New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 55 - PROSTHETIC AND ORTHOTIC SERVICES › Subchapter 2 - CENTERS FOR MEDICARE AND MEDICAID SERVICES HEALTHCARE COMMON PROCEDURE CODING SYSTEM HCPCS › Section 10:55-2.3 - HCPCS Procedure Codes and Maximum Fee Allowance Schedule for Orthotic Services

Current through Register Vol. 56, No. 14, July 15, 2024
HCPCS
Description
Maximum
Code
Fee
Allowance $
(a) ORTHOTIC DEVICES (L0100-L0999)
1. SPINAL: CERVICAL
L0112
Cranial cervical orthosis, congenital torticollis
879.82
type, with or without soft interface material,
adjustable range of motion joint, custom fabricated
L0113
Cranial cervical orthosis, tortcollis type, with or
B.R.
without joint, with or without soft interface
material, prefabricated, includes fitting and
adjustment
L0120
Cervical, flexible, nonadjustable (foam collar)
13.04
L0130
Cervical, flexible, thermoplastic collar, molded to
54.40
patient
L0140
Cervical, semi-rigid, adjustable (plastic collar)
24.40
L0150
Cervical, semi-rigid, adjustable molded chin up
75.20
(plastic collar with mandibular/occipital piece)
L0160
Cervical, semi-rigid, wire frame
100.00
occipital/mandibular support
L0170
Cervical collar, molded to patient model
300.00
L0172
Cervical collar, semi-rigid, thermoplastic foam,
68.34
two piece
L0174
Cervical collar, semi-rigid, thermoplastic foam,
113.90
two piece with thoracic extension
2. MULTIPLE POST COLLAR
L0180
Cervical, multiple post collar occipital/mandibular
163.80
supports, adjustable
L0190
Cervical, multiple post collar,
240.00
occipital/mandibular supports, adjustable cervical
bars (Somi, Guilford, Taylor types)
L0200
Cervical, multiple post collar,
175.00
occipital/mandibular supports, adjustable cervical
bars, and thoracic extension
3. SPINAL: THORACIC
L0210
Thoracic rib belt, custom fitted
13.20
L0220
Thoracic rib belt, custom fabricated
24.40
4. SPINAL: THORACIC-LUMBAR-SACRAL ORTHOSIS (TLSO)
L0430
Spinal orthosis, anterior-posterior-lateral
880.92
control, with interface material, custom fitted
(Dewall posture protector only)
L0450
TLSO, flexible, provides trunk support, upper
122.58
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
L0452
TLSO, flexible, provides trunk support, upper
264.68
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
L0454
TLSO, flexible, provides trunk support, extends
220.09
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
L0456
TLSO, flexible, provides trunk support, thoracic
region, rigid posterior panel and soft anterior apron,
extends from the sacrococcygeal junction and
220.96
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
L0458
TLSO, triplanar control, modular segmented spinal
440.57
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 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
L0460
TLSO, triplanar control, modular segmented spinal
440.57
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, includes
straps and closures, prefabricated, includes fitting
and adjustment
L0462
TLSO, triplanar control, modular segmented spinal
440.57
system, three 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, includes
straps and closures, prefabricated, includes fitting
and adjustment
L0464
TLSO, triplanar control, modular segmented spinal
437.70
system, four rigid plastic shells, posterior extends
from sacrococcygeal junction and terminates just
inferior to scapular spine, anterior extends from
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, includes
straps and closures, prefabricated, includes fitting
and adjustment
L0466
TLSO, sagittal control, rigid posterior frame and
224.99
flexible soft anterior apron with straps, closures and
padding, restricts gross trunk motion in sagittal
plane, produces intracavity pressure to reduce load on
intervertebral disks, includes fitting and shaping the
frame, prefabricated, includes fitting and adjustment
L0468
TLSO, sagittal-coronal control, rigid posterior
frame and flexible soft anterior apron with straps,
closures and padding, extends from sacrococcygeal
276.04
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
L0470
TLSO, triplanar control, rigid posterior frame and
447.64
flexible soft anterior apron with straps, closures and
padding, extends from sacrococcygeal junction to
scapular, 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
L0472
TLSO, triplanar control, hyperextension, rigid
291.60
anterior and lateral frame extends from symphysis
pubis to sternal notch with two anterior components
(one public 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.
L0474
TLSO, triplanar control, rigid posterior frame with
499.65
flexible soft apron anterior 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 the 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
L0480
TLSO, triplanar control, one piece rigid plastic
1,035.33
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
L0482
TLSO, triplanar control, one piece rigid plastic
shell with interface liner, multiple straps and
closures, posterior extends from sacrococcygeal
1,153.79
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
L0484
TLSO, triplanar control, two piece rigid plastic
1,146.26
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
L0486
TLSO, triplanar control, two piece rigid plastic
1,218.72
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
L0488
TLSO, triplanar control, one piece rigid plastic
895.12
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
L0490
TLSO, sagittal-coronal control, one piece rigid
677.26
plastic shell, with overlapping reinforced anterior,
with multiple straps and closures, posterior extends
from sacrococcygeal junction and terminates at or
before the T-9 vertebra, anterior extends from
symphysis pubis to xiphoid, anterior opening,
restricts gross trunk motion in sagittal and coronal
planes, prefabricated, includes fitting and adjustment
5. SPINAL: LUMBAR--SACRAL--ORTHOSIS (LSO)--FLEXIBLE
L0491
TLSO, sagittal-coronal control, modular segmented
475.12
spinal system, two rigid plastic shells, posterior
extends from the sacroccygeal 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 and
coronal planes, lateral strength is provided by
overlapping plastic and stabilizing closures, includes
straps and closures, prefabricated, includes fitting
and adjustment
L0492
TLSO, sagittal-coronal control, modular segmented
spinal system, three rigid plastic shells, posterior
extends from the sacroccygeal junction and terminates
312.11
just inferior to the scapular spine, anterior extends
from the symphysis pubis to the xiphoid, soft liner,
restricts gross trunk motion in the sagittal and
coronal planes, lateral strength is provided by
overlapping plastic and stabilizing closures,
prefabricated, includes fitting and adjustment
6. SPINAL: SACROILIAC/FLEXIBLE
L0600
Sacroiliac, flexible (sacroiliac surgical support),
40.72
custom fitted
L0610
Sacroiliac, flexible (sacroiliac surgical support),
89.28
custom fabricated
7. SEMI-RIGID
L0620
Sacroiliac, semi-rigid (Goldthwaite, Osgood types),
192.00
with apron front
8. SPINAL: CERVICAL-THORACIC-LUMBAR-SACRAL-HALO PROCEDURE
ANTERIOR-POSTERIOR-LATERAL CONTROL
L0621
Sacroiliac orthosis, flexible, provides
57.33
pelvic-sacral support, reduces motion about the
sacroiliac joint, includes straps, closures, may
include pendulous abdomen design, may be
prefabricated, includes fitting and adjustment
L0622
Sacroiliac orthosis, flexible, provides
153.10
pelvic-sacral support, reduces motion about the
sacroiliac joint, includes straps, closures, may
include pendulous abdomen design, custom fabricated
L0623
Sacroiliac orthosis, provides pelvic-sacral
B.R.
support, with rigid or semi-rigid panels over the
sacrum and abdomen, reduces motion about the
sacroiliac joint, includes straps, closures, may
include pendulous abdomen design, prefabricated,
includes fitting and adjustment
L0624
Sacroiliac orthosis, provides pelvic-sacral
B.R.
support, with rigid or semi-rigid panels placed over
the sacrum and abdomen, reduces motion about the
sacroiliac joint, includes straps, closures, may
include pendulous abdomen design, custom fabricated
L0625
Lumbar orthosis, flexible provides lumbar support,
34.07
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 adjustments
L0626
Lumbar orthosis, sagittal control, with rigid
48.22
posterior panel(s), posterior extends from L-1 below
L-5 vertebra, produces intracavitary pressure to
reduce load on the invertebral discs, includes straps,
closures, may include padding, stays, shoulder straps,
pendulous abdomen design, prefabricated, includes
fitting and adjustment
L0627
Lumbar orthosis, sagittal control, with rigid
anterior and posterior panels, posterior extends from
254.29
L-1 to below L-5 vertebra, produces intracavitary
pressure to reduce load on the invertebral discs,
includes straps, closures, may include padding,
shoulder straps, pendulous abdomen design,
prefabricated, includes fitting and adjustment
L0628
Lumbar-sacral, flexible provides lumbo-sacral
51.90
support, posterior extends from sacrococcygeal
junction to T-9 vertebra, produces intracavitary
pressure to reduce load on the invertebral discs,
includes straps, closures, may include stays, shoulder
straps, pendulous abdomen design, prefabricated,
includes fitting and adjustment
L0629
Lumbar-sacral orthosis, flexible, provides
B.R.
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
L0630
Lumbar-sacral orthosis, sagittal control, with
100.19
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
L0631
Lumbar-sacral orthosis sagittal control, with rigid
635.08
anterior and posterior panels, posterior extends from
sacroccygeal junction 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
L0632
Lumbar-sacral orthosis sagittal control, with rigid
B.R.
anterior and posterior panels, posterior extends from
sacroccygeal junction 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
custom fabricated
L0633
Lumbar-sacral orthosis, sagittal-coronal control,
177.39
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
intervertebral discs, includes straps, closures, may
include padding, stays, shoulder straps, penduloud
abdomen design, prefabricated, includes fitting and
adjustment
L0634
Lumbar-sacral orthosis, sagittal-coronal, with
rigid posterior frame/panel(s), posterior extends from
B.R.
sacroccygeal junction to T-9 vertebra, lateral
strength provided by rigid lateral frame/panel(s),
produces intracavitary pressure to reduce load on
intervertebral discs, includes straps, closures, may
include padding, stays, shoulder straps, pendulous
abdomen design, custom fabricated
L0635
Lumbar-sacral orthosis, sagittal-coronal control,
603.06
lumbar flexion rigid posterior frame/panels, lateral
articulating design to flex the lumbar spine,
posterior extends from sacrococcygeal junction T-9
vertebra, lateral strength provided by rigid lateral
frames/panel(s), produces intracavitary pressure to
reduce load on intervertebral discs, include padding,
anterior panel, pendulous abdomen design,
prefabricated, includes fitting and adjustment
L0636
Lumbar-sacral orthosis, sagittal-coronal control,
894.38
lumbar flexion, rigid posterior frames/panels, 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 intervertebral discs, includes straps,
closures, may include padding, anterior panel,
pendulous abdomen design, custom fabricated
L0637
Lumbar-sacral orthosis, sagittal-coronal, control,
664.58
lumbarflexion, rigid posterior frame/panels, posterior
extends from sacrococcygeal junction to T-9 vertebra,
lateral sacrococcygeal junction to T-9 vertebra,
lateral, shoulder straps, pendulous abdomen design,
prefabricated includes fitting and adjustment
L0638
Lumbar-sacral orthosis, sagittal-coronal control,
815.91
with rigid anterior and posterior frames/panels,
posterior extends from sacrococcygeal junction to T-9
vertebra, lateral strength provided by rigid lateral
frames/panels, produces intracavitary pressure to
reduce load on intervertebral discs, includes straps,
closures, may include padding shoulder straps,
pendulous abdomen design, prefabricated includes
fitting and adjustment
L0639
Lumbar-sacral orthosis, sagittal-coronal control,
664.58
rigid shell(s)/panel(s), posterior extends from
sacrococcygeal junction to T-9 vertebra, anterior
extends from symphysis pubis to xyphoid, produces
intracavitary pressure to reduce load on the
intervertebral discs, overall strength is provided by
overlapping rigid material and stabilizing closures,
includes straps, closures, may include soft interface,
pendulous abdomen design, custom prefabricated
includes fitting and adjustment
L0640
Lumbar-sacral orthosis, sagittal-coronal control,
rigid shell(s)/panel(s), posterior extends from
sacrococcygeal junction to T-9 vertebra, anterior
647.33
extends from symphysis pubis to xyphoid, produces
intracavitary pressure to reduce load on the
intervertebral discs, overall strength is provided by
overlapping rigid material and stabilizing closures,
includes straps, closures, may include soft interface,
pendulous abdomen design, custom fabricated
L0700
Cervical-thoracic-lumbarsacral-orthoses (CTLSO),
1,160.00
anterior-posterior-lateral-control, molded to patient
model (Minerva type)
L0710
CTLSO, anterior-posterior-lateral-control, molded
1,280.00
to patient model, with interface material (Minerva
type)
9. HALO PROCEDURE
L0810
Halo procedure, cervical halo incorporated into
1,677.11
jacket vest
L0820
Halo procedure, cervical halo incorporated into
1,200.00
plaster body jacket
L0830
Halo procedure, cervical halo incorporated into
2,053.61
Milwaukee type orthosis
L0859
Addition to halo procedure, magnetic resonance
721.98
image compatible systems, rings and pins, any material
L0861
Addition to halo procedure, replacement liner,
135.48
interface material
10. ADDITIONS TO SPINAL ORTHOSES
L0970
TLSO, corset front
33.60
L0972
LSO, corset front
69.20
L0974
TLSO, full corset
88.20
L0976
LSO, full corset
103.88
L0978
Axillary crutch extension
35.00
L0980
Peroneal straps, pair
11.33
L0982
Stocking supporter grips, set of four (4)
9.60
L0984
Protective body sock, each
34.12
L0999
Addition to spinal orthosis, not otherwise
B.R.
specified
(b) ORTHOTIC DEVICES--SCOLIOSIS PROCEDURES (L1000-L1499)
The orthotic care of scoliosis differs from other care in that the
treatment is more dynamic in nature and uses ongoing continual modification of
the orthosis to the patient's changing condition. This coding structure uses
the proper names or eponyms of the procedures because they have historic and
universal acceptance in the profession. It should be recognized that
variations to the basic procedures described by the founders/developers are
accepted in various medical and orthotic practices throughout the country. All
procedures include model of patient when indicated.
1. SCOLIOSIS: CERVICAL--THORACIC--LUMBAR--SACRAL ORTHOSIS
(CTLSO) (MILWAUKEE)
L1000
Cervical-thoracic-lumbar-sacral orthosis (CTLSO),
1,134.00
inclusive of furnishing initial orthoses including
model
L1001
Cervical-thoracic-lumbar-sacral orthosis,
B.R.
immobilizer, infant size, prefabricated, includes
fitting and adjustment
L1005
Tension based scoliosis orthosis and accessory
1,990.05
pads, includes fitting and adjustment
L1010
Additions to (CTLSO) or scoliosis orthosis, axilla
44.88
sling
L1020
Addition to CTLSO or scoliosis orthosis, kyphosis
25.00
pad
L1025
Addition to CTLSO or scoliosis orthosis, kyphosis
77.29
pad, floating
L1030
Addition to CTLSO or scoliosis orthosis, lumbar
40.83
bolster pad
L1040
Addition to CTLSO or scoliosis orthosis, lumbar or
39.00
lumbar rib pad
L1050
Addition to CTLSO or scoliosis orthosis, sternal
39.00
pad
L1060
Addition to CTLSO or scoliosis orthosis, thoracic
39.00
pad
L1070
Addition to CTLSO or scoliosis orthosis, trapezius
51.00
sling
L1080
Addition to CTLSO or scoliosis orthosis, outrigger
35.42
L1085
Addition to CTLSO or scoliosis orthosis, outrigger
108.45
bilateral with vertical extensions
L1090
Addition to CTLSO or scoliosis orthosis, lumbar
51.00
sling
L1100
Addition to CTLSO or scoliosis orthosis, ring
66.00
flange, plastic or leather
L1110
Addition to CTLSO or scoliosis orthosis, ring
90.00
flange, plastic or leather, molded to patient model
L1120
Addition to CTLSO or scoliosis orthosis, cover for
26.05
upright, each
2. SCOLIOSIS: THORACIC--LUMBAR--SACRAL ORTHOSIS (TLSO) (LOW
PROFILE)
L1200
Thoracic-lumbar-sacral-orthosis (TLSO), inclusive
1,037.53
of furnishing initial orthosis only
L1210
Additions to TLSO, (low profile), lateral thoracic
175.00
extension
L1220
Additions to TLSO, (low profile), anterior thoracic
175.00
extension
L1230
Additions to TLSO, (low profile), Milwaukee type
340.00
superstructure
L1240
Additions to TLSO, (low profile), lumbar derotation
44.75
pad
L1250
Addition to TLSO, (low profile), anterior asis pad
44.75
L1260
Addition to TLSO, (low profile), anterior thoracic
44.75
derotation pad
L1270
Addition to TLSO, (low profile), abdominal pad
44.75
L1280
Addition to TLSO, (low profile), rib gusset
61.02
(elastic), each
L1290
Addition to TLSO, (low profile), lateral
40.68
trochanteric pad
3. OTHER SCOLIOSIS PROCEDURES
L1300
Other scoliosis procedure, body jacket molded to
1,200.00
patient model
L1310
Other scoliosis procedure, post-operative body
1,200.00
jacket
L1499
Unlisted procedure for spinal orthosis
B.R.
4. THORACIC--HIP--KNEE--ANKLE ORTHOSIS (THKAO)
L1500
Thoracic-hip-knee-ankle orthoses (THKAO), mobility
1,243.33
frame (Newington, Parapodium types)
L1510
THKAO, standing frame
877.67
L1520
THKAO, swivel walker
1,487.44
(c) ORTHOTIC DEVICES--LOWER LIMB (L1600-L2699)
The procedures in L1600-L2999 are considered as "base" or "basic
procedures" and may be modified by listing procedures from the "additions"
sections and adding them to the base procedures.
1. LOWER LIMB: HIP--FLEXIBLE
L1600
Hip orthoses (HO), abduction control of hip joints,
40.32
flexible, Frejka type with cover
L1610
HO, abduction control of hip joints, flexible,
25.00
(Frejka cover only)
L1620
HO, abduction control of hip joints, flexible,
75.00
(Pavlik harness)
L1630
HO, abduction control of hip joints, semi-flexible
111.31
(Von Rosen type)
L1640
HO, abduction control of hip joints, static, pelvic
250.00
band or spreader bar, thigh cuffs
L1650
HO, abduction control of hip joints, static,
150.00
adjustable, custom fitted (Ilfled type)
L1652
Hip orthosis, bilateral thigh cuffs with adjustable
224.08
abductor spreader bar, adult size, prefabricated,
includes fitting and adjustment, any type
L1660
HO, abduction control of hip joints, static,
109.07
plastic, custom fitted
L1680
HO, abduction control of hip joints, dynamic,
802.72
pelvic control, adjustable hip motion control, thigh
cuffs (Rancho hip action type)
L1685
HO, abduction control of hip joints, postoperative
610.20
hip adduction type, custom fabricated
L1686
HO, abduction control of hip joint, postoperative
600.00
hip abduction type, custom fitted
L1690
Combination, bilateral, lumbo-sacral, hip, femur
1,040.29
orthosis providing adduction and internal rotation
control
2. LOWER LIMB--LEGG PERTHES
L1700
Legg Perthes orthosis, (Toronto type)
996.07
L1710
Legg Perthes orthosis, (Newington type)
1,159.26
L1720
Legg Perthes orthosis, trilateral, (Tachdijan type)
852.85
L1730
Legg Perthes orthosis, (Scottish Rite type)
739.21
L1750
Legg Perthes orthosis, Legg Perthes sling (Sam
80.00
Brown
L1755
Legg Perthes orthosis, (Patten Bottom type)
854.40
3. LOWER LIMB: KNEE
L1810
KO, elastic with joints
61.04
L1820
KO, elastic with condyle pads and joints
72.40
L1830
KO, immobilizer; canvas longitudinal
52.88
L1831
KO, Locking knee joint(s), positional orthosis,
185.00
prefabricated includes fitting and adjustment
L1832
KO, adjustable knee joints, positional orthosis,
320.00
rigid support, custom fitted
L1834
KO, without knee joint, rigid, molded to patient
388.00
model
L1836
Knee orthosis, rigid, without joint(s), includes
83.87
soft interface material, prefabricated, includes
fitting and adjustment
L1840
KO, derotation, medial-lateral, anterior cruciate
520.00
ligament, custom fabricated to patient model
L1843
Knee orthosis (KO); single upright, thigh and calf,
392.81
with adjustable flexion and extension joint,
medial-lateral and rotation control, custom fitted
L1844
KO, single upright, thigh and calf, with adjustable
852.38
flexion and extension joint, medial-lateral and
rotation control, molded to patient model
L1845
KO, double upright, thigh and calf, with adjustable
468.00
flexion and extension joint, medial-lateral and
rotation control, custom fitted
L1846
KO, double upright, thigh and calf, with adjustable
528.80
flexion and extension joint, medial-lateral and
rotation control, molded to patient model
L1847
Knee orthosis (KO); double upright with adjustable
309.42
joint, with inflatable air support chamber(s)
L1850
KO, Swedish type
148.00
L1858
KO, molded plastic, polycentric knee joints,
610.20
pneumatic knee pads (CTI)
L1860
KO, modification of supracondylar prosthetic
555.68
socket, molded to patient model (SK)
4. LOWER LIMB: ANKLE-FOOT
L1900
Ankle-foot orthoses (AFO), spring wire,
158.64
dorsiflexion assist calf band
L1901
Ankle orthosis, elastic, prefabricated, includes
11.13
fitting and adjustment (for example, neoprene, lycra)
L1902
AFO, ankle gauntlet, custom fitted
48.81
L1904
AFO, molded ankle gauntlet, molded to patient model
284.76
L1906
AFO, multiligamentus ankle support
75.00
L1907
AFO, Supramalleolar with straps, with or without
353.71
interface/pads, custom fabricated
L1910
AFO, posterior, single bar, clasp attachment to
192.99
shoe counter
L1920
AFO, single upright with static or adjustable stop
200.00
(Phelps or Perlstein type)
L1930
AFO, custom fitted, plastic
156.80
L1932
AFO, rigid anterior tibial section, total carbon
552.04
fiber equal material, prefabricated, includes fitting
and adjustment
L1940
AFO, molded to patient model, plastic
387.94
L1945
AFO, molded to patient model, plastic, rigid
540.00
anterior tibial section (floor reaction)
L1950
AFO, spiral, molded to patient model (Irm type),
593.22
plastic
L1951
AFO, spiral, (Institute of Rehabilitative Medicine
527.61
type), plastic or other material, prefabricated,
includes fitting and adjustment
L1960
AFO, posterior solid ankle, molded to patient
421.60
model, plastic
L1970
AFO, plastic molded to patient model, with ankle
513.35
joint
L1971
AFO, plastic or other material, with ankle joint,
294.64
prefabricated, includes fitting and adjustment
L1980
AFO, single upright free plantar dorsiflexion,
229.60
solid stirrup, calf band/cuff (single bar "BK"
orthosis)
L1990
AFO, double upright free plantar dorsiflexion,
287.20
solid stirrup, calf band/cuff (double bar "BK"
orthosis)
X4005
Tone reducing orthoses knee high, custom molded,
1,121.00
supply by orthotist, each
X4006
Tone reducing orthoses ankle high, custom molded,
350.00
supply by orthotist, each
X4007
Swedo ankle orthoses, each
90.00
X4450
AFO, posterior leaf spring molded to patient model
386.40
(Tirr, Rancho) includes casting
5. LOWER LIMB: HIP-KNEE-ANKLE-FOOT ORTHOSIS (KAFO)--OR ANY
COMBINATION
L2000, L2020, and L2036 are base procedures which may be used with any
knee joint; L2010 and L2030 shall only be used with no knee joint.
L2000
Knee-ankle-foot-orthoses (KAFO), single upright,
760.00
free knee, free ankle, solid stirrup, thigh and calf
bands/cuffs (single bar "AK" orthosis)
L2005
Knee-ankle-foot-orthosis (KAFO); single or double
2,534.97
upright, stance control, automatic lock and swing
phase release, mechanical activation, includes ankle
joint, any type, custom fabricated
L2010
KAFO, single upright, free ankle, solid stirrup,
568.68
thigh and calf bands/cuffs (single bar "AK" orthosis),
without knee joint
L2020
KAFO, double upright, free knee, free ankle, solid
786.13
stirrup, thigh and calf bands/cuffs (double bar "AK"
orthosis)
L2030
KAFO, double upright, free ankle, solid stirrup,
571.20
thigh and calf bands/cuffs (double bar "AK" orthosis),
without knee joint
L2034
Full plastic single upright, with or without free
1,289.57
motion knee, medial lateral, rotation control, with or
without free motion ankle, custom fabricated
L2035
Knee-ankle-foot-orthosis (KAFO); full plastic,
B.R.
static, prefabricated (pediatric size)
L2036
KAFO, full plastic, double upright, free knee,
1,000.00
molded to patient model
L2037
KAFO, full plastic, single upright, free knee,
900.00
molded to patient model
L2038
KAFO, full plastic, without knee joint, multiaxis
900.00
molded to patient model (lively orthosis or equal)
6. TORSION CONTROL
L2040
Hip-knee-ankle-foot orthosis (HKAFO), torsion
131.05
control, bilateral rotation straps, pelvic band/belt
L2050
HKAFO, torsion control, bilateral torsion cables,
223.44
hip joint, pelvic band/belt
L2060
HKAFO, torsion control, bilateral torsion cables,
250.00
ball bearing hip joint, pelvic band/belt
L2070
HKAFO, torsion control, unilateral rotation straps,
90.76
pelvic band/belt
L2080
HKAFO, torsion control, unilateral torsion cable,
200.00
hip joint, pelvic band/belt
L2090
HKAFO, torsion control, unilateral torsion cable,
200.00
ball bearing hip joint, pelvic band/belt
7. FRACTURE ORTHOSES
L2106
AFO, fracture orthosis, tibial fracture cast
284.76
orthosis, thermoplastic type casting material, molded
to patient
L2108
AFO, fracture orthosis, tibial fracture cast
569.60
orthosis, molded to patient model
L2112
AFO, fracture orthosis, tibial fracture orthosis,
244.08
soft custom fitted
L2114
AFO, fracture orthosis, tibial fracture orthosis,
321.37
semi-rigid custom fitted
L2116
AFO, fracture orthosis, tibial fracture orthosis,
366.40
rigid custom fitted
L2126
KAFO, fracture orthosis, femoral fracture cast
651.20
orthosis, thermoplastic type casting material, molded
to patient
L2128
KAFO, fracture orthosis, femoral fracture cast,
895.20
molded to patient model
L2132
KAFO, fracture orthosis, femoral fracture cast
488.16
orthosis, soft custom fitted
L2134
KAFO, fracture orthosis, femoral fracture cast
528.81
orthosis, semi-rigid custom fitted
L2136
KAFO, fracture orthosis, femoral fracture cast
630.40
orthosis, rigid custom fitted
8. ADDITIONS TO FRACTURE ORTHOSIS
L2180
Addition to lower extremity fracture orthosis,
53.69
plastic shoe insert with ankle joints
L2182
Addition to lower extremity fracture orthosis, drop
48.80
lock knee joint
L2184
Addition to lower extremity fracture orthosis,
69.16
limited motion knee joint
L2186
Addition to lower extremity fracture orthosis,
101.70
adjustable motion knee joint, Lerman type
L2188
Addition to lower extremity fracture orthosis,
203.40
quadrilateral brim
L2190
Addition to lower extremity fracture orthosis,
48.81
waist belt
L2192
Addition to lower extremity fracture orthosis, hip
203.40
joint pelvic band, thigh flange, and pelvic belt
9. ADDITIONS TO LOWER EXTREMITY ORTHOSIS;
SHOE--ANKLE--SHIN--KNEE
L2200
Addition to lower extremity, limited ankle motion,
30.80
each joint
L2210
Addition to lower extremity, dorsiflexion assist
48.00
(plantar flexion resist), each joint
L2220
Addition to lower extremity, dorsiflexion and
59.65
plantar flexion assist/resist, each joint
L2230
Addition to lower extremity, split flat caliper
49.95
stirrups and plate attachment
L2232
Addition to lower extremity orthosis, rocker bottom
61.57
for total contact ankle foot orthosis, for custom
fabricated orthosis only
L2240
Addition to lower extremity, round caliper and
54.10
plate attachment
L2250
Addition to lower extremity, foot plate, molded to
234.08
patient model, stirrup attachment
L2260
Addition to lower extremity, reinforced solid
169.83
stirrup (Scott-Craig type)
L2265
Addition to lower extremity, long tongue stirrup
32.00
L2270
Addition to lower extremity, varus/valgus
35.03
correction ("T") strap, padded/lined or malleolus pad
L2275
Addition to lower extremity, varus/vulgus
65.71
corrections, plastic modification, padded/lined
L2280
Addition to lower extremity, molded inner boot
105.76
L2300
Addition to lower extremity, abduction bar
175.00
(bilateral hip involvement), jointed, adjustable
L2310
Addition to lower extremity, abduction bar,
80.01
straight
L2320
Addition to lower extremity, nonmolded lacer
96.00
L2330
Addition to lower extremity, lacer molded to
190.00
patient model
L2335
Addition to lower extremity, anterior swing band
122.04
L2340
Addition to lower extremity, pretibial shell,
284.80
molded to patient model
L2350
Addition to lower extremity, prosthetic type, (BK)
447.52
socket, molded to patient model (used for "PTB" "AFO"
orthoses)
L2360
Addition to lower extremity, extended steel shank
41.16
L2370
Addition to lower extremity, patten bottom
164.00
L2375
Addition to lower extremity, torsion control, ankle
75.80
joint and half solid stirrup
L2380
Addition to lower extremity, torsion control,
32.00
straight knee joint, each joint
L2385
Addition to lower extremity, straight knee joint,
52.88
heavy duty, each joint
L2387
Addition to lower extremity, polycentric knee
98.08
joint, for custom fabricated knee ankle foot orthosis,
each joint
L2390
Addition to lower extremity, offset knee joint,
52.88
each joint
L2395
Addition to lower extremity, offset knee joint,
73.60
heavy duty, each joint
L2397
Addition to lower extremity orthosis, suspension
61.53
sleeve
10. ADDITIONS TO STRAIGHT KNEE OR OFFSET KNEE JOINTS
L2405
Addition to knee joint, drop lock, each joint
24.80
L2415
Addition to knee joint, cam lock (Swiss, French
101.60
Bail types), each joint
L2425
Addition to knee joint, disc or dial lock for
142.00
adjustable knee flexion, each joint
L2435
Addition to knee joint, polycentric joint, each
97.63
joint
L2492
Addition to knee joint, lift loop for drop lock
68.80
ring
11. ADDITIONS--THIGH/WEIGHT BEARING--GLUTEAL/ISCHIAL WEIGHT
BEARING
L2500
Addition to lower extremity, thigh/weight bearing,
117.60
gluteal/ischial weight bearing, ring
L2510
Addition to lower extremity, thigh/weight bearing,
508.81
quadrilateral brim, molded to patient model
L2520
Addition to lower extremity, thigh/weight bearing,
336.00
quadrilateral brim, custom fitted
L2525
Addition to lower extremity, thigh/weight bearing,
660.00
ischial containment/narrow M-L brim molded to patient
model
L2526
Addition to lower extremity, thigh/weight bearing,
380.00
ischial containment/narrow M-L brim, custom fitted
L2530
Addition to lower extremity, thigh/weight bearing,
146.48
lacer, nonmolded
L2540
Addition to lower extremity, thigh/weight bearing,
196.00
lacer, molded to patient model
L2550
Addition to lower extremity, thigh/weight bearing,
61.04
high roll cuff
12. ADDITIONS: PELVIC AND THORACIC CONTROL
L2570
Addition to lower extremity, pelvic control, hip
280.00
joint, clevis type two position joint, each
L2580
Addition to lower extremity, pelvic control, pelvic
240.00
sling
L2600
Addition to lower extremity, pelvic control, hip
108.00
joint, clevis type, or thrust bearing, free, each
L2610
Addition to lower extremity, pelvic control, hip
132.00
joint, clevis or thrust bearing, lock, each
L2620
Addition to lower extremity, pelvic control, hip
160.00
joint, heavy-duty, each
L2622
Addition to lower extremity, pelvic control, hip
170.85
joint, adjustable flexion, each
L2624
Addition to lower extremity, pelvic control, hip
102.40
joint, adjustable flexion, extension, abduction
control, each
L2627
Addition to lower extremity, pelvic control,
840.00
plastic, molded to patient model, reciprocating hip
joint and cables
L2628
Addition to lower extremity, pelvic control, metal
840.00
frame, reciprocating hip joint and cables
L2630
Addition to lower extremity, pelvic control, band
166.88
and belt, unilateral
L2640
Addition to lower extremity, pelvic control, band
201.60
and belt, bilateral
L2650
Addition to lower extremity, pelvic and thoracic
86.80
control, gluteal pad, each
L2660
Addition to lower extremity, thoracic control,
18.00
thoracic band
L2670
Addition to lower extremity, thoracic control,
32.00
paraspinal uprights
L2680
Addition to lower extremity, thoracic control,
32.00
lateral support uprights
(d) ADDITIONS--GENERAL (L2750-L2999)
L2750
Addition to lower extremity orthosis, plating
52.00
chrome or nickel, per bar
L2755
High strength, lightweight material, all hybrid
82.12
lamination/prepeg composite, per segment, for custom
fabricated orthosis only
L2760
Addition to lower extremity orthosis, extension,
32.00
per extension, per bar (for lineal adjustment for
growth)
L2768
Orthotic side bar disconnect device, per bar
81.01
L2795
Addition to lower extremity orthosis, knee control,
62.21
full kneecap
L2800
Addition to lower extremity orthosis, knee control,
64.80
kneecap, medical or lateral pull
L2810
Addition to lower extremity orthosis, knee control,
54.57
condylar pad
L2820
Addition to lower extremity orthosis, soft
40.68
interface for molded plastic, below knee section
L2830
Addition to lower extremity orthosis, soft
40.68
interface for molded plastic, above knee section
L2840
Addition to lower extremity orthosis, tibial length
28.00
sock, fracture or equal, each
L2850
Addition to lower extremity orthosis, femoral
33.60
length sock, fracture or equal, each
L2861
Addition to lower extremity joint, knee or ankle,
B.R.
concentric adjustable torsion style mechanism for
custom fabricated orthotics only, each
L2999
Unlisted procedures for lower extremity orthoses
B.R.
(e) FOOT, ORTHOPEDIC SHOES MODIFICATIONS, TRANSFERS
1. FOOT, INSERTS, REMOVABLE, MOLDED TO PATIENT MODEL
L3000
Foot insert, removable, molded to patient model,
140.00
"UCB" type, Berkeley shell, each
L3001
Foot insert, removable, molded to patient model;
76.00
Spenco, each Qualifier: Custom Spenco device
L3002
Foot insert, removable, molded to patient model,
76.00
Plastazote or equal, each
L3003
Foot insert, removable, molded to patient model,
76.00
silicone gel, each
L3010
Foot insert, removable, molded to patient model;
76.00
longitudinal arch support, each Qualifier: Any custom
leather/metal device (Example: Schaeffer, Whitman)
L3020
Foot insert, removable, molded to patient model;
88.00
longitudinal/metatarsal support, each Qualifier: Any
custom leather/plastic device, full foot only
L3030
Foot insert, removable, formed to patient foot,
48.00
each Qualifier: Only off-the-shelf Spenco
L3031
Foot, insert/plate, removable, addition to lower
B.R.
extremity orthosis, high strength, lightweight
material, all hybrid lamination/prepreg composite,
each
2. ARCH SUPPORTS, REMOVABLE, PREMOLDED
L3040
Foot, arch support, removable, premolded;
29.60
longitudinal, each Qualifier: Only off-the-shelf
plastazote
L3050
Foot, arch support, removable, premolded
32.00
metatarsal, each Qualifier: Only off-the-shelf with
metatarsal or heel pad with no longitudinal control
L3060
Foot, arch support, removable, premolded,
48.00
longitudinal/metatarsal, each Qualifier: Only
off-the-shelf with longitudinal control
3. ARCH SUPPORT, NON-REMOVABLE, ATTACHED TO SHOE
L3070
Foot, arch support, nonremovable, attached to shoe,
16.00
longitudinal, each
L3080
Foot, arch support, nonremovable, attached to shoe,
20.00
metatarsal, each
L3090
Foot, arch support, nonremovable, attached to shoe
24.00
longitudinal/metatarsal, each
L3100
Hallus-Valgus night dynamic splint
20.00
4. ABDUCTION AND ROTATION BARS
L3140
Foot, rotation positioning device, including
56.00
shoe(s)
L3150
Foot, rotation positioning device, without shoe(s)
60.00
L3160
Foot, adjustable shoe-style positioning device
B.R.
L3170
Foot, plastic heel stabilizer
112.00
5. ORTHOPEDIC FOOTWEAR
L3201
Orthopedic shoe, oxford with supinator or pronator,
48.00
infant
L3202
Orthopedic shoe, oxford with supinator or pronator,
48.00
child
L3203
Orthopedic shoe, oxford with supinator or pronator,
48.00
junior
L3204
Orthopedic shoe, hightop with supinator or
48.00
pronator, infant
L3206
Orthopedic shoe, hightop with supinator or
48.00
pronator, child
L3207
Orthopedic shoe, hightop with supinator or
48.00
pronator, junior
L3208
Surgical boot, each infant
24.00
L3209
Surgical boot, each child
24.00
L3211
Surgical boot, each junior
24.00
L3212
Benesch boot, pair, infant
48.00
L3213
Benesch boot, pair, child
48.00
L3214
Benesch boot, pair, junior
48.00
L3215
Orthopedic footwear, ladies shoes, oxford
76.00
L3216
Orthopedic footwear, ladies shoes, depth inlay
100.00
L3217
Orthopedic footwear, ladies shoes, hightop, depth
116.00
inlay
L3219
Orthopedic footwear, men's shoes, oxford
76.00
L3221
Orthopedic footwear, men's shoes, depth inlay
100.00
L3222
Orthopedic footwear, men's shoes, hightop, depth
116.00
inlay
L3224
Orthopedic footwear, woman's shoe, oxford, used as
B.R.
an integral part of a brace (orthosis)
L3225
Orthopedic footwear, man's shoe, oxford, used as an
B.R.
integral part of a brace (orthosis)
L3230
Orthopedic footwear, custom shoes, depth inlay
380.00
L3250
Orthopedic footwear, custom molded shoe, removable
250.00
inner mold, prosthetic shoe, each
L3251
Foot, shoe molded to patient model, silicone shoe,
280.00
each
L3252
Foot, shoe molded to patient model, Plastazote (or
256.00
similar), custom fabricated, each
L3253
Foot, molded shoe Plastazote (or similar), custom
112.00
fitted, each
L3254
Nonstandard size or width
20.00
L3255
Nonstandard size or length
20.00
L3257
Orthopedic footwear, additional charge for split
50.00
size
L3260
Ambulatory surgical boot, each
88.00
L3265
Plastazote sandal, each
56.00
6. SHOE MODIFICATION--LIFTS
L3300
Lift, elevation, heel, tapered to metatarsals, per
64.00
inch
L3310
Lift, elevation, heel and sole, neoprene, per inch
64.00
L3320
Lift, elevation, heel and sole, cork, per inch
100.00
L3330
Lift, elevation, metal extension (skate)
316.00
L3332
Lift, elevation, inside shoe, tapered, up to
44.00
one-half inch
L3334
Lift, elevation, heel, per inch
36.00
7. WEDGES
L3340
Heel wedge, Sach
10.40
L3350
Heel wedge
12.00
L3360
Sole wedge, outside sole
12.00
L3370
Sole wedge, between sole
14.40
L3380
Clubfoot wedge
12.00
L3390
Outflare wedge
16.00
L3400
Metatarsal bar wedge, rocker
16.00
L3410
Metatarsal bar wedge, between sole
16.00
L3420
Full sole and heel wedge, between sole
24.00
L3430
Heel, counter, plastic reinforced
24.00
L3440
Heel, counter, leather reinforced
24.00
L3450
Heel, Sach cushion type
64.00
L3455
Heel, new leather, standard
8.00
L3460
Heel, new rubber, standard
8.00
L3465
Heel, Thomas with wedge
20.00
L3470
Heel, Thomas extended to ball
24.00
L3480
Heel, pad and depression for spur
16.00
L3485
Heel, pad, removable for spur
32.00
8. MISCELLANEOUS SHOE ADDITIONS
L3500
Miscellaneous shoe addition, insole, leather
4.00
L3510
Miscellaneous shoe addition, insole, rubber
8.00
L3520
Miscellaneous shoe additions, insole, felt covered
8.00
with leather
L3530
Miscellaneous shoe addition, sole, half
12.00
L3540
Miscellaneous shoe addition, sole, full
36.00
L3550
Miscellaneous shoe addition, toe tap, standard
4.00
L3560
Miscellaneous shoe addition, toe tap, horseshoe
6.40
L3570
Miscellaneous shoe addition, special extension to
152.00
instep (leather with eyelets)
L3580
Miscellaneous shoe addition, convert instep to
13.60
Velcro closure
L3590
Miscellaneous shoe addition, convert firm shoe
28.00
counter to soft counter
L3595
Miscellaneous shoe addition, March bar
12.00
9. TRANSFER OR REPLACEMENT
L3600
Transfer of an orthosis from one shoe to another,
48.00
caliper plate, existing
L3610
Transfer of an orthosis from one shoe to another,
76.00
caliper plate, new
L3620
Transfer of an orthosis from one shoe to another,
39.04
solid stirrup, existing
L3630
Transfer of an orthosis from one shoe to another,
76.00
solid stirrup, new
L3640
Transfer of an orthosis from one shoe to another,
28.00
Dennis Browne splint (Riveton), both shoes
L3649
Unlisted procedures for foot orthopedic shoes, shoe
B.R.
modifications and transfers
(f) ORTHOTIC DEVICES--UPPER LIMB (L3650-L3999)
Note: The procedures in this section are considered as "base" or "basic
procedures" and may be modified by listing procedures from the "additions"
sections and adding them to the base procedure.
1. UPPER LIMB: SHOULDER
L3650
Shoulder orthosis, (SO), figure of "8" design
32.00
abduction restrainer
L3660
SO, figure of "8" design abduction restrainer,
60.00
canvas and webbing
L3670
SO, acromion/clavicular (canvas and webbing type)
88.62
L3671
Shoulder orthosis, shoulder cap design, without
507.32
joints, may include soft interface, straps, custom
fabricated, includes fitting and adjustment
L3672
Shoulder orthosis, abduction positioning (airplane
630.88
design), thoracic component and support bar, without
joints, may include soft interface, straps, custom
fabricated, includes fitting and adjustment
L3673
Shoulder orthosis, abduction positioning (airplane
687.58
design), thoracic component and support bar, includes
non torsion joint/turnbuckle, may include soft
interface, straps, custom fabricated, includes fitting
and adjustment
L3675
Shoulder orthosis, (SO); vest type abduction
85.92
restrainer, canvas webbing type, or equal
L3677
Hard plastic, shoulder stabilizer, prefabricated,
B.R.
includes fitting and adjustment
2. UPPER LIMB: ELBOW
L3702
Elbow orthosis (EO), without joints, may include
162.57
soft interface, straps, custom fabricated, includes
fitting and adjustment
L3710
EO, elastic with metal joints
60.00
L3720
EO, double upright with forearm/arm cuffs, free
520.00
motion
L3730
EO, double upright with forearm/arm cuffs,
617.71
extension/flexion assist
L3740
EO, double upright with forearm/arm cuffs,
692.08
adjustable position with lock with active control
L3760
Elbow orthosis (EO), with adjustable position
272.89
locking joint(s), prefabricated, includes fitting and
adjustment
L3762
Elbow orthosis, rigid, without joints, includes
61.51
soft interface material prefabricated, includes
fitting and adjustment
3. UPPER LIMB: WRIST-HAND-FINGER
L3763
Elbow wrist hand orthosis; rigid, without joints,
433.83
may include soft interface, straps, custom fabricated,
includes fitting and adjustment
L3764
Elbow wrist hand orthosis; includes one or more
545.99
nontorsion joints, elastic bands, turnbuckles, may
include soft interface, straps, custom fabricated,
includes fitting and adjustment
L3765
Elbow wrist hand finger orthosis, rigid without
721.91
joints, may include soft interface, straps, custom
fabricated, includes fitting and adjustment
L3766
Elbow wrist hand finger orthosis, includes one or
764.45
more nontorsion joints, elastic bands, turnbuckles,
may include soft interface, straps, custom fabricated,
includes fitting and adjustment
L3806
Wrist-hand-finger-orthoses (WHFO); includes one or
255.75
more nontorsion joint(s), turnbuckles, elastic
bands/springs, may include soft interface material,
straps, custom fabricated, includes fitting and
adjustment
L3807
WHFO, extension assist, with inflatable Palmer Air
135.08
support, with or without thumb extension
L3808
Wrist-hand-finger-orthoses (WHFO); rigid without
228.44
joints, may include soft interface material; straps,
custom fabricated, includes fitting and adjustment
4. ADDITIONS
L3891
Addition to upper extremity joint, wrist or elbow,
B.R.
concentric adjustable torsion style mechanism for
custom fabricated orthotics only, each
5. DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/FLEXION,
FINGER FLEXION/EXTENSION
L3900
WHFO, dynamic flexor hinge; reciprocal wrist
800.00
extension/flexion, finger flexion/extension, wrist or
finger driven
L3901
WHFO, dynamic flexor hinge; reciprocal wrist
884.00
extension/flexion, finger flexion/extension, cable
driven
6. EXTERNAL POWER
L3904
WHFO, external powered, electric
369.00
L3905
Wrist hand orthosis, includes one or more
558.35
nontorsion joints, elastic bands, turnbuckles, may
include soft interface, straps, custom fabricated,
includes fitting and adjustment
7. OTHER WRIST-HAND-FINGER ORTHOSES--CUSTOM FITTED
L3906
WHFO, wrist gauntlet, molded to patient model
267.41
L3908
WHFO, wrist extension control cock-up, non-molded
50.13
L3911
Wrist hand finger orthosis, elastic, prefabricated,
B.R.
includes fitting and adjustment (for example,
neoprene, lycra)
L3912
WHFO, flexion glove with elastic finger control
67.25
L3913
Hand finger orthosis, without joints, may include
152.49
soft interface, straps, custom fabricated, includes
fitting and adjustment
L3915
Wrist-hand orthosis, includes one or more
299.27
nontorsion joint(s), elastic bands, turnbuckles, may
include soft interface straps, prefabricated, includes
fitting and adjustment
L3917
Hand orthosis, metacarpal fracture orthosis,
22.26
prefabricated, includes fitting and adjustment
8. UPPER LIMB: SHOULDER-ELBOW-WRIST-HAND ABDUCTION
POSITIONING--CUSTOM FITTED
L3960
Shoulder-elbow-wrist-hand orthosis (SEWHO),
460.00
abduction positioning, airplane design
L3961
SEWHO, shoulder cap design, without joints, may
945.92
include soft interface, straps, custom fabricated,
includes fitting and adjustment
L3962
SEWHO, abduction positioning, Erbs Palsey design
420.00
L3963
SEWHO, molded shoulder, arm, forearm, and wrist,
847.70
with articulating elbow joint
L3964
SEWHO, mobile arm support attached to wheelchair,
520.00
balanced and fitted to patient, adjustable
L3965
SEWHO, radial arm support attached to wheelchair,
759.66
balanced and fitted to patient, adjustable rancho type
L3966
SEWHO, mobile arm support attached to wheelchair,
488.00
balanced and fitted to patient, reclining
L3967
SEWHO, abduction positioning (airplane design),
1,116.82
thoracic component and support bar, without joints,
may include soft interface, straps, custom fabricated,
includes fitting and adjustment
L3968
SEWHO, mobile arm support attached to wheelchair,
680.00
balanced and fitted to patient, friction arm support
(friction dampening to proximal and distal joints)
L3969
SEWHO, mobile arm support, monosuspension arm and
417.06
hand support, overhead elbow forearm hand sling
support, yoke type arm suspension support
9. ADDITIONS TO MOBILE ARM SUPPORTS
L3970
SEWHO, addition to mobile arm support, elevating
200.00
proximal arm
L3971
SEWHO, shoulder cap design, includes one or more
1,060.12
nontorsion joints, elastic bands, turnbuckles, may
include soft interface, straps, custom fabricated,
includes fitting and adjustment
L3972
SEWHO, addition to mobile arm support, offset or
112.00
lateral rocker arm with elastic balance control
L3973
SEWHO, abduction positioning (airplane design),
1,116.82
thoracic component and support bar, includes one or
more nontorsion joints, elastic bands, turnbuckles,
may include soft interface, straps, custom fabricated,
includes fitting and adjustment
L3974
SEWHO, addition to mobile arm support, supinator
112.00
L3975
SEWHO, without joints, may include soft interface,
945.92
straps, custom fabricated, includes fitting and
adjustment
L3976
SEWHO, abduction positioning (airplane design),
945.92
thoracic component and support bar, without joints,
may include soft interface, straps, custom fabricated,
includes fitting and adjustment
L3977
SEWHO, shoulder cap design, includes one or more
1,060.12
nontorsion joints, elastic bands, turnbuckles, may
include soft interface, straps, custom fabricated,
includes fitting and adjustment
L3978
SEWHO, abduction positioning (airplane design),
1,116.82
thoracic component and support bar, includes one or
more nontorsion joints, elastic bands, turnbuckles,
may include soft interface, straps, custom fabricated,
includes fitting and adjustment
10. UPPER LIMB--FRACTURE ORTHOSIS
L3980
Upper extremity fracture orthosis, humeral
163.17
L3982
Upper extremity fracture orthosis, radius/ulnar
172.00
L3984
Upper extremity fracture orthosis, wrist
122.40
L3995
Addition to upper extremity orthosis, sock,
14.80
fracture or equal, each
L3999
Unlisted procedures for upper limb orthosis
B.R.
(g) SPECIFIC REPAIR (L4000-L4199)
L4000
Replace girdle for Milwaukee orthosis
696.00
L4002
Replacement strap, any orthosis, includes all
18.00
components, any length, any type
L4010
Replace trilateral socket brim
444.59
L4020
Replace quadrilateral socket brim, molded to
532.00
patient model
L4030
Replace quadrilateral socket brim, custom fitted
373.06
L4040
Replace molded thigh lacer
272.53
L4045
Replace nonmolded thigh lacer
140.00
L4050
Replace molded calf lacer
331.80
L4055
Replace nonmolded calf lacer
61.02
L4060
Replace high roll cuff
136.00
L4070
Replace proximal and distal upright for KAFO
168.00
L4080
Replace metal bands KAFO, proximal thigh
72.00
L4090
Replace metal bands KAFO-AFO, calf or distal thigh
60.00
L4100
Replace leather cuff KAFO, proximal thigh
80.00
L4110
Replace leather cuff KAFO-AFO, calf or distal thigh
52.00
L4130
Replace pretibial shell
331.45
(h) REPAIRS (L4200-L4299)
L4205
Repair of orthotic device, quarter-hour rate
10.60
L4210
Repair of orthotic device, repair or replace minor
69.00
parts
(i) ANCILLARY ORTHOTIC SERVICES (L4300-L4399 AND X3680)
L4350
Pneumatic ankle control splint (for example,
52.00
aircast)
L4360
Pneumatic walking splint (for example, aircast)
160.00
L4370
Pneumatic full leg splint (for example, aircast)
88.00
L4380
Pneumatic knee splint (for example, aircast)
56.00
L4386
Non-pneumatic walking splint, with or without
99.66
joints, prefabricated, includes fitting and adjustment
L4392
Replace soft interface material, ankle contracture
13.56
splint
L4394
Replace soft interface material, foot drop splint
9.90
L4396
Ankle contracture splint
96.67
L4398
Foot drop splint, recumbent positioning device
44.52
X3680
Travel time per round trip, per day
40.72