Regence BlueShield of Idaho

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Regence BlueShield of Idaho
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A4206
A4208
A4209
A4210
A4211
A4212
A4213
A4215
A4216
A4217
A4217AU
A4221
A4222
A4230
A4231
A4232
A4233
A4233NU
A4234
A4234NU
A4235
A4235NU
A4236
A4236NU
A4244
A4245
A4245NU
A4246
A4247
A4248
Modifier
AU
NU
NU
NU
NU
NU
Description
1 CC sterile syringe&needle
3 CC sterile syringe&needle
5+ CC sterile syringe&needle
Nonneedle injection device
Supp for self-adm injections
Non coring needle or stylet
20+ CC syringe only
Sterile needle
Sterile water/saline, 10 ml
Sterile water/saline, 500 ml
Sterile water/saline, 500 ml
Maint drug infus cath per wk
Infusion supplies with pump
Infusion, non-needle
Infusion Set Needle
Cartridge/Reservoir
Alkalin batt for glucose mon
Alkalin batt for glucose mon
J-cell batt for glucose mon
J-cell batt for glucose mon
Lithium batt for glucose mon
Lithium batt for glucose mon
Silvr oxide batt glucose mon
Silvr oxide batt glucose mon
Alcohol or peroxide per pint
Alcohol wipes per box
Alcohol wipes per box
Betadine/phisohex solution
Betadine/iodine swabs/wipes
Chlorhexidine antisept
Page 1 of 116
Effective Date
Maximum Allowable
12/1/2013
0.32
12/1/2013
0.47
12/1/2013
0.64
12/1/2013
1.49
12/1/2013
14.00
12/1/2013
10.50
12/1/2013
0.43
12/1/2013
0.13
12/1/2013
0.24
12/1/2013
1.95
12/1/2013
1.95
12/1/2013
20.49
12/1/2013
40.65
12/1/2013
9.00
12/1/2013
10.00
12/1/2013
2.55
12/1/2013
0.49
12/1/2013
0.49
12/1/2013
2.13
12/1/2013
2.13
12/1/2013
0.90
12/1/2013
0.90
12/1/2013
1.01
12/1/2013
1.01
12/1/2013
2.48
12/1/2013
3.75
12/1/2013
3.75
12/1/2013
7.67
12/1/2013
4.21
12/1/2013
1.60
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A4250
A4252
A4253
A4253NU
A4255
A4256
A4256KL
A4257
A4258
A4258KL
A4259
A4265
A4267
A4280
A4281
A4282
A4283
A4284
A4285
A4286
A4290
A4310
A4311
A4312
A4313
A4314
A4315
A4316
A4320
A4321
Modifier
NU
KL
KL
Description
Urine reagent strips/tablets
Blood ketone test or strip
Blood glucose/reagent strips
Blood glucose/reagent strips
Glucose monitor platforms
Calibrator solution/chips
Calibrator solution/chips
Replace Lensshield Cartridge
Lancet device each
Lancet device each
Lancets per box
Paraffin
Male condom
Brst prsths adhsv attchmnt
Replacement breastpump tube
Replacement breastpump adpt
Replacement breastpump cap
Replcmnt breast pump shield
Replcmnt breast pump bottle
Replcmnt breastpump lok ring
Sacral nerve stim test lead
Insert tray w/o bag/cath
Catheter w/o bag 2-way latex
Cath w/o bag 2-way silicone
Catheter w/bag 3-way
Cath w/drainage 2-way latex
Cath w/drainage 2-way silcne
Cath w/drainage 3-way
Irrigation tray
Cath therapeutic irrig agent
Page 2 of 116
Effective Date
Maximum Allowable
12/1/2013
17.95
12/1/2013
3.67
12/1/2013
27.00
12/1/2013
27.00
12/1/2013
3.79
12/1/2013
8.25
12/1/2013
8.25
12/1/2013
11.74
12/1/2013
8.75
12/1/2013
8.75
12/1/2013
8.75
12/1/2013
3.33
12/1/2013
0.35
12/1/2013
3.41
12/1/2013
6.75
12/1/2013
10.89
12/1/2013
2.40
12/1/2013
6.11
12/1/2013
4.45
12/1/2013
3.71
12/1/2013
62.92
12/1/2013
4.98
12/1/2013
9.26
12/1/2013
10.70
12/1/2013
12.94
12/1/2013
15.77
12/1/2013
17.00
12/1/2013
18.30
12/1/2013
3.30
12/1/2013
8.02
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A4322
A4326
A4327
A4328
A4330
A4331
A4332
A4333
A4334
A4335
A4336
A4338
A4340
A4344
A4346
A4349
A4351
A4352
A4353
A4354
A4355
A4356
A4357
A4358
A4360
A4361
A4362
A4363
A4364
A4366
Modifier
Description
Irrigation syringe
Male external catheter
Fem urinary collect dev cup
Fem urinary collect pouch
Stool collection pouch
Extension drainage tubing
Lube sterile packet
Urinary cath anchor device
Urinary cath leg strap
Incontinence supply
Urethral insert
Indwelling catheter latex
Indwelling catheter special
Cath indw foley 2 way silicn
Cath indw foley 3 way
Disposable male external cat
Straight tip urine catheter
Coude tip urinary catheter
Intermittent urinary cath
Cath insertion tray w/bag
Bladder irrigation tubing
Ext ureth clmp or compr dvc
Bedside drainage bag
Urinary leg or abdomen bag
Disposable ext urethral dev
Ostomy face plate
Solid skin barrier
Ostomy clamp, replacement
Adhesive, liquid or equal
Ostomy vent
Page 3 of 116
Effective Date
Maximum Allowable
12/1/2013
1.97
12/1/2013
6.73
12/1/2013
36.32
12/1/2013
10.69
12/1/2013
9.95
12/1/2013
2.11
12/1/2013
0.08
12/1/2013
1.43
12/1/2013
3.18
12/1/2013
0.31
12/1/2013
1.95
12/1/2013
7.64
12/1/2013
20.47
12/1/2013
10.32
12/1/2013
11.63
12/1/2013
1.11
12/1/2013
1.00
12/1/2013
3.34
12/1/2013
4.00
12/1/2013
9.60
12/1/2013
6.70
12/1/2013
35.41
12/1/2013
6.45
12/1/2013
4.05
12/1/2013
0.49
12/1/2013
11.74
12/1/2013
2.61
12/1/2013
1.60
12/1/2013
3.70
12/1/2013
1.33
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A4367
A4368
A4369
A4371
A4372
A4373
A4375
A4376
A4377
A4378
A4379
A4380
A4381
A4382
A4383
A4384
A4385
A4387
A4388
A4389
A4390
A4391
A4392
A4393
A4394
A4395
A4396
A4397
A4398
A4399
Modifier
Description
Ostomy belt
Ostomy filter
Skin barrier liquid per oz
Skin barrier powder per oz
Skin barrier solid 4x4 equiv
Skin barrier with flange
Drainable plastic pch w fcpl
Drainable rubber pch w fcplt
Drainable plstic pch w/o fp
Drainable rubber pch w/o fp
Urinary plastic pouch w fcpl
Urinary rubber pouch w fcplt
Urinary plastic pouch w/o fp
Urinary hvy plstc pch w/o fp
Urinary rubber pouch w/o fp
Ostomy faceplt/silicone ring
Ost skn barrier sld ext wear
Ost clsd pouch w att st barr
Drainable pch w ex wear barr
Drainable pch w st wear barr
Drainable pch ex wear convex
Urinary pouch w ex wear barr
Urinary pouch w st wear barr
Urine pch w ex wear bar conv
Ostomy pouch liq deodorant
Ostomy pouch solid deodorant
Peristomal hernia supprt blt
Irrigation supply sleeve
Ostomy irrigation bag
Ostomy irrig cone/cath w brs
Page 4 of 116
Effective Date
Maximum Allowable
12/1/2013
6.27
12/1/2013
0.45
12/1/2013
4.69
12/1/2013
5.98
12/1/2013
4.05
12/1/2013
5.87
12/1/2013
12.92
12/1/2013
51.11
12/1/2013
4.61
12/1/2013
48.65
12/1/2013
22.00
12/1/2013
75.00
12/1/2013
4.96
12/1/2013
18.51
12/1/2013
59.59
12/1/2013
7.23
12/1/2013
3.84
12/1/2013
4.16
12/1/2013
4.58
12/1/2013
6.58
12/1/2013
8.85
12/1/2013
5.89
12/1/2013
9.15
12/1/2013
7.07
12/1/2013
2.58
12/1/2013
0.15
12/1/2013
30.44
12/1/2013
4.38
12/1/2013
17.67
12/1/2013
9.22
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A4400
A4402
A4404
A4405
A4406
A4407
A4408
A4409
A4410
A4411
A4412
A4413
A4414
A4415
A4416
A4417
A4418
A4419
A4420
A4421
A4422
A4423
A4424
A4425
A4426
A4427
A4428
A4429
A4430
A4431
Modifier
Description
Ostomy irrigation set
Lubricant per ounce
Ostomy ring each
Nonpectin based ostomy paste
Pectin based ostomy paste
Ext wear ost skn barr <=4sq"
Ext wear ost skn barr >4sq"
Ost skn barr convex <=4 sq i
Ost skn barr extnd >4 sq
Ost skn barr extnd =4sq
Ost pouch drain high output
2 pc drainable ost pouch
Ost sknbar w/o conv<=4 sq in
Ost skn barr w/o conv >4 sqi
Ost pch clsd w barrier/filtr
Ost pch w bar/bltinconv/fltr
Ost pch clsd w/o bar w filtr
Ost pch for bar w flange/flt
Ost pch clsd for bar w lk fl
Ostomy supply misc
Ost pouch absorbent material
Ost pch for bar w lk fl/fltr
Ost pch drain w bar & filter
Ost pch drain for barrier fl
Ost pch drain 2 piece system
Ost pch drain/barr lk flng/f
Urine ost pouch w faucet/tap
Urine ost pouch w bltinconv
Ost urine pch w b/bltin conv
Ost pch urine w barrier/tapv
Page 5 of 116
Effective Date
Maximum Allowable
12/1/2013
44.62
12/1/2013
1.21
12/1/2013
1.77
12/1/2013
4.89
12/1/2013
7.42
12/1/2013
6.50
12/1/2013
7.42
12/1/2013
5.25
12/1/2013
6.80
12/1/2013
4.60
12/1/2013
4.60
12/1/2013
4.60
12/1/2013
3.62
12/1/2013
4.51
12/1/2013
2.40
12/1/2013
3.84
12/1/2013
2.14
12/1/2013
1.28
12/1/2013
1.30
12/1/2013
9.61
12/1/2013
0.13
12/1/2013
1.50
12/1/2013
3.58
12/1/2013
2.51
12/1/2013
2.06
12/1/2013
2.25
12/1/2013
5.89
12/1/2013
6.21
12/1/2013
7.32
12/1/2013
4.72
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A4432
A4433
A4434
A4435
A4450
A4450AU
A4450AV
A4450AW
A4452
A4452AU
A4452AV
A4452AW
A4455
A4456
A4458
A4461
A4463
A4465
A4466
A4481
A4483
A4490
A4495
A4500
A4510
A4520
A4554
A4556
A4557
A4558
Modifier
AU
AV
AW
AU
AV
AW
Description
Os pch urine w bar/fange/tap
Urine ost pch bar w lock fln
Ost pch urine w lock flng/ft
1pc ost pch drain hgh output
Non-waterproof tape
Non-waterproof tape
Non-waterproof tape
Non-waterproof tape
Waterproof tape
Waterproof tape
Waterproof tape
Waterproof tape
Adhesive remover per ounce
Adhesive remover, wipes
Reusable enema bag
Surgicl dress hold non-reuse
Surgical dress holder reuse
Non-elastic extremity binder
Elastic garment/covering
Tracheostoma filter
Moisture exchanger
Above knee surgical stocking
Thigh length surg stocking
Below knee surgical stocking
Full length surg stocking
Incontinence garment anytype
Disposable underpads
Electrodes, pair
Lead wires, pair
Conductive gel or paste
Page 6 of 116
Effective Date
Maximum Allowable
12/1/2013
2.90
12/1/2013
2.75
12/1/2013
2.90
12/1/2013
6.26
12/1/2013
0.06
12/1/2013
0.06
12/1/2013
0.06
12/1/2013
0.06
12/1/2013
0.17
12/1/2013
0.17
12/1/2013
0.17
12/1/2013
0.17
12/1/2013
13.41
12/1/2013
0.25
12/1/2013
2.80
12/1/2013
2.11
12/1/2013
8.59
12/1/2013
34.45
12/1/2013
32.25
12/1/2013
0.95
12/1/2013
5.22
12/1/2013
21.88
12/1/2013
18.69
12/1/2013
16.83
12/1/2013
25.95
12/1/2013
0.66
12/1/2013
0.75
12/1/2013
7.83
12/1/2013
14.00
12/1/2013
5.99
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A4559
A4561
A4562
A4565
A4570
A4595
A4601
A4604
A4604NU
A4605
A4605NU
A4606
A4608
A4611
A4611NU
A4611RR
A4611UE
A4612
A4612NU
A4612RR
A4612UE
A4613
A4613NU
A4613RR
A4613UE
A4614
A4615
A4616
A4617
A4618
Modifier
NU
NU
NU
RR
UE
NU
RR
UE
NU
RR
UE
Description
Coupling gel or paste
Pessary rubber, any type
Pessary, non rubber,any type
Slings
Splint
TENS suppl 2 lead per month
Lith ion batt, non-pros use
Tubing with heating element
Tubing with heating element
Trach suction cath close sys
Trach suction cath close sys
Oxygen probe used w oximeter
Transtracheal oxygen cath
Heavy duty battery
Heavy duty battery
Heavy duty battery
Heavy duty battery
Battery cables
Battery cables
Battery cables
Battery cables
Battery charger
Battery charger
Battery charger
Battery charger
Hand-held PEFR meter
Cannula nasal
Tubing (oxygen) per foot
Mouth piece
Breathing circuits
Page 7 of 116
Effective Date
Maximum Allowable
12/1/2013
0.09
12/1/2013
21.60
12/1/2013
32.02
12/1/2013
4.95
12/1/2013
16.04
12/1/2013
15.57
12/1/2013
106.08
12/1/2013
49.87
12/1/2013
49.87
12/1/2013
14.20
12/1/2013
14.20
12/1/2013
39.95
12/1/2013
43.42
12/1/2013
15.94
12/1/2013
153.68
12/1/2013
15.94
12/1/2013
115.27
12/1/2013
7.49
12/1/2013
73.57
12/1/2013
7.49
12/1/2013
56.09
12/1/2013
13.27
12/1/2013
132.72
12/1/2013
13.27
12/1/2013
95.98
12/1/2013
16.25
12/1/2013
0.51
12/1/2013
0.75
12/1/2013
2.05
12/1/2013
0.80
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A4618NU
A4618RR
A4618UE
A4619
A4619NU
A4620
A4623
A4624
A4624NU
A4625
A4626
A4627
A4628
A4628NU
A4629
A4630
A4630NU
A4633
A4633NU
A4635
A4635NU
A4635RR
A4635UE
A4636
A4636NU
A4636RR
A4636UE
A4637
A4637NU
A4637RR
Modifier
Description
NU
Breathing circuits
RR
Breathing circuits
UE
Breathing circuits
Face tent
NU
Face tent
Variable concentration mask
Tracheostomy inner cannula
Tracheal suction tube
NU
Tracheal suction tube
Trach care kit for new trach
Tracheostomy cleaning brush
Spacer bag/reservoir
Oropharyngeal suction cath
NU
Oropharyngeal suction cath
Tracheostomy care kit
Repl bat t.e.n.s. own by pt
NU
Repl bat t.e.n.s. own by pt
Uvl replacement bulb
NU
Uvl replacement bulb
Underarm crutch pad
NU
Underarm crutch pad
RR
Underarm crutch pad
UE
Underarm crutch pad
Handgrip for cane etc
NU
Handgrip for cane etc
RR
Handgrip for cane etc
UE
Handgrip for cane etc
Repl tip cane/crutch/walker
NU
Repl tip cane/crutch/walker
RR
Repl tip cane/crutch/walker
Page 8 of 116
Effective Date
Maximum Allowable
12/1/2013
6.95
12/1/2013
0.80
12/1/2013
5.22
12/1/2013
1.20
12/1/2013
1.20
12/1/2013
0.51
12/1/2013
4.22
12/1/2013
1.40
12/1/2013
1.40
12/1/2013
4.47
12/1/2013
2.06
12/1/2013
10.00
12/1/2013
2.00
12/1/2013
2.00
12/1/2013
2.99
12/1/2013
3.42
12/1/2013
3.42
12/1/2013
37.77
12/1/2013
37.77
12/1/2013
0.50
12/1/2013
4.95
12/1/2013
0.50
12/1/2013
3.47
12/1/2013
0.35
12/1/2013
3.51
12/1/2013
0.35
12/1/2013
2.46
12/1/2013
1.00
12/1/2013
10.03
12/1/2013
1.00
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A4637UE
A4639
A4639NU
A4640
A4640NU
A4640RR
A4640UE
A4927
A4930
A4931
A5051
A5052
A5053
A5054
A5055
A5056
A5057
A5061
A5062
A5063
A5071
A5072
A5073
A5081
A5082
A5083
A5093
A5102
A5105
A5112
Modifier
Description
UE
Repl tip cane/crutch/walker
Infrared ht sys replcmnt pad
NU
Infrared ht sys replcmnt pad
Alternating pressure pad
NU
Alternating pressure pad
RR
Alternating pressure pad
UE
Alternating pressure pad
Non-sterile gloves
Sterile, gloves per pair
Reusable oral thermometer
Pouch clsd w barr attached
Clsd ostomy pouch w/o barr
Clsd ostomy pouch faceplate
Clsd ostomy pouch w/flange
Stoma cap
1 pc ost pouch w filter
1 pc ost pou w built-in conv
Pouch drainable w barrier at
Drnble ostomy pouch w/o barr
Drain ostomy pouch w/flange
Urinary pouch w/barrier
Urinary pouch w/o barrier
Urinary pouch on barr w/flng
Continent stoma plug
Continent stoma catheter
Stoma absorptive cover
Ostomy accessory convex inse
Bedside drain btl w/wo tube
Urinary suspensory
Urinary leg bag
Page 9 of 116
Effective Date
Maximum Allowable
12/1/2013
7.02
12/1/2013
264.32
12/1/2013
264.32
12/1/2013
5.37
12/1/2013
49.53
12/1/2013
5.37
12/1/2013
37.13
12/1/2013
4.58
12/1/2013
0.40
12/1/2013
3.39
12/1/2013
2.14
12/1/2013
1.12
12/1/2013
1.24
12/1/2013
1.46
12/1/2013
1.68
12/1/2013
5.05
12/1/2013
10.40
12/1/2013
2.60
12/1/2013
1.68
12/1/2013
1.98
12/1/2013
6.72
12/1/2013
3.79
12/1/2013
2.90
12/1/2013
3.04
12/1/2013
7.60
12/1/2013
0.37
12/1/2013
2.54
12/1/2013
20.77
12/1/2013
43.79
12/1/2013
30.00
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
Modifier
Description
A5113
Latex leg strap
A5114
Foam/fabric leg strap
A5120
Skin barrier, wipe or swab
A5120AU AU
Skin barrier, wipe or swab
A5120AV AV
Skin barrier, wipe or swab
A5121
Solid skin barrier 6x6
A5122
Solid skin barrier 8x8
A5126
Disk/foam pad +or- adhesive
A5131
Appliance cleaner
A5200
Percutaneous catheter anchor
A5500
Diab shoe for density insert
A5501
Diabetic custom molded shoe
A5503
Diabetic shoe w/roller/rockr
A5504
Diabetic shoe with wedge
A5505
Diab shoe w/metatarsal bar
A5506
Diabetic shoe w/off set heel
A5507
Modification diabetic shoe
A5510
Compression form shoe insert
A5512
Multi den insert direct form
A5513
Multi den insert custom mold
A6010
Collagen based wound filler
A6011
Collagen gel/paste wound fil
A6021
Collagen dressing <=16 sq in
A6022
Collagen drsg>16<=48 sq in
A6023
Collagen dressing >48 sq in
A6024
Collagen dsg wound filler
A6025
Silicone gel sheet, each
A6154
Wound pouch each
A6196
Alginate dressing <=16 sq in
A6197
Alginate drsg >16 <=48 sq in
Page 10 of 116
Effective Date
Maximum Allowable
12/1/2013
3.04
12/1/2013
6.20
12/1/2013
0.30
12/1/2013
0.30
12/1/2013
0.30
12/1/2013
13.07
12/1/2013
19.34
12/1/2013
0.85
12/1/2013
11.92
12/1/2013
8.50
12/1/2013
39.95
12/1/2013
175.52
12/1/2013
28.51
12/1/2013
28.51
12/1/2013
28.51
12/1/2013
28.51
12/1/2013
28.51
12/1/2013
20.10
12/1/2013
23.87
12/1/2013
35.62
12/1/2013
19.96
12/1/2013
1.47
12/1/2013
13.55
12/1/2013
18.92
12/1/2013
202.30
12/1/2013
4.66
12/1/2013
64.48
12/1/2013
19.36
12/1/2013
4.74
12/1/2013
10.59
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A6198
A6199
A6203
A6204
A6205
A6206
A6207
A6208
A6209
A6210
A6211
A6212
A6213
A6214
A6215
A6216
A6217
A6218
A6219
A6220
A6221
A6222
A6223
A6224
A6229
A6230
A6231
A6232
A6233
A6234
Modifier
Description
alginate dressing > 48 sq in
Alginate drsg wound filler
Composite drsg <= 16 sq in
Composite drsg >16<=48 sq in
Composite drsg > 48 sq in
Contact layer <= 16 sq in
Contact layer >16<= 48 sq in
Contact layer > 48 sq in
Foam drsg <=16 sq in w/o bdr
Foam drg >16<=48 sq in w/o b
Foam drg > 48 sq in w/o brdr
Foam drg <=16 sq in w/border
Foam drg >16<=48 sq in w/bdr
Foam drg > 48 sq in w/border
Foam dressing wound filler
Non-sterile gauze<=16 sq in
Non-sterile gauze>16<=48 sq
Non-sterile gauze > 48 sq in
Gauze <= 16 sq in w/border
Gauze >16 <=48 sq in w/bordr
Gauze > 48 sq in w/border
Gauze <=16 in no w/sal w/o b
Gauze >16<=48 no w/sal w/o b
Gauze > 48 in no w/sal w/o b
Gauze >16<=48 sq in watr/sal
Gauze > 48 sq in water/salne
Hydrogel dsg<=16 sq in
Hydrogel dsg>16<=48 sq in
Hydrogel dressing >48 sq in
Hydrocolld drg <=16 w/o bdr
Page 11 of 116
Effective Date
Maximum Allowable
12/1/2013
29.92
12/1/2013
3.84
12/1/2013
2.16
12/1/2013
4.02
12/1/2013
4.52
12/1/2013
5.75
12/1/2013
5.04
12/1/2013
11.34
12/1/2013
4.82
12/1/2013
12.84
12/1/2013
18.93
12/1/2013
6.26
12/1/2013
8.65
12/1/2013
9.95
12/1/2013
11.74
12/1/2013
0.03
12/1/2013
0.39
12/1/2013
0.39
12/1/2013
1.20
12/1/2013
2.04
12/1/2013
3.42
12/1/2013
1.38
12/1/2013
1.56
12/1/2013
2.33
12/1/2013
2.33
12/1/2013
2.22
12/1/2013
3.01
12/1/2013
6.87
12/1/2013
12.37
12/1/2013
4.22
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A6235
A6236
A6237
A6238
A6239
A6240
A6241
A6242
A6243
A6244
A6245
A6246
A6247
A6248
A6250
A6251
A6252
A6253
A6254
A6255
A6256
A6257
A6258
A6259
A6260
A6261
A6262
A6266
A6402
A6403
Modifier
Description
Hydrocolld drg >16<=48 w/o b
Hydrocolld drg > 48 in w/o b
Hydrocolld drg <=16 in w/bdr
Hydrocolld drg >16<=48 w/bdr
Hydrocolld drg > 48 in w/bdr
Hydrocolld drg filler paste
Hydrocolloid drg filler dry
Hydrogel drg <=16 in w/o bdr
Hydrogel drg >16<=48 w/o bdr
Hydrogel drg >48 in w/o bdr
Hydrogel drg <= 16 in w/bdr
Hydrogel drg >16<=48 in w/b
Hydrogel drg > 48 sq in w/b
Hydrogel drsg gel filler
Skin seal protect moisturizr
Absorpt drg <=16 sq in w/o b
Absorpt drg >16 <=48 w/o bdr
Absorpt drg > 48 sq in w/o b
Absorpt drg <=16 sq in w/bdr
Absorpt drg >16<=48 in w/bdr
Absorpt drg > 48 sq in w/bdr
Transparent film <= 16 sq in
Transparent film >16<=48 in
Transparent film > 48 sq in
Wound cleanser any type/size
Wound filler gel/paste /oz
Wound filler dry form / gram
Impreg gauze no h20/sal/yard
Sterile gauze <= 16 sq in
Sterile gauze>16 <= 48 sq in
Page 12 of 116
Effective Date
Maximum Allowable
12/1/2013
11.84
12/1/2013
17.57
12/1/2013
7.21
12/1/2013
14.80
12/1/2013
16.73
12/1/2013
38.71
12/1/2013
1.66
12/1/2013
4.42
12/1/2013
8.04
12/1/2013
25.79
12/1/2013
7.55
12/1/2013
23.33
12/1/2013
21.89
12/1/2013
10.86
12/1/2013
6.48
12/1/2013
1.94
12/1/2013
2.16
12/1/2013
4.42
12/1/2013
0.78
12/1/2013
1.96
12/1/2013
2.67
12/1/2013
1.00
12/1/2013
2.78
12/1/2013
7.06
12/1/2013
8.72
12/1/2013
87.02
12/1/2013
3.59
12/1/2013
3.71
12/1/2013
0.07
12/1/2013
0.54
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
Modifier
Description
A6404
Sterile gauze > 48 sq in
A6407
Packing strips, non-impreg
A6410
Sterile eye pad
A6411
Non-sterile eye pad
A6412
Occlusive eye patch
A6413
Adhesive bandage, first-aid
A6441
Pad band w>=3" <5"/yd
A6442
Conform band n/s w<3"/yd
A6443
Conform band n/s w>=3"<5"/yd
A6444
Conform band n/s w>=5"/yd
A6445
Conform band s w <3"/yd
A6446
Conform band s w>=3" <5"/yd
A6447
Conform band s w >=5"/yd
A6448
Lt compres band <3"/yd
A6449
Lt compres band >=3" <5"/yd
A6450
Lt compres band >=5"/yd
A6451
Mod compres band w>=3"<5"/yd
A6452
High compres band w>=3"<5"yd
A6453
Self-adher band w <3"/yd
A6454
Self-adher band w>=3" <5"/yd
A6455
Self-adher band >=5"/yd
A6456
Zinc paste band w >=3"<5"/yd
A6457
Tubular dressing
A6504
Cmprsburngarment glove-wrist
A6530
Compression stocking BK18-30
A6531
Compression stocking BK30-40
A6531AW AW
Compression stocking BK30-40
A6532
Compression stocking BK40-50
A6532AW AW
Compression stocking BK40-50
A6533
Gc stocking thighlngth 18-30
Page 13 of 116
Effective Date
Maximum Allowable
12/1/2013
7.43
12/1/2013
1.20
12/1/2013
0.38
12/1/2013
0.31
12/1/2013
0.31
12/1/2013
0.07
12/1/2013
0.43
12/1/2013
0.83
12/1/2013
0.18
12/1/2013
0.58
12/1/2013
2.12
12/1/2013
0.34
12/1/2013
1.79
12/1/2013
0.72
12/1/2013
1.08
12/1/2013
1.78
12/1/2013
2.67
12/1/2013
3.65
12/1/2013
0.39
12/1/2013
0.52
12/1/2013
0.89
12/1/2013
0.83
12/1/2013
0.74
12/1/2013
148.50
12/1/2013
35.02
12/1/2013
43.78
12/1/2013
43.78
12/1/2013
51.48
12/1/2013
51.48
12/1/2013
62.37
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A6534
A6535
A6536
A6537
A6538
A6539
A6540
A6541
A6544
A6545
A6545AW
A6549
A6550
A7000
A7000NU
A7001
A7001NU
A7002
A7002NU
A7003
A7003NU
A7004
A7004NU
A7005
A7005NU
A7006
A7006NU
A7007
A7007NU
A7008
Modifier
AW
NU
NU
NU
NU
NU
NU
NU
NU
Description
Gc stocking thighlngth 30-40
Gc stocking thighlngth 40-50
Gc stocking full lngth 18-30
Gc stocking full lngth 30-40
Gc stocking full lngth 40-50
Gc stocking waistlngth 18-30
Gc stocking waistlngth 30-40
Gc stocking waistlngth 40-50
Gc stocking garter belt
Grad comp non-elastic BK
Grad comp non-elastic BK
G compression stocking
Neg pres wound ther drsg set
Disposable canister for pump
Disposable canister for pump
Nondisposable pump canister
Nondisposable pump canister
Tubing used w suction pump
Tubing used w suction pump
Nebulizer administration set
Nebulizer administration set
Disposable nebulizer sml vol
Disposable nebulizer sml vol
Nondisposable nebulizer set
Nondisposable nebulizer set
Filtered nebulizer admin set
Filtered nebulizer admin set
Lg vol nebulizer disposable
Lg vol nebulizer disposable
Disposable nebulizer prefill
Page 14 of 116
Effective Date
Maximum Allowable
12/1/2013
71.28
12/1/2013
84.15
12/1/2013
84.15
12/1/2013
84.15
12/1/2013
84.15
12/1/2013
89.95
12/1/2013
89.95
12/1/2013
128.70
12/1/2013
29.95
12/1/2013
148.50
12/1/2013
148.50
12/1/2013
75.00
12/1/2013
21.76
12/1/2013
4.63
12/1/2013
4.63
12/1/2013
19.23
12/1/2013
19.23
12/1/2013
2.24
12/1/2013
2.24
12/1/2013
1.77
12/1/2013
1.77
12/1/2013
1.24
12/1/2013
1.24
12/1/2013
17.91
12/1/2013
17.91
12/1/2013
8.78
12/1/2013
8.78
12/1/2013
2.99
12/1/2013
2.99
12/1/2013
7.10
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A7008NU
A7009
A7009NU
A7010
A7010NU
A7011
A7012
A7012NU
A7013
A7013NU
A7014
A7014NU
A7015
A7015NU
A7016
A7016NU
A7017
A7017NU
A7017RR
A7017UE
A7018
A7020
A7020NU
A7025
A7025NU
A7026
A7026NU
A7027
A7027NU
A7028
Modifier
Description
NU
Disposable nebulizer prefill
Nebulizer reservoir bottle
NU
Nebulizer reservoir bottle
Disposable corrugated tubing
NU
Disposable corrugated tubing
Nondispos corrugated tubing
Nebulizer water collec devic
NU
Nebulizer water collec devic
Disposable compressor filter
NU
Disposable compressor filter
Compressor nondispos filter
NU
Compressor nondispos filter
Aerosol mask used w nebulize
NU
Aerosol mask used w nebulize
Nebulizer dome & mouthpiece
NU
Nebulizer dome & mouthpiece
Nebulizer not used w oxygen
NU
Nebulizer not used w oxygen
RR
Nebulizer not used w oxygen
UE
Nebulizer not used w oxygen
Water distilled w/nebulizer
Interface, cough stim device
NU
Interface, cough stim device
Replace chest compress vest
NU
Replace chest compress vest
Replace chst cmprss sys hose
NU
Replace chst cmprss sys hose
Combination oral/nasal mask
NU
Combination oral/nasal mask
Repl oral cushion combo mask
Page 15 of 116
Effective Date
Maximum Allowable
12/1/2013
7.10
12/1/2013
24.43
12/1/2013
24.43
12/1/2013
15.03
12/1/2013
15.03
12/1/2013
1.00
12/1/2013
2.31
12/1/2013
2.31
12/1/2013
0.53
12/1/2013
0.53
12/1/2013
2.61
12/1/2013
2.61
12/1/2013
1.60
12/1/2013
1.60
12/1/2013
4.20
12/1/2013
4.20
12/1/2013
86.39
12/1/2013
86.39
12/1/2013
8.64
12/1/2013
60.47
12/1/2013
0.25
12/1/2013
45.95
12/1/2013
45.95
12/1/2013
400.28
12/1/2013
400.28
12/1/2013
26.46
12/1/2013
26.46
12/1/2013
165.06
12/1/2013
165.06
12/1/2013
45.60
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A7028NU
A7029
A7029NU
A7030
A7030NU
A7031
A7031NU
A7032
A7032NU
A7033
A7033NU
A7034
A7034NU
A7035
A7035NU
A7036
A7036NU
A7037
A7037NU
A7038
A7038NU
A7039
A7039NU
A7040
A7041
A7042
A7043
A7044
A7044NU
A7045
Modifier
Description
NU
Repl oral cushion combo mask
Repl nasal pillow comb mask
NU
Repl nasal pillow comb mask
CPAP full face mask
NU
CPAP full face mask
Replacement facemask interfa
NU
Replacement facemask interfa
Replacement nasal cushion
NU
Replacement nasal cushion
Replacement nasal pillows
NU
Replacement nasal pillows
Nasal application device
NU
Nasal application device
Pos airway press headgear
NU
Pos airway press headgear
Pos airway press chinstrap
NU
Pos airway press chinstrap
Pos airway pressure tubing
NU
Pos airway pressure tubing
Pos airway pressure filter
NU
Pos airway pressure filter
Filter, non disposable w pap
NU
Filter, non disposable w pap
One way chest drain valve
Water seal drain container
Implanted pleural catheter
Vacuum drainagebottle/tubing
PAP oral interface
NU
PAP oral interface
Repl exhalation port for PAP
Page 16 of 116
Effective Date
Maximum Allowable
12/1/2013
45.60
12/1/2013
18.62
12/1/2013
18.62
12/1/2013
140.83
12/1/2013
140.83
12/1/2013
52.09
12/1/2013
52.09
12/1/2013
30.26
12/1/2013
30.26
12/1/2013
21.21
12/1/2013
21.21
12/1/2013
87.82
12/1/2013
87.82
12/1/2013
29.66
12/1/2013
29.66
12/1/2013
13.58
12/1/2013
13.58
12/1/2013
30.62
12/1/2013
30.62
12/1/2013
4.03
12/1/2013
4.03
12/1/2013
11.44
12/1/2013
11.44
12/1/2013
34.19
12/1/2013
64.26
12/1/2013
155.27
12/1/2013
24.35
12/1/2013
90.26
12/1/2013
90.26
12/1/2013
1.45
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A7045NU
A7045RR
A7045UE
A7046
A7046NU
A7501
A7502
A7503
A7504
A7505
A7506
A7507
A7508
A7509
A7520
A7521
A7522
A7523
A7524
A7525
A7526
A7527
A8000
A8000NU
A8000RR
A8000UE
A8001
A8001NU
A8001RR
A8001UE
Modifier
Description
NU
Repl exhalation port for PAP
RR
Repl exhalation port for PAP
UE
Repl exhalation port for PAP
Repl water chamber, PAP dev
NU
Repl water chamber, PAP dev
Tracheostoma valve w diaphra
Replacement diaphragm/fplate
HMES filter holder or cap
Tracheostoma HMES filter
HMES or trach valve housing
HMES/trachvalve adhesivedisk
Integrated filter & holder
Housing & Integrated Adhesiv
Heat & moisture exchange sys
Trach/laryn tube non-cuffed
Trach/laryn tube cuffed
Trach/laryn tube stainless
Tracheostomy shower protect
Tracheostoma stent/stud/bttn
Tracheostomy mask
Tracheostomy tube collar
Trach/laryn tube plug/stop
Soft protect helmet prefab
NU
Soft protect helmet prefab
RR
Soft protect helmet prefab
UE
Soft protect helmet prefab
Hard protect helmet prefab
NU
Hard protect helmet prefab
RR
Hard protect helmet prefab
UE
Hard protect helmet prefab
Page 17 of 116
Effective Date
Maximum Allowable
12/1/2013
14.53
12/1/2013
1.45
12/1/2013
10.90
12/1/2013
14.56
12/1/2013
14.56
12/1/2013
90.25
12/1/2013
79.95
12/1/2013
58.00
12/1/2013
4.95
12/1/2013
13.00
12/1/2013
2.50
12/1/2013
4.75
12/1/2013
6.55
12/1/2013
1.37
12/1/2013
69.95
12/1/2013
89.95
12/1/2013
99.95
12/1/2013
26.95
12/1/2013
89.95
12/1/2013
1.89
12/1/2013
2.90
12/1/2013
7.95
12/1/2013
14.11
12/1/2013
141.13
12/1/2013
14.11
12/1/2013
105.87
12/1/2013
14.11
12/1/2013
141.13
12/1/2013
14.11
12/1/2013
105.87
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
A9270
A9274
A9276
A9277
A9278
B4034
B4035
B4036
B4081
B4082
B4083
B4087
B4088
B4100
B4102
B4103
B4104
B4149
B4150
B4152
B4153
B4154
B4155
B4157
B4158
B4159
B4160
B4161
B4162
B4164
Modifier
Description
Non-covered item or service
Disposable pump
Sensor
Transmitter
Receiver
Enter feed supkit syr by day
Enteral feed supp pump per d
Enteral feed sup kit grav by
Enteral ng tubing w/ stylet
Enteral ng tubing w/o stylet
Enteral stomach tube levine
Gastro/jejuno tube, std
Gastro/jejuno tube, low-pro
Food thickener oral
EF adult fluids and electro
EF ped fluid and electrolyte
Additive for enteral formula
EF blenderized foods
EF complet w/intact nutrient
EF calorie dense>/=1.5Kcal
EF hydrolyzed/amino acids
EF spec metabolic noninherit
EF incomplete/modular
EF special metabolic inherit
EF ped complete intact nut
EF ped complete soy based
EF ped caloric dense>/=0.7kc
EF ped hydrolyzed/amino acid
EF ped specmetabolic inherit
Parenteral 50% dextrose solu
Page 18 of 116
Effective Date
Maximum Allowable
12/1/2013
0.97
12/1/2013
27.50
12/1/2013
11.00
12/1/2013
575.00
12/1/2013
500.00
12/1/2013
4.68
12/1/2013
6.94
12/1/2013
6.14
12/1/2013
20.73
12/1/2013
15.41
12/1/2013
2.37
12/1/2013
34.21
12/1/2013
34.21
12/1/2013
0.57
12/1/2013
5.31
12/1/2013
5.31
12/1/2013
1.49
12/1/2013
1.50
12/1/2013
0.69
12/1/2013
0.53
12/1/2013
1.62
12/1/2013
1.09
12/1/2013
1.62
12/1/2013
4.15
12/1/2013
1.24
12/1/2013
1.24
12/1/2013
1.29
12/1/2013
2.19
12/1/2013
2.87
12/1/2013
16.24
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
B4168
B4176
B4178
B4180
B4185
B4189
B4193
B4197
B4199
B4216
B4220
B4222
B4224
B5000
B5100
B9000
B9000NU
B9000RR
B9000UE
B9002
B9002NU
B9002RR
B9002UE
B9004
B9004NU
B9004RR
B9004UE
B9006
B9006NU
B9006RR
Modifier
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Description
Parenteral sol amino acid 3.
Parenteral sol amino acid 7Parenteral sol amino acid >
Parenteral sol carb > 50%
Parenteral sol 10 gm lipids
Parenteral sol amino acid &
Parenteral sol 52-73 gm prot
Parenteral sol 74-100 gm pro
Parenteral sol > 100gm prote
Parenteral nutrition additiv
Parenteral supply kit premix
Parenteral supply kit homemi
Parenteral administration ki
Parenteral sol renal-amirosy
Parenteral sol hepatic-fream
Enter infusion pump w/o alrm
Enter infusion pump w/o alrm
Enter infusion pump w/o alrm
Enter infusion pump w/o alrm
Enteral infusion pump w/ ala
Enteral infusion pump w/ ala
Enteral infusion pump w/ ala
Enteral infusion pump w/ ala
Parenteral infus pump portab
Parenteral infus pump portab
Parenteral infus pump portab
Parenteral infus pump portab
Parenteral infus pump statio
Parenteral infus pump statio
Parenteral infus pump statio
Page 19 of 116
Effective Date
Maximum Allowable
12/1/2013
23.67
12/1/2013
45.81
12/1/2013
54.99
12/1/2013
23.31
12/1/2013
10.74
12/1/2013
169.87
12/1/2013
219.50
12/1/2013
267.24
12/1/2013
305.36
12/1/2013
7.38
12/1/2013
7.65
12/1/2013
9.43
12/1/2013
23.89
12/1/2013
11.36
12/1/2013
4.44
12/1/2013
95.74
12/1/2013
1,041.91
12/1/2013
95.74
12/1/2013
781.44
12/1/2013
94.05
12/1/2013
940.54
12/1/2013
94.05
12/1/2013
658.38
12/1/2013
381.72
12/1/2013
2,411.31
12/1/2013
381.72
12/1/2013
1,808.48
12/1/2013
381.72
12/1/2013
2,411.31
12/1/2013
381.72
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
B9006UE
E0100
E0100NU
E0100RR
E0100UE
E0105
E0105NU
E0105RR
E0105UE
E0110
E0110NU
E0110RR
E0110UE
E0111
E0111NU
E0111RR
E0111UE
E0112
E0112NU
E0112RR
E0112UE
E0113
E0113NU
E0113RR
E0113UE
E0114
E0114NU
E0114RR
E0114UE
E0116
Modifier
Description
UE
Parenteral infus pump statio
Cane adjust/fixed with tip
NU
Cane adjust/fixed with tip
RR
Cane adjust/fixed with tip
UE
Cane adjust/fixed with tip
Cane adjust/fixed quad/3 pro
NU
Cane adjust/fixed quad/3 pro
RR
Cane adjust/fixed quad/3 pro
UE
Cane adjust/fixed quad/3 pro
Crutch forearm pair
NU
Crutch forearm pair
RR
Crutch forearm pair
UE
Crutch forearm pair
Crutch forearm each
NU
Crutch forearm each
RR
Crutch forearm each
UE
Crutch forearm each
Crutch underarm pair wood
NU
Crutch underarm pair wood
RR
Crutch underarm pair wood
UE
Crutch underarm pair wood
Crutch underarm each wood
NU
Crutch underarm each wood
RR
Crutch underarm each wood
UE
Crutch underarm each wood
Crutch underarm pair no wood
NU
Crutch underarm pair no wood
RR
Crutch underarm pair no wood
UE
Crutch underarm pair no wood
Crutch underarm each no wood
Page 20 of 116
Effective Date
Maximum Allowable
12/1/2013
1,808.48
12/1/2013
1.36
12/1/2013
13.58
12/1/2013
1.36
12/1/2013
9.51
12/1/2013
3.17
12/1/2013
31.66
12/1/2013
3.17
12/1/2013
22.16
12/1/2013
4.70
12/1/2013
46.95
12/1/2013
4.70
12/1/2013
32.87
12/1/2013
3.27
12/1/2013
32.66
12/1/2013
3.27
12/1/2013
22.86
12/1/2013
2.39
12/1/2013
23.85
12/1/2013
2.39
12/1/2013
16.70
12/1/2013
4.02
12/1/2013
19.45
12/1/2013
4.02
12/1/2013
14.59
12/1/2013
2.48
12/1/2013
24.75
12/1/2013
2.48
12/1/2013
17.33
12/1/2013
4.22
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0116NU
E0116RR
E0116UE
E0117
E0117NU
E0117RR
E0117UE
E0118
E0130
E0130NU
E0130RR
E0130UE
E0135
E0135NU
E0135RR
E0135UE
E0140
E0140NU
E0140RR
E0140UE
E0141
E0141NU
E0141RR
E0141UE
E0143
E0143NU
E0143RR
E0143UE
E0144
E0144NU
Modifier
Description
NU
Crutch underarm each no wood
RR
Crutch underarm each no wood
UE
Crutch underarm each no wood
Underarm springassist crutch
NU
Underarm springassist crutch
RR
Underarm springassist crutch
UE
Underarm springassist crutch
Crutch substitute
Walker rigid adjust/fixed ht
NU
Walker rigid adjust/fixed ht
RR
Walker rigid adjust/fixed ht
UE
Walker rigid adjust/fixed ht
Walker folding adjust/fixed
NU
Walker folding adjust/fixed
RR
Walker folding adjust/fixed
UE
Walker folding adjust/fixed
Walker w trunk support
NU
Walker w trunk support
RR
Walker w trunk support
UE
Walker w trunk support
Rigid wheeled walker adj/fix
NU
Rigid wheeled walker adj/fix
RR
Rigid wheeled walker adj/fix
UE
Rigid wheeled walker adj/fix
Walker folding wheeled w/o s
NU
Walker folding wheeled w/o s
RR
Walker folding wheeled w/o s
UE
Walker folding wheeled w/o s
Enclosed walker w rear seat
NU
Enclosed walker w rear seat
Page 21 of 116
Effective Date
Maximum Allowable
12/1/2013
25.53
12/1/2013
4.22
12/1/2013
19.22
12/1/2013
17.72
12/1/2013
177.36
12/1/2013
17.72
12/1/2013
133.03
12/1/2013
350.00
12/1/2013
4.82
12/1/2013
48.24
12/1/2013
4.82
12/1/2013
33.77
12/1/2013
4.66
12/1/2013
46.58
12/1/2013
4.66
12/1/2013
32.61
12/1/2013
28.62
12/1/2013
286.12
12/1/2013
28.62
12/1/2013
214.60
12/1/2013
15.09
12/1/2013
91.45
12/1/2013
15.09
12/1/2013
68.59
12/1/2013
6.65
12/1/2013
66.50
12/1/2013
6.65
12/1/2013
46.55
12/1/2013
25.27
12/1/2013
252.60
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0144RR
E0144UE
E0147
E0147NU
E0147RR
E0147UE
E0148
E0148NU
E0148RR
E0148UE
E0149
E0149NU
E0149RR
E0149UE
E0153
E0153NU
E0153RR
E0153UE
E0154
E0154NU
E0154RR
E0154UE
E0155
E0155NU
E0155RR
E0155UE
E0156
E0156NU
E0156RR
E0156UE
Modifier
Description
RR
Enclosed walker w rear seat
UE
Enclosed walker w rear seat
Walker variable wheel resist
NU
Walker variable wheel resist
RR
Walker variable wheel resist
UE
Walker variable wheel resist
Heavyduty walker no wheels
NU
Heavyduty walker no wheels
RR
Heavyduty walker no wheels
UE
Heavyduty walker no wheels
Heavy duty wheeled walker
NU
Heavy duty wheeled walker
RR
Heavy duty wheeled walker
UE
Heavy duty wheeled walker
Forearm crutch platform atta
NU
Forearm crutch platform atta
RR
Forearm crutch platform atta
UE
Forearm crutch platform atta
Walker platform attachment
NU
Walker platform attachment
RR
Walker platform attachment
UE
Walker platform attachment
Walker wheel attachment,pair
NU
Walker wheel attachment,pair
RR
Walker wheel attachment,pair
UE
Walker wheel attachment,pair
Walker seat attachment
NU
Walker seat attachment
RR
Walker seat attachment
UE
Walker seat attachment
Page 22 of 116
Effective Date
Maximum Allowable
12/1/2013
25.27
12/1/2013
189.44
12/1/2013
31.93
12/1/2013
319.29
12/1/2013
31.93
12/1/2013
223.50
12/1/2013
18.83
12/1/2013
188.27
12/1/2013
18.83
12/1/2013
131.79
12/1/2013
12.40
12/1/2013
123.99
12/1/2013
12.40
12/1/2013
86.79
12/1/2013
4.47
12/1/2013
44.72
12/1/2013
4.47
12/1/2013
31.30
12/1/2013
4.68
12/1/2013
46.82
12/1/2013
4.68
12/1/2013
32.77
12/1/2013
1.49
12/1/2013
14.90
12/1/2013
1.49
12/1/2013
10.43
12/1/2013
1.96
12/1/2013
19.58
12/1/2013
1.96
12/1/2013
13.71
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0157
E0157NU
E0157RR
E0157UE
E0158
E0158NU
E0158RR
E0158UE
E0159
E0159NU
E0159RR
E0159UE
E0160
E0160NU
E0160RR
E0160UE
E0161
E0161NU
E0161RR
E0161UE
E0162
E0162NU
E0162RR
E0162UE
E0163
E0163NU
E0163RR
E0163UE
E0165
E0165NU
Modifier
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
Description
Walker crutch attachment
Walker crutch attachment
Walker crutch attachment
Walker crutch attachment
Walker leg extenders set of4
Walker leg extenders set of4
Walker leg extenders set of4
Walker leg extenders set of4
Brake for wheeled walker
Brake for wheeled walker
Brake for wheeled walker
Brake for wheeled walker
Sitz type bath or equipment
Sitz type bath or equipment
Sitz type bath or equipment
Sitz type bath or equipment
Sitz bath/equipment w/faucet
Sitz bath/equipment w/faucet
Sitz bath/equipment w/faucet
Sitz bath/equipment w/faucet
Sitz bath chair
Sitz bath chair
Sitz bath chair
Sitz bath chair
Commode chair with fixed arm
Commode chair with fixed arm
Commode chair with fixed arm
Commode chair with fixed arm
Commode chair with detacharm
Commode chair with detacharm
Page 23 of 116
Effective Date
Maximum Allowable
12/1/2013
7.14
12/1/2013
64.99
12/1/2013
7.14
12/1/2013
48.74
12/1/2013
1.98
12/1/2013
19.82
12/1/2013
1.98
12/1/2013
13.87
12/1/2013
1.48
12/1/2013
14.84
12/1/2013
1.48
12/1/2013
10.39
12/1/2013
2.13
12/1/2013
21.31
12/1/2013
2.13
12/1/2013
14.92
12/1/2013
1.69
12/1/2013
16.90
12/1/2013
1.69
12/1/2013
11.83
12/1/2013
11.95
12/1/2013
113.99
12/1/2013
11.95
12/1/2013
88.39
12/1/2013
6.00
12/1/2013
59.95
12/1/2013
6.00
12/1/2013
41.97
12/1/2013
4.20
12/1/2013
41.97
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0165RR
E0167
E0167NU
E0167RR
E0167UE
E0168
E0168NU
E0168RR
E0168UE
E0170
E0170NU
E0170RR
E0171
E0171NU
E0171RR
E0175
E0175NU
E0175RR
E0175UE
E0181
E0181NU
E0181RR
E0182
E0182NU
E0182RR
E0184
E0184NU
E0184RR
E0184UE
E0185
Modifier
Description
RR
Commode chair with detacharm
Commode chair pail or pan
NU
Commode chair pail or pan
RR
Commode chair pail or pan
UE
Commode chair pail or pan
Heavyduty/wide commode chair
NU
Heavyduty/wide commode chair
RR
Heavyduty/wide commode chair
UE
Heavyduty/wide commode chair
Commode chair electric
NU
Commode chair electric
RR
Commode chair electric
Commode chair non-electric
NU
Commode chair non-electric
RR
Commode chair non-electric
Commode chair foot rest
NU
Commode chair foot rest
RR
Commode chair foot rest
UE
Commode chair foot rest
Press pad alternating w/ pum
NU
Press pad alternating w/ pum
RR
Press pad alternating w/ pum
Replace pump, alt press pad
NU
Replace pump, alt press pad
RR
Replace pump, alt press pad
Dry pressure mattress
NU
Dry pressure mattress
RR
Dry pressure mattress
UE
Dry pressure mattress
Gel pressure mattress pad
Page 24 of 116
Effective Date
Maximum Allowable
12/1/2013
4.20
12/1/2013
0.77
12/1/2013
7.74
12/1/2013
0.77
12/1/2013
5.42
12/1/2013
9.73
12/1/2013
97.27
12/1/2013
9.73
12/1/2013
68.09
12/1/2013
147.92
12/1/2013
1,479.20
12/1/2013
147.92
12/1/2013
26.62
12/1/2013
266.20
12/1/2013
26.62
12/1/2013
6.09
12/1/2013
60.95
12/1/2013
6.09
12/1/2013
44.86
12/1/2013
23.98
12/1/2013
239.80
12/1/2013
23.98
12/1/2013
24.09
12/1/2013
240.90
12/1/2013
24.09
12/1/2013
22.43
12/1/2013
179.19
12/1/2013
22.43
12/1/2013
137.42
12/1/2013
40.42
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0185NU
E0185RR
E0185UE
E0186
E0186NU
E0186RR
E0187
E0187NU
E0187RR
E0188
E0188NU
E0188RR
E0188UE
E0189
E0189NU
E0189RR
E0189UE
E0191
E0191NU
E0191RR
E0191UE
E0193
E0193NU
E0193RR
E0194
E0194NU
E0194RR
E0196
E0196NU
E0196RR
Modifier
Description
NU
Gel pressure mattress pad
RR
Gel pressure mattress pad
UE
Gel pressure mattress pad
Air pressure mattress
NU
Air pressure mattress
RR
Air pressure mattress
Water pressure mattress
NU
Water pressure mattress
RR
Water pressure mattress
Synthetic sheepskin pad
NU
Synthetic sheepskin pad
RR
Synthetic sheepskin pad
UE
Synthetic sheepskin pad
Lambswool sheepskin pad
NU
Lambswool sheepskin pad
RR
Lambswool sheepskin pad
UE
Lambswool sheepskin pad
Protector heel or elbow
NU
Protector heel or elbow
RR
Protector heel or elbow
UE
Protector heel or elbow
Powered air flotation bed
NU
Powered air flotation bed
RR
Powered air flotation bed
Air fluidized bed
NU
Air fluidized bed
RR
Air fluidized bed
Gel pressure mattress
NU
Gel pressure mattress
RR
Gel pressure mattress
Page 25 of 116
Effective Date
Maximum Allowable
12/1/2013
294.36
12/1/2013
40.42
12/1/2013
225.91
12/1/2013
18.68
12/1/2013
186.80
12/1/2013
18.68
12/1/2013
21.36
12/1/2013
213.60
12/1/2013
21.36
12/1/2013
2.43
12/1/2013
22.07
12/1/2013
2.43
12/1/2013
16.57
12/1/2013
5.18
12/1/2013
47.83
12/1/2013
5.18
12/1/2013
35.87
12/1/2013
0.94
12/1/2013
9.20
12/1/2013
0.94
12/1/2013
6.86
12/1/2013
716.63
12/1/2013
7,166.30
12/1/2013
716.63
12/1/2013
2,995.00
12/1/2013
29,950.00
12/1/2013
2,995.00
12/1/2013
25.41
12/1/2013
254.10
12/1/2013
25.41
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0197
E0197NU
E0197RR
E0197UE
E0198
E0198NU
E0198RR
E0198UE
E0199
E0199NU
E0199RR
E0199UE
E0200
E0200NU
E0200RR
E0200UE
E0202
E0202NU
E0202RR
E0203
E0205
E0205NU
E0205RR
E0205UE
E0210
E0210NU
E0210RR
E0210UE
E0215
E0215NU
Modifier
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
UE
NU
RR
UE
NU
Description
Air pressure pad for mattres
Air pressure pad for mattres
Air pressure pad for mattres
Air pressure pad for mattres
Water pressure pad for mattr
Water pressure pad for mattr
Water pressure pad for mattr
Water pressure pad for mattr
Dry pressure pad for mattres
Dry pressure pad for mattres
Dry pressure pad for mattres
Dry pressure pad for mattres
Heat lamp without stand
Heat lamp without stand
Heat lamp without stand
Heat lamp without stand
Phototherapy light w/ photom
Phototherapy light w/ photom
Phototherapy light w/ photom
Therapeutic lightbox tabletp
Heat lamp with stand
Heat lamp with stand
Heat lamp with stand
Heat lamp with stand
Electric heat pad standard
Electric heat pad standard
Electric heat pad standard
Electric heat pad standard
Electric heat pad moist
Electric heat pad moist
Page 26 of 116
Effective Date
Maximum Allowable
12/1/2013
28.13
12/1/2013
203.92
12/1/2013
28.13
12/1/2013
179.13
12/1/2013
21.13
12/1/2013
203.92
12/1/2013
21.13
12/1/2013
154.73
12/1/2013
2.94
12/1/2013
29.50
12/1/2013
2.94
12/1/2013
22.13
12/1/2013
8.51
12/1/2013
72.96
12/1/2013
8.51
12/1/2013
54.75
12/1/2013
48.98
12/1/2013
489.80
12/1/2013
48.98
12/1/2013
179.95
12/1/2013
16.69
12/1/2013
151.81
12/1/2013
16.69
12/1/2013
113.85
12/1/2013
2.53
12/1/2013
25.33
12/1/2013
2.53
12/1/2013
17.73
12/1/2013
3.88
12/1/2013
38.81
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0215RR
E0215UE
E0217
E0217NU
E0217RR
E0217UE
E0225
E0225NU
E0225RR
E0225UE
E0235
E0235NU
E0235RR
E0236
E0236NU
E0236RR
E0239
E0239NU
E0239RR
E0239UE
E0240
E0241
E0242
E0243
E0244
E0245
E0246
E0247
E0248
E0249
Modifier
Description
RR
Electric heat pad moist
UE
Electric heat pad moist
Water circ heat pad w pump
NU
Water circ heat pad w pump
RR
Water circ heat pad w pump
UE
Water circ heat pad w pump
Hydrocollator unit
NU
Hydrocollator unit
RR
Hydrocollator unit
UE
Hydrocollator unit
Paraffin bath unit portable
NU
Paraffin bath unit portable
RR
Paraffin bath unit portable
Pump for water circulating p
NU
Pump for water circulating p
RR
Pump for water circulating p
Hydrocollator unit portable
NU
Hydrocollator unit portable
RR
Hydrocollator unit portable
UE
Hydrocollator unit portable
Bath/shower chair
Bath tub wall rail
Bath tub rail floor
Toilet rail
Toilet seat raised
Tub stool or bench
Transfer tub rail attachment
Trans bench w/wo comm open
HDtrans bench w/wo comm open
Pad water circulating heat u
Page 27 of 116
Effective Date
Maximum Allowable
12/1/2013
3.88
12/1/2013
27.17
12/1/2013
50.86
12/1/2013
456.91
12/1/2013
50.86
12/1/2013
342.65
12/1/2013
35.26
12/1/2013
357.67
12/1/2013
35.26
12/1/2013
268.24
12/1/2013
15.50
12/1/2013
155.00
12/1/2013
15.50
12/1/2013
40.61
12/1/2013
406.10
12/1/2013
40.61
12/1/2013
35.19
12/1/2013
351.88
12/1/2013
35.19
12/1/2013
263.93
12/1/2013
182.07
12/1/2013
39.95
12/1/2013
39.95
12/1/2013
35.85
12/1/2013
34.35
12/1/2013
39.95
12/1/2013
39.95
12/1/2013
78.95
12/1/2013
140.00
12/1/2013
9.16
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0249NU
E0249RR
E0249UE
E0250
E0250NU
E0250RR
E0251
E0251NU
E0251RR
E0255
E0255NU
E0255RR
E0256
E0256NU
E0256RR
E0260
E0260NU
E0260RR
E0261
E0261NU
E0261RR
E0265
E0265NU
E0265RR
E0266
E0266NU
E0266RR
E0271
E0271NU
E0271RR
Modifier
Description
NU
Pad water circulating heat u
RR
Pad water circulating heat u
UE
Pad water circulating heat u
Hosp bed fixed ht w/ mattres
NU
Hosp bed fixed ht w/ mattres
RR
Hosp bed fixed ht w/ mattres
Hosp bed fixd ht w/o mattres
NU
Hosp bed fixd ht w/o mattres
RR
Hosp bed fixd ht w/o mattres
Hospital bed var ht w/ mattr
NU
Hospital bed var ht w/ mattr
RR
Hospital bed var ht w/ mattr
Hospital bed var ht w/o matt
NU
Hospital bed var ht w/o matt
RR
Hospital bed var ht w/o matt
Hosp bed semi-electr w/ matt
NU
Hosp bed semi-electr w/ matt
RR
Hosp bed semi-electr w/ matt
Hosp bed semi-electr w/o mat
NU
Hosp bed semi-electr w/o mat
RR
Hosp bed semi-electr w/o mat
Hosp bed total electr w/ mat
NU
Hosp bed total electr w/ mat
RR
Hosp bed total electr w/ mat
Hosp bed total elec w/o matt
NU
Hosp bed total elec w/o matt
RR
Hosp bed total elec w/o matt
Mattress innerspring
NU
Mattress innerspring
RR
Mattress innerspring
Page 28 of 116
Effective Date
Maximum Allowable
12/1/2013
91.67
12/1/2013
9.16
12/1/2013
68.75
12/1/2013
73.02
12/1/2013
730.20
12/1/2013
73.02
12/1/2013
55.87
12/1/2013
558.70
12/1/2013
55.87
12/1/2013
79.21
12/1/2013
792.10
12/1/2013
79.21
12/1/2013
60.40
12/1/2013
604.00
12/1/2013
60.40
12/1/2013
111.42
12/1/2013
1,114.20
12/1/2013
111.42
12/1/2013
108.62
12/1/2013
1,086.20
12/1/2013
108.62
12/1/2013
158.55
12/1/2013
1,585.50
12/1/2013
158.55
12/1/2013
132.96
12/1/2013
1,329.60
12/1/2013
132.96
12/1/2013
18.29
12/1/2013
176.13
12/1/2013
18.29
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0271UE
E0272
E0272NU
E0272RR
E0272UE
E0275
E0275NU
E0275RR
E0275UE
E0276
E0276NU
E0276RR
E0276UE
E0277
E0277NU
E0277RR
E0280
E0280NU
E0280RR
E0280UE
E0290
E0290NU
E0290RR
E0291
E0291NU
E0291RR
E0292
E0292NU
E0292RR
E0293
Modifier
Description
UE
Mattress innerspring
Mattress foam rubber
NU
Mattress foam rubber
RR
Mattress foam rubber
UE
Mattress foam rubber
Bed pan standard
NU
Bed pan standard
RR
Bed pan standard
UE
Bed pan standard
Bed pan fracture
NU
Bed pan fracture
RR
Bed pan fracture
UE
Bed pan fracture
Powered pres-redu air mattrs
NU
Powered pres-redu air mattrs
RR
Powered pres-redu air mattrs
Bed cradle
NU
Bed cradle
RR
Bed cradle
UE
Bed cradle
Hosp bed fx ht w/o rails w/m
NU
Hosp bed fx ht w/o rails w/m
RR
Hosp bed fx ht w/o rails w/m
Hosp bed fx ht w/o rail w/o
NU
Hosp bed fx ht w/o rail w/o
RR
Hosp bed fx ht w/o rail w/o
Hosp bed var ht w/o rail w/o
NU
Hosp bed var ht w/o rail w/o
RR
Hosp bed var ht w/o rail w/o
Hosp bed var ht w/o rail w/
Page 29 of 116
Effective Date
Maximum Allowable
12/1/2013
137.58
12/1/2013
14.25
12/1/2013
136.44
12/1/2013
14.25
12/1/2013
101.85
12/1/2013
1.47
12/1/2013
14.09
12/1/2013
1.47
12/1/2013
10.57
12/1/2013
1.23
12/1/2013
10.47
12/1/2013
1.23
12/1/2013
8.23
12/1/2013
558.00
12/1/2013
5,580.00
12/1/2013
558.00
12/1/2013
2.86
12/1/2013
28.43
12/1/2013
2.86
12/1/2013
21.33
12/1/2013
55.11
12/1/2013
551.10
12/1/2013
55.11
12/1/2013
39.40
12/1/2013
394.00
12/1/2013
39.40
12/1/2013
61.09
12/1/2013
610.90
12/1/2013
61.09
12/1/2013
49.30
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0293NU
E0293RR
E0294
E0294NU
E0294RR
E0295
E0295NU
E0295RR
E0296
E0296NU
E0296RR
E0297
E0297NU
E0297RR
E0300
E0300NU
E0300RR
E0300UE
E0301
E0301NU
E0301RR
E0302
E0302NU
E0302RR
E0303
E0303NU
E0303RR
E0304
E0304NU
E0304RR
Modifier
Description
NU
Hosp bed var ht w/o rail w/
RR
Hosp bed var ht w/o rail w/
Hosp bed semi-elect w/ mattr
NU
Hosp bed semi-elect w/ mattr
RR
Hosp bed semi-elect w/ mattr
Hosp bed semi-elect w/o matt
NU
Hosp bed semi-elect w/o matt
RR
Hosp bed semi-elect w/o matt
Hosp bed total elect w/ matt
NU
Hosp bed total elect w/ matt
RR
Hosp bed total elect w/ matt
Hosp bed total elect w/o mat
NU
Hosp bed total elect w/o mat
RR
Hosp bed total elect w/o mat
Enclosed ped crib hosp grade
NU
Enclosed ped crib hosp grade
RR
Enclosed ped crib hosp grade
UE
Enclosed ped crib hosp grade
HD hosp bed, 350-600 lbs
NU
HD hosp bed, 350-600 lbs
RR
HD hosp bed, 350-600 lbs
Ex hd hosp bed > 600 lbs
NU
Ex hd hosp bed > 600 lbs
RR
Ex hd hosp bed > 600 lbs
Hosp bed hvy dty xtra wide
NU
Hosp bed hvy dty xtra wide
RR
Hosp bed hvy dty xtra wide
Hosp bed xtra hvy dty x wide
NU
Hosp bed xtra hvy dty x wide
RR
Hosp bed xtra hvy dty x wide
Page 30 of 116
Effective Date
Maximum Allowable
12/1/2013
493.00
12/1/2013
49.30
12/1/2013
103.63
12/1/2013
1,036.30
12/1/2013
103.63
12/1/2013
101.01
12/1/2013
1,010.10
12/1/2013
101.01
12/1/2013
130.25
12/1/2013
1,302.50
12/1/2013
130.25
12/1/2013
110.76
12/1/2013
1,107.60
12/1/2013
110.76
12/1/2013
225.16
12/1/2013
2,251.64
12/1/2013
225.16
12/1/2013
1,688.73
12/1/2013
214.74
12/1/2013
2,147.40
12/1/2013
214.74
12/1/2013
567.49
12/1/2013
5,674.90
12/1/2013
567.49
12/1/2013
241.12
12/1/2013
2,411.20
12/1/2013
241.12
12/1/2013
611.31
12/1/2013
6,113.10
12/1/2013
611.31
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0305
E0305NU
E0305RR
E0310
E0310NU
E0310RR
E0310UE
E0316
E0316NU
E0316RR
E0325
E0325NU
E0325RR
E0325UE
E0326
E0326NU
E0326RR
E0326UE
E0371
E0371NU
E0371RR
E0372
E0372NU
E0372RR
E0373
E0373NU
E0373RR
E0424
E0424RR
E0431
Modifier
NU
RR
NU
RR
UE
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
NU
RR
RR
Description
Rails bed side half length
Rails bed side half length
Rails bed side half length
Rails bed side full length
Rails bed side full length
Rails bed side full length
Rails bed side full length
Bed safety enclosure
Bed safety enclosure
Bed safety enclosure
Urinal male jug-type
Urinal male jug-type
Urinal male jug-type
Urinal male jug-type
Urinal female jug-type
Urinal female jug-type
Urinal female jug-type
Urinal female jug-type
Nonpower mattress overlay
Nonpower mattress overlay
Nonpower mattress overlay
Powered air mattress overlay
Powered air mattress overlay
Powered air mattress overlay
Nonpowered pressure mattress
Nonpowered pressure mattress
Nonpowered pressure mattress
Stationary compressed gas 02
Stationary compressed gas 02
Portable gaseous 02
Page 31 of 116
Effective Date
Maximum Allowable
12/1/2013
13.46
12/1/2013
134.60
12/1/2013
13.46
12/1/2013
16.35
12/1/2013
137.40
12/1/2013
16.35
12/1/2013
103.07
12/1/2013
159.66
12/1/2013
1,596.60
12/1/2013
159.66
12/1/2013
1.39
12/1/2013
9.31
12/1/2013
1.39
12/1/2013
6.15
12/1/2013
0.94
12/1/2013
8.82
12/1/2013
0.94
12/1/2013
6.60
12/1/2013
352.56
12/1/2013
3,525.60
12/1/2013
352.56
12/1/2013
427.80
12/1/2013
4,278.00
12/1/2013
427.80
12/1/2013
487.41
12/1/2013
4,874.10
12/1/2013
487.41
12/1/2013
141.89
12/1/2013
141.89
12/1/2013
23.74
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0431RR
E0433
E0433RR
E0434
E0434RR
E0439
E0439RR
E0441
E0442
E0443
E0444
E0445
E0450
E0450RR
E0457
E0457NU
E0457RR
E0457UE
E0459
E0459NU
E0459RR
E0460
E0460RR
E0461
E0461RR
E0462
E0462NU
E0462RR
E0463
E0463RR
Modifier
Description
RR
Portable gaseous 02
Portable liquid oxygen sys
RR
Portable liquid oxygen sys
Portable liquid 02
RR
Portable liquid 02
Stationary liquid 02
RR
Stationary liquid 02
Stationary O2 contents, gas
Stationary O2 contents, liq
Portable 02 contents, gas
Portable 02 contents, liquid
Oximeter non-invasive
Vol control vent invasiv int
RR
Vol control vent invasiv int
Chest shell
NU
Chest shell
RR
Chest shell
UE
Chest shell
Chest wrap
NU
Chest wrap
RR
Chest wrap
Neg press vent portabl/statn
RR
Neg press vent portabl/statn
Vol control vent noninv int
RR
Vol control vent noninv int
Rocking bed w/ or w/o side r
NU
Rocking bed w/ or w/o side r
RR
Rocking bed w/ or w/o side r
Press supp vent invasive int
RR
Press supp vent invasive int
Page 32 of 116
Effective Date
Maximum Allowable
12/1/2013
23.74
12/1/2013
41.30
12/1/2013
41.30
12/1/2013
23.74
12/1/2013
23.74
12/1/2013
141.89
12/1/2013
141.89
12/1/2013
61.96
12/1/2013
61.96
12/1/2013
61.96
12/1/2013
61.96
12/1/2013
98.95
12/1/2013
753.37
12/1/2013
753.37
12/1/2013
56.56
12/1/2013
565.54
12/1/2013
56.56
12/1/2013
424.12
12/1/2013
46.83
12/1/2013
468.30
12/1/2013
46.83
12/1/2013
675.11
12/1/2013
675.11
12/1/2013
753.37
12/1/2013
753.37
12/1/2013
268.18
12/1/2013
2,681.80
12/1/2013
268.18
12/1/2013
1,294.31
12/1/2013
1,294.31
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0464
E0464RR
E0470
E0470NU
E0470RR
E0471
E0471NU
E0471RR
E0472
E0472NU
E0472RR
E0480
E0480NU
E0480RR
E0482
E0482NU
E0482RR
E0483
E0483NU
E0483RR
E0484
E0484NU
E0484RR
E0484UE
E0500
E0500RR
E0550
E0550NU
E0550RR
E0560
Modifier
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
UE
RR
NU
RR
Description
Press supp vent noninv int
Press supp vent noninv int
RAD w/o backup non-inv intfc
RAD w/o backup non-inv intfc
RAD w/o backup non-inv intfc
RAD w/backup non inv intrfc
RAD w/backup non inv intrfc
RAD w/backup non inv intrfc
RAD w backup invasive intrfc
RAD w backup invasive intrfc
RAD w backup invasive intrfc
Percussor elect/pneum home m
Percussor elect/pneum home m
Percussor elect/pneum home m
Cough stimulating device
Cough stimulating device
Cough stimulating device
Chest compression gen system
Chest compression gen system
Chest compression gen system
Non-elec oscillatory pep dvc
Non-elec oscillatory pep dvc
Non-elec oscillatory pep dvc
Non-elec oscillatory pep dvc
Ippb all types
Ippb all types
Humidif extens supple w ippb
Humidif extens supple w ippb
Humidif extens supple w ippb
Humidifier supplemental w/ i
Page 33 of 116
Effective Date
Maximum Allowable
12/1/2013
1,294.31
12/1/2013
1,294.31
12/1/2013
203.54
12/1/2013
2,035.40
12/1/2013
203.54
12/1/2013
509.38
12/1/2013
5,093.80
12/1/2013
509.38
12/1/2013
509.38
12/1/2013
5,093.80
12/1/2013
509.38
12/1/2013
40.44
12/1/2013
404.40
12/1/2013
40.44
12/1/2013
395.76
12/1/2013
3,957.60
12/1/2013
395.76
12/1/2013
978.41
12/1/2013
9,784.10
12/1/2013
978.41
12/1/2013
3.39
12/1/2013
33.98
12/1/2013
3.39
12/1/2013
25.50
12/1/2013
92.79
12/1/2013
92.79
12/1/2013
46.14
12/1/2013
461.40
12/1/2013
46.14
12/1/2013
13.56
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0560NU
E0560RR
E0560UE
E0561
E0561NU
E0561RR
E0561UE
E0562
E0562NU
E0562RR
E0562UE
E0565
E0565NU
E0565RR
E0570
E0570NU
E0570RR
E0572
E0572NU
E0572RR
E0574
E0574NU
E0574RR
E0575
E0575NU
E0575RR
E0580
E0580NU
E0580RR
E0580UE
Modifier
Description
NU
Humidifier supplemental w/ i
RR
Humidifier supplemental w/ i
UE
Humidifier supplemental w/ i
Humidifier nonheated w PAP
NU
Humidifier nonheated w PAP
RR
Humidifier nonheated w PAP
UE
Humidifier nonheated w PAP
Humidifier heated used w PAP
NU
Humidifier heated used w PAP
RR
Humidifier heated used w PAP
UE
Humidifier heated used w PAP
Compressor air power source
NU
Compressor air power source
RR
Compressor air power source
Nebulizer with compression
NU
Nebulizer with compression
RR
Nebulizer with compression
Aerosol compressor adjust pr
NU
Aerosol compressor adjust pr
RR
Aerosol compressor adjust pr
Ultrasonic generator w svneb
NU
Ultrasonic generator w svneb
RR
Ultrasonic generator w svneb
Nebulizer ultrasonic
NU
Nebulizer ultrasonic
RR
Nebulizer ultrasonic
Nebulizer for use w/ regulat
NU
Nebulizer for use w/ regulat
RR
Nebulizer for use w/ regulat
UE
Nebulizer for use w/ regulat
Page 34 of 116
Effective Date
Maximum Allowable
12/1/2013
127.02
12/1/2013
13.56
12/1/2013
95.27
12/1/2013
8.47
12/1/2013
84.87
12/1/2013
8.47
12/1/2013
63.65
12/1/2013
22.47
12/1/2013
224.88
12/1/2013
22.47
12/1/2013
168.66
12/1/2013
54.09
12/1/2013
540.90
12/1/2013
54.09
12/1/2013
7.30
12/1/2013
72.95
12/1/2013
7.30
12/1/2013
35.05
12/1/2013
350.50
12/1/2013
35.05
12/1/2013
24.90
12/1/2013
249.00
12/1/2013
24.90
12/1/2013
92.01
12/1/2013
920.10
12/1/2013
92.01
12/1/2013
10.01
12/1/2013
100.07
12/1/2013
10.01
12/1/2013
75.04
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0585
E0585NU
E0585RR
E0600
E0600NU
E0600RR
E0601
E0601NU
E0601RR
E0602
E0602NU
E0602RR
E0602UE
E0603
E0604
E0605
E0605NU
E0605RR
E0605UE
E0606
E0606NU
E0606RR
E0607
E0607NU
E0607RR
E0607UE
E0610
E0610NU
E0610RR
E0610UE
Modifier
NU
RR
NU
RR
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
UE
NU
RR
UE
Description
Nebulizer w/ compressor & he
Nebulizer w/ compressor & he
Nebulizer w/ compressor & he
Suction pump portab hom modl
Suction pump portab hom modl
Suction pump portab hom modl
Cont airway pressure device
Cont airway pressure device
Cont airway pressure device
Manual breast pump
Manual breast pump
Manual breast pump
Manual breast pump
Electric breast pump
Hosp grade elec breast pump
Vaporizer room type
Vaporizer room type
Vaporizer room type
Vaporizer room type
Drainage board postural
Drainage board postural
Drainage board postural
Blood glucose monitor home
Blood glucose monitor home
Blood glucose monitor home
Blood glucose monitor home
Pacemaker monitr audible/vis
Pacemaker monitr audible/vis
Pacemaker monitr audible/vis
Pacemaker monitr audible/vis
Page 35 of 116
Effective Date
Maximum Allowable
12/1/2013
27.43
12/1/2013
274.30
12/1/2013
27.43
12/1/2013
42.13
12/1/2013
421.30
12/1/2013
42.13
12/1/2013
88.61
12/1/2013
886.10
12/1/2013
88.61
12/1/2013
4.99
12/1/2013
49.94
12/1/2013
4.99
12/1/2013
34.96
12/1/2013
289.93
12/1/2013
1,430.00
12/1/2013
2.50
12/1/2013
22.90
12/1/2013
2.50
12/1/2013
18.86
12/1/2013
21.12
12/1/2013
211.20
12/1/2013
21.12
12/1/2013
6.15
12/1/2013
61.49
12/1/2013
6.15
12/1/2013
46.11
12/1/2013
20.67
12/1/2013
206.76
12/1/2013
20.67
12/1/2013
155.07
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0615
E0615NU
E0615RR
E0615UE
E0617
E0617NU
E0617RR
E0618
E0618NU
E0618RR
E0620
E0620NU
E0620RR
E0620UE
E0621
E0621NU
E0621RR
E0621UE
E0627
E0627NU
E0627RR
E0627UE
E0628
E0628NU
E0628RR
E0628UE
E0629
E0629NU
E0629RR
E0629UE
Modifier
NU
RR
UE
NU
RR
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
Description
Pacemaker monitr digital/vis
Pacemaker monitr digital/vis
Pacemaker monitr digital/vis
Pacemaker monitr digital/vis
Automatic ext defibrillator
Automatic ext defibrillator
Automatic ext defibrillator
Apnea monitor
Apnea monitor
Apnea monitor
Cap bld skin piercing laser
Cap bld skin piercing laser
Cap bld skin piercing laser
Cap bld skin piercing laser
Patient lift sling or seat
Patient lift sling or seat
Patient lift sling or seat
Patient lift sling or seat
Seat lift incorp lift-chair
Seat lift incorp lift-chair
Seat lift incorp lift-chair
Seat lift incorp lift-chair
Seat lift for pt furn-electr
Seat lift for pt furn-electr
Seat lift for pt furn-electr
Seat lift for pt furn-electr
Seat lift for pt furn-non-el
Seat lift for pt furn-non-el
Seat lift for pt furn-non-el
Seat lift for pt furn-non-el
Page 36 of 116
Effective Date
Maximum Allowable
12/1/2013
47.51
12/1/2013
440.66
12/1/2013
47.51
12/1/2013
330.51
12/1/2013
279.81
12/1/2013
2,798.10
12/1/2013
279.81
12/1/2013
258.02
12/1/2013
2,580.20
12/1/2013
258.02
12/1/2013
80.46
12/1/2013
804.70
12/1/2013
80.46
12/1/2013
603.53
12/1/2013
8.07
12/1/2013
80.64
12/1/2013
8.07
12/1/2013
60.48
12/1/2013
31.05
12/1/2013
310.45
12/1/2013
31.05
12/1/2013
232.83
12/1/2013
31.05
12/1/2013
310.45
12/1/2013
31.05
12/1/2013
232.83
12/1/2013
30.44
12/1/2013
304.36
12/1/2013
30.44
12/1/2013
228.24
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0630
E0630NU
E0630RR
E0635
E0635NU
E0635RR
E0636
E0636NU
E0636RR
E0650
E0650NU
E0650RR
E0650UE
E0651
E0651NU
E0651RR
E0651UE
E0652
E0652NU
E0652RR
E0652UE
E0655
E0655NU
E0655RR
E0655UE
E0656
E0656NU
E0656RR
E0656UE
E0657
Modifier
NU
RR
NU
RR
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
Description
Patient lift hydraulic
Patient lift hydraulic
Patient lift hydraulic
Patient lift electric
Patient lift electric
Patient lift electric
PT support & positioning sys
PT support & positioning sys
PT support & positioning sys
Pneuma compresor non-segment
Pneuma compresor non-segment
Pneuma compresor non-segment
Pneuma compresor non-segment
Pneum compressor segmental
Pneum compressor segmental
Pneum compressor segmental
Pneum compressor segmental
Pneum compres w/cal pressure
Pneum compres w/cal pressure
Pneum compres w/cal pressure
Pneum compres w/cal pressure
Pneumatic appliance half arm
Pneumatic appliance half arm
Pneumatic appliance half arm
Pneumatic appliance half arm
Segmental pneumatic trunk
Segmental pneumatic trunk
Segmental pneumatic trunk
Segmental pneumatic trunk
Segmental pneumatic chest
Page 37 of 116
Effective Date
Maximum Allowable
12/1/2013
91.46
12/1/2013
914.60
12/1/2013
91.46
12/1/2013
112.61
12/1/2013
1,126.10
12/1/2013
112.61
12/1/2013
970.52
12/1/2013
9,705.20
12/1/2013
970.52
12/1/2013
73.60
12/1/2013
662.82
12/1/2013
73.60
12/1/2013
497.11
12/1/2013
86.34
12/1/2013
845.23
12/1/2013
86.34
12/1/2013
633.93
12/1/2013
420.65
12/1/2013
4,206.53
12/1/2013
420.65
12/1/2013
3,154.89
12/1/2013
10.23
12/1/2013
99.33
12/1/2013
10.23
12/1/2013
74.59
12/1/2013
53.11
12/1/2013
531.67
12/1/2013
53.11
12/1/2013
398.80
12/1/2013
49.86
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0657NU
E0657RR
E0657UE
E0660
E0660NU
E0660RR
E0660UE
E0665
E0665NU
E0665RR
E0665UE
E0666
E0666NU
E0666RR
E0666UE
E0667
E0667NU
E0667RR
E0667UE
E0668
E0668NU
E0668RR
E0668UE
E0669
E0669NU
E0669RR
E0669UE
E0670
E0670NU
E0670RR
Modifier
Description
NU
Segmental pneumatic chest
RR
Segmental pneumatic chest
UE
Segmental pneumatic chest
Pneumatic appliance full leg
NU
Pneumatic appliance full leg
RR
Pneumatic appliance full leg
UE
Pneumatic appliance full leg
Pneumatic appliance full arm
NU
Pneumatic appliance full arm
RR
Pneumatic appliance full arm
UE
Pneumatic appliance full arm
Pneumatic appliance half leg
NU
Pneumatic appliance half leg
RR
Pneumatic appliance half leg
UE
Pneumatic appliance half leg
Seg pneumatic appl full leg
NU
Seg pneumatic appl full leg
RR
Seg pneumatic appl full leg
UE
Seg pneumatic appl full leg
Seg pneumatic appl full arm
NU
Seg pneumatic appl full arm
RR
Seg pneumatic appl full arm
UE
Seg pneumatic appl full arm
Seg pneumatic appli half leg
NU
Seg pneumatic appli half leg
RR
Seg pneumatic appli half leg
UE
Seg pneumatic appli half leg
Seg pneum int legs/trunk
NU
Seg pneum int legs/trunk
RR
Seg pneum int legs/trunk
Page 38 of 116
Effective Date
Maximum Allowable
12/1/2013
499.49
12/1/2013
49.86
12/1/2013
374.65
12/1/2013
15.30
12/1/2013
147.02
12/1/2013
15.30
12/1/2013
110.25
12/1/2013
12.95
12/1/2013
126.08
12/1/2013
12.95
12/1/2013
94.67
12/1/2013
13.10
12/1/2013
127.08
12/1/2013
13.10
12/1/2013
95.34
12/1/2013
33.64
12/1/2013
297.97
12/1/2013
33.64
12/1/2013
223.48
12/1/2013
34.11
12/1/2013
345.67
12/1/2013
34.11
12/1/2013
259.26
12/1/2013
16.88
12/1/2013
168.71
12/1/2013
16.88
12/1/2013
126.56
12/1/2013
120.36
12/1/2013
1,156.88
12/1/2013
120.36
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0670UE
E0671
E0671NU
E0671RR
E0671UE
E0672
E0672NU
E0672RR
E0672UE
E0673
E0673NU
E0673RR
E0673UE
E0675
E0675NU
E0675RR
E0691
E0691NU
E0691RR
E0691UE
E0692
E0692NU
E0692RR
E0692UE
E0693
E0693NU
E0693RR
E0693UE
E0694
E0694NU
Modifier
Description
UE
Seg pneum int legs/trunk
Pressure pneum appl full leg
NU
Pressure pneum appl full leg
RR
Pressure pneum appl full leg
UE
Pressure pneum appl full leg
Pressure pneum appl full arm
NU
Pressure pneum appl full arm
RR
Pressure pneum appl full arm
UE
Pressure pneum appl full arm
Pressure pneum appl half leg
NU
Pressure pneum appl half leg
RR
Pressure pneum appl half leg
UE
Pressure pneum appl half leg
Pneumatic compression device
NU
Pneumatic compression device
RR
Pneumatic compression device
Uvl pnl 2 sq ft or less
NU
Uvl pnl 2 sq ft or less
RR
Uvl pnl 2 sq ft or less
UE
Uvl pnl 2 sq ft or less
Uvl sys panel 4 ft
NU
Uvl sys panel 4 ft
RR
Uvl sys panel 4 ft
UE
Uvl sys panel 4 ft
Uvl sys panel 6 ft
NU
Uvl sys panel 6 ft
RR
Uvl sys panel 6 ft
UE
Uvl sys panel 6 ft
Uvl md cabinet sys 6 ft
NU
Uvl md cabinet sys 6 ft
Page 39 of 116
Effective Date
Maximum Allowable
12/1/2013
867.62
12/1/2013
38.24
12/1/2013
382.25
12/1/2013
38.24
12/1/2013
286.68
12/1/2013
29.71
12/1/2013
297.01
12/1/2013
29.71
12/1/2013
222.77
12/1/2013
24.68
12/1/2013
246.80
12/1/2013
24.68
12/1/2013
185.12
12/1/2013
353.91
12/1/2013
3,539.10
12/1/2013
353.91
12/1/2013
82.70
12/1/2013
826.98
12/1/2013
82.70
12/1/2013
620.24
12/1/2013
103.84
12/1/2013
1,038.46
12/1/2013
103.84
12/1/2013
778.85
12/1/2013
128.02
12/1/2013
1,280.13
12/1/2013
128.02
12/1/2013
960.09
12/1/2013
407.46
12/1/2013
4,074.53
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0694RR
E0694UE
E0700
E0705
E0705NU
E0705RR
E0705UE
E0710
E0720
E0720NU
E0730
E0730NU
E0731
E0731NU
E0740
E0740NU
E0740RR
E0740UE
E0744
E0744NU
E0744RR
E0745
E0745NU
E0745RR
E0747
E0747NU
E0747RR
E0747UE
E0748
E0748NU
Modifier
Description
RR
Uvl md cabinet sys 6 ft
UE
Uvl md cabinet sys 6 ft
Safety equipment
Transfer device
NU
Transfer device
RR
Transfer device
UE
Transfer device
Restraints any type
Tens two lead
NU
Tens two lead
Tens four lead
NU
Tens four lead
Conductive garment for tens/
NU
Conductive garment for tens/
Incontinence treatment systm
NU
Incontinence treatment systm
RR
Incontinence treatment systm
UE
Incontinence treatment systm
Neuromuscular stim for scoli
NU
Neuromuscular stim for scoli
RR
Neuromuscular stim for scoli
Neuromuscular stim for shock
NU
Neuromuscular stim for shock
RR
Neuromuscular stim for shock
Elec osteogen stim not spine
NU
Elec osteogen stim not spine
RR
Elec osteogen stim not spine
UE
Elec osteogen stim not spine
Elec osteogen stim spinal
NU
Elec osteogen stim spinal
Page 40 of 116
Effective Date
Maximum Allowable
12/1/2013
407.46
12/1/2013
3,055.91
12/1/2013
46.44
12/1/2013
3.67
12/1/2013
36.74
12/1/2013
3.67
12/1/2013
25.72
12/1/2013
15.92
12/1/2013
338.28
12/1/2013
338.28
12/1/2013
120.00
12/1/2013
120.00
12/1/2013
190.00
12/1/2013
190.00
12/1/2013
33.70
12/1/2013
336.98
12/1/2013
33.70
12/1/2013
235.89
12/1/2013
84.28
12/1/2013
842.80
12/1/2013
84.28
12/1/2013
40.00
12/1/2013
400.00
12/1/2013
40.00
12/1/2013
358.14
12/1/2013
3,604.00
12/1/2013
358.14
12/1/2013
2,677.70
12/1/2013
358.05
12/1/2013
3,580.65
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0748RR
E0748UE
E0749
E0749NU
E0749RR
E0760
E0760NU
E0760RR
E0760UE
E0762
E0762NU
E0762RR
E0762UE
E0764
E0764NU
E0764RR
E0764UE
E0765
E0765NU
E0765RR
E0765UE
E0776
E0776NU
E0776RR
E0776UE
E0779
E0779NU
E0779RR
E0780
E0780NU
Modifier
Description
RR
Elec osteogen stim spinal
UE
Elec osteogen stim spinal
Elec osteogen stim implanted
NU
Elec osteogen stim implanted
RR
Elec osteogen stim implanted
Osteogen ultrasound stimltor
NU
Osteogen ultrasound stimltor
RR
Osteogen ultrasound stimltor
UE
Osteogen ultrasound stimltor
Trans elec jt stim dev sys
NU
Trans elec jt stim dev sys
RR
Trans elec jt stim dev sys
UE
Trans elec jt stim dev sys
Functional neuromuscularstim
NU
Functional neuromuscularstim
RR
Functional neuromuscularstim
UE
Functional neuromuscularstim
Nerve stimulator for tx n&v
NU
Nerve stimulator for tx n&v
RR
Nerve stimulator for tx n&v
UE
Nerve stimulator for tx n&v
Iv pole
NU
Iv pole
RR
Iv pole
UE
Iv pole
Amb infusion pump mechanical
NU
Amb infusion pump mechanical
RR
Amb infusion pump mechanical
Mech amb infusion pump <8hrs
NU
Mech amb infusion pump <8hrs
Page 41 of 116
Effective Date
Maximum Allowable
12/1/2013
358.05
12/1/2013
2,685.50
12/1/2013
261.71
12/1/2013
2,617.10
12/1/2013
261.71
12/1/2013
297.56
12/1/2013
2,975.46
12/1/2013
297.56
12/1/2013
2,231.59
12/1/2013
68.50
12/1/2013
685.00
12/1/2013
68.50
12/1/2013
479.50
12/1/2013
1,018.48
12/1/2013
10,184.90
12/1/2013
1,018.48
12/1/2013
7,638.68
12/1/2013
7.75
12/1/2013
77.43
12/1/2013
7.75
12/1/2013
58.09
12/1/2013
7.84
12/1/2013
78.42
12/1/2013
7.84
12/1/2013
54.89
12/1/2013
15.39
12/1/2013
153.90
12/1/2013
15.39
12/1/2013
9.55
12/1/2013
9.55
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0781
E0781NU
E0781RR
E0782
E0782NU
E0782RR
E0782UE
E0783
E0783NU
E0783RR
E0783UE
E0784
E0784NU
E0784RR
E0785
E0785KF
E0786
E0786NU
E0786RR
E0786UE
E0791
E0791NU
E0791RR
E0840
E0840NU
E0840RR
E0840UE
E0849
E0849NU
E0849RR
Modifier
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
KF
NU
RR
UE
NU
RR
NU
RR
UE
NU
RR
Description
External ambulatory infus pu
External ambulatory infus pu
External ambulatory infus pu
Non-programble infusion pump
Non-programble infusion pump
Non-programble infusion pump
Non-programble infusion pump
Programmable infusion pump
Programmable infusion pump
Programmable infusion pump
Programmable infusion pump
Ext amb infusn pump insulin
Ext amb infusn pump insulin
Ext amb infusn pump insulin
Replacement impl pump cathet
Replacement impl pump cathet
Implantable pump replacement
Implantable pump replacement
Implantable pump replacement
Implantable pump replacement
Parenteral infusion pump sta
Parenteral infusion pump sta
Parenteral infusion pump sta
Tract frame attach headboard
Tract frame attach headboard
Tract frame attach headboard
Tract frame attach headboard
Cervical pneum trac equip
Cervical pneum trac equip
Cervical pneum trac equip
Page 42 of 116
Effective Date
Maximum Allowable
12/1/2013
243.76
12/1/2013
2,437.60
12/1/2013
243.76
12/1/2013
395.15
12/1/2013
3,951.27
12/1/2013
395.15
12/1/2013
2,963.46
12/1/2013
729.67
12/1/2013
7,296.76
12/1/2013
729.67
12/1/2013
5,472.56
12/1/2013
390.00
12/1/2013
3,900.00
12/1/2013
390.00
12/1/2013
369.62
12/1/2013
369.62
12/1/2013
734.93
12/1/2013
7,349.44
12/1/2013
734.93
12/1/2013
5,512.08
12/1/2013
291.01
12/1/2013
2,910.10
12/1/2013
291.01
12/1/2013
15.02
12/1/2013
67.43
12/1/2013
15.02
12/1/2013
50.55
12/1/2013
38.90
12/1/2013
389.00
12/1/2013
38.90
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0849UE
E0850
E0850NU
E0850RR
E0850UE
E0855
E0855NU
E0855RR
E0855UE
E0856
E0856NU
E0856RR
E0856UE
E0860
E0860NU
E0860RR
E0860UE
E0870
E0870NU
E0870RR
E0870UE
E0880
E0880NU
E0880RR
E0880UE
E0890
E0890NU
E0890RR
E0890UE
E0900
Modifier
Description
UE
Cervical pneum trac equip
Traction stand free standing
NU
Traction stand free standing
RR
Traction stand free standing
UE
Traction stand free standing
Cervical traction equipment
NU
Cervical traction equipment
RR
Cervical traction equipment
UE
Cervical traction equipment
Cervic collar w air bladder
NU
Cervic collar w air bladder
RR
Cervic collar w air bladder
UE
Cervic collar w air bladder
Tract equip cervical tract
NU
Tract equip cervical tract
RR
Tract equip cervical tract
UE
Tract equip cervical tract
Tract frame attach footboard
NU
Tract frame attach footboard
RR
Tract frame attach footboard
UE
Tract frame attach footboard
Trac stand free stand extrem
NU
Trac stand free stand extrem
RR
Trac stand free stand extrem
UE
Trac stand free stand extrem
Traction frame attach pelvic
NU
Traction frame attach pelvic
RR
Traction frame attach pelvic
UE
Traction frame attach pelvic
Trac stand free stand pelvic
Page 43 of 116
Effective Date
Maximum Allowable
12/1/2013
272.30
12/1/2013
13.27
12/1/2013
85.87
12/1/2013
13.27
12/1/2013
64.40
12/1/2013
45.49
12/1/2013
454.83
12/1/2013
45.49
12/1/2013
341.10
12/1/2013
14.16
12/1/2013
141.75
12/1/2013
14.16
12/1/2013
106.33
12/1/2013
5.99
12/1/2013
35.46
12/1/2013
5.99
12/1/2013
27.16
12/1/2013
10.77
12/1/2013
107.05
12/1/2013
10.77
12/1/2013
80.64
12/1/2013
18.15
12/1/2013
115.54
12/1/2013
18.15
12/1/2013
87.45
12/1/2013
26.97
12/1/2013
110.81
12/1/2013
26.97
12/1/2013
89.26
12/1/2013
25.42
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0900NU
E0900RR
E0900UE
E0910
E0910NU
E0910RR
E0911
E0911NU
E0911RR
E0912
E0912NU
E0912RR
E0920
E0920NU
E0920RR
E0930
E0930NU
E0930RR
E0935
E0935RR
E0940
E0940NU
E0940RR
E0941
E0941NU
E0941RR
E0942
E0942NU
E0942RR
E0942UE
Modifier
Description
NU
Trac stand free stand pelvic
RR
Trac stand free stand pelvic
UE
Trac stand free stand pelvic
Trapeze bar attached to bed
NU
Trapeze bar attached to bed
RR
Trapeze bar attached to bed
HD trapeze bar attach to bed
NU
HD trapeze bar attach to bed
RR
HD trapeze bar attach to bed
HD trapeze bar free standing
NU
HD trapeze bar free standing
RR
HD trapeze bar free standing
Fracture frame attached to b
NU
Fracture frame attached to b
RR
Fracture frame attached to b
Fracture frame free standing
NU
Fracture frame free standing
RR
Fracture frame free standing
Cont pas motion exercise dev
RR
Cont pas motion exercise dev
Trapeze bar free standing
NU
Trapeze bar free standing
RR
Trapeze bar free standing
Gravity assisted traction de
NU
Gravity assisted traction de
RR
Gravity assisted traction de
Cervical head harness/halter
NU
Cervical head harness/halter
RR
Cervical head harness/halter
UE
Cervical head harness/halter
Page 44 of 116
Effective Date
Maximum Allowable
12/1/2013
117.92
12/1/2013
25.42
12/1/2013
88.47
12/1/2013
14.73
12/1/2013
147.30
12/1/2013
14.73
12/1/2013
39.53
12/1/2013
395.30
12/1/2013
39.53
12/1/2013
90.81
12/1/2013
908.10
12/1/2013
90.81
12/1/2013
36.10
12/1/2013
361.00
12/1/2013
36.10
12/1/2013
42.04
12/1/2013
420.40
12/1/2013
42.04
12/1/2013
17.79
12/1/2013
17.79
12/1/2013
27.58
12/1/2013
275.80
12/1/2013
27.58
12/1/2013
33.95
12/1/2013
339.50
12/1/2013
33.95
12/1/2013
2.16
12/1/2013
18.27
12/1/2013
2.16
12/1/2013
13.69
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0944
E0944NU
E0944RR
E0944UE
E0945
E0945NU
E0945RR
E0945UE
E0946
E0946NU
E0946RR
E0947
E0947NU
E0947RR
E0947UE
E0948
E0948NU
E0948RR
E0948UE
E0950
E0950NU
E0950RR
E0950UE
E0951
E0951NU
E0951RR
E0951UE
E0952
E0952NU
E0952RR
Modifier
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Description
Pelvic belt/harness/boot
Pelvic belt/harness/boot
Pelvic belt/harness/boot
Pelvic belt/harness/boot
Belt/harness extremity
Belt/harness extremity
Belt/harness extremity
Belt/harness extremity
Fracture frame dual w cross
Fracture frame dual w cross
Fracture frame dual w cross
Fracture frame attachmnts pe
Fracture frame attachmnts pe
Fracture frame attachmnts pe
Fracture frame attachmnts pe
Fracture frame attachmnts ce
Fracture frame attachmnts ce
Fracture frame attachmnts ce
Fracture frame attachmnts ce
Tray
Tray
Tray
Tray
Loop heel
Loop heel
Loop heel
Loop heel
Toe loop/holder, each
Toe loop/holder, each
Toe loop/holder, each
Page 45 of 116
Effective Date
Maximum Allowable
12/1/2013
4.19
12/1/2013
41.82
12/1/2013
4.19
12/1/2013
31.37
12/1/2013
3.73
12/1/2013
37.37
12/1/2013
3.73
12/1/2013
28.02
12/1/2013
54.45
12/1/2013
544.50
12/1/2013
54.45
12/1/2013
49.19
12/1/2013
474.41
12/1/2013
49.19
12/1/2013
355.80
12/1/2013
53.97
12/1/2013
539.84
12/1/2013
53.97
12/1/2013
380.75
12/1/2013
8.26
12/1/2013
82.46
12/1/2013
8.26
12/1/2013
61.85
12/1/2013
1.55
12/1/2013
15.05
12/1/2013
1.55
12/1/2013
11.29
12/1/2013
1.55
12/1/2013
14.93
12/1/2013
1.55
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0952UE
E0955
E0955NU
E0955RR
E0955UE
E0956
E0956NU
E0956RR
E0956UE
E0957
E0957NU
E0957RR
E0957UE
E0958
E0958NU
E0958RR
E0959
E0959NU
E0959RR
E0959UE
E0960
E0960NU
E0960RR
E0960UE
E0961
E0961NU
E0961RR
E0961UE
E0966
E0966NU
Modifier
Description
UE
Toe loop/holder, each
Cushioned headrest
NU
Cushioned headrest
RR
Cushioned headrest
UE
Cushioned headrest
W/c lateral trunk/hip suppor
NU
W/c lateral trunk/hip suppor
RR
W/c lateral trunk/hip suppor
UE
W/c lateral trunk/hip suppor
W/c medial thigh support
NU
W/c medial thigh support
RR
W/c medial thigh support
UE
W/c medial thigh support
Whlchr att- conv 1 arm drive
NU
Whlchr att- conv 1 arm drive
RR
Whlchr att- conv 1 arm drive
Amputee adapter
NU
Amputee adapter
RR
Amputee adapter
UE
Amputee adapter
W/c shoulder harness/straps
NU
W/c shoulder harness/straps
RR
W/c shoulder harness/straps
UE
W/c shoulder harness/straps
Wheelchair brake extension
NU
Wheelchair brake extension
RR
Wheelchair brake extension
UE
Wheelchair brake extension
Wheelchair head rest extensi
NU
Wheelchair head rest extensi
Page 46 of 116
Effective Date
Maximum Allowable
12/1/2013
11.21
12/1/2013
16.05
12/1/2013
160.38
12/1/2013
16.05
12/1/2013
120.27
12/1/2013
7.82
12/1/2013
78.19
12/1/2013
7.82
12/1/2013
58.64
12/1/2013
10.94
12/1/2013
109.41
12/1/2013
10.94
12/1/2013
82.06
12/1/2013
40.15
12/1/2013
401.50
12/1/2013
40.15
12/1/2013
4.10
12/1/2013
40.68
12/1/2013
4.10
12/1/2013
30.79
12/1/2013
7.23
12/1/2013
72.17
12/1/2013
7.23
12/1/2013
54.14
12/1/2013
2.43
12/1/2013
23.27
12/1/2013
2.43
12/1/2013
11.97
12/1/2013
6.48
12/1/2013
65.69
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0966RR
E0966UE
E0967
E0967NU
E0967RR
E0967UE
E0968
E0968NU
E0968RR
E0969
E0969NU
E0969RR
E0969UE
E0971
E0971NU
E0971RR
E0971UE
E0973
E0973NU
E0973RR
E0973UE
E0974
E0974NU
E0974RR
E0974UE
E0978
E0978NU
E0978RR
E0978UE
E0980
Modifier
Description
RR
Wheelchair head rest extensi
UE
Wheelchair head rest extensi
Manual wc hand rim w project
NU
Manual wc hand rim w project
RR
Manual wc hand rim w project
UE
Manual wc hand rim w project
Wheelchair commode seat
NU
Wheelchair commode seat
RR
Wheelchair commode seat
Wheelchair narrowing device
NU
Wheelchair narrowing device
RR
Wheelchair narrowing device
UE
Wheelchair narrowing device
Wheelchair anti-tipping devi
NU
Wheelchair anti-tipping devi
RR
Wheelchair anti-tipping devi
UE
Wheelchair anti-tipping devi
W/Ch access det adj armrest
NU
W/Ch access det adj armrest
RR
W/Ch access det adj armrest
UE
W/Ch access det adj armrest
W/Ch access anti-rollback
NU
W/Ch access anti-rollback
RR
W/Ch access anti-rollback
UE
W/Ch access anti-rollback
W/C acc,saf belt pelv strap
NU
W/C acc,saf belt pelv strap
RR
W/C acc,saf belt pelv strap
UE
W/C acc,saf belt pelv strap
Wheelchair safety vest
Page 47 of 116
Effective Date
Maximum Allowable
12/1/2013
6.48
12/1/2013
49.26
12/1/2013
5.94
12/1/2013
59.45
12/1/2013
5.94
12/1/2013
44.57
12/1/2013
14.03
12/1/2013
140.30
12/1/2013
14.03
12/1/2013
14.27
12/1/2013
144.15
12/1/2013
14.27
12/1/2013
108.12
12/1/2013
3.90
12/1/2013
39.00
12/1/2013
3.90
12/1/2013
27.30
12/1/2013
8.69
12/1/2013
91.20
12/1/2013
8.69
12/1/2013
68.40
12/1/2013
7.65
12/1/2013
72.16
12/1/2013
7.65
12/1/2013
54.53
12/1/2013
3.26
12/1/2013
32.60
12/1/2013
3.26
12/1/2013
24.46
12/1/2013
3.04
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0980NU
E0980RR
E0980UE
E0981
E0981NU
E0981RR
E0981UE
E0982
E0982NU
E0982RR
E0982UE
E0983
E0983NU
E0983RR
E0984
E0984NU
E0984RR
E0984UE
E0985
E0985NU
E0985RR
E0985UE
E0986
E0986NU
E0986RR
E0986UE
E0988
E0988NU
E0988RR
E0990
Modifier
Description
NU
Wheelchair safety vest
RR
Wheelchair safety vest
UE
Wheelchair safety vest
Seat upholstery, replacement
NU
Seat upholstery, replacement
RR
Seat upholstery, replacement
UE
Seat upholstery, replacement
Back upholstery, replacement
NU
Back upholstery, replacement
RR
Back upholstery, replacement
UE
Back upholstery, replacement
Add pwr joystick
NU
Add pwr joystick
RR
Add pwr joystick
Add pwr tiller
NU
Add pwr tiller
RR
Add pwr tiller
UE
Add pwr tiller
W/c seat lift mechanism
NU
W/c seat lift mechanism
RR
W/c seat lift mechanism
UE
W/c seat lift mechanism
Man w/c push-rim pow assist
NU
Man w/c push-rim pow assist
RR
Man w/c push-rim pow assist
UE
Man w/c push-rim pow assist
Lever-activated wheel drive
NU
Lever-activated wheel drive
RR
Lever-activated wheel drive
Wheelchair elevating leg res
Page 48 of 116
Effective Date
Maximum Allowable
12/1/2013
30.42
12/1/2013
3.04
12/1/2013
22.69
12/1/2013
3.81
12/1/2013
37.40
12/1/2013
3.81
12/1/2013
28.31
12/1/2013
4.09
12/1/2013
40.87
12/1/2013
4.09
12/1/2013
30.66
12/1/2013
230.02
12/1/2013
2,300.20
12/1/2013
230.02
12/1/2013
138.92
12/1/2013
1,494.58
12/1/2013
138.92
12/1/2013
1,153.26
12/1/2013
18.68
12/1/2013
186.69
12/1/2013
18.68
12/1/2013
140.00
12/1/2013
447.67
12/1/2013
4,476.61
12/1/2013
447.67
12/1/2013
3,357.47
12/1/2013
264.89
12/1/2013
2,648.90
12/1/2013
264.89
12/1/2013
10.49
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E0990NU
E0990RR
E0990UE
E0992
E0992NU
E0992RR
E0992UE
E0994
E0994NU
E0994RR
E0994UE
E0995
E0995NU
E0995RR
E0995UE
E1002
E1002NU
E1002RR
E1002UE
E1003
E1003NU
E1003RR
E1003UE
E1004
E1004NU
E1004RR
E1004UE
E1005
E1005NU
E1005RR
Modifier
Description
NU
Wheelchair elevating leg res
RR
Wheelchair elevating leg res
UE
Wheelchair elevating leg res
Wheelchair solid seat insert
NU
Wheelchair solid seat insert
RR
Wheelchair solid seat insert
UE
Wheelchair solid seat insert
Wheelchair arm rest
NU
Wheelchair arm rest
RR
Wheelchair arm rest
UE
Wheelchair arm rest
Wheelchair calf rest
NU
Wheelchair calf rest
RR
Wheelchair calf rest
UE
Wheelchair calf rest
Pwr seat tilt
NU
Pwr seat tilt
RR
Pwr seat tilt
UE
Pwr seat tilt
Pwr seat recline
NU
Pwr seat recline
RR
Pwr seat recline
UE
Pwr seat recline
Pwr seat recline mech
NU
Pwr seat recline mech
RR
Pwr seat recline mech
UE
Pwr seat recline mech
Pwr seat recline pwr
NU
Pwr seat recline pwr
RR
Pwr seat recline pwr
Page 49 of 116
Effective Date
Maximum Allowable
12/1/2013
93.14
12/1/2013
10.49
12/1/2013
72.78
12/1/2013
8.51
12/1/2013
87.58
12/1/2013
8.51
12/1/2013
65.69
12/1/2013
1.64
12/1/2013
16.22
12/1/2013
1.64
12/1/2013
12.17
12/1/2013
2.36
12/1/2013
23.47
12/1/2013
2.36
12/1/2013
17.61
12/1/2013
321.50
12/1/2013
3,215.09
12/1/2013
321.50
12/1/2013
2,411.31
12/1/2013
348.33
12/1/2013
3,483.27
12/1/2013
348.33
12/1/2013
2,612.45
12/1/2013
386.21
12/1/2013
3,862.22
12/1/2013
386.21
12/1/2013
2,896.66
12/1/2013
418.05
12/1/2013
4,180.55
12/1/2013
418.05
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E1005UE
E1006
E1006NU
E1006RR
E1006UE
E1007
E1007NU
E1007RR
E1007UE
E1008
E1008NU
E1008RR
E1008UE
E1010
E1010NU
E1010RR
E1010UE
E1014
E1014NU
E1014RR
E1014UE
E1015
E1015NU
E1015RR
E1015UE
E1016
E1016NU
E1016RR
E1016UE
E1020
Modifier
Description
UE
Pwr seat recline pwr
Pwr seat combo w/o shear
NU
Pwr seat combo w/o shear
RR
Pwr seat combo w/o shear
UE
Pwr seat combo w/o shear
Pwr seat combo w/shear
NU
Pwr seat combo w/shear
RR
Pwr seat combo w/shear
UE
Pwr seat combo w/shear
Pwr seat combo pwr shear
NU
Pwr seat combo pwr shear
RR
Pwr seat combo pwr shear
UE
Pwr seat combo pwr shear
Add pwr leg elevation
NU
Add pwr leg elevation
RR
Add pwr leg elevation
UE
Add pwr leg elevation
Reclining back add ped w/c
NU
Reclining back add ped w/c
RR
Reclining back add ped w/c
UE
Reclining back add ped w/c
Shock absorber for man w/c
NU
Shock absorber for man w/c
RR
Shock absorber for man w/c
UE
Shock absorber for man w/c
Shock absorber for power w/c
NU
Shock absorber for power w/c
RR
Shock absorber for power w/c
UE
Shock absorber for power w/c
Residual limb support system
Page 50 of 116
Effective Date
Maximum Allowable
12/1/2013
3,135.43
12/1/2013
512.07
12/1/2013
5,120.79
12/1/2013
512.07
12/1/2013
3,840.60
12/1/2013
693.38
12/1/2013
6,933.75
12/1/2013
693.38
12/1/2013
5,200.31
12/1/2013
693.43
12/1/2013
6,934.38
12/1/2013
693.43
12/1/2013
5,200.79
12/1/2013
90.73
12/1/2013
907.27
12/1/2013
90.73
12/1/2013
680.46
12/1/2013
33.61
12/1/2013
336.05
12/1/2013
33.61
12/1/2013
252.02
12/1/2013
10.55
12/1/2013
105.57
12/1/2013
10.55
12/1/2013
79.17
12/1/2013
10.43
12/1/2013
104.16
12/1/2013
10.43
12/1/2013
78.12
12/1/2013
19.30
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E1020NU
E1020RR
E1020UE
E1028
E1028NU
E1028RR
E1028UE
E1029
E1029NU
E1029RR
E1029UE
E1030
E1030NU
E1030RR
E1030UE
E1031
E1031NU
E1031RR
E1035
E1035NU
E1035RR
E1036
E1036NU
E1036RR
E1037
E1037NU
E1037RR
E1038
E1038NU
E1038RR
Modifier
Description
NU
Residual limb support system
RR
Residual limb support system
UE
Residual limb support system
W/c manual swingaway
NU
W/c manual swingaway
RR
W/c manual swingaway
UE
W/c manual swingaway
W/c vent tray fixed
NU
W/c vent tray fixed
RR
W/c vent tray fixed
UE
W/c vent tray fixed
W/c vent tray gimbaled
NU
W/c vent tray gimbaled
RR
W/c vent tray gimbaled
UE
W/c vent tray gimbaled
Rollabout chair with casters
NU
Rollabout chair with casters
RR
Rollabout chair with casters
Patient transfer system <300
NU
Patient transfer system <300
RR
Patient transfer system <300
Patient transfer system >300
NU
Patient transfer system >300
RR
Patient transfer system >300
Transport chair, ped size
NU
Transport chair, ped size
RR
Transport chair, ped size
Transport chair pt wt<=300lb
NU
Transport chair pt wt<=300lb
RR
Transport chair pt wt<=300lb
Page 51 of 116
Effective Date
Maximum Allowable
12/1/2013
193.08
12/1/2013
19.30
12/1/2013
144.80
12/1/2013
16.38
12/1/2013
163.83
12/1/2013
16.38
12/1/2013
122.87
12/1/2013
29.31
12/1/2013
293.13
12/1/2013
29.31
12/1/2013
219.84
12/1/2013
92.43
12/1/2013
924.32
12/1/2013
92.43
12/1/2013
693.23
12/1/2013
39.52
12/1/2013
395.20
12/1/2013
39.52
12/1/2013
564.34
12/1/2013
5,643.40
12/1/2013
564.34
12/1/2013
791.15
12/1/2013
7,911.50
12/1/2013
791.15
12/1/2013
99.84
12/1/2013
998.40
12/1/2013
99.84
12/1/2013
16.58
12/1/2013
165.80
12/1/2013
16.58
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E1039
E1039NU
E1039RR
E1050
E1050NU
E1050RR
E1060
E1060NU
E1060RR
E1070
E1070NU
E1070RR
E1083
E1083NU
E1083RR
E1084
E1084NU
E1084RR
E1087
E1087NU
E1087RR
E1088
E1088NU
E1088RR
E1092
E1092NU
E1092RR
E1093
E1093NU
E1093RR
Modifier
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
Description
Transport chair pt wt >300lb
Transport chair pt wt >300lb
Transport chair pt wt >300lb
Whelchr fxd full length arms
Whelchr fxd full length arms
Whelchr fxd full length arms
Wheelchair detachable arms
Wheelchair detachable arms
Wheelchair detachable arms
Wheelchair detachable foot r
Wheelchair detachable foot r
Wheelchair detachable foot r
Hemi-wheelchair fixed arms
Hemi-wheelchair fixed arms
Hemi-wheelchair fixed arms
Hemi-wheelchair detachable a
Hemi-wheelchair detachable a
Hemi-wheelchair detachable a
Wheelchair lightwt fixed arm
Wheelchair lightwt fixed arm
Wheelchair lightwt fixed arm
Wheelchair lightweight det a
Wheelchair lightweight det a
Wheelchair lightweight det a
Wheelchair wide w/ leg rests
Wheelchair wide w/ leg rests
Wheelchair wide w/ leg rests
Wheelchair wide w/ foot rest
Wheelchair wide w/ foot rest
Wheelchair wide w/ foot rest
Page 52 of 116
Effective Date
Maximum Allowable
12/1/2013
31.47
12/1/2013
314.70
12/1/2013
31.47
12/1/2013
79.66
12/1/2013
796.60
12/1/2013
79.66
12/1/2013
113.21
12/1/2013
1,132.10
12/1/2013
113.21
12/1/2013
100.80
12/1/2013
1,008.00
12/1/2013
100.80
12/1/2013
72.47
12/1/2013
724.70
12/1/2013
72.47
12/1/2013
76.75
12/1/2013
767.50
12/1/2013
76.75
12/1/2013
116.44
12/1/2013
1,164.40
12/1/2013
116.44
12/1/2013
138.76
12/1/2013
1,387.60
12/1/2013
138.76
12/1/2013
118.28
12/1/2013
1,182.80
12/1/2013
118.28
12/1/2013
101.71
12/1/2013
1,017.10
12/1/2013
101.71
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E1100
E1100NU
E1100RR
E1110
E1110NU
E1110RR
E1150
E1150NU
E1150RR
E1160
E1160NU
E1160RR
E1161
E1161NU
E1161RR
E1161UE
E1170
E1170NU
E1170RR
E1171
E1171NU
E1171RR
E1172
E1172NU
E1172RR
E1180
E1180NU
E1180RR
E1190
E1190NU
Modifier
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
UE
NU
RR
NU
RR
NU
RR
NU
RR
NU
Description
Whchr s-recl fxd arm leg res
Whchr s-recl fxd arm leg res
Whchr s-recl fxd arm leg res
Wheelchair semi-recl detach
Wheelchair semi-recl detach
Wheelchair semi-recl detach
Wheelchair standard w/ leg r
Wheelchair standard w/ leg r
Wheelchair standard w/ leg r
Wheelchair fixed arms
Wheelchair fixed arms
Wheelchair fixed arms
Manual adult wc w tiltinspac
Manual adult wc w tiltinspac
Manual adult wc w tiltinspac
Manual adult wc w tiltinspac
Whlchr ampu fxd arm leg rest
Whlchr ampu fxd arm leg rest
Whlchr ampu fxd arm leg rest
Wheelchair amputee w/o leg r
Wheelchair amputee w/o leg r
Wheelchair amputee w/o leg r
Wheelchair amputee detach ar
Wheelchair amputee detach ar
Wheelchair amputee detach ar
Wheelchair amputee w/ foot r
Wheelchair amputee w/ foot r
Wheelchair amputee w/ foot r
Wheelchair amputee w/ leg re
Wheelchair amputee w/ leg re
Page 53 of 116
Effective Date
Maximum Allowable
12/1/2013
95.53
12/1/2013
955.30
12/1/2013
95.53
12/1/2013
93.55
12/1/2013
935.50
12/1/2013
93.55
12/1/2013
69.47
12/1/2013
694.70
12/1/2013
69.47
12/1/2013
53.02
12/1/2013
530.20
12/1/2013
53.02
12/1/2013
217.75
12/1/2013
2,177.54
12/1/2013
217.75
12/1/2013
1,633.18
12/1/2013
82.20
12/1/2013
822.00
12/1/2013
82.20
12/1/2013
73.77
12/1/2013
737.70
12/1/2013
73.77
12/1/2013
90.15
12/1/2013
901.50
12/1/2013
90.15
12/1/2013
93.26
12/1/2013
932.60
12/1/2013
93.26
12/1/2013
107.75
12/1/2013
1,077.50
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E1190RR
E1195
E1195NU
E1195RR
E1200
E1200NU
E1200RR
E1221
E1221NU
E1221RR
E1222
E1222NU
E1222RR
E1223
E1223NU
E1223RR
E1224
E1224NU
E1224RR
E1225
E1225NU
E1225RR
E1226
E1226NU
E1226RR
E1226UE
E1227
E1227NU
E1227RR
E1227UE
Modifier
Description
RR
Wheelchair amputee w/ leg re
Wheelchair amputee heavy dut
NU
Wheelchair amputee heavy dut
RR
Wheelchair amputee heavy dut
Wheelchair amputee fixed arm
NU
Wheelchair amputee fixed arm
RR
Wheelchair amputee fixed arm
Wheelchair spec size w foot
NU
Wheelchair spec size w foot
RR
Wheelchair spec size w foot
Wheelchair spec size w/ leg
NU
Wheelchair spec size w/ leg
RR
Wheelchair spec size w/ leg
Wheelchair spec size w foot
NU
Wheelchair spec size w foot
RR
Wheelchair spec size w foot
Wheelchair spec size w/ leg
NU
Wheelchair spec size w/ leg
RR
Wheelchair spec size w/ leg
Manual semi-reclining back
NU
Manual semi-reclining back
RR
Manual semi-reclining back
Manual fully reclining back
NU
Manual fully reclining back
RR
Manual fully reclining back
UE
Manual fully reclining back
Wheelchair spec sz spec ht a
NU
Wheelchair spec sz spec ht a
RR
Wheelchair spec sz spec ht a
UE
Wheelchair spec sz spec ht a
Page 54 of 116
Effective Date
Maximum Allowable
12/1/2013
107.75
12/1/2013
115.62
12/1/2013
1,156.20
12/1/2013
115.62
12/1/2013
80.08
12/1/2013
800.80
12/1/2013
80.08
12/1/2013
37.17
12/1/2013
371.70
12/1/2013
37.17
12/1/2013
62.39
12/1/2013
623.90
12/1/2013
62.39
12/1/2013
68.12
12/1/2013
681.20
12/1/2013
68.12
12/1/2013
63.93
12/1/2013
639.30
12/1/2013
63.93
12/1/2013
41.60
12/1/2013
416.00
12/1/2013
41.60
12/1/2013
51.68
12/1/2013
502.17
12/1/2013
51.68
12/1/2013
376.59
12/1/2013
24.58
12/1/2013
245.86
12/1/2013
24.58
12/1/2013
184.39
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E1228
E1228NU
E1228RR
E1230
E1230NU
E1230RR
E1230UE
E1232
E1232NU
E1232RR
E1232UE
E1233
E1233NU
E1233RR
E1233UE
E1234
E1234NU
E1234RR
E1234UE
E1235
E1235NU
E1235RR
E1235UE
E1236
E1236NU
E1236RR
E1236UE
E1237
E1237NU
E1237RR
Modifier
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
Description
Wheelchair spec sz spec ht b
Wheelchair spec sz spec ht b
Wheelchair spec sz spec ht b
Power operated vehicle
Power operated vehicle
Power operated vehicle
Power operated vehicle
Folding ped wc tilt-in-space
Folding ped wc tilt-in-space
Folding ped wc tilt-in-space
Folding ped wc tilt-in-space
Rig ped wc tltnspc w/o seat
Rig ped wc tltnspc w/o seat
Rig ped wc tltnspc w/o seat
Rig ped wc tltnspc w/o seat
Fld ped wc tltnspc w/o seat
Fld ped wc tltnspc w/o seat
Fld ped wc tltnspc w/o seat
Fld ped wc tltnspc w/o seat
Rigid ped wc adjustable
Rigid ped wc adjustable
Rigid ped wc adjustable
Rigid ped wc adjustable
Folding ped wc adjustable
Folding ped wc adjustable
Folding ped wc adjustable
Folding ped wc adjustable
Rgd ped wc adjstabl w/o seat
Rgd ped wc adjstabl w/o seat
Rgd ped wc adjstabl w/o seat
Page 55 of 116
Effective Date
Maximum Allowable
12/1/2013
25.79
12/1/2013
257.90
12/1/2013
25.79
12/1/2013
174.01
12/1/2013
1,769.33
12/1/2013
174.01
12/1/2013
1,399.31
12/1/2013
196.81
12/1/2013
1,968.00
12/1/2013
196.81
12/1/2013
1,476.02
12/1/2013
203.91
12/1/2013
2,039.16
12/1/2013
203.91
12/1/2013
1,529.37
12/1/2013
177.55
12/1/2013
1,775.23
12/1/2013
177.55
12/1/2013
1,331.41
12/1/2013
170.95
12/1/2013
1,709.41
12/1/2013
170.95
12/1/2013
1,282.06
12/1/2013
150.82
12/1/2013
1,508.14
12/1/2013
150.82
12/1/2013
1,131.10
12/1/2013
152.13
12/1/2013
1,521.31
12/1/2013
152.13
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E1237UE
E1238
E1238NU
E1238RR
E1238UE
E1240
E1240NU
E1240RR
E1270
E1270NU
E1270RR
E1280
E1280NU
E1280RR
E1295
E1295NU
E1295RR
E1296
E1296NU
E1296RR
E1296UE
E1297
E1297NU
E1297RR
E1297UE
E1298
E1298NU
E1298RR
E1298UE
E1310
Modifier
Description
UE
Rgd ped wc adjstabl w/o seat
Fld ped wc adjstabl w/o seat
NU
Fld ped wc adjstabl w/o seat
RR
Fld ped wc adjstabl w/o seat
UE
Fld ped wc adjstabl w/o seat
Whchr litwt det arm leg rest
NU
Whchr litwt det arm leg rest
RR
Whchr litwt det arm leg rest
Wheelchair lightweight leg r
NU
Wheelchair lightweight leg r
RR
Wheelchair lightweight leg r
Whchr h-duty det arm leg res
NU
Whchr h-duty det arm leg res
RR
Whchr h-duty det arm leg res
Wheelchair heavy duty fixed
NU
Wheelchair heavy duty fixed
RR
Wheelchair heavy duty fixed
Wheelchair special seat heig
NU
Wheelchair special seat heig
RR
Wheelchair special seat heig
UE
Wheelchair special seat heig
Wheelchair special seat dept
NU
Wheelchair special seat dept
RR
Wheelchair special seat dept
UE
Wheelchair special seat dept
Wheelchair spec seat depth/w
NU
Wheelchair spec seat depth/w
RR
Wheelchair spec seat depth/w
UE
Wheelchair spec seat depth/w
Whirlpool non-portable
Page 56 of 116
Effective Date
Maximum Allowable
12/1/2013
1,141.00
12/1/2013
150.82
12/1/2013
1,508.14
12/1/2013
150.82
12/1/2013
1,131.10
12/1/2013
94.81
12/1/2013
948.10
12/1/2013
94.81
12/1/2013
72.66
12/1/2013
726.60
12/1/2013
72.66
12/1/2013
120.79
12/1/2013
1,207.90
12/1/2013
120.79
12/1/2013
111.78
12/1/2013
1,117.80
12/1/2013
111.78
12/1/2013
39.72
12/1/2013
397.22
12/1/2013
39.72
12/1/2013
297.93
12/1/2013
10.69
12/1/2013
96.27
12/1/2013
10.69
12/1/2013
72.19
12/1/2013
33.91
12/1/2013
331.41
12/1/2013
33.91
12/1/2013
248.56
12/1/2013
169.03
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E1310NU
E1310RR
E1310UE
E1353
E1355
E1372
E1372NU
E1372RR
E1372UE
E1390
E1390RR
E1391
E1391RR
E1392
E1392RR
E1405
E1405RR
E1406
E1406RR
E1700
E1700NU
E1700RR
E1700UE
E1701
E1702
E1800
E1800NU
E1800RR
E1801
E1801NU
Modifier
Description
NU
Whirlpool non-portable
RR
Whirlpool non-portable
UE
Whirlpool non-portable
Oxygen supplies regulator
Oxygen supplies stand/rack
Oxy suppl heater for nebuliz
NU
Oxy suppl heater for nebuliz
RR
Oxy suppl heater for nebuliz
UE
Oxy suppl heater for nebuliz
Oxygen concentrator
RR
Oxygen concentrator
Oxygen concentrator, dual
RR
Oxygen concentrator, dual
Portable oxygen concentrator
RR
Portable oxygen concentrator
O2/water vapor enrich w/heat
RR
O2/water vapor enrich w/heat
O2/water vapor enrich w/o he
RR
O2/water vapor enrich w/o he
Jaw motion rehab system
NU
Jaw motion rehab system
RR
Jaw motion rehab system
UE
Jaw motion rehab system
Repl cushions for jaw motion
Repl measr scales jaw motion
Adjust elbow ext/flex device
NU
Adjust elbow ext/flex device
RR
Adjust elbow ext/flex device
SPS elbow device
NU
SPS elbow device
Page 57 of 116
Effective Date
Maximum Allowable
12/1/2013
1,976.28
12/1/2013
169.03
12/1/2013
1,482.21
12/1/2013
24.54
12/1/2013
18.48
12/1/2013
18.53
12/1/2013
150.03
12/1/2013
18.53
12/1/2013
111.06
12/1/2013
141.89
12/1/2013
141.89
12/1/2013
141.89
12/1/2013
141.89
12/1/2013
41.30
12/1/2013
41.30
12/1/2013
167.70
12/1/2013
167.70
12/1/2013
155.84
12/1/2013
155.84
12/1/2013
31.12
12/1/2013
317.36
12/1/2013
31.12
12/1/2013
238.02
12/1/2013
9.77
12/1/2013
20.77
12/1/2013
112.74
12/1/2013
1,127.40
12/1/2013
112.74
12/1/2013
118.72
12/1/2013
1,187.20
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E1801RR
E1802
E1802NU
E1802RR
E1805
E1805NU
E1805RR
E1806
E1806NU
E1806RR
E1810
E1810NU
E1810RR
E1811
E1811NU
E1811RR
E1812
E1812NU
E1812RR
E1815
E1815NU
E1815RR
E1816
E1816NU
E1816RR
E1818
E1818NU
E1818RR
E1820
E1820NU
Modifier
Description
RR
SPS elbow device
Adjst forearm pro/sup device
NU
Adjst forearm pro/sup device
RR
Adjst forearm pro/sup device
Adjust wrist ext/flex device
NU
Adjust wrist ext/flex device
RR
Adjust wrist ext/flex device
SPS wrist device
NU
SPS wrist device
RR
SPS wrist device
Adjust knee ext/flex device
NU
Adjust knee ext/flex device
RR
Adjust knee ext/flex device
SPS knee device
NU
SPS knee device
RR
SPS knee device
Knee ext/flex w act res ctrl
NU
Knee ext/flex w act res ctrl
RR
Knee ext/flex w act res ctrl
Adjust ankle ext/flex device
NU
Adjust ankle ext/flex device
RR
Adjust ankle ext/flex device
SPS ankle device
NU
SPS ankle device
RR
SPS ankle device
SPS forearm device
NU
SPS forearm device
RR
SPS forearm device
Soft interface material
NU
Soft interface material
Page 58 of 116
Effective Date
Maximum Allowable
12/1/2013
118.72
12/1/2013
300.76
12/1/2013
3,007.60
12/1/2013
300.76
12/1/2013
116.28
12/1/2013
1,162.80
12/1/2013
116.28
12/1/2013
97.48
12/1/2013
974.80
12/1/2013
97.48
12/1/2013
24.52
12/1/2013
245.15
12/1/2013
24.52
12/1/2013
123.44
12/1/2013
1,234.40
12/1/2013
123.44
12/1/2013
79.13
12/1/2013
791.30
12/1/2013
79.13
12/1/2013
18.92
12/1/2013
189.21
12/1/2013
18.92
12/1/2013
125.38
12/1/2013
1,253.80
12/1/2013
125.38
12/1/2013
128.00
12/1/2013
1,280.00
12/1/2013
128.00
12/1/2013
7.11
12/1/2013
70.97
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E1820RR
E1820UE
E1821
E1821NU
E1821RR
E1821UE
E1825
E1825NU
E1825RR
E1830
E1830NU
E1830RR
E1831
E1831NU
E1831RR
E1840
E1840NU
E1840RR
E1841
E1841NU
E1841RR
E2000
E2000NU
E2000RR
E2100
E2100NU
E2100RR
E2100UE
E2101
E2101NU
Modifier
Description
RR
Soft interface material
UE
Soft interface material
Replacement interface SPSD
NU
Replacement interface SPSD
RR
Replacement interface SPSD
UE
Replacement interface SPSD
Adjust finger ext/flex devc
NU
Adjust finger ext/flex devc
RR
Adjust finger ext/flex devc
Adjust toe ext/flex device
NU
Adjust toe ext/flex device
RR
Adjust toe ext/flex device
Static str toe dev ext/flex
NU
Static str toe dev ext/flex
RR
Static str toe dev ext/flex
Adj shoulder ext/flex device
NU
Adj shoulder ext/flex device
RR
Adj shoulder ext/flex device
Static str shldr dev rom adj
NU
Static str shldr dev rom adj
RR
Static str shldr dev rom adj
Gastric suction pump hme mdl
NU
Gastric suction pump hme mdl
RR
Gastric suction pump hme mdl
Bld glucose monitor w voice
NU
Bld glucose monitor w voice
RR
Bld glucose monitor w voice
UE
Bld glucose monitor w voice
Bld glucose monitor w lance
NU
Bld glucose monitor w lance
Page 59 of 116
Effective Date
Maximum Allowable
12/1/2013
7.11
12/1/2013
53.23
12/1/2013
9.67
12/1/2013
96.86
12/1/2013
9.67
12/1/2013
72.67
12/1/2013
116.28
12/1/2013
1,162.80
12/1/2013
116.28
12/1/2013
116.28
12/1/2013
1,162.80
12/1/2013
116.28
12/1/2013
58.48
12/1/2013
584.80
12/1/2013
58.48
12/1/2013
352.21
12/1/2013
3,522.10
12/1/2013
352.21
12/1/2013
416.89
12/1/2013
4,168.90
12/1/2013
416.89
12/1/2013
47.70
12/1/2013
477.00
12/1/2013
47.70
12/1/2013
50.31
12/1/2013
503.14
12/1/2013
50.31
12/1/2013
377.37
12/1/2013
17.35
12/1/2013
173.54
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2101RR
E2101UE
E2120
E2120NU
E2120RR
E2201
E2201NU
E2201RR
E2201UE
E2202
E2202NU
E2202RR
E2202UE
E2203
E2203NU
E2203RR
E2203UE
E2204
E2204NU
E2204RR
E2204UE
E2205
E2205NU
E2205RR
E2205UE
E2206
E2206NU
E2206RR
E2206UE
E2207
Modifier
Description
RR
Bld glucose monitor w lance
UE
Bld glucose monitor w lance
Pulse gen sys tx endolymp fl
NU
Pulse gen sys tx endolymp fl
RR
Pulse gen sys tx endolymp fl
Man w/ch acc seat w>=20"<24"
NU
Man w/ch acc seat w>=20"<24"
RR
Man w/ch acc seat w>=20"<24"
UE
Man w/ch acc seat w>=20"<24"
Seat width 24-27 in
NU
Seat width 24-27 in
RR
Seat width 24-27 in
UE
Seat width 24-27 in
Frame depth less than 22 in
NU
Frame depth less than 22 in
RR
Frame depth less than 22 in
UE
Frame depth less than 22 in
Frame depth 22 to 25 in
NU
Frame depth 22 to 25 in
RR
Frame depth 22 to 25 in
UE
Frame depth 22 to 25 in
Manual wc accessory, handrim
NU
Manual wc accessory, handrim
RR
Manual wc accessory, handrim
UE
Manual wc accessory, handrim
Complete wheel lock assembly
NU
Complete wheel lock assembly
RR
Complete wheel lock assembly
UE
Complete wheel lock assembly
Crutch and cane holder
Page 60 of 116
Effective Date
Maximum Allowable
12/1/2013
17.35
12/1/2013
130.15
12/1/2013
260.93
12/1/2013
2,609.30
12/1/2013
260.93
12/1/2013
34.34
12/1/2013
343.37
12/1/2013
34.34
12/1/2013
257.52
12/1/2013
43.62
12/1/2013
436.20
12/1/2013
43.62
12/1/2013
327.17
12/1/2013
44.07
12/1/2013
440.88
12/1/2013
44.07
12/1/2013
330.64
12/1/2013
74.87
12/1/2013
748.59
12/1/2013
74.87
12/1/2013
561.43
12/1/2013
2.94
12/1/2013
29.55
12/1/2013
2.94
12/1/2013
22.19
12/1/2013
3.67
12/1/2013
36.82
12/1/2013
3.67
12/1/2013
27.63
12/1/2013
3.94
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2207NU
E2207RR
E2207UE
E2208
E2208NU
E2208RR
E2208UE
E2209
E2209NU
E2209RR
E2209UE
E2210
E2210NU
E2210RR
E2210UE
E2211
E2211NU
E2211RR
E2211UE
E2212
E2212NU
E2212RR
E2212UE
E2213
E2213NU
E2213RR
E2213UE
E2214
E2214NU
E2214RR
Modifier
Description
NU
Crutch and cane holder
RR
Crutch and cane holder
UE
Crutch and cane holder
Cylinder tank carrier
NU
Cylinder tank carrier
RR
Cylinder tank carrier
UE
Cylinder tank carrier
Arm trough each
NU
Arm trough each
RR
Arm trough each
UE
Arm trough each
Wheelchair bearings
NU
Wheelchair bearings
RR
Wheelchair bearings
UE
Wheelchair bearings
Pneumatic propulsion tire
NU
Pneumatic propulsion tire
RR
Pneumatic propulsion tire
UE
Pneumatic propulsion tire
Pneumatic prop tire tube
NU
Pneumatic prop tire tube
RR
Pneumatic prop tire tube
UE
Pneumatic prop tire tube
Pneumatic prop tire insert
NU
Pneumatic prop tire insert
RR
Pneumatic prop tire insert
UE
Pneumatic prop tire insert
Pneumatic caster tire each
NU
Pneumatic caster tire each
RR
Pneumatic caster tire each
Page 61 of 116
Effective Date
Maximum Allowable
12/1/2013
39.23
12/1/2013
3.94
12/1/2013
29.42
12/1/2013
9.26
12/1/2013
92.63
12/1/2013
9.26
12/1/2013
69.48
12/1/2013
8.35
12/1/2013
83.60
12/1/2013
8.35
12/1/2013
62.70
12/1/2013
0.52
12/1/2013
5.19
12/1/2013
0.52
12/1/2013
3.91
12/1/2013
3.14
12/1/2013
32.01
12/1/2013
3.14
12/1/2013
23.41
12/1/2013
0.57
12/1/2013
5.32
12/1/2013
0.57
12/1/2013
4.00
12/1/2013
2.78
12/1/2013
27.53
12/1/2013
2.78
12/1/2013
20.62
12/1/2013
3.51
12/1/2013
33.13
12/1/2013
3.51
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2214UE
E2215
E2215NU
E2215RR
E2215UE
E2219
E2219NU
E2219RR
E2219UE
E2220
E2220NU
E2220RR
E2220UE
E2221
E2221NU
E2221RR
E2221UE
E2222
E2222NU
E2222RR
E2222UE
E2224
E2224NU
E2224RR
E2224UE
E2225
E2225NU
E2225RR
E2225UE
E2226
Modifier
Description
UE
Pneumatic caster tire each
Pneumatic caster tire tube
NU
Pneumatic caster tire tube
RR
Pneumatic caster tire tube
UE
Pneumatic caster tire tube
Foam caster tire any size ea
NU
Foam caster tire any size ea
RR
Foam caster tire any size ea
UE
Foam caster tire any size ea
Solid propulsion tire each
NU
Solid propulsion tire each
RR
Solid propulsion tire each
UE
Solid propulsion tire each
Solid caster tire each
NU
Solid caster tire each
RR
Solid caster tire each
UE
Solid caster tire each
Solid caster integrated whl
NU
Solid caster integrated whl
RR
Solid caster integrated whl
UE
Solid caster integrated whl
Propulsion whl excludes tire
NU
Propulsion whl excludes tire
RR
Propulsion whl excludes tire
UE
Propulsion whl excludes tire
Caster wheel excludes tire
NU
Caster wheel excludes tire
RR
Caster wheel excludes tire
UE
Caster wheel excludes tire
Caster fork replacement only
Page 62 of 116
Effective Date
Maximum Allowable
12/1/2013
24.84
12/1/2013
0.87
12/1/2013
8.70
12/1/2013
0.87
12/1/2013
6.51
12/1/2013
4.35
12/1/2013
38.51
12/1/2013
4.35
12/1/2013
28.89
12/1/2013
2.53
12/1/2013
26.26
12/1/2013
2.53
12/1/2013
20.08
12/1/2013
2.29
12/1/2013
23.12
12/1/2013
2.29
12/1/2013
17.35
12/1/2013
1.92
12/1/2013
19.38
12/1/2013
1.92
12/1/2013
14.55
12/1/2013
8.51
12/1/2013
85.08
12/1/2013
8.51
12/1/2013
63.83
12/1/2013
1.60
12/1/2013
16.01
12/1/2013
1.60
12/1/2013
12.00
12/1/2013
3.49
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2226NU
E2226RR
E2226UE
E2227
E2227NU
E2227RR
E2227UE
E2228
E2228NU
E2228RR
E2228UE
E2231
E2231NU
E2231RR
E2231UE
E2310
E2310NU
E2310RR
E2310UE
E2311
E2311NU
E2311RR
E2311UE
E2312
E2312NU
E2312RR
E2312UE
E2313
E2313NU
E2313RR
Modifier
Description
NU
Caster fork replacement only
RR
Caster fork replacement only
UE
Caster fork replacement only
Gear reduction drive wheel
NU
Gear reduction drive wheel
RR
Gear reduction drive wheel
UE
Gear reduction drive wheel
Mwc acc, wheelchair brake
NU
Mwc acc, wheelchair brake
RR
Mwc acc, wheelchair brake
UE
Mwc acc, wheelchair brake
Solid seat support base
NU
Solid seat support base
RR
Solid seat support base
UE
Solid seat support base
Electro connect btw control
NU
Electro connect btw control
RR
Electro connect btw control
UE
Electro connect btw control
Electro connect btw 2 sys
NU
Electro connect btw 2 sys
RR
Electro connect btw 2 sys
UE
Electro connect btw 2 sys
Mini-prop remote joystick
NU
Mini-prop remote joystick
RR
Mini-prop remote joystick
UE
Mini-prop remote joystick
PWC harness, expand control
NU
PWC harness, expand control
RR
PWC harness, expand control
Page 63 of 116
Effective Date
Maximum Allowable
12/1/2013
34.93
12/1/2013
3.49
12/1/2013
26.19
12/1/2013
165.53
12/1/2013
1,655.38
12/1/2013
165.53
12/1/2013
1,241.52
12/1/2013
86.16
12/1/2013
861.65
12/1/2013
86.16
12/1/2013
646.25
12/1/2013
14.14
12/1/2013
141.43
12/1/2013
14.14
12/1/2013
106.06
12/1/2013
92.82
12/1/2013
928.26
12/1/2013
92.82
12/1/2013
696.19
12/1/2013
187.94
12/1/2013
1,879.31
12/1/2013
187.94
12/1/2013
1,409.47
12/1/2013
178.47
12/1/2013
1,784.64
12/1/2013
178.47
12/1/2013
1,338.46
12/1/2013
28.36
12/1/2013
283.40
12/1/2013
28.36
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2313UE
E2321
E2321NU
E2321RR
E2321UE
E2322
E2322NU
E2322RR
E2322UE
E2323
E2323NU
E2323RR
E2323UE
E2324
E2324NU
E2324RR
E2324UE
E2325
E2325NU
E2325RR
E2325UE
E2326
E2326NU
E2326RR
E2326UE
E2327
E2327NU
E2327RR
E2327UE
E2328
Modifier
Description
UE
PWC harness, expand control
Hand interface joystick
NU
Hand interface joystick
RR
Hand interface joystick
UE
Hand interface joystick
Mult mech switches
NU
Mult mech switches
RR
Mult mech switches
UE
Mult mech switches
Special joystick handle
NU
Special joystick handle
RR
Special joystick handle
UE
Special joystick handle
Chin cup interface
NU
Chin cup interface
RR
Chin cup interface
UE
Chin cup interface
Sip and puff interface
NU
Sip and puff interface
RR
Sip and puff interface
UE
Sip and puff interface
Breath tube kit
NU
Breath tube kit
RR
Breath tube kit
UE
Breath tube kit
Head control interface mech
NU
Head control interface mech
RR
Head control interface mech
UE
Head control interface mech
Head/extremity control inter
Page 64 of 116
Effective Date
Maximum Allowable
12/1/2013
212.54
12/1/2013
126.06
12/1/2013
1,260.51
12/1/2013
126.06
12/1/2013
945.40
12/1/2013
111.86
12/1/2013
1,118.73
12/1/2013
111.86
12/1/2013
839.04
12/1/2013
5.48
12/1/2013
54.86
12/1/2013
5.48
12/1/2013
41.14
12/1/2013
3.46
12/1/2013
34.76
12/1/2013
3.46
12/1/2013
26.07
12/1/2013
106.84
12/1/2013
1,068.33
12/1/2013
106.84
12/1/2013
801.26
12/1/2013
27.55
12/1/2013
275.36
12/1/2013
27.55
12/1/2013
206.51
12/1/2013
207.21
12/1/2013
2,072.19
12/1/2013
207.21
12/1/2013
1,554.14
12/1/2013
393.06
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2328NU
E2328RR
E2328UE
E2329
E2329NU
E2329RR
E2329UE
E2330
E2330NU
E2330RR
E2330UE
E2340
E2340NU
E2340RR
E2340UE
E2341
E2341NU
E2341RR
E2341UE
E2342
E2342NU
E2342RR
E2342UE
E2343
E2343NU
E2343RR
E2343UE
E2351
E2351NU
E2351RR
Modifier
Description
NU
Head/extremity control inter
RR
Head/extremity control inter
UE
Head/extremity control inter
Head control nonproportional
NU
Head control nonproportional
RR
Head control nonproportional
UE
Head control nonproportional
Head control proximity switc
NU
Head control proximity switc
RR
Head control proximity switc
UE
Head control proximity switc
W/c wdth 20-23 in seat frame
NU
W/c wdth 20-23 in seat frame
RR
W/c wdth 20-23 in seat frame
UE
W/c wdth 20-23 in seat frame
W/c wdth 24-27 in seat frame
NU
W/c wdth 24-27 in seat frame
RR
W/c wdth 24-27 in seat frame
UE
W/c wdth 24-27 in seat frame
W/c dpth 20-21 in seat frame
NU
W/c dpth 20-21 in seat frame
RR
W/c dpth 20-21 in seat frame
UE
W/c dpth 20-21 in seat frame
W/c dpth 22-25 in seat frame
NU
W/c dpth 22-25 in seat frame
RR
W/c dpth 22-25 in seat frame
UE
W/c dpth 22-25 in seat frame
Electronic SGD interface
NU
Electronic SGD interface
RR
Electronic SGD interface
Page 65 of 116
Effective Date
Maximum Allowable
12/1/2013
3,930.65
12/1/2013
393.06
12/1/2013
2,948.00
12/1/2013
140.09
12/1/2013
1,400.93
12/1/2013
140.09
12/1/2013
1,050.69
12/1/2013
271.44
12/1/2013
2,714.47
12/1/2013
271.44
12/1/2013
2,035.86
12/1/2013
32.99
12/1/2013
329.80
12/1/2013
32.99
12/1/2013
247.38
12/1/2013
49.47
12/1/2013
494.74
12/1/2013
49.47
12/1/2013
371.06
12/1/2013
41.23
12/1/2013
412.28
12/1/2013
41.23
12/1/2013
309.22
12/1/2013
65.95
12/1/2013
659.66
12/1/2013
65.95
12/1/2013
494.74
12/1/2013
55.44
12/1/2013
554.17
12/1/2013
55.44
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2351UE
E2359
E2359NU
E2359RR
E2359UE
E2360
E2360NU
E2360RR
E2360UE
E2361
E2361NU
E2361RR
E2361UE
E2362
E2362NU
E2362RR
E2362UE
E2363
E2363NU
E2363RR
E2363UE
E2364
E2364NU
E2364RR
E2364UE
E2365
E2365NU
E2365RR
E2365UE
E2366
Modifier
Description
UE
Electronic SGD interface
Gr34 sealed leadacid battery
NU
Gr34 sealed leadacid battery
RR
Gr34 sealed leadacid battery
UE
Gr34 sealed leadacid battery
22nf nonsealed leadacid
NU
22nf nonsealed leadacid
RR
22nf nonsealed leadacid
UE
22nf nonsealed leadacid
22nf sealed leadacid battery
NU
22nf sealed leadacid battery
RR
22nf sealed leadacid battery
UE
22nf sealed leadacid battery
Gr24 nonsealed leadacid
NU
Gr24 nonsealed leadacid
RR
Gr24 nonsealed leadacid
UE
Gr24 nonsealed leadacid
Gr24 sealed leadacid battery
NU
Gr24 sealed leadacid battery
RR
Gr24 sealed leadacid battery
UE
Gr24 sealed leadacid battery
U1nonsealed leadacid battery
NU
U1nonsealed leadacid battery
RR
U1nonsealed leadacid battery
UE
U1nonsealed leadacid battery
U1 sealed leadacid battery
NU
U1 sealed leadacid battery
RR
U1 sealed leadacid battery
UE
U1 sealed leadacid battery
Battery charger, single mode
Page 66 of 116
Effective Date
Maximum Allowable
12/1/2013
415.62
12/1/2013
15.41
12/1/2013
154.08
12/1/2013
15.41
12/1/2013
115.57
12/1/2013
10.39
12/1/2013
103.39
12/1/2013
10.39
12/1/2013
77.54
12/1/2013
10.89
12/1/2013
108.80
12/1/2013
10.89
12/1/2013
81.59
12/1/2013
8.32
12/1/2013
83.24
12/1/2013
8.32
12/1/2013
62.42
12/1/2013
14.52
12/1/2013
145.07
12/1/2013
14.52
12/1/2013
108.82
12/1/2013
10.39
12/1/2013
103.39
12/1/2013
10.39
12/1/2013
77.54
12/1/2013
8.75
12/1/2013
87.50
12/1/2013
8.75
12/1/2013
65.65
12/1/2013
17.82
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2366NU
E2366RR
E2366UE
E2367
E2367NU
E2367RR
E2367UE
E2368
E2368NU
E2368RR
E2368UE
E2369
E2369NU
E2369RR
E2369UE
E2370
E2370NU
E2370RR
E2370UE
E2371
E2371NU
E2371RR
E2371UE
E2373
E2373NU
E2373RR
E2373UE
E2374
E2374NU
E2374RR
Modifier
Description
NU
Battery charger, single mode
RR
Battery charger, single mode
UE
Battery charger, single mode
Battery charger, dual mode
NU
Battery charger, dual mode
RR
Battery charger, dual mode
UE
Battery charger, dual mode
Power wc motor replacement
NU
Power wc motor replacement
RR
Power wc motor replacement
UE
Power wc motor replacement
Pwr wc gear box replacement
NU
Pwr wc gear box replacement
RR
Pwr wc gear box replacement
UE
Pwr wc gear box replacement
Pwr wc motor/gear box combo
NU
Pwr wc motor/gear box combo
RR
Pwr wc motor/gear box combo
UE
Pwr wc motor/gear box combo
Gr27 sealed leadacid battery
NU
Gr27 sealed leadacid battery
RR
Gr27 sealed leadacid battery
UE
Gr27 sealed leadacid battery
Hand/chin ctrl spec joystick
NU
Hand/chin ctrl spec joystick
RR
Hand/chin ctrl spec joystick
UE
Hand/chin ctrl spec joystick
Hand/chin ctrl std joystick
NU
Hand/chin ctrl std joystick
RR
Hand/chin ctrl std joystick
Page 67 of 116
Effective Date
Maximum Allowable
12/1/2013
177.74
12/1/2013
17.82
12/1/2013
133.31
12/1/2013
33.24
12/1/2013
332.42
12/1/2013
33.24
12/1/2013
249.32
12/1/2013
40.98
12/1/2013
409.76
12/1/2013
40.98
12/1/2013
307.33
12/1/2013
35.70
12/1/2013
356.90
12/1/2013
35.70
12/1/2013
267.66
12/1/2013
63.68
12/1/2013
636.83
12/1/2013
63.68
12/1/2013
477.62
12/1/2013
11.97
12/1/2013
119.57
12/1/2013
11.97
12/1/2013
89.68
12/1/2013
62.22
12/1/2013
622.06
12/1/2013
62.22
12/1/2013
466.57
12/1/2013
42.36
12/1/2013
423.61
12/1/2013
42.36
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2374UE
E2375
E2375NU
E2375RR
E2375UE
E2376
E2376NU
E2376RR
E2376UE
E2377
E2377NU
E2377RR
E2377UE
E2378
E2378NU
E2378RR
E2378UE
E2381
E2381NU
E2381RR
E2381UE
E2382
E2382NU
E2382RR
E2382UE
E2383
E2383NU
E2383RR
E2383UE
E2384
Modifier
Description
UE
Hand/chin ctrl std joystick
Non-expandable controller
NU
Non-expandable controller
RR
Non-expandable controller
UE
Non-expandable controller
Expandable controller, repl
NU
Expandable controller, repl
RR
Expandable controller, repl
UE
Expandable controller, repl
Expandable controller, initl
NU
Expandable controller, initl
RR
Expandable controller, initl
UE
Expandable controller, initl
Pw actuator replacement
NU
Pw actuator replacement
RR
Pw actuator replacement
UE
Pw actuator replacement
Pneum drive wheel tire
NU
Pneum drive wheel tire
RR
Pneum drive wheel tire
UE
Pneum drive wheel tire
Tube, pneum wheel drive tire
NU
Tube, pneum wheel drive tire
RR
Tube, pneum wheel drive tire
UE
Tube, pneum wheel drive tire
Insert, pneum wheel drive
NU
Insert, pneum wheel drive
RR
Insert, pneum wheel drive
UE
Insert, pneum wheel drive
Pneumatic caster tire
Page 68 of 116
Effective Date
Maximum Allowable
12/1/2013
317.71
12/1/2013
67.93
12/1/2013
679.44
12/1/2013
67.93
12/1/2013
509.57
12/1/2013
106.47
12/1/2013
1,064.71
12/1/2013
106.47
12/1/2013
798.55
12/1/2013
38.52
12/1/2013
385.28
12/1/2013
38.52
12/1/2013
288.97
12/1/2013
47.10
12/1/2013
470.89
12/1/2013
47.10
12/1/2013
353.18
12/1/2013
5.92
12/1/2013
59.41
12/1/2013
5.92
12/1/2013
44.57
12/1/2013
1.60
12/1/2013
16.18
12/1/2013
1.60
12/1/2013
12.15
12/1/2013
11.84
12/1/2013
118.46
12/1/2013
11.84
12/1/2013
88.86
12/1/2013
6.30
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2384NU
E2384RR
E2384UE
E2385
E2385NU
E2385RR
E2385UE
E2386
E2386NU
E2386RR
E2386UE
E2387
E2387NU
E2387RR
E2387UE
E2388
E2388NU
E2388RR
E2388UE
E2389
E2389NU
E2389RR
E2389UE
E2390
E2390NU
E2390RR
E2390UE
E2391
E2391NU
E2391RR
Modifier
Description
NU
Pneumatic caster tire
RR
Pneumatic caster tire
UE
Pneumatic caster tire
Tube, pneumatic caster tire
NU
Tube, pneumatic caster tire
RR
Tube, pneumatic caster tire
UE
Tube, pneumatic caster tire
Foam filled drive wheel tire
NU
Foam filled drive wheel tire
RR
Foam filled drive wheel tire
UE
Foam filled drive wheel tire
Foam filled caster tire
NU
Foam filled caster tire
RR
Foam filled caster tire
UE
Foam filled caster tire
Foam drive wheel tire
NU
Foam drive wheel tire
RR
Foam drive wheel tire
UE
Foam drive wheel tire
Foam caster tire
NU
Foam caster tire
RR
Foam caster tire
UE
Foam caster tire
Solid drive wheel tire
NU
Solid drive wheel tire
RR
Solid drive wheel tire
UE
Solid drive wheel tire
Solid caster tire
NU
Solid caster tire
RR
Solid caster tire
Page 69 of 116
Effective Date
Maximum Allowable
12/1/2013
63.12
12/1/2013
6.30
12/1/2013
47.33
12/1/2013
3.86
12/1/2013
38.62
12/1/2013
3.86
12/1/2013
28.95
12/1/2013
11.74
12/1/2013
117.39
12/1/2013
11.74
12/1/2013
88.05
12/1/2013
5.05
12/1/2013
50.64
12/1/2013
5.05
12/1/2013
37.97
12/1/2013
4.00
12/1/2013
39.96
12/1/2013
4.00
12/1/2013
29.99
12/1/2013
2.18
12/1/2013
21.70
12/1/2013
2.18
12/1/2013
16.26
12/1/2013
3.39
12/1/2013
33.94
12/1/2013
3.39
12/1/2013
25.44
12/1/2013
1.63
12/1/2013
16.25
12/1/2013
1.63
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2391UE
E2392
E2392NU
E2392RR
E2392UE
E2394
E2394NU
E2394RR
E2394UE
E2395
E2395NU
E2395RR
E2395UE
E2396
E2396NU
E2396RR
E2396UE
E2397
E2397NU
E2397RR
E2397UE
E2402
E2402NU
E2402RR
E2500
E2500NU
E2500RR
E2500UE
E2502
E2502NU
Modifier
Description
UE
Solid caster tire
Solid caster tire, integrate
NU
Solid caster tire, integrate
RR
Solid caster tire, integrate
UE
Solid caster tire, integrate
Drive wheel excludes tire
NU
Drive wheel excludes tire
RR
Drive wheel excludes tire
UE
Drive wheel excludes tire
Caster wheel excludes tire
NU
Caster wheel excludes tire
RR
Caster wheel excludes tire
UE
Caster wheel excludes tire
Caster fork
NU
Caster fork
RR
Caster fork
UE
Caster fork
Pwc acc, lith-based battery
NU
Pwc acc, lith-based battery
RR
Pwc acc, lith-based battery
UE
Pwc acc, lith-based battery
Neg press wound therapy pump
NU
Neg press wound therapy pump
RR
Neg press wound therapy pump
SGD digitized pre-rec <=8min
NU
SGD digitized pre-rec <=8min
RR
SGD digitized pre-rec <=8min
UE
SGD digitized pre-rec <=8min
SGD prerec msg >8min <=20min
NU
SGD prerec msg >8min <=20min
Page 70 of 116
Effective Date
Maximum Allowable
12/1/2013
12.20
12/1/2013
4.29
12/1/2013
42.74
12/1/2013
4.29
12/1/2013
32.05
12/1/2013
6.10
12/1/2013
60.89
12/1/2013
6.10
12/1/2013
45.67
12/1/2013
4.33
12/1/2013
43.27
12/1/2013
4.33
12/1/2013
32.46
12/1/2013
5.05
12/1/2013
50.46
12/1/2013
5.05
12/1/2013
37.85
12/1/2013
38.11
12/1/2013
381.14
12/1/2013
38.11
12/1/2013
285.83
12/1/2013
1,361.53
12/1/2013
13,615.30
12/1/2013
1,361.53
12/1/2013
36.00
12/1/2013
359.89
12/1/2013
36.00
12/1/2013
269.91
12/1/2013
110.06
12/1/2013
1,100.50
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2502RR
E2502UE
E2504
E2504NU
E2504RR
E2504UE
E2506
E2506NU
E2506RR
E2506UE
E2508
E2508NU
E2508RR
E2508UE
E2510
E2510NU
E2510RR
E2510UE
E2601
E2601NU
E2601RR
E2601UE
E2602
E2602NU
E2602RR
E2602UE
E2603
E2603NU
E2603RR
E2603UE
Modifier
Description
RR
SGD prerec msg >8min <=20min
UE
SGD prerec msg >8min <=20min
SGD prerec msg>20min <=40min
NU
SGD prerec msg>20min <=40min
RR
SGD prerec msg>20min <=40min
UE
SGD prerec msg>20min <=40min
SGD prerec msg > 40 min
NU
SGD prerec msg > 40 min
RR
SGD prerec msg > 40 min
UE
SGD prerec msg > 40 min
SGD spelling phys contact
NU
SGD spelling phys contact
RR
SGD spelling phys contact
UE
SGD spelling phys contact
SGD w multi methods msg/accs
NU
SGD w multi methods msg/accs
RR
SGD w multi methods msg/accs
UE
SGD w multi methods msg/accs
Gen w/c cushion wdth < 22 in
NU
Gen w/c cushion wdth < 22 in
RR
Gen w/c cushion wdth < 22 in
UE
Gen w/c cushion wdth < 22 in
Gen w/c cushion wdth >=22 in
NU
Gen w/c cushion wdth >=22 in
RR
Gen w/c cushion wdth >=22 in
UE
Gen w/c cushion wdth >=22 in
Skin protect wc cus wd <22in
NU
Skin protect wc cus wd <22in
RR
Skin protect wc cus wd <22in
UE
Skin protect wc cus wd <22in
Page 71 of 116
Effective Date
Maximum Allowable
12/1/2013
110.06
12/1/2013
825.39
12/1/2013
145.19
12/1/2013
1,451.71
12/1/2013
145.19
12/1/2013
1,088.77
12/1/2013
212.86
12/1/2013
2,128.65
12/1/2013
212.86
12/1/2013
1,596.45
12/1/2013
329.15
12/1/2013
3,291.58
12/1/2013
329.15
12/1/2013
2,468.70
12/1/2013
622.89
12/1/2013
6,228.89
12/1/2013
622.89
12/1/2013
4,671.66
12/1/2013
4.86
12/1/2013
48.51
12/1/2013
4.86
12/1/2013
36.39
12/1/2013
9.48
12/1/2013
94.71
12/1/2013
9.48
12/1/2013
71.03
12/1/2013
12.04
12/1/2013
120.24
12/1/2013
12.04
12/1/2013
90.18
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2604
E2604NU
E2604RR
E2604UE
E2605
E2605NU
E2605RR
E2605UE
E2606
E2606NU
E2606RR
E2606UE
E2607
E2607NU
E2607RR
E2607UE
E2608
E2608NU
E2608RR
E2608UE
E2611
E2611NU
E2611RR
E2611UE
E2612
E2612NU
E2612RR
E2612UE
E2613
E2613NU
Modifier
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
Description
Skin protect wc cus wd>=22in
Skin protect wc cus wd>=22in
Skin protect wc cus wd>=22in
Skin protect wc cus wd>=22in
Position wc cush wdth <22 in
Position wc cush wdth <22 in
Position wc cush wdth <22 in
Position wc cush wdth <22 in
Position wc cush wdth>=22 in
Position wc cush wdth>=22 in
Position wc cush wdth>=22 in
Position wc cush wdth>=22 in
Skin pro/pos wc cus wd <22in
Skin pro/pos wc cus wd <22in
Skin pro/pos wc cus wd <22in
Skin pro/pos wc cus wd <22in
Skin pro/pos wc cus wd>=22in
Skin pro/pos wc cus wd>=22in
Skin pro/pos wc cus wd>=22in
Skin pro/pos wc cus wd>=22in
Gen use back cush wdth <22in
Gen use back cush wdth <22in
Gen use back cush wdth <22in
Gen use back cush wdth <22in
Gen use back cush wdth>=22in
Gen use back cush wdth>=22in
Gen use back cush wdth>=22in
Gen use back cush wdth>=22in
Position back cush wd <22in
Position back cush wd <22in
Page 72 of 116
Effective Date
Maximum Allowable
12/1/2013
14.93
12/1/2013
149.46
12/1/2013
14.93
12/1/2013
112.11
12/1/2013
21.36
12/1/2013
213.51
12/1/2013
21.36
12/1/2013
160.17
12/1/2013
33.32
12/1/2013
333.10
12/1/2013
33.32
12/1/2013
249.81
12/1/2013
22.99
12/1/2013
229.92
12/1/2013
22.99
12/1/2013
172.44
12/1/2013
27.61
12/1/2013
276.11
12/1/2013
27.61
12/1/2013
207.08
12/1/2013
24.77
12/1/2013
247.77
12/1/2013
24.77
12/1/2013
185.84
12/1/2013
33.52
12/1/2013
335.17
12/1/2013
33.52
12/1/2013
251.37
12/1/2013
31.18
12/1/2013
311.76
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2613RR
E2613UE
E2614
E2614NU
E2614RR
E2614UE
E2615
E2615NU
E2615RR
E2615UE
E2616
E2616NU
E2616RR
E2616UE
E2619
E2619NU
E2619RR
E2619UE
E2620
E2620NU
E2620RR
E2620UE
E2621
E2621NU
E2621RR
E2621UE
E2622
E2622NU
E2622RR
E2622UE
Modifier
Description
RR
Position back cush wd <22in
UE
Position back cush wd <22in
Position back cush wd>=22in
NU
Position back cush wd>=22in
RR
Position back cush wd>=22in
UE
Position back cush wd>=22in
Pos back post/lat wdth <22in
NU
Pos back post/lat wdth <22in
RR
Pos back post/lat wdth <22in
UE
Pos back post/lat wdth <22in
Pos back post/lat wdth>=22in
NU
Pos back post/lat wdth>=22in
RR
Pos back post/lat wdth>=22in
UE
Pos back post/lat wdth>=22in
Replace cover w/c seat cush
NU
Replace cover w/c seat cush
RR
Replace cover w/c seat cush
UE
Replace cover w/c seat cush
WC planar back cush wd <22in
NU
WC planar back cush wd <22in
RR
WC planar back cush wd <22in
UE
WC planar back cush wd <22in
WC planar back cush wd>=22in
NU
WC planar back cush wd>=22in
RR
WC planar back cush wd>=22in
UE
WC planar back cush wd>=22in
Adj skin pro w/c cus wd<22in
NU
Adj skin pro w/c cus wd<22in
RR
Adj skin pro w/c cus wd<22in
UE
Adj skin pro w/c cus wd<22in
Page 73 of 116
Effective Date
Maximum Allowable
12/1/2013
31.18
12/1/2013
233.83
12/1/2013
43.15
12/1/2013
431.46
12/1/2013
43.15
12/1/2013
323.60
12/1/2013
35.89
12/1/2013
358.79
12/1/2013
35.89
12/1/2013
269.08
12/1/2013
48.27
12/1/2013
482.74
12/1/2013
48.27
12/1/2013
362.07
12/1/2013
4.07
12/1/2013
40.70
12/1/2013
4.07
12/1/2013
30.56
12/1/2013
43.45
12/1/2013
434.44
12/1/2013
43.45
12/1/2013
325.84
12/1/2013
45.59
12/1/2013
455.91
12/1/2013
45.59
12/1/2013
341.94
12/1/2013
26.30
12/1/2013
262.92
12/1/2013
26.30
12/1/2013
197.19
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2623
E2623NU
E2623RR
E2623UE
E2624
E2624NU
E2624RR
E2624UE
E2625
E2625NU
E2625RR
E2625UE
E2626
E2626NU
E2626RR
E2626UE
E2627
E2627NU
E2627RR
E2627UE
E2628
E2628NU
E2628RR
E2628UE
E2629
E2629NU
E2629RR
E2629UE
E2630
E2630NU
Modifier
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
Description
Adj skin pro wc cus wd>=22in
Adj skin pro wc cus wd>=22in
Adj skin pro wc cus wd>=22in
Adj skin pro wc cus wd>=22in
Adj skin pro/pos cus<22in
Adj skin pro/pos cus<22in
Adj skin pro/pos cus<22in
Adj skin pro/pos cus<22in
Adj skin pro/pos wc cus>=22
Adj skin pro/pos wc cus>=22
Adj skin pro/pos wc cus>=22
Adj skin pro/pos wc cus>=22
Seo mobile arm sup att to wc
Seo mobile arm sup att to wc
Seo mobile arm sup att to wc
Seo mobile arm sup att to wc
Arm supp att to wc rancho ty
Arm supp att to wc rancho ty
Arm supp att to wc rancho ty
Arm supp att to wc rancho ty
Mobile arm supports reclinin
Mobile arm supports reclinin
Mobile arm supports reclinin
Mobile arm supports reclinin
Friction dampening arm supp
Friction dampening arm supp
Friction dampening arm supp
Friction dampening arm supp
Monosuspension arm/hand supp
Monosuspension arm/hand supp
Page 74 of 116
Effective Date
Maximum Allowable
12/1/2013
33.46
12/1/2013
334.56
12/1/2013
33.46
12/1/2013
250.91
12/1/2013
26.52
12/1/2013
265.09
12/1/2013
26.52
12/1/2013
198.83
12/1/2013
33.55
12/1/2013
335.58
12/1/2013
33.55
12/1/2013
251.68
12/1/2013
57.15
12/1/2013
571.63
12/1/2013
57.15
12/1/2013
428.68
12/1/2013
91.24
12/1/2013
912.13
12/1/2013
91.24
12/1/2013
684.10
12/1/2013
68.71
12/1/2013
687.15
12/1/2013
68.71
12/1/2013
515.35
12/1/2013
86.95
12/1/2013
869.57
12/1/2013
86.95
12/1/2013
652.18
12/1/2013
60.81
12/1/2013
608.09
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
E2630RR
E2630UE
E2631
E2631NU
E2631RR
E2631UE
E2632
E2632NU
E2632RR
E2632UE
E2633
E2633NU
E2633RR
E2633UE
K0001
K0001NU
K0001RR
K0002
K0002NU
K0002RR
K0003
K0003NU
K0003RR
K0004
K0004NU
K0004RR
K0005
K0005NU
K0005RR
K0005UE
Modifier
Description
RR
Monosuspension arm/hand supp
UE
Monosuspension arm/hand supp
Elevat proximal arm support
NU
Elevat proximal arm support
RR
Elevat proximal arm support
UE
Elevat proximal arm support
Offset/lat rocker arm w/ela
NU
Offset/lat rocker arm w/ela
RR
Offset/lat rocker arm w/ela
UE
Offset/lat rocker arm w/ela
Mobile arm support supinator
NU
Mobile arm support supinator
RR
Mobile arm support supinator
UE
Mobile arm support supinator
Standard wheelchair
NU
Standard wheelchair
RR
Standard wheelchair
Stnd hemi (low seat) whlchr
NU
Stnd hemi (low seat) whlchr
RR
Stnd hemi (low seat) whlchr
Lightweight wheelchair
NU
Lightweight wheelchair
RR
Lightweight wheelchair
High strength ltwt whlchr
NU
High strength ltwt whlchr
RR
High strength ltwt whlchr
Ultralightweight wheelchair
NU
Ultralightweight wheelchair
RR
Ultralightweight wheelchair
UE
Ultralightweight wheelchair
Page 75 of 116
Effective Date
Maximum Allowable
12/1/2013
60.81
12/1/2013
456.06
12/1/2013
20.68
12/1/2013
206.75
12/1/2013
20.68
12/1/2013
155.07
12/1/2013
13.14
12/1/2013
131.47
12/1/2013
13.14
12/1/2013
98.60
12/1/2013
13.13
12/1/2013
131.19
12/1/2013
13.13
12/1/2013
98.40
12/1/2013
14.91
12/1/2013
149.14
12/1/2013
14.91
12/1/2013
64.01
12/1/2013
640.05
12/1/2013
64.01
12/1/2013
70.09
12/1/2013
700.90
12/1/2013
70.09
12/1/2013
26.96
12/1/2013
269.60
12/1/2013
26.96
12/1/2013
167.30
12/1/2013
1,672.97
12/1/2013
167.30
12/1/2013
1,254.74
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
K0006
K0006NU
K0006RR
K0007
K0007NU
K0007RR
K0009
K0009NU
K0009RR
K0010
K0010NU
K0010RR
K0011
K0011NU
K0011RR
K0012
K0012NU
K0012RR
K0015
K0015NU
K0015RR
K0015UE
K0017
K0017NU
K0017RR
K0017UE
K0018
K0018NU
K0018RR
K0018UE
Modifier
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
UE
NU
RR
UE
NU
RR
UE
Description
Heavy duty wheelchair
Heavy duty wheelchair
Heavy duty wheelchair
Extra heavy duty wheelchair
Extra heavy duty wheelchair
Extra heavy duty wheelchair
Other manual wheelchair/base
Other manual wheelchair/base
Other manual wheelchair/base
Stnd wt frame power whlchr
Stnd wt frame power whlchr
Stnd wt frame power whlchr
Stnd wt pwr whlchr w control
Stnd wt pwr whlchr w control
Stnd wt pwr whlchr w control
Ltwt portbl power whlchr
Ltwt portbl power whlchr
Ltwt portbl power whlchr
Detach non-adjus hght armrst
Detach non-adjus hght armrst
Detach non-adjus hght armrst
Detach non-adjus hght armrst
Detach adjust armrest base
Detach adjust armrest base
Detach adjust armrest base
Detach adjust armrest base
Detach adjust armrst upper
Detach adjust armrst upper
Detach adjust armrst upper
Detach adjust armrst upper
Page 76 of 116
Effective Date
Maximum Allowable
12/1/2013
15.53
12/1/2013
155.30
12/1/2013
15.53
12/1/2013
164.27
12/1/2013
1,642.71
12/1/2013
164.27
12/1/2013
65.78
12/1/2013
657.81
12/1/2013
65.78
12/1/2013
392.04
12/1/2013
3,920.40
12/1/2013
392.04
12/1/2013
471.45
12/1/2013
4,714.53
12/1/2013
471.45
12/1/2013
299.03
12/1/2013
2,990.30
12/1/2013
299.03
12/1/2013
14.16
12/1/2013
141.73
12/1/2013
14.16
12/1/2013
106.30
12/1/2013
3.99
12/1/2013
39.86
12/1/2013
3.99
12/1/2013
29.89
12/1/2013
2.22
12/1/2013
22.28
12/1/2013
2.22
12/1/2013
16.71
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
K0019
K0019NU
K0019RR
K0019UE
K0020
K0020NU
K0020RR
K0020UE
K0037
K0037NU
K0037RR
K0037UE
K0038
K0038NU
K0038RR
K0038UE
K0039
K0039NU
K0039RR
K0039UE
K0040
K0040NU
K0040RR
K0040UE
K0041
K0041NU
K0041RR
K0041UE
K0042
K0042NU
Modifier
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
Description
Arm pad each
Arm pad each
Arm pad each
Arm pad each
Fixed adjust armrest pair
Fixed adjust armrest pair
Fixed adjust armrest pair
Fixed adjust armrest pair
High mount flip-up footrest
High mount flip-up footrest
High mount flip-up footrest
High mount flip-up footrest
Leg strap each
Leg strap each
Leg strap each
Leg strap each
Leg strap h style each
Leg strap h style each
Leg strap h style each
Leg strap h style each
Adjustable angle footplate
Adjustable angle footplate
Adjustable angle footplate
Adjustable angle footplate
Large size footplate each
Large size footplate each
Large size footplate each
Large size footplate each
Standard size footplate each
Standard size footplate each
Page 77 of 116
Effective Date
Maximum Allowable
12/1/2013
1.37
12/1/2013
13.67
12/1/2013
1.37
12/1/2013
10.26
12/1/2013
3.63
12/1/2013
36.23
12/1/2013
3.63
12/1/2013
27.17
12/1/2013
2.90
12/1/2013
32.47
12/1/2013
2.90
12/1/2013
24.36
12/1/2013
1.89
12/1/2013
18.92
12/1/2013
1.89
12/1/2013
14.18
12/1/2013
4.22
12/1/2013
42.03
12/1/2013
4.22
12/1/2013
31.51
12/1/2013
5.82
12/1/2013
58.23
12/1/2013
5.82
12/1/2013
43.68
12/1/2013
4.12
12/1/2013
41.29
12/1/2013
4.12
12/1/2013
30.95
12/1/2013
2.46
12/1/2013
24.56
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
K0042RR
K0042UE
K0043
K0043NU
K0043RR
K0043UE
K0044
K0044NU
K0044RR
K0044UE
K0045
K0045NU
K0045RR
K0045UE
K0046
K0046NU
K0046RR
K0046UE
K0047
K0047NU
K0047RR
K0047UE
K0050
K0050NU
K0050RR
K0050UE
K0051
K0051NU
K0051RR
K0051UE
Modifier
Description
RR
Standard size footplate each
UE
Standard size footplate each
Ftrst lower extension tube
NU
Ftrst lower extension tube
RR
Ftrst lower extension tube
UE
Ftrst lower extension tube
Ftrst upper hanger bracket
NU
Ftrst upper hanger bracket
RR
Ftrst upper hanger bracket
UE
Ftrst upper hanger bracket
Footrest complete assembly
NU
Footrest complete assembly
RR
Footrest complete assembly
UE
Footrest complete assembly
Elevat legrst low extension
NU
Elevat legrst low extension
RR
Elevat legrst low extension
UE
Elevat legrst low extension
Elevat legrst up hangr brack
NU
Elevat legrst up hangr brack
RR
Elevat legrst up hangr brack
UE
Elevat legrst up hangr brack
Ratchet assembly
NU
Ratchet assembly
RR
Ratchet assembly
UE
Ratchet assembly
Cam relese assem ftrst/lgrst
NU
Cam relese assem ftrst/lgrst
RR
Cam relese assem ftrst/lgrst
UE
Cam relese assem ftrst/lgrst
Page 78 of 116
Effective Date
Maximum Allowable
12/1/2013
2.46
12/1/2013
18.42
12/1/2013
1.52
12/1/2013
15.23
12/1/2013
1.52
12/1/2013
11.43
12/1/2013
1.30
12/1/2013
12.99
12/1/2013
1.30
12/1/2013
9.72
12/1/2013
8.54
12/1/2013
85.37
12/1/2013
8.54
12/1/2013
59.76
12/1/2013
1.52
12/1/2013
15.23
12/1/2013
1.52
12/1/2013
11.43
12/1/2013
5.97
12/1/2013
59.64
12/1/2013
5.97
12/1/2013
44.74
12/1/2013
2.52
12/1/2013
25.35
12/1/2013
2.52
12/1/2013
19.02
12/1/2013
4.10
12/1/2013
41.02
12/1/2013
4.10
12/1/2013
30.76
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
K0052
K0052NU
K0052RR
K0052UE
K0053
K0053NU
K0053RR
K0053UE
K0056
K0056NU
K0056RR
K0056UE
K0065
K0065NU
K0065RR
K0065UE
K0069
K0069NU
K0069RR
K0069UE
K0070
K0070NU
K0070RR
K0070UE
K0071
K0071NU
K0071RR
K0071UE
K0072
K0072NU
Modifier
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
Description
Swingaway detach footrest
Swingaway detach footrest
Swingaway detach footrest
Swingaway detach footrest
Elevate footrest articulate
Elevate footrest articulate
Elevate footrest articulate
Elevate footrest articulate
Seat ht <17 or >=21 ltwt wc
Seat ht <17 or >=21 ltwt wc
Seat ht <17 or >=21 ltwt wc
Seat ht <17 or >=21 ltwt wc
Spoke protectors
Spoke protectors
Spoke protectors
Spoke protectors
Rear whl complete solid tire
Rear whl complete solid tire
Rear whl complete solid tire
Rear whl complete solid tire
Rear whl compl pneum tire
Rear whl compl pneum tire
Rear whl compl pneum tire
Rear whl compl pneum tire
Front castr compl pneum tire
Front castr compl pneum tire
Front castr compl pneum tire
Front castr compl pneum tire
Frnt cstr cmpl sem-pneum tir
Frnt cstr cmpl sem-pneum tir
Page 79 of 116
Effective Date
Maximum Allowable
12/1/2013
7.23
12/1/2013
72.10
12/1/2013
7.23
12/1/2013
54.06
12/1/2013
7.96
12/1/2013
79.57
12/1/2013
7.96
12/1/2013
59.66
12/1/2013
8.62
12/1/2013
86.05
12/1/2013
8.62
12/1/2013
64.57
12/1/2013
4.02
12/1/2013
40.23
12/1/2013
4.02
12/1/2013
30.18
12/1/2013
9.05
12/1/2013
90.40
12/1/2013
9.05
12/1/2013
67.80
12/1/2013
16.58
12/1/2013
165.76
12/1/2013
16.58
12/1/2013
124.32
12/1/2013
9.91
12/1/2013
98.85
12/1/2013
9.91
12/1/2013
74.15
12/1/2013
5.58
12/1/2013
55.92
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
K0072RR
K0072UE
K0073
K0073NU
K0073RR
K0073UE
K0077
K0077NU
K0077RR
K0077UE
K0098
K0098NU
K0098RR
K0098UE
K0105
K0105NU
K0105RR
K0105UE
K0108
K0195
K0195NU
K0195RR
K0455
K0455RR
K0552
K0601
K0601NU
K0602
K0602NU
K0603
Modifier
Description
RR
Frnt cstr cmpl sem-pneum tir
UE
Frnt cstr cmpl sem-pneum tir
Caster pin lock each
NU
Caster pin lock each
RR
Caster pin lock each
UE
Caster pin lock each
Front caster assem complete
NU
Front caster assem complete
RR
Front caster assem complete
UE
Front caster assem complete
Drive belt power wheelchair
NU
Drive belt power wheelchair
RR
Drive belt power wheelchair
UE
Drive belt power wheelchair
Iv hanger
NU
Iv hanger
RR
Iv hanger
UE
Iv hanger
W/c component-accessory NOS
Elevating whlchair leg rests
NU
Elevating whlchair leg rests
RR
Elevating whlchair leg rests
Pump uninterrupted infusion
RR
Pump uninterrupted infusion
Supply/ext inf pump syr type
Repl batt silver oxide 1.5 v
NU
Repl batt silver oxide 1.5 v
Repl batt silver oxide 3 v
NU
Repl batt silver oxide 3 v
Repl batt alkaline 1.5 v
Page 80 of 116
Effective Date
Maximum Allowable
12/1/2013
5.58
12/1/2013
41.95
12/1/2013
3.03
12/1/2013
30.29
12/1/2013
3.03
12/1/2013
22.70
12/1/2013
5.32
12/1/2013
53.24
12/1/2013
5.32
12/1/2013
39.92
12/1/2013
2.07
12/1/2013
20.59
12/1/2013
2.07
12/1/2013
15.47
12/1/2013
8.98
12/1/2013
89.97
12/1/2013
8.98
12/1/2013
67.50
12/1/2013
75.49
12/1/2013
15.08
12/1/2013
150.79
12/1/2013
15.08
12/1/2013
243.76
12/1/2013
243.76
12/1/2013
2.55
12/1/2013
1.77
12/1/2013
1.77
12/1/2013
1.77
12/1/2013
1.77
12/1/2013
1.77
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
K0603NU
K0604
K0604NU
K0605
K0605NU
K0606
K0606NU
K0606RR
K0607
K0607NU
K0607RR
K0607UE
K0608
K0608NU
K0608RR
K0608UE
K0609
K0609KF
K0672
K0730
K0730NU
K0730RR
K0730UE
K0733
K0733NU
K0733RR
K0733UE
K0738
K0738NU
K0738RR
Modifier
Description
NU
Repl batt alkaline 1.5 v
Repl batt lithium 3.6 v
NU
Repl batt lithium 3.6 v
Repl batt lithium 4.5 v
NU
Repl batt lithium 4.5 v
AED garment w elec analysis
NU
AED garment w elec analysis
RR
AED garment w elec analysis
Repl batt for AED
NU
Repl batt for AED
RR
Repl batt for AED
UE
Repl batt for AED
Repl garment for AED
NU
Repl garment for AED
RR
Repl garment for AED
UE
Repl garment for AED
Repl electrode for AED
KF
Repl electrode for AED
Removable soft interface LE
Ctrl dose inh drug deliv sys
NU
Ctrl dose inh drug deliv sys
RR
Ctrl dose inh drug deliv sys
UE
Ctrl dose inh drug deliv sys
12-24hr sealed lead acid
NU
12-24hr sealed lead acid
RR
12-24hr sealed lead acid
UE
12-24hr sealed lead acid
Portable gas oxygen system
NU
Portable gas oxygen system
RR
Portable gas oxygen system
Page 81 of 116
Effective Date
Maximum Allowable
12/1/2013
1.77
12/1/2013
1.77
12/1/2013
1.77
12/1/2013
1.77
12/1/2013
1.77
12/1/2013
2,317.59
12/1/2013
23,175.90
12/1/2013
2,317.59
12/1/2013
17.88
12/1/2013
178.76
12/1/2013
17.88
12/1/2013
134.06
12/1/2013
11.18
12/1/2013
111.55
12/1/2013
11.18
12/1/2013
83.67
12/1/2013
741.85
12/1/2013
823.64
12/1/2013
80.28
12/1/2013
158.66
12/1/2013
1,586.63
12/1/2013
158.66
12/1/2013
1,189.97
12/1/2013
2.41
12/1/2013
23.96
12/1/2013
2.41
12/1/2013
17.99
12/1/2013
41.30
12/1/2013
413.04
12/1/2013
41.30
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
K0800
K0800NU
K0800RR
K0800UE
K0801
K0801NU
K0801RR
K0801UE
K0802
K0802NU
K0802RR
K0802UE
K0806
K0806NU
K0806RR
K0806UE
K0807
K0807NU
K0807RR
K0807UE
K0808
K0808NU
K0808RR
K0808UE
K0813
K0813NU
K0813RR
K0814
K0814NU
K0814RR
Modifier
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
UE
NU
RR
NU
RR
Description
POV group 1 std up to 300lbs
POV group 1 std up to 300lbs
POV group 1 std up to 300lbs
POV group 1 std up to 300lbs
POV group 1 hd 301-450 lbs
POV group 1 hd 301-450 lbs
POV group 1 hd 301-450 lbs
POV group 1 hd 301-450 lbs
POV group 1 vhd 451-600 lbs
POV group 1 vhd 451-600 lbs
POV group 1 vhd 451-600 lbs
POV group 1 vhd 451-600 lbs
POV group 2 std up to 300lbs
POV group 2 std up to 300lbs
POV group 2 std up to 300lbs
POV group 2 std up to 300lbs
POV group 2 hd 301-450 lbs
POV group 2 hd 301-450 lbs
POV group 2 hd 301-450 lbs
POV group 2 hd 301-450 lbs
POV group 2 vhd 451-600 lbs
POV group 2 vhd 451-600 lbs
POV group 2 vhd 451-600 lbs
POV group 2 vhd 451-600 lbs
PWC gp 1 std port seat/back
PWC gp 1 std port seat/back
PWC gp 1 std port seat/back
PWC gp 1 std port cap chair
PWC gp 1 std port cap chair
PWC gp 1 std port cap chair
Page 82 of 116
Effective Date
Maximum Allowable
12/1/2013
102.55
12/1/2013
1,025.45
12/1/2013
102.55
12/1/2013
769.09
12/1/2013
165.30
12/1/2013
1,653.24
12/1/2013
165.30
12/1/2013
1,239.93
12/1/2013
187.09
12/1/2013
1,870.94
12/1/2013
187.09
12/1/2013
1,403.21
12/1/2013
124.05
12/1/2013
1,240.52
12/1/2013
124.05
12/1/2013
930.39
12/1/2013
188.24
12/1/2013
1,882.35
12/1/2013
188.24
12/1/2013
1,411.77
12/1/2013
291.24
12/1/2013
2,912.39
12/1/2013
291.24
12/1/2013
2,184.28
12/1/2013
287.03
12/1/2013
2,870.30
12/1/2013
287.03
12/1/2013
367.43
12/1/2013
3,674.30
12/1/2013
367.43
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
K0815
K0815NU
K0815RR
K0816
K0816NU
K0816RR
K0820
K0820NU
K0820RR
K0821
K0821NU
K0821RR
K0822
K0822NU
K0822RR
K0823
K0823NU
K0823RR
K0824
K0824NU
K0824RR
K0825
K0825NU
K0825RR
K0826
K0826NU
K0826RR
K0827
K0827NU
K0827RR
Modifier
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
Description
PWC gp 1 std seat/back
PWC gp 1 std seat/back
PWC gp 1 std seat/back
PWC gp 1 std cap chair
PWC gp 1 std cap chair
PWC gp 1 std cap chair
PWC gp 2 std port seat/back
PWC gp 2 std port seat/back
PWC gp 2 std port seat/back
PWC gp 2 std port cap chair
PWC gp 2 std port cap chair
PWC gp 2 std port cap chair
PWC gp 2 std seat/back
PWC gp 2 std seat/back
PWC gp 2 std seat/back
PWC gp 2 std cap chair
PWC gp 2 std cap chair
PWC gp 2 std cap chair
PWC gp 2 hd seat/back
PWC gp 2 hd seat/back
PWC gp 2 hd seat/back
PWC gp 2 hd cap chair
PWC gp 2 hd cap chair
PWC gp 2 hd cap chair
PWC gp 2 vhd seat/back
PWC gp 2 vhd seat/back
PWC gp 2 vhd seat/back
PWC gp vhd cap chair
PWC gp vhd cap chair
PWC gp vhd cap chair
Page 83 of 116
Effective Date
Maximum Allowable
12/1/2013
418.36
12/1/2013
4,183.62
12/1/2013
418.36
12/1/2013
400.67
12/1/2013
4,006.73
12/1/2013
400.67
12/1/2013
306.59
12/1/2013
3,065.90
12/1/2013
306.59
12/1/2013
393.56
12/1/2013
3,935.59
12/1/2013
393.56
12/1/2013
475.63
12/1/2013
4,756.30
12/1/2013
475.63
12/1/2013
478.77
12/1/2013
4,787.71
12/1/2013
478.77
12/1/2013
576.19
12/1/2013
5,761.90
12/1/2013
576.19
12/1/2013
527.50
12/1/2013
5,275.00
12/1/2013
527.50
12/1/2013
745.96
12/1/2013
7,459.60
12/1/2013
745.96
12/1/2013
634.28
12/1/2013
6,342.80
12/1/2013
634.28
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
K0828
K0828NU
K0828RR
K0829
K0829NU
K0829RR
K0835
K0835NU
K0835RR
K0836
K0836NU
K0836RR
K0837
K0837NU
K0837RR
K0838
K0838NU
K0838RR
K0839
K0839NU
K0839RR
K0840
K0840NU
K0840RR
K0841
K0841NU
K0841RR
K0842
K0842NU
K0842RR
Modifier
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
Description
PWC gp 2 xtra hd seat/back
PWC gp 2 xtra hd seat/back
PWC gp 2 xtra hd seat/back
PWC gp 2 xtra hd cap chair
PWC gp 2 xtra hd cap chair
PWC gp 2 xtra hd cap chair
PWC gp2 std sing pow opt s/b
PWC gp2 std sing pow opt s/b
PWC gp2 std sing pow opt s/b
PWC gp2 std sing pow opt cap
PWC gp2 std sing pow opt cap
PWC gp2 std sing pow opt cap
PWC gp 2 hd sing pow opt s/b
PWC gp 2 hd sing pow opt s/b
PWC gp 2 hd sing pow opt s/b
PWC gp 2 hd sing pow opt cap
PWC gp 2 hd sing pow opt cap
PWC gp 2 hd sing pow opt cap
PWC gp2 vhd sing pow opt s/b
PWC gp2 vhd sing pow opt s/b
PWC gp2 vhd sing pow opt s/b
PWC gp2 xhd sing pow opt s/b
PWC gp2 xhd sing pow opt s/b
PWC gp2 xhd sing pow opt s/b
PWC gp2 std mult pow opt s/b
PWC gp2 std mult pow opt s/b
PWC gp2 std mult pow opt s/b
PWC gp2 std mult pow opt cap
PWC gp2 std mult pow opt cap
PWC gp2 std mult pow opt cap
Page 84 of 116
Effective Date
Maximum Allowable
12/1/2013
821.96
12/1/2013
8,219.60
12/1/2013
821.96
12/1/2013
754.81
12/1/2013
7,548.09
12/1/2013
754.81
12/1/2013
482.77
12/1/2013
4,827.70
12/1/2013
482.77
12/1/2013
500.65
12/1/2013
5,006.50
12/1/2013
500.65
12/1/2013
576.19
12/1/2013
5,761.89
12/1/2013
576.19
12/1/2013
515.46
12/1/2013
5,154.57
12/1/2013
515.46
12/1/2013
745.96
12/1/2013
7,459.60
12/1/2013
745.96
12/1/2013
1,130.11
12/1/2013
11,301.10
12/1/2013
1,130.11
12/1/2013
513.85
12/1/2013
5,138.51
12/1/2013
513.85
12/1/2013
513.85
12/1/2013
5,138.50
12/1/2013
513.85
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
K0843
K0843NU
K0843RR
K0848
K0848NU
K0848RR
K0849
K0849NU
K0849RR
K0850
K0850NU
K0850RR
K0851
K0851NU
K0851RR
K0852
K0852NU
K0852RR
K0853
K0853NU
K0853RR
K0854
K0854NU
K0854RR
K0855
K0855NU
K0855RR
K0856
K0856NU
K0856RR
Modifier
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
Description
PWC gp2 hd mult pow opt s/b
PWC gp2 hd mult pow opt s/b
PWC gp2 hd mult pow opt s/b
PWC gp 3 std seat/back
PWC gp 3 std seat/back
PWC gp 3 std seat/back
PWC gp 3 std cap chair
PWC gp 3 std cap chair
PWC gp 3 std cap chair
PWC gp 3 hd seat/back
PWC gp 3 hd seat/back
PWC gp 3 hd seat/back
PWC gp 3 hd cap chair
PWC gp 3 hd cap chair
PWC gp 3 hd cap chair
PWC gp 3 vhd seat/back
PWC gp 3 vhd seat/back
PWC gp 3 vhd seat/back
PWC gp 3 vhd cap chair
PWC gp 3 vhd cap chair
PWC gp 3 vhd cap chair
PWC gp 3 xhd seat/back
PWC gp 3 xhd seat/back
PWC gp 3 xhd seat/back
PWC gp 3 xhd cap chair
PWC gp 3 xhd cap chair
PWC gp 3 xhd cap chair
PWC gp3 std sing pow opt s/b
PWC gp3 std sing pow opt s/b
PWC gp3 std sing pow opt s/b
Page 85 of 116
Effective Date
Maximum Allowable
12/1/2013
618.66
12/1/2013
6,186.60
12/1/2013
618.66
12/1/2013
628.75
12/1/2013
6,287.45
12/1/2013
628.75
12/1/2013
604.52
12/1/2013
6,045.20
12/1/2013
604.52
12/1/2013
729.33
12/1/2013
7,293.30
12/1/2013
729.33
12/1/2013
701.25
12/1/2013
7,012.50
12/1/2013
701.25
12/1/2013
842.70
12/1/2013
8,426.98
12/1/2013
842.70
12/1/2013
865.67
12/1/2013
8,656.70
12/1/2013
865.67
12/1/2013
1,146.81
12/1/2013
11,468.11
12/1/2013
1,146.81
12/1/2013
1,083.33
12/1/2013
10,833.34
12/1/2013
1,083.33
12/1/2013
674.90
12/1/2013
6,749.00
12/1/2013
674.90
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
K0857
K0857NU
K0857RR
K0858
K0858NU
K0858RR
K0859
K0859NU
K0859RR
K0860
K0860NU
K0860RR
K0861
K0861NU
K0861RR
K0862
K0862NU
K0862RR
K0863
K0863NU
K0863RR
K0864
K0864NU
K0864RR
L0112
L0113
L0120
L0130
L0140
L0150
Modifier
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
NU
RR
Description
PWC gp3 std sing pow opt cap
PWC gp3 std sing pow opt cap
PWC gp3 std sing pow opt cap
PWC gp3 hd sing pow opt s/b
PWC gp3 hd sing pow opt s/b
PWC gp3 hd sing pow opt s/b
PWC gp3 hd sing pow opt cap
PWC gp3 hd sing pow opt cap
PWC gp3 hd sing pow opt cap
PWC gp3 vhd sing pow opt s/b
PWC gp3 vhd sing pow opt s/b
PWC gp3 vhd sing pow opt s/b
PWC gp3 std mult pow opt s/b
PWC gp3 std mult pow opt s/b
PWC gp3 std mult pow opt s/b
PWC gp3 hd mult pow opt s/b
PWC gp3 hd mult pow opt s/b
PWC gp3 hd mult pow opt s/b
PWC gp3 vhd mult pow opt s/b
PWC gp3 vhd mult pow opt s/b
PWC gp3 vhd mult pow opt s/b
PWC gp3 xhd mult pow opt s/b
PWC gp3 xhd mult pow opt s/b
PWC gp3 xhd mult pow opt s/b
Cranial cervical orthosis
Cranial cervical torticollis
Cerv flexible non-adjustable
Flex thermoplastic collar mo
Cervical semi-rigid adjustab
Cerv semi-rig adj molded chn
Page 86 of 116
Effective Date
Maximum Allowable
12/1/2013
688.42
12/1/2013
6,884.23
12/1/2013
688.42
12/1/2013
837.36
12/1/2013
8,373.61
12/1/2013
837.36
12/1/2013
798.57
12/1/2013
7,985.75
12/1/2013
798.57
12/1/2013
1,196.26
12/1/2013
11,962.60
12/1/2013
1,196.26
12/1/2013
675.98
12/1/2013
6,759.80
12/1/2013
675.98
12/1/2013
837.36
12/1/2013
8,373.60
12/1/2013
837.36
12/1/2013
1,196.26
12/1/2013
11,962.64
12/1/2013
1,196.26
12/1/2013
1,423.56
12/1/2013
14,235.63
12/1/2013
1,423.56
12/1/2013
1,275.47
12/1/2013
269.99
12/1/2013
30.89
12/1/2013
171.85
12/1/2013
74.52
12/1/2013
99.24
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L0160
L0170
L0172
L0174
L0180
L0190
L0200
L0220
L0430
L0450
L0454
L0456
L0458
L0460
L0462
L0464
L0466
L0468
L0470
L0472
L0480
L0482
L0484
L0486
L0488
L0490
L0491
L0492
L0621
L0622
Modifier
Description
Cerv semi-rig wire occ/mand
Cervical collar molded to pt
Cerv col thermplas foam 2 pi
Cerv col foam 2 piece w thor
Cer post col occ/man sup adj
Cerv collar supp adj cerv ba
Cerv col supp adj bar & thor
Thor rib belt custom fabrica
Dewall posture protector
TLSO flex prefab thoracic
TLSO flex prefab sacrococ-T9
TLSO flex prefab
TLSO 2Mod symphis-xipho pre
TLSO2Mod symphysis-stern pre
TLSO 3Mod sacro-scap pre
TLSO 4Mod sacro-scap pre
TLSO rigid frame pre soft ap
TLSO rigid frame prefab pelv
TLSO rigid frame pre subclav
TLSO rigid frame hyperex pre
TLSO rigid plastic custom fa
TLSO rigid lined custom fab
TLSO rigid plastic cust fab
TLSO rigidlined cust fab two
TLSO rigid lined pre one pie
TLSO rigid plastic pre one
TLSO 2 piece rigid shell
TLSO 3 piece rigid shell
SIO flex pelvisacral prefab
SIO flex pelvisacral custom
Page 87 of 116
Effective Date
Maximum Allowable
12/1/2013
136.73
12/1/2013
663.24
12/1/2013
119.70
12/1/2013
252.02
12/1/2013
367.45
12/1/2013
516.97
12/1/2013
577.26
12/1/2013
115.01
12/1/2013
1,169.79
12/1/2013
200.38
12/1/2013
316.06
12/1/2013
906.36
12/1/2013
812.72
12/1/2013
914.76
12/1/2013
1,137.84
12/1/2013
1,354.57
12/1/2013
411.89
12/1/2013
494.39
12/1/2013
593.40
12/1/2013
421.39
12/1/2013
1,453.01
12/1/2013
1,480.85
12/1/2013
1,551.47
12/1/2013
1,646.03
12/1/2013
914.76
12/1/2013
257.80
12/1/2013
699.87
12/1/2013
460.34
12/1/2013
105.50
12/1/2013
280.00
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L0625
L0626
L0627
L0628
L0630
L0631
L0633
L0635
L0636
L0637
L0638
L0639
L0640
L0700
L0710
L0810
L0820
L0830
L0859
L0861
L0970
L0972
L0974
L0976
L0978
L0980
L0982
L0984
L1000
L1005
Modifier
Description
LO flexibl L1-below L5 pre
LO sag stays/panels pre-fab
LO sagitt rigid panel prefab
LO flex w/o rigid stays pre
LSO post rigid panel pre
LSO sag-coro rigid frame pre
LSO flexion control prefab
LSO sagit rigid panel prefab
LSO sagittal rigid panel cus
LSO sag-coronal panel prefab
LSO sag-coronal panel custom
LSO s/c shell/panel prefab
LSO s/c shell/panel custom
Ctlso a-p-l control molded
Ctlso a-p-l control w/ inter
Halo cervical into jckt vest
Halo cervical into body jack
Halo cerv into milwaukee typ
MRI compatible system
Halo repl liner/interface
Tlso corset front
Lso corset front
Tlso full corset
Lso full corset
Axillary crutch extension
Peroneal straps pair
Stocking supp grips set of f
Protective body sock each
Ctlso milwauke initial model
Tension based scoliosis orth
Page 88 of 116
Effective Date
Maximum Allowable
12/1/2013
50.19
12/1/2013
71.02
12/1/2013
374.59
12/1/2013
76.46
12/1/2013
147.59
12/1/2013
650.00
12/1/2013
261.32
12/1/2013
962.96
12/1/2013
1,255.55
12/1/2013
750.00
12/1/2013
1,201.91
12/1/2013
1,024.27
12/1/2013
953.58
12/1/2013
1,764.99
12/1/2013
1,993.52
12/1/2013
2,400.35
12/1/2013
2,357.33
12/1/2013
3,306.48
12/1/2013
1,063.54
12/1/2013
196.42
12/1/2013
99.78
12/1/2013
89.85
12/1/2013
161.72
12/1/2013
170.90
12/1/2013
179.14
12/1/2013
16.21
12/1/2013
15.13
12/1/2013
59.68
12/1/2013
2,122.84
12/1/2013
2,916.72
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L1010
L1020
L1025
L1030
L1040
L1050
L1060
L1070
L1080
L1085
L1090
L1100
L1110
L1120
L1200
L1210
L1220
L1230
L1240
L1250
L1260
L1270
L1280
L1290
L1300
L1310
L1600
L1610
L1620
L1630
Modifier
Description
Ctlso axilla sling
Kyphosis pad
Kyphosis pad floating
Lumbar bolster pad
Lumbar or lumbar rib pad
Sternal pad
Thoracic pad
Trapezius sling
Outrigger
Outrigger bil w/ vert extens
Lumbar sling
Ring flange plastic/leather
Ring flange plas/leather mol
Covers for upright each
Furnsh initial orthosis only
Lateral thoracic extension
Anterior thoracic extension
Milwaukee type superstructur
Lumbar derotation pad
Anterior asis pad
Anterior thoracic derotation
Abdominal pad
Rib gusset (elastic) each
Lateral trochanteric pad
Body jacket mold to patient
Post-operative body jacket
Abduct hip flex frejka w cvr
Abduct hip flex frejka covr
Abduct hip flex pavlik harne
Abduct control hip semi-flex
Page 89 of 116
Effective Date
Maximum Allowable
12/1/2013
60.77
12/1/2013
89.09
12/1/2013
108.86
12/1/2013
57.06
12/1/2013
84.25
12/1/2013
89.47
12/1/2013
98.38
12/1/2013
88.92
12/1/2013
54.97
12/1/2013
143.48
12/1/2013
86.78
12/1/2013
157.69
12/1/2013
260.94
12/1/2013
42.91
12/1/2013
1,823.83
12/1/2013
228.43
12/1/2013
236.61
12/1/2013
496.27
12/1/2013
72.46
12/1/2013
66.28
12/1/2013
69.96
12/1/2013
67.64
12/1/2013
78.35
12/1/2013
70.10
12/1/2013
1,474.78
12/1/2013
1,651.87
12/1/2013
112.50
12/1/2013
38.32
12/1/2013
123.24
12/1/2013
159.79
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L1640
L1650
L1652
L1660
L1680
L1685
L1686
L1690
L1700
L1710
L1720
L1730
L1755
L1810
L1820
L1830
L1831
L1832
L1834
L1836
L1840
L1843
L1844
L1845
L1846
L1847
L1850
L1860
L1900
L1902
Modifier
Description
Pelv band/spread bar thigh c
HO abduction hip adjustable
HO bi thighcuffs w sprdr bar
HO abduction static plastic
Pelvic & hip control thigh c
Post-op hip abduct custom fa
HO post-op hip abduction
Combination bilateral HO
Leg perthes orth toronto typ
Legg perthes orth newington
Legg perthes orthosis trilat
Legg perthes orth scottish r
Legg perthes patten bottom t
Ko elastic with joints
Ko elas w/ condyle pads & jo
Ko immobilizer canvas longit
Knee orth pos locking joint
KO adj jnt pos rigid support
Ko w/0 joint rigid molded to
Rigid KO wo joints
Ko derot ant cruciate custom
KO single upright custom fit
Ko w/adj jt rot cntrl molded
Ko w/ adj flex/ext rotat cus
Ko w adj flex/ext rotat mold
KO adjustable w air chambers
Ko swedish type
Ko supracondylar socket mold
Afo sprng wir drsflx calf bd
Afo ankle gauntlet
Page 90 of 116
Effective Date
Maximum Allowable
12/1/2013
421.41
12/1/2013
202.13
12/1/2013
324.84
12/1/2013
161.90
12/1/2013
1,418.28
12/1/2013
1,038.44
12/1/2013
807.54
12/1/2013
1,762.21
12/1/2013
1,433.85
12/1/2013
1,734.81
12/1/2013
1,210.19
12/1/2013
1,032.54
12/1/2013
1,382.20
12/1/2013
99.53
12/1/2013
125.94
12/1/2013
97.61
12/1/2013
268.21
12/1/2013
530.77
12/1/2013
677.69
12/1/2013
121.60
12/1/2013
928.56
12/1/2013
600.00
12/1/2013
1,836.77
12/1/2013
741.06
12/1/2013
1,116.18
12/1/2013
524.15
12/1/2013
280.61
12/1/2013
1,145.37
12/1/2013
259.65
12/1/2013
85.46
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L1904
L1906
L1907
L1910
L1920
L1930
L1932
L1940
L1945
L1950
L1951
L1960
L1970
L1971
L1980
L1990
L2000
L2005
L2010
L2020
L2030
L2034
L2035
L2036
L2037
L2038
L2040
L2050
L2060
L2070
Modifier
Description
Afo molded ankle gauntlet
Afo multiligamentus ankle su
AFO supramalleolar custom
Afo sing bar clasp attach sh
Afo sing upright w/ adjust s
Afo plastic
Afo rig ant tib prefab TCF/=
Afo molded to patient plasti
Afo molded plas rig ant tib
Afo spiral molded to pt plas
AFO spiral prefabricated
Afo pos solid ank plastic mo
Afo plastic molded w/ankle j
AFO w/ankle joint, prefab
Afo sing solid stirrup calf
Afo doub solid stirrup calf
Kafo sing fre stirr thi/calf
KAFO sng/dbl mechanical act
Kafo sng solid stirrup w/o j
Kafo dbl solid stirrup band/
Kafo dbl solid stirrup w/o j
KAFO pla sin up w/wo k/a cus
KAFO plastic pediatric size
Kafo plas doub free knee mol
Kafo plas sing free knee mol
Kafo w/o joint multi-axis an
Hkafo torsion bil rot straps
Hkafo torsion cable hip pelv
Hkafo torsion ball bearing j
Hkafo torsion unilat rot str
Page 91 of 116
Effective Date
Maximum Allowable
12/1/2013
410.53
12/1/2013
104.99
12/1/2013
512.77
12/1/2013
295.31
12/1/2013
391.19
12/1/2013
241.20
12/1/2013
813.20
12/1/2013
463.80
12/1/2013
911.93
12/1/2013
867.02
12/1/2013
765.34
12/1/2013
483.90
12/1/2013
645.78
12/1/2013
427.15
12/1/2013
409.77
12/1/2013
495.15
12/1/2013
1,180.66
12/1/2013
3,734.24
12/1/2013
1,065.80
12/1/2013
1,359.18
12/1/2013
1,170.54
12/1/2013
1,847.97
12/1/2013
163.98
12/1/2013
2,089.55
12/1/2013
1,723.85
12/1/2013
1,452.18
12/1/2013
199.47
12/1/2013
421.78
12/1/2013
597.16
12/1/2013
117.41
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L2080
L2090
L2106
L2108
L2112
L2114
L2116
L2126
L2128
L2132
L2134
L2136
L2180
L2182
L2184
L2186
L2188
L2190
L2192
L2200
L2210
L2220
L2230
L2232
L2240
L2250
L2260
L2265
L2270
L2275
Modifier
Description
Hkafo unilat torsion cable
Hkafo unilat torsion ball br
Afo tib fx cast plaster mold
Afo tib fx cast molded to pt
Afo tibial fracture soft
Afo tib fx semi-rigid
Afo tibial fracture rigid
Kafo fem fx cast thermoplas
Kafo fem fx cast molded to p
Kafo femoral fx cast soft
Kafo fem fx cast semi-rigid
Kafo femoral fx cast rigid
Plas shoe insert w ank joint
Drop lock knee
Limited motion knee joint
Adj motion knee jnt lerman t
Quadrilateral brim
Waist belt
Pelvic band & belt thigh fla
Limited ankle motion ea jnt
Dorsiflexion assist each joi
Dorsi & plantar flex ass/res
Split flat caliper stirr & p
Rocker bottom, contact AFO
Round caliper and plate atta
Foot plate molded stirrup at
Reinforced solid stirrup
Long tongue stirrup
Varus/valgus strap padded/li
Plastic mod low ext pad/line
Page 92 of 116
Effective Date
Maximum Allowable
12/1/2013
361.99
12/1/2013
510.42
12/1/2013
611.84
12/1/2013
1,046.19
12/1/2013
422.30
12/1/2013
518.21
12/1/2013
621.50
12/1/2013
1,045.40
12/1/2013
1,995.99
12/1/2013
704.25
12/1/2013
882.99
12/1/2013
1,032.44
12/1/2013
102.24
12/1/2013
94.08
12/1/2013
108.15
12/1/2013
151.32
12/1/2013
283.31
12/1/2013
76.24
12/1/2013
311.28
12/1/2013
55.34
12/1/2013
61.51
12/1/2013
84.49
12/1/2013
82.24
12/1/2013
90.69
12/1/2013
73.69
12/1/2013
413.62
12/1/2013
175.01
12/1/2013
102.81
12/1/2013
62.51
12/1/2013
136.54
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L2280
L2300
L2310
L2320
L2330
L2335
L2340
L2350
L2360
L2370
L2375
L2380
L2385
L2387
L2390
L2395
L2397
L2405
L2415
L2425
L2430
L2492
L2500
L2510
L2520
L2525
L2526
L2530
L2540
L2550
Modifier
Description
Molded inner boot
Abduction bar jointed adjust
Abduction bar-straight
Non-molded lacer
Lacer molded to patient mode
Anterior swing band
Pre-tibial shell molded to p
Prosthetic type socket molde
Extended steel shank
Patten bottom
Torsion ank & half solid sti
Torsion straight knee joint
Straight knee joint heavy du
Add LE poly knee custom KAFO
Offset knee joint each
Offset knee joint heavy duty
Suspension sleeve lower ext
Knee joint drop lock ea jnt
Knee joint cam lock each joi
Knee disc/dial lock/adj flex
Knee jnt ratchet lock ea jnt
Knee lift loop drop lock rin
Thi/glut/ischia wgt bearing
Th/wght bear quad-lat brim m
Th/wght bear quad-lat brim c
Th/wght bear nar m-l brim mo
Th/wght bear nar m-l brim cu
Thigh/wght bear lacer non-mo
Thigh/wght bear lacer molded
Thigh/wght bear high roll cu
Page 93 of 116
Effective Date
Maximum Allowable
12/1/2013
395.91
12/1/2013
293.07
12/1/2013
143.20
12/1/2013
229.47
12/1/2013
405.56
12/1/2013
217.13
12/1/2013
481.81
12/1/2013
877.62
12/1/2013
60.23
12/1/2013
239.48
12/1/2013
98.64
12/1/2013
109.42
12/1/2013
116.94
12/1/2013
177.29
12/1/2013
95.57
12/1/2013
136.59
12/1/2013
115.38
12/1/2013
79.45
12/1/2013
110.67
12/1/2013
130.63
12/1/2013
130.63
12/1/2013
92.31
12/1/2013
295.71
12/1/2013
721.36
12/1/2013
424.98
12/1/2013
1,132.85
12/1/2013
797.29
12/1/2013
214.18
12/1/2013
465.55
12/1/2013
273.57
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L2570
L2580
L2600
L2610
L2620
L2622
L2624
L2627
L2628
L2630
L2640
L2650
L2660
L2670
L2680
L2750
L2755
L2760
L2768
L2780
L2785
L2795
L2800
L2810
L2820
L2830
L2840
L2850
L3000
L3001
Modifier
Description
Hip clevis type 2 posit jnt
Pelvic control pelvic sling
Hip clevis/thrust bearing fr
Hip clevis/thrust bearing lo
Pelvic control hip heavy dut
Hip joint adjustable flexion
Hip adj flex ext abduct cont
Plastic mold recipro hip & c
Metal frame recipro hip & ca
Pelvic control band & belt u
Pelvic control band & belt b
Pelv & thor control gluteal
Thoracic control thoracic ba
Thorac cont paraspinal uprig
Thorac cont lat support upri
Plating chrome/nickel pr bar
Carbon graphite lamination
Extension per extension per
Ortho sidebar disconnect
Non-corrosive finish
Drop lock retainer each
Knee control full kneecap
Knee cap medial or lateral p
Knee control condylar pad
Soft interface below knee se
Soft interface above knee se
Tibial length sock fx or equ
Femoral lgth sock fx or equa
Ft insert ucb berkeley shell
Foot insert remov molded spe
Page 94 of 116
Effective Date
Maximum Allowable
12/1/2013
428.37
12/1/2013
478.85
12/1/2013
207.68
12/1/2013
250.30
12/1/2013
274.57
12/1/2013
267.72
12/1/2013
289.09
12/1/2013
1,496.61
12/1/2013
1,950.20
12/1/2013
228.36
12/1/2013
355.90
12/1/2013
139.69
12/1/2013
162.72
12/1/2013
153.96
12/1/2013
136.62
12/1/2013
85.73
12/1/2013
119.09
12/1/2013
54.17
12/1/2013
118.72
12/1/2013
78.78
12/1/2013
30.54
12/1/2013
91.96
12/1/2013
106.75
12/1/2013
68.19
12/1/2013
75.82
12/1/2013
82.02
12/1/2013
38.14
12/1/2013
54.05
12/1/2013
286.26
12/1/2013
120.53
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L3002
L3003
L3010
L3020
L3030
L3040
L3050
L3060
L3070
L3080
L3090
L3100
L3140
L3150
L3170
L3224
L3225
L3300
L3310
L3330
L3332
L3334
L3340
L3350
L3360
L3370
L3380
L3390
L3400
L3410
Modifier
Description
Foot insert plastazote or eq
Foot insert silicone gel eac
Foot longitudinal arch suppo
Foot longitud/metatarsal sup
Foot arch support remov prem
Ft arch suprt premold longit
Foot arch supp premold metat
Foot arch supp longitud/meta
Arch suprt att to sho longit
Arch supp att to shoe metata
Arch supp att to shoe long/m
Hallus-valgus nght dynamic s
Abduction rotation bar shoe
Abduct rotation bar w/o shoe
Foot plastic heel stabilizer
Woman's shoe oxford brace
Man's shoe oxford brace
Sho lift taper to metatarsal
Shoe lift elev heel/sole neo
Lifts elevation metal extens
Shoe lifts tapered to one-ha
Shoe lifts elevation heel /i
Shoe wedge sach
Shoe heel wedge
Shoe sole wedge outside sole
Shoe sole wedge between sole
Shoe clubfoot wedge
Shoe outflare wedge
Shoe metatarsal bar wedge ro
Shoe metatarsal bar between
Page 95 of 116
Effective Date
Maximum Allowable
12/1/2013
147.18
12/1/2013
158.80
12/1/2013
158.80
12/1/2013
180.80
12/1/2013
69.55
12/1/2013
42.88
12/1/2013
42.88
12/1/2013
67.21
12/1/2013
28.94
12/1/2013
28.94
12/1/2013
37.09
12/1/2013
39.40
12/1/2013
81.14
12/1/2013
74.18
12/1/2013
46.39
12/1/2013
51.34
12/1/2013
59.06
12/1/2013
47.50
12/1/2013
74.18
12/1/2013
515.74
12/1/2013
67.21
12/1/2013
34.78
12/1/2013
77.67
12/1/2013
20.88
12/1/2013
32.45
12/1/2013
45.18
12/1/2013
45.18
12/1/2013
45.18
12/1/2013
37.09
12/1/2013
84.60
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L3420
L3430
L3440
L3450
L3455
L3460
L3465
L3470
L3480
L3500
L3510
L3520
L3530
L3540
L3550
L3560
L3570
L3580
L3590
L3595
L3600
L3610
L3620
L3630
L3640
L3650
L3660
L3670
L3671
L3674
Modifier
Description
Full sole/heel wedge btween
Sho heel count plast reinfor
Heel leather reinforced
Shoe heel sach cushion type
Shoe heel new leather standa
Shoe heel new rubber standar
Shoe heel thomas with wedge
Shoe heel thomas extend to b
Shoe heel pad & depress for
Ortho shoe add leather insol
Orthopedic shoe add rub insl
O shoe add felt w leath insl
Ortho shoe add half sole
Ortho shoe add full sole
O shoe add standard toe tap
O shoe add horseshoe toe tap
O shoe add instep extension
O shoe add instep velcro clo
O shoe convert to sof counte
Ortho shoe add march bar
Trans shoe calip plate exist
Trans shoe caliper plate new
Trans shoe solid stirrup exi
Trans shoe solid stirrup new
Shoe dennis browne splint bo
Shlder fig 8 abduct restrain
Abduct restrainer canvas&web
Acromio/clavicular canvas&we
SO cap design w/o jnts CF
SO airplane w/wo joint CF
Page 96 of 116
Effective Date
Maximum Allowable
12/1/2013
49.84
12/1/2013
146.04
12/1/2013
69.55
12/1/2013
96.20
12/1/2013
37.09
12/1/2013
31.28
12/1/2013
53.32
12/1/2013
56.78
12/1/2013
56.78
12/1/2013
26.65
12/1/2013
26.65
12/1/2013
28.94
12/1/2013
28.94
12/1/2013
46.39
12/1/2013
8.09
12/1/2013
20.88
12/1/2013
77.67
12/1/2013
59.10
12/1/2013
48.67
12/1/2013
38.24
12/1/2013
69.55
12/1/2013
91.55
12/1/2013
69.55
12/1/2013
91.55
12/1/2013
39.40
12/1/2013
54.00
12/1/2013
87.80
12/1/2013
100.41
12/1/2013
747.33
12/1/2013
980.34
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L3675
L3702
L3710
L3720
L3730
L3740
L3760
L3762
L3763
L3764
L3765
L3766
L3806
L3807
L3808
L3900
L3901
L3904
L3905
L3906
L3908
L3912
L3913
L3915
L3917
L3919
L3921
L3923
L3925
L3927
Modifier
Description
Canvas vest SO
EO w/o joints CF
Elbow elastic with metal joi
Forearm/arm cuffs free motio
Forearm/arm cuffs ext/flex a
Cuffs adj lock w/ active con
EO withjoint, Prefabricated
Rigid EO wo joints
EWHO rigid w/o jnts CF
EWHO w/joint(s) CF
EWHFO rigid w/o jnts CF
EWHFO w/joint(s) CF
WHFO w/joint(s) custom fab
WHFO,no joint, prefabricated
WHFO, rigid w/o joints
Hinge extension/flex wrist/f
Hinge ext/flex wrist finger
Whfo electric custom fitted
WHO w/nontorsion jnt(s) CF
WHO w/o joints CF
Wrist cock-up non-molded
Flex glove w/elastic finger
HFO w/o joints CF
WHO w nontor jnt(s) prefab
Prefab metacarpl fx orthosis
HO w/o joints CF
HFO w/joint(s) CF
HFO w/o joints PF
FO pip/dip with joint/spring
FO pip/dip w/o joint/spring
Page 97 of 116
Effective Date
Maximum Allowable
12/1/2013
145.54
12/1/2013
239.48
12/1/2013
105.60
12/1/2013
667.43
12/1/2013
897.94
12/1/2013
916.63
12/1/2013
414.75
12/1/2013
89.18
12/1/2013
613.16
12/1/2013
688.46
12/1/2013
1,063.44
12/1/2013
1,126.10
12/1/2013
376.73
12/1/2013
207.39
12/1/2013
298.85
12/1/2013
1,244.12
12/1/2013
1,538.12
12/1/2013
2,501.75
12/1/2013
822.49
12/1/2013
354.04
12/1/2013
68.25
12/1/2013
108.02
12/1/2013
224.62
12/1/2013
440.85
12/1/2013
87.63
12/1/2013
224.62
12/1/2013
266.40
12/1/2013
81.67
12/1/2013
53.02
12/1/2013
28.99
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L3929
L3931
L3933
L3935
L3960
L3961
L3962
L3967
L3971
L3973
L3975
L3976
L3977
L3978
L3980
L3982
L3984
L3995
L4000
L4010
L4020
L4030
L4040
L4045
L4050
L4055
L4060
L4070
L4080
L4090
Modifier
Description
HFO nontorsion joint, prefab
WHFO nontorsion joint prefab
FO w/o joints CF
FO nontorsion joint CF
Sewho airplan desig abdu pos
SEWHO cap design w/o jnts CF
Sewho erbs palsey design abd
SEWHO airplane w/o jnts CF
SEWHO cap design w/jnt(s) CF
SEWHO airplane w/jnt(s) CF
SEWHFO cap design w/o jnt CF
SEWHFO airplane w/o jnts CF
SEWHFO cap desgn w/jnt(s) CF
SEWHFO airplane w/jnt(s) CF
Upp ext fx orthosis humeral
Upper ext fx orthosis rad/ul
Upper ext fx orthosis wrist
Sock fracture or equal each
Repl girdle milwaukee orth
Replace trilateral socket br
Replace quadlat socket brim
Replace socket brim cust fit
Replace molded thigh lacer
Replace non-molded thigh lac
Replace molded calf lacer
Replace non-molded calf lace
Replace high roll cuff
Replace prox & dist upright
Repl met band kafo-afo prox
Repl met band kafo-afo calf/
Page 98 of 116
Effective Date
Maximum Allowable
12/1/2013
80.91
12/1/2013
159.79
12/1/2013
176.95
12/1/2013
183.21
12/1/2013
705.96
12/1/2013
1,393.42
12/1/2013
762.90
12/1/2013
1,645.16
12/1/2013
1,561.64
12/1/2013
1,645.16
12/1/2013
1,393.42
12/1/2013
1,393.42
12/1/2013
1,561.64
12/1/2013
1,645.16
12/1/2013
264.10
12/1/2013
318.92
12/1/2013
306.90
12/1/2013
31.01
12/1/2013
1,264.60
12/1/2013
698.74
12/1/2013
836.56
12/1/2013
576.85
12/1/2013
475.15
12/1/2013
288.88
12/1/2013
434.25
12/1/2013
236.75
12/1/2013
352.76
12/1/2013
290.81
12/1/2013
104.58
12/1/2013
105.02
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L4100
L4110
L4130
L4350
L4360
L4370
L4386
L4392
L4394
L4396
L4398
L4631
L5000
L5010
L5020
L5050
L5060
L5100
L5105
L5150
L5160
L5200
L5210
L5220
L5230
L5250
L5270
L5280
L5301
L5312
Modifier
Description
Repl leath cuff kafo prox th
Repl leath cuff kafo-afo cal
Replace pretibial shell
Ankle control orthosi prefab
Pneumati walking boot prefab
Pneumatic full leg splint
Non-pneum walk boot prefab
Replace AFO soft interface
Replace foot drop spint
Static AFO
Foot drop splint recumbent
Afo, walk boot type, cus fab
Sho insert w arch toe filler
Mold socket ank hgt w/ toe f
Tibial tubercle hgt w/ toe f
Ank symes mold sckt sach ft
Symes met fr leath socket ar
Molded socket shin sach foot
Plast socket jts/thgh lacer
Mold sckt ext knee shin sach
Mold socket bent knee shin s
Kne sing axis fric shin sach
No knee/ankle joints w/ ft b
No knee joint with artic ali
Fem focal defic constant fri
Hip canad sing axi cons fric
Tilt table locking hip sing
Hemipelvect canad sing axis
BK mold socket SACH ft endo
Knee disart, SACH ft, endo
Page 99 of 116
Effective Date
Maximum Allowable
12/1/2013
121.41
12/1/2013
98.71
12/1/2013
577.51
12/1/2013
85.95
12/1/2013
322.31
12/1/2013
219.75
12/1/2013
144.49
12/1/2013
21.09
12/1/2013
15.37
12/1/2013
150.37
12/1/2013
69.23
12/1/2013
1,394.07
12/1/2013
469.94
12/1/2013
1,132.34
12/1/2013
2,099.94
12/1/2013
2,507.19
12/1/2013
3,326.96
12/1/2013
2,598.71
12/1/2013
3,667.66
12/1/2013
3,792.33
12/1/2013
4,626.75
12/1/2013
3,788.70
12/1/2013
3,009.26
12/1/2013
3,420.58
12/1/2013
4,574.81
12/1/2013
5,953.20
12/1/2013
6,378.09
12/1/2013
6,314.31
12/1/2013
2,605.73
12/1/2013
4,090.55
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L5321
L5331
L5341
L5400
L5410
L5420
L5430
L5450
L5460
L5500
L5505
L5510
L5520
L5530
L5535
L5540
L5560
L5570
L5580
L5585
L5590
L5595
L5600
L5610
L5611
L5613
L5614
L5616
L5617
L5618
Modifier
Description
AK open end SACH
Hip disart canadian SACH ft
Hemipelvectomy canadian SACH
Postop dress & 1 cast chg bk
Postop dsg bk ea add cast ch
Postop dsg & 1 cast chg ak/d
Postop dsg ak ea add cast ch
Postop app non-wgt bear dsg
Postop app non-wgt bear dsg
Init bk ptb plaster direct
Init ak ischal plstr direct
Prep BK ptb plaster molded
Perp BK ptb thermopls direct
Prep BK ptb thermopls molded
Prep BK ptb open end socket
Prep BK ptb laminated socket
Prep AK ischial plast molded
Prep AK ischial direct form
Prep AK ischial thermo mold
Prep AK ischial open end
Prep AK ischial laminated
Hip disartic sach thermopls
Hip disart sach laminat mold
Above knee hydracadence
Ak 4 bar link w/fric swing
Ak 4 bar ling w/hydraul swig
4-bar link above knee w/swng
Ak univ multiplex sys frict
AK/BK self-aligning unit ea
Test socket symes
Page 100 of 116
Effective Date
Maximum Allowable
12/1/2013
4,025.42
12/1/2013
5,711.59
12/1/2013
5,961.35
12/1/2013
1,243.81
12/1/2013
478.12
12/1/2013
1,502.34
12/1/2013
468.94
12/1/2013
410.37
12/1/2013
543.35
12/1/2013
1,194.55
12/1/2013
1,617.73
12/1/2013
1,467.28
12/1/2013
1,337.53
12/1/2013
1,866.53
12/1/2013
1,927.98
12/1/2013
2,057.87
12/1/2013
2,010.45
12/1/2013
2,114.59
12/1/2013
2,422.41
12/1/2013
2,684.85
12/1/2013
2,350.47
12/1/2013
4,198.64
12/1/2013
5,292.10
12/1/2013
2,470.48
12/1/2013
1,640.94
12/1/2013
2,279.38
12/1/2013
1,540.77
12/1/2013
1,263.22
12/1/2013
510.86
12/1/2013
290.55
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L5620
L5622
L5624
L5626
L5628
L5629
L5630
L5631
L5632
L5634
L5636
L5637
L5638
L5639
L5640
L5642
L5643
L5644
L5645
L5646
L5647
L5648
L5649
L5650
L5651
L5652
L5653
L5654
L5655
L5656
Modifier
Description
Test socket below knee
Test socket knee disarticula
Test socket above knee
Test socket hip disarticulat
Test socket hemipelvectomy
Below knee acrylic socket
Syme typ expandabl wall sckt
Ak/knee disartic acrylic soc
Symes type ptb brim design s
Symes type poster opening so
Symes type medial opening so
Below knee total contact
Below knee leather socket
Below knee wood socket
Knee disarticulat leather so
Above knee leather socket
Hip flex inner socket ext fr
Above knee wood socket
Bk flex inner socket ext fra
Below knee cushion socket
Below knee suction socket
Above knee cushion socket
Isch containmt/narrow m-l so
Tot contact ak/knee disart s
Ak flex inner socket ext fra
Suction susp ak/knee disart
Knee disart expand wall sock
Socket insert symes
Socket insert below knee
Socket insert knee articulat
Page 101 of 116
Effective Date
Maximum Allowable
12/1/2013
275.89
12/1/2013
389.11
12/1/2013
350.32
12/1/2013
508.60
12/1/2013
562.34
12/1/2013
295.58
12/1/2013
471.04
12/1/2013
408.66
12/1/2013
275.36
12/1/2013
328.04
12/1/2013
292.37
12/1/2013
276.91
12/1/2013
513.11
12/1/2013
1,175.33
12/1/2013
778.42
12/1/2013
768.34
12/1/2013
1,661.85
12/1/2013
613.37
12/1/2013
742.12
12/1/2013
545.52
12/1/2013
739.85
12/1/2013
612.35
12/1/2013
1,871.86
12/1/2013
533.77
12/1/2013
1,116.97
12/1/2013
405.50
12/1/2013
665.29
12/1/2013
360.34
12/1/2013
322.88
12/1/2013
460.02
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L5658
L5661
L5665
L5666
L5668
L5670
L5671
L5672
L5673
L5676
L5677
L5678
L5679
L5680
L5681
L5682
L5683
L5684
L5685
L5686
L5688
L5690
L5692
L5694
L5695
L5696
L5697
L5698
L5699
L5700
Modifier
Description
Socket insert above knee
Multi-durometer symes
Multi-durometer below knee
Below knee cuff suspension
Socket insert w/o lock lower
Bk molded supracondylar susp
BK/AK locking mechanism
Bk removable medial brim sus
Socket insert w lock mech
Bk knee joints single axis p
Bk knee joints polycentric p
Bk joint covers pair
Socket insert w/o lock mech
Bk thigh lacer non-molded
Intl custm cong/latyp insert
Bk thigh lacer glut/ischia m
Initial custom socket insert
Bk fork strap
Below knee sus/seal sleeve
Bk back check
Bk waist belt webbing
Bk waist belt padded and lin
Ak pelvic control belt light
Ak pelvic control belt pad/l
Ak sleeve susp neoprene/equa
Ak/knee disartic pelvic join
Ak/knee disartic pelvic band
Ak/knee disartic silesian ba
Shoulder harness
Replace socket below knee
Page 102 of 116
Effective Date
Maximum Allowable
12/1/2013
450.91
12/1/2013
566.01
12/1/2013
476.23
12/1/2013
66.07
12/1/2013
104.36
12/1/2013
275.48
12/1/2013
616.85
12/1/2013
300.13
12/1/2013
666.24
12/1/2013
392.63
12/1/2013
499.82
12/1/2013
44.01
12/1/2013
555.20
12/1/2013
329.77
12/1/2013
1,201.04
12/1/2013
588.07
12/1/2013
1,201.04
12/1/2013
59.69
12/1/2013
116.95
12/1/2013
59.29
12/1/2013
64.92
12/1/2013
98.71
12/1/2013
145.04
12/1/2013
224.10
12/1/2013
151.68
12/1/2013
229.45
12/1/2013
99.55
12/1/2013
116.30
12/1/2013
228.63
12/1/2013
3,396.15
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L5701
L5702
L5703
L5704
L5705
L5706
L5707
L5710
L5711
L5712
L5714
L5716
L5718
L5722
L5724
L5726
L5728
L5780
L5781
L5782
L5785
L5790
L5795
L5810
L5811
L5812
L5814
L5816
L5818
L5822
Modifier
Description
Replace socket above knee
Replace socket hip
Symes ankle w/o (SACH) foot
Custom shape cover BK
Custom shape cover AK
Custom shape cvr knee disart
Custom shape cvr hip disart
Kne-shin exo sng axi mnl loc
Knee-shin exo mnl lock ultra
Knee-shin exo frict swg & st
Knee-shin exo variable frict
Knee-shin exo mech stance ph
Knee-shin exo frct swg & sta
Knee-shin pneum swg frct exo
Knee-shin exo fluid swing ph
Knee-shin ext jnts fld swg e
Knee-shin fluid swg & stance
Knee-shin pneum/hydra pneum
Lower limb pros vacuum pump
HD low limb pros vacuum pump
Exoskeletal bk ultralt mater
Exoskeletal ak ultra-light m
Exoskel hip ultra-light mate
Endoskel knee-shin mnl lock
Endo knee-shin mnl lck ultra
Endo knee-shin frct swg & st
Endo knee-shin hydral swg ph
Endo knee-shin polyc mch sta
Endo knee-shin frct swg & st
Endo knee-shin pneum swg frc
Page 103 of 116
Effective Date
Maximum Allowable
12/1/2013
4,127.03
12/1/2013
4,941.75
12/1/2013
2,279.02
12/1/2013
567.18
12/1/2013
931.13
12/1/2013
922.87
12/1/2013
1,311.90
12/1/2013
423.20
12/1/2013
572.91
12/1/2013
514.32
12/1/2013
389.04
12/1/2013
677.89
12/1/2013
847.29
12/1/2013
986.54
12/1/2013
1,493.84
12/1/2013
1,807.89
12/1/2013
2,406.05
12/1/2013
1,064.87
12/1/2013
3,653.35
12/1/2013
3,851.46
12/1/2013
577.27
12/1/2013
695.07
12/1/2013
998.63
12/1/2013
517.11
12/1/2013
678.33
12/1/2013
587.06
12/1/2013
3,391.05
12/1/2013
790.99
12/1/2013
893.19
12/1/2013
1,583.86
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L5824
L5826
L5828
L5830
L5840
L5845
L5848
L5850
L5855
L5856
L5857
L5858
L5859
L5910
L5920
L5925
L5930
L5940
L5950
L5960
L5961
L5962
L5964
L5966
L5968
L5970
L5971
L5972
L5973
L5974
Modifier
Description
Endo knee-shin fluid swing p
Miniature knee joint
Endo knee-shin fluid swg/sta
Endo knee-shin pneum/swg pha
Multi-axial knee/shin system
Knee-shin sys stance flexion
Knee-shin sys hydraul stance
Endo ak/hip knee extens assi
Mech hip extension assist
Elec knee-shin swing/stance
Elec knee-shin swing only
Stance phase only
Knee-shin pro flex/ext cont
Endo below knee alignable sy
Endo ak/hip alignable system
Above knee manual lock
High activity knee frame
Endo bk ultra-light material
Endo ak ultra-light material
Endo hip ultra-light materia
Endo poly hip, pneu/hyd/rot
Below knee flex cover system
Above knee flex cover system
Hip flexible cover system
Multiaxial ankle w dorsiflex
Foot external keel sach foot
SACH foot, replacement
Flexible keel foot
Ank-foot sys dors-plant flex
Foot single axis ankle/foot
Page 104 of 116
Effective Date
Maximum Allowable
12/1/2013
1,426.36
12/1/2013
2,962.08
12/1/2013
2,626.53
12/1/2013
2,290.13
12/1/2013
3,754.03
12/1/2013
1,636.56
12/1/2013
981.85
12/1/2013
118.98
12/1/2013
382.99
12/1/2013
21,919.10
12/1/2013
7,777.74
12/1/2013
16,969.64
12/1/2013
14,039.11
12/1/2013
336.86
12/1/2013
493.50
12/1/2013
405.64
12/1/2013
3,073.33
12/1/2013
580.06
12/1/2013
833.77
12/1/2013
952.96
12/1/2013
4,512.32
12/1/2013
728.93
12/1/2013
1,049.36
12/1/2013
1,360.45
12/1/2013
3,318.04
12/1/2013
228.15
12/1/2013
228.15
12/1/2013
364.62
12/1/2013
16,051.29
12/1/2013
288.98
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L5975
L5976
L5978
L5979
L5980
L5981
L5982
L5984
L5985
L5986
L5987
L5988
L5990
L6000
L6010
L6020
L6025
L6050
L6055
L6100
L6110
L6120
L6130
L6200
L6205
L6250
L6300
L6310
L6320
L6350
Modifier
Description
Combo ankle/foot prosthesis
Energy storing foot
Ft prosth multiaxial ankl/ft
Multi-axial ankle/ft prosth
Flex foot system
Flex-walk sys low ext prosth
Exoskeletal axial rotation u
Endoskeletal axial rotation
Lwr ext dynamic prosth pylon
Multi-axial rotation unit
Shank ft w vert load pylon
Vertical shock reducing pylo
User adjustable heel height
Part hand thumb rem
Part hand little/ring
Part hand no fingers
Part hand disart myoelectric
Wrst MLd sck flx hng tri pad
Wrst mold sock w/exp interfa
Elb mold sock flex hinge pad
Elbow mold sock suspension t
Elbow mold doub splt soc ste
Elbow stump activated lock h
Elbow mold outsid lock hinge
Elbow molded w/ expand inter
Elbow inter loc elbow forarm
Shlder disart int lock elbow
Shoulder passive restor comp
Shoulder passive restor cap
Thoracic intern lock elbow
Page 105 of 116
Effective Date
Maximum Allowable
12/1/2013
423.29
12/1/2013
582.28
12/1/2013
329.08
12/1/2013
2,803.54
12/1/2013
3,770.61
12/1/2013
3,046.64
12/1/2013
710.74
12/1/2013
671.92
12/1/2013
257.85
12/1/2013
711.17
12/1/2013
6,568.41
12/1/2013
1,824.06
12/1/2013
1,656.51
12/1/2013
1,647.74
12/1/2013
1,833.67
12/1/2013
1,709.61
12/1/2013
7,306.76
12/1/2013
2,019.32
12/1/2013
3,015.16
12/1/2013
2,175.07
12/1/2013
2,218.43
12/1/2013
2,789.60
12/1/2013
3,210.33
12/1/2013
3,294.67
12/1/2013
4,127.74
12/1/2013
3,072.50
12/1/2013
4,321.87
12/1/2013
3,587.50
12/1/2013
1,589.47
12/1/2013
4,857.48
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L6360
L6370
L6380
L6382
L6384
L6386
L6388
L6400
L6450
L6500
L6550
L6570
L6580
L6582
L6584
L6586
L6588
L6590
L6600
L6605
L6610
L6611
L6615
L6616
L6620
L6621
L6623
L6624
L6625
L6628
Modifier
Description
Thoracic passive restor comp
Thoracic passive restor cap
Postop dsg cast chg wrst/elb
Postop dsg cast chg elb dis/
Postop dsg cast chg shlder/t
Postop ea cast chg & realign
Postop applicat rigid dsg on
Below elbow prosth tiss shap
Elb disart prosth tiss shap
Above elbow prosth tiss shap
Shldr disar prosth tiss shap
Scap thorac prosth tiss shap
Wrist/elbow bowden cable mol
Wrist/elbow bowden cbl dir f
Elbow fair lead cable molded
Elbow fair lead cable dir fo
Shdr fair lead cable molded
Shdr fair lead cable direct
Polycentric hinge pair
Single pivot hinge pair
Flexible metal hinge pair
Additional switch, ext power
Disconnect locking wrist uni
Disconnect insert locking wr
Flexion/extension wrist unit
Flex/ext wrist w/wo friction
Spring-ass rot wrst w/ latch
Flex/ext/rotation wrist unit
Rotation wrst w/ cable lock
Quick disconn hook adapter o
Page 106 of 116
Effective Date
Maximum Allowable
12/1/2013
3,950.02
12/1/2013
1,889.10
12/1/2013
1,271.87
12/1/2013
1,497.29
12/1/2013
1,895.56
12/1/2013
429.35
12/1/2013
471.90
12/1/2013
2,407.99
12/1/2013
3,268.81
12/1/2013
3,306.17
12/1/2013
4,422.72
12/1/2013
4,930.06
12/1/2013
1,675.43
12/1/2013
1,331.41
12/1/2013
2,262.15
12/1/2013
1,933.34
12/1/2013
3,273.54
12/1/2013
3,016.30
12/1/2013
189.04
12/1/2013
178.35
12/1/2013
162.65
12/1/2013
375.94
12/1/2013
198.78
12/1/2013
72.44
12/1/2013
311.34
12/1/2013
2,088.48
12/1/2013
669.76
12/1/2013
3,438.73
12/1/2013
572.80
12/1/2013
537.92
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L6629
L6630
L6632
L6635
L6637
L6638
L6640
L6641
L6642
L6645
L6646
L6647
L6648
L6650
L6655
L6660
L6665
L6670
L6672
L6675
L6676
L6677
L6680
L6682
L6684
L6686
L6687
L6688
L6689
L6690
Modifier
Description
Lamination collar w/ couplin
Stainless steel any wrist
Latex suspension sleeve each
Lift assist for elbow
Nudge control elbow lock
Elec lock on manual pw elbow
Shoulder abduction joint pai
Excursion amplifier pulley t
Excursion amplifier lever ty
Shoulder flexion-abduction j
Multipo locking shoulder jnt
Shoulder lock actuator
Ext pwrd shlder lock/unlock
Shoulder universal joint
Standard control cable extra
Heavy duty control cable
Teflon or equal cable lining
Hook to hand cable adapter
Harness chest/shlder saddle
Harness figure of 8 sing con
Harness figure of 8 dual con
UE triple control harness
Test sock wrist disart/bel e
Test sock elbw disart/above
Test socket shldr disart/tho
Suction socket
Frame typ socket bel elbow/w
Frame typ sock above elb/dis
Frame typ socket shoulder di
Frame typ sock interscap-tho
Page 107 of 116
Effective Date
Maximum Allowable
12/1/2013
136.33
12/1/2013
200.45
12/1/2013
60.43
12/1/2013
175.74
12/1/2013
404.13
12/1/2013
2,283.36
12/1/2013
320.43
12/1/2013
159.72
12/1/2013
216.02
12/1/2013
368.72
12/1/2013
2,879.83
12/1/2013
474.09
12/1/2013
2,970.13
12/1/2013
318.00
12/1/2013
93.16
12/1/2013
98.61
12/1/2013
45.86
12/1/2013
47.42
12/1/2013
180.05
12/1/2013
111.70
12/1/2013
137.32
12/1/2013
270.86
12/1/2013
221.27
12/1/2013
281.51
12/1/2013
431.34
12/1/2013
618.39
12/1/2013
536.49
12/1/2013
656.95
12/1/2013
804.06
12/1/2013
852.73
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L6691
L6692
L6693
L6694
L6695
L6696
L6697
L6698
L6703
L6704
L6706
L6707
L6708
L6709
L6711
L6712
L6713
L6714
L6715
L6721
L6722
L6805
L6810
L6880
L6881
L6882
L6883
L6884
L6885
L6890
Modifier
Description
Removable insert each
Silicone gel insert or equal
Lockingelbow forearm cntrbal
Elbow socket ins use w/lock
Elbow socket ins use w/o lck
Cus elbo skt in for con/atyp
Cus elbo skt in not con/atyp
Below/above elbow lock mech
Term dev, passive hand mitt
Term dev, sport/rec/work att
Term dev mech hook vol open
Term dev mech hook vol close
Term dev mech hand vol open
Term dev mech hand vol close
Ped term dev, hook, vol open
Ped term dev, hook, vol clos
Ped term dev, hand, vol open
Ped term dev, hand, vol clos
Term device, multi art digit
Hook/hand, hvy dty, vol open
Hook/hand, hvy dty, vol clos
Term dev modifier wrist unit
Term dev precision pinch dev
Elec hand ind art digits
Term dev auto grasp feature
Microprocessor control uplmb
Replc sockt below e/w disa
Replc sockt above elbow disa
Replc sockt shldr dis/interc
Prefab glove for term device
Page 108 of 116
Effective Date
Maximum Allowable
12/1/2013
368.91
12/1/2013
520.14
12/1/2013
2,592.22
12/1/2013
666.24
12/1/2013
555.20
12/1/2013
1,201.04
12/1/2013
1,201.04
12/1/2013
616.85
12/1/2013
307.08
12/1/2013
582.86
12/1/2013
370.75
12/1/2013
1,308.00
12/1/2013
912.71
12/1/2013
1,308.84
12/1/2013
613.87
12/1/2013
1,130.25
12/1/2013
1,426.51
12/1/2013
1,208.25
12/1/2013
2,882.69
12/1/2013
2,147.51
12/1/2013
1,851.32
12/1/2013
393.39
12/1/2013
186.15
12/1/2013
21,815.60
12/1/2013
3,732.87
12/1/2013
2,831.54
12/1/2013
1,905.98
12/1/2013
2,604.51
12/1/2013
3,950.02
12/1/2013
172.71
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L6895
L6900
L6905
L6910
L6915
L6920
L6925
L6930
L6935
L6940
L6945
L6950
L6955
L6960
L6965
L6970
L6975
L7007
L7008
L7009
L7040
L7045
L7170
L7180
L7181
L7185
L7186
L7190
L7191
L7260
Modifier
Description
Custom glove for term device
Hand restorat thumb/1 finger
Hand restoration multiple fi
Hand restoration no fingers
Hand restoration replacmnt g
Wrist disarticul switch ctrl
Wrist disart myoelectronic c
Below elbow switch control
Below elbow myoelectronic ct
Elbow disarticulation switch
Elbow disart myoelectronic c
Above elbow switch control
Above elbow myoelectronic ct
Shldr disartic switch contro
Shldr disartic myoelectronic
Interscapular-thor switch ct
Interscap-thor myoelectronic
Adult electric hand
Pediatric electric hand
Adult electric hook
Prehensile actuator
Pediatric electric hook
Electronic elbow hosmer swit
Electronic elbow sequential
Electronic elbo simultaneous
Electron elbow adolescent sw
Electron elbow child switch
Elbow adolescent myoelectron
Elbow child myoelectronic ct
Electron wrist rotator otto
Page 109 of 116
Effective Date
Maximum Allowable
12/1/2013
576.62
12/1/2013
1,805.99
12/1/2013
1,820.77
12/1/2013
1,494.38
12/1/2013
675.36
12/1/2013
7,237.39
12/1/2013
7,915.13
12/1/2013
7,852.48
12/1/2013
8,298.96
12/1/2013
9,401.65
12/1/2013
10,416.97
12/1/2013
9,819.73
12/1/2013
11,108.61
12/1/2013
12,098.54
12/1/2013
13,662.66
12/1/2013
13,565.37
12/1/2013
14,863.34
12/1/2013
3,244.95
12/1/2013
5,620.16
12/1/2013
3,509.42
12/1/2013
2,801.48
12/1/2013
1,503.34
12/1/2013
5,679.25
12/1/2013
34,076.51
12/1/2013
36,585.10
12/1/2013
5,965.34
12/1/2013
8,227.20
12/1/2013
7,410.79
12/1/2013
8,596.95
12/1/2013
2,111.09
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L7261
L7360
L7362
L7364
L7366
L7367
L7368
L7400
L7401
L7402
L7403
L7404
L7405
L7900
L7902
L8000
L8001
L8002
L8015
L8020
L8030
L8031
L8032
L8035
L8040
L8040KM
L8040KN
L8041
L8041KM
L8041KN
Modifier
KM
KN
KM
KN
Description
Electron wrist rotator utah
Six volt bat otto bock/eq ea
Battery chrgr six volt otto
Twelve volt battery utah/equ
Battery chrgr 12 volt utah/e
Replacemnt lithium ionbatter
Lithium ion battery charger
Add UE prost be/wd, ultlite
Add UE prost a/e ultlite mat
Add UE prost s/d ultlite mat
Add UE prost b/e acrylic
Add UE prost a/e acrylic
Add UE prost s/d acrylic
Male vacuum erection system
Tension ring, vac erect dev
Mastectomy bra
Breast prosthesis bra & form
Brst prsth bra & bilat form
Ext breastprosthesis garment
Mastectomy form
Breast prosthes w/o adhesive
Breast prosthesis w adhesive
Reusable nipple prosthesis
Custom breast prosthesis
Nasal prosthesis
Nasal prosthesis
Nasal prosthesis
Midfacial prosthesis
Midfacial prosthesis
Midfacial prosthesis
Page 110 of 116
Effective Date
Maximum Allowable
12/1/2013
4,424.58
12/1/2013
246.85
12/1/2013
255.87
12/1/2013
484.67
12/1/2013
626.46
12/1/2013
355.49
12/1/2013
460.82
12/1/2013
279.85
12/1/2013
313.29
12/1/2013
338.33
12/1/2013
336.25
12/1/2013
507.50
12/1/2013
663.74
12/1/2013
494.41
12/1/2013
18.18
12/1/2013
38.40
12/1/2013
114.52
12/1/2013
150.63
12/1/2013
56.84
12/1/2013
224.09
12/1/2013
293.43
12/1/2013
293.43
12/1/2013
37.14
12/1/2013
3,345.18
12/1/2013
2,282.83
12/1/2013
2,168.67
12/1/2013
913.13
12/1/2013
2,751.73
12/1/2013
2,614.12
12/1/2013
1,100.69
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L8042
L8042KM
L8042KN
L8043
L8043KM
L8043KN
L8044
L8044KM
L8044KN
L8045
L8045KM
L8045KN
L8046
L8046KM
L8046KN
L8047
L8047KM
L8047KN
L8300
L8310
L8320
L8330
L8400
L8410
L8415
L8417
L8420
L8430
L8435
L8440
Modifier
KM
KN
KM
KN
KM
KN
KM
KN
KM
KN
KM
KN
Description
Orbital prosthesis
Orbital prosthesis
Orbital prosthesis
Upper facial prosthesis
Upper facial prosthesis
Upper facial prosthesis
Hemi-facial prosthesis
Hemi-facial prosthesis
Hemi-facial prosthesis
Auricular prosthesis
Auricular prosthesis
Auricular prosthesis
Partial facial prosthesis
Partial facial prosthesis
Partial facial prosthesis
Nasal septal prosthesis
Nasal septal prosthesis
Nasal septal prosthesis
Truss single w/ standard pad
Truss double w/ standard pad
Truss addition to std pad wa
Truss add to std pad scrotal
Sheath below knee
Sheath above knee
Sheath upper limb
Pros sheath/sock w gel cushn
Prosthetic sock multi ply BK
Prosthetic sock multi ply AK
Pros sock multi ply upper lm
Shrinker below knee
Page 111 of 116
Effective Date
Maximum Allowable
12/1/2013
3,091.81
12/1/2013
2,937.21
12/1/2013
1,236.72
12/1/2013
3,462.83
12/1/2013
3,289.69
12/1/2013
1,385.14
12/1/2013
3,833.85
12/1/2013
3,642.18
12/1/2013
1,533.54
12/1/2013
2,406.66
12/1/2013
2,286.32
12/1/2013
962.65
12/1/2013
2,473.44
12/1/2013
2,349.78
12/1/2013
989.36
12/1/2013
1,267.63
12/1/2013
1,204.26
12/1/2013
507.06
12/1/2013
97.48
12/1/2013
136.53
12/1/2013
51.98
12/1/2013
45.92
12/1/2013
17.26
12/1/2013
24.60
12/1/2013
25.26
12/1/2013
68.66
12/1/2013
18.66
12/1/2013
21.32
12/1/2013
26.08
12/1/2013
38.90
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L8460
L8465
L8470
L8480
L8485
L8500
L8501
L8507
L8509
L8510
L8511
L8512
L8513
L8514
L8515
L8600
L8603
L8605
L8606
L8609
L8610
L8612
L8613
L8614
L8615
L8616
L8617
L8618
L8619
L8621
Modifier
Description
Shrinker above knee
Shrinker upper limb
Pros sock single ply BK
Pros sock single ply AK
Pros sock single ply upper l
Artificial larynx
Tracheostomy speaking valve
Trach-esoph voice pros pt in
Trach-esoph voice pros md in
Voice amplifier
Indwelling trach insert
Gel cap for trach voice pros
Trach pros cleaning device
Repl trach puncture dilator
Gel cap app device for trach
Implant breast silicone/eq
Collagen imp urinary 2.5 ml
Inj bulking agent anal canal
Synthetic implnt urinary 1ml
Artificial cornea
Ocular implant
Aqueous shunt prosthesis
Ossicular implant
Cochlear device
Coch implant headset replace
Coch implant microphone repl
Coch implant trans coil repl
Coch implant tran cable repl
Coch imp ext proc/contr rplc
Repl zinc air battery
Page 112 of 116
Effective Date
Maximum Allowable
12/1/2013
81.17
12/1/2013
45.37
12/1/2013
6.21
12/1/2013
11.41
12/1/2013
13.38
12/1/2013
726.13
12/1/2013
112.36
12/1/2013
38.25
12/1/2013
99.72
12/1/2013
230.71
12/1/2013
66.41
12/1/2013
1.98
12/1/2013
4.75
12/1/2013
86.10
12/1/2013
57.63
12/1/2013
678.30
12/1/2013
409.70
12/1/2013
653.97
12/1/2013
207.75
12/1/2013
5,949.07
12/1/2013
617.01
12/1/2013
673.60
12/1/2013
279.96
12/1/2013
17,472.62
12/1/2013
411.81
12/1/2013
95.92
12/1/2013
83.77
12/1/2013
23.95
12/1/2013
7,500.87
12/1/2013
0.56
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
L8622
L8623
L8624
L8627
L8628
L8629
L8630
L8631
L8641
L8642
L8658
L8659
L8670
L8680
L8681
L8682
L8683
L8684
L8685
L8686
L8687
L8688
L8689
L8690
L8691
L8693
L8695
Q0478
Q0479
Q0480
Modifier
Description
Repl alkaline battery
Lith ion batt CID,non-earlvl
Lith ion batt CID, ear level
CID ext speech process repl
CID ext controller repl
CID transmit coil and cable
Metacarpophalangeal implant
MCP joint repl 2 pc or more
Metatarsal joint implant
Hallux implant
Interphalangeal joint spacer
Interphalangeal joint repl
Vascular graft, synthetic
Implt neurostim elctr each
Pt prgrm for implt neurostim
Implt neurostim radiofq rec
Radiofq trsmtr for implt neu
Radiof trsmtr implt scrl neu
Implt nrostm pls gen sng rec
Implt nrostm pls gen sng non
Implt nrostm pls gen dua rec
Implt nrostm pls gen dua non
External recharg sys intern
Aud osseo dev, int/ext comp
Osseointegrated snd proc rpl
Aud osseo dev, abutment
External recharg sys extern
Power adapter, combo vad
Power module combo vad, rep
Driver pneumatic vad, rep
Page 113 of 116
Effective Date
Maximum Allowable
12/1/2013
0.30
12/1/2013
59.06
12/1/2013
147.25
12/1/2013
6,327.48
12/1/2013
1,173.39
12/1/2013
163.49
12/1/2013
313.35
12/1/2013
1,982.20
12/1/2013
434.10
12/1/2013
285.67
12/1/2013
378.49
12/1/2013
1,761.95
12/1/2013
517.74
12/1/2013
435.71
12/1/2013
1,003.38
12/1/2013
5,654.72
12/1/2013
4,977.44
12/1/2013
736.69
12/1/2013
12,403.49
12/1/2013
7,914.43
12/1/2013
16,141.88
12/1/2013
10,299.82
12/1/2013
1,575.00
12/1/2013
4,343.65
12/1/2013
2,434.75
12/1/2013
1,384.51
12/1/2013
15.20
12/1/2013
167.79
12/1/2013
11,027.83
12/1/2013
82,235.52
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
Q0481
Q0482
Q0483
Q0484
Q0485
Q0486
Q0487
Q0489
Q0490
Q0491
Q0492
Q0493
Q0494
Q0495
Q0496
Q0497
Q0498
Q0499
Q0500
Q0501
Q0502
Q0503
Q0504
Q0506
Q4001
Q4002
Q4003
Q4004
Q4005
Q4006
Modifier
Description
Microprcsr cu elec vad, rep
Microprcsr cu combo vad, rep
Monitor elec vad, rep
Monitor elec or comb vad rep
Monitor cable elec vad, rep
Mon cable elec/pneum vad rep
Leads any type vad, rep only
Pwr pck base combo vad, rep
Emr pwr source elec vad, rep
Emr pwr source combo vad rep
Emr pwr cbl elec vad, rep
Emr pwr cbl combo vad, rep
Emr hd pmp elec/combo, rep
Charger elec/combo vad, rep
Battery elec/combo vad, rep
Bat clps elec/comb vad, rep
Holster elec/combo vad, rep
Belt/vest elec/combo vad rep
Filters elec/combo vad, rep
Shwr cov elec/combo vad, rep
Mobility cart pneum vad, rep
Battery pneum vad replacemnt
Pwr adpt pneum vad, rep veh
Lith-ion batt elec/pneum VAD
Cast sup body cast plaster
Cast sup body cast fiberglas
Cast sup shoulder cast plstr
Cast sup shoulder cast fbrgl
Cast sup long arm adult plst
Cast sup long arm adult fbrg
Page 114 of 116
Effective Date
Maximum Allowable
12/1/2013
13,267.73
12/1/2013
4,155.71
12/1/2013
17,119.65
12/1/2013
3,324.59
12/1/2013
320.98
12/1/2013
267.16
12/1/2013
311.68
12/1/2013
14,841.81
12/1/2013
641.99
12/1/2013
1,009.28
12/1/2013
81.30
12/1/2013
231.53
12/1/2013
195.92
12/1/2013
3,813.96
12/1/2013
1,368.89
12/1/2013
427.45
12/1/2013
469.01
12/1/2013
152.38
12/1/2013
27.88
12/1/2013
466.30
12/1/2013
593.66
12/1/2013
1,187.34
12/1/2013
626.53
12/1/2013
779.89
12/1/2013
47.00
12/1/2013
177.62
12/1/2013
33.75
12/1/2013
116.86
12/1/2013
12.45
12/1/2013
28.05
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
Q4007
Q4008
Q4009
Q4010
Q4011
Q4012
Q4013
Q4014
Q4015
Q4016
Q4017
Q4018
Q4019
Q4020
Q4021
Q4022
Q4023
Q4024
Q4025
Q4026
Q4027
Q4028
Q4029
Q4030
Q4031
Q4032
Q4033
Q4034
Q4035
Q4036
Modifier
Description
Cast sup long arm ped plster
Cast sup long arm ped fbrgls
Cast sup sht arm adult plstr
Cast sup sht arm adult fbrgl
Cast sup sht arm ped plaster
Cast sup sht arm ped fbrglas
Cast sup gauntlet plaster
Cast sup gauntlet fiberglass
Cast sup gauntlet ped plster
Cast sup gauntlet ped fbrgls
Cast sup lng arm splint plst
Cast sup lng arm splint fbrg
Cast sup lng arm splnt ped p
Cast sup lng arm splnt ped f
Cast sup sht arm splint plst
Cast sup sht arm splint fbrg
Cast sup sht arm splnt ped p
Cast sup sht arm splnt ped f
Cast sup hip spica plaster
Cast sup hip spica fiberglas
Cast sup hip spica ped plstr
Cast sup hip spica ped fbrgl
Cast sup long leg plaster
Cast sup long leg fiberglass
Cast sup lng leg ped plaster
Cast sup lng leg ped fbrgls
Cast sup lng leg cylinder pl
Cast sup lng leg cylinder fb
Cast sup lngleg cylndr ped p
Cast sup lngleg cylndr ped f
Page 115 of 116
Effective Date
Maximum Allowable
12/1/2013
6.23
12/1/2013
14.02
12/1/2013
8.31
12/1/2013
18.70
12/1/2013
4.15
12/1/2013
9.36
12/1/2013
15.13
12/1/2013
25.51
12/1/2013
7.57
12/1/2013
12.75
12/1/2013
8.75
12/1/2013
13.94
12/1/2013
4.38
12/1/2013
6.98
12/1/2013
6.47
12/1/2013
11.68
12/1/2013
3.25
12/1/2013
5.84
12/1/2013
36.29
12/1/2013
113.30
12/1/2013
18.15
12/1/2013
56.67
12/1/2013
27.75
12/1/2013
73.05
12/1/2013
13.87
12/1/2013
36.52
12/1/2013
25.88
12/1/2013
64.38
12/1/2013
12.94
12/1/2013
32.20
Confidential and Proprietary
Regence BlueShield of Idaho
DMEPOS Fee Schedule
Effective December 1, 2013
Confidential and Proprietary
All Published Regence BlueShield of Idaho Administrative Guidelines Apply
Payment shall be per the terms of your Participating Agreement and the Member's benefit plan.
Additional information related to this fee schedule can be found in the Supplemental Information document.
All services performed must be within the scope of the provider's license.
The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify
Regence BlueShield of Idaho immediately if you have questions concerning any code that may or may not be included on
this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack there of.
Code
Q4037
Q4038
Q4039
Q4040
Q4041
Q4042
Q4043
Q4044
Q4045
Q4046
Q4047
Q4048
Q4049
Modifier
Description
Cast sup shrt leg plaster
Cast sup shrt leg fiberglass
Cast sup shrt leg ped plster
Cast sup shrt leg ped fbrgls
Cast sup lng leg splnt plstr
Cast sup lng leg splnt fbrgl
Cast sup lng leg splnt ped p
Cast sup lng leg splnt ped f
Cast sup sht leg splnt plstr
Cast sup sht leg splnt fbrgl
Cast sup sht leg splnt ped p
Cast sup sht leg splnt ped f
Finger splint, static
Page 116 of 116
Effective Date
Maximum Allowable
12/1/2013
15.79
12/1/2013
39.56
12/1/2013
7.91
12/1/2013
19.77
12/1/2013
19.20
12/1/2013
32.78
12/1/2013
9.61
12/1/2013
16.39
12/1/2013
11.15
12/1/2013
17.93
12/1/2013
5.56
12/1/2013
8.97
12/1/2013
2.03

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