EXHIBIT 10.25
AMENDMENT TO
MANAGED CARE ALLIANCE AGREEMENT
THIS AMENDMENT (the "Amendment") is entered into this 1st day of January, 2005
by and between CIGNA Health Corporation, for and on behalf of its Affiliates
(individually and collectively, "CIGNA"), and Gentiva CareCentrix, Inc. ("MCA").
W I T N E S S E T H
WHEREAS, CIGNA and MCA entered into a Managed Care Alliance Agreement which
became effective January 1, 2004, ("the Agreement"), whereby MCA agreed to
provide or arrange for the provision of certain home health care services to
Participants, as that term is defined in the Agreement;
WHEREAS, the parties wish to amend certain provisions of the Agreement as set
forth below;
NOW THEREFORE, CIGNA and MCA agree as follows:
1. Effective January 1, 2005, Exhibit A HMO Program Attachment - Capitation
Schedule of Capitation Rates is hereby deleted and replaced with a new
Exhibit A HMO Program Attachment - Capitation Schedule of Capitation Rates
attached hereto.
2. Effective January 1, 2005, Exhibit A HMO Program Attachment - Fee for
Service Reimbursement For Other Services is hereby deleted and replaced
with a new Exhibit A HMO Program Attachment - Fee for Service
Reimbursement For Other Services attached hereto.
3. Effective January 1, 2005, Exhibit A PPO & Indemnity Program Attachment -
Fee for Service Reimbursement For Other Services is hereby deleted and
replaced with a new Exhibit A PPO & Indemnity Program Attachment
Reimbursement For Other Services attached hereto.
4. Effective January 1, 2005, Exhibit A Gatekeeper Program Attachment -
Capitation Schedule of Capitation Rates is hereby deleted and replaced
with a new Exhibit A Gatekeeper Program Attachment - Capitation Schedule
of Capitation Rates attached hereto.
5. Effective January 1, 2005, Exhibit A Gatekeeper Program Attachment - Fee
for Service Reimbursement For Other Services is hereby deleted and
replaced with a new Exhibit A Gatekeeper Program Attachment - Fee for
Service Reimbursement For Other Services attached hereto.
6. The Parties agree to incorporate any new or modified HIPAA codes if and
when such codes become effective.
7. The parties acknowledge that bone growth stimulators are reimbursed on a
fee-for-service basis. At the request of CIGNA, MCA agrees that CIGNA may
*.
8. MCA agrees that all new or established Participants receiving factor
concentrates through MCA as of * and who so agree, shall be * such that
any refill scheduled for those Participants for the period following *
shall be filled by *.
9. CIGNA has requested, and MCA agrees, that any self administered specialty
drug product that CIGNA Tel-Drug has the capability to dispense shall be *
CIGNA Tel-Drug. Further, MCA agrees to work with CIGNA Tel-Drug to
continue to evaluate collaborative opportunities.
* Confidential Treatment Requested
10. The parties agree that the blended HMO/Gatekeeper capitation rate of *
shall be increased by * effective * should CIGNA elect not to integrate
its * markets into the Agreement. Should CIGNA elect to integrate its *
markets into the Agreement or MCA elects * in this Section 10, the blended
HMO/ Gatekeeper capitation rate shall remain at *. If MCA elects to
proceed relative to these markets, the parties agree to work in good faith
to establish a * amount for all Covered Home Care Services rendered to
Participants by all providers of Covered Home Care Services in the *
markets ("Baseline"). Once the Baseline is agreed upon by the parties, the
parties agree that CIGNA's medical expense for Covered Home Care Services
rendered to Participants by all providers of Covered Home Care Services in
these markets ("Actual Medical Expense") shall not exceed the Baseline.
Prior to the effective date for these markets, the parties agree to
establish terms by which MCA shall reimburse CIGNA the amount, if any, by
which Actual Medical Expense exceeds the Baseline. The election to proceed
by either party shall be made by February 28, 2005. The effective date for
these markets shall be by mutual agreement between the parties, but no
sooner than April 5, 2005.
11. The parties agree that the blended HMO/Gatekeeper capitation rate of *
shall be increased by * effective * should CIGNA fail to deliver a PPO
claims paid report for the quarter ending June 2004 on or before January
15, 2005.
To the extent that the provisions in the Agreement, including any prior
amendments, conflict with the terms of this Amendment (including the exhibits
and schedules hereto), the terms in this Amendment shall supersede and control.
All other terms and conditions of the Agreement, as previously amended,
including the Program Attachments and the Exhibits attached thereto, shall
remain the same and in full force and effect. Capitalized terms not defined
herein but defined in the Agreement shall have the same meaning as defined in
the Agreement.
This Amendment shall take effect commencing on January 1, 2005.
IN WITNESS WHEREOF, CIGNA and MCA have caused their duly authorized
representatives to execute this Amendment as of the date first written above.
CIGNA HEALTH CORPORATION
By: _________________________________
Its: Senior Vice President
Dated: _________________________________
*Confidential Treatment Requested
2
GENTIVA CARECENTRIX, INC.
By: _________________________________
Its: President and COO
Dated: _________________________________
3
EXHIBIT A
HMO PROGRAM ATTACHMENT - CAPITATION
SCHEDULE OF CAPITATION RATES
CAPITATION RATES EFFECTIVE 1/1/05 - 12/31/05
These are the capitation rates that apply to services rendered to Patient Panel
Participants enrolled in HMO Programs. An "HMO Program" means a
non-governmental, fully insured HMO or Point of Service product that is
underwritten based on a community rating methodology (i.e. community rating,
community rating by class, adjusted community rating by class).
Gentiva
Homehealth
Infusion and
DME/HME
Capitation
Rate PMPM
--------------------------------------------------------------------------------
All Commercial HMO Capitated Affiliates
EXHIBIT A
HMO PROGRAM ATTACHMENT - FEE FOR SERVICE
REIMBURSEMENT FOR OTHER SERVICES
RATE AREA DESIGNATIONS:
STATE RATE AREA RATE DESIGNATION
----------------------------------------------------------------------------------------
Alabama * *
Alaska * *
Arizona * *
Arkansas * *
California * *
Colorado * *
Connecticut * *
Delaware * *
District of Columbia * *
Florida * *
Georgia * *
Hawaii * *
Idaho * *
Illinois * *
Indiana * *
Iowa * *
Kansas * *
Kentucky * *
Louisiana * *
Maine * *
Maryland * *
Massachusetts * *
Michigan * *
Minnesota * *
Mississippi * *
Missouri * *
Montana * *
Nebraska * *
Nevada * *
New Hampshire * *
New Jersey * *
New Mexico * *
New York * *
North Carolina * *
North Dakota * *
Ohio * *
Oklahoma * *
Oregon * *
Pennsylvania * *
Rhode Island * *
South Carolina * *
South Dakota * *
Tennessee * *
Texas * *
Utah * *
Vermont * *
Virginia * *
Washington * *
West Virginia * *
Wisconsin * *
Wyoming * *
*Confidential Treatment Requested
TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATE
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICES HAVE BOTH VISIT AND HOURLY RATES.
Notes 1, 2, 3, 4, 5 and 6 apply
XXXX 0 XXXX 0 XXXX 0
------------------------------------------------------------------------
VISIT HOUR VISIT HOUR VISIT HOUR
---------------------------------------------------------------------------------------------------------------------------------
CERTIFIED NURSES AIDE * * * * * *
HOME HEALTH AIDE * * * * * *
LVN/LPN * * * * * *
LVN/LPN - HIGH TECH * * * * * *
PEDIATRIC HIGH TECH LVN/LPN * * * * * *
PEDIATRIC HIGH TECH RN * * * * * *
PEDIATRIC LVN/LPN * * * * * *
PEDIATRIC RN * * * * * *
RN * * * * * *
RN HIGH TECH INFUSION * * * * * *
RN HIGH TECH OTHER * * * * * *
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICES HAVE VISIT ONLY RATES.
Notes 1, 3, 4, 5, 7 and 8 apply
XXXX 0 XXXX 0 XXXX 0
------------------------------------------------------------------------
VISIT HOUR VISIT HOUR VISIT HOUR
---------------------------------------------------------------------------------------------------------------------------------
DIABETIC NURSE * N/A * N/A * N/A
DIETITIAN * N/A * N/A * N/A
ENTEROSTOMAL THERAPIST * N/A * N/A * N/A
MATERNAL CHILD HEALTH * N/A * N/A * N/A
MEDICAL SOCIAL WORKER * N/A * N/A * N/A
OCCUPATIONAL THERAPIST * N/A * N/A * N/A
OCCUPATIONAL THERAPIST ASSISTANT * N/A * N/A * N/A
PHLEBOTOMIST * N/A * N/A * N/A
PHOTOTHERAPY PACKAGE SERVICE * N/A * N/A * N/A
PHYSICAL THERAPIST * N/A * N/A * N/A
PHYSICAL THERAPIST ASSISTANT * N/A * N/A * N/A
PSYCHIATRIC NURSE * N/A * N/A * N/A
REHABILITATION NURSE * N/A * N/A * N/A
RESPIRATORY THERAPIST * N/A * N/A * N/A
RESPIRATORY THERAPIST - CPAP clinic * N/A * N/A * N/A
RN ASSESSMENT, INITIAL * N/A * N/A * N/A
RN SKILLED NURSING VISIT-EXTENSIVE * N/A * N/A * N/A
SPEECH THERAPIST * N/A * N/A * N/A
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICE HAS HOURLY ONLY RATES.
Notes 3, 4 and 5 apply
XXXX 0 XXXX 0 XXXX 0
------------------------------------------------------------------------
VISIT HOUR VISIT HOUR VISIT HOUR
---------------------------------------------------------------------------------------------------------------------------------
HOMEMAKER N/A * N/A * N/A *
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICE IS PRICED ON A PER DIEM BASIS.
Notes 3, 4 and 5 apply
XXXX 0 XXXX 0 XXXX 0
------------------------------
PER DIEM PER DIEM PER DIEM
---------------------------------------------------------------------------------------
COMPANION/LIVE IN * * *
NOTES:
1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).
2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.
3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.
4. Above prices have no exclusions.
5. All services not listed above will be billed at * until rates are mutually
established and become part of the fee schedule.
6. RN High Tech Infusion visit and hourly utilization/costs to be reported
with HIT.
7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.
8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume
specialty certification which is not readily available in the home care
environment. Use requires special coordination.
*Confidential Treatment Requested
HOME INFUSION RATES
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES EXCLUDE DRUGS. DRUGS ARE
PRICED AS A PERCENTAGE DISCOUNT OFF AWP (IF APPLICABLE), AND THERE IS NO PRICE
DIFFERENCE BETWEEN PRIMARY AND MULTIPLE THERAPIES
PRIMARY OR PRIMARY OR PRIMARY OR
MULTIPLE THERAPY MULTIPLE THERAPY MULTIPLE THERAPY
PER DIEM DISPENSING FEE DRUG DISCOUNT OFF AWP
----------------------------------------------------------------------------------------------------------------
Ancillary Drugs * *
Biological Response Modifiers * *
Cardiac (Inotropic) Therapy * *
Chelation Therapy * *
Chemotherapy * *
Enteral Therapy * N/A
Enzyme Therapy * *
Growth Hormone * *
IV Immune Globulin * *
Other Injectable Therapies * *
Other Infusion Therapies * *
Pain Management Therapy * *
Steroid Therapy * *
Thrombolytic (Anticoagulation) Therapy * *
Synagis * *
Remodulin Therapy * *
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES EXCLUDE DRUGS. DRUGS ARE
PRICED AS A PERCENTAGE DISCOUNT OFF AWP, AND THERE IS A PRICE DIFFERENCE BETWEEN
PRIMARY AND MULTIPLE ANTI-INFECTIVE THERAPIES
PER DIEM DRUG DISCOUNT OFF AWP
----------------------------------------------------------------------------------------------------------------
Anti-Infectives - Primary Anti-Infective * *
Anti-Infectives - Multiple Anti-Infective * *
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATE EXCLUDES DRUGS. DRUGS ARE
PRICED PER VIAL, AND THERE IS NO PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE
ANTI-INFECTIVE THERAPIES
PRIMARY OR
MULTIPLE THERAPY
PER DIEM COST OF DRUG
-------------------------------------------------------------------------------------------------------------
Flolan Therapy *
Flolan 0.5 mg vial *
Flolan 1.5 mg vial *
Flolan diluent vial *
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES INCLUDE DRUGS, AND THERE IS NO
PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE THERAPIES
PRIMARY OR
MULTIPLE THERAPY
PER DIEM
-------------------------------------------------------------------------------------------------------------
Enteral Therapy *
Hydration Therapy *
Total Parenteral Nutrition *
*Confidential Treatment Requested
SCHEDULE 2A, PAGE 2: HOME INFUSION HMO/FLEX FEE-FOR-SERVICE THERAPY RATES
NOTES:
1. Per Diems EXCLUDING drugs include all costs related to the therapy except
the cost of drugs, including but not limited to facility overhead,
supplies, delivery, professional labor including compounding and
monitoring, all nursing required, maintenance of specialized catheters,
equipment/patient supplies, disposables, pumps, general and administrative
expenses, etc.
2. Per Diems INCLUDING drugs include ALL costs - including but not limited to
cost of drugs, facility overhead, supplies, delivery, professional labor
including compounding and monitoring, all nursing required, maintenance of
specialized catheters, equipment/patient supplies, disposables, pumps,
general and administrative expenses, etc.
3. "DISPENSING FEE" is defined as per each time the drug is dispensed by the
home infusion provider.
4. "PER DIEM" costs are the same for primary or multiple treatments for all
drug categories, except ANTI-INFECTIVES.
5. The per diem rate shall only be charged for those days the Participant
receives medication.
6. For home infusion pharmaceuticals not listed on fee schedule, * will
apply.
7. Case Managers should utilize Enteral Therapy WITHOUT drugs as an infusion
benefit infrequently. Generally, patient's requiring Enteral Therapy
WITHOUT drugs should have services coordinated through the DME benefit.
THE FOLLOWING ARE FOR THE STATED ITEM ONLY. UNLESS OTHERWISE NOTED, NURSING,
SUPPLIES, ETC. ARE NOT INCLUDED.
Blood Transfusion per Unit (Tubing, Filters) *
Catheter Care Per Diem *
Midline Insertion (Catheter & Supplies) *
PICC Line Insertion (Catheter & Supplies) *
Blood Product *
*Confidential Treatment Requested
SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES
FACTOR CONCENTRATES
VIAL PRICE UNIT PRICE
-----------------------------------------------------------------------------------------------------------
FACTOR VII
Novoseven 1200MCG Vial *
Novoseven 4800MCG Vial *
Novoseven in 1200MCG or 4800MCG QTY *
FACTOR VIII (RECOMBINANT)
Recombinate *
Kogenate or Helixate *
Bioclate N/A
Helixate FS *
Kogenate FS *
Refacto *
Advate *
FACTOR VIII (MONOCLONAL)
Hemofil-M or A. R. C. Method M *
Monoclate P *
Monarc-M *
FACTOR VIII (OTHER)
Koate *
Humate *
Alphanate SDHT *
FACTOR IX (RECOMBINANT)
BeneFix *
FACTOR IX (MONOCLONAL/HIGH PURITY)
Mononine *
Alphanine *
FACTOR IX (OTHER)
Konyne - 80 N/A
Proplex T *
Bebulin *
Profilnine SD *
ANTI-INHIBITOR COMPLEX
Autoplex-T *
Feiba-VH *
Hyate-C *
HEMOSTATIC AGENTS
DDAVP - 10ml vial *
Stimate - 2.5xx xxxx *
Above rates include all necessary ancillary supplies and waste disposal unit;
24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation
*Confidential Treatment Requested
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
---------------------------------------------------------------------------------------------------------------------
A4660 DM590 2520 MONITOR, BLOOD PRESSURE (A4660) W/STETH & CUFF *
A4670 DM590 2518 MONITOR, BLOOD PRESSURE (A4670), AUTOMATIC *
A9900 A9900 7552 BREEZE (A9900) CPAP/BIPAP MASK *
A9900 A9900 7553 FULL FACE (A9900) MIRAGE CPAP/BIPAP MASK *
A9900 A9900 7554 GEL/SILICON (A9900) CPAP/BIPAP MASK INCL GLD SEAL, PHANTM, MONARCH *
A9900 A9900 7556 SPECIALTY (A9900) CPAP/BIPAP MASK (PROFILE OR SIMPICITY) *
DM590 HI531 2570 PUMP, ENTERAL (B9002) * *
B9998 DM590 6828 ENTERAL SUPPLIES (B9998) *
DM590 DM570 7551 BACK-PACK (E1399), FOR PORTABLE ENTERAL PUMP *
DM590 DM590 2522 CANNULA, NASAL *
DM590 DM590 7509 ENTERAL PUMP, PORTABLE (B9002) * *
DM590 DM590 7508 MASK, CPAP GEL OR SILICONE (K0183) *
E0100 E0100 2020 CANE (E0100), ADJ OR FIX, W/ TIP *
E0105 E0105 2021 CANE, QUAD (E0105) OR THREE PRONG, ADJ OR FIX, W/ TIPS *
E0110 E0110 2028 CRUTCHES, FOREARM (E0110), ADJ OR FIX, PAIR, W/ TIPS, GRIPS *
E0111 E0111 2023 CRUTCH FOREARM (E0111), ADJ OR FIX, EACH, W/ TIP AND GRIPS *
E0112 E0112 2027 CRUTCHES UNDERARM, WOOD (E0112), ADJ OR FIX, PAIR, COMPLETE *
E0113 E0113 2025 CRUTCH UNDERARM, WOOD (E0113), ADJ OR FIX, EACH, COMPLETE *
E0114 E0114 2026 CRUTCHES UNDERARM, ALUM (E0114), ADJ OR FIX, PAIR, COMPLETE *
E0116 E0116 2024 CRUTCH UNDERARM, ALUM (E0116), ADJ OR FIX, EACH, COMPLETE *
E0130 E0130 2037 XXXXXX, RIGID (E0130) (PICKUP), ADJ OR FIX HEIGHT *
E0135 E0135 2036 XXXXXX, FOLDING (E0135) (PICKUP), ADJ OR FIX HEIGHT *
E0141 E0141 2040 XXXXXX, WHEELED (E0141), W/OUT SEAT *
E0142 DM570 2034 RIGID XXXXXX (E0142), WHEELED, W/ SEAT, *
E0143 E0143 2029 XXXXXX FOLDING, WHEELED (E0143), W/OUT SEAT *
E0145 DM570 2039 XXXXXX (E0145), WHEELED, W/ SEAT AND CRUTCH ATTACHMENTS *
E0146 DM570 2038 XXXXXX, WHEELED, W/ SEAT (E0146) *
E0147 E0147 2030 XXXXXX HVY DUT (E0147), MULT BRAKING SYS, VAR WHEEL RESISTANCE *
E0153 E0153 2032 CRUTCH PLATFORM ATTACHMENT (E0153), FOREARM EA *
E0154 E0154 2033 XXXXXX PLATFORM ATTACHMENT (E0154), EA *
E0155 E0155 2041 XXXXXX WHEEL ATTACHMENT (E0155), RIGID (PICKUP) XXXXXX *
E0156 DM570 2035 XXXXXX SEAT ATTACHMENT (E0156) *
E0157 E0157 2022 XXXXXX, CRUTCH ATTACHMENT (E0157), EACH *
E0158 E0158 2031 XXXXXX LEG EXTENSIONS (E0158) *
E0163 E0163 2047 COMMODE CHAIR, STATIONARY (E0163), W/ FIX ARMS *
E0164 E0164 2045 COMMODE CHAIR, MOBILE (E0164), W/ FIX ARMS *
E0165 E0165 2046 COMMODE CHAIR (E0165), STATIONARY, W/ DETACH ARMS *
E0165 E0165 2591 COMMODE, XXWIDE(E0165) *
E0166 E0166 2044 COMMODE CHAIR (E0166), MOBILE, W/ DETACH ARMS *
E0167 E0167 2051 COMMODE CHAIR, PAIL OR PAN (E0167) *
E0176 E0176 2142 CUSHION (E0176) OR AIR PRESSURE PAD, NON-POSITIONING *
E0176 E0176 2394 REPLACEMENT PAD (E0176) ALTERNATING PRESS *
E0177 E0177 2224 CUSHION OR WATER PRESS PAD (E0177), NONPOSITIONING *
E0178 E0178 2160 CUSHION OR GEL PRESS PAD (E0178), NONPOSITIONING *
E0179 E0179 2154 CUSHION (E0179) OR DRY PRESSURE PAD, NONPOSTIONING *
E0180 E0180 2196 PUMP (E0180), ALTERNATING PRESSURES W/PAD * *
E0181 E0181 2197 PUMP (E0181), ALTERNATING PRESS W/PAD, HVY DUTY * *
E0184 E0184 2074 MATTRESS, DRY PRESSURE (E0184) *
E0185 E0185 2076 MATTRESS (E0185), GEL OR GEL-LIKE PRESSURE PAD *
E0186 E0186 2064 MATTRESS, AIR PRESSURE (E0186) *
E0187 E0187 2099 MATTRESS, WATER PRESSURE (E0187) *
E0188 DM570 2217 PAD, SYNTHETIC SHEEPSKIN (A9900) *
E0189 DM570 2177 PAD, LAMBSWOOL SHEEPSKIN (E0189), ANY SIZE *
E0192 E0192 2573 CUSHION, XXX FOR W/C (E0192) * *
E0192 E0192 2572 CUSHION, ROHO FOR W/C (E0192) * *
E0192 E0192 2178 W/C PAD (E0192), LOW PRESS AND POSITIONING EQUALIZATION * *
E0193 E0193 2098 MATTRESS, LOW AIR LOSS (E0193), INCL. BED * * *
E0194 DM570 2063 AIR FLUIDIZED BED (E0194) * *
E0270 E1399 6887 HOSPITAL BED INSTITUTIONAL * *
E0196 E0196 2077 MATTRESS, GEL PRESSURE (E0196) *
E0197 E0197 2065 MATTRESS, AIR PRESSURE PAD (E0197) *
E0198 E0198 2100 MATTRESS (E0198), WATER PRESSURE PAD *
E0199 E0199 2075 MATTRESS, DRY PRESSURE PAD (E0199) *
E0200 E0200 2228 HEAT LAMP (E0200), W/OUT STAND, INCL/BULB, OR INFRARED ELEMENT *
E0202 E0202 2229 PHOTOTHERAPY (BILIRUBIN) (E0202), LIGHT WIT *
E0202 E0202 2524 PHOTOTHERAPY, BILI BLANKET (E0202) *
E0205 E0205 2227 HEAT LAMP (E0205), WITH STAND, INCL/ BULB, OR INFRARED ELEMENT *
E0210 DM570 2156 HEATING PAD, STANDARD (E0210) *
E0215 DM570 2155 HEATING PAD (E0215), ELECTRIC, MOIST *
E0218 DM570 2560 COLD THERAPY UNIT (E0218) * * *
E0235 DM570 2187 PARAFFIN BATH UNIT, PORT (E0235) *
E0236 DM570 2199 PUMP (E0236) FOR WATER CIRCULATING PAD *
E0237 DM570 2223 HEAT COLD WATER (E0237) CIRCULATING PAD W/PUMP *
E0238 DM570 2179 HEATING PAD (E0238), MOIST, NON-ELECTRIC *
*Confidential Treatment Requested
7
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
---------------------------------------------------------------------------------------------------------------------
E0241 DM570 2867 BATH TUB RAIL (E0241), WALL, L-SHAPE *
E0241 DM570 2862 BATH TUB RAIL, WALL, 12" (E0241) *
E0241 DM570 2863 BATH TUB RAIL, WALL, 16" (E0241) *
E0241 DM570 2864 BATH TUB RAIL, WALL, 18" (E0241) *
E0241 DM570 2865 BATH TUB RAIL, WALL, 24" (E0241) *
E0241 DM570 2866 BATH TUB RAIL, WALL, 36" (E0241) *
E0241 DM570 2043 BATH TUB RAIL, WALL, UNSPECIFIED SIZE *
E0242 DM570 2042 BATH TUB RAIL, FLOOR BASE (E0242) *
E0243 DM570 2056 TOILET RAIL, EACH (E0243) *
E0244 E0244 2587 TOILET SEAT (E0244) RAISED WITH ARMS *
E0244 E0244 2052 TOILET SEAT, RAISED (E0244) *
E0245 DM570 2575 BATH BENCH WITH BACK (E0245) *
E0245 DM570 2058 BATH TUB STOOL OR BENCH (E0245) *
E0245 DM570 2578 TRANSFER BENCH, NON-PADDED (E0245) *
E0245 DM570 2577 TRANSFER BENCH, PADDED (E0245) *
E0246 DM570 2057 TRANSFER TUB RAIL(E0246), ATTACHMENT *
E0249 DM570 2186 HEAT UNIT (E0249), WATER CIRCULATING PAD *
E0255 E0255 2090 HOSP BED (E0255), VAR HEIGHT, HI-LO, W/ SIDE RAILS, W/ MATTRESS * *
E0256 E0256 2091 HOSP BED (E0256), VAR HEIGHT, HI-LO, W/ SIDE RAILS, W/O MATTRESS * *
E0260 E0260 2083 HOSP BED (E0260), SEMI-ELEC, W/ SIDE RAILS, W/ MATTRESS * *
E0261 E0261 2084 HOSP BED (E0261), SEMI-ELEC, W/ SIDE RAILS, W/OUT MATTRESS * *
E0265 E0265 2086 HOSP BED (E0265), TOTAL ELEC, W/ SIDE RAILS, W/ MATTRESS * *
E0266 E0266 2087 HOSP BED (E0266), TOTAL ELEC, W/ SIDE RAILS, W/OUT MATTRESS * *
E0271 E0271 2096 MATTRESS, INNERSPRING (E0271) *
E0272 E0272 2095 MATTRESS, FOAM RUBBER (E0272) *
E0273 DM570 2068 BED BOARD (E1399) *
E0274 DM570 2097 OVER-BED TABLE (E0274) *
E0275 E0275 2071 BED PAN, STANDARD (E0275), METAL OR PLASTIC *
E0276 E0276 2070 BED PAN, FRACTURE (E0276), METAL OR PLASTIC *
E0277 E0277 2066 MATTRESS (E0277), LOW AIR LOSS, ALT PRESSURE * * *
E0280 DM570 2069 BED CRADLE, ANY TYPE (E1399) *
E0292 E0292 2092 HOSP BED (E0292), VAR HEIGHT, HI-LO, W/OUT S/ RAILS, W/ MATTRESS * *
E0293 E0293 2093 HOSP BED (E0293), VAR HEIGHT, HI-LO, NO SIDE RAILS, NO MATTRESS * *
E0294 E0294 2085 HOSP BED (E0294), SEMI-ELEC, W/OUT SIDE RAILS, W/ MATTRESS * *
E0295 E0295 2094 HOSP BED (E0295), SEMI-ELEC, W/OUT SIDE RAILS, W/OUT MATTRESS * *
E0296 E0296 2089 HOSP BED (E0296), TOTAL ELEC, W/OUT SIDE RAILS, W/OUT MATTRESS * *
E0297 E0297 2088 HOSP BED (E0297), TOTAL ELEC, W/OUT SIDE RAILS, W/ MATTRESS * *
E0305 E0305 2073 BED SIDE RAILS (E0305), HALF LENGTH *
E0310 E0310 2072 BED SIDE RAILS (E0310), FULL LENGTH *
E0315 DM570 2067 BED ACCESSORIES: BOARDS OR TABLES, ANY TYPE *
E0325 E0325 2060 URINAL; MALE (E0325), JUG-TYPE, ANY MATERIAL *
E0326 E0326 2059 URINAL; FEMALE (E0326), JUG-TYPE, ANY MATERIAL *
E0372 E0372 7008 MATTRESS (E0372) POWERED AIR OVERLAY * *
E0410 E0444 2369 O2 CONTENTS, LIQUID (E0444), PER POUND *
E0416 E0443 2371 O2 REFILL FOR PORT (E0443) GAS SYSTEM ONLY, UP TO 23 CUBIC FEET *
E0424 E0424 2385 O2 SYS STATIONARY (E0424) COMPR GAS, RENT *
E0430 E0430 2374 O2 SYS PORT GAS, PURCH (E0430) *
E0431 E0431 2574 O2 SYS PORT GAS, LIGHTWEIGHT (E0431) W/CONSERV DEVICE, NO CONTENT * *
E0431 E0431 2375 O2 SYS PORT GAS, RENT (E0431) *
E0434 E0434 2377 O2 SYS PORT LIQUID, RENT (E0434) *
E0435 E0435 2376 O2 SYS PORT LIQUID, PURCH (E0435) *
E0439 E0439 2388 O2 SYS STATIONARY (E0439) LIQUID, RENT *
E0440 E0440 2387 O2 SYS STATIONARY (E0440) LIQUID, PURCH *
E0443 E0400 2869 O2 CONTENTS, H/K CYLINDER (E0400), 200-300 CUBIC FT *
E0444 E0444 2379 O2 CONTENTS, PORT LIQUID (E0444), PER UNIT (1 UNIT = 1 LB.) *
E0450 E0450 7555 POSITIVE PRESSURE VENTS (E0450)(E.G. T-BIRD) *
E0450 E0450 7926 POSITIVE PRESSURE VENTS, EMERGENCY BACKUP (E.G. T-BIRD)(E0450) *
E0450 E0450 2392 VENTILATOR VOLUME (E0450), STATIONARY OR PORT * *
E0450 E0450 7522 VENTILATOR, VOLUME, (E0450) EMERGENCY BACKUP UNIT * *
E0452 E0452 2332 BILEVEL INTERMITTENT (E0452) ASSIST DEVICE,(BIPAP) * *
E0453 E0453 2390 VENTILATOR THERAPEUTIC (E0453); FOR USE 12 HOURS OR LESS PER DAY * *
E0455 E0455 2372 O2 TENT (E0455), EXCLUDING CROUP OR PEDIATRIC TENTS * *
E0457 E0457 2323 CHEST SHELL (CUIRASS) (E0457) * *
E0459 E0459 2324 CHEST WRAP (E0459) * *
E0460 E0460 2339 VENTILATOR (E0460), NEGATIVE PRESSURE, PORTABLE OR STATIONARY * *
E0480 DM570 2373 PERCUSSOR (E0480), ELEC OR PNEUM, HOME MODEL * *
E0500 E0500 2333 IPPB, W/ BUILT-IN NEB (E0500) MAN OR AUTO VALVES; INT/EXT POWER * *
E0550 E0550 2328 HUMIDIFIER (E0550) DURABLE FOR EXTENSIV SUP/ HUMID W/ IPPB OR O2 * *
E0555 E0555 2330 HUMIDIFIER (E0555), DURABLE, GLASS, FOR USE W/ REG OR FLOWMETER *
E0565 E0565 2325 COMPRESSOR, AIR POWER (E0565) * *
E0570 E0570 2336 NEBULIZER, W/ COMPRESSOR (E0570) *
E0575 DM570 2571 NEBULIZER (E0575), ULTRASONIC, AC/DC * *
E0575 DM570 2338 NEBULIZER; ULTRASONIC (E0575) * *
E0585 E0585 2337 NEBULIZER(E0585), W/ COMPRESSOR AND HEATER * *
*Confidential Treatment Requested
8
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
---------------------------------------------------------------------------------------------------------------------
E0600 E0600 2389 SUCTION PUMP (E0600), HOME MODEL * *
E0600 E0600 7523 SUCTION UNIT, (E0600), PORTABLE AC/DC * *
E0601 E0601 2326 CONTINUOUS POSITVE (E0601) AIRWAY PRESSURE DEVICE (CPAP) * *
E0601 E0601 6965 CPAP, SELF TITRATING (E0601) * *
E0601 E0601 7935 CPAP, C-Flex * *
E0601 E0601 8363 CPAP, C Flex Pro with Compliance Monitoring * *
E0605 DM570 2391 VAPORIZER, ROOM TYPE (E0605) *
E0606 DM570 2380 POSTURAL DRAINAGE BOARD (E0606) *
E0607 E0607 6874 MONITOR, B/GLUCOSE (E0607) ACCUCHEK AD *
E0607 E0607 2164 MONITOR, BLOOD GLUCOSE (E0607) *
E0608 E0608 2322 APNEA MONITOR (E0608) * *
E0608 E0608 2576 APNEA MONITOR (E0608) W/MEM (INCL SMART) * *
E0609 E0609 2146 MONITOR, BLOOD GLUCOSE (E0609) W/SPECIAL FEATURES *
E0621 E0621 2215 PATIENT LIFT (E0621), SLING OR SEAT, CANVAS OR NYLON *
E0625 DM570 2191 PATIENT LIFT (E0625), KARTOP, BATHROOM OR TOILET *
E0627 E0627 4553 HIP CHAIR (E0627) * *
E0627 DM570 2395 SEAT LIFT CHAIR/MOTORIZED (E0627) *
E0627 DM570 2205 SEAT LIFT MECH (E0627) INCORPORATED INTO A COMB LIFT-CHAIR MECH *
E0630 E0630 2190 PATIENT LIFT, HYDRAULIC (E0630), W/ SEAT OR SLING * *
E0635 DM570 2189 PATIENT LIFT (E0635), ELEC W/ SEAT OR SLING *
E0650 E0650 2192 PNEUM COMPRESSOR (E0650), NON-SEG HOME MODEL * *
E0651 E0651 2194 PNEUM COMPRESSOR (E0651), SEG HOME MODEL W/OUT CALIB GRAD PRES * *
E0652 E0652 2193 PNEUM COMPRESSOR (E0652), SEG HOME MODEL W/ CALIB GRAD PRES * *
E0655 E0655 2182 PNEUM COMPRESSOR (E0655), NON-SEG APPLIANCE, HALF ARM *
E0660 E0660 2181 PNEUM COMPRESSOR (E0660), NON-SEG APPLIANCE, FULL LEG *
E0665 E0665 2180 PNEUM COMPRESSOR (E0665), NON-SEG APPLIANCE, FULL ARM *
E0666 E0666 2183 PNEUM COMPRESSOR (E0666), NON-SEG APPLIANCE, HALF LEG *
E0667 E0667 2210 PNEUM APPLIANCE (E0667), SEG, FULL LEG *
E0668 E0668 2209 PNEUM APPLIANCE (E0668), SEG, FULL ARM *
E0669 E0669 2212 PNEUM APPLIANCE (E0669), SEG, HALF LEG *
E0670 E0670 2211 PNEUM APPLIANCE (E0670), SEG, HALF ARM *
E0671 E0671 2207 PNEUM APPLIANCE (E0671), SEG GRAD PRESS, FULL LEG *
E0672 E0672 2206 PNEUM APPLIANCE (E0672), SEG GRAD PRESS, FULL ARM *
E0673 E0673 2208 PNEUM APPLIANCE (E0673), SEG GRAD PRESS, HALF LEG *
E0690 DM570 2221 ULTRAVIOLET CABINET (E0690), APPROPRIATE FOR HOME USE *
E0700 DM570 2204 SAFETY EQUIP (E0700) (E.G., BELT, HARNESS OR VEST) *
E0710 DM570 2202 RESTRAINTS (E0710), ANY TYPE (BODY, CHEST, WRIST OR ANKLE) *
E0720 E0720 2219 TENS (E0720), TWO LEAD, LOCALIZED STIMULATION * *
E0730 E0730 2218 TENS (E0730), FOUR LEAD, LARGER AREA/MULTIPLE NERVE STIMULATION * *
E0731 E0731 2159 TENS OR NMES (E0731), CONDUCTIVE GARMENT *
E0744 E0744 2120 STIMULATOR (E0744), NEUROMUSCULAR FOR SCOLIOSIS * *
E0745 E0745 2120 STIMULATOR (E0745), NEUROMUSCULAR, ELECTRONIC SHOCK UNIT * *
E0745 E0745 6915 STIMULATOR FOUR CH (E0745), NEUROMUSCULAR * *
E0746 DM570 2109 ELECTROMYOGRAPHY (EMG) (E0746), BIOFEEDBACK DEVICE * *
E0747 DM570 2122 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE *
E0747 DM570 8386 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, EBI *
E0747 DM570 8387 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, ORTHOFIX *
E0747 DM570 8388 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, ORTHOLOGIC *
E0748 DM570 2124 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL APPLICATIONS *
E0748 DM570 8389 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, EBI *
E0748 DM570 8390 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, ORTHOFIX *
E0748 DM570 8391 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, ORTHOLOGIC *
E0755 DM570 2157 STIMULATOR (E0755), ELECTRONIC SALIVARY REFLEX, NON INVASIVE *
E0776 E0776 2175 IV POLE (E0776) * *
E0784 E0784 2158 PUMP (E0784), EXT AMBULATORY INFUSION, MINIMED, INSULIN *
E0784 E0784 7773 PUMP (E0784), EXT AMBULATORY INFUSION, DELTEC, INSULIN *
E0784 E0784 7925 PUMP, EXT INFUSION, NON - XXXX PREMIUM, INSULIN (E0784) *
E0784 E0784 6771 PUMP (E0784), INSULIN EXT INFUSION DISETRONICS OR OTHER *
E0840 E0840 2133 TRACTION FRAME (E0840), ATTACH TO HEADBOARD, CERVICAL TRACTION *
E0850 E0850 2134 TRACTION STAND (E0850), FREE STANDING, CERVICAL TRACTION * *
E0855 E0855 7484 TRACTION (E0855), W/O FRAME OR STAND * *
E0860 E0860 2130 TRACTION EQUIP (E0860), OVERDOOR, CERVICAL *
E0870 E0870 2131 TRACTION FRAME (E0870), ATTACH TO FOOTBOARD, EXTREMITY, BUCKS * *
E0880 E0880 2135 TRACTION STAND (E0880) FREE/STAND EXTREMITY TRACTION, EG, BUCK'S * *
E0890 E0890 2132 TRACTION FRAME (E0890), ATTACH TO FOOTBOARD, PELVIC TRACTION * *
E0900 E0900 2136 TRACTION STAND (E0900) FREE/ STAND PELVIC TRACTION,(EG, BUCK'S) * *
E0910 E0910 2138 TRAPEZE BARS (E0910), A/K/A PT HELPER, ATTACH TO BED W/ GRAB BAR * *
E0920 E0920 2111 FRACTURE FRAME (E0920), ATTACH TO BED, INCLUDING WEIGHTS * *
E0935 E0935 2125 PASSIVE MOTION (E0935) EXERCISE DEVICE *
E0935 E0935 2859 PASSIVE MOTION (E0935) EXERCISE DEVICE, ANKLE *
E0935 E0935 2860 PASSIVE MOTION (E0935) EXERCISE DEVICE, ELBOW *
E0935 E0935 2857 PASSIVE MOTION (E0935) EXERCISE DEVICE, HAND *
E0935 E0935 2858 PASSIVE MOTION (E0935) EXERCISE DEVICE, SHOULDER *
E0935 E0935 2861 PASSIVE MOTION (E0935) EXERCISE DEVICE, WRIST *
*Confidential Treatment Requested
9
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
---------------------------------------------------------------------------------------------------------------------
E0940 E0940 2137 TRAPEZE BAR (E0940), FREE STANDING, COMPLETE W/ GRAB BAR * *
E0941 E0941 2116 TRACTION DEVICE (E0941), GRAVITY ASSISTED * *
E0942 E0942 2101 HARNESS/HALTER (E0942), CERVICAL HEAD *
E0944 E0944 2126 HARNESS (E0944), PELVIC BELT, BOOT *
E0945 DM570 2110 HARNESS (E0945), EXTREMITY BELT *
E0946 E0946 2115 FRACTURE, FRAME (E0946), DUAL W/ CROSS BARS, ATTACH TO BED * *
E0947 E0947 2113 FRACTURE FRAME (E0947), ATTACHMENTS FOR COMPLEX PELVIC TRACTION * *
E0948 E0948 2112 FRACTURE FRAME (E0948) ATTACHMENTS FOR COMPLEX CERVICAL TRACTION * *
E0950 DM570 2139 TRAY (E0950) *
E0958 E0958 2307 W/C PART ATTACHMENT (E0958) TO CONVERT ANY W/C TO ONE ARM DRIVE *
E0959 E0959 2237 W/C PART AMPUTEE ADAPTER(E0959) (COMPENSATE FOR TRANS OF WEIGHT) *
E0962 E0962 2232 CUSHION FOR WC 1" (E0962) *
E0963 E0963 2233 CUSHION FOR WC 2" (E0963) *
E0964 E0964 2234 CUSHION FOR WC 3" (E0964) *
E0965 E0965 2235 CUSHION FOR WC 4" (E0965) *
E0972 DM570 2230 TRANSFER BOARD OR DEVICE (E0972) *
E0977 E0977 2317 CUSHION, WEDGE FOR W/C (E0977) *
E0978 E0978 2248 BELT, SAFETY (E0978) W/ AIRPLANE BUCKLE, W/C *
E0979 DM570 2249 BELT, SAFETY (E0979) W/ VELCRO CLOSURE, W/C *
E0980 DM570 2292 SAFETY VEST (E0980), W/C *
E1031 E1031 2291 ROLLABOUT CHAIR (E1031), W/ CASTORS 5" OR GREATER * *
E1050 E1050 2260 W/C FULL/REC (E1050), FIX ARMS, SWING AWAY DETACH ELEV LEG RESTS * *
E1060 E1060 2259 W/C FULL/REC (E1070), DETACH ARMS, SWING AWAY DETACH FOOTREST * *
E1065 E1065 2287 W/C POWER ATTACHMENT (E1065) *
E1066 E1066 2247 BATTERY CHARGER (E1066) *
E1069 E1069 2255 BATTERY, DEEP CYCLE (E1069) *
E1070 E1070 2258 W/C FULL/REC (E1060), DETACH ARMS, SWING AWAY DET/ ELEV LEGRESTS * *
E1083 E1083 2263 W/C HEMI (E1083), FIX ARMS, SWING AWAY DETACH ABLE ELEV LEG REST * *
E1084 E1084 2262 W/C HEMI (E1084), DETACH ARMS, SWING AWAY DETACH ELEV LEG RESTS * *
E1085 E1085 2264 W/C HEMI (E1085), FIX ARMS, SWING AWAY DETACH ABLE FOOT RESTS * *
E1086 E1086 2261 W/C HEMI (E1086), DETACH ARMS, SWING AWAY DETACH FOOTRESTS * *
E1087 E1087 2265 W/C HI STRENGTH LT-WT (E1087), FIX ARMS, S/AWAY ELEV LEG RESTS * *
E1088 E1088 2268 W/C HI STRENGTH LT-WGT (E1088), D/ ARMS, S/AWAY ELEV LEG RESTS * *
E1089 E1089 2266 W/C HI STRENGTH LT-WGT (E1089), FIX ARMS, S/AWAY DETACH FOOTREST * *
E1090 E1090 2267 W/C HI STRENGTH XX-XX (E1090), DETACH ARMS, S/AWAY D/FOOT RESTS * *
E1091 E1091 2321 W/C YOUTH, ANY TYPE (E1091) * *
E1092 E1092 2319 W/C WIDE HVY DUTY (E1092), DETACH ARMS S/AWAY DETACH ELEVAT LEGS * *
E1093 E1093 2320 W/C WIDE HVY DUTY (E1093), DETACH ARMS S/AWAY DETACH FOOTRESTS * *
E1100 E1100 2296 W/C SEMI-RECLINING (E1100), SWING AWAY DETACH ELEV LEG RESTS * *
E1110 E1110 2295 W/C SEMI-RECLINING (E1110), DETACH ARMS ELEV LEG REST * *
E1130 E1130 2303 W/C STANDARD (E1130), FIX OR SWING AWAY DETACH FOOTRESTS * *
E1140 E1140 2313 W/C (E1140), DETACH ARMS SWING AWAY DETACH FOOTRESTS * *
E1150 E1150 2314 W/C (E1150), DETACH ARMS, SWING AWAY DETACH ELEVAT LEGRESTS * *
E1160 E1160 2315 W/C (E1160), W/ FIX ARMS, SWING AWAY DETACH ELEVAT LEGRESTS * *
E1160 E1160 2396 W/C (E1160), W/FIX ARMS REMOVABLE FOOTRESTS * *
E1170 E1170 2241 W/C AMPUTEE (E1170), FIX ARMS, SWING AWAY DETACH ELEV LEGRESTS * *
E1171 E1171 2242 W/C AMPUTEE (E1171), FIX ARMS, W/OUT FOOTRESTS OR LEGREST * *
E1172 E1172 2240 W/C AMPUTEE (E1172), DETACH ARMS W/OUT FOOTRESTS OR LEGREST * *
E1180 E1180 2239 W/C AMPUTEE (E1180), DETACH ARMS SWING AWAY DETACH FOOTRESTS * *
E1190 E1190 2238 W/C AMPUTEE (E1190), DETACH ARMS SWING AWAY DETACH ELEV LEGRESTS * *
E1195 E1195 2273 W/C HVY DUTY (E1195), FIX ARMS, SWING AWAY DETACH ELEV LEGRESTS * *
E1200 E1200 2243 W/C AMPUTEE (E1200), FIX FULL LENGTH ARMS, S/AWAY D/FOOTREST * *
E1210 E1210 2281 W/C MOTORIZED (E1210), FIX ARMS, S/AWAY DETACH ELEV LEG RESTS * *
E1211 E1211 2279 W/C MOTORIZED (E1211), DETACH ARMS, S/AWAY DETACH FOOT RESTS * *
E1212 E1212 2282 W/C MOTORIZED (E1212), FIX ARMS, SWING AWAY DETACH FOOT RESTS * *
E1213 E1213 2280 W/C MOTORIZED (E1213), DETACH ARMS S/AWAY, DETACH ELEV LEG REST * *
E1220 E1220 2551 W/C CUSTOM (E1220) *
E1220 E1220 2579 W/C XXWIDE (E1220) *
E1230 E1230 2288 SCOOTER (E1230), THREE OR 4 WHEEL * *
E1240 E1240 2276 W/C LT-WGT (E1240), DETACH ARMS SWING AWAY DETACH, ELEV LEGREST * *
E1250 E1250 2278 W/C LT-WGT (E1250), FIX ARMS, SWING AWAY DETACH FOOTREST * *
E1260 E1260 2275 W/C LT-WGT (E1260), DETACH ARMS SWING AWAY DETACH FOOTREST * *
E1270 E1270 2277 W/C LT-WGT (E1270), FIX ARMS, SWING AWAY DETACH ELEV LEGRESTS * *
E1280 E1280 2270 W/C HVY DUTY (E1280), DETACH ARMS ELEV LEGRESTS * *
E1285 E1285 2274 W/C HVY DUTY (E1285), FIX ARMS, SWING AWAY DETACH FOOTREST * *
E1290 E1290 2271 W/C HVY DUTY (E1290), DETACH ARMS SWING AWAY DETACH FOOTREST * *
E1295 E1295 2272 W/C HVY DUTY (E1295), FIX ARMS, ELEV LEGREST * *
E1300 DM570 2062 WHIRLPOOL (E1300), PORT (OVERTUB TYPE) *
E1310 DM570 2061 WHIRLPOOL (E1399), NON-PORT (BUILT-IN TYPE) *
E1353 E1353 2381 O2 REGULATOR (E1353) * *
E1355 E1355 2384 CYLINDER STAND/RACK (E1355) *
E1372 E1372 2331 IMMERSION EXT HEATER (E1372) FOR NEBULIZER * *
E1375 E1375 2334 NEBULIZER PORT (E1375) W/ SMALL COMPRESSOR, W/ LIMITED FLOW *
E1399 DM570 2568 ADAPTER (A9900), AC/DC *
*Confidential Treatment Requested
10
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
---------------------------------------------------------------------------------------------------------------------
E1399 E1399 2586 APNEA MONITOR DOWNLOAD (E1399) *
E1399 DM570 2552 BATH LIFT (E1399), CUSTOM *
E1399 DM570 2563 BED WEDGE (E1399), 12" *
E1399 DM570 2856 BEDROOM EQUIPMENT (E1399), CUSTOM *
E1399 E1399 2525 BREAST PUMP, ELECTRIC (E1399) * *
E1399 DM570 2581 BREAST PUMP, INSTITUTIONAL (E1399) *
E1399 E1399 2580 BREAST PUMP, MANUAL (E1399) *
E1399 DM570 2593 COLD THERAPY UNIT, PAD (E1399) *
E1399 E1399 2565 COMMODE (E1399), DROP ARM, HEAVY DUTY *
E1399 E1399 2582 COMPRESSION PUMP BOOT (E1399) *
E1399 E1399 2583 COMPRESSION PUMP, FOOT (E1399) *
E1399 A9900 2569 CPAP HUMIDIFIER (A9900), HEATED * *
E1399 A9900 2635 CPAP/BIPAP SUPPLIES (A9900) *
E1399 E1399 2327 DURABLE MEDICAL EQUIP (E1399), MISCELLANEOUS *
E1399 E1220 2584 XXXX CHAIR (E1399), THREE POSITION RECLINING *
E1399 DM570 6780 XXXXXX MONITOR (G0004) *
E1399 E0265 2590 HOSP BED (E1399), ELECTRIC, XLONG, W/MATTRESS & SIDE RAILS * *
E1399 E0200 2868 LAMP, ULTRAVIOLET (E1399) *
E1399 DM570 2588 MONITOR (E1399), XXXXX XXXXX *
E1399 DM570 2529 O2 ANALYZER (A9900) * *
E1399 A9900 2594 O2 CONSERVATION DEVICE (A9900) * *
E1399 DM570 6775 OXIMETRY TEST (E1399) *
E1399 DM570 2555 PATIENT LIFT, CUSTOM (E1399) *
E1399 DM570 2561 PEAK FLOW METER (E1399) *
E1399 E1399 4559 PEDIATRIC XXXXXX (E1399) *
E1399 DM570 2567 PNEUMOGRAM (E1399) *
E1399 E1399 2553 POSITIONING, CUSTOM (E1399) *
E1399 E1399 2526 PULSE OXIMETER (E1399) * *
E1399 E1399 2527 PULSE OXIMETER W/ PROBE (E1399) * *
E1399 DM570 2562 SHOWER, HAND HELD (E1399) *
E1399 DM570 2592 SLEEP STUDY, ADULT (E1399) *
E1399 DM590 7483 STIMULATOR (E1399), MUSCLE, LOW VOLTAGE OR INTERFERENTIAL * *
E1399 DM570 2855 THERAPY EQUIPMENT, CUSTOM (E1399) *
E1399 DM570 6774 THERAPY PERCUSSION, GENERATOR ONLY * *
E1399 E1399 7506 W/C, CUSTOM (E1399) MANUAL ADULT *
E1399 E1399 7504 W/C, CUSTOM (E1399) MANUAL PEDIATRIC *
E1399 E1399 7507 W/C, CUSTOM (E1399) POWER ADULT *
E1399 E1399 7505 W/C, CUSTOM (E1399) POWER PEDIATRIC *
E1399 E1399 2564 XXXXXX (E1399), HEAVY DUTY, EXTRA WIDE *
E1399 E1399 2585 XXXXXX (E1399), HEMI *
K0538 DM570 6873 WOUND SUCTION DEVICE (K0538) *
K0539 DM570 7914 DRESSING SET, FOR WOUND SUCTION DEVICE (K0539) *
K0540 DM570 7915 CANISTER SET, FOR WOUND SUCTION DEVICE (K0540) *
E1400 E1390 2361 O2 CONC (E1390), MANUF SPEC MAXFLOWRATE = 2 LTS PER MIN@85% * *
G0015 DM570 6779 CARDIAC EVENT MONITOR (G0015) *
K0163 DM590 3713 ERECTION SYSTEM, VACUUM (K0163) *
K0183 DM590 2516 CPAP MASK (K0183) *
K0184 DM590 2515 NASAL PILLOWS/SEALS (K0184) REPLACEMENT FOR NASAL APP/ DVC, PAIR *
K0185 DM590 2514 CPAP HEADGEAR (K0185) *
K0186 DM590 2513 CPAP CHIN STRAP (K0186) *
K0187 DM590 2512 CPAP TUBING (K0187) *
K0188 DM590 2511 CPAP FILTER (A9900), DISPOSABLE *
K0189 DM590 2510 CPAP FILTER (A9900), NON-DISPOSABLE *
K0268 DM590 2509 CPAP HUMIDIFIER (K0268), COOL *
K0413 DM590 6889 MATTRESS (K0413), NONPOWERED, EQUIVALENT *
E1399 E1399 7673 MATTRESS (E1399) V-CUE DYNAMIC AIR THERAPY *
A4608 A9900 7621 CATHETER TRACH (A4608) 11CM 1 SCOOP *
E1399 A9900 7664 COFFLATOR (E1399CF) MANUAL SECRETION MOBIL DEVICE *
E0168B A9900 7643 COMMODE (E0168B) HVY DUTY BEDSIDE CHAIR 000-000 XXX. *
E0168C A9900 7644 COMMODE (E0168C) HVY DUTY DROP ARM 451-850 LBS. *
A6234 HH591 7626 DRESSING <16 SQ IN (A6234) HYDROCOLLOID DRESSING, EA *
A6258 HH591 7627 DRESSING >16 SQ IN (A6258) TRANSPAREN FILM, EA *
A46203 HH591 7625 DRESSING COMPOSITE <16 SQ IN (A46203) SELF ADH, EA *
B9998B DM590 7655 ENT (B9998B) EXT SET Y SITE F/KANGAROO PUMP *
B9998C DM590 7656 ENT (B9998C) EXT SET W/ CLAMP BASIC *
B9998D DM590 7657 ENT (B9998D) XXXXXXX GASTRIC RELIEF VLV *
B9998E DM590 7658 ENT (B9998E) GASTRO EXT SET *
B9998F DM590 7659 ENT (B9998F) GASTRO TUBE ANY SIZE MIC-KEY OR HIDE A PORT *
E1399 A9900 7620 HUMID-VENT (E1399) ARTIFICIAL NOSE *
E1399 A9900 0000 XXXX (E1399) UNIV SET UP W/MANIFOLD NEBULIZER *
K0105 A9900 7639 IV POLE (K0105) ATTACH F/ W/C *
E1399 A9900 7641 MECHANICAL SCALE (E1399) PEDIATRIC/NEONATAL *
A7008 A9900 7661 NEBULIZER (A7008) KIT PREFILL W/STR H20 1L BAX *
E1399 A9900 7663 O2 CONNECTOR (E1399) XXXX/IRRIGATION NOZZLE BAX *
*Confidential Treatment Requested
11
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
---------------------------------------------------------------------------------------------------------------------
E1399 A9900 7615 O2 HUMIDIFIER (E1399) AQUA+NEONATAL EA HUD *
E1399 A9900 7623 O2 SWIVEL (E1399) ADAPTER ANGLED STERILE *
L8501 A9900 7624 SPEAKING VALVE (L8501) WHITE PAS *
A4319 HH591 7629 STERILE WATER (A4319) F/IRRIG 1L BAX *
A7001 HH591 7619 SUCTION BOTTLE (A7001) W/LID & TUBING *
E1399 A9900 7616 SUCTION FILTER (E1399) BACTERIA *
A6265 HH591 7628 TAPE ALL TYPES (A6265) EXCLUDING MICROFOAM, PER 18 SQ INCHES *
A4481 A9900 7622 TRACH FILTER (A4481) BACTERIA ELECTROSTATIC *
A4623 A9900 7618 TRACH INNER (A4623) CANNULA *
A4621 A9900 7617 TRACH TUBE MASK (A4621) COLLAR OR HOLDER *
A7010 A9900 7662 TUBING (A7010) AEROSOL CORRUGATED PER FOOT *
E1399 A9900 7631 VENT ADAPTER (E1399) MDI HUD *
A9900 A9900 7630 VENT BATTERY CHARGER (A9900) 12V GEL *
E1399 A9900 7632 VENT CONNECTOR (E1399) PED OR ADULT OMNIFLEX DISP *
E1399 A9900 7633 VENT FILTER (E1399) HYGROBAC S ELECTOSTATIC MAL *
E1399 A9900 7634 VENT THERMOMETER (E1399) W/ ADAPTER *
K0108 A9900 7638 W/C BRAKE EXTENSION (K0108) TIP BLK 10/PK *
E1399 A9900 7635 XXXXXX BASKET (E1399) VINYL COATED *
E0159 A9900 7640 XXXXXX BRAKE (E0159) ATTACHMENT *
E0148 A9900 7636 XXXXXX HVY DUTY (E0148) FOLDING X-WIDE *
E0149 A9900 7637 XXXXXX HVY DUTY (E0149) W/ WHEELS *
E1399 A9900 7645 CPAP (E1399) DC BATTERY ADAPTER CABLE *
E1399 A9900 7646 CPAP (E1399) EXHALATION PORT DISP *
E1399 A9900 7647 CPAP (E1399) FUSE KIT INTERNATIONAL A/C *
E1399 A9900 7648 CPAP (E1399) HUMIDIFIER CHAMBER KIT DISP *
E1399 A9900 7649 CPAP (E1399) HUMIDIFIER CHAMBER REUSABLE *
E1399 A9900 7650 CPAP (E1399) HUMIDIFIER MOUNTING TRAY *
E1399 A9900 7651 CPAP (E1399) INVERTOR AC/DC *
E1399 A9900 7652 CPAP (E1399) POWER CORD F/ARIA-SYNC *
E1399 A9900 7653 CPAP (E1399) SHELL W/O PRESSURE TAP *
A9900 DM590 7566 CPAP CALIBRATION SHELL (A9900) *
A9900 DM590 7565 CPAP SHORT TUBING (A9900) *
E0601 E0601 7690 VENT, CONTINUOUS POSITIVE (E0500) AIRWAY PRESSURE DEVICE N/A *
E0452 E0452 7691 VENT, BILEVEL INTERMITTENT (E0500) ASSIST DEVICE (BIPAP) N/A *
E0747 DM570 6875 STIMULATOR, OSTEOGENIC, ULTRASOUND *
A9900 A9900 7695 GEL/SILICON GOLD SEAL CPAP/BIPAP MASK (A9900) *
A9900 A9900 7701 VENT THERAPEUTIC ST BIPAP W/ BACKUP RATE (K0533) N/A *
A9900 A9900 7703 O2 SYS HELIOS PORT LIQUID, RENT (E1399) *
HH591 HH591 7704 PUMP, EXT INFUSION, XXXX DIABECARE, INSULIN (E0784) *
E0784 E0784 7731 PUMP, EXT INFUSION, ANIMAS, INSULIN (E0784) *
A9900 A9900 7737 CPAP DREAM SEAL INTERFACE FOR USE WITH BREEZE MASK (A9900) *
DM590 DM590 7738 CPAP CHIN STRAP DELUXE (K0186) *
E1340 E1340 7768 W/C REPAIRS - CUSTOM (E1340) *
The following may be charged under extraordinary circumstances:
E1399 E1399 4551 LABOR/SERVICE/SHIPPING CHARGES *
E1399 E1399 2731 SHIPPING AND HANDLING FEES *
The following may be charged if over and above routine on rental equipment:
E1350 E1350 2382 REPAIR OR NON-ROUTINE (E1350) SERVICE REQUIRING SKILL OF A TECH *
E1340 E1340 2554 W/C REPAIRS - STANDARD (E1340) *
E1399 E1399 4552 MISCELLANEOUS SUPPLIES * *
E1399 E1399 2589 REPAIR (E1399), RESPIRATORY EQUIPMENT *
E1399 E1399 4561 RESPIRATORY SUPPLIES (A4618) * *
E1399 E1399 4549 TENS/APNEA SUPPLIES * *
NOTES:
1. Whether rental or purchase, rates include all shipping, labor and set-up.
2. If item is rented, rates include all supplies to enable the equipment to
function effectively, with the exception of supplies for CPAP, BIPAP,
Ventilators, Suction, Enteral Pumps and CPM. Such exception supplies will
be billed at *.
3. If item is rented, rates include repair and maintenance costs.
4. If item is purchased, supplies, repair and maintenance will be billed at
*.
5. All equipment not listed above will be billed at * until rates are
mutually established and become part of the fee schedule.
6. Rates effective through 12/31/2005.
7. CPAPs - A new model will be implemented which emphasizes a personal
delivery system without an RT on-site
There will be an additional charge should an additional clinic or home
visit be required
Clinic Model - *
Home RT Model - *
*Confidential Treatment Requested
12
EXHIBIT A
PPO & INDEMNITY PROGRAM ATTACHMENT - FEE FOR SERVICE
REIMBURSEMENT FOR OTHER SERVICES
RATE AREA DESIGNATIONS:
STATE RATE AREA RATE DESIGNATION
---------------------------------------------------------------------------------
Alabama * *
Alaska * *
Arizona * *
Arkansas * *
California * *
Colorado * *
Connecticut * *
Delaware * *
District of Columbia * *
Florida * *
Georgia * *
Hawaii * *
Idaho * *
Illinois * *
Indiana * *
Iowa * *
Kansas * *
Kentucky * *
Louisiana * *
Maine * *
Maryland * *
Massachusetts * *
Michigan * *
Minnesota * *
Mississippi * *
Missouri * *
Montana * *
Nebraska * *
Nevada * *
New Hampshire * *
New Jersey * *
New Mexico * *
New York * *
North Carolina * *
North Dakota * *
Ohio * *
Oklahoma * *
Oregon * *
Pennsylvania * *
Rhode Island * *
South Carolina * *
South Dakota * *
Tennessee * *
Texas * *
Utah * *
Vermont * *
Virginia * *
Washington * *
West Virginia * *
Wisconsin * *
Wyoming * *
* Confidential Treatment Requested
TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATE
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICES HAVE BOTH VISIT AND HOURLY RATES.
Notes 1, 2, 3, 4, 5 and 6 apply
XXXX 0 XXXX 0 XXXX 0
-------------------------------------------------
VISIT HOUR VISIT HOUR VISIT HOUR
-------------------------------------------------------------------------------------------
CERTIFIED NURSES AIDE * * * * * *
HOME HEALTH AIDE * * * * * *
LVN/LPN * * * * * *
LVN/LPN - HIGH TECH * * * * * *
PEDIATRIC HIGH TECH LVN/LPN * * * * * *
PEDIATRIC HIGH TECH RN * * * * * *
PEDIATRIC LVN/LPN * * * * * *
PEDIATRIC RN * * * * * *
RN * * * * * *
RN HIGH TECH INFUSION * * * * * *
RN HIGH TECH OTHER * * * * * *
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICES HAVE VISIT ONLY RATES.
Notes 1, 3, 4, 5, 7 and 8 apply
XXXX 0 XXXX 0 XXXX 0
-----------------------------------------------------
VISIT HOUR VISIT HOUR VISIT HOUR
--------------------------------------------------------------------------------------------------
DIABETIC NURSE * N/A * N/A * N/A
DIETITIAN * N/A * N/A * N/A
ENTEROSTOMAL THERAPIST * N/A * N/A * N/A
MATERNAL CHILD HEALTH * N/A * N/A * N/A
MEDICAL SOCIAL WORKER * N/A * N/A * N/A
OCCUPATIONAL THERAPIST * N/A * N/A * N/A
OCCUPATIONAL THERAPIST ASSISTANT * N/A * N/A * N/A
PHLEBOTOMIST * N/A * N/A * N/A
PHOTOTHERAPY PACKAGE SERVICE * N/A * N/A * N/A
PHYSICAL THERAPIST * N/A * N/A * N/A
PHYSICAL THERAPIST ASSISTANT * N/A * N/A * N/A
PSYCHIATRIC NURSE * N/A * N/A * N/A
REHABILITATION NURSE * N/A * N/A * N/A
RESPIRATORY THERAPIST * N/A * N/A * N/A
RESPIRATORY THERAPIST - CPAP clinic * N/A * N/A * N/A
RN ASSESSMENT, INITIAL * N/A * N/A * N/A
RN SKILLED NURSING VISIT-EXTENSIVE * N/A * N/A * N/A
SPEECH THERAPIST * N/A * N/A * N/A
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICE HAS HOURLY ONLY RATES.
Notes 3, 4 and 5 apply
XXXX 0 XXXX 0 XXXX 0
----------------------------------------------------------
VISIT HOUR VISIT HOUR VISIT HOUR
--------------------------------------------------------------------------------------------
HOMEMAKER N/A * N/A * N/A *
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICE IS PRICED ON A PER DIEM BASIS.
Notes 3, 4 and 5 apply
XXXX 0 XXXX 0 XXXX 0
----------------------------------------------------
PER DIEM PER DIEM PER DIEM
------------------------------------------------------------------------------------
COMPANION/LIVE IN * * *
NOTES:
1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).
2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.
3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.
4. Above prices have no exclusions.
5. All services not listed above will be billed at * until rates are mutually
established and become part of the fee schedule.
6. RN High Tech Infusion visit and hourly utilization/costs to be reported
with HIT.
7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.
8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty
certification which is not readily available in the home care environment.
Use requires special coordination.
* Confidential Treatment Requested
HOME INFUSION RATES
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES EXCLUDE DRUGS. DRUGS ARE
PRICED AS A PERCENTAGE DISCOUNT OFF AWP (IF APPLICABLE), AND THERE IS NO PRICE
DIFFERENCE BETWEEN PRIMARY AND MULTIPLE THERAPIES
PRIMARY OR PRIMARY OR PRIMARY OR
MULTIPLE THERAPY MULTIPLE THERAPY MULTIPLE THERAPY
PER DIEM DISPENSING FEE DRUG DISCOUNT OFF AWP
-----------------------------------------------------------------------------------------------------------
Ancillary Drugs * *
Biological Response Modifiers * *
Cardiac (Inotropic) Therapy * *
Chelation Therapy * *
Chemotherapy * *
Enteral Therapy * N/A
Enzyme Therapy * *
Growth Hormone * *
IV Immune Globulin * *
Other Injectable Therapies * *
Other Infusion Therapies * *
Pain Management Therapy * *
Steroid Therapy * *
Thrombolytic (Anticoagulation) Therapy * *
Synagis * *
Remodulin Therapy * *
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES EXCLUDE DRUGS. DRUGS ARE
PRICED AS A PERCENTAGE DISCOUNT OFF AWP, AND THERE IS A PRICE DIFFERENCE BETWEEN
PRIMARY AND MULTIPLE ANTI-INFECTIVE THERAPIES
PER DIEM DRUG DISCOUNT OFF AWP
---------------------------------------------------------------------------------------------------------
Anti-Infectives - Primary Anti-Infective * *
Anti-Infectives - Multiple Anti-Infective * *
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATE EXCLUDES DRUGS. DRUGS ARE
PRICED PER VIAL, AND THERE IS NO PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE
ANTI-INFECTIVE THERAPIES
PRIMARY OR
MULTIPLE THERAPY
PER DIEM COST OF DRUG
----------------------------------------------------------------------------------------------------
Flolan Therapy *
Flolan 0.5 mg vial *
Flolan 1.5 mg vial *
Flolan diluent vial *
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES INCLUDE DRUGS, AND THERE IS NO
PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE THERAPIES
PRIMARY OR
MULTIPLE THERAPY
PER DIEM
---------------------------------------------------------------------------
Enteral Therapy *
Hydration Therapy *
Total Parenteral Nutrition *
* Confidential Treatment Requested
SCHEDULE 2A, PAGE 2: HOME INFUSION HMO/FLEX FEE-FOR-SERVICE THERAPY RATES
NOTES:
1. Per Diems EXCLUDING drugs include all costs related to the therapy except
the cost of drugs, including but not limited to facility overhead,
supplies, delivery, professional labor including compounding and
monitoring, all nursing required, maintenance of specialized catheters,
equipment/patient supplies, disposables, pumps, general and administrative
expenses, etc.
2. Per Diems INCLUDING drugs include ALL costs - including but not limited to
cost of drugs, facility overhead, supplies, delivery, professional labor
including compounding and monitoring, all nursing required, maintenance of
specialized catheters, equipment/patient supplies, disposables, pumps,
general and administrative expenses, etc.
3. "DISPENSING FEE" is defined as per each time the drug is dispensed by the
home infusion provider.
4. "PER DIEM" costs are the same for primary or multiple treatments for all
drug categories, except ANTI-INFECTIVES.
5. The per diem rate shall only be charged for those days the Participant
receives medication.
6. For home infusion pharmaceuticals not listed on fee schedule, * will apply.
7. Case Managers should utilize Enteral Therapy WITHOUT drugs as an infusion
benefit infrequently. Generally, patient's requiring Enteral Therapy
WITHOUT drugs should have services coordinated through the DME benefit.
THE FOLLOWING ARE FOR THE STATED ITEM ONLY. UNLESS OTHERWISE NOTED, NURSING,
SUPPLIES, ETC. ARE NOT INCLUDED.
Blood Transfusion per Unit (Tubing, Filters) *
Catheter Care Per Diem *
Midline Insertion (Catheter & Supplies) *
PICC Line Insertion (Catheter & Supplies) *
Blood Product *
* Confidential Treatment Requested
SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES
FACTOR CONCENTRATES
Vial price Unit Price
---------------------------------------------------------------------------
FACTOR VII
Novoseven 1200MCG Vial *
Novoseven 4800MCG Vial *
Novoseven in 1200MCG or 4800MCG QTY *
FACTOR VIII (RECOMBINANT)
Recombinate *
Kogenate or Helixate *
Bioclate N/A
Helixate FS *
Kogenate FS *
Refacto *
Advate *
FACTOR VIII (MONOCLONAL)
Hemofil-M or A. R. C. Method M *
Monoclate P *
Monarc-M *
FACTOR VIII (OTHER)
Koate *
Humate *
Alphanate SDHT *
FACTOR IX (RECOMBINANT)
BeneFix *
FACTOR IX (MONOCLONAL/HIGH PURITY)
Mononine *
Alphanine *
FACTOR IX (OTHER)
Konyne - 80 N/A
Proplex T *
Bebulin *
Profilnine SD *
ANTI-INHIBITOR COMPLEX
Autoplex-T *
Feiba-VH *
Hyate-C *
HEMOSTATIC AGENTS
DDAVP - 10ml vial *
Stimate - 2.5xx xxxx *
Above rates include all necessary ancillary supplies and waste disposal unit;
24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation
* Confidential Treatment Requested
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
------------------------------------------------------------------------------------------------------------------------
A4660 DM590 2520 MONITOR, BLOOD PRESSURE (A4660) W/STETH & CUFF *
A4670 DM590 2518 MONITOR, BLOOD PRESSURE (A4670), AUTOMATIC *
A9900 A9900 7552 BREEZE (A9900) CPAP/BIPAP MASK *
A9900 A9900 7553 FULL FACE (A9900) MIRAGE CPAP/BIPAP MASK *
A9900 A9900 7554 GEL/SILICON (A9900) CPAP/BIPAP MASK INCL GLD SEAL, PHANTM, MONARCH *
A9900 A9900 7556 SPECIALTY (A9900) CPAP/BIPAP MASK (PROFILE OR SIMPICITY) *
DM590 HI531 2570 PUMP, ENTERAL (B9002) * *
B9998 DM590 6828 ENTERAL SUPPLIES (B9998) *
DM590 DM570 7551 BACK-PACK (E1399), FOR PORTABLE ENTERAL PUMP *
DM590 DM590 2522 CANNULA, NASAL *
DM590 DM590 7509 ENTERAL PUMP, PORTABLE (B9002) * *
DM590 DM590 7508 MASK, CPAP GEL OR SILICONE (K0183) *
E0100 E0100 2020 CANE (E0100), ADJ OR FIX, W/ TIP *
E0105 E0105 2021 CANE, QUAD (E0105) OR THREE PRONG, ADJ OR FIX, W/ TIPS *
E0110 E0110 2028 CRUTCHES, FOREARM (E0110), ADJ OR FIX, PAIR, W/ TIPS, GRIPS *
E0111 E0111 2023 CRUTCH FOREARM (E0111), ADJ OR FIX, EACH, W/ TIP AND GRIPS *
E0112 E0112 2027 CRUTCHES UNDERARM, WOOD (E0112), ADJ OR FIX, PAIR, COMPLETE *
E0113 E0113 2025 CRUTCH UNDERARM, WOOD (E0113), ADJ OR FIX, EACH, COMPLETE *
E0114 E0114 2026 CRUTCHES UNDERARM, ALUM (E0114), ADJ OR FIX, PAIR, COMPLETE *
E0116 E0116 2024 CRUTCH UNDERARM, ALUM (E0116), ADJ OR FIX, EACH, COMPLETE *
E0130 E0130 2037 XXXXXX, RIGID (E0130) (PICKUP), ADJ OR FIX HEIGHT *
E0135 E0135 2036 XXXXXX, FOLDING (E0135) (PICKUP), ADJ OR FIX HEIGHT *
E0141 E0141 2040 XXXXXX, WHEELED (E0141), W/OUT SEAT *
E0142 DM570 2034 RIGID XXXXXX (E0142), WHEELED, W/ SEAT, *
E0143 E0143 2029 XXXXXX FOLDING, WHEELED (E0143), W/OUT SEAT *
E0145 DM570 2039 XXXXXX (E0145), WHEELED, W/ SEAT AND CRUTCH ATTACHMENTS *
E0146 DM570 2038 XXXXXX, WHEELED, W/ SEAT (E0146) *
E0147 E0147 2030 XXXXXX HVY DUT (E0147), MULT BRAKING SYS, VAR WHEEL RESISTANCE *
E0153 E0153 2032 CRUTCH PLATFORM ATTACHMENT (E0153), FOREARM EA *
E0154 E0154 2033 XXXXXX PLATFORM ATTACHMENT (E0154), EA *
E0155 E0155 2041 XXXXXX WHEEL ATTACHMENT (E0155), RIGID (PICKUP) XXXXXX *
E0156 DM570 2035 XXXXXX SEAT ATTACHMENT (E0156) *
E0157 E0157 2022 XXXXXX, CRUTCH ATTACHMENT (E0157), EACH *
E0158 E0158 2031 XXXXXX LEG EXTENSIONS (E0158) *
E0163 E0163 2047 COMMODE CHAIR, STATIONARY (E0163), W/ FIX ARMS *
E0164 E0164 2045 COMMODE CHAIR, MOBILE (E0164), W/ FIX ARMS *
E0165 E0165 2046 COMMODE CHAIR (E0165), STATIONARY, W/ DETACH ARMS *
E0165 E0165 2591 COMMODE, XXWIDE (E0165) *
E0166 E0166 2044 COMMODE CHAIR (E0166), MOBILE, W/ DETACH ARMS *
E0167 E0167 2051 COMMODE CHAIR, PAIL OR PAN (E0167) *
E0176 E0176 2142 CUSHION (E0176) OR AIR PRESSURE PAD, NON-POSITIONING *
E0176 E0176 2394 REPLACEMENT PAD (E0176) ALTERNATING PRESS *
E0177 E0177 2224 CUSHION OR WATER PRESS PAD (E0177), NONPOSITIONING *
E0178 E0178 2160 CUSHION OR GEL PRESS PAD (E0178), NONPOSITIONING *
E0179 E0179 2154 CUSHION (E0179) OR DRY PRESSURE PAD, NONPOSTIONING *
E0180 E0180 2196 PUMP (E0180), ALTERNATING PRESSURES W/PAD * *
E0181 E0181 2197 PUMP (E0181), ALTERNATING PRESS W/PAD, HVY DUTY * *
E0184 E0184 2074 MATTRESS, DRY PRESSURE (E0184) *
E0185 E0185 2076 MATTRESS (E0185), GEL OR GEL-LIKE PRESSURE PAD *
E0186 E0186 2064 MATTRESS, AIR PRESSURE (E0186) *
E0187 E0187 2099 MATTRESS, WATER PRESSURE (E0187) *
E0188 DM570 2217 PAD, SYNTHETIC SHEEPSKIN (A9900) *
E0189 DM570 2177 PAD, LAMBSWOOL SHEEPSKIN (E0189), ANY SIZE *
E0192 E0192 2573 CUSHION, XXX FOR W/C (E0192) * *
E0192 E0192 2572 CUSHION, ROHO FOR W/C (E0192) * *
E0192 E0192 2178 W/C PAD (E0192), LOW PRESS AND POSITIONING EQUALIZATION * *
E0193 E0193 2098 MATTRESS, LOW AIR LOSS (E0193), INCL. BED * * *
E0194 DM570 2063 AIR FLUIDIZED BED (E0194) * *
E0270 E1399 6887 HOSPITAL BED INSTITUTIONAL * *
E0196 E0196 2077 MATTRESS, GEL PRESSURE (E0196) *
E0197 E0197 2065 MATTRESS, AIR PRESSURE PAD (E0197) *
E0198 E0198 2100 MATTRESS (E0198), WATER PRESSURE PAD *
E0199 E0199 2075 MATTRESS, DRY PRESSURE PAD (E0199) *
E0200 E0200 2228 HEAT LAMP (E0200), W/OUT STAND, INCL/BULB, OR INFRARED ELEMENT *
E0202 E0202 2229 PHOTOTHERAPY (BILIRUBIN) (E0202), LIGHT WIT *
E0202 E0202 2524 PHOTOTHERAPY, BILI BLANKET (E0202) *
E0205 E0205 2227 HEAT LAMP (E0205), WITH STAND, INCL/ BULB, OR INFRARED ELEMENT *
E0210 DM570 2156 HEATING PAD, STANDARD (E0210) *
E0215 DM570 2155 HEATING PAD (E0215), ELECTRIC, MOIST *
E0218 DM570 2560 COLD THERAPY UNIT (E0218) * * *
E0235 DM570 2187 PARAFFIN BATH UNIT, PORT (E0235) *
E0236 DM570 2199 PUMP (E0236) FOR WATER CIRCULATING PAD *
E0237 DM570 2223 HEAT COLD WATER (E0237) CIRCULATING PAD W/PUMP *
E0238 DM570 2179 HEATING PAD (E0238), MOIST, NON-ELECTRIC *
* Confidential Treatment Requested
6
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
------------------------------------------------------------------------------------------------------------------------
E0241 DM570 2867 BATH TUB RAIL (E0241), WALL, L-SHAPE *
E0241 DM570 2862 BATH TUB RAIL, WALL, 12" (E0241) *
E0241 DM570 2863 BATH TUB RAIL, WALL, 16" (E0241) *
E0241 DM570 2864 BATH TUB RAIL, WALL, 18" (E0241) *
E0241 DM570 2865 BATH TUB RAIL, WALL, 24" (E0241) *
E0241 DM570 2866 BATH TUB RAIL, WALL, 36" (E0241) *
E0241 DM570 2043 BATH TUB RAIL, WALL, UNSPECIFIED SIZE *
E0242 DM570 2042 BATH TUB RAIL, FLOOR BASE (E0242) *
E0243 DM570 2056 TOILET RAIL, EACH (E0243) *
E0244 E0244 2587 TOILET SEAT (E0244) RAISED WITH ARMS *
E0244 E0244 2052 TOILET SEAT, RAISED (E0244) *
E0245 DM570 2575 BATH BENCH WITH BACK (E0245) *
E0245 DM570 2058 BATH TUB STOOL OR BENCH (E0245) *
E0245 DM570 2578 TRANSFER BENCH, NON-PADDED (E0245) *
E0245 DM570 2577 TRANSFER BENCH, PADDED (E0245) *
E0246 DM570 2057 TRANSFER TUB RAIL(E0246), ATTACHMENT *
E0249 DM570 2186 HEAT UNIT (E0249), WATER CIRCULATING PAD *
E0255 E0255 2090 HOSP BED (E0255), VAR HEIGHT, HI-LO, W/ SIDE RAILS, W/ MATTRESS * *
E0256 E0256 2091 HOSP BED (E0256), VAR HEIGHT, HI-LO, W/ SIDE RAILS, W/O MATTRESS * *
E0260 E0260 2083 HOSP BED (E0260), SEMI-ELEC, W/ SIDE RAILS, W/ MATTRESS * *
E0261 E0261 2084 HOSP BED (E0261), SEMI-ELEC, W/ SIDE RAILS, W/OUT MATTRESS * *
E0265 E0265 2086 HOSP BED (E0265), TOTAL ELEC, W/ SIDE RAILS, W/ MATTRESS * *
E0266 E0266 2087 HOSP BED (E0266), TOTAL ELEC, W/ SIDE RAILS, W/OUT MATTRESS * *
E0271 E0271 2096 MATTRESS, INNERSPRING (E0271) *
E0272 E0272 2095 MATTRESS, FOAM RUBBER (E0272) *
E0273 DM570 2068 BED BOARD (E1399) *
E0274 DM570 2097 OVER-BED TABLE (E0274) *
E0275 E0275 2071 BED PAN, STANDARD (E0275), METAL OR PLASTIC *
E0276 E0276 2070 BED PAN, FRACTURE (E0276), METAL OR PLASTIC *
E0277 E0277 2066 MATTRESS (E0277), LOW AIR LOSS, ALT PRESSURE * * *
E0280 DM570 2069 BED CRADLE, ANY TYPE (E1399) *
E0292 E0292 2092 HOSP BED (E0292), VAR HEIGHT, HI-LO, W/OUT S/ RAILS, W/ MATTRESS * *
E0293 E0293 2093 HOSP BED (E0293), VAR HEIGHT, HI-LO, NO SIDE RAILS, NO MATTRESS * *
E0294 E0294 2085 HOSP BED (E0294), SEMI-ELEC, W/OUT SIDE RAILS, W/ MATTRESS * *
E0295 E0295 2094 HOSP BED (E0295), SEMI-ELEC, W/OUT SIDE RAILS, W/OUT MATTRESS * *
E0296 E0296 2089 HOSP BED (E0296), TOTAL ELEC, W/OUT SIDE RAILS, W/OUT MATTRESS * *
E0297 E0297 2088 HOSP BED (E0297), TOTAL ELEC, W/OUT SIDE RAILS, W/ MATTRESS * *
E0305 E0305 2073 BED SIDE RAILS (E0305), HALF LENGTH *
E0310 E0310 2072 BED SIDE RAILS (E0310), FULL LENGTH *
E0315 DM570 2067 BED ACCESSORIES: BOARDS OR TABLES, ANY TYPE *
E0325 E0325 2060 URINAL; MALE (E0325), JUG-TYPE, ANY MATERIAL *
E0326 E0326 2059 URINAL; FEMALE (E0326), JUG-TYPE, ANY MATERIAL *
E0372 E0372 7008 MATTRESS (E0372) POWERED AIR OVERLAY * *
E0410 E0444 2369 O2 CONTENTS, LIQUID (E0444), PER POUND *
E0416 E0443 2371 O2 REFILL FOR PORT (E0443) GAS SYSTEM ONLY, UP TO 23 CUBIC FEET *
E0424 E0424 2385 O2 SYS STATIONARY (E0424) COMPR GAS, RENT *
E0430 E0430 2374 O2 SYS PORT GAS, PURCH (E0430) *
E0431 E0431 2574 O2 SYS PORT GAS, LIGHTWEIGHT (E0431) W/CONSERV DEVICE, NO CONTENT * *
E0431 E0431 2375 O2 SYS PORT GAS, RENT (E0431) *
E0434 E0434 2377 O2 SYS PORT LIQUID, RENT (E0434) *
E0435 E0435 2376 O2 SYS PORT LIQUID, PURCH (E0435) *
E0439 E0439 2388 O2 SYS STATIONARY (E0439) LIQUID, RENT *
E0440 E0440 2387 O2 SYS STATIONARY (E0440) LIQUID, PURCH *
E0443 E0400 2869 O2 CONTENTS, H/K CYLINDER (E0400), 200-300 CUBIC FT *
E0444 E0444 2379 O2 CONTENTS, PORT LIQUID (E0444), PER UNIT (1 UNIT = 1 LB.) *
E0450 E0450 7555 POSITIVE PRESSURE VENTS (E0450)(E.G. T-BIRD) *
E0450 E0450 7926 POSITIVE PRESSURE VENTS, EMERGENCY BACKUP (E.G. T-BIRD)(E0450) *
E0450 E0450 2392 VENTILATOR VOLUME (E0450), STATIONARY OR PORT * *
E0450 E0450 7522 VENTILATOR, VOLUME, (E0450) EMERGENCY BACKUP UNIT * *
E0452 E0452 2332 BILEVEL INTERMITTENT (E0452) ASSIST DEVICE,(BIPAP) * *
E0453 E0453 2390 VENTILATOR THERAPEUTIC (E0453); FOR USE 12 HOURS OR LESS PER DAY * *
E0455 E0455 2372 O2 TENT (E0455), EXCLUDING CROUP OR PEDIATRIC TENTS * *
E0457 E0457 2323 CHEST SHELL (CUIRASS) (E0457) * *
E0459 E0459 2324 CHEST WRAP (E0459) * *
E0460 E0460 2339 VENTILATOR (E0460), NEGATIVE PRESSURE, PORTABLE OR STATIONARY * *
E0480 DM570 2373 PERCUSSOR (E0480), ELEC OR PNEUM, HOME MODEL * *
E0500 E0500 2333 IPPB, W/ BUILT-IN NEB (E0500) MAN OR AUTO VALVES; INT/EXT POWER * *
E0550 E0550 2328 HUMIDIFIER (E0550) DURABLE FOR EXTENSIV SUP/ HUMID W/ IPPB OR O2 * *
E0555 E0555 2330 HUMIDIFIER (E0555), DURABLE, GLASS, FOR USE W/ REG OR FLOWMETER *
E0565 E0565 2325 COMPRESSOR, AIR POWER (E0565) * *
E0570 E0570 2336 NEBULIZER, W/ COMPRESSOR (E0570) *
E0575 DM570 2571 NEBULIZER (E0575), ULTRASONIC, AC/DC * *
E0575 DM570 2338 NEBULIZER; ULTRASONIC (E0575) * *
E0585 E0585 2337 NEBULIZER(E0585), W/ COMPRESSOR AND HEATER * *
* Confidential Treatment Requested
7
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
------------------------------------------------------------------------------------------------------------------------
E0600 E0600 2389 SUCTION PUMP (E0600), HOME MODEL * *
E0600 E0600 7523 SUCTION UNIT, (E0600), PORTABLE AC/DC * *
E0601 E0601 2326 CONTINUOUS POSITVE (E0601) AIRWAY PRESSURE DEVICE (CPAP) * *
E0601 E0601 6965 CPAP, SELF TITRATING (E0601) * *
E0601 E0601 7935 CPAP, C-Flex * *
E0601 E0601 8363 CPAP, C Flex Pro with Compliance Monitoring * *
E0605 DM570 2391 VAPORIZER, ROOM TYPE (E0605) *
E0606 DM570 2380 POSTURAL DRAINAGE BOARD (E0606) *
E0607 E0607 6874 MONITOR, B/GLUCOSE (E0607) ACCUCHEK AD *
E0607 E0607 2164 MONITOR, BLOOD GLUCOSE (E0607) *
E0608 E0608 2322 APNEA MONITOR (E0608) * *
E0608 E0608 2576 APNEA MONITOR (E0608) W/MEM (INCL SMART) * *
E0609 E0609 2146 MONITOR, BLOOD GLUCOSE (E0609) W/SPECIAL FEATURES *
E0621 E0621 2215 PATIENT LIFT (E0621), SLING OR SEAT, CANVAS OR NYLON *
E0625 DM570 2191 PATIENT LIFT (E0625), KARTOP, BATHROOM OR TOILET *
E0627 E0627 4553 HIP CHAIR (E0627) * *
E0627 DM570 2395 SEAT LIFT CHAIR/MOTORIZED (E0627) *
E0627 DM570 2205 SEAT LIFT MECH (E0627) INCORPORATED INTO A COMB LIFT-CHAIR MECH *
E0630 E0630 2190 PATIENT LIFT, HYDRAULIC (E0630), W/ SEAT OR SLING * *
E0635 DM570 2189 PATIENT LIFT (E0635), ELEC W/ SEAT OR SLING *
E0650 E0650 2192 PNEUM COMPRESSOR (E0650), NON-SEG HOME MODEL * *
E0651 E0651 2194 PNEUM COMPRESSOR (E0651), SEG HOME MODEL W/OUT CALIB GRAD PRES * *
E0652 E0652 2193 PNEUM COMPRESSOR (E0652), SEG HOME MODEL W/ CALIB GRAD PRES * *
E0655 E0655 2182 PNEUM COMPRESSOR (E0655), NON-SEG APPLIANCE, HALF ARM *
E0660 E0660 2181 PNEUM COMPRESSOR (E0660), NON-SEG APPLIANCE, FULL LEG *
E0665 E0665 2180 PNEUM COMPRESSOR (E0665), NON-SEG APPLIANCE, FULL ARM *
E0666 E0666 2183 PNEUM COMPRESSOR (E0666), NON-SEG APPLIANCE, HALF LEG *
E0667 E0667 2210 PNEUM APPLIANCE (E0667), SEG, FULL LEG *
E0668 E0668 2209 PNEUM APPLIANCE (E0668), SEG, FULL ARM *
E0669 E0669 2212 PNEUM APPLIANCE (E0669), SEG, HALF LEG *
E0670 E0670 2211 PNEUM APPLIANCE (E0670), SEG, HALF ARM *
E0671 E0671 2207 PNEUM APPLIANCE (E0671), SEG GRAD PRESS, FULL LEG *
E0672 E0672 2206 PNEUM APPLIANCE (E0672), SEG GRAD PRESS, FULL ARM *
E0673 E0673 2208 PNEUM APPLIANCE (E0673), SEG GRAD PRESS, HALF LEG *
E0690 DM570 2221 ULTRAVIOLET CABINET (E0690), APPROPRIATE FOR HOME USE *
E0700 DM570 2204 SAFETY EQUIP (E0700) (E.G., BELT, HARNESS OR VEST) *
E0710 DM570 2202 RESTRAINTS (E0710), ANY TYPE (BODY, CHEST, WRIST OR ANKLE) *
E0720 E0720 2219 TENS (E0720), TWO LEAD, LOCALIZED STIMULATION * *
E0730 E0730 2218 TENS (E0730), FOUR LEAD, LARGER AREA/MULTIPLE NERVE STIMULATION * *
E0731 E0731 2159 TENS OR NMES (E0731), CONDUCTIVE GARMENT *
E0744 E0744 2120 STIMULATOR (E0744), NEUROMUSCULAR FOR SCOLIOSIS * *
E0745 E0745 2120 STIMULATOR (E0745), NEUROMUSCULAR, ELECTRONIC SHOCK UNIT * *
E0745 E0745 6915 STIMULATOR FOUR CH (E0745), NEUROMUSCULAR * *
E0746 DM570 2109 ELECTROMYOGRAPHY (EMG) (E0746), BIOFEEDBACK DEVICE * *
E0747 DM570 2122 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE *
E0747 DM570 8386 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, EBI *
E0747 DM570 8387 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, ORTHOFIX *
E0747 DM570 8388 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, ORTHOLOGIC *
E0748 DM570 2124 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL APPLICATIONS *
E0748 DM570 8389 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, EBI *
E0748 DM570 8390 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, ORTHOFIX *
E0748 DM570 8391 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, ORTHOLOGIC *
E0755 DM570 2157 STIMULATOR (E0755), ELECTRONIC SALIVARY REFLEX, NON INVASIVE *
E0776 E0776 2175 IV POLE (E0776) * *
E0784 E0784 2158 PUMP (E0784), EXT AMBULATORY INFUSION, MINIMED, INSULIN *
E0784 E0784 7773 PUMP (E0784), EXT AMBULATORY INFUSION, DELTEC, INSULIN *
E0784 E0784 7925 PUMP, EXT INFUSION, NON - XXXX PREMIUM, INSULIN (E0784) *
E0784 E0784 6771 PUMP (E0784), INSULIN EXT INFUSION DISETRONICS OR OTHER *
E0840 E0840 2133 TRACTION FRAME (E0840), ATTACH TO HEADBOARD, CERVICAL TRACTION *
E0850 E0850 2134 TRACTION STAND (E0850), FREE STANDING, CERVICAL TRACTION * *
E0855 E0855 7484 TRACTION (E0855), W/O FRAME OR STAND * *
E0860 E0860 2130 TRACTION EQUIP (E0860), OVERDOOR, CERVICAL *
E0870 E0870 2131 TRACTION FRAME (E0870), ATTACH TO FOOTBOARD, EXTREMITY, BUCKS * *
E0880 E0880 2135 TRACTION STAND (E0880) FREE/STAND EXTREMITY TRACTION, EG, BUCK'S * *
E0890 E0890 2132 TRACTION FRAME (E0890), ATTACH TO FOOTBOARD, PELVIC TRACTION * *
E0900 E0900 2136 TRACTION STAND (E0900) FREE/ STAND PELVIC TRACTION,(EG, BUCK'S) * *
E0910 E0910 2138 TRAPEZE BARS (E0910), A/K/A PT HELPER, ATTACH TO BED W/ GRAB BAR * *
E0920 E0920 2111 FRACTURE FRAME (E0920), ATTACH TO BED, INCLUDING WEIGHTS * *
E0935 E0935 2125 PASSIVE MOTION (E0935) EXERCISE DEVICE *
E0935 E0935 2859 PASSIVE MOTION (E0935) EXERCISE DEVICE, ANKLE *
E0935 E0935 2860 PASSIVE MOTION (E0935) EXERCISE DEVICE, ELBOW *
E0935 E0935 2857 PASSIVE MOTION (E0935) EXERCISE DEVICE, HAND *
E0935 E0935 2858 PASSIVE MOTION (E0935) EXERCISE DEVICE, SHOULDER *
E0935 E0935 2861 PASSIVE MOTION (E0935) EXERCISE DEVICE, WRIST *
* Confidential Treatment Requested
8
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
------------------------------------------------------------------------------------------------------------------------
E0940 E0940 2137 TRAPEZE BAR (E0940), FREE STANDING, COMPLETE W/ GRAB BAR * *
E0941 E0941 2116 TRACTION DEVICE (E0941), GRAVITY ASSISTED * *
E0942 E0942 2101 HARNESS/HALTER (E0942), CERVICAL HEAD *
E0944 E0944 2126 HARNESS (E0944), PELVIC BELT, BOOT *
E0945 DM570 2110 HARNESS (E0945), EXTREMITY BELT *
E0946 E0946 2115 FRACTURE, FRAME (E0946), DUAL W/ CROSS BARS, ATTACH TO BED * *
E0947 E0947 2113 FRACTURE FRAME (E0947), ATTACHMENTS FOR COMPLEX PELVIC TRACTION * *
E0948 E0948 2112 FRACTURE FRAME (E0948) ATTACHMENTS FOR COMPLEX CERVICAL TRACTION * *
E0950 DM570 2139 TRAY (E0950) *
E0958 E0958 2307 W/C PART ATTACHMENT (E0958) TO CONVERT ANY W/C TO ONE ARM DRIVE *
E0959 E0959 2237 W/C PART AMPUTEE ADAPTER(E0959) (COMPENSATE FOR TRANS OF WEIGHT) *
E0962 E0962 2232 CUSHION FOR WC 1" (E0962) *
E0963 E0963 2233 CUSHION FOR WC 2" (E0963) *
E0964 E0964 2234 CUSHION FOR WC 3" (E0964) *
E0965 E0965 2235 CUSHION FOR WC 4" (E0965) *
E0972 DM570 2230 TRANSFER BOARD OR DEVICE (E0972) *
E0977 E0977 2317 CUSHION, WEDGE FOR W/C (E0977) *
E0978 E0978 2248 BELT, SAFETY (E0978) W/ AIRPLANE BUCKLE, W/C *
E0979 DM570 2249 BELT, SAFETY (E0979) W/ VELCRO CLOSURE, W/C *
E0980 DM570 2292 SAFETY VEST (E0980), W/C *
E1031 E1031 2291 ROLLABOUT CHAIR (E1031), W/ CASTORS 5" OR GREATER * *
E1050 E1050 2260 W/C FULL/REC (E1050), FIX ARMS, SWING AWAY DETACH ELEV LEG RESTS * *
E1060 E1060 2259 W/C FULL/REC (E1070), DETACH ARMS, SWING AWAY DETACH FOOTREST * *
E1065 E1065 2287 W/C POWER ATTACHMENT (E1065) *
E1066 E1066 2247 BATTERY CHARGER (E1066) *
E1069 E1069 2255 BATTERY, DEEP CYCLE (E1069) *
E1070 E1070 2258 W/C FULL/REC (E1060), DETACH ARMS, SWING AWAY DET/ ELEV LEGRESTS * *
E1083 E1083 2263 W/C HEMI (E1083), FIX ARMS, SWING AWAY DETACH ABLE ELEV LEG REST * *
E1084 E1084 2262 W/C HEMI (E1084), DETACH ARMS, SWING AWAY DETACH ELEV LEG RESTS * *
E1085 E1085 2264 W/C HEMI (E1085), FIX ARMS, SWING AWAY DETACH ABLE FOOT RESTS * *
E1086 E1086 2261 W/C HEMI (E1086), DETACH ARMS, SWING AWAY DETACH FOOTRESTS * *
E1087 E1087 2265 W/C HI STRENGTH LT-WT (E1087), FIX ARMS, S/AWAY ELEV LEG RESTS * *
E1088 E1088 2268 W/C HI STRENGTH LT-WGT (E1088), D/ARMS, S/AWAY ELEV LEG RESTS * *
E1089 E1089 2266 W/C HI STRENGTH LT-WGT (E1089), FIX ARMS, S/AWAY DETACH FOOTREST * *
E1090 E1090 2267 W/C HI STRENGTH XX-XX (E1090), DETACH ARMS, S/AWAY D/FOOT RESTS * *
E1091 E1091 2321 W/C YOUTH, ANY TYPE (E1091) * *
E1092 E1092 2319 W/C WIDE HVY DUTY (E1092), DETACH ARMS S/AWAY DETACH ELEVAT LEGS * *
E1093 E1093 2320 W/C WIDE HVY DUTY (E1093), DETACH ARMS S/AWAY DETACH FOOTRESTS * *
E1100 E1100 2296 W/C SEMI-RECLINING (E1100), SWING AWAY DETACH ELEV LEG RESTS * *
E1110 E1110 2295 W/C SEMI-RECLINING (E1110), DETACH ARMS ELEV LEG REST * *
E1130 E1130 2303 W/C STANDARD (E1130), FIX OR SWING AWAY DETACH FOOTRESTS * *
E1140 E1140 2313 W/C (E1140), DETACH ARMS SWING AWAY DETACH FOOTRESTS * *
E1150 E1150 2314 W/C (E1150), DETACH ARMS, SWING AWAY DETACH ELEVAT LEGRESTS * *
E1160 E1160 2315 W/C (E1160), W/ FIX ARMS, SWING AWAY DETACH ELEVAT LEGRESTS * *
E1160 E1160 2396 W/C (E1160), W/FIX ARMS REMOVABLE FOOTRESTS * *
E1170 E1170 2241 W/C AMPUTEE (E1170), FIX ARMS, SWING AWAY DETACH ELEV LEGRESTS * *
E1171 E1171 2242 W/C AMPUTEE (E1171), FIX ARMS, W/OUT FOOTRESTS OR LEGREST * *
E1172 E1172 2240 W/C AMPUTEE (E1172), DETACH ARMS W/OUT FOOTRESTS OR LEGREST * *
E1180 E1180 2239 W/C AMPUTEE (E1180), DETACH ARMS SWING AWAY DETACH FOOTRESTS * *
E1190 E1190 2238 W/C AMPUTEE (E1190), DETACH ARMS SWING AWAY DETACH ELEV LEGRESTS * *
E1195 E1195 2273 W/C HVY DUTY (E1195), FIX ARMS, SWING AWAY DETACH ELEV LEGRESTS * *
E1200 E1200 2243 W/C AMPUTEE (E1200), FIX FULL LENGTH ARMS, S/AWAY D/FOOTREST * *
E1210 E1210 2281 W/C MOTORIZED (E1210), FIX ARMS, S/AWAY DETACH ELEV LEG RESTS * *
E1211 E1211 2279 W/C MOTORIZED (E1211), DETACH ARMS, S/AWAY DETACH FOOT RESTS * *
E1212 E1212 2282 W/C MOTORIZED (E1212), FIX ARMS, SWING AWAY DETACH FOOT RESTS * *
E1213 E1213 2280 W/C MOTORIZED (E1213), DETACH ARMS S/AWAY, DETACH ELEV LEG REST * *
E1220 E1220 2551 W/C CUSTOM (E1220) *
E1220 E1220 2579 W/C XXWIDE (E1220) *
E1230 E1230 2288 SCOOTER (E1230), THREE OR 4 WHEEL * *
E1240 E1240 2276 W/C LT-WGT (E1240), DETACH ARMS SWING AWAY DETACH, ELEV LEGREST * *
E1250 E1250 2278 W/C LT-WGT (E1250), FIX ARMS, SWING AWAY DETACH FOOTREST * *
E1260 E1260 2275 W/C LT-WGT (E1260), DETACH ARMS SWING AWAY DETACH FOOTREST * *
E1270 E1270 2277 W/C LT-WGT (E1270), FIX ARMS, SWING AWAY DETACH ELEV LEGRESTS * *
E1280 E1280 2270 W/C HVY DUTY (E1280), DETACH ARMS ELEV LEGRESTS * *
E1285 E1285 2274 W/C HVY DUTY (E1285), FIX ARMS, SWING AWAY DETACH FOOTREST * *
E1290 E1290 2271 W/C HVY DUTY (E1290), DETACH ARMS SWING AWAY DETACH FOOTREST * *
E1295 E1295 2272 W/C HVY DUTY (E1295), FIX ARMS, ELEV LEGREST * *
E1300 DM570 2062 WHIRLPOOL (E1300), PORT (OVERTUB TYPE) *
E1310 DM570 2061 WHIRLPOOL (E1399), NON-PORT (BUILT-IN TYPE) *
E1353 E1353 2381 O2 REGULATOR (E1353) * *
E1355 E1355 2384 CYLINDER STAND/RACK (E1355) *
E1372 E1372 2331 IMMERSION EXT HEATER (E1372) FOR NEBULIZER * *
E1375 E1375 2334 NEBULIZER PORT (E1375) W/ SMALL COMPRESSOR, W/ LIMITED FLOW *
E1399 DM570 2568 ADAPTER (A9900), AC/DC *
* Confidential Treatment Requested
9
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
------------------------------------------------------------------------------------------------------------------------
E1399 E1399 2586 APNEA MONITOR DOWNLOAD (E1399) *
E1399 DM570 2552 BATH LIFT (E1399), CUSTOM *
E1399 DM570 2563 BED WEDGE (E1399), 12" *
E1399 DM570 2856 BEDROOM EQUIPMENT (E1399), CUSTOM *
E1399 E1399 2525 BREAST PUMP, ELECTRIC (E1399) * *
E1399 DM570 2581 BREAST PUMP, INSTITUTIONAL (E1399) *
E1399 E1399 2580 BREAST PUMP, MANUAL (E1399) *
E1399 DM570 2593 COLD THERAPY UNIT, PAD (E1399) *
E1399 E1399 2565 COMMODE (E1399), DROP ARM, HEAVY DUTY *
E1399 E1399 2582 COMPRESSION PUMP BOOT (E1399) *
E1399 E1399 2583 COMPRESSION PUMP, FOOT (E1399) *
E1399 A9900 2569 CPAP HUMIDIFIER (A9900), HEATED * *
E1399 A9900 2635 CPAP/BIPAP SUPPLIES (A9900) *
E1399 E1399 2327 DURABLE MEDICAL EQUIP (E1399), MISCELLANEOUS *
E1399 E1220 2584 XXXX CHAIR (E1399), THREE POSITION RECLINING *
E1399 DM570 6780 XXXXXX MONITOR (G0004) *
E1399 E0265 2590 HOSP BED (E1399), ELECTRIC, XLONG, W/MATTRESS & SIDE RAILS * *
E1399 E0200 2868 LAMP, ULTRAVIOLET (E1399) *
E1399 DM570 2588 MONITOR (E1399), XXXXX XXXXX *
E1399 DM570 2529 O2 ANALYZER (A9900) * *
E1399 A9900 2594 O2 CONSERVATION DEVICE (A9900) * *
E1399 DM570 6775 OXIMETRY TEST (E1399) *
E1399 DM570 2555 PATIENT LIFT, CUSTOM (E1399) *
E1399 DM570 2561 PEAK FLOW METER (E1399) *
E1399 E1399 4559 PEDIATRIC XXXXXX (E1399) *
E1399 DM570 2567 PNEUMOGRAM (E1399) *
E1399 E1399 2553 POSITIONING, CUSTOM (E1399) *
E1399 E1399 2526 PULSE OXIMETER (E1399) * *
E1399 E1399 2527 PULSE OXIMETER W/ PROBE (E1399) * *
E1399 DM570 2562 SHOWER, HAND HELD (E1399) *
E1399 DM570 2592 SLEEP STUDY, ADULT (E1399) *
E1399 DM590 7483 STIMULATOR (E1399), MUSCLE, LOW VOLTAGE OR INTERFERENTIAL * *
E1399 DM570 2855 THERAPY EQUIPMENT, CUSTOM (E1399) *
E1399 DM570 6774 THERAPY PERCUSSION, GENERATOR ONLY * *
E1399 E1399 7506 W/C, CUSTOM (E1399) MANUAL ADULT *
E1399 E1399 7504 W/C, CUSTOM (E1399) MANUAL PEDIATRIC *
E1399 E1399 7507 W/C, CUSTOM (E1399) POWER ADULT *
E1399 E1399 7505 W/C, CUSTOM (E1399) POWER PEDIATRIC *
E1399 E1399 2564 XXXXXX (E1399), HEAVY DUTY, EXTRA WIDE *
E1399 E1399 2585 XXXXXX (E1399), HEMI *
K0538 DM570 6873 WOUND SUCTION DEVICE (K0538) *
K0539 DM570 7914 DRESSING SET, FOR WOUND SUCTION DEVICE (K0539) *
K0540 DM570 7915 CANISTER SET, FOR WOUND SUCTION DEVICE (K0540) *
E1400 E1390 2361 O2 CONC (E1390), MANUF SPEC MAXFLOWRATE = 2 LTS PER MIN@85% * *
G0015 DM570 6779 CARDIAC EVENT MONITOR (G0015) *
K0163 DM590 3713 ERECTION SYSTEM, VACUUM (K0163) *
K0183 DM590 2516 CPAP MASK (K0183) *
K0184 DM590 2515 NASAL PILLOWS/SEALS (K0184) REPLACEMENT FOR NASAL APP/ DVC, PAIR *
K0185 DM590 2514 CPAP HEADGEAR (K0185) *
K0186 DM590 2513 CPAP CHIN STRAP (K0186) *
K0187 DM590 2512 CPAP TUBING (K0187) *
K0188 DM590 2511 CPAP FILTER (A9900), DISPOSABLE *
K0189 DM590 2510 CPAP FILTER (A9900), NON-DISPOSABLE *
K0268 DM590 2509 CPAP HUMIDIFIER (K0268), COOL *
K0413 DM590 6889 MATTRESS (K0413), NONPOWERED, EQUIVALENT *
E1399 E1399 7673 MATTRESS (E1399) V-CUE DYNAMIC AIR THERAPY *
A4608 A9900 7621 CATHETER TRACH (A4608) 11CM 1 SCOOP *
E1399 A9900 7664 COFFLATOR (E1399CF) MANUAL SECRETION MOBIL DEVICE *
E0168B A9900 7643 COMMODE (E0168B) HVY DUTY BEDSIDE CHAIR 000-000 XXX. *
E0168C A9900 7644 COMMODE (E0168C) HVY DUTY DROP ARM 451-850 LBS. *
A6234 HH591 7626 DRESSING <16 SQ IN (A6234) HYDROCOLLOID DRESSING, EA *
A6258 HH591 7627 DRESSING >16 SQ IN (A6258) TRANSPAREN FILM, EA *
A46203 HH591 7625 DRESSING COMPOSITE <16 SQ IN (A46203) SELF ADH, EA *
B9998B DM590 7655 ENT (B9998B) EXT SET Y SITE F/KANGAROO PUMP *
B9998C DM590 7656 ENT (B9998C) EXT SET W/ CLAMP BASIC *
B9998D DM590 7657 ENT (B9998D) XXXXXXX GASTRIC RELIEF VLV *
B9998E DM590 7658 ENT (B9998E) GASTRO EXT SET *
B9998F DM590 7659 ENT (B9998F) GASTRO TUBE ANY SIZE MIC-KEY OR HIDE A PORT *
E1399 A9900 7620 HUMID-VENT (E1399) ARTIFICIAL NOSE *
E1399 A9900 0000 XXXX (E1399) UNIV SET UP W/MANIFOLD NEBULIZER *
K0105 A9900 7639 IV POLE (K0105) ATTACH F/ W/C *
E1399 A9900 7641 MECHANICAL SCALE (E1399) PEDIATRIC/NEONATAL *
A7008 A9900 7661 NEBULIZER (A7008) KIT PREFILL W/STR H20 1L BAX *
E1399 A9900 7663 O2 CONNECTOR (E1399) XXXX/IRRIGATION NOZZLE BAX *
* Confidential Treatment Requested
10
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
------------------------------------------------------------------------------------------------------------------------
E1399 A9900 7615 O2 HUMIDIFIER (E1399) AQUA+NEONATAL EA HUD *
E1399 A9900 7623 O2 SWIVEL (E1399) ADAPTER ANGLED STERILE *
L8501 A9900 7624 SPEAKING VALVE (L8501) WHITE PAS *
A4319 HH591 7629 STERILE WATER (A4319) F/IRRIG 1L BAX *
A7001 HH591 7619 SUCTION BOTTLE (A7001) W/LID & TUBING *
E1399 A9900 7616 SUCTION FILTER (E1399) BACTERIA *
A6265 HH591 7628 TAPE ALL TYPES (A6265) EXCLUDING MICROFOAM, PER 18 SQ INCHES *
A4481 A9900 7622 TRACH FILTER (A4481) BACTERIA ELECTROSTATIC *
A4623 A9900 7618 TRACH INNER (A4623) CANNULA *
A4621 A9900 7617 TRACH TUBE MASK (A4621) COLLAR OR HOLDER *
A7010 A9900 7662 TUBING (A7010) AEROSOL CORRUGATED PER FOOT *
E1399 A9900 7631 VENT ADAPTER (E1399) MDI HUD *
A9900 A9900 7630 VENT BATTERY CHARGER (A9900) 12V GEL *
E1399 A9900 7632 VENT CONNECTOR (E1399) PED OR ADULT OMNIFLEX DISP *
E1399 A9900 7633 VENT FILTER (E1399) HYGROBAC S ELECTOSTATIC MAL *
E1399 A9900 7634 VENT THERMOMETER (E1399) W/ ADAPTER *
K0108 A9900 7638 W/C BRAKE EXTENSION (K0108) TIP BLK 10/PK *
E1399 A9900 7635 XXXXXX BASKET (E1399) VINYL COATED *
E0159 A9900 7640 XXXXXX BRAKE (E0159) ATTACHMENT *
E0148 A9900 7636 XXXXXX HVY DUTY (E0148) FOLDING X-WIDE *
E0149 A9900 7637 XXXXXX HVY DUTY (E0149) W/ WHEELS *
E1399 A9900 7645 CPAP (E1399) DC BATTERY ADAPTER CABLE *
E1399 A9900 7646 CPAP (E1399) EXHALATION PORT DISP *
E1399 A9900 7647 CPAP (E1399) FUSE KIT INTERNATIONAL A/C *
E1399 A9900 7648 CPAP (E1399) HUMIDIFIER CHAMBER KIT DISP *
E1399 A9900 7649 CPAP (E1399) HUMIDIFIER CHAMBER REUSABLE *
E1399 A9900 7650 CPAP (E1399) HUMIDIFIER MOUNTING TRAY *
E1399 A9900 7651 CPAP (E1399) INVERTOR AC/DC *
E1399 A9900 7652 CPAP (E1399) POWER CORD F/ARIA-SYNC *
E1399 A9900 7653 CPAP (E1399) SHELL W/O PRESSURE TAP *
A9900 DM590 7566 CPAP CALIBRATION SHELL (A9900) *
A9900 DM590 7565 CPAP SHORT TUBING (A9900) *
E0601 E0601 7690 VENT, CONTINUOUS POSITIVE (E0500) AIRWAY PRESSURE DEVICE N/A *
E0452 E0452 7691 VENT, BILEVEL INTERMITTENT (E0500) ASSIST DEVICE (BIPAP) N/A *
E0747 DM570 6875 STIMULATOR, OSTEOGENIC, ULTRASOUND *
A9900 A9900 7695 GEL/SILICON GOLD SEAL CPAP/BIPAP MASK (A9900) *
A9900 A9900 7701 VENT THERAPEUTIC ST BIPAP W/ BACKUP RATE (K0533) N/A *
A9900 A9900 7703 O2 SYS HELIOS PORT LIQUID, RENT (E1399) *
HH591 HH591 7704 PUMP, EXT INFUSION, XXXX DIABECARE, INSULIN (E0784) *
E0784 E0784 7731 PUMP, EXT INFUSION, ANIMAS, INSULIN (E0784) *
A9900 A9900 7737 CPAP DREAM SEAL INTERFACE FOR USE WITH BREEZE MASK (A9900) *
DM590 DM590 7738 CPAP CHIN STRAP DELUXE (K0186) *
E1340 E1340 7768 W/C REPAIRS - CUSTOM (E1340) *
The following may be charged under extraordinary circumstances:
E1399 E1399 4551 LABOR/SERVICE/SHIPPING CHARGES *
E1399 E1399 2731 SHIPPING AND HANDLING FEES *
The following may be charged if over and above routine on rental equipment:
E1350 E1350 2382 REPAIR OR NON-ROUTINE (E1350) SERVICE REQUIRING SKILL OF A TECH *
E1340 E1340 2554 W/C REPAIRS - STANDARD (E1340) *
E1399 E1399 4552 MISCELLANEOUS SUPPLIES * *
E1399 E1399 2589 REPAIR (E1399), RESPIRATORY EQUIPMENT *
E1399 E1399 4561 RESPIRATORY SUPPLIES (A4618) * *
E1399 E1399 4549 TENS/APNEA SUPPLIES * *
NOTES:
1. Whether rental or purchase, rates include all shipping, labor and set-up.
2. If item is rented, rates include all supplies to enable the equipment to
function effectively, with the exception of supplies for CPAP, BIPAP,
Ventilators, Suction, Enteral Pumps and CPM. Such exception supplies will
be billed at *.
3. If item is rented, rates include repair and maintenance costs.
4. If item is purchased, supplies, repair and maintenance will be billed at *.
5. All equipment not listed above will be billed at * until rates are mutually
established and become part of the fee schedule.
6. Rates effective through 12/31/2005.
7. CPAPs - A new model will be implemented which emphasizes a personal
delivery system without an RT on-site
There will be an additional charge should an additional clinic or home
visit be required
Clinic Model - *
Home RT Model - *
* Confidential Treatment Requested
11
EXHIBIT A
GATEKEEPER PROGRAM ATTACHMENT - CAPITATION
SCHEDULE OF CAPITATION RATES
CAPITATION RATES EFFECTIVE 1/1/05 - 12/31/05
These are the capitation rates that apply to services rendered to Patient Panel
Participants enrolled in Gatekeeper Programs. An "Gatekeeper Program" means (i)
a product that includes fully insured Standard HMO, Point of Service, or
Gatekkeper PPO benefits and which is underwritten by a licensed insurance
company based on an experience rating methodology, or (ii) a self funded product
which includes Standard HMO, Point of Service, or Gatekeeper PPO benefits. This
definition includes, but is not limited to, Participants covered under Flexcare
plans insured/administered by Connecticut Life Insurance Company.
Gentiva
Homehealth
Infusion and
DME/HME
Capitation
Rate PMPM
-----------
All Commercial HMO Capitated Affiliates
EXHIBIT A
GATEKEEPER PROGRAM ATTACHMENT - FEE FOR SERVICE
REIMBURSEMENT FOR OTHER SERVICES
RATE AREA DESIGNATIONS:
STATE RATE AREA RATE DESIGNATION
--------------------------------------------------------------------
Alabama * *
Alaska * *
Arizona * *
Arkansas * *
California * *
Colorado * *
Connecticut * *
Delaware * *
District of Columbia * *
Florida * *
Georgia * *
Hawaii * *
Idaho * *
Illinois * *
Indiana * *
Iowa * *
Kansas * *
Kentucky * *
Louisiana * *
Maine * *
Maryland * *
Massachusetts * *
Michigan * *
Minnesota * *
Mississippi * *
Missouri * *
Montana * *
Nebraska * *
Nevada * *
New Hampshire * *
New Jersey * *
New Mexico * *
New York * *
North Carolina * *
North Dakota * *
Ohio * *
Oklahoma * *
Oregon * *
Pennsylvania * *
Rhode Island * *
South Carolina * *
South Dakota * *
Tennessee * *
Texas * *
Utah * *
Vermont * *
Virginia * *
Washington * *
West Virginia * *
Wisconsin * *
Wyoming * *
* Confidential Treatment Requested
TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATE
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICES HAVE BOTH VISIT AND HOURLY RATES.
Notes 1, 2, 3, 4, 5 and 6 apply
XXXX 0 XXXX 0 XXXX 0
------------------ ----------------- -----------------
VISIT HOUR VISIT HOUR VISIT HOUR
------------------------------------------------------------------------------------------------------------------------------
CERTIFIED NURSES AIDE * * * * * *
HOME HEALTH AIDE * * * * * *
LVN/LPN * * * * * *
LVN/LPN - HIGH TECH * * * * * *
PEDIATRIC HIGH TECH LVN/LPN * * * * * *
PEDIATRIC HIGH TECH RN * * * * * *
PEDIATRIC LVN/LPN * * * * * *
PEDIATRIC RN * * * * * *
RN * * * * * *
RN HIGH TECH INFUSION * * * * * *
RN HIGH TECH OTHER * * * * * *
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICES HAVE VISIT ONLY RATES.
Notes 1, 3, 4, 5, 7 and 8 apply
XXXX 0 XXXX 0 XXXX 0
------------------ ------------------ ------------------
VISIT HOUR VISIT HOUR VISIT HOUR
------------------------------------------------------------------------------------------------------------------------------------
DIABETIC NURSE * N/A * N/A * N/A
DIETITIAN * N/A * N/A * N/A
ENTEROSTOMAL THERAPIST * N/A * N/A * N/A
MATERNAL CHILD HEALTH * N/A * N/A * N/A
MEDICAL SOCIAL WORKER * N/A * N/A * N/A
OCCUPATIONAL THERAPIST * N/A * N/A * N/A
OCCUPATIONAL THERAPIST ASSISTANT * N/A * N/A * N/A
PHLEBOTOMIST * N/A * N/A * N/A
PHOTOTHERAPY PACKAGE SERVICE * N/A * N/A * N/A
PHYSICAL THERAPIST * N/A * N/A * N/A
PHYSICAL THERAPIST ASSISTANT * N/A * N/A * N/A
PSYCHIATRIC NURSE * N/A * N/A * N/A
REHABILITATION NURSE * N/A * N/A * N/A
RESPIRATORY THERAPIST * N/A * N/A * N/A
RESPIRATORY THERAPIST - CPAP clinic * N/A * N/A * N/A
RN ASSESSMENT, INITIAL * N/A * N/A * N/A
RN SKILLED NURSING VISIT-EXTENSIVE * N/A * N/A * N/A
SPEECH THERAPIST * N/A * N/A * N/A
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICE HAS HOURLY ONLY RATES.
Notes 3, 4 and 5 apply
XXXX 0 XXXX 0 XXXX 0
------------------ ------------------ ------------------
VISIT HOUR VISIT HOUR VISIT HOUR
-------------------------------------------------------------------------------------------------------------------------------
HOMEMAKER N/A * N/A * N/A *
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICE IS PRICED ON A PER DIEM BASIS.
NOTES 3, 4 AND 5 XXXXX
XXXX 0 XXXX 0 XXXX 0
-------- -------- --------
PER DIEM PER DIEM PER DIEM
----------------------------------------------------------------------------------------
COMPANION/LIVE IN * * *
NOTES:
1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).
2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.
3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.
4. Above prices have no exclusions.
5. All services not listed above will be billed at * until rates are mutually
established and become part of the fee schedule.
6. RN High Tech Infusion visit and hourly utilization/costs to be reported
with HIT.
7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.
8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume
specialty certification which is not readily available in the home care
environment. Use requires special coordination.
* Confidential Treatment Requested
HOME INFUSION RATES
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES EXCLUDE DRUGS. DRUGS ARE
PRICED AS A PERCENTAGE DISCOUNT OFF AWP (IF APPLICABLE), AND THERE IS NO PRICE
DIFFERENCE BETWEEN PRIMARY AND MULTIPLE THERAPIES
PRIMARY OR PRIMARY OR PRIMARY OR
MULTIPLE THERAPY MULTIPLE THERAPY MULTIPLE THERAPY
PER DIEM DISPENSING FEE DRUG DISCOUNT OFF AWP
-----------------------------------------------------------------------------------------------------------------
Ancillary Drugs * *
Biological Response Modifiers * *
Cardiac (Inotropic) Therapy * *
Chelation Therapy * *
Chemotherapy * *
Enteral Therapy * N/A
Enzyme Therapy * *
Growth Hormone * *
IV Immune Globulin * *
Other Injectable Therapies * *
Other Infusion Therapies * *
Pain Management Therapy * *
Steroid Therapy * *
Thrombolytic (Anticoagulation) Therapy * *
Synagis * *
Remodulin Therapy * *
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES EXCLUDE DRUGS. DRUGS ARE
PRICED AS A PERCENTAGE DISCOUNT OFF AWP, AND THERE IS A PRICE DIFFERENCE BETWEEN
PRIMARY AND MULTIPLE ANTI-INFECTIVE THERAPIES
PER DIEM DRUG DISCOUNT OFF AWP
----------------------------------------------------------------------------------------------------------------
Anti-Infectives - Primary Anti-Infective * *
Anti-Infectives - Multiple Anti-Infective * *
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATE EXCLUDES DRUGS. DRUGS ARE
PRICED PER VIAL, AND THERE IS NO PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE
ANTI-INFECTIVE THERAPIES
PRIMARY OR
MULTIPLE THERAPY
PER DIEM COST OF DRUG
------------------------------------------------------------------------------------------------------------
Flolan Therapy *
Flolan 0.5 mg vial *
Flolan 1.5 mg vial *
Flolan diluent vial *
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES INCLUDE DRUGS, AND THERE IS NO
PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE THERAPIES
PRIMARY OR
MULTIPLE THERAPY
PER DIEM
-------------------------------------------------------------------
Enteral Therapy *
Hydration Therapy *
Total Parenteral Nutrition *
* Confidential Treatment Requested
SCHEDULE 2A, PAGE 2: HOME INFUSION HMO/FLEX FEE-FOR-SERVICE THERAPY RATES
NOTES:
1. Per Diems EXCLUDING drugs include all costs related to the therapy except
the cost of drugs, including but not limited to facility overhead,
supplies, delivery, professional labor including compounding and
monitoring, all nursing required, maintenance of specialized catheters,
equipment/patient supplies, disposables, pumps, general and administrative
expenses, etc.
2. Per Diems INCLUDING drugs include ALL costs - including but not limited to
cost of drugs, facility overhead, supplies, delivery, professional labor
including compounding and monitoring, all nursing required, maintenance of
specialized catheters, equipment/patient supplies, disposables, pumps,
general and administrative expenses, etc.
3. "DISPENSING FEE" is defined as per each time the drug is dispensed by the
home infusion provider.
4. "PER DIEM" costs are the same for primary or multiple treatments for all
drug categories, except ANTI-INFECTIVES.
5. The per diem rate shall only be charged for those days the Participant
receives medication.
6. For home infusion pharmaceuticals not listed on fee schedule, * will
apply.
7. Case Managers should utilize Enteral Therapy WITHOUT drugs as an infusion
benefit infrequently. Generally, patient's requiring Enteral Therapy
WITHOUT drugs should have services coordinated through the DME benefit.
THE FOLLOWING ARE FOR THE STATED ITEM ONLY. UNLESS OTHERWISE NOTED, NURSING,
SUPPLIES, ETC. ARE NOT INCLUDED.
Blood Transfusion per Unit (Tubing, Filters) *
Catheter Care Per Diem *
Midline Insertion (Catheter & Supplies) *
PICC Line Insertion (Catheter & Supplies) *
Blood Product *
* Confidential Treatment Requested
SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES
FACTOR CONCENTRATES
VIAL PRICE UNIT PRICE
-----------------------------------------------------------------------------------------------------------
FACTOR VII
Novoseven 1200MCG Vial *
Novoseven 4800MCG Vial *
Novoseven in 1200MCG or 4800MCG QTY *
FACTOR VIII (RECOMBINANT)
Recombinate *
Kogenate or Helixate *
Bioclate N/A
Helixate FS *
Kogenate FS *
Refacto *
Advate *
FACTOR VIII (MONOCLONAL)
Hemofil-M or A. R. C. Method M *
Monoclate P *
Monarc-M *
FACTOR VIII (OTHER)
Koate *
Humate *
Alphanate SDHT *
FACTOR IX (RECOMBINANT)
BeneFix *
FACTOR IX (MONOCLONAL/HIGH PURITY)
Mononine *
Alphanine *
FACTOR IX (OTHER)
Konyne - 80 N/A
Proplex T *
Bebulin *
Profilnine SD *
ANTI-INHIBITOR COMPLEX
Autoplex-T *
Feiba-VH *
Hyate-C *
HEMOSTATIC AGENTS
DDAVP - 10ml vial *
Stimate - 2.5xx xxxx *
Above rates include all necessary ancillary supplies and waste disposal unit;
24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation
* Confidential Treatment Requested
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
------------------------------------------------------------------------------------------------------------------------------------
A4660 DM590 2520 MONITOR, BLOOD PRESSURE (A4660) W/STETH & CUFF *
A4670 DM590 2518 MONITOR, BLOOD PRESSURE (A4670), AUTOMATIC *
A9900 A9900 7552 BREEZE (A9900) CPAP/BIPAP MASK *
A9900 A9900 7553 FULL FACE (A9900) MIRAGE CPAP/BIPAP MASK *
A9900 A9900 7554 GEL/SILICON (A9900) CPAP/BIPAP MASK INCL GLD SEAL, PHANTM, MONARCH *
A9900 A9900 7556 SPECIALTY (A9900) CPAP/BIPAP MASK (PROFILE OR SIMPICITY) *
DM590 HI531 2570 PUMP, ENTERAL (B9002) * *
B9998 DM590 6828 ENTERAL SUPPLIES (B9998) *
DM590 DM570 7551 BACK-PACK (E1399), FOR PORTABLE ENTERAL PUMP *
DM590 DM590 2522 CANNULA, NASAL *
DM590 DM590 7509 ENTERAL PUMP, PORTABLE (B9002) * *
DM590 DM590 7508 MASK, CPAP GEL OR SILICONE (K0183) *
E0100 E0100 2020 CANE (E0100), ADJ OR FIX, W/ TIP *
E0105 E0105 2021 CANE, QUAD (E0105) OR THREE PRONG, ADJ OR FIX, W/ TIPS *
E0110 E0110 2028 CRUTCHES, FOREARM (E0110), ADJ OR FIX, PAIR, W/ TIPS, GRIPS *
E0111 E0111 2023 CRUTCH FOREARM (E0111), ADJ OR FIX, EACH, W/ TIP AND GRIPS *
E0112 E0112 2027 CRUTCHES UNDERARM, WOOD (E0112), ADJ OR FIX, PAIR, COMPLETE *
E0113 E0113 2025 CRUTCH UNDERARM, WOOD (E0113), ADJ OR FIX, EACH, COMPLETE *
E0114 E0114 2026 CRUTCHES UNDERARM, ALUM (E0114), ADJ OR FIX, PAIR, COMPLETE *
E0116 E0116 2024 CRUTCH UNDERARM, ALUM (E0116), ADJ OR FIX, EACH, COMPLETE *
E0130 E0130 2037 XXXXXX, RIGID (E0130) (PICKUP), ADJ OR FIX HEIGHT *
E0135 E0135 2036 XXXXXX, FOLDING (E0135) (PICKUP), ADJ OR FIX HEIGHT *
E0141 E0141 2040 XXXXXX, WHEELED (E0141), W/OUT SEAT *
E0142 DM570 2034 RIGID XXXXXX (E0142), WHEELED, W/ SEAT, *
E0143 E0143 2029 XXXXXX FOLDING, WHEELED (E0143), W/OUT SEAT *
E0145 DM570 2039 XXXXXX (E0145), WHEELED, W/ SEAT AND CRUTCH ATTACHMENTS *
E0146 DM570 2038 XXXXXX, WHEELED, W/ SEAT (E0146) *
E0147 E0147 2030 XXXXXX HVY DUT (E0147), MULT BRAKING SYS, VAR WHEEL RESISTANCE *
E0153 E0153 2032 CRUTCH PLATFORM ATTACHMENT (E0153), FOREARM EA *
E0154 E0154 2033 XXXXXX PLATFORM ATTACHMENT (E0154), EA *
E0155 E0155 2041 XXXXXX WHEEL ATTACHMENT (E0155), RIGID (PICKUP) XXXXXX *
E0156 DM570 2035 XXXXXX SEAT ATTACHMENT (E0156) *
E0157 E0157 2022 XXXXXX, CRUTCH ATTACHMENT (E0157), EACH *
E0158 E0158 2031 XXXXXX LEG EXTENSIONS (E0158) *
E0163 E0163 2047 COMMODE CHAIR, STATIONARY (E0163), W/ FIX ARMS *
E0164 E0164 2045 COMMODE CHAIR, MOBILE (E0164), W/ FIX ARMS *
E0165 E0165 2046 COMMODE CHAIR (E0165), STATIONARY, W/ DETACH ARMS *
E0165 E0165 2591 COMMODE, XXWIDE(E0165) *
E0166 E0166 2044 COMMODE CHAIR (E0166), MOBILE, W/ DETACH ARMS *
E0167 E0167 2051 COMMODE CHAIR, PAIL OR PAN (E0167) *
E0176 E0176 2142 CUSHION (E0176) OR AIR PRESSURE PAD, NON-POSITIONING *
E0176 E0176 2394 REPLACEMENT PAD (E0176) ALTERNATING PRESS *
E0177 E0177 2224 CUSHION OR WATER PRESS PAD (E0177), NONPOSITIONING *
E0178 E0178 2160 CUSHION OR GEL PRESS PAD (E0178), NONPOSITIONING *
E0179 E0179 2154 CUSHION (E0179) OR DRY PRESSURE PAD, NONPOSTIONING *
E0180 E0180 2196 PUMP (E0180), ALTERNATING PRESSURES W/PAD * *
E0181 E0181 2197 PUMP (E0181), ALTERNATING PRESS W/PAD, HVY DUTY * *
E0184 E0184 2074 MATTRESS, DRY PRESSURE (E0184) *
E0185 E0185 2076 MATTRESS (E0185), GEL OR GEL-LIKE PRESSURE PAD *
E0186 E0186 2064 MATTRESS, AIR PRESSURE (E0186) *
E0187 E0187 2099 MATTRESS, WATER PRESSURE (E0187) *
E0188 DM570 2217 PAD, SYNTHETIC SHEEPSKIN (A9900) *
E0189 DM570 2177 PAD, LAMBSWOOL SHEEPSKIN (E0189), ANY SIZE *
E0192 E0192 2573 CUSHION, XXX FOR W/C (E0192) * *
E0192 E0192 2572 CUSHION, ROHO FOR W/C (E0192) * *
E0192 E0192 2178 W/C PAD (E0192), LOW PRESS AND POSITIONING EQUALIZATION * *
E0193 E0193 2098 MATTRESS, LOW AIR LOSS (E0193), INCL. BED * * *
E0194 DM570 2063 AIR FLUIDIZED BED (E0194) * *
E0270 E1399 6887 HOSPITAL BED INSTITUTIONAL * *
E0196 E0196 2077 MATTRESS, GEL PRESSURE (E0196) *
E0197 E0197 2065 MATTRESS, AIR PRESSURE PAD (E0197) *
E0198 E0198 2100 MATTRESS (E0198), WATER PRESSURE PAD *
E0199 E0199 2075 MATTRESS, DRY PRESSURE PAD (E0199) *
E0200 E0200 2228 HEAT LAMP (E0200), W/OUT STAND, INCL/BULB, OR INFRARED ELEMENT *
E0202 E0202 2229 PHOTOTHERAPY (BILIRUBIN) (E0202), LIGHT WIT *
E0202 E0202 2524 PHOTOTHERAPY, BILI BLANKET (E0202) *
E0205 E0205 2227 HEAT LAMP (E0205), WITH STAND, INCL/ BULB, OR INFRARED ELEMENT *
E0210 DM570 2156 HEATING PAD, STANDARD (E0210) *
E0215 DM570 2155 HEATING PAD (E0215), ELECTRIC, MOIST *
E0218 DM570 2560 COLD THERAPY UNIT (E0218) * * *
E0235 DM570 2187 PARAFFIN BATH UNIT, PORT (E0235) *
E0236 DM570 2199 PUMP (E0236) FOR WATER CIRCULATING PAD *
E0237 DM570 2223 HEAT COLD WATER (E0237) CIRCULATING PAD W/PUMP *
E0238 DM570 2179 HEATING PAD (E0238), MOIST, NON-ELECTRIC *
* Confidential Treatment Requested
7
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
------------------------------------------------------------------------------------------------------------------------------------
E0241 DM570 2867 BATH TUB RAIL (E0241), WALL, L-SHAPE *
E0241 DM570 2862 BATH TUB RAIL, WALL, 12" (E0241) *
E0241 DM570 2863 BATH TUB RAIL, WALL, 16" (E0241) *
E0241 DM570 2864 BATH TUB RAIL, WALL, 18" (E0241) *
E0241 DM570 2865 BATH TUB RAIL, WALL, 24" (E0241) *
E0241 DM570 2866 BATH TUB RAIL, WALL, 36" (E0241) *
E0241 DM570 2043 BATH TUB RAIL, WALL, UNSPECIFIED SIZE *
E0242 DM570 2042 BATH TUB RAIL, FLOOR BASE (E0242) *
E0243 DM570 2056 TOILET RAIL, EACH (E0243) *
E0244 E0244 2587 TOILET SEAT (E0244) RAISED WITH ARMS *
E0244 E0244 2052 TOILET SEAT, RAISED (E0244) *
E0245 DM570 2575 BATH BENCH WITH BACK (E0245) *
E0245 DM570 2058 BATH TUB STOOL OR BENCH (E0245) *
E0245 DM570 2578 TRANSFER BENCH, NON-PADDED (E0245) *
E0245 DM570 2577 TRANSFER BENCH, PADDED (E0245) *
E0246 DM570 2057 TRANSFER TUB RAIL(E0246), ATTACHMENT *
E0249 DM570 2186 HEAT UNIT (E0249), WATER CIRCULATING PAD *
E0255 E0255 2090 HOSP BED (E0255), VAR HEIGHT, HI-LO, W/ SIDE RAILS, W/ MATTRESS * *
E0256 E0256 2091 HOSP BED (E0256), VAR HEIGHT, HI-LO, W/ SIDE RAILS, W/O MATTRESS * *
E0260 E0260 2083 HOSP BED (E0260), SEMI-ELEC, W/ SIDE RAILS, W/ MATTRESS * *
E0261 E0261 2084 HOSP BED (E0261), SEMI-ELEC, W/ SIDE RAILS, W/OUT MATTRESS * *
E0265 E0265 2086 HOSP BED (E0265), TOTAL ELEC, W/ SIDE RAILS, W/ MATTRESS * *
E0266 E0266 2087 HOSP BED (E0266), TOTAL ELEC, W/ SIDE RAILS, W/OUT MATTRESS * *
E0271 E0271 2096 MATTRESS, INNERSPRING (E0271) *
E0272 E0272 2095 MATTRESS, FOAM RUBBER (E0272) *
E0273 DM570 2068 BED BOARD (E1399) *
E0274 DM570 2097 OVER-BED TABLE (E0274) *
E0275 E0275 2071 BED PAN, STANDARD (E0275), METAL OR PLASTIC *
E0276 E0276 2070 BED PAN, FRACTURE (E0276), METAL OR PLASTIC *
E0277 E0277 2066 MATTRESS (E0277), LOW AIR LOSS, ALT PRESSURE * * *
E0280 DM570 2069 BED CRADLE, ANY TYPE (E1399) *
E0292 E0292 2092 HOSP BED (E0292), VAR HEIGHT, HI-LO, W/OUT S/ RAILS, W/ MATTRESS * *
E0293 E0293 2093 HOSP BED (E0293), VAR HEIGHT, HI-LO, NO SIDE RAILS, NO MATTRESS * *
E0294 E0294 2085 HOSP BED (E0294), SEMI-ELEC, W/OUT SIDE RAILS, W/ MATTRESS * *
E0295 E0295 2094 HOSP BED (E0295), SEMI-ELEC, W/OUT SIDE RAILS, W/OUT MATTRESS * *
E0296 E0296 2089 HOSP BED (E0296), TOTAL ELEC, W/OUT SIDE RAILS, W/OUT MATTRESS * *
E0297 E0297 2088 HOSP BED (E0297), TOTAL ELEC, W/OUT SIDE RAILS, W/ MATTRESS * *
E0305 E0305 2073 BED SIDE RAILS (E0305), HALF LENGTH *
E0310 E0310 2072 BED SIDE RAILS (E0310), FULL LENGTH *
E0315 DM570 2067 BED ACCESSORIES: BOARDS OR TABLES, ANY TYPE *
E0325 E0325 2060 URINAL; MALE (E0325), JUG-TYPE, ANY MATERIAL *
E0326 E0326 2059 URINAL; FEMALE (E0326), JUG-TYPE, ANY MATERIAL *
E0372 E0372 7008 MATTRESS (E0372) POWERED AIR OVERLAY * *
E0410 E0444 2369 O2 CONTENTS, LIQUID (E0444), PER POUND *
E0416 E0443 2371 O2 REFILL FOR PORT (E0443) GAS SYSTEM ONLY, UP TO 23 CUBIC FEET *
E0424 E0424 2385 O2 SYS STATIONARY (E0424) COMPR GAS, RENT *
E0430 E0430 2374 O2 SYS PORT GAS, PURCH (E0430) *
E0431 E0431 2574 O2 SYS PORT GAS, LIGHTWEIGHT (E0431) W/CONSERV DEVICE, NO CONTENT * *
E0431 E0431 2375 O2 SYS PORT GAS, RENT (E0431) *
E0434 E0434 2377 O2 SYS PORT LIQUID, RENT (E0434) *
E0435 E0435 2376 O2 SYS PORT LIQUID, PURCH (E0435) *
E0439 E0439 2388 O2 SYS STATIONARY (E0439) LIQUID, RENT *
E0440 E0440 2387 O2 SYS STATIONARY (E0440) LIQUID, PURCH *
E0443 E0400 2869 O2 CONTENTS, H/K CYLINDER (E0400), 200-300 CUBIC FT *
E0444 E0444 2379 O2 CONTENTS, PORT LIQUID (E0444), PER UNIT (1 UNIT = 1 LB.) *
E0450 E0450 7555 POSITIVE PRESSURE VENTS (E0450)(E.G. T-BIRD) *
E0450 E0450 7926 POSITIVE PRESSURE VENTS, EMERGENCY BACKUP (E.G. T-BIRD)(E0450) *
E0450 E0450 2392 VENTILATOR VOLUME (E0450), STATIONARY OR PORT * *
E0450 E0450 7522 VENTILATOR, VOLUME, (E0450) EMERGENCY BACKUP UNIT * *
E0452 E0452 2332 BILEVEL INTERMITTENT (E0452) ASSIST DEVICE,(BIPAP) * *
E0453 E0453 2390 VENTILATOR THERAPEUTIC (E0453); FOR USE 12 HOURS OR LESS PER DAY * *
E0455 E0455 2372 O2 TENT (E0455), EXCLUDING CROUP OR PEDIATRIC TENTS * *
E0457 E0457 2323 CHEST SHELL (CUIRASS) (E0457) * *
E0459 E0459 2324 CHEST WRAP (E0459) * *
E0460 E0460 2339 VENTILATOR (E0460), NEGATIVE PRESSURE, PORTABLE OR STATIONARY * *
E0480 DM570 2373 PERCUSSOR (E0480), ELEC OR PNEUM, HOME MODEL * *
E0500 E0500 2333 IPPB, W/ BUILT-IN NEB (E0500) MAN OR AUTO VALVES; INT/EXT POWER * *
E0550 E0550 2328 HUMIDIFIER (E0550) DURABLE FOR EXTENSIV SUP/ HUMID W/ IPPB OR O2 * *
E0555 E0555 2330 HUMIDIFIER (E0555), DURABLE, GLASS, FOR USE W/ REG OR FLOWMETER *
E0565 E0565 2325 COMPRESSOR, AIR POWER (E0565) * *
E0570 E0570 2336 NEBULIZER, W/ COMPRESSOR (E0570) *
E0575 DM570 2571 NEBULIZER (E0575), ULTRASONIC, AC/DC * *
E0575 DM570 2338 NEBULIZER; ULTRASONIC (E0575) * *
E0585 E0585 2337 NEBULIZER(E0585), W/ COMPRESSOR AND HEATER * *
* Confidential Treatment Requested
8
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
------------------------------------------------------------------------------------------------------------------------------------
E0600 E0600 2389 SUCTION PUMP (E0600), HOME MODEL * *
E0600 E0600 7523 SUCTION UNIT, (E0600), PORTABLE AC/DC * *
E0601 E0601 2326 CONTINUOUS POSITVE (E0601) AIRWAY PRESSURE DEVICE (CPAP) * *
E0601 E0601 6965 CPAP, SELF TITRATING (E0601) * *
E0601 E0601 7935 CPAP, C-Flex * *
E0601 E0601 8363 CPAP, C Flex Pro with Compliance Monitoring * *
E0605 DM570 2391 VAPORIZER, ROOM TYPE (E0605) *
E0606 DM570 2380 POSTURAL DRAINAGE BOARD (E0606) *
E0607 E0607 6874 MONITOR, B/GLUCOSE (E0607) ACCUCHEK AD *
E0607 E0607 2164 MONITOR, BLOOD GLUCOSE (E0607) *
E0608 E0608 2322 APNEA MONITOR (E0608) * *
E0608 E0608 2576 APNEA MONITOR (E0608) W/MEM (INCL SMART) * *
E0609 E0609 2146 MONITOR, BLOOD GLUCOSE (E0609) W/SPECIAL FEATURES *
E0621 E0621 2215 PATIENT LIFT (E0621), SLING OR SEAT, CANVAS OR NYLON *
E0625 DM570 2191 PATIENT LIFT (E0625), KARTOP, BATHROOM OR TOILET *
E0627 E0627 4553 HIP CHAIR (E0627) * *
E0627 DM570 2395 SEAT LIFT CHAIR/MOTORIZED (E0627) *
E0627 DM570 2205 SEAT LIFT MECH (E0627) INCORPORATED INTO A COMB LIFT-CHAIR MECH *
E0630 E0630 2190 PATIENT LIFT, HYDRAULIC (E0630), W/ SEAT OR SLING * *
E0635 DM570 2189 PATIENT LIFT (E0635), ELEC W/ SEAT OR SLING *
E0650 E0650 2192 PNEUM COMPRESSOR (E0650), NON-SEG HOME MODEL * *
E0651 E0651 2194 PNEUM COMPRESSOR (E0651), SEG HOME MODEL W/OUT CALIB GRAD PRES * *
E0652 E0652 2193 PNEUM COMPRESSOR (E0652), SEG HOME MODEL W/ CALIB GRAD PRES * *
E0655 E0655 2182 PNEUM COMPRESSOR (E0655), NON-SEG APPLIANCE, HALF ARM *
E0660 E0660 2181 PNEUM COMPRESSOR (E0660), NON-SEG APPLIANCE, FULL LEG *
E0665 E0665 2180 PNEUM COMPRESSOR (E0665), NON-SEG APPLIANCE, FULL ARM *
E0666 E0666 2183 PNEUM COMPRESSOR (E0666), NON-SEG APPLIANCE, HALF LEG *
E0667 E0667 2210 PNEUM APPLIANCE (E0667), SEG, FULL LEG *
E0668 E0668 2209 PNEUM APPLIANCE (E0668), SEG, FULL ARM *
E0669 E0669 2212 PNEUM APPLIANCE (E0669), SEG, HALF LEG *
E0670 E0670 2211 PNEUM APPLIANCE (E0670), SEG, HALF ARM *
E0671 E0671 2207 PNEUM APPLIANCE (E0671), SEG GRAD PRESS, FULL LEG *
E0672 E0672 2206 PNEUM APPLIANCE (E0672), SEG GRAD PRESS, FULL ARM *
E0673 E0673 2208 PNEUM APPLIANCE (E0673), SEG GRAD PRESS, HALF LEG *
E0690 DM570 2221 ULTRAVIOLET CABINET (E0690), APPROPRIATE FOR HOME USE *
E0700 DM570 2204 SAFETY EQUIP (E0700) (E.G., BELT, HARNESS OR VEST) *
E0710 DM570 2202 RESTRAINTS (E0710), ANY TYPE (BODY, CHEST, WRIST OR ANKLE) *
E0720 E0720 2219 TENS (E0720), TWO LEAD, LOCALIZED STIMULATION * *
E0730 E0730 2218 TENS (E0730), FOUR LEAD, LARGER AREA/MULTIPLE NERVE STIMULATION * *
E0731 E0731 2159 TENS OR NMES (E0731), CONDUCTIVE GARMENT *
E0744 E0744 2120 STIMULATOR (E0744), NEUROMUSCULAR FOR SCOLIOSIS * *
E0745 E0745 2120 STIMULATOR (E0745), NEUROMUSCULAR, ELECTRONIC SHOCK UNIT * *
E0745 E0745 6915 STIMULATOR FOUR CH (E0745), NEUROMUSCULAR * *
E0746 DM570 2109 ELECTROMYOGRAPHY (EMG) (E0746), BIOFEEDBACK DEVICE * *
E0747 DM570 2122 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE *
E0747 DM570 8386 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, EBI *
E0747 DM570 8387 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, ORTHOFIX *
E0747 DM570 8388 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, ORTHOLOGIC *
E0748 DM570 2124 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL APPLICATIONS *
E0748 DM570 8389 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, EBI *
E0748 DM570 8390 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, ORTHOFIX *
E0748 DM570 8391 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, ORTHOLOGIC *
E0755 DM570 2157 STIMULATOR (E0755), ELECTRONIC SALIVARY REFLEX, NON INVASIVE *
E0776 E0776 2175 IV POLE (E0776) * *
E0784 E0784 2158 PUMP (E0784), EXT AMBULATORY INFUSION, MINIMED, INSULIN *
E0784 E0784 7773 PUMP (E0784), EXT AMBULATORY INFUSION, DELTEC, INSULIN *
E0784 E0784 7925 PUMP, EXT INFUSION, NON - XXXX PREMIUM, INSULIN (E0784) *
E0784 E0784 6771 PUMP (E0784), INSULIN EXT INFUSION DISETRONICS OR OTHER *
E0840 E0840 2133 TRACTION FRAME (E0840), ATTACH TO HEADBOARD, CERVICAL TRACTION *
E0850 E0850 2134 TRACTION STAND (E0850), FREE STANDING, CERVICAL TRACTION * *
E0855 E0855 7484 TRACTION (E0855), W/O FRAME OR STAND * *
E0860 E0860 2130 TRACTION EQUIP (E0860), OVERDOOR, CERVICAL *
E0870 E0870 2131 TRACTION FRAME (E0870), ATTACH TO FOOTBOARD, EXTREMITY, BUCKS * *
E0880 E0880 2135 TRACTION STAND (E0880) FREE/STAND EXTREMITY TRACTION, EG, BUCK'S * *
E0890 E0890 2132 TRACTION FRAME (E0890), ATTACH TO FOOTBOARD, PELVIC TRACTION * *
E0900 E0900 2136 TRACTION STAND (E0900) FREE/ STAND PELVIC TRACTION,(EG, BUCK'S) * *
E0910 E0910 2138 TRAPEZE BARS (E0910), A/K/A PT HELPER, ATTACH TO BED W/ GRAB BAR * *
E0920 E0920 2111 FRACTURE FRAME (E0920), ATTACH TO BED, INCLUDING WEIGHTS * *
E0935 E0935 2125 PASSIVE MOTION (E0935) EXERCISE DEVICE *
E0935 E0935 2859 PASSIVE MOTION (E0935) EXERCISE DEVICE, ANKLE *
E0935 E0935 2860 PASSIVE MOTION (E0935) EXERCISE DEVICE, ELBOW *
E0935 E0935 2857 PASSIVE MOTION (E0935) EXERCISE DEVICE, HAND *
E0935 E0935 2858 PASSIVE MOTION (E0935) EXERCISE DEVICE, SHOULDER *
E0935 E0935 2861 PASSIVE MOTION (E0935) EXERCISE DEVICE, WRIST *
* Confidential Treatment Requested
9
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
------------------------------------------------------------------------------------------------------------------------------------
E0940 E0940 2137 TRAPEZE BAR (E0940), FREE STANDING, COMPLETE W/ GRAB BAR * *
E0941 E0941 2116 TRACTION DEVICE (E0941), GRAVITY ASSISTED * *
E0942 E0942 2101 HARNESS/HALTER (E0942), CERVICAL HEAD *
E0944 E0944 2126 HARNESS (E0944), PELVIC BELT, BOOT *
E0945 DM570 2110 HARNESS (E0945), EXTREMITY BELT *
E0946 E0946 2115 FRACTURE, FRAME (E0946), DUAL W/ CROSS BARS, ATTACH TO BED * *
E0947 E0947 2113 FRACTURE FRAME (E0947), ATTACHMENTS FOR COMPLEX PELVIC TRACTION * *
E0948 E0948 2112 FRACTURE FRAME (E0948) ATTACHMENTS FOR COMPLEX CERVICAL TRACTION * *
E0950 DM570 2139 TRAY (E0950) *
E0958 E0958 2307 W/C PART ATTACHMENT (E0958) TO CONVERT ANY W/C TO ONE ARM DRIVE *
E0959 E0959 2237 W/C PART AMPUTEE ADAPTER(E0959) (COMPENSATE FOR TRANS OF WEIGHT) *
E0962 E0962 2232 CUSHION FOR WC 1" (E0962) *
E0963 E0963 2233 CUSHION FOR WC 2" (E0963) *
E0964 E0964 2234 CUSHION FOR WC 3" (E0964) *
E0965 E0965 2235 CUSHION FOR WC 4" (E0965) *
E0972 DM570 2230 TRANSFER BOARD OR DEVICE (E0972) *
E0977 E0977 2317 CUSHION, WEDGE FOR W/C (E0977) *
E0978 E0978 2248 BELT, SAFETY (E0978) W/ AIRPLANE BUCKLE, W/C *
E0979 DM570 2249 BELT, SAFETY (E0979) W/ VELCRO CLOSURE, W/C *
E0980 DM570 2292 SAFETY VEST (E0980), W/C *
E1031 E1031 2291 ROLLABOUT CHAIR (E1031), W/ CASTORS 5" OR GREATER * *
E1050 E1050 2260 W/C FULL/REC (E1050), FIX ARMS, SWING AWAY DETACH ELEV LEG RESTS * *
E1060 E1060 2259 W/C FULL/REC (E1070), DETACH ARMS, SWING AWAY DETACH FOOTREST * *
E1065 E1065 2287 W/C POWER ATTACHMENT (E1065) *
E1066 E1066 2247 BATTERY CHARGER (E1066) *
E1069 E1069 2255 BATTERY, DEEP CYCLE (E1069) *
E1070 E1070 2258 W/C FULL/REC (E1060), DETACH ARMS, SWING AWAY DET/ ELEV LEGRESTS * *
E1083 E1083 2263 W/C HEMI (E1083), FIX ARMS, SWING AWAY DETACH ABLE ELEV LEG REST * *
E1084 E1084 2262 W/C HEMI (E1084), DETACH ARMS, SWING AWAY DETACH ELEV LEG RESTS * *
E1085 E1085 2264 W/C HEMI (E1085), FIX ARMS, SWING AWAY DETACH ABLE FOOT RESTS * *
E1086 E1086 2261 W/C HEMI (E1086), DETACH ARMS, SWING AWAY DETACH FOOTRESTS * *
E1087 E1087 2265 W/C HI STRENGTH LT-WT (E1087), FIX ARMS, S/AWAY ELEV LEG RESTS * *
E1088 E1088 2268 W/C HI STRENGTH LT-WGT (E1088), D/ ARMS, S/AWAY ELEV LEG RESTS * *
E1089 E1089 2266 W/C HI STRENGTH LT-WGT (E1089), FIX ARMS, S/AWAY DETACH FOOTREST * *
E1090 E1090 2267 W/C HI STRENGTH XX-XX (E1090), DETACH ARMS, S/AWAY D/FOOT RESTS * *
E1091 E1091 2321 W/C YOUTH, ANY TYPE (E1091) * *
E1092 E1092 2319 W/C WIDE HVY DUTY (E1092), DETACH ARMS S/AWAY DETACH ELEVAT LEGS * *
E1093 E1093 2320 W/C WIDE HVY DUTY (E1093), DETACH ARMS S/AWAY DETACH FOOTRESTS * *
E1100 E1100 2296 W/C SEMI-RECLINING (E1100), SWING AWAY DETACH ELEV LEG RESTS * *
E1110 E1110 2295 W/C SEMI-RECLINING (E1110), DETACH ARMS ELEV LEG REST * *
E1130 E1130 2303 W/C STANDARD (E1130), FIX OR SWING AWAY DETACH FOOTRESTS * *
E1140 E1140 2313 W/C (E1140), DETACH ARMS SWING AWAY DETACH FOOTRESTS * *
E1150 E1150 2314 W/C (E1150), DETACH ARMS, SWING AWAY DETACH ELEVAT LEGRESTS * *
E1160 E1160 2315 W/C (E1160), W/ FIX ARMS, SWING AWAY DETACH ELEVAT LEGRESTS * *
E1160 E1160 2396 W/C (E1160), W/FIX ARMS REMOVABLE FOOTRESTS * *
E1170 E1170 2241 W/C AMPUTEE (E1170), FIX ARMS, SWING AWAY DETACH ELEV LEGRESTS * *
E1171 E1171 2242 W/C AMPUTEE (E1171), FIX ARMS, W/OUT FOOTRESTS OR LEGREST * *
E1172 E1172 2240 W/C AMPUTEE (E1172), DETACH ARMS W/OUT FOOTRESTS OR LEGREST * *
E1180 E1180 2239 W/C AMPUTEE (E1180), DETACH ARMS SWING AWAY DETACH FOOTRESTS * *
E1190 E1190 2238 W/C AMPUTEE (E1190), DETACH ARMS SWING AWAY DETACH ELEV LEGRESTS * *
E1195 E1195 2273 W/C HVY DUTY (E1195), FIX ARMS, SWING AWAY DETACH ELEV LEGRESTS * *
E1200 E1200 2243 W/C AMPUTEE (E1200), FIX FULL LENGTH ARMS, S/AWAY D/FOOTREST * *
E1210 E1210 2281 W/C MOTORIZED (E1210), FIX ARMS, S/AWAY DETACH ELEV LEG RESTS * *
E1211 E1211 2279 W/C MOTORIZED (E1211), DETACH ARMS, S/AWAY DETACH FOOT RESTS * *
E1212 E1212 2282 W/C MOTORIZED (E1212), FIX ARMS, SWING AWAY DETACH FOOT RESTS * *
E1213 E1213 2280 W/C MOTORIZED (E1213), DETACH ARMS S/AWAY, DETACH ELEV LEG REST * *
E1220 E1220 2551 W/C CUSTOM (E1220) *
E1220 E1220 2579 W/C XXWIDE (E1220) *
E1230 E1230 2288 SCOOTER (E1230), THREE OR 4 WHEEL * *
E1240 E1240 2276 W/C LT-WGT (E1240), DETACH ARMS SWING AWAY DETACH, ELEV LEGREST * *
E1250 E1250 2278 W/C LT-WGT (E1250), FIX ARMS, SWING AWAY DETACH FOOTREST * *
E1260 E1260 2275 W/C LT-WGT (E1260), DETACH ARMS SWING AWAY DETACH FOOTREST * *
E1270 E1270 2277 W/C LT-WGT (E1270), FIX ARMS, SWING AWAY DETACH ELEV LEGRESTS * *
E1280 E1280 2270 W/C HVY DUTY (E1280), DETACH ARMS ELEV LEGRESTS * *
E1285 E1285 2274 W/C HVY DUTY (E1285), FIX ARMS, SWING AWAY DETACH FOOTREST * *
E1290 E1290 2271 W/C HVY DUTY (E1290), DETACH ARMS SWING AWAY DETACH FOOTREST * *
E1295 E1295 2272 W/C HVY DUTY (E1295), FIX ARMS, ELEV LEGREST * *
E1300 DM570 2062 WHIRLPOOL (E1300), PORT (OVERTUB TYPE) *
E1310 DM570 2061 WHIRLPOOL (E1399), NON-PORT (BUILT-IN TYPE) *
E1353 E1353 2381 O2 REGULATOR (E1353) * *
E1355 E1355 2384 CYLINDER STAND/RACK (E1355) *
E1372 E1372 2331 IMMERSION EXT HEATER (E1372) FOR NEBULIZER * *
E1375 E1375 2334 NEBULIZER PORT (E1375) W/ SMALL COMPRESSOR, W/ LIMITED FLOW *
E1399 DM570 2568 ADAPTER (A9900), AC/DC *
* Confidential Treatment Requested
10
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
------------------------------------------------------------------------------------------------------------------------------------
E1399 E1399 2586 APNEA MONITOR DOWNLOAD (E1399) *
E1399 DM570 2552 BATH LIFT (E1399), CUSTOM *
E1399 DM570 2563 BED WEDGE (E1399), 12" *
E1399 DM570 2856 BEDROOM EQUIPMENT (E1399), CUSTOM *
E1399 E1399 2525 BREAST PUMP, ELECTRIC (E1399) * *
E1399 DM570 2581 BREAST PUMP, INSTITUTIONAL (E1399) *
E1399 E1399 2580 BREAST PUMP, MANUAL (E1399) *
E1399 DM570 2593 COLD THERAPY UNIT, PAD (E1399) *
E1399 E1399 2565 COMMODE (E1399), DROP ARM, HEAVY DUTY *
E1399 E1399 2582 COMPRESSION PUMP BOOT (E1399) *
E1399 E1399 2583 COMPRESSION PUMP, FOOT (E1399) *
E1399 A9900 2569 CPAP HUMIDIFIER (A9900), HEATED * *
E1399 A9900 2635 CPAP/BIPAP SUPPLIES (A9900) *
E1399 E1399 2327 DURABLE MEDICAL EQUIP (E1399), MISCELLANEOUS *
E1399 E1220 2584 XXXX CHAIR (E1399), THREE POSITION RECLINING *
E1399 DM570 6780 XXXXXX MONITOR (G0004) *
E1399 E0265 2590 HOSP BED (E1399), ELECTRIC, XLONG, W/MATTRESS & SIDE RAILS * *
E1399 E0200 2868 LAMP, ULTRAVIOLET (E1399) *
E1399 DM570 2588 MONITOR (E1399), XXXXX XXXXX *
E1399 DM570 2529 O2 ANALYZER (A9900) * *
E1399 A9900 2594 O2 CONSERVATION DEVICE (A9900) * *
E1399 DM570 6775 OXIMETRY TEST (E1399) *
E1399 DM570 2555 PATIENT LIFT, CUSTOM (E1399) *
E1399 DM570 2561 PEAK FLOW METER (E1399) *
E1399 E1399 4559 PEDIATRIC XXXXXX (E1399) *
E1399 DM570 2567 PNEUMOGRAM (E1399) *
E1399 E1399 2553 POSITIONING, CUSTOM (E1399) *
E1399 E1399 2526 PULSE OXIMETER (E1399) * *
E1399 E1399 2527 PULSE OXIMETER W/ PROBE (E1399) * *
E1399 DM570 2562 SHOWER, HAND HELD (E1399) *
E1399 DM570 2592 SLEEP STUDY, ADULT (E1399) *
E1399 DM590 7483 STIMULATOR (E1399), MUSCLE, LOW VOLTAGE OR INTERFERENTIAL * *
E1399 DM570 2855 THERAPY EQUIPMENT, CUSTOM (E1399) *
E1399 DM570 6774 THERAPY PERCUSSION, GENERATOR ONLY * *
E1399 E1399 7506 W/C, CUSTOM (E1399) MANUAL ADULT *
E1399 E1399 7504 W/C, CUSTOM (E1399) MANUAL PEDIATRIC *
E1399 E1399 7507 W/C, CUSTOM (E1399) POWER ADULT *
E1399 E1399 7505 W/C, CUSTOM (E1399) POWER PEDIATRIC *
E1399 E1399 2564 XXXXXX (E1399), HEAVY DUTY, EXTRA WIDE *
E1399 E1399 2585 XXXXXX (E1399), HEMI *
K0538 DM570 6873 WOUND SUCTION DEVICE (K0538) *
K0539 DM570 7914 DRESSING SET, FOR WOUND SUCTION DEVICE (K0539) *
K0540 DM570 7915 CANISTER SET, FOR WOUND SUCTION DEVICE (K0540) *
E1400 E1390 2361 O2 CONC (E1390), MANUF SPEC MAXFLOWRATE = 2 LTS PER MIN@85% * *
G0015 DM570 6779 CARDIAC EVENT MONITOR (G0015) *
K0163 DM590 3713 ERECTION SYSTEM, VACUUM (K0163) *
K0183 DM590 2516 CPAP MASK (K0183) *
K0184 DM590 2515 NASAL PILLOWS/SEALS (K0184) REPLACEMENT FOR NASAL APP/ DVC, PAIR *
K0185 DM590 2514 CPAP HEADGEAR (K0185) *
K0186 DM590 2513 CPAP CHIN STRAP (K0186) *
K0187 DM590 2512 CPAP TUBING (K0187) *
K0188 DM590 2511 CPAP FILTER (A9900), DISPOSABLE *
K0189 DM590 2510 CPAP FILTER (A9900), NON-DISPOSABLE *
K0268 DM590 2509 CPAP HUMIDIFIER (K0268), COOL *
K0413 DM590 6889 MATTRESS (K0413), NONPOWERED, EQUIVALENT *
E1399 E1399 7673 MATTRESS (E1399) V-CUE DYNAMIC AIR THERAPY *
A4608 A9900 7621 CATHETER TRACH (A4608) 11CM 1 SCOOP *
E1399 A9900 7664 COFFLATOR (E1399CF) MANUAL SECRETION MOBIL DEVICE *
E0168B A9900 7643 COMMODE (E0168B) HVY DUTY BEDSIDE CHAIR 000-000 XXX. *
E0168C A9900 7644 COMMODE (E0168C) HVY DUTY DROP ARM 451-850 LBS. *
A6234 HH591 7626 DRESSING <16 SQ IN (A6234) HYDROCOLLOID DRESSING, EA *
A6258 HH591 7627 DRESSING >16 SQ IN (A6258) TRANSPAREN FILM, EA *
A46203 HH591 7625 DRESSING COMPOSITE <16 SQ IN (A46203) SELF ADH, EA *
B9998B DM590 7655 ENT (B9998B) EXT SET Y SITE F/KANGAROO PUMP *
B9998C DM590 7656 ENT (B9998C) EXT SET W/ CLAMP BASIC *
B9998D DM590 7657 ENT (B9998D) XXXXXXX GASTRIC RELIEF VLV *
B9998E DM590 7658 ENT (B9998E) GASTRO EXT SET *
B9998F DM590 7659 ENT (B9998F) GASTRO TUBE ANY SIZE MIC-KEY OR HIDE A PORT *
E1399 A9900 7620 HUMID-VENT (E1399) ARTIFICIAL NOSE *
E1399 A9900 0000 XXXX (E1399) UNIV SET UP W/MANIFOLD NEBULIZER *
K0105 A9900 7639 IV POLE (K0105) ATTACH F/ W/C *
E1399 A9900 7641 MECHANICAL SCALE (E1399) PEDIATRIC/NEONATAL *
A7008 A9900 7661 NEBULIZER (A7008) KIT PREFILL W/STR H20 1L BAX *
E1399 A9900 7663 O2 CONNECTOR (E1399) XXXX/IRRIGATION NOZZLE BAX *
* Confidential Treatment Requested
11
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE JANUARY 1, 2005 - DECEMBER 31, 2005
HCPCS CHC GENTIVA PURCHASE RENTAL DAILY
CODE CODE CODE DESCRIPTION PRICE PRICE PRICE
------------------------------------------------------------------------------------------------------------------------------------
E1399 A9900 7615 O2 HUMIDIFIER (E1399) AQUA+NEONATAL EA HUD *
E1399 A9900 7623 O2 SWIVEL (E1399) ADAPTER ANGLED STERILE *
L8501 A9900 7624 SPEAKING VALVE (L8501) WHITE PAS *
A4319 HH591 7629 STERILE WATER (A4319) F/IRRIG 1L BAX *
A7001 HH591 7619 SUCTION BOTTLE (A7001) W/LID & TUBING *
E1399 A9900 7616 SUCTION FILTER (E1399) BACTERIA *
A6265 HH591 7628 TAPE ALL TYPES (A6265) EXCLUDING MICROFOAM, PER 18 SQ INCHES *
A4481 A9900 7622 TRACH FILTER (A4481) BACTERIA ELECTROSTATIC *
A4623 A9900 7618 TRACH INNER (A4623) CANNULA *
A4621 A9900 7617 TRACH TUBE MASK (A4621) COLLAR OR HOLDER *
A7010 A9900 7662 TUBING (A7010) AEROSOL CORRUGATED PER FOOT *
E1399 A9900 7631 VENT ADAPTER (E1399) MDI HUD *
A9900 A9900 7630 VENT BATTERY CHARGER (A9900) 12V GEL *
E1399 A9900 7632 VENT CONNECTOR (E1399) PED OR ADULT OMNIFLEX DISP *
E1399 A9900 7633 VENT FILTER (E1399) HYGROBAC S ELECTOSTATIC MAL *
E1399 A9900 7634 VENT THERMOMETER (E1399) W/ ADAPTER *
K0108 A9900 7638 W/C BRAKE EXTENSION (K0108) TIP BLK 10/PK *
E1399 A9900 7635 XXXXXX BASKET (E1399) VINYL COATED *
E0159 A9900 7640 XXXXXX BRAKE (E0159) ATTACHMENT *
E0148 A9900 7636 XXXXXX HVY DUTY (E0148) FOLDING X-WIDE *
E0149 A9900 7637 XXXXXX HVY DUTY (E0149) W/ WHEELS *
E1399 A9900 7645 CPAP (E1399) DC BATTERY ADAPTER CABLE *
E1399 A9900 7646 CPAP (E1399) EXHALATION PORT DISP *
E1399 A9900 7647 CPAP (E1399) FUSE KIT INTERNATIONAL A/C *
E1399 A9900 7648 CPAP (E1399) HUMIDIFIER CHAMBER KIT DISP *
E1399 A9900 7649 CPAP (E1399) HUMIDIFIER CHAMBER REUSABLE *
E1399 A9900 7650 CPAP (E1399) HUMIDIFIER MOUNTING TRAY *
E1399 A9900 7651 CPAP (E1399) INVERTOR AC/DC *
E1399 A9900 7652 CPAP (E1399) POWER CORD F/ARIA-SYNC *
E1399 A9900 7653 CPAP (E1399) SHELL W/O PRESSURE TAP *
A9900 DM590 7566 CPAP CALIBRATION SHELL (A9900) *
A9900 DM590 7565 CPAP SHORT TUBING (A9900) *
E0601 E0601 7690 VENT, CONTINUOUS POSITIVE (E0500) AIRWAY PRESSURE DEVICE N/A *
E0452 E0452 7691 VENT, BILEVEL INTERMITTENT (E0500) ASSIST DEVICE (BIPAP) N/A *
E0747 DM570 6875 STIMULATOR, OSTEOGENIC, ULTRASOUND *
A9900 A9900 7695 GEL/SILICON GOLD SEAL CPAP/BIPAP MASK (A9900) *
A9900 A9900 7701 VENT THERAPEUTIC ST BIPAP W/ BACKUP RATE (K0533) N/A *
A9900 A9900 7703 O2 SYS HELIOS PORT LIQUID, RENT (E1399) *
HH591 HH591 7704 PUMP, EXT INFUSION, XXXX DIABECARE, INSULIN (E0784) *
E0784 E0784 7731 PUMP, EXT INFUSION, ANIMAS, INSULIN (E0784) *
A9900 A9900 7737 CPAP DREAM SEAL INTERFACE FOR USE WITH BREEZE MASK (A9900) *
DM590 DM590 7738 CPAP CHIN STRAP DELUXE (K0186) *
E1340 E1340 7768 W/C REPAIRS - CUSTOM (E1340) *
The following may be charged under extraordinary circumstances:
E1399 E1399 4551 LABOR/SERVICE/SHIPPING CHARGES *
E1399 E1399 2731 SHIPPING AND HANDLING FEES *
The following may be charged if over and above routine on rental equipment:
E1350 E1350 2382 REPAIR OR NON-ROUTINE (E1350) SERVICE REQUIRING SKILL OF A TECH *
E1340 E1340 2554 W/C REPAIRS - STANDARD (E1340) *
E1399 E1399 4552 MISCELLANEOUS SUPPLIES * *
E1399 E1399 2589 REPAIR (E1399), RESPIRATORY EQUIPMENT *
E1399 E1399 4561 RESPIRATORY SUPPLIES (A4618) * *
E1399 E1399 4549 TENS/APNEA SUPPLIES * *
NOTES:
1. Whether rental or purchase, rates include all shipping, labor and set-up.
2. If item is rented, rates include all supplies to enable the equipment to
function effectively, with the exception of supplies for CPAP, BIPAP,
Ventilators, Suction, Enteral Pumps and CPM. Such exception supplies will
be billed at *.
3. If item is rented, rates include repair and maintenance costs.
4. If item is purchased, supplies, repair and maintenance will be billed at
*.
5. All equipment not listed above will be billed at * until rates are
mutually established and become part of the fee schedule.
6. Rates effective through 12/31/2005.
7. CPAPs - A new model will be implemented which emphasizes a personal
delivery system without an RT on-site
There will be an additional charge should an additional clinic or home
visit be required
Clinic Model - *
Home RT Model - *
* Confidential Treatment Requested
12
