Durable Medical Equipment, Orthotics and Prosthetics Multiple Frequency Policy

Transcription

1 Policy Number REIMBURSEMENT POLICY Durable Medical Equipment, Orthotics and Prosthetics Multiple Frequency Policy 2015R0109C Annual Approval Date 7/8/2015 Approved By Payment Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT *), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider contracts, the enrollee s benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. UnitedHealthcare Community Plan uses a customized version of the Optum Claims Editing System known as ices Clearinghouse to process claims in accordance with UnitedHealthcare Community Plan reimbursement policies. *CPT is a registered trademark of the American Medical Association Proprietary information of UnitedHealthcare Community and State Copyright 2015 United HealthCare Services, Inc. Application This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid and Medicare products. This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a ) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Payment Policies for Medicare & Retirement and Employer & Individual please use this link. Medicare & Retirement Policies are listed under Medicare Advantage Reimbursement Policies.

2 Employer & Individual is listed under Reimbursement Policies-Commercial. Table of Contents Policy Overview Reimbursement Guidelines Rental or Purchase Modifiers Monthly Rental Daily Rental Rental to Purchase Maintenance and Service Fees HCPCS Codes A9900, A9901 and L9900 State Exceptions Definitions Questions and Answers Attachments Resources History Policy Overview This policy describes how UnitedHealthcare Community Plan reimburses for the rental and/or purchase of certain items of Durable Medical Equipment (DME), Prosthetics and Orthotics. The provisions of this policy apply to the Same Specialty Physicians and Other Health Care Professionals, which includes DME, Prosthetic and Orthotic vendors, renting or selling DME, Prosthetics or Orthotics. For purposes of this policy, Same Specialty Physician or Other Health Care Professional is defined as physicians and/or other health care professionals of the same group and same specialty reporting the same Federal Tax Identification number (TIN). Refer to the UnitedHealthcare Community Plan "Maximum Frequency per Day" policy for additional information pertaining to reimbursement for physician claims submitted with multiple units for the same CPT or HCPCS code on the same date of service. Reimbursement Guidelines Rental or Purchase Modifiers Some DME items are eligible for rental as well as for purchase. The codes representing these items are listed in Modifier Required Code in the Attachments section below and must be reported with the appropriate rental or purchase modifier in order to be considered for reimbursement. Rental guidelines are explained further in the sections titled Monthly Rental and Daily Rental.

3 Rental Modifiers (Medicaid)** The vendor must specify monthly rental of equipment using one or more of the following modifiers: RR Rental KH Initial Claim, purchase or first month rental KI Second or third monthly rental KJ Capped rental months four to fifteen KR Partial month LL Lease/rental (use the LL modifier when DME equipment rental is to be applied against the purchase price. Rental Modifiers (Medicare): RR Rental KH Initial Claim, purchase or first month rental KI Second or third monthly rental KJ Capped rental months four to fifteen KR Partial month Purchase Modifiers (Medicaid and Mecdicare)** The following modifiers indicate that an item has been purchased: NU New Equipment (use the NR modifier when DME which was new at the time of rental is subsequently purchased) UE Used Equipment NR New when rented KM Replacement of facial prosthesis including new impression/moulage KN Replacement of facial prosthesis using previous master model Other Allowable DME Modifiers MS Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty ** AZ has a State-specific list that is different from above. See Attachments section at end of policy for list. Monthly Rental Monthly Rental Monthly rental of DME, orthotics, or prosthetics identified by the applicable code with a rental modifier RR and/or modifiers KH, KI, KJ, KR, LL appended will be reimbursed once per Calendar Month to the Same Specialty Physician or Other Health Care Professional. A Calendar Month is the period of duration from a day of one month to the corresponding day of the next month (please see Definitions) and is determined based on the From date reported on the claim. If a code is submitted with modifier RR and/or modifiers KH, KI, KJ, KR, LL with units greater than 1, or multiple times during the same Calendar Month, UnitedHealthcare Community Plan will only reimburse one monthly rate per Calendar Month to the Same Specialty Physician or Other Health Care Professional except where noted below. Modifiers RT and LT An additional rental rate will be allowed in the same Calendar Month for codes with a rental modifier when both modifiers RT and LT are submitted for the same HCPCS code on separate lines. Modifiers RT and LT may be used to report an item for the right or left side of the body and convey that multiples of that item are being utilized. Backup Ventilator One additional rental rate will be allowed in the same Calendar Month for a backup ventilator reported with a rental modifier plus modifier TW (backup equipment), appended to HCPCS codes

4 E0450, E0460, E0461, E0463 or E0464. Codes with Extension/Flexion, Supination/Pronation, or Each in the Description Up to two rental rates will be allowed in the same Calendar Month for codes with "extension/flexion," "supination/pronation" or "each" in the description. These codes describe services where multiple devices may be reported. If these codes are reported with modifiers RT and LT and multiple units, UnitedHealthcare Community Plan will consider for separate reimbursement up to two units for each side for a total of up to four rental rates in the same Calendar Month. For additional information, refer to the Questions and Answers section, Q&A #4, and the Attachments section. Reporting Monthly Rental Monthly rental of DME, Orthotics, or Prosthetics should be reported on a 1500 Health Insurance Claim Form (a/k/a ) or its electronic equivalent or its successor form according to the National Uniform Billing Committee (NUBC) and the National Uniform Claim Committee (NUCC) guidelines. The appropriate HCPCS code and rental modifier are submitted with one unit for each Calendar Month time span. The rental initiation date is entered in the "From" field, and the end date in the "To" field. In the following example, the rental for HCPCS code E1130 (Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests), is initiated on 1/10/2013, and the item is rented for 3 months. The claim should be submitted as follows: Code Modifier Units From Date To Date E1130 RR 1 1/10/2013 2/9/2013 E1130 RR 1 2/10/2013 3/9/2013 E1130 RR 1 3/10/2013 4/9/2013 E1130-RR reported with 3 units, a From Date of 1/10/2013 and a To Date of 4/9/2013 on one line will result in reimbursement of only 1 unit. Daily Rental UnitedHealthcare Community Plan will allow a daily rental for the following items to the Same Specialty Physician or Other Health Care Professional. HCPCS codes E0935 (Continuous passive motion exercise device for use on knee only), and E0936 (Continuous passive motion exercise device for use other than knee) are reimbursed on a daily basis consistent with CMS guidelines. The following HCPCS codes are also reimbursed on a daily basis: E0193, Powered air flotation bed (low air loss therapy) E0194, Air fluidized bed E0277, Powered pressure-reducing air mattress E0304, Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress E0371, Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width E0372, Powered air overlay for mattress, standard mattress length and width E0373, Nonpowered advanced pressure reducing mattress E1639, Scale, each E2402, Negative pressure wound therapy electrical pump, stationary or portable

5 Rental to Purchase Rental fees from a single vendor are payable up to either the purchase price of an item or a maximum number of rental months, whichever is less. The maximum number of rental months for comparison to the purchase price varies according to the vendor s contract. Once the Rent-to-Purchase maximum (or Rental Cap) specified in the contract is reached, the item is considered purchased and is not reimbursable. Daily rental items may also be subject to rental limits, depending on the vendor s contract. These rental limits do not apply to oxygen equipment or to ventilators. The vendor is responsible for complying with all the terms of their contract with UnitedHealthcare Community Plan, including the provision that requires the vendor to stop billing for rental of items when the maximum rental amount for those items specified in their contract has been reached. Identification of whether the equipment was rented or purchased must be documented by the use of the applicable modifier referenced in the Rental or Purchase Modifiers section above. Maintenance and Service Fees The UnitedHealthcare Community Plan allows for reimbursement of maintenance and service once every six months to the Same Specialty Physician or Other Health Care Professional. The appropriate HCPCS code appended with modifier MS (maintenance/service fee) is required to identify such services. The Maintenance and Service modifier (MS) must be reported on a separate line in order to be considered for separate reimbursement from the rental or purchase of the equipment. Maintenance and Service includes the following: regular routine maintenance and performance checks as required to maintain the warranty or performance standards re-education compliance with alerts and recalls necessary supplies in accordance with the applicable agreement back-up equipment emergency availability and replacement equipment when out-of-service for repair. For the purposes of this policy, maintenance and servicing does not apply to Orthotics or Prosthetics. HCPCS Codes A9900, A9901 and L9900 Delivery, set-up and supplies are included in the payment rates associated with a DME, Orthotic, or Prosthetic item. They are not reimbursable services when submitted alone or with another service. Therefore, UnitedHealthcare Community Plan will not separately reimburse the following codes: A9900 (Miscellaneous DME supply, accessory, and/or service component of another HCPCS code) A9901 (DME delivery, set up, and/or dispensing service component of another HCPCS code) L9900 (Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code) State Exceptions Arizona Arizona has separately designated code and modifier lists. Arizona Medicaid is exempt from monthly rental limit due to State requirements. Kansas The State of Kansas allows an RR modifier for 1 month rental (when appropriate) on the following hearing aid codes: V5030, V5040, V5050, V5060, V5120, V5130, V5140, V5160, V5210, V5220, V5242, V5243, V5244, V5245, V5246, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255,

6 Michigan Ohio REIMBURSEMENT POLICY V5256, V5257, V5258, V5259, V5260, V5261, V5264, V5266. The State of Kansas allows code E0202 to be billed as daily rental. The State of Kansas allows ventilators to be reimbursed at a daily rate. The State of Kansas allows a monthly limit of 6 boxes of test strips (HCPC A4253) for insulin dependent diabetics and 2 box of test strips for non-insulin dependent diabetics. The State of Kansas reimburses code E0463 as a daily rental. Kansas uses a customized, state identified DME Modifier Required list Michigan excludes codes E0202, E0604, E0619, E2000, K0606, and S9001 from rental to purchase. Ohio does not require modifiers on all codes in the policy. The codes that are excluded can be found on the Ohio DME Modifier Bypass Texas For code A4253 Texas allows 2 units per month for insulin dependent diabetics and 1 unit per month for noninsulin dependent diabetics. For codes A4253 and A9275 Texas allows a combined total of 2 units per month for insulin dependent diabetics and a combined total of 1 unit per month for noninsulin dependent diabetics. Wisconsin Exempt from monthly rental limit due to State requirements. Definitions Calendar Month Durable Medical Equipment Orthotic Prosthetic Same Specialty Physician or Other Health Care Professional The period from a day of one month to the corresponding day of the next month. Medical equipment which: *Can withstand repeated use *Is not disposable *Is used to serve a medical purpose *Is generally not useful to a person in the absence of sickness or injury *Is appropriate for use in the home An external appliance such as a brace or splint that prevents or assists movement of the spine or limbs. A brace is used for the purpose of supporting a weak or deformed body part of a Customer or restricting or eliminating motion in a diseased or injured part of the body. A device that replaces all or part of an external body organ or all or part of the function of a permanently inoperative or malfunctioning external body organ. Physicians and/or other health care professionals of the same group and same specialty reporting the same Federal Tax Identification number. Questions and Answers 1 Q: Why is a rental month defined as a Calendar Month when months vary as to their number of days? A: The rationale for reimbursing rental once per Calendar Month rather than once per 30 day period is due to the fact that some months are less or greater than 30 days. Vendor billing trends indicate that rentals are reported on a cycle billing method; i.e., item dispensed on 1/9/13, and rented for 3 continuous months. Resulting bills will be submitted with 1/9/13 and 2/9/13 and 3/9/13 dates of

7 2 3 service. Q: How should monthly rental of DME items be reported? REIMBURSEMENT POLICY A: According to the National Uniform Billing Committee (NUBC) and the National Uniform Claim Committee (NUCC), monthly rental of an item should be reported on a single claim line with one unit and a single calendar month date span that is, for one month, enter the rental initiation date in the From field and the end date of that month s rental in the To field. Rental charges for multiple months should not be reported on the same line. If two claims are submitted that show From dates in the same month for the same item from the Same Specialty Physician or Other Health Care Professional, only one claim will be allowed and the second claim for the same month will not be covered. See the policy section titled Reporting Monthly Rental for an example of how to report more than one month s rental for the same item. Note that each line in the example has a From date in a different month. Q: Why does UnitedHealthcare Community Plan pay a full Calendar Month rental rate when modifier KR is used, which indicates the item is only rented for a partial Calendar Month? A: Regardless of whether the item is used for a full Calendar Month or only a few days within a Calendar Month, UnitedHealthcare's Community Plan contracted rental rates will be allowed once per Calendar Month to the same vendor. For example, E0202 (Phototherapy (bilirubin) light with photometer) is reported with modifier KR and 7 units to indicate the number of days it was used in a Calendar Month. Regardless of the number of days it is used within that Calendar Month, UnitedHealthcare Community Plan pays a single monthly rate to the same vendor and does not prorate the services to allow a daily rate. This is consistent with the terms of our participating agreements. The exceptions to the above are the items listed in the section titled Daily Rental. 4 Q: How should a vendor report a device that has been provided for extension and flexion on both sides of the body, e.g., code E1800 (Dynamic adjustable elbow extension/flexion device, includes soft interface material)? A: Because two devices were used on both sides of the body, it is appropriate to report this as E1800-RR-RT with two units for the right side, and E1800-RR-LT with two units for the left side. Attachments 2015A UnitedHealthcare Community Plan Codes with Each in Description 2015A UnitedHealthcare Community Plan Codes with Flexion, Extension, Pronation or Supination in Description 2015B UnitedHealthcare Community Plan MEDICAID DME Policy Modifier Required Code 2015A UnitedHealthcare Community Plan MEDICARE DME Policy Modifier Required Code A list of codes indicating that more than one device or service may be reported. A list of codes indicating that more than one device or service may be reported. of codes requiring a Rental or Purchase modifier for Medicaid of codes requiring a Rental or Purchase modifier for Medicare

8 2015A UnitedHealthcare Community Plan DME Policy Arizona Modifier Required Code 2015A UnitedHealthcare Community Plan DME Policy Arizona Modifier 2015A Ohio DME Modifier Bypass REIMBURSEMENT POLICY APIPA Specific list of codes requiring a Rental or Purchase modifier APIPA Specific list of acceptable modifiers indicating whether the item was rented or purchased of codes that do not require a rental or purchase modifier for Ohio Resources Individual state Medicaid regulations, manuals & fee schedules American Medical Association, Current Procedural Terminology ( CPT ) Professional Edition and associated publications and services Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets History 7/8/2015 Policy Approval Date Change: No new version 3/8/2015 Attachments Section: Items Eligible for Rental or Purchase list updated. 3/1/2015 Application Section: Removed reference to location of policy for MS CHIP 1/1/2015 Annual Version Change History Section: Entries prior to 1/1/13 archived 10/12/2014 Reimbursement Guidelines: Revised the description for the KJ modifier and updated Q&A #3 to #4 in the Codes with Extension/Flexion, Supination/Pronation, or Each in the Description section. 9/28/2014 Attachments Section: Codes with Flexion, Extension, Pronation or Supination in Description updated. 9/11/2014 Application Section: Updated State Exceptions Section Updated: Added exception for Michigan 9/5/2014 State Exceptions Section Updated: Added exception for Texas 8/4/2014 Application Section: Removed reference to location of policy for Florida Medicaid and Rhode Island Medicaid and added including, but not limited to verbiage. State Exceptions Section: Added Kansas exception regarding Modifier Required 5/25/2014 Question and Answer Section: Q&A #2 added. Attachments Section: UnitedHealthcare Community Plan Codes with Each in Description updated.

9 5/19/2014 State Exceptions Section: Added Kansas exception regarding code E0463 5/14/2014 Annual renewal of policy approved by National Reimbursement Forum REIMBURSEMENT POLICY 5/6/2014 Application Section: Added verbiage stating this policy applies to UnitedHealthcare Community Plan Medicaid and Medicare products Policy Change: UnitedHealthcare Community Plan Medicaid DME Policy Modifier Required Code updated. Attachments Section: Added UnitedHealthcare Community Plan Medicare DME Policy Modifier Required Code 4/1/2014 State Exceptions Section: Added Kansas Policy Verbiage Update: Rental to Purchase section updated 3/31/2014 Disclaimer: Revised Policy Verbiage Update: Rental or Purchase section updated with Medicare information History prior to 12/10/2012 archived 2/15/2014 Application and Overview Sections: Revised to expand policy application beyond contracted DMEOP vendors to all network and non-network providers. Reimbursement Guidelines: Revised language throughout for clarity, to remove restricted applicability to contracted vendors only and to capitalize defined terms Definitions: Removed Rental Month, Same Vendor. Added Same Specialty Physician or Other Health Care Professional. Q&A Section: Revised for clarity and to capitalize defined terms. 1/27/2014 Annual renewal of policy approved by United HealthCare Community & State Payment Policy Committee 1/1/2014 Annual Version Change. Attachments Section: Codes with Flexion, Extension, Pronation or Supination in Description and Arizona Modifier Required codes updated Policy Verbiage Changes: Sections in Reimbursement Guidelines reordered to show Monthly and Daily Rental separately. Rental or Purchase Modifiers section in Reimbursement Guidelines updated to refer to requirement that certain items be reported with a rental or purchase modifier. Definitions: Calendar Month added. Q&A Section: Q&A #1 revised. 9/20/2013 Rental vs. Purchase Modifier section updated to clarify MS modifier 7/7/2013 Policy Verbiage Changes: Sections in Reimbursement Guidelines reordered to show Monthly and Daily Rental separately. Definitions: Calendar Month added. Q&A Section: Q&A #1 revised. 6/22/2013 Policy verbiage update: State specific section updated, Ohio added Attachments update: OH DME Modifier Bypass added; Codes with Each in Description updated History prior to 5/16/2011 archived 5/8/2013 NRF annual renewal of policy approved. 1/13/2013 Policy Change: Codes with Each in Description updated. South Carolina exception removed 1/1/2013 Annual Policy Version Change Attachments Section: Codes with Flexion, Extension, Pronation or Supination in Description updated

10 3/15/2009 Policy implemented by UnitedHealthcare Community & State 2015A UnitedHealthcare Community Plan Codes with Each in Description E0111 E0958 E1016 E2216 E2358 E2387 K0018 K0051 E0113 E0959 E1017 E2217 E2359 E2388 K0019 K0052 E0116 E0961 E1018 E2218 E2361 E2389 K0037 K0053 E0117 E0967 E2205 E2219 E2363 E2390 K0038 K0065 E0153 E0971 E2206 E2220 E2365 E2391 K0039 K0069 E0154 E0973 E2207 E2221 E2371 E2392 K0040 K0070 E0157 E0974 E2209 E2222 E2381 E2394 K0041 K0071 E0159 E0990 E2211 E2224 E2382 E2395 K0042 K0072 E0175 E0994 E2212 E2225 E2383 E2396 K0043 K0073 E0951 E0995 E2213 E2226 E2384 E2619 K0044 K0077 E0952 E1009 E2214 E2227 E2385 K0015 K0046 L8032 E0957 E1015 E2215 E2228 E2386 K0017 K A UnitedHealthcare Community Plan Codes with Flexion, Extension, Pronation or Supination in Description E1800 E1806 E1815 E1825 K0901 L1845 L3900 L3901 L6624 E1801 E1810 E1816 E1830 K0902 L1846 L5859 L3925 L6645 E1802 E1811 E1818 E1831 L1843 L2624 L5973 L6621 L5961 E1805 E1812 E1820 E1840 L1844 L3730 L B UnitedHealthcare Community Plan DME Policy Modifier Required Code A4604 E0217 E0574 E0870 E1084 E1840 E2384 K0045 A4611 E0218 E0575 E0880 E1085 E1841 E2385 K0046 A4612 E0221 E0580 E0890 E1086 E2000 E2386 K0047 A4613 E0225 E0585 E0900 E1087 E2100 E2387 K0050 A4618 E0235 E0600 E0910 E1088 E2101 E2388 K0051 A4635 E0236 E0601 E0911 E1089 E2120 E2389 K0052 A4636 E0239 E0602 E0912 E1090 E2201 E2390 K0053 A4637 E0247 E0603 E0920 E1092 E2202 E2391 K0056 A4639 E0249 E0604 E0930 E1093 E2203 E2392 K0065 A4640 E0250 E0605 E0940 E1100 E2204 E2394 K0069 A7017 E0251 E0606 E0941 E1110 E2205 E2395 K0070 A7025 E0255 E0607 E0942 E1130 E2206 E2396 K0071 A7045 E0256 E0610 E0944 E1140 E2207 E2397 K0072 A8000 E0260 E0615 E0945 E1150 E2208 E2402 K0073 A8001 E0261 E0617 E0946 E1160 E2209 E2500 K0077 B9000 E0265 E0620 E0947 E1161 E2210 E2502 K0098

11 2015B UnitedHealthcare Community Plan DME Policy Modifier Required Code B9002 E0266 E0621 E0948 E1170 E2211 E2504 K0105 B9004 E0271 E0627 E0950 E1171 E2212 E2506 K0195 B9006 E0272 E0628 E0951 E1172 E2213 E2508 K0455 E0100 E0273 E0629 E0952 E1180 E2214 E2510 K0607 E0105 E0274 E0630 E0955 E1190 E2215 E2601 K0608 E0110 E0275 E0635 E0956 E1195 E2219 E2602 K0730 E0111 E0276 E0636 E0957 E1200 E2220 E2603 K0733 E0112 E0277 E0637 E0958 E1221 E2221 E2604 K0800 E0113 E0280 E0638 E0959 E1222 E2222 E2605 K0801 E0114 E0290 E0650 E0960 E1223 E2224 E2606 K0802 E0116 E0291 E0651 E0961 E1224 E2225 E2607 K0806 E0117 E0292 E0652 E0966 E1225 E2226 E2608 K0807 E0130 E0293 E0655 E0967 E1226 E2227 E2611 K0808 E0135 E0294 E0656 E0968 E1227 E2228 E2612 K0813 E0140 E0295 E0657 E0969 E1228 E2231 E2613 K0814 E0141 E0296 E0660 E0970 E1230 E2310 E2614 K0815 E0143 E0297 E0665 E0971 E1232 E2311 E2615 K0816 E0144 E0300 E0666 E0973 E1233 E2312 E2616 K0820 E0147 E0301 E0667 E0974 E1234 E2313 E2619 K0821 E0148 E0302 E0668 E0978 E1235 E2321 E2620 K0822 E0149 E0303 E0669 E0980 E1236 E2322 E2621 K0823 E0153 E0304 E0670 E0981 E1237 E2323 E2622 K0824 E0154 E0305 E0671 E0982 E1238 E2324 E2623 K0825 E0155 E0310 E0672 E0983 E1240 E2325 E2624 K0826 E0156 E0316 E0673 E0984 E1250 E2326 E2625 K0827 E0157 E0325 E0675 E0985 E1260 E2327 E2626 K0828 E0158 E0326 E0691 E0986 E1270 E2328 E2627 K0829 E0159 E0371 E0692 E0990 E1280 E2329 E2628 K0830 E0160 E0372 E0693 E0992 E1285 E2330 E2629 K0831 E0161 E0373 E0694 E0994 E1290 E2340 E2630 K0835 E0162 E0445 E0705 E0995 E1295 E2341 E2631 K0836 E0163 E0450 E0720 E1002 E1296 E2342 E2632 K0837 E0165 E0457 E0730 E1003 E1297 E2343 E2633 K0838 E0167 E0459 E0740 E1004 E1298 E2351 K0001 K0839 E0168 E0460 E0744 E1005 E1310 E2359 K0002 K0840 E0170 E0461 E0745 E1006 E1353 E2360 K0003 K0841 E0171 E0462 E0747 E1007 E1355 E2361 K0004 K0842 E0175 E0463 E0748 E1008 E1372 E2362 K0005 K0843 E0181 E0464 E0749 E1010 E1390 E2363 K0006 K0848 E0182 E0470 E0760 E1014 E1391 E2364 K0007 K0849 E0184 E0471 E0762 E1015 E1392 E2365 K0010 K0850 E0185 E0472 E0764 E1016 E1700 E2366 K0011 K0851

12 2015B UnitedHealthcare Community Plan DME Policy Modifier Required Code E0186 E0480 E0765 E1020 E1800 E2367 K0012 K0852 E0187 E0482 E0776 E1028 E1801 E2368 K0015 K0853 E0188 E0483 E0782 E1029 E1802 E2369 K0017 K0854 E0189 E0484 E0783 E1030 E1805 E2370 K0018 K0855 E0191 E0500 E0784 E1031 E1806 E2371 K0019 K0856 E0193 E0550 E0786 E1035 E1810 E2373 K0020 K0857 E0194 E0555 E0791 E1036 E1812 E2374 K0037 K0858 E0196 E0560 E0840 E1037 E1815 E2375 K0038 K0859 E0197 E0561 E0849 E1038 E1816 E2376 K0039 K0860 E0198 E0562 E0850 E1039 E1818 E2377 K0040 K0861 E0199 E0565 E0855 E1050 E1820 E2378 K0041 K0862 E0200 E0570 E0856 E1060 E1821 E2381 K0042 K0863 E0205 E0572 E0860 E1070 E1825 E2382 K0043 K0864 E0210 E1083 E1830 E2383 K0044 E A UnitedHealthcare Community Plan MEDICARE DME Policy Modifier Required Code A4604 E0200 E0550 E0776 E1014 E1310 E2340 E2625 K0822 A4611 E0205 E0555 E0782 E1015 E1353 E2341 E2626 K0823 A4612 E0210 E0560 E0783 E1016 E1355 E2342 E2627 K0824 A4613 E0215 E0561 E0784 E1020 E1372 E2343 E2628 K0825 A4618 E0217 E0562 E0786 E1028 E1390 E2351 E2629 K0826 A4635 E0218 E0565 E0791 E1029 E1391 E2359 E2630 K0827 A4636 E0221 E0570 E0840 E1030 E1392 E2360 E2631 K0828 A4637 E0225 E0572 E0849 E1031 E1700 E2361 E2632 K0829 A4640 E0235 E0574 E0850 E1035 E1800 E2362 E2633 K0830 A7017 E0236 E0575 E0855 E1036 E1801 E2363 K0001 K0831 A7045 E0239 E0580 E0856 E1037 E1802 E2364 K0002 K0835 A8000 E0247 E0585 E0860 E1038 E1805 E2365 K0003 K0836 A8001 E0249 E0600 E0870 E1039 E1806 E2366 K0004 K0837 B9000 E0250 E0601 E0880 E1050 E1810 E2367 K0005 K0838 B9002 E0251 E0602 E0890 E1060 E1812 E2368 K0006 K0839 B9004 E0255 E0603 E0900 E1070 E1815 E2369 K0007 K0840 B9006 E0256 E0604 E0910 E1083 E1816 E2370 K0010 K0841 E0100 E0260 E0605 E0911 E1084 E1818 E2371 K0011 K0842 E0105 E0261 E0606 E0912 E1085 E1820 E2373 K0012 K0843 E0110 E0265 E0607 E0920 E1086 E1821 E2374 K0015 K0848 E0111 E0266 E0610 E0930 E1087 E1825 E2375 K0017 K0849 E0112 E0271 E0615 E0940 E1088 E1830 E2376 K0018 K0850 E0113 E0272 E0617 E0941 E1089 E1840 E2377 K0019 K0851 E0114 E0273 E0620 E0942 E1090 E1841 E2378 K0020 K0852

13 2015A UnitedHealthcare Community Plan MEDICARE DME Policy Modifier Required Code E0116 E0274 E0621 E0944 E1092 E2000 E2381 K0037 K0853 E0117 E0275 E0627 E0945 E1093 E2100 E2382 K0038 K0854 E0130 E0276 E0628 E0946 E1100 E2101 E2383 K0039 K0855 E0135 E0277 E0629 E0947 E1110 E2120 E2384 K0040 K0856 E0140 E0280 E0630 E0948 E1130 E2201 E2385 K0041 K0857 E0141 E0290 E0635 E0950 E1140 E2202 E2386 K0042 K0858 E0143 E0291 E0636 E0951 E1150 E2203 E2387 K0043 K0859 E0144 E0292 E0637 E0952 E1160 E2204 E2388 K0044 K0860 E0147 E0293 E0638 E0955 E1161 E2205 E2389 K0045 K0861 E0148 E0294 E0650 E0956 E1170 E2206 E2390 K0046 K0862 E0149 E0295 E0651 E0957 E1171 E2207 E2391 K0047 K0863 E0153 E0296 E0652 E0958 E1172 E2208 E2392 K0050 K0864 E0154 E0297 E0655 E0959 E1180 E2209 E2394 K0051 E0155 E0300 E0656 E0960 E1190 E2210 E2395 K0052 E0156 E0301 E0657 E0961 E1195 E2211 E2396 K0053 E0157 E0302 E0660 E0966 E1200 E2212 E2397 K0056 E0158 E0303 E0665 E0967 E1221 E2213 E2402 K0065 E0159 E0304 E0666 E0968 E1222 E2214 E2500 K0069 E0160 E0305 E0667 E0969 E1223 E2215 E2502 K0070 E0161 E0310 E0668 E0970 E1224 E2219 E2504 K0071 E0162 E0316 E0669 E0971 E1225 E2220 E2506 K0072 E0163 E0325 E0670 E0973 E1226 E2221 E2508 K0073 E0165 E0326 E0671 E0974 E1227 E2222 E2510 K0077 E0167 E0371 E0672 E0978 E1228 E2224 E2601 K0098 E0168 E0372 E0673 E0980 E1230 E2225 E2602 K0105 E0170 E0373 E0675 E0981 E1232 E2226 E2603 K0195 E0171 E0445 E0691 E0982 E1233 E2227 E2604 K0455 E0175 E0450 E0692 E0983 E1234 E2228 E2605 K0607 E0181 E0457 E0693 E0984 E1235 E2231 E2606 K0608 E0182 E0459 E0694 E0985 E1236 E2310 E2607 K0730 E0184 E0460 E0705 E0986 E1237 E2311 E2608 K0733 E0185 E0461 E0720 E0990 E1238 E2312 E2611 K0800 E0186 E0462 E0730 E0992 E1240 E2313 E2612 K0801 E0187 E0463 E0740 E0994 E1250 E2321 E2613 K0802 E0188 E0464 E0744 E0995 E1260 E2322 E2614 K0806 E0189 E0470 E0745 E1002 E1270 E2323 E2615 K0807 E0191 E0471 E0747 E1003 E1280 E2324 E2616 K0808 E0193 E0472 E0748 E1004 E1285 E2325 E2619 K0813 E0194 E0480 E0749 E1005 E1290 E2326 E2620 K0814 E0196 E0482 E0760 E1006 E1295 E2327 E2621 K0815 E0197 E0483 E0762 E1007 E1296 E2328 E2622 K0816 E0198 E0484 E0764 E1008 E1297 E2329 E2623 K0820

14 2015A UnitedHealthcare Community Plan MEDICARE DME Policy Modifier Required Code E0199 E0500 E0765 E1010 E1298 E2330 E2624 K A UnitedHealthcare Community Plan DME Policy Arizona Modifier Required Code A4580 E0480 E1170 E2508 L0640 L2820 L5160 L6582 Q0490 A4590 E0481 E1171 E2510 L0700 L2830 L5200 L6584 Q0491 A4660 E0482 E1172 E2511 L0710 L2840 L5210 L6586 Q0492 A4663 E0483 E1180 E2512 L0810 L2850 L5220 L6588 Q0493 A4670 E0484 E1190 E2599 L0820 L2861 L5230 L6590 Q0494 A4671 E0485 E1195 E2601 L0830 L2999 L5250 L6600 Q0495 A4672 E0486 E1200 E2602 L0859 L3000 L5270 L6605 Q0496 A4673 E0487 E1220 E2603 L0861 L3001 L5280 L6610 Q0497 A4674 E0500 E1221 E2604 L0970 L3002 L5301 L6611 Q0498 A4680 E0550 E1222 E2605 L0972 L3003 L5311 L6615 Q0499 A4690 E0555 E1223 E2606 L0974 L3010 L5321 L6616 Q0500 A4706 E0560 E1224 E2607 L0976 L3020 L5331 L6620 Q0501 A4707 E0561 E1225 E2608 L0978 L3030 L5341 L6621 Q0502 A4708 E0562 E1226 E2609 L0980 L3031 L5400 L6623 Q0503 A5500 E0565 E1227 E2610 L0982 L3040 L5410 L6624 Q0504 A5501 E0570 E1228 E2611 L0984 L3050 L5420 L6625 Q0505 A5503 E0571 E1229 E2612 L0999 L3060 L5430 L6628 Q0506 A5504 E0572 E1230 E2613 L1000 L3070 L5450 L6629 Q0510 A5505 E0574 E1231 E2614 L1001 L3080 L5460 L6630 Q0511 A5506 E0575 E1232 E2615 L1005 L3090 L5500 L6632 Q0512 A5507 E0580 E1233 E2616 L1010 L3100 L5505 L6635 Q3001 A5508 E0585 E1234 E2617 L1020 L3140 L5510 L6637 S1040 A5510 E0600 E1235 E2619 L1025 L3150 L5520 L6638 S5035 A6530 E0601 E1236 E2620 L1030 L3160 L5530 L6639 S5036 A6531 E0602 E1237 E2621 L1040 L3170 L5535 L6640 S5160 A6532 E0603 E1238 E2622 L1050 L3201 L5540 L6641 S5161 A6533 E0604 E1239 E2623 L1060 L3202 L5560 L6642 S8262 A6534 E0605 E1240 E2624 L1070 L3203 L5570 L6645 S8270 A6535 E0606 E1250 E2625 L1080 L3204 L5580 L6646 S8420 A6536 E0607 E1260 E8000 L1085 L3206 L5585 L6647 S8421 A6537 E0610 E1270 E8001 L1090 L3207 L5590 L6648 S8422 A6538 E0615 E1280 E8002 L1100 L3208 L5595 L6650 S8423 A6539 E0616 E1285 K0001 L1110 L3209 L5600 L6655 S8424

15 2015A UnitedHealthcare Community Plan DME Policy Arizona Modifier Required Code A6540 E0617 E1290 K0002 L1120 L3211 L5610 L6660 S8425 A6541 E0618 E1295 K0003 L1200 L3212 L5611 L6665 S8426 A6544 E0619 E1296 K0004 L1210 L3213 L5613 L6670 S8427 A6545 E0620 E1297 K0005 L1220 L3214 L5614 L6672 S8428 A6549 E0621 E1298 K0006 L1230 L3215 L5616 L6675 S8429 A7025 E0625 E1300 K0007 L1240 L3216 L5617 L6676 S9001 A7026 E0627 E1310 K0009 L1250 L3217 L5618 L6677 S9007 A8000 E0628 E1340 K0010 L1260 L3219 L5620 L6680 T5001 A8001 E0629 E1353 K0011 L1270 L3221 L5622 L6682 T5999 A8002 E0630 E1354 K0012 L1280 L3222 L5624 L6684 V2020 A8003 E0635 E1355 K0014 L1290 L3224 L5626 L6686 V2025 A8004 E0636 E1356 K0015 L1300 L3225 L5628 L6687 V2100 A9280 E0637 E1357 K0017 L1310 L3230 L5629 L6688 V2101 A9281 E0638 E1358 K0018 L1499 L3250 L5630 L6689 V2102 A9284 E0639 E1372 K0019 L1500 L3251 L5631 L6690 V2103 A9300 E0640 E1390 K0020 L1510 L3252 L5632 L6691 V2104 A9999 E0641 E1391 K0037 L1520 L3253 L5634 L6692 V2105 B9000 E0642 E1392 K0038 L1600 L3254 L5636 L6693 V2106 B9002 E0650 E1399 K0039 L1610 L3255 L5637 L6694 V2107 B9004 E0651 E1405 K0040 L1620 L3257 L5638 L6695 V2108 B9006 E0652 E1406 K0041 L1630 L3260 L5639 L6696 V2109 E0100 E0655 E1500 K0042 L1640 L3265 L5640 L6697 V2110 E0105 E0656 E1510 K0043 L1650 L3300 L5642 L6698 V2111 E0110 E0657 E1520 K0044 L1652 L3310 L5643 L6703 V2112 E0111 E0660 E1530 K0045 L1660 L3320 L5644 L6704 V2113 E0112 E0665 E1540 K0046 L1680 L3330 L5645 L6706 V2114 E0113 E0666 E1550 K0047 L1685 L3332 L5646 L6707 V2115 E0114 E0667 E1560 K0050 L1686 L3334 L5647 L6708 V2118 E0116 E0668 E1570 K0051 L1690 L3340 L5648 L6709 V2121 E0117 E0669 E1575 K0052 L1700 L3350 L5649 L6711 V2199 E0118 E0671 E1580 K0053 L1710 L3360 L5650 L6712 V2200 E0130 E0672 E1590 K0056 L1720 L3370 L5651 L6713 V2201 E0135 E0673 E1592 K0065 L1730 L3380 L5652 L6714 V2202 E0140 E0675 E1594 K0069 L1755 L3390 L5653 L6721 V2203 E0141 E0676 E1600 K0070 L1800 L3400 L5654 L6722 V2204 E0143 E0691 E1610 K0071 L1810 L3410 L5655 L6805 V2205 E0144 E0692 E1615 K0072 L1815 L3420 L5656 L6810 V2206

16 2015A UnitedHealthcare Community Plan DME Policy Arizona Modifier Required Code E0147 E0693 E1620 K0073 L1820 L3430 L5658 L6881 V2207 E0148 E0694 E1625 K0077 L1825 L3440 L5661 L6882 V2208 E0149 E0700 E1630 K0098 L1830 L3450 L5665 L6883 V2209 E0153 E0705 E1632 K0105 L1831 L3455 L5666 L6884 V2210 E0154 E0710 E1634 K0108 L1832 L3460 L5668 L6885 V2211 E0155 E0720 E1635 K0195 L1834 L3465 L5670 L6890 V2212 E0156 E0730 E1636 K0606 L1836 L3470 L5671 L6895 V2213 E0157 E0731 E1637 K0607 L1840 L3480 L5672 L6900 V2214 E0158 E0740 E1639 K0608 L1843 L3485 L5673 L6905 V2215 E0159 E0744 E1699 K0609 L1844 L3500 L5676 L6910 V2218 E0160 E0745 E1700 K0669 L1845 L3510 L5677 L6915 V2219 E0161 E0746 E1701 K0672 L1846 L3520 L5678 L6920 V2220 E0162 E0747 E1702 K0730 L1847 L3530 L5679 L6925 V2221 E0163 E0748 E1800 K0733 L1850 L3540 L5680 L6930 V2299 E0165 E0749 E1801 K0738 L1860 L3550 L5681 L6935 V2300 E0167 E0755 E1802 K0800 L1900 L3560 L5682 L6940 V2301 E0168 E0760 E1805 K0801 L1901 L3570 L5683 L6945 V2302 E0170 E0761 E1806 K0802 L1902 L3580 L5684 L6950 V2303 E0171 E0762 E1810 K0806 L1904 L3590 L5685 L6955 V2304 E0172 E0764 E1811 K0807 L1906 L3595 L5686 L6960 V2305 E0175 E0765 E1812 K0808 L1907 L3600 L5688 L6965 V2306 E0181 E0769 E1815 K0812 L1910 L3610 L5690 L6970 V2307 E0182 E0770 E1816 K0813 L1920 L3620 L5692 L6975 V2308 E0184 E0776 E1818 K0814 L1930 L3630 L5694 L7007 V2309 E0185 E0779 E1820 K0815 L1932 L3640 L5695 L7008 V2310 E0186 E0780 E1821 K0816 L1940 L3649 L5696 L7009 V2311 E0187 E0781 E1825 K0820 L1945 L3650 L5697 L7040 V2312 E0188 E0782 E1830 K0821 L1950 L3651 L5698 L7045 V2313 E0189 E0783 E1831 K0822 L1951 L3652 L5699 L7170 V2314 E0190 E0784 E1840 K0823 L1960 L3670 L5700 L7180 V2315 E0191 E0785 E1841 K0824 L1970 L3671 L5701 L7181 V2318 E0193 E0786 E1902 K0825 L1971 L3674 L5702 L7185 V2319 E0194 E0791 E2000 K0826 L1980 L3677 L5703 L7186 V2320 E0196 E0830 E2100 K0827 L1990 L3700 L5704 L7190 V2321 E0197 E0840 E2101 K0828 L2000 L3701 L5705 L7191 V2399 E0198 E0849 E2120 K0829 L2005 L3702 L5706 L7260 V2410 E0199 E0850 E2201 K0830 L2010 L3710 L5707 L7261 V2430

17 2015A UnitedHealthcare Community Plan DME Policy Arizona Modifier Required Code E0200 E0855 E2202 K0831 L2020 L3720 L5710 L7266 V2499 E0202 E0856 E2203 K0835 L2030 L3730 L5711 L7272 V2500 E0203 E0860 E2204 K0836 L2034 L3740 L5712 L7274 V2501 E0205 E0870 E2205 K0837 L2035 L3760 L5714 L7360 V2502 E0210 E0880 E2206 K0838 L2036 L3762 L5716 L7362 V2503 E0215 E0890 E2207 K0839 L2037 L3763 L5718 L7364 V2510 E0217 E0900 E2208 K0840 L2038 L3764 L5722 L7366 V2511 E0218 E0910 E2209 K0841 L2040 L3765 L5724 L7400 V2512 E0221 E0911 E2210 K0842 L2050 L3766 L5726 L7401 V2513 E0225 E0912 E2211 K0843 L2060 L3806 L5728 L7402 V2520 E0231 E0920 E2212 K0848 L2070 L3807 L5780 L7403 V2521 E0232 E0930 E2213 K0849 L2080 L3808 L5781 L7404 V2522 E0235 E0935 E2214 K0850 L2090 L3891 L5782 L7405 V2523 E0236 E0936 E2215 K0851 L2106 L3900 L5785 L7499 V2530 E0238 E0940 E2216 K0852 L2108 L3901 L5790 L7500 V2531 E0239 E0941 E2217 K0853 L2112 L3904 L5795 L7510 V2599 E0240 E0942 E2218 K0854 L2114 L3905 L5810 L7520 V2600 E0241 E0944 E2219 K0855 L2116 L3906 L5811 L7600 V2610 E0242 E0945 E2220 K0856 L2126 L3908 L5812 L7900 V2615 E0243 E0946 E2221 K0857 L2128 L3909 L5814 L8000 V2623 E0244 E0947 E2222 K0858 L2132 L3911 L5816 L8001 V2624 E0245 E0948 E2223 K0859 L2134 L3912 L5818 L8002 V2625 E0246 E0950 E2224 K0860 L2136 L3913 L5822 L8010 V2626 E0247 E0951 E2225 K0861 L2180 L3915 L5824 L8015 V2627 E0248 E0952 E2226 K0862 L2182 L3917 L5826 L8020 V2628 E0249 E0955 E2227 K0863 L2184 L3919 L5828 L8030 V2629 E0250 E0956 E2228 K0864 L2186 L3921 L5830 L8031 V2630 E0251 E0957 E2230 K0868 L2188 L3923 L5840 L8032 V2631 E0255 E0958 E2231 K0869 L2190 L3925 L5845 L8035 V2632 E0256 E0959 E2291 K0870 L2192 L3927 L5848 L8039 V2700 E0260 E0960 E2292 K0871 L2200 L3929 L5850 L8040 V2702 E0261 E0961 E2293 K0877 L2210 L3931 L5855 L8041 V2710 E0265 E0966 E2294 K0878 L2220 L3933 L5856 L8042 V2715 E0266 E0967 E2295 K0879 L2230 L3935 L5857 L8043 V2718 E0270 E0968 E2300 K0880 L2232 L3956 L5858 L8044 V2730 E0271 E0969 E2301 K0884 L2240 L3960 L5910 L8045 V2744 E0272 E0970 E2310 K0885 L2250 L3961 L5920 L8046 V2745

18 2015A UnitedHealthcare Community Plan DME Policy Arizona Modifier Required Code E0273 E0971 E2311 K0886 L2260 L3962 L5925 L8047 V2750 E0274 E0973 E2312 K0890 L2265 L3964 L5930 L8048 V2755 E0275 E0974 E2313 K0891 L2270 L3965 L5940 L8049 V2756 E0276 E0978 E2321 K0898 L2275 L3966 L5950 L8300 V2760 E0277 E0980 E2322 K0899 L2280 L3967 L5960 L8310 V2761 E0280 E0981 E2323 L0112 L2300 L3968 L5961 L8320 V2762 E0290 E0982 E2324 L0113 L2310 L3969 L5962 L8330 V2770 E0291 E0983 E2325 L0120 L2320 L3970 L5964 L8400 V2780 E0292 E0984 E2326 L0130 L2330 L3971 L5966 L8410 V2781 E0293 E0985 E2327 L0140 L2335 L3972 L5968 L8415 V2782 E0294 E0986 E2328 L0150 L2340 L3973 L5970 L8417 V2783 E0295 E0990 E2329 L0160 L2350 L3974 L5971 L8420 V2784 E0296 E0992 E2330 L0170 L2360 L3975 L5972 L8430 V2786 E0297 E0994 E2331 L0172 L2370 L3976 L5973 L8435 V2797 E0300 E0995 E2340 L0174 L2375 L3977 L5974 L8440 V2799 E0301 E1002 E2341 L0180 L2380 L3978 L5975 L8460 V5030 E0302 E1003 E2342 L0190 L2385 L3980 L5976 L8465 V5040 E0303 E1004 E2343 L0200 L2387 L3982 L5978 L8470 V5050 E0304 E1005 E2351 L0210 L2390 L3984 L5979 L8480 V5060 E0305 E1006 E2360 L0220 L2395 L3995 L5980 L8485 V5070 E0310 E1007 E2361 L0430 L2397 L3999 L5981 L8499 V5080 E0315 E1008 E2362 L0450 L2405 L4000 L5982 L8500 V5095 E0316 E1009 E2363 L0452 L2415 L4002 L5984 L8501 V5100 E0325 E1010 E2364 L0454 L2425 L4010 L5985 L8505 V5120 E0326 E1011 E2365 L0456 L2430 L4020 L5986 L8507 V5130 E0328 E1014 E2366 L0458 L2492 L4030 L5987 L8509 V5140 E0329 E1015 E2367 L0460 L2500 L4040 L5988 L8510 V5150 E0350 E1016 E2368 L0462 L2510 L4045 L5990 L8511 V5170 E0352 E1017 E2369 L0464 L2520 L4050 L5999 L8512 V5180 E0370 E1018 E2370 L0466 L2525 L4055 L6000 L8513 V5190 E0371 E1020 E2371 L0468 L2526 L4060 L6010 L8514 V5210 E0372 E1028 E2372 L0470 L2530 L4070 L6020 L8515 V5220 E0373 E1029 E2373 L0472 L2540 L4080 L6025 L8600 V5230 E0424 E1030 E2374 L0480 L2550 L4090 L6050 L8609 V5242 E0425 E1031 E2375 L0482 L2570 L4100 L6055 L8610 V5243 E0430 E1035 E2376 L0484 L2580 L4110 L6100 L8612 V5244 E0431 E1036 E2377 L0486 L2600 L4130 L6110 L8613 V5245

19 2015A UnitedHealthcare Community Plan DME Policy Arizona Modifier Required Code E0433 E1037 E2381 L0488 L2610 L4205 L6120 L8614 V5246 E0434 E1038 E2382 L0490 L2620 L4210 L6130 L8615 V5247 E0435 E1039 E2383 L0491 L2622 L4350 L6200 L8616 V5248 E0439 E1050 E2384 L0492 L2624 L4360 L6205 L8617 V5249 E0440 E1060 E2385 L0621 L2627 L4370 L6250 L8618 V5250 E0441 E1070 E2386 L0622 L2628 L4380 L6300 L8619 V5251 E0442 E1083 E2387 L0623 L2630 L4386 L6310 L8691 V5252 E0443 E1084 E2388 L0624 L2640 L4392 L6320 L8692 V5253 E0444 E1085 E2389 L0625 L2650 L4394 L6350 L8693 V5254 E0445 E1086 E2390 L0626 L2660 L4396 L6360 L8695 V5255 E0446 E1087 E2391 L0627 L2670 L4398 L6370 L8699 V5256 E0450 E1088 E2392 L0628 L2680 L4631 L6380 L9900 V5257 E0455 E1089 E2393 L0629 L2750 L5000 L6382 Q0480 V5258 E0457 E1090 E2394 L0630 L2755 L5010 L6384 Q0481 V5259 E0459 E1092 E2395 L0631 L2760 L5020 L6386 Q0482 V5260 E0460 E1093 E2396 L0632 L2768 L5050 L6388 Q0483 V5261 E0461 E1100 E2397 L0633 L2770 L5060 L6400 Q0484 V5262 E0462 E1110 E2399 L0634 L2780 L5100 L6450 Q0485 V5263 E0463 E1130 E2402 L0635 L2785 L5105 L6500 Q0486 V5264 E0464 E1140 E2500 L0636 L2795 L5150 L6550 Q0487 V5265 E0470 E1150 E2502 L0637 L2800 L6570 Q0488 V5266 E0471 E1160 E2504 L0638 L2810 L6580 Q0489 V5267 E0472 E1161 E2506 L A UnitedHealthcare Community Plan DME Policy Arizona Modifier Modifier LL NR NU RA RB RR Description Lease/rental New when Rented New equipment Replacement of DME item Replacement of a part of DME DME Rental 2015A UnitedHealthcare Community Plan Ohio DME Modifier Bypass

20 E0193 E0424 E0439 E0463 E0500 E0791 E1391 E0194 E0431 E0450 E0471 E0604 E0935 E1392 E0202 E0434 E0460 E0472 E0781 E1390 K0738 REIMBURSEMENT POLICY