Code Status Indicator
HCPCS
Code Modifier Description PA?
Included in NF Daily Rate
Policy/Comments
E0621 Sling or seat, patient lift, canvas or nylon
No Yes Purchase only NC E0625 Patient lift, bathroom or
toilet, not otherwise classified
No
NC E0627 Seat lift mechanism incorporated into a combination lift-chair mechanism
No
NC E0628 Separate seat lift mechanism for use with patient owned furniture – electric
No
NC E0629 Separate seat lift mechanism for use with patient owned furniture - nonelectric
No
E0630 NU RR
Patient lift, hydraulic, with seat or sling
Yes for Rental Yes Considered purchased after 1 years’ rental. Limit of 1 per client every 5 years. (Includes bath.) E0635 NU RR
Patient lift, electric, with seat or sling
Yes Yes Considered purchased after 1 years’ rental DC E0636 Multipositional patient
support system, with integrated lift, patient accessible controls
See E0635
NC E0640 Patient lift, fixed system, includes all components/ accessories
Note: Billing provision limited to a one-month rental. One month equals 30 days.
BR = By Report D = Discontinued
DC = Same/similar covered code in fee schedule DP = Service managed through a different program NC = Not covered N = New NF = Nursing Facility P = Policy change PA = Prior Authorization Required
Code Status Indicator
HCPCS
Code Modifier Description PA?
Included in NF Daily Rate
Policy/Comments
NC E0656 Segmental pneumatic appliance for use with pneumatic compressor, trunk
NC E0657 Segmental pneumatic appliance for use with pneumatic compressor, chest
NC E0766 Electrical stimulation device used for cancer treatment, includes all accessories, any type NC A4555 to be used with E0766 Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only NC E0769 Electrical stimulation or
electromagnetic wound treatment device, not otherwise classified. NC E0770 Functional electrical
stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified DC E0830 Ambulatory traction
device, all types, each. E0840 Traction frame, attached
to headboard, cervical traction.
Note: Billing provision limited to a one-month rental. One month equals 30 days.
BR = By Report D = Discontinued
DC = Same/similar covered code in fee schedule DP = Service managed through a different program
Code Status Indicator
HCPCS
Code Modifier Description PA?
Included in NF Daily Rate
Policy/Comments
DC E0849 Traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible. E0850 Traction stand,
freestanding, cervical traction.
No Yes Purchase only. Limit of 1 per client every 5 years. DC E0855 Cervical traction
equipment not requiring additional stand or frame. DC E0856 Cervical traction device,
cervical collar with inflatable air bladder. E0860 Traction equipment,
overdoor, cervical.
No Yes Purchase only. Limit of 1 per client every 5 years. E0870 Traction frame, attached
to footboard, simple extremity traction (e.g. Buck's).
No Yes Purchase only. Limit of 1 per client every 5 years. E0880 Traction stand,
freestanding, extremity traction (e.g., Buck's).
No Yes Purchase only. Limit of 1 per client every 5 years. E0890 Traction frame, attached
to footboard, pelvic traction.
No Yes Purchase only. Limit of 1 per client every 5 years.
Note: Billing provision limited to a one-month rental. One month equals 30 days.
BR = By Report D = Discontinued
DC = Same/similar covered code in fee schedule DP = Service managed through a different program NC = Not covered N = New NF = Nursing Facility P = Policy change PA = Prior Authorization Required
Code Status Indicator
HCPCS
Code Modifier Description PA?
Included in NF Daily Rate
Policy/Comments
E0900 Traction stand, freestanding, pelvic traction (e.g., Buck's).
No Yes Purchase only. Limit of 1 per client every 5 years. E0910 NU
RR
Trapeze bar, also known as patient helper, attached to bed with grab bar.
Yes for Rental Yes Considered purchased after 1 years’ rental. Limit of 1 per client every 5 years. E0911 NU RR
Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed with grab bar Yes for Rental. Yes Considered purchased after 1 years’ rental. Limit of 1 per client every 5 years. E0912 NU RR
Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, free standing, complete with grab bar.
Yes for Rental Yes Considered purchased after 1 years’ rental. Limit of 1 per client every 5 years. E0920 NU RR
Fracture frame, attached to bed. Includes weights.
Yes for Rental Yes Considered purchased after 1 years’ rental. Limit of 1 per client every 5 years. E0930 NU RR Fracture frame, freestanding, includes weights. Yes for Rental Yes Considered purchased after 1 years’ rental. Limit of 1 per client every 5 years.
Note: Billing provision limited to a one-month rental. One month equals 30 days.
BR = By Report D = Discontinued
DC = Same/similar covered code in fee schedule DP = Service managed through a different program
Code Status Indicator
HCPCS
Code Modifier Description PA?
Included in NF Daily Rate Policy/Comments E0940 NU RR
Trapeze bar, freestanding, complete with grab bar.
Yes for Rental Yes Considered purchased after 1 years’ rental. Limit of 1 per client every 5 years. E0941 NU RR
Gravity assisted traction device, any type.
Yes for Rental Yes Considered purchased after 1 years’ rental. Limit of 1 per client every 5 years. E0946 NU RR
Fracture frame, dual with cross bars, attached to bed (e.g., Balken, 4-poster).
Yes for Rental Yes Considered purchased after 1 years’ rental. Limit of 1 per client every 5 years.
E0947 Fracture frame,
attachments for complex pelvic traction.
No Yes Purchase only. Limit of 1 per client every 5 years. E0948 Fracture frame,
attachments for complex cervical traction.
No Yes Purchase only. Limit of 1 per client every 5 years. E0705 Transfer board or device,
any type, each.
No Yes Purchase only. Limit of 1 per client every 5 years.
Note: Billing provision limited to a one-month rental. One month equals 30 days.
BR = By Report D = Discontinued
DC = Same/similar covered code in fee schedule DP = Service managed through a different program NC = Not covered N = New NF = Nursing Facility P = Policy change PA = Prior Authorization Required