016.06.06 Ark. Code R. 056

Current through Register Vol. 49, No. 9, September, 2024

Rule 016.06.06-056 - Prosthetics Provider Manual Update Transmittal # 85

242.121Food Thickeners, All Ages

Food thickeners, including "Thick-It," "Thick-It II," "Simply Thick," "Thick and Easy" and "Thik and Clear" are not subject to the $250 medical supply benefit limit.

The modifier NU must be used with the procedure code found in this section and when food thickeners are to be administered enterally, the modifier "BA" must be used in conjunction with the procedure code.

When food thickeners are billed, total units are to be calculated to the nearest full ounce. Partial units may not be rounded up. When a date span is billed, the product cannot be billed until the end date has elapsed.

The maximum number of units allowed for food thickeners is 16 units per date of service.

Procedure Code	M1	M2	TOS	Description
B4100	NU		H	Food thickener, administered orally, peroz.
B4100	NU	BA	H	Food thickener, administered enterally, peroz.

242.180Orthotic Appliances, All Ages

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP orNU.

Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS code "H" for individuals age 21 and older.

Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS code "H" for individuals age 21 and older.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.

Prior authorization requirements are shown under the heading PA. If prior authorization is needed for individuals age 21 and older, that information is indicated with a "Y" in the column; if not, an "N" is shown. When prior authorization is not applicable (for U21) that information is shown with an "N/A" in the column.

When codes are payable for all ages, "AN" is indicated in the column, "U21" is shown when the code is payable only for individuals underage 21 and "21+" is shown when the code is payable only for those individuals age 21 and older.

** This item is not a covered service for the diagnosis of Carpal Tunnel Syndrome prior to surgery.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Effective for dates of service on and after March 1, 2006, this procedure code does not require prior authorization; however, the beneficiary's medical condition must fall within the diagnosis range of 250.00 and 251.93.

Orthotic Appliances, All Ages (section 242.180)

Procedure Code	M1	M2	TOS	Description	All U21 21 +	PA 21 +	Payment Method
A5500"	NU		H	For diabetics only, fitting (including follow-up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe	21 +	N	Purchase
A5501"	NU		H	For diabetics only, fitting (including follow-up) custom preparation and supply of molded from cast(s) of patient's foot (custom molded shoe), per shoe	21 +	N	Purchase
A5503"	NU		H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe	21 +	N	Purchase
A5504"	NU		H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe	21 +	N	Purchase
A5505"	NU		H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe	21 +	N	Purchase
A5506"	NU		H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe	21 +	N	Purchase
A5507	NU		H	For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe	21 +	Y	Purchase
A5510"	NU		H	For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe	21 +	N	Purchase
A5512	NU		H	For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of % inch material of shore a 35 durometer of 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each	21 +	Y	Purchase
A5513	NU		H	For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of % inch material of shore a 35 durometerof 3/16 inch material of shore a 40 durometer (or higher), includes arch filler and other shaping material custom fabricated, each	21 +	Y	Purchase
L0100	NU EP		H 6	Cranial orthosis (helmet), with or without soft interface, molded to patient model	All	N	Purchase
L0110	NU EP		H 6	Cranial orthosis (helmet), with or without soft interface, non-molded	All	N	Purchase
L0120	NU EP		H 6	Cervical, flexible, nonadjustable (foam collar)	All	N	Purchase
L0130	NU EP		H 6	Cervical, flexible, thermoplastic collar, molded to patient	All	N	Purchase
L0140	NU EP		H 6	Cervical, semi-rigid, adjustable (plastic collar)	All	N	Purchase
L0150	NU EP		H 6	Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)	All	N	Purchase
L0160	NU EP		H 6	Cervical, semi-rigid wire frame occipital/mandibular support	All	N	Purchase
L0170	NU EP		H 6	Cervical, collar, molded to patient model	All	N	Purchase
L0172	NU EP		H 6	Cervical, collar, semi-rigid thermoplastic foam, two piece	All	N	Purchase
L0174	NU EP		H 6	Cervical, collar, semi-rigid thermoplastic foam, two piece with thoracic extension	All	N	Purchase
L0180	NU EP		H 6	Cervical, multiple post collar, occipital/mandibular supports, adjustable	All	N	Purchase
L0190	NU EP		H 6	Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi, Guilford, Taylor types)	All	N	Purchase
L0200	NU EP		H 6	Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension	All	N	Purchase
L0210	NU EP		H 6	Thoracic, rib belt	All	N	Purchase
L0220	NU EP		H 6	Thoracic, rib belt, custom fabricated	All	N	Purchase
L0450	NU EP		H 6	TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustment	All	N	Purchase
L0452	NU EP		H 6	TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated	All	N	Purchase
L0454	NU EP		H 6	TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustment	All	N	Purchase
L0456	NU EP		H 6	TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0458	NU EP		H 6	TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0460	NU EP		H 6	TLSO, triplanar control modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0462	NU EP		H 6	TLSO, triplanar control modular segmented spinal system, three rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0464	NU EP		H 6	TLSO, triplanar control modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0466	NU EP		H 6	TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0468	NU EP		H 6	TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0470	NU EP		H 6	TLSO, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal and transverse planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0472	NU EP		H 6	TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal) posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	N	Purchase
L0474	NU EP		H 6	TLSO, triplanar control, rigid posterior frame with multiple straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal and transverse planes, produces intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0480	NU EP		H 6	TLSO, triplanar control, one-piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	All	Y	Purchase
L0482	NU EP		H 6	TLSO, triplanar control, one-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	All	Y	Purchase
L0484	NU EP		H 6	TLSO, triplanar control, two-piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	All	Y	Purchase
L0486	NU EP		H 6	TLSO, triplanar control, two-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	All	Y	Purchase
L0488	NU EP		H 6	TLSO, triplanar control, one-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0490	NU EP		H 6	TLSO, sagittal-coronal control, one-piece rigid plastic shell with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0621	NU EP		H 6	SO, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0622	NU EP		H 6	SO, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated	All	N	Purchase
L0623	NU EP		H 6	SO, flexible, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0624	NU EP		H 6	SO, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated	All	N	Manually Priced
L0625	NU EP		H 6	LO, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, includes fitting and adjustment	All	N	Purchase
L0626	NU EP		H 6	LO, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0627	NU EP		H 6	LO, sagittal control, with rigid anterior and posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0628	NU EP		H 6	LSO, flexible, provides lumbosacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0629	NU EP		H 6	LSO, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Manually Priced
L0630	NU EP		H 6	LSO, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0631	NU EP		H 6	LSO, sagittal control, with rigid anterior and posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0632	NU EP		H 6	LSO, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Manually Priced
L0633	NU EP		H 6	LSO, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0634	NU EP		H 6	LSO, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Manually Priced
L0635	NU EP		H 6	LSO, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0636	NU EP		H 6	LSO, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated	All	N	Purchase
L0637	NU EP		H 6	LSO, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0638	NU EP		H 6	LSO, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Purchase
L0639	NU EP		H 6	LSO, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
L0640	NU EP		H 6	LSO, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated	All	N	Purchase
L0700	NU EP		H 6	Cervical-thoracic-lumbar-sacral orthoses (CTLSO), anterior-posterior-lateral control, molded to patient model (Minerva type)	All	Y	Purchase
L0710	NU EP		H 6	CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type)	All	Y	Purchase
L0810	NU EP		H 6	Halo procedure, cervical halo incorporated into jacket vest	All	Y	Purchase
L0820	NU EP		H 6	Halo procedure, cervical halo incorporated into plaster body jacket	All	Y	Purchase
L0830	NU EP		H 6	Halo procedure, cervical halo incorporated into Milwaukee type orthosis	All	Y	Purchase
L0859	NU EP		H 6	Addition to halo procedure, magnetic resonance image compatible system, rings and pins, any material	All	Y	Purchase
L0960	NU EP		H 6	Torso support, post surgical support, pads for post surgical support	All	N	Purchase
L0970	NU EP		H 6	TLSO, corset front	All	N	Purchase
L0972	NU EP		H 6	LSO, corset front	All	N	Purchase
L0974	NU EP		H 6	TLSO, full corset	All	N	Purchase
L0976	NU EP		H 6	LSO, full corset	All	N	Purchase
L0978	NU EP		H 6	Axillary crutch extension	All	N	Purchase
L0980	NU EP		H 6	Peroneal straps, pair	All	N	Purchase
L0982	NU EP		H 6	Stocking supporter grips, set of four (4)	All	N	Purchase
L0984	NU		H	Protective body sock, each	21 +	N	Purchase
L1000	NU EP		H 6	CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model	All	Y	Purchase
L1010	NU EP		H 6	TLSO or scoliosis orthosis, axilla sling	All	N	Purchase
L1020	NU EP		H 6	Addition to CTLSO or scoliosis orthosis, kyphosis pad	All	N	Purchase
L1025	NU EP		H 6	Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating	All	N	Purchase
L1030	NU EP		H 6	Addition to CTLSO or scoliosis orthosis, lumbar bolster pad	All	N	Purchase
L1040	NU EP		H 6	Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad	All	N	Purchase
L1050	NU EP		H 6	Addition to CTLSO or scoliosis orthosis, sternal pad	All	N	Purchase
L1060	NU EP		H 6	Addition to CTLSO or scoliosis orthosis, thoracic pad	All	N	Purchase
L1070	NU EP		H 6	Addition to CTLSO or scoliosis orthosis, trapezius sling	All	N	Purchase
L1080	NU EP		H 6	Addition to CTLSO or scoliosis orthosis, outrigger	All	N	Purchase
L1085	NU EP		H 6	Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions	All	N	Purchase
L1090	NU EP		H 6	Addition to CTLSO or scoliosis orthosis, lumbar sling	All	N	Purchase
L1100	NU EP		H 6	Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather	All	N	Purchase
L1110	NU EP		H 6	Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model	All	N	Purchase
L1120	NU EP		H 6	Addition to CTLSO, scoliosis orthosis, cover for upright, each	All	N	Purchase
L1200	NU EP		H 6	Thoracic-lumbar-sacra l-orthosis (TLSO), inclusive of furnishing initial orthosis only	All	Y	Purchase
L1210	NU EP		H 6	Addition to TLSO (low profile), lateral thoracic extension	All	N	Purchase
L1220	NU EP		H 6	Addition to TLSO (low profile), anterior thoracic extension	All	N	Purchase
L1230	NU EP		H 6	Addition to TLSO (low profile), Milwaukee type superstructure	All	N	Purchase
L1240	NU EP		H 6	Addition to TLSO (low profile), lumbar derotation pad	All	N	Purchase
L1250	NU EP		H 6	Addition to TLSO (low profile), anterior ASIS pad	All	N	Purchase
L1260	NU EP		H 6	Addition to TLSO (low profile), anterior thoracic derotation pad	All	N	Purchase
L1270	NU EP		H 6	Addition to TLSO (low profile), abdominal pad	All	N	Purchase
L1280	NU EP		H 6	Addition to TLSO (low profile), rib gusset (elastic), each	All	N	Purchase
L1290	NU EP		H 6	Addition to TLSO (low profile), lateral trochanteric pad	All	N	Purchase
L1300	NU EP		H 6	Other scoliosis procedure, body jacket molded to patient model	All	Y	Purchase
L1310	NU EP		H 6	Other scoliosis procedure, postoperative body jacket	All	Y	Purchase
L1499	NU EP		H 6	Spinal orthosis, not otherwise specified. ***(The manufacturer's invoice must be attached to all claims.)	All	Y	Manually Priced
L1500	NU EP		H 6	THKAO, mobility frame (Newington, Parapodium types)	All	Y	Purchase
L1510	NU EP		H 6	THKAO, standing frame, with or without tray and accessories	All	Y	Purchase
L1520	NU EP		H 6	THKAO, swivel walker	All	Y	Purchase
L1600	NU EP		H 6	HO, abduction control of hip joints, flexible, Frejka type with cover, prefabricated, includes fitting and adjustment	All	N	Purchase
L1610	NU EP		H 6	HO, abduction control of hip joints, flexible (Frejka cover only), prefabricated, includes fitting and adjustment	All	N	Purchase
L1620	NU EP		H 6	HO, abduction control of hip joints, flexible (Pavlik harness), prefabricated, includes fitting and adjustment	All	N	Purchase
L1630	NU EP		H 6	HO, abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated	All	N	Purchase
L1640	NU EP		H 6	HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated	All	N	Purchase
L1650	NU EP		H 6	HO, abduction control of hip joints, static, adjustable, custom fitted (llfled type), prefabricated, includes fitting and adjustment	All	N	Purchase
L1660	NU EP		H 6	HO, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment	All	N	Purchase
L1680	NU EP		H 6	HO; abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type), custom fabricated	All	Y	Purchase
L1685	NU EP		H 6	HO, abduction control of hip joint, post operative hip abduction type, custom fabricated	All	Y	Purchase
L1686	NU EP		H 6	HO, abduction control of hip joint, post operative hip abduction type, prefabricated, includes fitting and adjustments	All	Y	Purchase
L1690	NU		H	Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment	21 +	Y	Purchase
L1700	NU EP		H 6	Legg Perthes orthosis (Toronto type), custom fabricated	All	Y	Purchase
L1710	NU EP		H 6	Legg Perthes orthosis (Newington type), custom fabricated	All	Y	Purchase
L1720	NU EP		H 6	Legg Perthes orthosis, trilateral (Tachdijan type), custom fabricated	All	Y	Purchase
L1730	NU EP		H 6	Legg Perthes orthosis (Scottish Rite type) custom fabricated	All	Y	Purchase
L1750	NU EP		H 6	Legg Perthes orthosis, Legg Perthes sling (Sam Brown type), prefabricated, includes fitting and adjustment	All	Y	Purchase
L1755	NU EP		H 6	Legg Perthes orthosis (Patten bottom type), custom fabricated	All	Y	Purchase
L1800	NU EP		H 6	KO, elastic with stays, prefabricated, includes fitting and adjustment	All	N	Purchase
L1810	NU EP		H 6	KO, elastic with joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L1815	NU EP		H 6	KO, elastic or other elastic type material with condylar pad(s), prefabricated, includes fitting and adjustment	All	N	Purchase
L1820	NU EP		H 6	KO, elastic with condyle pads and joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L1825	NU EP		H 6	KO, elastic knee cap. prefabricated, includes fitting and adjustment	All	N	Purchase
L1830	NU EP		H 6	KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment	All	N	Purchase
L1832	NU EP		H 6	KO, adjustable knee joints, positional orthosis, rigid support, prefabricated, includes fitting and adjustment rigid support	All	N	Purchase
L1834	NU EP		H 6	KO, without knee joint, rigid, custom fabricated	All	N	Purchase
L1840	NU EP		H 6	KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated	All	Y	Purchase
L1843	NU		H	Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment	21 +	Y	Purchase
L1844	NU		H	KO, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated	21 +	Y	Purchase
L1845	NU EP		H 6	KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, prefabricated, includes fitting and adjustment	All	Y	Purchase
L1846	NU EP		H 6	KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, custom fabricated	All	Y	Purchase
L1847	NU		H	Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s) prefabricated, includes fitting and adjustment	21 +	N	Purchase
L1850	NU EP		H 6	KO, Swedish type, prefabricated, includes fitting and adjustment	All	N	Purchase
L1855	NU EP		H 6	KO, molded plastic, thigh and calf sections, with double upright knee joints, custom fabricated	All	Y	Purchase
L1858	NU EP		H 6	KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom fabricated	All	Y	Purchase
L1860	NU EP		H 6	KO, modification of supracondylar prosthetic socket, custom fabricated (SK)	All	Y	Purchase
L1870	NU EP		H 6	KO, double upright, thigh and calf lacers, with knee joints, custom fabricated	All	Y	Purchase
L1880	NU EP		H 6	KO, double upright, nonmolded thigh and calf cuff/lacers with knee joints, custom fabricated	All	N	Purchase
L1900	NU EP		H 6	AFO, spring wire, dorsiflexion assist calf band, custom fabricated	All	N	Purchase
L1902	NU EP		H 6	AFO, ankle gauntlet, prefabricated, includes fitting and adjustment	All	N	Purchase
L1904	NU EP		H 6	AFO, molded ankle gauntlet, custom fabricated	All	N	Purchase
L1906	NU EP		H 6	AFO, multigamentus ankle support, prefabricated, includes fitting and adjustment	All	N	Purchase
L1907	NU EP		H 6	AFO, supramalleolar with straps, with or without interface/pads, custom fabricated	All	N	Purchase
L1910	NU EP		H 6	AFO, posterior, single bar, clasp attachment to shoe counter prefabricated, includes fitting and adjustment	All	N	Purchase
L1920	NU EP		H 6	AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated	All	N	Purchase
L1920	EP		6	***(Custom night "A" frame-KAFO, torsion control, bilateral night "A" frame) AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated	U21	N/A	Purchase
L1930	NU EP		H 6	AFO, plastic or other material, prefabricated, includes fitting and adjustment	All	N	Purchase
L1932	NU EP		H 6	AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment	All	N	Purchase
L1940	NU EP		H 6	AFO, plastic or other material, custom-fabricated	All	N	Purchase
L1945	NU EP		H 6	AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated	All	Y	Purchase
L1950	NU EP		H 6	AFO, spiral (Institute of Rehabilitative Medicine type), plastic, custom fabricated	All	N	Purchase
L1960	NU EP		H 6	AFO, posterior solid ankle, plastic, custom fabricated	All	N	Purchase
L1970	NU EP		H 6	AFO, plastic, with ankle joint, custom fabricated	All	N	Purchase
L1980	NU EP		H 6	AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar "BK" orthosis), custom fabricated	All	N	Purchase
L1990	NU EP		H 6	AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar "BK" orthosis), custom fabricated	All	N	Purchase
L2000	NU EP		H 6	KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar "AK" orthosis), custom fabricated	All	Y	Purchase
L2005	NU EP		H 6	KAFO, any material, single or double upright, stance control, automatic lock and swing phase release, mechanical activation, includes ankle joint, any type, custom fabricated	All	N	Purchase
L2010	NU EP		H 6	KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar "AK" orthosis), without knee joint, custom fabricated	All	Y	Purchase
L2020	NU EP		H 6	KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar "AK" orthosis), custom fabricated	All	Y	Purchase
L2030	NU EP		H 6	KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar "AK" orthosis), without knee joint, custom fabricated	All	Y	Purchase
L2035	NU		H	KAFO, full plastic, static prefabricated (pediatric size) prefabricated, includes fitting and adjustment	21 +	N	Purchase
L2036	NU EP		H 6	KAFO, full plastic, double upright, free knee, custom fabricated	All	Y	Purchase
L2037	NU EP		H 6	KAFO, full plastic, single upright, free knee, custom fabricated	All	Y	Purchase
L2038	NU EP		H 6	KAFO, full plastic, without knee joint, multi-axis ankle, (Lively orthosis or equal), custom fabricated	All	Y	Purchase
L2039	NU		H	KAFO, full plastic, single upright, poly-axial hinge, medial lateral rotation control, custom fabricated	21 +	Y	Purchase
L2040	NU EP		H 6	HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated	All	N	Purchase
L2040	NU EP	U1 U1		***(Night "A" frame-KAFO, torsion control, bilateral night "A" frame) HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated	All	N	Manually Priced Purchase
L2040	NU EP	U1 U1		H 6	***(Night "A" frame-KAFO, torsion control, bilateral night "A" frame) HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated	All	N
L2050	NU EP		H 6	HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2060	NU EP		H 6	HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2070	NU EP		H 6	HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated	All	N	Purchase
L2080	NU EP		H 6	HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2090	NU EP		H 6	HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2106	NU EP		H 6	AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated	All	N	Purchase
L2108	NU EP		H 6	AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated	All	Y	Purchase
L2112	NU EP		H 6	AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment	All	N	Purchase
L2114	NU EP		H 6	AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment	All	N	Purchase
L2116	NU EP		H 6	AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment	All	N	Purchase
L2126	NU EP		H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, molded to patient	All	Y	Purchase
L2128	NU EP		H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated	All	Y	Purchase
L2132	NU EP		H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment	All	Y	Purchase
L2134	NU EP		H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid custom fitted	All	Y	Purchase
L2136	NU EP		H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment	All	Y	Purchase
L2180	NU EP		H 6	Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints	All	N	Purchase
L2182	NU EP		H 6	Addition to lower extremity fracture orthosis, drop lock knee joint	All	N	Purchase
L2184	NU EP		H 6	Addition to lower extremity fracture orthosis, limited motion knee joint	All	N	Purchase
L2186	NU EP		H 6	Addition to lower extremity fracture orthosis, adjustable motion knee joint (Lerman type)	All	N	Purchase
L2188	NU EP		H 6	Addition to lower extremity fracture orthosis, quadrilateral brim	All	N	Purchase
L2190	NU EP		H 6	Addition to lower extremity fracture orthosis, waist belt	All	N	Purchase
L2192	NU EP		H 6	Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt	All	N	Purchase
L2200	NU EP		H 6	Additions to lower extremity, dorsiflexion and plantar flexion	All	N	Purchase
L2210	NU EP		H 6	Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint	All	N	Purchase
L2220	NU EP		H 6	Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint	All	N	Purchase
L2230	NU EP		H 6	Addition to lower extremity, split flat caliper stirrups and plate attachment	All	N	Purchase
L2232	NU EP		H 6	Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only	All	N	Manually Priced
L2240	NU EP		H 6	Addition to lower extremity, round caliper and plate attachment	All	N	Purchase
L2250	NU EP		H 6	Addition to lower extremity, foot plate, molded to patient model, stirrup attachment	All	N	Purchase
L2260	NU EP		H 6	Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)	All	N	Purchase
L2265	NU EP		H 6	Addition to lower extremity, long tongue stirrup	All	N	Purchase
L2270	NU EP		H 6	Addition to lower extremity, varus/valgus correction ("T") strap, padded/lined or malleolus pad	All	N	Purchase
L2275	NU		H	Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined	21 +	N	Purchase
L2280	NU EP		H 6	Addition to lower extremity, molded inner boot	All	N	Purchase
L2300	NU EP		H 6	Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable	All	N	Purchase
L2310	NU EP		H 6	Addition to lower extremity, abduction bar straight	All	N	Purchase
L2320	NU EP		H 6	Addition to lower extremity, nonmolded lacer	All	N	Purchase
L2330	NU EP		H 6	Addition to lower extremity, lacer molded to patient model	All	N	Purchase
L2335	NU EP		H 6	Addition to lower extremity, anterior swing band	All	N	Purchase
L2340	NU EP		H 6	Addition to lower extremity, pretidial shell, molded to patient model	All	N	Purchase
L2350	NU EP		H 6	Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for "PTB" "AFO" orthoses)	All	Y	Purchase
L2360	NU EP		H 6	Addition to lower extremity, extended steel shank	All	N	Purchase
L2370	NU EP		H 6	Addition to lower extremity, Patten bottom	All	N	Purchase
L2375	NU EP		H 6	Addition to lower extremity, torsion control, ankle joint and half solid stirrup	All	N	Purchase
L2380	NU EP		H 6	Addition to lower extremity, torsion control, straight knee joint, each joint	All	N	Purchase
L2385	NU EP		H 6	Addition to lower extremity, straight knee joint, heavy duty, each joint	All	N	Purchase
L2390	NU EP		H 6	Addition to lower extremity, offset knee joint, each joint	All	N	Purchase
L2395	NU EP		H 6	Addition to lower extremity, offset knee joint, heavy duty, each joint	All	N	Purchase
L2397	NU		H	Addition to lower extremity orthosis, suspension sleeve	21 +	N	Purchase
L2405	NU EP		H 6	Addition to knee joint, lock; drop, stance or swing phase, each joint	All	N	Purchase
L2415	NU EP		H 6	Addition to knee lock with integrated release mechanism, (bail, cable or equal, any material, each joint	All	N	Purchase
L2425	NU EP		H 6	Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint	All	N	Purchase
L2430	NU EP		H 6	Addition to knee joint, ratchet lock for active and progressive knee extension, each joint	All	N	Purchase
L2492	NU EP		H 6	Addition to knee joint, lift loop for drop lock ring	All	N	Purchase
L2500	NU EP		H 6	Addition to lower extremity, thigh/weight bearing, gulteal/ischial weight bearing, ring	All	N	Purchase
L2510	NU EP		H 6	Addition to lower extremity, thigh/weight bearing, quadrilateral brim, molded to patient model	All	N	Purchase
L2520	NU EP		H 6	Addition to lower extremity, thigh/weight bearing, quadrilateral brim, custom fitted	All	N	Purchase
L2525	NU EP		H 6	Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model	All	N	Purchase
L2526	NU EP		H 6	Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted	All	N	Purchase
L2530	NU EP		H 6	Addition to lower extremity, thigh/weight bearing, lacer, non-molded	All	N	Purchase
L2540	NU EP		H 6	Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model	All	N	Purchase
L2550	NU EP		H 6	Addition to lower extremity, thigh/weight bearing, high roll cuff	All	N	Purchase
L2570	NU EP		H 6	Addition to lower extremity, pelvic control, hip joint, clevis type two position joint, each	All	N	Purchase
L2580	NU EP		H 6	Addition to lower extremity, pelvic control, pelvic sling	All	N	Purchase
L2600	NU EP		H 6	Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing free, each	All	N	Purchase
L2610	NU EP		H 6	Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each	All	N	Purchase
L2620	NU EP		H 6	Addition to lower extremity, pelvic control, hip joint, heavy duty, each	All	N	Purchase
L2622	NU EP		H 6	Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each	All	N	Purchase
L2624	NU EP		H 6	Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each	All	N	Purchase
L2627	NU EP		H 6	Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables	All	N	Purchase
L2628	NU EP		H 6	Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables	All	N	Purchase
L2630	NU EP		H 6	Addition to lower extremity, pelvic control, band and belt unilateral	All	N	Purchase
L2640	NU EP		H 6	Addition to lower extremity, pelvic control, band and belt bilateral	All	N	Purchase
L2650	NU EP		H 6	Addition to lower extremity, pelvic and thoracic control, gluteal pad, each	All	N	Purchase
L2660	NU EP		H 6	Addition to lower extremity, thoracic control, thoracic band	All	N	Purchase
L2670	NU EP		H 6	Addition to lower extremity, thoracic control, paraspinal uprights	All	N	Purchase
L2680	NU EP		H 6	Addition to lower extremity, thoracic control, lateral support uprights	All	N	Purchase
L2750	NU EP		H 6	Addition to lower extremity orthosis, plating chrome or nickel, per bar	All	N	Purchase
L2755	NU		H	Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment	21 +	N	Purchase
L2755	NU EP		H 6	***(Carbon composite ankles; addition to AFO) Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment	All	N	Manually Priced Purchase
L2760	NU EP		H 6	Addition to lower extremity orthosis, extension, per extension, per bar (for linear adjustment for growth)	All	N	Purchase
L2770	NU EP		H 6	Addition to lower extremity orthosis, any material, per bar or joint	All	N	Purchase
L2780	NU EP		H 6	Addition to lower extremity orthosis, non-corrosive finish, per bar	All	N	Purchase
L2785	NU EP		H 6	Addition to lower extremity orthosis, drop lock retainer, each	All	N	Purchase
L2795	NU EP		H 6	Addition to lower extremity orthosis, knee control, full kneecap	All	N	Purchase
L2800	NU EP		H 6	Addition to lower extremity orthosis, knee control, kneecap, medial or lateral pull	All	N	Purchase
L2810	NU EP		H 6	Addition to lower extremity orthosis, knee control, condylar pad	All	N	Purchase
L2810	EP		6	***(Custom night "A" frame-KAFO, torsion control, bilateral night "A" frame) Addition to lower extremity orthosis, knee control, condylar pad	U21	N/A	Purchase
L2820	NU EP		H 6	Addition to lower extremity orthosis, soft interface for molded plastic, below knee section	All	N	Purchase
L2830	NU EP		H 6	Addition to lower extremity orthosis, soft interface for molded plastic, above knee section	All	N	Purchase
L2840	NU EP		H 6	Addition to lower extremity orthosis, tibial length sock, fracture or equal, each	All	N	Purchase
L2850	NU EP		H 6	Addition to lower extremity orthosis, femoral length sock, fracture or equal, each	All	N	Purchase
L2999	NU EP		H 6	Lower extremity orthoses, NOS	All	N	Manually Priced
L2999	NU EP		H 6	***(Unlisted prosthetic devices or orthotic appliances; the manufacturer's invoice must be attached to all claims.) Lower extremity orthoses, NOS	All	Y	Manually Priced
L3000	NU EP		H 6	Foot insert, removable, molded to patient model, "UCB" type, Berkeley shell, each	All	N	Purchase
L3002	NU EP		H 6	Foot insert, removable, molded to patient model, Plastazote or equal, each	All	N	Manually Priced
L3010	NU EP		H 6	Foot insert, removable, molded to patient model, longitudinal arch support, each	All	N	Purchase
L3020	NU EP		H 6	Foot insert, removable, molded to patient model, longitudinal/|metatarsal support, each	All	N	Purchase
L3030	NU EP		H 6	Foot insert, removable, formed to patient foot, each	All	N	Purchase
L3040	NU EP		H 6	Foot, arch support, removable, premolded, longitudinal, each	All	N	Purchase
L3050	NU EP		H 6	Foot, arch support, removable, premolded, metatarsal, each	All	N	Purchase
L3060	NU EP		H 6	Foot, arch support, removable, premolded, longitudinal/metatarsal, each	All	N	Purchase
L3070	NU EP		H 6	Foot, arch support, non-removable, attached to shoe, longitudinal, each	All	N	Purchase
L3080	NU EP		H 6	Foot, arch support, non-removable, attached to shoe, metatarsal, each	All	N	Purchase
L3090	NU EP		H 6	Foot, arch support, non-removable, attached to shoe, longitudinal/|metatarsal, each	All	N	Purchase
L3100	NU EP		H 6	Hallus-valgus night dynamic splint	All	N	Purchase
L3140	NU EP	UB	H 6	***(Bebox foot orthosis club foot abduction orthosis) Foot, abduction rotation bar, including shoes	All	N	Manually Priced Purchase
L3140	NU		H	***(Don Joy knee orthosis) Foot, abduction rotation bar, including shoes	21 +	Y	Manually Priced
L3150	NU EP		H 6	Foot, abduction rotation bar, without shoes	All	N	Purchase
L3150	EP		6	***(Custom night "A" frame-KAFO, torsion control, bilateral night "A" frame) Foot, abduction rotation bar, without shoes	U21	N/A	Purchase
L3170	NU EP		H 6	Foot, plastic heel stabilizer	All	N	Purchase
L3202	EP		6	Orthopedic shoe, oxford with supinator or pronator, child	U21	N/A	Purchase
L3204	EP		6	Orthopedic shoe, high-top with supinator or pronator, infant	U21	N/A	Purchase
L3204	NU EP		H 6	***(Straight last high-top shoe, each, size 2-8) Orthopedic shoe, high-top with supinator or pronator, infant	All	N	Manually Priced Purchase
L3204	NU EP	U1	H 6	***(Straight last high-top shoe, each, size81/2-12) Orthopedic shoe, high-top with supinator or pronator, infant	All	N	Manually Priced Purchase
L3204	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 3-6) Orthopedic shoe, high-top with supinator or pronator, infant	All	N	Manually Priced Purchase
L3204	NU EP	U1	H 6	***(Regular last high-top shoe, each, size81/2-12) Orthopedic shoe, high-top with supinator or pronator, infant	All	N	Purchase
L3204	NU EP	U1	H 6	***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, infant	All	N	Manually Priced Purchase
L3204	NU	H	***(Orthopedic shoe, high-top, normal last, each, size 3-8) Orthopedic shoe, high-top with supinator or pronator, infant	21 +	N	Manually Priced
L3204	NU EP	U1	H 6	***(Orthopedic shoe, high-top, normal last, each, size 81/4-12) Orthopedic shoe, high-top with supinator or pronator, infant	All	N	Manually Priced Purchase
L3206	NU EP	H 6	***(Straight last high-top shoe, each, size 2-8) Orthopedic shoe, high-top with supinator or pronator, child	All	N	Manually Priced Purchase
L3206	NU EP	U1	H 6	***(Straight last high-top shoe, each, size81/2-12) Orthopedic shoe, high-top with supinator or pronator, child	All	N	Manually Priced Purchase
L3206	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 3-6) Orthopedic shoe, high-top with supinator or pronator, child	All	N	Manually Priced Purchase
L3206	NU EP	U1	H 6	***(Regular last high-top shoe, each, size81/2-12) Orthopedic shoe, high-top with supinator or pronator, child	All	N	Purchase
L3206	NU EP	U1	H 6	***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, child	All	N	Manually Priced Purchase
L3206	NU	H	***(Orthopedic shoe, high-top, normal last, each, size 3-8) Orthopedic shoe, high-top with supinator or pronator, child	21 +	N	Manually Priced
L3206	NU EP	U1	H 6	***(Orthopedic shoe, high-top, normal last, each, size 81/4-12) Orthopedic shoe, high-top with supinator or pronator, child	All	N	Manually Priced Purchase
L3207	NU EP		H 6	***(Straight last high-top shoe, each, size 2-8) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3207	NU EP	U1	H 6	***(Straight last high-top shoe, each, size81/2-12) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3207	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 3-6) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3207	NU EP	U1	H 6	***(Regular last high-top shoe, each, size81/2-12) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Purchase
L3207	NU EP	U1	H 6	***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3207	NU		H	***(Orthopedic shoe, high-top, normal last, each, size 3-8) Orthopedic shoe, high-top with supinator or pronator, junior	21 +	N	Manually Priced
L3207	NU EP	U1	H 6	***(Orthopedic shoe, high-top, normal last, each, size 81/4-12) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3207	NU EP		H 6	***(Orthopedic shoe, high-top, normal last, each, size 81/4-12) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3208	EP		6	Surgical boot, each, infant	U21	N/A	Purchase
L3209	EP		6	Surgical boot, each, child	U21	N/A	Purchase
L3215	NU EP		H 6	Orthopedic footwear, woman's shoes, oxford	All	Y	Manually Priced
L3216	NU EP		H 6	Orthopedic footwear, woman's shoes, depth inlay	All	Y	Purchase
L3217	NU EP		H 6	***(Straight last high-top shoe, each, size 2-8) Orthopedic footwear, woman's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3217	NU EP	U1 U1	H 6	***(Straight last high-top shoe, each, size81/2-12) Orthopedic footwear, woman's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3217	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 3-6) Orthopedic footwear, woman's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3217	NU EP	U1	H 6	***(Regular last high-top shoe, each, size81/2-12) Orthopedic footwear, woman's shoes, high-top, depth inlay	All	N	Purchase
L3217	NU EP	U1	H 6	***(Reverse last closed toe) Orthopedic footwear, woman's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3219	NU EP		H 6	Orthopedic footwear, man's shoes, oxford	All	Y	Manually Priced
L3221	NU EP		H 6	Orthopedic footwear, man's shoes, depth inlay	All	Y	Purchase
L3222	NU EP		H 6	***(Straight last high-top shoe, each, size 2-8) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3222	NU EP	U1	H 6	***(Straight last high-top shoe, each, size81/2-12) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3222	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 3-6) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3222	NU EP	U1	H 6	***(Regular last high-top shoe, each, size81/2-12) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Purchase
L3222	NU EP	U1	H 6	***(Reverse last closed toe) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3224	NU		H	Orthopedic footwear, woman's shoe, Oxford, used as an integral part of a brace (orthosis)	21 +	N	Purchase
L3225	NU		H	Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis)	21 +	N	Purchase
L3230	NU EP		H 6	Orthopedic footwear, custom shoes, depth inlay	All	Y	Purchase
L3250	NU EP		H 6	Orthopedic footwear, custom molded shoe, removable inner molded, prosthetic shoe, each	All	Y	Manually Priced
L3253	NU EP		H 6	Foot, molded shoe Plastazote (or similar), custom fitted, each	All	Y	Purchase
L3257	NU EP		H 6	Orthopedic footwear, additional charge for split size	All	Y	Purchase
L3260	NU EP		H 6	Surgical boot/shoe, each	All	N	Purchase
L3265	NU EP		H 6	Plastazote sandal, each	All	N	Purchase
L3310	NU EP		H 6	Lift, elevation, heel and sole, neoprene, per inch	All	N	Purchase
L3332	NU EP		H 6	Lift, elevation, inside shoe, tapered, up to one-half inch	All	N	Purchase
L3334	NU EP		H 6	Lift, elevation, heel, per inch	All	N	Purchase
L3350	NU EP		H 6	Heel wedge	All	N	Purchase
L3360	NU EP		H 6	Sole wedge, outside sole	All	N	Purchase
L3370	NU EP		H 6	Sole wedge, between sole	All	N	Purchase
L3400	NU EP		H 6	Metatarsal bar wedge, rocker	All	N	Purchase
L3420	NU EP		H 6	Full sole and heel wedge, between sole	All	N	Purchase
L3450	NU EP		H 6	Heel, SACH cushion type	All	N	Purchase
L3455	NU EP		H 6	Heel, new leather, standard	All	N	Purchase
L3465	NU EP		H 6	Heel, Thomas with wedge	All	N	Purchase
L3540	NU EP		H 6	Orthopedic shoe addition, sole full	All	N	Purchase
L3580	NU EP		H 6	Orthopedic shoe addition, convert instep to velcro closure	All	N	Purchase
L3590	NU EP		H 6	Orthopedic shoe addition, convert firm shoe counter to soft counter	All	N	Purchase
L3600	NU EP		H 6	Transfer for an orthosis from one shoe to another, caliper plate, existing	All	N	Purchase
L3620	NU EP		H 6	Transfer of an orthosis from one shoe to another, solid stirrup, existing	All	N	Purchase
L3630	NU EP		H 6	Transfer of an orthosis from one shoe to another, solid stirrup, new	All	N	Purchase
L3649	EP		6	Orthopedic shoe, modification, addition or transfer, NOS	U21	N/A	Manually Priced
L3649	NU EP	U1	H 6	***(Unlisted prosthetic devices or orthotic appliances; the manufacturer's invoice must be attached to all claims.) Orthopedic shoe, modification, addition or transfer, NOS	All	Y	Manually Priced Purchase
L3649	NU EP		H 6	***(Orthopedic footwear, wooden sole shoe, each) Orthopedic shoe, modification, addition or transfer, NOS	All	N	Manually Priced Purchase
L3650	NU EP		H 6	SO, figure of eight design abduction re-strainer prefabricated, includes fitting and adjustment	All	N	Purchase
L3660	NU EP		H 6	SO, figure of eight design, abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustment	All	N	Purchase
L3670	NU EP		H 6	SO, acromio/clavicular (canvas and webbing type) prefabricated, includes fitting and adjustment	All	N	Purchase
L3675	NU		H	SO, vest type abduction restrainer, canvas webbing type, or equal, prefabricated, includes fitting and adjustment	21 +	N	Purchase
L3700	NU EP		H 6	Elbow orthoses (EO), elastic with stays, prefabricated, includes fitting and adjustment	All	N	Purchase
L3710	NU EP		H 6	EO, elastic with metal joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L3720	NU EP		H 6	EO, double upright with forearm/arm cuffs, free motion, custom fabricated	All	N	Purchase
L3730	NU EP		H 6	EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated	All	Y	Purchase
L3740	NU EP		H 6	EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated	All	Y	Purchase
L3800	NU EP		H 6	WHFO, short opponens, no attachments, custom fabricated	All	N	Purchase
L3805	NU EP		H 6	WHFO, long opponens, no attachment, custom fabricated	All	N	Purchase
L3807	NU EP		H 6	WHFO, without joint(s), prefabricated, includes fitting and adjustments, any type	All	N	Purchase
L3810	NU EP		H 6	WHFO, addition to short and long opponens, thumb abduction ("C") bar	All	N	Purchase
L3815	NU EP		H 6	WHFO, addition to short and long opponens, second M.P. abduction assist	All	N	Purchase
L3820	NU EP		H 6	WHFO, addition to short and long opponens, I.P. extension assist, with M.P. extension stop	All	N	Purchase
L3825	NU EP		H 6	WHFO, addition to short and long opponens, M.P. extension stop	All	N	Purchase
L3830	NU EP		H 6	WHFO, addition to short and long opponens, M.P. extension assist	All	N	Purchase
L3835	NU EP		H 6	WHFO, addition to short and long opponens, M.P. spring extension assist	All	N	Purchase
L3840	NU EP		H 6	WHFO, addition to short and long opponens, spring swivel thumb	All	N	Purchase
L3845	NU EP		H 6	WHFO, addition to short and long opponens, thumb I.P. extension assist, with M.P. stop	All	N	Purchase
L3850	NU EP		H 6	WHO, addition to short and long opponens, action wrist with dorsiflexion assist	All	N	Purchase
L3855	NU EP		H 6	WHFO, addition to short and long opponens, adjustable M.P. flexion control	All	N	Purchase
L3860	NU EP		H 6	WHFO, addition to short and long opponens, adjustable M.P. flexion control and LP.	All	N	Purchase
L3900	NU EP		H 6	WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated	All	Y	Purchase
L3901	NU EP		H 6	WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated	All	Y	Purchase
L3902	NU EP		H 6	WHFO, external powered, compressed gas, custom fabricated	All	Y	Purchase
L3904	NU EP		H 6	WHFO, external powered, electric, custom fabricated	All	Y	Purchase
L3906**	NU EP		H 6	WHFO, wrist gauntlet, molded to patient model, custom fabricated	All	N	Purchase
L3907**	NU EP		H 6	WHFO, wrist gauntlet with thumb spica, molded to patient model, custom fabricated	All	N	Purchase
L3908	NU EP		H 6	WHFO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment	All	N	Purchase
L3910	NU EP		H 6	WHFO, Swanson design, prefabricated, includes fitting and adjustment	All	N	Purchase
L3912	NU EP		H 6	HFO, flexion glove with elastic finger control, prefabricated, includes fitting and adjustment	All	N	Purchase
L3914	NU EP		H 6	WHO, wrist extension (cock-up) prefabricated, includes fitting and adjustment	All	N	Purchase
L3916	NU EP		H 6	WHFO, wrist extension (cock-up), with outrigger, prefabricated, includes fitting and adjustment	All	N	Purchase
L3918	NU EP		H 6	HFO, knuckle bender prefabricated, includes fitting and adjustment	All	N	Purchase
L3920	NU EP		H 6	HFO, knuckle bender, with outrigger prefabricated, includes fitting and adjustment	All	N	Purchase
L3922	NU EP		H 6	HFO, knuckle bender, two segment to flex joints prefabricated, includes fitting and adjustment	All	N	Purchase
L3924	NU EP		H 6	WHFO, Oppenheimer, prefabricated, includes fitting and adjustment	All	N	Purchase
L3926	NU EP		H 6	WHFO, Thomas suspension, prefabricated, includes fitting and adjustment	All	N	Purchase
L3928	NU EP		H 6	HFO, finger extension, with lock spring, prefabricated, includes fitting and adjustment	All	N	Purchase
L3930	NU EP		H 6	WHFO, finger extension, with wrist support, prefabricated, includes fitting and adjustment	All	N	Purchase
L3932	NU EP		H 6	FO, safety pin, spring wire, prefabricated, includes fitting and adjustment	All	N	Purchase
L3934	NU EP		H 6	FO, safety pin, modified, prefabricated, includes fitting and adjustment	All	N	Purchase
L3936	NU EP		H 6	WHFO, Palmer prefabricated, includes fitting and adjustment	All	N	Purchase
L3938	NU EP		H 6	WHFO, Dorsal wrist, prefabricated, includes fitting and adjustment	All	N	Purchase
L3940	NU EP		H 6	WHFO, Dorsal wrist, with outrigger attachment, prefabricated, includes fitting and adjustment	All	N	Purchase
L3942	NU EP		H 6	HFO, reverse knuckle bender, prefabricated, includes fitting and adjustment	All	N	Purchase
L3944	NU EP		H 6	HFO, reverse knuckle bender, with outrigger, prefabricated, includes fitting and adjustment	All	N	Purchase
L3946	NU EP		H 6	HFO, composite elastic, prefabricated, includes fitting and adjustment	All	N	Purchase
L3948	NU EP		H 6	FO, finger knuckle bender, prefabricated, includes fitting and adjustment	All	N	Purchase
L3950	NU EP		H 6	WHFO, combination Oppenheimer, with knuckle bender and two attachments, prefabricated, includes fitting and adjustment	All	N	Purchase
L3952	NU EP		H 6	WHFO, combination Oppenheimer, with reverse knuckle and two attachments, prefabricated, includes fitting and adjustment	All	N	Purchase
L3954	NU EP		H 6	HFO, spreading hand, prefabricated, includes fitting and adjustment	All	N	Purchase
L3956	NU		H	Addition of joint to upper extremity orthosis, any material; per joint	21 +	N	Purchase
L3960	NU EP		H 6	SEWHO, abduction, positioning, airplane design, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3962	NU EP		H 6	SEWHO, abduction positioning, Erb's palsy design, prefabricated, includes fitting and adjustment	All	N	Purchase
L3963	NU EP		H 6	SEWHO, molded shoulder, arm, forearm, and wrist, with articulating elbow joint, custom fabricated	All	Y	Purchase
L3964	NU EP		H 6	SEO, mobile arm supports attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment	All	N	Purchase
L3965	NU EP		H 6	SEO mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3966	NU EP		H 6	SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3968	NU EP		H 6	SEO, mobile arm support attached to wheelchair, balanced, friction arm support, (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment	All	Y	Purchase
L3969	NU EP		H 6	SEO, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type arm suspension support, prefabricated, includes fitting and adjustment	All	N	Purchase
L3970	NU EP		H 6	SEO, addition to mobile arm support elevating proximal arm	All	N	Purchase
L3972	NU EP		H 6	SEO, addition to mobile arm support, offset or lateral rocker arm with elastic balance control	All	N	Purchase
L3974	NU EP		H 6	SEO, addition to mobile arm support, supinator	All	N	Purchase
L3980	NU EP		H 6	Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment	All	N	Purchase
L3982	NU EP		H 6	Upper extremity fracture orthosis, radius/ulnar prefabricated, includes fitting and adjustment	All	N	Purchase
L3984	NU EP		H 6	Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment	All	N	Purchase
L3985	NU EP		H 6	Upper extremity fracture orthosis, forearm, hand with wrist hinge, custom fabricated	All	N	Purchase
L3986	NU EP		H 6	Upper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist (example - Colles' fracture), custom fabricated	All	N	Purchase
L3995	NU EP		H 6	Addition to upper extremity orthosis sock, fracture or equal, each	All	N	Purchase
L3999	EP		6	Upper limb orthosis, NOS	U21	N/A	Manually Priced
L3999	NU EP		H 6	***(The manufacturer's invoice must be attached to all claims.) Upper limb orthosis, NOS	All	Y	Manually Priced Manually Priced
L4000	NU EP		H 6	Replace girdle for spinal orthosis (CTLSO or SO)	All	Y	Purchase
L4002	NU EP		H 6	Replace strap, any orthosis, includes all components, any length, any type	All	N	Manually Priced
L4010	NU EP		H 6	Replace trilateral socket brim	All	N	Purchase
L4020	NU EP		H 6	Replace quadrilateral socket brim, molded to patient model	All	N	Purchase
L4030	NU EP		H 6	Replace quadrilateral socket brim, custom fitted	All	N	Purchase
L4040	NU EP		H 6	Replace molded thigh lacer	All	N	Purchase
L4045	NU EP		H 6	Replace nonmolded thigh lacer	All	N	Purchase
L4050	NU EP		H 6	Replace molded calf lacer	All	N	Purchase
L4055	NU EP		H 6	Replace nonmolded calf lacer	All	N	Purchase
L4060	NU EP		H 6	Replace high roll cuff	All	N	Purchase
L4070	NU EP		H 6	Replace proximal and distal upright for KAFO	All	N	Purchase
L4080	NU EP		H 6	Replace metal bands KAFO, proximal thigh	All	N	Purchase
L4090	EP		6	***(Custom night "A" frame-KAFO, torsion control, bilateral night "A" frame) Replace metal bands KAFO-AFO, calf or distal thigh	U21	N/A	Purchase
L4090	NU EP		H 6	Replace metal bands KAFO-AFO, calf or distal thigh	All	N	Purchase
L4100	NU EP		H 6	Replace leather cuff KAFO, proximal thigh	All	N	Purchase
L4110	NU EP		H 6	Replace leather cuff KAFO-AFO, calf or distal thigh	All	N	Purchase
L4130	NU EP		H 6	Replace pretibial shell	All	N	Purchase
L4205	NU EP		H 6	Repair of orthotic device, labor component, per 15 minutes	All	Y	Manually Priced Purchase
L4210	NU EP		H 6	Repair of orthotic device, repair or replace minor parts	All	Y	Manually Priced Purchase
L4350	NU EP		H 6	Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment	All	N	Purchase
L4360	NU EP		H 6	Walking boot, pneumatic with or without joints, with or without interface material, prefabricated, includes fitting and adjustment	All	N	Purchase
L4370	NU EP		H 6	Pneumatic full leg splint, prefabricated, includes fitting and adjustment	All	N	Purchase
L4380	NU EP		H 6	Pneumatic knee splint, prefabricated, includes fitting and adjustment	All	N	Purchase
L4392				Replacement soft interface material, static AFO	21 +	N	Purchase
L4394	NU		H	Replace soft interface material, foot drop splint	21 +	N	Purchase
L4396	NU		H	Static AFO, including soft interface material, adjustable for fit, for positioning, pressure reduction, may be used for minimal ambulation, prefabricated, includes fitting and adjustment	21 +	N	Purchase
L4398	NU		H	Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment	21 +	N	Purchase
L5999	NU EP		H 6	***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.) Lower extremity prosthesis, not otherwise specified	All	Y	Manually Priced Manually Priced
L7499	NU EP		H 6	***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.) Upper extremity prosthesis, not otherwise specified	All	Y	Manually Priced Manually Priced
L7510	NU EP	UB	H 6	Repair of prosthetic device, hourly rate	All	Y	Manually Priced Purchase
L7520	NU EP		H 6	Repair prosthetic device, labor component, per 15 minutes	All	Y	Manually Priced Purchase
L8499	NU EP		H 6	***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.) Unlisted procedure for miscellaneous prosthetic services	All	Y	Manually Priced Purchase

242.193Augmentative Communication Device, All Ages

The augmentative communication device must be billed using the procedure code assigned to each component. The specific components will be reimbursed, as needed, for the procedure codes listed below and will count toward the lifetime limit of $7,500 per beneficiary.

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP orNU.

Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) "6" for individuals under age 21 or TOS "H" for individuals age 21 and over.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a "Y" in the column; if not, an "N" is shown.

NOTE: Attach a manufacturer's invoice to the claim and indicate the item or parts billed on the invoice. A description and the amount billed for each item must be attached to the claim. If more than one item is billed under a procedure code, the description and billed amount of each item must be listed separately under each procedure code and attached to the claim. The total billed for each procedure code should be reflected in field 24F.

* Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Augmentative Communication Device, All Ages (section 242.193)

Procedure Code	M1	M2	TOS	PA	Description	Payment Method
E2500	NU EP		H 6	Y*	***(Light Technology Communication Aids -communication aids that do not have the memory component to store the information. They are often used in conjunction with higher tech devices as part of a multi-modal communication system.) Speech-generating device, digitized speech, using pre-recorded messages less than or equal to 8 minutes recording time	Purchase
E2502	NU EP		H 6	Y4	***(Simple Voice Output Device - simple devices with limited storage capacity and voice output only.) Speech-generating device, digitized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time	Purchase
E2504	NU EP		H 6	Y*	***(Simple Voice Output Device - simple devices with limited storage capacity and voice output only) Speech-generating device, digitized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time	Purchase
E2506	NU EP		H 6	Y*	***(Simple Voice Output Device - simple devices with limited storage capacity and voice output only) Speech-generating device, digitized speech, using pre-recorded messages, greater than 40 minutes recording time.	Purchase
E2508	NU EP		H 6	Y*	***(More Advanced Voice Output Communication Aids - offer more storage capacity and often have other output methods in addition to voice output; e.g., LED display) Speech-generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device	Purchase
E2510	NU EP		6	Y4	***(Higher Technology Voice Output Communication Aids - offer greater memory capabilities, various types of output, computer interface options, etc.) Speech-generating device synthesized speech, permitting multiple methods of message formulation and multiple methods of device access	Purchase
E2510	NU EP		H 6	Y*	***(State-of-the-Art Voice Output Communication Aids - represents state-of-the-art communication aid technology. Have extensive memory capabilities, various output methods, computer interface options; offer a variety of input methods in a single device and advanced functions such as auditory scanning, icon and word prediction, etc.) Speech-generating device synthesized speech, permitting multiple methods of message formulation and multiple methods of device access	Purchase
E2511	NU EP		H 6	Y*	***(Software - often recommended for augmentative communication device. Software may change as the child matures.) Speech-generating software program, for personal computer or personal digital assistant	Purchase
E2512	NU EP		H 6	Y	Accessory for speech generating device, mounting system	Manually Priced
E2599	NU EP		H 6	Y*	***(Switches - used with training aids and augmentative communication devices as a means of access) Accessory for speech generating device, not otherwise classified	Manually Priced
V5336	NU EP		H 6	Y	***(Augmentative Communication Device Repair - parts only) Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)	N/A
V5336	NU EP		H 6	Y	***(Augmentative Communication Device Repair - labor only) Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)	N/A

Note: When repair charges for both parts and labor of the ACD is provided and/or billed on the same date of service, only one detail (parts only or labor only) of procedure code V5336 may be billed per beneficiary per date of service. Information must be specified on the paper claim to clarify the charges billed by the provider. Parts and labor charges must be itemized by narrative and documentation.

A.The charge for parts must be clearly documented. A manufacturer's invoice for the parts must be attached.

B.The labor charge and the time represented by the labor charge must be clearly documented.

016.06.06 Ark. Code R. 056

9/8/2006