New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 57 - PODIATRY SERVICES › Subchapter 3 - CENTERS FOR MEDICARE AND MEDICAID SERVICES CMS HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:57-3.3 - Descriptions of Level II Codes

Current through Register Vol. 56, No. 14, July 15, 2024
IND
HCPCS Code
Mod
Description
S
Maximum Fee Allowance $
NS
G0001
Routine venipuncture
1.80
1.80
QUALIFIER: This service is
reimbursable in the provider office
laboratory (POL) when the specimen
is referred out to an independent
clinical laboratory for testing.
Venipuncture is not reimbursable
when billed by the independent
clinical laboratory. It is
considered all inclusive as part of
the laboratory test.
G0127
Trimming dystrophic nails, 1-10
7.00
7.00
J0690
Injection, cefazolin sodium, (ancef, kefzol) up to 500 mg
2.83
2.83
J0696
Injection, ceftriaxone sodium, (rocephin) per 250 mg
12.97
12.97
J1100
Injection, dexamethasone sodium phosphate, up to 4 mg/ml
0.13
0.13
J1200
Injection, diphenhydramine HCl
0.55
0.55
(benedryl), up to 50 mg
L1902
AFO, ankle gauntlet, custom fitted
48.81
48.81
L1906
AFO, multiligaments ankle support
75.00
75.00
L1907
Ankle-foot-orthosis(AFO)
Supramalleolar with straps, with or
without interface/pads, custom
fabricated
353.71
353.71
L1930
AFO, custom fitted, plastic
156.80
156.80
L1940
AFO, molded to patient model,
plastic
387.94
387.94
L1951
AFO, Spiral, Institute of
Rehabilitative Medicine type,
Plastic or other material,
prefabricated, includes fitting and
adjustment
527.61
527.61
L1971
AFO, Plastic or other material with
ankle joint, prefabricated, includes
fitting and adjustment
294.64
294.64
L2108
AFO, fracture orthosis, tibial
569.60
569.60
fracture cast orthosis, molded to
patient model
L2112
AFO, fracture orthosis, tibial
244.08
244.08
fracture orthosis, custom fitted
L2114
AFO, fracture orthosis, tibial
321.37
321.37
fracture orthosis, semi-rigid custom
fitted
L2116
AFO, fracture orthosis, tibial
366.00
366.00
fracture orthosis, rigid custom
fitted
L3000
Foot insert, removable, molded to
140.00
140.00
patient model "UCB" type, Berkeley
shell, each
L3001
Foot insert, removable, molded to
76.00
76.00
patient model, Spenco, each
QUALIFIER: Custom Spenco Device
L3002
Foot insert, removable, molded to
76.00
76.00
patient model, Plastazote or equal,
each
L3003
Foot insert, removable, molded to
76.00
76.00
patient model, silicone gel, each
L3010
Foot insert, removable, molded to
76.00
76.00
patient model, longitudinal arch
support, each
QUALIFIER: Any Custom Leather/Metal
Device (Example: Schaeffer, Whitman)
L3020
Foot insert, removable, molded to
88.00
88.00
patient model, longitudinal/
metatarsal support, each
QUALIFIER: Any Custom Leather/Plastic
Device, Full Foot Only
L3030
Foot insert, removable, formed to
48.00
48.00
patient foot, each
QUALIFIER: Only Off-The Shelf Spenco
L3031
Foot, Insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each
80.34
80.34
L3040
Foot, arch support, removable,
29.60
29.60
premolded, longitudinal, each
QUALIFIER: Only Off-The Shelf
Plastazote
L3050
Foot, arch support, removable,
32.00
32.00
premolded, metatarsal, each
L3060
Foot, arch support, removable,
48.00
48.00
premolded, longitudinal/metatarsal,
each
L3070
Foot, arch support, nonremovable,
16.00
16.00
attached to shoe, longitudinal, each
L3080
Foot, arch support, nonremovable,
20.00
20.00
attached to shoe, metatarsal, each
L3090
Foot, arch support, nonremovable,
24.00
24.00
attached to shoe, longitudinal/
metatarsal, each
L3100
Hallus-Valgus night dynamic splint
20.00
20.00
L3140
Foot, rotation positioning device,
56.00
56.00
including shoe(s)
L3150
Foot, rotation positioning device,
60.00
60.00
without shoe(s)
L3170
Foot, plastic heel stabilizer
112.00
112.00
L3201
Orthopedic shoe, oxford with
48.00
48.00
supinator or pronator, infant
L3202
Orthopedic shoe, oxford with
48.00
48.00
supinator or pronator, child
L3203
Orthopedic shoe, oxford with
48.00
48.00
supinator or pronator, junior
L3204
Orthopedic shoe, hightop with
48.00
48.00
supinator or pronator, infant
L3206
Orthopedic shoe, hightop with
48.00
48.00
supinator or pronator, child
L3207
Orthopedic shoe, hightop with
48.00
48.00
supinator or pronator, junior
L3208
Surgical boot, each, infant
24.00
24.00
L3209
Surgical boot, each, child
24.00
24.00
L3211
Surgical boot, each, junior
24.00
24.00
L3212
Benesch boot, pair, infant
48.00
48.00
L3213
Benesch boot, pair, child
48.00
48.00
L3214
Benesch boot, pair, junior
48.00
48.00
L3215
Orthopedic footwear, woman's shoes, oxford
38.00
38.00
L3216
Orthopedic footwear, woman's shoes, depth inlay
50.00
50.00
L3217
Orthopedic footwear, woman's shoes, hightop, depth inlay
58.00
58.00
L3219
Orthopedic footwear, man's shoes, oxford
38.00
38.00
L3221
Orthopedic footwear, man's shoes, depth inlay
50.00
50.00
L3222
Orthopedic footwear, man's shoes, hightop, depth inlay
58.00
58.00
L3230
Orthopedic footwear, custom shoes, depth inlay
190.00
190.00
L3250
Orthopedic footwear, custom molded
shoe, removable inner mold,
prosthetic shoe, each
250.00
250.00
L3251
Foot, shoe molded to patient model,
280.00
280.00
silicone shoe, each
L3252
Foot, shoe molded to patient model,
Plastozote (or similar), custom
fabricated, each
256.00
256.00
L3253
Foot, molded shoe Plastazote (or
similar), custom fitted, each
112.00
112.00
L3254
Nonstandard size or width
20.00
20.00
L3255
Nonstandard size or length
20.00
20.00
L3257
Orthopedic footwear, additional
50.00
50.00
charge for split size
L3260
Ambulatory surgical boot, each
88.00
88.00
L3265
Plastazote sandal, each
56.00
56.00
L3300
Lift, elevation, heel, tapered to metatarsals, per inch
32.78
32.78
L3310
Lift, elevation, heel and
51.17
51.17
sole, neoprene, per inch
L3320
Lift, elevation, heel and sole, cork,
100.00
100.00
per inch
L3332
Lift, elevation, inside shoe,
44.00
44.00
tapered, up to one-half inch
L3334
Lift, elevation, heel, per inch
23.98
23.98
L3340
Heel wedge, Sach
10.40
10.40
L3350
Heel wedge
12.00
12.00
L3360
Sole wedge, outside sole
12.00
12.00
L3370
Sole wedge, between sole
14.40
14.40
L3380
Club foot wedge
12.00
12.00
L3390
Outflare wedge
16.00
16.00
L3400
Metatarsal bar wedge, rocker
16.00
16.00
L3410
Metatarsal bar wedge, between sole
16.00
16.00
L3420
Full sole and heel wedge, between sole
24.00
24.00
L3430
Heel, counter, plastic reinforced
24.00
24.00
L3440
Heel, counter, leather reinforced
24.00
24.00
L3450
Heel, Sach cushion type
64.00
64.00
L3455
Heel, new leather, standard
8.00
8.00
L3460
Heel, new rubber, standard
8.00
8.00
L3465
Heel, Thomas with wedge
20.00
20.00
L3470
Heel, Thomas extended to ball
24.00
24.00
L3480
Heel, pad and depression for spur
16.00
16.00
L3485
Heel, pad, removable for spur
32.00
32.00
L3500
Miscellaneous shoe addition, insole,
4.00
4.00
leather
L3510
Miscellaneous shoe addition, insole,
8.00
8.00
rubber
L3520
Miscellaneous shoe additions, insole,
8.00
8.00
felt covered with leather
L3530
Miscellaneous shoe addition, sole,
12.00
12.00
half
L3540
Miscellaneous shoe addition, sole,
36.00
36.00
full
L3550
Miscellaneous shoe addition, toe tap,
4.00
4.00
standard
L3560
Miscellaneous shoe addition, toe tap,
6.40
6.40
horseshoe
L3580
Miscellaneous shoe addition, convert
13.60
13.60
instep to Velcro closure
L3580
52
Velcro straps, attached to a pair of
14.00
14.00
shoes, per pair
L3649
52
Foot Casting
50.00
50.00
L3649
22
Foot, ankle casting
65.00
65.00
L3649
Orthopedic shoe, modification, addition or transfer, NOS
28.00
28.00
L4205
Repair of orthotic device, quarter-
hour rate
10.60
10.60
L5673
Addition to lower extremity, below
knee/above knee, custom fabricated
from existing mold or prefabricated
socket insert, silicone gel,
elastomeric or equal, for use with
locking mechanism
506.15
506.15
L5679
Addition to lower extremity, below
knee/above knee, custom fabricated
from existing mold or prefabricated
socket insert, silicone gel,
elastomeric or equal, not for use
with locking mechanism
421.77
421.77
L5681
Addition to lower extremity, below
knee/above 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 L5673 or L5679)
828.47
828.47
L5683
Addition to lower extremity, below
knee/above 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 L5673 or
L5679)
828.47
828.47
Q0112
All potassium hydroxide (KOH) preparations
0.10
0.10