2021 Jurisdiction List

NOTE: Deleted codes are valid for dates of service on or before the date of deletion.

NOTE: Updated codes are in bold.

NOTE: The jurisdiction list includes codes that are not payable by Medicare. Please consult the Medicare contractor in whose jurisdiction a claim would be filed in order to determine coverage under Medicare.

NOTE: All Local Carrier language has been changed to Part B MAC

SEARCH TIP: Enter only the first two or three digits of the HCPCS code in the search box to display range of codes, then scroll down page to find specific code.

 
HCPCS DESCRIPTION JURISDICTION COMMENT
A4206 - A4209 Medical, Surgical, and Self-Administered Injection Supplies Part B MAC if incident to a physician's service (not separately payable). If other, DME MAC.  
A4210 Needle Free Injection Device DME MAC  
A4211 Medical, Surgical, and Self-Administered Injection Supplies Part B MAC if incident to a physician's service (not separately payable). If other, DME MAC.  
A4213 - A4215 Medical, Surgical, and Self-Administered Injection Supplies Part B MAC if incident to a physician's service (not separately payable). If other, DME MAC.  
A4216 - A4218 Saline Part B MAC if incident to a physician's service (not separately payable). If other, DME MAC.  
A4221 - A4236 Self-Administered Injection and Diabetic Supplies DME MAC  
A4244 - A4250 Medical, Surgical, and Self-Administered Injection Supplies Part B MAC if incident to a physician's service (not separately payable). If other, DME MAC.  
A4252 - A4259 Diabetic Supplies DME MAC  
A4265 Paraffin Part B MAC if incident to a physician's service (not separately payable). If other, DME MAC.  
A4280 Accessory for Breast Prosthesis DME MAC  
A4281 - A4286 Accessory for Breast Pump DME MAC  
A4305 - A4306 Disposable Drug Delivery System Part B MAC if incident to a physician's service (not separately payable). If other, DME MAC.  
A4310 - A4358 Incontinence Supplies/Urinary Supplies If provided in the physician's office for a temporary condition, the item is incident to the physician's service & billed to the Part B MAC. If provided in the physician's office or other place of service for a permanent condition, the item is a prosthetic device & billed to the DME MAC.  
A4360 - A4435 Urinary Supplies If provided in the physician's office for a temporary condition, the item is incident to the physician's service & billed to the Part B MAC. If provided in the physician's office or other place of service for a permanent condition, the item is a prosthetic device & billed to the DME MAC.  
A4450 - A4452 Tape; Adhesive Remover Part B MAC if incident to a physician's service (not separately payable), or if supply for implanted prosthetic device. If other, DME MAC.  
A4453 Enema Catheter DME MAC *** Effective 10/1/21
A4455 - A4456 Tape; Adhesive Remover Part B MAC if incident to a physician's service (not separately payable), or if supply for implanted prosthetic device. If other, DME MAC.  
A4458 - A4459 Enema Bag/System DME MAC  
A4461 - A4463 Surgical Dressing Holders Part B MAC if incident to a physician's service (not separately payable). If other, DME MAC.  
A4465 - A4467 Non-elastic Binder and Garment, Strap, Covering DME MAC  
A4481 Tracheostomy Supply Part B MAC if incident to a physician's service (not separately payable). If other, DME MAC.  
A4483 Moisture Exchanger DME MAC  
A4490 - A4510 Surgical Stockings DME MAC  
A4520 Diapers DME MAC  
A4553 - A4554 Underpads DME MAC  
A4555 - A4558 Electrodes; Lead Wires; Con-ductive Paste Part B MAC if incident to a physician's service (not separately payable). If other, DME MAC.  
A4559 Coupling Gel Part B MAC if incident to a physician's service (not separately payable). If other, DME MAC.  
A4575 Topical Hyperbaric Oxygen Chamber, Disposable DME MAC  
A4595 TENS Supplies Part B MAC if incident to a physician's service (not separately payable). If other, DME MAC.  
A4600 Sleeve for Intermittent Limb Compression Device DME MAC  
A4601 - A4602 Lithium Replacement Batteries DME MAC  
A4604 Tubing for Positive Airway Pressure Device DME MAC  
A4605 Tracheal Suction Catheter DME MAC  
A4606 Oxygen Probe for Oximeter DME MAC  
A4608 Transtracheal Oxygen Catheter DME MAC  
A4611 - A4613 Oxygen Equipment Batteries and Supplies DME MAC  
A4614 Peak Flow Rate Meter Part B MAC if incident to a physician's service (not separately payable). If other, DME MAC.  
A4615 - A4629 Oxygen & Tracheostomy Supplies Part B MAC if incident to a physician's service (not separately payable). If other, DME MAC.  
A4630 - A4640 DME Supplies DME MAC  
A4649 Miscellaneous Surgical Supplies Part B MAC if incident to a physician's service (not separately payable), or if supply for implanted prosthetic device or implanted DME. If other, DME MAC.  
A4651 - A4932 Supplies for ESRD DME MAC (not separately payable)  
A5051 - A5093 Additional Ostomy Supplies If provided in the physician's office for a temporary condition, the item is incident to the physician's service & billed to the Part B MAC. If provided in the physician's office or other place of service for a permanent condition, the item is a prosthetic device & billed to the DME MAC.  
A5102 - A5200 Additional Incontinence and Ostomy Supplies If provided in the physician's office for a temporary condition, the item is incident to the physician's service & billed to the Part B MAC. If provided in the physician's office or other place of service for a permanent condition, the item is a prosthetic device & billed to the DME MAC.  
A5500 - A5514 Therapeutic Shoes DME MAC  
A6000 Non-Contact Wound Warming Cover DME MAC  
A6010 - A6024 Surgical Dressing Part B MAC if incident to a physician's service (not separately payable) or if supply for implanted prosthetic device or implanted DME. If other, DME MAC.  
A6025 Silicone Gel Sheet Part B MAC if incident to a physician's service (not separately payable) or if supply for implanted prosthetic device or implanted DME. If other, DME MAC.  
A6154 - A6411 Surgical Dressing Part B MAC if incident to a physician's service (not separately payable) or if supply for implanted prosthetic device or implanted DME. If other, DME MAC.  
A6412 Eye Patch Part B MAC if incident to a physician's service (not separately payable) or if supply for implanted prosthetic device or implanted DME. If other, DME MAC.  
A6413 Adhesive Bandage Part B MAC if incident to a physician's service (not separately payable) or if supply for implanted prosthetic device or implanted DME. If other, DME MAC.  
A6441 - A6457 Surgical Dressings Part B MAC if incident to a physician's service (not separately payable), or if supply for implanted prosthetic device or implanted DME. If other, DME MAC.  
A6501 - A6512 Surgical Dressing Part B MAC if incident to a physician's service (not separately payable) or if supply for implanted prosthetic device or implanted DME. If other, DME MAC  
A6513 Compression Burn Mask DME MAC  
A6530 - A6549 Compression Gradient Stockings DME MAC  
A6550 Supplies for Negative Pressure Wound Therapy Electrical Pump DME MAC  
A7000 - A7002 Accessories for Suction Pumps DME MAC  
A7003 - A7039 Accessories for Nebulizers, Aspirators and Ventilators DME MAC  
A7044 - A7047 Respiratory Accessories DME MAC  
A7501 - A7527 Tracheostomy Supplies DME MAC  
A8000 - A8004 Protective Helmets DME MAC  
A9270 Noncovered Items or Services DME MAC  
A9272 Disposable Wound Suction Pump DME MAC  
A9273 Hot Water Bottles, Ice Caps or Collars, and Heat and/or Cold Wraps DME MAC  
A9274 - A9278 Glucose Monitoring DME MAC  
A9279 Monitoring Feature/Device DME MAC  
A9280 Alarm Device DME MAC  
A9281 Reaching/Grabbing Device DME MAC  
A9282 Wig DME MAC  
A9283 Foot Off Loading Device DME MAC  
A9284 - A9286 Non-electric Spirometer, Inversion Devices and Hygienic Items DME MAC  
A9300 Exercise Equipment DME MAC  
A9900 Miscellaneous DME Supply or Accessory Part B MAC if used with implanted DME. If other, DME MAC.  
A9901 Delivery DME MAC  
A9999 Miscellaneous DME Supply or Accessory Part B MAC if used with implanted DME. If other, DME MAC.  
B4034 - B9999 Enteral and Parenteral Therapy DME MAC  
E0100 - E0105 Canes DME MAC  
E0110 - E0118 Crutches DME MAC  
E0130 - E0159 Walkers DME MAC  
E0160 - E0175 Commodes DME MAC  
E0181 - E0199 Decubitus Care Equipment DME MAC  
E0200 - E0239 Heat/Cold Applications DME MAC  
E0240 - E0248 Bath and Toilet Aids DME MAC  
E0249 Pad for Heating Unit DME MAC  
E0250 - E0304 Hospital Beds DME MAC  
E0305 - E0326 Hospital Bed Accessories DME MAC  
E0328 - E0329 Pediatric Hospital Beds DME MAC  
E0350 - E0352 Electronic Bowel Irrigation System DME MAC  
E0370 Heel Pad DME MAC  
E0371 - E0373 Decubitus Care Equipment DME MAC  
E0424 - E0484 Oxygen and Related Respiratory Equipment DME MAC  
E0485 - E0486 Oral Device to Reduce Airway Collapsibility DME MAC  
E0487 Electric Spirometer DME MAC  
E0500 IPPB Machine DME MAC  
E0550 - E0585 Compressors/Nebulizers DME MAC  
E0600 Suction Pump DME MAC  
E0601 CPAP Device DME MAC  
E0602 - E0604 Breast Pump DME MAC  
E0605 Vaporizer DME MAC  
E0606 Drainage Board DME MAC  
E0607 Home Blood Glucose Monitor DME MAC  
E0610 - E0615 Pacemaker Monitor DME MAC  
E0617 External Defibrillator DME MAC  
E0618 - E0619 Apnea Monitor DME MAC  
E0620 Skin Piercing Device DME MAC  
E0621 - E0636 Patient Lifts DME MAC  
E0637 - E0642 Standing Devices/Lifts DME MAC  
E0650 - E0676 Pneumatic Compressor and Appliances DME MAC  
E0691 - E0694 Ultraviolet Light Therapy Systems DME MAC  
E0700 Safety Equipment DME MAC  
E0705 Transfer Board DME MAC  
E0710 Restraints DME MAC  
E0720 - E0745 Electrical Nerve Stimulators DME MAC  
E0747 - E0748 Osteogenic Stimulators DME MAC  
E0755 - E0770 Stimulation Devices DME MAC  
E0776 IV Pole DME MAC  
E0779 - E0780 External Infusion Pumps DME MAC  
E0781 Ambulatory Infusion Pump DME MAC  
E0784 Infusion Pumps, Insulin DME MAC  
E0791 Parenteral Infusion Pump DME MAC  
E0830 Ambulatory Traction Device DME MAC  
E0840 - E0900 Traction Equipment DME MAC  
E0910 - E0930 Trapeze/Fracture Frame DME MAC  
E0935 - E0936 Passive Motion Exercise Device DME MAC  
E0940 Trapeze Equipment DME MAC  
E0941 Traction Equipment DME MAC  
E0942 - E0945 Orthopedic Devices DME MAC  
E0946 - E0948 Fracture Frame DME MAC  
E0950 - E1298 Wheelchairs DME MAC  
E1300 - E1310 Whirlpool Equipment DME MAC  
E1352 - E1392 Additional Oxygen Related Equipment DME MAC  
E1399 Miscellaneous DME Part B MAC if implanted DME. If other, DME MAC.  
E1405 - E1406 Additional Oxygen Equipment DME MAC  
E1500 - E1699 Artificial Kidney Machines and Accessories DME MAC (not separately payable)  
E1700 - E1702 TMJ Device and Supplies DME MAC  
E1800 - E1841 Dynamic Flexion Devices DME MAC  
E1902 Communication Board DME MAC  
E2000 Gastric Suction Pump DME MAC  
E2100 - E2101 Blood Glucose Monitors with Special Features DME MAC  
E2120 Pulse Generator for Tympanic Treatment of Inner Ear DME MAC  
E2201 - E2398 Wheelchair Accessories DME MAC  
E2402 Negative Pressure Wound Therapy Pump DME MAC  
E2500 - E2599 Speech Generating Device DME MAC  
E2601 - E2633 Wheelchair Cushions and Accessories DME MAC  
E8000 - E8002 Gait Trainers DME MAC  
G0333 Dispensing Fee DME MAC  
J0120 - J1094 Injection Part B MAC if incident to a physician's service or used in an implanted infusion pump. If other, DME MAC.  
J1100 - J2786 Injection Part B MAC if incident to a physician's service or used in an implanted infusion pump. If other, DME MAC.  
J2788 - J3570 Injection Part B MAC if incident to a physician's service or used in an implanted infusion pump. If other, DME MAC.  
J7030 - J7131 Miscellaneous Drugs and Solutions Part B MAC if incident to a physician's service or used in an implanted infusion pump. If other, DME MAC.  
J7340 Carbidopa/Levodopa Part B MAC if incident to a physician's service or used in an implanted infusion pump. If other, DME MAC.  
J7500 - J7599 Immunosuppressive Drugs Part B MAC if incident to a physician's service or used in an implanted infusion pump. If other, DME MAC.  
J7604 - J7699 Inhalation Solutions Part B MAC if incident to a physician's service. If other, DME MAC.  
J7799 - J7999 NOC Drugs, Other than Inhalation Drugs Part B MAC if incident to a physician's service or used in an implanted infusion pump. If other, DME MAC.  
J8498 Anti-emetic Drug DME MAC  
J8499 Prescription Drug, Oral, Non Chemotherapeutic Part B MAC if incident to a physician's service. If other, DME MAC.  
J8501 - J8999 Oral Anti-Cancer Drugs DME MAC  
J9000 - J9999 Chemotherapy Drugs Part B MAC if incident to a physician's service or used in an implanted infusion pump. If other, DME MAC.  
K0001 - K0108 Wheelchairs DME MAC  
K0195 Elevating Leg Rests DME MAC  
K0455 Infusion Pump used for Uninterrupted Administration of Epoprostenal DME MAC  
K0462 Loaner Equipment DME MAC  
K0552 - K0605 External Infusion Pump Supplies & Continuous Glucose Monitor DME MAC  
K0606 - K0609 Defibrillator Accessories DME MAC  
K0669 Wheelchair Cushion DME MAC  
K0672 Soft Interface for Orthosis DME MAC  
K0730 Inhalation Drug Delivery System DME MAC  
K0733 Power Wheelchair Accessory DME MAC  
K0738 Oxygen Equipment DME MAC  
K0739 Repair or Nonroutine Service for DME Part B MAC if implanted DME. If other, DME MAC  
K0740 Repair or Nonroutine Service for Oxygen Equipment DME MAC  
K0743 - K0746 Suction Pump and Dressings DME MAC  
K0800 - K0899 Power Mobility Devices DME MAC  
K0900 Custom DME, other than Wheelchair DME MAC  
K1001 - K1004 Devices DME MAC when the supplier considers the item DMEPOS. Part B MAC if the supplier considers the item something other than DMEPOS (e.g., supplies furnished incident to the professional service of a physician)  
K1005 Device Accessory DME MAC when the supplier considers the item DMEPOS. Part B MAC if the supplier considers the item something other than DMEPOS (e.g., supplies furnished incident to the professional service of a physician)  
K1006 - K1012 Devices DME MAC when the supplier considers the item DMEPOS. Part B MAC if the supplier considers the item something other than DMEPOS (e.g., supplies furnished incident to the professional service of a physician)  
K1013 - K1020 Devices DME MAC when the supplier considers the item DMEPOS. Part B MAC if the supplier considers the item something other than DMEPOS (e.g., supplies furnished incident to the professional service of a physician)  
K1021 Accessory DME MAC *** Effective 10/1/2021
K1022 - K1027 Devices DME MAC when the supplier considers the item DMEPOS. Part B MAC if the supplier considers the item something other than DMEPOS (e.g., supplies furnished incident to the professional service of a physician) *** Effective 10/1/2021
L0112 - L4631 Orthotics & Devices DME MAC  
L5000 - L5999 Lower Limb Prosthetics DME MAC  
L6000 - L7499 Upper Limb Prosthetics DME MAC  
L7510 - L7520 Repair of Prosthetic Device Part B MAC if repair of implanted prosthetic device. If other, DME MAC.  
L7600 - L8485 Prosthetics DME MAC  
L8499 Unlisted Procedure for Miscellaneous Prosthetic Services Part B MAC if implanted prosthetic device. If other, DME MAC.  
L8500 - L8501 Artificial Larynx; Tracheostomy Speaking Valve DME MAC  
L8505 Artificial Larynx Accessory DME MAC  
L8507 Voice Prosthesis, Patient Inserted DME MAC  
L8509 Voice Prosthesis, Inserted by a Licensed Health Care Provider Part B MAC for dates of service on or after 10/01/2010. DME MAC for dates of service prior to 10/01/2010  
L8510 Voice Prosthesis DME MAC  
L8511 - L8515 Voice Prosthesis Part B MAC if used with tracheoesophageal voice prostheses inserted by a licensed health care provider. If other, DME MAC  
L8701 - L8702 Assist Device DME MAC  
L9900 Miscellaneous Orthotic or Prosthetic Component or Accessory Part B MAC if used with implanted prosthetic device. If other, DME MAC.  
Q0144 Azithromycin Dihydrate Part B MAC if incident to a physician's service. If other, DME MAC.  
Q0161 - Q0181 Anti-emetic DME MAC  
Q0510 - Q0514 Drug Dispensing Fees DME MAC  
Q2049 - Q2050 Doxorubicin Part B MAC if incident to a physician's service or used in an implanted infusion pump. If other, DME MAC.  
Q2052 IVIG Demonstration DME MAC  
Q4074 Inhalation Drug Part B MAC if incident to a physician's service. If other, DME MAC.  
Q5101 - Q5121 Injection Part B MAC if incident to a physician's service or used in an implanted infusion pump. If other, DME MAC.  
Q9991 - Q9992 Injection Part B MAC if incident to a physician's service or used in an implanted infusion pump. If other, DME MAC.  
V2020 - V2025 Frames DME MAC  
V2100 - V2513 Lenses DME MAC  
V2520 - V2523 Hydrophilic Contact Lenses Part B MAC if incident to a physician's service. If other, DME MAC.  
V2524 Device DME MAC when the supplier considers the item DMEPOS. Part B MAC if the supplier considers the item something other than DMEPOS (e.g., supplies furnished incident to the professional service of a physician)  
V2530 - V2531 Contact Lenses, Scleral DME MAC  
V2599 Contact Lens, Other Type Part B MAC if incident to a physician's service. If other, DME MAC.  
V2600 - V2615 Low Vision Aids DME MAC  
V2623 - V2629 Prosthetic Eyes DME MAC  
V2700 - V2780 Miscellaneous Vision Service DME MAC  
V2781 Progressive Lens DME MAC  
V2782 - V2784 Lenses DME MAC  
V2786 Lens DME MAC  
V2797 Vision Supply DME MAC  
V2799 Miscellaneous Vision Service Part B MAC if supply for an implanted prosthetic device. If other, DME MAC  
V5336 Repair/Modification of Augmentative Communicative System or Device DME MAC  

 

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