product categories and hcpcs codes...product categories and hcpcs codes . commode chairs 2...

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program • Round 2021

Product Categories and HCPCS Codes

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10 11 12 13 16 19 20

Commode Chairs Continuous Positive Airway Pressure (CPAP) Devices and Related Accessories (RADs) Enteral Nutrition Hospital Beds Nebulizers Negative Pressure Wound Therapy (NPWT) Pumps Non-Invasive Ventilators Off-The-Shelf Back Braces Off-The-Shelf Knee Braces Oxygen and Oxygen Equipment Patient Lifts and Seat Lifts Standard Manual Wheelchairs Standard Power Mobility Devices Support Surfaces (Groups 1 and 2) Transcutaneous Electrical Nerve Stimulation (TENS) Devices Walkers 21

On April 9, 2020, the non-invasive ventilators product category was removed from Round 2021 due to the novel COVID-19 pandemic. On October 27, 2020, the Centers for Medicare & Medicaid Services (CMS) announced the single payment amounts and began offering contracts for the off-the-shelf (OTS) back braces and OTS knee braces product categories. All other product categories were removed from Round 2021. Please see the CMS announcement for additional information. The items listed above were not revised to remove the product categories in order to preserve information available at the time of bidding (i.e., prior to removal of the product categories on October 27, 2020).

https://www.cms.gov/files/document/round-2021-dmepos-cbp-single-payment-amts-fact-sheet.pdf

DMEPOS Competitive Bidding Program Product Category HCPCS Codes

Round 2021

Commode Chairs

Lead Item HCPCS Code Lead Item HCPCS Code Description Relative

Ratio

Ratio HCPCS Modifiers

E0163 Commode Chair, Mobile Or Stationary, With Fixed Arms NU

Non-Lead Item HCPCS Code Non-Lead Item HCPCS Code Description Relative

Ratio


E0160 Sitz Type Bath Or Equipment, Portable, Used With Or Without Commode 0.297690 NU E0161 Sitz Type Bath Or Equipment, Portable, Used With Or Without Commode, With Faucet Attachments 0.227971 NU E0165 Commode Chair, Mobile Or Stationary, With Detachable Arms 0.163797 RR E0167 Pail Or Pan For Use With Commode Chair, Replacement Only 0.107266 NU E0168 Commode Chair, Extra Wide And/Or Heavy Duty, Stationary Or Mobile, With Or Without Arms, Any Type, Each 1.412432 NU E0170 Commode Chair With Integrated Seat Lift Mechanism, Electric, Any Type 1.504158 RR E0171 Commode Chair With Integrated Seat Lift Mechanism, Non-Electric, Any Type 0.270643 RR E0275 Bed Pan, Standard, Metal Or Plastic 0.136245 NU E0276 Bed Pan, Fracture, Metal Or Plastic 0.118690 NU E0325 Urinal; Male, Jug-Type, Any Material 0.087442 NU E0326 Urinal; Female, Jug-Type, Any Material 0.093994 NU

March 2019 2


Round 2021

Continuous Positive Airway Pressure (CPAP) Devices and Respiratory Assist Devices (RADs)


Ratio


E0601 Continuous Positive Airway Pressure (CPAP) Device RR


Ratio


A4604 Tubing With Integrated Heating Element For Use With Positive Airway Pressure Device 0.626673 NU A7027 Combination Oral/Nasal Mask, Used With Continuous Positive Airway Pressure Device, Each 1.990718 NU A7028 Oral Cushion For Combination Oral/Nasal Mask, Replacement Only, Each 0.539424 NU A7029 Nasal Pillows For Combination Oral/Nasal Mask, Replacement Only, Pair 0.220225 NU A7030 Full Face Mask Used With Positive Airway Pressure Device, Each 1.769907 NU A7031 Face Mask Interface, Replacement For Full Face Mask, Each 0.654617 NU A7032 Cushion For Use On Nasal Mask Interface, Replacement Only, Each 0.380264 NU A7033 Pillow For Use On Nasal Cannula Type Interface, Replacement Only, Pair 0.266536 NU A7034 Nasal Interface (Mask Or Cannula Type) Used With Positive Airway Pressure Device, With Or Without Head Strap 1.103664 NU A7035 Headgear Used With Positive Airway Pressure Device 0.356619 NU A7036 Chinstrap Used With Positive Airway Pressure Device 0.157401 NU A7037 Tubing Used With Positive Airway Pressure Device 0.378407 NU A7038 Filter, Disposable, Used With Positive Airway Pressure Device 0.046702 NU A7039 Filter, Non Disposable, Used With Positive Airway Pressure Device 0.134734 NU A7044 Oral Interface Used With Positive Airway Pressure Device, Each 1.134441 NU A7045 Exhalation Port With Or Without Swivel Used With Accessories For Positive Airway Devices, Replacement Only 0.182609 NU A7046 Water Chamber For Humidifier, Used With Positive Airway Pressure Device, Replacement, Each 0.183000 NU

E0470 Respiratory Assist Device, Bi-Level Pressure Capability, Without Backup Rate Feature, Used With Noninvasive Interface, E.G., Nasal Or Facial Mask (Intermittent Assist Device With Continuous Positive Airway Pressure Device) 2.264289 RR

E0471 Respiratory Assist Device, Bi-Level Pressure Capability, With Back-Up Rate Feature, Used With Noninvasive Interface, E.G., Nasal Or Facial Mask (Intermittent Assist Device With Continuous Positive Airway Pressure Device) 5.659990 RR

E0472 Respiratory Assist Device, Bi-Level Pressure Capability, With Backup Rate Feature, Used With Invasive Interface, E.G., Tracheostomy Tube (Intermittent Assist Device With Continuous Positive Airway Pressure Device) 5.659990 RR

E0561 Humidifier, Non-Heated, Used With Positive Airway Pressure Device 1.005569 NU E0562 Humidifier, Heated, Used With Positive Airway Pressure Device 2.826185 NU

March 2019 3


Round 2021

Enteral Nutrition


Ratio


B4035 Enteral Feeding Supply Kit; Pump Fed, Per Day, Includes But Not Limited To Feeding/Flushing Syringe, Administration Set Tubing, Dressings, Tape


Ratio


B4034 Enteral Feeding Supply Kit; Syringe Fed, Per Day, Includes But Not Limited To Feeding/Flushing Syringe, Administration Set Tubing, Dressings, Tape 0.523849

B4036 Enteral Feeding Supply Kit; Gravity Fed, Per Day, Includes But Not Limited To Feeding/Flushing Syringe, Administration Set Tubing, Dressings, Tape 0.686192

B4081 Nasogastric Tubing With Stylet 1.854393 B4082 Nasogastric Tubing Without Stylet 1.378243 B4083 Stomach Tube - Levine Type 0.211715 B4087 Gastrostomy/Jejunostomy Tube, Standard, Any Material, Any Type, Each 3.060251 B4088 Gastrostomy/Jejunostomy Tube, Low-Profile, Any Material, Any Type, Each 3.060251

B4149 Enteral Formula, Manufactured Blenderized Natural Foods With Intact Nutrients, Includes Proteins, Fats, Carbohydrates, Vitamins And Minerals, May Include Fiber, Administered Through An Enteral Feeding Tube, 100 Calories = 1 Unit 0.134728

B4150 Enteral Formula, Nutritionally Complete With Intact Nutrients, Includes Proteins, Fats, Carbohydrates, Vitamins And Minerals, May Include Fiber, Administered Through An Enteral Feeding Tube, 100 Calories = 1 Unit 0.058577

B4152 Enteral Formula, Nutritionally Complete, Calorically Dense (Equal To Or Greater Than 1.5 kcal/ml) With Intact Nutrients, Includes Proteins, Fats, Carbohydrates, Vitamins And Minerals, May Include Fiber, Administered Through An Enteral Feeding Tube, 100 Calories = 1 Unit 0.047699

B4153 Enteral Formula, Nutritionally Complete, Hydrolyzed Proteins (Amino Acids And Peptide Chain), Includes Fats, Carbohydrates, Vitamins And Minerals, May Include Fiber, Administered Through An Enteral Feeding Tube, 100 Calories = 1 Unit 0.164017

B4154 Enteral Formula, Nutritionally Complete, For Special Metabolic Needs, Excludes Inherited Disease Of Metabolism, Includes Altered Composition Of Proteins, Fats, Carbohydrates, Vitamins And/Or Minerals, May Include Fiber, Administered Through An Enteral Feeding Tube, 100 Calories = 1 Unit 0.104603

B4155 Enteral Formula, Nutritionally Incomplete/Modular Nutrients, Includes Specific Nutrients, Carbohydrates (E.G., Glucose Polymers), Proteins/Amino Acids (E.G., Glutamine, Arginine), Fat (E.G., Medium Chain Triglycerides) Or Combination, Administered Through An Enteral Feeding Tube, 100 Calories = 1 Unit 0.081172

B9002 Enteral Nutrition Infusion Pump, Any Type 105.155649 NU E0776BA IV Pole 8.744770 NUBA

March 2019 4


Round 2021

Hospital Beds


Ratio


E0260 Hospital Bed, Semi-Electric (Head And Foot Adjustment), With Any Type Side Rails, With Mattress RR


Ratio


E0250 Hospital Bed, Fixed Height, With Any Type Side Rails, With Mattress 0.661929 RR E0251 Hospital Bed, Fixed Height, With Any Type Side Rails, Without Mattress 0.507962 RR E0255 Hospital Bed, Variable Height, Hi-Lo, With Any Type Side Rails, With Mattress 0.804435 RR E0256 Hospital Bed, Variable Height, Hi-Lo, With Any Type Side Rails, Without Mattress 0.569504 RR E0261 Hospital Bed, Semi-Electric (Head And Foot Adjustment), With Any Type Side Rails, Without Mattress 0.924245 RR E0271 Mattress, Innerspring 1.511162 NU E0272 Mattress, Foam Rubber 1.392023 NU E0280 Bed Cradle, Any Type 0.263804 NU E0290 Hospital Bed, Fixed Height, Without Side Rails, With Mattress 0.500744 RR E0291 Hospital Bed, Fixed Height, Without Side Rails, Without Mattress 0.363521 RR E0292 Hospital Bed, Variable Height, Hi-Lo, Without Side Rails, With Mattress 0.572779 RR E0293 Hospital Bed, Variable Height, Hi-Lo, Without Side Rails, Without Mattress 0.485489 RR E0294 Hospital Bed, Semi-Electric (Head And Foot Adjustment), Without Side Rails, With Mattress 0.892469 RR E0295 Hospital Bed, Semi-Electric (Head And Foot Adjustment), Without Side Rails, Without Mattress 0.846703 RR

E0301 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, Without Mattress 1.882423 RR

E0302 Hospital Bed, Extra Heavy Duty, Extra Wide, With Weight Capacity Greater Than 600 Pounds, With Any Type Side Rails, Without Mattress 5.099568 RR

E0303 Hospital Bed, Heavy Duty, Extra Wide, With Weight Capacity Greater Than 350 Pounds, But Less Than Or Equal To 600 Pounds, With Any Type Side Rails, With Mattress 2.118396 RR

E0304 Hospital Bed, Extra Heavy Duty, Extra Wide, With Weight Capacity Greater Than 600 Pounds, With Any Type Side Rails, With Mattress 5.491740 RR

E0305 Bed Side Rails, Half Length 0.119586 RR E0310 Bed Side Rails, Full Length 1.329737 NU E0910 Trapeze Bars, A/K/A Patient Helper, Attached To Bed, With Grab Bar 0.136702 RR E0911 Trapeze Bar, Heavy Duty, For Patient Weight Capacity Greater Than 250 Pounds, Attached To Bed, With Grab Bar 0.356154 RR E0912 Trapeze Bar, Heavy Duty, For Patient Weight Capacity Greater Than 250 Pounds, Free Standing, Complete With Grab Bar 0.818053 RR E0940 Trapeze Bar, Free Standing, Complete With Grab Bar 0.236568 RR

March 2019 5


Round 2021

Nebulizers


Ratio


E0570 Nebulizer, With Compressor RR


Ratio


A7003 Administration Set, With Small Volume Nonfiltered Pneumatic Nebulizer, Disposable 0.164054 NU A7004 Small Volume Nonfiltered Pneumatic Nebulizer, Disposable 0.103583 NU A7005 Administration Set, With Small Volume Nonfiltered Pneumatic Nebulizer, Non-Disposable 1.790594 NU A7006 Administration Set, With Small Volume Filtered Pneumatic Nebulizer 0.588466 NU A7007 Large Volume Nebulizer, Disposable, Unfilled, Used With Aerosol Compressor 0.277156 NU A7010 Corrugated Tubing, Disposable, Used With Large Volume Nebulizer, 100 Feet 1.398656 NU A7012 Water Collection Device, Used With Large Volume Nebulizer 0.224524 NU A7013 Filter, Disposable, Used With Aerosol Compressor Or Ultrasonic Generator 0.048152 NU A7014 Filter, Nondisposable, Used With Aerosol Compressor Or Ultrasonic Generator 0.273796 NU A7015 Aerosol Mask, Used With DME Nebulizer 0.111422 NU A7017 Nebulizer, Durable, Glass Or Autoclavable Plastic, Bottle Type, Not Used With Oxygen 8.361142 NU A7018 Water, Distilled, Used With Large Volume Nebulizer, 1000 ml 0.022956 E0565 Compressor, Air Power Source For Equipment Which Is Not Self-Contained Or Cylinder Driven 3.559910 RR E0572 Aerosol Compressor, Adjustable Pressure, Light Duty For Intermittent Use 2.322508 RR E0585 Nebulizer, With Compressor And Heater 2.104143 RR E1372 Immersion External Heater For Nebulizer 9.556551 NU

March 2019 6


Round 2021

Negative Pressure Wound Therapy (NPWT) Pumps


Ratio


E2402 Negative Pressure Wound Therapy Electrical Pump, Stationary Or Portable RR


Ratio


A6550 Wound Care Set, For Negative Pressure Wound Therapy Electrical Pump, Includes All Supplies And Accessories 0.015986 A7000 Canister, Disposable, Used With Suction Pump, Each 0.005278 NU

March 2019 7


Round 2021

Non-Invasive Ventilators


Ratio


E0466 Home Ventilator, Any Type, Used With Non-Invasive Interface, (E.G., Mask, Chest Shell) RR


Ratio


March 2019 8


Round 2021

Off-The-Shelf Back Braces


Ratio


L0650

Lumbar-Sacral Orthosis, Sagittal-Coronal Control, With Rigid Anterior And Posterior Frame/Panel(S), Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Lateral Strength Provided By Rigid Lateral Frame/Panel(S), Produces Intracavitary Pressure To Reduce Load On Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf


Ratio


L0450 Tlso, Flexible, Provides Trunk Support, Upper Thoracic Region, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Disks With Rigid Stays Or Panel(S), Includes Shoulder Straps And Closures, Prefabricated, Off-The-Shelf 0.157249

L0455 Tlso, Flexible, Provides Trunk Support, Extends From Sacrococcygeal Junction To Above T-9 Vertebra, Restricts Gross Trunk Motion In The Sagittal Plane, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Disks With Rigid Stays Or Panel(S), Includes Shoulder Straps And Closures, Prefabricated, Off-The-Shelf 0.291917

L0457

Tlso, Flexible, Provides Trunk Support, Thoracic Region, Rigid Posterior Panel And Soft Anterior Apron, Extends From The Sacrococcygeal Junction And Terminates Just Inferior To The Scapular Spine, Restricts Gross Trunk Motion In The Sagittal Plane, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Disks, Includes Straps And Closures, Prefabricated, Off-The-Shelf 0.837131

L0467 Tlso, Sagittal Control, Rigid Posterior Frame And Flexible Soft Anterior Apron With Straps, Closures And Padding, Restricts Gross Trunk Motion In Sagittal Plane, Produces Intracavitary Pressure To Reduce Load On Intervertebral Disks, Prefabricated, Off-The-Shelf 0.327391

L0469

Tlso, Sagittal-Coronal Control, Rigid Posterior Frame And Flexible Soft Anterior Apron With Straps, Closures And Padding, Extends From Sacrococcygeal Junction Over Scapulae, Lateral Strength Provided By Pelvic, Thoracic, And Lateral Frame Pieces, Restricts Gross Trunk Motion In Sagittal And Coronal Planes, Produces Intracavitary Pressure To Reduce Load On Intervertebral Disks, Prefabricated, Off-The-Shelf 0.417156

L0621 Sacroiliac Orthosis, Flexible, Provides Pelvic-Sacral Support, Reduces Motion About The Sacroiliac Joint, Includes Straps, Closures, May Include Pendulous Abdomen Design, Prefabricated, Off-The-Shelf 0.082906

L0623 Sacroiliac Orthosis, Provides Pelvic-Sacral Support, With Rigid Or Semi-Rigid Panels Over The Sacrum And Abdomen, Reduces Motion About The Sacroiliac Joint, Includes Straps, Closures, May Include Pendulous Abdomen Design, Prefabricated, Off-The-Shelf 0.148609

L0625 Lumbar Orthosis, Flexible, Provides Lumbar Support, Posterior Extends From L-1 To Below L-5 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Pendulous Abdomen Design, Shoulder Straps, Stays, Prefabricated, Off-The-Shelf 0.046380

L0628 Lumbar-Sacral Orthosis, Flexible, Provides Lumbo-Sacral Support, Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Stays, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf 0.070622

L0641 Lumbar Orthosis, Sagittal Control, With Rigid Posterior Panel(S), Posterior Extends From L-1 To Below L-5 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Stays, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf 0.065620

L0642 Lumbar Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From L-1 To Below L-5 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf 0.346065

L0643 Lumbar-Sacral Orthosis, Sagittal Control, With Rigid Posterior Panel(S), Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Stays, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf 0.136339

L0648 Lumbar-Sacral Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf 0.864262

L0649

Lumbar-Sacral Orthosis, Sagittal-Coronal Control, With Rigid Posterior Frame/Panel(S), Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Lateral Strength Provided By Rigid Lateral Frame/Panels, Produces Intracavitary Pressure To Reduce Load On Intervertebral Discs, Includes Straps, Closures, May Include Padding, Stays, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf 0.241419

L0651

Lumbar-Sacral Orthosis, Sagittal-Coronal Control, Rigid Shell(S)/Panel(S), Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Anterior Extends From Symphysis Pubis To Xyphoid, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Overall Strength Is Provided By Overlapping Rigid Material And Stabilizing Closures, Includes Straps, Closures, May Include Soft Interface, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf 1.000000

March 2019 9


Round 2021

Off-The-Shelf Knee Braces


Ratio


L1833 Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The Shelf


Ratio


L1812 Knee Orthosis, Elastic With Joints, Prefabricated, Off-The-Shelf 0.154062 L1830 Knee Orthosis, Immobilizer, Canvas Longitudinal, Prefabricated, Off-The-Shelf 0.138816 L1836 Knee Orthosis, Rigid, Without Joint(S), Includes Soft Interface Material, Prefabricated, Off-The-Shelf 0.196289 L1850 Knee Orthosis, Swedish Type, Prefabricated, Off-The-Shelf 0.452098

L1851 Knee Orthosis (Ko), Single Upright, Thigh And Calf, With Adjustable Flexion And Extension Joint (Unicentric Or Polycentric), Medial-Lateral And Rotation Control, With Or Without Varus/Valgus Adjustment, Prefabricated, Off-The-Shelf 1.319920

L1852 Knee Orthosis (Ko), Double Upright, Thigh And Calf, With Adjustable Flexion And Extension Joint (Unicentric Or Polycentric), Medial-Lateral And Rotation Control, With Or Without Varus/Valgus Adjustment, Prefabricated, Off-The-Shelf 1.259182

March 2019 10


Round 2021

Oxygen and Oxygen Equipment


Ratio


E1390 Oxygen Concentrator, Single Delivery Port, Capable Of Delivering 85 Percent Or Greater Oxygen Concentration At The Prescribed Flow Rate RR


Ratio


E0424 Stationary Compressed Gaseous Oxygen System, Rental; Includes Container, Contents, Regulator, Flowmeter, Humidifier, Nebulizer, Cannula Or Mask, And Tubing 1.000000 RR

E0431 Portable Gaseous Oxygen System, Rental; Includes Portable Container, Regulator, Flowmeter, Humidifier, Cannula Or Mask, And Tubing 0.168141 RR

E0433 Portable Liquid Oxygen System, Rental; Home Liquefier Used To Fill Portable Liquid Oxygen Containers, Includes Portable Containers, Regulator, Flowmeter, Humidifier, Cannula Or Mask And Tubing, With Or Without Supply Reservoir And Contents Gauge 0.285375 RR

E0434 Portable Liquid Oxygen System, Rental; Includes Portable Container, Supply Reservoir, Humidifier, Flowmeter, Refill Adaptor, Contents Gauge, Cannula Or Mask, And Tubing 0.285375 RR

E0439 Stationary Liquid Oxygen System, Rental; Includes Container, Contents, Regulator, Flowmeter, Humidifier, Nebulizer, Cannula Or Mask, & Tubing 1.000000 RR

E0441 Stationary Oxygen Contents, Gaseous, 1 Month's Supply = 1 Unit 0.428090 E0442 Stationary Oxygen Contents, Liquid, 1 Month's Supply = 1 Unit 0.428090 E0443 Portable Oxygen Contents, Gaseous, 1 Month's Supply = 1 Unit 0.428090 E0444 Portable Oxygen Contents, Liquid, 1 Month's Supply = 1 Unit 0.428090

E0447 Portable Oxygen Contents, Liquid, 1 Month's Supply = 1 Unit, Prescribed Amount At Rest Or Nighttime Exceeds 4 Liters Per Minute (Lpm) 0.642162

E1391 Oxygen Concentrator, Dual Delivery Port, Capable Of Delivering 85 Percent Or Greater Oxygen Concentration At The Prescribed Flow Rate, Each 1.000000 RR

E1392 Portable Oxygen Concentrator, Rental 0.285375 RR

K0738 Portable Gaseous Oxygen System, Rental; Home Compressor Used To Fill Portable Oxygen Cylinders; Includes Portable Containers, Regulator, Flowmeter, Humidifier, Cannula Or Mask, And Tubing 0.285375 RR

March 2019 11


Round 2021

Patient Lifts and Seat Lifts


Ratio


E0630 Patient Lift, Hydraulic Or Mechanical, Includes Any Seat, Sling, Strap(S) Or Pad(S) RR


Ratio


E0621 Sling Or Seat, Patient Lift, Canvas Or Nylon 0.922935 NU E0627 Seat Lift Mechanism, Electric, Any Type 3.431232 NU E0629 Seat Lift Mechanism, Non-Electric, Any Type 3.380347 NU E0635 Patient Lift, Electric With Seat Or Sling 1.198285 RR

E0636 Multipositional Patient Support System, With Integrated Lift, Patient Accessible Controls 10.830844 RR

E1035 Multi-Positional Patient Transfer System, With Integrated Seat, Operated By Care Giver, Patient Weight Capacity Up To And Including 300 Lbs 6.297935 RR

E1036 Multi-Positional Patient Transfer System, Extra-Wide, With Integrated Seat, Operated By Caregiver, Patient Weight Capacity Greater Than 300 Lbs 8.829001 RR

March 2019 12


Round 2021

Standard Manual Wheelchairs


Ratio


K0001 Standard Wheelchair RR


Ratio


E0705 Transfer Device, Any Type, Each 1.025009 NU E0950 Wheelchair Accessory, Tray, Each 1.658622 NU E0951 Heel Loop/Holder, Any Type, With Or Without Ankle Strap, Each 0.321441 NU E0952 Toe Loop/Holder, Any Type, Each 0.313221 NU E0953 Wheelchair Accessory, Lateral Thigh Or Knee Support, Any Type Including Fixed Mounting Hardware, Each 1.655474 NU E0954 Wheelchair Accessory, Foot Box, Any Type, Includes Attachment And Mounting Hardware, Each Foot 1.040399 NU E0955 Wheelchair Accessory, Headrest, Cushioned, Any Type, Including Fixed Mounting Hardware, Each 3.395593 NU E0956 Wheelchair Accessory, Lateral Trunk Or Hip Support, Any Type, Including Fixed Mounting Hardware, Each 1.655474 NU E0957 Wheelchair Accessory, Medial Thigh Support, Any Type, Including Fixed Mounting Hardware, Each 2.316544 NU E0958 Manual Wheelchair Accessory, One-Arm Drive Attachment, Each 0.813221 RR E0959 Manual Wheelchair Accessory, Adapter For Amputee, Each 0.839279 NU E0960 Wheelchair Accessory, Shoulder Harness/Straps Or Chest Strap, Including Any Type Mounting Hardware 1.527982 NU E0961 Manual Wheelchair Accessory, Wheel Lock Brake Extension (Handle), Each 0.527807 NU E0966 Manual Wheelchair Accessory, Headrest Extension, Each 1.362015 NU E0967 Manual Wheelchair Accessory, Hand Rim With Projections, Any Type, Replacement Only, Each 1.274047 NU E0971 Manual Wheelchair Accessory, Anti-Tipping Device, Each 0.845226 NU E0973 Wheelchair Accessory, Adjustable Height, Detachable Armrest, Complete Assembly, Each 1.801679 NU E0974 Manual Wheelchair Accessory, Anti-Rollback Device, Each 1.399440 NU E0978 Wheelchair Accessory, Positioning Belt/Safety Belt/Pelvic Strap, Each 0.692025 NU E0981 Wheelchair Accessory, Seat Upholstery, Replacement Only, Each 0.775271 NU E0982 Wheelchair Accessory, Back Upholstery, Replacement Only, Each 0.822315 NU E0985 Wheelchair Accessory, Seat Lift Mechanism 3.952606 NU E0990 Wheelchair Accessory, Elevating Leg Rest, Complete Assembly, Each 1.912732 NU E0992 Manual Wheelchair Accessory, Solid Seat Insert 1.883351 NU E0995 Wheelchair Accessory, Calf Rest/Pad, Replacement Only, Each 0.507520 NU E1015 Shock Absorber For Manual Wheelchair, Each 2.235047 NU E1020 Residual Limb Support System For Wheelchair, Any Type 4.087793 NU

E1028 Wheelchair Accessory, Manual Swingaway, Retractable Or Removable Mounting Hardware For Joystick, Other Control Interface Or Positioning Accessory 3.468695 NU

E1031 Rollabout Chair, Any And All Types With Casters 5" Or Greater 0.923225 RR E1037 Transport Chair, Pediatric Size 2.113676 RR E1038 Transport Chair, Adult Size, Patient Weight Capacity Up To And Including 300 Pounds 0.351347 RR E1039 Transport Chair, Adult Size, Heavy Duty, Patient Weight Capacity Greater Than 300 Pounds 0.666142 RR E1225 Wheelchair Accessory, Manual Semi-Reclining Back, (Recline Greater Than 15 Degrees, But Less Than 80 Degrees), Each 0.829836 RR E1226 Wheelchair Accessory, Manual Fully Reclining Back, (Recline Greater Than 80 Degrees), Each 10.240644 NU E2201 Manual Wheelchair Accessory, Nonstandard Seat Frame, Width Greater Than Or Equal To 20 Inches And Less Than 24 Inches 7.269850 NU E2202 Manual Wheelchair Accessory, Nonstandard Seat Frame Width, 24-27 Inches 9.235222 NU E2203 Manual Wheelchair Accessory, Nonstandard Seat Frame Depth, 20 To Less Than 22 Inches 9.334383 NU E2204 Manual Wheelchair Accessory, Nonstandard Seat Frame Depth, 22 To 25 Inches 15.849073 NU

E2205 Manual Wheelchair Accessory, Handrim Without Projections (Includes Ergonomic Or Contoured), Any Type, Replacement Only, Each 0.633788 NU

E2206 Manual Wheelchair Accessory, Wheel Lock Assembly, Complete, Replacement Only, Each 0.789262 NU E2207 Wheelchair Accessory, Crutch And Cane Holder, Each 0.840853 NU E2208 Wheelchair Accessory, Cylinder Tank Carrier, Each 1.985834 NU E2209 Accessory, Arm Trough, With Or Without Hand Support, Each 1.791885 NU E2210 Wheelchair Accessory, Bearings, Any Type, Replacement Only, Each 0.109829 NU E2211 Manual Wheelchair Accessory, Pneumatic Propulsion Tire, Any Size, Each 0.809724 NU E2212 Manual Wheelchair Accessory, Tube For Pneumatic Propulsion Tire, Any Size, Each 0.114026 NU E2213 Manual Wheelchair Accessory, Insert For Pneumatic Propulsion Tire (Removable), Any Type, Any Size, Each 0.590066 NU E2214 Manual Wheelchair Accessory, Pneumatic Caster Tire, Any Size, Each 0.662819 NU E2215 Manual Wheelchair Accessory, Tube For Pneumatic Caster Tire, Any Size, Each 0.186079 NU E2216 Manual Wheelchair Accessory, Foam Filled Propulsion Tire, Any Size, Each 0.886360 NU E2217 Manual Wheelchair Accessory, Foam Filled Caster Tire, Any Size, Each 0.784016 NU E2218 Manual Wheelchair Accessory, Foam Propulsion Tire, Any Size, Each 0.886360 NU E2219 Manual Wheelchair Accessory, Foam Caster Tire, Any Size, Each 0.784190 NU E2220 Manual Wheelchair Accessory, Solid (Rubber/Plastic) Propulsion Tire, Any Size, Replacement Only, Each 0.529906 NU

March 2019 13


Ratio


E2221 Manual Wheelchair Accessory, Solid (Rubber/Plastic) Caster Tire (Removable), Any Size, Replacement Only, Each 0.495628 NU E2222 Manual Wheelchair Accessory, Solid (Rubber/Plastic) Caster Tire With Integrated Wheel, Any Size, Replacement Only, Each 0.410458 NU E2224 Manual Wheelchair Accessory, Propulsion Wheel Excludes Tire, Any Size, Replacement Only, Each 1.784190 NU E2225 Manual Wheelchair Accessory, Caster Wheel Excludes Tire, Any Size, Replacement Only, Each 0.339105 NU E2226 Manual Wheelchair Accessory, Caster Fork, Any Size, Replacement Only, Each 0.739419 NU E2228 Manual Wheelchair Accessory, Wheel Braking System And Lock, Complete, Each 18.242917 NU E2231 Manual Wheelchair Accessory, Solid Seat Support Base (Replaces Sling Seat), Includes Any Type Mounting Hardware 2.994229 NU E2601 General Use Wheelchair Seat Cushion, Width Less Than 22 Inches, Any Depth 1.026932 NU E2602 General Use Wheelchair Seat Cushion, Width 22 Inches Or Greater, Any Depth 2.005072 NU E2603 Skin Protection Wheelchair Seat Cushion, Width Less Than 22 Inches, Any Depth 2.545645 NU E2604 Skin Protection Wheelchair Seat Cushion, Width 22 Inches Or Greater, Any Depth 3.164218 NU E2605 Positioning Wheelchair Seat Cushion, Width Less Than 22 Inches, Any Depth 4.520462 NU E2606 Positioning Wheelchair Seat Cushion, Width 22 Inches Or Greater, Any Depth 7.052466 NU E2607 Skin Protection And Positioning Wheelchair Seat Cushion, Width Less Than 22 Inches, Any Depth 4.867786 NU E2608 Skin Protection And Positioning Wheelchair Seat Cushion, Width 22 Inches Or Greater, Any Depth 5.845750 NU E2611 General Use Wheelchair Back Cushion, Width Less Than 22 Inches, Any Height, Including Any Type Mounting Hardware 5.245715 NU E2612 General Use Wheelchair Back Cushion, Width 22 Inches Or Greater, Any Height, Including Any Type Mounting Hardware 7.096187 NU

E2613 Positioning Wheelchair Back Cushion, Posterior, Width Less Than 22 Inches, Any Height, Including Any Type Mounting Hardware 6.600735 NU

E2614 Positioning Wheelchair Back Cushion, Posterior, Width 22 Inches Or Greater, Any Height, Including Any Type Mounting Hardware 9.134837 NU

E2615 Positioning Wheelchair Back Cushion, Posterior-Lateral, Width Less Than 22 Inches, Any Height, Including Any Type Mounting Hardware 7.596013 NU

E2616 Positioning Wheelchair Back Cushion, Posterior-Lateral, Width 22 Inches Or Greater, Any Height, Including Any Type Mounting Hardware 10.220532 NU

E2619 Replacement Cover For Wheelchair Seat Cushion Or Back Cushion, Each 0.861840 NU

E2620 Positioning Wheelchair Back Cushion, Planar Back With Lateral Supports, Width Less Than 22 Inches, Any Height, Including Any Type Mounting Hardware 9.197971 NU

E2621 Positioning Wheelchair Back Cushion, Planar Back With Lateral Supports, Width 22 Inches Or Greater, Any Height, Including Any Type Mounting Hardware 9.652676 NU

E2626 Wheelchair Accessory, Shoulder Elbow, Mobile Arm Support Attached To Wheelchair, Balanced, Adjustable 11.972893 NU E2627 Wheelchair Accessory, Shoulder Elbow, Mobile Arm Support Attached To Wheelchair, Balanced, Adjustable Rancho Type 18.663344 NU E2628 Wheelchair Accessory, Shoulder Elbow, Mobile Arm Support Attached To Wheelchair, Balanced, Reclining 14.027107 NU

E2629 Wheelchair Accessory, Shoulder Elbow, Mobile Arm Support Attached To Wheelchair, Balanced, Friction Arm Support (Friction Dampening To Proximal And Distal Joints) 17.728052 NU

E2630 Wheelchair Accessory, Shoulder Elbow, Mobile Arm Support, Monosuspension Arm And Hand Support, Overhead Elbow Forearm Hand Sling Support, Yoke Type Suspension Support 12.460126 NU

E2631 Wheelchair Accessory, Addition To Mobile Arm Support, Elevating Proximal Arm 4.971319 NU E2632 Wheelchair Accessory, Addition To Mobile Arm Support, Offset Or Lateral Rocker Arm With Elastic Balance Control 3.151277 NU E2633 Wheelchair Accessory, Addition To Mobile Arm Support, Supinator 2.686429 NU K0002 Standard Hemi (Low Seat) Wheelchair 1.527282 RR K0003 Lightweight Wheelchair 1.679958 RR K0004 High Strength, Lightweight Wheelchair 2.496502 RR K0006 Heavy Duty Wheelchair 2.339279 RR K0007 Extra Heavy Duty Wheelchair 3.416754 RR K0015 Detachable, Non-Adjustable Height Armrest, Replacement Only, Each 3.037251 NU K0017 Detachable, Adjustable Height Armrest, Base, Replacement Only, Each 0.854495 NU K0018 Detachable, Adjustable Height Armrest, Upper Portion, Replacement Only, Each 0.477440 NU K0019 Arm Pad, Replacement Only, Each 0.289612 NU K0020 Fixed, Adjustable Height Armrest, Pair 0.776845 NU K0037 High Mount Flip-Up Footrest, Each 0.835432 NU K0038 Leg Strap, Each 0.405736 NU K0039 Leg Strap, H Style, Each 0.900839 NU K0040 Adjustable Angle Footplate, Each 1.248513 NU K0041 Large Size Footplate, Each 0.884925 NU K0042 Standard Size Footplate, Replacement Only, Each 0.578699 NU K0043 Footrest, Lower Extension Tube, Replacement Only, Each 0.326338 NU K0044 Footrest, Upper Hanger Bracket, Replacement Only, Each 0.278244 NU K0045 Footrest, Complete Assembly, Replacement Only, Each 0.992130 NU K0046 Elevating Legrest, Lower Extension Tube, Replacement Only, Each 0.326338 NU K0047 Elevating Legrest, Upper Hanger Bracket, Replacement Only, Each 1.278594 NU K0050 Ratchet Assembly, Replacement Only 0.543372 NU K0051 Cam Release Assembly, Footrest Or Legrest, Replacement Only, Each 0.879503 NU K0052 Swingaway, Detachable Footrests, Replacement Only, Each 1.545645 NU K0053 Elevating Footrests, Articulating (Telescoping), Each 1.705666 NU K0056 Seat Height Less Than 17" Or Equal To Or Greater Than 21" For A High Strength, Lightweight, Or Ultralightweight Wheelchair 1.844176 NU K0065 Spoke Protectors, Each 0.862364 NU K0069 Rear Wheel Assembly, Complete, With Solid Tire, Spokes Or Molded, Replacement Only, Each 1.937740 NU

March 2019 14


Ratio


K0070 Rear Wheel Assembly, Complete, With Pneumatic Tire, Spokes Or Molded, Replacement Only, Each 3.551941 NU K0071 Front Caster Assembly, Complete, With Pneumatic Tire, Replacement Only, Each 2.119272 NU K0072 Front Caster Assembly, Complete, With Semi-Pneumatic Tire, Replacement Only, Each 1.259182 NU K0073 Caster Pin Lock, Each 0.663694 NU K0077 Front Caster Assembly, Complete, With Solid Tire, Replacement Only, Each 1.141658 NU K0105 IV Hanger, Each 1.928821 NU K0195 Elevating Leg Rests, Pair (For Use With Capped Rental Wheelchair Base) 0.342952 RR

March 2019 15


Round 2021

Standard Power Mobility Devices


Ratio


K0823 Power Wheelchair, Group 2 Standard, Captains Chair, Patient Weight Capacity Up To And Including 300 Pounds RR


Ratio


E0705 Transfer Device, Any Type, Each 0.101312 NU E0950 Wheelchair Accessory, Tray, Each 0.163938 NU E0951 Heel Loop/Holder, Any Type, With Or Without Ankle Strap, Each 0.031771 NU E0952 Toe Loop/Holder, Any Type, Each 0.030959 NU E0953 Wheelchair Accessory, Lateral Thigh Or Knee Support, Any Type Including Fixed Mounting Hardware, Each 0.163627 NU E0954 Wheelchair Accessory, Foot Box, Any Type, Includes Attachment And Mounting Hardware, Each Foot 0.102833 NU E0955 Wheelchair Accessory, Headrest, Cushioned, Any Type, Including Fixed Mounting Hardware, Each 0.335621 NU E0956 Wheelchair Accessory, Lateral Trunk Or Hip Support, Any Type, Including Fixed Mounting Hardware, Each 0.163627 NU E0957 Wheelchair Accessory, Medial Thigh Support, Any Type, Including Fixed Mounting Hardware, Each 0.228968 NU E0960 Wheelchair Accessory, Shoulder Harness/Straps Or Chest Strap, Including Any Type Mounting Hardware 0.151026 NU E0973 Wheelchair Accessory, Adjustable Height, Detachable Armrest, Complete Assembly, Each 0.178078 NU E0978 Wheelchair Accessory, Positioning Belt/Safety Belt/Pelvic Strap, Each 0.068400 NU E0981 Wheelchair Accessory, Seat Upholstery, Replacement Only, Each 0.076628 NU E0982 Wheelchair Accessory, Back Upholstery, Replacement Only, Each 0.081278 NU E0985 Wheelchair Accessory, Seat Lift Mechanism 0.390676 NU E0990 Wheelchair Accessory, Elevating Leg Rest, Complete Assembly, Each 0.189055 NU E0992 Manual Wheelchair Accessory, Solid Seat Insert 0.186151 NU E0995 Wheelchair Accessory, Calf Rest/Pad, Replacement Only, Each 0.050163 NU E1016 Shock Absorber For Power Wheelchair, Each 0.217974 NU E1020 Residual Limb Support System For Wheelchair, Any Type 0.404038 NU

E1028 Wheelchair Accessory, Manual Swingaway, Retractable Or Removable Mounting Hardware For Joystick, Other Control Interface Or Positioning Accessory 0.342846 NU

E2207 Wheelchair Accessory, Crutch And Cane Holder, Each 0.083110 NU E2208 Wheelchair Accessory, Cylinder Tank Carrier, Each 0.196280 NU E2209 Accessory, Arm Trough, With Or Without Hand Support, Each 0.177110 NU E2210 Wheelchair Accessory, Bearings, Any Type, Replacement Only, Each 0.010855 NU E2359 Power Wheelchair Accessory, Group 34 Sealed Lead Acid Battery, Each (E.G., Gel Cell, Absorbed Glassmat) 0.328793 NU E2361 Power Wheelchair Accessory, 22NF Sealed Lead Acid Battery, Each, (E.G., Gel Cell, Absorbed Glassmat) 0.230420 NU E2363 Power Wheelchair Accessory, Group 24 Sealed Lead Acid Battery, Each (E.G., Gel Cell, Absorbed Glassmat) 0.307393 NU E2365 Power Wheelchair Accessory, U-1 Sealed Lead Acid Battery, Each (E.G., Gel Cell, Absorbed Glassmat) 0.185390 NU

E2366 Power Wheelchair Accessory, Battery Charger, Single Mode, For Use With Only One Battery Type, Sealed Or Non-Sealed, Each 0.409137 NU E2367 Power Wheelchair Accessory, Battery Charger, Dual Mode, For Use With Either Battery Type, Sealed Or Non-Sealed, Each 0.695615 NU E2368 Power Wheelchair Component, Drive Wheel Motor, Replacement Only 0.857461 NU E2369 Power Wheelchair Component, Drive Wheel Gear Box, Replacement Only 0.746850 NU E2370 Power Wheelchair Component, Integrated Drive Wheel Motor And Gear Box Combination, Replacement Only 1.332648 NU E2371 Power Wheelchair Accessory, Group 27 Sealed Lead Acid Battery, (E.G., Gel Cell, Absorbed Glassmat), Each 0.250212 NU

E2375 Power Wheelchair Accessory, Non-Expandable Controller, Including All Related Electronics And Mounting Hardware, Replacement Only 1.419146 NU

E2378 Power Wheelchair Component, Actuator, Replacement Only 0.098546 RR E2381 Power Wheelchair Accessory, Pneumatic Drive Wheel Tire, Any Size, Replacement Only, Each 0.125841 NU E2382 Power Wheelchair Accessory, Tube For Pneumatic Drive Wheel Tire, Any Size, Replacement Only, Each 0.034312 NU

E2383 Power Wheelchair Accessory, Insert For Pneumatic Drive Wheel Tire (Removable), Any Type, Any Size, Replacement Only, Each 0.250990 NU E2384 Power Wheelchair Accessory, Pneumatic Caster Tire, Any Size, Replacement Only, Each 0.133723 NU E2385 Power Wheelchair Accessory, Tube For Pneumatic Caster Tire, Any Size, Replacement Only, Each 0.082436 NU E2386 Power Wheelchair Accessory, Foam Filled Drive Wheel Tire, Any Size, Replacement Only, Each 0.248725 NU E2387 Power Wheelchair Accessory, Foam Filled Caster Tire, Any Size, Replacement Only, Each 0.109644 NU E2388 Power Wheelchair Accessory, Foam Drive Wheel Tire, Any Size, Replacement Only, Each 0.083456 NU E2389 Power Wheelchair Accessory, Foam Caster Tire, Any Size, Replacement Only, Each 0.045341 NU E2390 Power Wheelchair Accessory, Solid (Rubber/Plastic) Drive Wheel Tire, Any Size, Replacement Only, Each 0.070889 NU E2391 Power Wheelchair Accessory, Solid (Rubber/Plastic) Caster Tire (Removable), Any Size, Replacement Only, Each 0.033949 NU

E2392 Power Wheelchair Accessory, Solid (Rubber/Plastic) Caster Tire With Integrated Wheel, Any Size, Replacement Only, Each 0.089419 NU E2394 Power Wheelchair Accessory, Drive Wheel Excludes Tire, Any Size, Replacement Only, Each 0.127431 NU E2395 Power Wheelchair Accessory, Caster Wheel Excludes Tire, Any Size, Replacement Only, Each 0.090543 NU

March 2019 16

NR93

Cross-Out

NR93

Cross-Out

NR93

Cross-Out

NR93

Cross-Out

NR93

Text Box

Removed from Round 2021 on 7/1/19


Ratio


E2396 Power Wheelchair Accessory, Caster Fork, Any Size, Replacement Only, Each 0.110992 NU E2397 Power Wheelchair Accessory, Lithium-Based Battery, Each 0.797566 NU E2601 General Use Wheelchair Seat Cushion, Width Less Than 22 Inches, Any Depth 0.101502 NU E2602 General Use Wheelchair Seat Cushion, Width 22 Inches Or Greater, Any Depth 0.198182 NU E2603 Skin Protection Wheelchair Seat Cushion, Width Less Than 22 Inches, Any Depth 0.251612 NU E2604 Skin Protection Wheelchair Seat Cushion, Width 22 Inches Or Greater, Any Depth 0.312752 NU E2605 Positioning Wheelchair Seat Cushion, Width Less Than 22 Inches, Any Depth 0.446803 NU E2606 Positioning Wheelchair Seat Cushion, Width 22 Inches Or Greater, Any Depth 0.697067 NU E2607 Skin Protection And Positioning Wheelchair Seat Cushion, Width Less Than 22 Inches, Any Depth 0.481133 NU E2608 Skin Protection And Positioning Wheelchair Seat Cushion, Width 22 Inches Or Greater, Any Depth 0.577795 NU E2611 General Use Wheelchair Back Cushion, Width Less Than 22 Inches, Any Height, Including Any Type Mounting Hardware 0.518487 NU E2612 General Use Wheelchair Back Cushion, Width 22 Inches Or Greater, Any Height, Including Any Type Mounting Hardware 0.701388 NU

E2613 Positioning Wheelchair Back Cushion, Posterior, Width Less Than 22 Inches, Any Height, Including Any Type Mounting Hardware 0.652417 NU

E2614 Positioning Wheelchair Back Cushion, Posterior, Width 22 Inches Or Greater, Any Height, Including Any Type Mounting Hardware 0.902888 NU

E2615 Positioning Wheelchair Back Cushion, Posterior-Lateral, Width Less Than 22 Inches, Any Height, Including Any Type Mounting Hardware 0.750791 NU

E2616 Positioning Wheelchair Back Cushion, Posterior-Lateral, Width 22 Inches Or Greater, Any Height, Including Any Type Mounting Hardware 1.010199 NU

E2619 Replacement Cover For Wheelchair Seat Cushion Or Back Cushion, Each 0.085184 NU

E2620 Positioning Wheelchair Back Cushion, Planar Back With Lateral Supports, Width Less Than 22 Inches, Any Height, Including Any Type Mounting Hardware 0.909129 NU

E2621 Positioning Wheelchair Back Cushion, Planar Back With Lateral Supports, Width 22 Inches Or Greater, Any Height, Including Any Type Mounting Hardware 0.954072 NU

E2626 Wheelchair Accessory, Shoulder Elbow, Mobile Arm Support Attached To Wheelchair, Balanced, Adjustable 1.183402 NU E2627 Wheelchair Accessory, Shoulder Elbow, Mobile Arm Support Attached To Wheelchair, Balanced, Adjustable Rancho Type 1.844687 NU E2628 Wheelchair Accessory, Shoulder Elbow, Mobile Arm Support Attached To Wheelchair, Balanced, Reclining 1.386441 NU

E2629 Wheelchair Accessory, Shoulder Elbow, Mobile Arm Support Attached To Wheelchair, Balanced, Friction Arm Support (Friction Dampening To Proximal And Distal Joints) 1.752243 NU

E2630 Wheelchair Accessory, Shoulder Elbow, Mobile Arm Support, Monosuspension Arm And Hand Support, Overhead Elbow Forearm Hand Sling Support, Yoke Type Suspension Support 1.231560 NU

E2631 Wheelchair Accessory, Addition To Mobile Arm Support, Elevating Proximal Arm 0.491366 NU E2632 Wheelchair Accessory, Addition To Mobile Arm Support, Offset Or Lateral Rocker Arm With Elastic Balance Control 0.311473 NU E2633 Wheelchair Accessory, Addition To Mobile Arm Support, Supinator 0.265527 NU K0015 Detachable, Non-Adjustable Height Armrest, Replacement Only, Each 0.300202 NU K0017 Detachable, Adjustable Height Armrest, Base, Replacement Only, Each 0.084458 NU K0018 Detachable, Adjustable Height Armrest, Upper Portion, Replacement Only, Each 0.047190 NU K0019 Arm Pad, Replacement Only, Each 0.028625 NU K0020 Fixed, Adjustable Height Armrest, Pair 0.076783 NU K0037 High Mount Flip-Up Footrest, Each 0.082574 NU K0038 Leg Strap, Each 0.040103 NU K0039 Leg Strap, H Style, Each 0.089039 NU K0040 Adjustable Angle Footplate, Each 0.123403 NU K0041 Large Size Footplate, Each 0.087466 NU K0042 Standard Size Footplate, Replacement Only, Each 0.057199 NU K0043 Footrest, Lower Extension Tube, Replacement Only, Each 0.032255 NU K0044 Footrest, Upper Hanger Bracket, Replacement Only, Each 0.027502 NU K0045 Footrest, Complete Assembly, Replacement Only, Each 0.098062 NU K0046 Elevating Legrest, Lower Extension Tube, Replacement Only, Each 0.032255 NU K0047 Elevating Legrest, Upper Hanger Bracket, Replacement Only, Each 0.126376 NU K0050 Ratchet Assembly, Replacement Only 0.053707 NU K0051 Cam Release Assembly, Footrest Or Legrest, Replacement Only, Each 0.086930 NU K0052 Swingaway, Detachable Footrests, Replacement Only, Each 0.152772 NU K0053 Elevating Footrests, Articulating (Telescoping), Each 0.168588 NU

K0056 Seat Height Less Than 17" Or Equal To Or Greater Than 21" For A High Strength, Lightweight, Or Ultralightweight Wheelchair 0.182279 NU K0098 Drive Belt For Power Wheelchair, Replacement Only 0.044321 NU K0105 IV Hanger, Each 0.190645 NU K0195 Elevating Leg Rests, Pair (For Use With Capped Rental Wheelchair Base) 0.033897 RR K0733 Power Wheelchair Accessory, 12 To 24 Amp Hour Sealed Lead Acid Battery, Each (E.G., Gel Cell, Absorbed Glassmat) 0.050146 NU K0800 Power Operated Vehicle, Group 1 Standard, Patient Weight Capacity Up To And Including 300 Pounds 2.141847 NU K0801 Power Operated Vehicle, Group 1 Heavy Duty, Patient Weight Capacity 301 To 450 Pounds 3.453130 NU K0802 Power Operated Vehicle, Group 1 Very Heavy Duty, Patient Weight Capacity 451 To 600 Pounds 3.907849 NU

K0813 Power Wheelchair, Group 1 Standard, Portable, Sling/Solid Seat And Back, Patient Weight Capacity Up To And Including 300 Pounds 0.599523 RR

K0814 Power Wheelchair, Group 1 Standard, Portable, Captains Chair, Patient Weight Capacity Up To And Including 300 Pounds 0.767454 RR

K0815 Power Wheelchair, Group 1 Standard, Sling/Solid Seat And Back, Patient Weight Capacity Up To And Including 300 Pounds 0.873831 RR

March 2019 17

NR93

Cross-Out

NR93

Cross-Out

NR93

Cross-Out

NR93

Cross-Out

NR93

Text Box

Removed from Round 2021 on 7/1/19

Non-Lead Item

HCPCS Code Non-Lead Item HCPCS Code Description Relative Ratio


K0816 Power Wheelchair, Group 1 Standard, Captains Chair, Patient Weight Capacity Up To And Including 300 Pounds 0.836874 RR

K0820 Power Wheelchair, Group 2 Standard, Portable, Sling/Solid Seat/Back, Patient Weight Capacity Up To And Including 300 Pounds 0.640369 RR K0821 Power Wheelchair, Group 2 Standard, Portable, Captains Chair, Patient Weight Capacity Up To And Including 300 Pounds 0.822026 RR K0822 Power Wheelchair, Group 2 Standard, Sling/Solid Seat/Back, Patient Weight Capacity Up To And Including 300 Pounds 0.993466 RR K0824 Power Wheelchair, Group 2 Heavy Duty, Sling/Solid Seat/Back, Patient Weight Capacity 301 To 450 Pounds 1.203488 RR K0825 Power Wheelchair, Group 2 Heavy Duty, Captains Chair, Patient Weight Capacity 301 To 450 Pounds 1.101796 RR K0826 Power Wheelchair, Group 2 Very Heavy Duty, Sling/Solid Seat/Back, Patient Weight Capacity 451 To 600 Pounds 1.558106 RR K0827 Power Wheelchair, Group 2 Very Heavy Duty, Captains Chair, Patient Weight Capacity 451 To 600 Pounds 1.324817 RR K0828 Power Wheelchair, Group 2 Extra Heavy Duty, Sling/Solid Seat/Back, Patient Weight Capacity 601 Pounds Or More 1.716824 RR K0829 Power Wheelchair, Group 2 Extra Heavy Duty, Captains Chair, Patient Weight 601 Pounds Or More 1.576567 RR

March 2019 18


Round 2021

Support Surfaces (Groups 1 and 2)


Ratio


E0277 Powered Pressure-Reducing Air Mattress RR


Ratio


A4640 Replacement Pad For Use With Medically Necessary Alternating Pressure Pad Owned By Patient 0.099560 NU E0181 Powered Pressure Reducing Mattress Overlay/Pad, Alternating, With Pump, Includes Heavy Duty 0.043967 RR E0182 Pump For Alternating Pressure Pad, For Replacement Only 0.041374 RR E0184 Dry Pressure Mattress 0.301740 NU E0185 Gel Or Gel-Like Pressure Pad For Mattress, Standard Mattress Length And Width 0.504116 NU E0186 Air Pressure Mattress 0.033910 RR E0187 Water Pressure Mattress 0.038388 RR E0188 Synthetic Sheepskin Pad 0.042957 NU E0189 Lambswool Sheepskin Pad, Any Size 0.087030 NU E0193 Powered Air Flotation Bed (Low Air Loss Therapy) 1.277495 RR E0196 Gel Pressure Mattress 0.052215 RR E0197 Air Pressure Pad For Mattress, Standard Mattress Length And Width 0.352598 NU E0199 Dry Pressure Pad For Mattress, Standard Mattress Length And Width 0.055864 NU E0371 Nonpowered Advanced Pressure Reducing Overlay For Mattress, Standard Mattress Length And Width 0.628524 RR E0372 Powered Air Overlay For Mattress, Standard Mattress Length And Width 0.762673 RR E0373 Nonpowered Advanced Pressure Reducing Mattress 0.869757 RR

March 2019 19


Round 2021

Transcutaneous Electrical Nerve Stimulation (TENS) Devices


Ratio


A4595 Electrical Stimulator Supplies, 2 Lead, Per Month, (E.G., TENS, NMES)


Ratio


A4557 Lead Wires, (E.G., Apnea Monitor), Per Pair 0.676259 E0720 Transcutaneous Electrical Nerve Stimulation (TENS) Device, Two Lead, Localized Stimulation 12.162340 NU E0730 Transcutaneous Electrical Nerve Stimulation (TENS) Device, Four Or More Leads, For Multiple Nerve Stimulation 12.596184 NU

E0731 Form Fitting Conductive Garment For Delivery Of TENS Or NMES (With Conductive Fibers Separated From The Patient's Skin By Layers Of Fabric) 11.934939 NU

March 2019 20


Round 2021

Walkers


Ratio


E0143 Walker, Folding, Wheeled, Adjustable Or Fixed Height NU


Ratio


E0130 Walker, Rigid (Pickup), Adjustable Or Fixed Height 0.581699 NU E0135 Walker, Folding (Pickup), Adjustable Or Fixed Height 0.707046 NU E0140 Walker, With Trunk Support, Adjustable Or Fixed Height, Any Type 3.101262 NU E0141 Walker, Rigid, Wheeled, Adjustable Or Fixed Height 0.965977 NU E0148 Walker, Heavy Duty, Without Wheels, Rigid Or Folding, Any Type, Each 1.092488 NU E0149 Walker, Heavy Duty, Wheeled, Rigid Or Folding, Any Type 1.919062 NU E0154 Platform Attachment, Walker, Each 0.593339 NU E0155 Wheel Attachment, Rigid Pick-Up Walker, Per Pair 0.258752 NU E0156 Seat Attachment, Walker 0.232340 NU E0157 Crutch Attachment, Walker, Each 0.654311 NU E0158 Leg Extensions For Walker, Per Set Of Four (4) 0.265109 NU E0159 Brake Attachment For Wheeled Walker, Replacement, Each 0.153460 NU

March 2019 21

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