016.06.04 Ark. Code R. § 065 Prosthetics Provider Manual Update #60

• Library: Arkansas Administrative Code
• Edition: 2023
• Currency: Current through Register Vol. 48, No. 12, December, 2023
• Citation: 016.06.04 Ark. Code R. § 065
• Year: 2023

Section II Prosthetics

242.110 Respiratory and Diabetic Equipment All Ages Effective for dates of service on and after October 13, 2003 when billing either electronically or on paper, procedure codes found in this section must be billed with modifier EP for recipients under 21 years of age or modifier NU for recipients age 21 and over. When a second modifier is listed that modifier must be used in conjunction with either EP or NU. Additionally, when billing on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS "H" for individuals age 21 and over. Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed the information is indicated with a "Y" in the column, if not, an "N" is shown. 7 Procedure code became payable July 1, 2004. * Prior authorization is not required when another insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. Respiratory and Diabetic Equipment All Ages (section 242.110)

National Code	M1	M2	TOS	Description	PA	Capped Rental, Purchase or Rental Only
E0424	Stationary compressed gaseous oxygen system, rental includes container, contents, regulator, flowmeter, humidifier, nebulizer cannula or mask, and tubing	Y4	Rental Only
E0430	Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula or mask, and tubing	Y*	Rental Only
E0435	Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge cannula or mask, tubing and refill adapter	Y*	Rental Only
E0439	Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing	Y*	Rental Only
E0441	Oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned), one month's supply = I unit	Y	Purchase
E0442	Oxygen contents, liquid (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned), one month's supply = 1 unit	Y	Purchase

E0443	Portable oxygen contents, gaseous (for use only with portable gaseous systems when no stationary gas or liquid system is used), one month's supply=1 unit	Y*	Purchase
E0444	Portable oxygen contents, liquid (for use only with portable liquid systems when no stationary gas or liquid system is used), one month's supply=1 unit	Y*	Purchase
E04707	NU EP	01 a: a: a:	H 6	Respiratory assist device, bi-level pressure capacity , w/o backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)	Y Y	Rental Only
E04717	NU EP	RR RR	H 6	Respiratory assist device, bi-level press capacity, w/backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)	Y Y	Rental Only
E04727	NU EP	RR RR	H 6	Respiratory assist device, bi-level pressure capacity, w/backup rate feature, used with invasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)	Y Y	Rental Only
E0560	Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery	N	Purchase
E05617	NU EP	H 6	Humidifier, non-heated, used w/positive airway pressure device	Y Y	Purchase
E05627	NU EP	H 6	Humidifier, heated, used w/positive airway pressure device	Y Y	Purchase
E0570	Nebulizer, with compressor	Y*	Purchase
E0575	Nebulizer, ultrasonic, large volume	Y*	Capped Rental
E0600	Respiratory suction pump, home model, portable or stationary, electric	N	Rental Only
E1390	Oxygen concentrator, single delivery port, capable of delivering 85 % or greater oxygen concentration at the prescribed flow rate	Y*	Rental Only

E13917	NU	H	02 concentrator, dual delivery port, capable of delivering 85% or [GREATER THAN] 02 concentration at the prescribed flow rate, each	Y	Purchase
E13917	NU	I	02 concentrator, dual delivery port, 85% or [GREATER THAN] 02 concentration at the prescribed flow rate, each	Y	Purchase

Respiratory and Diabetic Equipment All Ages (section 242.110)

National Code	M1	M2	TOS	Local Code	Description	PA	Capped Rental, Purchase or Rental Only
E1340	NU	H	Z0425	Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes (DME Repair: Parts Only Repairs will not be approved for more than the allowed purchase price of new equipment.) (The manufacturer's invoice must be attached to the repair claim for all parts.)	N	Manually Priced
A99997	NU	H	Z0428	Misc. DME supply or accessory, not otherwise specified Unlisted Durable Medical Equipment. (The manufacturer's invoice must be attached to the claim form.)	Y	Manually Priced
E0779	NU	RR	Z1569	Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater (payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home).	Y*	Rental Only

A7034 NU

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