| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| A5500 |
For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe |
11,231 |
8,302 |
$388K |
| A5512 |
For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each |
11,309 |
8,427 |
$239K |
| A5503 |
For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with roller or rigid rocker bottom, per shoe |
9,390 |
7,313 |
$160K |
| T4527 |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
1,482 |
1,463 |
$156K |
| B4154 |
Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
1,486 |
1,350 |
$140K |
| T4528 |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each |
981 |
972 |
$136K |
| B4035 |
Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
4,470 |
3,971 |
$114K |
| B4152 |
Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
2,773 |
2,515 |
$101K |
| T4526 |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
892 |
884 |
$90K |
| T4541 |
Incontinence product, disposable underpad, large, each |
1,341 |
1,325 |
$83K |
| T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
1,712 |
1,690 |
$76K |
| B9002 |
Enteral nutrition infusion pump, any type |
2,290 |
2,033 |
$25K |
| B4150 |
Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit |
703 |
625 |
$14K |
| A5061 |
Ostomy pouch, drainable; with barrier attached, (1 piece), each |
492 |
485 |
$7K |
| A4409 |
Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 x 4 inches or smaller, each |
354 |
347 |
$5K |
| A5063 |
Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each |
800 |
777 |
$4K |
| A4357 |
Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each |
3,656 |
3,509 |
$3K |
| B4034 |
Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape |
282 |
270 |
$1K |
| A4388 |
Ostomy pouch, drainable, with extended wear barrier attached, (1 piece), each |
102 |
102 |
$1K |
| A4338 |
Indwelling catheter; foley type, two-way latex with coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each |
2,196 |
2,164 |
$1K |
| A4314 |
Insertion tray with drainage bag with indwelling catheter, foley type, two-way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.) |
1,344 |
1,225 |
$1K |
| A4414 |
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each |
150 |
137 |
$1K |
| E0776 |
Iv pole |
1,441 |
1,395 |
$998.19 |
| A4310 |
Insertion tray without drainage bag and without catheter (accessories only) |
2,196 |
2,157 |
$861.96 |
| A4407 |
Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 x 4 inches or smaller, each |
15 |
15 |
$795.86 |
| A4425 |
Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each |
104 |
102 |
$780.41 |
| A4927 |
Gloves, non-sterile, per 100 |
36 |
36 |
$454.13 |
| A4385 |
Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each |
107 |
98 |
$386.37 |
| A4394 |
Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce |
126 |
112 |
$185.29 |
| A4333 |
Urinary catheter anchoring device, adhesive skin attachment, each |
266 |
237 |
$168.67 |
| A5120 |
Skin barrier, wipes or swabs, each |
263 |
238 |
$113.14 |
| A4334 |
Urinary catheter anchoring device, leg strap, each |
248 |
202 |
$53.52 |
| A4358 |
Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each |
118 |
113 |
$49.24 |
| A4623 |
Tracheostomy, inner cannula |
99 |
99 |
$35.70 |
| A4456 |
Adhesive remover, wipes, any type, each |
92 |
84 |
$32.91 |
| A4371 |
Ostomy skin barrier, powder, per oz |
101 |
93 |
$14.64 |
| A4406 |
Ostomy skin barrier, pectin-based, paste, per ounce |
124 |
111 |
$12.38 |
| A4320 |
Irrigation tray with bulb or piston syringe, any purpose |
49 |
42 |
$6.59 |
| A4629 |
Tracheostomy care kit for established tracheostomy |
77 |
76 |
$0.00 |