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 10:55-2.4 - HCPCS Procedure Codes and Maximum Fee Allowance Schedule for Prosthetic Services

Current through Register Vol. 56, No. 14, July 15, 2024
HCPCS
Description
Maximum
Code
Fee
Allowance $
(a) PROSTHETIC PROCEDURES--LOWER LIMB (L5000-L5999)
The procedures in this section are considered as "base" or "basic
procedures" and may be modified by listing items/procedures or special
material from the "additions" section and adding them to the base procedure.
1. PARTIAL FOOT
L5000
Partial foot, shoe insert with longitudinal arch,
339.53
toe filler
L5010
Partial foot, molded socket, ankle height, with
680.00
toe filler
L5020
Partial foot, molded socket, tibial tubercle
1,040.00
height, with toe filler
2. ANKLE
L5050
Ankle, Syme, molded socket, Sach foot
1,360.00
L5060
Ankle, Syme, metal frame, molded leather socket,
2,000.00
articulated ankle/foot
3. BELOW KNEE
L5100
Below knee, molded socket, shin, Sach foot
1,036.56
L5105
Below knee, plastic socket, joints and thigh
2,000.00
lacer, Sach foot
4. KNEE DISARTICULATION
L5150
Knee disarticulation (or through knee), molded
2,500.00
socket, external knee joints, shin, Sach foot
L5160
Knee disarticulation (or through knee), molded
2,683.30
socket, bent knee configuration, external knee
joints, shin, Sach foot
5. ABOVE KNEE
L5200
Above knee, molded socket, single axis constant
1,301.76
friction knee, shin, Sach foot
L5210
Above knee, short prosthesis, no knee joint
1,360.00
("stubbies"), with foot blocks, no ankle joints, each
L5220
Above knee, short prosthesis, no knee joint
1,680.00
("stubbies"), with articulated ankle/foot,
dynamically aligned, each
L5230
Above knee, for proximal femoral focal deficiency,
1,607.20
constant friction knee, shin, Sach foot
6. HIP DISARTICULATION
L5250
Hip disarticulation, Canadian type; molded socket,
3,040.00
hip joint, single axis constant friction knee, shin
Sach foot
L5270
Hip disarticulation, tilt table type, molded
3,040.00
socket, locking hip joint, single axis constant
friction knee, shin, Sach foot
7. HEMIPELVECTOMY
L5280
Hemipelvectomy, Canadian type; molded socket, hip
3,440.00
joint, single axis constant friction knee, shin, Sach
foot
8. ENDOSKELETAL: BELOW KNEE
L5301
Below knee, molded socket, shin, each foot
1,379.04
endoskeletal system
9. ENDOSKELETAL: KNEE DISARTICULATION
L5311
Knee disarticulation (or through knee), molded
2,129.46
socket, external knee joints, shin, Sach foot,
endoskeletal system
10. ENDOSKELETAL: ABOVE KNEE
L5321
Above knee, molded socket, open end, Sach foot,
2,085.72
endoskeletal system, single axis knee
11. ENDOSKELETAL: HIP DISARTICULATION
L5331
Hip disarticulation, Canadian type, molded socket,
2,951.37
endoskeletal system, hip joint, single axis knee,
each foot
12. ENDOSKELETAL: HEMIPELVECTOMY
L5341
Hemipelvectomy, Canadian type, molded socket,
3,231.24
endoskeletal system, hip joint, single axis knee,
each foot
13. IMMEDIATE POSTSURGICAL OR EARLY FITTING PROCEDURES
L5400
Immediate postsurgical or early fitting,
844.78
application of initial rigid dressing, including
fitting, alignment, suspension, and one cast change,
below knee
L5410
Immediate postsurgical or early fitting,
328.42
application of initial rigid dressing, including
fitting, alignment and suspension, below knee, each
additional cast change and realignment
L5420
Immediate postsurgical or early fitting,
1,070.47
application of initial rigid dressing, including
fitting, alignment and suspension and one cast change
"AK" or knee disarticulation
L5430
Immediate postsurgical or early fitting,
461.40
application of initial rigid dressing, including
fitting, alignment and suspension, "AK" or knee
disarticulation, each additional cast change and
realignment
L5450
Immediate postsurgical or early fitting,
200.00
application of nonweight bearing rigid dressing,
below knee
L5460
Immediate postsurgical or early fitting,
240.00
application of nonweight bearing rigid dressing,
above knee
14. INITIAL PROSTHESIS
L5500
Initial, below knee "PTB" type socket, "USMC" or
726.60
equal pylon, no cover, Sach foot, plaster socket,
direct formed
L5505
Initial, above knee--knee disarticulation, ischial
980.00
level socket, "USMC" or equal pylon, no cover, Sach
foot plaster socket, direct formed
15. PREPARATORY PROSTHESIS
L5510
Preparatory, below knee "PTB" type socket, "USMC"
726.60
or equal pylon, no cover, Sach foot, plaster socket,
molded to model
L5520
Preparatory, below knee "PTB" type socket, "USMC"
960.00
or equal pylon, no cover, Sach foot, thermoplastic or
equal, direct formed
L5530
Preparatory, below knee "PTB" type socket, "USMC"
1,120.00
or equal pylon, no cover, Sach foot, thermoplastic or
equal, molded to model
L5535
Preparatory, below knee "PTB" type socket, "USMC"
1,000.00
or equal pylon, no cover, Sach foot, prefabricated,
adjustable open end socket
L5540
Preparatory, below knee "PTB" type socket, "USMC"
1,146.60
or equal pylon, no cover, Sach foot, laminated
socket, molded to model
L5560
Preparatory, above knee--knee disarticulation,
1,120.00
ischial level socket, "USMC" or equal pylon, no
cover, Sach foot, plaster socket, molded to model
L5570
Preparatory, above knee--knee disarticulation,
1,200.00
ischial level socket, "USMC" or equal pylon, no
cover, Sach foot, thermoplastic or equal, direct
formed
L5580
Preparatory, above knee--knee disarticulation,
1,320.00
ischial level socket, "USMC" or equal pylon, no cover
Sach foot, thermoplastic or equal, molded to model
L5585
Preparatory, above knee--knee disarticulation,
1,248.88
ischial level socket, "USMC" or equal pylon, no
cover, Sach foot, prefabricated adjustable open end
socket
L5590
Preparatory, above knee--knee disarticulation,
1,499.40
ischial level socket, "USMC" or equal pylon, no
cover, Sach foot, laminated socket, molded to model
L5595
Preparatory, hip disarticulation-hemipelvectomy,
2,120.00
pylon, no cover, Sach foot, thermoplastic or equal,
molded to patient model
16. ADDITIONS TO LOWER EXTREMITY
L5600
Preparatory, hip disarticulation-hemipelvectomy,
2,240.00
pylon, no cover, Sach foot, laminated socket, molded
to patient model
L5610
Addition to lower extremity, above knee,
1,454.31
hydracadence system
L5611
Addition to lower extremity, above knee--knee
768.00
disarticulation, 4-bar linkage, with friction swing
phase control
L5613
Addition to lower extremity, above knee--knee
1,240.00
disarticulation, 4-bar linkage, with hydraulic swing
phase control
L5614
Addition to lower extremity, above knee--knee
2,307.16
disarticulation, 4-bar linkage, with pneumatic swing
phase control
L5616
Additions to lower extremity, above knee,
720.00
universal multiplex system, friction swing phase
control
L5617
Addition to lower extremity, quick self-aligning
320.52
unit, above knee or below knee, each
17. ADDITIONS: TEST SOCKETS
L5618
Addition to lower extremity, test socket, Symes
160.00
L5620
Addition to lower extremity, test socket, below
208.63
knee
L5622
Addition to lower extremity, test socket, knee
264.00
disarticulation
L5624
Addition to lower extremity, test socket, above
240.00
knee
L5626
Addition to lower extremity, test socket, hip
300.00
disarticulation
L5628
Addition to lower extremity, test socket,
340.00
hemipelvectomy
L5629
Addition to lower extremity, below knee, acrylic
289.07
socket
18. ADDITIONS: SOCKET VARIATIONS
L5630
Addition to lower extremity, Symes type,
280.00
expandable wall socket
L5631
Addition to lower extremity, above knee or knee
320.00
disarticulation, acrylic socket
L5632
Addition to lower extremity, Symes type, "PTB"
180.02
brim design socket
L5634
Addition to lower extremity, Symes type, posterior
231.74
opening (Canadian) socket
L5636
Addition to lower extremity, Symes type, medial
196.85
opening socket
L5637
Addition to lower extremity, below knee, total
160.00
contact
L5638
Addition to lower extremity, below knee, leather
320.00
socket
L5639
Addition to lower extremity, below knee, wood
600.00
socket
L5640
Addition to lower extremity, knee disarticulation,
400.00
leather socket
L5642
Addition to lower extremity, above knee, leather
400.00
socket
L5643
Addition to lower extremity, hip disarticulation,
691.20
flexible inner socket, external frame
L5644
Addition to lower extremity, above knee, wood
400.00
socket
L5645
Addition to lower extremity, below knee, flexible
325.44
inner socket, external frame
L5646
Addition to lower extremity, below knee, air
260.00
cushion socket
L5647
Addition to lower extremity, below knee, suction
223.74
socket
L5648
Addition to lower extremity, above knee, air
300.00
cushion socket
L5649
Addition to lower extremity, ischial
1,354.99
containment/narrow M-L socket
L5650
Addition to lower extremity, total contact, above
354.91
knee or knee disarticulation socket
L5651
Addition to lower extremity, above knee, flexible
528.84
inner socket, external frame
L5652
Addition to lower extremity, suction suspension,
310.53
above knee or knee disarticulation socket
L5653
Addition to lower extremity, knee disarticulation,
408.96
expandable wall socket
19. ADDITIONS SOCKET INSERT AND SUSPENSION
L5654
Addition to lower extremity, socket insert, Symes
231.71
(Kemblo, Pelite, Aliplast, Plastazote or equal)
L5655
Addition to lower extremity, socket insert, below
184.80
knee (Kemblo, Pelite, Aliplast, Plastazote or equal)
L5656
Addition to lower extremity, socket insert, knee
273.00
disarticulation (Kemblo, Pelite, Aliplast, Plastazote
or equal)
L5658
Addition to lower extremity, socket insert, above
259.38
knee (Kemblo, Pelite, Aliplast, Plastazote or equal)
L5661
Addition to lower extremity, socket insert,
438.84
multi-durometer, Symes
L5665
Addition to lower extremity, socket insert,
223.74
multidurometer, below knee
L5666
Addition to lower extremity, below knee, cuff
40.72
suspension
L5668
Addition to lower extremity, below knee, molded
77.53
distal cushion
L5670
Addition to lower extremity, below knee, molded
199.00
supracondylar suspension ("PTS" or similar)
L5671
Addition to lower extremity: below knee, molded
315.64
supracondylar suspension ("PTS" or similar)
L5672
Addition to lower extremity, below knee, removable
220.00
medial brim suspension
L5673
Addition to lower extremity, below knee/above
506.15
knee, custom fabricated from existing mold or
prefabricated, socket insert, silicone gel,
elastomeric or equal, for use with locking mechanisms
L5676
Addition to lower extremity, below knee, knee
178.96
joints, single axis, pair
L5677
Addition to lower extremity, below knee, knee
203.40
joints, polycentric, pair
L5678
Addition to lower extremity, below knee joint
20.00
covers, pair
L5679
Addition to lower extremity, below knee/above
421.77
knee, custom fabricated from existing mold or
prefabricated, socket insert, silicone gel,
elastomeric or equal, not for use with locking
mechanism
L5680
Addition to lower extremity, below knee, thigh
172.88
lacer, nonmolded
L5681
Addition to lower extremity, below knee/above
828.47
knee, custom fabricated socket insert for congenital
or atypical traumatic amputee, silicone gel
elastomeric or equal, for use with or without locking
mechanism, initial only (for other than initial, use
code L5673 or L5679)
L5682
Addition to lower extremity, below knee, thigh
420.00
lacer, gluteal/ischial, molded
L5683
Addition to lower extremity, below knee/above
828.47
knee, custom fabricated socket insert for other than
congenital or atypical traumatic amputee, silicone
gel elastomeric or equal, for use with or without
locking mechanism, initial only (for other than
initial, use code L5673 or L5679)
L5684
Addition to lower extremity, below knee, fork
32.56
strap
L5685
Addition to lower extremity prosthesis, below
79.39
knee, suspension/sealing sleeve, with or without
valve, any material, each
L5686
Addition to lower extremity, below knee, back
32.00
check (extension control)
L5688
Addition to lower extremity, below knee, waist
40.72
belt, webbing
L5690
Addition to lower extremity, below knee, waist
71.62
belt, padded and lined
L5692
Addition to lower extremity, above knee, pelvic
69.20
control belt, light
L5694
Addition to lower extremity, above knee, pelvic
125.53
control belt, padded and lined
L5695
Addition to lower extremity, below knee, pelvic
100.00
control, sleeve suspension, neoprene or equal, Sach
L5696
Addition to lower extremity, above knee or knee
140.00
disarticulation, pelvic joint
L5697
Addition to lower extremity, above knee or knee
32.56
disarticulation, pelvic band
L5698
Addition to lower extremity, above knee or knee
72.40
disarticulation, silesian bandage
L5699
All lower extremity prostheses, shoulder harness
113.40
20. REPLACEMENTS/ADDITIONS: EXOSKELETAL KNEE-SHIN SYSTEM
L5700
Replacement, socket, below knee, molded to patient
1,549.30
model
L5701
Replacement, socket, above knee-knee
1,922.04
disarticulation, including attachment plate, molded
to patient model
L5702
Replacement, socket, hip disarticulation,
2,422.44
including hip joint, molded to patient model
L5703
Ankle, symes, molded to patient model, socket
1,468.67
without solid ankle cushion heel (Sach) foot,
replacement only
L5704
Replacement, custom shaped protective cover, below
315.89
knee
L5705
Replacement, custom shaped protective cover, above
579.14
knee
L5706
Replacement, custom shaped protective cover, knee
564.88
disarticulation
L5707
Replacement, custom shaped protective cover, hip
758.92
disarticulation
L5710
Addition, exoskeletal knee-shin system, single
174.96
axis, manual lock
L5711
Addition, exoskeletal knee-shin system, single
284.80
axis, manual lock, ultra-light material
L5712
Addition, exoskeletal knee-shin system, single
252.00
axis, friction swing and stance phase control (safety
knee)
L5714
Addition, exoskeletal knee-shin system, single
280.00
axis, variable friction swing phase control (safety
knee)
L5716
Addition, exoskeletal knee-shin system,
420.00
polycentric, mechanical stance phase lock
L5718
Addition, exoskeletal knee-shin system,
420.00
polycentric, friction swing and stance phase control
L5722
Addition, exoskeletal knee-shin system, single
633.19
axis, pneumatic swing, friction stance phase control
L5724
Addition, exoskeletal knee-shin system, single
880.00
axis, fluid swing phase control
L5726
Addition, exoskeletal knee-shin system, single
1,000.00
axis, external joints fluid swing phase control
L5728
Addition, exoskeletal knee-shin system, single
1,540.00
axis, fluid swing and stance phase control
L5780
Addition, exoskeletal knee-shin system, single
600.00
axis, pneumatic/hydra pneumatic swing phase control
L5781
Addition to lower limb prosthesis, vacuum pump,
2,520.06
residual limb volume management and moisture
evacuation system
L5782
Addition to lower limb prosthesis, vacuum pump,
B.R.
residual limb volume management and moisture
evacuation system, heavy duty
21. COMPONENT MODIFICATION
L5785
Addition, exoskeletal system, below knee,
203.40
ultra-light material (titanium, carbon fiber or
equal)
L5790
Addition, exoskeletal system, above knee,
305.10
ultra-light material (titanium, carbon fiber or
equal)
L5795
Addition, exoskeletal system, hip disarticulation,
406.80
ultra-light material (titanium, carbon fiber or
equal)
22. ENDOSKELETAL
L5810
Addition, endoskeletal knee-shin system, single
264.62
axis, manual lock
L5811
Addition, endoskeletal knee-shin system, single
325.44
axis, manual lock, ultra-light material
L5812
Addition, endoskeletal knee-shin system, single
284.80
axis, friction swing and stance phase control (safety
knee)
L5814
Addition, endoskeletal knee-shin system,
400.00
polycentric; hydraulic swing phase control,
mechanical stance phase lock
L5816
Addition, endoskeletal knee-shin system,
386.46
polycentric, mechanical stance phase lock
L5818
Addition, endoskeletal knee-shin system,
552.00
polycentric, friction swing and stance phase control
L5822
Addition, endoskeletal knee-shin system, single
1,120.00
axis, pneumatic swing, friction stance phase control
L5824
Addition, endoskeletal knee-shin system, single
610.20
axis, fluid swing phase control
L5826
Addition, endoskeletal knee-shin system, single
B.R.
axis; hydraulic swing phase control, with miniature
high activity frame.
L5828
Addition, endoskeletal knee-shin system, single
1,440.00
axis, fluid swing and stance phase control
L5830
Addition, endoskeletal knee-shin system, single
1,076.00
axis, pneumatic/swing phase control
L5840
Addition, endoskeletal knee-shin system,
1,262.80
multi-axial, pneumatic/swing phase control
L5845
Addition, endoskeletal, knee-shin system, stance
2,211.66
flexion feature, adjustable
L5848
Addition to endoskeletal, knee-shin system,
677.28
hydraulic stance extension, dampening feature,
adjustable
L5850
Addition, endoskeletal system, above knee or hip
64.80
disarticulation, knee extension assist
L5855
Addition, endoskeletal system, hip
171.52
disarticulation, mechanical hip extension assist
L5856
Addition to lower extremity prosthesis,
15,188.22
endoskeletal knee-shin system, microprocessor control
feature, swing and stance phase includes electronic
sensor(s), any type
L5857
Addition to lower extremity prosthesis,
5,347.34
endoskeletal knee-shin system, microprocessor control
feature, swing phase only, includes electronic
sensor(s), any type
L5858
Addition to lower extremity prosthesis,
11,519.80
endoskeletal knee shin system, microprocessor control
feature, stance phase only, includes electronic
sensor(s), any type
L5910
Addition, endoskeletal system, below knee,
280.25
alignable system
L5920
Addition, endoskeletal system, above knee or hip
252.00
disarticulation, alignable system
L5925
Addition, endoskeletal system, above knee, knee
186.61
disarticulation or hip disarticulation, manual lock
L5930
Addition, endoskeletal system, high activity knee
1,928.18
control frame
L5940
Addition, endoskeletal system, below knee,
224.00
ultra-light material (titanium, carbon fiber or
equal)
L5950
Addition, endoskeletal system, above knee,
500.00
ultra-light material (titanium, carbon fiber or
equal)
L5960
Addition, endoskeletal system, hip
467.82
disarticulation, ultra-light material (titanium,
carbon fiber or equal)
L5962
Addition, endoskeletal system, below knee,
326.45
flexible protective outer surface covering system
L5964
Addition, endoskeletal system, above knee,
566.20
flexible protective outer surface covering system
L5966
Addition, endoskeletal system, hip
729.36
disarticulation, flexible protective outer surface
covering system
L5968
All lower extremity prosthesis; ankle, multiaxial
1,958.73
shock absorbing system
L5970
All lower extremity prostheses, foot, external
78.40
keel, Sach foot
L5971
All lower extremity prosthesis, solid ankle
128.23
cushion heel (Sach) foot, replacement only
L5972
All lower extremity prostheses, flexible keel foot
122.40
(Safe, Sten, Bock Dynamic or equal)
L5974
All lower extremity prostheses, foot, single axis
109.60
ankle/foot
L5975
All lower extremity prosthesis; combination single
249.89
axis ankle and flexible kneel foot
L5976
All lower extremity prostheses, energy storing
284.80
foot (Seattle Carbon Copy II or equal)
L5978
All lower extremity prostheses, foot, multi-axial
135.20
ankle/foot
L5979
All lower extremity prostheses, multi-axial
1,267.27
ankle/foot, dynamic response
L5980
All lower extremity prostheses, flex-foot system
2,033.60
L5981
All lower extremity prostheses, flex-walk system
1,723.48
or equal
L5982
All exoskeletal lower extremity prostheses, axial
406.40
rotation unit
L5984
All endoskeletal lower extremity prostheses, axial
304.80
rotation unit
L5985
All endoskeletal lower extremity prostheses,
362.49
dynamic prosthetic pylon
L5986
All lower extremity prostheses, multi-axial
304.80
rotation unit ("MCP" or equal)
L5987
All lower extremity prostheses, shank foot system
4,152.19
with vertical loading pylon
L5988
All lower extremity prosthesis, combination
1,076.78
vertical shock and multiaxial rotation/torsional
force reducing pylon
L5990
Addition to lower extremity prosthesis; user
1,130.21
adjustable heel height
L5999
Unlisted procedures for lower extremity prosthesis
B.R.
(b) UPPER LIMB (L6000-L6699)
The procedures in L6000-L6699 are base procedures which may be modified
by listing procedures from the "additions" sections. The base procedures
include only standard friction wrist and control cable system, unless
otherwise specified.
1. PARTIAL HAND
L6000
Partial hand, Robin-aids, thumb remaining (or
924.32
equal)
L6010
Partial hand, Robin-aids, little and/or ring
1,000.00
finger remaining (or equal)
L6020
Partial hand, Robin-aids, no finger remaining (or
953.27
equal)
L6025
Transcarpal/metacarpal or partial hand
5040.17
disarticulation prosthesis, external power,
self-suspended, inner socket with removable forearm
section, electrodes and cables, two batteries,
charger, myoelectric control of terminal device
2. WRIST DISARTICULATION
L6050
Wrist disarticulation, molded socket, flexible
1,120.00
elbow hinges, triceps pad
L6055
Wrist disarticulation, molded socket with
1,287.00
expandable interface, flexible elbow hinges, triceps
pad
3. BELOW ELBOW
L6100
Below elbow, molded socket, flexible elbow hinge,
1,120.00
triceps pad
L6110
Below elbow, molded socket (Muenster or
1,420.00
Northwestern suspension types)
L6120
Below elbow, molded double wall split socket,
1,520.00
step-up hinges, half cuff
L6130
Below elbow, molded double wall split socket,
1,975.33
stump activated locking hinge, half cuff
4. ELBOW DISARTICULATION
L6200
Elbow disarticulation, molded socket, outside
1,504.00
locking hinge, forearm
L6205
Elbow disarticulation, molded socket with
2,522.40
expandable interface, outside locking hinges, forearm
5. ABOVE ELBOW
L6250
Above elbow, molded double wall socket, internal
1,760.00
locking elbow, forearm
6. SHOULDER DISARTICULATION
L6300
Shoulder disarticulation, molded socket, shoulder
2,120.00
bulkhead, humeral section, internal locking elbow
forearm
L6310
Shoulder disarticulation, passive restoration
1,840.00
(complete prosthesis)
L6320
Shoulder disarticulation, passive restoration
1,200.00
(shoulder cap only)
7. INTERSCAPULAR THORACIC
L6350
Interscapular thoracic, molded socket, shoulder
2,380.00
bulkhead, humeral section, internal locking elbow,
forearm
L6360
Interscapular thoracic, passive restoration
1,545.84
(complete prosthesis)
L6370
Interscapular thoracic, passive restoration
1,400.00
(shoulder cap only)
8. IMMEDIATE AND EARLY POST SURGICAL PROCEDURES
L6380
Immediate postsurgical or early fitting,
691.56
application of initial rigid dressing, including
fitting alignment and suspension of components, and
one cast change, wrist disarticulation or below elbow
L6382
Immediate postsurgical or early fitting,
813.60
application of initial rigid dressing, including
fitting alignment and suspension of components, and
one cast change, elbow disarticulation or above elbow
L6384
Immediate postsurgical or early fitting,
976.00
application of initial rigid dressing, including
fitting alignment and suspension of components, and
one cast change, shoulder disarticulation or
interscapular thoracic
L6386
Immediate postsurgical or early fitting, each
223.74
additional cast change and realignment
L6388
Immediate postsurgical or early fitting,
203.40
application of rigid dressing only
9. ENDOSKELETAL: BELOW ELBOW
L6400
Below elbow, molded socket, endoskeletal system,
1,204.00
including soft prosthetic tissue shaping
10. ENDOSKELETAL: ELBOW DISARTICULATION
L6450
Elbow disarticulation, molded socket, endoskeletal
1,301.60
system, including soft prosthetic tissue shaping
11. ENDOSKELETAL: ABOVE ELBOW
L6500
Above elbow, molded socket, endoskeletal system,
1,512.00
including soft prosthetic tissue shaping
12. ENDOSKELETAL: SHOULDER DISARTICULATION
L6550
Shoulder disarticulation, molded socket,
1,760.00
endoskeletal system, including soft prosthetic tissue
shaping
13. ENDOSKELETAL: INTERSCAPULAR THORACIC
L6570
Interscapular thoracic, molded socket,
2,160.00
endoskeletal system, including soft prosthetic tissue
shaping
L6580
Preparatory, wrist disarticulation or below elbow,
813.60
single wall plastic socket, friction wrist, flexible
elbow hinges, figure of eight harness, humeral cuff,
Bowen cable control, "USMC" or equal pylon, no cover,
molded to patient model
L6582
Preparatory, wrist disarticulation or below elbow,
691.56
single wall socket, friction wrist, flexible elbow
hinges, figure of eight harness, humeral cuff, Bowen
cable control, "USMC" or equal pylon, no cover,
direct formed
L6584
Preparatory, elbow disarticulation or above elbow,
1,159.38
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
L6586
Preparatory, elbow disarticulation or below elbow,
996.66
single wall socket, friction wrist, locking elbow,
figure of eight harness, humeral cuff, fair lead
cable control, "USMC" or equal pylon, no cover,
direct formed
L6588
Preparatory, shoulder disarticulation or
1,732.80
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
L6590
Preparatory, shoulder disarticulation or
1,586.40
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
14. ADDITIONS: UPPER LIMB
The following procedures/modifications/components may be added to other
base procedures. The items in this section should reflect the additional
complexity of each modification procedure, in addition to base procedure, at
the time of the original order.
L6600
Upper extremity additions, polycentric hinge, pair
52.00
L6605
Upper extremity additions, single pivot hinge,
116.00
pair
L6610
Upper extremity additions, flexible metal hinge,
46.00
pair
L6611
Addition to upper extremity prosthesis, external
255.21
powered, additional switch, any type
L6615
Upper extremity addition, disconnect locking wrist
60.00
unit
L6616
Upper extremity addition, additional disconnect
59.89
insert for locking wrist unit, each
L6620
Upper extremity addition, flexion-friction wrist
211.56
unit
L6621
Flexion/extension wrist with or without friction,
2,334.37
for use with external powered terminal device
L6623
Upper extremity addition, spring assisted
386.40
rotational wrist unit with latch release
L6624
Flexion/extension and rotation wrist unit
2,334.37
L6625
Upper extremity addition, rotation wrist unit with
160.00
cable lock
L6628
Upper extremity addition, quick disconnect hook
284.76
adapter, Otto Bock or equal
L6629
Upper extremity addition, quick disconnect
73.22
lamination collar with coupling piece, Otto Bock or
equal
L6630
Upper extremity addition, stainless steel, any
68.00
wrist
L6632
Upper extremity addition, latex suspension sleeve,
32.54
each
L6635
Upper extremity addition, lift assist for elbow
152.48
L6637
Upper extremity addition, nudge control elbow lock
251.68
L6638
Upper extremity addition to prosthesis, electric
1,575.48
locking feature, only for use with manually powered
elbow
L6640
Upper extremity additions, shoulder abduction
130.40
joint, pair
L6641
Upper extremity addition, excursion amplifier,
97.60
pulley type
L6642
Upper extremity addition, excursion amplifier,
138.40
lever type
L6645
Upper extremity addition, shoulder
65.00
flexion-abduction joint, each
L6646
Upper extremity addition, shoulder joint,
1,986.49
multipositional locking, flexion, adjustable
abduction friction control, for use with body powered
or external powered system
L6647
Upper extremity addition, shoulder lock mechanism,
327.03
body powered actuator
L6648
Upper extremity addition, shoulder lock mechanism,
2,048.78
external powered actuator
L6650
Upper extremity addition, shoulder universal
200.00
joint, each
L6655
Upper extremity addition, standard control cable,
35.00
extra
L6660
Upper extremity addition, heavy duty control cable
56.00
L6665
Upper extremity addition, Teflon, or equal, cable
24.00
lining
L6670
Upper extremity addition, hook to hand, cable
43.40
adapter
L6672
Upper extremity addition, harness, chest or
108.00
shoulder, saddle type
L6675
Upper extremity addition, harness, figure of ("8")
80.42
eight type, for single control
L6676
Upper extremity addition, harness, figure of ("8")
86.32
eight type, for dual control
L6677
Harness, triple control, simultaneous operation of
183.87
terminal device and elbow
L6680
Upper extremity addition, test socket, wrist
160.00
disarticulation or below elbow
L6682
Upper extremity addition, test socket, elbow
180.00
disarticulation or above elbow
L6684
Upper extremity addition, test socket, shoulder
148.00
disarticulation or interscapular thoracic
L6686
Upper extremity addition, suction socket
406.80
L6687
Upper extremity addition, frame type socket, below
244.08
elbow or wrist disarticulation
L6688
Upper extremity addition, frame type socket, above
284.76
elbow or elbow disarticulation
L6689
Upper extremity addition, frame type socket,
325.60
shoulder disarticulation
L6690
Upper extremity addition, frame type socket,
366.40
interscapular-thoracic
L6691
Upper extremity addition, removable insert, each
244.08
L6692
Upper extremity addition, silicone gel insert or
240.00
equal, each
L6693
Upper extremity additions; external locking elbow,
1,530.26
forearm counter balance
L6694
Addition to upper extremity prosthesis, below
421.90
elbow/above elbow, custom fabricated from existing
mold or prefabricated, socket insert, silicone gel,
elastomeric or equal, for use with locking mechanism
L6695
Addition to upper extremity prosthesis, below
elbow/above elbow, custom fabricated from existing
351.58
mold or prefabricated, socket insert, silicone gel,
elastomeric or equal, not for use with locking
mechanism
L6696
Addition to upper extremity prosthesis, below
815.32
elbow/above elbow, custom fabricated socket insert
for congenital or atypical traumatic amputee,
silicone gel, elastomeric or equal, for use with or
without locking mechanism, initial only (for other
than initial, use code L6694 or L6695)
L6697
Addition to upper extremity prosthesis, below
815.32
elbow/above elbow, custom fabricated socket insert
for other than congenital or atypical traumatic
amputee, silicone gel, elastomeric or equal, for use
with or without locking mechanism, initial only (for
other than initial, use code L6694 or L6695)
L6698
Addition to upper extremity prosthesis, below
314.06
elbow/above elbow, lock mechanism, excludes socket
insert
(c) TERMINAL DEVICES (L6700-L6899)
1. HOOKS
L6703
Terminal device, passive hand/mitt, any material,
273.68
any size
L6704
Terminal device, sport/recreational/work
370.47
attachment, any material, any size
L6706
Terminal device, hook, mechanical, voluntary
220.31
opening, any material, any size, lined or unlined
L6707
Terminal device, hook, mechanical, voluntary
865.54
closing, any material, any size, lined or unlined
L6708
Terminal device, hand, mechanical, voluntary
580.03
opening, any material, any size
L6709
Terminal device, hand, mechanical, voluntary
776.50
closing, any material, any size
L6711
Terminal device, hook, mechanical, voluntary
416.72
opening, any material, any size, lined or unlined,
pediatric
L6712
Terminal device, hook, mechanical, voluntary
767.27
closing, any material, any size, lined or unlined,
pediatric
L6713
Terminal device, hand, mechanical, voluntary
968.38
opening, any material, any size, pediatric
L6714
Terminal device, hand, mechanical, voluntary
820.20
closing, any material, any size, pediatric
L6721
Terminal device, hook or hand, heavy duty, size,
1,457.83
mechanical, voluntary opening, any material, any
lined or unlined
L6722
Terminal device, hook or hand, heavy duty,
1,256.77
mechanical, voluntary closing, any material, any
size, lined or unlined
L6810
Terminal device, pincher tool, Otto Bock or equal
104.24
2. HANDS
L6881
Automatic grasp feature, addition to upper limb
2,546.90
electric prosthetic terminal device
L6882
Microprocessor control feature, addition to upper
1,931.94
limb prosthetic terminal device (MCM:2133)
L6883
Replacement socket, below elbow/wrist
1,335.93
disarticulation, molded to patient model, for use
with or without external power
L6884
Replacement socket, above elbow/elbow with or
1,469.13
disarticulation, molded to patient model, for use
without external power
L6885
Replacement socket, shoulder
2,011.10
disarticulation/interscapular thoracic, molded to
patient model, for use with or without external power
3. GLOVES FOR ABOVE HANDS
L6890
Terminal device, glove for above hands,
84.00
production, glove
L6895
Terminal device, glove for above hands, custom
296.00
glove
(d) HAND RESTORATION (L6900-L6999)
L6900
Hand restoration (casts, shading and measurements
1,000.00
included), partial hand, with glove, thumb or one
finger remaining
L6905
Hand restoration (casts, shading and measurements
1,000.00
included), partial hand, with glove, multiple fingers
remaining)
L6910
Hand restoration (casts, shading and measurements
1,000.00
included), partial hand, with glove, no fingers
remaining
L6915
Hand restoration (shading and measurements
320.00
included), replacement glove for above
1. EXTERNAL POWER--BASE DEVICES
L6920
Wrist disarticulation, external power,
3,789.90
self-suspended inner socket, removable forearm shell,
Otto Bock or equal, switch, cables, two batteries and
one charger, switch control of terminal device
L6925
Wrist disarticulation, external power,
4,350.58
self-suspended inner socket, removable forearm shell,
Otto Bock or equal, electrodes, cables, two batteries
and one charger, myoelectronic control of terminal
device
L6930
Below elbow, external power, self-suspended inner
3,807.50
socket, removable forearm shell, Otto Bock or equal,
switch, cables, two batteries and one charger, switch
control of terminal device
L6935
Below elbow, external power, self-suspended inner
4,384.65
socket, removable forearm shell, Otto Bock or equal,
electrodes, cables, two batteries and one charger,
myoelectronic control of terminal device
L6940
Elbow disarticulation, external power, molded
5,210.69
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
L6945
Elbow disarticulation, external power, molded
5,780.01
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
L6950
Above elbow, external power, molded inner socket,
5,761.18
removable humeral shell, internal locking elbow
forearm, Otto Bock or equal, switch, cables, two
batteries and one charger, switch control of terminal
device
L6955
Above elbow, external power, molded inner socket,
6,850.89
removable humeral shell, internal locking elbow,
forearm, Otto Bock or equal, electrodes, cables, two
batteries and one charger, myoelectronic control of
terminal device
L6960
Shoulder disarticulation, external power, molded
6,950.69
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
L6965
Shoulder disarticulation, external power, molded
7,934.50
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
L6970
Interscapular-thoracic, external power, molded
8,475.55
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
L6975
Interscapular-thoracic, external power, molded
9,418.54
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
(e) EXTERNAL POWER--TERMINAL DEVICES (L7000-L7499)
L7008
Electric hand, switch or myoelectric controlled;
3,880.11
pediatric
L7009
Electric hook, switch or myoelectric controlled;
2,348.40
adult
L7040
Prehensile actuator, Hosmer or equal, switch
1,616.36
controlled
L7045
Electronic hook, child, Michigan or equal, switch
854.01
controlled
1. EXTERNAL POWER--ELBOW
L7170
Electronic elbow, Hosmer or equal, switch
3,238.90
controlled
L7180
Electronic elbow, Utah or equal, myoelectronically
19,382.46
controlled
L7181
Electronic elbow, microprocessor simultaneous
B.R.
control of elbow and terminal device
L7185
Electronic elbow, adolescent, Variety Village or
3,625.58
equal, switch controlled
L7186
Electronic elbow, child, Variety Village or equal,
4,800.00
switch controlled
L7190
Electronic elbow, adolescent, Variety Village or
5,177.71
equal, myoelectronically controlled
L7191
Electronic elbow, child, Variety Village or equal,
5,072.00
myoelectronically controlled
L7260
Electronic wrist rotator, Otto Bock or equal
1,342.44
L7261
Electronic wrist rotator, for Utah arm
2,000.62
L7266
Servo control, Steeper or equal
554.90
L7272
Analogue control, UNB or equal
1,216.24
L7274
Proportional control, 12 volt, Utah or equal
3,666.11
2. EXTERNAL POWER--BATTERY COMPONENTS
L7360
Six volt battery, Otto Bock or equal, each
167.90
L7362
Battery charger, six volt, Otto Bock or equal
150.23
L7364
Twelve volt battery, Utah or equal, each
296.74
L7366
Battery charger, twelve volt, Utah or equal
398.67
L7367
Lithium ion battery, replacement
245.20
L7368
Lithium ion battery charger
317.88
L7400
Addition to upper extremity prosthesis; below
189.97
elbow/wrist disarticulation, ultralight material
(titanium, carbon fiber or equal)
L7401
Above elbow disarticulation, ultralight material
212.67
(titanium, carbon fiber or equal)
L7402
Shoulder disarticulation/interscapular thoracic,
212.67
ultralight material (titanium, carbon fiber or equal)
L7403
Below elbow/wrist disarticulation, acrylic
228.26
material
L7404
Above elbow disarticulation, acrylic material
344.51
L7405
Shoulder disarticulation/interscapular thoracic,
450.58
acrylic material
L7499
Unlisted procedures for upper extremity prosthesis
B.R.
(f) REPAIRS (L7500-L7599 AND X3680-3690)
L7500
Repair of prosthetic device, hourly rate
40.72
L7510
Repair prosthetic device, repair or replace minor
B.R.
parts
X3680
Travel time per round trip, per day
40.72
(g) GENERAL (L8000-L8399)
1. BREAST PROSTHESES
L8000
Breast prosthesis, mastectomy bra
B.R.
L8001
Breast prosthesis, mastectomy bra, with integrated
B.R.
breast prosthesis form, unilateral (MCM: 2130.A)
L8002
Breast prosthesis, mastectomy bra, with integrated
102.72
breast prosthesis form, bilateral (MM:2130.A)
L8010
Breast prosthesis, mastectomy sleeve
40.56
L8015
External breast prosthesis garment, with
30.58
mastectomy form, post mastectomy
L8020
Breast prosthesis, mastectomy form
132.00
L8030
Breast prosthesis, silicone or equal
B.R.
L8035
Custom breast prosthesis, post mastectomy, molded
1,974.74
to patient model
L8039
Breast prosthesis; not otherwise specified
B.R.
2. TRUSSES
L8300
Truss, single with standard pad
51.28
L8310
Truss, double with standard pads
101.68
L8320
Truss, addition to standard pad, water pad
24.00
L8330
Truss, addition to standard pad, scrotal pad
33.65
(h) PROSTHETIC SOCKS (L8400-L8499)
L8400
Prosthetic sheath, below knee, each
12.00
L8410
Prosthetic sheath, above knee, each
12.00
L8415
Prosthetic sheath, upper limb, each
11.20
L8417
Prosthetic sheath/sock, including a gel cushion
59.09
layer, below knee or above knee, each
L8420
Prosthetic sock, wool, below knee, each
14.94
L8430
Prosthetic sock, wool, above knee, each
18.40
L8435
Prosthetic sock, wool, upper limb, each
8.14
L8440
Prosthetic shrinker, below knee, each
33.60
L8460
Prosthetic shrinker, above knee, each
41.60
L8465
Prosthetic shrinker, upper limb, each
33.60
L8470
Stump sock, single ply, fitting, below knee, each
2.52
L8480
Stump sock, single ply, fitting, above knee, each
2.52
L8485
Stump sock, single ply, fitting, upper limb, each
6.21
L8499
Unlisted procedure for miscellaneous prosthetic
B.R.
services
(i) HEAD (SKULL, FACIAL BONES AND TEMPEROMANDIBULAR JOINT)
L8619
Cochlear implant external speech processor,
replacement
B.R.
(j) MISCELLANEOUS
L7600
Prosthetic donning sleeve, any material, each
B.R.
L8470
Orthotic and prosthetic supply, accessory and/or
service component of another HCPCS "L" Code
B.R