Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.07-063 - Prosthetics Provider Manual Update Transmittal #94

Current through Register Vol. 49, No. 6, June, 2024
Section II
Prosthetics
242.111
Initial Rental of a DME Item for Individuals of All Ages 10-1-07
Procedure codes found in this section must be billed either
				electronically or on paper with modifier
KH
to indicate an initial
				rental of an item. Modifiers are indicated below with the headings of M1 and
				M2.
Procedure codes shown in the list below are either covered for
				all ages (AA), for only individuals under age 21 (U21) or for only individuals
				age 21 and over (21+). A column in the list below defines the
				differences.
* Prior authorization is not required when other insurance pays
				at least 50% of the
Medicaid maximum allowable reimbursement amount.
***
(...) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
Initial Rental of a DME Item for Individuals of All Ages
				(section 242.111)
Procedure Code
M1
M2
Description
All
U21
21+
A7034*
***(CPAP Device Nasal Continuous Positive Airway
						  Pressure (CPAP) Device; includes necessary accessory items.
NOTE: For
						  21+, complete medical data pertinent to the request must be submitted with the
						  prior authorization request.
Nasal interface (mask or cannula type) used
						  with positive airway pressure device, with or without head strap
AA
E0181
Pressure pad, alternating with pump, heavy duty
U21
E0200
Heat lamp, without stand (table model), includes bulb,
						  or infrared element
U21
E0205
Heat lamp, with stand includes bulb, or infrared
						  element
U21
E0217
Water circulating heat pad with pump
U21
E0225
Hydrocollator unit, includes pad
U21
E0236
Pump for water circulating pad
U21
E0239
Hydrocollator unit, portable
U21
E0250*
Hospital bed, fixed height, with any type side rails,
						  with mattress
AA
E0255*
Hospital bed, variable height; hi-lo, with any type
						  side rails, with mattress
U21
E0255
KH
Hospital bed, variable height; hi-lo, with any type
						  side rails, with mattress
21+
E0260*
Hospital bed, semi-electric (head and foot adjustment),
						  with any type side rails with mattress
U21
E0260*
KH
Hospital bed, semi-electric (head and foot adjustment),
						  with any type side rails with mattress
21+
E0271
Mattress, inner spring
U21
E0272
Mattress, foam rubber
U21
E0303
Hospital bed, heavy duty, extra wide, with weight
						  capacity [GREATER THAN] 350 but [LESS THAN] or = 600, any type side rails,
						  w/mattress
AA
E0424
Stationary compressed gaseous oxygen system, rental;
						  includes container, contents, regulator flowmeter, humidifier, nebulizer
						  cannula or mask, and tubing
AA
E0430*
Portable gaseous oxygen system, purchase, includes
						  regulator, flowmeter, humidifier, cannula, or mask, and tubing
AA
E0435*
Portable liquid oxygen system, purchase; includes
						  portable container, supply reservoir, flowmeter, humidifier, contents gauge,
						  cannula or mask, tubing and refill adapter
AA
E0439
Stationary liquid oxygen system, rental; includes
						  container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or
						  mask, and tubing
AA
E0445*
Oximeter for measuring blood oxygen levels
						  non-invasively.
***
(Pulse oximeter, including 4 disposable
						  probes)
AA
E0480
Percussor, electric or pneumatic, home model
U21
E0565*
Compressor, air power source for equipment which is not
						  self-contained or cylinder driven
U21
E05754
Nebulizer, ultrasonic, large volume
AA
E0585
Nebulizer, with compressor and heater
U21
E0600
Respiratory suction pump, home model, portable or
						  stationary, electric
AA
E0606
Vaporizer, room type
U21
E06304
Patient lift, hydraulic, with seat or sling
U21
E0630
KH
Patient lift, hydraulic, with seat or sling
21+
E0650*
Pneumatic compressor, nonsegmental home model
U21
E0667*
Segmental pneumatic appliance for use with pneumatic
						  compressor, full leg
U21
E0668*
Segmental pneumatic appliance for use with pneumatic
						  compressor, full arm
U21
E0691
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; treatment area two square feet or
						  less
U21
E0692
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; four foot panel
U21
E0693
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; six foot panel
U21
E0694
Ultraviolet multidirectional light therapy system in
						  six foot cabinet includes bulbs/lamps, timer and eye protection
U21
E0720*
TENS, two lead, localized stimulation
U21
E0730*
Transcutaneous electrical nerve stimulation device four
						  or more leads, for multiple nerve stimulation
AA
E0745*
Neuromuscular stimulator, electronic shock unit
U21
E0779*
***(Ambulatory infusion device, payable only when
						  services are provided to patients receiving chemotherapy, pain management or
						  antibiotic treatment in the home) Ambulatory infusion device pump, mechanical,
						  reusable, for infusion 8 hours or greater
AA
E0910
Trapeze bars, also known as Patient Helper, attached to
						  bed, with grab bar
AA
E0920
Fracture frame, attached to bed, includes
						  weights
U21
E0930
Fracture frame, freestanding, includes weights
U21
E09354
Passive motion exercise device
U21
E0940
Trapeze bar, freestanding, complete with grab
						  bar
U21
E0941
Gravity assisted traction device, any type
U21
E1130*
Standard wheelchair, fixed full-length arms, fixed or
						  swing-away, detachable footrests
U21
E11304
KH
Standard wheelchair, fixed full-length arms, fixed or
						  swing-away, detachable footrests
21+
E1224*
Wheelchair with detachable arms, elevating
						  legrests
AA
E1390
Oxygen concentrator, single delivery port, capable of
						  delivering 85% or greater oxygen concentration at the prescribed flow
						  rate
AA
Providers will be reimbursed for a minimum of 30 days of rental
				when the equipment is used less than 30 days. Initial rental codes must be
				billed when equipment is used less than 30 days during the first month of
				rental.
Arkansas Medicaid will only reimburse for one initial minimum
				30 days of rental per state fiscal year period per beneficiary per procedure
				code. The provider will not be reimbursed for the same procedure code utilizing
				another modifier for the same time period.
242.150
Nutritional Formulae for Child
			 Health Services (EPSDT) 10-1-07
Beneficiaries Under 21 Years of Age
The coverage listed is payable only if the service is
				prescribed as a result of a Child Health Services (EPSDT)
				screening/referral.
NOTE: The Women, Infant and Children program (WIC) must
				be accessed first for children from birth through five years of
				age.
Procedure codes found in this section must be billed either
				electronically or on paper with modifier
EP
for beneficiaries
				under 21 years of age. Modifier "
BO
" is used to bill for oral
				usage. When a second or third modifier is listed, that modifier must be used in
				conjunction with
EP
.
Modifiers in this section are indicated by the headings M1, M2
				and M3.
Nutritional Formulae for Child Health Services (EPSDT)
				Beneficiaries Under 21 Years of Age (section 242.150)
Procedure Code
M1
M2
M3
Description
Covered Formulae
B4149 B4149
EP EP
BO
Enteral formula, blenderized natural foods with intact
						  nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may
						  include fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
Compleat
B4150 B4150
EP EP
BO
Enteral formula, nutritionally complete with intact
						  nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may
						  include fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
See list below
Covered Formulae:
Boost
Fibersource HN
Nutren 1.0 with Fiber
Boost with
Benefib
er and
FOS
Fortison
Osmolite
Carnation In
stant B
reakfa
st -
Intraolite
Osmolite 1.0 CAL
Lactose F
ree
Isocal
Osmolite HN
Ensure
Isocal HN
Portagen
Ensure Fibe
r with F
OS
IsoSource
Probalance
Ensure Hig
h Protei
n
IsoSource HN
Promote
Ensure HN
Jevity 1.0 CAL
Promote with Fiber
Ensure Pow
der
Nutrapack
Ultracal
Fibersource
Nutren 1.0
B4150
EP
U1
BO
Enteral formula, nutritionally complete with intact
						  nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may
						  include fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
Boost Pudding Ensure Pudding
B4152 B4152
EP EP
BO
Enteral formula, nutritionally complete, calorically
						  dense (equal to or greater than 1.5 Kcal/ml), with intact nutrients, includes
						  proteins, fats, carbohydrates, vitamins and minerals, may include fiber,
						  administered through an enteral feeding tube, 100 calories = 1 unit
Boost Plus
Carnation Instant Breakfast Lactose Free Plus Comply
						  Ensure Plus Novasource 2.0 Nutren 1.5 Nutren 2.0 Osmolite 1.5 Cal Scandishake
						  Two-Cal HN
B4153 B4153
EP EP
BO
Enteral formula, nutritionally complete, hydrolyzed
						  proteins (amino acids and peptide chain), includes fats, carbohydrates,
						  vitamins and minerals, may include fiber, administered through an enteral
						  feeding tube, 100 calories = 1 unit
Alitraq
Criticare HN
Isotein HN
Peptamen
Peptamen 1.5
Peptamen VHP
Peptamen with Prebio 1
Perative
Tolerex
Vital HN
Vivonex Plus
Vivonex TEN
B4154 B4154
EP EP
BO
Enteral formula, nutritionally complete, for special
						  metabolic needs, includes inherited disease of metabolism, includes altered
						  composition of proteins, fats, carbohydrates, vitamins and/or minerals, may
						  include fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
See list below
Covered formulae:
Advera
Impact with Fiber
Pulmocare
AminAid
IsoSource VHN
Resource Diabetic
Boost Diabeti
c
Ketocal
Respalor
Forta Drink
Lipisorb
Similac 60/40
Glucerna
Lofenalac
Suplena
Glytrol
Nepro
Traumacal
Hepatic Aid
NutriHep
Trumaid Powder
Impact
Protain XL
B4155 B4155
EP EP
BO
Enteral formula, nutritionally incomplete/modular
						  nutrients, includes specific nutrients, carbohydrates (e.g., glucose
Casec Powder Fructose Powder MCT Oil Polycose
						  Liquid
Bill on paper (Indicate specific name of formula on
						  claims.)
polymers), proteins/amino acids (e.g., glutamine,
						  arganine), fat (e.g., medium chain triglycerides) or combination, administered
						  through an enteral feeding tube, 100 calories = 1 unit
Procel Protein Power
Provimin
Sumacal
B4155 B4155
EP EP
U1 U1
BO
Enteral formula, nutritionally incomplete/modular
						  nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers),
						  proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain
						  triglycerides) or combination, administered through an enteral feeding tube,
						  100 calories = 1 unit
Polycose Powder
Dextrose
Scandical
B4155 B4155
EP EP
U2 U2
BO
Enteral formula, nutritionally incomplete/modular
						  nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers),
						  proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain
						  triglycerides) or combination, administered through an enteral feeding tube,
						  100 calories = 1 unit
Microlipids
B4155 B4155
EP EP
U3 U3
BO
Enteral formula, nutritionally incomplete/modular
						  nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers),
						  proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain
						  triglycerides) or combination, administered through an enteral feeding tube,
						  100 calories = 1 unit
Product 80056
PKU 1, 2 and 3
RCF
Try 1 and 2
B4158 B4158
EP EP
BO
Enteral formula, for pediatrics, nutritionally complete
						  with intact nutrients, includes proteins, fats, carbohydrates, vitamins and
						  minerals, may include fiber and/or iron, administered through an enteral
						  feeding tube, 100 calories = 1 unit
Enfamil
Enfamil AR Lipil Enfamil Lactofree Enfamil Lactofree
						  Lipil Enfamil Lipil Low Iron Enfamil Lipil with Iron Enfamil Next Step Lipil
						  Nutren Jr.
Nutren JF with Fiber Resource for Kids Resource Just
						  for Kids with Fiber
B4159 B4159
EP EP
BO
Enteral formula, for pediatrics, nutritionally complete
						  soy base with intact nutrients, includes proteins, fats, carbohydrates,
						  vitamins and minerals, may include fiber and/or iron, administered through an
						  enteral feeding tube, 100 calories = 1 unit
Enfamil Next Step
Prosobee Lipil
Enfamil Prosobee Lipil Isomil Isomil Advance Soy
						  with
Iron Prosobee
B4160 B4160
EP EP
BO
Enteral formula, for pediatrics, nutritionally
						  calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients,
						  includes proteins, fats, carbohydrates, vitamins and minerals, may include
						  fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
Enfamil Enfacare Lipil
Powder Kindercal
Kindercal with Fiber Pediasure Pediasure with
						  Fiber
B4160 B4160
EP EP
U1 U1
BO
Enteral formula, for pediatrics, nutritionally
						  calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients,
						  includes proteins, fats, carbohydrates, vitamins and minerals, may include
						  fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
Enfamil Premature Lipil
24 Cal Low Iron Enfamil Premature Lipil
24 Cal with Iron Similac Neosure Similac Neosure
						  Advance Special Care Advance 20 Special Care Advance 20
with Iron Special Care Advance 24 Special Care Advance
						  24
with Iron
B4161 B4161
EP EP
BO
Enteral formula, for pediatrics, hydrolyzed/amino acids
						  and peptide chain proteins, includes fats, carbohydrates, vitamins and
						  minerals, may include fiber, administered through an enteral feeding tube, 100
						  calories = 1 unit
Alimentum
ELECARE
Enfamil Nutramigen Lipil
Enfamil Pregestimil
Neocate Infant Formula
Neocate Jr
Neocate One + (Pediatric
E028) Liquid Neocate One + Powder Nutramigen Peptamen
						  Jr Pregestimil Similac Alimentum
Advance with Iron Vivonex Pediatric
B4162 B4162
EP EP
BO
Enteral formula, for pediatrics, special metabolic
						  needs for inherited disease of metabolism, includes fats, carbohydrates,
						  vitamins and minerals, may include fiber, administered through an enteral
						  feeding tube, 100 calories = 1 unit
See list below
Covered Formulae:
Calcilo XD
Low Phe Try Diet Powder
Periflex Advanced
Cyclinex-1
Maxamaid MSUD
Periflex Infant
Cyclinex-2
Maxamum MSUD
Periflex Junior
Hominex-1
MSUD Analog
Phenex-1
Hominex-2
MSUD 1 and 2
Phenex-2
I-Valex-1
Phenyl Free 1
I-Valex-2
Phenyl Free 2
Ketonex-1
Propimex-1
Ketonex-2
Propimex-2 XLys, XTrp Maxamaid Xphe Maxamaid XPhe, XTyr
						  Maxamaid Xphe Maxamum XPhe, XTyr Analog
B4162 B4162
EP EP
U1 U1
BO
Enteral formula, for pediatrics, special metabolic
						  needs for inherited disease of metabolism, includes fats, carbohydrates,
						  vitamins and minerals, may include fiber, administered through an enteral
						  feeding tube, 100 calories = 1 unit
XMTVI Maximaid
One unit of service equals 100 calories with a reimbursable
				maximum of 30 units per day. Supplies furnished by prosthetics providers in
				conjunction with the nutritional formula must be billed to Medicaid with the
				prosthetics medical supply codes. These formulae are covered as nutritional
				supplements rather than as the sole source of nutrition.
NOTE: Beneficiaries who require enteral nutrition as the
				sole source of nutrition with the formulae being administered through a
				nasogastric, jejunostomy or gastrostomy tube should be referred to a
				hyperalimentation provider enrolled in the Medicaid Program.
Each claim should reflect a "from" and "through" date of
				service. The claims must not be filed until after the "through" date has
				elapsed. Claims may be submitted on either a weekly or a monthly basis. Units
				may not be rounded up. Providers must bill a date span according to the
				prescribed daily volume.
NOTE: If a specific formula is not listed but is
				prescribed as the result of the EPSDT
screening of an Arkansas Medicaid beneficiary, the
				provider may forward a copy of the screening and prescription, along with
				product information, to Utilization Review for consideration.
View
				or print the Utilization Review Section contact
				information
.
242.160
Durable Medical Equipment, All
			 Ages 10-1-07
Procedure codes found in this section must be billed either
				electronically or on paper with modifier
EP
for beneficiaries
				under 21 years of age or modifier
NU
for beneficiaries age 21 and
				older. When a second modifier is listed, that modifier must be used in
				conjunction with either
EP
or
NU
. Modifier
UE
is required when billing for used equipment.
Modifiers in this section are indicated by the headings M1 and
				M2. Prior authorization requirements are shown under the heading PA. If prior
				authorization is needed, that information is indicated with a "Y" in the
				column; if not, an "N" is shown.
* The purchase of wheelchairs for individuals age 21 and older
				is limited to one per five-year period.
*** This procedure code may not be billed for used
				equipment.
* Prior authorization is not required when other insurance pays
				at least 50% of the Medicaid maximum allowable reimbursement amount.
***
(...) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
Durable Medical Equipment, All Ages (section
				242.160)
Procedure Code
M1
M2
M3
PA
Description
Payment Method
A4635
NU EP UE
N
Underarm pad, crutch, replacement, each
Purchase
A4636
N
Replacement, handgrip, cane, crutch, or walker,
						  each
Purchase
A4637
N
Replacement, tip, cane, crutch, walker, each
Purchase
E0100
N
Cane, includes canes of all materials, adjustable or
						  fixed, with tip
Purchase
E0105
N
Cane, quad or three-prong, includes canes of all
						  materials, adjustable or fixed, with tips
Purchase
E0110
N
Crutches, forearm, includes crutches of various
						  materials, adjustable or fixed, pair, complete with tips and handgrips
Purchase
E0111
NU EP UE
U1
N
Crutch, forearm, includes crutches of various
						  materials, adjustable or fixed, each, with tip and handgrip
Purchase
E0112
NU EP UE
N
Crutches, underarm, wood, adjustable or fixed, pair,
						  with pads, tips and handgrips
Purchase
E0113
NU EP UE
N
Crutch, underarm, wood, adjustable or fixed, each, with
						  pad, tip and handgrip
Purchase
E0114
N
Crutches, underarm, other than wood, adjustable or
						  fixed, pair, with pads, tips and handgrips
Purchase
E0116
N
Crutch, underarm, other than wood, adjustable or fixed,
						  each, with pad, tip and handgrip
Purchase
E0130
N
Walker, rigid (pickup), adjustable or fixed
						  height
Purchase
E0135
N
Walker, folding (pickup), adjustable or fixed
						  height
Purchase
E0140
NU EP
N
Walker, w/trunk support, adjustable or fixed height,
						  any type
Purchase
E0141
N
Walker, rigid, wheeled, adjustable or fixed
						  height
Purchase
E0143
N
Walker, folding, wheeled, adjustable or fixed
						  height
Purchase
E0147
N
Walker, heavy duty, multiple braking system, variable
						  wheel resistance
Purchase
E0153
N
Platform attachment, forearm crutch, each
Purchase
E0154
N
Platform attachment, walker, each
Purchase
E0155
N
Wheel attachment, rigid pick-up walker, per pair seat
						  attachment, walker
Purchase
E0156
NU EP
N
Seat attachment, walker
Purchase
E0157
N
Crutch attachment, walker, each
Purchase
E0158
NU EP UE
N
Leg extensions for walker, per set of four (4)
Purchase
E0159
NU EP
N
Brake attachment for wheeled walker, replacement,
						  each
Purchase
E0160
N
Sitz type bath or equipment, portable, used with or
						  without commode
Purchase
E0161
N
Sitz type bath or equipment, portable, used with or
						  without commode, with faucet attachment(s)
Purchase
E0163
N
Commode chair, stationary, with fixed arms
Purchase
E0167
N
Pail or pan for use with commode chair
Purchase
E0175
N
Foot rest, for use with commode chair, each
Purchase
E0181
N
Pressure pad, alternating with pump, heavy duty
Capped Rental
E0182
NU EP UE
U1
N
Pump for alternating pressure pad
Purchase
E0184
N
Dry pressure mattress
Purchase
E0185
N
Gel or gel-like pressure pad for mattress, standard
						  mattress length and width
Purchase
E0186
NU EP
Y
Air pressure mattress
Purchase
E0187
NU EP
Y
Water pressure mattress
Purchase
E0189
N
Lambswool sheepskin pad, any size
Purchase
E0190
NU UE
N
Positioning cushion/pillow/wedge, any shape or
						  size
Purchase
E0190
EP
N
Positioning cushion/pillow/wedge, any shape or size
***
(Tumble Form Therapy Roll 4")
Purchase
E0190
EP
U1
N
Positioning cushion/pillow/wedge, any shape or size
***
(Tumble Form Therapy Roll 6")
Purchase
E0190
EP
U2
N
Positioning cushion/pillow/wedge, any shape or size
***
(Tumble Form Therapy Wedge 4"
Purchase
E0190
EP
U3
N
Positioning cushion/pillow/wedge, any shape or size
***
(Tumble Form Therapy Roll 8")
Purchase
E0190
EP
U4
N
Positioning cushion/pillow/wedge, any shape or size
***
(Tumble Form Therapy Wedge 6")
Purchase
E0190
EP
U5
N
Positioning cushion/pillow/wedge, any shape or size
***
(Floor Sitter Wedge 4")
Purchase
E0190
EP
U6
N
Positioning cushion/pillow/wedge, any shape or size
***
(Tumble Form Therapy Roll 12")
Purchase
E0190
EP
U7
N
Positioning cushion/pillow/wedge, any shape or size
***
(Deluxe Wedge with strap 4")
Purchase
E0190
EP
U8
N
Positioning cushion/pillow/wedge, any shape or size
***
(Deluxe Wedge with strap 6")
Purchase
E0190
EP
U9
N
Positioning cushion/pillow/wedge, any shape or size
***
(Tumble Form Therapy Wedge 10")
Purchase
E0190
EP
KA
U1
N
Positioning cushion/pillow/wedge, any shape or size
***
(Tumble Form Therapy Roll 14")
Purchase
E0190
EP
KA
U2
N
Positioning cushion/pillow/wedge, any shape or size
***
(Tumble Form Therapy Roll 16")
Purchase
E0190
EP
KA
U3
N
Positioning cushion/pillow/wedge, any shape or size
***
(Tumble Form Therapy Wedge 8")
Purchase
E0191
NU EP UE
N
Heel or elbow protector, each
Purchase
E0196
NU EP
N
Gel pressure mattress
Purchase
E0197
NU EP UE
N
Air pressure pad for mattress, standard mattress length
						  and width
Purchase
E0198
NU EP
Y
Water pressure pad for mattress, standard mattress
						  length and width
Purchase
E0200
NU EP UE
N
Heat lamp, without stand (table model), includes bulb,
						  or infrared element
Capped Rental
E0202
NU EP UE
N
Phototherapy (bilirubin) light with photometer
Rental Only
E0205
NU EP UE
N
Heat lamp, with stand includes bulb, or infrared
						  element
Capped Rental
E0217
NU EP UE
N
Water circulating heat pad with pump
Capped Rental
E0225
NU EP UE
N
Hydrocollator unit, includes pad
Capped Rental
E0235
NU EP UE
N
Paraffin bath unit, portable (see medical supply code
						  A4265 for paraffin)
Purchase
E0236
NU EP UE
N
Pump for water circulating pad
Capped Rental
E0238
NU EP UE
N
Nonelectric heat pad, moist
Purchase
E0239
NU EP UE
N
Hydrocollator unit, portable
Capped Rental
E0240
NU EP NU EP NU EP NU EP
U1 U1 U2 U2 U3 U3
N
Bath/shower chair w/wo wheels, any size
Purchase
E0244
NU EP
Y
Raised toilet seat
Purchase
E0245***
NU EP
U1 U1
N
***(Bath Frame Support, Large) Tub stool or
						  bench
Purchase
E0247
NU EP NU EP
U1 U1
N
Transfer bench, tub/toilet, w/wo commode opening
Purchase
E0248
NU EP NU EP
U1 U1
N
Transfer bench, heavy duty, tub/toilet w/wo commode
						  opening
Purchase
E0249
NU EP UE
N
Pad for water circulating heat unit
Purchase
E0250
UE
Y*
Hospital bed, fixed height, with any type side rails,
						  with mattress
Capped Rental
E0250
NU EP
Y*
***(Hospital bed, with side rails, fixed height, with
						  mattress, purchase) Hospital bed, fixed height, with any type side rails, with
						  mattress
Purchase
E0255
UE
Y*
Hospital bed, variable height; hi-lo, with any type
						  side rails, with mattress
Capped Rental
E0255
NU EP
U1
Y*
***(Hospital bed, with side rails, variable height;
						  hi-lo, with mattress, purchase) Hospital bed, variable height; hi-lo, with any
						  type side rails, with mattress
Purchase
E0260
NU EP UE
R R R R
Y*
Hospital bed, semi-electric, head and foot adjustment,
						  with any type side rails with mattress
Capped Rental
E0260
NU EP
Y*
***(Hospital bed, with side rails, semi-electric, head
						  and foot adjustments, with mattress, purchase) Hospital bed, semi-electric,
						  head and foot adjustment, with any type side rails with mattress
Purchase
E0271
NU EP UE
N
Mattress, inner spring
Capped Rental
E0272
NU EP UE
N
Mattress, foam rubber
Capped Rental
E0273
NU EP UE
N
Bed board
Purchase
E0275
NU EP UE
N
Bed pan, standard, metal or plastic
Purchase
E0276
NU EP UE
N
Bed pan, fracture, metal or plastic
Purchase
E0280
NU EP UE
N
Bed cradle, any type
Purchase
E0300
EP EP
R R
Y Y
Pediatric crib, hospital grade, fully enclosed
Purchase
Rental Only
E0303
NU EP UE
Y Y Y
Hospital bed, heavy duty, extra wide, with weight
						  capacity [GREATER THAN] 350 but [LESS THAN] or = 600, any type side rails,
						  w/mattress
Rental Only (Rent to Purchase)
E0325
NU NU EP UE
U1
N
Urinal; male, jug-type, any material
Purchase
E0326
NU EP UE
N
Urinal; female, jug-type, any material
Purchase
E0445***
NU EP
Y*
***(Pulse oximeter, including 4 disposable probes)
						  Oximeter for measuring blood oxygen levels noninvasively
Rental Only
E0480
NU EP UE
N
Percussor, electric or pneumatic, home model
Capped Rental
E0565
NU EP UE
Y*
Compressor, air power source for equipment which is not
						  self-contained or cylinder driven
Capped Rental
E0570
NU EP UE
Y
Nebulizer, with compressor
Purchase
E0585
NU EP UE
N
Nebulizer, with compressor and heater
Capped Rental
E0605
NU EP UE
N
Vaporizer, room type
Purchase
E0606
NU EP UE
N
Postural drainage board
Capped Rental
E0607***
NU EP
N
Home blood glucose monitor
Purchase
E0621
NU
N
Sling or seat, patient lift, canvas or nylon
Purchase
E0630
NU EP UE
Y*
Patient lift, hydraulic, with seat or sling
Capped Rental
E0650
NU EP UE
Y*
Pneumatic compressor, nonsegmental home model
Capped Rental
E0667
NU EP UE
Y*
Segmental pneumatic appliance for use with pneumatic
						  compressor, full leg
Capped Rental
E0668
NU EP UE
Y*
Segmental pneumatic appliance for use with pneumatic
						  compressor, full arm
Capped Rental
E0691
NU EP UE
N
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; treatment area two square feet or
						  less
Rental Only
E0692
NU EP
N
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; four foot panel
Rental Only
E0693
NU EP
N
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; six foot panel
Rental Only
E0694
NU EP
N
Ultraviolet multidirectional light therapy system in
						  six foot cabinet includes bulbs/lamps, timer and eye protection
Rental Only
E0720
NU EP UE
Y*
TENS, two lead, localized stimulation
Capped Rental
E0730
NU EP UE
Y
*
Transcutaneous electrical nerve stimulation device four
						  or more leads, for multiple nerve stimulation
Capped Rental
E0740
NU EP UE
N
Incontinence treatment system, pelvic floor stimulator,
						  monitor, sensor and/or trainer
Purchase
E0745
NU EP UE
Y*
Neuromuscular stimulator, electronic shock unit
Capped Rental
E0747
NU EP UE
Y*
Osteogenesis stimulator, electrical noninvasive, other
						  than spinal applications
Purchase
E0748
NU EP
N
Osteogenesis stimulator, electrical noninvasive, spinal
						  applications
Purchase
E0760
NU EP
Y
Osteogenesis stimulator, low intensity ultrasound,
						  noninvasive
Rental Only
E0779
NU
Y*
***(Ambulatory infusion device, payable only when
						  services are provided to patients receiving chemotherapy, pain management or
						  antibiotic treatment in the home) Ambulatory infusion pump, mechanical,
						  reusable, for infusion 8 hours or greater
Rental Only
E0840
NU EP UE
N
Traction frame, attached to headboard, cervical
						  traction
Purchase
E0850
NU EP UE
N
Traction stand, freestanding, cervical traction
Purchase
E0860
NU EP UE
N
Traction equipment, overdoor, cervical
Purchase
E0870
NU EP UE
N
Traction frame, attached to footboard, extremity
						  traction (e.g., Buck's)
Purchase
E0880
NU EP UE
N
Traction stand, freestanding, extremity traction (e.g.,
						  Buck's)
Purchase
E0890
NU EP UE
N
Traction frame, attached to footboard, pelvic
						  traction
Purchase
E0900
NU EP UE
N
Traction stand, freestanding, pelvic traction (e.g.,
						  Buck's)
Purchase
E0910
NU EP UE
N
Trapeze bars, also known as Patient Helper, attached to
						  bed, with grab bar
Capped Rental
E0920
NU EP UE
N
Fracture frame, attached to bed, includes
						  weights
Capped Rental
E0930
NU EP UE
N
Fracture frame, freestanding, includes weights
Capped Rental
E0935
NU EP UE
Y*
Continuous passive motion exercise device for use on
						  knee only
Capped Rental
E0936
NU EP
Y*
Continuous passive motion exercise device for use other
						  than knee
Manually Priced
E0940
NU EP UE
N
Trapeze bar, freestanding, complete with grab
						  bar
Capped Rental
E0941
NU EP UE
N
Gravity assisted traction device, any type
Capped Rental
E0942
NU EP UE
N
Cervical head harness/halter
Purchase
E0944
NU EP UE
N
Pelvic belt/harness/boot
Purchase
E0945
NU EP UE
N
Extremity belt/harness
Purchase
E0946
NU EP UE
N
Fracture frame, dual with cross bars, attached to bed
						  (e.g., Balken, Four Poster)
Purchase
E0947
NU EP UE
N
Fracture frame, attachments for complex pelvic
						  traction
Purchase
E0948
NU EP UE
N
Fracture frame, attachments for complex cervical
						  traction
Purchase
E0950
NU EP UE
N
Wheelchair accessory, tray, each
Purchase
E1130*
NU EP UE
Y*
Standard wheelchair, fixed full-length arms, fixed or
						  swing-away, detachable footrests
Capped Rental
E1140*
NU EP UE
Y*
Wheelchair, detachable arms, desk or full-length,
						  swing-away, detachable footrests
Capped Rental
E1150*
NU EP UE
Y*
Wheelchair; detachable arms, desk or full-length,
						  swing-away, detachable, elevating legrests
Capped Rental
E1160*
NU EP UE
Y*
Wheelchair; fixed full-length arms, swing-away,
						  detachable, elevating legrests
Capped Rental
E1224*
NU EP UE
Y*
Wheelchair with detachable arms, elevating leg
						  rests
Capped Rental
E1340
NU
N
***(DME Repairs/Parts Only Repairs will not be approved
						  for more than the allowed purchase price of new equipment.
The
						  manufacturer's invoice must be attached to the repair claim for all
						  parts.
) Repair or nonroutine service for durable medical equipment
						  requiring the skill of a technician, labor component, per 15 minutes
Manually Priced
E1340***
NU EP
U1 U1
N
***(Labor Only; a maximum of twenty [20] units [20
						  units = 5 hours of labor] per date of service is allowable.) Repair or
						  non-routine service for durable medical equipment requiring the skill of a
						  technician, labor component, per 15 minutes
Manually Priced
E1399
NU
N
Durable medical equipment, miscellaneous
Manually Priced
S8096***
Z2211 (Bill on Paper)
NU EP
NU EP
N Y
***(Peak flow meter used by asthmatic patients)
						  Portable peak flow meter
Power Kit/Batteries
Purchase Purchase
Procedure codes
E0250*
,
E0255*
and
E0260*
must be billed when hospital beds are purchased for
				Medicaid beneficiaries of all ages. Providers must only provide these
				purchase-only services to beneficiaries who are expected to require the bed for
				a long period of time.
Each procedure code for hospital beds listed above may
				only be billed once every 10 years.
Procedure codes
E0250*
,
E0255*
and
E0260
*must also be used to bill for equipment that does not meet
				the purchase-only criteria. They are reimbursed on a capped rental basis. The
				capped rental items must be used until the equipment is no longer repairable or
				until it is no longer appropriate for the beneficiary as verified by the
				physician.
242.180
Orthotic Appliances, All Ages 10-1-07
Procedure codes found in this section must be billed either
				electronically or on paper with modifier
EP
for beneficiaries
				under 21 years of age or modifier
NU
for beneficiaries age 21 and
				older. When a second modifier is listed, that modifier must be used in
				conjunction with either
EP
or
NU
.
Modifiers in this section are indicated by the headings M1 and
				M2. Prior authorization requirements are shown under the heading PA. If prior
				authorization is needed for individuals age 21 and older, that information is
				indicated with a "Y" in the column; if not, an "N" is shown. When prior
				authorization is not applicable (for U21) that information is shown with an
				"N/A" in the column.
When codes are payable for all ages, "All" is indicated in the
				column, "U21" is shown when the code is payable only for individuals under age
				21 and "21+" is shown when the code is payable only for those individuals age
				21 and older.
** This item is not a covered service for the diagnosis of
				Carpal Tunnel Syndrome prior to surgery.
***
(...) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
Effective for dates of service on and after March 1, 2006,
				this procedure code does not require prior authorization; however, the
				beneficiary's medical condition must fall within the diagnosis range of 250.00
				and 251.93.
Orthotic Appliances, All Ages (section 242.180)
Procedure Code
M1
M2
Description
All
U21
21+
PA 21+
Payment Method
A5500"
NU
For diabetics only, fitting (including follow-up)
						  custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to
						  accommodate multi-density insert(s), per shoe
21+
N
Purchase
A5501'
NU
For diabetics only, fitting (including follow-up)
						  custom preparation and supply of molded from cast(s) of patient's foot (custom
						  molded shoe), per shoe
21+
N
Purchase
A5503'
NU
For diabetics only, modification (including fitting) of
						  off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid
						  rocker bottom, per shoe
21+
N
Purchase
A5504'
NU
For diabetics only, modification (including fitting) of
						  off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per
						  shoe
21+
N
Purchase
A5505'
NU
For diabetics only, modification (including fitting) of
						  off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per
						  shoe
21+
N
Purchase
A5506'
NU
For diabetics only, modification (including fitting) of
						  off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per
						  shoe
21+
N
Purchase
A5507
NU
For diabetics only, not otherwise specified
						  modification (including fitting) of off-the-shelf depth-inlay shoe or custom
						  molded shoe, per shoe
21+
N
Purchase
A5510'
NU
For diabetics only, direct formed, compression molded
						  to patient's foot without external heat source, multiple-density insert(s)
						  prefabricated, per shoe
21+
N
Purchase
A5512
NU
For diabetics only, multiple density insert, direct
						  formed, molded to foot after external heat source of 230 degrees Fahrenheit or
						  higher, total contact with patient's foot, including arch, base layer minimum
						  of ¼ inch material of shore a 35 durometer of 3/16 inch material of
						  shore a 40 durometer (or higher), prefabricated, each
21+
N
Purchase
A5513
NU
For diabetics only, multiple density insert, custom
						  molded from model of patient's foot, total contact with patient's foot,
						  including arch, base layer minimum of ¼ inch material of shore a 35
						  durometer of 3/16 inch material of shore a 40 durometer (or higher), includes
						  arch filler and other shaping material custom fabricated, each
21+
N
Purchase
A8000
EP NU
Helmet, protective, soft, prefabricated, includes all
						  components and accessories
All
N
Purchase
A8001
EP NU
Helmet, protective, hard, prefabricated, includes all
						  components and accessories
All
N
Purchase
A8002
EP NU
Helmet, protective, soft, custom fabricated, includes
						  all components and accessories
All
N
Purchase
A8003
EP NU
Helmet, protective, hard, custom fabricated, includes
						  all components and accessories
All
N
Purchase
L0120
NU EP
Cervical, flexible, nonadjustable (foam collar)
All
N
Purchase
L0130
NU EP
Cervical, flexible, thermoplastic collar, molded to
						  patient
All
N
Purchase
L0140
NU EP
Cervical, semi-rigid, adjustable (plastic
						  collar)
All
N
Purchase
L0150
NU EP
Cervical, semi-rigid, adjustable molded chin cup
						  (plastic collar with mandibular/occipital piece)
All
N
Purchase
L0160
NU EP
Cervical, semi-rigid wire frame occipital/mandibular
						  support
All
N
Purchase
L0170
NU EP
Cervical, collar, molded to patient model
All
N
Purchase
L0172
NU EP
Cervical, collar, semi-rigid thermoplastic foam, two
						  piece
All
N
Purchase
L0174
NU EP
Cervical, collar, semi-rigid thermoplastic foam, two
						  piece with thoracic extension
All
N
Purchase
L0180
NU EP
Cervical, multiple post collar, occipital/mandibular
						  supports, adjustable
All
N
Purchase
L0190
NU EP
Cervical, multiple post collar, occipital/mandibular
						  supports, adjustable cervical bars (Somi, Guilford, Taylor types)
All
N
Purchase
L0200
NU EP
Cervical, multiple post collar, occipital/mandibular
						  supports, adjustable cervical bars, and thoracic extension
All
N
Purchase
L0210
NU EP
Thoracic, rib belt
All
N
Purchase
L0220
NU EP
Thoracic, rib belt, custom fabricated
All
N
Purchase
L0450
NU EP
TLSO, flexible, provides trunk support, upper thoracic
						  region, produces intracavitary pressure to reduce load on the intervertebral
						  disks with rigid stays or panel(s), includes shoulder straps and closures,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L0452
NU EP
TLSO, flexible, provides trunk support, upper thoracic
						  region, produces intracavitary pressure to reduce load on the intervertebral
						  disks with rigid stays or panel(s), includes shoulder straps and closures,
						  custom fabricated
All
N
Purchase
L0454
NU EP
TLSO, flexible, provides trunk support, extends from
						  sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in
						  the sagittal plane, produces intracavitary pressure to reduce load on the
						  intervertebral disks with rigid stays or panel(s), includes shoulder straps and
						  closures, prefabricated, includes fitting and adjustment
All
N
Purchase
L0456
NU EP
TLSO, flexible, provides trunk support, thoracic
						  region, rigid posterior panel and soft anterior apron, extends from
						  sacrococcygeal junction and terminates just inferior to the scapular spine,
						  restricts gross trunk motion in the sagittal plane, produces intracavitary
						  pressure to reduce load on the intervertebral disks, includes straps and
						  closures, prefabricated, includes fitting and adjustment
All
Y
Purchase
L0458
NU EP
TLSO, triplanar control, modular segmented spinal
						  system, two rigid plastic shells, posterior extends from sacrococcygeal
						  junction and terminates just inferior to the scapular spine, anterior extends
						  from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk
						  motion in the sagittal, coronal and transverse planes, lateral strength is
						  provided by overlapping plastic and stabilizing closures, includes straps and
						  closures, prefabricated, includes fitting and adjustment
All
Y
Purchase
L0460
NU EP
TLSO, triplanar control modular segmented spinal
						  system, two rigid plastic shells, posterior extends from the sacrococcygeal
						  junction and terminates just inferior to the scapular spine, anterior extends
						  from the symphysis pubis to the sternal notch, soft liner, restricts gross
						  trunk motion in the sagittal, coronal and transverse planes, lateral strength
						  is provided by overlapping plastic and stabilizing closures, including straps
						  and closures, prefabricated, includes fitting and adjustment
All
Y
Purchase
L0462
NU EP
TLSO, triplanar control modular segmented spinal
						  system, three rigid plastic shells, posterior extends from sacrococcygeal
						  junction and terminates just inferior to the scapular spine, anterior extends
						  from the symphysis pubis to the sternal notch, soft liner, restricts gross
						  trunk motion in the sagittal, coronal and transverse planes, lateral strength
						  is provided by overlapping plastic and stabilizing closures, including straps
						  and closures, prefabricated, includes fitting and adjustment
All
Y
Purchase
L0464
NU EP
TLSO, triplanar control modular segmented spinal
						  system, four rigid plastic shells, posterior extends from sacrococcygeal
						  junction and terminates just inferior to the scapular spine, anterior extends
						  from the symphysis pubis to the sternal notch, soft liner, restricts gross
						  trunk motion in sagittal, coronal and transverse planes, lateral strength is
						  provided by overlapping plastic and stabilizing closures, including straps and
						  closures, prefabricated, includes fitting and adjustment
All
Y
Purchase
L0466
NU EP
TLSO, sagittal control, rigid posterior frame and
						  flexible soft anterior apron with straps, closures and padding, restricts gross
						  trunk motion in sagittal plane, produces intracavitary pressure to reduce load
						  on intervertebral disks, includes fitting and shaping the frame, prefabricated,
						  includes fitting and adjustment
All
Y
Purchase
L0468
NU EP
TLSO, sagittal-coronal control, rigid posterior frame
						  and flexible soft anterior apron with straps, closures and padding, extends
						  from sacrococcygeal junction over scapulae, lateral strength provided by
						  pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in
						  sagittal and coronal planes, produces intracavitary pressure to reduce load on
						  intervertebral disks, includes fitting and shaping the frame, prefabricated,
						  includes fitting and adjustment
All
Y
Purchase
L0470
NU EP
TLSO, triplanar control, rigid posterior frame and
						  flexible soft anterior apron with straps, closures and padding, extends from
						  sacrococcygeal junction to scapula, lateral strength provided by pelvic,
						  thoracic, and lateral frame pieces, rotational strength provided by
						  subclavicular extensions, restricts gross trunk motion in sagittal, coronal and
						  transverse planes, produces intracavitary pressure to reduce load on
						  intervertebral disks, includes fitting and shaping the frame, prefabricated,
						  includes fitting and adjustment
All
Y
Purchase
L0472
NU EP
TLSO, triplanar control, hyperextension, rigid anterior
						  and lateral frame extends from symphysis pubis to sternal notch with two
						  anterior components (one pubic and one sternal) posterior and lateral pads with
						  straps and closures, limits spinal flexion, restricts gross trunk motion in
						  sagittal, coronal and transverse planes, includes fitting and shaping the
						  frame, prefabricated, includes fitting and adjustment
All
N
Purchase
L0474
NU EP
TLSO, triplanar control, rigid posterior frame with
						  multiple straps, closures and padding, extends from sacrococcygeal junction to
						  scapula, lateral strength provided by pelvic, thoracic, and lateral frame
						  pieces, rotational strength provided by subclavicular extensions, restricts
						  gross trunk motion in sagittal, coronal and transverse planes, produces
						  intracavitary pressure to reduce load on the intervertebral disks, includes
						  fitting and shaping the frame, prefabricated, includes fitting and
						  adjustment
All
Y
Purchase
L0480
NU EP
TLSO, triplanar control, one-piece rigid plastic shell
						  without interface liner, with multiple straps and closures, posterior extends
						  from sacrococcygeal junction and terminates just inferior to scapular spine,
						  anterior extends from symphysis pubis to sternal notch, anterior or posterior
						  opening, restricts gross trunk motion in sagittal, coronal and transverse
						  planes, includes a carved plaster or CAD-CAM model, custom fabricated
All
Y
Purchase
L0482
NU EP
TLSO, triplanar control, one-piece rigid plastic shell
						  with interface liner, multiple straps and closures, posterior extends from
						  sacrococcygeal junction and terminates just inferior to scapular spine,
						  anterior extends from symphysis pubis to sternal notch, anterior or posterior
						  opening, restricts gross trunk motion in sagittal, coronal and transverse
						  planes, includes a carved plaster or CAD-CAM model, custom fabricated
All
Y
Purchase
L0484
NU EP
TLSO, triplanar control, two-piece rigid plastic shell
						  without interface liner, with multiple straps and closures, posterior extends
						  from sacrococcygeal junction and terminates just inferior to scapular spine,
						  anterior extends from symphysis pubis to sternal notch, lateral strength is
						  enhanced by overlapping plastic, restricts gross trunk motion in the sagittal,
						  coronal and transverse planes, includes a carved plaster or CAD-CAM model,
						  custom fabricated
All
Y
Purchase
L0486
NU EP
TLSO, triplanar control, two-piece rigid plastic shell
						  with interface liner, multiple straps and closures, posterior extends from
						  sacrococcygeal junction and terminates just inferior to scapular spine,
						  anterior extends from symphysis pubis to sternal notch, lateral strength is
						  enhanced by overlapping plastic, restricts gross trunk motion in the sagittal,
						  coronal and transverse planes, includes a carved plaster or CAD-CAM model,
						  custom fabricated
All
Y
Purchase
L0488
NU EP
TLSO, triplanar control, one-piece rigid plastic shell
						  with interface liner, multiple straps and closures, posterior extends from
						  sacrococcygeal junction and terminates just inferior to scapular spine,
						  anterior extends from symphysis pubis to sternal notch, anterior or posterior
						  opening, restricts gross trunk motion in sagittal, coronal and transverse
						  planes, prefabricated, includes fitting and adjustment
All
Y
Purchase
L0490
NU EP
TLSO, sagittal-coronal control, one-piece rigid plastic
						  shell with overlapping reinforced anterior, with multiple straps and closures,
						  posterior extends from sacrococcygeal junction and terminates at or before the
						  T9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior
						  opening, restricts gross trunk motion in sagittal and coronal planes,
						  prefabricated, includes fitting and adjustment
All
Y
Purchase
L0621
NU EP
Sacroiliac orthosis, flexible, provides pelvic-sacral
						  support, reduces motion about the sacroiliac joint, includes straps, closures,
						  may include pendulous abdomen design, prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L0622
NU EP
SO, flexible, provides pelvic-sacral support, reduces
						  motion about the sacroiliac joint, includes straps, closures, may include
						  pendulous abdomen design, custom fabricated
All
N
Purchase
L0623
NU EP
SO, flexible, provides pelvic-sacral support, with
						  rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about
						  the sacroiliac joint, includes straps, closures, may include pendulous abdomen
						  design, prefabricated, includes fitting and adjustment
All
N
Purchase
L0624
NU EP
SO, provides pelvic-sacral support, with rigid or
						  semi-rigid panels over the sacrum and abdomen, reduces motion about the
						  sacroiliac joint, includes straps, closures, may include pendulous abdomen
						  design, custom fabricated
All
N
Manually Priced
L0625
NU EP
Lumbar orthosis, flexible, provides lumbar support,
						  posterior extends from L-1 to below L-5 vertebra, produces intracavitary
						  pressure to reduce load on the intervertebral discs, includes straps, closures,
						  may include pendulous abdomen design, shoulder straps, stays, prefabricated,
						  includes fitting and adjustment
All
N
Purchase
L0626
NU EP
LO, sagittal control, with rigid posterior panel(s),
						  posterior extends from L-1 to below L-5 vertebra, produces intracavitary
						  pressure to reduce load on the intervertebral discs, includes straps, closures,
						  may include padding, stays, shoulder straps, pendulous abdomen design,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L0627
NU EP
LO, sagittal control, with rigid anterior and posterior
						  panel(s), posterior extends from L-1 to below L-5 vertebra, produces
						  intracavitary pressure to reduce load on the intervertebral discs, includes
						  straps, closures, may include padding, shoulder straps, pendulous abdomen
						  design, prefabricated, includes fitting and adjustment
All
N
Purchase
L0628
NU EP
Lumbar-sacral orthosis, flexible, provides lumbo-sacral
						  support, posterior extends from sacrococcygeal junction to T-9 vertebra,
						  produces intracavitary pressure to reduce load on the intervertebral discs,
						  includes straps, closures, may include stays, shoulder straps, pendulous
						  abdomen design, prefabricated, includes fitting and adjustment
All
N
Purchase
L0629
NU EP
LSO, flexible, provides lumbo-sacral support, posterior
						  extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary
						  pressure to reduce load on the intervertebral discs, includes straps, closures,
						  may include stays, shoulder straps, pendulous abdomen design, custom
						  fabricated
All
N
Manually Priced
L0630
NU EP
LSO, sagittal control, with rigid posterior panel(s),
						  posterior extends from sacrococcygeal junction to T-9 vertebra, produces
						  intracavitary pressure to reduce load on the intervertebral discs, includes
						  straps, closures, may include padding, stays, shoulder straps, pendulous
						  abdomen design, prefabricated, includes fitting and adjustment
All
N
Purchase
L0631
NU EP
LSO, sagittal control, with rigid anterior and
						  posterior panel(s), posterior extends from sacrococcygeal junction to T-9
						  vertebra, produces intracavitary pressure to reduce load on the intervertebral
						  discs, includes straps, closures, may include padding, shoulder straps,
						  pendulous abdomen design, prefabricated, includes fitting and adjustment
All
N
Purchase
L0632
NU EP
LSO, sagittal control, with rigid anterior and
						  posterior panels, posterior extends from sacrococcygeal junction to T-9
						  vertebra, produces intracavitary pressure to reduce load on the intervertebral
						  discs, includes straps, closures, may include padding, shoulder straps,
						  pendulous abdomen design, custom fabricated
All
N
Manually Priced
L0633
NU EP
LSO, sagittal-coronal control, with rigid posterior
						  frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra,
						  lateral strength provided by rigid lateral frame/panels, produces intracavitary
						  pressure to reduce load on the intervertebral discs, includes straps, closures,
						  may include padding, stays, shoulder straps, pendulous abdomen design,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L0634
NU EP
LSO, sagittal-coronal control, with rigid posterior
						  frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra,
						  lateral strength provided by rigid lateral frame/panel(s), produces
						  intracavitary pressure to reduce load on the intervertebral discs, includes
						  straps, closures, may include padding, stays, shoulder straps, pendulous
						  abdomen design, custom fabricated
All
N
Manually Priced
L0635
NU EP
LSO, sagittal-coronal control, lumbar flexion, rigid
						  posterior frame/panel(s), lateral articulating design to flex the lumbar spine,
						  posterior extends from sacrococcygeal junction to T-9 vertebra, lateral
						  strength provided by rigid lateral frame/panel(s), produces intracavitary
						  pressure to reduce load on the intervertebral discs, includes straps, closures,
						  may include padding, anterior panel, pendulous abdomen design, prefabricated,
						  includes fitting and adjustment
All
N
Purchase
L0636
NU EP
LSO, sagittal-coronal control, lumbar flexion, rigid
						  posterior frame/panel(s), lateral articulating design to flex the lumbar spine,
						  posterior extends from sacrococcygeal junction to T-9 vertebra, lateral
						  strength provided by rigid lateral frame/panels, produces intracavitary
						  pressure to reduce load on the intervertebral discs, includes straps, closures,
						  may include padding, anterior panel, pendulous abdomen design, custom
						  fabricated
All
N
Purchase
L0637
NU EP
LSO, sagittal-coronal control, with rigid anterior and
						  posterior frame/panels, posterior extends from sacrococcygeal junction to T-9
						  vertebra, lateral strength provided by rigid lateral frame/panels, produces
						  intracavitary pressure to reduce load on the intervertebral discs, includes
						  straps, closures, may include padding, shoulder straps, pendulous abdomen
						  design, prefabricated, includes fitting and adjustment
All
N
Purchase
L0638
NU EP
LSO, sagittal-coronal control, with rigid anterior and
						  posterior frame/panels, posterior extends from sacrococcygeal junction to T-9
						  vertebra, lateral strength provided by rigid lateral frame/panels, produces
						  intracavitary pressure to reduce load on the intervertebral discs, includes
						  straps, closures, may include padding, shoulder straps, pendulous abdomen
						  design, custom fabricated
All
N
Purchase
L0639
NU EP
LSO, sagittal-coronal control, rigid shell(s)/panel(s),
						  posterior extends from sacrococcygeal junction to T-9 vertebra, anterior
						  extends from symphysis pubis to xiphoid, produces intracavitary pressure to
						  reduce load on the intervertebral discs, overall strength provided by
						  overlapping rigid material and stabilizing closures, includes straps, closures,
						  may include soft interface, pendulous abdomen design, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L0640
NU EP
LSO, sagittal-coronal control, rigid shell(s)/panel(s),
						  posterior extends from sacrococcygeal junction to T-9 vertebra, anterior
						  extends from symphysis pubis to xiphoid, produces intracavitary pressure to
						  reduce load on the intervertebral discs, overall strength provided by
						  overlapping rigid material and stabilizing closures, includes straps, closures,
						  may include soft interface, pendulous abdomen design, custom fabricated
All
N
Purchase
L0700
NU EP
Cervical-thoracic-lumbar-sacral orthoses (CTLSO),
						  anterior-posterior-lateral control, molded to patient model (Minerva
						  type)
All
Y
Purchase
L0710
NU EP
CTLSO, anterior-posterior-lateral control, molded to
						  patient model, with interface material (Minerva type)
All
Y
Purchase
L0810
NU EP
Halo procedure, cervical halo incorporated into jacket
						  vest
All
Y
Purchase
L0820
NU EP
Halo procedure, cervical halo incorporated into plaster
						  body jacket
All
Y
Purchase
L0830
NU EP
Halo procedure, cervical halo incorporated into
						  Milwaukee type orthosis
All
Y
Purchase
L0859
NU EP
Addition to halo procedure, magnetic resonance image
						  compatible system, rings and pins, any material
All
Y
Purchase
L0960
NU EP
Torso support, post surgical support, pads for post
						  surgical support
All
N
Purchase
L0970
NU EP
TLSO, corset front
All
N
Purchase
L0972
NU EP
LSO, corset front
All
N
Purchase
L0974
NU EP
TLSO, full corset
All
N
Purchase
L0976
NU EP
LSO, full corset
All
N
Purchase
L0978
NU EP
Axillary crutch extension
All
N
Purchase
L0980
NU EP
Peroneal straps, pair
All
N
Purchase
L0982
NU EP
Stocking supporter grips, set of four (4)
All
N
Purchase
L0984
NU
Protective body sock, each
21+
N
Purchase
L1000
NU EP
CTLSO (Milwaukee), inclusive of furnishing initial
						  orthosis, including model
All
Y
Purchase
L1010
NU EP
TLSO or scoliosis orthosis, axilla sling
All
N
Purchase
L1020
NU EP
Addition to CTLSO or scoliosis orthosis, kyphosis
						  pad
All
N
Purchase
L1025
NU EP
Addition to CTLSO or scoliosis orthosis, kyphosis pad,
						  floating
All
N
Purchase
L1030
NU EP
Addition to CTLSO or scoliosis orthosis, lumbar bolster
						  pad
All
N
Purchase
L1040
NU EP
Addition to CTLSO or scoliosis orthosis, lumbar or
						  lumbar rib pad
All
N
Purchase
L1050
NU EP
Addition to CTLSO or scoliosis orthosis, sternal
						  pad
All
N
Purchase
L1060
NU EP
Addition to CTLSO or scoliosis orthosis, thoracic
						  pad
All
N
Purchase
L1070
NU EP
Addition to CTLSO or scoliosis orthosis, trapezius
						  sling
All
N
Purchase
L1080
NU EP
Addition to CTLSO or scoliosis orthosis,
						  outrigger
All
N
Purchase
L1085
NU EP
Addition to CTLSO or scoliosis orthosis, outrigger,
						  bilateral with vertical extensions
All
N
Purchase
L1090
NU EP
Addition to CTLSO or scoliosis orthosis, lumbar
						  sling
All
N
Purchase
L1100
NU EP
Addition to CTLSO or scoliosis orthosis, ring flange,
						  plastic or leather
All
N
Purchase
L1110
NU EP
Addition to CTLSO or scoliosis orthosis, ring flange,
						  plastic or leather, molded to patient model
All
N
Purchase
L1120
NU EP
Addition to CTLSO, scoliosis orthosis, cover for
						  upright, each
All
N
Purchase
L1200
NU EP
Thoracic-lumbar-sacral-orthosis (TLSO), inclusive of
						  furnishing initial orthosis only
All
Y
Purchase
L1210
NU EP
Addition to TLSO (low profile), lateral thoracic
						  extension
All
N
Purchase
L1220
NU EP
Addition to TLSO (low profile), anterior thoracic
						  extension
All
N
Purchase
L1230
NU EP
Addition to TLSO (low profile), Milwaukee type
						  superstructure
All
N
Purchase
L1240
NU EP
Addition to TLSO (low profile), lumbar derotation
						  pad
All
N
Purchase
L1250
NU EP
Addition to TLSO (low profile), anterior ASIS
						  pad
All
N
Purchase
L1260
NU EP
Addition to TLSO (low profile), anterior thoracic
						  derotation pad
All
N
Purchase
L1270
NU EP
Addition to TLSO (low profile), abdominal pad
All
N
Purchase
L1280
NU EP
Addition to TLSO (low profile), rib gusset (elastic),
						  each
All
N
Purchase
L1290
NU EP
Addition to TLSO (low profile), lateral trochanteric
						  pad
All
N
Purchase
L1300
NU EP
Other scoliosis procedure, body jacket molded to
						  patient model
All
Y
Purchase
L1310
NU EP
Other scoliosis procedure, postoperative body
						  jacket
All
Y
Purchase
L1499
NU EP
Spinal orthosis, not otherwise specified. ***(The
						  manufacturer's invoice must be attached to all claims.)
All
Y
Manually Priced
L1500
NU EP
THKAO, mobility frame (Newington, Parapodium
						  types)
All
Y
Purchase
L1510
NU EP
THKAO, standing frame, with or without tray and
						  accessories
All
Y
Purchase
L1520
NU EP
THKAO, swivel walker
All
Y
Purchase
L1600
NU EP
HO, abduction control of hip joints, flexible, Frejka
						  type with cover, prefabricated, includes fitting and adjustment
All
N
Purchase
L1610
NU EP
HO, abduction control of hip joints, flexible (Frejka
						  cover only), prefabricated, includes fitting and adjustment
All
N
Purchase
L1620
NU EP
HO, abduction control of hip joints, flexible (Pavlik
						  harness), prefabricated, includes fitting and adjustment
All
N
Purchase
L1630
NU EP
HO, abduction control of hip joints, semi-flexible (Von
						  Rosen type), custom fabricated
All
N
Purchase
L1640
NU EP
HO, abduction control of hip joints, static, pelvic
						  band or spreader bar, thigh cuffs, custom fabricated
All
N
Purchase
L1650
NU EP
HO, abduction control of hip joints, static,
						  adjustable, custom fitted (Ilfled type), prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L1660
NU EP
HO, abduction control of hip joints, static, plastic,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L1680
NU EP
HO; abduction control of hip joints, dynamic, pelvic
						  control, adjustable hip motion control, thigh cuffs (Rancho hip action type),
						  custom fabricated
All
Y
Purchase
L1685
NU EP
HO, abduction control of hip joint, post operative hip
						  abduction type, custom fabricated
All
Y
Purchase
L1686
NU EP
HO, abduction control of hip joint, post operative hip
						  abduction type, prefabricated, includes fitting and adjustments
All
Y
Purchase
L1690
NU
Combination, bilateral, lumbo-sacral, hip, femur
						  orthosis providing adduction and internal rotation control, prefabricated,
						  includes fitting and adjustment
21+
Y
Purchase
L1700
NU EP
Legg Perthes orthosis (Toronto type), custom
						  fabricated
All
Y
Purchase
L1710
NU EP
Legg Perthes orthosis (Newington type), custom
						  fabricated
All
Y
Purchase
L1720
NU EP
Legg Perthes orthosis, trilateral (Tachdijan type),
						  custom fabricated
All
Y
Purchase
L1730
NU EP
Legg Perthes orthosis (Scottish Rite type) custom
						  fabricated
All
Y
Purchase
L1750
NU EP
Legg Perthes orthosis, Legg Perthes sling (Sam Brown
						  type), prefabricated, includes fitting and adjustment
All
Y
Purchase
L1755
NU EP
Legg Perthes orthosis (Patten bottom type), custom
						  fabricated
All
Y
Purchase
L1800
NU EP
KO, elastic with stays, prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L1810
NU EP
KO, elastic with joints, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L1815
NU EP
KO, elastic or other elastic type material with
						  condylar pad(s), prefabricated, includes fitting and adjustment
All
N
Purchase
L1820
NU EP
KO, elastic with condyle pads and joints,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L1825
NU EP
KO, elastic knee cap. prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L1830
NU EP
KO, immobilizer, canvas longitudinal, prefabricated,
						  includes fitting and adjustment
All
N
Purchase
L1832
NU EP
KO, adjustable knee joints, positional orthosis, rigid
						  support, prefabricated, includes fitting and adjustment rigid support
All
N
Purchase
L1834
NU EP
KO, without knee joint, rigid, custom fabricated
All
N
Purchase
L1840
NU EP
KO, derotation, medial-lateral, anterior cruciate
						  ligament, custom fabricated
All
Y
Purchase
L1843
NU
Knee orthosis, single upright, thigh and calf, with
						  adjustable flexion and extension joint, medial-lateral and rotation control,
						  with or without varus/valgus adjustment, prefabricated, includes fitting and
						  adjustment
21+
Y
Purchase
L1844
NU
KO, single upright, thigh and calf, with adjustable
						  flexion and extension joint, medial-lateral and rotation control, with or
						  without varus/valgus adjustment, custom fabricated
21+
Y
Purchase
L1845
NU EP
KO, double upright, thigh and calf, with adjustable
						  flexion and extension joint, medial-lateral and rotation control,
						  prefabricated, includes fitting and adjustment
All
Y
Purchase
L1846
NU EP
KO, double upright, thigh and calf, with adjustable
						  flexion and extension joint, medial-lateral and rotation control, custom
						  fabricated
All
Y
Purchase
L1847
NU
Knee orthosis, double upright with adjustable joint,
						  with inflatable air support chamber(s) prefabricated, includes fitting and
						  adjustment
21+
N
Purchase
L1850
NU EP
KO, Swedish type, prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L1855
NU EP
KO, molded plastic, thigh and calf sections, with
						  double upright knee joints, custom fabricated
All
Y
Purchase
L1858
NU EP
KO, molded plastic, polycentric knee joints, pneumatic
						  knee pads (CTI), custom fabricated
All
Y
Purchase
L1860
NU EP
KO, modification of supracondylar prosthetic socket,
						  custom fabricated (SK)
All
Y
Purchase
L1870
NU EP
KO, double upright, thigh and calf lacers, with knee
						  joints, custom fabricated
All
Y
Purchase
L1880
NU EP
KO, double upright, nonmolded thigh and calf
						  cuff/lacers with knee joints, custom fabricated
All
N
Purchase
L1900
NU EP
AFO, spring wire, dorsiflexion assist calf band, custom
						  fabricated
All
N
Purchase
L1902
NU EP
AFO, ankle gauntlet, prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L1904
NU EP
AFO, molded ankle gauntlet, custom fabricated
All
N
Purchase
L1906
NU EP
AFO, multigamentus ankle support, prefabricated,
						  includes fitting and adjustment
All
N
Purchase
L1907
NU EP
AFO, supramalleolar with straps, with or without
						  interface/pads, custom fabricated
All
N
Purchase
L1910
NU EP
AFO, posterior, single bar, clasp attachment to shoe
						  counter prefabricated, includes fitting and adjustment
All
N
Purchase
L1920
NU EP
AFO, single upright with static or adjustable stop
						  (Phelps or Perlstein type), custom fabricated
All
N
Purchase
L1920
EP
***(Custom night "A" frame-KAFO, torsion control,
						  bilateral night "A" frame) AFO, single upright with static or adjustable stop
						  (Phelps or Perlstein type), custom fabricated
U21
N/A
Purchase
L1930
NU EP
AFO, plastic or other material, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L1932
NU EP
AFO, rigid anterior tibial section, total carbon fiber
						  or equal material, prefabricated, includes fitting and adjustment
All
N
Purchase
L1940
NU EP
AFO, plastic or other material,
						  custom-fabricated
All
N
Purchase
L1945
NU EP
AFO, molded to patient model, plastic, rigid anterior
						  tibial section (floor reaction), custom fabricated
All
Y
Purchase
L1950
NU EP
AFO, spiral (Institute of Rehabilitative Medicine
						  type), plastic, custom fabricated
All
N
Purchase
L1960
NU EP
AFO, posterior solid ankle, plastic, custom
						  fabricated
All
N
Purchase
L1970
NU EP
AFO, plastic, with ankle joint, custom
						  fabricated
All
N
Purchase
L1980
NU EP
AFO, single upright free plantar dorsiflexion, solid
						  stirrup, calf band/cuff (single bar "BK" orthosis), custom fabricated
All
N
Purchase
L1990
NU EP
AFO, double upright free plantar dorsiflexion, solid
						  stirrup, calf band/cuff (double bar "BK" orthosis), custom fabricated
All
N
Purchase
L2000
NU EP
KAFO, single upright, free knee, free ankle, solid
						  stirrup, thigh and calf bands/cuffs (single bar "AK" orthosis), custom
						  fabricated
All
Y
Purchase
L2005
NU EP
KAFO, any material, single or double upright, stance
						  control, automatic lock and swing phase release, mechanical activation,
						  includes ankle joint, any type, custom fabricated
All
N
Purchase
L2010
NU EP
KAFO, single upright, free knee, free ankle, solid
						  stirrup, thigh and calf bands/cuffs (single bar "AK" orthosis), without knee
						  joint, custom fabricated
All
Y
Purchase
L2020
NU EP
KAFO, double upright, free knee, free ankle, solid
						  stirrup, thigh and calf bands/cuffs (double bar "AK" orthosis), custom
						  fabricated
All
Y
Purchase
L2030
NU EP
KAFO, double upright, free knee, free ankle, solid
						  stirrup, thigh and calf bands/cuffs, (double bar "AK" orthosis), without knee
						  joint, custom fabricated
All
Y
Purchase
L2035
NU
KAFO, full plastic, static prefabricated (pediatric
						  size) prefabricated, includes fitting and adjustment
21+
N
Purchase
L2036
NU EP
KAFO, full plastic, double upright, free knee, custom
						  fabricated
All
Y
Purchase
L2037
NU EP
KAFO, full plastic, single upright, free knee, custom
						  fabricated
All
Y
Purchase
L2038
NU EP
KAFO, full plastic, without knee joint, multi-axis
						  ankle, (Lively orthosis or equal), custom fabricated
All
Y
Purchase
L2039
NU
KAFO, full plastic, single upright, poly-axial hinge,
						  medial lateral rotation control, custom fabricated
21+
Y
Purchase
L2040
NU EP
HKAFO, torsion control, bilateral rotation straps,
						  pelvic band/belt, custom fabricated
All
N
Purchase
L2040
NU EP
U1 U1
***(Night "A" frame-KAFO, torsion control, bilateral
						  night "A" frame) HKAFO, torsion control, bilateral rotation straps, pelvic
						  band/belt, custom fabricated
All
N
Manually Priced
Purchase
L2040
NU EP
U1 U1
***(Night "A" frame-KAFO, torsion control, bilateral
						  night "A" frame) HKAFO, torsion control, bilateral rotation straps, pelvic
						  band/belt, custom fabricated
All
N
Manually Priced
Purchase
L2050
NU EP
HKAFO, torsion control, bilateral torsion cables, hip
						  joint, pelvic band/belt, custom fabricated
All
N
Purchase
L2060
NU EP
HKAFO, torsion control, bilateral torsion cables, ball
						  bearing hip joint, pelvic band/belt, custom fabricated
All
N
Purchase
L2070
NU EP
HKAFO, torsion control, unilateral rotation straps,
						  pelvic band/belt, custom fabricated
All
N
Purchase
L2080
NU EP
HKAFO, torsion control, unilateral torsion cable, hip
						  joint, pelvic band/belt, custom fabricated
All
N
Purchase
L2090
NU EP
HKAFO, torsion control, unilateral torsion cable, ball
						  bearing hip joint, pelvic band/belt, custom fabricated
All
N
Purchase
L2106
NU EP
AFO, fracture orthosis, tibial fracture cast orthosis,
						  thermoplastic type casting material, custom fabricated
All
N
Purchase
L2108
NU EP
AFO, fracture orthosis, tibial fracture cast orthosis,
						  custom fabricated
All
Y
Purchase
L2112
NU EP
AFO, fracture orthosis, tibial fracture orthosis, soft,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L2114
NU EP
AFO, fracture orthosis, tibial fracture orthosis,
						  semi-rigid, prefabricated, includes fitting and adjustment
All
N
Purchase
L2116
NU EP
AFO, fracture orthosis, tibial fracture orthosis,
						  rigid, prefabricated, includes fitting and adjustment
All
N
Purchase
L2126
NU EP
KAFO, fracture orthosis, femoral fracture cast
						  orthosis, thermoplastic type casting material, molded to patient
All
Y
Purchase
L2128
NU EP
KAFO, fracture orthosis, femoral fracture cast
						  orthosis, thermoplastic type casting material, custom fabricated
All
Y
Purchase
L2132
NU EP
KAFO, fracture orthosis, femoral fracture cast
						  orthosis, soft, prefabricated, includes fitting and adjustment
All
Y
Purchase
L2134
NU EP
KAFO, fracture orthosis, femoral fracture cast
						  orthosis, semi-rigid custom fitted
All
Y
Purchase
L2136
NU EP
KAFO, fracture orthosis, femoral fracture cast
						  orthosis, rigid, prefabricated, includes fitting and adjustment
All
Y
Purchase
L2180
NU EP
Addition to lower extremity fracture orthosis, plastic
						  shoe insert with ankle joints
All
N
Purchase
L2182
NU EP
Addition to lower extremity fracture orthosis, drop
						  lock knee joint
All
N
Purchase
L2184
NU EP
Addition to lower extremity fracture orthosis, limited
						  motion knee joint
All
N
Purchase
L2186
NU EP
Addition to lower extremity fracture orthosis,
						  adjustable motion knee joint (Lerman type)
All
N
Purchase
L2188
NU EP
Addition to lower extremity fracture orthosis,
						  quadrilateral brim
All
N
Purchase
L2190
NU EP
Addition to lower extremity fracture orthosis, waist
						  belt
All
N
Purchase
L2192
NU EP
Addition to lower extremity fracture orthosis, hip
						  joint, pelvic band, thigh flange, and pelvic belt
All
N
Purchase
L2200
NU EP
Additions to lower extremity, dorsiflexion and plantar
						  flexion
All
N
Purchase
L2210
NU EP
Addition to lower extremity, dorsiflexion assist
						  (plantar flexion resist), each joint
All
N
Purchase
L2220
NU EP
Addition to lower extremity, dorsiflexion and plantar
						  flexion assist/resist, each joint
All
N
Purchase
L2230
NU EP
Addition to lower extremity, split flat caliper
						  stirrups and plate attachment
All
N
Purchase
L2232
NU EP
Addition to lower extremity orthosis, rocker bottom for
						  total contact ankle foot orthosis, for custom fabricated orthosis only
All
N
Manually Priced
L2240
NU EP
Addition to lower extremity, round caliper and plate
						  attachment
All
N
Purchase
L2250
NU EP
Addition to lower extremity, foot plate, molded to
						  patient model, stirrup attachment
All
N
Purchase
L2260
NU EP
Addition to lower extremity, reinforced solid stirrup
						  (Scott-Craig type)
All
N
Purchase
L2265
NU EP
Addition to lower extremity, long tongue stirrup
All
N
Purchase
L2270
NU EP
Addition to lower extremity, varus/valgus correction
						  ("T") strap, padded/lined or malleolus pad
All
N
Purchase
L2275
NU
Addition to lower extremity, varus/valgus correction,
						  plastic modification, padded/lined
21+
N
Purchase
L2280
NU EP
Addition to lower extremity, molded inner boot
All
N
Purchase
L2300
NU EP
Addition to lower extremity, abduction bar (bilateral
						  hip involvement), jointed, adjustable
All
N
Purchase
L2310
NU EP
Addition to lower extremity, abduction bar
						  straight
All
N
Purchase
L2320
NU EP
Addition to lower extremity, nonmolded lacer
All
N
Purchase
L2330
NU EP
Addition to lower extremity, lacer molded to patient
						  model
All
N
Purchase
L2335
NU EP
Addition to lower extremity, anterior swing band
All
N
Purchase
L2340
NU EP
Addition to lower extremity, pretidial shell, molded to
						  patient model
All
N
Purchase
L2350
NU EP
Addition to lower extremity, prosthetic type, (BK)
						  socket, molded to patient model, (used for "PTB" "AFO" orthoses)
All
Y
Purchase
L2360
NU EP
Addition to lower extremity, extended steel
						  shank
All
N
Purchase
L2370
NU EP
Addition to lower extremity, Patten bottom
All
N
Purchase
L2375
NU EP
Addition to lower extremity, torsion control, ankle
						  joint and half solid stirrup
All
N
Purchase
L2380
NU EP
Addition to lower extremity, torsion control, straight
						  knee joint, each joint
All
N
Purchase
L2385
NU EP
Addition to lower extremity, straight knee joint, heavy
						  duty, each joint
All
N
Purchase
L2390
NU EP
Addition to lower extremity, offset knee joint, each
						  joint
All
N
Purchase
L2395
NU EP
Addition to lower extremity, offset knee joint, heavy
						  duty, each joint
All
N
Purchase
L2397
NU
Addition to lower extremity orthosis, suspension
						  sleeve
21+
N
Purchase
L2405
NU EP
Addition to knee joint, lock; drop, stance or swing
						  phase, each joint
All
N
Purchase
L2415
NU EP
Addition to knee lock with integrated release mechanism
						  , (bail, cable or equal, any material, each joint
All
N
Purchase
L2425
NU EP
Addition to knee joint, disc or dial lock for
						  adjustable knee flexion, each joint
All
N
Purchase
L2430
NU EP
Addition to knee joint, ratchet lock for active and
						  progressive knee extension, each joint
All
N
Purchase
L2492
NU EP
Addition to knee joint, lift loop for drop lock
						  ring
All
N
Purchase
L2500
NU EP
Addition to lower extremity, thigh/weight bearing,
						  gluteal/ischial weight bearing, ring
All
N
Purchase
L2510
NU EP
Addition to lower extremity, thigh/weight bearing,
						  quadrilateral brim, molded to patient model
All
N
Purchase
L2520
NU EP
Addition to lower extremity, thigh/weight bearing,
						  quadrilateral brim, custom fitted
All
N
Purchase
L2525
NU EP
Addition to lower extremity, thigh/weight bearing,
						  ischial containment/narrow M-L brim molded to patient model
All
N
Purchase
L2526
NU EP
Addition to lower extremity, thigh/weight bearing,
						  ischial containment/narrow M-L brim, custom fitted
All
N
Purchase
L2530
NU EP
Addition to lower extremity, thigh/weight bearing,
						  lacer, non-molded
All
N
Purchase
L2540
NU EP
Addition to lower extremity, thigh/weight bearing,
						  lacer, molded to patient model
All
N
Purchase
L2550
NU EP
Addition to lower extremity, thigh/weight bearing, high
						  roll cuff
All
N
Purchase
L2570
NU EP
Addition to lower extremity, pelvic control, hip joint,
						  clevis type two position joint, each
All
N
Purchase
L2580
NU EP
Addition to lower extremity, pelvic control, pelvic
						  sling
All
N
Purchase
L2600
NU EP
Addition to lower extremity, pelvic control, hip joint,
						  Clevis type, or thrust bearing free, each
All
N
Purchase
L2610
NU EP
Addition to lower extremity, pelvic control, hip joint,
						  Clevis or thrust bearing, lock, each
All
N
Purchase
L2620
NU EP
Addition to lower extremity, pelvic control, hip joint,
						  heavy duty, each
All
N
Purchase
L2622
NU EP
Addition to lower extremity, pelvic control, hip joint,
						  adjustable flexion, each
All
N
Purchase
L2624
NU EP
Addition to lower extremity, pelvic control, hip joint,
						  adjustable flexion, extension, abduction control, each
All
N
Purchase
L2627
NU EP
Addition to lower extremity, pelvic control, plastic,
						  molded to patient model, reciprocating hip joint and cables
All
N
Purchase
L2628
NU EP
Addition to lower extremity, pelvic control, metal
						  frame, reciprocating hip joint and cables
All
N
Purchase
L2630
NU EP
Addition to lower extremity, pelvic control, band and
						  belt unilateral
All
N
Purchase
L2640
NU EP
Addition to lower extremity, pelvic control, band and
						  belt bilateral
All
N
Purchase
L2650
NU EP
Addition to lower extremity, pelvic and thoracic
						  control, gluteal pad, each
All
N
Purchase
L2660
NU EP
Addition to lower extremity, thoracic control, thoracic
						  band
All
N
Purchase
L2670
NU EP
Addition to lower extremity, thoracic control,
						  paraspinal uprights
All
N
Purchase
L2680
NU EP
Addition to lower extremity, thoracic control, lateral
						  support uprights
All
N
Purchase
L2750
NU EP
Addition to lower extremity orthosis, plating chrome or
						  nickel, per bar
All
N
Purchase
L2755
NU
Addition to lower extremity orthosis, high strength,
						  lightweight material, all hybrid lamination/prepreg composite, per
						  segment
21+
N
Purchase
L2755
NU EP
***(Carbon composite ankles; addition to AFO) Addition
						  to lower extremity orthosis, high strength, lightweight material, all hybrid
						  lamination/prepreg composite, per segment
All
N
Manually Priced
Purchase
L2760
NU EP
Addition to lower extremity orthosis, extension, per
						  extension, per bar (for linear adjustment for growth)
All
N
Purchase
L2770
NU EP
Addition to lower extremity orthosis, any material, per
						  bar or joint
All
N
Purchase
L2780
NU EP
Addition to lower extremity orthosis, non-corrosive
						  finish, per bar
All
N
Purchase
L2785
NU EP
Addition to lower extremity orthosis, drop lock
						  retainer, each
All
N
Purchase
L2795
NU EP
Addition to lower extremity orthosis, knee control,
						  full kneecap
All
N
Purchase
L2800
NU EP
Addition to lower extremity orthosis, knee control,
						  kneecap, medial or lateral pull
All
N
Purchase
L2810
NU EP
Addition to lower extremity orthosis, knee control,
						  condylar pad
All
N
Purchase
L2810
EP
***(Custom night "A" frame-KAFO, torsion control,
						  bilateral night "A" frame) Addition to lower extremity orthosis, knee control,
						  condylar pad
U21
N/A
Purchase
L2820
NU EP
Addition to lower extremity orthosis, soft interface
						  for molded plastic, below knee section
All
N
Purchase
L2830
NU EP
Addition to lower extremity orthosis, soft interface
						  for molded plastic, above knee section
All
N
Purchase
L2840
NU EP
Addition to lower extremity orthosis, tibial length
						  sock, fracture or equal, each
All
N
Purchase
L2850
NU EP
Addition to lower extremity orthosis, femoral length
						  sock, fracture or equal, each
All
N
Purchase
L2999
NU EP
Lower extremity orthoses, NOS
All
N
Manually Priced
L2999
NU EP
***(Unlisted prosthetic devices or orthotic appliances;
						  the manufacturer's invoice must be attached to all claims.) Lower extremity
						  orthoses, NOS
All
Y
Manually Priced
L3000
NU EP
Foot insert, removable, molded to patient model, "UCB"
						  type, Berkeley shell, each
All
N
Purchase
L3002
NU EP
Foot insert, removable, molded to patient model,
						  Plastazote or equal, each
All
N
Manually Priced
L3010
NU EP
Foot insert, removable, molded to patient model,
						  longitudinal arch support, each
All
N
Purchase
L3020
NU EP
Foot insert, removable, molded to patient model,
						  longitudinal/metatarsal support, each
All
N
Purchase
L3030
NU EP
Foot insert, removable, formed to patient foot,
						  each
All
N
Purchase
L3040
NU EP
Foot, arch support, removable, premolded, longitudinal,
						  each
All
N
Purchase
L3050
NU EP
Foot, arch support, removable, premolded, metatarsal,
						  each
All
N
Purchase
L3060
NU EP
Foot, arch support, removable, premolded,
						  longitudinal/metatarsal, each
All
N
Purchase
L3070
NU EP
Foot, arch support, non-removable, attached to shoe,
						  longitudinal, each
All
N
Purchase
L3080
NU EP
Foot, arch support, non-removable, attached to shoe,
						  metatarsal, each
All
N
Purchase
L3090
NU EP
Foot, arch support, non-removable, attached to shoe,
						  longitudinal/metatarsal, each
All
N
Purchase
L3100
NU EP
Hallus-valgus night dynamic splint
All
N
Purchase
L3140
NU EP
UB
***(Bebox foot orthosis club foot abduction orthosis)
						  Foot, abduction rotation bar, including shoes
All
N
Manually Priced
Purchase
L3140
NU
***(Don Joy knee orthosis) Foot, abduction rotation
						  bar, including shoes
21+
Y
Manually Priced
L3150
NU EP
Foot, abduction rotation bar, without shoes
All
N
Purchase
L3150
EP
***(Custom night "A" frame-KAFO, torsion control,
						  bilateral night "A" frame) Foot, abduction rotation bar, without shoes
U21
N/A
Purchase
L3170
NU EP
Foot, plastic heel stabilizer
All
N
Purchase
L3202
EP
Orthopedic shoe, oxford with supinator or pronator,
						  child
U21
N/A
Purchase
L3204
EP
Orthopedic shoe, high-top with supinator or pronator,
						  infant
U21
N/A
Purchase
L3204
NU EP
***(Straight last high-top shoe, each, size 2-8)
						  Orthopedic shoe, high-top with supinator or pronator, infant
All
N
Manually Priced
Purchase
L3204
NU EP
U1
***(Straight last high-top shoe, each, size
						  8½-12) Orthopedic shoe, high-top with supinator or pronator,
						  infant
All
N
Manually Priced
Purchase
L3204
NU EP
U1
***(Regular last high-top shoe, each, size 3-6)
						  Orthopedic shoe, high-top with supinator or pronator, infant
All
N
Manually Priced
Purchase
L3204
NU EP
U1
***(Regular last high-top shoe, each, size
						  8½-12) Orthopedic shoe, high-top with supinator or pronator,
						  infant
All
N
Purchase
L3204
NU EP
U1
***(Reverse last closed toe) Orthopedic shoe, high-top
						  with supinator or pronator, infant
All
N
Manually Priced
Purchase
L3204
NU
***(Orthopedic shoe, high-top, normal last, each, size
						  3-8) Orthopedic shoe, high-top with supinator or pronator, infant
21+
N
Manually Priced
L3204
NU EP
U1
***(Orthopedic shoe, high-top, normal last, each, size
						  8½-12) Orthopedic shoe, high-top with supinator or pronator,
						  infant
All
N
Manually Priced
Purchase
L3206
NU EP
***(Straight last high-top shoe, each, size 2-8)
						  Orthopedic shoe, high-top with supinator or pronator, child
All
N
Manually Priced
Purchase
L3206
NU EP
U1
***(Straight last high-top shoe, each, size
						  8½-12) Orthopedic shoe, high-top with supinator or pronator,
						  child
All
N
Manually Priced
Purchase
L3206
NU EP
U1
***(Regular last high-top shoe, each, size 3-6)
						  Orthopedic shoe, high-top with supinator or pronator, child
All
N
Manually Priced
Purchase
L3206
NU EP
U1
***(Regular last high-top shoe, each, size
						  8½-12) Orthopedic shoe, high-top with supinator or pronator,
						  child
All
N
Purchase
L3206
NU EP
U1
***(Reverse last closed toe) Orthopedic shoe, high-top
						  with supinator or pronator, child
All
N
Manually Priced
Purchase
L3206
NU
***(Orthopedic shoe, high-top, normal last, each, size
						  3-8) Orthopedic shoe, high-top with supinator or pronator, child
21+
N
Manually Priced
L3206
NU EP
U1
***(Orthopedic shoe, high-top, normal last, each, size
						  8½-12) Orthopedic shoe, high-top with supinator or pronator,
						  child
All
N
Manually Priced
Purchase
L3207
NU EP
***(Straight last high-top shoe, each, size 2-8)
						  Orthopedic shoe, high-top with supinator or pronator, junior
All
N
Manually Priced
Purchase
L3207
NU EP
U1
***(Straight last high-top shoe, each, size
						  8½-12) Orthopedic shoe, high-top with supinator or pronator,
						  junior
All
N
Manually Priced
Purchase
L3207
NU EP
U1
***(Regular last high-top shoe, each, size 3-6)
						  Orthopedic shoe, high-top with supinator or pronator, junior
All
N
Manually Priced
Purchase
L3207
NU EP
U1
***(Regular last high-top shoe, each, size
						  8½-12) Orthopedic shoe, high-top with supinator or pronator,
						  junior
All
N
Purchase
L3207
NU EP
U1
***(Reverse last closed toe) Orthopedic shoe, high-top
						  with supinator or pronator, junior
All
N
Manually Priced
Purchase
L3207
NU
***(Orthopedic shoe, high-top, normal last, each, size
						  3-8) Orthopedic shoe, high-top with supinator or pronator, junior
21+
N
Manually Priced
L3207
NU EP
U1
***(Orthopedic shoe, high-top, normal last, each, size
						  8½-12) Orthopedic shoe, high-top with supinator or pronator,
						  junior
All
N
Manually Priced
Purchase
L3207
NU EP
***(Orthopedic shoe, high-top, normal last, each, size
						  8½-12) Orthopedic shoe, high-top with supinator or pronator,
						  junior
All
N
Manually Priced
Purchase
L3208
EP
Surgical boot, each, infant
U21
N/A
Purchase
L3209
EP
Surgical boot, each, child
U21
N/A
Purchase
L3215
NU EP
Orthopedic footwear, woman's shoes, oxford
All
Y
Manually Priced
L3216
NU EP
Orthopedic footwear, woman's shoes, depth inlay
All
Y
Purchase
L3217
NU EP
***(Straight last high-top shoe, each, size 2-8)
						  Orthopedic footwear, woman's shoes, high-top, depth inlay
All
N
Manually Priced
Purchase
L3217
NU EP
U1 U1
***(Straight last high-top shoe, each, size
						  8½-12) Orthopedic footwear, woman's shoes, high-top, depth inlay
All
N
Manually Priced
Purchase
L3217
NU EP
U1
***(Regular last high-top shoe, each, size 3-6)
						  Orthopedic footwear, woman's shoes, high-top, depth inlay
All
N
Manually Priced
Purchase
L3217
NU EP
U1
***(Regular last high-top shoe, each, size
						  8½-12) Orthopedic footwear, woman's shoes, high-top, depth inlay
All
N
Purchase
L3217
NU EP
U1
***(Reverse last closed toe) Orthopedic footwear,
						  woman's shoes, high-top, depth inlay
All
N
Manually Priced
Purchase
L3219
NU EP
Orthopedic footwear, man's shoes, oxford
All
Y
Manually Priced
L3221
NU EP
Orthopedic footwear, man's shoes, depth inlay
All
Y
Purchase
L3222
NU EP
***(Straight last high-top shoe, each, size 2-8)
						  Orthopedic footwear, man's shoes, high-top, depth inlay
All
N
Manually Priced
Purchase
L3222
NU EP
U1
***(Straight last high-top shoe, each, size
						  8½-12) Orthopedic footwear, man's shoes, high-top, depth inlay
All
N
Manually Priced
Purchase
L3222
NU EP
U1
***(Regular last high-top shoe, each, size 3-6)
						  Orthopedic footwear, man's shoes, high-top, depth inlay
All
N
Manually Priced
Purchase
L3222
NU EP
U1
***(Regular last high-top shoe, each, size
						  8½-12) Orthopedic footwear, man's shoes, high-top, depth inlay
All
N
Purchase
L3222
NU EP
U1
***(Reverse last closed toe) Orthopedic footwear, man's
						  shoes, high-top, depth inlay
All
N
Manually Priced
Purchase
L3224
NU
Orthopedic footwear, woman's shoe, Oxford, used as an
						  integral part of a brace (orthosis)
21+
N
Purchase
L3225
NU
Orthopedic footwear, man's shoe, oxford, used as an
						  integral part of a brace (orthosis)
21+
N
Purchase
L3230
NU EP
Orthopedic footwear, custom shoes, depth inlay
All
Y
Purchase
L3250
NU EP
Orthopedic footwear, custom molded shoe, removable
						  inner molded, prosthetic shoe, each
All
Y
Manually Priced
L3253
NU EP
Foot, molded shoe Plastazote (or similar), custom
						  fitted, each
All
Y
Purchase
L3257
NU EP
Orthopedic footwear, additional charge for split
						  size
All
Y
Purchase
L3260
NU EP
Surgical boot/shoe, each
All
N
Purchase
L3265
NU EP
Plastazote sandal, each
All
N
Purchase
L3310
NU EP
Lift, elevation, heel and sole, neoprene, per
						  inch
All
N
Purchase
L3332
NU EP
Lift, elevation, inside shoe, tapered, up to one-half
						  inch
All
N
Purchase
L3334
NU EP
Lift, elevation, heel, per inch
All
N
Purchase
L3350
NU EP
Heel wedge
All
N
Purchase
L3360
NU EP
Sole wedge, outside sole
All
N
Purchase
L3370
NU EP
Sole wedge, between sole
All
N
Purchase
L3400
NU EP
Metatarsal bar wedge, rocker
All
N
Purchase
L3420
NU EP
Full sole and heel wedge, between sole
All
N
Purchase
L3450
NU EP
Heel, SACH cushion type
All
N
Purchase
L3455
NU EP
Heel, new leather, standard
All
N
Purchase
L3465
NU EP
Heel, Thomas with wedge
All
N
Purchase
L3540
NU EP
Orthopedic shoe addition, sole full
All
N
Purchase
L3580
NU EP
Orthopedic shoe addition, convert instep to velcro
						  closure
All
N
Purchase
L3590
NU EP
Orthopedic shoe addition, convert firm shoe counter to
						  soft counter
All
N
Purchase
L3600
NU EP
Transfer for an orthosis from one shoe to another,
						  caliper plate, existing
All
N
Purchase
L3620
NU EP
Transfer of an orthosis from one shoe to another, solid
						  stirrup, existing
All
N
Purchase
L3630
NU EP
Transfer of an orthosis from one shoe to another, solid
						  stirrup, new
All
N
Purchase
L3649
EP
Orthopedic shoe, modification, addition or transfer,
						  NOS
U21
N/A
Manually Priced
L3649
NU EP
U1
***(Unlisted prosthetic devices or orthotic appliances;
						  the manufacturer's invoice must be attached to all claims.) Orthopedic shoe,
						  modification, addition or transfer, NOS
All
Y
Manually Priced
Purchase
L3649
NU EP
***(Orthopedic footwear, wooden sole shoe, each)
						  Orthopedic shoe, modification, addition or transfer, NOS
All
N
Manually Priced
Purchase
L3650
NU EP
SO, figure of eight design abduction re-strainer
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3660
NU EP
SO, figure of eight design, abduction restrainer,
						  canvas and webbing, prefabricated, includes fitting and adjustment
All
N
Purchase
L3670
NU EP
SO, acromio/clavicular (canvas and webbing type)
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3675
NU
SO, vest type abduction restrainer, canvas webbing
						  type, or equal, prefabricated, includes fitting and adjustment
21+
N
Purchase
L3700
NU EP
Elbow orthoses (EO), elastic with stays, prefabricated,
						  includes fitting and adjustment
All
N
Purchase
L3710
NU EP
EO, elastic with metal joints, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L3720
NU EP
EO, double upright with forearm/arm cuffs, free motion,
						  custom fabricated
All
N
Purchase
L3730
NU EP
EO, double upright with forearm/arm cuffs,
						  extension/flexion assist, custom fabricated
All
Y
Purchase
L3740
NU EP
EO, double upright with forearm/arm cuffs, adjustable
						  position lock with active control, custom fabricated
All
Y
Purchase
L3800
NU EP
WHFO, short opponens, no attachments, custom
						  fabricated
All
N
Purchase
L3805
NU EP
WHFO, long opponens, no attachment, custom
						  fabricated
All
N
Purchase
L3807
NU EP
WHFO, without joint(s), prefabricated, includes fitting
						  and adjustments, any type
All
N
Purchase
L3810
NU EP
WHFO, addition to short and long opponens, thumb
						  abduction ("C") bar
All
N
Purchase
L3815
NU EP
WHFO, addition to short and long opponens, second M.P.
						  abduction assist
All
N
Purchase
L3820
NU EP
WHFO, addition to short and long opponens, I.P.
						  extension assist, with M.P. extension stop
All
N
Purchase
L3825
NU EP
WHFO, addition to short and long opponens, M.P.
						  extension stop
All
N
Purchase
L3830
NU EP
WHFO, addition to short and long opponens, M.P.
						  extension assist
All
N
Purchase
L3835
NU EP
WHFO, addition to short and long opponens, M.P. spring
						  extension assist
All
N
Purchase
L3840
NU EP
WHFO, addition to short and long opponens, spring
						  swivel thumb
All
N
Purchase
L3845
NU EP
WHFO, addition to short and long opponens, thumb I.P.
						  extension assist, with M.P. stop
All
N
Purchase
L3850
NU EP
WHO, addition to short and long opponens, action wrist
						  with dorsiflexion assist
All
N
Purchase
L3855
NU EP
WHFO, addition to short and long opponens, adjustable
						  M.P. flexion control
All
N
Purchase
L3860
NU EP
WHFO, addition to short and long opponens, adjustable
						  M.P. flexion control and I.P.
All
N
Purchase
L3900
NU EP
WHFO, dynamic flexor hinge, reciprocal wrist
						  extension/flexion, finger flexion/extension, wrist or finger driven, custom
						  fabricated
All
Y
Purchase
L3901
NU EP
WHFO, dynamic flexor hinge, reciprocal wrist
						  extension/flexion, finger flexion/extension, cable driven, custom
						  fabricated
All
Y
Purchase
L3904
NU EP
WHFO, external powered, electric, custom
						  fabricated
All
Y
Purchase
L3906**
NU EP
WHFO, wrist gauntlet, molded to patient model, custom
						  fabricated
All
N
Purchase
L3907**
NU EP
WHFO, wrist gauntlet with thumb spica, molded to
						  patient model, custom fabricated
All
N
Purchase
L3908
NU EP
WHFO, wrist extension control cock-up, nonmolded,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3910
NU EP
WHFO, Swanson design, prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L3912
NU EP
HFO, flexion glove with elastic finger control,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3915
NU EP
Wrist hand orthosis, includes one or more nontorsion
						  joint(s), elastic bands, turnbuckles, may include soft interface, straps,
						  prefabricated, included fitting and adjustment
All
N
Manually Priced
L3916
NU EP
WHFO, wrist extension (cock-up), with outrigger,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3918
NU EP
HFO, knuckle bender prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L3920
NU EP
HFO, knuckle bender, with outrigger prefabricated,
						  includes fitting and adjustment
All
N
Purchase
L3922
NU EP
HFO, knuckle bender, two segment to flex joints
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3924
NU EP
WHFO, Oppenheimer, prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L3926
NU EP
WHFO, Thomas suspension, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L3928
NU EP
HFO, finger extension, with lock spring, prefabricated,
						  includes fitting and adjustment
All
N
Purchase
L3930
NU EP
WHFO, finger extension, with wrist support,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3932
NU EP
FO, safety pin, spring wire, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L3934
NU EP
FO, safety pin, modified, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L3936
NU EP
WHFO, Palmer prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L3938
NU EP
WHFO, Dorsal wrist, prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L3940
NU EP
WHFO, Dorsal wrist, with outrigger attachment,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3942
NU EP
HFO, reverse knuckle bender, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L3944
NU EP
HFO, reverse knuckle bender, with outrigger,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3946
NU EP
HFO, composite elastic, prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L3948
NU EP
FO, finger knuckle bender, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L3950
NU EP
WHFO, combination Oppenheimer, with knuckle bender and
						  two attachments, prefabricated, includes fitting and adjustment
All
N
Purchase
L3952
NU EP
WHFO, combination Oppenheimer, with reverse knuckle and
						  two attachments, prefabricated, includes fitting and adjustment
All
N
Purchase
L3954
NU EP
HFO, spreading hand, prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L3956
NU
Addition of joint to upper extremity orthosis, any
						  material; per joint
21+
N
Purchase
L3960
NU EP
SEWHO, abduction, positioning, airplane design,
						  prefabricated, includes fitting and adjustment
All
Y
Purchase
L3962
NU EP
SEWHO, abduction positioning, Erb's palsy design,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3963
NU EP
SEWHO, molded shoulder, arm, forearm, and wrist, with
						  articulating elbow joint, custom fabricated
All
Y
Purchase
L3964
NU EP
SEO, mobile arm supports attached to wheelchair,
						  balanced, adjustable, prefabricated, includes fitting and adjustment
All
N
Purchase
L3965
NU EP
SEO mobile arm support attached to wheelchair,
						  balanced, adjustable Rancho type, prefabricated, includes fitting and
						  adjustment
All
Y
Purchase
L3966
NU EP
SEO, mobile arm support attached to wheelchair,
						  balanced, reclining, prefabricated, includes fitting and adjustment
All
Y
Purchase
L3968
NU EP
SEO, mobile arm support attached to wheelchair,
						  balanced, friction arm support, (friction dampening to proximal and distal
						  joints), prefabricated, includes fitting and adjustment
All
Y
Purchase
L3969
NU EP
SEO, mobile arm support, monosuspension arm and hand
						  support, overhead elbow forearm hand sling support, yoke type arm suspension
						  support, prefabricated, includes fitting and adjustment
All
N
Purchase
L3970
NU EP
SEO, addition to mobile arm support elevating proximal
						  arm
All
N
Purchase
L3972
NU EP
SEO , addition to mobile arm support, offset or lateral
						  rocker arm with elastic balance control
All
N
Purchase
L3974
NU EP
SEO, addition to mobile arm support, supinator
All
N
Purchase
L3980
NU EP
Upper extremity fracture orthosis, humeral,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3982
NU EP
Upper extremity fracture orthosis, radius/ulnar
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3984
NU EP
Upper extremity fracture orthosis, wrist,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3985
NU EP
Upper extremity fracture orthosis, forearm, hand with
						  wrist hinge, custom fabricated
All
N
Purchase
L3986
NU EP
Upper extremity fracture orthosis, combination of
						  humeral, radius/ulnar, wrist (example - Colles' fracture), custom
						  fabricated
All
N
Purchase
L3995
NU EP
Addition to upper extremity orthosis sock, fracture or
						  equal, each
All
N
Purchase
L3999
EP
Upper limb orthosis, NOS
U21
N/A
Manually Priced
L3999
NU EP
***(The manufacturer's invoice must be attached to all
						  claims.) Upper limb orthosis, NOS
All
Y
Manually Priced
Manually Priced
L4000
NU EP
Replace girdle for spinal orthosis (CTLSO or SO)
All
Y
Purchase
L4002
NU EP
Replace strap, any orthosis, includes all components,
						  any length, any type
All
N
Manually Priced
L4010
NU EP
Replace trilateral socket brim
All
N
Purchase
L4020
NU EP
Replace quadrilateral socket brim, molded to patient
						  model
All
N
Purchase
L4030
NU EP
Replace quadrilateral socket brim, custom fitted
All
N
Purchase
L4040
NU EP
Replace molded thigh lacer
All
N
Purchase
L4045
NU EP
Replace nonmolded thigh lacer
All
N
Purchase
L4050
NU EP
Replace molded calf lacer
All
N
Purchase
L4055
NU EP
Replace nonmolded calf lacer
All
N
Purchase
L4060
NU EP
Replace high roll cuff
All
N
Purchase
L4070
NU EP
Replace proximal and distal upright for KAFO
All
N
Purchase
L4080
NU EP
Replace metal bands KAFO, proximal thigh
All
N
Purchase
L4090
EP
***(Custom night "A" frame-KAFO, torsion control,
						  bilateral night "A" frame) Replace metal bands KAFO-AFO, calf or distal
						  thigh
U21
N/A
Purchase
L4090
NU EP
Replace metal bands KAFO-AFO, calf or distal
						  thigh
All
N
Purchase
L4100
NU EP
Replace leather cuff KAFO, proximal thigh
All
N
Purchase
L4110
NU EP
Replace leather cuff KAFO-AFO, calf or distal
						  thigh
All
N
Purchase
L4130
NU EP
Replace pretibial shell
All
N
Purchase
L4205
NU EP
Repair of orthotic device, labor component, per 15
						  minutes
All
Y
Manually Priced
Purchase
L4210
NU EP
Repair of orthotic device, repair or replace minor
						  parts
All
Y
Manually Priced
Purchase
L4350
NU EP
Ankle control orthosis, stirrup style, rigid, includes
						  any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L4360
NU EP
Walking boot, pneumatic with or without joints, with or
						  without interface material, prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L4370
NU EP
Pneumatic full leg splint, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L4380
NU EP
Pneumatic knee splint, prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L4392
Replacement soft interface material, static AFO
21+
N
Purchase
L4394
NU
Replace soft interface material, foot drop
						  splint
21+
N
Purchase
L4396
NU
Static AFO, including soft interface material,
						  adjustable for fit, for positioning, pressure reduction, may be used for
						  minimal ambulation, prefabricated, includes fitting and adjustment
21+
N
Purchase
L4398
NU
Foot drop splint, recumbent positioning device,
						  prefabricated, includes fitting and adjustment
21+
N
Purchase
L5999
NU EP
***(Unlisted Prosthetic Devices or Orthotic Appliances;
the manufacturer's invoice must be attached to all claims.
) Lower
						  extremity prosthesis, not otherwise specified
All
Y
Manually Priced
Manually Priced
L7499
NU EP
***(Unlisted Prosthetic Devices or Orthotic Appliances;
the manufacturer's invoice must be attached to all claims.
) Upper
						  extremity prosthesis, not otherwise specified
All
Y
Manually Priced
Manually Priced
L7510
NU EP
UB
Repair of prosthetic device, hourly rate
All
Y
Manually Priced
Purchase
L7520
NU EP
Repair prosthetic device, labor component, per 15
						  minutes
All
Y
Manually Priced
Purchase
L8499
NU EP
***(Unlisted Prosthetic Devices or Orthotic Appliances;
the manufacturer's invoice must be attached to all claims.
)
						  Unlisted procedure for miscellaneous prosthetic services
All
Y
Manually Priced
Purchase
242.192
Specialized Rehabilitative Equipment, All Ages 10-1-07
Procedure codes found in this section must be billed either
				electronically or on paper with modifier
EP
for beneficiaries
				under 21 years of age or modifier
NU
for beneficiaries age 21 and
				over. When a second modifier is listed, that modifier must be used in
				conjunction with either
EP
or
NU
.
Modifiers in this section are indicated by the headings M1 and
				M2. Prior authorization requirements are shown under the heading PA. If prior
				authorization is needed, that information is indicated with a "Y" in the
				column; if not, an "N" is shown.
** Indicates that providers may bill only for individuals
				under age 21.
* Prior authorization is not required when other
				insurance pays at least 50% of the Medicaid maximum allowable reimbursement
				amount.
«%(...) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the
				product.
Specialized Rehabilitative Equipment, All Ages (section
				242.192 )
Procedure Code
M1
M2
Description
PA
Payment Method
E0149
NU EP
***
(4 Wheel Reverse Walker) Walker, heavy
						  duty, wheeled, rigid or folding, any type
N
Purchase
E0163
EP
U1
***(Potty Chair - Sm) Commode chair, stationary, with
						  fixed arms
Y
Purchase
E0168
NU
U1
***(Rehab Shower/Commode Chair) Commode chair, extra
						  wide and/or heavy duty, stationary or mobile, with or without arms, any type,
						  each
Y*
Purchase
E0168
EP
***(Rehab Shower/Commode Chair) Commode chair, extra
						  wide and/or heavy duty, stationary or mobile, with or without arms, any type,
						  each
Y*
Purchase
E0168
NU
***(Adaptive Commode Chair) Commode chair, extra wide
						  and/or heavy duty, stationary or mobile, with or without arms, any type,
						  each
N
Purchase
E0168
EP
UB
***(Adaptive Commode Chair) Commode chair, extra wide
						  and/or heavy duty, stationary or mobile, with or without arms, any type,
						  each
N
Purchase
E0241
NU EP
***(Bolt-on Sm. Grab Bar) Bathroom wall rail,
						  each
N
Purchase
E0241
NU EP
U1 U1
***(Bolt-on Lg. Grab Bar) Bathroom wall rail,
						  each
N
Purchase
E0241
NU EP
U2 U2
***(Bolt-on Med. Grab Bar) Bathroom wall rail,
						  each
N
Purchase
E0245
NU EP
U3 U3
***(30" Bath Chair) Tub stool or bench
N
Purchase
E0245
NU EP
U4 U4
***(38" Bath Chair) Tub stool or bench
N
Purchase
E0245
NU EP
U5 U5
***(47" Bath Chair) Tub stool or bench
N
Purchase
E0245
NU EP
U6 U6
***(56" Bath Chair) Tub stool or bench
N
Purchase
E0245
NU EP
U2 U2
***(Padded Tub Transfer Bench) Tub stool or
						  bench
N
Purchase
E0245
NU EP
UB UB
***(Non-padded tub transfer bench) Tub stool or
						  bench
N
Purchase
E0245
NU EP
***(Adj. Bath Chair w/Back) Tub stool or bench
N
Purchase
E0246
NU EP
***(Clamp-on Tub Grab Bar) Transfer tub rail
						  attachment
N
Purchase
E0638
NU EP
Standing frame system, any size, with or without
						  wheels
Y
Purchase
E0638
EP EP
U1 U2
Standing frame system, any size, with or without
						  wheels
Y
Purchase
E0700
NU EP
***(Chin Guard for Safety Helmet, sm) Safety equipment,
						  e.g., belt, harness or vest
N
Purchase
E0950
NU EP
U1 U1
***(Tray for gait trainer) Wheelchair accessory, tray,
						  each
N
Purchase
E1031**
EP
U5
***(Low Back Activity Chair) Rollabout chair, any and
						  all types with casters five inches or greater
N
Purchase
E1031**
EP
***(Transition Toddler Chair - Sm.) Rollabout chair,
						  any and all types with casters five inches or greater
N
Purchase
E1031**
EP
***(Transition Toddler Chair - Lg.) Rollabout chair,
						  any and all types with casters five inches or greater
Y
Purchase
E1031**
EP
U1
***(Corner Chair w/Tray & Casters - Sm.) Rollabout
						  chair, any and all types with casters five inches or greater
N
Purchase
E1031**
EP
U3
***(Corner Chair w/Tray & Casters - Lg.) Rollabout
						  chair, any and all types with casters five inches or greater
N
Purchase
E1031**
EP
U4
***(Bolster Chair w/Tray, Chest Support & Casters -
						  Sm.) Rollabout chair, any and all types with casters five inches or
						  greater
N
Purchase
E1035**
EP
***(Carrie Seat - Pre School) Multi-positional patient
						  transfer system, with integrated seat, operated by care giver
Y
Purchase
E1035**
EP
U1
***(Carrie Seat - Elementary) Multi-positional patient
						  transfer system, with integrated seat, operated by care giver
Y
Purchase
E1035**
EP
U2
***(Carrie Seat - Jr.) Multi-positional patient
						  transfer system, with integrated seat, operated by care giver
Y
Purchase
E1035
NU EP
U3 U3
***(Carrie Seat - Sm. Adult) Multi-positional patient
						  transfer system, with integrated seat, operated by care giver
Y*
Purchase
E8000
EP
***(14") Gait trainer, pediatric size, posterior
						  support, includes all accessories and components
Y
Purchase
E8000
EP
U1
***(19") Gait trainer, pediatric size, posterior
						  support, includes all accessories and components
Y
Purchase
E8000
EP
U2
***(Intermediate) Gait trainer, pediatric size,
						  posterior support, includes all accessories and components
Y
Purchase
E8001
EP
***(14") Gait trainer, pediatric size, upright support,
						  includes all accessories and components
Y
Purchase
E8001
EP
U1
***(19") Gait trainer, pediatric size, upright support,
						  includes all accessories and components
Y
Purchase
E8001
EP
U2
***(Intermediate) Gait trainer, pediatric size, upright
						  support, includes all accessories and components
Y
Purchase
E8002
EP
***(14") Gait trainer, pediatric size, anterior
						  support, includes all accessories and components
Y
Purchase
E8002
EP
U1
***(19") Gait trainer, pediatric size, anterior
						  support, includes all accessories and components
Y
Purchase
E8002
EP
U2
***(Intermediate) Gait trainer, pediatric size,
						  anterior support, includes all accessories and components
Y
Purchase
The following list of codes may only be billed on paper.
Specialized Rehabilitative Equipment, All Ages (section
				242.192 )
No
National
Code
M1
Local Code
Description
PA
Payment Method
Bill on paper
NU EP
Z1996
Sm. 51" Supine Stander
Y*
Purchase
Bill on paper
NU EP
Z1997
Lg. 71" Supine Stander
Y*
Purchase
Bill on paper
EP
Z1998**
27" Prone Stander
Y
Purchase
Bill on paper
EP
Z1999**
35" Prone Stander
Y
Purchase
Bill on paper
EP
Z2000**
42" Prone Stander
Y*
Purchase
Bill on paper
NU EP
Z2001
50" Prone Stander
Y*
Purchase
Bill on paper
NU EP
Z2002
Adj. Abduction Wedge w/hip stabilizer
N
Purchase
Bill on paper
NU EP
Z2003
Tray for Stander-Prone
N
Purchase
Bill on paper
NU EP
Z2004
Tray for Stander-Supine
N
Purchase
Bill on paper
NU EP
Z2005
Foot Sandals for Standers
N
Purchase
Bill on paper
EP
Z2006**
Up Rite Stander - Sm.
Y
Purchase
Bill on paper
EP
Z2007**
Up Rite Stander - Med.
Y
Purchase
Bill on paper
NU EP
Z2008
Up Rite Stander - Lg.
Y
Purchase
Bill on paper
NU EP
Z2009
Caster Base for Up Rite Stander -Sm.
N
Purchase
Bill on paper
NU EP
Z2010
Caster Base for Up Rite Stander -Med.
N
Purchase
Bill on paper
NU EP
Z2011
Caster Base for Up Rite Stander - Lg.
N
Purchase
Bill on paper
EP
Z2012**
Tumble Form Tri Stander w/Tray -Sm.
Y*
Purchase
Bill on paper
EP
Z2013**
Tumble Form Tri Stander w/Tray - Lg.
Y*
Purchase
Bill on paper
EP
Z2015**
48" Side Lyer
N
Purchase
Bill on paper
EP
Z2016**
72" Side Lyer
N
Purchase
Bill on paper
EP
Z2017**
Tumble Form Feeder Seat - Sm.
N
Purchase
Bill on paper
NU EP
Z2018**
Tumble Form Feeder Seat - Med.
N
Purchase
Bill on paper
EP
Z2019**
Tumble Form Feeder Seat - Lg.
N
Purchase
Bill on paper
EP
Z2021**
Mobile Floor Sitter Med/Lg.
N
Purchase
Bill on paper
EP
Z2038**
Therapy Ball - Sm.
N
Purchase
Bill on paper
EP
Z2039**
Therapy Ball - Med.
N
Purchase
Bill on paper
EP
Z2040**
Therapy Ball - Lg.
N
Purchase
Bill on paper
EP
Z2043**
Seat & Back Pad for Toddler Chairs
Y
Purchase
Bill on paper
EP
Z2044**
Tray for Toddler Chair
Y
Purchase
Bill on paper
EP
Z2045**
14" T&S High Back w/Support Activity Chair
Y
Purchase
Bill on paper
EP
Z2046**
16" T&S High Back w/Support Activity Chair
Y
Purchase
Bill on paper
NU EP
Z2047
Orthopedic Car Seat
Y
Purchase
Bill on paper
NU EP
Z2072
Lg. Wrap Around Bath Support
N
Purchase
Bill on paper
NU EP
Z2073
Sm. Wrap Around Back Support
N
Purchase
Bill on paper
NU EP
Z2074
Lg. Toilet Support w/Hi Back
N
Purchase
Bill on paper
NU EP
Z2075
Sm. Toilet Support w/Hi Back
N
Purchase
Bill on paper
NU EP
Z2077
Flexible Shower Hose
N
Purchase
Bill on paper
NU EP
Z2089
Toilet Seat Reducer Ring (Padded)
N
Purchase
Bill on paper
NU EP
Z2093
Adult Gait Trainer
Y*
Purchase
Bill on paper
EP
Z2094**
Tyke Strider Walker w/2 Wheels
N
Purchase
Bill on paper
EP
Z2095**
Tweener Strider Walker w/2 Wheels
N
Purchase
Bill on paper
EP
Z2096**
Middle Strider Walker w/2 Wheels
N
Purchase
Bill on paper
NU EP
Z2097
Adult Strider Walker w/2 Wheels
N
Purchase
Bill on paper
NU EP
Z2099
4 Wheel Reverse Walker
N
Purchase
Bill on paper
NU EP
Z2100
4 Wheel Reverse Walker
N
Purchase
Bill on paper
NU EP
Z2101
4 Wheel Reverse Walker
N
Purchase
Bill on paper
NU EP
Z2102
4 Wheel Reverse Walker
N
Purchase
Bill on paper
NU EP
Z2104
4 Wheel Front Swivel Reverse Walker
N
Purchase
Bill on paper
NU EP
Z2105
4 Wheel Front Swivel Reverse Walker
N
Purchase
Bill on paper
NU EP
Z2106
4 Wheel Front Swivel Reverse Walker
N
Purchase
Bill on paper
NU EP
Z2107
4 Wheel Front Swivel Reverse Walker
N
Purchase
Bill on paper
NU EP
Z2239
Bath Chair Headrest
N
Purchase
Bill on paper
NU EP
Z2605
Diverter Valve for Handheld Shower
N
Purchase