HCPCS codeCPAP device Respiratory assist device, bilevel pressure capability, without backup rate Respiratory assist device, bilevel pressure capability, with backup rate Heated humidifier Heated tubing Combination oral/nasal mask Oral cushion Nasal pillows for combination oral/nasal mask Full face mask Full face mask interface replacement Nasal cushion Nasal pillows Nasal interface Headgear Chinstrap Tubing Disposable filter Non-disposable filter Oral interface Exhalation port Water chamber Supply allowance for adjunctive continuous glucose monitor Supply allowance for non-adjunctive continuous glucose monitor Adjunctive continuous glucose monitor or receiver Non-adjunctive continuous glucose monitor or receiver Blood glucose test or reagent strips Lancets Normal, low and high calibrator solution/chips Spring-powered device for lancet Sealed lead-acid battery, 22NF Sealed lead-acid battery, group 24 Sealed lead-acid battery, U-1 Sealed lead-acid battery, group 27 Lithium-based battery Sealed lead-acid battery, 12-24 amp-hour Wheelchair component/accessory, not otherwise specified Wheelchair accessory, manual swingaway/retractable mounting hardware Arm pad replacement Repair or nonroutine service for DME other than oxygen requiring skill of technician Temporary replacement for patient-owned equipment being repaired Oxygen concentrator Portable gaseous oxygen system Portable liquid oxygen system Portable oxygen contents, gaseous Stationary oxygen contents, gaseous Stationary oxygen contents, liquid Portable oxygen contents, liquid Hospital bed, fixed height, with side rails Hospital bed, variable height, with side rails Hospital bed, semi-electric, with side rails Hospital bed, semi-electric, without side rails Hospital bed, fixed height, without side rails Bed side rails Bed board Powered pressure reducing mattress overlay/pad Dry pressure mattress Gel or gel-like pressure mattress pad Air pressure mattress Powered pressure-reducing air mattress Enteral feeding supply kit, syringe fed Enteral feeding supply kit, pump fed Enteral feeding supply kit, gravity fed Enteral formula, nutritionally complete Enteral nutrition infusion pump Intermittent urinary catheter, straight tip Intermittent urinary catheter, coude tip Intermittent urinary catheter, with insertion supplies Bedside drainage bag Urinary drainage bag, leg or abdomen Insertion tray without drainage bag and catheter Insertion tray with drainage bag but without catheter Insertion tray with drainage bag and catheter Cane, includes canes of all materials Cane, quad or three prong Crutches, forearm Crutches, underarm, other than wood Walker, folding, wheeled, adjustable or fixed height Walker, folding, wheeled, with seat Seat attachment for walker State or territorySelect state AL AK AZ AR CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY Date of service TransactionInitial equipment or supply Continued rental Replacement Recurring supply refill Repair or replacement part
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