Type of Service (TOS) Indicator L: ESRD Supplies

Special Considerations/Exceptions
For injection codes with more than one possible TOS designation, use the following guidelines when assigning the TOS:
When the choice is L or 1,

HCPCS codes

CodeDescription
A4215  Needle, sterile, any size, each  
A4216  Sterile water, saline and/or dextrose, diluent/flush, 10 ml  
A4217  Sterile water/saline, 500 ml  
A4218  Sterile saline or water, metered dose dispenser, 10 ml  
A4244  Alcohol or peroxide, per pint  
A4245  Alcohol wipes, per box  
A4246  Betadine or phisohex solution, per pint  
A4247  Betadine or iodine swabs/wipes, per box  
A4248  Chlorhexidine containing antiseptic, 1 ml  
A4450  Tape, non-waterproof, per 18 square inches  
A4452  Tape, waterproof, per 18 square inches  
A4651  Calibrated microcapillary tube, each  
A4652  Microcapillary tube sealant  
A4653  Peritoneal dialysis catheter anchoring device, belt, each  
A4656  NEEDLE, ANY SIZE, EACH  
A4657  Syringe, with or without needle, each  
A4660  Sphygmomanometer/blood pressure apparatus with cuff and stethoscope  
A4663  Blood pressure cuff only  
A4670  Automatic blood pressure monitor  
A4671  Disposable cycler set used with cycler dialysis machine, each  
A4672  Drainage extension line, sterile, for dialysis, each  
A4673  Extension line with easy lock connectors, used with dialysis  
A4674  Chemicals/antiseptics solution used to clean/sterilize dialysis equipment, per 8 oz  
A4680  Activated carbon filter for hemodialysis, each  
A4690  Dialyzer (artificial kidneys), all types, all sizes, for hemodialysis, each  
A4706  Bicarbonate concentrate, solution, for hemodialysis, per gallon  
A4707  Bicarbonate concentrate, powder, for hemodialysis, per packet  
A4708  Acetate concentrate solution, for hemodialysis, per gallon  
A4709  Acid concentrate, solution, for hemodialysis, per gallon  
A4714  Treated water (deionized, distilled, or reverse osmosis) for peritoneal dialysis, per gallon  
A4719  "y set" tubing for peritoneal dialysis  
A4720  Dialysate solution, any concentration of dextrose, fluid volume greater than 249 cc, but less than or equal to 999 cc, for peritoneal dialysis  
A4721  Dialysate solution, any concentration of dextrose, fluid volume greater than 999 cc but less than or equal to 1999 cc, for peritoneal dialysis  
A4722  Dialysate solution, any concentration of dextrose, fluid volume greater than 1999 cc but less than or equal to 2999 cc, for peritoneal dialysis  
A4723  Dialysate solution, any concentration of dextrose, fluid volume greater than 2999 cc but less than or equal to 3999 cc, for peritoneal dialysis  
A4724  Dialysate solution, any concentration of dextrose, fluid volume greater than 3999 cc but less than or equal to 4999 cc, for peritoneal dialysis  
A4725  Dialysate solution, any concentration of dextrose, fluid volume greater than 4999 cc but less than or equal to 5999 cc, for peritoneal dialysis  
A4726  Dialysate solution, any concentration of dextrose, fluid volume greater than 5999 cc, for peritoneal dialysis  
A4728  Dialysate solution, non-dextrose containing, 500 ml  
A4730  Fistula cannulation set for hemodialysis, each  
A4736  Topical anesthetic, for dialysis, per gram  
A4737  Injectable anesthetic, for dialysis, per 10 ml  
A4740  Shunt accessory, for hemodialysis, any type, each  
A4750  Blood tubing, arterial or venous, for hemodialysis, each  
A4755  Blood tubing, arterial and venous combined, for hemodialysis, each  
A4760  Dialysate solution test kit, for peritoneal dialysis, any type, each  
A4765  Dialysate concentrate, powder, additive for peritoneal dialysis, per packet  
A4766  Dialysate concentrate, solution, additive for peritoneal dialysis, per 10 ml  
A4770  Blood collection tube, vacuum, for dialysis, per 50  
A4771  Serum clotting time tube, for dialysis, per 50  
A4772  Blood glucose test strips, for dialysis, per 50  
A4773  Occult blood test strips, for dialysis, per 50  
A4774  Ammonia test strips, for dialysis, per 50  
A4802  Protamine sulfate, for hemodialysis, per 50 mg  
A4860  Disposable catheter tips for peritoneal dialysis, per 10  
A4870  Plumbing and/or electrical work for home hemodialysis equipment  
A4890  Contracts, repair and maintenance, for hemodialysis equipment  
A4911  Drain bag/bottle, for dialysis, each  
A4913  Miscellaneous dialysis supplies, not otherwise specified  
A4918  Venous pressure clamp, for hemodialysis, each  
A4927  Gloves, non-sterile, per 100  
A4928  Surgical mask, per 20  
A4929  Tourniquet for dialysis, each  
A4930  Gloves, sterile, per pair  
A4931  Oral thermometer, reusable, any type, each  
A6215  Foam dressing, wound filler, sterile, per gram  
A6216  Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing  
A6250  Skin sealants, protectants, moisturizers, ointments, any type, any size  
A6260  Wound cleansers, any type, any size  
A6402  Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing  
E0210  Electric heat pad, standard  
E1500  Centrifuge, for dialysis  
E1510  Kidney, dialysate delivery syst kidney machine, pump recirculating, air removal syst, flowrate meter, power off, heater and temperature control with alarm, i.v. poles, pressure gauge, concentrate container  
E1520  Heparin infusion pump for hemodialysis  
E1530  Air bubble detector for hemodialysis, each, replacement  
E1540  Pressure alarm for hemodialysis, each, replacement  
E1550  Bath conductivity meter for hemodialysis, each  
E1560  Blood leak detector for hemodialysis, each, replacement  
E1570  Adjustable chair, for esrd patients  
E1575  Transducer protectors/fluid barriers, for hemodialysis, any size, per 10  
E1580  Unipuncture control system for hemodialysis  
E1590  Hemodialysis machine  
E1592  Automatic intermittent peritoneal dialysis system  
E1594  Cycler dialysis machine for peritoneal dialysis  
E1600  Delivery and/or installation charges for hemodialysis equipment  
E1610  Reverse osmosis water purification system, for hemodialysis  
E1615  Deionizer water purification system, for hemodialysis  
E1620  Blood pump for hemodialysis, replacement  
E1625  Water softening system, for hemodialysis  
E1630  Reciprocating peritoneal dialysis system  
E1632  Wearable artificial kidney, each  
E1634  Peritoneal dialysis clamps, each  
E1635  Compact (portable) travel hemodialyzer system  
E1636  Sorbent cartridges, for hemodialysis, per 10  
E1637  Hemostats, each  
E1639  Scale, each  
E1699  Dialysis equipment, not otherwise specified  
J0881  Injection, darbepoetin alfa, 1 microgram (non-esrd use)  
J0882  Injection, darbepoetin alfa, 1 microgram (for esrd on dialysis)  
J0886  Injection, epoetin alfa, 1000 units (for esrd on dialysis)  
J1440  Injection, filgrastim (g-csf), 300 mcg  
J1644  Injection, heparin sodium, per 1000 units  
Q0137  INJECTION, DARBEPOETIN ALFA, 1 MCG (NON-ESRD USE)  
Q4054  INJECTION, DARBEPOETIN ALFA, 1 MCG (FOR ESRD ON DIALYSIS)  
Q4055  INJECTION, EPOETIN ALFA, 1000 UNITS (FOR ESRD ON DIALYSIS)  
Q4081  Injection, epoetin alfa, 100 units (for esrd on dialysis)  
Q4082  Drug or biological, not otherwise classified, part b drug competitive acquisition program (cap)  
Q5001  Hospice or home health care provided in patient's home/residence  
Q5002  Hospice or home health care provided in assisted living facility  
Q5003  Hospice care provided in nursing long term care facility (ltc) or non-skilled nursing facility (nf)  
Q5004  Hospice care provided in skilled nursing facility (snf)  
Q5005  Hospice care provided in inpatient hospital  
Q5006  Hospice care provided in inpatient hospice facility  
Q5007  Hospice care provided in long term care facility  
Q5008  Hospice care provided in inpatient psychiatric facility  
Q5009  Hospice or home health care provided in place not otherwise specified (nos)  
Q5010  Hospice home care provided in a hospice facility  
Q5101  Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram  
Q5102  Injection, infliximab, biosimilar, 10 mg  
Q5103  Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg  
Q5104  Injection, infliximab-abda, biosimilar, (renflexis), 10 mg  
Q5105  Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units  
Q5106  Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units  
Q5107  Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg  
Q5108  Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg  
Q5109  Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg  
Q5110  Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram  
Q5111  Injection, pegfilgrastim-cbqv, biosimilar, (udenyca), 0.5 mg  
Q5112  Injection, trastuzumab-dttb, biosimilar, (ontruzant), 10 mg  
Q5113  Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mg  
Q5114  Injection, trastuzumab-dkst, biosimilar, (ogivri), 10 mg  
Q5115  Injection, rituximab-abbs, biosimilar, (truxima), 10 mg  
Q5116  Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg  
Q5117  Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg  
Q5118  Injection, bevacizumab-bvzr, biosimilar, (zirabev), 10 mg  
Q5119  Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg  
Q5120  Injection, pegfilgrastim-bmez, biosimilar, (ziextenzo), 0.5 mg  
Q5121  Injection, infliximab-axxq, biosimilar, (avsola), 10 mg  
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