Product Categories and HCPCS Codes - (DMEPOS) Competitive Bidding ...
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Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS) Competitive Bidding Program • Round 2021
Product Categories and HCPCS Codes
Commode Chairs 2
Continuous Positive Airway Pressure (CPAP) Devices
3
and Related Accessories (RADs)
Enteral Nutrition 4
Hospital Beds 5
Nebulizers 6
Negative Pressure Wound Therapy (NPWT) Pumps 7
Non-Invasive Ventilators 8
Off-The-Shelf Back Braces 9
Off-The-Shelf Knee Braces 10
Oxygen and Oxygen Equipment 11
Patient Lifts and Seat Lifts 12
Standard Manual Wheelchairs 13
Standard Power Mobility Devices 16
Support Surfaces (Groups 1 and 2) 19
Transcutaneous Electrical Nerve Stimulation (TENS) Devices 20
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).DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Commode Chairs
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
E0163 Commode Chair, Mobile Or Stationary, With Fixed Arms NU
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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 2DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Continuous Positive Airway Pressure (CPAP) Devices and Respiratory Assist Devices (RADs)
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
E0601 Continuous Positive Airway Pressure (CPAP) Device RR
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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
Respiratory Assist Device, Bi-Level Pressure Capability, Without Backup Rate Feature, Used With Noninvasive Interface, E.G.,
E0470 2.264289 RR
Nasal Or Facial Mask (Intermittent Assist Device With Continuous Positive Airway Pressure Device)
Respiratory Assist Device, Bi-Level Pressure Capability, With Back-Up Rate Feature, Used With Noninvasive Interface, E.G., Nasal
E0471 5.659990 RR
Or Facial Mask (Intermittent Assist Device With Continuous Positive Airway Pressure Device)
Respiratory Assist Device, Bi-Level Pressure Capability, With Backup Rate Feature, Used With Invasive Interface, E.G.,
E0472 5.659990 RR
Tracheostomy Tube (Intermittent Assist Device With Continuous Positive Airway Pressure Device)
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 3DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Enteral Nutrition
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
Enteral Feeding Supply Kit; Pump Fed, Per Day, Includes But Not Limited To Feeding/Flushing Syringe, Administration Set Tubing,
B4035
Dressings, Tape
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
Enteral Feeding Supply Kit; Syringe Fed, Per Day, Includes But Not Limited To Feeding/Flushing Syringe, Administration Set Tubing,
B4034 0.523849
Dressings, Tape
Enteral Feeding Supply Kit; Gravity Fed, Per Day, Includes But Not Limited To Feeding/Flushing Syringe, Administration Set Tubing,
B4036 0.686192
Dressings, Tape
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
Enteral Formula, Manufactured Blenderized Natural Foods With Intact Nutrients, Includes Proteins, Fats, Carbohydrates, Vitamins
B4149 0.134728
And Minerals, May Include Fiber, Administered Through An Enteral Feeding Tube, 100 Calories = 1 Unit
Enteral Formula, Nutritionally Complete With Intact Nutrients, Includes Proteins, Fats, Carbohydrates, Vitamins And Minerals, May
B4150 0.058577
Include Fiber, Administered Through An Enteral Feeding Tube, 100 Calories = 1 Unit
Enteral Formula, Nutritionally Complete, Calorically Dense (Equal To Or Greater Than 1.5 kcal/ml) With Intact Nutrients, Includes
B4152 Proteins, Fats, Carbohydrates, Vitamins And Minerals, May Include Fiber, Administered Through An Enteral Feeding Tube, 100
Calories = 1 Unit 0.047699
Enteral Formula, Nutritionally Complete, Hydrolyzed Proteins (Amino Acids And Peptide Chain), Includes Fats, Carbohydrates,
B4153
Vitamins And Minerals, May Include Fiber, Administered Through An Enteral Feeding Tube, 100 Calories = 1 Unit 0.164017
Enteral Formula, Nutritionally Complete, For Special Metabolic Needs, Excludes Inherited Disease Of Metabolism, Includes Altered
B4154 Composition Of Proteins, Fats, Carbohydrates, Vitamins And/Or Minerals, May Include Fiber, Administered Through An Enteral
Feeding Tube, 100 Calories = 1 Unit 0.104603
Enteral Formula, Nutritionally Incomplete/Modular Nutrients, Includes Specific Nutrients, Carbohydrates (E.G., Glucose Polymers),
B4155 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 4DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Hospital Beds
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
E0260 Hospital Bed, Semi-Electric (Head And Foot Adjustment), With Any Type Side Rails, With Mattress RR
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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
Hospital Bed, Heavy Duty, Extra Wide, With Weight Capacity Greater Than 350 Pounds, But Less Than Or Equal To 600 Pounds,
E0301 1.882423 RR
With Any Type Side Rails, Without Mattress
Hospital Bed, Extra Heavy Duty, Extra Wide, With Weight Capacity Greater Than 600 Pounds, With Any Type Side Rails, Without
E0302 5.099568 RR
Mattress
Hospital Bed, Heavy Duty, Extra Wide, With Weight Capacity Greater Than 350 Pounds, But Less Than Or Equal To 600 Pounds,
E0303 2.118396 RR
With Any Type Side Rails, With Mattress
Hospital Bed, Extra Heavy Duty, Extra Wide, With Weight Capacity Greater Than 600 Pounds, With Any Type Side Rails, With
E0304 5.491740 RR
Mattress
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 5DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Nebulizers
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
E0570 Nebulizer, With Compressor RR
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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 6DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Negative Pressure Wound Therapy (NPWT) Pumps
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
E2402 Negative Pressure Wound Therapy Electrical Pump, Stationary Or Portable RR
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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 7DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Non-Invasive Ventilators
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
E0466 Home Ventilator, Any Type, Used With Non-Invasive Interface, (E.G., Mask, Chest Shell) RR
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
March 2019 8DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Off-The-Shelf Back Braces
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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
L0650
Pressure To Reduce Load On Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous
Abdomen Design, Prefabricated, Off-The-Shelf
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
Tlso, Flexible, Provides Trunk Support, Upper Thoracic Region, Produces Intracavitary Pressure To Reduce Load On The
L0450 0.157249
Intervertebral Disks With Rigid Stays Or Panel(S), Includes Shoulder Straps And Closures, Prefabricated, Off-The-Shelf
Tlso, Flexible, Provides Trunk Support, Extends From Sacrococcygeal Junction To Above T-9 Vertebra, Restricts Gross Trunk
L0455 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
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,
L0457
Produces Intracavitary Pressure To Reduce Load On The Intervertebral Disks, Includes Straps And Closures, Prefabricated, Off-
The-Shelf 0.837131
Tlso, Sagittal Control, Rigid Posterior Frame And Flexible Soft Anterior Apron With Straps, Closures And Padding, Restricts Gross
L0467 Trunk Motion In Sagittal Plane, Produces Intracavitary Pressure To Reduce Load On Intervertebral Disks, Prefabricated, Off-The-
Shelf 0.327391
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
L0469
Gross Trunk Motion In Sagittal And Coronal Planes, Produces Intracavitary Pressure To Reduce Load On Intervertebral Disks,
Prefabricated, Off-The-Shelf 0.417156
Sacroiliac Orthosis, Flexible, Provides Pelvic-Sacral Support, Reduces Motion About The Sacroiliac Joint, Includes Straps,
L0621 0.082906
Closures, May Include Pendulous Abdomen Design, Prefabricated, Off-The-Shelf
Sacroiliac Orthosis, Provides Pelvic-Sacral Support, With Rigid Or Semi-Rigid Panels Over The Sacrum And Abdomen, Reduces
L0623 Motion About The Sacroiliac Joint, Includes Straps, Closures, May Include Pendulous Abdomen Design, Prefabricated, Off-The-
Shelf 0.148609
Lumbar Orthosis, Flexible, Provides Lumbar Support, Posterior Extends From L-1 To Below L-5 Vertebra, Produces Intracavitary
L0625 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
Lumbar-Sacral Orthosis, Flexible, Provides Lumbo-Sacral Support, Posterior Extends From Sacrococcygeal Junction To T-9
L0628 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
Lumbar Orthosis, Sagittal Control, With Rigid Posterior Panel(S), Posterior Extends From L-1 To Below L-5 Vertebra, Produces
L0641 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
Lumbar Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From L-1 To Below L-5 Vertebra,
L0642 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
Lumbar-Sacral Orthosis, Sagittal Control, With Rigid Posterior Panel(S), Posterior Extends From Sacrococcygeal Junction To T-9
L0643 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
Lumbar-Sacral Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From Sacrococcygeal
L0648 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
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
L0649
Load On Intervertebral Discs, Includes Straps, Closures, May Include Padding, Stays, Shoulder Straps, Pendulous Abdomen
Design, Prefabricated, Off-The-Shelf 0.241419
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
L0651
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 9DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Off-The-Shelf Knee Braces
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
L1833 Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The Shelf
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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
Knee Orthosis (Ko), Single Upright, Thigh And Calf, With Adjustable Flexion And Extension Joint (Unicentric Or Polycentric), Medial-
L1851 1.319920
Lateral And Rotation Control, With Or Without Varus/Valgus Adjustment, Prefabricated, Off-The-Shelf
Knee Orthosis (Ko), Double Upright, Thigh And Calf, With Adjustable Flexion And Extension Joint (Unicentric Or Polycentric), Medial-
L1852 1.259182
Lateral And Rotation Control, With Or Without Varus/Valgus Adjustment, Prefabricated, Off-The-Shelf
March 2019 10DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Oxygen and Oxygen Equipment
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
Oxygen Concentrator, Single Delivery Port, Capable Of Delivering 85 Percent Or Greater Oxygen Concentration At The Prescribed
E1390 RR
Flow Rate
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
Stationary Compressed Gaseous Oxygen System, Rental; Includes Container, Contents, Regulator, Flowmeter, Humidifier,
E0424 1.000000 RR
Nebulizer, Cannula Or Mask, And Tubing
Portable Gaseous Oxygen System, Rental; Includes Portable Container, Regulator, Flowmeter, Humidifier, Cannula Or Mask, And
E0431 0.168141 RR
Tubing
Portable Liquid Oxygen System, Rental; Home Liquefier Used To Fill Portable Liquid Oxygen Containers, Includes Portable
E0433 Containers, Regulator, Flowmeter, Humidifier, Cannula Or Mask And Tubing, With Or Without Supply Reservoir And Contents
Gauge 0.285375 RR
Portable Liquid Oxygen System, Rental; Includes Portable Container, Supply Reservoir, Humidifier, Flowmeter, Refill Adaptor,
E0434 0.285375 RR
Contents Gauge, Cannula Or Mask, And Tubing
Stationary Liquid Oxygen System, Rental; Includes Container, Contents, Regulator, Flowmeter, Humidifier, Nebulizer, Cannula Or
E0439 1.000000 RR
Mask, & Tubing
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
Portable Oxygen Contents, Liquid, 1 Month's Supply = 1 Unit, Prescribed Amount At Rest Or Nighttime Exceeds 4 Liters Per Minute
E0447 0.642162
(Lpm)
Oxygen Concentrator, Dual Delivery Port, Capable Of Delivering 85 Percent Or Greater Oxygen Concentration At The Prescribed
E1391 1.000000 RR
Flow Rate, Each
E1392 Portable Oxygen Concentrator, Rental 0.285375 RR
Portable Gaseous Oxygen System, Rental; Home Compressor Used To Fill Portable Oxygen Cylinders; Includes Portable
K0738 0.285375 RR
Containers, Regulator, Flowmeter, Humidifier, Cannula Or Mask, And Tubing
March 2019 11DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Patient Lifts and Seat Lifts
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
E0630 Patient Lift, Hydraulic Or Mechanical, Includes Any Seat, Sling, Strap(S) Or Pad(S) RR
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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
Multi-Positional Patient Transfer System, With Integrated Seat, Operated By Care Giver, Patient Weight Capacity Up To And
E1035 6.297935 RR
Including 300 Lbs
Multi-Positional Patient Transfer System, Extra-Wide, With Integrated Seat, Operated By Caregiver, Patient Weight Capacity
E1036 8.829001 RR
Greater Than 300 Lbs
March 2019 12DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Standard Manual Wheelchairs
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
K0001 Standard Wheelchair RR
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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
Wheelchair Accessory, Manual Swingaway, Retractable Or Removable Mounting Hardware For Joystick, Other Control Interface Or
E1028 3.468695 NU
Positioning Accessory
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
Manual Wheelchair Accessory, Handrim Without Projections (Includes Ergonomic Or Contoured), Any Type, Replacement Only,
E2205 0.633788 NU
Each
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 13Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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
Positioning Wheelchair Back Cushion, Posterior-Lateral, Width Less Than 22 Inches, Any Height, Including Any Type Mounting
E2615 7.596013 NU
Hardware
Positioning Wheelchair Back Cushion, Posterior-Lateral, Width 22 Inches Or Greater, Any Height, Including Any Type Mounting
E2616 10.220532 NU
Hardware
E2619 Replacement Cover For Wheelchair Seat Cushion Or Back Cushion, Each 0.861840 NU
Positioning Wheelchair Back Cushion, Planar Back With Lateral Supports, Width Less Than 22 Inches, Any Height, Including Any
E2620 9.197971 NU
Type Mounting Hardware
Positioning Wheelchair Back Cushion, Planar Back With Lateral Supports, Width 22 Inches Or Greater, Any Height, Including Any
E2621 9.652676 NU
Type Mounting Hardware
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
Wheelchair Accessory, Shoulder Elbow, Mobile Arm Support Attached To Wheelchair, Balanced, Friction Arm Support (Friction
E2629 17.728052 NU
Dampening To Proximal And Distal Joints)
Wheelchair Accessory, Shoulder Elbow, Mobile Arm Support, Monosuspension Arm And Hand Support, Overhead Elbow Forearm
E2630 12.460126 NU
Hand Sling Support, Yoke Type Suspension Support
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 14Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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 15DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Standard Power Mobility Devices
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
K0823 Power Wheelchair, Group 2 Standard, Captains Chair, Patient Weight Capacity Up To And Including 300 Pounds RR
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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 Removed from Round 2021 on 7/1/19 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
Wheelchair Accessory, Manual Swingaway, Retractable Or Removable Mounting Hardware For Joystick, Other Control Interface Or
E1028 0.342846 NU
Positioning Accessory
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
Power Wheelchair Accessory, Non-Expandable Controller, Including All Related Electronics And Mounting Hardware, Replacement
E2375 1.419146 NU
Only
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 16Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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
Positioning Wheelchair Back Cushion, Posterior-Lateral, Width Less Than 22 Inches, Any Height, Including Any Type Mounting
E2615 0.750791 NU
Hardware
Positioning Wheelchair Back Cushion, Posterior-Lateral, Width 22 Inches Or Greater, Any Height, Including Any Type Mounting
E2616 1.010199 NU
Hardware
E2619 Replacement Cover For Wheelchair Seat Cushion Or Back Cushion, Each 0.085184 NU
Positioning Wheelchair Back Cushion, Planar Back With Lateral Supports, Width Less Than 22 Inches, Any Height, Including Any
E2620 0.909129 NU
Type Mounting Hardware
Positioning Wheelchair Back Cushion, Planar Back With Lateral Supports, Width 22 Inches Or Greater, Any Height, Including Any
E2621 0.954072 NU
Type Mounting Hardware
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
Wheelchair Accessory, Shoulder Elbow, Mobile Arm Support Attached To Wheelchair, Balanced, Friction Arm Support (Friction
E2629 1.752243 NU
Dampening To Proximal And Distal Joints)
Wheelchair Accessory, Shoulder Elbow, Mobile Arm Support, Monosuspension Arm And Hand Support, Overhead Elbow Forearm
E2630 1.231560 NU
Hand Sling Support, Yoke Type Suspension Support
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
Removed from Round 2021 on 7/1/19
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
Power Wheelchair, Group 1 Standard, Portable, Sling/Solid Seat And Back, Patient Weight Capacity Up To And Including 300
K0813 0.599523 RR
Pounds
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 17Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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 18DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Support Surfaces (Groups 1 and 2)
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
E0277 Powered Pressure-Reducing Air Mattress RR
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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 19DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Transcutaneous Electrical Nerve Stimulation (TENS) Devices
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
A4595 Electrical Stimulator Supplies, 2 Lead, Per Month, (E.G., TENS, NMES)
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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
Form Fitting Conductive Garment For Delivery Of TENS Or NMES (With Conductive Fibers Separated From The Patient's Skin By
E0731 11.934939 NU
Layers Of Fabric)
March 2019 20DMEPOS Competitive Bidding Program
Product Category HCPCS Codes
Round 2021
Walkers
Ratio
Lead Item Relative
Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
E0143 Walker, Folding, Wheeled, Adjustable Or Fixed Height NU
Ratio
Non-Lead Item Relative
Non-Lead Item HCPCS Code Description HCPCS
HCPCS Code Ratio
Modifiers
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
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