Documentation Checklists
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- Ankle-Foot/Knee-Ankle-Foot Orthosis
- Commodes
- Continuous Glucose Monitors and Supplies
- Enteral Nutrition
- Glucose Monitors and Supplies
- Hospital Beds and Accessories
- Immunosuppressive Drugs
- Knee Orthoses
- Lower Limb Prostheses
- Manual Wheelchairs
- Nebulizers & Inhalation Drugs: Iloprost and Treprostinil
- Nebulizers & Inhalation Drugs: Large Volume Nebulizers
- Nebulizers & Inhalation Drugs: Small Volume Nebulizers
- Negative Pressure Wound Therapy Pumps
- Orthopedic Footwear
- Osteogenesis Stimulators
- Ostomy Supplies
- Oxygen and Oxygen Equipment — Beneficiaries Meeting Group I & II Criteria
- Pneumatic Compression Devices (E0650, E0651, & E0652)
- Positive Airway Pressure (PAP) Accessories and Supplies
- Positive Airway Pressure (PAP) Devices for the Treatment of OSA
- Power Mobility: Group 1 PWCs (K0813 – K0816) & Group 2 PWCs (K0820 – K0829)
- Power Mobility: Group 2 Single Power Option PWCs (K0835 – K0840) & Group 2 Multiple Power Option PWCs (K0841 – K0843)
- Power Mobility: Group 3 No Power Option PWCs (K0848 – K0855), Group 3 Single Power Option PWCs (K0856 – K0860), & Group 3 Multiple Power Option PWCs (K0861 – K0864)
- Power Mobility: Group 5 (Pediatric) PWCs with Single (K0890) or Multiple (K0891) Power Options & Push-Rim Activated Power Assist Device (E0986) for a Manual Wheelchair
- Power Mobility: POVs (HCPCS Codes K0800 – K0802 and K0806 – K0808)
- Replacement Orthosis During Reasonable Useful Lifetime
- Respiratory Assist Device – E0470 Bi-Level Pressure Capacity without Backup Rate
- Respiratory Assist Device – E0471 Bi-Level Pressure Capacity with Backup Rate
- Spinal Orthoses
- Support Surfaces: Group 1 Pressure Reducing Support Surface
- Support Surfaces: Group 2 Pressure Reducing Support Surface
- Support Surfaces: Group 3 Pressure Reducing Support Surface
- Surgical Dressings
- Therapeutic Shoes for Persons with Diabetes
- Urological Supplies: Intermittent Catheters
Updated: 03.12.24