Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.05-041 - Prosthetics Update #67

Current through Register Vol. 49, No. 6, June, 2024
Section II
Prosthetics
203.000
Documentation Requirements
Prosthetics providers must keep and properly maintain written
				records. At a minimum, the following records must be included in the provider?s
				files.
203.100
General Records
General records that must be available for review
				include:
A. A copy of the Medicaid
			 contract (form DMS-653) for participation in the Arkansas Medicaid
			 Program.
B. Copies of the staff?s
			 licensures and/or certifications.
C. Statistical fiscal and other records
			 necessary for reporting and accountability.
203.200
Documentation in Beneficiary
			 Files
The provider must develop and maintain sufficient written
				documentation to support each service for which billing is made. All entries in
				a beneficiary?s file must be signed and dated by the individual who provided
				the service, along with the individual?s title. The documentation must be kept
				in the beneficiary?s case file.
Documentation should consist of, at a minimum, material that
				includes:
A. An audit trail between
			 the prosthetics provider, the beneficiary, the beneficiary?s primary care
			 physician and the Division of Medical Services.
B. When applicable, documentation including
			 the request for and approval of prior authorization and/or the request for and
			 approval of extension of benefits for services provided.
C. The prescription for prosthetics services,
			 signed and dated by the beneficiary?s primary care physician.
D. The prosthetics provider?s signed and
			 dated:
1. Certification that used equipment
			 is reconditioned, is in good working order and has no defects in workmanship or
			 material
2. The beneficiary?s
			 consent to receive services
3.
			 Notification of termination of prosthetics services
4. Documentation to reflect that necessary
			 training and orientation has been provided to the beneficiary and any other
			 applicable persons
5. Any
			 additional or special documentation, requested in writing, that is needed to
			 provide fair and impartial review of individual cases, requested in
			 writing.
203.300
Record Keeping Requirements
All records must be completed promptly, filed and retained for
				a period of five (5) years from the date of service or until all audit
				questions, appeal hearings, investigations or court cases are resolved,
				whichever is longer.
All documentation must be made available, upon request, to
				authorized representatives of the Arkansas Division of Medical Services, the
				state Medicaid Fraud Control Unit, representatives of the Department of Health
				and Human Services and its authorized agents or officials.
At the time of an audit by the Division of Medical Services
				Medicaid Field Audit Unit, all documentation must be available at the
				provider?s place of business during normal business hours. Requested
				documentation that is stored off-site must be made available to DMS personnel
				within 3 business days.
In the case of recoupment, there will be no more than thirty
				days allowed after the date of the recoupment notice in which additional
				documentation will be accepted. Additional documentation will not be accepted
				after the thirty-day period.
Failure to furnish records upon request may result in sanctions
				being imposed.
211.200
Physician?s Role in the Prosthetics Program
At least once every 6 months, the primary care physician must
				certify the medical necessity for prosthetics services and prescribe them by
				signing and dating a prescription and, when applicable, completing a Medical
				Equipment Request for Prior Authorization and Prescription Form (form DMS-679).
View or print form DMS-679 and instructions for
				completion.
211.300
Prosthetics Service Provision
At least once every 6 months, the prosthetics provider must
				receive a prescription for prosthetics services from the beneficiary?s primary
				care physician and, when applicable:
A. Prepare a Medical Equipment Request for
			 Prior Authorization and Prescription Form (form DMS-679) for individuals 21
			 years of age or older and for specified services for individuals under age 21.
View or print form DMS-679 and instructions for
			 completion.
B.
			 Send the prepared request for prior authorization (form DMS-679) to the
			 beneficiary?s primary care physician for prescription and
C. Send the completed Medical Equipment
			 Request for Prior Authorization and Prescription Form (form DMS-679) to the
			 Utilization Review Section for prior authorization.
View or
			 print Utilization Review Section contact information.
As necessary, the prosthetics provider must:
A. Deliver and set up the prescribed
			 prosthetics equipment in the patient?s home,
B. Teach the patient, families and care
			 givers the correct use and maintenance of prosthetics equipment,
C. Repair prosthetics equipment within 3
			 working days of notification,
D.
			 Retrieve from the patient?s home prosthetics equipment no longer prescribed for
			 the patient and
E. Provide
			 necessary documentation.
211.400
Prescription and Referral
			 Renewal
At least once every 6 months, but within 30 working days before
				the end of currently prescribed or prior authorized prosthetics services, the
				prosthetics provider must obtain a new prescription from the beneficiary?s
				primary care physician and, if applicable, send a new Medical Equipment Request
				for Prior Authorization and Prescription Form (form DMS-679) to the Utilization
				Review Section. The primary care physician must initially review form DMS-679
				and, based upon the physician?s certification of medical necessity, prescribe
				prosthetics services. Form DMS-679 must then be reviewed by the Utilization
				Review Section and prosthetics services must be prior authorized. If
				prosthetics services are prescribed, and when applicable, prior authorized,
				prosthetics services may be furnished for a maximum of 6 months from the date
				of the prescription.
211.500
Service Initiation
			 Delays
If all prescribed prosthetics services are not begun by the
				prosthetics provider within 30 working days of the prescription date, the
				prosthetics provider must notify the beneficiary and the beneficiary?s primary
				care physician in writing and explain the delay. The provider must retain
				documentation justifying the service delay.
211.600
Termination of Services
If prosthetics services are terminated, the provider must
				notify the beneficiary?s primary care physician and the beneficiary (if not
				deceased) in writing, within 10 working days of the termination, documenting
				the effective date of and reasons for the termination.
211.700
Exclusions
Services that are not covered under the Arkansas Medicaid
				Prosthetics Program include but are not limited to:
A. Over-the-counter items provided through
			 the Arkansas Medicaid Pharmacy Program (except as specified).
B. Over-the-counter drugs (except as
			 specified).
C. Products that bear
			 the Federal legend ?Caution: Federal Law Prohibits Dispensing Without A
			 Prescription? (except as specified).
D. Specialized wheelchair equipment that has
			 been previously purchased by any payer. Specialized wheelchair equipment may
			 not be reordered unless the patient?s condition changes and necessitates a
			 change in prescription. This change in condition must be thoroughly
			 documented.
E. Wheelchairs for
			 individuals under 21 years of age within two years of the purchase of a
			 specialized wheelchair.
F.
			 Wheelchairs for individuals age 21 and over within five years of the purchase
			 or rental of a wheelchair.
G.
			 Foodstuffs.
H.
			 Hyperalimentation.
I. Services that
			 duplicate any other service provided to the patient or that replace existing
			 patient supports.
211.800
Electronic Filing of Extension
			 of Benefits
Form DMS-699, titled Request for Extension of Benefits, serves
				as both a request form and a notification of approval or denial of extension of
				benefits. If the benefit extension is approved, the form returned to the
				provider will contain a Benefit Extension Control Number. The approval
				notification will also list the procedure codes approved for benefit extension,
				the approved dates or date-of-service range and the number of units of service
				(or dollars, when applicable) authorized.
Upon notification of a benefit extension approval, providers
				may file the benefit extension claims electronically, entering the assigned
				Benefit Extension Control Number in the Prior Authorization (PA) number field.
				Subsequent benefit extension requests to UR will be necessary only when the
				Benefit Extension Control Number expires or when a patient?s need for services
				unexpectedly exceeds the amount or number of services granted under the benefit
				extension.
212.000
Services Provided
212.100
Diapers and Underpads for Individuals Age 3 and Older
Diapers and underpads are covered by the Arkansas Medicaid
				Program but are benefit limited and must be medically necessary.
A. Medical Necessity
Diaper services must be medically necessary. Only patients with
				a medical condition that results in incontinence of the bladder and/or bowel
				may receive diapers through the Home Health and Prosthetics Programs. This
				coverage does not apply to infants who would be in diapers regardless of their
				medical condition. Medicaid does not cover underpads or diapers for
				beneficiaries under the age of 3 years.
B. Benefit Limit
The benefit limit for diapers and underpads is $130.00 per
				month, per beneficiary, for diapers of any size and underpads. The benefit
				limit applies to any diaper or underpad, or any combination, whether provided
				through the Prosthetics Program, the Home Health Program or both. The limit on
				diapers and underpads is separate from the limit established for home health
				and durable medical equipment (DME) medical supplies.
The benefit may be extended with proper documentation.
C. Extension of Benefits for
			 Diapers and Underpads
To obtain an extension of benefits for diapers and underpads,
				the following information must be submitted to the Prosthetics Services
				Reviewer, DMS Utilization Review.
View or print the DMS
				Utilization Review contact information
.
1. A Medicaid claim form for each month for
			 which extension of benefits for diapers and underpads is being requested.
View or print form DMS-699.
2. An invoice for each diaper or underpad
			 item included in the request showing the actual cost to the prosthetics
			 provider for each item.
3.
			 Documentation supported by the medical record substantiating the medical
			 necessity of an extension of benefits.
212.200
Durable Medical Equipment
			 (DME), All Ages
Durable medical equipment (DME) is equipment that can withstand
				repeated use and is used to serve a medical purpose.
Depending on the item involved, DME may be purchased for or by
				a beneficiary or may be rented. The equipment may be new or, in special
				circumstances, used equipment.
212.201
(DME) Apnea Monitors for Infants Under Age 1
Arkansas Medicaid covers apnea monitors only for infants less
				than one (1) year of age. Use of the apnea monitor must be medically necessary
				and prescribed by a physician.
A primary care physician (PCP) is not required until an
				infant's Medicaid eligibility has been determined. No PCP referral for medical
				services is required for retroactive eligibility periods.
Prior authorization is not required for the initial one-month
				period of use of the monitor. If the apnea monitor is needed longer than an
				initial one-month period, prior authorization will be required.
Prior authorization of the apnea monitor is required after an
				infant has been monitored for one month. A new referral and prescription is
				required. Compliance during the initial thirty-day period and proof of medical
				necessity for the continuation of monitoring must be documented.
After the initial thirty-day period, the prescribing physician
				must sign form DMS-679?Medical Equipment Request for Prior Authorization and
				Prescription. The physician?s signature must be an original, not a stamp. When
				an apnea monitor is prescribed during a hospital discharge, the physician
				ordering the apnea monitor must be a neonatologist or pulmonologist.
As necessary, the PCP?s name and provider number must also be
				indicated on form DMS-679. The PCP's signature is not required on the initial
				certification but he or she must sign all re-certifications.
Documentation from the physician describing the education of
				the family regarding their understanding of the importance of the apnea monitor
				must be included after the initial one-month period.
The following criteria, which follow the guidelines set by the
National Institute of Health Consensus Statement on Infantile Apnea on
				Home Monitoring, Consensus Development Conference Statement, September
				29-October 1, 1986
, will be utilized in evaluating the need for an
				apnea monitor after the initial one-month period:
A. Cardio-respiratory monitoring for certain
			 groups of infants at high risk for sudden death is medically indicated. The
			 following indications will determine medical necessity.
1. Infants with one or more severe Apparent
			 Life Threatening Events (ALTEs) requiring mouth-to-mouth resuscitation or
			 vigorous stimulation
2. Symptomatic
			 pre-term infant
3. Siblings with
			 two or more SIDS victims
4. Infants
			 with central hypoventilation
B. Other groups with the following
			 indications will be considered on a case-by-case basis:
1. Infants with less severe ALTEs
2. Infants with tracheotomies
3. Infants born of cocaine- or opiate-abusing
			 mothers
4. Asymptomatic pre-term
			 infants with certain residual diseases may be considered for
			 monitoring
C.
			 Pneumograms will not be considered as screening tools.
D. Caregivers should receive:
1. A psychosocial assessment of the
			 caregiver
2. Informed consent
			 process
3. Guidance to help prepare
			 the caregiver for the demands of home monitoring
4. Training and demonstrated proficiency in
			 infant CPR and resuscitation methods
5. Written guidelines on home
			 monitoring
6. Discharge planning,
			 including discussion of follow-up services and procedures for
			 discontinuation
E. For
			 an apnea monitor to be discontinued in the home, one or more of the following
			 conditions must be met:
1. Four (4) weeks
			 apnea free or one normal download
2. Patient off respiratory stimulants for two
			 consecutive weeks
3. 48-week
			 adjusted gestational age
F. The caregiver must understand that he or
			 she will be financially liable if he or she does not return the equipment to
			 the DME company when the infant no longer requires monitoring according to the
			 discontinuation criteria listed above.
Prior authorization for the apnea monitor must be submitted on
				form DMS-679, Medical Equipment Request for Prior Authorization and
				Prescription, to Utilization Review.
View or
				print
form DMS-679 and instructions for completion.
				View or print Utilization Review Section contact
				information.
212.202
(DME) Augmentative Communication Device (ACD), All Ages
The augmentative communication device (ACD) is covered for
				individuals of all ages. Coverage for beneficiaries under 21 years of age must
				result from an EPSDT screen. There is a $7,500.00 lifetime benefit for
				augmentative communication devices. When a beneficiary who is under age 21 has
				met the lifetime benefit and it is determined that additional equipment is
				medically necessary, the provider can request an extension of benefits by
				submitting the DMS-699 form.
View or print form
				DMS-699.
The ACD is also covered for Medicaid beneficiaries 21 years old
				and older. Prior authorization is required on the device and on repairs of the
				device. For individuals who are age 21 and above, there is a $7,500.00 lifetime
				benefit without benefit extensions.
The Arkansas Medicaid Program will not cover ACDs that are
				prescribed solely for social or educational development.
Training in the use of the device is not included and is not a
				covered cost.
Prior authorization
must
be requested for repairs
				of equipment or associated items after the expiration of the initial
				maintenance agreement.
The following information must be submitted when requesting
				prior authorization for ACDs for Medicaid beneficiaries.
Submit form DMS-679?Medical Equipment Request for Prior
				Authorization and Prescription.
View or print form DMS-679
				and instructions for completion.
The form should be
				accompanied by:
A. A current
			 augmentative communication evaluation completed by a multidisciplinary team
			 consisting of, at least, a speech/language pathologist and an occupational
			 therapist. The team may consist of a physical therapist, regular and special
			 educators, caregivers and parents. The speech-language pathologist must lead
			 the team and sign the ACD evaluation report. (For the qualifications of the
			 team members, see the Hospital/Critical Access Hospital/End Stage Renal Disease
			 provider manual.)
1. The team must use an
			 interdisciplinary approach in the evaluation, incorporating the goals,
			 objectives, skills and knowledge of various disciplines. The team must use at
			 least three ACD systems, with written documentation of each usage included in
			 the ACD assessment.
2. The
			 evaluation report must indicate the medical reason for the ACD. The report must
			 give specific recommendations of the system and justification of why one system
			 is more appropriate than another.
3. The evaluation report must be submitted to
			 the prosthetics provider who will request prior authorization for the
			 ACD.
B. Written denial
			 from the insurance company if the individual has other insurance.
This information
must
be submitted to the
				Utilization Review Section of the Division of Medical Services.
View or print Utilization Review Section contact
				information.
Benefit Limit
There is a $7500 lifetime benefit for augmentative
				communication devices. When the beneficiary under age 21 has met the limit and
				it is determined that additional equipment is necessary, the provider may
				request an extension of benefits.
In order to obtain an extension of the $7,500.00 lifetime
				benefit for beneficiaries under 21 years of age, a medical necessity
				determination for additional equipment is required. The provider must submit a
				Request for Extension of Benefits (form DMS-699), a completed Medicaid claim
				and medical records substantiating medical necessity that the beneficiary
				cannot function using his or her existing equipment and whether the equipment
				can be repaired or needs repair. The information must be sent to Benefit
				Extension Requests, Utilization Review Section.
View or print
				form DMS-699, titled Request for Extension of Benefits
.
View or print the Benefit Extension Requests Utilization
				Review Section contact information
.
The provider will be notified in writing of the approval or
				denial of the request for extended benefits.
212.203
(RESERVED)
212.204
(DME) Electronic Blood
			 Pressure Monitor and Cuff for Individuals Under Age 21
Arkansas Medicaid covers the automatic electronic blood
				pressure monitor for individuals under age 21 as a rental-only item. A provider
				must substantiate that an accurate blood pressure reading cannot be obtained by
				using a regular blood pressure monitor. Providers must also supply one
				disposable blood pressure cuff each month.
Prior authorization is required for the use of this item.
				Providers may request prior authorization by submitting the Medical Equipment
				Request for Prior Authorization and Prescription form (form DMS-679) to the
				Utilization Review Section.
View or print Form DMS-679 and
				instructions for completion. View or print Utilization Review Section contact
				information.
212.205
(DME) Enteral Nutrition
			 Infusion Pump and Enteral Feeding Pump Supply Kit for Individuals Under Age
			 21
The request for an enteral nutrition pump is covered on a
				case-by-case basis for individuals under age 21 who require supplemental
				feeding because of medical necessity. Sufficient medical documentation must be
				provided to establish that the enteral nutrition infusion pump is medically
				necessary (e.g., supplemental feeding must be given over an extended period of
				time due to reflux, cystic fibrosis, etc.). The PCP or appropriate physician
				specialist must prescribe the pump, citing the medical reason that bolus feeds
				are inappropriate.
Reimbursement for use in the home may be made for the pump
				supply kit when the feeding method involves an enteral nutrition infusion pump.
				The pump supply kit and the infusion pump require prior authorization from the
				Utilization Review Section of the Division of Medical Services using form
				DMS-679, Medical Equipment Request for Prior Authorization and Prescription.
View or print Utilization Review Section contact information.
				View or print form DMS-679 and instructions for
				completion.
The enteral feeding pump supply kit, necessary for the
				administration of the nutrients when the feeding method involves an enteral
				nutrition infusion pump, is reimbursed on a per-unit basis with 1 day equaling
				1 unit of service. A maximum of 1 unit per day is allowed. The pump supply kit
				includes pump sets, containers and syringes necessary for administration of the
				nutrients.
Reimbursement for the enteral nutrition infusion pump is based
				on a rent-to-purchase methodology. Each unit reimbursed by Medicaid will apply
				towards the purchase price established by Medicaid. Reimbursement will only be
				approved for new equipment. Used equipment will not be prior authorized.
View or print form DMS-679 and instructions for
				completion.
Requests for prior authorization for enteral pump repairs must
				be mailed to the Utilization Review Section, Division of Medical Services. Form
				DMS-679, Medical Equipment Request for Prior Authorization and Prescription,
				must be used to request prior authorization.
View or print
				form DMS-679 and instructions for completion.
212.206
(DME) Home Blood
			 Glucose Monitor, Pregnant Women Only, All Ages
Arkansas Medicaid covers the home blood glucose monitor for
				pregnant women of all ages. Prior authorization is not required for use of this
				device.
A. Patient Eligibility
1. Pregestational diabetes. Women on an oral
			 hypoglycemic or insulin when the pregnancy is diagnosed.
2. Women that are being followed by a
			 physician for elevated fasting hyperglycemia, but not on an oral hypoglycemic
			 or insulin when the pregnancy is diagnosed.
3. Women demonstrating glucose intolerance
			 during the pregnancy as demonstrated by an elevated three-hour glucose
			 tolerance test.
B.
			 Criteria for glucose intolerance
1.
			 Demonstration of an elevated one-hour glucose tolerance test of greater than
			 140 mg/deciliter on a non-fasting value.
2. Elevation of two or more values on a
			 three-hour glucose tolerance test above the accepted cut-off points of:
a. Fasting, less than 105
b. One-hour, less than 190
c. Two-hour, less than 165
d. Three-hour, less than 145
212.207
(DME) Insulin Pump and Supplies, All Ages
Insulin pumps and supplies are covered by Arkansas Medicaid for
				individuals of all ages.
Prior authorization is required for the insulin pump. A
				prescription and proof of medical necessity are required. The patient must be
				educated on the use of the pump, but the education is not a covered
				service.
Insulin is also not covered because it is covered in the
				prescription drug program.
The following criteria will be utilized in evaluating the need
				for the insulin pump:
A.
			 Insulin-dependent diabetes that is difficult to control.
B. Fluctuation in blood sugars causing both
			 high and low blood sugars in a patient on at least 3. if not 4, injections per
			 day.
C. Patient?s motivation level
			 in controlling diabetes and willingness to do frequent blood glucose
			 monitoring.
D. Patient?s ability to
			 learn how to use the pump effectively. This will have to be evaluated and
			 documented by a professional with experience in the use of the pump.
E. Determination of the patient?s suitability
			 to use the pump should be made by a diabetes specialist or
			 endocrinologist.
F. Patients not
			 included in one of these categories will be considered on an individual basis.
Prior authorization requests for the insulin pump and supplies
				must be submitted on Form DMS-679, Medical Equipment Request for Prior
				Authorization and Prescription, to Utilization Review.
View or print form DMS-679 and instructions
				for completion. View or print Utilization Review Section contact
				information.
212.208
(RESERVED)
212.209
(DME) MIC-KEY Skin Level
			 Gastrostomy Tube (Mic-Key Button) and Supplies for Individuals Under Age
			 21
The Arkansas Medicaid Program reimburses for the MIC-KEY Skin
				Level Gastrostomy Tube (Mic-Key button) and supplies for Medicaid-eligible
				individuals under age 21. Prior authorization (PA) from the Utilization Review
				Section is required.
The procedure codes may also be authorized for
				Medicaid-eligible children ages 0 through 5 years who receive their sole-source
				enteral formula through the Women, Infants and Children (WIC) Program. The
				Utilization Review Section must be contacted to receive the prior
				authorization.
When requesting prior authorization, form DMS-679, Medical
				Equipment Request for Prior Authorization and Prescription, must be completed
				and sent, along with sufficient medical documentation, to the Utilization
				Review Section.
The MIC-KEY Kit is benefit limited to 2 per state fiscal year
				(SFY). The accessories, extension sets and adapters are covered under the $250
				medical supply benefit limit.
Benefit extensions will be considered on a case-by-case basis
				if proven to be medically necessary. Prior authorization must be obtained from
				the Utilization Review Section for any extensions using form DMS-679.
View or print Utilization Review Section contact information.
				View or print form DMS-679 and instructions for
				completion.
212.210
(RESERVED)
212.211
(RESERVED)
212.212
(DME) Specialized
			 Rehabilitative Equipment, All Ages
Arkansas Medicaid covers specialized rehabilitative equipment
				for Medicaid-eligible individuals of all ages.
Some items of specialized equipment require prior authorization
				from the Utilization Review Unit.
View or print form DMS-679 and instructions
				for completion. View or print Utilization Review Section contact
				information.
212.213
(DME) Specialized Wheelchairs and Wheelchair Seating
			 Systems for Individuals Age Two Through Adult
Arkansas Medicaid covers specialized wheelchairs and wheelchair
				seating systems for individuals age two through adulthood.
Some items of specialized equipment require prior authorization
				from the Utilization Review Unit.
View or print form DMS-679 and instructions
				for completion. View or print Utilization Review Section contact
				information.
212.214
(RESERVED)
212.300
Medical Supplies, All
			 Ages
The Arkansas Medicaid Program reimburses home health providers
				and prosthetics providers for covered medical supplies up to a maximum of
				$250.00 per month, per beneficiary. The $250.00 may be provided by the Home
				Health Program, the Prosthetics Program or a combination of the two.
A beneficiary may not receive more than a total of $250.00 of
				supplies per month unless an extension has been granted. Extensions will be
				considered for beneficiaries under age 21 in the Child Health Services (EPSDT)
				Program if documentation verifies medical necessity.
A provider must request an extension of the benefit limit for a
				Medicaid beneficiary under age 21 by completing the Request for Extension of
				Benefits for Medical Supplies for Medicaid Recipients Under Age 21 (form
				DMS-602.)
View or print form DMS-602 and instructions for
				completion
.
The Arkansas Medicaid Program covers medical supplies using a
				specific HCPCS procedure code for each specific item. Only supply items that
				are listed and have a corresponding payable HCPCS procedure code are
				covered.
212.400
Nutritional Formulae for Individuals Under Age 21
Nutritional formulae may be covered by the Arkansas Medicaid
				Program when prescribed by a physician and documented as medically
necessary for beneficiaries under age 21 participating in the
				Child Health Services (EPSDT) Program
.
The Women, Infants
				and Children Program (WIC) must be accessed first for individuals who are age 0
				through age 5.
Nutritional formula may not be billed for the same beneficiary
				by more than one provider or in more than one program (e.g., Prosthetics and
				Hyperalimentation) for the same date of service.
Covered formulae represent the nutritional supplements most
				requested for medical purposes. However, if none of the formulae are
				appropriate and another formula is prescribed by a physician as a result of
				Child Health Services (EPSDT) screening, the prescribed formula will be
				reviewed for medical necessity.
Formulae are covered as nutritional supplements rather than as
				the sole source of nutrition. 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.
One unit of service equals 100 calories with an allowable
				maximum of 30 units per day. This is a separate benefit limit from the limit
				established for medical supplies. Supplies provided in conjunction with the
				nutritional formulae through the Prosthetics Program must be billed under the
				medical supply codes, if those supplies are covered by the program.
There are certain nutritional formulae available to eligible
				beneficiaries through the WIC Program and the Food Stamp Program. These two
				programs should be accessed by beneficiaries prior to requesting Medicaid
				reimbursement for nutritional formulae. The coverage of these formulae through
				the Medicaid Program is limited to beneficiaries requiring nutrition therapy
				due to medical necessity and only when prescribed by a
				physician.
212.500
Food Thickeners, All Ages
Arkansas Medicaid covers food thickeners for Medicaid-eligible
				individuals who have impaired swallowing and a risk of food aspiration.
Food thickeners are not subject to the $250 benefit limit for
				other medical supplies.
212.600
Orthotic Appliances and
			 Prosthetic Devices, All Ages
A. The
			 Arkansas Medicaid Program covers orthotic appliances and prosthetic devices for
			 individuals under age 21 in the Child Health Services (EPSDT) Program.
			 Providers of orthotic appliances and prosthetic devices may be reimbursed by
			 the Arkansas Medicaid Program when the items are prescribed by a physician and
			 documented as medically necessary for beneficiaries under age 21 participating
			 in the Child Health Services (EPSDT) Program.
1. No prior authorization is required to
			 obtain these services for individuals under age 21.
2. No benefit limits apply to orthotic
			 appliances and prosthetic devices for individuals under age 21.
B. Arkansas Medicaid covers
			 orthotic appliances for individuals age 21 and over. The following provisions
			 must be met before services may be provided.
1. Prior authorization is required for
			 orthotic appliances valued at or above the Medicaid maximum allowable
			 reimbursement rate of $500.00 per item for use by individuals age 21 and over.
			 Prior authorization may be requested by submitting the Medical Equipment
			 Request for Prior Authorization and Prescription Form (form DMS-679) to the
			 Utilization Review (UR) Section.
View or print form DMS-679
			 and instructions for completion. View or print Utilization Review Section
			 contact information.
2. For individuals age 21 and over, a benefit
			 limit of $3,000 per state fiscal year (SFY; July 1 through June 30) has been
			 established for reimbursement for orthotic appliances. No extension of benefits
			 will be granted.
The following restrictions apply to the coverage of orthotic
				appliances for individuals age 21 and over:
a. Orthotic appliances may not be replaced
			 for 12 months from the date of purchase. If a patient?s condition warrants a
			 modification or replacement and the $3000.00 SFY benefit limit has not been
			 met, the provider may submit documentation to the Division of Medical Services,
			 Utilization Review Section, to substantiate medical necessity. The Utilization
			 Review Section will issue a prior authorization number. Section 221.000 of this
			 provider manual may be referenced for information regarding prior authorization
			 procedures.
b. Custom-molded
			 orthotics are not covered for a diagnosis of carpal tunnel syndrome prior to
			 surgery.
C.
			 Arkansas Medicaid covers prosthetic devices for individuals age 21 and over;
			 however, the following provisions must be met before services may be provided.
1. Prior authorization will be required for
			 prosthetic device items valued at or in excess of the $1000.00 per item
			 Medicaid maximum allowable reimbursement rate for use by individuals age 21 and
			 over. Prior authorization may be requested by submitting the Medical Equipment
			 Request for Prior Authorization and Prescription form (form DMS-679) to the
			 Utilization Review (UR) Section. View or print form DMS-679 and instructions
			 for completion.
2. For individuals
			 age 21 and over, a benefit limit of $20,000 per SFY has been established for
			 reimbursement for prosthetic devices. No extension of benefits will be
			 granted.
3. The following
			 restrictions apply to coverage of prosthetic devices for individuals age 21 and
			 over:
a. Prosthetic devices may be replaced
			 only after five years have elapsed from their date of purchase. If the
			 patient?s condition warrants a modification or replacement, and the $20,000 SFY
			 benefit limit has not been met, the provider may submit documentation to the
			 Division of Medical Services, Utilization Review Section, to substantiate
			 medical necessity. The Utilization Review Section will issue a prior
			 authorization number. Section 220.000 of this provider manual may be referenced
			 for information regarding prior authorization procedures.
b. Myoelectric prosthetic devices may be
			 purchased only when needed to replace myoelectric devices received by
			 individuals who were under age 21 when they received the original
			 device.
D.
			 Six forms, listed below, are available for evaluating the need of individuals
			 age 21 and over for orthotic appliances and prosthetic devices, and prescribing
			 the needed appliances and equipment. The Medicaid Program does not require
			 providers to use the forms, but the information the forms are designed to
			 collect is required by Medicaid to process requests for prior authorization of
			 orthotic appliances and prosthetic devices for individuals aged 21 and over.
The appropriate forms (or the required information in a
				different format) must accompany the form DMS-679.
View or
				print Medical Equipment Request for Prior Authorization and Prescription form
				DMS-679 and instructions for completion
.
The forms and their titles are as follows:
1. DMS-646
Evaluation Form Lower Limb.
View or
						  print form DMS-646
.
2. DMS-647
Gait Analysis: Full Body.
View or
						  print form DMS-647
.
3. DMS-648
Prosthetic-Orthotic Upper-Limb Amputee Evaluation.
View or print form DMS-648
.
4. DMS-649
Upper-Limb Prosthetic Prescription.
View or print form DMS-649
.
5. DMS-650
Prosthetic-Orthotic Lower-Limb Amputee Evaluation.
View or print form DMS-650
.
6. DMS-651
Lower-Limb Prosthetic Prescription.
View or print form DMS-651
.
212.700
Oxygen and Oxygen Supplies,
			 All Ages
A prescription for oxygen must be accompanied by a current
				arterial blood gas (ABG) laboratory report from a certified laboratory or the
				patient?s attending physician. A current laboratory report is defined as one
				performed within a maximum of 30 days prior to the prescription for
				oxygen.
A prescription for oxygen must specify the oxygen flow rate,
				frequency and duration of use, estimate of the period of need for oxygen and
				method of delivery of oxygen to the patient (e.g., two liters per minute, 10
				minutes per hour, by nasal cannula for a period of two months). A prescription
				containing only ?oxygen PRN? is not sufficient.
The following medical criteria will be utilized in evaluating
				coverage of oxygen:
A. Chronic
			 Respiratory Disease
1. Continuous oxygen
			 therapy Resting Pa02 less than 55 mm Hg
2. Nocturnal oxygen therapy Resting
			 Pa02 less than 60 mm Hg
3. Exercise oxygen therapy
Pa02 with exercise less than 55 mm
				Hg
B. Congestive
			 Heart Failure
Symptomatic at rest, with Pa02 less than
				60 mm Hg
C. Carcinoma of
			 the Lung Resting Pa02 less than 60 mm Hg
D. Others
Reviewed on an individual basis
E. Children
O2 saturation below 94% by pulse
				oximeter with elevated PCO2 by capillary blood gas or
				end-tidal CO2 on two separate occasions.
The prior authorization request for all oxygen and respiratory
				equipment must be submitted on form DMS-679, Medical Equipment Request for
				Prior Authorization and Prescription, to the Utilization Review Section for
				individuals of all ages.
View or print form DMS-679 and
				instructions for completion.
221.200
Filing
			 for Prior Authorization with the Utilization Review Section
The original and the first copy of the Medical Equipment
				Request for Prior Authorization and Prescription Form (form DMS-679) must be
				forwarded to the Division of Medical Services, Utilization Review Section.
View or print Utilization Review Section contact
				information.
The third copy should be retained in the provider?s
				records.
221.300
Approvals of Prior Authorization
The Utilization Review Section reviews requests for prior
				authorization. If necessary, the Utilization Review Section may request
				additional information.
When a request is approved, a prior authorization control
				number will be assigned by the Utilization Review Section. Determination of
				?purchase,? ?rental only,? or ?capped rental? will be made and an expiration
				date for ?rental only? and ?capped rental? items will be assigned. This
				information will be indicated on the copy of the form DMS-679 that is returned
				to the provider from Utilization Review within 30 working days of receipt of
				the prior authorization request.
Prior authorization may only be approved for a maximum of six
				(6) months (180 days) for individuals of all ages. Within 30 working days
				before the end of currently prior authorized prosthetics services, the
				prosthetics provider must obtain a new prescription. If applicable, the
				provider must prepare and send a new Medical Equipment Request for Prior
				Authorization and Prescription Form (Form DMS-679), signed by the physician, to
				the Utilization Review Section.
The effective date of the prior authorization will be the date
				on which the beneficiary?s physician prescribed prosthetics services or the day
				following the last day of the previously prior authorized time period,
				whichever comes last.
Providers should note the following authorization process
				exception.
Prior authorization numbers for ?capped rental? items will be
				effective for the entire ?capped rental? time period of 15 months. Therefore,
				only one prior authorization number is needed.
A. Providers may use the one prior
			 authorization number for billing of ?capped rental? items for all 15
			 months.
B. Previous prior
			 authorization for an item will count toward the total 15-month
			 period.
C. Providers must resubmit
			 a request for prior authorization after the first 180 days.
D. Necessary information will be indicated on
			 the copy of the form DMS-679 that is returned to the provider within 30 working
			 days of receipt of the prior authorization request.
221.400
Denial of Prior Authorization
			 Request
Denied requests will be returned to the provider within 30
				working days of receipt of the prior authorization request, with the reason for
				denial indicated.
232.000
Specialized Wheelchair, Seating and Rehabilitative Equipment
Reimbursement for Repairs
Reimbursement for
repairs
of specialized
				wheelchairs will be the manufacturer?s list price for parts listed less 40%
				manual equipment (dealer discount), 30% power equipment (dealer discount), plus
				35% (profit margin), plus labor billed by the unit (15 min. = 1 unit). A
				maximum of twenty (20) units (20 units = 5 hours of labor) per date of service
				is allowable.
Any applicable pages from the manufacturer?s catalog
				and the manufacturer?s invoice for parts must be attached to the claim
				form
.
Reimbursement for specialized wheelchair equipment, seating and
				rehab items
requiring manual pricing
is calculated
				using the manufacturer?s current published suggested retail price less 15%.
Any applicable pages from the manufacturer?s catalog that reflect a
				description and the manufacturer?s current published suggested retail price
				must be attached to the claim
.
Kaye Products will be reimbursed at a set rate; therefore, the
				Kaye Products (procedure codes
E1031
, modifiers
EP
,
U1
;
E1031
, modifiers
EP
,
U3
; and
E1031
, modifiers
EP
,
U4
) may be billed electronically.
233.000
Orthotic and Prosthetic
			 Reimbursement for Repairs
Providers must bill for the repair of orthotic appliances and
				prosthetic devices utilizing the procedure codes listed in the table below. One
				unit of service equals 15 minutes. A maximum of 20 units of service is allowed
				per date of service.
Any applicable pages from the manufacturer?s
				catalog and the manufacturer?s invoice for parts must be attached to all repair
				claims
.
National Code
Required Modifier
Description
L4205
?
Repair of orthotic appliances and prosthetic devices
						  (non-EPSDT)
L4210
?
L7510
?
L7520
?
L4205
EP
Repair of orthotic appliances and prosthetic devices
						  (EPSDT)
L4210
EP
L7510
EP, UB
L7520
?
Reimbursement for orthotic appliances and prosthetic devices
				requiring
manual pricing
will be calculated using the
				manufacturer?s invoice price plus 10%.
The manufacturer invoice
				must be attached to all repair claims
.
234.000
Durable Medical Equipment
			 (DME) Reimbursement for Repairs
Reimbursement for
repairs
of durable medical
				equipment (DME) will be manufacturer?s invoice price for parts plus 10% and
				labor billed per unit (15 minutes = 1 unit of service). A maximum of twenty
				(20) units (20 units = 5 hours of labor) per date of service is allowable.
The manufacturer?s invoice must be attached to the repair claim for
				all parts
.
Reimbursement for unlisted DME requiring
manual pricing
will be calculated using the manufacturer?s invoice price plus 10%.
The manufacturer?s invoice must be attached to all repair
				claims
.
236.000
Reimbursement for Repair of
			 the Enteral Nutrition Pump
Reimbursement for repairs to the enteral nutrition infusion
				pump requires prior authorization. Repairs will be approved only on equipment
				purchased by Medicaid. Therefore, no repairs will be reimbursable prior to the
				equipment becoming the property of the Medicaid beneficiary.
Requests for prior authorization for enteral pump repairs must
				be mailed to the Utilization Review Section, Division of Medical Services
(view or print Utilization Review Section contact
				information)
on form DMS-679, titled Request for Prior
				Authorization and Prescription.
(View or print form DMS-679
				and instructions for completion.)
The repair invoice and the serial number of the equipment must
				accompany the prior authorization request form. Total repair costs to an
				infusion pump may not exceed $290.93. Medicaid will not reimburse for
				additional repairs to an infusion pump after the provider has billed repair
				invoices totaling $290.93. If the equipment is still not in proper working
				order after the provider has billed the Medicaid maximum allowed for repairs,
				the provider must supply the beneficiary with a new infusion pump and may bill
				either procedure code B9000 or B9002 after receiving prior authorization for
				the new piece of equipment.
237.000
Rate Appeal Process
A provider may request reconsideration of a program decision by
				writing to the Assistant Director, Division of Medial Services. The request
				must be received within 20 calendar days following the application of policy
				and/or procedure or the notification of the provider of its rate. Upon receipt
				of the request for review, the Assistant Director will determine the need for a
				program/provider conference and will contact the provider to arrange a
				conference if needed. Regardless of the program decision, the provider will be
				afforded the opportunity for a conference, if he or she so wishes, for a full
				explanation of the factors involved and the program decision. Following review
				of the matter, the Assistant Director will notify the provider of the action to
				be taken by the Division within 20 calendar days of receipt of the request for
				review or the date of the program/provider conference.
When the provider disagrees with the decision of the Assistant
				Director, Division of Medical Services, the provider may appeal the question to
				a standing rate review panel established by the Director of the Division of
				Medical Services. The rate review panel will include one member of the Division
				of Medical Services, a representative of the provider association and a member
				of the Department of Human Services (DHS) management staff, who will serve as
				chairperson.
The request for review by the rate review panel must be
				postmarked within 15 calendar days following the notification of the initial
				decision by the Assistant Director, Division of Medical Services. The rate
				review panel will meet to consider the question(s) within 15 calendar days
				after receipt of a request for such appeal. The panel will hear the question(s)
				and a recommendation will be submitted to the Director of the Division of
				Medical Services.
240.000
BILLING PROCEDURES
241.000
Introduction to Billing
Prosthetics providers use the CMS-1500 form to bill the
				Arkansas Medicaid Program on paper for services provided to eligible Medicaid
				beneficiaries. Each claim may contain charges for only one beneficiary.
Section III of this manual contains information about Provider
				Electronic Solutions (PES) and other available options for electronic claim
				submission.
242.000
CMS-1500 Billing Procedures
242.100
HCPCS Procedure Codes
242.105
Payment
			 Methodology
Arkansas Medicaid has several methods of payment for all items
				covered by the Program. The following is a breakdown of the methods.
A. Purchase items are equipment that is
			 purchased for or purchased by an eligible Medicaid beneficiary. The equipment
			 may be new or used.
B. Rental-only
			 items are those items paid by Arkansas Medicaid to providers for an unspecified
			 time period on an as-needed basis. The equipment may be new or used.
C. A capped rental item is equipment whose
			 purchase price exceeds $150.00. The items may be new or used. The items are
			 reimbursed utilizing a daily rental rate. Medicaid pays the daily rental rate
			 not to exceed a fifteen- (15-) month rental maximum (455 days). A period of
			 continuous use allows for periods of interruption up to 60 consecutive days. If
			 the interruption is 60 or fewer consecutive days, a new 15-month rental period
			 will not begin. If the interruption is more than 60 days, a new 15-month rental
			 period will begin.
D. After the
			 total cost of a capped rental item has been reimbursed by Medicaid, the item
			 remains the property of the DME provider. For items that have reached a
			 15-month rental cap, claims will be paid for maintenance and servicing fees
			 after six months have passed from the end of the final paid rental month or
			 from the end of the period the item is no longer covered under the supplier?s
			 or manufacturer?s warranty, whichever is later.
E. Providers may be reimbursed for capped
			 rental and rental-only items if the equipment is used fewer than 30 consecutive
			 days from the first day of rental. This ensure the provider of adequate
			 reimbursement for equipment used fewer than 30 days.
F. A rent-to-purchase item is an item for
			 which Arkansas Medicaid reimburses a provider for the Medicaid-established
			 purchase price of the item. After reimbursement has reached the maximum
			 allowed, the equipment will become the property of the Medicaid beneficiary.
			 Reimbursement is only approved for new equipment.
G. Initial rental transactions are those for
			 which equipment is used in a beneficiary?s home for fewer than 30 consecutive
			 days. Initial rental transactions must not be used by the provider to bill a
			 month in advance. Arkansas Medicaid will only pay after services are rendered.
			 An example of an initial rental transaction is that of a hospital bed delivered
			 on July 2 and removed from the home after 10 days.
H. Manually priced items are those for which
			 Arkansas Medicaid pays the manufacturer?s invoice price plus 10 percent. The
			 provider must attach the invoice with their claim for services
			 rendered.
I. A used item is any
			 item that has been rented for 90 days or longer by anyone prior to the current
			 Medicaid ?rental only? or capped rental? transaction. The provider must
			 maintain documentation that certifies a used item is reconditioned and in good
			 working order and has no defect in workmanship or material.
J. Repair of a ?rental only? item is covered
			 in the rental fee. Repair of ?purchased? items is covered separately. Total
			 (cumulative) repair costs must not exceed 50% of the item?s total purchase
			 cost.
242.110
Respiratory and Diabetic Equipment, All Ages
When billed either electronically or on paper, procedure codes
				found in this section must be billed 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.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code ?6? for individuals under age 21 or
				TOS ?H? for individuals age 21 and over.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS. Prior authorization
				requirements are shown under the heading PA. If prior authorization is needed,
				the information is indicated with a ?Y? in the column; if not, an ?N? is
				shown.
NOTE: Prosthetics providers may continue to use modifier
				52 for claims with dates of service through October 31, 2005. Effective for
				claims with dates of service on and after November 1, 2005, modifier 52 will be
				replaced with modifier UB.
* Prior authorization is not required when another 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.
Respiratory and Diabetic Equipment, All Ages (section
				242.110)
Procedure Code
M1
M2
TOS
Description
PA
Payment Method
A4230
NU
H
Infusion set for external insulin pump, nonneedle
						  cannula type (each)
Y*
Purchase
A4231
NU
H
Infusion set for external insulin pump, needle type
						  (each)
Y*
Purchase
A4232
NU
H
Syringe with needle for external insulin pump, sterile,
						  3 cc (each)
Y*
Purchase
A4627
NU
UB
H
***(Spacer bag or reservoir
without
						  mask
, for use with metered dose inhaler) Spacer, bag or reservoir,
						  with or without mask, for use with metered dose inhaler
N
Purchase
A4627
NU
H
***(Spacer bag or reservoir
with
						  mask
, for use with metered dose inhaler) Spacer, bag or reservoir,
						  with or without mask, for use with metered dose inhaler
N
Purchase
A4632
H
Replacement battery for external infusion pump, any
						  type, each
Y*
Purchase
A6021
NU
H
Collagen dressing, pad size 16 sq. in. or less,
						  each
Y*
Purchase
A6022
NU
H
Collagen dressing, pad size more than 16 sq. in. but
						  less than or equal to 48 sq. in., each
Y*
Purchase
A6023
NU
H
Collagen dressing, pad size more than 48 sq. in.,
						  each
Y*
Purchase
A6024
NU
H
Collagen dressing wound filler, per 6 in.
Y*
Purchase
A7034
NU
RR
H
***(CPAP Device Nasal Continuous Positive Airway
						  Pressure (CPAP) Device; includes necessary accessory items)
NOTE: Complete medical data pertinent to the
						  request must be submitted with the prior authorization request. NOTE: Bill
						  A7034 as the Global Monthly Rental Service.
Nasal interface (mask or
						  cannula type) used with positive airway pressure device, with or without head
						  strap
Y*
Rental Only
A7045
NU
Exhalation port with or without swivel used with
						  accessories for positive airway devices, replacement only
N
Purchase
A9999
NU
H
***(Unlisted Durable Medical Equipment.
The
						  manufacturer?s invoice must be attached to the claim form.)
Misc. DME
						  supply or accessory, not otherwise specified
Y
Manually Priced
E0424
Stationary compressed gaseous oxygen system, rental;
						  includes container, contents, regulator, flowmeter, humidifier, nebulizer,
						  cannula or mask, and tubing
Y
*
Rental Only
E0430
Portable gaseous oxygen system, purchase, includes
						  regulator, flowmeter, humidifier, cannula or mask, and tubing
Y
*
Rental Only
E0435
Portable liquid oxygen system, purchase; includes
						  portable container, supply reservoir, flowmeter, humidifier, contents gauge,
						  cannula or mask, tubing and refill adapter
Y
*
Rental Only
E0439
Stationary liquid oxygen system, rental; includes
						  container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or
						  mask, and tubing
Y
*
Rental Only
E0441
Oxygen contents, gaseous (for use with owned gaseous
						  stationary systems or when both a stationary and portable gaseous system are
						  owned), one month?s supply = I unit
Y
Purchase
E0442
Oxygen contents, liquid (for use with owned liquid
						  stationary systems or when both a stationary and portable liquid system are
						  owned), one month?s supply = 1 unit
Y
Purchase
E0443
Portable oxygen contents, gaseous (for use only with
						  portable gaseous systems when no stationary gas or liquid system is used), one
						  month?s supply=1 unit
Y
*
Purchase
E0444
Portable oxygen contents, liquid (for use only with
						  portable liquid systems when no stationary gas or liquid system is used), one
						  month?s supply=1 unit
Y
*
Purchase
E0470
RR
H
***(BIPAP Device, Nasal Bi-level Positive Airway
						  support system; includes necessary accessory items.
NOTE: Complete
						  medical data pertinent to the request must be submitted with the prior
						  authorization request.
) Respiratory assist device, bi-level pressure
						  capability, without backup rate feature, used with noninvasive interface, e.g.,
						  nasal or facial mask (intermittent assist device with continuous positive
						  airway pressure device)
Y
Capped Rental
E0470
NU EP
RR RR
H 6
Respiratory assist device, bi-level pressure capacity,
						  without backup rate feature, used with noninvasive interface, e.g., nasal or
						  facial mask (intermittent assist device with continuous positive airway
						  pressure device)
Y Y
Rental Only
E0471
NU EP
RR RR
H 6
Respiratory assist device, bi-level pressure capacity,
						  with backup rate feature, used with noninvasive interface, e.g., nasal or
						  facial mask (intermittent assist device with continuous positive airway
						  pressure device)
Y Y
Rental Only
E0472
NU EP
RR RR
H 6
Respiratory assist device, bi-level pressure capacity,
						  with backup rate feature, used with invasive interface, e.g., nasal or facial
						  mask (intermittent assist device with continuous positive airway pressure
						  device)
Y Y
Rental Only
E0483
NU
RR
H
***(Bronchial Drainage System) High-frequency chest
						  wall oscillation air-pulse generator system (includes hoses and vest),
						  each
Y*
Rental Only
E0483
NU
UB
H
***(
Pulmonary Vest.
The
						  manufacturer invoice must be attached to the claim form.)
High-frequency
						  chest wall oscillation air-pulse generator system (includes hoses and vest),
						  each
Y*
Purchase
E0560
Humidifier, durable for supplemental humidification
						  during IPPB treatment or oxygen delivery
N
Purchase
E0561
NU EP
H 6
Humidifier, non-heated, used w/positive airway pressure
						  device
Y Y
Purchase
E0562
NU EP
H 6
Humidifier, heated, used w/positive airway pressure
						  device
Y Y
Purchase
E0570
Nebulizer, with compressor
Y
*
Purchase
E0575
Nebulizer, ultrasonic, large volume
Y
*
Capped Rental
E0600
Respiratory suction pump, home model, portable or
						  stationary, electric
N
Rental Only
E0779
NU
RR
***(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
Y*
Rental Only
E0784
NU
H
External ambulatory infusion pump, insulin
Y*
Purchase
E1340
NU
H
***(DME Repair: 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
N
Manually Priced
E1340
NU
U4
H
***(Maintenance for Capped Rental items) Repair or
						  nonroutine service for durable medical equipment requiring the skill of a
						  technician, labor component, per 15 minutes
N
N/A
E1340
NU
U1
H
***(Labor Only; a maximum of twenty (20) units per date
						  of service is allowable. 20 units = 5 hours of labor) Repair or nonroutine
						  service for durable medical equipment requiring the skill of a technician,
						  labor component, per 15 minutes
N
Manually Priced
E1340
EP
U1
6
***(Labor Only; a maximum of twenty (20) units per date
						  of service is allowable. 20 units = 5 hours of labor) Repair or nonroutine
						  service for durable medical equipment requiring the skill of a technician,
						  labor component, per 15 minutes
N
Manually Priced
E1390
Oxygen concentrator, single delivery port, capable of
						  delivering 85 % or greater oxygen concentration at the prescribed flow
						  rate
Y
*
Rental Only
E1391
NU
H
O2 concentrator, dual delivery port, capable of
						  delivering 85% or [GREATER THAN] O2 concentration at the prescribed flow rate,
						  each
Y
Purchase
E1391
NU
I
O2 concentrator, dual delivery port, 85% or [GREATER
						  THAN] O2 concentration at the prescribed flow rate, each
Y
Purchase
242.111
Initial Rental of a DME Item
			 for Individuals of All Ages
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.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code ?I? for initial rental. Type of
				service is indicated by the heading of TOS.
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 another 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.
Procedure Code
M1
M2
TOS
Description
All
U21
21+
A7034*
I
***(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
E0143*
I
Walker, folding, wheeled, adjustable or fixed
						  height
21+
E0166
Commode chair, mobile, with detachable arms
U21
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
U21
E0250
I
Hospital bed, fixed height, with any type side rails,
						  with mattress
21+
E0255*
Hospital bed, variable height; hi-lo, with any type
						  side rails, with mattress
U21
E0255
KH
I
Hospital bed, variable height; hi-lo, with any type
						  side rails, with mattress
21+
E0260*
I
Hospital bed, semi-electric (head and foot adjustment),
						  with any type side rails with mattress
U21
E0260*
KH
I
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
I
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
E0480
Percussor, electric or pneumatic, home model
U21
E0445*
***(Pulse oximeter, including 4 disposable probes)
						  Oximeter for measuring blood oxygen levels noninvasively
U21
E0565*
Compressor, air power source for equipment which is not
						  self-contained or cylinder driven
U21
E0575*
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
E0630*
Patient lift, hydraulic, with seat or sling
U21
E0630
KH
I
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
I
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; four foot panel
U21
E0693
I
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; six foot panel
U21
E0694
I
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
U21
E0730
KH
I
Transcutaneous electrical nerve stimulation device four
						  or more leads, for multiple nerve stimulation
21+
E0745*
I
Neuromuscular stimulator, electronic shock unit
U21
E0747*
Osteogenesis stimulator, electrical noninvasive, other
						  than spinal applications
U21
E0779*
I
***(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
U21
E0910
KH
I
Trapeze bars, also known as Patient Helper, attached to
						  bed, with grab bar
21+
E0920
Fracture frame, attached to bed, includes
						  weights
U21
E0930
Fracture frame, freestanding, includes weights
U21
E0935*
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
E1130*
KH
I
Standard wheelchair, fixed full-length arms, fixed or
						  swing?away, detachable footrests
21+
E1224*
Wheelchair with detachable arms, elevating
						  legrests
U21
E1224*
I
Wheelchair with detachable arms, elevating
						  legrests
21+
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 should only
				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 and type of service for the same time period.
242.112
Home Blood Glucose
			 Monitor and Supplies ? Pregnant Women
Only, All Ages
Procedure codes found in this section must be billed either
				electronically or on paper with modifier NU for individuals of all ages. When a
				second modifier is listed, that modifier must be used in conjunction with the
				NU modifier.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code ?H? for individuals of all ages.
				Modifiers in the section are indicated by the headings M1 and M2. Type of
				service is indicated by the heading TOS. Prior authorization is indicated by
				the heading PA.
Procedure Code
M1
M2
TOS
Description
PA
Payment Method
E0607
NU
U1
H
Home Blood Glucose Monitor
N
Purchase
A4253
NU
U1
H
Blood glucose test or reagent strips for home glucose
						  monitor, per 50 strips
N
Purchase
A4259
NU
U2
H
Lancets, per box of 100
N
Purchase
242.120
Medical Supplies, All Ages
Procedure codes found in this section must be billed either
				electronically or on paper with modifier NU for individuals of all ages. When a
				second modifier is listed, that modifier must be used in conjunction with the
				modifier NU.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code ?H? for individuals of all
				ages.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS.
NOTE: Prosthetics providers may continue to use modifier
				52 for claims with dates of service through October 31, 2005. Effective for
				claims with dates of service on and after November 1, 2005, modifier 52 will be
				replaced with modifier UB.
1
			 These supplies must be prior authorized. Form DMS-679 may be used for the
			 request for prior authorization.
View or print form DMS-679
			 and instructions for completion.
Please note: Compression
			 burn garments are manually priced.
Medical Supplies, All Ages (section
				242.120)
Procedure Code
M1
M2
TOS
Description
A4206
NU
H
Syringe with needle, sterile, 1 cc, ea
A4207
NU
Syringe with needle, sterile, 2 cc, ea
A4209
NU
Syringe with needle, sterile, 5 cc or greater,
						  ea
A4216
NU
H
Sterile water/saline, 10 ml
A4217
NU
H
Sterile water/saline, 500 ml
A42211
NU
Supplies for maintenance of drug infusion catheter, per
						  week (list drug separately)
A42221
NU
Supplies for external drug infusion pump, per cassette
						  or bag (list drug separately)
A4253
NU
Blood glucose test or reagent strips for home blood
						  glucose monitor, per 50 strips
A4253
NU
UB
H
Blood glucose test or reagent strips for home blood
						  glucose monitor, per 50 strips
A4256
NU
Normal, low, and high calibrator solution/chips
A4259
NU
Lancets, per box of 100
A4265
NU
Paraffin, per pound
A4310
NU
Insertion tray without drainage bag and without
						  catheter (accessories only)
A4311
NU
Insertion tray without drainage bag with indwelling
						  catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone
						  elastomer or hydrophilic, etc.)
A4312
NU
Insertion tray without drainage bag with indwelling
						  catheter, Foley type, two-way, all silicone
A4313
NU
Insertion tray without drainage bag with indwelling
						  catheter, Foley type, three-way, for continuous irrigation
A4314
NU
Insertion tray with drainage bag with indwelling
						  catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone
						  elastomer or hydrophilic, etc.
A4315
NU
Insertion tray with drainage bag with indwelling
						  catheter, Foley type, two-way, all silicone
A4316
NU
Insertion tray with drainage bag with indwelling
						  catheter, Foley type, three-way, for continuous irrigation
A4320
NU
Irrigation tray with bulb or piston syringe, any
						  purpose
A4322
NU
Irrigation syringe, bulb or piston, each
A4326
NU
Male external catheter specialty type with intergral
						  collection chamber, each
A4327
NU
Female external urinary collection device; metal cup,
						  each
A4328
NU
Female external urinary collection device; pouch,
						  each
A4330
NU
Perianal fecal collection pouch with adhesive,
						  each
A4331
NU
Extension drainage tubing, any type, any length, with
						  connector/adaptor, for use with urinary leg bag or urostomy pouch, each
A4338
NU
Indwelling catheter, Foley type, two-way latex with
						  coating (Teflon, silicone, silicone elastomer or hydrophilic, etc), each
A4340
NU
Indwelling catheter; specialty type (e.g., coude,
						  mushroom, wing, etc.), each
A4344
NU
Indwelling catheter, Foley type, two-way, all silicone,
						  each
A4346
NU
Indwelling catheter, Foley type, three-way for
						  continuous irrigation, each
A4348
NU
Male external catheter with integral collection
						  compartment, extended wear, each (e.g., 2 per month)
A4349
NU
Male external catheter with or without adhesive,
						  disposable, each
A4351
NU
Intermittent urinary catheter; straight tip, with or
						  without coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.),
						  each
A4351
NU
U1
Intermittent urinary catheter; straight tip, with or
						  without coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.),
						  each
A4352
NU
Intermittent urinary catheter; coude (curved) tip, with
						  or without coating (Teflon, silicone, silicone elastomeric or hydrophilic,
						  etc.), each
A4352
NU
U1
Intermittent urinary catheter; coude (curved) tip, with
						  or without coating (Teflon, silicone, silicone elastomeric or hydrophilic,
						  etc.), each
A4353
NU
U2
H
Intermittent urinary catheter, with insertion supplies
						  (tray)
A4354
NU
Insertion tray with drainage bag but without
						  catheter
A4355
NU
Irrigation tubing set for continuous bladder irrigation
						  through a three-way indwelling Foley catheter, each
A4356
NU
External urethral clamp or compression device (not to
						  be used for catheter clamp), each
A4357
NU
Bedside drainage bag, day or night, with or without
						  anti-reflux device, with or without tube, each
A4358
NU
Urinary drainage bag, leg or abdomen, vinyl, with or
						  without tube, with straps, each
A4359
NU
Urinary suspensory without leg bag, each
A4361
NU
Ostomy faceplate, each
A4362
NU
Skin barrier; solid, four by four or equivalent;
						  each
A4364
NU
Adhesive, liquid, or equal, any type, per ounce
A4365
NU
H
Adhesive remover wipes, any type, per 50
A4367
NU
Ostomy belt, each
A4368
NU
H
Ostomy filter, any type, each
A4369
NU
Ostomy skin barrier, liquid, (spray, brush, etc), per
						  oz
A4371
NU
Ostomy skin barrier, power, per oz
A4394
NU
H
Ostomy deodorant for use in ostomy pouch, liquid, per
						  fluid ounce
A4397
NU
Irrigation supply; sleeve, each
A4398
NU
Ostomy irrigation supply; bag, each
A4399
NU
Ostomy irrigation supply; cone/catheter, including
						  brush
A4400
NU
Ostomy irrigation set
A4402
NU
Lubricant, per ounce
A4404
NU
Ostomy ring, each
A4405
NU
Ostomy skin barrier, non-pectin based, paste, per
						  ounce
A4406
NU
Ostomy skin barrier, pectin based, paste, per
						  ounce
A4414
NU
Ostomy skin barrier, with flange (solid, flexible or
						  accordion), without built-in convexity, 4 x 4 inches or smaller, each
A4450
NU
U1
Tape, non-waterproof, per 18 square inches
A4450
NU
H
Tape, non-waterproof, per 18 square inches
A4452
NU
Tape, waterproof, per 18 square inches
A4455
NU
Adhesive remover or solvent (for tape, cement or other
						  adhesive), per ounce
A4483
NU
H
Moisture exchanger, disposable, for use with invasive
						  mechanical ventilation
A4558
NU
Conductive paste or gel
A4561
NU
U1
Pessary, rubber, any type
A4562
NU
Pessary, non rubber, any type
A4623
NU
Tracheostomy, inner cannula
A4625
NU
Tracheostomy care kit for new tracheostomy
A4626
NU
Tracheostomy cleaning brush, each
A4628
NU
Oropharyngeal suction catheter, each
A4629
NU
Tracheostomy care kit for established
						  tracheostomy
A4772
NU
Blood glucose test strips, for dialysis, per 50
A4927
NU
Gloves, non-sterile, per 100
A5051
NU
Ostomy pouch, closed; with barrier attached (one
						  piece), each
A5052
NU
Ostomy pouch, closed; without barrier attached (one
						  piece), each
A5053
NU
Ostomy pouch, closed; for use on faceplate, each
A5054
NU
Ostomy pouch, closed; for use on barrier with flange
						  (two piece), each
A5055
NU
Stoma cap
A5061
NU
U1
Ostomy pouch, drainable; with barrier attached (one
						  piece), each
A5062
NU
Ostomy pouch, drainable; without barrier attached (one
						  piece), each
A5063
NU
Ostomy pouch, drainable; for use on barrier with flange
						  (two piece system), each
A5071
NU
Ostomy pouch, urinary; with barrier attached (one
						  piece), each
A5072
NU
Ostomy pouch, urinary; without barrier attached (one
						  piece), each
A5073
NU
Ostomy pouch, urinary; for use on barrier with flange
						  (two piece), each
A5081
NU
Continent device; plug for continent stoma
A5082
NU
Continent device; catheter for continent stoma
A5093
NU
Ostomy accessory; convex insert
A5102
NU
Bedside drainage bottle, with or without tubing, rigid
						  or expandable, each
A5105
NU
Urinary suspensory; with leg bag, with or without
						  tube
A5112
NU
Urinary leg bag; latex
A5113
NU
Leg strap; latex, replacement only, per set
A5114
NU
Leg strap; foam or fabric, replacement only, per
						  set
A5119
NU
Skin barrier; wipes, box per 50
A5121
NU
Skin barrier; solid, 6 x 6 or equivalent, each
A5122
NU
Skin barrier; solid, 8 x 8 or equivalent, each
A5126
NU
Adhesive or non-adhesive; disk or foam pad
A5131
NU
Appliance cleaner, incontinence and ostomy appliances,
						  per 16 oz.
A6154
NU
Wound pouch, each
A6196
NU
H
Alginate or other fiber gelling dressing, wound cover,
						  pad size 16 sq. in. or less, each dressing
A6197
NU
UB
H
Alginate or other fiber gelling dressing, wound cover,
						  pad size more than 16 sq. in. but less than or equal to 48 sq. in, each
						  dressing
A6197
NU
UB
H
Alginate or other fiber gelling dressing, wound cover,
						  pad size more than 16 sq. in. but less than or equal to 48 sq. in, each
						  dressing (1 linear yard)
A6198
NU
H
Alginate or other fiber gelling dressing, wound cover,
						  pad size more than 48 sq. in., each dressing
A6203
NU
H
Composite dressing, pad size 16 sq. in. or less, with
						  any size adhesive border, each dressing
A6204
NU
H
Composite dressing, pad size more than 16 sq. in. but
						  less than 48 sq. in., with any size adhesive border, each dressing
A6205
NU
H
Composite dressing, pad size more than 48 sq. in., with
						  any size adhesive border, each dressing
A6211
NU
H
Foam dressing, wound cover, pad size more than 48 sq.
						  in., without adhesive border, each dressing
A6212
NU
H
Foam dressing, wound cover, pad size 16 sq. in. or
						  less, with any size adhesive border, each dressing
A6213
NU
H
Foam dressing, wound cover, pad size more than 16 sq.
						  in but less than or equal to 48 sq. in., with any size adhesive border, each
						  dressing
A6216
NU
H
Gauze, non-impregnated, non-sterile, pad size 16 sq.
						  in. or less, without adhesive border, each dressing
A6219
NU
H
Gauze, non-impregnated, 16 sq. in. or less with any
						  size adhesive border, each dressing
A6220
NU
H
Gauze, non-impregnated, pad more than 16 sq. in., but
						  less than or equal to 48 sq. in., with any size adhesive border, each
						  dressing
A6221
NU
H
Gauze, non-impregnated, pad size more than 48 sq. in.,
						  with any size adhesive border, each dressing
A6228
NU
H
Gauze, impregnated, water or normal saline, pad, size
						  16 sq. in. or less, without adhesive border, each dressing
A6229
NU
H
Gauze, impregnated, water or normal saline, pad size
						  more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive
						  border, each dressing
A6230
NU
H
Gauze, impregnated, water or normal saline, pad more
						  than 48 sq. in., without adhesive border, each dressing
A6234
NU
U1
Hydrocolloid dressing, wound cover, pad size 16 sq. in.
						  or less, without adhesive border, each dressing
A6234
NU
H
Hydrocolloid dressing, wound cover, pad size 16 sq. in.
						  or less, without adhesive border, each dressing
A6235
NU
H
Hydrocolloid dressing, wound cover, pad size more
						  than
16 sq. in., but less than or equal to 48 sq. in.,
						  without adhesive border, each dressing
A6236
NU
H
Hydrocolloid dressing, wound cover, pad size more than
						  48 sq. in., without adhesive border, each dressing
A6237
NU
H
Hydrocolloid dressing, wound cover, pad size 16 sq. in.
						  or less, with any size adhesive border, each dressing
A6238
NU
H
Hydrocolloid dressing, wound cover, pad size more than
						  16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border,
						  each dressing
A6238
NU
U1
H
Hydrocolloid dressing, wound cover, pad size more than
						  16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border,
						  each dressing
A6239
NU
H
Hydrocolloid dressing, wound cover, pad size more than
						  48 sq. in., with any size adhesive border, each dressing
A6241
NU
Hydrocolloid dressing, wound filler, dry form, per
						  gram
A6242
NU
Hydrocolloid dressing, wound cover, pad size 16 sq. in.
						  or less, without adhesive border, each dressing
A6242
NU
U1
Hydrocolloid dressing, wound cover, pad size 16 sq. in.
						  or less, without adhesive border, each dressing
A6242
NU
H
Hydrogel dressing, wound cover, pad size 16 sq. in. or
						  less, without adhesive border, each dressing
A6243
NU
H
Hydrogel dressing, wound cover, pad size more than 16
						  sq. in., but less than or equal to 48 sq. in., without adhesive border, each
						  dressing
A6244
NU
H
Hydrogel dressing, wound cover, pad size more than 48
						  sq. in. without adhesive border, each dressing
A6245
NU
H
Hydrogel dressing, wound cover, pad size 16 sq. in. or
						  less, with any size adhesive border, each dressing
A6246
NU
H
Hydrogel dressing, wound cover, pad size more than 16
						  sq. in., but less than or equal to 48 sq. in., with any size adhesive border,
						  each dressing
A6247
NU
H
Hydrogel dressing, wound cover, pad size more than 48
						  sq. in. with any size adhesive border, each dressing
A6248
NU
Hydrogel dressing, wound filler, gel, per fluid
						  ounce
A6248
NU
U1
Hydrogel dressing, wound filler, gel, per fluid
						  ounce
A6248
NU
H
Hydrogel dressing, wound filler, gel, per fluid
						  ounce
A6257
NU
H
Transparent film, 16 sq. in. or less, each
						  dressing
A6258
NU
H
Transparent film, more than 16 sq. in., but less than
						  or equal to 48 sq. in., each dressing
A6259
NU
H
Transparent film, more than 48 sq. in., each
						  dressing
A6403
NU
H
Gauze, non-impregnated, sterile, pad size more than 16
						  sq. in. but less than 48 sq. in., without adhesive border, each dressing
A6404
NU
H
Gauze, non-impregnated, sterile, pad size more than 48
						  sq. in., without adhesive border, each dressing
A6441
NU
H
Padding bandage, non-elastic, non-woven/non-knitted,
						  width [GREATER THAN] or = 3 inches & [LESS THAN] 5 in, per yd
A6442
NU
Conforming bandage, non-elastic, knitted/woven,
						  non-sterile, width [LESS THAN] 3 in, per yd
A6443
NU
H
Conforming bandage, non-elastic, knitted/woven,
						  non-sterile, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per
						  yd
A6444
NU
H
Conforming bandage, non-elastic, knitted/woven,
						  non-sterile, width [GREATER THAN] or = 5 in, per yd
A6445
NU
Conforming bandage, non-elastic, knitted/woven sterile,
						  width [LESS THAN]3 in, per yd
A6446
NU
H
Conforming bandage, non-elastic, knitted/woven,
						  sterile, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd
A6447
NU
H
Conforming bandage, non-elastic, knitted/woven,
						  sterile, width [GREATER THAN] or = 5 in, per yd
A6448
NU
Light compression bandage, elastic, knitted/woven
						  width[LESS THAN]3in, per yd
A6449
NU
H
Light compression bandage, elastic, knitted/woven,
						  width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd
A6450
NU
H
Light compression bandage, elastic, knitted/woven,
						  width [GREATER THAN] or = 5 in, per yd
A6451
NU
H
Moderate compress bandage, elastic, knitted/woven load
						  resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width [GREATER
						  THAN] or = 3 in & [LESS THAN] 5 in, per yd
A6452
NU
H
High compress bandage, elastic, knitted/woven, load
						  resistance greater than or equal to 1.35 foot pounds at 50 % maximum stretch,
						  width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd
A6453
NU
Self-adherent bandage, elastic, non-knitted/non-woven,
						  width[LESS THAN]3in, per yd
A6454
NU
Self-adherent bandage, elastic, non-knitted/non-woven,
						  width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd
A6455
NU
Self-adherent bandage, elastic, non-knitted/non-woven,
						  width [GREATER THAN] or = 5 in, per yd
A65011
NU
Compression burn garment, body suit (head to foot),
						  custom fabricated
A65021
NU
Compression burn garment, chin strap, custom
						  fabricated
A65031
NU
Compression burn garment, facial hood, custom
						  fabricated
A65041
NU
Compression burn garment, glove to wrist, custom
						  fabricated
A65051
NU
Compression burn garment, glove to elbow, custom
						  fabricated
A65061
NU
Compression burn garment, glove to axilla, custom
						  fabricated
A65071
NU
Compression burn garment, foot to knee length, custom
						  fabricated
A65081
NU
Compression burn garment, foot to thigh length, custom
						  fabricated
A65091
NU
Compression burn garment, upper trunk to waist
						  including arm openings (vest), custom fabricated
A65101
NU
Compression burn garment, trunk including arms down to
						  leg openings (leotard), custom fabricated
A65111
NU
Compression burn garment, lower trunk including leg
						  openings (panty), custom fabricated
A65121
NU
Compression burn garment, not otherwise
						  classified
A7520
NU
Trachestomy/Laryngectomy tube, non-cuffed, PVC,
						  silicone or equal, each
A7521
Trachestoomy/Laryngectomy tube, cuffed, PVC, silicone
						  or equal, each
A7522
Trachestomy/Laryngectomy tube, stainless steel or
						  equal, (sterilizable and reusable), each
A7524
PO-Tracheostoma stent/stud/button, each
A7525
Tracheostomy mask, each
B4086
NU
Gastrostomy/jejunostomy tube, any material, any type,
						  (standard or low profile), each
E0776
NU
IV pole
242.121
Food Thickeners, All Ages
Food thickeners, including ?Thick-It,? ?Thick-It II,? ?Simply
				Thick? and ?Thick and Easy,? are not subject to the $250 medical supply benefit
				limit.
When food thickeners are to be administered enterally, the
				modifier ?BA? must be used in conjunction with the procedure code.
When food thickeners are billed, total units are to be
				calculated to the nearest full ounce. Partial units may not be rounded up. When
				a date span is billed, the product cannot be billed until the end date has
				elapsed.
The maximum number of units allowed for food thickeners is 16
				units per date of service.
Procedure Code
M1
M2
TOS
Description
B4100
H
Food thickener, administered orally, per oz.
B4100
BA
H
Food thickener, administered enterally, per oz.
242.122
Jobst Stocking, All Ages
The gradient compression stocking (Jobst) is payable for
				individuals of all ages. However, before supplying the item, the Jobst stocking
				must be prior authorized by Utilization Review.
View or print
				form DMS-679 and instructions for completion.
Documentation
				accompanying form DMS-679 must indicate that the patient has severe varicose
				veins with edema, or a venous statis ulcer, unresponsive to conventional
				therapy such as wrappings, over-the-counter stockings and Unna boots. The
				documentation must include clinical medical records from a physician detailing
				the failure of conventional therapy.
Procedure Code
M1
M2
TOS
Description Maximum Units
L8239
NU
H
Gradient compression stocking, NOS Maximum 2 units per
						  (Jobst); 1 unit = 1 stocking date of service
242.130
Diapers and Underpads, 3 Years Old and Older
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.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code ?6? for individuals under age 21 or
				TOS ?H? for individuals age 21 and over.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS. Prior authorization is
				indicated by the heading PA. If prior authorization is required, that
				information is indicated with a ?Y? in the column, or if not, an ?N? is
				shown.
***
(?) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
Diapers and Underpads, 3 Years Old and Older (section
				242.130)
Procedure Code
M1
M2
TOS
Description
PA
Payment Method
A4335
EP
6
***(Small Child-Size Diaper) Incontinence supply;
						  miscellaneous
N
Purchase
A4335
EP
U1
6
***(Medium Child-Size Diaper) Incontinence supply;
						  miscellaneous
N
Purchase
A4335
EP
U2
6
***(Large Child-Size Diaper) Incontinence supply;
						  miscellaneous
N
Purchase
A4335
NU EP
U1 U3
H 6
AIncontinence supply; miscellaneous (Under-Garment One
						  size fits all)
N
Purchase
A4554
NU
H
Disposable underpads, all sizes (e.g., Chux?s)
N
Purchase
T4521
NU
H
Adult-sized disposable incontinence product,
						  brief/diaper, small, each
N
Purchase
T4522
NU
H
Adult-sized disposable incontinence product,
						  brief/diaper, medium, each
N
Purchase
T4523
NU
H
Adult-sized disposable incontinence product,
						  brief/diaper, large, each
N
Purchase
T4524
NU
H
Adult-sized disposable incontinence product,
						  brief/diaper, extra large, each
N
Purchase
T4526
NU EP
H 6
Adult-sized disposable incontinence product, protective
						  underwear/pull-on, medium size, each
N
Purchase
T4527
NU EP
H 6
Adult-sized disposable incontinence product, protective
						  underwear/pull-on, large size, each
N
Purchase
T4528
NU EP
H 6
Adult-sized disposable incontinence product, protective
						  underwear/pull-on, extra large size, each
N
Purchase
T4529
EP
6
Pediatric-sized disposable incontinence product,
						  brief/diaper, small/medium size, each
N
Purchase
T4529
EP
U1
6
Pediatric-sized disposable incontinence product,
						  brief/diaper, small/medium size, each
N
Purchase
T4530
EP
6
Pediatric-sized disposable incontinence product,
						  brief/diaper, large size, each
N
Purchase
T4531
EP
6
Pediatric-sized disposable incontinence product,
						  brief/diaper, reusable, small/medium size, each
N
Purchase
T4531
EP
U1
6
Pediatric-sized disposable incontinence product,
						  brief/diaper, reusable, small/medium size, each
N
Purchase
T4532
EP
6
Pediatric-sized disposable incontinence product,
						  brief/diaper, reusable, large size, each
N
Purchase
T4532
EP
U1
6
Pediatric-sized disposable incontinence product,
						  brief/diaper, reusable, large size, each
N
Purchase
T4533
EP
6
Youth-sized disposable incontinence product,
						  brief/diaper, each
N
Purchase
T4535
NU EP
H 6
Disposable liner/shield/guard/pad/undergarment for
						  incontinence, each
N
Purchase
T4535
NU EP
U1 U1
H 6
Disposable liner/shield/guard/pad/undergarment for
						  incontinence, each
N
Purchase
Reimbursement is based on a per unit basis with one unit
				equaling one item (diaper, underpad). When billing for these services that are
				benefit limited to a dollar amount per month, providers must bill according to
				the calendar month.
Providers must not span calendar months when billing for
				diapers and/or underpads. The date of delivery is the date of service.
				Providers should not bill ?from? and ?through? dates of service.
Refer to section 212.500 of this manual for coverage
				information on diapers and underpads.
242.140
Electronic Blood Pressure
			 Monitor and Cuff, All Ages
The procedure code found in this section must be billed either
				electronically or on paper using modifier NU for individuals of all
				ages.
Additionally, when billed on paper, the procedure code must be
				billed with a type of service (TOS) ?H? for individuals of all ages.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS. 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.
*Prior authorization is not required when another insurance
				pays at least 50% of the Medicaid maximum allowable reimbursement
				amount.
Procedure Code
M1
M2
TOS
Description
PA
Payment Method
A4670
NU
H
Automatic blood pressure monitor
Y*
Rental Only
Included with the rental of this monitor, the provider will
				need to supply one (1) disposable blood pressure cuff each month.
242.150
Nutritional
			 Formulae, for Child Health Services (EPSDT)
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
: WIC must be accessed first for individuals
				age 0 through the fifth birthday.
Procedure codes found in this section must be billed either
				electronically or on paper with modifier EP for beneficiaries under 21 years of
				age. When a second modifier is listed, that modifier must be used in
				conjunction with EP.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code ?6? for individuals under age
				21.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS. Modifier ?BO? is used to
				bill for oral usage.
Nutritional Formulae, for Child Health Services (EPSDT)
				Beneficiaries Under 21 Years of Age (section 242.150)
Procedure Code
M1
M2
M3
T O S
Description
Covered Formulae
B4149 B4149
EP EP
BO
6 6
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
6 6
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 Fiber
Fortison
Osmolite
Carnation Instant Breakfast ?
Intraolite
Osmolite 1.0 CAL
Lactose Free
Isocal
Osmolite HN
Ensure
Isocal HN
Portagen
Ensure Fiber with FOS
IsoSource
Probalance
Ensure High Protein
IsoSource HN
Promote
Ensure HN
Jevity 1.0 CAL
Promote with Fiber
Ensure Powder
Nutrapack
Resource
Fibersource
Nutren 1.0
Ultracal
B4150
EP
U1
BO
6
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
6 6
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 Deliver 2.0 Ensure Plus Ensure
						  Plus HN Nutren 1.5 Nutren 2.0 Resource Plus Scandishake Two-Cal HN
B4153 B4153
EP EP
BO
6 6
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
6 6
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
Choice DM
Ketocal
Respalor
Forta Drink
Lipisorb
Similac 60/40
Glucerna
Lofenalac
Suplena
Glytrol
Nepro
Traumacal
Hepatic Aid
NutriHep
Trumaid Powder
Impact
Protain XL
B4155 B4155
Bill on pape specific nam formula on
EP EP
r (Indi e of claims
BO
cate .)
6 6
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
Casec Powder Fructose Powder MCT Oil Moducal Polycose
						  Liquid Promod Provimin Sumacal
B4155 B4155
EP EP
U1 U1
BO
6 6
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
6 6
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
6 6
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
6 6
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
6 6
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
6 6
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 Pediasure Pediasure with Fiber
B4160 B4160
EP EP
U1 U1
BO
6 6
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
6 6
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
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
6 6
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
Cyclinex-1
Maxamaid MSUD
Phenex-1
Cyclinex-2
Maxamaid XLYS-TRY
Phenex-2
Hominex-1
Maxamaid Xp
Phenyl Free 1
Hominex-2
Maxamaid Xphen Try
Phenyl Free 2
I-Valex-1
Maxamum MSUD
Propimex-1
I-Valex-2
Maxamum XP
Propimex-2
Ketonex-1
MSUD Analog
XP Analog
Ketonex-2
MSUD 1 and 2
Xphen, Try Analog
B4162 B4162
EP EP
U1 U1
BO
6 6
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 maximum of 30
				units per day reimbursable. Supplies provided in conjunction with the
				nutritional formula through the prosthetics programs must be billed under the
				prosthetics medical supply code. These formulae are covered as nutritional
				supplements rather than 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 should not be filed until the ?through? date has elapsed.
				Claims may be submitted on either a weekly or monthly basis.
NOTE: If a specific formula is not listed but is the same
				as a formula listed, it may be billed using the procedure code for the
				comparable formula. It is the responsibility of the provider to prove
				comparability when audited.
242.151
Pedia-Pop
The procedure code found in this section must be billed with
				modifier EP. Additionally, when billed on paper, the procedure code must be
				billed with a type of service (TOS) code ?6.? Pedia-Pop is only for oral
				consumption, and only in frozen form.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS.
Procedure Code
M1
M2
TOS
Description
Maximum Units
Z2487
EP
6
Pedia-Pop; 1 unit = 1 box
2 units per date of service
242.152
Enteral Nutrition Infusion
			 Pump and Enteral Feeding Pump Supply
Kit
Procedure codes found in this section must be billed either
				electronically or on paper with modifier EP for beneficiaries under 21 years of
				age. When a second modifier is listed, that modifier must be used in
				conjunction with EP.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code ?6? for individuals under age
				21.
The procedure codes will require prior authorization from the
				Utilization Review Section of the Division of Medical Services.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS. 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.
***
(?) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
Procedure Code
M1
M2
TOS
Description
Maximum Units
PA
Payment Method
B4035
EP
6
Enteral feeding supply kit, pump fed, per day (1 unit =
						  1 day)
1 per day
Y
Purchase
B9000
EP
6
Enteral nutrition infusion pump ? without alarm (1 day
						  = 1 unit)
1 per day
Y
Rent to Purchase
B9002
EP
6
Enteral nutrition infusion pump ? with alarm (1 day = 1
						  unit)
1 per day
Y
Rent to Purchase
E1340
EP
U2
6
***(Repair - Enteral nutrition infusion pump) Repair or
						  nonroutine service for durable medical equipment requiring the skill of a
						  technician, labor component
Y
Enteral Nutrition Infusion Pump
Reimbursement for the enteral nutrition infusion pump is based
				on a rent-to-purchase methodology. Each unit reimbursed by Medicaid will apply
				towards the purchase price established by Medicaid. Reimbursement will only be
				approved for new equipment. Used equipment will not be prior authorized. Codes
B9000
and
B9002
represent a new piece of equipment
				being reimbursed by Medicaid on the rent-to-purchase plan. Codes
B9000
and
B9002
are reimbursed on a per unit basis with 1 day
				equaling 1 unit of service per day. Medicaid will reimburse on the
				rent-to-purchase plan for a total of 304 units of service. After reimbursement
				has been made for 304 units, the equipment will become the property of the
				Medicaid beneficiary. Prior authorization is required for codes
B9000
and
B9002
. The prior authorization request must include the
				serial number of the infusion pump being provided to the beneficiary.
See section 236.000 for reimbursement when the Medicaid Program
				is billed for repairs made to the enteral infusion pump.
242.153
MIC-KEY Skin Level Gastrostomy
			 Tube (Mic-Key Button)
and Supplies for Individuals Under Age 21
Procedure codes found in this section must be billed with
				modifier EP for beneficiaries under 21 years of age. Additionally, when billed
				on paper, procedure codes must be billed with a type of service (TOS) code ?6?
				for individuals under age 21.
Procedure Code
M1
M2
PA
Description
Payment Method
B9998
Y
MIC-KEY Kit
Purchase
B9998
EP
U1
Y
SECUR-LOK Extension Set with 2 Port ?Y? and Clamp 12?
						  Length
Purchase
B9998
EP
U2
Y
SECUR-LOK Extension Set with 2 Port ?Y? and Clamp 24?
						  Length
Purchase
B9998
EP
U3
Y
Bolus Extension Set with Single Port Clamp 12?
						  Length
Purchase
B9998
EP
U4
Y
Bolus Extension Set with Single Port Clamp 24?
						  Length
Purchase
B9998
EP
U5
Y
Bolus SECUR-LOK Extension Set Single Port w/Clamp 12?
						  Length
Purchase
B9998
EP
U6
Y
Bolus SECUR-LOK Extension Set Single Port w/Clamp 24?
						  Length
Purchase
B9998
EP
U7
Y
Microvasive Adapter
Purchase
B9998
EP
U8
Y
Microvasive Decompression Tube
Purchase
242.160
Durable Medical Equipment, All
			 Ages
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.
				Modifier UE must be used to bill for used equipment.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code ?6? for individuals under age 21 and
				TOS ?H? for individuals age 21 and over. TOS ?U? must be used to bill for used
				equipment.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS. 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 over
				is limited to one per five-year period
.
*** This procedure code may not be billed for TOS ?U? (used
				equipment).
* Prior authorization is not required when another 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
T O S
PA
Description
Payment Method
A4635
NU EP UE
H 6 U
N
Underarm pad, crutch, replacement, each
Purchase
A4636
NU EP UE
H 6 U
N
Replacement, handgrip, cane, crutch, or walker,
						  each
Purchase
A4637
H 6 U
N
Replacement, tip, cane, crutch, walker, each
Purchase
E0100
H 6 U
N
Cane, includes canes of all materials, adjustable or
						  fixed, with tip
Purchase
E0105
H 6 U
N
Cane, quad or three-prong, includes canes of all
						  materials, adjustable or fixed, with tips
Purchase
E0110
H 6 U
N
Crutches, forearm, includes crutches of various
						  materials, adjustable or fixed, pair, complete with tips and handgrips
Purchase
E0111
NU EP UE
U1
H 6 U
N
Crutch, forearm, includes crutches of various
						  materials, adjustable or fixed, each, with tip and handgrip
Purchase
E0112
H 6 U
N
Crutches, underarm, wood, adjustable or fixed, pair,
						  with pads, tips and handgrips
Purchase
E0113
H 6 U
N
Crutch, underarm, wood, adjustable or fixed, each, with
						  pad, tip and handgrip
Purchase
E0114
H 6 U
N
Crutches, underarm, other than wood, adjustable or
						  fixed, pair, with pads, tips and handgrips
Purchase
E0116
NU EP UE
H 6 U
N
Crutch, underarm, other than wood, adjustable or fixed,
						  each, with pad, tip and handgrip
Purchase
E0130
H 6 U
N
Walker, rigid (pickup), adjustable or fixed
						  height
Purchase
E0135
H 6 U
N
Walker, folding (pickup), adjustable or fixed
						  height
Purchase
E0140
NU EP
H 6
N
Walker, w/trunk support, adjustable or fixed height,
						  any type
Purchase
E0141
H 6 U
N
Walker, rigid, wheeled, adjustable or fixed
						  height
Purchase
E0143
H 6 U
N
Walker, folding, wheeled, adjustable or fixed
						  height
Purchase
E0147
NU EP UE
H 6 U
N
Walker, heavy duty, multiple braking system, variable
						  wheel resistance
Purchase
E0153
H 6 U
N
Platform attachment, forearm crutch, each
Purchase
E0154
H 6 U
N
Platform attachment, walker, each
Purchase
E0155
H 6 U
N
Wheel attachment, rigid pick-up walker, per pair seat
						  attachment, walker
Purchase
E0156
NU EP
H 6
N
Seat attachment, walker
Purchase
E0157
H 6 U
N
Crutch attachment, walker, each
Purchase
E0158
H 6 U
N
Leg extensions for walker, per set of four (4)
Purchase
E0159
NU EP
H 6
N
Brake attachment for wheeled walker, replacement,
						  each
Purchase
E0160
H 6 U
N
Sitz type bath or equipment, portable, used with or
						  without commode
Purchase
E0161
H 6 U
N
Sitz type bath or equipment, portable, used with or
						  without commode, with faucet attachment(s)
Purchase
E0163
NU EP UE
H 6 U
N
Commode chair, stationary, with fixed arms
Purchase
E0164
H 6 U
N
Commode chair, mobile, with fixed arms
Purchase
E0166
H 6 U
N
PO-Commode chair, mobile, w/detachable arms
Capped Rental
E0166
NU EP UE
U2 U2 U2
H 6 U
N
PO-Commode chair, mobile, w/detachable arms
Purchase
E0167
H 6 U
N
Pail or pan for use with commode chair
Purchase
E0175
NU EP UE
H 6 U
N
Foot rest, for use with commode chair, each
Purchase
E0180
NU EP UE
H 6 U
N
Pressure pad, alternating with pump
Purchase
E0181
H 6 U
N
Pressure pad, alternating with pump, heavy duty
Capped Rental
E0182
U1
H 6 U
N
Pump for alternating pressure pad
Purchase
E0184
H 6 U
N
Dry pressure mattress
Purchase
E0185
H 6 U
N
Gel or gel-like pressure pad for mattress, standard
						  mattress length and width
Purchase
E0186
NU EP
H 6
Y
Air pressure mattress
Purchase
E0187
NU EP
H 6
Y
Water pressure mattress
Purchase
E0189
NU EP UE
H 6 U
N
Lambswool sheepskin pad, any size
Purchase
E0190
NU UE
H U
N
Positioning cushion/pillow/wedge, any shape or
						  size
Purchase
E0190
EP
EP
EP
EP
EP
EP
EP
EP
EP
EP
EP
EP
EP
U1
U2
U3
U4
U5
U6
U7
U8
U9
KA/U1
KA/U2
KA/U3
6
6
6
6
6
6
6
6
6
6
6
6
6
N
Positioning cushion/pillow/wedge, any shape or
						  size
Purchase
E0191
H 6 U
N
Heel or elbow protector, each
Purchase
E0196
NU EP
H 6
N
Gel pressure mattress
Purchase
E0197
NU EP UE
H 6 U
N
Air pressure pad for mattress, standard mattress length
						  and width
Purchase
E0198
NU EP
H 6
Y
Water pressure pad for mattress, standard mattress
						  length and width
Purchase
E0200
NU EP UE
H 6 U
N
Heat lamp, without stand (table model), includes bulb,
						  or infrared element
Capped Rental
E0202
NU EP UE
H 6 U
N
Phototherapy (bilirubin) light with photometer
Rental Only
E0205
NU EP UE
H 6 U
N
Heat lamp, with stand includes bulb, or infrared
						  element
Capped Rental
E0217
NU EP UE
H 6 U
N
Water circulating heat pad with pump
Capped Rental
E0225
NU EP UE
H 6 U
N
Hydrocollator unit, includes pad
Capped Rental
E0235
NU EP UE
H 6 U
N
Paraffin bath unit, portable (see medical supply code
						  A4265 for paraffin)
Purchase
E0236
NU EP UE
H 6 U
N
Pump for water circulating pad
Capped Rental
E0238
NU EP UE
H 6 U
N
Nonelectric heat pad, moist
Purchase
E0239
NU EP UE
H 6 U
N
Hydrocollator unit, portable
Capped Rental
E0240
NU EP NU EP NU EP NU EP
U1 U1 U2 U2 U3 U3
H 6 H 6 H 6 H 6
N
Bath/shower chair w/wo wheels, any size
Purchase
E0244
NU EP
H 6
Y
Raised toilet seat
Purchase
E0245***
NU EP
U1 U1
H 6
N
***(Bath Frame Support, Large) Tub stool or
						  bench
Purchase
E0247
NU EP NU EP
U1 U1
H 6 H 6
N
Transfer bench, tub/toilet, w/wo commode opening
Purchase
E0248
NU EP NU EP
U1 U1
H 6 H 6
N
Transfer bench, heavy duty, tub/toilet w/wo commode
						  opening
Purchase
E0249
NU EP UE
H 6 U
N
Pad for water circulating heat unit
Purchase
E0250
UE
U
Y*
Hospital bed, fixed height, with any type side rails,
						  with mattress
Capped Rental
E0250
NU EP
H 6
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
U
Y*
Hospital bed, variable height; hi-lo, with any type
						  side rails, with mattress
Capped Rental
E0255
NU EP
U1
H 6
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
RR RR
H 6 U
Y*
Hospital bed, semi-electric, head and foot adjustment,
						  with any type side rails with mattress
Capped Rental
E0260
NU EP
H 6
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
H 6 U
N
Mattress, inner spring
Capped Rental
E0272
NU EP UE
H 6 U
N
Mattress, foam rubber
Capped Rental
E0273
NU EP UE
H 6 U
N
Bed board
Purchase
E0275
NU EP UE
H 6 U
N
Bed pan, standard, metal or plastic
Purchase
E0276
NU EP UE
H 6 U
N
Bed pan, fracture, metal or plastic
Purchase
E0280
NU EP UE
H 6 U
N
Bed cradle, any type
Purchase
E0300
EP EP
RR
6 6
Y Y
Pediatric crib, hospital grade, fully enclosed
Purchase
Rental Only
E0303
NU EP UE
H 6 U
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
H H 6 U
N
Urinal; male, jug-type, any material
Purchase
E0326
NU EP UE
H 6 U
N
Urinal; female, jug-type, any material
Purchase
E0445***
NU EP
H 6
Y*
***(Pulse oximeter, including 4 disposable probes)
						  Oximeter for measuring blood oxygen levels non-invasively
Rental Only
E0480
NU EP UE
H 6 U
N
Percussor, electric or pneumatic, home model
Capped Rental
E0565
NU EP UE
H 6 U
Y*
Compressor, air power source for equipment which is not
						  self-contained or cylinder driven
Capped Rental
E0570
NU EP UE
H 6 U
Y
Nebulizer, with compressor
Purchase
E0585
NU EP UE
H 6 U
N
Nebulizer, with compressor and heater
Capped Rental
E0605
NU EP UE
H 6 U
N
Vaporizer, room type
Purchase
E0606
NU EP UE
H 6 U
N
Postural drainage board
Capped Rental
E0607***
NU EP
H 6
N
Home blood glucose monitor
Purchase
E0621
NU
H
N
Sling or seat, patient lift, canvas or nylon
Purchase
E0630
NU EP UE
H 6 U
Y*
Patient lift, hydraulic, with seat or sling
Capped Rental
E0650
NU EP UE
H 6 U
Y*
Pneumatic compressor, nonsegmental home model
Capped Rental
E0667
NU EP UE
H 6 U
Y*
Segmental pneumatic appliance for use with pneumatic
						  compressor, full leg
Capped Rental
E0668
NU EP UE
H 6 U
Y*
Segmental pneumatic appliance for use with pneumatic
						  compressor, full arm
Capped Rental
E0691
NU EP UE
H 6 U
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
H 6
N
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; four foot panel
Rental Only
E0693
NU EP
H 6
N
Ultraviolet light therapy system panel, includes
						  bulbs/lamps, timer and eye protection; six foot panel
Rental Only
E0694
NU EP
H 6
N
Ultraviolet multidirectional light therapy system in
						  six foot cabinet includes bulbs/lamps, timer and eye protection
Rental Only
E0720
NU EP UE
H 6 U
Y*
TENS, two lead, localized stimulation
Capped Rental
E0730
NU EP UE
H 6 U
Y
*
Transcutaneous electrical nerve stimulation device four
						  or more leads, for multiple nerve stimulation
Capped Rental
E0740
NU EP UE
H 6 U
N
Incontinence treatment system, pelvic floor stimulator,
						  monitor, sensor and/or trainer
Purchase
E0745
NU EP UE
H 6 U
Y*
Neuromuscular stimulator, electronic shock unit
Capped Rental
E0747
NU EP UE
H 6 U
Y*
Osteogenesis stimulator, electrical noninvasive, other
						  than spinal applications
Rental Only
E0748
NU EP
H 6
N
Osteogenesis stimulator, electrical noninvasive, spinal
						  applications
Purchase
E0749
NU EP UE
H 6 U
Y*
Osteogenesis stimulator, electrical , surgically
						  implanted
Purchase
E0779
NU
H
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
H 6 U
N
Traction frame, attached to headboard, cervical
						  traction
Purchase
E0850
NU EP UE
H 6 U
N
Traction stand, freestanding, cervical traction
Purchase
E0860
NU EP UE
H 6 U
N
Traction equipment, overdoor, cervical
Purchase
E0870
NU EP UE
H 6 U
N
Traction frame, attached to footboard, extremity
						  traction (e.g., Buck?s)
Purchase
E0880
NU EP UE
H 6 U
N
Traction stand, freestanding, extremity traction (e.g.,
						  Buck?s)
Purchase
E0890
NU EP UE
H 6 U
N
Traction frame, attached to footboard, pelvic
						  traction
Purchase
E0900
NU EP UE
H 6 U
N
Traction stand, freestanding, pelvic traction (e.g.,
						  Buck?s)
Purchase
E0910
NU EP UE
H 6 U
N
Trapeze bars, also known as Patient Helper, attached to
						  bed, with grab bar
Capped Rental
E0920
NU EP UE
H 6 U
N
Fracture frame, attached to bed, includes
						  weights
Capped Rental
E0930
NU EP UE
H 6 U
N
Fracture frame, freestanding, includes weights
Capped Rental
E0935
NU EP UE
H 6 U
Y*
Passive motion exercise device
Capped Rental
E0940
NU EP UE
H 6 U
N
Trapeze bar, freestanding, complete with grab
						  bar
Capped Rental
E0941
NU EP UE
H 6 U
N
Gravity assisted traction device, any type
Capped Rental
E0942
NU EP UE
H 6 U
N
Cervical head harness/halter
Purchase
E0944
NU EP UE
H 6 U
N
Pelvic belt/harness/boot
Purchase
E0945
NU EP UE
H 6 U
N
Extremity belt/harness
Purchase
E0946
NU EP UE
H 6 U
N
Fracture frame, dual with cross bars, attached to bed
						  (e.g., Balken, Four Poster)
Purchase
E0947
NU EP UE
H 6 U
N
Fracture frame, attachments for complex pelvic
						  traction
Purchase
E0948
NU EP UE
H 6 U
N
Fracture frame, attachments for complex cervical
						  traction
Purchase
E0950
NU EP UE
H 6 U
N
Wheelchair accessory, tray, each
Purchase
E1130*
NU EP UE
H 6 U
Y*
Standard wheelchair, fixed full-length arms, fixed or
						  swing?away, detachable footrests
Capped Rental
E1140*
NU EP UE
H 6 U
Y*
Wheelchair, detachable arms, desk or full-length,
						  swing?away, detachable footrests
Capped Rental
E1150*
NU EP UE
H 6 U
Y*
Wheelchair; detachable arms, desk or full-length,
						  swing?away, detachable, elevating legrests
Capped Rental
E1160*
NU EP UE
H 6 U
Y*
Wheelchair; fixed full-length arms, swing?away,
						  detachable, elevating legrests
Capped Rental
E1224*
NU EP UE
H 6 U
Y*
Wheelchair with detachable arms, elevating leg
						  rests
Capped Rental
E1340
NU
H
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
H 6
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
H
N
Durable medical equipment, miscellaneous
Manually Priced
S8096***
NU EP
H 6
N
***(Peak flow meter used by asthmatic patients)
						  Portable peak flow meter
Purchase
Procedure codes
E0250*
,
E0255*
and
E0260*
must be billed when hospital beds are purchased for
				eligible Medicaid beneficiaries of all ages.
The hospital beds must be new, not used. When billed
				electronically, the above procedure codes must be billed with modifier NU for
				individuals age 21 and over or modifier EP for individuals under the age of 21.
				A type of service code ?6? must be used for billing paper claims for
				beneficiaries under age 21 and type of service code ?H? for beneficiaries age
				21 and over. The codes all require prior authorization. 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
*remain payable and must 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.
242.161
Used Durable Medical
			 Equipment, Age 21 and Over
Procedure codes found in this section must be billed either
				electronically or on paper with modifier UE for used equipment.
Additionally, when billing on paper, bill for beneficiaries age
				21 and over using these procedure codes with a type of service code ?U,? for
used
equipment.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS. 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 over
				is limited to one per five-year period.
* Prior authorization is not required when another 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.
Used Durable Medical Equipment, Age 21 and Over (section
				242.161)
Procedure Code
M1
M2
TOS
Description
PA
Payment Method
E0105
UE
U
Cane, quad or three-prong, includes canes of all
						  materials, adjustable or fixed, with tips
N
Purchase
E0143
UE
U
***(Walker, folding, wheeled, with seat) Walker,
						  folding, wheeled, adjustable or fixed height
N
Capped Rental
E0143
UE
U
Walker, folding, wheeled, adjustable or fixed
						  height
N
Purchase
E0163
UE
U
Commode chair, stationary with fixed arms
N
Purchase
E0180
UE
U
Pressure pad, alternating with pump
N
Purchase
E0191
UE
U
Heel or elbow protector, each
N
Purchase
E0192
UE
U
Low pressure and positioning equalization pad for
						  wheelchair
N
Purchase
E0202
UE
U
Phototherapy (bilirubin) light with photometer
N
Rental Only
E0255
UE
U
***(Hospital bed, with side rails, variable height;
						  hi-lo, with mattress) Hospital bed, variable height; hi-lo, with any type side
						  rails, with mattress
Y
Capped Rental
E0260
UE
U
***(Hospital bed, with side rails, semi-electric; head
						  and foot adjustment, with mattress) Hospital bed, semi-electric, head and foot
						  adjustment, with any type side rails with mattress
Y*
Capped Rental
E0630
UE
U
Patient lift, hydraulic, with seat or sling
Y*
Capped Rental
E0730
UE
U
Transcutaneous electrical nerve stimulation device,
						  four or more leads, for multiple nerve stimulation
Y*
Capped Rental
E0910
UE
U
***(Trapeze bars, attached to bed, complete with grab
						  bar) Trapeze bars, also known as Patient Helper, attached to bed, with grab
						  bar
N
Capped Rental
E1130*
UE
U
Standard wheelchair; fixed full-length arms, fixed or
						  swing-away, detachable footrests
Y*
Capped Rental
E1224*
UE
U
***(Footrest wheelchair with detachable arms, elevating
						  legrests) Wheelchair with detachable arms, elevating legrests
Y*
Capped Rental
242.170
Apnea Monitors for Individuals Under 1 Year 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 UE must be used to bill for used equipment.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code ?6? for individuals under 21 years of
				age or TOS ?U? for used equipment.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS. 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.
Sections 212.300 and 222.200 contain information regarding
				specific coverage and restrictions.
* Prior authorization is not required when another 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.
National Code
M1
M2
TOS
Local Code
Description
PA
Payment Method
E0618
EP
6
Apnea monitor, without recording feature
Y (on 31st day)*
Rental Only (Daily Rental)
E0619
EP
6
Apnea monitor, with recording feature
Y (on 31st day)*
Rental Only (Daily Rental)
E0619
***(Initial setup of apnea monitor, includes 30 days
						  rental) Apnea monitor, with recording feature
N
First 30 Days Rental
Bill on paper
6
Z1684
Technical and lab services for setting up pneumogram or
						  event recording (not including professional services)
N
Purchase
242.180
Orthotic Appliances, All Ages
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.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code ?6? for individuals under age 21 or
				TOS code ?H? for individuals age 21 and over.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS.
Prior authorization requirements are shown under the heading
				PA. If prior authorization is needed for individuals age 21 and over, 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 over.
NOTE: Prosthetics providers may continue to use modifier
				52 for claims with dates of service through October 31, 2005. Effective for
				claims with dates of service on and after November 1, 2005, modifier 52 will be
				replaced with modifier UB.
** 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.
Orthotic Appliances, All Ages (section
				242.180)
Procedure Code
M1
M2
TOS
Description
All
U21
21+
PA 21+
Payment Method
A5500
NU
H
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+
Y
Purchase
A5501
NU
H
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+
Y
Purchase
A5503
NU
H
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+
Y
Purchase
A5504
NU
H
For diabetics only, modification (including fitting) of
						  off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per
						  shoe
21+
Y
Purchase
A5505
NU
H
For diabetics only, modification (including fitting) of
						  off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per
						  shoe
21+
Y
Purchase
A5506
NU
H
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+
Y
Purchase
A5507
NU
H
For diabetics only, not otherwise specified
						  modification (including fitting) of off-the-shelf depth-inlay shoe or custom
						  molded shoe, per shoe
21+
Y
Purchase
A5509
NU
H
For diabetics only, direct formed, molded to foot with
						  external heat source (i.e., heat gun) multiple density inserts(s),
						  prefabricated, per shoe
21+
Y
Purchase
A5510
NU
H
For diabetics only, direct formed, compression molded
						  to patient?s foot without external heat source, multiple-density insert(s)
						  prefabricated, per shoe
21+
Y
Purchase
A5511
NU
H
For diabetics only, custom-molded from model of
						  patient?s foot multiple-density insert(s) custom-fabricated, per shoe
21+
Y
Purchase
K0630
NU EP
H 6
SO, 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
K0631
NU EP
H 6
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
K0632
NU EP
H 6
SO, flexible, provides pelvic-sacral support, with
						  rigid or semi-rigid panels over 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
K0634
NU EP
H 6
LO, 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
K0635
NU EP
H 6
LO, sagittal control, with rigid posterior panel(s),
						  includes straps, 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
K0636
NU EP
H 6
LO, sagittal control, with rigid anterior and posterior
						  panel(s), includes straps, 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
K0637
NU EP
H 6
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, prefabricated,
						  includes fitting and adjustment
All
N
Purchase
K0638
NU EP
H 6
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
Purchase
K0639
NU EP
H 6
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
K0640
NU EP
H 6
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
K0641
NU EP
H 6
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, custom fabricated
All
N
Purchase
K0642
NU EP
H 6
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
K0643
NU EP
H 6
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, custom
						  fabricated
All
N
Purchase
K0644
NU EP
H 6
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, prefabricated,
						  includes fitting and adjustment
All
N
Purchase
K0645
NU EP
H 6
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
K0646
NU EP
H 6
LSO, sagittal-coronal control, with rigid anterior and
						  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, shoulder straps, pendulous abdomen
						  design, prefabricated, includes fitting and adjustment
All
N
Purchase
K0647
NU EP
H 6
LSO, sagittal-coronal control, with rigid anterior and
						  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, shoulder straps, pendulous abdomen
						  design, custom fabricated
All
N
Purchase
K0648
NU EP
H 6
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 plastic and stabilizing closures, includes straps, closures,
						  may include soft interface, pendulous abdomen design, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
K0649
NU EP
H 6
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 plastic and stabilizing closures, includes straps, closures,
						  may include soft interface, pendulous abdomen design, custom fabricated
All
N
Purchase
L0100
NU EP
H 6
Cranial orthosis (helmet), with or without soft
						  interface, molded to patient model
All
N
Purchase
L0110
NU EP
H 6
Cranial orthosis (helmet), with or without soft
						  interface, non-molded
All
N
Purchase
L0120
NU EP
H 6
Cervical, flexible, nonadjustable (foam collar)
All
N
Purchase
L0130
NU EP
H 6
Cervical, flexible, thermoplastic collar, molded to
						  patient
All
N
Purchase
L0140
NU EP
H 6
Cervical, semi-rigid, adjustable (plastic
						  collar)
All
N
Purchase
L0150
NU EP
H 6
Cervical, semi-rigid, adjustable molded chin cup
						  (plastic collar with mandibular/occipital piece)
All
N
Purchase
L0160
NU EP
H 6
Cervical, semi-rigid wire frame occipital/mandibular
						  support
All
N
Purchase
L0170
NU EP
H 6
Cervical, collar, molded to patient model
All
N
Purchase
L0172
NU EP
H 6
Cervical, collar, semi-rigid thermoplastic foam, two
						  piece
All
N
Purchase
L0174
NU EP
H 6
Cervical, collar, semi-rigid thermoplastic foam, two
						  piece with thoracic extension
All
N
Purchase
L0180
NU EP
H 6
Cervical, multiple post collar, occipital/mandibular
						  supports, adjustable
All
N
Purchase
L0190
NU EP
H 6
Cervical, multiple post collar, occipital/mandibular
						  supports, adjustable cervical bars (Somi, Guilford, Taylor types)
All
N
Purchase
L0200
NU EP
H 6
Cervical, multiple post collar, occipital/mandibular
						  supports, adjustable cervical bars, and thoracic extension
All
N
Purchase
L0210
NU EP
H 6
Thoracic, rib belt
All
N
Purchase
L0220
NU EP
H 6
Thoracic, rib belt, custom fabricated
All
N
Purchase
L0450
NU EP
H 6
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
H 6
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
H 6
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
H 6
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
H 6
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
H 6
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
H 6
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
H 6
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
H 6
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
H 6
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
H 6
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
H 6
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
Y
Purchase
L0474
NU EP
H 6
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
H 6
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
H 6
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
H 6
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
H 6
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
H 6
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
H 6
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
L0700
NU EP
H 6
Cervical-thoracic-lumbar-sacral orthoses (CTLSO),
						  anterior-posterior-lateral control, molded to patient model (Minerva
						  type)
All
Y
Purchase
L0710
NU EP
H 6
CTLSO, anterior-posterior-lateral control, molded to
						  patient model, with interface material (Minerva type)
All
Y
Purchase
L0810
NU EP
H 6
Halo procedure, cervical halo incorporated into jacket
						  vest
All
Y
Purchase
L0820
NU EP
H 6
Halo procedure, cervical halo incorporated into plaster
						  body jacket
All
Y
Purchase
L0830
NU EP
H 6
Halo procedure, cervical halo incorporated into
						  Milwaukee type orthosis
All
Y
Purchase
L0860
NU EP
H 6
Addition to halo procedure, magnetic resonance image
						  compatible system
All
Y
Purchase
L0960
NU EP
H 6
Torso support, post surgical support, pads for post
						  surgical support
All
N
Purchase
L0970
NU EP
H 6
TLSO, corset front
All
N
Purchase
L0972
NU EP
H 6
LSO, corset front
All
N
Purchase
L0974
NU EP
H 6
TLSO, full corset
All
N
Purchase
L0976
NU EP
H 6
LSO, full corset
All
N
Purchase
L0978
NU EP
H 6
Axillary crutch extension
All
N
Purchase
L0980
NU EP
H 6
Peroneal straps, pair
All
N
Purchase
L0982
NU EP
H 6
Stocking supporter grips, set of four (4)
All
N
Purchase
L0984
NU
H
Protective body sock, each
21+
N
Purchase
L1000
NU EP
H 6
CTLSO (Milwaukee), inclusive of furnishing initial
						  orthosis, including model
All
Y
Purchase
L1010
NU EP
H 6
TLSO or scoliosis orthosis, axilla sling
All
N
Purchase
L1020
NU EP
H 6
Addition to CTLSO or scoliosis orthosis, kyphosis
						  pad
All
N
Purchase
L1025
NU EP
H 6
Addition to CTLSO or scoliosis orthosis, kyphosis pad,
						  floating
All
N
Purchase
L1030
NU EP
H 6
Addition to CTLSO or scoliosis orthosis, lumbar bolster
						  pad
All
N
Purchase
L1040
NU EP
H 6
Addition to CTLSO or scoliosis orthosis, lumbar or
						  lumbar rib pad
All
N
Purchase
L1050
NU EP
H 6
Addition to CTLSO or scoliosis orthosis, sternal
						  pad
All
N
Purchase
L1060
NU EP
H 6
Addition to CTLSO or scoliosis orthosis, thoracic
						  pad
All
N
Purchase
L1070
NU EP
H 6
Addition to CTLSO or scoliosis orthosis, trapezius
						  sling
All
N
Purchase
L1080
NU EP
H 6
Addition to CTLSO or scoliosis orthosis,
						  outrigger
All
N
Purchase
L1085
NU EP
H 6
Addition to CTLSO or scoliosis orthosis, outrigger,
						  bilateral with vertical extensions
All
N
Purchase
L1090
NU EP
H 6
Addition to CTLSO or scoliosis orthosis, lumbar
						  sling
All
N
Purchase
L1100
NU EP
H 6
Addition to CTLSO or scoliosis orthosis, ring flange,
						  plastic or leather
All
N
Purchase
L1110
NU EP
H 6
Addition to CTLSO or scoliosis orthosis, ring flange,
						  plastic or leather, molded to patient model
All
N
Purchase
L1120
NU EP
H 6
Addition to CTLSO, scoliosis orthosis, cover for
						  upright, each
All
N
Purchase
L1200
NU EP
H 6
Thoracic-lumbar-sacral-orthosis (TLSO), inclusive of
						  furnishing initial orthosis only
All
Y
Purchase
L1210
NU EP
H 6
Addition to TLSO (low profile), lateral thoracic
						  extension
All
N
Purchase
L1220
NU EP
H 6
Addition to TLSO (low profile), anterior thoracic
						  extension
All
N
Purchase
L1230
NU EP
H 6
Addition to TLSO (low profile), Milwaukee type
						  superstructure
All
N
Purchase
L1240
NU EP
H 6
Addition to TLSO (low profile), lumbar derotation
						  pad
All
N
Purchase
L1250
NU EP
H 6
Addition to TLSO (low profile), anterior ASIS
						  pad
All
N
Purchase
L1260
NU EP
H 6
Addition to TLSO (low profile), anterior thoracic
						  derotation pad
All
N
Purchase
L1270
NU EP
H 6
Addition to TLSO (low profile), abdominal pad
All
N
Purchase
L1280
NU EP
H 6
Addition to TLSO (low profile), rib gusset (elastic),
						  each
All
N
Purchase
L1290
NU EP
H 6
Addition to TLSO (low profile), lateral trochanteric
						  pad
All
N
Purchase
L1300
NU EP
H 6
Other scoliosis procedure, body jacket molded to
						  patient model
All
Y
Purchase
L1310
NU EP
H 6
Other scoliosis procedure, postoperative body
						  jacket
All
Y
Purchase
L1499
NU EP
H 6
Spinal orthosis, not otherwise specified. ***The
						  manufacturer?s invoice must be attached to all claims.
All
Y
Manually Priced
L1500
NU EP
H 6
THKAO, mobility frame (Newington, Parapodium
						  types)
All
Y
Purchase
L1510
NU EP
H 6
THKAO, standing frame, with or without tray and
						  accessories
All
Y
Purchase
L1520
NU EP
H 6
THKAO, swivel walker
All
Y
Purchase
L1600
NU EP
H 6
HO, abduction control of hip joints, flexible, Frejka
						  type with cover, prefabricated, includes fitting and adjustment
All
N
Purchase
L1610
NU EP
H 6
HO, abduction control of hip joints, flexible (Frejka
						  cover only), prefabricated, includes fitting and adjustment
All
N
Purchase
L1620
NU EP
H 6
HO, abduction control of hip joints, flexible (Pavlik
						  harness), prefabricated, includes fitting and adjustment
All
N
Purchase
L1630
NU EP
H 6
HO, abduction control of hip joints, semi-flexible (Von
						  Rosen type), custom fabricated
All
N
Purchase
L1640
NU EP
H 6
HO, abduction control of hip joints, static, pelvic
						  band or spreader bar, thigh cuffs, custom fabricated
All
N
Purchase
L1650
NU EP
H 6
HO, abduction control of hip joints, static,
						  adjustable, custom fitted (Ilfled type), prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L1660
NU EP
H 6
HO, abduction control of hip joints, static, plastic,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L1680
NU EP
H 6
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
H 6
HO, abduction control of hip joint, post operative hip
						  abduction type, custom fabricated
All
Y
Purchase
L1686
NU EP
H 6
HO, abduction control of hip joint, post operative hip
						  abduction type, prefabricated, includes fitting and adjustments
All
Y
Purchase
L1690
NU
H
Combination, bilateral, lumbo-sacral, hip, femur
						  orthosis providing adduction and internal rotation control, prefabricated,
						  includes fitting and adjustment
21+
Y
Purchase
L1700
NU EP
H 6
Legg Perthes orthosis (Toronto type), custom
						  fabricated
All
Y
Purchase
L1710
NU EP
H 6
Legg Perthes orthosis (Newington type), custom
						  fabricated
All
Y
Purchase
L1720
NU EP
H 6
Legg Perthes orthosis, trilateral (Tachdijan type),
						  custom fabricated
All
Y
Purchase
L1730
NU EP
H 6
Legg Perthes orthosis (Scottish Rite type) custom
						  fabricated
All
Y
Purchase
L1750
NU EP
H 6
Legg Perthes orthosis, Legg Perthes sling (Sam Brown
						  type), prefabricated, includes fitting and adjustment
All
Y
Purchase
L1755
NU EP
H 6
Legg Perthes orthosis (Patten bottom type), custom
						  fabricated
All
Y
Purchase
L1800
NU EP
H 6
KO, elastic with stays, prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L1810
NU EP
H 6
KO, elastic with joints, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L1815
NU EP
H 6
KO, elastic or other elsastic type material with
						  condylar pad(s), prefabricated, includes fitting and adjustment
All
N
Purchase
L1820
NU EP
H 6
KO, elastic with condyle pads and joints,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L1825
NU EP
H 6
KO, elastic knee cap. prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L1830
NU EP
H 6
KO, immobilizer, canvas longitudinal, prefabricated,
						  includes fitting and adjustment
All
N
Purchase
L1832
NU EP
H 6
KO, adjustable knee joints, positional orthosis, rigid
						  support, prefabricated, includes fitting and adjustment rigid support
All
N
Purchase
L1834
NU EP
H 6
KO, without knee joint, rigid, custom fabricated
All
N
Purchase
L1840
NU EP
H 6
KO, derotation, medial-lateral, anterior cruciate
						  ligament, custom fabricated
All
Y
Purchase
L1843
NU
H
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
H
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
H 6
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
H 6
KO, double upright, thigh and calf, with adjustable
						  flexion and extension joint, medial-lateral and rotation control, custom
						  fabricated
All
Y
Purchase
L1847
NU
H
Knee orthosis, double upright with adjustable joint,
						  with inflatable air support chamber(s) prefabricated, includes fitting and
						  adjustment
21+
N
Purchase
L1850
NU EP
H 6
KO, Swedish type, prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L1855
NU EP
H 6
KO, molded plastic, thigh and calf sections, with
						  double upright knee joints, custom fabricated
All
Y
Purchase
L1858
NU EP
H 6
KO, molded plastic, polycentric knee joints, pneumatic
						  knee pads (CTI), custom fabricated
All
Y
Purchase
L1860
NU EP
H 6
KO, modification of supracondylar prosthetic socket,
						  custom fabricated (SK)
All
Y
Purchase
L1870
NU EP
H 6
KO, double upright, thigh and calf lacers, with knee
						  joints, custom fabricated
All
Y
Purchase
L1880
NU EP
H 6
KO, double upright, nonmolded thigh and calf
						  cuff/lacers with knee joints, custom fabricated
All
N
Purchase
L1900
NU EP
H 6
AFO, spring wire, dorsiflexion assist calf band, custom
						  fabricated
All
N
Purchase
L1902
NU EP
H 6
AFO, ankle gauntlet, prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L1904
NU EP
H 6
AFO, molded ankle gauntlet, custom fabricated
All
N
Purchase
L1906
NU EP
H 6
AFO, multigamentus ankle support, prefabricated,
						  includes fitting and adjustment
All
N
Purchase
L1907
NU EP
H 6
AFO, supramalleolar with straps, with or without
						  interface/pads, custom fabricated
All
N
Purchase
L1910
NU EP
H 6
AFO, posterior, single bar, clasp attachment to shoe
						  counter prefabricated, includes fitting and adjustment
All
N
Purchase
L1920
NU EP
H 6
AFO, single upright with static or adjustable stop
						  (Phelps or Perlstein type), custom fabricated
All
N
Purchase
L1920
EP
6
***(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
H 6
AFO, plastic or other material, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L1932
NU EP
H 6
AFO, rigid anterior tibial section, total carbon fiber
						  or equal material, prefabricated, includes fitting and adjustment
All
N
Purchase
L1940
NU EP
H 6
AFO, plastic or other material,
						  custom-fabricated
All
N
Purchase
L1945
NU EP
H 6
AFO, molded to patient model, plastic, rigid anterior
						  tibial section (floor reaction), custom fabricated
All
Y
Purchase
L1950
NU EP
H 6
AFO, spiral (Institute of Rehabilitative Medicine
						  type), plastic, custom fabricated
All
N
Purchase
L1960
NU EP
H 6
AFO, posterior solid ankle, plastic, custom
						  fabricated
All
N
Purchase
L1970
NU EP
H 6
AFO, plastic, with ankle joint, custom
						  fabricated
All
N
Purchase
L1980
NU EP
H 6
AFO, single upright free plantar dorsiflexion, solid
						  stirrup, calf band/cuff (single bar ?BK? orthosis), custom fabricated
All
N
Purchase
L1990
NU EP
H 6
AFO, double upright free plantar dorsiflexion, solid
						  stirrup, calf band/cuff (double bar ?BK? orthosis), custom fabricated
All
N
Purchase
L2000
NU EP
H 6
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
H 6
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
H 6
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
H 6
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
H 6
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
H
KAFO, full plastic, static prefabricated (pediatric
						  size) prefabricated, includes fitting and adjustment
21+
N
Purchase
L2036
NU EP
H 6
KAFO, full plastic, double upright, free knee, custom
						  fabricated
All
Y?
Purchase
L2037
NU EP
H 6
KAFO, full plastic, single upright, free knee, custom
						  fabricated
All
Y
Purchase
L2038
NU EP
H 6
KAFO, full plastic, without knee joint, multi-axis
						  ankle, (Lively orthosis or equal), custom fabricated
All
Y
Purchase
L2039
NU
H
KAFO, full plastic, single upright, poly-axial hinge,
						  medial lateral rotation control, custom fabricated
21+
Y
Purchase
L2040
NU EP
H 6
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
H 6
***(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
H 6
HKAFO, torsion control, bilateral torsion cables, hip
						  joint, pelvic band/belt, custom fabricated
All
N
Purchase
L2060
NU EP
H 6
HKAFO, torsion control, bilateral torsion cables, ball
						  bearing hip joint, pelvic band/belt, custom fabricated
All
N
Purchase
L2070
NU EP
H 6
HKAFO, torsion control, unilateral rotation straps,
						  pelvic band/belt, custom fabricated
All
N
Purchase
L2080
NU EP
H 6
HKAFO, torsion control, unilateral torsion cable, hip
						  joint, pelvic band/belt, custom fabricated
All
N
Purchase
L2090
NU EP
H 6
HKAFO, torsion control, unilateral torsion cable, ball
						  bearing hip joint, pelvic band/belt, custom fabricated
All
N
Purchase
L2106
NU EP
H 6
AFO, fracture orthosis, tibial fracture cast orthosis,
						  thermoplastic type casting material, custom fabricated
All
N
Purchase
L2108
NU EP
H 6
AFO, fracture orthosis, tibial fracture cast orthosis,
						  custom fabricated
All
Y
Purchase
L2112
NU EP
H 6
AFO, fracture orthosis, tibial fracture orthosis, soft,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L2114
NU EP
H 6
AFO, fracture orthosis, tibial fracture orthosis,
						  semi-rigid, prefabricated, includes fitting and adjustment
All
N
Purchase
L2116
NU EP
H 6
AFO, fracture orthosis, tibial fracture orthosis,
						  rigid, prefabricated, includes fitting and adjustment
All
N
Purchase
L2126
NU EP
H 6
KAFO, fracture orthosis, femoral fracture cast
						  orthosis, thermoplastic type casting material, molded to patient
All
Y
Purchase
L2128
NU EP
H 6
KAFO, fracture orthosis, femoral fracture cast
						  orthosis, thermoplastic type casting material, custom fabricated
All
Y
Purchase
L2132
NU EP
H 6
KAFO, fracture orthosis, femoral fracture cast
						  orthosis, soft, prefabricated, includes fitting and adjustment
All
Y
Purchase
L2134
NU EP
H 6
KAFO, fracture orthosis, femoral fracture cast
						  orthosis, semi-rigid custom fitted
All
Y
Purchase
L2136
NU EP
H 6
KAFO, fracture orthosis, femoral fracture cast
						  orthosis, rigid, prefabricated, includes fitting and adjustment
All
Y
Purchase
L2180
NU EP
H 6
Addition to lower extremity fracture orthosis, plastic
						  shoe insert with ankle joints
All
N
Purchase
L2182
NU EP
H 6
Addition to lower extremity fracture orthosis, drop
						  lock knee joint
All
N
Purchase
L2184
NU EP
H 6
Addition to lower extremity fracture orthosis, limited
						  motion knee joint
All
N
Purchase
L2186
NU EP
H 6
Addition to lower extremity fracture orthosis,
						  adjustable motion knee joint (Lerman type)
All
N
Purchase
L2188
NU EP
H 6
Addition to lower extremity fracture orthosis,
						  quadrilateral brim
All
N
Purchase
L2190
NU EP
H 6
Addition to lower extremity fracture orthosis, waist
						  belt
All
N
Purchase
L2192
NU EP
H 6
Addition to lower extremity fracture orthosis, hip
						  joint, pelvic band, thigh flange, and pelvic belt
All
N
Purchase
L2200
NU EP
H 6
Additions to lower extremity, dorsiflexion and plantar
						  flexion
All
N
Purchase
L2210
NU EP
H 6
Addition to lower extremity, dorsiflexion assist
						  (plantar flexion resist), each joint
All
N
Purchase
L2220
NU EP
H 6
Addition to lower extremity, dorsiflexion and plantar
						  flexion assist/resist, each joint
All
N
Purchase
L2230
NU EP
H 6
Addition to lower extremity, split flat caliper
						  stirrups and plate attachment
All
N
Purchase
L2232
NU EP
H 6
Addition to lower extremity orthosis, rocker bottom for
						  total contact ankle foot orthosis, for custom fabricated orthosis only
All
N
Purchase
L2240
NU EP
H 6
Addition to lower extremity, round caliper and plate
						  attachment
All
N
Purchase
L2250
NU EP
H 6
Addition to lower extremity, foot plate, molded to
						  patient model, stirrup attachment
All
N
Purchase
L2260
NU EP
H 6
Addition to lower extremity, reinforced solid stirrup
						  (Scott-Craig type)
All
N
Purchase
L2265
NU EP
H 6
Addition to lower extremity, long tongue stirrup
All
N
Purchase
L2270
NU EP
H 6
Addition to lower extremity, varus/valgus correction
						  (?T?) strap, padded/lined or malleolus pad
All
N
Purchase
L2275
NU
H
Addition to lower extremity, varus/valgus correction,
						  plastic modification, padded/lined
21+
N
Purchase
L2280
NU EP
H 6
Addition to lower extremity, molded inner boot
All
N
Purchase
L2300
NU EP
H 6
Addition to lower extremity, abduction bar (bilateral
						  hip involvement), jointed, adjustable
All
N
Purchase
L2310
NU EP
H 6
Addition to lower extremity, abduction bar
						  straight
All
N
Purchase
L2320
NU EP
H 6
Addition to lower extremity, nonmolded lacer
All
N
Purchase
L2330
NU EP
H 6
Addition to lower extremity, lacer molded to patient
						  model
All
N
Purchase
L2335
NU EP
H 6
Addition to lower extremity, anterior swing band
All
N
Purchase
L2340
NU EP
H 6
Addition to lower extremity, pretidial shell, molded to
						  patient model
All
N
Purchase
L2350
NU EP
H 6
Addition to lower extremity, prosthetic type, (BK)
						  socket, molded to patient model, (used for ?PTB? ?AFO? orthoses)
All
Y
Purchase
L2360
NU EP
H 6
Addition to lower extremity, extended steel
						  shank
All
N
Purchase
L2370
NU EP
H 6
Addition to lower extremity, Patten bottom
All
N
Purchase
L2375
NU EP
H 6
Addition to lower extremity, torsion control, ankle
						  joint and half solid stirrup
All
N
Purchase
L2380
NU EP
H 6
Addition to lower extremity, torsion control, straight
						  knee joint, each joint
All
N
Purchase
L2385
NU EP
H 6
Addition to lower extremity, straight knee joint, heavy
						  duty, each joint
All
N
Purchase
L2390
NU EP
H 6
Addition to lower extremity, offset knee joint, each
						  joint
All
N
Purchase
L2395
NU EP
H 6
Addition to lower extremity, offset knee joint, heavy
						  duty, each joint
All
N
Purchase
L2397
NU
H
Addition to lower extremity orthosis, suspension
						  sleeve
21+
N
Purchase
L2405
NU EP
H 6
Addition to knee joint, lock; drop, stance or swing
						  phase, each joint
All
N
Purchase
L2415
NU EP
H 6
Addition to knee lock with integrated release mechanism
						  , (bail, cable or equal, any material, each joint
All
N
Purchase
L2425
NU EP
H 6
Addition to knee joint, disc or dial lock for
						  adjustable knee flexion, each joint
All
N
Purchase
L2430
NU
H
Addition to knee joint, ratchet lock for active and
						  progressive knee extension, each joint
21+
N
Purchase
L2492
NU EP
H 6
Addition to knee joint, lift loop for drop lock
						  ring
All
N
Purchase
L2500
NU EP
H 6
Addition to lower extremity, thigh/weight bearing,
						  gulteal/ischial weight bearing, ring
All
N
Purchase
L2510
NU EP
H 6
Addition to lower extremity, thigh/weight bearing,
						  quadrilateral brim, molded to patient model
All
N
Purchase
L2520
NU EP
H 6
Addition to lower extremity, thigh/weight bearing,
						  quadrilateral brim, custom fitted
All
N
Purchase
L2525
NU EP
H 6
Addition to lower extremity, thigh/weight bearing,
						  ischial containment/narrow M-L brim molded to patient model
All
N
Purchase
L2526
NU EP
H 6
Addition to lower extremity, thigh/weight bearing,
						  ischial containment/narrow M-L brim, custom fitted
All
N
Purchase
L2530
NU EP
H 6
Addition to lower extremity, thigh/weight bearing,
						  lacer, non-molded
All
N
Purchase
L2540
NU EP
H 6
Addition to lower extremity, thigh/weight bearing,
						  lacer, molded to patient model
All
N
Purchase
L2550
NU EP
H 6
Addition to lower extremity, thigh/weight bearing, high
						  roll cuff
All
N
Purchase
L2570
NU EP
H 6
Addition to lower extremity, pelvic control, hip joint,
						  clevis type two position joint, each
All
N
Purchase
L2580
NU EP
H 6
Addition to lower extremity, pelvic control, pelvic
						  sling
All
N
Purchase
L2600
NU EP
H 6
Addition to lower extremity, pelvic control, hip joint,
						  Clevis type, or thrust bearing free, each
All
N
Purchase
L2610
NU EP
H 6
Addition to lower extremity, pelvic control, hip joint,
						  Clevis or thrust bearing, lock, each
All
N
Purchase
L2620
NU EP
H 6
Addition to lower extremity, pelvic control, hip joint,
						  heavy duty, each
All
N
Purchase
L2622
NU EP
H 6
Addition to lower extremity, pelvic control, hip joint,
						  adjustable flexion, each
All
N
Purchase
L2624
NU EP
H 6
Addition to lower extremity, pelvic control, hip joint,
						  adjustable flexion, extension, abduction control, each
All
N
Purchase
L2627
NU EP
H 6
Addition to lower extremity, pelvic control, plastic,
						  molded to patient model, reciprocating hip joint and cables
All
N
Purchase
L2628
NU EP
H 6
Addition to lower extremity, pelvic control, metal
						  frame, reciprocating hip joint and cables
All
N
Purchase
L2630
NU EP
H 6
Addition to lower extremity, pelvic control, band and
						  belt unilateral
All
N
Purchase
L2640
NU EP
H 6
Addition to lower extremity, pelvic control, band and
						  belt bilateral
All
N
Purchase
L2650
NU EP
H 6
Addition to lower extremity, pelvic and thoracic
						  control, gluteal pad, each
All
N
Purchase
L2660
NU EP
H 6
Addition to lower extremity, thoracic control, thoracic
						  band
All
N
Purchase
L2670
NU EP
H 6
Addition to lower extremity, thoracic control,
						  paraspinal uprights
All
N
Purchase
L2680
NU EP
H 6
Addition to lower extremity, thoracic control, lateral
						  support uprights
All
N
Purchase
L2750
NU EP
H 6
Addition to lower extremity orthosis, plating chrome or
						  nickel, per bar
All
N
Purchase
L2755
NU
H
Addition to lower extremity orthosis, high strength,
						  lightweight material, all hybrid lamination/prepreg composite, per
						  segment
21+
N
Purchase
L2755
NU EP
H 6
***(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
H 6
Addition to lower extremity orthosis, extension, per
						  extension, per bar (for linear adjustment for growth)
All
N
Purchase
L2770
NU EP
H 6
Addition to lower extremity orthosis, any material, per
						  bar or joint
All
N
Purchase
L2780
NU EP
H 6
Addition to lower extremity orthosis, non-corrosive
						  finish, per bar
All
N
Purchase
L2785
NU EP
H 6
Addition to lower extremity orthosis, drop lock
						  retainer, each
All
N
Purchase
L2795
NU EP
H 6
Addition to lower extremity orthosis, knee control,
						  full kneecap
All
N
Purchase
L2800
NU EP
H 6
Addition to lower extremity orthosis, knee control,
						  kneecap, medial or lateral pull
All
N
Purchase
L2810
NU EP
H 6
Addition to lower extremity orthosis, knee control,
						  condylar pad
All
N
Purchase
L2810
EP
6
***(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
H 6
Addition to lower extremity orthosis, soft interface
						  for molded plastic, below knee section
All
N
Purchase
L2830
NU EP
H 6
Addition to lower extremity orthosis, soft interface
						  for molded plastic, above knee section
All
N
Purchase
L2840
NU EP
H 6
Addition to lower extremity orthosis, tibial length
						  sock, fracture or equal, each
All
N
Purchase
L2850
NU EP
H 6
Addition to lower extremity orthosis, femoral length
						  sock, fracture or equal, each
All
N
Purchase
L2999
NU EP
H 6
Lower extremity orthoses, NOS
All
N
Manually Priced
L2999
NU EP
H 6
***(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
H 6
Foot insert, removable, molded to patient model, ?UCB?
						  type, Berkeley shell, each
All
N
Purchase
L3002
NU EP
H 6
Foot insert, removable, molded to patient model,
						  Plastazote or equal, each
All
N
Manually Priced
L3010
NU EP
H 6
Foot insert, removable, molded to patient model,
						  longitudinal arch support, each
All
N
Purchase
L3020
NU EP
H 6
Foot insert, removable, molded to patient model,
						  longitudinal/metatarsal support, each
All
N
Purchase
L3030
NU EP
H 6
Foot insert, removable, formed to patient foot,
						  each
All
N
Purchase
L3040
NU EP
H 6
Foot, arch support, removable, premolded, longitudinal,
						  each
All
N
Purchase
L3050
NU EP
H 6
Foot, arch support, removable, premolded, metatarsal,
						  each
All
N
Purchase
L3060
NU EP
H 6
Foot, arch support, removable, premolded,
						  longitudinal/metatarsal, each
All
N
Purchase
L3070
NU EP
H 6
Foot, arch support, non-removable, attached to shoe,
						  longitudinal, each
All
N
Purchase
L3080
NU EP
H 6
Foot, arch support, non-removable, attached to shoe,
						  metatarsal, each
All
N
Purchase
L3090
NU EP
H 6
Foot, arch support, non-removable, attached to shoe,
						  longitudinal/metatarsal, each
All
N
Purchase
L3100
NU EP
H 6
Hallus?valgus night dynamic splint
All
N
Purchase
L3140
NU EP
UB
H 6
***(Bebox foot orthosis clubfood abduction orthosis)
						  Foot, abduction rotation bar, including shoes
All
N
Manually Priced
Purchase
L3140
NU
H
***(Don Joy knee orthosis) Foot, abduction rotation
						  bar, including shoes
21+
Y
Manually Priced
L3150
NU EP
H 6
Foot, abduction rotation bar, without shoes
All
N
Purchase
L3150
EP
6
***(Custom night ?A? frame-KAFO, torsion control,
						  bilateral night ?A? frame) Foot, abduction rotation bar, without shoes
U21
N/A
Purchase
L3170
NU EP
H 6
Foot, plastic heel stabilizer
All
N
Purchase
L3202
EP
6
Orthopedic shoe, oxford with supinator or pronator,
						  child
U21
N/A
Purchase
L3204
EP
6
Orthopedic shoe, high-top with supinator or pronator,
						  infant
U21
N/A
Purchase
L3204
NU EP
H 6
***(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
H 6
***(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
H 6
***(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
H 6
***(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
H 6
***(Reverse last closed toe) Orthopedic shoe, high-top
						  with supinator or pronator, infant
All
N
Manually Priced
Purchase
L3204
NU
H
***(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
H 6
***(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
H 6
***(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
H 6
***(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
H 6
***(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
H 6
***(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
H 6
***(Reverse last closed toe) Orthopedic shoe, high-top
						  with supinator or pronator, child
All
N
Manually Priced
Purchase
L3206
NU
H
***(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
H 6
***(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
H 6
***(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
H 6
***(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
H 6
***(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
H 6
***(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
H 6
***(Reverse last closed toe) Orthopedic shoe, high-top
						  with supinator or pronator, junior
All
N
Manually Priced
Purchase
L3207
NU
H
***(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
H 6
***(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
H 6
***(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
6
Surgical boot, each, infant
U21
N/A
Purchase
L3209
EP
6
Surgical boot, each, child
U21
N/A
Purchase
L3215
NU EP
H 6
Orthopedic footwear, woman?s shoes, oxford
All
Y
Manually Priced
L3216
NU EP
H 6
Orthopedic footwear, woman?s shoes, depth inlay
All
Y
Purchase
L3217
NU EP
H 6
***(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
H 6
***(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
H 6
***(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
H 6
***(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
H 6
***(Reverse last closed toe) Orthopedic footwear,
						  woman?s shoes, high-top, depth inlay
All
N
Manually Priced
Purchase
L3219
NU EP
H 6
Orthopedic footwear, man?s shoes, oxford
All
Y
Manually Priced
L3221
NU EP
H 6
Orthopedic footwear, man?s shoes, depth inlay
All
Y
Purchase
L3222
NU EP
H 6
***(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
H 6
***(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
H 6
***(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
H 6
***(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
H 6
***(Reverse last closed toe) Orthopedic footwear, man?s
						  shoes, high-top, depth inlay
All
N
Manually Priced
Purchase
L3224
NU
H
Orthopedic footwear, woman?s shoe, Oxford, used as an
						  integral part of a brace (orthosis)
21+
N
Purchase
L3225
NU
H
Orthopedic footwear, man?s shoe, oxford, used as an
						  integral part of a brace (orthosis)
21+
N
Purchase
L3230
NU EP
H 6
Orthopedic footwear, custom shoes, depth inlay
All
Y
Purchase
L3250
NU EP
H 6
Orthopedic footwear, custom molded shoe, removable
						  inner molded, prosthetic shoe, each
All
Y
Manually Priced
L3253
NU EP
H 6
Foot, molded shoe Plastazate (or similar), custom
						  fitted, each
All
Y
Purchase
L3257
NU EP
H 6
Orthopedic footwear, additional charge for split
						  size
All
Y
Purchase
L3260
NU EP
H 6
Surgical boot/shoe, each
All
N
Purchase
L3265
NU EP
H 6
Plastazote sandal, each
All
N
Purchase
L3310
NU EP
H 6
Lift, elevation, heel and sole, neoprene, per
						  inch
All
N
Purchase
L3332
NU EP
H 6
Lift, elevation, inside shoe, tapered, up to one-half
						  inch
All
N
Purchase
L3334
NU EP
H 6
Lift, elevation, heel, per inch
All
N
Purchase
L3350
NU EP
H 6
Heel wedge
All
N
Purchase
L3360
NU EP
H 6
Sole wedge, outside sole
All
N
Purchase
L3370
NU EP
H 6
Sole wedge, between sole
All
N
Purchase
L3400
NU EP
H 6
Metatarsal bar wedge, rocker
All
N
Purchase
L3420
NU EP
H 6
Full sole and heel wedge, between sole
All
N
Purchase
L3450
NU EP
H 6
Heel, SACH cushion type
All
N
Purchase
L3455
NU EP
H 6
Heel, new leather, standard
All
N
Purchase
L3465
NU EP
H 6
Heel, Thomas with wedge
All
N
Purchase
L3540
NU EP
H 6
Orthopedic shoe addition, sole full
All
N
Purchase
L3580
NU EP
H 6
Orthopedic shoe addition, convert instep to velcro
						  closure
All
N
Purchase
L3590
NU EP
H 6
Orthopedic shoe addition, convert firm shoe counter to
						  soft counter
All
N
Purchase
L3600
NU EP
H 6
Transfer for an orthosis from one shoe to another,
						  caliper plate, existing
All
N
Purchase
L3620
NU EP
H 6
Transfer of an orthosis from one shoe to another, solid
						  stirrup, existing
All
N
Purchase
L3630
NU EP
H 6
Transfer of an orthosis from one shoe to another, solid
						  stirrup, new
All
N
Purchase
L3649
EP
6
Orthopedic shoe, modification, addition or transfer,
						  NOS
U21
N/A
Manually Priced
L3649
NU EP
U1
H 6
***(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
H 6
***(Orthopedic footwear, wooden sole shoe, each)
						  Orthopedic shoe, modification, addition or transfer, NOS
All
N
Manually Priced
Purchase
L3650
NU EP
H 6
SO, figure of eight design abduction re-strainer
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3660
NU EP
H 6
SO, figure of eight design, abduction restrainer,
						  canvas and webbing, prefabricated, includes fitting and adjustment
All
N
Purchase
L3670
NU EP
H 6
SO, acromio/clavicular (canvas and webbing type)
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3675
NU
H
SO, vest type abduction restrainer, canvas webbing
						  type, or equal, prefabricated, includes fitting and adjustment
21+
N
Purchase
L3700
NU EP
H 6
Elbow orthoses (EO), elastic with stays, prefabricated,
						  includes fitting and adjustment
All
N
Purchase
L3710
NU EP
H 6
EO, elastic with metal joints, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L3720
NU EP
H 6
EO, double upright with forearm/arm cuffs, free motion,
						  custom fabricated
All
N
Purchase
L3730
NU EP
H 6
EO, double upright with forearm/arm cuffs,
						  extension/flexion assist, custom fabricated
All
Y
Purchase
L3740
NU EP
H 6
EO, double upright with forearm/arm cuffs, adjustable
						  position lock with active control, custom fabricated
All
Y
Purchase
L3800
NU EP
H 6
WHFO, short opponens, no attachments, custom
						  fabricated
All
N
Purchase
L3805
NU EP
H 6
WHFO, long opponens, no attachment, custom
						  fabricated
All
N
Purchase
L3810
NU EP
H 6
WHFO, addition to short and long opponens, thumb
						  abduction (?C?) bar
All
N
Purchase
L3815
NU EP
H 6
WHFO, addition to short and long opponens, second M.P.
						  abduction assist
All
N
Purchase
L3820
NU EP
H 6
WHFO, addition to short and long opponens, I.P.
						  extension assist, with M.P. extension stop
All
N
Purchase
L3825
NU EP
H 6
WHFO, addition to short and long opponens, M.P.
						  extension stop
All
N
Purchase
L3830
NU EP
H 6
WHFO, addition to short and long opponens, M.P.
						  extension assist
All
N
Purchase
L3835
NU EP
H 6
WHFO, addition to short and long opponens, M.P. spring
						  extension assist
All
N
Purchase
L3840
NU EP
H 6
WHFO, addition to short and long opponens, spring
						  swivel thumb
All
N
Purchase
L3845
NU EP
H 6
WHFO, addition to short and long opponens, thumb I.P.
						  extension assist, with M.P. stop
All
N
Purchase
L3850
NU EP
H 6
WHO, addition to short and long opponens, action wrist
						  with dorsiflexion assist
All
N
Purchase
L3855
NU EP
H 6
WHFO, addition to short and long opponens, adjustable
						  M.P. flexion control
All
N
Purchase
L3860
NU EP
H 6
WHFO, addition to short and long opponens, adjustable
						  M.P. flexion control and I.P.
All
N
Purchase
L3900
NU EP
H 6
WHFO, dynamic flexor hinge, reciprocal wrist
						  extension/flexion, finger flexion/extension, wrist or finger driven, custom
						  fabricated
All
Y
Purchase
L3901
NU EP
H 6
WHFO, dynamic flexor hinge, reciprocal wrist
						  extension/flexion, finger flexion/extension, cable driven, custom
						  fabricated
All
Y
Purchase
L3902
NU EP
H 6
WHFO, external powered, compressed gas, custom
						  fabricated
All
Y
Purchase
L3904
NU EP
H 6
WHFO, external powered, electric, custom
						  fabricated
All
Y
Purchase
L3906**
NU EP
H 6
WHFO, wrist gauntlet, molded to patient model, custom
						  fabricated
All
N
Purchase
L3907**
NU EP
H 6
WHFO, wrist gauntlet with thumb spica, molded to
						  patient model, custom fabricated
All
N
Purchase
L3908
NU EP
H 6
WHFO, wrist extension control cock-up, nonmolded,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3910
NU EP
H 6
WHFO, Swanson design, prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L3912
NU EP
H 6
HFO, flexion glove with elastic finger control,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3914
NU EP
H 6
WHO, wrist extension (cock-up) prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L3916
NU EP
H 6
WHFO, wrist extension (cock-up), with outrigger,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3918
NU EP
H 6
HFO, knuckle bender prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L3920
NU EP
H 6
HFO, knuckle bender, with outrigger prefabricated,
						  includes fitting and adjustment
All
N
Purchase
L3922
NU EP
H 6
HFO, knuckle bender, two segment to flex joints
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3924
NU EP
H 6
WHFO, Oppenheimer, prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L3926
NU EP
H 6
WHFO, Thomas suspension, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L3928
NU EP
H 6
HFO, finger extension, with lock spring, prefabricated,
						  includes fitting and adjustment
All
N
Purchase
L3930
NU EP
H 6
WHFO, finger extension, with wrist support,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3932
NU EP
H 6
FO, safety pin, spring wire, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L3934
NU EP
H 6
FO, safety pin, modified, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L3936
NU EP
H 6
WHFO, Palmer prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L3938
NU EP
H 6
WHFO, Dorsal wrist, prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L3940
NU EP
H 6
WHFO, Dorsal wrist, with outrigger attachment,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3942
NU EP
H 6
HFO, reverse knuckle bender, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L3944
NU EP
H 6
HFO, reverse knuckle bender, with outrigger,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3946
NU EP
H 6
HFO, composite elastic, prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L3948
NU EP
H 6
FO, finger knuckle bender, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L3950
NU EP
H 6
WHFO, combination Oppenheimer, with knuckle bender and
						  two attachments, prefabricated, includes fitting and adjustment
All
N
Purchase
L3952
NU EP
H 6
WHFO, combination Oppenheimer, with reverse knuckle and
						  two attachments, prefabricated, includes fitting and adjustment
All
N
Purchase
L3954
NU EP
H 6
HFO, spreading hand, prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L3956
NU
H
Addition of joint to upper extremity orthosis, any
						  material; per joint
21+
N
Purchase
L3960
NU EP
H 6
SEWHO, abduction, positioning, airplane design,
						  prefabricated, includes fitting and adjustment
All
Y
Purchase
L3962
NU EP
H 6
SEWHO, abduction positioning, Erb?s palsy design,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3963
NU EP
H 6
SEWHO, molded shoulder, arm, forearm, and wrist, with
						  articulating elbow joint, custom fabricated
All
Y
Purchase
L3964
NU EP
H 6
SEO, mobile arm supports attached to wheelchair,
						  balanced, adjustable, prefabricated, includes fitting and adjustment
All
N
Purchase
L3965
NU EP
H 6
SEO mobile arm support attached to wheelchair,
						  balanced, adjustable Rancho type, prefabricated, includes fitting and
						  adjustment
All
Y
Purchase
L3966
NU EP
H 6
SEO, mobile arm support attached to wheelchair,
						  balanced, reclining, prefabricated, includes fitting and adjustment
All
Y
Purchase
L3968
NU EP
H 6
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
H 6
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
H 6
SEO, addition to mobile arm support elevating proximal
						  arm
All
N
Purchase
L3972
NU EP
H 6
SEO , addition to mobile arm support, offset or lateral
						  rocker arm with elastic balance control
All
N
Purchase
L3974
NU EP
H 6
SEO, addition to mobile arm support, supinator
All
N
Purchase
L3980
NU EP
H 6
Upper extremity fracture orthosis, humeral,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3982
NU EP
H 6
Upper extremity fracture orthosis, radius/ulnar
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3984
NU EP
H 6
Upper extremity fracture orthosis, wrist,
						  prefabricated, includes fitting and adjustment
All
N
Purchase
L3985
NU EP
H 6
Upper extremity fracture orthosis, forearm, hand with
						  wrist hinge, custom fabricated
All
N
Purchase
L3986
NU EP
H 6
Upper extremity fracture orthosis, combination of
						  humeral, radius/ulnar, wrist (example ? Colles? fracture), custom
						  fabricated
All
N
Purchase
L3995
NU EP
H 6
Addition to upper extremity orthosis sock, fracture or
						  equal, each
All
N
Purchase
L3999
EP
6
Upper limb orthosis, NOS
U21
N/A
Manually Priced
L3999
NU EP
H 6
***(The manufacturer?s invoice must be attached to all
						  claims.) Upper limb orthosis, NOS
All
Y
Manually Priced
Manually Priced
L4000
NU EP
H 6
Replace girdle for spinal orthosis (CTLSO or SO)
All
Y
Purchase
L4002
NU EP
H 6
Replace strap, any orthosis, includes all components,
						  any length, any type
All
N
Purchase
L4010
NU EP
H 6
Replace trilateral socket brim
All
N
Purchase
L4020
NU EP
H 6
Replace quadrilateral socket brim, molded to patient
						  model
All
N
Purchase
L4030
NU EP
H 6
Replace quadrilateral socket brim, custom fitted
All
N
Purchase
L4040
NU EP
H 6
Replace molded thigh lacer
All
N
Purchase
L4045
NU EP
H 6
Replace nonmolded thigh lacer
All
N
Purchase
L4050
NU EP
H 6
Replace molded calf lacer
All
N
Purchase
L4055
NU EP
H 6
Replace nonmolded calf lacer
All
N
Purchase
L4060
NU EP
H 6
Replace high roll cuff
All
N
Purchase
L4070
NU EP
H 6
Replace proximal and distal upright for KAFO
All
N
Purchase
L4080
NU EP
H 6
Replace metal bands KAFO, proximal thigh
All
N
Purchase
L4090
EP
6
A(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
H 6
Replace metal bands KAFO-AFO, calf or distal
						  thigh
All
N
Purchase
L4100
NU EP
H 6
Replace leather cuff KAFO, proximal thigh
All
N
Purchase
L4110
NU EP
H 6
Replace leather cuff KAFO-AFO, calf or distal
						  thigh
All
N
Purchase
L4130
NU EP
H 6
Replace pretibial shell
All
N
Purchase
L4205
NU EP
H 6
Repair of orthotic device, labor component, per 15
						  minutes
All
Y
Manually Priced
Purchase
L4210
NU EP
H 6
Repair of orthotic device, repair or replace minor
						  parts
All
Y
Manually Priced
Purchase
L4350
NU EP
H 6
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
H 6
Walking boot, pneumatic with or without joints, with or
						  without interface material, prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L4370
NU EP
H 6
Pneumatic full leg splint, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L4380
NU EP
H 6
Pneumatic knee splint, prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L4392
Replacement soft interface material, static AFO
All
N
Purchase
L4394
NU
H
Replace soft interface material, foot drop
						  splint
21+
N
Purchase
L4396
NU
H
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
H
Foot drop splint, recumbent positioning device,
						  prefabricated, includes fitting and adjustment
21+
N
Purchase
L5999
NU EP
H 6
***(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
H 6
***(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
H 6
Repair of prosthetic device, hourly rate
All
Y
Manually Priced
Purchase
L7520
NU EP
H 6
Repair prosthetic device, labor component, per 15
						  minutes
All
Y
Manually Priced
Purchase
L8499
NU EP
H 6
***(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
242.190
Prosthetic Devices, All Ages
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 individuals age 21 and over. When a second modifier is
				listed, that modifier must be used in conjunction with either EP or NU.
Additionally, when billed on paper, procedure codes must be
				billed with type of service (TOS) code ?6? for individuals under age 21 or TOS
				code ?H? for beneficiaries age 21 and over.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS.
Prior authorization requirements are shown under the heading
				PA. If prior authorization is needed for individuals age 21 and over, that
				information is indicated with a ?Y? in the column; if not, an ?N? is shown.
				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
				over.
NOTE: Prosthetics providers may continue to use modifier
				52 for claims with dates of service through October 31, 2005. Effective for
				claims with dates of service on and after November 1, 2005, modifier 52 will be
				replaced with modifier UB.
* Replacement only
***
(?) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
Procedure Code
M1
M2
TOS
Description
All
U21
21+
PA 21+
Payment Method
L1499
NU EP
H 6
***(Unlisted Prosthetic Devices or Orthotic Appliances;
						  the manufacturer?s invoice must be attached to all claims.) Spinal orthosis,
						  not otherwise specified
All
Y
Manually Priced
Manually Priced
L2999
NU EP
H 6
***(Unlisted Prosthetic Devices or Orthotic Appliances;
						  the manufacturer?s invoice must be attached to all claims.) Lower extremity
						  orthoses, NOS
All
Y
Manually Priced
Manually Priced
L3649
NU EP
U1
H 6
***(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
Manually Priced
L3999
NU EP
H 6
***(Unlisted Prosthetic Devices or Orthotic Appliances;
						  the manufacturer?s invoice must be attached to all claims.) Upper limb
						  orthosis, NOS
All
Y
Manually Priced
Manually Priced
L4205
NU EP
H 6
***(Orthotics and Prosthetics Repairs) Repair of
						  orthotic device, labor component, per 15 minutes
All
Y
Manually Priced
Purchase
L4210
NU EP
H 6
***(Orthotics and Prosthetics Repairs) Repair of
						  orthotic device, repair or replace minor parts
All
Y
Manually Priced
Purchase
L5000
NU EP
H 6
Partial foot, shoe insert with longitudinal arch, toe
						  filler
All
N
Purchase
L5010
NU EP
H 6
Partial foot, molded socket, ankle height, with toe
						  filler
All
Y
Purchase
L5020
NU EP
H 6
Partial foot, molded socket, tibial tubercle height,
						  with toe filler
All
Y
Purchase
L5050
NU EP
H 6
Ankle, Symes, molded socket, SACH foot
All
Y
Purchase
L5060
NU EP
H 6
Ankle, Symes, metal frame, molded leather socket,
						  articulated ankle/foot
All
Y
Purchase
L5100
NU EP
H 6
Below knee, molded socket, shin, SACH foot
All
Y
Purchase
L5105
NU EP
H 6
Below knee, plastic socket, joints and thigh lacer,
						  SACH foot
All
Y
Purchase
L5150
NU EP
H 6
Knee disarticulation (or through knee), molded socket,
						  external knee joints, shin, SACH foot
All
Y
Purchase
L5160
NU EP
H 6
Knee disarticulation (or through knee), molded socket,
						  bent knee configuration, external knee joints, shin, SACH foot
All
Y
Purchase
L5200
NU EP
H 6
Above knee, molded socket, single axis constant
						  friction knee, shin, SACH foot
All
Y
Purchase
L5210
NU EP
H 6
Above knee, short prosthesis, no knee joint
						  (?stubbies?), with foot blocks, no ankle joints, each
All
Y
Purchase
L5220
NU EP
H 6
Above knee, short prosthesis, no knee joint (stubbies),
						  with articulated ankle/foot, dynamically aligned, each
All
Y
Purchase
L5230
NU EP
H 6
Above knee, for proximal femoral focal deficiency,
						  constant friction knee, shin, SACH foot
All
Y
Purchase
L5250
NU EP
H 6
Hip disarticulation, Canadian type, molded socket, hip
						  joint, single axis constant friction knee, shin, SACH foot
All
Y
Purchase
L5270
NU EP
H 6
Hip disarticulation, tilt table type, molded socket,
						  locking hip joint, single axis constant friction knee, shin, SACH foot
All
Y
Purchase
L5280
NU EP
H 6
Hemipelvectomy, Canadian type, molded socket, hip
						  joint, single axis constant friction knee, shin, SACH foot
All
Y
Purchase
L5301
NU EP
H 6
Below knee, molded socket, shin, SACH foot,
						  endoskeletal system
All
Y
Purchase
L5311
NU EP
H 6
Knee disarticulation (or through knee), molded socket,
						  external knee joints, shin, SACH foot, endoskeletal system
All
Y
Purchase
L5321
NU EP
H 6
Above knee, molded socket, open end, SACH foot,
						  endoskeletal system, single axis knee
All
Y
Purchase
L5331
NU EP
H 6
Hip disarticulation, Canadian type, molded socket,
						  endoskeletal system, hip joint, single axis knee, SACH foot
All
Y
Purchase
L5341
NU EP
H 6
Hemipelvectomy, Canadian type, molded socket,
						  endoskeletal system, hip joint, single axis knee, SACH foot
All
Y
Purchase
L5400
NU EP
H 6
Immediate post surgical or early fitting, application
						  of initial rigid dressing, including fitting, alignment, suspension, and one
						  cast change, below knee
All
N
Purchase
L5410
NU EP
H 6
Immediate post surgical or early fitting, application
						  of initial rigid dressing, including fitting, alignment and suspension, below
						  knee, each additional cast change and realignment
All
N
Purchase
L5420
NU EP
H 6
Immediate postsurgical or early fitting, application of
						  initial rigid dressing, including fitting, alignment and suspension, and one
						  cast change ?AK? or knee disarticulation
All
Y
Purchase
L5430
NU EP
H 6
Immediate postsurgical or early fitting, application of
						  initial rigid dressing, including fitting, alignment and suspension , ?AK? or
						  knee disarticulation, each additional cast change and realignment
All
N
Purchase
L5450
NU EP
H 6
Immediate postsurgical or early fitting, application of
						  nonweight bearing rigid dressing, below knee
All
N
Purchase
L5460
NU EP
H 6
Immediate post surgical or early fitting, application
						  of nonweight bearing rigid dressing, above knee
All
N
Purchase
L5500
NU EP
H 6
Initial, below knee (?PTB? type socket, non-alignable
						  system, pylon, no cover, SACH foot, plaster socket, direct formed
All
N
Purchase
L5505
NU EP
H 6
Initial, above knee-knee disarticulation (ischial level
						  socket, non-alignable system, pylon, no cover, SACH foot plaster socket, direct
						  formed
All
Y
Purchase
L5510
NU EP
H 6
Preparatory, below knee ?PTB? type socket,
						  non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to
						  model
All
Y
Purchase
L5520
NU EP
H 6
Preparatory, below knee ?PTB? type socket,
						  non-alignable pylon, no cover, SACH foot, thermoplastic or equal, direct
						  formed
All
Y
Purchase
L5530
NU EP
H 6
Preparatory, below knee ?PTB? type socket,
						  non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal,
						  molded to model
All
Y
Purchase
L5535
NU EP
H 6
Preparatory, below knee ?PTB? type socket,
						  non-alignable system, pylon, no cover, SACH foot, prefabricated, adjustable
						  open end socket
All
Y
Purchase
L5540
NU EP
H 6
Preparatory, below knee ?PTB? type socket, non
						  alignable, pylon, no cover, SACH foot, laminated socket, molded to model
All
Y
Purchase
L5560
NU EP
H 6
Preparatory, above knee-knee disarticulation ischial
						  level socket, non-alignable system, pylon, no cover, SACH foot, plaster socket,
						  molded to model
All
Y
Purchase
L5570
NU EP
H 6
Preparatory, above knee-knee disarticulation ischial
						  level socket, non-alignable system, pylon, no cover, SACH foot thermoplastic or
						  equal, direct formed
All
Y
Purchase
L5580
NU EP
H 6
Preparatory, above knee-knee disarticulation, ischial
						  level socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic
						  or equal, molded to model
All
Y
Purchase
L5585
NU EP
H 6
Preparatory, above knee-knee disarticulation, ischial
						  level socket, non-alignable system, pylon, no cover, SACH foot, prefabricated
						  adjustable open end socket
All
Y
Purchase
L5590
NU EP
H 6
Preparatory, above knee-knee disarticulation, ischial
						  level socket, non-alignable system, pylon, no cover, SACH foot, laminated
						  socket, molded to model
All
Y
Purchase
L5595
NU EP
H 6
Preparatory, hip disarticulation-hemipelvectomy, pylon,
						  no cover, SACH foot, thermoplastic or equal, molded to patient model
All
Y
Purchase
L5600
NU EP
H 6
Preparatory, hip disarticulation-hemipelvectomy, pylon,
						  no cover, SACH foot, laminated socket, molded to patient model
All
Y
Purchase
L5610
NU EP
H 6
Addition to lower extremity, endoskeletal system, above
						  knee, hydracadence system
All
Y
Purchase
L5611
NU EP
H 6
Addition to lower extremity, endoskeletal system, above
						  knee-knee disarticulation, 4-bar linkage, with friction swing phase
						  control
All
N
Purchase
L5613
NU EP
H 6
Addition to lower extremity, endoskeletal system, above
						  knee-knee disarticulation, 4-bar linkage, with hydraulic swing phase
						  control
All
Y
Purchase
L5614
NU
H
Addition to lower extremity, endoskeletal system, above
						  knee ? knee disarticulation, 4-bar linkage, with pneumatic swing phase
						  control
21+
Y
Purchase
L5616
NU EP
H 6
Addition to lower extremity, endoskeletal system above
						  knee, universal multiplex system, friction swing phase control
All
Y
Purchase
L5617
NU
H
Addition to lower extremity, quick change self-aligning
						  unit, above or below knee, each
21+
Y
Purchase
L5618
NU EP
H 6
Addition to lower extremity, test socket, Symes
All
N
Purchase
L5620
NU EP
H 6
Addition to lower extremity, test socket, below
						  knee
All
N
Purchase
L5622
NU EP
H 6
Addition to lower extremity, test socket, knee
						  disarticulation
All
N
Purchase
L5624
NU EP
H 6
Addition to lower extremity, test socket, above
						  knee
All
N
Purchase
L5626
NU EP
H 6
Addition to lower extremity, test socket, hip
						  disarticulation
All
N
Purchase
L5628
NU EP
H 6
Addition to lower extremity, test socket,
						  hemipelvectomy
All
N
Purchase
L5629
NU EP
H 6
Addition to lower extremity, below knee, acrylic
						  socket
All
N
Purchase
L5630
NU EP
H 6
Addition to lower extremity, Symes type, expandable
						  wall socket
All
N
Purchase
L5631
NU EP
H 6
Addition to lower extremity, above knee or knee
						  disarticulation, acrylic socket
All
N
Purchase
L5632
NU EP
H 6
Addition to lower extremity, Symes type, ?PTB? brim
						  design socket
All
N
Purchase
L5634
NU EP
H 6
Addition to lower extremity, Symes type posterior
						  opening (Canadian) socket
All
N
Purchase
L5636
NU EP
H 6
Additions to lower extremity, Symes type, medial
						  opening socket
All
N
Purchase
L5637
NU EP
H 6
Addition to lower extremity, below knee, total
						  contact
All
N
Purchase
L5638
NU EP
H 6
Addition to lower extremity, below knee, leather
						  socket
All
N
Purchase
L5639
NU EP
H 6
Addition to lower extremity, below knee, wood
						  socket
All
N
Purchase
L5640
NU EP
H 6
Addition to lower extremity, knee disarticulation,
						  leather socket
All
N
Purchase
L5642
NU EP
H 6
Addition to lower extremity, above knee, leather
						  socket
All
N
Purchase
L5643
NU EP
H 6
Addition to lower extremity, hip disarticulation,
						  flexible inner socket, external frame
All
Y
Purchase
L5644
NU EP
H 6
Addition to lower extremity, above knee, wood
						  socket
All
N
Purchase
L5645
NU EP
H 6
Addition to lower extremity, below knee, flexible inner
						  socket, external frame
All
N
Purchase
L5646
NU EP
H 6
Addition to lower extremity, below knee, air, fluid,
						  gel or equal, cushion socket
All
N
Purchase
L5647
NU EP
H 6
Addition to lower extremity, below knee suction
						  socket
All
N
Purchase
L5648
NU EP
H 6
Addition to lower extremity, above knee, air, fluid,
						  gel or equal, cushion socket
All
N
Purchase
L5649
NU EP
H 6
Addition to lower extremity, ischial containment/narrow
						  M-L socket
All
Y
Purchase
L5650
NU EP
H 6
Addition to lower extremity, total contact, above knee
						  or knee disarticulation socket
All
N
Purchase
L5651
NU EP
H 6
Addition to lower extremity, above knee, flexible inner
						  socket, external frame
All
N
Purchase
L5652
NU EP
H 6
Addition to lower extremity, suction suspension, above
						  knee or knee disarticulation, socket
All
N
Purchase
L5653
NU EP
H 6
Addition to lower extremity, knee disarticulation,
						  expandable wall socket
All
N
Purchase
L5654
NU EP
H 6
Addition to lower extremity, socket insert, Symes,
						  (Kemblo, Pelite, Aliplast, Plastazote or equal)
All
N
Purchase
L5655
NU EP
H 6
Addition to lower extremity, socket insert, below knee
						  (Kemblo, Pelite, Aliplast, Plastazote or equal)
All
N
Purchase
L5656
NU EP
H 6
Addition to lower extremity, socket insert, knee
						  disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal)
All
N
Purchase
L5658
NU EP
H 6
Addition to lower extremity, socket insert, above knee
						  (Kemblo, Pelite, Aliplast, Plastazote or equal)
All
N
Purchase
L5661
NU EP
H 6
Addition to lower extremity, socket insert, multi
						  durometer Symes
All
N
Purchase
L5665
EP
6
Addition to lower extremity, socket insert,
						  multo-durometer, below knee
U21
N/A
Purchase
L5666
NU EP
H 6
Additions to lower extremity, below knee, cuff
						  suspension
All
N
Purchase
L5668
NU EP
H 6
Addition to lower extremity, below knee, molded distal
						  cushion
All
N
Purchase
L5670
NU EP
H 6
Addition to lower extremity, below knee, molded
						  supracondyular suspension (?PTS? or similar)
All
N
Purchase
L5672
NU EP
H 6
Addition to lower extremity, below knee, removable
						  medial brim suspension
All
N
Purchase
L5676
NU EP
H 6
Addition to lower extremity, below knee, knee joints,
						  single axis, pair
All
N
Purchase
L5677
NU EP
H 6
Addition to lower extremity, below knee, knee joints,
						  polycentric, pair
All
N
Purchase
L5678
NU EP
H 6
Addition to lower extremity, below knee, joint covers,
						  pair
All
N
Purchase
L5680
NU EP
H 6
Addition to lower extremity, below knee, thigh lacer,
						  nonmolded
All
N
Purchase
L5682
NU EP
H 6
Addition to lower extremity, below knee, thigh lacer,
						  gluteal/ischial, molded
All
N
Purchase
L5684
NU EP
H 6
Addition to lower extremity, below knee, fork
						  strap
All
N
Purchase
L5685
NU EP
H 6
Addition to lower extremity prosthesis, below knee,
						  suspension/sealing sleeve, with or without valve, any material, each
All
N
Purchase
L5686
NU EP
H 6
Addition to lower extremity, below knee, back check
						  (extension control)
All
N
Purchase
L5688
NU EP
H 6
Addition to lower extremity, below knee, waist belt,
						  webbing
All
N
Purchase
L5690
NU EP
H 6
Addition to lower extremity, below knee, waist belt,
						  padded and lined
All
N
Purchase
L5692
NU EP
H 6
Addition to lower extremity, above knee, pelvic control
						  belt, light
All
N
Purchase
L5694
NU EP
H 6
Addition to lower extremity, above knee, pelvic control
						  belt, padded and lined
All
N
Purchase
L5695
NU EP
H 6
Addition to lower extremity, above knee, pelvic
						  control, sleeve suspension, neoprene or equal, each
All
N
Purchase
L5696
NU EP
H 6
Addition to lower extremity, above knee or knee
						  disarticulation, pelvic joint
All
N
Purchase
L5697
NU EP
H 6
Addition to lower extremity, above knee or knee
						  disarticulation, pelvic band
All
N
Purchase
L5698
NU EP
H 6
Addition to lower extremity, above knee or knee
						  disarticulation, silesian bandage
All
N
Purchase
L5699
NU EP
H 6
All lower extremity prosthesis, shoulder harness
All
N
Purchase
L5700
NU
H
Replacement, socket, below knee, molded to patient
						  model
21+
Y
Purchase
L5701
NU
H
Replacement, socket, above knee/knee disarticulation,
						  including attachment plate, molded to patient model
21+
Y
Purchase
L5702
NU
H
Replacement, socket, hip disarticulation, including hip
						  joint, molded to patient model
21+
Y
Purchase
L5704
NU
H
Custom shaped protective cover, below knee
21+
N
Purchase
L5705
NU
H
Custom shaped protective cover, above knee
21+
N
Purchase
L5706
NU
H
Custom shaped protective cover, knee
						  disarticulation
21+
N
Purchase
L5707
NU
H
Custom shaped protective cover, hip
						  disarticulation
21+
N
Purchase
L5710
NU EP
H 6
Addition, exoskeletal knee-shin system, single axis,
						  manual lock
All
N
Purchase
L5711
NU EP
H 6
Addition exoskeletal knee-shin system, single axis,
						  manual lock, ultra-light material
All
N
Purchase
L5712
NU EP
H 6
Addition exoskeletal knee-shin system, single axis,
						  friction swing and stance phase control (safety knee)
All
N
Purchase
L5714
NU EP
H 6
Addition, exoskeletal knee-shin system, single axis,
						  variable friction swing phase control
All
N
Purchase
L5716
NU EP
H 6
Addition, exoskeletal knee-shin system, polycentric,
						  mechanical stance phase lock
All
N
Purchase
L5718
NU EP
H 6
Addition, exoskeletal knee-shin system, polycentric,
						  friction swing and stance phase control
All
N
Purchase
L5722
NU EP
H 6
Addition, exoskeletal knee-shin system, single axis,
						  pneumatic swing, friction stance phase control
All
N
Purchase
L5724
NU EP
H 6
Addition, exoskeletal knee-shin system, single axis,
						  fluid swing phase control
All
Y
Purchase
L5726
NU EP
H 6
Addition, exoskeletal knee-shin system, single axis,
						  external joints, fluid swing phase control
All
Y
Purchase
L5728
NU EP
H 6
Addition, exoskeletal knee-shin system, single axis,
						  fluid swing and stance phase control
All
Y
Purchase
L5780
NU EP
H 6
Addition, exoskeletal knee-shin system, single axis,
						  pneumatic/hydra pneumatic swing phase control
All
N
Purchase
L5785
NU EP
H 6
Addition, exoskeletal system, below knee, ultra-light
						  material (titanium, carbon fiber or equal)
All
N
Purchase
L5790
NU EP
H 6
Addition, exoskeletal system, above knee, ultra-light
						  material (titanium, carbon fiber or equal)
All
N
Purchase
L5795
NU EP
H 6
Addition, exoskeletal system, hip disarticulation,
						  ultra-light material (titanium, carbon fiber or equal)
All
N
Purchase
L5810
NU EP
H 6
Addition, endoskeletal knee-shin system, single axis,
						  manual lock
All
N
Purchase
L5811
NU EP
H 6
Addition, endoskeletal knee-shin system, single axis,
						  manual lock, ultra-light material
All
N
Purchase
L5812
NU EP
H 6
Addition, endoskeletal knee-shin system, single axis,
						  friction swing and stance phase control (safety knee)
All
N
Purchase
L5816
NU EP
H 6
Addition, endoskeletal knee-shin system, polycentric,
						  mechanical stance phase lock
All
N
Purchase
L5818
NU EP
H 6
Addition, endoskeletal knee-shin system, polycentric,
						  friction swing, and stance phase control
All
N
Purchase
L5822
NU EP
H 6
Addition, endoskeletal knee-shin system, single axis,
						  pneumatic swing, friction stance phase control
All
Y
Purchase
L5824
NU EP
H 6
Addition, endoskeletal knee-shin system, single axis,
						  fluid swing phase control
All
Y
Purchase
L5826
NU
H
Addition, endoskeletal knee-shin system, single axis,
						  hydraulic swing phase control with miniature high activity frame
21+
Y
Purchase
L5828
NU EP
H 6
Addition, endoskeletal knee-shin system, single axis,
						  fluid swing and stance phase control
All
Y
Purchase
L5830
NU EP
H 6
Addition, endoskeletal knee-shin system, single axis,
						  pneumatic/swing phase control
All
Y
Purchase
L5840
NU
H
Addition, endoskeletal knee-shin system, 4-bar linkage
						  or multiaxial, pneumatic swing phase control
21+
N
Purchase
L5845
NU
H
Addition, endoskeletal knee-shin system, stance flexion
						  feature, adjustable
21+
Y
Purchase
L5850
NU EP
H 6
Addition, endoskeletal system, above knee or hip
						  disarticulation, knee extension assist
All
N
Purchase
L5855
NU EP
H 6
Addition, endoskeletal system, hip disarticulation,
						  mechanical hip extension assist
All
N
Purchase
L5910
NU EP
H 6
Addition, endoskeletal system, below knee, alignable
						  system
All
N
Purchase
L5920
NU EP
H 6
Addition, endoskeletal system, above knee or hip
						  disarticulation, alignable system
All
N
Purchase
L5925
NU
H
Addition, endoskeletal system, above knee, knee
						  disarticulation, manual lock
21+
N
Purchase
L5930
NU
H
Addition, endoskeletal system, high activity knee
						  control frame
21+
Y
Purchase
L5940
NU EP
H 6
Addition, endoskeletal system, below knee, ultra-light
						  material (titanium, carbon fiber or equal)
All
N
Purchase
L5950
NU EP
H 6
Addition, endoskeletal system, above knee, ultra-light
						  material (titanium, carbon fiber or equal)
All
N
Purchase
L5960
NU EP
H 6
Addition, endoskeletal system, hip disarticulation,
						  ultra-light material (titanium, carbon fiber or equal)
All
N
Purchase
L5962
NU
H
Addition, endoskeletal system, below knee, flexible
						  protective outer surface covering system
21+
N
Purchase
L5964
NU
H
Addition, endoskeletal system, above knee, flexible
						  protective outer surface covering system
21+
N
Purchase
L5966
NU
H
Addition, endoskeletal system, hip disarticulation,
						  flexible protective outer surface covering system
21+
N
Purchase
L5968
NU
H
Addition to lower limb prostheses, multiaxial ankle
						  with swing phase active dorsiflexion feature
21+
Y
Purchase
L5970
NU EP
H 6
All lower extremity prostheses, foot, external keel,
						  SACH foot
All
N
Purchase
L5972
NU EP
H 6
All lower extremity prostheses, flexible keel foot
						  (Safe, Sten, Bock Dynamic or equal)
All
N
Purchase
L5974
NU EP
H 6
All lower extremity prostheses, foot, single axis
						  ankle/foot
All
N
Purchase
L5975
NU
H
All lower extremity prosthesis, combination single axis
						  ankle and flexible keel foot
21+
N
Purchase
L5976
NU EP
H 6
All lower extremity prostheses, energy storing foot
						  (Seattle Carbon Copy II or equal)
All
N
Purchase
L5978
NU EP
H 6
All lower extremity prostheses, foot, multiaxial
						  ankle/foot
All
N
Purchase
L5979
NU
H
All lower extremity prostheses, multi-axial ankle,
						  dynamic response foot, one piece system
21+
Y
Purchase
L5980
NU EP
H 6
All lower extremity prostheses, flex-foot system
All
Y
Purchase
L5981
NU
H
All lower extremity prostheses, flex -walk system or
						  equal
21+
Y
Purchase
L5982
NU EP
H 6
All exoskeletal lower extremity prostheses, axial
						  rotation unit
All
N
Purchase
L5984
NU EP
H 6
All endoskeletal lower extremity prosthesis, axial
						  rotation unit, with or without adjustability
All
N
Purchase
L5985
NU
H
All endoskeletal lower extremity prostheses, dynamic
						  prosthetic pylon
21+
N
Purchase
L5986
NU EP
H 6
All lower extremity prostheses, multi-axial rotation
						  unit (?MCP? or equal)
All
N
Purchase
L5987
NU
H
All lower extremity prostheses, shank foot system with
						  vertical loading pylon
21+
Y
Purchase
L5988
NU
H
Addition to lower limb prosthesis, vertical shock
						  reducing pylon feature
21+
Y
Purchase
L5999
NU EP
H 6
***(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
L6000
NU EP
H 6
Partial hand, Robin-Aids, thumb remaining (or
						  equal)
All
N
Purchase
L6010
NU EP
H 6
Partial hand, Robin-Aids, little and/or ring finger
						  remaining (or equal)
All
N
Purchase
L6020
NU EP
H 6
Partial hand, Robin-Aids, no finger remaining (or
						  equal)
All
N
Purchase
L6050
NU EP
H 6
Wrist disarticulation, molded socket, flexible elbow
						  hinges, triceps pad
All
Y
Purchase
L6055
NU EP
H 6
Wrist disarticulation, molded socket with expandable
						  interface, flexible elbow hinges, triceps pad
All
Y
Purchase
L6100
NU EP
H 6
Below elbow, molded socket, flexible elbow hinge,
						  triceps pad
All
Y
Purchase
L6110
NU EP
H 6
Below elbow, molded socket (Muenster or Northwestern
						  suspension types)
All
Y
Purchase
L6120
NU EP
H 6
Below elbow, molded double wall split socket, step-up
						  hinges, half cuff
All
Y
Purchase
L6130
NU EP
H 6
Below elbow, molded double wall split socket, stump
						  activated locking hinge, half cuff
All
Y
Purchase
L6200
NU EP
H 6
Elbow disarticulation, molded socket, outside locking
						  hinge, forearm
All
Y
Purchase
L6205
NU EP
H 6
Elbow disarticulation, molded socket with expandable
						  interface, outside locking hinges, forearm
All
Y
Purchase
L6250
NU EP
H 6
Above elbow, molded double wall socket, internal
						  locking elbow, forearm
All
Y
Purchase
L6300
NU EP
H 6
Shoulder disarticulation, molded socket, shoulder
						  bulkhead, humeral section, internal locking elbow, forearm
All
Y
Purchase
L6310
NU EP
H 6
Shoulder disarticulation, passive restoration (complete
						  prosthesis)
All
Y
Purchase
L6320
NU EP
H 6
Shoulder disarticulation, passive restoration (shoulder
						  cap only)
All
Y
Purchase
L6350
NU
H
Interscapular thoracic, molded socket, shoulder
						  bulkhead, humeral section, internal locking elbow, forearm
21+
Y
Purchase
L6360
NU EP
H 6
Interscapular thoracic, passive restoration (complete
						  prosthesis)
All
Y
Purchase
L6370
NU EP
H 6
Interscapular thoracic, passive restoration (shoulder
						  cap only)
All
Y
Purchase
L6380
NU EP
H 6
Immediate postsurgical or early fitting, application of
						  initial rigid dressing, including fitting alignment and suspension of
						  components, and one cast change, wrist disarticulation or below elbow
All
N
Purchase
L6382
NU EP
H 6
Immediate postsurgical or early fitting, application of
						  initial rigid dressing including fitting alignment and suspension of
						  components, and one cast change, elbow disarticulation or above elbow
All
N
Purchase
L6384
NU EP
H 6
Immediate postsurgical or early fitting, application of
						  initial rigid dressing including fitting alignment and suspension of
						  components, and one cast change, shoulder disarticulation or interscapular
						  thoracic
All
Y
Purchase
L6386
NU EP
H 6
Immediate postsurgical or early fitting, each
						  additional cast change and realignment
All
N
Purchase
L6388
NU EP
H 6
Immediate postsurgical or early fitting, application of
						  rigid dressing only
All
N
Purchase
L6400
NU EP
H 6
Below elbow, molded socket, endoskeletal system,
						  including soft prosthetic tissue shaping
All
Y
Purchase
L6450
NU EP
H 6
Elbow disarticulation, molded socket, endoskeletal
						  system, including soft prosthetic tissue shaping
All
Y
Purchase
L6500
NU EP
H 6
Above elbow, molded socket, endoskeletal system,
						  including soft prosthetic tissue shaping
All
Y
Purchase
L6550
NU EP
H 6
Shoulder disarticulation, molded socket, endoskeletal
						  system, including soft prosthetic tissue shaping
All
Y
Purchase
L6570
NU EP
H 6
Interscapular thoracic, molded socket, endoskeletal
						  system including soft prosthetic tissue shaping
All
Y
Purchase
L6580
NU EP
H 6
Preparatory, wrist disarticulation or below elbow,
						  single wall plastic socket, friction wrist, flexible elbow hinges, figure of
						  eight harness, humeral cuff, Bowden cable control, ?USMC? or equal pylon, no
						  cover, molded to patient model
All
Y
Purchase
L6582
NU EP
H 6
Preparatory, wrist disarticulation or below elbow,
						  single wall socket, friction wrist, flexible elbow hinges, figure of eight
						  harness, humeral cuff, Bowden cable control, ?USMC? or equal pylon, no cover,
						  direct formed
All
N
Purchase
L6584
NU EP
H 6
Preparatory, elbow disarticulation or above elbow,
						  single wall plastic socket, friction wrist, locking elbow, figure of eight
						  harness, fair lead cable control, ?USMC? or equal pylon, no cover, molded to
						  patient model
All
Y
Purchase
L6586
NU EP
H 6
Preparatory, elbow disarticulation or above elbow,
						  single wall socket, friction wrist, locking elbow, figure of eight harness,
						  fair lead cable control, ?USMC? or equal pylon, no cover, direct formed
All
Y
Purchase
L6588
NU EP
H 6
Preparatory, shoulder disarticulation or interscapular
						  thoracic, single wall plastic socket, shoulder joint, locking elbow, friction
						  wrist, chest strap, fair lead cable control, ?USMC? or equal pylon, no cover,
						  molded to patient model
All
Y
Purchase
L6590
NU EP
H 6
Preparatory, shoulder disarticulation or interscapular
						  thoracic, single wall socket, shoulder joint, locking elbow, friction wrist,
						  chest strap, fair lead cable control, ?USMC? or equal pylon, no cover, direct
						  formed
All
Y
Purchase
L6600
NU EP
H 6
Upper extremity additions, polycentric hinge,
						  pair
All
N
Purchase
L6605
NU EP
H 6
Upper extremity additions, single pivot hinge,
						  pair
All
N
Purchase
L6610
NU EP
H 6
Upper extremity additions, flexible metal hinge,
						  pair
All
N
Purchase
L6615
NU EP
H 6
Upper extremity addition, disconnect locking wrist
						  unit
All
N
Purchase
L6616
NU EP
H 6
Upper extremity addition, additional disconnect insert
						  for locking wrist unit, each
All
N
Purchase
L6620
NU EP
H 6
Upper extremity addition, flexion/extension wrist unit,
						  with or without friction
All
N
Purchase
L6623
NU EP
H 6
Upper extremity addition, spring assisted rotational
						  wrist unit with latch release
All
N
Purchase
L6625
NU EP
H 6
Upper extremity addition, rotation wrist unit with
						  cable lock
All
N
Purchase
L6628
NU EP
H 6
Upper extremity addition, quick disconnect hook
						  adapter, Otto Bock or equal
All
N
Purchase
L6629
NU EP
H 6
Upper extremity addition, quick disconnect lamination
						  collar with coupling piece, Otto Bock or equal
All
N
Purchase
L6630
NU EP
H 6
Upper extremity addition, stainless steel, any
						  wrist
All
N
Purchase
L6632
NU EP
H 6
Upper extremity addition, latex suspension sleeve,
						  each
All
N
Purchase
L6635
NU EP
H 6
Upper extremity additions, lift assist for elbow
All
N
Purchase
L6637
NU EP
H 6
Upper extremity addition, nudge control elbow
						  lock
All
N
Purchase
L6640
NU EP
H 6
Upper extremity additions, shoulder abduction joint,
						  pair
All
N
Purchase
L6641
NU EP
H 6
Upper extremity addition, excursion amplifier, pulley
						  type
All
N
Purchase
L6642
NU EP
H 6
Upper extremity addition, excursion amplifier, lever
						  type
All
N
Purchase
L6645
NU EP
H 6
Upper extremity addition, shoulder flexion-abduction
						  joint, each
All
N
Purchase
L6650
NU EP
H 6
Upper extremity addition, shoulder universal joint,
						  each
All
N
Purchase
L6655
NU EP
H 6
Upper extremity addition, standard control cable,
						  extra
All
N
Purchase
L6660
NU EP
H 6
Upper extremity addition, heavy duty control
						  cable
All
N
Purchase
L6665
NU EP
H 6
Upper extremity addition, teflon, or equal, cable
						  lining
All
N
Purchase
L6670
NU EP
H 6
Upper extremity addition, hook to hand cable
						  adapter
All
N
Purchase
L6672
NU EP
H 6
Upper extremity addition, harness, chest or shoulder,
						  saddle type
All
N
Purchase
L6675
NU EP
H 6
Upper extremity addition, harness, (e.g., figure of
						  eight type), single cable design
All
N
Purchase
L6676
NU EP
H 6
Upper extremity additions, harness, (e.g., figure of
						  eight type), dual cable design
All
N
Purchase
L6680
NU EP
H 6
Upper extremity addition, test socket, wrist
						  disarticulation or below elbow
All
N
Purchase
L6682
NU EP
H 6
Upper extremity addition, test socket, elbow
						  disarticulation or above elbow
All
N
Purchase
L6684
NU EP
H 6
Upper extremity addition, test socket, shoulder
						  disarticulation or interscapular thoracic
All
N
Purchase
L6686
NU EP
H 6
Upper extremity addition, suction socket
All
N
Purchase
L6687
NU EP
H 6
Upper extremity addition, frame type socket, below
						  elbow or wrist disarticulation
All
N
Purchase
L6688
NU EP
H 6
Upper extremity addition, frame type socket, above
						  elbow or elbow disarticulation
All
N
Purchase
L6689
NU EP
H 6
Upper extremity addition, frame type socket, shoulder
						  disarticulation
All
N
Purchase
L6690
NU EP
H 6
Upper extremity addition, frame type socket,
						  interscapular-thoracic
All
N
Purchase
L6691
NU EP
H 6
Upper extremity addition, removable insert, each
All
N
Purchase
L6692
NU EP
H 6
Upper extremity addition, silicone gel insert or equal,
						  each
All
N
Purchase
L6693
NU
H
Upper extremity addition, locking elbow, forearm
						  counterbalance
21+
Y
Purchase
L6700
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  3
All
N
Purchase
L6705
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  3
All
N
Purchase
L6710
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  5x
All
N
Purchase
L6715
NU EP
H 6
Terminal device, hook, Dorrance or equal, Model #
						  5xa
All
N
Purchase
L6720
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  6
All
N
Purchase
L6725
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  7
All
N
Purchase
L6730
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  7LO
All
N
Purchase
L6735
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  8
All
N
Purchase
L6740
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  8x
All
N
Purchase
L6745
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  88x
All
N
Purchase
L6750
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  10P
All
N
Purchase
L6755
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  10x
All
N
Purchase
L6765
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  12P
All
N
Purchase
L6770
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  99x
All
N
Purchase
L6775
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  555
All
N
Purchase
L6780
NU EP
H 6
Terminal device, hook, Dorrance or equal, model #
						  SS555
All
N
Purchase
L6790
NU EP
H 6
Terminal device, hook-Accu hook or equal
All
N
Purchase
L6795
NU EP
H 6
Terminal device, hook 2 load or equal
All
N
Purchase
L6800
NU EP
H 6
Terminal device, hook-APRL VC or equal
All
N
Purchase
L6805
NU EP
H 6
Terminal device, modifier wrist flexion unit
All
N
Purchase
L6806
NU EP
H 6
Terminal device, hook, TRS grip, Grip III, VC, or
						  equal
All
Y
Purchase
L6807
NU EP
H 6
Terminal device, hook, Grip I, Grip II, VC, or
						  equal
All
N
Purchase
L6808
NU EP
H 6
Terminal device, hook, TRS Adept, infant or child, VC,
						  or equal
All
N
Purchase
L6809
NU EP
H 6
Terminal device, hook, TRS Super Sport, passive
All
N
Purchase
L6810
NU EP
H 6
Terminal device, pincher tool, Otto Bock or
						  equal
All
N
Purchase
L6825
NU EP
H 6
Terminal device, hand, Dorrance, VO
All
N
Purchase
L6830
NU EP
H 6
Terminal device, hand, APRL, VC
All
N
Purchase
L6835
NU EP
H 6
Terminal device, hand, Sierra, VO
All
N
Purchase
L6840
NU EP
H 6
Terminal device, hand, Becker Imperial
All
N
Purchase
L6845
NU EP
H 6
Terminal device, hand, Becker Lock Grip
All
N
Purchase
L6850
NU EP
H 6
Terminal device, hand, Becker Plylite
All
N
Purchase
L6855
NU EP
H 6
Terminal device, hand, Robin-Aids, VO
All
N
Purchase
L6860
NU EP
H 6
Terminal device, hand, Robin-Aids, VO soft
All
N
Purchase
L6865
NU EP
H 6
Terminal device, hand, passive hand
All
N
Purchase
L6867
NU EP
H 6
Terminal device, hand, Detroit Infant Hand
						  (mechanical)
All
N
Purchase
L6868
NU EP
H 6
Terminal device, hand, passive infant hand, Steeper,
						  Hosmer or equal
All
N
Purchase
L6870
NU EP
H 6
Terminal device, hand, child mitt
All
N
Purchase
L6872
NU EP
H 6
Terminal device, hand, NYU child hand
All
N
Purchase
L6873
NU EP
H 6
Terminal device, hand, mechanical infant hand, Steeper
						  or equal
All
N
Purchase
L6875
NU EP
H 6
Terminal device, hand, Bock, VC
All
N
Purchase
L6880
NU EP
H 6
Terminal device, hand, Bock, VO
All
N
Purchase
L6890
NU EP
H 6
Terminal device, gloves for above hands, production
						  glove
All
N
Purchase
L6895
NU EP
H 6
Terminal device, glove for above hands, custom
						  glove
All
N
Purchase
L6900
NU EP
H 6
Hand restoration (casts, shading and measurements
						  included), partial hand, with glove, thumb or one finger remaining
All
N
Purchase
L6905
NU EP
H 6
Hand restoration (casts, shading and measurements
						  included), partial hand, with glove, multiple fingers remaining
All
N
Purchase
L6910
NU EP
H 6
Hand restoration (casts, shading and measurements
						  included), partial hand, with glove, no fingers remaining
All
N
Purchase
L6915
NU EP
H 6
Hand restoration (shading and measurements included),
						  replacement glove for above
All
N
Purchase
L6920*
NU EP
H 6
Wrist disarticulation, external power, self-suspended
						  inner socket, removable forearm shell, Otto Bock or equal, switch, cables, two
						  batteries and one charger, switch control of terminal device
All
Y
Purchase
L6925*
NU EP
H 6
Wrist disarticulation, external power, self-suspended
						  inner socket, removable forearm shell, Otto Bock or equal electrodes, cables,
						  two batteries and one charger, myoelectronic control of terminal device
All
Y
Purchase
L6930*
NU EP
H 6
Below elbow, external power, self-suspended inner
						  socket, removable forearm shell, Otto Bock or equal switch, cables, two
						  batteries and one charger, switch control of terminal device
All
Y
Purchase
L6935*
NU EP
H 6
Below elbow, external power, self-suspended inner
						  socket, removable forearm shell, Otto Bock or equal electrodes, cables, two
						  batteries and one charger, myoelectronic control of terminal device
All
Y
Purchase
L6940*
NU EP
H 6
Elbow disarticulation, external power, molded inner
						  socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or
						  equal switch, cables, two batteries and one charger, switch control of terminal
						  device
All
Y
Purchase
L6945*
NU EP
H 6
Elbow disarticulation, external power, molded inner
						  socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or
						  equal electrodes, cables, two batteries and one charger, myoelectronic control
						  of terminal device
All
Y
Purchase
L6950*
NU EP
H 6
Above elbow, external power, molded inner socket,
						  removable humeral shell, internal locking elbow, forearm, Otto Bock or equal
						  switch, cables, two batteries and one charger, switch control of terminal
						  device
All
Y
Purchase
L6955*
NU EP
H 6
Above elbow, external power, molded inner socket,
						  removable humeral shell, internal locking elbow, forearm, Otto Bock or equal
						  electrodes, cables, two batteries and one charger, myoelectronic control of
						  terminal device
All
Y
Purchase
L6960*
NU EP
H 6
Shoulder disarticulation, external power, molded inner
						  socket, removable shoulder shell, shoulder bulkhead, humeral section,
						  mechanical elbow, forearm, Otto Bock or equal switch, cables, two batteries and
						  one charger, switch control of terminal device
All
Y
Purchase
L6965*
NU EP
H 6
Shoulder disarticulation, external power, molded inner
						  socket, removable shoulder shell, shoulder bulkhead, humeral section,
						  mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries
						  and one charger, myoelectronic control of terminal device
All
Y
Purchase
L6970*
NU EP
H 6
Interscapular-thoracic, external power, molded inner
						  socket, removable shoulder shell, shoulder bulkhead, humeral section,
						  mechanical elbow, forearm, Otto Bock or equal switch, cables, two batteries and
						  one charger, switch control of terminal device
All
Y
Purchase
L6975*
NU EP
H 6
Interscapular-thoracic, external power, molded inner
						  socket, removable shoulder shell, shoulder bulkhead, humeral section,
						  mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries
						  and one charger, myoelectronic control of terminal device
All
Y
Purchase
L7010*
NU EP
H 6
Electronic hand, Otto Bock, Steeper or equal, switch
						  controlled
All
Y
Purchase
L7015*
NU EP
H 6
Electronic hand, System Teknik, Variety Village or
						  equal, switch controlled
All
Y
Purchase
L7020*
NU EP
H 6
Electronic greifer, Otto Bock or equal, switch
						  controlled
All
Y
Purchase
L7025*
NU EP
H 6
Electronic hand, Otto Bock or equal, myoelectronically
						  controlled
All
Y
Purchase
L7030*
NU EP
H 6
Electronic hand, System Teknik, Variety Village or
						  equal, myoelectronically controlled
All
Y
Purchase
L7035*
NU EP
H 6
Electronic greifer, Otto Bock or equal,
						  myoelectronically controlled
All
Y
Purchase
L7040*
NU EP
H 6
Prehensile actuator, Hosmer or equal, switch
						  controlled
All
Y
Purchase
L7045*
NU EP
H 6
Electronic hook, child, Michigan or equal, switch
						  controlled
All
Y
Purchase
L7170*
NU EP
H 6
Electronic elbow, Hosmer or equal, switch
						  controlled
All
Y
Purchase
L7180*
NU EP
H 6
Electronic elbow, Utah or equal, myoelectronically
						  controlled
All
Y
Purchase
L7185
EP
6
Electronic elbow, adolescent, Variety Village or equal,
						  switch controlled
U21
N/A
Purchase
L7186
EP
6
Electronic elbow, child, Variety Village or equal,
						  switch controlled
U21
N/A
Purchase
L7190
EP
6
Electronic elbow, adolescent, Variety Village or equal,
						  myoelectronically controlled
U21
N/A
Purchase
L7191
EP
6
Electronic elbow, child, Variety Village or equal,
						  myoelectronically controlled
U21
N/A
Purchase
L7260*
NU EP
H 6
Electronic wrist rotator, Otto Bock or equal
All
Y
Purchase
L7261*
NU EP
H 6
Electronic wrist rotator, for Utah arm
All
Y
Purchase
L7266*
NU EP
H 6
Servo control, Steeper or equal
All
N
Purchase
L7272*
NU EP
H 6
Analogue control, UNB or equal
All
Y
Purchase
L7274*
NU EP
H 6
Proportional control, 6-12 volt, Liberty, Utah or
						  equal
All
Y
Purchase
L7360*
NU EP
H 6
Six volt battery, Otto Bock or equal, each
All
N
Purchase
L7362*
NU EP
H 6
Battery charger, six volt, Otto Bock or equal
All
N
Purchase
L7364*
NU EP
H 6
Twelve volt battery, Utah or equal, each
All
N
Purchase
L7366*
NU EP
H 6
Battery charger, twelve volt, Utah or equal
All
N
Purchase
L7499
NU EP
H 6
***(Unlisted Prosthetic Devices or Orthotic Appliances;
						  the manufacturer?s invoice must be attached to all claims.) Upper extremity
						  prosthesis, NOS
All
Y
Manually Priced
Manually Priced
L7510
NU EP
UB
H 6
***(Orthotics and Prosthetics Repairs) Repair of
						  prosthetic device, repair or replace minor parts
All
Y
Manually Priced
Purchase
L7510
NU EP
H 6
***(Twister cables - repair/replace) Repair of
						  prosthetic device, repair or replace minor parts
All
N
Manually Priced
Purchase
L7520
NU EP
H 6
***(Orthotics and Prosthetics Repairs) Repair
						  prosthetic device, labor component, per 15 minutes
All
Y
Manually Priced
Purchase
L8000
NU EP
H 6
Breast prosthesis, mastectomy bra
All
N
Purchase
L8010
NU EP
H 6
Breast prosthesis, mastectomy sleeve
All
N
Purchase
L8015
NU
H
External breast prosthesis garment, with mastectomy
						  form, post-mastectomy
21+
N
Purchase
L8020
NU EP
H 6
Breast prosthesis, mastectomy form
All
N
Purchase
L8030
NU EP
H 6
Breast prosthesis, silicone or equal
All
N
Purchase
L8100
NU EP
H 6
Gradient support compression stocking, below knee,
						  18-30 mmhg, each
All
N
Purchase
L8300
NU EP
H 6
Truss, single with standard pad
All
N
Purchase
L8310
NU EP
H 6
Truss, double with standard pads
All
N
Purchase
L8320
NU EP
H 6
Truss, addition to standard pad, water pad
All
N
Purchase
L8330
NU EP
H 6
Truss, addition to standard pad, scrotal pad
All
N
Purchase
L8400
NU EP
H 6
Prosthetic sheath, below knee, each
All
N
Purchase
L8410
NU EP
H 6
Prosthetic sheath, above knee, each
All
N
Purchase
L8415
NU EP
H 6
Prosthetic sheath, upper limb, each
All
N
Purchase
L8417
NU
H
Prosthetic sheath/sock, including a gel cushion layer,
						  below knee or above knee, each
21+
N
Purchase
L8420
NU EP
H 6
Prosthetic sock, multiple ply, below knee, each
All
N
Purchase
L8430
NU EP
H 6
Prosthetic sock, multiple ply, above knee, each
All
N
Purchase
L8435
NU EP
H 6
Prosthetic sock, multiple ply upper limb, each
All
N
Purchase
L8440
NU EP
H 6
Prosthetic shrinker, below knee, each
All
N
Purchase
L8460
NU EP
H 6
Prosthetic shrinker, above knee, each
All
N
Purchase
L8465
NU EP
H 6
Prosthetic shrinker, upper limb, each
All
N
Purchase
L8470
NU EP
H 6
Prosthetic sock, single ply, fitting below knee,
						  each
All
N
Purchase
L8480
NU EP
H 6
Prosthetic sock, single ply fitting, above knee,
						  each
All
N
Purchase
L8485
NU
H
Prosthetic sock, single ply, fitting, upper limb,
						  each
21+
N
Purchase
L8499
NU EP
H 6
***(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
Manually Priced
L8500
NU EP
H 6
Artificial larynx, any type
All
N
Purchase
L8501
NU EP
H 6
Tracheostomy speaking valve
All
N
Purchase
L8600
NU EP
H 6
Implantable breast prosthesis, silicone or equal
All
N
Manually Priced
242.191
Specialized Wheelchairs and
			 Wheelchair Seating Systems
for Individuals Age Two Through Adult
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.
Additionally, when billed on paper, procedure codes found in
				this section must be billed with a type of service (TOS) code ?6? for
				individuals under age 21 or TOS code ?H? for individuals age 21 and
				over.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS. 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.
Other coding information found in the chart:
NOTE: Prosthetics providers may continue to use modifier
				52 for claims with dates of service through October 31, 2005. Effective for
				claims with dates of service on and after November 1, 2005, modifier 52 will be
				replaced with modifier UB.
1
			 The purchase of this wheelchair component for individuals age 21 and over is
			 limited to one per five-year period.
2 The purchase of this wheelchair component
			 for individuals under age 21 is limited to one per two-year period.
* The purchase of wheelchairs for individuals age 21 and over
				is limited to one per five-year period.
** Bill only for TOS code ?6.?
# This procedure code is payable for individuals ages 2 through
				20, using TOS code ?6.? Prior authorization is required through Utilization
				Review.
**** Items listed require prior authorization (PA) when used in
				combination with other items listed and the total combined value exceeds the
				$1,000.00 Medicaid maximum allowable reimbursement limit.
* Prior authorization is not required when another insurance
				pays at least 50% of the Medicaid maximum allowable reimbursement
				amount.
Note: W/C or w/c indicates wheelchair.
***
(?) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
Specialized Wheelchairs and Wheelchair Seating Systems
				for Individuals Age Two Through Adult (section 242.191)
Procedure Code
M1
M2
TOS
Description
PA
Payment Method
E0700
NU EP
U2 U2
H 6
***
(Travel restraint auto safe harness,
						  E-Z on vest, no known comparable product) Safety equipment, e.g., belt, harness
						  or vest
N****
Purchase
E0950
NU EP
U7 U7
H 6
Wheelchair accessory, tray, each
N
Purchase
E0950
NU EP
U2 U2
H 6
***(ABS tray, 4-SM 5-LG) W/C accessory, tray,
						  each
N****
Purchase
E0950
NU EP
U5 U5
H 6
***(Clear upper Ex support system) W/C accessory, tray,
						  each
N****
Purchase
E0950
NU EP
U4 U4
H 6
***(Tray, customized) W/C accessory, tray, each
N
Purchase
E0950
NU EP
H 6
***(Tray for W/C) W/C accessory, tray, each
N
Purchase
E0950
NU EP UE
U7 U7
H 6 U
***(Removable Hinged Overlay for Tray) W/C accessory,
						  tray, each
N****
Purchase
E0950
NU EP
U8 U8
H 6
***(Lap Tray for Switch Array) Wheelchair accessory,
						  tray, each
Y
Purchase
E0950
NU EP
U6 U6
H 6
***(Lap Tray Switch Array) Wheelchair accessory, tray,
						  each
N****
Purchase
E0950
NU EP
U3 U3
H 6
***(W/C Tray, Custom) W/C accessory, tray, each
N****
Purchase
E0951
NU EP
H 6
Heel loop/holder, with or without ankle strap,
						  each
N****
Purchase
E0952
NU EP
H 6
Toe loop/holder, each
N****
Purchase
E0953
NU EP
H 6
***
(8? x 2? for manual W/C, each,
						  replacement) Pneumatic tire, each
N
Purchase
E0954
NU EP
H 6
Semi-pneumatic caster, each
N****
Purchase
E0955
NU EP
H 6
W/C accessory, headrest, cushioned, prefabricated,
						  w/fixed mounting hardware, each
N
Purchase
E0956
NU EP
H 6
***(Trunk supports for any W/C, other than travel, with
						  hardware) W/C accessory, lateral trunk or hip support, prefabricated w/fixed
						  mounting hardware, each
N****
Purchase
E0956
NU EP
U1 U1
H 6
***(Lateral trunk supports, swing away, ea.) W/C
						  accessory, lateral trunk or hip support, prefabricated w/fixed mounting
						  hardware, each
N****
Purchase
E0956
NU EP
U2 U2
H 6
***(Med. Chest Panel Support) W/C accessory, lateral
						  trunk or hip support, prefabricated w/fixed mounting hardware, each
N****
Purchase
E0956
NU EP
U3 U3
H 6
***(Chest/Thoracic Supports) W/C accessory, lateral
						  trunk or hip support, prefabricated w/fixed mounting hardware, each
N****
Purchase
E0957
NU EP
H 6
W/C accessory, medial thigh support, prefabricated,
						  w/fixed mounting hardware, each
N
Purchase
E0958
NU EP
H 6
Manual W/C accessory, one-arm drive attachment,
						  each
N****
Purchase
E0959
NU EP
U1 U1
H 6
Manual W/C accessory, adapter for amputee, each
N
Purchase
E0959
NU EP
H 6
***(Amputee adapters for conventional chair, ea.)
						  Manual W/C accessory, adapter for amputee, each
N****
Purchase
E0959
NU EP
H 6
***(Amputee axle plate for high performance manual W/C,
						  ea.) Manual W/C accessory, adapter for amputee, each
N****
Purchase
E0960
NU EP
H 6
W/C accessory, shoulder harness/straps or chest strap
						  including any type mounting hardware
N
Purchase
E0961
NU EP
H 6
Manual W/C accessory, wheel lock brake extension
						  (handle), each
N****
Purchase
E0966
NU EP
H 6
***(Headrest/Fixture, O.B., 46-LG 45-SM) Manual W/C
						  accessory, headrest extension, each
N****
Purchase
E0967
NU EP
H 6
***(Hand rim, any type) Manual W/C accessory, hand rim
						  w/projections, any type, replacement only, each
N****
Purchase
E0967
NU EP
U1 U1
H 6
***(Hand rim, any type) Manual W/C accessory, hand rim
						  w/projections, any type, replacement only, each
N****
Purchase
E0967
NU EP
U2 U2
H 6
***(Hand rim, any type) Manual W/C accessory, hand rim
						  w/projections, any type, replacement only, each
N****
Purchase
E0967
NU EP
U3 U3
H 6
***(Hand rim, any type) Manual W/C accessory, hand rim
						  w/projections, any type, replacement only, each
N****
Purchase
E0967
NU EP
U4 U4
H 6
***(Hand rim, any type) Manual W/C accessory, hand rim
						  w/projections, any type, replacement only, each
N****
Purchase
E0970
NU EP
H 6
No. 2 footplates, except for elevating legrest
N****
Purchase
E0971
NU EP
H 6
Anti-tipping device W/C
N****
Purchase
E0972
NU EP
U1 U1
H 6
***(Wood transfer board) W/C accessory, transfer board
						  or device, each
N
Purchase
E0972
NU EP
H 6
***(Plastic transfer board) W/C accessory, transfer
						  board or device, each
N
Purchase
E0973
NU EP
H 6
W/C accessory, adjustable height, detachable armrest,
						  complete assembly, each
N****
Purchase
E0973
NU EP
U1 U1
H 6
***(Height Adj. Arms, replacement) W/C accessory,
						  adjustable height, detachable armrest, complete assembly, each
N****
Purchase
E0974
NU EP
H 6
Manual W/C accessory, anti-rollback device, each
N****
Purchase
E0978
NU EP
U2
H 6
W/C accessory, safety belt/pelvic strap, each
N****
Purchase
E0978
NU EP
U1
H 6
***(Belt, safety or chest, w/pad) W/C accessory, safety
						  belt/ pelvic strap, each
N**** N
Purchase
E0980
NU EP
H 6
***(Chest panel, 21-SM 22-LG) Safety vest, W/C
N****
Purchase
E0980
NU EP
U1 U1
H 6
***(Shoulder retractors) Safety vest, W/C
N****
Purchase
E0981
NU EP
H 6
W/C accessory, seat upholstery, replacement only,
						  each
N
Purchase
E0982
NU EP
U1 U1
H 6
***(Standard back upholstery replacement) W/C
						  accessory, back upholstery, replacement only, each
N****
Purchase
E0990
EP
6
***(Elevating foot, leg rest) W/C accessory, elevating
						  leg rest, complete assembly, each
N****
Purchase
E0990
NU EP
U1 U1
H 6
***(Elevating Leg Rest 90 Degree, 12" -16" Width) W/C
						  accessory, elevating leg rest, complete assembly, each
N****
Purchase
E0992
NU EP
H 6
Manual w/c accessory, solid seat insert
N****
Purchase
E0992
NU EP
U3 U3
H 6
***(Foam & Plywood Seat, MPI Like) Manual w/c
						  access, solid seat insert
N****
Purchase
E0992
NU EP
U2 U2
H 6
***(Foam and Plywood Flat Side) Manual w/c access,
						  solid seat insert
N****
Purchase
E0992
NU EP
U4 U4
H 6
***(Adjustable solid standard seat w/hardware) Manual
						  w/c accessory, solid seat insert
N****
Purchase
E0992
NU EP
U1 U1
H 6
AManual w/c accessory, solid seat insert (Large
						  adjustable solid seat w/hardware)
N****
Purchase
E0994
NU EP
H 6
Armrest, each
N****
Purchase
E1001
NU
H
Wheel, single
N
Manually Priced
E1002
NU EP
H 6
W/C accessory, power seating system, tilt only
Y
Purchase
E1002
NU EP
H 6
W/C accessory power seating system, tilt only
Y*
Purchase
E1004
NU EP
H 6
W/C accessory, power seat system, recline only,
						  w/mechanical shear reduction
Y
Purchase
E1004
NU EP
H 6
W/C accessory, power seating system, recline only, with
						  mechanical shear reduction
Y
*
Purchase
E1006
NU EP
H 6
W/C accessory, power seating system, combination tilt
						  and recline, w/o shear reduction
Y
Purchase
E1006
NU EP
U1 U1
H 6
***(Power tilt and recline system with zero sheer) W/C
						  accessory, power seating system, combination tilt and recline, without
						  mechanical shear reduction
Y
*
Purchase
E1010
NU EP
H 6
W/C accessory, addition to power seating system, power
						  leg elevation system, including leg rest, each
Y
Purchase
E1019
NU EP
H 6
W/C accessory, power seating, heavy duty feature,
						  patient weight capacity greater than 250 lbs, and less than or equal to 400
						  lbs
Y
Purchase
E1020
NU EP
H 6
***(Adjustable Contour Lateral Thigh Support) Residual
						  limb support system for W/C
N****
Purchase
E1026
EP
6
***(Adjustable Contour Back, 10" - 12" Frame) Lateral
						  thoracic support, contoured, for pediatric W/C, each (includes hardware)
N****
Purchase
E1026
EP
U1
6
***(Adjustable Contour Back, 14" - 16" Frame) Lateral
						  thoracic support, contoured, for pediatric W/C, each (includes hardware)
N****
Purchase
E1029
NU EP
H 6
***(Ventilator Tray Wth Battery Tray) Wheelchair
						  accessory, ventilator tray, fixed
Y
Purchase
E1030
NU EP
H 6
Wheelchair accessory, ventilator tray, gimbaled
Y
Purchase
E1050*
NU EP
H 6
Full reclining W/C, fixed full-length arms, swing-away,
						  detachable elevating legrests
N****
Purchase
E1060*
NU EP
H 6
Full reclining W/C, detachable arms, desk or
						  full-length, swing-away detachable, elevating legrests
Y
*
Purchase
E1065*
NU EP
H 6
Power attachment (to convert any W/C to motorized W/C,
						  e.g., Solo)
Y
*
Purchase
E1070#
6
***
(A maximum use of three months only)
						  Fully reclining W/C, detachable arms, desk or full-length, swing-away,
						  detachable footrests
Y
Rental only
E1084*
NU EP
H 6
Hemi-W/C; detachable arms, desk or full-length,
						  swing-away, detachable, elevating leg rests
N****
Purchase
E1086*
NU EP
U1 U1
H 6
Hemi W/C, detachable arms, desk or full-length,
						  swing-away detachable footrests
Y
*
Purchase
E1086*
NU EP
H 6
Hemi W/C; detachable arms, desk or full-length,
						  swing-away, detachable footrests
N****
Purchase
E1088*
NU EP
H 6
High strength lightweight W/C; detachable arms, desk or
						  full-length, swing-away, detachable, elevating legrests
Y
*
Purchase
E1090
NU EP
H 6
High-strength lightweight W/C; detachable arms, desk or
						  full-length, swing-away, detachable footrests
N****
Purchase
E1091**
EP
UB
6
Youth stroller
N****
Purchase
E1091
NU EP
H 6
Youth positioning stroller
N
Purchase
E1091
NU EP
U1 U1
H 6
Youth positioning stroller
N
Manually Priced
E1092*
NU EP
H 6
Wide, heavy-duty W/C; detachable arms, desk or
						  full-length, swing-away, detachable, elevating legrests
Y
*
Purchase
E1093*
NU EP
H 6
Wide, heavy-duty W/C; detachable arms, desk or
						  full-length arms, swing-away, detachable footrests
Y
*
Purchase
E1110*
NU EP
H 6
Semi-reclining W/C; detachable arms, desk or
						  full-length, elevating legrest
Y
*
Purchase
E1161
NU EP
H 6
Manual adult size W/C, includes tilt in space
Y
*
Purchase
E1170*
NU EP
H 6
Amputee W/C; fixed full-length arms, swing-away,
						  detachable, elevating legrests
N****
Purchase
E1172*
NU EP
H 6
Amputee W/C; detachable arms, desk or full-length,
						  without footrests or legrests
Y
*
Purchase
E1180*
NU EP
H 6
Amputee W/C; detachable arms, desk or full-length,
						  swing-away, detachable footrests
Y
*
Purchase
E1200*
NU EP
H 6
Amputee W/C; fixed full-length arms, swing-away,
						  detachable footrests
N****
*
Purchase
E1211*
NU EP
H 6
Motorized W/C; detachable arms, desk or full-length,
						  swing-away, detachable, elevating legrests
Y*
Purchase
E1213*
NU EP
H 6
Motorized W/C; detachable arms, desk or full-length,
						  swing-away, detachable footrests
Y*
Purchase
E1220*
NU EP
H 6
W/C, specially sized or constructed (indicate brand
						  name, model number, if any, and justification)
Y
Manually Priced
E1225
NU EP
H 6
***(Folding Backrest, 8 Degree Bend, Low, 15" - 16")
						  Manual W/C accessory, semi-reclining back, (recline greater than 15 degrees,
						  but less than 80 degrees), each
N****
Purchase
E1226*
NU EP
H 6
Manual w/c accessory, fully reclining back, each
Y
Purchase
E1228
NU EP
U2 U2
H 6
***(Positioning tall back) Special back height for
						  W/C
N****
Purchase
E1228
NU EP
H 6
***(Folding Backrest, Tall, 19" - 20") Special back
						  height for W/C
N****
Purchase
E1228
NU EP
H 6
***(Folding Straight Backrest, Low, (15" -16") Special
						  back height for W/C
N****
Purchase
E1228
NU EP
H 6
***(Folding Straight Backrest, Tall, 19" -20") Special
						  back height for W/C
N****
Purchase
E1228
NU EP
U1 U1
H 6
***(High back contour seat) Special back height for
						  W/C
N****
Purchase
E1230*
NU EP
H 6
Power operated vehicle (three- or four-wheel
						  nonhighway), specify brand name and model number
Y*
Purchase
E1232*
EP
6
W/C, pediatric size, tilt-in-space, folding,
						  adjustable, with seating system
Y*
Purchase
E1233*
EP
6
W/C, pediatric size, tilt-in-space, rigid, adjustable,
						  without seating system
Y*
Purchase
E1234*
EP
6
W/C, pediatric size, tilt-in-space, folding,
						  adjustable, without seating system
Y*
Purchase
E1235*
NU EP
H 6
W/C, pediatric size, rigid, adjustable, with seating
						  system
Y*
Purchase
E1235
NU EP
H 6
***(Snug Seat I Mobility System) W/C, pediatric size,
						  rigid, adjustable, with seating system
Y*
Purchase
E12351,2
EP
U1 U1
6
***(Rigid W/C Frame) W/C, pediatric size, rigid,
						  adjustable with seating system
Y
Purchase
E1236
EP
6
Wheelchair, pediatric size, folding, adjustable, with
						  seating system
Y
Purchase
E1237*
NU EP
H 6
W/C, pediatric size, rigid, adjustable, without seating
						  system
Y*
Purchase
E1238*
NU EP
H 6
W/C, pediatric size, folding, adjustable, without
						  seating system
Y*
Purchase
E1240*
NU EP
H 6
Lightweight W/C; detachable arms, desk or full-length,
						  swing-away, detachable, elevating legrest
Y*
Purchase
E1260*
NU EP
H 6
Lightweight W/C; detachable arms, desk or full-length,
						  swing-away, detachable footrests
N****
Purchase
E1280*
NU EP
H 6
Heavy-duty W/C; detachable arms, desk or full-length,
						  elevating legrests
Y*
Purchase
E1290*
NU EP
H 6
Heavy-duty W/C; detachable arms, swing-away, detachable
						  footrests
Y*
Purchase
E1340
NU EP
U1 U1
H 6
***(Labor Only; a maximum of twenty [20] units [20
						  units = 5 hours of labor] per date of service is allowable.) Repair or
						  nonroutine service for durable medical equipment requiring the skill of a
						  technician, labor component, per 15 minutes
Y
Manually Priced
E1340
NU EP
U3 U3
H 6
***(Unlisted Repairs/Parts Only Wheelchairs;
applicable pages from the manufacturer?s catalog must be attached to the
						  claim form.)
Repair or nonroutine service for durable medical equipment
						  requiring the skill of a technician, labor component, per 15 minutes
N****
Manually Priced
E2201
NU EP
U3 U3
H 6
Manual w/c accessory, nonstandard seat frame width
						  [GREATER THAN] than or equal to 20 inches and [LESS THAN]24 inches
N****
Manually Priced
E2201
NU EP
U1 U1
H 6
***(Frame Width 14"-15") Manual w/c accessory,
						  nonstandard seat frame width[GREATER THAN]than or equal to 20 inches and [LESS
						  THAN]24 inches
N****
Manually Priced (21+)
Purchase
E2201
NU EP
U2 U2
H 6
***(Frame Wdth 19"-20") Manual w/c accessory,
						  nonstandard seat frame width[GREATER THAN]than or equal to 20 inches and [LESS
						  THAN]24 inches
N****
Manually Priced (21+)
Purchase
E2201
NU EP
H 6
***(Seat Wdth 20") Manual w/c accessory, nonstandard
						  seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN] 24
						  inches
N****
Manually Priced
Purchase
E2203
NU EP
U4 U4
H 6
Manual w/c accessory, nonstandard seat frame depth, 20
						  to less than 22 inches
N
Manually Priced
Purchase
E2203
NU EP
U2 U2
H 6
***(Frame, Long; 16", 17"3, 18", 19"3, 20" Depth)
						  Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22
						  inches
N****
Manually Priced (21+)
Purchase
E2203
NU EP
U3 U3
H 6
***(Seat Depth 19" - 20") Manual w/c accessory,
						  nonstandard seat frame depth, 20 to less than 22 inches
N****
Manually Priced
Purchase
E2203
NU EP
H 6
***(Seat Depth 15") Manual w/c accessory, nonstandard
						  seat frame depth, 20 to less than 22 inches
N****
Manually Priced
Purchase
E2203
NU EP
U1 U1
H 6
***(Seat Depth 17" - 18") Manual w/c accessory,
						  nonstandard seat frame depth, 20 to less than 22 inches
N****
Manually Priced
Purchase
E2206
NU EP
H 6
Manual wheelchair accessory, wheel lock assembly,
						  complete, each
N
Purchase
E2291
EP
6
Back, planar, for pediatric-size wheelchair, including
						  fixed attaching hardware
N
Purchase
E2292
EP
6
Seat, planar, for pediatric-size wheelchair, including
						  fixed attaching hardware
N
Purchase
E2293
NU EP
H 6
Back, contoured, for pediatric-size wheelchair,
						  including fixed attaching hardware
N
Purchase
E2294
NU EP
H 6
Seat, contoured, for pediatric-size wheelchair,
						  including fixed attaching hardware
N
Purchase
E2310
NU EP
H 6
Power w/c accessory, electronic connection between
						  wheelchair controller and one power seating system motor, including all related
						  electronics, indicator feature, mechanical function selection switch, and fixed
						  mounting hardware
Y
Purchase
E2311
NU EP
H 6
Power w/c accessory, electronic connection between
						  wheelchair controller and two or more power seating system motors, including
						  all related electronics, indicator feature, mechanical function selection
						  switch, and fixed mounting hardware
Y
Purchase
E2320
NU EP
H 6
Power w/c accessory, hand or chin control interface,
						  remote joystick or touchpad, proportional, including all related electronics
						  and fixed mounting hardware
Y
Purchase
E2322
NU EP
H 6
Power w/c accessory, hand control interface, multiple
						  mechanical switches, nonproportional, including all related electronics,
						  mechanical stop switch, and fixed mounting hardware
Y
Purchase
E2323
NU EP
H 6
Power w/c accessory, specialty joystick handle for hand
						  control interface, prefabricated
N
Purchase
E2324
NU EP
H 6
Power w/c accessory, chin cup for chin control
						  interface
N
Purchase
E2325
NU EP
H 6
Power w/c accessory, sip & puff interface
						  nonproportional, including all related electronics, mechanical stop switch, and
						  manual swingaway mounting hardware
Y
Purchase
E2326
NU EP
H 6
Power w/c accessory, breath tube kit for sip & puff
						  interface
Y
Purchase
E2327
NU EP
H 6
Power w/c accessory, head control interface,
						  mechanical, proportional, including all related electronics, mechanical
						  direction change switch, and fixed mounting hardware
Y
Purchase
E2360
NU EP
H 6
Power w/c accessory, 22 NF non-sealed lead acid
						  battery, each
N
Purchase
E2361
NU EP
H 6
Power w/c accessory, 22 NF sealed lead acid battery,
						  each, (e.g., gel cell, absorbed glassmat)
N
Purchase
E2362
NU EP
H 6
Power wheelchair accessory, group 24 non-sealed lead
						  acid battery, each
N
Purchase
E2363
EP
6
***(Group 24 Gel Batteries) Power W/C accessory, group
						  24 sealed lead acid battery, each, e.g., gel cell, absorbed glassmat
N****
Purchase
E2363
NU EP
H 6
Power w/c accessory, group 24 sealed lead acid battery,
						  each (e.g., gel cell, absorbed glassmat)
N
Purchase
E2363
NU EP
U1 U1
H 6
Power w/c accessory, group 24 sealed lead acid battery,
						  each (e.g., gel cell, absorbed glassmat)
N
Purchase
E2364
NU EP
H 6
Power wheelchair accessory, U-1 non-sealed lead acid
						  battery, each
N
Purchase
E2365
NU EP
H 6
***(U-1 gel cell battery, each) Power wheelchair
						  accessory, U-1 sealed lead acid battery, each, (e.g., gel cell, absorbed
						  glassmat)
N
Purchase
E2365
NU EP
H 6
Power w/c accessory, U-1 sealed lead acid battery,
						  each, gel cell
N
Purchase
E2365
NU EP
U1 U1
H 6
Power w/c accessory, U-1 sealed lead acid battery,
						  each, gel cell
N
Purchase
E2366
NU EP
H 6
***(24-Volt Battery Charger - Standard, Replacement)
						  Power w/c accessory, battery charger, single mode, for use with only one
						  battery type, sealed or non-sealed, each
N
Purchase
E2367
NU EP
H 6
***(24-Volt Battery Charger - Dual Mode, Replacement)
						  Power w/c accessory, battery charger, dual mode, sealed or non-sealed,
						  each
N
Purchase
E2368
NU EP
H 6
Power wheelchair component, motor, replacement
						  only
N
Purchase
E2369
NU EP
H 6
Power wheelchair component, gear box, replacement
						  only
N
Purchase
E2601
NU EP UE
H 6 H
General use wheelchair seat cushion, width less than 22
						  in., any depth
N
Purchase
E2602
NU EP UE
H 6 H
General use wheelchair seat cushion, width 22 in. or
						  greater, any depth
N
Purchase
E2611
NU EP UE
H 6 H
General use wheelchair back cushion, width less than 22
						  in., any height, including any type mounting hardware
N
Purchase
E2612
NU EP UE
H 6 H
General use wheelchair back cushion, width 22 in. or
						  greater, any height, including any type mounting hardware
N
Purchase
E2618
NU EP
H 6
Wheelchair accessory, solid seat support base (replaces
						  sling seat), for use with manual wheelchair or lightweight power wheelchair,
						  including any type mounting hardware
N
Manually Priced
E2619
NU EP
H 6
Replacement cover for wheelchair seat cushion or back
						  cushion, each
N
Purchase
E2620
NU
H
Positioning wheelchair back cushion, planar back with
						  lateral supports, width less than 22 in., any height, including any type
						  mounting hardware
N****
Purchase
E2621
NU
H
Positioning wheelchair back cushion, planar back with
						  lateral supports, width 22 in. or greater, any height, including any type
						  mounting hardware
N****
Purchase
K0004
NU EP
H 6
High-strength lightweight wheelchair
Y****
Purchase
K0005*
NU EP
H 6
***(High-performance manual W/C-adult) Ultralightweight
						  W/C
Y*
Purchase
K0005*
NU EP
U1 U1
H 6
***(High-performance manual W/C with growth
						  adjustability-child) Ultralightweight W/C
Y*
Purchase
K0010
NU EP
H 6
***(Motorized, standard frame, DA, swing away
						  footrests) Standard weight frame motorized/power W/C
Y*
Purchase
K0010
NU EP
U1 U1
H 6
***(Motorized, standard frame, DA, swing away ELR)
						  Standard weight frame motorized/power W/C
Y*
Purchase
K0011
NU EP
H 6
***(Motorized, power base or conventional frame w/c
						  DA/swing away footrests, programmable electronics and custom options)
						  Standard-weight frame motorized/power, W/C with programmable control parameters
						  for speed adjustment, tremor dampening, acceleration control and braking
Y*
Purchase
K0011
NU EP
U1 U1
H 6
***(Motorized, power base or conventional frame w/c
						  DA/swing away footrests, programmable electronics and custom options)
						  Standard-weight frame motorized/power, W/C with programmable control parameters
						  for speed adjustment, tremor dampening, acceleration control and braking
Y*
Purchase
K0012
NU EP
H 6
***(Motorized folding frame, DA, swing away footrests)
						  Lightweight portable motorized/power W/C
Y*
Purchase
K0012
NU EP
U1 U1
H 6
***(Motorized folding frame, DA, swing away ELR)
						  Lightweight portable motorized/power W/C
Y*
Purchase
K00141,2
NU EP
U1 U1
H 6
***(Center Drive power base) Other motorized/ power W/C
						  base
Y
Purchase
K0017
NU EP
U1 U1
H 6
***(Dual post and adjustable height DA) Detachable,
						  adjustable height armrest, base, each
N****
Purchase
K0017
NU EP
H 6
***(Receiver for height adj. arms, replacement)
						  Detachable, adjustable height armrest, base, each
N****
Purchase
K0019
NU EP
H 6
Arm pad, each
N
Purchase
K0020
NU EP
H 6
Fixed, adjustable height armrest, pair
N****
Purchase
K0038
NU EP
H 6
***(Single leg strap, each) Leg strap, each
N****
Purchase
K0038
NU EP
U2 U2
H 6
***(Foot straps, pair) Leg strap, each
N****
Purchase
K0038**
EP
U1
6
***(Knee strap) Leg strap, each
N
Purchase
K0039
NU EP
H 6
Leg strap, H style, each
N****
Purchase
K0040
NU EP
H 6
Adjustable angle footplate, each
N****
Purchase
K0043
NU EP
H 6
***(SWFR, replacement) Footrest, lower extension tube,
						  each
N
Purchase
K0044
NU EP
H 6
***(SWFR Hanger bracket, replacement) Footrest, upper
						  hanger bracket, each
N****
Purchase
K0045
NU EP
H 6
***(Padded custom foot box) Footrest, complete
						  assembly
N****
Purchase
K0047
NU EP
H 6
Elevating legrest, upper hanger bracket, each
N****
Purchase
K0056
NU EP
H 6
Seat height less than 17 inches or equal to or greater
						  than 21 inches for a high-strength, lightweight, or ultralightweight W/C
N****
Manually Priced
K0056
NU EP
U1 U1
H 6
***(Seat height 19.5"5) Seat height less than 17 inches
						  or equal to or greater than 21 inches for a high strength, lightweight or
						  ultralightweight W/C
N****
Purchase
K0064
NU EP
H 6
***(Zero pressure tube or wheel insert, each, rear
						  wheels) Zero pressure tube (flat free insert), any size, each
N****
Purchase
K0064
NU EP
U1 U1
H 6
***(12? or 14? flat free insert for power base, ea.)
						  Zero pressure tube (flat free insert), any size, each
N****
Purchase
K0065
NU EP
H 6
Spoke protectors, each
N****
Purchase
K0066
NU EP
H 6
***(20-26? Tires for manual W/C, ea., replacement)
						  Solid tire, any size, each
N
Purchase
K0067
NU EP
H 6
***(Pneumatic Caster 8 X 2 with Airless Insert)
						  Pneumatic tire, any size
N****
Purchase
K0068
NU EP
H 6
***(20-26? for manual W/C, ea., replacement) Pneumatic
						  tire tube, each
N
Purchase
K0070
NU EP
H 6
***(Wheel assembly, complete with pneumatic tires,
						  20?/22?/24?/26?/ea. replacement) Rear wheel assembly, complete with pneumatic
						  tire, spokes or molded, each
N****
Purchase
K0071
NU EP
U1 U1
H 6
***(Wheel assembly with pneumatic tires, 22?, pair,
						  rear wheels) Front caster assembly, complete, with pneumatic tire, each
N****
Purchase
K0071
NU EP
H 6
***(Polyeurethane casters, 5?, pair, front casters)
						  Front caster assembly, complete, with pneumatic tire, each
N****
Purchase
K0072
NU EP
H 6
***(Polyeurethane casters, 5?, pair, front casters)
						  Front caster assembly, complete, with semipneumatic tire, each
N****
Purchase
K0073
NU EP
H 6
Caster pin lock, each
N****
Purchase
K0074
NU EP
H 6
***(Pneumatic casters 8 x 1 1/4?, each, front casters)
						  Pneumatic caster tire, any size each
N****
Purchase
K0074
NU EP
H 6
***(Pneumatic casters 8 x 1 1/4?, each, front casters)
						  Pneumatic caster tire, any size each
N****
Purchase
K0074
NU EP
U2 U2
H 6
***
(9 x 2 3/4? pneumatic caster for power
						  base W/C) Pneumatic caster tire, any size each
N****
Purchase
K0074
NU EP
U1 U1
H 6
***(6?-8? tires for manual W/C, ea., replacement)
						  Pneumatic caster tire, any size, each
N
Purchase
K0074
NU EP
U3 U3
H 6
***(Pneumatic Caster 8 X 2) Pneumatic caster tire, any
						  size, each
N****
Purchase
K0075
NU EP
H 6
Semipneumatic caster tire, any size, each
N
Purchase
K0076
NU EP
U1 U1
H 6
***(10? x 3? Rear Wheel for Power W/C, ea.,
						  replacement) Solid caster tire, any size, each
N
Purchase
K0076
NU EP
H 6
***
(9? x 3? Caster Tire for Power W/C,
						  ea., replacement) Solid caster tire, any size, each
N
Purchase
K0076
NU EP
U2 U2
H 6
***(Polyurethane 5?, replacement) Solid caster tire,
						  any size, each
N****
Purchase
K0077
NU EP
H 6
Front caster assembly, complete, with solid tire,
						  each
N
Purchase
K0078
NU EP
H 6
***(6?-8? for manual W/C, each, replacement) Pneumatic
						  caster tire tube, each
N
Purchase
K0078
NU EP
U1 U1
H 6
APneumatic caster tire tube, each
N
Purchase
K0078
NU EP
U2 U2
H 6
***
(9? x 3? for Power W/C, ea.,
						  replacement) Pneumatic caster tire tube, each
N
Purchase
K0091
NU EP
U1 U1
H 6
***(20? x 2 1/8? tubes for power W/C, ea., replacement)
						  Rear wheel tire tube other than zero pressure for power W/C, any size,
						  each
N
Purchase
K0091
NU EP
H 6
***(10? x 3? Rear Wheel Caster Tube for Power W/C, ea.,
						  replacement) Rear wheel tire tube other than zero pressure for power W/C, any
						  size, each
N
Purchase
K0092
NU EP
H 6
Rear wheel assembly for power wheelchair, complete,
						  each
N
Purchase
K0093
NU EP
H 6
***(Zero pressure insert for rear wheel for power w/c,
						  ea.) Rear wheel zero pressure tire tube (flat free insert) for power W/C any
						  size, each
N****
Purchase
K0093
NU EP
U1 U1
H 6
***(Mag. Airless Insert, Drive Wheel) Rear wheel zero
						  pressure tire tube (flat free insert) for power W/C, any size, each
N****
Purchase
K0094
NU EP
H 6
***(20? x 2 1/8? replacement) Wheel tire for power
						  base, any size, each
N
Purchase
K0097
NU EP
H 6
Wheel, zero pressure tire tube (flat free insert) for
						  power base, any size, each
N****
Purchase
K0099
NU EP
H 6
***
(9 x 2 3/4? foam filled caster for
						  power base W/C) Front caster for power W/C
N****
Purchase
K0102
NU EP
H 6
Crutch and cane holder, each
N****
Purchase
K0104
NU EP
H 6
Cylinder tank carrier, each
N
Purchase
K0106
NU EP
H 6
Arm trough, each
N****
Purchase
K0108
NU EP
H 6
***(W/C miscellaneous equipment;
applicable pages
						  from the manufacturer?s catalog must be attached to the claim form.)
Other accessories
N****
Manually Priced
K0195
NU EP
H 6
Elevating legrest, pair (for use with capped rental
						  wheelchair base)
N
Rental Only
K0452
NU EP
U1 U1
H 6
***(Rear Wheel Stem, replacement) W/C bearings, any
						  type
N
Purchase
K0452
NU EP
H 6
***(Caster Bearing, replacement) W/C bearings, any
						  type
N
Purchase
K0452
NU EP
U2 U2
H 6
***(Power Base Wheel Bearing, replacement) W/C
						  bearings, any type
N****
Purchase
S1002
NU EP
H 6
***(Wheelchair, custom molded seating system only)
						  Customized item, list in addition to code for basic item
N****
Manually Priced
S1002
NU EP
U1 U1
H 6
***(Foam-in-place seat, Pindot quick foam contour
						  system) Customized item, list in addition to code for basic item
N****
Manually Priced
The following procedure codes may only be billed on
				paper.
Specialized Wheelchairs and Wheelchair Seating Systems
				for Individuals Age Two Through Adult (section 242.191)
No
National
Code
M1
M2
TOS
Local Code
Description
PA
Payment Method
Bill on paper
H 6
Z1613
One-piece footboard (each)
N****
Purchase
Bill on paper
H 6
Z1663
Group 27 deep cycle battery (each)
N
Purchase
Bill on paper
H 6
Z1785
W/C Mounting Kit, O.B.
N****
Purchase
Bill on paper
H 6
Z1789
Custom Headrest
N****
Purchase
Bill on paper
H 6
Z1793
Custom foot platform
N****
Purchase
Bill on paper
6
Z1824**
PC Car Seat/Snug Seat
Y
Purchase
Bill on paper
H 6
Z2137
Adjustable Rem. Abductor w/hardware (ea)
N****
Purchase
Bill on paper
H 6
Z2138
Adjustable Flip Down Abductor w/hardware (ea)
N****
Purchase
Bill on paper
H 6
Z2139
Lateral Hip/Thigh support w/hardware (ea)
N****
Purchase
Bill on paper
H 6
Z2140
Adductor - no hardware
N****
Purchase
Bill on paper
H 6
Z2141
Abductor - no hardware
N****
Purchase
Bill on paper
H 6
Z2142
Hip guides - no hardware
N
Purchase
Bill on paper
H 6
Z2143
Fluid supplement
N
Purchase
Bill on paper
H 6
Z2145
Laterals - no hardware
N****
Purchase
Bill on paper
H 6
Z2159
Fluid Flo-lite pad (Replacement)
N
Purchase
Bill on paper
H 6
Z2175
Power W/C Sleeve Top or Bottom Stem Bearing
						  (Replacement)
N****
Purchase
Bill on paper
H 6
Z2178
SWFR Pivot Saddle (Replacement)
N
Purchase
Bill on paper
H 6
Z2180
SWFR Latch Block (Replacement)
N
Purchase
Bill on paper
H 6
Z2181
SWFR Composite Foot Plate (Replacement)
N****
Purchase
Bill on paper
H 6
Z2183
Shoe Holders S/M/L/XL
N****
Purchase
Bill on paper
H 6
Z2184
X-Tube Assembly Folding W/C (Replacement)
N****
Purchase
Bill on paper
H 6
Z2185
Rigid Wheelchair Growth Kit
N
Purchase
Bill on paper
H 6
Z2186
Rigid Side Guard
N****
Purchase
Bill on paper
H 6
Z2187
Fabric Side Guard
N****
Purchase
Bill on paper
H 6
Z2188
Sub Occipital Three Piece Head Set W/REM
						  Hardware
N****
Purchase
Bill on paper
H 6
Z2189
Forehead Strap System
N****
Purchase
Bill on paper
H 6
Z2190
Regular Links
N****
Purchase
Bill on paper
H 6
Z2192
Pneumatic or Semi Casters (Replacement) 8 x 1 1/4 (ea)
						  or 8 x 1 3/4 (ea)
N****
Purchase
Bill on paper
H 6
Z2196
Swing Away Adj. Stroller Handles
N****
Purchase
Bill on paper
H 6
Z2200
Support Fixture for Head Rest
N****
Purchase
Bill on paper
H 6
Z2202
Lg. Chest Panel Support
N****
Purchase
Bill on paper
H 6
Z2203
Elbow Block w/Bracket
N****
Purchase
Bill on paper
H 6
Z2554
Swing Away Retractable Joystick Mount
N****
Purchase
Bill on paper
H 6
Z2571
Power Elevating Leg Rest With Calf Pads
N****
Purchase
Bill on paper
H 6
Z2582
Quick Release Axle
N****
Purchase
Bill on paper
H 6
Z2585
Growing Seat Pan
N****
Purchase
Bill on paper
H
Z2586
Growing Back Upholstery
N****
Purchase
Bill on paper
H 6
Z2588
Deep Contour Back 20" Width
N****
Purchase
Bill on paper
H 6
Z2589
Adjustable Contour Lateral Pelvic Support
N****
Purchase
Bill on paper
H 6
Z2591
1
Heavy Duty Motor Pack 350 Pounds
N
Purchase
Bill on paper
H 6
Z2592
Remote Joystick Module
N****
Purchase
Bill on paper
H
Z2596
Adjustable Contour Seat Attaching Hardware
N****
Purchase
Bill on paper
H 6
Z2599
Transit Option
N****
Purchase
Bill on paper
H 6
Z2604
Adjustable Back Upholstery
N****
Purchase
Bill on paper
H 6
Z2607
Lateral/Posterior Pelvic Support
N****
Purchase
Bill on paper
H 6
Z2608
Shoulder Harness Guide Kit
N****
Purchase
Bill on paper
H 6
Z2609
Universal Head Rest Kit
N****
Purchase
Bill on paper
H 6
Z2615
Remote Joystick With 1/8" Jacks
N****
Purchase
Bill on paper
H 6
Z2616
Swing Away Mount (Joystick)
N****
Purchase
242.192
Specialized Rehabilitative
			 Equipment, All Ages 9-1-04
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.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code ?6? for individuals under 21 years of
				age or TOS code ?H? for individuals age 21 or over.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS. 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.
NOTE: Prosthetics providers may continue to use modifier
				52 for claims with dates of service through October 31, 2005. Effective for
				claims with dates of service on and after November 1, 2005, modifier 52 will be
				replaced with modifier UB.
** Indicates that providers may bill only for individuals under
				age 21.
* Prior authorization is not required when another 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
TOS
Description
PA
Payment Method
E0149
NU EP
H 6
***
(4 Wheel Reverse Walker) Walker, heavy
						  duty, wheeled, rigid or folding, any type
N
Purchase
E0163
EP
6
***(Potty Chair - Sm) Commode chair, stationary, with
						  fixed arms
Y
Purchase
E0166
EP
U1
6
***(Potty Chair - Lg) Commode chair, mobile, with
						  detachable arms
Y
Purchase
E0168
NU
U1
H
***(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
6
***(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
H
***(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
6
***(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
H 6
***(Bolt-on Sm. Grab Bar) Bathroom wall rail,
						  each
N
Purchase
E0241
NU EP
U1 U1
H 6
***(Bolt-on Lg. Grab Bar) Bathroom wall rail,
						  each
N
Purchase
E0241
NU EP
U2 U2
H 6
***(Bolt-on Med. Grab Bar) Bathroom wall rail,
						  each
N
Purchase
E0245
NU EP
U3 U3
H 6
***(30? Bath Chair) Tub stool or bench
N
Purchase
E0245
NU EP
U4 U4
H 6
***(38? Bath Chair) Tub stool or bench
N
Purchase
E0245
NU EP
U5 U5
H 6
***(47? Bath Chair) Tub stool or bench
N
Purchase
E0245
NU EP
U6 U6
H 6
***(56? Bath Chair) Tub stool or bench
N
Purchase
E0245
NU EP
U2 U2
H 6
***(Padded Tub Transfer Bench) Tub stool or
						  bench
N
Purchase
E0245
NU EP
UB UB
H 6
***(Non-padded tub transfer bench) Tub stool or
						  bench
N
Purchase
E0245
NU EP
H 6
***(Adj. Bath Chair w/Back) Tub stool or bench
N
Purchase
E0246
NU EP
H 6
***(Clamp-on Tub Grab Bar) Transfer tub rail
						  attachment
N
Purchase
E0638
NU EP
H 6
Standing frame system, any size, with or without
						  wheels
Y
Purchase
E0638
EP EP
U1 U2
6 6
Standing frame system, any size, with or without
						  wheels
Y
Purchase
E0700
NU EP
H 6
***(Chin Guard for Safety Helmet, sm) Safety equipment,
						  e.g., belt, harness or vest
N
Purchase
E0701
NU EP
H 6
***(Soft Shell Helmets) Helmet with face guard and soft
						  interface material, prefabricated
N
Purchase
E0701
NU EP
U1
H 6
***(Hard Shell Helmets) Helmet with face guard and soft
						  interface material, prefabricated
N
Purchase
E0701
NU EP
U2 U2
H 6
***(Face guard for safety helmet) Helmet with face
						  guard and soft interface material, prefabricated
N
Purchase
E0950
NU EP
U1 U1
H 6
***(Tray for gait trainer) Wheelchair accessory, tray,
						  each
N
Purchase
E1031**
EP
U5
6
***(Low Back Activity Chair) Rollabout chair, any and
						  all types with casters five inches or greater
N
Purchase
E1031**
EP
6
***(Transition Toddler Chair - Sm.) Rollabout chair,
						  any and all types with casters five inches or greater
N
Purchase
E1031**
EP
6
***(Transition Toddler Chair - Lg.) Rollabout chair,
						  any and all types with casters five inches or greater
Y
Purchase
E1031**
EP
U1
6
***(Corner Chair w/Tray & Casters - Sm.) Rollabout
						  chair, any and all types with casters five inches or greater
N
Purchase
E1031**
EP
U3
6
***(Corner Chair w/Tray & Casters - Lg.) Rollabout
						  chair, any and all types with casters five inches or greater
N
Purchase
E1031**
EP
U4
6
***(Bolster Chair w/Tray, Chest Support & Casters -
						  Sm.) Rollabout chair, any and all types with casters five inches or
						  greater
N
Purchase
E1035**
EP
6
A(Carrie Seat - Pre School) Multi-positional patient
						  transfer system, with integrated seat, operated by care giver
Y
Purchase
E1035**
EP
U1
6
***(Carrie Seat - Elementary) Multi-positional patient
						  transfer system, with integrated seat, operated by care giver
Y
Purchase
E1035**
EP
U2
6
***(Carrie Seat - Jr.) Multi-positional patient
						  transfer system, with integrated seat, operated by care giver
Y
Purchase
E1035
NU EP
U3 U3
H 6
***(Carrie Seat - Sm. Adult) Multi-positional patient
						  transfer system, with integrated seat, operated by care giver
Y
*
Purchase
E8000
EP
6
***(14?) Gait trainer, pediatric size, posterior
						  support, includes all accessories and components
Y
Purchase
E8000
EP
U1
6
***(19?) Gait trainer, pediatric size, posterior
						  support, includes all accessories and components
Y
Purchase
E8000
EP
U2
6
***(Intermediate) Gait trainer, pediatric size,
						  posterior support, includes all accessories and components
Y
Purchase
E8001
EP
6
***(14?) Gait trainer, pediatric size, upright support,
						  includes all accessories and components
Y
Purchase
E8001
EP
U1
6
***(19?) Gait trainer, pediatric size, upright support,
						  includes all accessories and components
Y
Purchase
E8001
EP
U2
6
***(Intermediate) Gait trainer, pediatric size, upright
						  support, includes all accessories and components
Y
Purchase
E8002
EP
6
***(14?) Gait trainer, pediatric size, anterior
						  support, includes all accessories and components
Y
Purchase
E8002
EP
U1
6
***(19?) Gait trainer, pediatric size, anterior
						  support, includes all accessories and components
Y
Purchase
E8002
EP
U2
6
***(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
M2
TOS
Local Code
Description
PA
Payment Method
Bill on paper
H 6
Z1996
Sm. 51? Supine Stander
Y*
Purchase
Bill on paper
H 6
Z1997
Lg. 71? Supine Stander
Y*
Purchase
Bill on paper
6
Z1998**
27? Prone Stander
Y
Purchase
Bill on paper
6
Z2000**
42? Prone Stander
Y*
Purchase
Bill on paper
H 6
Z2001
50? Prone Stander
Y*
Purchase
Bill on paper
H 6
Z2002
Adj. Abduction Wedge w/hip stabilizer
N
Purchase
Bill on paper
H 6
Z2003
Tray for Stander-Prone
N
Purchase
Bill on paper
H 6
Z2004
Tray for Stander-Supine
N
Purchase
Bill on paper
H 6
Z2005
Foot Sandals for Standers
N
Purchase
Bill on paper
6
Z2006**
Up Rite Stander - Sm.
Y
Purchase
Bill on paper
6
Z2007**
Up Rite Stander - Med.
Y
Purchase
Bill on paper
H 6
Z2008
Up Rite Stander - Lg.
Y
Purchase
Bill on paper
H 6
Z2009
Caster Base for Up Rite Stander -Sm.
N
Purchase
Bill on paper
H 6
Z2010
Caster Base for Up Rite Stander -Med.
N
Purchase
Bill on paper
H 6
Z2011
Caster Base for Up Rite Stander -Lg.
N
Purchase
Bill on paper
6
Z2012**
Tumble Form Tri Stander w/Tray -Sm.
Y*
Purchase
Bill on paper
6
Z2013**
Tumble Form Tri Stander w/Tray -Lg.
Y*
Purchase
Bill on paper
6
Z2015**
48? Side Lyer
N
Purchase
Bill on paper
6
Z2016**
72? Side Lyer
N
Purchase
Bill on paper
6
Z2017**
Tumble Form Feeder Seat - Sm.
N
Purchase
Bill on paper
H 6
Z2018**
Tumble Form Feeder Seat - Med.
N
Purchase
Bill on paper
6
Z2019**
Tumble Form Feeder Seat - Lg.
N
Purchase
Bill on paper
6
Z2020**
Floor Sitter Wedge
N
Purchase
Bill on paper
6
Z2021**
Mobile Floor Sitter Med/Lg.
N
Purchase
Bill on paper
6
Z2022**
Tumble Form Therapy Wedge 4? -Sm.
N
Purchase
Bill on paper
6
Z2023**
Tumble Form Therapy Wedge 6? -Sm.
N
Purchase
Bill on paper
6
Z2026**
Tumble Form Therapy Wedge 8? -Med.
N
Purchase
Bill on paper
6
Z2029**
Tumble Form Therapy Wedge 10? - Lg.
N
Purchase
Bill on paper
6
Z2030**
Tumble Form Therapy Rolls 4?
N
Purchase
Bill on paper
6
Z2031**
Tumble Form Therapy Rolls 6?
N
Purchase
Bill on paper
6
Z2032**
Tumble Form Therapy Rolls 8?
N
Purchase
Bill on paper
6
Z2034**
Tumble Form Therapy Rolls 12?
N
Purchase
Bill on paper
6
Z2035**
Tumble Form Therapy Rolls 14?
N
Purchase
Bill on paper
6
Z2036**
Tumble Form Therapy Rolls 16?
N
Purchase
Bill on paper
6
Z2038**
Therapy Ball - Sm.
N
Purchase
Bill on paper
6
Z2039**
Therapy Ball - Med.
N
Purchase
Bill on paper
6
Z2040**
Therapy Ball - Lg.
N
Purchase
Bill on paper
6
Z2043**
Seat & Back Pad for Toddler Chairs
Y
Purchase
Bill on paper
6
Z2044**
Tray for Toddler Chair
Y
Purchase
Bill on paper
6
Z2045**
14? T&S High Back w/Support Activity Chair
Y
Purchase
Bill on paper
6
Z2046**
16? T&S High Back w/Support Activity Chair
Y
Purchase
Bill on paper
H 6
Z2047
Orthopedic Car Seat
Y
Purchase
Bill on paper
H 6
Z2048
4? Deluxe Wedge w/Strap
N
Purchase
Bill on paper
H 6
Z2072
Lg. Wrap Around Bath Support
N
Purchase
Bill on paper
H 6
Z2073
Sm. Wrap Around Back Support
N
Purchase
Bill on paper
H 6
Z2074
Lg. Toilet Support w/Hi Back
N
Purchase
Bill on paper
H 6
Z2075
Sm. Toilet Support w/Hi Back
N
Purchase
Bill on paper
H 6
Z2077
Flexible Shower Hose
N
Purchase
Bill on paper
H 6
Z2089
Toilet Seat Reducer Ring (Padded)
N
Purchase
Bill on paper
6
Z2090**
14? Gait Trainer
Y
Purchase
Bill on paper
6
Z2091**
19? Gait Trainer
Y*
Purchase
Bill on paper
6
Z2092**
Intermediate Gait Trainer
Y
*
Purchase
Bill on paper
H 6
Z2093
Adult Gait Trainer
Y
*
Purchase
Bill on paper
6
Z2094**
Tyke Strider Walker w/2 Wheels
N
Purchase
Bill on paper
6
Z2095**
Tweener Strider Walker w/2 Wheels
N
Purchase
Bill on paper
6
Z2096**
Middle Strider Walker w/2 Wheels
N
Purchase
Bill on paper
H 6
Z2097
Adult Strider Walker w/2 Wheels
N
Purchase
Bill on paper
H 6
Z2099
4 Wheel Reverse Walker
N
Purchase
Bill on paper
H 6
Z2100
4 Wheel Reverse Walker
N
Purchase
Bill on paper
H 6
Z2101
4 Wheel Reverse Walker
N
Purchase
Bill on paper
H 6
Z2102
4 Wheel Reverse Walker
N
Purchase
Bill on paper
H 6
Z2104
4 Wheel Front Swivel Reverse Walker
N
Purchase
Bill on paper
H 6
Z2105
4 Wheel Front Swivel Reverse Walker
N
Purchase
Bill on paper
H 6
Z2106
4 Wheel Front Swivel Reverse Walker
N
Purchase
Bill on paper
H
Z2107
4 Wheel Front Swivel Reverse Walker
N
Purchase
Bill on paper
H 6
Z2239
Bath Chair Headrest
N
Purchase
Bill on paper
H 6
Z2605
Diverter Valve for Handheld Shower
N
Purchase
242.193
Augmentative Communication
			 Device, All Ages
The augmentative communication device must be billed using the
				procedure code assigned to each component. The specific components will be
				reimbursed, as needed, for the procedure codes listed below and will count
				toward the lifetime limit of $7,500 per beneficiary.
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.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) "6" for individuals under age 21 or TOS "H"
				for individuals age 21 and over.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS. 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.
NOTE:
Attach a manufacturer?s invoice to the claim
				and indicate the item or parts billed on the invoice. A description and the
				amount billed for each item must be attached to the claim. If more than one
				item is billed under a procedure code, the description and billed amount of
				each item must be listed separately under each procedure code and attached to
				the claim. The total billed for each procedure code should be reflected in
				field 24F.
* Prior authorization is not required when another 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.
Augmentative Communication Device, All Ages (section
				242.193)
Procedure Code
M1
M2
TOS
PA
Description
Payment Method
E2500
NU EP
H 6
Y*
***(Light Technology Communication Aids -communication
						  aids that do not have the memory component to store the information. They are
						  often used in conjunction with higher tech devices as part of a multi-modal
						  communication system.) Speech-generating device, digitized speech, using
						  pre-recorded messages less than or equal to 8 minutes recording time
Purchase
E2502
NU EP
H 6
Y*
***(Simple Voice Output Device - simple devices with
						  limited storage capacity and voice output only.) Speech-generating device,
						  digitized speech, using pre-recorded messages, greater than 8 minutes but less
						  than or equal to 20 minutes recording time
Purchase
E2504
NU EP
H 6
Y*
***(Simple Voice Output Device - simple devices with
						  limited storage capacity and voice output only) Speech-generating device,
						  digitized speech, using pre-recorded messages, greater than 20 minutes but less
						  than or equal to 40 minutes recording time
Purchase
E2506
NU EP
H 6
Y*
***(Simple Voice Output Device - simple devices with
						  limited storage capacity and voice output only) Speech-generating device,
						  digitized speech, using pre-recorded messages, greater than 40 minutes
						  recording time.
Purchase
E2508
NU EP
H 6
Y*
***(More Advanced Voice Output Communication Aids -
						  offer more storage capacity and often have other output methods in addition to
						  voice output; e.g., LED display) Speech-generating device, synthesized speech,
						  requiring message formulation by spelling and access by physical contact with
						  the device
Purchase
E2510
NU EP
6
Y*
***(Higher Technology Voice Output Communication Aids -
						  offer greater memory capabilities, various types of output, computer interface
						  options, etc.) Speech-generating device synthesized speech, permitting multiple
						  methods of message formulation and multiple methods of device access
Purchase
E2510
NU EP
H 6
Y*
***(State-of-the-Art Voice Output Communication Aids -
						  represents state-of-the-art communication aid technology. Have extensive memory
						  capabilities, various output methods, computer interface options; offer a
						  variety of input methods in a single device and advanced functions such as
						  auditory scanning, icon and word prediction, etc.) Speech-generating device
						  synthesized speech, permitting multiple methods of message formulation and
						  multiple methods of device access
Purchase
E2511
NU EP
H 6
Y*
***(Software - often recommended for augmentative
						  communication device. Software may change as the child matures.)
						  Speech-generating software program, for personal computer or personal digital
						  assistant
Purchase
E2512
NU EP
H 6
Y
Accessory for speech generating device, mounting
						  system
Manually Priced
E2599
NU EP
H 6
Y*
***(Switches - used with training aids and augmentative
						  communication devices as a means of access) Accessory for speech generating
						  device, not otherwise classified
Manually Priced
V5336
NU EP
H 6
Y
***(Augmentative Communication Device Repair - parts
						  only) Repair/modification of augmentative communicative system or device
						  (excludes adaptive hearing aid)
Purchase
V5336
NU EP
H 6
Y
***(Augmentative Communication Device Repair - labor
						  only) Repair/modification of augmentative communicative system or device
						  (excludes adaptive hearing aid)
Purchase