE SIZE FOOTPLATE, EACH STANDARD SIZE FOOTPLATE, EACH FOOTREST, LOWER EXTENSION TUBE, EACH FOOTREST, UPPER HANGER BRACKET, EACH FOOTREST, COMPLETE ASSEMBLY ELEVATING LEGREST, LOWER EXTENSION TUBE, EACH ELEVATING LEGREST, UPPER HANGER BRACKET, EACH RATCHET ASSEMBLY CAM RELEASE ASSEMBLY, FOOTREST OR LEGREST, EACH SWINGAWAY, DETACHABLE FOOTRESTS, EACH ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH ELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE)

Quantity

Notes NC

CMN

CMN CMN

CMN CMN

SEAT WIDTH, DEPTH, HEIGHT HCS E1011 E2201 E2202

Description Quantity MODIFICATION TO PEDIATRIC WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO BE DISPENSED WITH INITIAL CHAIR) MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN OR EQUAL TO 20 IN & LESS THAN 24 INCHES MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24-27 INCHES Page 81

Notes

Updated Winter 2004 E2203 E2204 K0056

MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN 22 INCHES MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH, LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR

HANDRIMS WITHOUT PROJECTIONS HCS K0059

Description PLASTIC COATED HANDRIM, EACH

Quantity

Notes

K0060 K0061

STEEL HANDRIM, EACH ALUMINUM HANDRIM, EACH

Quantity

Notes

Quantity

Notes

Description Quantity REAR WHEEL TIRE FOR POWER WHEELCHAIR, ANY SIZE, EACH REAR WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE FOR POWER WHEELCHAIR, ANY SIZE, EACH REAR WHEEL ASSEMBLY FOR POWER WHEELCHAIR, COMPLETE, EACH REAR WHEEL, ZERO PRESSURE TIRE TUBE (FLAT FREE INSERT) FOR POWER WHEELCHAIR, ANY SIZE, EACH WHEEL TIRE FOR POWER BASE, ANY SIZE, EACH WHEEL TIRE TUBE OTHER THAN ZERO PRESSURE FOR EACH BASE, ANY SIZE, EACH WHEEL ASSEMBLY FOR POWER BASE, COMPLETE, EACH WHEEL ZERO PRESSURE TIRE TUBE (FLAT FREE INSERT) FOR POWER BASE, ANY SIZE, EACH DRIVE BELT FOR POWER WHEELCHAIR FRONT CASTER FOR POWER WHEELCHAIR, EACH

Notes

HANDRIMS WITH PROJECTIONS HCS E0967

Description HANDRIM WITH PROJECTIONS, EACH

REAR WHEELS HCS K0064 K0065 K0066 K0067 K0068 K0069 K0070

Description ZERO PRESSURE TUBE (FLAT FREE INSERTS), ANY SIZE, EACH SPOKE PROTECTORS, EACH SOLID TIRE, ANY SIZE, EACH PNEUMATIC TIRE, ANY SIZE, EACH PNEUMATIC TIRE TUBE, EACH REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR MOLDED, EACH REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDED, EACH

MOTORIZED/POWER WHEELCHAIR PARTS HCS K0090 K0091 K0092 K0093 K0094 K0095 K0096 K0097 K0098 K0099

BATTERIES/CHARGERS FOR MOTORIZED/POWER WHEELCHAIRS HCS E2360

Description 22 NF NON-SEALED LEAD ACID BATTERY, EACH Page 82

Quantity

Notes

Updated Winter 2004

E2361 E2362 E2363 E2364 E2365 E2366 E2367

22 NF SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL, ABSORBED GLASS MAT) GROUP 24 NON-SEALED LEAD ACID BATTERY, EACH GROUP 24 SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL ABSORBED GLASS MAT) U-1 NON-SEALED LEAD ACID BATTERY, EACH U-1 SEALED LEAD ACID BATTERY, EACH (E.G., GEL CELL, ABSORBED GLASS MAT) BATTERY CHARGER, SINGLE MODE, FOR USE WITH ONLY ONE BATTERY TYPE, SEALED OR NON-SEALED BATTERY CHARGER, DUAL MODE, FOR USE WITH EITHER BATTERY TYPE, SEALED OR NON-SEALED

FRONT CASTERS HCS K0071

Quantity

Notes

Quantity

Notes

Notes

E0959

Description Quantity WHEELCHAIR ATTACHMENT TO CONVERT ANY WHEELCHAIR TO ONE ARM DRIVE 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

E1018

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

E1226

MANUAL WHEELCHAIR ACCESSORY, FULLY RECLINING BACK, EACH

K0072 K0073 K0074 K0075 K0076 K0077 K0078

Description FRONT CASTER ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, EACH FRONT CASTER ASSEMBLY, COMPLETE, WITH SEMI-PNEUMATIC TIRE, EACH CASTER PIN LOCK,EACH PNEUMATIC CASTER TIRE, ANY SIZE, EACH SEMI-PNEUMATIC CASTER TIRE, ANY SIZE, EACH SOLID CASTER TIRE, ANY SIZE, EACH FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, EACH PNEUMATIC CASTER TIRE TUBE, EACH

WHEEL LOCK HCS E0961 K0081

Description WHEEL LOCK EXTENSION (HANDLE), EACH WHEEL LOCK ASSEMBLY, COMPLETE, EACH

MISCELLANEOUS ACCESSORIES HCS E0958

E1017

K0102

CRUTCH AND CANE HOLDER, EACH

K0104

CYLINDER TANK CARRIER, EACH

NC

Page 83

Updated Winter 2004 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



Page 84

Updated Winter 2004

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.

Page 85

Updated Winter 2004 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 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 Page 86

Updated Winter 2004 (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

Page 87

Updated Winter 2004 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.

Page 88

Updated Winter 2004 • •

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.

Page 89

Updated Winter 2004 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 HCS code with the appropriate modifier directly after it.

HCS Codes Equipment HCS E0424

E0425 E0430 E0431 E0434

E0435

Description STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING STATIONARY COMPRESSED GAS SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING PORTABLE GASEOUS OXYGEN SYSTEM, PURCHASE; INCLUDES REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, HUMIDIFIER, FLOWMETER, REFILL ADAPTOR, CONTENTS GAUGE, CANNULA OR MASK, AND TUBING PORTABLE LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, FLOWMETER, HUMIDIFIER, CONTENTS GAUGE, CANNULA OR MASK, TUBING AND REFILL ADAPTOR

Page 90

Quantity

Notes

Updated Winter 2004 E0439 E0440

E0441

E0442

E0443 E0444 E0445 E1390

STATIONARY LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, & TUBING STATIONARY LIQUID OXYGEN SYSTEM, PURCHASE; INCLUDES USE OF RESERVOIR, CONTENTS INDICATOR, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASK, AND TUBING 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 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 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 PORTABLE OXYGEN CONTENTS, LIQUID (FOR USE ONLY WITH PORTABLE LIQUID SYSTEMS WHEN NO STATIONARY GAS OR LIQUID SYSTEM IS USED), 1 MONTH'S SUPPLY = 1 UNIT OXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS NON-INVASIVELY OXYGEN CONCENTRATOR, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE

Accessories HCS A4575 A4606 A4608 A4615 A4616 A4617 A4619 A4620 A9900 E0455 E0555 E0580 E1353 E1355

Description TOPICAL HYPERBARIC OXYGEN CHAMBER, DISPOSABLE OXYGEN PROBE FOR USE WITH OXIMETER DEVICE, REPLACEMENT TRANSTRACHEAL OXYGEN CATHETER, EACH CANNULA, NASAL TUBING (OXYGEN), PER FOOT MOUTH PIECE FACE TENT VARIABLE CONCENTRATION MASK MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCS CODE OXYGEN TENT, EXCLUDING CROUP OR PEDIATRIC TENTS HUMIDIFIER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER NEBULIZER, DURABLE, GLASS OR AUTOCLAVABLE PLASTIC, BOTTLE TYPE, FOR USE WITH REGULATOR OR FLOWMETER REGULATOR STAND/RACK

Quantity

Notes

Explanations of Notes Column NMN NC NARR

Not Medically Necessary, payment will be based on the allowance for the least costly medical appropriate alternative. Not Covered. Narrative required. Call Allwin Data with the appropriate information.

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Updated Winter 2004 Explanations of Notes Column CR CMN

Capped Rental item. Certificate of Medical Neccessity required.

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Updated Winter 2004

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. 2. 3. 4.

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#. For Medicaid, use the states postal abbreviation followed by “MEDCO”, for example, in Mississippi you would put “MSMEDCO” in the Group Field. For TRICARE, you would put the word “TRICARE” in the Group Field. 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 nonComplementary 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 866238-9652 or log on to the following link: http://www.medicare.gov/supplier/Home.asp#NewSearch.

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Updated Winter 2004

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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Updated Winter 2004

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

REGION A,B,C,D C B A,B,C,D A,B B D C A,D D C B A A,B,C,D A,B,C,D B,D D B A,B,C C B B A D B C C A A A,C A C A,D C D D C B A,B,C,D B,C A,D D D Page 95

Updated Winter 2004 BCBS New Hampshire BCBS NEW JERSEY BCBS New Mexico BCBS North Carolina BCBS North Dakota BCBS Oklahoma BCBS RHODE ISLAND BCBS South Carolina (FEP) BCBS South Carolina (over 65) BCBS Texas BCBS VIRGINIA BCBS VIRGINIA (FEP) BCBS WESTERN NY BCBS Wisconsin BENEFIT PLANNERS Benefit Planners Ltd. Blue Shield of California Blue Shield of Idaho (FEP) C.A.R.E. Carefirst CATERPILLAR INC Celtic Life Ins Central States CLAIM PRO (ANTHEM INS CO) Claims istration Corp. (Mailhandlers) Companion Life Continental General Continental Life Insurance Dallas General Life Insurance ELECTRONIC DATA SYSTEMS Fortis Inc/Time FORTIS INSURANCE COMPANY GE Capital Ins Government Employee Hospital Association (GEHA) Group Health Inc. (GHI) GROUP HOSPITAL MEDICAL SERVICES HARRINGTON BENEFIT SERVICES Health Data Management (HDM) Heritage Health Plans Highmark Services Humana J.F. MOLLOY & ASSOC. King County King County (FEP) KIRKE-VAN ORSDEL INC. KPS

C B C C D A,B,C A C C C B B A B,C,D B C D D A C B D A,C,D B B,C C D C C A D A D A,B,C,D A,C B B B,C C D B,D B D D A,B D Page 96

Updated Winter 2004 KVI LOCKHEED-MARTEN MEDICAL MUTUAL OF OHIO Medical Service Corp Michigan Employed Benefit Services Monumental Insurance Company Mutual of Omaha NAT ASSOC LETTER CARRIERS (NALC) NORTH AMER INS CO. NorthWest Medical Olympic Health Management Oxford Life Ins Peoples Benefit Life Ins. Co. Physicians Mutual Pierce County Pierce County (FEP) Pioneer Life Premera BC Principal Financial Group PROVIDIAN LIFE/HEALTH Regence Blue Shield (Utah Only) SAMBA Savers Life Ins Seabury and Smith Inc. SECURITY HEALTH PLAN OF WISCONSIN SPECIAL AGENTS MUT BENEFIT Standard Life and Accident State Farm State Mutual Ins TRICARE Triple-S (Seguros de Servicio de Salud de Puerto Rico) Unicare Union Fidelity Life Ins. Co. UNITED AMERICAN INS. CO. UNITED COMMERCIAL TRAVELERS OF AMERICA United HealthCare United Teachers USAA USAA Life Insurance USAble Life Ins WEA INSURANCE COMPANY WELLMARK Westport Benefits World Ins WorldNet

D B A,B A,D D C,D A,B,C,D A,B,C,D A,D D A,B,C,D D C,D A,B,C,D D D A,B,C,D D D A D B D C B A A,C D D A,B,C,D C B,C,D A,C,D A,B,C,D B A,B,C,D C D C D B B D D B,C,D

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Updated Winter 2004

OCNA Number List Insurance Plan Name City A AND H CLAIMS CHICAGO A HERBERT AGENCY INC NEW YORK AAA LIFE INSURANCE CO HEATHROW AAL DES MOINES AARP MONTGOMERYVILLE AARP FT WASHINGTON ACADEMY LIFE INS CO ATLANTA ACCORDIA GOVT BENEFITS/AICI INDIANAPOLIS ACCORDIA SENIOR BENEFITS/ ANTHEM INS CO INDIANAPOLIS ACCORDIA/BCBS OF KY LOUISVILLE ACEDEMY LIFE BRISTOL ACORDIA BENEFITS ANAHEIM ACORDIA LOCAL GOV SER INDIANAPOLIS ACORDIA SENIOR BENEFITS INDIANAPOLIS ASTAR INC/ANTHEM DOCUMENT MGMT LOUISVILLE ISTAR LOUISVILLE ISTRATIVE SERVICES INC ATLANTA ADVANCED INS SERVICES MEMPHIS ADVANCED INSURANCE LITLE ROCK AEGON MEDICARE SUPPLEMENT MOOSIC AETNA LIFE AND CASUALTY MIDDLETOWN AFLAC (AMER FAMILY LIFE ASSU) COLUMBUS AFLAC NEW YORK ALBANY AGENCY SERVICES/AMERICARE MEMPHIS AGIA, INC. CARPINTERIA AGRICULTURAL INS LEWISTON AIAG CLEARWATER AID ASSOC FOR LUTHERANS APPLETON AIG LIFE INS CO WILMINGTON AIROMD MAILHANDLERS INS ROCKVILLE ALLIANCE HEALTH BEN PLAN WASHINGTON ALLIANZ LIFE INSURANCE CO MINNEAPOLIS ALTA HEALTH STRATEGIES BALTIMORE ALTA HLTH STRATEGIES SALT LAKE CITY AMALGAMATED LIFE AND - 79 CHICAGO AMER BANKERS INS CO OF FL MIAMI AMER COMBINED LIFE CLEARWATER AMER COMMUNITY MUTUAL LIVONIA AMER EXCHANGE LIFE INS CO/COMMUNITY MUTUAL RYE BROOK AMER HOECHSST PER WESTERN SPRINGS AMER INCOME LIFE INS WACO AMER INCOME LIFE INS WACO AMER INS CO OF TX FT WORTH AMER LIFE INS CO COLUMBUS AMER MANUFACTURERS MUTUAL LONG GROVE AMER PROGRESS LANDHIC OF NY RYE BROOK AMER PROTECTIVE LIFE INS CLEVELAND AMER TRAVELLERS INS DES MOINES AMERICAN ASSOCIATION LAKEWOOD

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St IL NY FL IA PA PA GA IN IN KY TN CA IN IN KY KY GA TN AR PA CT GA NY TN CA ID FL WI DE MD DC MN MD UT IL FL FL MI NY IL TX TX TX GA IL NY MS IA CA

OCNA Code 60630A001 53066A001 32740A001 50306A004 18936A001 18936A002 30328A001 46250A001 46254A001 40233B001 37625A002 92806A001 46240A001 46207A001 40299A001 40223A001 30345A001 38103A001 72211A001 18507A001 06457A001 31999A001 12205A001 37215A002 93013A001 83501A001 75201A001 54919A001 19801A001 20855A001 20065A001 55403A001 21201A001 84130A001 60607A001 33157A001 19047A001 48152A001 75221A001 60558A001 76702A001 76702A002 75266A001 31999A002 60049A001 10509A001 38732A001 19020A001 90712A001

Region(s) ABCD C C D BCD AD BCD ABCD AC A A B B B CD D B D C C A BC A BD AC ABCD C BCD ABCD BD ABCD C BC A ABCD ABD BCD ACD ABCD ABCD CD AB D A AC ABCD ABCD BCD ABCD

Updated Winter 2004 AMERICAN BANKERS INS AMERICAN CAPITAL INS CO AMERICAN FAMILY MUTUAL INS CO AMERICAN GENERAL AMERICAN GENERAL LIFE AND ACCIDENT AMERICAN HARDWARE MUTUAL AMERICAN INDEP LIFE INS CO AMERICAN INS CO OF TX AMERICAN INTEGRITY INS AMERICAN LIFE AND ACC AMERICAN LIFE AND HEALTH AMERICAN MOTORISTS INS CO AMERICAN NATIONAL INS CO AMERICAN PATRIOT HEALTH AMERICAN PIONEER LIFE INS AMERICAN REPUBLIC INS CO AMERICAN SERVICE LIFE INS CO AMERICAN STD LIFE AND ACC CO AMERICAN TRAVELLERS INS AMERICARE PROTECTION AMF, INC. AMOCO CASUALTY AND INDEM AMVETS INS PLAN AON SELECT, INC. AON SELECT, INC./NETWORK AMERICA LIFE APPALACHIAN LIFE INS CO APWU HEALTH PLAN ARMCO MED INS SVC CT ASSOC DOCTORS HEALTH AND LIFE ASSOC DOCTORS HLTH AND LIFE ASSOC MUTUAL HOSP SERV MI ASSOCIATED LIFE INS CO ATCHISON TOPEKA ATLANTIC AMER INS CO ATLANTIC AMER LIFE INS ATLANTIC AMER LIFE INS ATLANTIC AMER/BANKERS FIDEL ATLANTIC AND PACIFIC INS CO ATLANTIC COAST INS CO ATLANTIC INS CO OF SA AUSA MASTERCARE AUSA MASTERCARE INS AUTO OWNERS LIFE INS CO AWARE GOLD BADGER METER BANKERS COMMER LIFE INS BANKERS FIDELITY LIFE INS BANKERS FIDELITY LIFE INS/ATLANTIC AMERICAN BANKERS LIFE AND CASUALTY BANKERS LIFE AND CASUALTY BANKERS LIFE AND CASUALTY/CNA BANKERS MULTIPLE LINE BANKERS UNITED LIFE ASSUR

FORT WORTH HOUSTON MADISON NASHVILLE NASHVILLE MINNEAPOLIS KING OF PRUSSIA DALLAS HARRISBURG DALLAS MISSION VIEJO LONG GROVE GALVESTON CLEARWATER RYE BROOK DES MOINES FORT WORTH ENID WARRINGTON DES MOINES DES MOINES OMAHA MINNEAPOLIS HARSHAM HORSHAM HUNTINGTON SILVER SPRING WORTHIGNTON BIRMINGHAM TREVOSE WARREN INDIANAPOLIS TOPEKA ATLANTA ATLANTA ATLANTA ATLANTA ATLANTA GAINESVILLE AUSTIN DES MOINES DES MOINES LANSING ST PAUL DES MOINES HOUSTON ATLANTA ATLANTA CHICAGO CHICAGO CHICAGO DALLAS SCRANTON

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TX 76101A001 TX 77242A001 WI 53783A001 TN 37250A001 TN 37202A001 MN 55440A001 PA 19406A001 TX 75266A002 PA 19101A001 TX 75221A002 CA 92691A001 IL 60049A002 TX 77553A001 FL 33755A001 NY 32804A001 IA 50301A001 TX 76107A001 OK 73702A001 PA 18976A001 IA 50301A002 IA 50306A003 NE 68102A001 MN 43216A001 PA 64111A001 PA 19044N001 WV 25701A001 MD 20904A001 OH 43805A001 AL 35202A001 PA 35289A001 MI 48091A001 IN 46206A001 KS 66612A001 GA 30319A001 GA 30219A002 GA 30319A002 GA 31319A003 GA 30359A001 GA 30503A001 TX 78714A001 IA 50306A002 IA 50306A001 MI 48909A001 MN 55164A001 IA 50306B001 TX 75240B001 GA 30319B001 GA 30319A003 IL 02888B001 IL 60630B001 IL 60630B002 TX 75221B001 PA 18504B001

BD CD ABCD ACD B BCD BCD B BC BCD C AC BCD C AC ABCD ABCD BD B C D ABC BCD D AC ABCD A B B BCD AC B ABCD ABCD B CD B B AB BC D D BCD BCD D ABCD C BC BD ABCD A BC AC

Updated Winter 2004 BC OF PA/HIGHMARK BCBS CT-CONST HLTH CARE BCBS MOUNTAIN STATE BCBS OF ALABAMA BCBS OF ARIZONA BCBS OF ARKANSAS BCBS OF CALIFORNIA BCBS OF CALIFORNIA BCBS OF CALIFORNIA BCBS OF CALIFORNIA/UNICARE BCBS OF CENTRAL NY BCBS OF COLORADO BCBS OF COLORADO BCBS OF CONNECTICUT BCBS OF DELAWARE BCBS OF DELAWARE BCBS OF FED EMP. CLAIMS BCBS OF FED EMP. CLAIMS BCBS OF FLORIDA BCBS OF FLORIDA BCBS OF GEORGIA BCBS OF GREENVILLE BCBS OF ILLINOIS BCBS OF INDIANA BCBS OF IOWA BCBS OF KANSAS BCBS OF KANSAS CITY BCBS OF KY/ANTHEM DOC MGT BCBS OF LOUISIANA BCBS OF MAINE BCBS OF MARYLAND BCBS OF MASSACHUSETTS BCBS OF MEMPHIS BCBS OF MICHIGAN BCBS OF MINNESOTA BCBS OF MINNESOTA BCBS OF MISSISSIPPI BCBS OF MISSOURI BCBS OF MONTANA BCBS OF NATIONAL CAPITAL AR BCBS OF NEBRASKA BCBS OF NEVADA BCBS OF NEW HAMPSHIRE BCBS OF NEW JERSEY BCBS OF NEW JERSEY BCBS OF NEW JERSEY BCBS OF NEW MEXICO BCBS OF NEW MEXICO BCBS OF NEW YORK BCBS OF NEW YORK BCBS OF NEW YORK (NE) BCBS OF NEW YORK (WEST) BCBS OF NEW YORK (WEST)

PITTSBURGH NORTH HAVEN CHARLESTON BIRMINGHAM PHOENIX LITTLE ROCK WOODLAND HLS VAN NUYS OAKLAND OXNARD SYRACUSE DENVER DENVER NORTH HAVEN WILMINGTON WILMINGTON NORTH HAVEN NORTH HAVEN JACKSONVILLE WINTER HAVEN COLUMBUS GREENVILLE CHICAGO INDIANAPOLIS DES MOINES TOPEKA KANSAS CITY LOUISVILLE BATON ROUGE SO PORTLAND OWING MILLS N QUINCY MEMPHIS NEW HUDSON SAINT PAUL ST PAUL JACKSON SAINT LOUIS HELENA WASHINGTON OMAHA RENO MANCHESTER NEWARK NEWARK NEWARK ALBUQUERQUE ALBUQUERQUE MIDDLETOWN UTICA ALBANY BUFFALO BUFFALO Page 100

PA 15242B001 CT 06473C001 WV 25325B001 AL 35244B001 AZ 85069B001 AR 72203B001 CA 91365B001 CA 91470B001 CA 94612B001 CA 93031B002 NY 13221B001 CO 80203B001 CO 80203B002 CT 06473B001 DE 19801B001 DE 19899B001 CT 06473B002 CT 06473B003 FL 32202B001 FL 33883B001 GA 31908B001 SC 29615B002 IL 60601B001 IN 46204B001 IA 50309B001 KS 66629B001 KS 64141B001 KY 40223B001 LA 70898B001 ME 04106B001 MD 21117B001 MA 02171B001 TN 38101B001 MI 48226B001 MN 55164B001 MN 55164B002 MS 39215B001 MO 63108B001 MT 59604B001 DC 20065B001 NE 68180B001 NV 89520B001 NH 03306B001 NJ 07101B001 NJ 08206B001 NJ 08206B002 NM 87112B001 NM 87112B002 NY 10943B001 NY 13502B001 NY 12205B001 NY 14240B001 NY 14240B002

ABCD A ABCD ABC ABCD ABCD ABCD ABCD B AC ABCD ABCD C ABCD BCD A A A ABCD A ABCD A ABCD C ABCD ABCD ABCD ABCD ABCD ABCD ABCD ABCD ABCD ABCD BCD A ABCD ABCD ABCD ABCD ABCD ABC ABCD A ABCD C ABCD C A B ABCD ABCD D

Updated Winter 2004 BCBS OF NEW YORK UTICA-WATERTOWN BCBS OF NEW YORK/EMPIRE BCBS OF NORTH CAROLINA BCBS OF NORTH DAKOTA BCBS OF OHIO BCBS OF OHIO/MEDICAL MUTUAL BCBS OF OKLAHOMA BCBS OF OREGON BCBS OF PENNSYLVANIA BCBS OF RHODE ISLAND BCBS OF ROCHESTER BCBS OF SOUTH CAROLINA BCBS OF SOUTH DAKOTA BCBS OF TENNESSEE BCBS OF TEXAS BCBS OF UTAH BCBS OF VERMONT BCBS OF VIRGINIA BCBS OF VIRGINIA BCBS OF WASHINGTON DC BCBS OF WESTERN PA BCBS OF WISCONSIN BCBS OF WISCONSIN BCBS OF WYOMING BCBS UNITED OF WISCONSIN BCBS/TRIGON MUTUAL INS CO BD OF PENSIONS - PRESBY C BELL UNIT BENEFICIAL LIFE INS CO BENEFIT PLANNERS LTD BENEFIT TRUST LIFE INS BENEFIT TRUST LIFE TRUSTMARK INSURANCE BLUE CROSS KINGS COUNTY BLUE CROSS OF ARIZONA BLUE CROSS OF CALIFORNIA BLUE CROSS OF IDAHO BLUE CROSS OF MINNESOTA BLUE CROSS OF NEW YORK BLUE CROSS OF OHIO (SW) BLUE CROSS OF PA-INDEPEND BLUE CROSS OF TENNESSEE BLUE CROSS OF VIRGINIA BLUE CROSS OF WASHINGTON BLUE SHIELD NORTH DAKOTA BLUE SHIELD OF CALIFORNIA BLUE SHIELD OF CALIFORNIA BLUE SHIELD OF IDAHO BLUE SHIELD OF IDAHO BLUE SHIELD OF OREGON C M LIFE INS CO C. A. R. E. CAL FARM BUR HEALTH INS PRO CAPITAL SECURITY INS CO

UTICA NEW YORK DURHAM FARGO TOLEDO CLEVELAND TULSA PORTLAND CAMPHILL PROVIDENCE ROCHESTER COLUMBIA SIOUX FALLS CHATTANOOGA SAN ANTONIO SALT LAKE CITY MONTPELIER ROANOKE ROANOKE WASHINGTON CAMP HILL MILWAUKEE OSHKOSH CHEYENNE MILWAUKEE ROANOKE PHILADELPHIA CHICAGO PORTLAND BOERNE LAKE FOREST BOARDMAN SEATTLE PHOENIX OXNARD BOISE ROSEVILLE ALBANY CINCINNATI PHILADELPHIA NASHVILLE ROANOKE SEATTLE FARGO SAN FRANCISCO PLACERVILLE LEWISTON LEWISTON PORTLAND HARTFORD TEMPLE SACREMENTO DURHAM Page 101

NY 13501B001 NY 10156B001 NC 27702B001 ND 58121B001 OH 43697B001 OH 44115B001 OK 74102B001 OR 97207B001 PA 17011B001 RI 02903B001 NY 14604B001 SC 29219B001 SD 57104B001 TN 37402B001 TX 78228B001 UT 84130B001 VT 05601B001 VA 23230B001 VA 24045B001 DC 20024B001 PA 15222B001 WI 53203B001 WI 54901B001 WY 82003B001 WI 53201U001 VA 24031B001 PA 19101B001 IL 60690B001 OR 97207B002 TX 78006B001 IL 60045B001 OH 63127B001 WA 98111B002 AZ 85002B001 CA 93031B001 ID 83707B001 MN 55113B001 NY 12212B001 OH 45206B001 PA 19103B001 TN 37212B001 VA 24031B002 WA 98111B001 ND 58103B001 CA 94120B001 CA 95667B001 ID 83501B001 ID 86501B001 OR 97207B003 CT 06105C001 TX 76503C001 CA 95851C001 NC 27702C001

ACD ABCD ABCD ABD ABCD ABCD ABCD ABCD B ABCD C ABCD ABCD ABCD ABCD ABCD ABCD BCD A A C BCD D ABCD AC D ABCD ABCD ABCD C ABCD ABCD ABCD ABCD BCD ABCD A A A ABCD ABCD A ABCD ABCD BCD BCD B AC A BD A ABCD AC

Updated Winter 2004 CAREAMERICA LIFE INS CO CAREFIRST CARLE CARE CATHOLIC GOLDEN AGE INS CATHOLIC GOLDEN AGE INS CELTIC LIFE INS CO CENTRAL BENEFITS CENTRAL MASS HEALTH CENTRAL RESERVE LIFE INS CENTRAL SECURITY LIFE INS CENTRAL STATES CENTRAL STATES HEALTH AND LIFE CENTRAL STATES INS CENTRAL STATES OF OMAHA CERTIFIED LIFE INS CO CERTIFIED LIFE INS CO CHRISTIAN FIDELITY LIFE CINCINNATI LIFE INS CO CITIZENS INS CO OF AMER CITY OF OAK CREEK CIVIL SRVC EMPLOYEES INS CLALLAM COUNTY PHYS SVC CLINICIANS HEALTH NETWORK CNA/CONTINENTAL CASUALTY CNA/CONTINENTAL CASUALTY CNA/CONTINENTAL CASUALTY COASTAL STATES COLONIAL COLONIAL INSURANCE CO COLONIAL LIFE COLONIAL LIFE COLONIAL PENN INS CO COLONIAL PENN LIFE INS COLORADO PIPE IND INS COMBINED AMERICAN COMBINED INS CO OF AMER COMBINED UNDERWRITERS LIF COMMERCIAL LIFE INS COMMONWEALTH INS CO COMMONWEALTH NATIONAL LIFE COMMUNITY FINANCIAL AND INSURANCE CORP. COMMUNITY MUTUAL INS COMMUNITY MUTUAL INS COMPANION HEALTH CARE COMPANION LIFE COMPCARE HEALTH SERVICES INS CO COMPCARE HLTH SVCS INS CO COMPCARE HLTH SVCS INS CO COMPLETE HEALTH COMPLETE HEALTH, INC./SENIOR PARTNERS CONESTOGA LIFE ASSUR CO CONFEDERATION LIFE INS CO CONSECO DIRECT LIFE INS/COLONIAL LIFE

CHATSWORTH OWING MILLS URBANA SCRANTON SCRANTON BEDFORD PARK COLUMBUS WORCESTER STRONGSVILLE RICHARDSON OMAHA CHICAGO DES PLAINES OMAHA CHICAGO DALLAS WAXAHACHIE CINCINNATI AUSTIN DES MOINES SAN FRANCISCO PORT ANGELES BAKERSFIELD ATLANTA NASHVILLE CHICAGO OKLAHOMA CITY SPARTANSBURG CLEVELAND ATLANTA CHARLESTON PHILADELPHIA GREENVILLE DENVER CHICAGO BELLINGHAM TYLER SVANNAH COLUMBUS CLEVELAND MADISON WORTHINGTON CINCINNATI COLUMBIA COLUMBIA MILWAUKEE MILWAUKEE MILWAUKEE BIRMINGHAM BIRMINGHAM LANCASTER NO CHARLESTON PHILADELPHIA

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CA 91311C001 MD 21117C001 IL 61801C001 PA 18202C001 PA 18505C001 IL 60499C001 OH 43216C001 MA 01608C001 OH 44136C001 TX 75083C001 NE 66134C001 IL 60631C001 IL 60017C001 NE 68134C001 IL 60630C001 TX 75265C001 TX 75165C001 OH 45250C001 TX 78767C001 IA 50306C001 CA 94103C001 WA 98362C001 CA 93301C001 GA 30345C001 TN 37230C001 IL 60630C002 OK 73125C001 SC 29306C001 OH 44114C001 GA 29202C001 SC 29402C001 PA 19103C001 SC 29601C001 CO 80531C001 IL 60606C002 WA 60606C001 TX 75710C001 GA 31401C001 OH 43235C001 MS 38732C001 WI 53705C001 OH 43085C001 OH 45206C001 SC 29223C001 SC 29202C002 WE 53203C001 WI 53202C001 WI 53202C002 AL 35202C001 AL 35205S001 PA 17604C001 SC 29418C001 PA 19181C001

ABD C ABCD B ACD BCD ABCD ABCD ABC ABCD AC BD B BCD ABCD BC ABCD ABCD ABD D A AC ABCD ABCD BC BCD BD AB AC C AB B BC A BC CD BC B BD BCD A A BCD BC AC B A CD BCD AC AC AB CD

Updated Winter 2004 CONSECO SENIOR HEALTH INS CONSECO SENIOR HEALTH INS CONSUMER UNITED INS CO CONTINENTAL AMER LIFE CONTINENTAL ASSURANCE CONTINENTAL CASUALTY CONTINENTAL GENERAL INS CONTINENTAL GENERAL INS CONTINENTAL GENERAL INS CONTINENTAL LIFE COOPERATIVA DE SEGUROS CORNING GROUP INS DEPT CORPORATE LIFE INS CO CORROON AND BLACK COSMOPOLITAN LIFE INS CO COUNTRY LIFE INS CO CROLEY LIFE INS CO CRUS AZUL DE PUERTO RICO CUNA MUTUAL INS CO CUSTOM CARE DAIRY FARMERS OF AMERICA DALLAS GENERAL LIFE DEANCARE DIRECT OLIN DIRECT RESPONSE INS DURHAM LIFE INS CO EARLY AMER LIFE INS CO EASTERN INS CO EASTERN INS CO/AM FAM LIFE/EQUALIZER EASY CHOICE USA EBA EDS FEDERAL CORP EDS MEDICAL EDUCATORS MUTUAL EGIP ELECTRIC MUTUAL BENEFIT ELECTRONICS DATA SYSTEM EMPIRE BCBS OF NEW YORK EQUALIZER EQUITABLE LIFE ASSN SOC EQUITABLE LIFE ASSN SOC O EQUITABLE LIFE ASSN SOC O EQUITABLE LIFE ASSURANCE EQUITABLE LIFE ASSURANCE EQUITABLE LIFE ASSURANCE EQUITABLE LIFE INS CO EXECUTIVE FUND INS CO EXECUTIVE FUND LIFE INS FARM FAMILY LIFE INS CO FARMERS STOCKMAN INS FED LIFE INS CO FEDERAL HOME COMPANIES FEDERAL HOME LIFE

CLEARWATER CLEARWATER WASHINGTON WILMINGTON ATLANTA CHICAGO WICHITA OMAHA OMAHA BRENTWOOD SANJUAN CORNING WEST CHESTER NASHVILLE WOODLAND HILLS BLOOMINGTON GILMER SANJUAN PELHAM CHARLOTTE DES MOINES DALLAS MADISON STATFORD CHANHASSEN RALEIGH EAGAN COLUMBIA COLUMBUS CHARLESTON KANSAS CIY TOPEKA SACRAMENTO MURRAY OKLAHOMA CITY SALT LAKE CITY CHEYENNE NEW YORK DETROIT EASTON EASTON SALT LAKE CTY GREAT FALLS SHAWNNE MISSION ALBUQUERQUE CLEARWATER SANTA MONICA RALEIGH ALBANY SPOKANE RIVERWOODS BATTLE CREEK MILWAUKEE Page 103

FL 33757C001 FL 33767C001 DC 20063C001 DE 19850C001 GA 30326C001 IL 60604C001 KS 67201C001 NE 68114C001 NE 68124C001 TN 37024C001 PR 00936C001 NY 14830C001 PA 19381C001 TN 37230C002 CA 91365C001 IL 61702C001 TX 75644C001 PR 00936C002 AL 35124C001 NC 28235C001 IA 50306D001 TX 75221D001 WI 53705D001 CT 06497D001 MN 55438D001 NC 27611D001 MN 55121E001 SC 29219E001 GA 31999E001 WV 25301E001 MO 64193E001 KS 66604E001 CA 95852E001 UT 84107E001 OK 73124E001 UT 84127E001 WY 82003E001 NY 10016B001 MI 48226E001 PA 18042E001 PA 18942E001 UT 84110E001 MT 59405E001 KS 66205E001 NM 87190E001 FL 33755E001 CA 90403E001 NC 27605E001 NY 12201F001 WA 99210F001 IL 60015C001 MI 49017F001 WI 53214F001

C C ABC B AB ABCD BCD B CD ABC ABCD BD BD A ABD AC AB ABCD ABD AB D ABCD ABCD AB D ABCD ABC A AC ABCD AB ABD B B ABD ABCD B ABCD AB C B BCD A B BD C BCD C BCD BCD AB BC ABCD

Updated Winter 2004 FEDERAL HOME LIFE INS FEDERAL KEMPER INS CO FELRA FHP LIFE INS CO FIC INS GROUP FIREMAN’S FUND EMPL INS FIRST CENTENNIAL LIFE INS FIRST CONTINENTAL LIFE FIRST HEALTH OF AZ INC FIRST NATIONAL LIFE INS FIRST NATIONAL LIFE INS FLEET RESERVE ASSOC FLEET RESERVE ASSOC - FRA FLEET RESERVEASSOC FLIGHT-CARE FOREMOSE LIFE INS CO FORTIS BENEFITS FORTIS INSURANCE COMPANY/TIME FOUNDATION HEALTH PLAN FOUNDATION HEALTH PLAN FOUNDATION HEALTH PLAN FOUNDATION HLTH PLAN FRA INSURANCE PLANS FUTURE FINANCIAL GE CAPITAL ASSUARANCE CO GE LIFE ADN ANNUNITY GENERAL AMER LIFE GEORGIA LIFE AND HEALTH INS CO GERBER LIFE INS GERBER LIFE INS CO GH BENEFIT PLAN GIDDINGS AND LEWIS GILSBAR, INC. GLOBE LIFE AND ACCIDENT INS GLOBE LIFE AND ACCIDENT INS GOLDEN CARE GOLDEN INS CO GOLDEN RULE INS CO GOLDEN RULE INS CO GOLDEN STATE MUTUAL LIFE GOLDSTAR HEALTH CARE GOLDSTAR HEALTH CARE GOLDSTAR HEALTH CARE GOOD SAM INS CO GOVERNMENT WIDE INDEM GRANGE MUTUAL GRAYS HARBOR MED BUREAU GREAT AMER GREAT AMER RESERVE INS CO GREAT FIDELITY LIFE INS GREAT MIDWEST LIFE INS CO GREAT REPUBLIC INS CO GREAT WESTERN LIFE

ORLANDO DECATUR BALTIMORE SANTAANA AUSTIN MINNEAPOLIS FORT COLLINS PITTSBURGH SUN CITY PENSACOLA MONTGOMERY ALEXANDRIA DES MOINES W DES MOINES DES MOINES GRAND RAPIDS KANSAS CITY MILWAUKEE FRENSO CARMICHAEL RANCHO CORDOVA SACRAMENTO DES MOINES MILWAUKEE SEATTLE CLEARWATER ST LOUIS ATLANTA FREMONT GRAND RAPIDS DES MOINES DES MOINES COVINGTON DALLAS DALLAS MEMPHIS COLUMBIA INDIANAPOLIS LAWRENCEVILLE LOS ANGELES DELAWARE DELAWARE HOUSTON SANTA BARBARA BOISE NAMPA ABERDEEN ORLANDO CARMEL FORT WAYNE DALLAS SEATTLE COLUMBUS Page 104

FL 32887F001 IL 62526F001 MD 21212F001 CA 92708F001 TX 78714F001 MN 55440F001 CO 80522F001 PA 15230F001 AZ 85351F001 FL 32591F001 AL 36104F001 VA 20037F001 IA 50306F002 IA 50398F001 IA 50306F001 MI 49501F001 MI 64141P002 WI 53201T001 CA 93712F001 CA 95608F001 CA 95670F001 CA 95865F001 IA 50306F003 WI 53223F001 WA 98111G001 FL 32887G001 MO 65178G001 GA 30301G001 MI 49412G001 MI 10601G001 IA 50306G001 IA 50306G002 LA 70433G001 TX 55221U001 TX 75221G001 TN 38119G001 SC 29202G001 IN 46278G001 IL 62439G001 CA 90018G001 OH 43015G001 OH 46015G001 TX 77006G001 CA 93121G001 ID 83707G001 ID 85653G001 WA 98520G001 FL 32803G001 IN 46032G001 IN 46801G001 TX 75218G001 WA 98119G001 OH 43215G001

BCD B B ABC ABCD ABD ABC ABCD AB C BCD BC D D D ABCD A AB ABCD ABCD ABCD ACD D ABC C C AB ABD C ABCD AB D C B C ABCD AB CD ABCD A AC B C ABCD B A ABCD ABC ABCD BCD ABCD ABCD BD

Updated Winter 2004 GREAT WESTERN LIFE GREAT WESTERN LIFE GREATER LACROSSE HLTH GREATER MARSHFIELD OFFICE GREDE FOUNDRIES INC GROUP HEALTH COOP/S CTRL GROUP HEALTH INC GROUP HEALTH OF SPOKANE GROUP HEALTH OF SPOKANE GROUP HEALTH SRVS OF OK GROUP LIFE AND HEALTH INS GROUP MGMNT SERVICES INC GUARANTEE RESERVE LIFE GUARANTEE TRUST LIFE INS GUARDIAN LIFE GULF SOUTH HEALTH PLAN GVMNT EMP HOSP ASSOC INC HARBOR INS CO HARTFORD ACC AND INDEMNITY HARTFORD INS CO HARTFORD INS CO HARTFORD INS CO/KING COUNTY BLUE SHIELD HARTFORD INSURANCE HARTFORD LIFE AND ACC CO HARTFORD LIFE AND ACCIDENT HARVEST LIFE INS CO HAWKEYE NATIONAL LIFE INS CO HEALTH ABENEFIT PLAN HEALTH ADVANTAGE HEALTH AND LIFE INS HEALTH CARE HEALTH CARE BENEFIT HEALTH CARE BENEFIT HEALTH CARE SERVICE HEALTH DATA MANAGEMENT HEALTH FIRST PPO HEALTH LINK HEALTH PARTNERS ALABAMA HEALTHCARE MGMNT SVC/ME SENIOR COMP PLAN HEALTHGUARD SERVICES HEALTHGUARD SERVICES INC HERITAGE HEALTH PLANS HIGHMARK/BLUE SHIELD OF PA HILL COUNTRY LIFE INS CO HILL COUNTRY OF MONTANA HMO MIDWEST HMO OF WISCONSIN HOLY FAMILY SOCIETY OF US HOME BENEFICIAL LIFE INS HORACE MANN LIFE INS CO HORIZON BCBS OF NJ HUMANA CARE PLUS HUMANA GOLD CLAIMS

CLAYTON DENVER WAUSAU MARSHFIELD DES MOINES MADISON NEW YORK SPOKANE SPOKANE TULSA RICHARDSON NEW BERLIN CALUMET CITY GLENVIEW APPLETON BATON ROUGE INDEPENDENCE LOS ANGELES DES MOINES ALEXANDRIA SHAWNEE MISSION DES MOINES DES MOINES HARTFORD HARTFORD ORLANDO W DES MOINES PISCATAWAY FLORENCE ROCKFORD GREENACRES COLUMBIA CHICAGO CHICAGO OMAHA GREENVILLE SAINT LOUIS BIRMINGHAM LONG BEACH BELLINGHAM EUGENE GRAND PRAIRIE CAMP HILL AUSTIN BOZEMAN HUDSON SIOUX CITY JOLIET RICHMOND SPRINGFIELD NEWARK LOUISVILLE DENVER

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MO 63105G001 CO 80201G001 WI 54402G001 WI 54449G001 IA 50306G003 WI 53715G001 NY 10036G001 WA 92204G001 WA 99204G001 OK 74102G001 TX 75080G001 WI 53151G001 IL 60409G001 IL 60025G001 WI 54913G001 LA 70898G001 MO 64111G001 CA 90010H001 IA 50398H001 VA 22312H001 KS 66201H001 IA 50398H002 IA 50306H001 CT 06104H001 CT 06115H001 FL 32887H001 IA 50266H001 NJ 08854H001 SC 29501H001 IL 61105H001 WA 99016H001 SC 29260H001 IL 60685H001 IL 60601H001 NE 68154H001 SC 29605H001 MO 63132H001 AL 35209H001 CA 90802H001 WA 98227H001 OR 97440H001 TX 75050H001 PA 17089B001 TX 78720H001 MT 59771H001 WI 54016H001 WI 53583H001 IL 60434H001 VA 23261H001 IL 62715H001 NJ 07105H001 KY 40201H002 CO 80210H001

B BD ACD C D B ABCD B A C C ABC ABCD ABCD ABD AB A ABC BCD BCD B BD D BC D BCD ABC B B BCD ABCD ABCD ABCD ABCD CD BD BC ABCD AC ABCD ABC C ABCD ABCD B AC AC BD ABC AC C BCD ABC

Updated Winter 2004 HUMANA HEALTH CARE PLANS HUMANA HEALTH CARE PLANS HUMANA INC. IASD HEALTH SERVICES CORP ICI HEALTH CLAIMS SERVICES IDEALIFE INSURANCE CO IGG ASSOCIATION IHC SENIOR CARE ILLINOIS CENTRAL GULF INDEPENDENCE BC/BS INDEPENDENT LIFE INDUSTRIAL CASUALTY INS INTEGRITY NATIONAL LIFE INS INTER COUNTY HOSP PLAN IN INTERCONTINENTAL LIFE INS INTERCONTINETAL LIFE INS INTERGROUP PREPAID SCVS O INTL BENEFITS SERVICES CO INVESTORS CONSOLIDATED IN INVESTORS DIVERSIFIED INS INVESTORS HERITAGE LIFE ITT HARTFORD ITT LIFE INS CORP J C STEELE AND SONS INC JC PENNY LIFE INS CO JEFERSON LIFE INS CO JEFFERSON PILOT FINANCIAL JOCKEY INTERNATIONAL INC T BENEFIT TRUST KAISER GROWN HEALTH PLAN KAISER GROWN HLTH PLAN KAISER PERMANENTE KANAWHA INS CO KEYSTONE INS CO KING COUNTY BLUE SHIELD KING COUNTY BLUE SHIELD/KIRKE VAN ORSDEL KIRKE VAN ORSDEL KIRKE VAN ORSDEL KIRKE VAN ORSDEL KIRKE VAN ORSDEL KIRKE VAN ORSDEL INC KIRKE VAN ORSDEL INC KIRKE VAN ORSDEL INC KIRKE-VAN ORSDEL KIRKE-VAN ORSDEL INC KIRKE-VAN ORSDEL, INC KITSAP PHYSICIANS SERVICE KLAMATH MEDICAL LA-Z-BOY INCORPORATED LEGAL SECURITY LIFE INS LIBERTY LIFE INS CO LIBERTY MUTUAL INS CO LIBERTY NATIONAL LIFE INS CO

JACKSONVILLE LOUISVILLE LEXINGTON DES MOINES BOCAROPON CLEARWATER OMAHA SALT LAKE CITY LANSING CAMP HILL JACKSONVILLE OAK PARK LOUISVILLE HORSHAM AUSTIN PHILADELPHIA TUCSON FORT WORTH DURHAM BATON ROUGE FRANKFORT SIMSBURY MINNEAPOLIS DURHAM DALLAS DALLAS GREENSBORO DES MOINES LIVERMORE WAHSINGTON ROCKVILLE LOS ANGELEA LANCASTER PHILADELPHIA SEATTLE DES MOINES DES MOINES DES MOINES DES MOINES DES MOINES DES MOINES DES MOINES DES MOINES DES MOINES W DES MOINES WEST DES MOINES BREMERTON KLAMATH FALL DES MOINES DALLAS GREENVILLE LONG BEACH BIRMINGHAM

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FL 32245H001 KY 40201H001 KY 78229H001 IA 50309I001 FL 33427I001 FL 34618I001 NE 68175I001 UT 84111I001 MI 48909I001 PA 17089I001 FL 32276I001 IL 60301I001 KY 40232I001 PA 19044I001 TX 78714I001 PA 19101I001 AZ 85710I001 TX 76109I001 NC 27702I001 LA 70816I001 KY 40602I001 CT 06104I001 MN 55441I001 NC 27702J001 TX 75221J001 TX 75243J001 NC 27420J001 IA 50306J001 CA 94551J001 DC 20016H001 MD 20016K001 CA 90041K001 SC 29721K001 PA 19103K001 WA 50398K001 IA 50398K002 IA 50306K001 IA 50306K002 IA 50306K003 IA 50306K004 IA 50306K005 IA 50306K006 IA 50306K007 IA 50309K001 IA 50398K003 IA 50398A002 WA 98310K001 OR 97601K001 IA 50306L001 TX 75185L001 SV 29602L001 CA 90804L001 AL 35202L001

ABC AD ABCD C ABD A ABCD ABCD AB C C BCD BCD ABD ACD B ABC ABCD ABCD AB ABCD C ABCD ABCD ABD ABCD C D ABC B ACD BCD ABCD BCD CD ACD C D D D D D D D D A ABCD BCD D ABC ABCD BD B

Updated Winter 2004 LIBERTY NATL LIFE INS CO LIFE / HEALTH OF AMERICA LIFE AND HLTH INS CO OF AME LIFE INS CO OF CONNECTICUT LIFE INS CO OF GEORGIA LIFE INS CO OF GEORGIA LIFE INS CO OF VIRGINIA LIFE INSURANCE CO OF VA LIFE INSURANCE OF VA LIFE INVESTIRS CO LIFE INVESTORS CO LIFE INVESTORS INS CO LIFE OF AMERICA LIFE OF GEORGIA LIFE OF GEORGIA INS LINCOLN LIFE AND CAS CO LINCOLN MUT LIFE AND CAS IN LINCOLN NATIONAL INS LUMBERMENS MUTUAL CASLTY LUTHERAN BROTHERHOOD INS M AND I INSURANCE PLANS M AND M INSURANCE PLANS M PHYSICIANS MUTUAL MARICOPA MANAGED CARE SYS MARITIME ASSOC MARKET EMPLOYEES ASSOC MARSH AND MCCLELLAN GRP MASSACHUSETTS MUTUAL MASTERCARE MAXICARE MEAD MEDCENTERS SENIOR LINK MEDI PAK/BCBS ARKANSAS MEDI PAK/BCBS ARKANSAS MEDICAL ASSOC HMO MEDICAL ASSOC HMO MEDICAL SERV OF MI MEDICAL SERVICE ASSOC. MEDICAL SERVICE CORP MEDICAL SERVICE OF D C MEDICARE-AID MEDICO LIFE INS CO MEDICOMP MEDICOMP MEDIPLUS MEDIPLUS MEDIPLUS MEDIPLUS MEMORIAL LIFE INS CO MENNONITE MUTUAL AID METROPOLITAN LIFE INS METROPOLITAN LIFE INS METROPOLITAN LIFE INS/UNITED HEALTHCARE

BIRMINGHAM FORT WORTH PHILADELPHIA SIOUX FALLS BIRMINGHAM LANGHORNE TREVOSE RICHMOND DANVILLE CEDAR RAPIDS CEDAR RAPIDS SCRANTON HOUSTON FORT WASHINGTON COLUMBUS LINCOLN FARGO FREDRICK LONG GROVE MINNEAPOLIS DES MOINES DES MOINES OMAHA PHOENIX HOUSTON CHARLOTTE CHICAGO WASHINGTON DES MOINES CHARLOTTE DES MOINES MINNEAPOLIS LITTLE ROCK LITTLE ROCK DUBUQUE DUBUQUE DES MOINES CAMP HILL SPOKANE WASHINGTON RALEIGH OMAHA PORTLAND GREENVILLE DES MOINES DES MOINES DES MOINES CAROL STREAM WAUSAU GOSHEN PITTSBURGH AURORA BRIDGEWATER Page 107

AL 35207L001 TX 76102L001 PA 19103L001 SD 57193L001 AL 30348L001 PA 35289L001 PA 19053L001 VA 23240L001 VA 24540L001 IA 52402L001 IA 52102L001 PA 18504L001 TX 77019L001 PA 35209L001 GA 31999L001 NE 68501L001 ND 58107L001 MD 21701L001 IL 60049L001 MN 55415L001 IA 50306M003 IA 50306M004 NE 68131M002 AZ 85034M001 TX 77034M001 NC 28222M001 IL 60606M002 DC 20063M002 IA 50306M001 NC 28217M001 IA 50306M005 MN 55435M001 AR 72203M001 AR 77203M001 IA 52001C001 IA 52001M001 IA 50309M001 PA 17089M001 WA 99220M001 DC 20065M001 NC 27622M001 NE 68103M001 ME 04104M001 SC 29609M001 IA 50306M002 IA 50398M001 IA 50398M002 IL 60197M002 WI 54402M001 IN 46526M001 PA 15230M001 IL 60507M001 NJ 08807M001

ACD AC BCD ABCD B CD ABCD C ABCD ACD B AC ABCD BC BCD ABCD ABCD ABD AC ABCD D D D AB ABD ABD ABCD B CD ABD D ABD BC ACD A B ABC C ABCD ABCD ABD ACD B ABCD D BCD D D BD ABCD A A ABD

Updated Winter 2004 MID AMER MUT LIFE INS CO MID AMERICA MUTUAL LIFE MID SOUTH INS CO MII LIFE INCORPORATED MILICARE - FLEET RESERVE MILICARE/FLEETRESERVE MINNESOTA COMP HEALTH MINNESOTA PROTECTIVE LIFE MONTGOMERY WARD LIFE INS MONUMENTAL GENERAL INS MONUMENTAL LIFE MONY MOUNTAIN STATE BCBS MPS OF MICHIGAN MUTUAL BENEFIT CO MUTUAL INS. NATIONWIDE MUTUAL LIFE INS CO MUTUAL LIFE INS CO MUTUAL LIFE INS CO OF NY MUTUAL OF NEW YORK MUTUAL OF OMAHA/STANDARD LIFE MUTUAL PROT MEDICO LIFE MUTUAL PROTECTIVE MUTUAL SERVICE LIFE INS N CENTRAL 65 PLUS NALC - HEALTH BENEFIT PLN NATIONAL BENEFIT CORP NATIONAL CASUALTY INS NATIONAL COUNCIL SR CITIZEN NATIONAL FARMERS UNION LIFE NATIONAL FINANCIAL INS CO NATIONAL FINANCIAL/FOUNDATION LIFE NATIONAL GROUP LIFE NATIONAL HERITAGE INS NATIONAL HOME LIFE ASSUR NATIONAL HOME LIFE ASSUR NATIONAL LIBERTY GROUP NATIONAL LIFE AND ACCIDENT NATIONAL SECURITY INS CO NATIONAL STATES INS NATIONAL STATES INS CO NATIONAL TRAVELERS LIFE NATIONAL VISION NATIONWIDE LIFE INS CO NATL BENEFIT LIFE INS CO NATL FARMERS UNION LIFE NATL HEALTH INS CO NATL LIFE NATL LIFE AND ACC NATL LIFE INS CO OF TEXAS NAUS - UNISERVICE NAUS – UNISERVICE NEW ERA LIFE INS CO

SAINT PAUL CHICAGO FAYETTEVILLE SAINT PAUL W DES MOINES FAIRFAX SAINT PAUL OMAHA CAROL STREAM SCRANTON BALTIMORE HOUSTON WHEELING DETROIT COLUMBIA COLUMBUS WASHINGTON FAIRFIELD PURCHASE NEW YORK OMAHA OMAHA OMAHA SAINT PAUL WAUSAW ASHBURN KANSAS CITY SAINT LOUIS IRVINGTON DENVER DALLAS FORT WORTH ROCKFORD AUSTIN BINGHAMTON VALLEY FORGE VALLEY FORGE EVANSVILLE POTTSVILLE DES MOINES ST LOUIS DES MOINES PHOENIX COLUMBUS NEW YORK KANSAS CITY DALLAS OCEANSIDE NASHVILLE ARLINGTON ROCKVILLE ROCKVILLE HOUSTON Page 108

MN 55113M001 IL 60606M001 NC 28302M001 MN 55164M001 IA 20063M001 VA 20063M003 MN 55164M002 NE 68114M001 IL 60197M001 PA 18504M001 MD 21201M001 TX 77006M001 WV 26003M001 MI 48266M001 SC 29260M001 OH 43216M001 DC 20037M001 AL 35064M001 NY 10577M001 NY 10019M001 NE 68131M001 NE 68172M001 NE 68124M001 MN 55164M003 WI 54402N001 VA 22093N001 MO 64111N001 MO 63101N001 NY 10533N001 CO 80231N001 TX 75266N001 TX 76102N001 IL 61105N001 TX 78720N001 NY 13901N001 PA 19493N001 PA 19493N002 IN 47701N001 PA 17901N001 IA 50306N001 MO 63141N001 IA 50309N001 AZ 85060N001 OH 43216N001 NY 10016N001 MO 64199N001 TX 75261N001 CA 92049N001 TN 37250N001 TX 76015N001 MD 20852N001 MD 28052N001 TX 77210N001

BCD BC BCD ABCD BCD D ABCD ABCD ABCD ABCD C ABCD ABCD ABCD ABD C ABCD ABCD ABCD ABCD ABCD BCD C ABC BCD A ABCD BC ABD AB BD BCD AC ABD B BCD BCD C AB AB BD ABC ABCD ABCD ABCD ABCD ABC AB A ABCD AD B AC

Updated Winter 2004 NEW YORK LIFE NEW YORK LIFE INS NORTH AMER INS CO NORTH AMER INS CO NORTH AMER INS CO NORTH AMERICAN LIFE NORTH ATLANTIC CAS AND SURE NORTH CAROLINA MUTUAL NORTHWESTERN NATIONAL LIFE NORTHWESTERN PUBLIC SERV NW WASHINGTON MEDICAL BUR OCR CLAIMS OKLAHOMA STATE INS OLD AMER INS CO OLD SOUTHERN LIFE INS CO OLD SURETY LIFE INS CO OLYMPIC HEALTH MANAGEMENT OREGON PACIFIC STATES OXFORD LIFE INSURANCE OXFORD LIFE INSURANCE COM PACC HEALTH PLANS PACIFIC HEALTH PACIFIC HEALTH AND LIFE INS PACIFIC HERITAGE ASSURANC PACIFIC HOSPITAL ASSOC PACIFIC MUTUAL LIFE PACIFIC MUTUAL LIFE PACIFIC NORTHWEST LIFE PACIFICARE LIFE ASSURANCE PANHANDLE EASTERN CORP PARK AND SHOP INS PATRICK CUDAHY, INC. PAUL REVERE LIFE INS CO PEARCE IND PEHP PEIA HEALTH ECON CORP PEKIN LIFE INS CO PENINSULAR LIFE INS CO PENN GENERAL SERVICES OF GA PENN TREATY LIFE INS CO PENNSYLVANIA AMER PENNSYLVANIA LIFE INS PEOPLES BENEFIT LIFE INS PEOPLES LIFE - NORTH AMERICAN INS CO PEOPLES LIFE INS PEOPLES LIFE INS CO/UNITED HEALTHCARE PEOPLES SECURITY INS PEOPLES SECURITY LIFE INS/PUBLIC SAVINGS LIFE PERSONALCARE INS AIL INC PFL LIFE INSURANCE CO PFWB BENEVOLENT ASSO PHILADELPHIA AMER LIFE CO PHYSICIANS HEALTH PLAN

ATLANTA OMAHA MADISON MINNEAPOLIS KANSAS CITY DES MOINES INDIANAPOLIS NASHVILLE JACKSON HURON BELLINGHAM CHICO OKLAHOMA CITY KANSAS CITY MONTGOMERY OKLAHOMA CITY BELLINGHAM PORTLAND MADISON OMAHA CLACKAMAS HUNTINGTON BCH BEND OMAHA EUGENE GLENDALE FEDERAL WAY PORTLAND COSTA MESA HOUSTON SHEBOYGAN DES MOINES WORCHESTER HOUSTON SALT LAKE CITY CHARLESTON PEKIN RALEIGH ATLANTA ALLENTOWN HATTSBORO SANTA MONICA FRAZER MADISON GREENVILLE ROLLING MEADOWS DANVILLE DURHAM CHAMPAIGN SCRANTON DUNN HOUSTON MINNEAPOLIS

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GA 30348N001 NE 68131N001 WI 53744N001 MN 55440N001 MO 64111N002 IA 50306N002 IN 46206N001 TN 37202N001 MN 56143N001 SD 57350N001 WA 98227N001 CA 95927O001 OK 73124O001 MO 64141O001 AL 36101O001 OK 73154O001 WA 98227O001 OR 97207O001 WI 53744O001 NE 68154O001 OK 97015P001 CA 92647P001 OR 97701P001 NB 68172P001 OR 97401P001 CA 91203P001 WA 98003P001 OR 97207P001 CA 92708P001 TX 77251P001 WI 53801P001 IA 50306P001 MA 01608P001 TX 77235P001 UT 84102P001 WV 25362P001 IL 61558P001 NC 27605P001 GA 30358P001 PA 18105P001 PA 19034P001 CA 90406P001 PA 19493P002 WI 53703P001 SC 29609P001 IL 60008P001 VA 24540P001 NC 27702P001 IL 61820P001 PA 18504P001 NC 28335P001 TX 77210P001 MN 55440P001

BD B ABCD B BCD D ABCD ABD B BD D A AB ABCD AB ABCD ACD ABCD C D AC C AC AC ABCD AB AB ABCD C ABD ABCD D ABCD ABCD ABC B ABCD ABCD ABC BCD BD BC C C ABCD ABCD ABCD ABCD AC C ABCD C B

Updated Winter 2004 PHYSICIANS LIABILITY INS PHYSICIANS MUTUAL INS CO PIERCE COUNTY MED BUREAU PIERCE COUNTY MEDICAL BUR PILGRIM LIFE INS CO PILOT LIFE INS CO PIONEER LIFE INS CO PLAN 65 OF KANSAS PREFERRED ISTRATIVE PREFERRED BANKERS LIFE PREFERRED CHOICE PREFERRED HEALTH CARE PREFERRED LIFE INS CO OF NY PREFERRED RISK LIFE PREMERA BLUE CROSS PRESIDENTIAL LIFE PRIME CARE PLUS PRIME HEALTH PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GROUP PRINCIPAL FINANCIAL GRP PRINCIPAL HEALTH CARE PRINCIPAL MUTUAL INS PRINCIPAL MUTUAL LIFE PROTECTED HOME MUT LIFE PROTECTIVE LIFE INS CO PROVIDENCE LIFE PROVIDENTIAL LIFE INS CO PROVIDERS FIDELITY LIFE PROVIDIAN LIFE AND HEALTH PROVIDIAN LIFE/HEALTH PRUDENTIAL INSURANCE CO PYRAMID LIFE INS CO QUAL-MED INC

OKLAHOMA CITY OMAHA TACOMA TACOMA FOLCROFT NASHVILLE ROCKFORD TOPEKA MADISON DALLAS SAN DIEGO WICHITA NEW YORK W DES MOINES SEATTLE DALLAS COLUMBUS KANSAS CITY WALLINGFORD BALA CYNWYD JACKSONVILLE TAMPA TAMPA COLUMBUS AMES WEST DES MOINES WEST DES MOINES CEDAR RAPIDS WEST ALLIS AURORA SPRINGFIELD COLORADO SPRING BROOKLYN SAN ANTONIO SALT LAKE CITY PHOENIX FRESNO PORTLAND SEATTLE COLORADO SPRING KANSAS CITY BROOKLYN OMAHA SHARON BIRMINGHAM MEMPHIS LITTLE ROCK BLUE BELL LOUISVILLE FRAZIER ROSELAND SHAWNEE MISSION ALBUQUERQUE Page 110

OK 73126P001 NE 68131P001 WA 98401P001 WA 98101P001 PA 19032P001 TN 37220P001 IL 61105P001 KS 66629P001 WI 53715P001 TX 75205P001 CA 92196P001 KS 67214P001 NY 10019P001 IA 50265P001 WA 98111P001 TX 75228P001 OH 43235P001 MO 64134P001 CT 06492P001 PA 19004P001 FL 32256P001 FL 33607P001 FL 33631P001 OH 43229P001 IA 50014P001 IA 50265P002 IA 50266P001 IA 52402P001 WI 53227P001 IL 60504P001 MO 65802P001 CO 66210P001 MN 73134P001 TX 78279P001 UT 84157P001 AZ 85021P001 CA 93711P001 OR 97204P001 WA 98188P001 CO 80920P001 MO 64141P001 MN 55430P001 NE 68154P001 PA 16146P001 AL 35202P001 TN 38187P001 AR 72203P001 PA 19422P001 KY 19493P001 PA 19355N001 NJ 07068P001 KS 66202P001 NM 87110Q001

A ABD ABD D B B ABCD ABCD BCD ABC BD ABCD ABCD BCD D ABCD ABD ABCD C C C C C C C C C C C C C C C C C C C C C AC BCD BCD ABCD ABCD AB B ABCD ABCD C A A ABCD ABCD

Updated Winter 2004 R E HARRINGTON INC CHARLOTTE R J REYNOLDS TOBACCO ATLANTA RAND MCNALLY GREENVILLE REGENCE BCBS OF OREGON KLAMATH FALLS REGENCE BLUE SHIELD SEATTLE REGENCE BLUESHIELD SEATTLE REGENCE WASHINGTON HEALTH/KING CTY MEDICAL SEATTLE RELIABLE LIFE INS CO WEBSTER GRV RESERVE NATIONAL LIFE IN OKLAHOMA CITY RETIRED OFFICERS ASSOC ALEXANDRIA RETIRED OFFICERS ASSOC DES MOINES RHONE POULENE OF WY GREEN RIVER RHULEN INS CO MONTICELLO RISK MANAGEMENT INC FRESNO ROCKWELL AUTOMATION DES MOINES RURAL SECURITY LIFE INS MADISON SAN ANTONIO REG CLAIM CTR SAN ANTONIO SAVERS LIFE INS CO WINSTON SALEM SDC - SYSTEM DEVELOPMENT/SENIOR SECURITY LIFE OKLAHOMA CITY SEABURY AND SMITH WEST DES MOINES SECURE CARE VALLEY FORGE SECURE HORIZONS HEALTH PLAN CYPRESS SECURITY GENERAL INS/PROVIDENT CLAIM OFFICE CHATANOOGA SECURITY GENERAL LIFE INS OKLAHOMA CITY SECURITY HEALTH PLAN OF WI MARSHFIELD SECURITY LIFE INS CO HOUSTON SECURITY NATIONAL LIFE INS CO SALT LAKE CITY SECURITY TRUST LIFE INS DURHAM SEGUROS DE SERVICIO DE SAN JUAN SELECTCARE LINWOOD SENIOR CARE CANYON COUNTRY SENIOR SECURITY LIFE INS OKLAHOMA CITY SENTRY LIFE INS STEVENS POINT SEVENTYH DAY ADVENTISTS DES MOINES SHELTER LIFE INS CO COLUMBIA SIEBE TEMP AND APPL CONTROL DES MOINES SIERRA HEALTH AND LIFE INS LAS VEGAS SIGN AND DISPLAY INS PLAN DES MOINES SKAGIT CTY MED BUREAU INC MOUNT VERNON SOUTH ATLANTIC LIFE JACKSONVILLE SOUTH ATLANTIC LIFE SKOKIE SOUTH DAKOTA BLUE SHIELD SIOUX FALLS SOUTHERN FARM BUREAU LIFE JACKSON CITY SOUTHERN HEALTH PLAN MEMPHIS SOUTHLAND LIFE INS CO BIRMINGHAM SOUTHWEST ALHAMBRA SOUTHWEST HOME LIFE INS DALLAS SOUTHWEST SERVICE LIFE FT WORTH SOUTHWEST SERVICES LIFE FORT WORTH SOUTHWESTERN GENERAL LIFE DALLAS SPECIAL AGTS MUT BENEFIT ROCKVILLE ST MICHAELS PA MILWAUKEE STANDARD GUARANTY INS ATLANTA Page 111

NC 28226R001 GA 30348R001 SC 29609R001 OR 97601R001 WA 99362R001 WA 98401R001 WA 98101K001 MO 63119R001 OK 73118R001 VA 22314R001 IA 50306R001 WY 82935R001 NY 12701R001 CA 93794R001 IA 50306R002 WI 53705R001 TX 78216S001 NC 27103S001 OK 73154S002 IA 50398S001 PA 19493S001 CA 90630S001 TN 37422S001 OK 73154S001 WI 54449S001 TX 77019S001 UT 84157S001 NC 27702S001 PR 00936S001 NJ 08221S001 CA 91351S001 OK 73154S003 WI 54481S001 IA 50306S003 MO 65218S001 IA 50306S002 NV 89114S001 IA 50306S004 WA 98273S001 FL 33101S001 IL 60076S001 SD 57104S001 MS 39205S001 TN 38101S001 AL 35289S001 CA 90057S001 TX 75221S001 TX 76180S001 TX 76118S001 TX 75266S001 MD 20852S001 WI 53209S001 GA 30327S001

ABD A ABD D C C ABC ABCD ABCD D D BCD ABCD AB D AB ABCD BC ABCD C BCD ABCD B AB ABCD ABCD ABCD BCD ABCD B BD ACD ABCD D ABCD D ABCD D ABCD ABD ABD AC ABCD ABCD ABC ABC AC D ABCD AB A ABC AB

Updated Winter 2004 STANDARD LIFE AND ACC INS C STATE FARM HEALTH INS STATE FARM HLTH INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM INS CO STATE FARM MUT AUTO INS STATE FARM MUT AUTO INS STATE FARM MUT AUTO INS STATE FARM MUT AUTO INS STATE FARM MUT INS STATE FARM MUTUAL AUTO STATE FARM MUTUAL AUTO STATE GROUP BENEFITS STATE MUTUAL CO STATE MUTUAL INSURANCE CO STATES GENERAL LIFE INS STATESMAN NATL LIFE STATEWIDE INS CO STIRLING AND STIRLING SUMMIT NATIONAL LIFE INS CO SURGICAL CARE SVEDALA INDUSTRIES T AND N COMPANY

OKLAHOMACITY FREDERICK LINCOLN WAYNE CONCORDVILLE CHARLOTTESVILLE CHARLOTTESVILLE CHILHOWIE BLUEFIELD ELIZABETHTOWN WHITEVILLE LENIOR DELUTH JACKSONVILLE MURFREESBOURO NEWARK NEWARK WEST LAFAYETTE MARSHALL ST PAUL BLOOMINGTON BLOOMINGTON COLUMBIA MONROE TULSA DALLAS DALLAS GOODING WESTLAKE VILLAG COSTA MESA SANTA ANA BAKERSFIELD BAKERSFIELD ROHNERT PARK SALEM BALLSTON SPA BIRMINGHAM WEST LAFAYETTE AUSTIN WINTER HAVEN GREELEY TEMPE BATON ROUGE WORCHESTER ROME DALLAS HOUSTON MONROE MILFORD LANCASTER MILWAUKEE DES MOINES DES MOINES Page 112

OK 73125S001 MD 21709S001 NE 68501S001 NJ 07477S001 PA 19339S001 VA 22901S001 VA 22909S001 VA 24319S001 VA 24605S001 NC 28337S001 NC 28472S001 NC 28645S001 GA 30136S001 FL 32232S001 TN 37131S001 OH 43055S001 OH 43093S001 IN 47906S001 MI 49069S001 MN 55161S001 IL 61709S001 IL 61710S001 MO 65217S001 LA 71208S001 OK 74146S001 TX 75252S001 TX 75379S001 ID 83330S001 CA 91363S001 CA 92626S001 CA 92799S001 CA 93311S001 CA 93399S001 CA 94926S001 OR 97303S001 NY 12020S001 AL 35297S001 IN 47905S001 TX 78729S001 FL 33888S001 CO 80638S001 AZ 85289S001 LA 70804S001 MA 01653S001 GA 30162S001 TX 75214S001 TX 77006S001 NC 28110S001 CT 06460S001 PA 17601S001 WI 53201S001 IA 50306S001 IA 50306T002

ABCD AC ACD ABCD C B ACD ABCD ABCD ABCD ABCD ABCD ABD ABD ABCD C C C C ABD BCD C A ABCD C C C ABCD C C C C C C ABD AC AC AC A A AC AC ABD AB C ABC ABCD ABCD D BD ABCD D D

Updated Winter 2004 TAKE CARE HEALTH PLAN TEAM-CARE HEALTH CHOICE TENNECO TEXAS IMPERIAL LIFE THE PRINCIPAL FINANCIAL TRANSAMERICA ACC LIFE TRANSAMERICA INS TRANSPORT LIFE TRAVELERS INC CO TRAVELERS OMAHA TRIGON BCBS TRIGON MUTUAL INS CO/BCBS VA TROA GROUP HLTH INS TRS CARE TRUSTMARK INS CO TRUSTMARK INS CO U S HEALTH AND LIFE INS/IDEALIFE UNDERWRITERS LIFE INS CO UNICARE UNION BANKERS INS CO UNION BANKERS-RR CLAIMS/UAIAG UNION CARE LIFE INS CO UNION FIDELITY LIFE INS/COMBINED INS OF AMER UNION FIDELITY/MUTUAL LIFE UNION LABOR LIFE UNION LABOR LIFE INS CO UNION LOCAL 662 UNISYS BENEFITS OFFICE UNIT DROP FORGE CO INC UNITED AMER INS CO UNITED ASSURANCE CO OF PA UNITED COMMERCIAL TRAVLRS UNITED FAMILY LIFE INS UNITED FARM BUREAU FAM UNITED FOUNDERS LIFE UNITED FOUNDERS LIFE INS UNITED GENERAL LIFE UNITED GENERAL LIFE INS UNITED HEALTHCARE OF ALABAMA, INC UNITED HERITAGE MUTUAL UNITED INVESTORS LIFE INS UNITED LIFE OF NORTH AMER UNITED METHODIST GROUP UNITED NATIONAL LIFE INS UNITED OF OMAHA UNITED OF OMAHA UNITED SEC ASSURANCE CO UNITED TEACHER ASSOC UNITED TECHNOLOGIES UNIVERSAL FIDELITY LIFE UNIVERSAL LIFE INS CO US GUARDIAN HEALTH INS CO USAA LIFE INS CO

CONCORD MEMPHIS JACKSONVILLE HOUSTON OMAHA UPLAND WOODLAND HILLS FORT WORTH HAMDEN OMAHA ROANOKE WYTHEVILLE DES MOINES NASHVILLE LAKE FOREST LAKE FOREST CLEARWATER DALLAS ANDOVER DALLAS DALLAS WASHINGTON TREVOSE ALPHARETTA WASHINGTON NEW YORK DES MOINES LONDON DES MOINES DALLAS SOUDERTON COLUMBUS ATLANTA INDIANAPOLIS BIRMINGHAM OKLAHOMA CITY CLEARWATER CLEARWATER BIRMINGHAM NAMPA DALLAS VIENNA OMAHA GLENVIEW LANGHORNE TREVOSE SOUDERTON AUSTIN HARTFORD DUNCAN RICHMOND DALLAS SAN ANTONIO

Page 113

CA TN FL TX NE CA CA TX CT NE VA VA IA TN IL IL FL TX MA TX TX DC PA GA DC NY IA KY IA TX PA OH GA IN AL OK FL FL AL ID TX VA NE IL PA PA PA TX CT OK VA TX TX

94524T001 38174T001 32276T001 77242T001 68154T001 91785T001 91367T001 76102T001 06517T001 68175T001 24031T001 24382B001 50306T001 37202T001 55116T001 60045T001 34618U001 75238U001 93031U001 75265U001 75201U001 20001U001 19047C001 19049U001 20006U001 10010U001 50306U002 84130U001 50306U001 75221U001 19047U002 43215U001 30301U001 46206U001 35202U001 73112U001 34616U001 33743U001 35255U001 83653U001 75221U002 22182U001 68175U001 60025U001 19047U001 19049U003 18964U001 78755U001 06146U001 73533U001 23222U001 75244U001 78288U001

ABCD ABD ABD C C ABD ABC ABCD B BD BCD A BCD A C D AC B C BCD AC BCD ABCD BCD BCD BD D A D ABCD ABCD BCD BCD ABCD ABCD ABD BCD ABCD C ABCD A AB ABCD AC B A ABD ACD ABCD ABCD ABD AB ABCD

Updated Winter 2004 USABLE LIFE VALLEY HEALTH PLAN VASA NORTH ATLANTIC VASA/VARIABLE PROTECTION VETERANS ISTRATION VETERANS LIFE INS CO VFW MDGAP/NO AMER INS/PA VICTORY LIFE INS CO VIRGINIA HEALTH AND AS ASSOC VIRGINIA MUTUAL INS CO VIRGINIA SURETY CO INC VULCAN LIFE INS CO WALLA WALLA VALLEY MED WASHINGTON NATIONAL INS WASHINGTON NATL INS WC KUMMEROW AND CO WEA INSURANCE GROUP WEST BEND INSURANCE PLAN WESTERN AMER LIFE INS CO WESTERN FARM BUREAU INS WESTERN FIDELITY INS WHATCOM MEDICAL BUREAU WIS HEALTH ORG/WISCONSIN PHYSICIANS WISCONSIN PHYSICIANS SERV WIT AND CO INSURANCE PLANS WORLD INS CO WORLD LIFE AND HEALTH INS CO WORLD NET SERVICES CORP

LITTLE ROCK EAU CLAIRE INDIANAPOLIS CLEVELAND PHOENIX VALLEY FORGE HORSHAM MURFREESBORO EMPORIA RICHMOND CLEARWATER BIRMINGHAM WALLA WALLA EVANSTON LINCOLNSHIRE CRYSTAL LAKE MADISON DES MOINES RICHARDSON DENVER FORT WORTH BELLINGHAM MILWAUKEE MADISON DES MOINES OMAHA HARRISBURG PENSACOLA

Page 114

AK 72203U001 WI 54702V001 IN 46206V001 OH 44130V001 AZ 85012V001 PA 19493V001 PA 64111V001 TN 37133V001 VA 23847V001 VA 23225V001 FL 33755V001 AL 35201V001 WA 99362W001 IL 60201W001 IL 60069W001 IL 60014W001 WI 53708W002 IA 50306W002 TX 75083W001 CO 80217W001 TX 76101W001 WA 98227W001 WI 53212W001 WI 53701W001 IA 50306W001 NE 68130W001 PA 17105W001 FL 32501W001

ABCD ABCD C C AB ABCD ABCD ABCD BCD BC C AB ABD BD C ABC AB D AC ABCD ABCD ABCD ABCD ABCD D BCD BC C

Updated Winter 2004

XXIII - APPENDIX II – Non-covered HCS Item

HCS Code

Air Cleaner (includes electrostatic A9270 machines)

Coverage Guidelines (MCM or Title 18 SSA) Not primarily medical in nature/environmental control equipment/2100.1 B.2 1861(n) of the Act

Air Conditioners

11/10/2000 A9270 Convenience item/not primarily medical in nature/2100.1 B.2 1861(n) of the Act

Bathtub Lifts

E0625

Bathtub Seat/Stool/Bench/Rails Equipment

E0241 Bathtub Comfort or convenience item/hygienic equipment/not primarily wall rail medical in nature/2100.1 B.2 1861(n) of the Act.

Bed Accessory: Board, Table or Device, any type

E0242 Bathtub rail, floor base E0243 Toilet rail E0245 Tub stool or bench E0315 Convenience item/not primarily medical in nature/2100.1 B.2 1861(n) of the Act.

Bed Baths (home type)

A9270

Bedboards

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

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

8/30/1999 E0273-bed Not primarily medical in nature/2100.1 B.2 1861(n) of the Act. board overbed board/tableE0274

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.

Bidet Toilet Seats

A9270

Not medical equipment

Bio Therapy for the Treatment of Urinary Incontinence

7/26/1999 E0746 CIM 35-27.1Home use of bio therapy is not covered.

Page 115

Updated Winter 2004 Blood Glucose ANALYZER

Note: this is NOT the MONITOR

Unsuitable for home use/60-11

Carafes

A9270 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 A5510 the Patient's Body Heat and Weight)

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


Electrostatic Machines

A9270


Elastic Stockings

A9270 and Nonreuseable disposable supplies/2100.1A . 1861(n) of the Act. L8100-L8239

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 s

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.

Page 116

Updated Winter 2004 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


Incontinent Pads

A4554 Nonreuseable supply/hygienic item/2130.A. 1861(n) of the Act. Disposable under pads, all sizes (e.g., Chux's) or A4360 Adult incontinence garmet (e.g. brief, diaper)

Injectors (hypodermic jet pressure A4210 powered devices for insulin injections)

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

Insulin except used in a pump

J1820, K0548 Self istered 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 istered Drug. MCM 2049.

Non- wound warming device and accessories

E0231, E0232, CMS Benefit Determination. A6000

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

exercise equipment/2100.1.B.2

Patient Lift, Kartop, bathroom or E0625 toilet

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.

Page 117

Updated Winter 2004 Preset Portable Oxygen Units

A9270

Emergency, first aid, or precautionary equipment; essentially not therapeutic in nature.

Pressure Leotards

A9270


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 A4627 without mask, for use with metered dose inhaler

Supply used with self istered 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

Hose

A9270 and L8100-8239


Surgical Stocking

A4490, A4495, Nonreuseable supplies; not rental-type/MCM 2133. 1861(n) of the A4500, A4510 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.

Treill 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

Page 118

Updated Winter 2004

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

Surfaces

843

DMERC 02.03A

Motorized Wheelchairs

844

DMERC 02.03B

Manual Wheelchairs

845

DMERC 03.02

Continuous Positive Airway Pressure (AP) 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.

Page 119

Updated Winter 2004 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 HCS 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 HCS 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 recertification) 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. Page 120

Updated Winter 2004

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 s 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 ed 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 that the answers on CMNs are ed by information in the patient’s medical record.

SECTION C EXAMPLES Example 1: Item:

Codes:

HCS Description:

A

K0004

High strength, lightweight wheelchair.

B

K0195

Elevating leg rests, pair.

C

K0028

Fully reclining back. Page 121

Updated Winter 2004 Item:

Codes:

HCS 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:

HCS 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.

Page 122

Updated Winter 2004

HCS 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 HCS 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

Page 123

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

Updated Winter 2004

APPENDIX IV – Medicare As Secondary Payer Questionnaire (Short Form) XXV -

Beneficiary Name: __________________________________________ Age: _____________ HICN: ___________________________________________________ 1 2 3 4 5 6 7a 7b 8a 8b 9

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. Is this illness/injury covered under the Federal Black Lung Program? If yes, file claim with them. If no, go to #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. 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. 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. 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. Is the patient under 65 and entitled to Medicare due to a disability? If yes, go to #7b. If no, go to #8. 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. 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. 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

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

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: _______________________________________________________________

Page 124

Updated Winter 2004 NOTES

Page 125

Updated Winter 2004

Page 126

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