Attachment A: 2015 Jurisdiction List for DMEPOS HCPCS Codes
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1 A A0999 Ambulance Services Local Carrier A A4209 Medical, Surgical, and Self- Local Carrier if incident to a physician's Administered Injection Supplies A4210 Needle Free Injection Device DME MAC A4211 Medical, Surgical, and Self- Local Carrier if incident to a physician's Administered Injection Supplies A4212 Non Coring Needle or Stylet Local Carrier with or without Catheter A A4215 Medical, Surgical, and Self- Local Carrier if incident to a physician's Administered Injection Supplies A A4218 Saline Local Carrier if incident to a physician's A4220 Refill Kit for Implantable Pump Local Carrier A A4250 Medical, Surgical, and Self- Local Carrier if incident to a physician's Administered Injection Supplies A A4259 Diabetic Supplies DME MAC A4261 Cervical Cap for Contraceptive Local Carrier Use A A4263 Lacrimal Duct Implants Local Carrier A4264 Contraceptive Implant Local Carrier A4265 Paraffin Local Carrier if incident to a physician's A A4269 Contraceptives Local Carrier A4270 Endoscope Sheath Local Carrier A4280 Accessory for Breast Prosthesis DME MAC A A4286 Accessory for Breast Pump DME MAC A4290 Sacral Nerve Stimulation Test Lead Local Carrier A A4301 Implantable Catheter Local Carrier A A4306 Disposable Drug Delivery Local Carrier if incident to a physician's System 1
2 A A4358 Incontinence Supplies/ If provided in the physician's office for a Urinary Supplies temporary condition, the item is incident to the physician's service & billed to the Local Carrier. If provided in the physician's office or other place of service for a permanent condition, the item is a prosthetic device & billed to the A A4435 Urinary Supplies If provided in the physician's office for a temporary condition, the item is incident to the physician's service & billed to the Local Carrier. If provided in the physician's office or other place of service for a permanent condition, the item is a prosthetic device & billed to the A A4456 Tape; Adhesive Remover Local Carrier if incident to a physician's service (not separately payable), or if supply for implanted prosthetic device. If other, A4458-A4459 Enema Bag/System DME MAC A4461-A4463 Surgical Dressing Holders Local Carrier if incident to a physician's A A4466 Non-elastic Binder and Elastic Garment DME MAC A4470 Gravlee Jet Washer Local Carrier A4480 Vabra Aspirator Local Carrier A4481 Tracheostomy Supply Local Carrier if incident to a physician's A4483 Moisture Exchanger DME MAC A A4510 Surgical Stockings DME MAC A4520 Diapers DME MAC A4550 Surgical Trays Local Carrier A4554 Disposable Underpads DME MAC A A4558 Electrodes; Lead Wires; Con- Local Carrier if incident to a physician's ductive Paste A4559 Coupling Gel Local Carrier if incident to a physician's service 2
3 (not separately payable). If other, A A4562 Pessary Local Carrier A4565 Sling Local Carrier A4570 Splint Local Carrier A4575 Topical Hyperbaric Oxygen DME MAC Chamber, Disposable A A4590 Casting Supplies & Material Local Carrier A4595 TENS Supplies Local Carrier if incident to a physician's A4600 Sleeve for Intermittent Limb DME MAC Compression Device A4601-A4602 Lithium Replacement Batteries DME MAC A4604 Tubing for Positive Airway Pressure DME MAC Device A4605 Tracheal Suction Catheter DME MAC A4606 Oxygen Probe for Oximeter DME MAC A4608 Transtracheal Oxygen Catheter DME MAC A A4613 Oxygen Equipment Batteries and DME MAC Supplies A4614 Peak Flow Rate Meter Local Carrier if incident to a physician's A A4629 Oxygen & Tracheostomy Supplies Local Carrier if incident to a physician's A A4640 DME Supplies DME MAC A A4642 Imaging Agent; Contrast Material Local Carrier A4648 Tissue Marker, Implanted Local Carrier A4649 Miscellaneous Surgical Supplies Local Carrier if incident to a physician's service (not separately payable), or if supply for implanted prosthetic device or implanted DME. If other, A4650 Implantable Radiation Dosimeter Local Carrier A A4932 Supplies for ESRD DME MAC (not separately payable) A A5093 Additional Ostomy Supplies If provided in the physician's office for a temporary condition, the item is incident to the 3
4 physician's service & billed to the Local Carrier. If provided in the physician's office or other place of service for a permanent condition, the item is a prosthetic device & billed to the A A5200 Additional Incontinence and If provided in the physician's office for a Ostomy Supplies temporary condition, the item is incident to the physician's service & billed to the Local Carrier. If provided in the physician's office or other place of service for a permanent condition, the item is a prosthetic device & billed to the A A5513 Therapeutic Shoes DME MAC A6000 Non-Contact Wound Warming DME MAC Cover A6010-A6024 Surgical Dressing Local Carrier if incident to a physician's service (not separately payable) or if supply for implanted prosthetic device or implanted DME. If other, A6025 Silicone Gel Sheet Local Carrier if incident to a physician's service (not separately payable) or if supply for implanted prosthetic device or implanted DME. If other, A A6411 Surgical Dressing Local Carrier if incident to a physician's service (not separately payable) or if supply for implanted prosthetic device or implanted DME. If other, A6412 Eye Patch Local Carrier if incident to a physician's service (not separately payable) or if supply for implanted prosthetic device or implanted DME. If other, A6413 Adhesive Bandage Local Carrier if incident to a physician's service (not separately payable) or if supply for implanted prosthetic device or implanted DME. If other, A A6512 Surgical Dressings Local Carrier if incident to a physician's service (not separately payable), or if supply for implanted prosthetic device or implanted 4
5 DME. If other, A6513 Compression Burn Mask DME MAC A A6549 Compression Gradient Stockings DME MAC A6550 Supplies for Negative Pressure DME MAC Wound Therapy Electrical Pump A A7002 Accessories for Suction Pumps DME MAC A A7039 Accessories for Nebulizers, DME MAC Aspirators and Ventilators A A7041 Chest Drainage Supplies Local Carrier A A7047 Respiratory Accessories DME MAC A7048 Vacuum Drainage Supply Local Carrier A7501-A7527 Tracheostomy Supplies DME MAC A8000-A8004 Protective Helmets DME MAC A9150 Non-Prescription Drugs Local Carrier A A9153 Vitamins Local Carrier A9155 Artificial Saliva Local Carrier A9180 Lice Infestation Treatment Local Carrier A9270 Noncovered Items or Services DME MAC A9272 Disposable Wound Suction Pump DME MAC A9273 Hot Water Bottles, Ice Caps or Collars, and Heat and/or Cold Wraps DME MAC A A9278 Glucose Monitoring DME MAC A9279 Monitoring Feature/Device DME MAC A9280 Alarm Device DME MAC A9281 Reaching/Grabbing Device DME MAC A9282 Wig DME MAC A9283 Foot Off Loading Device DME MAC A9284 Non-electric Spirometer DME MAC A9300 Exercise Equipment DME MAC A A9700 Supplies for Radiology Procedures Local Carrier A9900 Miscellaneous DME Supply or Local Carrier if used with implanted DME. If Accessory other, A9901 Delivery DME MAC A9999 Miscellaneous DME Supply or Local Carrier if used with implanted DME. If Accessory other, B B9999 Enteral and Parenteral Therapy DME MAC D D9999 Dental Procedures Local Carrier 5
6 E E0105 Canes DME MAC E E0118 Crutches DME MAC E E0159 Walkers DME MAC E E0175 Commodes DME MAC E E0199 Decubitus Care Equipment DME MAC E E0239 Heat/Cold Applications DME MAC E E0248 Bath and Toilet Aids DME MAC E0249 Pad for Heating Unit DME MAC E E0304 Hospital Beds DME MAC E E0326 Hospital Bed Accessories DME MAC E E0329 Pediatric Hospital Beds DME MAC E E0352 Electronic Bowel Irrigation System DME MAC E0370 Heel Pad DME MAC E E0373 Decubitus Care Equipment DME MAC E E0484 Oxygen and Related Respiratory DME MAC Equipment E E0486 Oral Device to Reduce Airway DME MAC Collapsibility E0487 Electric Spirometer DME MAC E0500 IPPB Machine DME MAC E E0585 Compressors/Nebulizers DME MAC E0600 Suction Pump DME MAC E0601 CPAP Device DME MAC E E0604 Breast Pump DME MAC E0605 Vaporizer DME MAC E0606 Drainage Board DME MAC E0607 Home Blood Glucose Monitor DME MAC E E0615 Pacemaker Monitor DME MAC E0616 Implantable Cardiac Event Local Carrier Recorder E0617 External Defibrillator DME MAC E E0619 Apnea Monitor DME MAC E0620 Skin Piercing Device DME MAC E E0636 Patient Lifts DME MAC E E0642 Standing Devices/Lifts DME MAC E E0676 Pneumatic Compressor and DME MAC Appliances E E0694 Ultraviolet Light Therapy Systems DME MAC 6
7 E0700 Safety Equipment DME MAC E0705 Transfer Board DME MAC E0710 Restraints DME MAC E E0745 Electrical Nerve Stimulators DME MAC E0746 EMG Device Local Carrier E E0748 Osteogenic Stimulators DME MAC E0749 Implantable Osteogenic Stimulators Local Carrier E0755- E0770 Stimulation Devices DME MAC E0776 IV Pole DME MAC E E0780 External Infusion Pumps DME MAC E0781 Ambulatory Infusion Pump Billable to both the local carrier and the DME MAC. This item may be billed to the DME MAC whenever the infusion is initiated in the physician's office but the patient does not return during the same business day. E E0783 Infusion Pumps, Implantable Local Carrier E0784 Infusion Pumps, Insulin DME MAC E E0786 Implantable Infusion Pump Local Carrier Catheter E0791 Parenteral Infusion Pump DME MAC E0830 Ambulatory Traction Device DME MAC E E0900 Traction Equipment DME MAC E E0930 Trapeze/Fracture Frame DME MAC E E0936 Passive Motion Exercise Device DME MAC E0940 Trapeze Equipment DME MAC E0941 Traction Equipment DME MAC E E0945 Orthopedic Devices DME MAC E E0948 Fracture Frame DME MAC E E1298 Wheelchairs DME MAC E E1310 Whirlpool Equipment DME MAC E E1392 Additional Oxygen Related DME MAC Equipment E1399 Miscellaneous DME Local Carrier if implanted DME. If other, DME MAC. E E1406 Additional Oxygen Equipment DME MAC E E1699 Artificial Kidney Machines and DME MAC (not separately payable) Accessories E E1702 TMJ Device and Supplies DME MAC 7
8 E E1841 Dynamic Flexion Devices DME MAC E1902 Communication Board DME MAC E2000 Gastric Suction Pump DME MAC E E2101 Blood Glucose Monitors with DME MAC Special Features E2120 Pulse Generator for Tympanic Treatment of Inner Ear DME MAC E E2397 Wheelchair Accessories DME MAC E2402 Negative Pressure Wound DME MAC Therapy Pump E E2599 Speech Generating Device DME MAC E E2633 Wheelchair Cushions and Accessories DME MAC E E8002 Gait Trainers DME MAC G G0329 Misc. Professional Services Local Carrier G0333 Dispensing Fee DME MAC G G0365 Misc. Professional Services Local Carrier G0372 Misc. Professional Services Local Carrier G G9472 Misc. Professional Services Local Carrier J J3570 Injection Local Carrier if incident to a physician's service or used in an implanted infusion pump. If other, J3590 Unclassified Biologicals Local Carrier J J7131 Miscellaneous Drugs and Local Carrier if incident to a physician's Solutions service or used in an implanted infusion pump. If other, J7178 Fibrinogen Local Carrier J J7195 Antihemophilic Factor Local Carrier J J7197 Antithrombin III Local Carrier J7198 Anti-inhibitor; per I.U. Local Carrier J J7201 Other Hemophilia Clotting Factors Local Carrier J J7307 Contraceptives Local Carrier J J7309 Aminolevulinic Acid HCL Local Carrier J7310 Ganciclovir, Long-Acting Implant Local Carrier J J7316 Ophthalmic Drugs Local Carrier J J7327 Hyaluronan Local Carrier J7330 Autologous Cultured Chondrocytes, Local Carrier Implant J7336 Capsaicin Local Carrier 8
9 J J7599 Immunosuppressive Drugs Local Carrier if incident to a physician's service or used in an implanted infusion pump. If other, J J7699 Inhalation Solutions Local Carrier if incident to a physician's service. If other, J7799 NOC, Other than Inhalation Drugs Local carrier if incident to a physician's through DME service. If other, J8498 Anti-emetic Drug DME MAC J8499 Prescription Drug, Oral, Non Local carrier if incident to a physician's Chemotherapeutic service. If other, J J8999 Oral Anti-Cancer Drugs DME MAC J J9999 Chemotherapy Drugs Local Carrier if incident to a physician's service or used in an implanted infusion pump. If other, K K0108 Wheelchairs DME MAC K0195 Elevating Leg Rests DME MAC K0455 Infusion Pump used for DME MAC Uninterrupted Administration of Epoprostenal K0462 Loaner Equipment DME MAC K0552 External Infusion Pump Supplies DME MAC K K0605 External Infusion Pump Batteries DME MAC K K0609 Defibrillator Accessories DME MAC K0669 Wheelchair Cushion DME MAC K0672 Soft Interface for Orthosis DME MAC K0730 Inhalation Drug Delivery System DME MAC K0733 Power Wheelchair Accessory DME MAC K0738 Oxygen Equipment DME MAC Repair or Nonroutine Service for Local Carrier if implanted DME. If other, DME MAC K0739 DME K0740 Repair or Nonroutine Service for Oxygen Equipment DME MAC K K0746 Suction Pump and Dressings DME MAC K K0899 Power Mobility Devices DME MAC K0900 Custom DME, other than Wheelchair DME MAC K0901-K0902 Knee Orthoses DME MAC L L4631 Orthotics DME MAC L L5999 Lower Limb Prosthetics DME MAC 9
10 L L7499 Upper Limb Prosthetics DME MAC L L7520 Repair of Prosthetic Device Local Carrier if repair of implanted prosthetic device. If other, L7600 Prosthetic Donning Sleeve DME MAC L7900-L7902 Vacuum Erection System DME MAC L L8485 Prosthetics DME MAC L8499 Unlisted Procedure for Local Carrier if implanted prosthetic device. Miscellaneous Prosthetic Services If other, L L8501 Artificial Larynx; Tracheostomy DME MAC Speaking Valve L8505 Artificial Larynx Accessory DME MAC L8507 Voice Prosthesis, Patient Inserted DME MAC Local Carrier for dates of service on or after 10/01/2010. DME MAC for dates of service prior to 10/01/2010 Voice Prosthesis, Inserted by a L8509 Licensed Health Care Provider L8510 Voice Prosthesis DME MAC L L8515 Voice Prosthesis Local Carrier if used with tracheoesophageal voice prostheses inserted by a licensed health care provider. If other, DME MAC L L8699 Prosthetic Implants Local Carrier L9900 Miscellaneous Orthotic or Local Carrier if used with implanted prosthetic Prosthetic Component or device. If other, Accessory M M0301 Medical Services Local Carrier P P9615 Laboratory Tests Local Carrier Q0035 Influenza Vaccine; Cardio- Local Carrier kymography Q0081 Infusion Therapy Local Carrier Q Q0085 Chemotherapy Administration Local Carrier Q0091 Smear Preparation Local Carrier Q0092 Portable X-ray Setup Local Carrier Q Q0115 Miscellaneous Lab Services Local Carrier Q0138-Q0139 Ferumoxytol Injection Local Carrier Q0144 Azithromycin Dihydrate Local Carrier if incident to a physician's service. If other, Q Q0181 Anti-emetic DME MAC Q Q0509 Ventricular Assist Devices Local Carrier Q Q0514 Drug Dispensing Fees DME MAC Q0515 Sermorelin Acetate Local Carrier 10
11 Q Q1005 New Technology IOL Local Carrier Q2004 Irrigation Solution Local Carrier Q2009 Fosphenytoin Local Carrier Q2017 Teniposide Local Carrier Q2026-Q2028 Injectable Dermal Fillers Local Carrier Q Q2039 Influenza Vaccine Local Carrier Q2043 Sipuleucel-T Local Carrier Q2049-Q2050 Doxorubicin Local Carrier if incident to a physician's service or used in an implanted infusion pump. If other, Q3001 Supplies for Radiology Procedures Local Carrier Q3014 Telehealth Originating Site Local Carrier Facility Fee Q Q3028 Vaccines Local Carrier Q3031 Collagen Skin Test Local Carrier Q Q4051 Splints and Casts Local Carrier Q4074 Inhalation Drug Local Carrier if incident to a physician's service. If other, Q4081 Epoetin Local Carrier Q4082 Drug Subject to Competitive Local Carrier Acquisition Program Q Q4160 Skin Substitutes Local Carrier Q Q5010 Hospice Services Local Carrier Q Q9954 Imaging Agents Local Carrier Q Q9957 Microspheres Local Carrier Q Q9969 Imaging Agents Local Carrier R R0076 Diagnostic Radiology Services Local Carrier V V2025 Frames DME MAC V V2513 Lenses DME MAC V V2523 Hydrophilic Contact Lenses Local Carrier if incident to a physician's service. If other, V V2531 Contact Lenses, Scleral DME MAC V2599 Contact Lens, Other Type Local Carrier if incident to a physician's service. If other, V V2615 Low Vision Aids DME MAC V V2629 Prosthetic Eyes DME MAC 11
12 V V2632 Intraocular Lenses Local Carrier V V2780 Miscellaneous Vision Service DME MAC V2781 Progressive Lens DME MAC V V2784 Lenses DME MAC V2785 Processing--Corneal Tissue Local Carrier V2786 Lens DME MAC V V2788 Intraocular Lenses Local Carrier V2790 Amniotic Membrane Local Carrier V2797 Vision Supply DME MAC V2799 Miscellaneous Vision Service DME MAC V V5299 Hearing Services Local Carrier V5336 Repair/Modification of DME MAC Augmentative Communicative System or Device V V5364 Speech Screening Local Carrier 12
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