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,
- Use TOS L when the drug is used related to ESRD; or
- Use TOS 1 when the drug is not related to ESRD and is administered in the office.
HCPCS codes | ||
| Code | Description | |
|---|---|---|
| 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 | |
| E1629 | Tablo hemodialysis system for the billable dialysis service | |
| 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 | Fecal microbiota, live - jslm, 1 ml | |
| 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 (fulphila), biosimilar, 0.5 mg | |
| Q5109 | Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg | |
| Q5110 | Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram | |
| Q5111 | Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 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 (ziextenzo), biosimilar, 0.5 mg | |
| Q5121 | Injection, infliximab-axxq, biosimilar, (avsola), 10 mg | |
| Q5122 | Injection, pegfilgrastim-apgf (nyvepria), biosimilar, 0.5 mg | |
| Q5123 | Injection, rituximab-arrx, biosimilar, (riabni), 10 mg | |
| Q5124 | Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1 mg | |
| Q5125 | Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram | |
| Q5126 | Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg | |
| Q5127 | Injection, pegfilgrastim-fpgk (stimufend), biosimilar, 0.5 mg | |
| Q5128 | Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mg | |
| Q5129 | Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg | |
| Q5130 | Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg | |
| Q5131 | Injection, adalimumab-aacf (idacio), biosimilar, 20 mg | |
| Q5132 | Injection, adalimumab-afzb (abrilada), biosimilar, 10 mg | |
| Q5133 | Injection, tocilizumab-bavi (tofidence), biosimilar, 1 mg | |
| Q5134 | Injection, natalizumab-sztn (tyruko), biosimilar, 1 mg | |
| Q5135 | Injection, tocilizumab-aazg (tyenne), biosimilar, 1 mg | |
| Q5136 | Injection, denosumab-bbdz (jubbonti/wyost), biosimilar, 1 mg | |
| Q5137 | Injection, ustekinumab-auub (wezlana), biosimilar, subcutaneous, 1 mg | |
| Q5138 | Injection, ustekinumab-auub (wezlana), biosimilar, intravenous, 1 mg | |
| Q9004 | Department of veterans affairs whole health partner services | |
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