016.06.05 Ark. Code R. 015 - Ventilator Update #50

242.100 Ventilator Equipment and Supplies Procedure Codes

The following procedure codes must be used to bill for ventilator equipment and supplies:

Procedure Code	Modifier(s)	Description	PA Req'd	Max. Units	Capped Rental, Purchase or Rental Only
A4483	Nasal Prosthesis	No	N/A	Purchase
E02501	Hospital bed, fixed height, with any type side rails, with mattress	Yes*	1 per day (1 day = 1 unit)	Capped Rental
E02551	Hospital bed, variable height, hi-lo, with any type side rails, with mattress	Yes*	1 per day (1 day = 1 unit)	Capped Rental
E02601	Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress	Yes*	1 per day (1 day = 1 unit)	Capped Rental
E04241	Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator flowmeter, humidifier, nebulizer, cannula or mask, and tubing	Yes*	1 per day (1 day = 1 unit)	Rental Only
E04301	Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing	Yes*	1 per day (1 day = 1 unit)	Rental Only
E04351	Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing, and refill adapter	Yes*	1 per day (1 day = 1 unit)	Rental Only
E04391	Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing	Yes*	1 per day (1 day = 1 unit)	Rental Only

E0450	Positive Pressure Ventilator and Accessories (New Equipment) - Includes circuits, humidifier, low-pressure alarm, back-up emergency power, resuscitator bag, emergency call, 24 hours/day, 7 day/week availability and in-service training (used with invasive interface, e.g., tracheostomy tube)	Yes	1 per day (1 day = 1 unit)	Rental Only
E04501	UB	Positive Pressure Ventilator Supplies -Includes suction catheter kits, trach kits, trach tubes, sterile water and all respiratory care supplies (used with invasive interface, e.g., tracheostomy tube)	Yes	1 per day (1 day = 1 unit)	Purchase
E0450	UE	Positive Pressure Ventilator and Accessories (Used Equipment) - Includes circuits, humidifier, low pressure alarm, backup emergency power, resuscitator bag, emergency call, 24 hours/day, 7 day/week availability and in-service training (used with invasive interface, e.g., tracheostomy tube)	Yes	1 per day (1 day = 1 unit)	Rental Only
E0500	IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source	Yes	1 per day	Rental Only
E05701	Nebulizer, with compressor	Yes*	1 per day (1 day = 1 unit)	Purchase Only
E06001	Respiratory suction pump, home model, portable or stationary, electric	No	1 per day (1 day = 1 unit)	Rental Only

E06001	U1	Suction pump, home model, portable (Used Equipment)	Yes	1 per day (1 day = 1 unit)	Rental Only
E1390	Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate	Yes*	1 per day	Rental Only
G02372	EP, UA	Respiratory therapy services for ventilator-dependent patients	Yes	Frequency of visits as prescribed	N/A
G02382	EP, UA

1 Code may only be billed for a ventilator patient in his or her home. The code is not covered for a ventilator patient in a nursing facility.

2 Bill only for type of service (TOS) 6.

* Prior authorization is not required when another insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.

Notes

016.06.05 Ark. Code R. 015

6/6/2005